By Q. Potros.

First-line management involves dietary modification buy lipitor now cholesterol test urine, including a postgastrectomy diet of six small meals per day order generic lipitor online cholesterol test new, limitation of foods high in monosaccharides, substitution of monosaccharides with polysaccharides, avoidance of dairy products, and limitation of excessive fluid intake after meals. Recurrent Laryngeal Nerve Injury Recurrent laryngeal nerve injury is an uncommon complication following cervical anastomoses, with an incidence reported to be as low as approximately 3% in high volume centers [47]. Due to the risk of pulmonary complications, it is a complication that should be diagnosed and treated early. In the United States, surgical resection with a total or subtotal gastrectomy with chemotherapy or chemoradiotherapy provides the best option for long-term survival and cure [53]. Complications include wound issues, anemia, cardiopulmonary complications, thromboembolic events, and anastomotic stricture. Similar to other cancers, the extent of resection is based upon the site and extent of the primary tumor. However, an extended, D2 lymph node dissection, with a minimum of 15 nodes harvested, is the standard at this time. Perioperatively, early ambulation, pulmonary secretion clearance measures, judicious fluid management, and pain control are paramount. Similar to esophagectomy, Gastrografin swallow study remains the gold standard to rule out postoperative anastomotic leaks. Some clinicians elect to forgo such a study for asymptomatic patients, as a leak in an asymptomatic patient is unlikely to be clinically significant. When used, enteral feeding may be initiated and advanced slowly until the patient’s oral intake is sufficient. If a small, contained leak is identified, patients may be managed conservatively with nothing by mouth and parenteral nutrition. Reoperation may be necessary for an unstable patient, or for a patient with peritonitis or failure to resolve nonoperatively. In some circumstances, wide drainage with enteral feeding access (jejunostomy tube versus nasojejunal tube) may be sufficient. There are an increasing number of recent reports discussing the role of esophageal stents, particularly as an alternative to reoperation in high- risk patients. Theoretical benefits are that placement of a stent might allow for early enteral nutrition and be associated with a lower morbidity than reoperation. In comparison with non-stent endoscopic therapies (such as fibrin glue and endoscopically placed clips), esophageal stents had a greater sealing rate. Proposed risk factors include increasing age, inadequate closure of the stump, devascularization, duodenal distension (i. Tube duodenostomy or Roux-en-Y duodenojejunostomy (particularly if a disrupted stump that cannot be closed or if a tube duodenostomy cannot be placed) may be considered based on the degree of contamination and inflammation. The risk of death has been declining in recent years, in part due to screening colonoscopy and precancerous polyp removal. Surgical resection, chemotherapy (including targeted treatments), and radiotherapy may be used in various combinations based on the tumor location (colon versus rectum), tumor stage, and patient characteristics. Increasingly, minimally invasive techniques, such as laparoscopic, laparoscopic-assisted, or robotic approaches, may be used in addition to the traditional open operations. Low anterior resection and abdominoperineal resections may be used for more distal colon and rectal cancers not amenable to local resection. There is controversy on what constitutes a bowel preparation and specifically, the role of a mechanical bowel preparation, preoperative oral antibiotics, and perioperative parenteral antibiotics. However, some complications, such as anastomotic leaks as well as sexual and urinary dysfunction, deserve specific note. Anastomotic Leak Anastomotic leakage will occur in up to 20% of cases, usually within the first 7 days after surgery. Signs and symptoms may include fevers, tachycardia, increasing abdominal pain including peritonitis, or the presence of a fistula. While awaiting confirmation, patients should be made nothing by mouth, and broad-spectrum parenteral antibiotics may be initiated. Anastomotic leaks may be managed conservatively with bowel rest, intravenous antibiotics, and percutaneous drainage for a clinically stable patient without peritonitis. However, for a patient who is unstable, who has peritonitis, or who fails nonoperative management, exploration, abdominal washout, wide drainage, and diverting ileostomy or colostomy should be considered. Genitourinary Dysfunction Inadvertent injury to the sacral splanchnic and hypogastric nerves during rectal mobilization may lead to urinary and sexual dysfunction following rectal surgery. More than 50% of patients will have a reduced sexual function and about one-third will have alterations in urinary function. In men, sexual dysfunction may manifest as impotence and difficulties with ejaculation; women may experience dyspareunia and vaginal dryness. These known complications carry with them a significant reduction in psychosocial well-being and quality of life [60]. It remains unclear if laparoscopic resection offers any benefits compared to open surgery regarding these complications. If urinary dysfunction is a concern, particularly if there is involvement of the membranous urethra, Foley catheterization should be continued for an extended duration in the perioperative period. Patients may be discharged with a Foley catheter in place, to be discontinued later in the postoperative period. Buchler M, Friess H, Klempa I, et al: Role of octreotide in the prevention of postoperative complications following pancreatic resection. Montorsi M, Zago M, Mosca F, et al: Efficacy of octreotide in the prevention of pancreatic fistula after elective pancreatic resections: a prospective, controlled, randomized clinical trial. Pederzoli P, Bassi C, Falconi M, et al: Efficacy of octreotide in the prevention of complications of elective pancreatic surgery. Bassi C, Falconi M, Molinari E, et al: Reconstruction by pancreaticojejunostomy versus pancreaticogastrostomy following pancreatectomy: results of a comparative study. Suc B, Msika S, Fingerhut A, et al: Temporary fibrin glue occlusion of the main pancreatic duct in the prevention of intra-abdominal complications after pancreatic resection: prospective randomized trial. Tran K, Van Eijck C, Di Carlo V, et al: Occlusion of the pancreatic duct versus pancreaticojejunostomy: a prospective randomized trial. Riediger H, Adam U, Fischer E, et al: Long-term outcome after resection for chronic pancreatitis in 224 patients. Aurello P, Sirimarco D, Magistri P, et al: Management of duodenal stump fistula after gastrectomy for gastric cancer: systematic review. Cozzaglio L, Coladonato M, Biffi R, et al: Duodenal fistula after elective gastrectomy for malignant disease: an italian retrospective multicenter study. Under ideal circumstances, a detailed history (including comorbid illness and prior surgeries), a thorough physical examination, ordering appropriate laboratories, and targeted imaging would reveal the source of the symptoms. The challenge for the intensive care physician begins with the many potential obstacles to early diagnosis, including altered patient sensorium, limited ability to communicate due to mechanical ventilation, concurrent antibiotic therapy, and the masking of reliable physical examination signs.

If cheap 5 mg lipitor mastercard cholesterol zelf test, for example cheap lipitor is there cholesterol in eggs good for you, there is underlying hypovolemia, the urinary chloride concentration is low (<15 mEq/L); in comparison, the urinary chloride concentration is >20 mEq/L when the cause of renal bicarbonate retention is a reduction in glomerular filtration rate, as in the milk-alkali syndrome, or in patients with acute tubular necrosis who received large alkali loads. This decrease in2 respiration is owing to direct suppression of the medullary respiratory center by alkalemia. Treatment of Metabolic Alkalosis Rapid correction of metabolic alkalosis is usually not necessary because of the general rarity of adverse effects directly related to the rise in pH. As a result, there is ordinarily time to identify the cause of the disorder and to institute specific therapy. Because hypomagnesemia may be present in some patients with metabolic alkalosis, a serum magnesium level should be checked, particularly in patients with refractory hypokalemia, because hypomagnesemia predisposes to renal potassium wasting. Replacement of the − + + volume deficit with non–Cl -containing solutions of Na or K does not − correct the alkalosis or hypokalemia because non-Cl anions obligate + + further K and H excretion. Patients with vomiting or nasogastric suction may also benefit from H -blockers or other medications that2 − reduce gastric acid secretion. They are not, however, substitutes for Cl replacement, which is still necessary to correct the already present chloride deficit. Although renal perfusion is characteristically reduced, leading to a low − − urinary Cl concentration, Cl administration (e. In extremely rare instances, these maneuvers may be insufficient, or the metabolic alkalosis may be so severe that adverse neurologic symptoms of alkalemia are present. Because the very low pH of this solution can injure small veins and tissues, particularly if extravasation occurs, administration should generally occur over at least 24 hours using a large (central) vein. Dialytic therapy may be helpful in the unusual patient presenting with metabolic alkalosis, volume overload, and renal failure. It is important to note that citrate used for anticoagulation in some continuous dialytic therapies can lead to metabolic alkalosis as well [13]. Chloride-Resistant Metabolic Alkalosis Individuals with a urinary chloride concentration greater than 15 mEq − per L are unlikely to respond to Cl -containing solutions such as physiologic saline, with correction of the metabolic alkalosis. Because the − effective renal blood flow is already normal or Cl reabsorption must be − impaired, the administered Cl is rapidly excreted in the urine. Moreover, + enhanced distal Na presentation increases Na–K exchange, leading to a + rise in urinary K excretion with more severe hypokalemia in states of primary mineralocorticoid excess. Removing the source of aldosterone (by adrenalectomy when an aldosterone-secreting adenoma is present) or blocking its action (with a + K -sparing diuretic, such as spironolactone) is usually sufficient to correct the hypokalemia and metabolic alkalosis and to control hypertension in this disorder. Therapy is, therefore, directed at improving the laboratory abnormalities, particularly hypokalemia and metabolic alkalosis. Angiotensin-converting enzyme + inhibitors or K -sparing diuretics may be useful alone or in combination, but they have the potential risk of causing the already slightly low blood pressure to fall. It is important to exclude surreptitious diuretic use or forced vomiting in these individuals before assigning a diagnostic or therapeutic regimen used for Bartter’s syndrome or Gitelman’s syndrome because the former are far more common disorders. They are defined as plasma Na concentration below 135 mEq per L and above 145 mEq per L, respectively. The correct management of patients with these disorders depends on an understanding of normal salt (NaCl) and water (H O) physiology. However, the presence of hyponatremia or hypernatremia cannot be used to assess the volume status of a patient. Furthermore, the plasma sodium concentration has little relationship to the urinary sodium concentration. Although water retention causes extracellular volume expansion, this is slight, as approximately two-thirds of the water enters the cells. Because urea can cross almost all cell membranes readily, it cannot promote the movement of water between the intracellular and extracellular spaces. This pump also maintains a high + (approximately 130 mEq per L) intracellular K concentration; thus, potassium is the principal effective osmole inside cells. In fact, osmolality is equal throughout all body compartments, explaining the need for only one osmoreceptor. Moreover, loss of potassium from the body, as might occur with diuretic + administration, affects the plasma Na concentration. Sodium movement into cells + to maintain electroneutrality lowers the plasma Na, and loss of potassium from the gastrointestinal tract or kidneys causes a fall in the plasma potassium with a larger fall in the intracellular potassium. The result is a reduction in the intracellular osmolality that leads to water movement from cells to the extracellular compartment. Regulation of Plasma Osmolality + Maintenance of the plasma Na concentration within narrow limits (285 to 292 mOsm per kg) depends on the ability of the kidneys to excrete water and on a normal thirst mechanism with access to water. Under normal conditions, the quantity of water that can be excreted in the urine far exceeds the amount ingested. The typical American diet affords a solute intake between 600 and 1,200 mOsm—average 900 mOsm—per day. Assuming an output that approximates intake, the daily urinary solute excretion of a typical adult would also average 900 mOsm. The individual who excretes 900 mOsm of solute per day and who can dilute urine maximally (down to 50 mOsm per kg) has the capacity to excrete up to 18 L of water in a 24-hour period: 900 mOsm/50 mOsm/kg = 18 L p. This portion of the nephron, which is impermeable to water, is often referred to as the diluting segment. As filtrate passes through the loop of Henle, solute is removed by the Na/K/2Cl transporter located in the cells of thick ascending limb and by the NaCl carrier in the distal tubule. Solute entering the early proximal tubule has an osmolality identical to that of plasma; fluid is isotonically reabsorbed in this nephron segment. Separation of solute from water (H2O) within the tubule begins in the thick ascending limb of Henle, which is impermeable to H2O. For example, for a patient unable to achieve urinary dilution below an osmolality of 300 mOsm per kg, the amount of water that can be excreted on a normal diet is reduced to 3 L: 900 mOsm/300 mOsm/kg = 3 L As discussed earlier, solute excretion is normally determined by dietary intake. A reduction in dietary sodium and protein intake, as is seen in the patient on a “tea-and-toast” diet, limits the capacity to excrete water. If solute intake falls to 150 mOsm per day, for instance, water excretion is limited to approximately 3 L even when urinary dilution is normal: 150 mOsm/50 mOsm/kg = 3 L It is easy to see that the combination of impaired diluting ability with a concomitant reduction in solute intake is more likely to impair water excretion and result in hyponatremia than either disturbance alone. Hyponatremia In most settings, the development of hyponatremia with hypoosmolality represents the retention of ingested or administered water. Thus, the causes of hyponatremia can be divided into those in which water excretion is abnormal and those in which water excretion is normal, but water ingestion is considerably increased. An exception to this rule occurs when solute intake is markedly reduced, as in the patient subsisting on a solute-poor diet. Solute excretion tends to be reduced in these settings, which are characterized by enhanced tubular salt reabsorption. The ability to excrete dilute urine is impaired by diuretics, whether they act in the thick ascending limb of Henle (loop diuretics) or in the distal tubule (thiazide diuretics). Loop diuretics inhibit the Na-K-2Cl cotransporter in the medullary portion of the thick ascending limb of Henle, whereas thiazides block a simple NaCl carrier in the cortical portion of the distal tubule. These differences explain, in part, the susceptibility of individuals treated with thiazide-type diuretics to the development of hyponatremia (see text for details).

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They are Tubal disease characterized by low gonadotrophins buy cheap lipitor 40mg on-line cholesterol levels healthy, a normal prolactin the incidence of tubal disease is very dependent on and low oestrogen levels buy lipitor with a mastercard cholesterol symptoms. Three conditions are included: whether the woman has primary or secondary infertility. It is often caused by excessive cially those who have had an ectopic pregnancy, have a exercise, lean body mass, weight loss, severe dietary much higher incidence of tubal disease. The treatment must be aimed at the underlying Uterine and/or peritoneal disorders cause. Even with infection, brain/pituitary radiation, pituitary apoplexy, severe endometriosis, natural conception is still possible head trauma, and drugs such as glucocorticoids, narcot- and up to 70% of women with mild to moderate endome- ics and chemotherapy. However, up to Hypopituitarism is typically caused by a pituitary 30–50% of women with endometriosis may experience tumour or its treatment by surgery and/or radiotherapy infertility irrespective of the severity of the disease and but may be due to extra‐pituitary tumours, sarcoidosis, infertile women are six to eight times more likely to have haemochromatosis and Sheehan’s syndrome. Endometriosis is cal manifestations depend on the cause and both the thought to influence fertility in several ways, including type and degree of hormonal insufficiency. Patients may distorted pelvic anatomy, adhesions, pelvic inflamma- be asymptomatic or present with symptoms related to tion, altered immune system functioning and impaired hormone deficiency or a space‐occupying lesion. Adhesions are reported to be the leading cause of sec- They are characterized by normal oestrogen levels, ondary infertility in women and are thought to be Subfertility 693 responsible for approximately 22% (15–40%) of all infer- or chemotherapy, although in the majority of cases (66%) tility cases [1]. Obstructive azoospermia is adnexal anatomy and the tubo‐ovarian relationship and/ uncommon, with a prevalence of less than 2%. It is often or by preventing or impairing the ability of the fallopian associated with congenital bilateral absence of vas defer- tube to pick up the oocyte at ovulation and then trans- ens, which itself is commonly associated with cystic port it. This may be due to the ovary being encapsulated fibrosis mutations or renal tract abnormality. The American Fertility Society classification uncommon but may result from spinal cord injury, pros- for adnexal adhesions [2] can be used to quantify the tatectomy, retroperitoneal lymph node dissection, dia- severity of the adhesions, which is predictive of term betes mellitus, transverse myelitis, multiple sclerosis, or pregnancy rates. Varicoceles are more common in men with abnormal Fibroids have been associated with infertility. It is unclear if, or why, varicoceles impair fertility recent data suggest that fibroids may still have a negative and spermatogenesis but any effect is likely to be due to effect on fertility even if the cavity appears hysteroscopi- elevated scrotal temperature and impaired semen cally normal due to effects on uterine blood flow, quality. Despite this, many women with relatively large fibroids conceive without difficulty. When asso- ciated with amenorrhoea, they are referred to as Given the various causes and presentations of infertility, Asherman’s syndrome. The adhesions lead to partial or it is essential that patients are managed as individuals complete obliteration of the uterine cavity and/or the from their initial referral through to their ultimate treat- cervical canal, resulting in menstrual abnormalities and/ ment. Secondary infertility is seen critical consideration of clinical features and used to in 43% of women with intrauterine adhesions and may be inform patient management and counselling. All health- due to obstruction of sperm into the cervix or prevention care practitioners working in fertility must therefore of embryo migration and/or implantation. However, typical management of a heterosexual couple for the impaired semen quality, azoospermia and inadequate simple reason that this reflects most referrals to second- coitus are contributing factors in nearly 50% of infertile ary care. Please mostly dysfunctional and unable to fertilize an oocyte substitute ‘no partner’ or ‘second female partner’ where but a proportion are often functionally normal. Take a critical history Azoospermia may be due to hypothalamic–pituitary failure, primary testicular failure (non‐obstructive azoo- Couples who experience problems in conceiving should spermia) or obstruction of the genital tract (obstructive be seen together because both partners are affected by azoospermia). Primary testicular failure is the most com- decisions surrounding investigation and treatment. It is important to specifically enquire about 694 Reproductive Problems sexual history, including the frequency and timing of bleeding could be hormonal or reflect local or endome- intercourse. Again, these symptoms would be an indi- to define ‘subfertility’ and therefore the need for investi- cation for pelvic and ultrasound examination possibly gation or treatment. Tubal disease the tests offered to the woman and her prognosis, while and adhesions that may impair the tubo‐ovarian rela- the presence of children invariably has implications for tionship are more common after pelvic infection, sexu- funding. It is also important to assess the couple’s life- ally transmitted infection, abdomino‐pelvic surgery, style as this impacts on their chance of natural concep- particularly that involving the pelvic organs, and ectopic tion and influences the success of treatment. They consider any religious or ethical objections the couple may also occur in women with endometriosis. This information is often volunteered and does not require Male direct questioning. The male history is often redundant, as most couples will Primary care physicians generally have a good under- be referred with the results of a seminal fluid analysis. Make sure these are available and confirm the value in taking a detailed history from the male partner. Missing a diagnosis of However, a specific enquiry regarding any psychosexual severe oligospermia or azoospermia or failing to realize problems including erectile or ejaculatory dysfunction is this until the end of the consultation will mean that much essential. Make sure you gather all clinically rele- those who have been shown to have abnormal results, a vant information and any test results before you see the more detailed history is indicated. A history of problems couple and share these with them at the appropriate time with testicular descent, puberty, trauma or surgery, depending on what they show and what the couple know. No cause will be identified in Female approximately 30–50% of men with poor semen Having already ascertained the woman’s age and parity, quality. Most Perform a relevant examination women (95%) who menstruate every 23–35 days are ovu- lating. Those with irregular menstrual cycles or who are Just like the clinical history, examination of the male and amenorrhoeic are not ovulating or, if they are, ovulate female partner is often unremarkable. These during the consultation and at examination, also pro- conditions may also be associated with chronic pelvic vides an opportunity to consider lifestyle issues such as pain and/or deep dyspareunia. Where relevant, a gen- Heavy periods may reflect dysfunctional uterine bleed- eral inspection should be conducted to look for signs of ing but could be due to fibroids, adenomyosis, endome- systemic disease, such as thyroid dysfunction, acromeg- triosis or endometrial polyps, all of which may impair aly and other endocrine disorders, and phenotypic implantation. More rarely, insulin resistance may lead to acanthosis nig- the levels of these hormones cannot be interpreted in ricans. Virilism can lead to male pattern baldness and the absence of serum estradiol and all three tests are clitoromegaly. Breast examination is often not indicated needed to assess hypothalamic–pituitary–ovarian func- but when performed should include Tanner’s staging. However, it is should be checked along with other hormones depend- rare to find an unexpected mass or demonstrate abdomi- ing on the clinical picture. However, there are more accurate tests for opportunistically or if cervical pathology is evident; the lat- ovarian reserve, namely antral follicle counts and serum ter requires referral for colposcopic examination. These have been Bimanual examination can provide critical information used to triage treatment as they provide some informa- that impacts on investigation and management. However, this requires more tender, retroverted uterus is highly suggestive of adhe- research and, at present, there is insufficient evidence to sions and the presence of chronic pelvic inflammation or preclude treatment or fast‐track patients on the basis of endometriosis. The scrotum and its contents should be progesterone to confirm ovulation, but a day 21 proges- gently palpated to identify the vas deferens and exclude terone is only relevant for women with a 28‐day cycle. The volume of each testi- There is little value in measuring serum progesterone in cle should be assessed using an orchidometer and a women with amenorrhoea or oligomenorrhoea and it recorded. Thyroid function and prolactin are not indicated in women with a regular cycle Perform directed investigations unless there are associated clinical features.

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The width of the baffle should be the same because the baffle will now function as the interatrial septum and form part of the inflow tract for drainage of the superior and inferior venae cavae into the new pulmonary ventricle through the mitral valve lipitor 20mg with mastercard cholesterol test and alcohol consumption. Coronary Sinus It is often helpful to extensively incise into the coronary sinus as well as into the superior limbus to reduce the angulation (and thereby baffle obstruction) of the superior and inferior limbs order discount lipitor line cholesterol lowering foods pdf. Technique for Preparing the Baffle the size of the caval openings should be noted, and the two limbs of the baffle should be wide enough to be sewn well away from the caval orifices. Regardless of the baffle material used, proper shape and size are significant factors in the prevention of baffle complications. This pattern is placed on the sheet of pericardium, and the baffle is prepared by cutting around the pattern with a knife. Gore-Tex is easier to handle than pericardium and probably will not undergo shrinkage or deformation, and is therefore the material of choice for some surgeons. However, when autologous pericardium is pretreated with glutaraldehyde, it becomes fixed and changes minimally over time. In any case, baffle shrinkage is generally limited to a great extent by the degree of tension created by a secure suture line. Therefore, only attention to detail in preparing a baffle of adequate shape and size and meticulously suturing it in place will prevent many of the complications often associated with this procedure. Right Atrial Incision the right atrium is opened with an oblique incision, anterior to and parallel with the sulcus terminalis, and its edges are suspended to the pericardium or skin towels. Injury to the Sinoatrial Node the sinoatrial node is always prone to injury from cannulation, passage of tape around the superior vena cava, and atriotomy. The incision should be well away from the sinoatrial node, and its superior extension should be limited to 0. If additional length is required, the incision can be extended anteriorly onto the right atrial appendage. Excision of the Atrial Septum the atrial septum, including the fossa ovalis (which may have already been torn by a previous balloon septostomy), is now partially excised. The line of incision begins in the foramen ovale and is extended superiorly toward the center of the superior vena cava orifice for a short distance (approximately 7 mm). It is then continued posteriorly toward the base of the interatrial septum and is finally curved inferiorly (parallel with the septum). An incision is made from the anterior margin of the fossa ovalis inferiorly, avoiding the coronary sinus, and is extended toward the ostium of the inferior vena cava. The septal remnant is now removed, and the raw edges of the septum are endothelialized using interrupted sutures of 6-0 Prolene. Excision of the Septum the artery to the sinoatrial node traverses the anterosuperior quadrant of the atrial wall. This can be achieved by starting the excision through the foramen ovale superiorly and then continuing it posteriorly toward the interatrial groove. Preferential Conduction Tracts There are three main preferential conduction tracts joining the sinoatrial node to the atrioventricular node. The middle tract also lies anterior to the fossa ovalis but may pass through or just posterior to the coronary sinus. The posterior preferential tract crosses in the posterior wall of the right atrium between the cavae and then curves forward toward the coronary sinus. Although the middle tract and the posterior tract are more likely to be sacrificed during excision of the atrial septum, every precaution should be made not to injure or traumatize the anterior conduction tract. Baffle Insertion the baffle is sutured in place with 5-0 or 6-0 continuous Prolene suture starting between the left superior pulmonary vein and the left atrial appendage. The suture line continues along the posterior wall of the left atrium toward the base of the most lateral aspect of the superior vena cava and then curves gradually onto the right atrial wall around the orifice of the superior vena cava before continuing back along the edge of the already cut atrial septum. Similarly, the other end of the suture is continued along the margin of the left inferior pulmonary vein and the posterior atrial wall and toward the lateral margin of the Eustachian valve of the inferior vena cava. It then curves around the orifice of the inferior vena cava onto the right atrial wall before returning along the cut edge of the atrial septum behind the coronary sinus to be tied to the other end of the suture. Pulmonary Venous Obstruction the suture line should be a good distance away from orifices of the pulmonary veins to avoid causing pulmonary venous obstruction. Direction of the Caval Legs of the Baffle the caval legs of the baffle should extend obliquely toward the base of lateral margins of the superior and inferior venae cavae to lessen the possibility of pulmonary vein obstruction due to future baffle constriction. Preventing Obstruction to the Superior Vena Cava Special care should be taken to ensure a wide superior vena caval opening by suturing some distance away from the margin of the orifice. Small bites of the right atrial wall followed by relatively larger bites on the baffle result in ballooning of the baffle, lessening the possibility of future obstruction to the superior vena cava. Preventing Obstruction to the Inferior Vena Cava the same precautions should be taken to prevent obstruction to the inferior vena cava. The suture line of the baffle is continued along the border of the Eustachian valve so as not to impinge on the inferior vena caval orifice. Relationship of the Coronary Sinus to the Baffle Because of the close proximity of the conduction tracts and atrioventricular node to the coronary sinus, the baffle suture line is continued behind the coronary sinus. Suture Line Leaks With the aid of a fine nerve hook, the surgeon must check the suture line for possible leaks that may be corrected with additional sutures at this time to prevent postoperative shunting. This can also be accomplished by releasing the caval tapes, and briefly occluding the venous cannulas. The baffle will balloon out and reveal any possible leaks, and also provide an opportunity to assess the size and configuration of the caval baffle. Obstruction of the Mitral Valve If there is some redundancy of the baffle, it may obstruct the mitral valve orifice during diastole. The patient must undergo another operation as soon as possible, the redundant area must be excised, and the defect sutured together. B: Excision of gross redundancy of the baffle to prevent obstruction of the mitral valve orifice during diastole. At the time of surgery, primary closure may be possible, but more commonly a patch of Gore- Tex or pericardium is used to make up for the shrunken pericardium and to reduce tension on the suture line. Obstruction to the Superior Vena Cava Obstruction to the superior vena cava may have important sequelae related to elevated central venous pressure in the upper body. Obstruction is usually due to inadequate width and length of the superior limb of the baffle or due to suturing too close to the ostium of the superior vena cava. Unless the gradient across the caval ostium is minimal, these patients should undergo surgical correction of the obstruction. It is incised longitudinally, and the superior vena cava inflow is enlarged by suturing an appropriately sized Gore-Tex patch in place. Obstruction to the Inferior Vena Cava Obstruction to the inferior vena cava is seen less commonly, but when it occurs, it can be approached in the same manner as obstruction to the superior vena cava. Stenosis of the systemic venous baffle involving the superior or inferior vena caval portion can be successfully managed with balloon dilation in the cardiac catheterization laboratory in most instances.