Pouch Techniques in Rectal Cancer Surgery

Rectal cancer of the middle and distal third of the rectum are nowadays managed by low or ultra-low anterior resection with total mesorectal excision and coloanal anastomosis.Following straight coloanal anastomosis,patients often suffer from high stool frequency,urgency and,occasionally,fecal incontinence.To overcome these problems,several types of colonic reservoirs(pouches) have been proposed.The following article elucidates the indications and contraindications for the creation of a pouch.Furthermore,the paper gives a short overview of the different pouch designs that are widely accepted and currently in use,with special emphasis of the typical advantages,disadvantages and feasibility.Current guide-lines recommend to perform a colonic pouch since it provides functional benefits over straight coloanal anastomosis with no increase in postoperative complications.     

Dermatologic emergencies

Being able to recognize and treat a dermatologic emergency is extremely important to the primary care physician. This ability is very rewarding for the patient and gratifying to the physician. In this article, some of the more commonly encountered emergencies are discussed.     

Dermatologic emergencies

Life-threatening dermatologic conditions include Rocky Mountain spotted fever; necrotizing fasciitis; toxic epidermal necrolysis; and Stevens-Johnson syndrome. Rocky Mountain spotted fever is the most common rickettsial disease in the United States, with an overall mortality rate of 5 to 10 percent. Classic symptoms include fever, headache, and rash in a patient with a history of tick bite or exposure. Doxycycline is the first-line treatment. Necrotizing fasciitis is a rapidly progressive infection of the deep fascia, with necrosis of the subcutaneous tissues. It usually occurs after surgery or trauma. Patients have erythema and pain out of proportion to the physical findings. Immediate surgical debridement and antibiotic therapy should be initiated. Stevens-Johnson syndrome and toxic epidermal necrolysis are acute hypersensitivity cutaneous reactions. Stevens-Johnson syndrome is characterized by target lesions with central dusky purpura or a central bulla. Toxic epidermal necrolysis is a more severe reaction with full-thickness epidermal necrosis and exfoliation. Most cases of Stevens-Johnson syndrome and toxic epidermal necrolysis are drug induced. The causative drug should be discontinued immediately, and the patient should be hospitalized for supportive care.     

Techniques to Optimize Multimodal Analgesia in Ambulatory Surgery

Purpose of Review

Ambulatory surgery has grown in popularity in recent decades due to the advancement in both surgical and anesthetic techniques resulting in quicker recovery times, fewer complications, higher patient satisfaction, and reduced costs of care. We review common approaches to multimodal analgesia.

Recent Findings

A multimodal approach can help reduce perioperative opioid requirements and improve patient recovery. Analgesic options may include NSAIDs, acetaminophen, gabapentinoids, corticosteroids, alpha-2 agonists, local anesthetics, and the use of regional anesthesia.

Summary

We highlight important aspects related to pain management in the ambulatory surgery setting. A coordinated approach is required by the entire healthcare team to help expedite patient recovery and facilitate a resumption of normal activity following surgery. Implementation and development of standardized analgesic protocols will further improve patient care and outcomes.

     

Dermatologic emergencies

Primary care physicians are the gatekeepers of the medical community. They are the physicians to whom patients first present, and they are often the physicians with whom patients have the longest lasting relationships. Primary care physicians, as a result of these long-term relationships, have been endowed with a unique responsibility to the health of their patients. By the very nature of their practice, primary care physicians do not have the resources to treat emergent life-threatening conditions. They must, however, be able to diagnose these potentially life-threatening conditions and be able to stabilize and appropriately refer a patient for urgent evaluation by specialists or emergency physicians. There are many types of emergencies encountered in the outpatient setting, ranging from cardiac to toxicologic. As important as recognizing signs and symptoms of cardiac ischemia is the ability to recognize potentially life-threatening dermatologic disorders or dermatologic manifestations of life-threatening systemic diseases.     

Dermatologic formulary

The formulary for dermatologic use in the emergency department must not only encompass drugs that are essential for advanced cardiac and trauma life support, but must have specific drugs that are indicated for common dermatologic conditions that are evaluated in the emergency department. First and foremost is the selection of the appropriate drug for the disease. Other factors, such as the vehicle in which the drug is compounded, become equally important, as this directly affects the delivery of medication to the patient. Although this formulary is by no means complete, it is a reasonable guide for emergency medicine physicians to utilize when comtemplating dermatologic care. It is important when selecting a drug for dermatologic care that the physician be cognizant of the patient--the type, location, and condition of the skin--and of the disease he or she is treating. When these factors are given due consideration, the appropriate drug for the disease will be utilized for the ultimate benefit of the patient.     

Dermatologic complications in HIV.

The skin is unique in its accessibility for the diagnosis of diseases acquired because of decreased immunity in human immunodeficiency virus (HIV) infection. A majority of HIV-infected patients will have dermatologic problems at some time during their illness. Many of the cutaneous conditions identified will provide the means by which systemic opportunistic infections, neoplasms, and complications of therapy can be identified. The skin provides an opportunity for the recognition of new or foreign conditions as well as exotic manifestations of diseases that complicate HIV infection. A high degree of suspicion and a willingness to examine the entire skin thoroughly and frequently can enable practitioners to reduce the morbidity and mortality associated with HIV infection.     

Sonography of Dermatologic Emergencies

Dermatologic conditions may be the subjects of potential emergency consultations, and the knowledge of their sonographic appearance can facilitate an early diagnosis and management. In this pictorial essay, the sonographic dermatologic anatomy, technique, and conditions that can be supported by a prompt sonographic diagnosis are reviewed. The sonographic signs that may help diagnose these entities are discussed with a practical approach.     

Readysource Seclected Dermatologic Problems

ReadySource is intended for the reader who wishes more information on or education in the particular subject area. It is drawn from several sources: the Educational Resource Index, a computerized listing developed by the Department of Continuing Education, University of Wisconsin-Extension; announcements by individual medical schools and teaching hospitals; information provided by the author; and our own files. Listing does not necessarily imply endorsement by the university, POSTGRADUATE MEDICINE, or the author of the article. Readers interested in a meeting or audiovisual aid should write directly to the contact listed.     

麻醉综合技术在结直肠外科快速手术流程中的应用进展

20世纪90年代以来,随着微创手术、减轻围手术期应激反应和控制疼痛等新技术和新理念的出现,使得传统的外科正在经受着潜移默化的革新,将这些新技术结合起来,以多学科团队协作（multidisciplinary treatment,MDT）为基础,     

Dermatologic manifestations of infectious diseases in pregnancy

Several pathogens that have been identified as teratogenic or fetotoxic have associated dermatologic changes when active infection is present. Viral and bacterial teratogenic pathogens include herpes simplex virus 1, herpes simplex virus 2, varicella-zoster virus, cytomegalovirus, human papilloma virus, human parvovirus B19, rubella, viral hepatitis, syphilis, and gonorrhea. This article focuses on the characteristic dermatologic manifestation of these diseases in pregnancy; diagnostic strategies; interpretation of maternal and fetal laboratory test results; treatment of the pregnant woman, fetus, and newborn; and congenital outcomes of treated and untreated infection. Emphasis is placed on vaccination and prevention of transmission of infection to pregnant women.