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If 20 % or less of the proximal stom- between the duodenal tube site and the abdominal wall order 10 mg celexa with mastercard medicine 513, the ach remains buy generic celexa 20mg line professional english medicine, reconstruction should be with a Roux limb or a site should be covered with omentum buy celexa 10mg low price treatment zinc toxicity. We favor total gastrectomy for proximal gastric cancer though occasionally we have used a Adenocarcinoma of the stomach often extends submuco- proximal gastrectomy with esophagogastrostomy without sally much farther than is appreciated on gross examination 10 mg celexa mastercard 88 treatment essence. In this Early metastasis is usually to regional lymph nodes, but the instance, we always add a feeding jejunostomy. A better lymphatic drainage of the stomach is extensive and often option for reconstruction following proximal gastric resec- unpredictable. These facts support a generous gastric resec- tion may be isoperistaltic jejunal interposition (Henley loop). We margin may be acceptable for the intestinal subtype of gas- favor the construction of some sort of jejunal reservoir, tric cancer. The goal of operation for gastric cancer is an R-0 though there are studies that show this makes little differ- resection with negative margins and an adequate lymph ence. Frozen section analysis is important for the and nutritional status with jejunal pouch after total gastrec- intraoperative confirmation of negative margins. Roux-en-Y esophagojejunostomy past two decades, the standard operation performed for gas- with a J-pouch is easy to construct and functions well. Cancers of the cardia or fundus a minimum of 15 lymph nodes must be removed and assessed are treated with total gastrectomy or proximal subtotal gas- pathologically. While it is generally acknowledged in this trectomy with high ligation of the left gastric artery and situation that the more lymph nodes removed the better, the removal of the gastrosplenic ligament and lesser omentum role of extended lymph node dissection for gastric cancer together with the crural lymphatic tissue. Despite increasing interest in more extensive sur- pyloric and infrapyloric, right and left crural), while a D2 gical procedures for the treatment of gastric adenocarci- dissection removes level N1 and N2 nodes (nodes along the noma, none has definitively improved the cure rate left gastric, common hepatic, celiac, and splenic arteries). Splenectomy and distal pancreatectomy are not routinely 28 Concepts in Surgery of the Stomach and Duodenum 275 performed as part of D2 gastrectomy, as this extensive bariatric surgery center for evaluation. Surgical weight loss surgery has been shown to increase perioperative morbidity options include laparoscopic adjustable gastric band, sleeve without improving the cure rate. The operative trials comparing extended lymphadenectomy to D1 lymph- mortality risk varies inversely with the expected weight loss adenectomy in gastric cancer have failed to show a survival and directly with the extent of comorbidities and patient size. Duodenal switch has a mortality risk of 1–2 % advantage of D2 over D1, except in patients T3 or T4 tumors and an expected durable weight loss of 40–50 %. Preoperative, intraoperative, and postoperative care by a Laparoscopy multidisciplinary experienced bariatric team optimizes out- comes and maximizes patient safety. The answer to this postoperative death, now a relatively rare event following question depends somewhat on the surgeon’s attitude toward bariatric surgery. Preoperative cardiac assessment should be traindicated if liver or peritoneal disease is extensive. Intraoperative testing of gastric anastomo- Laparoscopy helps avoid a major unnecessary operation in sis or staple lines is routine. Finally, it is clear that in experi- Each bariatric operation has a specific set of possible long- enced hands, laparoscopic radical gastrectomy for gastric term complications, nutritional and otherwise. Lap-band slippage can be a surgical emergency since gastric necrosis may ensue, but band erosion into the stomach typi- Operation for Morbid Obesity cally is handled with elective band removal and drainage. Duodenal switch and biliopancreatic ered for bariatric surgery and referral to a multidisciplinary diversion are not commonly performed bariatric procedures. For interstitial cells of Cajal, and though they may occur any- safe application, it is important to adhere to certain principles. There are three histologic sub- dividing stomach or duodenum if the staples are too types: spindle cell (70 %), epithelioid (20 %), and mixed big, excessive staple-line bleeding can occur or rarely (10 %). If the staples are too small, they will not go patients with completely resected nonmetastatic disease, full thickness through both walls and the staples will prognosis is related to (inter alia) tumor size and mitotic not form correctly. It is probably better to use a staple size that kinase blocker imatinib (Gleevec). There may be a role for preoperative imatinib for pany’s stapler for 10 years cannot assume that she knows very large tumors that appear marginally resectable on exactly how to use the other company’s similar stapler. Patients who experience disease familiar with the new instrument before using it in the progression or intolerable side effects on imatinib are operating room. This is why when stapling across an existing antrum and pylorus, resulting in gastric stasis. When feasible, staple lines in the stomach and duodenum mosis and Roux duodenojejunostomy. Instillation 28 Concepts in Surgery of the Stomach and Duodenum 277 of methylene blue and intraoperative endoscopy are other Pancreatitis useful methods to confirm staple-line integrity. Staple-line bleeding into the lumen can be problematic Pancreatitis following gastroduodenal operation is generally and rarely can be life threatening. Either of the papillae can be injured during aggres- rhage and bleeders controlled. More com- gastrojejunostomy, intraoperative endoscopy should monly, the more proximal minor papilla is occluded or be performed if excessive staple-line hemorrhage is transected. The problems are interrelated in that infection predisposes to the other two complications, and all Postoperative Complications three share risk factors. Wound infection is related to intra- operative contamination, which is more significant in the set- Pulmonary Problems ting of acid suppression, gastric cancer, and obstruction. Appropriate use of prophylactic antibiotics and good surgical Atelectasis is probably the most common complication technique are important preventative measures. Adequate analgesia, incentive spi- disease, abdominal distension, obesity, infection, malnutri- rometry, and early ambulation help minimize this prob- tion, and steroid therapy have all been shown to increase the lem. Pulmonary embolism is unusual with current prophylactic practices but should be considered Early Gastric Stasis in any postoperative patient with acute shortness of breath, chest pain, or unexplained fever and tachycardia. Occasionally in the hospitalized patient who is recovering from gastric surgery, the nasogastric tube “cannot be removed” because of persistent nausea and vomiting. Alternative methods of gastric intubation and alimentation Following a gastric or duodenal operation, any suture line are preferable to a major reoperation during the first 6 weeks may leak and create a potentially fatal situation. These prob- postoperatively when the inflammatory response in the sur- lems manifest by the fifth or sixth postoperative day and are gical field may be intense. Reoperation during this early associated with increasing abdominal pain, fever, distension, postoperative period is often difficult, hazardous, and usually and leukocytosis. In patients and drainage of the peritoneal cavity, decompression of the with a small gastric remnant where a Stamm gastrostomy leaking segment (e. If the initial Witzel technique), and another (distal) tube may be placed operation was laparoscopic, sometimes an adequate reopera- antegrade as a Witzel feeding jejunostomy. Reoperation should thus usually be delayed for patients with postvagotomy diarrhea respond to cholestyr- 3–6 months after the first operation unless a high-grade or amine, and in others codeine or loperamide is useful. Following ablation or resection of the pylorus, most patients have bile in the stomach on endoscopic examination along with some degree of gross or microscopic gastric inflamma- Dumping Syndrome tion (Malagelada et al. Attributing post- operative symptoms to bile reflux is therefore problematic, Clinically significant dumping occurs in 5–10 % of patients as most asymptomatic patients also have bile reflux.

The regions are : (1) Right left to right buy celexa 10 mg without prescription treatment 02, whereas in the latter it will be from right to hypochondrium cheap celexa 10mg mastercard medicine song, (2) Epigastrium discount 40mg celexa overnight delivery medications zanx, (3) Left left buy 40 mg celexa medications zanx. Rare cases of obstruction in intestine from malignant hypochondrium, (4) Right lumbar, (5) growth or enlarged lymph nodes may demonstrate Umbilical region, (6) Left lumbar, (7) Right similar visible peristalsis. It must be remembered that a swelling over the hernial site may not necessarily be a hernia. Malignancy of the testis may lead to metastasis in the pre-and para-aortic lymph nodes. There may be difficulties when some part of the swelling disappears under the costal margin or the pelvis. Is it of same consistency throughout the swelling or there is variable consistency at different parts of the swelling. In case of a cystic swelling tests for fluctuation and fluid thrill should be performed. Of course if the cyst becomes tense, fluid thrill test may be negative and fluctuation will be difficult to elicit. This is an up and down movement and must not be confused with the anteroposterior movement of the abdominal wall during respiration. During inspiration the swelling will move downwards alongwith the downward excursion of the diaphragm. A mesenteric cyst moves freely at right angle to the line of attachment of the mesentery but not so along the line (the line of attachment of the mesentery is an oblique line starting 1 inch to the left of the midline and 1 inch below the transpyloric plane and extending downwards and to the right for about 6 inches). If the swelling is parietal the swelling will be more prominent when the abdominal muscles are made taut and will be freely movable over the taut muscle. If the swelling is parietal but fixed to the abdominal muscle the swelling will not be movable when the muscles are made taut e. If the swelling disappears or becomes smaller when the abdominal muscles are made taut, the swelling is an intra­ abdominal one. Another differentiating point is that if the swelling moves vertically with respiration it is obviously an intra-abdominal swelling. A swelling in front of the abdominal aorta will be separated from the aorta and will become nonpulsatile, whereas an aneurysm will continue to pulsate. A swelling at any of the hernial sites should be tested for expansile impulse on coughing and reducibility. This is possible more readily in case of renal swelling but hardly in cases of hepatic and splenic swellings. If the coils of intestine overlie the swelling the percussion note will be resonant even if the swelling is a solid one. That is why a swelling arising from a liver or a spleen is dull on percussion whereas a renal swelling is resonant. Only if the kidney is considerably enlarged that the coils of intestine are moved aside and the swelling becomes dull on percussion, but even then a band of colonic resonance may be discovered. Another differentiating point between renal swelling and splenic swelling is to percuss the loin just outside the erector spinae. In case of renal swelling this area will be dull as the colon is pushed out by the swelling but in case of a splenic swelling normal resonance is preserved. In ascites, dullness is present over the flanks and it shifts as the patient rolls over. With a renal tumour the Hydatid thrill is elicited by placing 3 fingers over the resonance is replaced by dullness but with swelling and percussing over the middle one and after a splenic enlargement the normal thrill will be felt by other 2 fingers. The upper limit of the liver dullness is raised in subphrenic abscess, liver abscess and hydatid cyst occurring at the superior aspect of the liver. Should the cyst be situated at the upper surface of the liver, X-ray will confirm the diagnosis. Liver scan and selective angiography will help in the diagnosis of liver swelling particularly if the case is one of carcinoma (primary or secondary). Stone in the gallbladder and bile duct as well as empyema of the gallbladder can be diagnosed by non-invasive technique like ultrasound. Examination of stool for the presence of muscle fibres and for estimation of fat and fatty acids, and examination of the urine for its diastase index and for sugar should be carried out. Carcinoma of the head of the pancreas can be diagnosed by hypotonic duodenography (see under the chapter of "Examination of Chronic abdominal conditions"). Retrograde endoscopic pancreaticocholangiography will help in the diagnosis of ca-ampulla of Vater, stone near the ampulla and chronic pancreatitis. Carcinoma of the pancreas can also be diagnosed by selective angiography and pancreatic scan. A thin film of barium lining the lumen of the colon demarcates its outlines and any filling-defect is readily demonstrated. It gives rise to a soft cystic and fluctuating swelling with no signs of inflammation. Irregularity in the affected rib or deformity of the spine, if present, clinches the diagnosis. Hepatic swellings are continuous with the liver dullness and move up and down with respiration. Causes of enlargement of liver are many, but the important surgical conditions are considered here. It is likely to be mistaken for an enlarged gallbladder but it is more wide and flat than the gallbladder and lacks the spherical outline of the distended gallbladder. Subcutaneous oedema which pits on pressure is an additional finding and should always be looked for. Aspiration of anchovy sauce (chocolate colour) pus leaves no doubt about the diagnosis. X-ray and ultrasound are helpful when the cyst occurs at the upper surface of the liver. Secondary carcinoma of the liver is much commoner and results from metastasis from carcinoma of the gastro­ intestinal tract via portal vein or from organs like breast through lymphatics. In this condition the liver is enlarged, irregular with nodules of varying size and shape and becomes hard. An enlarged liver with malignant melanoma anywhere in the body should clinch the diagnosis. In pre-cirrhotic stage the liver may be firm, irregular with small nodules which are never umbilicated (cf. These cases often come to the surgical clinic with haematemesis from rupture of oesophageal varices. It comes out of the lower border of the liver and moves freely up and down with respiration along with liver.

This maneuver appears to lessen some of the postoperative discomfort and may accelerate sloughing of the strangulated mass discount 40 mg celexa visa medicine cabinets recessed. The redundant rectal mucosa just proximal to the hemorrhoid bulges into the slot of the anoscope buy discount celexa 10mg online symptoms type 2 diabetes. Postoperative Care Inform the patient that postoperatively he or she may feel a vague discomfort in the area of the rectum accompanied by mild tenesmus discount celexa 40 mg with amex treatment yeast in urine, especially for 1–2 days after the procedure celexa 20mg low cost medicine everyday therapy. Apprehensive patients do well if this medication is supple- mented by a tranquilizer such as diazepam. Warn the patient prior to the procedure that on rare occa- sions sometime between the seventh and tenth postoperative days, when the slough separates, there may be active bleed- ing into the rectum. A serious degree of bleeding requiring hospitalization occurs in no more than 1–2 % of cases. For constipated patients, Senokot-S (two tablets nightly) helps to keep the stool soft and stimulates colonic peristalsis. Complications Sepsis This dreaded complication is distinctly rare, but can be fatal. The typical patient suffering postbanding sepsis complains of rectal pain and urinary retention on the third or fourth postop- Fig. The physical examination and leukocyte count at 68 Rubber Band Ligation of Internal Hemorrhoids 643 this time may be normal. Suction out all the clots and identify the Proctoscopic examination at this stage demonstrates bleeding point. In some cases the bleeding point can be marked edema of the rectum and necrosis at the sites of grasped with Allis tissue forceps and a rubber band again banding; fever and leukocytosis are also notable at this time, applied to the area. At autopsy, marked rectal and pelvic anesthesia, use either electrocautery or a suture to control edema, sometimes phlegmonous, is common, occasionally the bleeding. Injection of a local anesthetic solu- All the patients who survived this complication were tion into hemorrhoidal bundle following rubber band ligation. Intensive, early treatment with intravenous antibiotics aimed at clostridia, other anaerobes, and gram-negative rods Further Reading is essential. Patients who undergo banding must be told that if they experience urinary symptoms, fever, or pain 1–4 days Barron J. Chassin† Indications Pitfalls and Danger Points Persistent bleeding or protrusion Narrowing the lumen of the anus, thereby inducing anal Symptomatic second- and third-degree (combined internal- stenosis external) hemorrhoids Trauma to sphincter Symptomatic hemorrhoids combined with mucosal prolapse Failing to identify associated pathology (e. Preserving viable anoderm is much more important A sodium phosphate packaged enema (Fleet) is adequate than removal of all external hemorrhoids and redundant skin. One method of preventing anal stenosis is to insert a large Sigmoidoscopy, colonoscopy, or both are done as indicated anal retractor, such as the Fansler or large Ferguson, after by the patient’s symptoms. If the incisions in the mucosa and Routine preoperative blood coagulation profile (partial anoderm (“closed hemorrhoidectomy”) can be sutured with thromboplastin time, prothrombin time, platelet count) is the retractor in place, anal stenosis should not occur if good performed if there is any suspicion of liver disease. Preoperative shaving of the perianal area is preferred by some surgeons but is not necessary. Carver Traditionally, surgeons have depended on mass ligature of College of Medicine, University of Iowa, the hemorrhoid “pedicle” for achieving hemostasis. In fact, the concept of a “pedicle” as being the Operative Technique source of a hemorrhoidal mass is largely erroneous. A hemorrhoidal mass is not a varicose vein situated at the Closed Hemorrhoidectomy termination of the portal venous system. Local Anesthesia Therefore it is important to control bleeding from each ves- Choosing an Anesthetic Agent sel as it is transected during the operation. As pointed out by with epinephrine 1:200,000 and 150–300 units of hyaluroni- Goldberg and associates (Goldberg et al. Therefore, it is perianal injection of these agents is painful, premedicate the well to achieve perfect hemostasis before suturing the defect patient 1 h before the operation with an intramuscular injec- following hemorrhoid excision. Alternatively, give diazepam in a dose of 5–10 mg intravenously just before Associated Pathology the perianal injection. Even though hemorrhoidectomy is a minor operation, a com- Techniques of Local Anesthesia plete history and physical examination are necessary to rule With the technique originally introduced by Kratzer (1974 ), out important systemic diseases such as leukemia. Leukemic the anesthetic agent is placed in a syringe with a 25-gauge infiltrates in the rectum can cause severe pain and can mimic needle. Operating erroneously on an the injection at a point 2–3 cm lateral to the middle of the undiagnosed acute leukemia patient is fraught with the dan- anus. Inject 10–15 ml of the solution in the subcutaneous gers of bleeding, failure to heal, and sepsis. Crohn’s disease tissues surrounding the right half of the anal canal including must also be ruled out by history, local examination, and sig- the area of the anoderm at the anal verge. Repeat this maneuver Another extremely important condition sometimes over- through a needle puncture site to the left of the anal canal. It may resemble nothing more needle into the tissues just underneath the anoderm and into than a small ulceration on what appears to be a hemorrhoid. If the injection of the overlying mucosa should be suspected of being a car- creates a wheal in the mucosa similar to that seen in the skin cinoma, as should any ulcer of the anoderm, except for the after an intradermal injection, the needle is in a too-shallow classic anal fissure located in the posterior commissure. An injection into the proper submucosal plane pro- Before scheduling hemorrhoidectomy, biopsy all ulcerations duces no visible change in the overlying mucosa. It is prudent to submit 3–4 ml of anesthetic solution during the course of withdraw- label each hemorrhoid by location and submit for pathologi- ing the needle. Documentation Basics Satisfactory relaxation of the sphincters is achieved without the need to inject solution directly into the muscles or to Coding for anorectal procedures is complex. Wait 5–10 min for complete relaxation Terminology book for details (American Medical Association and anesthesia. In general, it is important to document: In 1982, Nivatvongs described a technique to minimize • Findings pain (Nivatvongs 1982). It consisted, first, of inserting a • Internal versus external hemorrhoids small anoscope into the anal canal. Make the first injection • Presence or absence of strangulation into the submucosal plane 2 mm above the dentate line. In some cases additional anesthetic agent is necessary for complete circumferential anesthesia. Nivatvongs stated that this technique pro- vides excellent relaxation of the sphincters and permits operation such as hemorrhoidectomy to be accomplished without general anesthesia. For a lateral sphincterotomy, it is not necessary to anesthetize the entire circumference of the anal canal when using this technique. Intravenous Fluids Because local anesthesia has few systemic effects, it is not necessary to administer a large volume of intravenous fluid during the operation. If large volumes of fluid are adminis- tered intraoperatively, the bladder becomes rapidly dis- tended. In the presence of general anesthesia or even heavy sedation during local anesthesia, the patient is not suffi- ciently alert to have the desire to void. By the time the patient is alert, the bladder muscle has been stretched and may be too weak to empty the bladder, especially if the patient also has anal pain and some degree of prostatic hypertrophy. All of this can be prevented by avoiding general anesthesia and heavy premedication and by limiting the dos- age of intravenous fluids to 100–200 ml during and after hemorrhoidectomy. Positioning the Patient We prefer to place the patient in the semiprone jackknife position with either a sandbag or rolled-up sheet under the hips and a small pillow to support the feet.

Amyloidosis Diffuse narrowing of or nodular protrusions into Submucosal deposition of the proteinaceous (Fig C 40-9) the tracheal lumen discount 40 mg celexa with visa medicine 1950. Tracheopathia osteoplastica Multiple sessile nodular masses (often with Multiple submucosal osteocartilaginous growths (Fig C 40-10) rimming calcification) buy celexa 40 mg on line symptoms 37 weeks pregnant. The posterior membranous wall is typically spared discount celexa 10mg on line medications zetia, unlike the circumferential pattern in amyloidosis quality 10 mg celexa medications you cant take while breastfeeding. This represented a tooth that was as- pirated after the patient sustained mul- tiple mandibular fractures following a motor vehicle accident. Chronic granulomatous disorder that primarily affects the nose, paranasal sinuses, and pharynx but may extend to involve the proximal and even the entire trachea. During the healing stage, the granulation tissue is replaced by fibrous tissue with resultant stenoses of the respiratory tract. Usually supraglottic but may extend into the subglottic region or, rarely, into the distal trachea. Relapsing polychondritis Diffuse, symmetric luminal narrowing (initially Characteristic clinical syndrome of recurrent (Fig C 40-11) involves the larynx and the subglottic trachea). Laryngeal and tracheal involvement (in 50% of cases) may result in airway obstruction or recurrent pneumonia. May rarely involve the subglottic larynx and (Fig C 40-12) proximal trachea, although much more common in the upper or lower respiratory tract. Chronic obstructive Narrowing of the coronal diameter of the The lateral walls of the trachea are usually thick- pulmonary disease intrathoracic trachea (to half that of the sagittal ened, and there is often evidence of ossification of (“saber-sheath” trachea) diameter or less). The trachea abruptly (Fig C 40-13) changes to a normal rounded configuration at the thoracic outlet. Long segment of tra- from the subglottic region to its bifurcation (arrows) in cheal narrowing that extends from the subglottic space this patient with long-standing disease. Affected patients are typically young and present with signs and symptoms of obstruction or compression of the superior vena cava, pulmonary veins or arteries, central airways, or esophagus. However, this may be difficult when mucus is thick and tenacious and adherent to nondependent portions of the airway. In such cases, repeating the examination after having the patient cough vigorously may demonstrate disappearance of the “lesion. Unlike parenchymal lesions, endobronchial hamartomas are often symptomatic because of airway obstruction, which can cause hemoptysis, cough, dyspnea, and obstructive pneumonia. In some masses containing fat or calcification, a specific diagnosis of hamartoma can be made. Solitary papilloma of the tracheobronchial tree is less common and is often associated with cigarette smoking. Although the condition is usually benign in children and may regress, in adults it can infiltrate and become malignant. Involvement of the distal airway can produce pulmonary nodules, which frequently cavitate. Inflammatory polyp Thought to be related to some form of underlying irritation or inflammatory process (including foreign body and inhalation of hot or corrosive gas), this lesion typically occurs in the large airways. Amyloid More commonly, amyloidosis is a diffuse tracheo- (Fig C 41-4) bronchial disease causing diffuse mural thickening and luminal narrowing. A mass (black ar- rows) of mixed fat (white arrow) and soft-tissue attenuation in- volves the right middle lobe bronchus, resulting in atelectasis of the right middle lobe. Wegener’s granulomatosis Focal or diffuse wall thickening and airway nar- (Figs C 41-6 and C 41-7) rowing may be associated with calcification of the cartilaginous tracheal rings. Tracheopathia Idiopathic condition characterized by multiple osteochondroplastica sessile, submucosal osteocartilaginous nodules over (Fig C 41-8) a long segment of the trachea. Narrowing of long segments of the trachea and calcification of tracheal rings or multiple nodules are typically seen. In contrast to amyloid and relapsing polychondritis, tracheopathia osteochondroplastica spares the posterior membranous wall of the trachea. Coronal reformatted image shows diffuse nar- Fig C 41-4 rowing of the left main bronchus (straight arrow) and its bifur- Amyloidosis. Diffuse circumferential thickening of the cating branches surrounded by conglomerate mediastinal and bronchial walls bilaterally (arrows). Note occlusion of the left upper lobe uation regions in the bronchial walls that likely repre- bronchus (curved arrows) by the same process. Coronal reformatted image shows two focal strictures (arrows) in a diffusely narrowed left main bronchus. They typically occur in older patients with the risk factors of cigarette or alcohol abuse. These aggressive tumors with a poor prognosis appear as large, irregular tracheal masses. Most of the other malignant tumors are adenoid cystic carcinomas, which are less aggressive and have a better prognosis. Usually occurring during the third to fifth decades of life, they generally appear as focal polypoid endoluminal masses involving the posterolateral wall of the middle to lower third of the trachea. Metastasis Infrequent occurrence that may result from direct (Figs C 41-12 and C 41-13) involvement of the bronchial wall due to aspiration of tumor cells; lymphatic spread; hematogenous metastasis that causes a polypoid lesion inside the bronchial lumen; or tumor cells in the lymph nodes or lung parenchyma that surround the bronchus and grow along it, with some portion of the lesion invading through the bronchial wall. Primary malignancies with a tendency to metastasize to the airways include renal cell carcinoma, melanoma, adenocarcinoma, and sarcoma. Metastases typi- cally appear as focal lesions of the airway; direct invasion from an adjacent source often produces more diffuse disease. Miscellaneous tumors Granular cell tumor, hemangioma, fibroma Carcinoid (Figs C 41-14 Most carcinoids are primarily endobronchial le- and C 41-15) sions, and some small tumors are located entirely within the bronchial lumen. However, some display a dominant extraluminal component and a small endoluminal portion (“iceberg” lesion). Circumferential thick- Diffuse, irregular narrowing of the trachea with cal- 2 cification of the lateral walls. An 8-mm soft-tissue mass (arrow) in the right main bronchus represents a metastasis from colon carcinoma. Polypoid mass arising from the posterolateral wall of the trachea and protruding into the lumen. Endo- luminal masses of granulation initially produce irregular areas of stenosis. If untreated, this may lead to smooth fibrotic stenoses with associated distal pulmonary collapse or pneumonia. Fibrosing mediastinis, usually due to histoplasmosis, can cause diffuse airway narrowing by extrinsic compression and appear as a calcified infiltrating mass. Rhinoscle- roma is a chronic, progressive, granulomatous infection (caused by Klebsiella rhinoscleromatis) that affects the respiratory tract from the nose to the bronchi. Mass (arrowhead) in the orifice of the left upper lobe bronchus, representing a metastasis from renal cell carcinoma, causes collapse of the left upper lobe (arrow).