A spontaneous hepatic haemorrhage is an acute presentation of a spectrum of conditions that requires early diagnosis and multidisciplinary management.
Renal water handling is regulated by the release of arginine vasopressin (AVP) and the subsequent insertion of aquaporin 2 (AQP2) in the apical membrane of collecting duct cells. This in turn increases the membrane permeability to water and the passive reabsorption of water down the concentration gradient present in the medulla. Aquaporin 2 can be detected in the urine under conditions of antidiuresis. We wish to validate an assay for urinary AQP2. Fourteen volunteers participated in studies of water loading and water deprivation followed by the administration of 1-deamino-8-D-arginine vasopressin (dDAVP). Urine osmolality was measured by vapour pressure osmometry. Urinary AQP2 was measured by using a chemiluminescent assay. Baseline correlations between serum AVP levels, urinary osmolality and urinary AQP2 levels were not significant. Following the administration of dDAVP, a positive correlation between urine osmolality and urinary AQP2 was evident (r = 0.762). For specific conditions where renal water retention is stimulated via AVP, urinary AQP2 measurements provide a reproducible measurement of the renal actions of AVP.
The stomach is the preferred conduit for esophageal replacement in majority of the cases for its reliable blood supply, low intraluminal bacterial burden, and the need for only a single anastomosis. Occasionally, the stomach is not available because of previous abdominal or gastric surgery or involvement with tumor [1][2][3][4][5]. The esophageal surgeon should be equipped with the knowledge and skills to use alternative conduits for reconstruction. Most surgeons will then utilize the colon as a second option for an alternative conduit. The left colon in particular has an advantage over the right colon in that its lumen is smaller and more closely approximates that of the esophagus. The vascular anatomy on the left is more consistent than on the right; however, involvement by atherosclerotic disease of the inferior mesenteric artery is more common than in any other mesenteric vessel. Preoperative evaluation is crucial in all cases where colon is anticipated as a conduit. Complete surgical history including knowledge of prior abdominal surgery that may have interrupted either the arterial blood supply or venous drainage of the colon that may render a segment of the colon unusable is important. The inferior mesenteric vein drains into the splenic vein, and prior severe pancreatitis or other causes of splenic vein thrombosis may render the left colon unusable as a conduit because of inferior mesenteric vein thrombosis. Colonscopy and CT angiography are performed in the preoperative evaluation to rule out colonic disease or vascular anomalies including neoplasia, stricture, or extensive diverticulosis. Mechanical and antibiotic bowel preparations are administered prior to surgery.A midline laparotomy is performed, and the abdomen is explored for metastatic disease. The peritoneal attachments of the left colon to the retroperitoneum are divided along the white line of Toldt. We use an umbilical tape from the proposed proximal line of transection of the esophagus through the proposed route of placement of the conduit to the point of proposed anastomosis to the stomach. The umbilical tape length is used to estimate the conduit length that is needed and can then be used to measure an appropriate length of colon.The vessels supplying the left colon are visualized by transillumination and the middle colic artery is test clamped. A palpable pulse should still be present in the marginal artery. If there is any question, a Doppler probe is used to assess the quality of the pulse, a clamp is then left in place, and the conduit inspected for adequate perfusion. Once the conduit is deemed of satisfactory quality, we proceed with the esophagectomy. The left colon is then prepared. The omentum is separated from the left colon and splenic flexure that is to be used as a conduit. The middle colic artery is divided, and the mesentery is divided
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