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1.
Am Surg ; 90(8): 2011-2013, 2024 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-38557206

RESUMO

BACKGROUND: Approximately 10% of intraoperative cholangiograms identify choledocholithiasis (CDL), stones in the common bile duct. Choledocholithiasis management options include endoscopic retrograde cholangiopancreatography (ERCP) followed by cholecystectomy, laparoscopic cholecystectomy (LC) followed by ERCP (LC + ERCP), cholecystectomy with open common bile duct exploration, or laparoscopic cholecystectomy with laparoscopic common bile duct exploration (LC + LCBDE). The goal of these interventions is to clear the obstruction from CDL. METHODS: Patients from a single-center community hospital undergoing LC with intraoperative cholangiogram (LC + IOC) progressing to LC + LCBDE from July 2020 to August 2022 were evaluated for hospital length of stay (LOS), operative times, and complications. These were compared to the prior standard practice of pre/post-operative ERCP. RESULTS: The results were evaluated using ANOVA, Student-Newman-Keuls, and chi square analysis. In comparison of LC + CBDE to ERCP + cholecystectomy, LOS was reduced (1.8 vs 4.6 days P < .0001). No difference in LOS between LC + IOC and LC + CBDE (1.4 vs 1.8 days, P > .05) was found. No difference in complication rates was found. Mean operative time differed between LC + IOC and LC + CBDE (63 vs 113 minutes, P < .0001). Fifty-five attempts of LC + CBDE were performed with only 10 requiring post-operative ERCP. DISCUSSION: Since implementation of LC + CBDE, there has been reduced LOS without increasing complication rates. Operative times are increased with LC + CBDE but offset by reduced LOS, additional anesthesia events, and procedures. Our institution will continue to pursue LC + CBDE when indicated with efforts to improve resource allocation.


Assuntos
Colangiopancreatografia Retrógrada Endoscópica , Colecistectomia Laparoscópica , Coledocolitíase , Ducto Colédoco , Hospitais Comunitários , Tempo de Internação , Humanos , Coledocolitíase/cirurgia , Coledocolitíase/diagnóstico por imagem , Masculino , Feminino , Pessoa de Meia-Idade , Tempo de Internação/estatística & dados numéricos , Ducto Colédoco/cirurgia , Estudos Retrospectivos , Duração da Cirurgia , Idoso , Complicações Pós-Operatórias/epidemiologia , Adulto , Colangiografia
2.
Am Surg ; 89(8): 3482-3483, 2023 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-36876386

RESUMO

Endoscopic sleeve gastroplasty (ESG) is performed by using endoscopic suctioning to reduce the volume of the stomach by plicating the greater curvature with an endoscopic suturing device or stapler. This allows for the endoscopist to perform an elective outpatient weight loss procedure. We will describe a single case of post-procedure day zero complication involving ESG resulting in ischemia, perforation, and peritonitis; what was discovered intra-operatively; and our operative management.


Assuntos
Gastroplastia , Obesidade Mórbida , Humanos , Endoscopia/métodos , Gastroplastia/efeitos adversos , Gastroplastia/métodos , Obesidade/cirurgia , Obesidade Mórbida/cirurgia , Estômago/cirurgia , Resultado do Tratamento
3.
Am Surg ; 89(7): 3136-3139, 2023 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-36857190

RESUMO

BACKGROUND: During a laparoscopic cholecystectomy, the critical view of safety is obtained through dissection of the gallbladder from the liver until there is anterior and posterior visualization of the cystic duct and cystic artery. This view is used to allow for proper identification of the cystic duct and artery that will be clipped and incised during the operation. Indocyanine green (ICG) can be used during the operation to directly visualize the biliary tract because of its excretion through the biliary system and elimination via the GI tract. Using a laparoscope capable of visualizing ICG allows for identification of bile duct anatomy to include: common hepatic bile duct, cystic duct, and aberrant, or accessory bile ducts. Additionally, visualization of the biliary structures using ICG prior to clipping and incision will allow for identification and prevention of missed biliary anatomy which could reduce incidence of bile leak, a known complication of cholecystectomies. We propose that visualization of the critical view of safety with ICG fluoroscopy be termed the critical view of safety plus. PURPOSE: We hypothesized that using the critical view of safety plus method for laparoscopic cholecystectomy will yield better scores and increase the decision of the control surgeon to choose to cut and proceed with the operation when compared with the traditional critical view of safety. RESEARCH DESIGN: Comparision of operative photos of critical view of safety and critical view of safety plus which were randomized, double blinded, and graded by a single control surgeon. STUDY SAMPLE: Our study consisted of fifty patients of which 72% female (n = 36) and 28% male (n = 14). The ethnic background included 76% non-Hispanic (n = 38) and 24% Hispanic or of Latino/a origin (n = 12). The average age of our patient was 49 years old (range 20 to 93 years old). Inclusion criteria consisted of patients undergoing laparoscopic cholecystectomy greater than or equal to 18 years old. Exclusion criteria included allergy to indocyanine dye or iodine and pregnancy. ANALYSIS: The scores were evaluated using Chi-squared and paired T-test analysis using MedCalc, MedCalc Sofware Ltd, Belgium. RESULTS: The decision to cut and proceed with the operation was chosen 29 times (58%) when viewing the critical view of safety plus vs 22 times (44%) with the critical view of safety (χ2 = 65.822, p < 0.0001). The decision to proceed with further dissection to isolate the cystic duct viewing the critical view of safety plus was chosen 8 times (16%) vs 11 times (22%) with critical view of safety (χ2 = 65.822, p < 0.0001) as shown in Fig. 2. The comparison of total scores with critical view of safety plus vs critical view of safety showed an average of 4.36 vs 4.04, p = 0.0733. The critical view of safety plus and critical view of safety individual criteria scores are: "two structures connected to the gallbladder" (average 1.54 vs 1.50, p = 0.598), "cystic plate clearance" (average 1.42 vs 1.28, p = 0.018), and "hepatocystic triangle clearance" (average 1.4 vs 1.26, p =0.0334). CONCLUSION: We recommend routine use of ICG fluoroscopy to obtain the critical view of safety plus to allow for improved visualization of the biliary tree, identification of aberrant biliary anatomy, and the potential to reduce risk of bile duct injury.


Assuntos
Doenças dos Ductos Biliares , Sistema Biliar , Colecistectomia Laparoscópica , Adulto , Idoso , Idoso de 80 Anos ou mais , Humanos , Pessoa de Meia-Idade , Adulto Jovem , Colangiografia/métodos , Colecistectomia Laparoscópica/métodos , Corantes , Verde de Indocianina
4.
Am Surg ; 89(7): 3241-3242, 2023 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-36799729

RESUMO

BACKGROUND: Amyand hernias are rare as they represent 0.5% of all hernias. An Amyand hernia that is discovered due to acute appendicitis is even rarer, accounting for approximately 0.11% of cases. Furthermore, appendiceal neoplasms are infrequently encountered in only 0.7-1.7% of appendectomy specimens. PURPOSE: This paper presents the case of an 85 year-old man presenting with acute appendicitis located within an amyand hernia as well as a serrated adenoma noted on final pathology. CONCLUSIONS: An Amyand hernia is a rare diagnosis. We proceeded with laparoscopic appendectomy and interval inguinal hernia repair. Pathology should be reviewed for all patients and proper follow up ensured for all incidental findings.


Assuntos
Adenoma , Apendicite , Neoplasias Gastrointestinais , Hérnia Inguinal , Masculino , Humanos , Idoso de 80 Anos ou mais , Apendicite/complicações , Apendicite/diagnóstico , Apendicite/cirurgia , Achados Incidentais , Apendicectomia , Hérnia Inguinal/complicações , Hérnia Inguinal/diagnóstico , Hérnia Inguinal/cirurgia , Doença Aguda , Neoplasias Gastrointestinais/complicações , Adenoma/complicações , Adenoma/diagnóstico , Adenoma/cirurgia
5.
Am Surg ; 84(12): 1906-1912, 2018 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-30606347

RESUMO

Ventilator-associated pneumonia (VAP) is associated with significant morbidity (ventilator days, ICU days, and cost) and mortality increase in trauma patients. Multidrug-resistant strains of causative VAP pathogens are becoming increasingly common. Aerosolized antibiotics achieve high alveolar concentrations and provide valuable adjuncts in the treatment of VAP. This study examined the impact of aerosolized antibiotics in the treatment of VAP in trauma patients. Patients with either Acinetobacter baumannii or Pseudomonas aeruginosa VAP over 10 years treated with aerosolized antibiotics (cases) were stratified by age, severity of shock, and injury severity. A frequency-matched (by causative pathogen) control group treated without aerosolized antibiotics was used for comparison. Multivariable logistic regression was used to identify predictors for the use of aerosolized antibiotics. One hundred twenty VAP episodes were identified in 100 patients. Microbiologic resolution was achieved in all patients treated with aerosolized antibiotics. There was no difference in mortality (14.5% vs 15.7%, P = 0.87) and no antibiotic-related complications in either group. Multivariable logistic regression identified VAP persistence and relapse as independent predictors for the use of aerosolized antibiotics. Combined with systemic therapy, aerosolized antibiotics broaden the spectrum of therapy. They are valuable adjuncts with minimal risk of antibiotic resistance and/or systemic complications.


Assuntos
Antibacterianos/administração & dosagem , Bacilos e Cocos Aeróbios Gram-Negativos/isolamento & purificação , Pneumonia Bacteriana/tratamento farmacológico , Pneumonia Associada à Ventilação Mecânica/tratamento farmacológico , Ferimentos e Lesões/complicações , Acinetobacter baumannii/isolamento & purificação , Administração por Inalação , Adolescente , Adulto , Aerossóis/administração & dosagem , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pneumonia Bacteriana/complicações , Pneumonia Bacteriana/microbiologia , Pneumonia Associada à Ventilação Mecânica/complicações , Pneumonia Associada à Ventilação Mecânica/microbiologia , Pseudomonas aeruginosa/isolamento & purificação , Adulto Jovem
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