Closed drainage versus open packing of infected pancreatic necrosis.

Infected pancreatic necrosis is the most lethal form of pancreatic infections. We have compared our results of open packing and closed catheter drainage after surgical debridement in 20 patients between 1978 and 1993. There were 18 men and 2 women, ages 18 to 72 (mean 54 years). Pancreatitis was attributed to alcohol in eight patients, gallstones in four, surgery in four, hyperlipidemia in one, and was unknown in one. The most common infectious organisms were Strep. viridans, E. coli, Staph aureus, and Candida albicans. Surgical debridement and closed catheter drainage without lavage was the initial treatment in nine patients. Seven of 9 (78%) required reoperation for recurrent abscess and necrosis. Procedure related morbidity was 70 per cent and overall mortality was 44 per cent. Sepsis was the cause of death in three patients and multi-system organ failure in one patient. Surgical debridement and open packing was performed in 11 patients. Each patient had scheduled reoperations for repeat debridement and packing an average of 10 times over 21 days. Procedure-related morbidity was 73 per cent and overall mortality was 18 per cent. One patient died of cardiac failure and one of multisystem organ failure. Retroperitoneal hemorrhage and recurrent abscesses were more frequent after closed drainage, whereas gastric fistula and incisional hernia were more frequent after open packing. Ventilator dependence, pancreatic and intestinal fistula, and organ failure occurred at the same rate. In conclusion, surgical debridement and open packing, with planned redebridement and packing, is more effective in controlling the septic process than is closed catheter drainage of infected pancreatic necrosis.

[Endoscopic surgery in neoplasms of Vater's ampulla]. / Cirugia endoscópica en neoplasia de ampolla de Vater.

Twenty patients with tumors located in the ampulla of Vater underwent an endoscopic papillo-sphincterectomy. Four of them were palliative procedures and 16 were curative. The patients complaints were: obstructive jaundice, pain on the right hypochondrium, digestive hemorrhage or neoplastic syndrome. The mean age was 72.6 years ranging from 54 to 87. Ten were males and 10 females. The overall mean survival was 36.2 months (S.E.+ - 5.6) ranging between 9 and 50 months. The actuarial survival 18 months after the procedure was 63.5% (S.E.+ - 13%). The survival correlated with the macroscopic shapes according to Tasaka. A comparative analysis was made between the results obtained with palliative endoscopic surgery and radical open surgery.

Sociedad de Cirujanos de Mar del Plata: hidatidosis hepática; experiencia de 28 casos / Surgeons' Society of Mar del Plata: hepatic echinococcosis; experience on 28 cases

El objetivo de este trabajo es comunicar los resultados del tratamiento quirúrgico efectuado en pacientes portadores de hidatidosis hepática. Entre noviembre de 1988 y octubre de 1990 se trataron 20 pacientes, de los cuales 17 correspondieron al sexo femenino y 11 al masculino con rango etario entre 18 y 76 años. En 7 pacientes se comprobaron más de un quiste (25//), ligero predominio en lóbulo derecho (18) sobre el izquierdo (14) con 1 ubicado lóbulo de Spiegel. El diagnóstico preoperatorio se estavleció por ecografia completado en su mayoria por tomografia computada. El tratamiento efectuado consistió en 18 periquistectomias, 11 resecciones parciales (Mabit) y 4 drenajes simples. En 5 se comprobaron comunicaciones con la vía biliar (17//) tratados con coledocotomía en un caso y papilotomia endoscópica en 4, con buen resultado. Como complicaciones se registraron 2 abscesos subfréneticos derechos drenados por via percutánea, I fístula quístico-biliar y un derrame pleural izquierdo. Como conclusión, los mejores resultados se obtuvieron con la periquistectomia en cuanto a morvilidad y acortamiento del postoperatorio. No obstante se considera que las otras técnicas empleadas tienen su indicación con resultado final aceptable

Sociedad de Cirujanos de Mar del Plata: hidatidosis hepática; experiencia de 28 casos / Surgeons Society of Mar del Plata: hepatic echinococcosis; experience on 28 cases

El objetivo de este trabajo es comunicar los resultados del tratamiento quirúrgico efectuado en pacientes portadores de hidatidosis hepática. Entre noviembre de 1988 y octubre de 1990 se trataron 20 pacientes, de los cuales 17 correspondieron al sexo femenino y 11 al masculino con rango etario entre 18 y 76 años. En 7 pacientes se comprobaron más de un quiste (25//), ligero predominio en lóbulo derecho (18) sobre el izquierdo (14) con 1 ubicado lóbulo de Spiegel. El diagnóstico preoperatorio se estavleció por ecografia completado en su mayoria por tomografia computada. El tratamiento efectuado consistió en 18 periquistectomias, 11 resecciones parciales (Mabit) y 4 drenajes simples. En 5 se comprobaron comunicaciones con la vía biliar (17//) tratados con coledocotomía en un caso y papilotomia endoscópica en 4, con buen resultado. Como complicaciones se registraron 2 abscesos subfréneticos derechos drenados por via percutánea, I fístula quístico-biliar y un derrame pleural izquierdo. Como conclusión, los mejores resultados se obtuvieron con la periquistectomia en cuanto a morvilidad y acortamiento del postoperatorio. No obstante se considera que las otras técnicas empleadas tienen su indicación con resultado final aceptable (AU)

Cirugia endoscópica en neoplasia de ampolla de Vater. / [Endoscopic surgery in neoplasms of Vaters ampulla]

Twenty patients with tumors located in the ampulla of Vater underwent an endoscopic papillo-sphincterectomy. Four of them were palliative procedures and 16 were curative. The patients complaints were: obstructive jaundice, pain on the right hypochondrium, digestive hemorrhage or neoplastic syndrome. The mean age was 72.6 years ranging from 54 to 87. Ten were males and 10 females. The overall mean survival was 36.2 months (S.E.+ - 5.6) ranging between 9 and 50 months. The actuarial survival 18 months after the procedure was 63.5

(S.E.+ - 13

). The survival correlated with the macroscopic shapes according to Tasaka. A comparative analysis was made between the results obtained with palliative endoscopic surgery and radical open surgery.

Cirugia endoscópica en neoplasia de ampolla de Vater. / [Endoscopic surgery in neoplasms of Vaters ampulla]

Twenty patients with tumors located in the ampulla of Vater underwent an endoscopic papillo-sphincterectomy. Four of them were palliative procedures and 16 were curative. The patients complaints were: obstructive jaundice, pain on the right hypochondrium, digestive hemorrhage or neoplastic syndrome. The mean age was 72.6 years ranging from 54 to 87. Ten were males and 10 females. The overall mean survival was 36.2 months (S.E.+ - 5.6) ranging between 9 and 50 months. The actuarial survival 18 months after the procedure was 63.5

(S.E.+ - 13

). The survival correlated with the macroscopic shapes according to Tasaka. A comparative analysis was made between the results obtained with palliative endoscopic surgery and radical open surgery.

Ictericia por metimazol / Jaundice due to methimazole

Se presentan 3 pacientes de sexo femenino que bajo tratamiento con metimazol instituido a raíz de hipertiroidismo presentaron un cuadro caracterizado por ictericia, intenso prurito e hipocolia. Ninguna de las pacientes presentó antecedentes de alcoholismo o ingesta de drogas potencialmente hepatotóxicas. El laboratorio se caracterizó en todos los casos por una elevación de la bilirrubina con un máximo de 14.5 mg% a predominio de la fracción conjugada, aumento de la fosfatasa alcalina y de la gamma glutamil transpeptidasa con una sola moderada movilización de las aminotransferasas no superando el nivel sérico de 10 veces su valor normal. Los marcadores virales fueron reiteradamente negativos para los virus A y B de hepatitis en las tres pacientes. La biopsia hepática reveló en todos los casos una intensa colestasis con reacción inflamatória de grado moderado en los campos portales. La ictericia apareció aproximadamente al mes de instituído el tratamiento y desapareció al cabo de la suspensión del mismo en forma lenta, demorando en un caso hasta un año

Ictericia por metimazol / Jaundice due to methimazole

Se presentan 3 pacientes de sexo femenino que bajo tratamiento con metimazol instituido a raíz de hipertiroidismo presentaron un cuadro caracterizado por ictericia, intenso prurito e hipocolia. Ninguna de las pacientes presentó antecedentes de alcoholismo o ingesta de drogas potencialmente hepatotóxicas. El laboratorio se caracterizó en todos los casos por una elevación de la bilirrubina con un máximo de 14.5 mg% a predominio de la fracción conjugada, aumento de la fosfatasa alcalina y de la gamma glutamil transpeptidasa con una sola moderada movilización de las aminotransferasas no superando el nivel sérico de 10 veces su valor normal. Los marcadores virales fueron reiteradamente negativos para los virus A y B de hepatitis en las tres pacientes. La biopsia hepática reveló en todos los casos una intensa colestasis con reacción inflamatória de grado moderado en los campos portales. La ictericia apareció aproximadamente al mes de instituído el tratamiento y desapareció al cabo de la suspensión del mismo en forma lenta, demorando en un caso hasta un año (AU)

[Jaundice caused by methimazole]. / Ictericia por metimazol.

Three female patients with cholestatic jaundice related to methimazole therapy are presented. The jaundice appeared after more or less 30 days of therapy. Markers for hepatitis A and B were negative in all. None of them had previous history of alcoholism or ingestion of potentially hepatotoxic drugs. Characteristically there was a marked elevation of alkaline phosphatase and gamma-glutamyltranspeptidase with only moderate increase of the aminotransferases. Liver biopsy performed in all showed intensive cholestasis with low degree of inflammatory reaction confined to the portal tracts. The three patients presented a prolonged duration of the liver injury in spite of the interruption of the drug lasting in one of them up to one year, but all ultimately resolved.

Ictericia por metimazol. / [Jaundice caused by methimazole]

Three female patients with cholestatic jaundice related to methimazole therapy are presented. The jaundice appeared after more or less 30 days of therapy. Markers for hepatitis A and B were negative in all. None of them had previous history of alcoholism or ingestion of potentially hepatotoxic drugs. Characteristically there was a marked elevation of alkaline phosphatase and gamma-glutamyltranspeptidase with only moderate increase of the aminotransferases. Liver biopsy performed in all showed intensive cholestasis with low degree of inflammatory reaction confined to the portal tracts. The three patients presented a prolonged duration of the liver injury in spite of the interruption of the drug lasting in one of them up to one year, but all ultimately resolved.

The role of primary varicose veins in venous ulceration.

"Venous" ulceration is usually ascribed to deep venous insufficiency. We record the cases of 20 patients with 23 ulcers without a history suggestive of deep vein disease who were found to have a normal deep venous system when evaluated by Doppler ultrasound, ambulatory venous pressures, and photoplethysmography. All had gross varicose veins present for many years (mean 24 years; range 10 to 35 years), and only 14 limbs had incompetent calf perforating veins. Effective treatment is facilitated by recognition of the relationship of varicose ulcer to superficial venous disease, usually incompetence of the saphenofemoral junction, with or without the presence of incompetent calf perforating veins.