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U. Rozhov, M.B.A., M.D.

Associate Professor, Louisiana State University School of Medicine in Shreveport

Some of the fluid passes into the vascular system to help push the blood out of the body, as well, and becomes part of the drainage. Drainage, composed of blood and blood clots, interstitial fluid, lymphatic fluid, and embalming solution,17 is a crucial part of the arterial embalming: although drainage itself does not actually embalm the body, the embalming will be more thorough if drainage takes place. Blood also rapidly decomposes after death, leading to additional discoloration, odor, and the possible formation of gas. In some bodies there may be little to no drainage for various reasons, including prior decomposition of blood, extensive loss of blood from traumatic hemorrhaging, and internal or alternate drainage routes. If the blood drains into the abdominal cavity, aspiration of the blood should relieve any swelling. If the blood is draining through an alternate route such through the intestinal tract or through pathological lesions in the skin, just let the blood drain out as you inject. As long as there is distribution and diffusion along with no swelling, the lack of drainage should not be a concern. There are only a few methods of drainage: alternate, concurrent, and intermittent. Alternate drainage is when the arterial solution is injected for a time, after which the injection of solution is stopped and drainage is employed. This increases the time of preparation somewhat significantly, and can cause distention in the tissue. Concurrent drainage is when the injection of arterial solution and venous drainage occur at the same time. It may be difficult to obtain any vascular pressure with this method because drainage is open the entire time; it might, however, help with bodies containing excessive moisture. Intermittent drainage is when the injection of arterial solution continues throughout the entire arterial embalming process, but the drainage is open for a time, and then closed for a time. It may be difficult to obtain any creates vascular pressure, which helps with drainage, vascula anddrainage is open the entire time; it might, however, also helps the body retain fluids. Intermittent drainage Once the embalmer is satisfied with how the arterial is when continues throughout the entire arterial be embalming is going, a number of other things can embalming accomplished simultaneously. This creates vas a time, and then closed Thedrainage, and thoroughly and continuously fluids. However, sometimes Once the embalmer is satisfied with how the arteria warm water is not can be accomplished embalmers other things available. Regardless, the bod head, and hands, since these areas are most visible can be re dirt, cosmetic, ink, and anything else that during viewing. The embalmer must clean under the fingernails, using an instrument to remove dirt and Particular attention should be paid to out other matter. The embalmer must c braids or mats, then wash the hair with germicidal soap or a commercial shampoo. Prior to rinse can beor mats, then on longthe hair on allgermicidal braids used, not only wash hair, but with hair, to help with deodorizing. If there is scaling on the Conditioner or hair rinse hands, a solvent such skin, particularly on the face and can be used, not only on l deodorizing. If more embalming is needed, additional arteries may need to be raised in the areas needing embalming. Another option to more thoroughly embalm a body or to provide additional embalming to areas that may not have been embalmed very well is hypodermic embalming, discussed on page 19. Once the embalmer is completely satisfied with the embalming after arterial and supplemental embalmings, the embalmer can proceed with the cavity embalming. Some embalmers choose to do this prior to cavity embalming, but it can be more practical to wait: if disruption from the cavity embalming causes leakage at the incision sites, it is best to treat this prior to sealing the incisions. Once each artery and vein used have been tied off, the incision(s) can be packed and stitched up. Embalming chemical companies make numerous types of sealants, including putty and powder form. Once sealant is placed in the incision, prep cotton can be packed in, along with more sealant on top. The embalmer may choose to partially begin the suture prior to packing the incision.

De Vries and coworkers treated nine patients with advanced unresectable metastatic cancer confined to liver and reported a considerable treatment mortality of 33% but did observe significant antitumor activity. Antitumor activity was observed in three of six patients with ocular melanoma to liver and in zero of five patients with colorectal cancer. The modest antitumor activity may be secondary to the low doses of agents used, only 0. Responses were consistent across all histologies treated, including ocular melanoma and colorectal cancer and observed in those with advanced disease (Table 52. Response to Isolated Hepatic Perfusion Based on Number of Lesions, Diameter of Largest Tumor, or Percent Hepatic Replacement in Patients Treated with Tumor Necrosis Factor and Melphalan Chemoembolization Chemoembolization involves the administration of chemotherapy followed by vascular occlusion using a variety of agents such as degradable starch microspheres, gelatin powders, polyvinyl chloride, or pledgets. Responding patients usually undergo multiple procedures over time as tumors and vasculature regrow. This approach has been widely applied in the treatment of primary hepatocellular carcinoma (see Chapter 33. For patients with metastatic cancer, the most common application is in patients with unresectable metastases from carcinoid or islet cell tumors. Because most tumors are highly vascular and have an indolent course in many patients, a partial response can provide long-term palliation. Furthermore, many patients who do not achieve an objective response have improvements in symptoms resulting from hormonal secretion. The overall objective response rate tends to be in the range of 30% to 50%, and the great majority of patients show reduced hormone secretion and improvement of symptoms (Table 52. Although there has been a shift in practice from embolization alone to chemoembolization with a variety of agents, there is no clear evidence that the use of chemotherapy improves response or patient outcome. Outcome in Patients with Neuroendocrine Tumors Metastatic to the Liver after Chemoembolization Chemoembolization has also been attempted for patients with colorectal cancer metastatic to the liver. In contrast to neuroendocrine tumors, most patients with metastatic colorectal cancer demonstrate a more aggressive course both within the liver and systemically. Two small randomized trials showed no statistically significant benefit of chemoembolization over embolization only (Table 52. Outcome in Patients with Colorectal Cancer Metastatic to the Liver after Chemoembolization Embolization procedures cause significant pain (requiring narcotic analgesics), fever, nausea, and malaise lasting 2 to 7 days in nearly all patients. Portal venous thrombosis, while rarely seen (in contrast to hepatocellular carcinoma), is an absolute contraindication to hepatic arterial embolization. Chemoembolization Plus Adjuvant Chemotherapy Chemoembolization appears to have value as a local therapy for patients with liver-only or liver-predominant unresectable carcinoma. Given the potential value of adjuvant chemotherapy after hepatic resection, at least two groups have sought to investigate the potential value of adjuvant chemotherapy after chemoembolization in patients with gastrointestinal malignancies metastatic to the liver. Although this group believed that toxicity was acceptable with this regimen, they did have grade 3 toxicities occur in 81% of patients and grade 4 in 31%. This group found an overall response rate of 29% with a median survival of 14 months. Thus, the value of combining hepatic chemoembolization with adjuvant chemotherapy using agents currently available does not appear promising. Currently, their use is indicated in patients who are not surgical candidates, for those whose tumors are not amenable to resection because of multiple tumors involving both lobes, tumors arising in cirrhotic livers in which preservation of parenchyma is imperative, tumors straddling the interlobar plane that would otherwise require an extended resection, recurrent tumors after previous resection in which reresection may be unsafe or anatomically impossible, and as an adjunct to surgical resection by treating microscopically positive margins. Techniques for Local Ablation Limitations of local ablation therapies include the inability to treat subclinical or occult tumor deposits, inability to treat tumors larger than several centimeters in diameter, inability to treat tumors abutting major vascular structures, and difficulty in assessing the adequacy of tissue destruction during therapy. James Arnott first used freezing to decrease the size of breast and cervical cancers in England in 1845. Subsequently, encouraging results have been reported with deep tumors of the liver, lung, breast, prostate, and brain. The process of freezing tissue can cause direct cellular destruction that is dependent on the rate of tissue cooling, and this can be variable during cryosurgery. Microcirculatory failure secondary to freezing within the vasculature and subsequent vascular damage may be an additional tumoricidal mechanism. The first is the development of vacuum-insulated cryoprobes that allow controlled freezing of tumors deep within the liver, and the second is the use of intraoperative ultrasound to allow precise probe placement into the center of tumors and to monitor the progression of the freeze margin in real time. The probe is placed into the center of the lesion under ultrasound guidance to ensure that uniform freezing will extend symmetrically in all directions from the tip of the probe.

Micturition Reflex Micturition is a less-often used, but proper term for urination or voiding. It results from an interplay of involuntary and voluntary actions by the internal and external urethral sphincters. When bladder volume reaches about 150 mL, an urge to void is sensed but is easily overridden. Voluntary control of urination 94 relies on consciously preventing relaxation of the external urethral sphincter to maintain urinary continence. Ultimately, voluntary constraint fails with resulting incontinence, which will occur as bladder volume approaches 300 to 400 mL. Normal micturition is a result of stretch receptors in the bladder wall that transmit nerve impulses to the sacral region of the spinal cord to generate a spinal reflex. The resulting parasympathetic neural outflow causes contraction of the detrusor muscle and relaxation of the involuntary internal urethral sphincter. At the same time, the spinal cord inhibits somatic motor neurons, resulting in the relaxation of the skeletal muscle of the external urethral sphincter. The micturition reflex is active in infants but with maturity, children learn to override the reflex by asserting external sphincter control, thereby delaying voiding (potty training). This reflex may be preserved even in the face of spinal cord injury that results in paraplegia or quadriplegia. However, relaxation of the external sphincter may not be possible in all cases, and therefore, periodic catheterization may be necessary for bladder emptying. Nerves involved in the control of urination include the hypogastric, pelvic, and pudendal (Figure). Voluntary micturition requires an intact spinal cord and functional pudendal nerve arising from the sacral micturition center. Since the external urinary sphincter is voluntary skeletal muscle, actions by cholinergic neurons maintain contraction (and thereby continence) during filling of the bladder. At the same time, sympathetic nervous activity via the hypogastric nerves suppresses contraction of the detrusor muscle. With further bladder stretch, afferent signals traveling over sacral pelvic nerves activate parasympathetic neurons. This activates efferent neurons to release acetylcholine at the neuromuscular junctions, producing detrusor contraction and bladder emptying. Nerves Innervating the Urinary System 95 Ureters the kidneys and ureters are completely retroperitoneal, and the bladder has a peritoneal covering only over the dome. As urine is formed, it drains into the calyces of the kidney, which merge to form the funnel-shaped renal pelvis in the hilum of each kidney. This is important because it creates an one-way valve (a physiological sphincter rather than an anatomical sphincter) that allows urine into the bladder but prevents reflux of urine from the bladder back into the ureter. The inner mucosa is lined with transitional epithelium (Figure) and scattered goblet cells that secrete protective mucus. The muscular layer of the ureter consists of longitudinal and circular smooth muscles that create the peristaltic contractions to move the urine into the bladder without the aid of gravity. Finally, a loose adventitial layer composed of collagen and fat anchors the ureters between the parietal peritoneum and the posterior abdominal wall. They are roughly the size of your fist, and the male kidney is typically a bit larger than the female kidney. The kidneys are well vascularized, receiving about 25 percent of the cardiac output at rest. External Anatomy the left kidney is located at about the T12 to L3 vertebrae, whereas the right is lower due to slight displacement by the liver. Upper portions of the kidneys are somewhat protected by the eleventh and twelfth ribs (Figure). This capsule is covered by a shock-absorbing layer of adipose tissue called the renal fat pad, which in turn is encompassed by a tough renal fascia.

A phase I trial of continuous hypethermic peritoneal perfusion with tumor necrosis factor and cisplatin in the treatment of peritoneal carcinomatosis. Malignancy-related ascites and ascitic fluid humoral tests of malignancy [editorial]. Ferrandez-Izquierdo A, Navarro-Fos S, Gonzalez-Devesa M, Gil-Benso R, Llombart-Bosch A. Immunocytochemical typification of mesothelial cells in effusions: in vivo and in vitro models. Carcinoembryonic antigen levels in the peritoneal cavity: useful guide to peritoneal recurrence and prognosis for gastric cancer. Interleukin-6 level in serum and ascites as a prognostic factor in patients with epithelial ovarian cancer. Measurement of human chorionic gonadotropin-related immunoreactivity in serum, ascites and tumour cysts of patients with gynaecologic malignancies. Markedly elevated levels of vascular endothelial growth factor in malignant ascites. Tumor oncogenic expression in malignant effusions as a possible method to enhance cytologic diagnostic sensitivity. Port site metastases after laparoscopic colorectal surgery for cure of malignancy. Lymphatic drainage of the peritoneal cavity and its significance in ovarian cancer. Treatment and prevention of malignant ascites associated with disseminated intraperitoneal malignancies by aggressive combined-modality therapy. High mortality after abdominal operaton in patients with large-volume malignant ascites. Mobilization of malignant ascites with diuretics is dependent on ascitic fluid characteristics. Ultrasonically guided insertion of a peritoneo-gastric shunt in patients with malignant ascites. Use of nitrogen mustard in the treatment of serous effusions of neoplastic origin. Pharmacokinetic rationale for peritoneal drug administration in the treatment of ovarian cancer. Mitoxantrone in the treatment of recurrent ascites of pretreated ovarian carcinoma. Long-term survival of advanced refractory ovarian carcinoma patients with small-volume disease treated with intraperitoneal chemotherapy. High-dose biweekly intraperitoneal cisplatin: an effective way to increase cisplatin dose intensity. Clinical trials with intraperitoneal cisplatin microspheres for malignant ascitesa pilot study. A comparison of intravenous versus intraperitoneal chemotherapy for the initial treatment of ovarian cancer. Intracavitary therapy of neoplastic effusions with cytokines: comparison among interferon alpha, beta and interleukin-2. Intraperitoneal infusion of recombinant human tumor necrosis factor and mitoxantrone in neoplastic ascites: a feasibility study. The requirements for successful immunotherapy of intraperitoneal cancer using interleukin-2 and lymphokine-activated killer cells. In vitro and in vivo regulation of human tumor antigen expression by human recombinant interferons: a review. A phase I trial of intraperitoneal recombinant gamma-interferon in advanced ovarian carcinoma. Hemostatic changes in human adoptive immunotherapy with activated blood monocytes or derived macrophages.

Discussions will focus on details of private practice versus academics, contract analysis, networking skills, negotiating skills, and work-life balance. Visit the Registration Desk in the Main Lobby (Street Level) for registration information, however, this event may be sold out. Female gastroenterologists from a variety of medical backgrounds will address the issues of being a female subspecialist, balancing career and family, and opportunities for women in medicine, and more specifically, gastroenterology. Visit the Registration Desk in the Main Lobby (Street Level) for registration information, however, this event may be sold out. The winning team receives a trophy which they can proudly display back at their home institution. This luncheon is available to all trainees in gastroenterology and hepatology, and has a fee of $40. Visit the Registration Desk in the Main Lobby (Street Level) for registration information, however, this event may be sold out. The challenge began in August with a preliminary knowledge round open to all secondand third-year fellows. The top scoring fellows from each year were then invited to participate in a skills challenge. Join us in the Hands-On Workshop area of the Exhibit Hall to cheer on the competitors. Expert faculty will demonstrate techniques and devices and attendees will then have an opportunity to practice using the equipment. Watch expert faculty demonstrate various endoscopic procedures, and try out the latest products and equipment. Hands-On Registration will move and reopen in the Exhibit Hall starting October 27 at 3:00 pm and remain there throughout the duration of the workshops. He is currently Chair of the Department of Gastroenterology and Hepatology, and Professor of Medicine in the Lerner College of Medicine at Cleveland Clinic, Ohio. The David Sun Lecture, held during the Postgraduate Course, was established by Mrs. Edward Berk Distinguished Lecture is awarded to individuals prominent in gastroenterology or a related area. The lectureship was established in recognition of the significant contributions made by J. Kelly is Professor of Medicine at Harvard Medical School and Director of Gastroenterology Training at Beth Israel Deaconess Medical Center in Boston, Massachusetts. Kelly earned his medical degree from Trinity College in Dublin, Ireland where he was a Foundation Scholar and recipient of numerous academic awards. Kelly is an internationally recognized expert in the diagnosis and management of celiac disease and leads research programs on disease pathogenesis, diagnosis, and new treatment approaches. Kelly has authored more than 250 clinical and basic original research articles, as well as book chapters and invited reviews appearing in medical and scientific journals, including the American Journal of Gastroenterology, the Journal of Clinical Investigation, Gastroenterology, the Lancet and the New England Journal of Medicine. Learn how to define "early" detection, recognize its benefits, and identify early detection barriers, when Dr. He moved to the United States in 1993, where he completed a residency at the University of Arizona and a Fellowship in Gastroenterology at the Mayo Clinic, before joining the faculty at Mayo Rochester in 1999. He is currently Professor of Medicine, and Consultant in Gastroenterology and Hepatology, at Mayo Clinic in Rochester, where he has previously served as Director of the Pancreas Clinic. He is past Councilor and President of the American Pancreatic Association and International Association of Pancreatology. He is the Editor-in-Chief of Pancreatology, the journal of the International Association of Pancreatology.