Vez de diminuir

Eu não discipliná-lo ou de qualquer forma fisicamente abusar dele. Que muito, pelo menos, é o meu crédito. Eu não tentou vencer a Deus por ele do jeito que meus pais tinham tentado a bater-lhe em mim.

Eu levei o Dr. Benny Gerton, um psiquiatra, quando tudo o resto falhou. Ele está tendo dificuldade em aceitar a morte de sua mãe, eu disse Gerton. Ele não é só ... enfrentamento. Estou preocupada com ele.

Depois de três sessões com Benny durante um período de duas onde comprar viagra semanas, Dr. Gerton ligou para dizer que já não precisava ver Benny. "Ele vai dar tudo certo, Mr. Fallon. Você não precisa se preocupar sobre ele.

Mas você está errado, eu insisti. Ele precisa de análise. Ele ainda não é ... enfrentamento.
Mr. Fallon, você já disse isso antes, mas eu nunca fui capaz de obter uma explicação clara do que o comportamento greves você como prova de sua incapacidade de lidar. O que ele está fazendo que preocupa tanto?

Ele está orando, eu disse. Ele ora a Deus para manter sua mãe segura e feliz. E ele fala com sua mãe, como se ele tem certeza que ela ouve, fala com ela todas as noites.

Oh, Sr. Fallon, se isso é tudo o que foi incomodando, posso garantir-vos que não há necessidade de se preocupar. Conversando com sua mãe, orando por ela, tudo o que é perfeitamente normal e.
Todas as noites! Eu repeti.

Dez vezes por dia estaria tudo bem. Realmente, não há nada insalubres sobre o assunto. Falar com Deus sobre sua mãe e conversando com sua mãe no céu ... é apenas um mecanismo psicológico pelo qual ele pode se ajusta ao fato de que ela não esteja mais na verdade aqui na terra com ele. É perfeitamente normal.
Eu tenho cialis melhor preço medo eu gritei: Não é perfeitamente normal nesta casa, Dr. Gerton. Estamos ateus!

Ele ficou em silêncio, então suspirou. Mr. Fallon, você tem que lembrar que seu filho é mais do que o seu filho, ele é uma pessoa em seu próprio direito. Uma pessoa pouco, mas uma pessoa, no entanto. Você não pode pensar nele como propriedade ou como uma mente mal formada para ser moldada.

Eu tenho o maior respeito pelo indivíduo, Dr. Gerton. Muito mais respeito do que os cantores hino que valorizam seus semelhantes menos do que seu mestre imaginário no céu.
Seu silêncio durou mais tempo do que antes. Finalmente ele disse: Tudo bem. Então certamente você percebe que não há garantia de o filho vai ser a mesma pessoa em todos os aspectos como o pai. Ele vai ter idéias e desejos de sua autoria. E idéias sobre a religião pode ser uma área em que o desacordo entre os dois de vocês vão aumentar ao longo dos anos em vez de diminuir. Isto pode não ser apenas um mecanismo psicológico que ele está genérico cialis usando para se adaptar a morte de sua mãe. Ele também pode vir a ser o começo da fé ao longo da vida. Pelo menos você tem que estar preparado para a possibilidade. Eu não vou tê-lo, eu disse com firmeza.

Seu silêncio terceira foi a mais longa de todas. Então: Mr. Fallon, não tenho necessidade de ver Benny novamente. Não há nada que eu possa fazer para ele, porque não há nada que ele realmente precisa de mim. Mas talvez você deve considerar alguns conselhos para você mesmo.
Eu desliguei na cara dele.

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Although this form of anticoagulant therapy is much less convenient heparin has a short life span in the body and will be cleared rapidly after stopping therapy. Coumadin&reg for several days while continuing to thin the blood with heparin up until the elective operation is performed. Coumadin&reg effect has worn off (usually about 3 days) the heparin can be stopped shortly before the start of the elective operation. Coumadin&reg is then restarted when the patient can take oral medications. Coumadin&reg effect has been obtained again heparin infusions are stopped. The safety of operating without any anticoagulation on board must be weighed against the inconvenience(s) of these additional steps. Coumadin&reg is still in effect at the time of your surgery. However it is potentially dangerous to undergo some elective operations while anticoagulated. You should conference with your surgeon and ask whether Coumadin&reg should be temporarily stopped around the time of the upcoming operation.

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It should be noted that zhelcheistechenie in the first postoperative day up to 200 ml of 95% of patients, according to the performed ERCP was not associated with damage of the main bile duct and ended on its own within 7-10 days without any long-term complications. If you have any zhelcheistecheniya for the control of drainage in the first 2-3 days after the operation for more than 200 ml, the patients underwent abdominal ultrasonography, ERCP, and if necessary, laparoscopic sanitation of the abdominal cavity with drainage zatekov, and then decompressed biliary tract using nazobilliarnogo drainage or endoscopic papillotomy.

For 10 years the clinic indicated tactic was used in 16 patients. The result is good, were no deaths.

Another tactic is used in wound trunk channels. If the duct injury is not more than half the diameter, wound closure was performed with the installation of a frame (T-) drainage, the knee is performed above or below the level of injury. Carcass was left for drainage for up to 6 months. Four of these patients were examined within 3 years after surgery. Long-term results are satisfactory.

Complete intersection of the main duct or excision of part of it for 10 years in our clinic was noted in 13 patients. In the acute phase in 5 patients produced gepatikoeyunostomiyu on transhepatic external drainage, which were removed after several substitutions, only two years later. In 4 patients underwent bilio-bilioanastomozy end to end with no substructure drainage with the use of precision equipment. In one case developed anastomotic stricture and required a second operation. In four cases made staple the ends of transected gepatikoholedoha on the T-shaped drainage, which was further reinforced polypropylene net, fixed in a box, above and below the intersection. Drains removed after 6 months, long-term results are satisfactory.

It should be noted that 17.4% of patients damaged duct system were not detected during a second operation. Encountered in postoperative biliary complications (zhelcheistechenie on drainage and drainage by a bandage, jaundice, diffuse biliary peritonitis) require serious thought-out action programs to the formulation of specific algorithms for each type of damage. Often - is a two-step tactic, the first stage of which - the struggle with peritonitis (detoxification, forced sanifying operation with external diverting bile) and reconstructive intervention after stabilization of the patients on the second stage.

No less formidable and serious complication was a wound to major vessels: the hepatic artery, portal vein or hepatic veins. With such complications, we brand viagra met in 11 patients. For unusual variations of blood supply increases the risk of vascular injury and of bleeding, which in turn can lead to injury of the ducts in the implementation of hemostasis [7].

In all cases, a laparotomy was performed and produced by ligation of the branches of the hepatic artery in 8 patients with 2 - completed joint portal vein. In one case, was traumatized by a major branch of right hepatic vein, which closely approached the bed of the gallbladder, its flashing did not lead to a complete stop bleeding. In this case, the patient died of continuous bleeding.

Injuries to adjacent organs, the result of electrosurgical injury during laparoscopic cholecystectomy (diaphragm injury, injury to the wall 12n-gut) gave rise to the conversion in 2 cases. In the first case holds suture of the diaphragm with drainage of the pleural cavity, the second - wound closure of the duodenum with the imposition of retrocolic anastomosis and conduct a probe for food. Mortality rate was 2,1%

Conclusions:

For the prevention and treatment of iatrogenic injuries of the zone of surgery for laparoscopic cholecystectomy is required well-designed programs of action, including assessing the causes or risk factors for possible complications and application of sound tactics when choosing a method of surgical correction.

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November 19, 2010 Research Center of Surgery named after Academician BV Petrovsky, Russian Academy of Medical Sciences conducted the fourth international conference on "Russian School of colorectal surgery." This will be a unique event, to participate in which will come top 500 colorectal and endoscopic surgery of the CIS countries, USA, Korea, Japan, China, etc.

The central theme of the upcoming brand viagra online conference - the present value of less invasive methods of surgical treatment of colon cancer.

During the meeting, scientists can observe the work of surgeons at two operating rooms, where they will undergo surgery using the latest techniques and technologies for treating this type of disease. Conference participants from the floor will be able generic viagra to ask doctors questions and get answers to them.

The purpose of the conference "Russian School of colorectal surgery" - learn from the experience and technology of colorectal surgery at the leading domestic and foreign experts. At the moment our country - among the laggards in this area.

About adhesive disease of peritoneum (SBB) annually in the brand name levitra surgical wards treated 1% of the previously operated patients, intestinal obstruction occurs in 50-75% of patients with PRSP and its conservative treatment is ineffective. After surgery for abdominal adhesions relapses of the disease are 32-71% mortality in adhesive intestinal obstruction in the range 13-55%, reliable means of preventing postoperative adhesions of the abdominal cavity (SPBP) to date are under development [2, 4 , 7, 11, 12].

Most authors are unanimous that the main etiopathogenetic factor in the disease is damage to the peritoneal mesothelium and inflammation with a predominance of its proliferative phase [1, 8, 13].

Many surgical diseases are accompanied by marked changes in the immune system, characterized as a state of secondary immunodeficiency. This is facilitated by a complex pathological factors underlying disease, stress, pain management, surgical trauma [6]. Investigation of immune status and attempts to correct for surgical patients showed that the use of immunomodulators in complex of modern methods of treatment promotes the elimination of postoperative complications, speeds up the healing of tissues, reduces the rehabilitation of patients after surgery [9].

Leading role in the induction of inflammation are polymorphonuclear leukocytes. They migrate cialis without prescription from the bloodstream into the tissues and carry out their protective functions. Products stimulated neutrophils affect the activity of macrophages, lymphocytes, platelets cause degranulation of mast cells, activate the complement system, blood coagulation, fibrinolysis in the area of traumatic injury of the peritoneum [3, 10]. In modern literature there is no unambiguous data on the status of immunity and nonspecific resistance factors in the PRSP.

Accordingly, the purpose of our study was to investigate the dynamic changes of factors of nonspecific resistance of the organism in experimental SPBP.

Experiments were conducted on healthy adult male rats of Wistar, weighing 250-300 g, contained on a standard diet of food and drink in a vivarium CSMU. Studies carried out in compliance with the principles set forth in the Convention for the Protection of Vertebrate Animals used for experimental and other purposes (Strasbourg, France, 1986).

In sterile conditions, under anesthesia rometarovym simulated SPBP. After a median incision was performed laparotomic hydraulic dissection abdominal ventral wall with subsequent excision of an area of 1 x 1 cm and 1 cm away from the edge of the median wound. Caecum been scarification on the entire generic levitra surface until the "bloody dew."

Animals were removed from the experiment by an overdose of anesthesia at 3, 7 and 14 days. Evaluated morphological changes in the abdominal cavity using a visual-descriptive method and the estimation of SPBP method of semantic differential. Bodies involved in SPBP were removed from cadavers were fixed in 10% neutral formalin with subsequent manufacturing of paraffin sections and hematoxylin-eosin, Pikra-Sirius red and Mallory.

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Conservative therapy

Conservative therapy in the liver of acute and chronic hemorrhoids is becoming increasingly important. This is due to the advent of the pharmaceutical market sufficiently effective pain medications, thrombolytic, and flebotonicheskih hemostatic agents.

Works of national and foreign scientists determined that the basis for hemorrhoids is pathology of the cavernous vascular structures embedded in the course of normal embryogenesis in the submucosal layer of distal colon. We conclude that, in addition to vascular, in the pathogenesis of hemorrhoids plays an important role and dystrophic muscle factor. At the heart dysfunction is the first vessel, resulting in increased inflow of arterial blood in the cavernous bodies and reduce the outflow of cavernous veins, which leads to an increase in their size and the development of hemorrhoids. The second leading factor is the degenerative processes in the longitudinal muscle, submucosal layer of the rectum, and bunch of Parkes, retaining hemorrhoids in the anal canal. Under the influence of unfavorable factors is an increase of hemorrhoids, their displacement in the distal direction, and ultimately - loss of the anal canal. Most of these violations occur in high-risk groups, which include seating people or professions involved in heavy physical labor, suffering from constipation.

Hemorrhoids can occur with chronic or acute course, which is phase one and the same process. For hemorrhoids typical two main symptoms - bleeding and prolapse of hemorrhoids. Note that the symptoms of diseases of the colon rather monotonous, and the bleeding is a symptom not only of hemorrhoids, but also diseases brand viagra such as cancer, polyps, hemangioma of the colon, ulcerative colitis. Prolapse hemorrhoids frequently should be differentiated from prolapse of the rectum, prolapse of villous tumor. Therefore, for correct diagnosis, it is mandatory to carry out not only the examination of the perianal region, but the research and digital rectal and sigmoidoscopy. At the slightest suspicion of neoplasm or detection of multiple polyps in the rectum is carried out columns or irrigoskopiyu.

Hemorrhoids rarely observed symptoms such as discomfort in the anal canal, anal itching, abnormal discharge, pain in the main characteristic of acute hemorrhoids. They tend to occur in response to spasm of the sphincter, irritating the walls of the anal canal and anal fissures.

We have proposed a classification of chronic hemorrhoids, divided the clinical course of 4 stages:

Stage 1 - selection of blood from the anal canal, without loss of hemorrhoids

Stage 2 - loss of hemorrhoids with an independent reduction in the anal canal (with or without bleeding)

Stage 3 - the need to manually reposition nodes on a roll (with or without bleeding)

Stage 4 - permanent loss of nodes and the inability to reposition the anal canal (with or without bleeding).

In our opinion, this classification makes it possible in practice to choose an adequate method of treatment.

The basis for the development of acute thrombosis of a hemorrhoid. Inflammatory process that develops at the site and surrounding tissues, is often its consequence.

Acute hemorrhoids on the clinical course, we share in 3 stages:

1. Thrombosis hemorrhoids without inflammation.

2. Thrombosis, complicated by inflammation of hemorrhoids.

3. Thrombosis, complicated by inflammation of the subcutaneous tissue and perianal skin.

The indications for conservative treatment are the initial stages of chronic hemorrhoids and severe disease course. This therapy consists of general and local treatment. Certainly, in acute hemorrhoids shown conservative treatment, but it should be noted that to prevent it in the need to normalize the activities of the digestive tract, the treatment of constipation, which occurs more than 75% of patients with hemorrhoids. We assign enzyme preparations, affecting flora, and peristalsis of small intestine and large intestine, hydrophilic colloids (dietary fiber) during the regular and adequate fluid intake. As a source of dietary fiber in our country has traditionally used wheat bran, sea kale and flax seed in their natural form or in the form of pharmaceutical preparations. Abroad often use the seeds and husk psyllium and flaxseed in the form of drugs such as agiolaks, fayberlaks, nutriklinz and others that have a high water-holding capacity. We will not be in this article, consider drug therapy of irritable bowel syndrome, but the consistency of the regulation of intestinal contents and its transit through the colon is a prerequisite not only prevention but also the successful treatment of hemorrhoids.

Local treatment

Local treatment is aimed at eliminating pain, thrombosis, or inflammation of hemorrhoids and bleeding. When selecting the topical treatment of acute hemorrhoids one must take into account the prevalence of symptoms (pain, thrombosis), the prevalence of inflammation and the presence of a destructive component. When bleeding should clearly estimate the blood loss, and its activity and severity of post-hemorrhagic anemia.

Pain syndrome with hemorrhoids often associated with infringement of a thrombosed haemorrhoid or the appearance of acute anal fissure. Most often in the mechanism of its formation is a spasm of the anal sphincter due to inflammation in the hemorrhoidal node. Therefore, to eliminate pain demonstrates the use of non-narcotic analgesics and local anesthetics combined. For the local treatment of hemorrhoids, we use drugs such as aurobin, ulraprokt, proktoglivenol and others from this group stands out for its efficacy new drug neflyuan containing high concentrations of lidocaine and neomycin.

Thrombosis hemorrhoids complicated by viagra the frequency of erections and orgasms their inflammation is an indication for the use of combined preparations containing analgesics, thrombolytic and anti-inflammatory components. This group of drugs includes Proctosedyl, nigepan (a combination of heparin and anestezina) and gepatrombin T, issued in the form of ointment, gel and suppositories bases. Action gepatrombina F lies in the fact that heparin and allantoin, linking pay attention plasma coagulation factors and exerting an inhibitory effect on hemostasis, causing thrombolytic effect, and panthenol stimulates metabolic processes, granulation tissue and epithelization. Preference for using this drug is that it has a strong thrombolytic and anti-inflammatory effect and does not contain glucocorticoids.

Thrombosis of hemorrhoids - Indications of anticoagulants local action. This group includes heparin and troksevazinovaya ointment nigepan, gepatrombin G. In 70-80% of cases, thrombosis of hemorrhoids complicated by inflammation of the transition to subcutaneous tissue and the perianal region. In this case, the above-mentioned drugs used in combination with water-based ointments, possessing potent anti-inflammatory action (levasin, levomekol, mafinid).

Bleeding - one of the main symptoms of hemorrhoids. Ongoing bleeding for 1 hour is a sign of an acute process. To eliminate it you can use candles containing epinephrine. In addition, use these local hemostatic materials, such as adrokson, beriplast, tahikomb, spongostan consisting of fibrinogen and thrombin. When introduced into the anal canal, they dissolve, forming a fibrin film.

General treatment

The basis of the general treatment is the use of flebotropnyh drugs that increase the tone of veins and improves microcirculation in the cavernous bodies. This group includes many products, but in our opinion, the most effective in this group is diosmin. Treatment with this drug was performed in 120 patients with acute hemorrhoids. Each group of patients was 60 people in the study group patients received diosmin, and in control - placebo. In the study group, pain decreased in 83% of cases, loss of nodes decreased by 91%, and bleeding hemorrhoids - in 91% and almost 2-fold decreased receiving non-narcotic analgesics. In 98% of treated patients had stihaniya inflammation and the rate of annual exacerbations decreased by 2,2 times. Treatment with these drugs allows more than 2-fold to reduce the length of exacerbations and in 1,5 times - their severity.

Conservative therapy is also carried out in conjunction with widespread invasive methods of treatment used primarily outpatient, and surgical interventions that are shown in the later stages of hemorrhoids.

Should indicate that the complex conservative treatment only temporarily causes a decrease in the inflammatory component and normalizes the function of arteriovenous shunts, thus only temporarily improve blood flow in the cavernous Pacinian rectum.

Despite the use of modern effective drugs conservative treatment in acute phase of illness, is still palliative measure, and gives only short-term positive effect. Resumption of constipation, the error in diet, increased physical activity leads to the next exacerbation, which required re-treatment. Therefore, the ineffectiveness of conservative treatment, especially in the later stages of the disease, there should be a combined treatment including conservative in conjunction with minimally invasive or surgical methods.

If conservative treatment of acute and chronic hemorrhoids can be done by general practitioners, the minimally invasive techniques should be performed by a doctor-Coloproctologists on an outpatient basis, or on the testimony - in steady-state. Surgery, hemorrhoidectomy should also be carried out in specialized clinics.

The correct choice of treatment of hemorrhoids, depending on its stage and severity of symptoms with medication, minimally invasive and surgical techniques both separately and in combination, can achieve good results in 99% of patients.

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