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By O. Ramirez. University of the Pacific.

Acute I Immobile abdomen and patient abdominal pain can signal a few potentially life- T Tenderness with involuntary guarding O Obstruction threatening conditions that must be considered frst generic silagra 100 mg free shipping. Chapter 3 • Abdominal Pain 13 ulcer (pain with stomach empty) buy 100 mg silagra overnight delivery, whereas pain imme- Severity and Progression diately after eating occurs with esophagitis silagra 50mg for sale. It is helpful to use a less than 1 hour and rarely longer than 3 hours and scale of 1 to 10 in adults. The African American child version of the Oucher was developed and copyrighted in 1990 by Mary J. The white child version of the Oucher was developed and copyrighted in 1983 by Judith E. The Hispanic child version of the Oucher was developed and copy- righted in 1990 by Antonia M. Chronic or The viscera are innervated bilaterally so that pain is recurrent episodes of pain can be handled in a more perceived in the midline. Visceral pain originates from Pain that is steady, severe, and progressive is worri- epigastric, periumbilical, and hypogastric causes; some. Pain that causes one to awake from sleep is seri- from intraabdominal, extraperitoneal organs (pan- ous. A sudden pain severe enough to cause fainting creas, kidneys, ureters, great vessels, pelvic organs); suggests perforated ulcer, ruptured aneurysm, or ecto- or from a referred source. A severe knifelike pain usually indi- Parietal (also known as peritoneal or somatic) pain cates an emergency. Tearing pain is characteristic of an is more localized and is described as a sharp pain. Appendicitis is often described as an Peritoneal pain originates from intraabdominal and initial ache that gets progressively worse. Initially Children are poor historians regarding the severity the infammation is limited to the serosa covering an of pain. The pain is visceral and is felt dif- child’s pain is by a description of the activity level of fusely. In general, avoidance of favorite activities or parietal peritoneum, it produces a more severe local- motion indicates an organic problem. Organic disease ized pain that is perceived in the corresponding area of awakens the child from sleep. Children generally have a poor ability to localize pain and are not helpful in the majority of Last Bowel Movement cases. Obstipation (the absence of stools) occurs with com- The Apley rule states that the further the localiza- plete obstruction, but diarrhea can be present with tion of pain from the umbilicus, the more likely it is partial obstruction. Children have a poor When blood, pus, or gastric fuid suddenly foods sense of stool patterns and may not know what it the peritoneal cavity, the pain is frequently reported means to be constipated. The onset maximum intensity of pain at the onset is likely to be of constipation can cause severe abdominal pain. Previous Pain Irritating fuid from a perforated duodenal ulcer pro- Chronic pain could result when a potential surgical duces pain in the right hypochondrium, lumbar, and event is partially controlled, but is not totally resolved. Pain that ra- Key Questions diates will do so to the area of distribution of the l Where is the pain? Pricking, itching, or burning pain comes from whereas renal colic in males is frequently felt in the superfcial causes such as herpes zoster. Remember, however, that despite descriptions of characteristic or typical abdominal pain, presentation What do the pain characteristics tell me? Eating before sleeping can aggravate gastro- Colicky or cramping pain occurs with obstruction of a esophageal refux. Generally there Pain that is made worse by deep inspiration and is are pain-free intervals when the pain is much less in- stopped or diminished by a respiratory pause indicates tense but still present, although it is subtle. If the cause is peritonitis, intraperito- painful episodes, the patient is exceedingly agitated neal abscess, or abdominal distention from intestinal and restless, and often pale and diaphoretic. When the pain from biliary colic often causes inhibition of move- obstruction site is in the proximal small intestine rather ment of the diaphragm. The pa- Steady pain is associated with perforation, ischemia, tient with parietal pain usually lies still and does not infammation, and blood in the peritoneal cavity. Pain from a duode- ary to peritoneal irritation usually appear quiet and nal ulcer has been described as burning or “gnawing. The area behind the Food or antacids can relieve pain caused by an ulcer or obstruction becomes dilated, and, as each peristaltic gastritis. Both colicky pain and lar fbers are temporarily increased; therefore the pain infammatory pain are alleviated signifcantly with an- of colic usually occurs in spasms. The chemoreceptor trigger zone is stimulated by drugs such as cardiac glycosides, ergot alkaloids, and Are there any precipitating events that will help narrow morphine or by uremia, diabetic ketoacidosis, or my diagnosis? Impulses to the medullary vom- Key Questions iting center activate the vomiting process. In sudden and severe stimulation of the peritoneum or mesentery, vomiting comes soon after the pain. In Relation to Other Events acute obstruction of the urethra or bile duct, vomiting Pain that is relieved by defecation, fatus, laxatives, or is early, sudden, and intense. If the duodenum is obstructed, vomiting Pain with sexual activity (dyspareunia) suggests a occurs with the onset of pain. Pain that occurs with position changes bowel causes very late or infrequent vomiting. Appearance of Vomitus Key Questions Clear vomitus suggests gastric fuid; bile-colored vom- l Are you vomiting? Infants with duodenal atresia, Vomiting and small bowel volvulus, will vomit bilious fuid, but Vomiting that precedes the onset of abdominal pain is in pyloric stenosis no bile is seen. Anorexia Diarrhea is a nonspecifc symptom, but its absence makes serious Diarrhea (see Chapter 12) is associated with infamma- disease less likely. The presence of blood in the abdomen may be from one of the following three stool suggests that the pain originates in the intestinal causes: tract. Blood can indicate neoplasm, intussusception, l Severe irritation of the nerves of the peritoneum or infammatory lesions, or an invasive organism. Sudden stimulation of many sympathetic Diarrhea can precede perforation of the appendix as nerves causes vomiting to occur early and to be a result of irritation of the sigmoid colon by an infam- persistent. Some patients will report gas stoppage l Obstruction of an involuntary muscular tube. Obstruc- symptoms: the sensation of fullness that suggests the tion of any of the muscular tubes causes peristaltic need for a bowel movement. With appendicitis, the contraction and consequent stretching of the muscle patient often attempts to defecate but without relief. Chapter 3 • Abdominal Pain 17 In children, mild diarrhea associated with the onset Pain relieved by burping suggests distention of the of pain suggests acute gastroenteritis but can also oc- stomach by gas. A low-lying appendix, Key Questions close to the sigmoid colon and rectum, can induce an Genitourinary system (see Chapters 5, 18, 27, and infammatory process of the muscle wall of the sig- 35 to 37): moid colon.

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A chronic arthritis may appear months after Systemic Disorders the initial infection order silagra. The knee is a commonly Leukemia is the most common cancer in children order silagra 50 mg otc, and affected joint silagra 50mg free shipping. The patient has an antalgic limp with bone and joint pain is the most common presenting diffuse swelling and warmth of the knee joint anteri- complaint. The bone pain is diffuse and nonspecifc orly, as well as local synovial thickening. Radiographs of the limb at the distal end of the femur and the proximal end of the tibia show Neuroblastoma abnormal areas of radiolucency. Neuroblastoma is a malignant tumor that usually oc- curs in children under 5 years of age. It originates from Sickle Cell Disease cells in the sympathetic ganglia and adrenal medulla Sickle cell disease is a genetic disorder characterized by but can arise from any part of the sympathetic nervous production of hemoglobin S, an anemia secondary to system and metastasize to the bone. The presenting short erythrocyte survival, and sickle-shaped erythro- complaint may be varied, but bone pain, limp, pallor, cytes. In the urine, The child presents with painful or vaso-occlusive crises 3-methoxy-4-hydroxymandelic acid and homovanillic characterized by symmetrical, painful swelling of the acid levels are elevated. Older people report pain in long bones and joints, abdominal pain, decreased appetite, fever, Osteogenic Sarcoma and malaise. The laboratory fndings reveal a hemoglo- Osteogenic sarcoma occurs in people 10 to 25 years bin S genotype and anemia, but fndings can vary de- old, with the most common site being the distal femur pending on the hemoglobin genotype, age, gender, and or the proximal tibia. Sickle cell disease of local intermittent pain that quickly progresses to a is associated with osteonecrosis of the hip. Chapter 22 • Lower Extremity Limb Pain 271 Nerve Entrapment Syndromes Neuritis Peroneal Nerve Compression Vascular metabolism affected by systemic disorders, Peroneal nerve compression can be caused by a cast, such as diabetes mellitus, can cause a nerve to become sports injury, or trauma. Pain is felt across the head of ischemic, producing toxins that can directly damage the fbula and can result in footdrop. Soft tissue infammation contribut- Tarsal Tunnel Syndrome ing to neuropathy can be caused by collagen disorders Tarsal tunnel syndrome is occasionally associated (e. The Diabetes mellitus is commonly associated with posterior tibial nerve is involved, and the pain is felt sensory peripheral neuropathy and results in pain across the ankle and proximal foot. Patients may not and sensory loss that is more intense in the lower remember a specifc onset but report pain and weak- extremities. Tapping the posterior tibial Alcoholism is associated with distal, demyelinating nerve posterior and inferior to the medial malleolus neuropathy that may resolve with cessation of alcohol elicits pain. References and Readings Logan K: Stress fracture in the adolescent athlete, Pediatr Ann 36:738, 2007. It is helpful to distinguish between limb pain that affects the bones, muscles, and tendons. Key Questions Pain at the base of the thumb that occurs with grip or l Have you had a recent injury? If the injury does not warrant urgent attention, obtain l Were you able to use the limb after the injury? Constitutional Symptoms Strain The presence of generalized symptoms, such as fever, A strain is an injury to a muscle or tendon (fbrous weight loss, general malaise, or hot, swollen joints, cords that connect muscles to bone). Strains usually suggests the presence of a systemic disorder such as involve repetitive trauma. Treat- thritis include bacterial endocarditis, Lyme disease, ment usually consists of rest, splinting, ice, and nonste- syphilis, and such viruses as hepatitis B, rubella, cyto- roidal antiinfammatory medicines. Golfers will often megalovirus, human immunodefciency virus, Epstein- have wrist and elbow strain. Sprain Severity of Pain A sprain is a stretch or tear of a ligament (fbrous bands Unrelenting diffuse pain, often occurring at night, is an that connect bone to bone across a joint). Sprains of the indication of bone involvement, either through bone fngers are common. Humeral fracture is fairly common after a for the Type and Severity of Humeral blow to the arm. Obese children have an increased risk of sustaining mus- culoskeletal injuries compared with normal-weight peers If there is no history of trauma or a precipitating event, and are at greater risk of sustaining forearm fractures, what else is causing the pain? Activities A person may adapt to chronic musculoskeletal prob- Pain associated with fracture is often severe. Bursitis pain is duce symmetrical discomfort and pain with inactivity often associated with swelling and limited joint motion while noninfammatory conditions are often associated (see Chapter 22). In upper extremity (shoulder, wrist, elbow) joint pain with injury, what do I need to know about the specifc Key Questions l Is there any swelling? Generally, swelling secondary to trauma such as a l Did you engage in any activities that required over- strain develops immediately or within 2 hours after an use of one or more joints? Swelling 6 to 24 hours after an injury is usually of synovial origin, such as a subluxation, dislocation, Pain in the dominant hand may indicate repetitive mi- or ligamentous damage (sprain). Chapter 23 • Upper Extremity Limb Pain 277 Severe ligament sprain is manifested as an immedi- Night Pain ately disabling pain at the moment of the injury. Pain Rotator cuff tears can cause shoulder pain and upper experienced hours after an injury or physical activity is extremity numbness when sleeping on one’s affected usually caused by acute extensor injury or overuse. Patients may report noticing pain, weakness, or diff- culty in activities of daily living, such as using a hair Chronic diseases, such as sickle cell anemia, infam- dryer, opening jars, holding a pen, or handling eating matory bowel disease, Crohn disease, hypothyroidism utensils. Gonorrhea disseminates to the musculoskeletal system in 1% to 3% of infected individuals. Exposure to Key Questions other infectious agents, such as Chlamydia trachoma- l Have you had any joint stiffness? Stiffness is a common feature of any infammatory ar- Viral infections may cause diffuse myalgia. With most in- fammatory arthropathies, stiffness and pain are allevi- Figures 23-1 to 23-3 depict anatomic landmarks of the ated by activity; in contrast, mechanical problems are shoulder, elbow, hand, and wrist. Musculoskeletal tumors com- monly present with mild joint stiffness because of Observe Patient Walking, Removing Coat/Jacket muscle involvement but rarely demonstrate instability. People who have septic joints appear ill, and move- ment of the joint will increase pain. Shoulder pain from rotator cuff tendinitis is felt Medications over the lateral aspect of the deltoid. Transient arthralgia may occur 6 to 8 weeks after receiv- Swelling of the elbow may compress the ulnar ing immunizations. Recurrent or permanent arthritis may nerve, producing a tingling sensation in the fourth and follow rubella vaccination, especially in adult women. Inspect the Skin and Nails Osteoarthritis typically involves the distal interpha- Inspect the skin for redness and infammation. Joints are swollen with a fusiform- distends the joint in a smooth, symmetrical manner. Assess Vital Signs Elevated temperatures are seen with neoplastic, sys- Measure Limb Circumference and Length temic, and infectious processes such as osteomyelitis, Use a tape measure to locate points at which to mea- septic arthritis and septic hip in children, and rheu- sure and compare limb circumference. Chapter 23 • Upper Extremity Limb Pain 279 Heat over the affected joint can indicate infamma- tion or infection.

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Most children abscesses buy silagra us, synovial fuid aspirate generic 50 mg silagra overnight delivery, or material from who have a fever without localizing signs have neither needle aspiration or bone biopsy order silagra. Kawasaki disease is an acute mucocutaneous lymph In the history and physical examination, always in- node syndrome that is classifed as a vasculitic syn- vestigate any abnormal growth suggestive of a possible drome (of which fever is only one sign) affecting infants preexisting chronic disease. Fevers are of a frequent respiratory tract infections may point to cystic high-spiking remittent pattern in the range of 38° C to fbrosis or immunodefciency. Herpangina, nonexudative 24 months, with Streptococcus pneumoniae being the pharyngitis with or without lymphadenopathy, generally organism most commonly responsible. Periodic Fever in Children Occult Bacteremia This condition is characterized by an abrupt fever that Occult bacteremia is diagnosed in children older than occurs in children 2 to 5 years of age on a regularly 3 months who have positive blood cultures but do not recurring basis, generally every 6 weeks. The fever lasts have the usual clinical manifestation of sepsis or septic an average of 4 days. Occult means hidden from view; the child looks malaise, sore throat, cervical adenopathy, and aphthous well. The white blood cell count may be elevated playful are at low risk for bacteremia despite fever. There are no3 Those who look ill or who are toxic are at signifcant associated diseases or other physical examination and risk. The child has normal growth and percentage of those children who develop secondary development. Seashore C, Lohr J: Fever of unknown origin, Pediatr Ann 40:26, Centers for Disease Control and Prevention: Locally acquired dengue— 2011. Sund-Levander M, Grodzinsky E: Time for a change to assess and Fox T, Manaloor J, Christenson J: Travel-related infections in children, evaluate body temperature in clinical practice, Int J Nurs Pract Pediatr Clin North Am 60:507, 2013. Hematuria, oliguria, and Uof conditions from infections, infammation, and pain are the most common symptoms. Any part of the renal/urological/ Kidney, prostate, and bladder neoplasms are more com- reproductive tract can be involved. Kidney and bladder neoplasms often localized to a single site but can also be vague or be produce painless hematuria. Dysuria in males is most commonly caused by Kidney problems can range from asymptomatic urethritis, prostatitis, cystitis, or mechanical irritation blood chemical changes to life-threatening abnormal of the urethra. Infammation, although infrequent in renal function that could manifest in fuid-electrolyte young males, increases with age until elderly men are and acid-base imbalances. A discussion of renal urethra or prostate, or occurs secondary to urethral instru- insuffciency and renal failure is beyond the scope of mentation. The male patient with urinary problems may also l Have you been able to pass any urine? Urine fow may be altered by compression of the urethra as it Fever and Chills passes through an enlarged prostate, obstructing the The presence of fever and/or chills suggests a systemic fow of urine and producing hesitancy, slowing of the infammatory response and indicates that the patient urinary stream, dribbling, and nocturia. Urinary stones can occur anywhere in the urinary tract and are common Immunocompromised Patients causes of obstructive symptoms, bleeding, and pain. Immunocompromised patients are susceptible to over- Trauma to the urinary tract may be caused by pen- whelming infections by both common and atypical etrating, straddle, blunt, and crushing injuries, or by organisms, and aggressive investigation is warranted. Patients with prerenal upper or lower tract tumor, systemic coagulopathy, or failure usually have a history of volume depletion or a excessive anticoagulant effect. Less common causes in- reduction in arterial blood volume such as in low car- clude acute necrosis or sloughing of a papilla. Patients with intrarenal failure may men, painless hematuria may be a late presenting sign of present with history of renal damage from nephrotoxic renal cancer. Postrenal failure is the least likely cause of anuria, but it should be ruled out frst because when Can the symptoms be localized within the urinary tract? Key Questions l Do you have frequency, urgency, painful urination, l Have you noticed blood or blood clots in your urine? In men older than 50, the presence of slow urinary stream, hesitancy, intermittency and dribbling of urine Hematuria with a gradual onset over time indicates obstructive Blood can enter the urinary tract at any site. The most com- classify symptoms as mild (0 to 7), moderate (8 to 19), mon causes of gross hematuria from the kidney are or severe (20 to 35). Low Back, Flank, or Abdominal Pain Patient reports of low back, fank, or abdominal pain Timing are often indicative of ureteral and kidney involve- Initial hematuria becomes clear during voiding and ment. Terminal hematuria kidney stones will produce an acute ureteral pain that begins with clear urine, then becomes bloody, and is is colicky and cyclic in nature. Gross blood in the urine suggestive of prostatic lesions or lesions in the pros- and infection may accompany the ureteral pain. Total hematuria is usually characteristic pain can radiate to the abdomen, testes, and penis. Re- True renal pain can originate from the calyces or renal cent trauma to the kidneys can also produce hematuria. Pain can result from stretching of the kidney Gross hematuria is often transient but may continue capsule, interstitial edema, or infammation of the microscopically. Table 18-1 The American Urological Association Symptom Index Patients rate their answers to each question on a scale of 0 to 5. Over the past month, how often have you had to 0 1 2 3 4 5 urinate again less than 2 hours after you fnished urinating? Over the past month, how often have you found you 0 1 2 3 4 5 stopped and started again several times when you urinated? Over the past month, how often have you found it 0 1 2 3 4 5 diffcult to postpone urination? Over the past month, how often have you had to push 0 1 2 3 4 5 or strain to begin urination? Over the past month, how many times did you typically 0 1 2 3 4 5 get up to urinate from the time you went to bed at night until the time you got up in the morning? Chapter 18 • Genitourinary Problems in Males 211 Testicular/Scrotal Pain excess solute excretion. Diabetes insipidus may also be Acute pain in the scrotum or testicles may indicate in- implicated. Nocturia can occur with the mobilization of fection or a pathological condition of the scrotal con- fuid during sleep, secondary to congestive heart failure. Pain in the scrotum or testicles is charac- Are there any risk factors to point me in the right teristic of infammation of the testicles, epididymitis, direction? Key Questions Aching in the Perineal Area l Have you had this or similar problems before? Prostate pain is often interpreted by the patient as a l Do you have a family history of kidney problems, vague ache in the perineal area. Bladder pain is most often caused by infection; Patients with previous urinary problems are at risk for however, it can also be produced by obstruction and chronic relapsing conditions such as unresolved infec- bladder distention as the result of a tumor or stones. Recurrent infections, pyelonephritis, or complications Penile Discharge With Frequency, Urgency, warrant urological referral for workup and evaluation. Familial disorders that may be implicated in kidney disease include diabetes mellitus, hypertension, colla- Nocturia gen vascular disease, nephrolithiasis, and polycystic Primary bladder disease from infection, stones, or tu- kidney disease. Patients who report daytime frequency without noc- Patients have diffculty starting the urine stream; the turia are usually free of organic disease. Chlamydia is the major Polyuria cause of prostatitis, epididymitis, and nongonococcal Polyuria is defned as a volume greater than 3 L of urine/ urethritis in males under 40 years of age.

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After the vein is controlled buy silagra now, the remainder of the gland is dissected free and the gland is withdrawn as above buy 50mg silagra with amex. The patient is intubated on the stretcher and positioned prone on the operating table with slight flexion at the hips and knees cheap silagra 100mg line. Bolsters are placed under the hips and chest to allow space for the abdomen and pannus. Three ports are placed horizontally below the costal margin into the retroperitoneal space. The posterior retroperitoneal plane is developed, separating perinephric and periadrenal fat away from the peritoneum and paraspinous muscles. The inferior border of the adrenal is divided from the superior pole of the kidney, which is rotated inferiorly and medially to help expose the adrenal vein. These structures further facilitate identification of the adrenal vein, which is ligated and divided with clips or an energy sealant device. Once controlled, the adrenal gland is separated from the filmy attachments to the peritoneum and removed via an extraction bag. Robot-assisted approach: Both robotic transperitoneal and retroperitoneal adrenalectomy have been described. Advantages of the robot include a 3- dimensional view of the operative field, superior ergonomics, and a stable camera platform. Although patient outcomes have been comparable to that of laparoscopic adrenalectomy, training and cost are major drawbacks to the approach. Adrenalectomy is the traditional treatment for hyperadrenocorticism 2° adrenal carcinoma. In addition, a fragile vasculature predisposes these patients to easy bruising and difficult vascular access. Conn’s syndrome: Hyperaldosteronism can be primary (Conn’s syndrome–adrenal adenoma or hyperplasia) or secondary (caused by excess renin secretion related to renal dysfunction). These patients are typically hypokalemic and alkalotic → muscle weakness, paresthesias, tetany and polyuria. If postop epidural analgesia is planned, placement of catheter prior to anesthetic induction is helpful in establishing correct placement in the epidural space and ensuring a bilateral block (accomplished by placing 5–7 mL of 1% lidocaine via the epidural and eliciting a segmental block). Epidurals cannot be used for a posterior approach because they are in the operative field. The tumor is usually found unilaterally in one of the adrenal glands, but also can be found anywhere in the body that chromaffin tissue arises (e. These patients require extensive preop preparation, consisting of α-blockade (phenoxybenzamine 40–400 mg/d) and should ideally be monitored closely by the anesthesiologist who is to provide the intraop management. Patients with tachydysrhythmias may require ß-blockade to control reflex tachycardia but only after institution of α- blockers. Inadequate preop preparation will increase the perioperative morbidity of patients with pheochromocytomas. It is anticipated that some degree of postural hypotension will be observed during titration of phenoxybenzamine. Femoral or axillary arterial pressure monitoring is preferred over radial artery because of the concern over monitoring “central” arterial pressures in a patient who may experience high catecholamine levels during surgery with intense vasoconstriction. If postop epidural analgesia is planned (open surgical procedures), placement of catheter prior to anesthetic induction is helpful in establishing correct placement in the epidural space and ensuring a bilateral block (accomplished by placing 5–7 mL of 2% lidocaine without epinephrine) via the epidural and eliciting a segmental block. Epidural catheters cannot be used for a posterior approach because they are in the operative field. Epidurals block neurally mediated sympathetic responses and may → ↓ tumor release of catecholamines, but do not block catecholamine release resulting from direct surgical manipulation of tumor. The retroperitoneal space is developed by retracting the peritoneum medially and cephalad exposing the iliac vessels. The external iliac artery and vein are identified and surrounding lymphatics are ligated and divided. The external iliac vein is clamped first and the renal-vein-to-iliac-vein anastomosis is performed. Then the external iliac artery is clamped and an artery-to renal-artery anastomosis is performed. The patient should be euvolemic at this point; mannitol and/or furosemide can be given. The bladder is filled with an antibiotic irrigation solution to facilitate the implantation of the ureter. The detrusor muscle is then reapproximated over 3–4 cm of ureter to create an antireflux valve. Sketch of a kidney transplant labeled 1, 2, 3 in the order of the surgical anastomoses. Less commonly, pancreas transplantation is done for patients with brittle diabetes or with impending complications while they still enjoy normal or near-normal kidney function. The pancreas transplant is placed in the right iliac fossa, and the kidney transplant is placed in the left iliac fossa. This can be done through a transperitoneal lower midline incision or through two separate extraperitoneal lower-quadrant incisions in the same manner as kidney transplantation. For arterial in-flow, a Y-graft is fashioned using the donor iliac artery bifurcation. The portal vein coming off the pancreatic graft is anastomosed to the external iliac vein. The Y extension vascular graft is then anastomosed to the recipient external or common iliac artery. The donor duodenum is anastomosed to a loop of small bowel or to the urinary bladder to drain the exocrine secretions (Fig. With pancreas transplantation, there may be significant blood loss if the graft mesenteric vessels are not occluded properly. After the pancreas is implanted, the kidney transplant is placed into the opposite iliac fossa (as described in Kidney Transplantation, p. In normal individuals, 50% of secreted insulin is extracted from the circulation in the first pass through the liver. This more physiologic approach, however, is associated with a higher technical failure rate and requires a long upper midline incision (Fig. Pancreatic islet cells may be infused via a radiological portal vein approach, a procedure that is usually performed in the radiology/angio suite. Rarely, patients will present for transplant surgery + without adequate preparation (e. Spinal, epidural, or combined spinal- epidural anesthesia may be considered for renal transplantation, if coagulation and platelet function acceptable.