Asunto(s)
Infecciones por Caliciviridae/complicaciones , Urgencias Médicas , Perforación del Esófago/diagnóstico , Perforación del Esófago/etiología , Gastroenteritis/complicaciones , Enfermedades del Mediastino/diagnóstico , Enfermedades del Mediastino/etiología , Norovirus , Anciano , Diagnóstico Diferencial , Empiema Pleural/diagnóstico , Empiema Pleural/etiología , Empiema Pleural/cirugía , Perforación del Esófago/cirugía , Esofagoscopía , Extravasación de Materiales Terapéuticos y Diagnósticos/diagnóstico , Extravasación de Materiales Terapéuticos y Diagnósticos/etiología , Extravasación de Materiales Terapéuticos y Diagnósticos/cirugía , Estudios de Seguimiento , Humanos , Interpretación de Imagen Asistida por Computador , Masculino , Enfermedades del Mediastino/cirugía , Enfisema Mediastínico/diagnóstico , Enfisema Mediastínico/etiología , Enfisema Mediastínico/cirugía , Mediastinitis/diagnóstico , Mediastinitis/etiología , Mediastinitis/cirugía , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/cirugía , Reoperación , Stents , Tomografía Computarizada por Rayos XRESUMEN
Single-port access surgery (SPA), the most recent development in laparoscopic surgery allows operations to be carried out through only a single incision using special multichannel ports. By the use of a smaller access tissue trauma and access-related complications, such as wound infections, adhesions and incisional hernias can be decreased considerably. Because of less postoperative pain earlier mobilization of patients can also be achieved. By placing the access transumbilically, e.g. in SPA cholecystectomy (SPA-CHE), the scar is perfectly covered achieving an optimal cosmetic result. Meanwhile various so-called single ports and camera systems have been developed. Great importance is attached to the development of special (double) bended and/or articulating instruments because with these instrument triangulation is possible through only one incision. Nevertheless the stereoscopic situation in SPA-CHE implicates some factors related to retraction, exposition and release of the gallbladder but some difficult situations can be managed safely with some tips and tricks.Because of the already worldwide spread of SPA-CHE this technique will soon become an established minimally invasive technique. However, appropriate studies confirming the clear advantages of the technique are still lacking.
Asunto(s)
Colecistectomía Laparoscópica/instrumentación , Colecistectomía Laparoscópica/métodos , Adulto , Factores de Edad , Índice de Masa Corporal , Cicatriz/prevención & control , Diseño de Equipo , Seguridad de Equipos , Femenino , Hernia Abdominal/prevención & control , Humanos , Masculino , Complicaciones Posoperatorias/prevención & control , Factores de Riesgo , Factores Sexuales , Infección de la Herida Quirúrgica/prevención & controlRESUMEN
Nowadays laparoscopy is the approach of choice for the majority of abdominal pathologies. As the emphasis on minimising the technique continues, new methods as natural orifice translumenal endoscopic surgery (NOTES) and, just recently, single port access surgery (SPA) are evolving rapidly. SPA may represent the next generation of minimally invasive surgery as it combines some of the cosmetic advantage of the natural orifice translumenal endoscopic surgery (NOTES) and allows the performance of the surgical procedure with standard surgical instruments. To perform SPA, the abdomen is approached through a 2 cm incision via the umbilicus and a single-port access device is inserted as sole access to the abdomen. Depending on the single-port system, usually a multichannel cannula, two or three laparoscopic instruments can be used at the same time. The special design of the channels prevents gas leakage while changing instruments. There is also an extra channel for the gas insufflation and an additional element for retracting the abdominal wall. Single-port laparoscopic procedures are safe and feasible. Tissue trauma and port-related complications such as organ damage, adhesions, bleedings, wound infections and hernias could be decreased and the cosmesis is comparable with that of NOTES. Additional experience and continued investigation are warranted.
Asunto(s)
Laparoscopios , Procedimientos Quirúrgicos Mínimamente Invasivos/instrumentación , Diseño de Equipo , Estudios de Factibilidad , Humanos , Seguridad , Ombligo/cirugíaRESUMEN
It is frequently difficult to determine whether a bile duct stricture is benign or harbors a malignant tumor based on medical history alone. Therefore, cholestasis of unknown etiology requires a thorough diagnostic evaluation to make a definitive diagnosis and choose the best course of treatment for the patient. We report the case of a 42-year-old man who developed cholestasis 6 years after undergoing orthotopic liver transplantation for end-stage liver disease. The bile duct was dilated by interventional endoscopy, and a brush cytology was obtained. Cytology revealed an inflammatory reaction. Three months later, the stricture persisted. We performed a forceps biopsy, and the diagnosis of a cholangiocarcinoma was confirmed histologically. We conclude that a combined application of brush biopsy/forceps biopsy and endoscopic measures is essential in cases of bile duct strictures of unknown etiology. Occasionally, surgical confirmation may be required. In any case, a single brush cytology is insufficient for diagnosis.
Asunto(s)
Neoplasias de los Conductos Biliares/diagnóstico , Neoplasias de los Conductos Biliares/terapia , Colangiocarcinoma/diagnóstico , Colangiocarcinoma/terapia , Colangitis/diagnóstico , Colestasis Intrahepática/etiología , Colestasis/etiología , Errores Diagnósticos , Endoscopía , Complicaciones Posoperatorias/diagnóstico , Adulto , Neoplasias de los Conductos Biliares/complicaciones , Neoplasias de los Conductos Biliares/patología , Biopsia/efectos adversos , Biopsia/instrumentación , Biopsia/métodos , Colangiocarcinoma/complicaciones , Colangiocarcinoma/patología , Colestasis/diagnóstico , Técnicas Citológicas , Diagnóstico Diferencial , Reacciones Falso Negativas , Resultado Fatal , Hepatitis Alcohólica/complicaciones , Humanos , Trasplante de Hígado , Masculino , Siembra Neoplásica , Neoplasias Peritoneales/diagnóstico , Neoplasias Peritoneales/etiología , Complicaciones Posoperatorias/cirugía , Stents , Instrumentos QuirúrgicosRESUMEN
A cystectomy for indications other than transitional cell cancer of the bladder or general bladder cancer is frequently performed in cooperation with other surgical specialties such as general surgery or gynecology. In these cases the urological procedure as well as the oncological and surgical concepts of other specialties have to be combined. We studied our cystectomy patients who had undergone such a combined procedure for a non-urothelial indication concerning perioperative and postoperative complications.A total of 204 cystectomies were performed by the Department of Urology at the University of Hamburg, Germany between 1995 and 2003. Bladder cancer was the indication for cystectomy in 162 patients, but 42 patients had a non-urothelial indication for this procedure. These patients included 12 cases of advanced rectal cancer, 9 cases of advanced cervical cancer, 6 cases of advanced sigmoid cancer, 4 cases of advanced prostate cancer, 1 case of prostate sarcoma, 5 cases of complex vesicointestinal fistulae, 2 cases of urachal cancer, 1 leiomyosarcoma, 1 rhabdomyoma, and 1 rhabdomyosarcoma, respectively. Perioperative and postoperative complications of those patients were compared to patients who underwent cystectomy for transitional cell cancer of the bladder.Those 42 patients who underwent cystectomy for non-urothelial indications included 14 male and 28 female patients. The mean age was 58.2 years with a range of 3-78 years. For urinary diversion 30 ileum conduits, 4 sigma conduits, and 8 ileum neobladders were used. The mean operative time was 6.25 h. The mean blood loss was 2200 ml. An average of four red blood cell concentrates (RBC) had to be given. Postoperative hydronephrosis had to be treated in three (7%) patients unilaterally and in two (5%) patients bilaterally with a temporary nephrostomy. Postoperative urinary leakage lasting more than 30 days was found in two (5%) patients. A deep vein thrombosis as well as an ileus was found in five (12%) patients each, respectively. There was no perioperative mortality in this study. When comparing the complications of those patients with the 162 patients who underwent cystectomy for bladder cancer, the only significant difference ( p=0.033, chi-square test) was a higher ileus rate in the patients with cystectomy for a non-urothelial indication. Complications with cystectomy for non-urothelial indications are in large comparable to those for transitional cell carcinoma of the bladder. The higher ileus rate in non-urothelial patients can be explained by the more radical procedures in this group of patients. Even though the group of patients undergoing cystectomy for indications other than bladder cancer was small in this trial, the procedure is standardized in combination with other specialties. Larger patient numbers and a longer follow-up will lead to more data in this special group of patients.
Asunto(s)
Cistectomía/métodos , Neoplasias Pélvicas/cirugía , Neoplasias de la Próstata/cirugía , Neoplasias del Recto/cirugía , Neoplasias del Colon Sigmoide/cirugía , Neoplasias del Cuello Uterino/cirugía , Adolescente , Adulto , Anciano , Niño , Preescolar , Cistectomía/efectos adversos , Femenino , Alemania/epidemiología , Humanos , Hidronefrosis/etiología , Ileus/etiología , Masculino , Persona de Mediana Edad , Resultado del Tratamiento , Neoplasias de la Vejiga Urinaria/cirugía , Incontinencia Urinaria/etiología , Trombosis de la Vena/etiologíaRESUMEN
Intractable hiccup can be an unbearable circumstance and its treatment is often frustrating. More than 100 causes for hiccup have been described in the literature; the most common cause is gastroesophageal reflux disease (GERD). We report a case of a 31-year-old patient who suffered from intractable hiccup starting 3 weeks after laparoscopic Nissen fundoplication for GERD, a potential surgical complication that has not been described. After frustrating medical treatment, the patient underwent computed tomography and nerve stimulator-guided blockade of vagal and phrenic nerves on each side separately. Hiccup ceased only after blockade of the right phrenic nerve with 4 ml/h l% ropivacaine and relapsed soon after discontinuation. He underwent thoracoscopic right phrenicectomy, which rendered him symptom free for well over 2 months, at the time of this writing.
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Fundoplicación/efectos adversos , Reflujo Gastroesofágico/cirugía , Hipo/etiología , Hipo/cirugía , Laparoscopía/efectos adversos , Complicaciones Posoperatorias/etiología , Adulto , Reflujo Gastroesofágico/complicaciones , Hipo/tratamiento farmacológico , Humanos , Masculino , Bloqueo Nervioso , Nervio Frénico/efectos de los fármacos , Nervio Frénico/cirugía , Complicaciones Posoperatorias/tratamiento farmacológico , Complicaciones Posoperatorias/cirugía , Recurrencia , Nervio Vago/efectos de los fármacosRESUMEN
BACKGROUND/PURPOSE: Pulmonary hypertension and pulmonary hypoplasia account for the high mortality rate associated with congenital diaphragmatic hernia (CDH). In animal models of CDH, postnatal nitric oxide (NO) inhalation resulted in significantly better survival rates and antenatal glucocorticoid administration in improved lung compliance. The objective of this study was to evaluate the combined effect of prenatal glucocorticoid administration and postnatal NO inhalation on the survival rate of newborn rats with nitrofen-induced CDH. METHODS: Right-sided CDH was induced by maternal administration of a single oral dose (100 mg, intraperitoneally) of nitrofen on day 11.5 of pregnancy. Dexamethasone (DEX, 0.25 mg/kg) was given in groups III and IV by maternal intraperitoneal injection on day 18.5 and 19.5 of pregnancy. Control animals (groups I and II) received vehicle alone. After spontaneous delivery, the newborn animals were exposed to either NO (80 ppm; groups II and IV) or room air (groups I and III). Vitality (Rat-Score), sO(2) and survival were monitored continuously for 12 hours until animals were killed. Hernia size was estimated as percentage of total thoracic content. RESULTS: Right-sided CDH was observed in 392 of 491 newborn rats (81%). Animals with large hernias (>50%) died within 4 hours after birth, irrespective of treatment. Hernias with less than 50% of the thoracic volume were considered clinically relevant hernias. In this category, 12.5% of animals without treatment (group I) survived compared with 63.6% after NO treatment alone (group II; P <.01). Survival rate after DEX treatment alone (group III) was 69.4% (group III v I; P <.01). In group IV (DEX and NO) 95.2% of the animals survived (group IV v I; P <.001). In contrast to DEX alone, NO administration resulted in significantly better sO(2)(group II and IV) compared with group I (P <.05). CONCLUSION: Combination of prenatal maternal glucocorticoids and postnatal NO inhalation significantly improved survival rate of newborn rats with nitrofen-induced CDH.
Asunto(s)
Dexametasona/administración & dosificación , Hernia Diafragmática/tratamiento farmacológico , Hernias Diafragmáticas Congénitas , Óxido Nítrico/administración & dosificación , Administración por Inhalación , Animales , Femenino , Hernia Diafragmática/inducido químicamente , Hernia Diafragmática/fisiopatología , Inyecciones Intraperitoneales , Rendimiento Pulmonar/efectos de los fármacos , Masculino , Éteres Fenílicos , Embarazo , Efectos Tardíos de la Exposición Prenatal , Ratas , Ratas Sprague-Dawley , Tasa de SupervivenciaRESUMEN
Heterotopic pancreas, usually a silent gastrointestinal malformation, may become clinically evident when complicated by chronic inflammation. We report a case of pancreatitis and extensive pseudocyst formation in the gastric antrum, which caused gastric outlet obstruction. The diagnosis was obscured by a history of emesis during pregnancy and a previously resected gastric polyp. The nature of the obstructive lesion was not diagnosed preoperatively in spite of endosonographic evaluation. Intraoperatively, a cystic tumor of the stomach wall was found, the lesion was excised, and a pyloroplasty was performed to close the excision site. Histology revealed heterotopic pancreatic tissue with chronic inflammation, fibrosis and pseudocyst formation and adjacent to this lesion a myoglandular hamartoma. The patient is symptom-free two years after surgery and no recurrence was found. The nature of heterotopic pancreatic tissue, its diagnosis and management are discussed.
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Coristoma/diagnóstico , Obstrucción de la Salida Gástrica/diagnóstico , Hamartoma/diagnóstico , Seudoquiste Pancreático/diagnóstico , Pancreatitis/diagnóstico , Gastropatías/diagnóstico , Adulto , Coristoma/patología , Coristoma/cirugía , Enfermedad Crónica , Diagnóstico Diferencial , Femenino , Obstrucción de la Salida Gástrica/patología , Obstrucción de la Salida Gástrica/cirugía , Hamartoma/patología , Hamartoma/cirugía , Humanos , Seudoquiste Pancreático/patología , Seudoquiste Pancreático/cirugía , Pancreatitis/patología , Pancreatitis/cirugía , Trastornos Puerperales/diagnóstico , Trastornos Puerperales/patología , Trastornos Puerperales/cirugía , Píloro/patología , Píloro/cirugía , Gastropatías/patología , Gastropatías/cirugíaRESUMEN
Soft tissue sarcomas embrace a wide variety of rare tumours. This often means excision without wide margins, and the unexpected malignancy leads to diversity of postoperative treatment. As a rule all lesions of a soft tissue tumour should be biopsied if persisting for more than 6 weeks. The extent of the biopsy is determined by the tumour characteristics, but should not aggravate later resection of a malignant tumour. Preoperative diagnostic studies should be standardised and include MNR, while the tumour is characterised according to the recent edition of the UICC GTNM system. The primary tumour should be excised in a limb-sparing way with wide margins, if necessary including the neighbouring fascia. Local recurrence should be approached aggressively like primary tumours, with curative intention. In cases of distant metastases, which usually occur in the lungs, a grading-associated approach is necessary. In G3 metastases chemotherapy should be administered before the surgical intervention. Radiation therapy is saved for patients in whom the tumour cannot be resected with wide margins or is larger than 10 cm maximum diameter. In the light of current knowledge, radiation therapy should be given as an adjuvant for patients whose tumour was resected without wide margins and for tumours larger than 10 cm in diameter. The use of palliative chemotherapy is still controversial and identification of new prognostic markers for patient selection is necessary. Since most patients with soft tissue sarcoma die from distant metastases and not the primary or locally recurrent tumour, the need for effective chemotherapy in an adjuvant setting is obvious. Controlled studies with as many enrolled patients as possible are necessary if valid data are to be collected. The management of soft tissue sarcoma patients is in principle multidisciplinary and should be confined to specialised centres.
Asunto(s)
Sarcoma/diagnóstico , Sarcoma/terapia , Humanos , Metástasis de la Neoplasia , Recurrencia Local de Neoplasia , Sarcoma/patologíaAsunto(s)
Trasplante de Hígado , Donantes de Tejidos , Adolescente , Cadáver , Niño , Preescolar , Enfermedades Transmisibles/epidemiología , Familia , Femenino , Estudios de Seguimiento , Alemania , Humanos , Lactante , Trasplante de Hígado/inmunología , Trasplante de Hígado/mortalidad , Masculino , Complicaciones Posoperatorias/epidemiología , Reoperación , Tasa de Supervivencia , Factores de TiempoRESUMEN
Since living related liver transplantation was first performed in 1989, more than 150 cases have been performed worldwide, mostly in the United States and Japan. This paper reports the first series of living related liver transplantation in Europe. Twenty living related liver transplantation surgeries were performed over a 13-mo period, with an overall patient survival of 85%. For patients who underwent elective transplantation (n = 13), the survival rate was 100%. Technical complications included one arterial thrombosis necessitating retransplantation and five bile leaks requiring surgical revision. The technical improvements that permit avoidance of these complications are discussed. A detailed description of the living related liver procurement is given. All procurements yielded grafts of excellent quality. No intraoperative complications occurred, and no reoperations were necessary. No heterologous blood transfusion was needed. In two patients, incisional hernias developed after wound infection. Living related liver transplantation does not absolve the transplant community of efforts to promote cadaveric organ procurement. Nevertheless, living related liver transplantation does have the advantage of a readily available graft of excellent quality, permitting transplantation with optimal timing under elective conditions. Several centers are now preparing living related segmental liver transplants, following the model of our protocol, for three reasons: (a) to obtain superior results compared with cadaveric liver transplantation; (b) to overcome cadaveric organ shortage and further reduce pretransplantation mortality and (c) to provide viable organs in countries where cadaveric organ procurement is not established. When performed by a team experienced in pediatric liver transplantation and in adult liver resection, living related liver transplantation is an excellent modality for the treatment of end-stage liver disease in children.
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Trasplante de Hígado/métodos , Padres , Donantes de Tejidos , Adulto , Niño , Preescolar , Femenino , Rechazo de Injerto , Supervivencia de Injerto , Humanos , Lactante , Trasplante de Hígado/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Tasa de SupervivenciaRESUMEN
A patient with malignant haemangiopericytoma of the right second rib is described. En-bloc resection of this rare tumour with the adjacent upper lobe of the lung and part of the chest wall could be achieved. The clinical and morphologic features of this case are presented. On account of the high risk of local recurrence and distant metastasis, we think an adjuvant chemo- and radiotherapy is indicated.