RESUMO
AIM: This study assessed the effect of intra-operative electrical nerve stimulation (INS) on pelvic autonomic nerve preservation (PANP) during laparoscopic resection for rectal cancer. METHOD: A total of 189 consecutive cases of radical laparoscopic proctectomy were included. PANP was assessed visually or with INS. Urinary function was evaluated by residual urine volume (RUV), International Prostatic Symptom Score (IPSS) and recatheterization rate. Erectile function was evaluated using the International Index of Erectile Function (IIEF-5) scale. RESULTS: INS successfully confirmed PANP in 65 (91.5%) patients, while direct vision confirmed PANP in only 72 (61.0%) patients. Compared with the successfully confirmed patients, failed patients in the INS group exhibited higher postoperative RUV (100.0 ± 34.6 vs 25.2 ± 13.6 ml, P = 0.003), higher IPSS (7 days, 20.0 ± 8.6 vs 6.5 ± 2.4, P = 0.012; 1 month, 13.5 ± 6.0 vs 5.3 ± 1.9, P = 0.020; 6 months, 11.7 ± 5.1 vs 4.5 ± 1.7, P = 0.018), a greater number of incidences of a micturition disorder (66.7% vs 1.5%, P = 0.000), higher recatheterization rates (33.3% vs 1.5%, P = 0.017) and a lower IIEF score at 3 months (8.25 ± 0.96 vs 10.93 ± 1.99, P = 0.012) and 6 months (12.50 ± 1.29 vs 15.63 ± 1.65, P = 0.001) postoperatively. Compared with the vision group, the INS group had less deterioration in postoperative RUV (31.5 ± 26.4 vs 54.0 ± 46.7 ml, P = 0.000), lower IPSS (7 days, 7.7 ± 5.0 vs 11.0 ± 6.6, P = 0.000; 1 month, 6.0 ± 3.3 vs 7.6 ± 5.4, P = 0.012) and higher IIEF score (3 months, 10.69 ± 2.07 vs 9.42 ± 2.05, P = 0.001; 6 months, 15.36 ± 1.85 vs 13.64 ± 2.00, P = 0.000) as well as a lower incidence of urination disorders (7.0% vs 17.8%, P = 0.038). CONCLUSION: INS is effective for the accurate evaluation of PANP during radical laparoscopic proctectomy. Combined with INS, laparoscopic proctectomy is more effective in urogenital function protection.
Assuntos
Vias Autônomas , Terapia por Estimulação Elétrica/métodos , Tratamentos com Preservação do Órgão/métodos , Pelve/inervação , Neoplasias Retais/cirurgia , Adulto , Idoso , Feminino , Humanos , Laparoscopia/métodos , Masculino , Pessoa de Meia-Idade , Ereção Peniana/fisiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Micção/fisiologia , Transtornos Urinários/etiologia , Transtornos Urinários/prevenção & controle , Sistema Urogenital/inervação , Sistema Urogenital/fisiopatologiaRESUMO
Urinary and sexual dysfunctions due to intraoperative pelvic autonomic nerve injury have become the most common complications of rectal cancer surgery, seriously affecting postoperative quality of life. How to protect the nerve and urogenital function while ensuring radical resection for rectal cancer has become the focus of research. We previously carried out a series of systematic studies on Denonvilliers fascia, an important anatomical structure closely related to protection of pelvic autonomic nerve, and demonstrated the importance of Denonvilliers fascia in preservation of intraoperative pelvic autonomic nerve and protection of postoperative urogenital function from aspects of anatomy, physiology, tissue, operation practice and so on. Meanwhile, based on the interim results of our multicenter randomized controlled study, we confirmed that total mesorectal excision with preservation of Denonvilliers fascia (innovative TME, iTME) could effectively reduce the incidence of postoperative urinary and sexual dysfunctions in male patients with mid-low rectal cancer, without sacrificing oncologic outcome. In this article, combined with our research results, we review the literature on anatomy research progress of Denonvilliers fascia to demonstrate the significance and research prospect of Denonvilliers fascia in the pelvic autonomic nerve preservation surgery for rectal cancer.
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Qualidade de Vida , Neoplasias Retais , Vias Autônomas , Fáscia , Humanos , Masculino , Estudos Multicêntricos como Assunto , Pelve/cirurgia , Ensaios Clínicos Controlados Aleatórios como Assunto , Neoplasias Retais/cirurgia , Reto/cirurgiaRESUMO
Objective: Total mesorectal excision (TME) is the gold standard for surgical treatment of mid-low rectal cancer, but the postoperative incidence of urination and sexual dysfunction is relatively high. Preserving the Denonvilliers fascia (DF) during TME can reduce the postoperative incidence of urination and sexual dysfunction. In this study, high resolution magnetic resonance imaging (MRI) was used to observe the imaging performance and display of DF, so as to determine the value of this technique in preoperative evaluation of the preservation of DF. Methods: A descriptive cohort study was carried out. Clinical data of patients with rectal cancer who underwent TME and received preoperative high-resolution MRI at department of Gastrointestinal Surgery, the Third Affiliated Hospital of Sun Yat-sen University from August 2015 to June 2017 were retrospectively analyzed. The characteristics of DF were examined, and the shortest distance (d) between the anterior edge of tumor and DF was measured on high-resolution MRI. The distance d was compared between patients with stage T1-T2 and those with stage T3. Receiver operating characteristic (ROC) analysis was used to determine the predictive value of d for stage T1-T2 disease. Results: Thirty-two patients were enrolled in the study, including 27 males and 5 females with mean age of (62.9±8.9) years. DF was visualized in 96.9% (31/32) of cases on the T2WI sequence. The mean distance d in patients with stage T1-T2 disease (n=23) was (6.73±2.65) mm, and in those with stage T3 disease (n=9) was (1.30±1.15) mm (t=5.893, P<0.001). A cutoff of d >3 mm yielded specificity and positive predictive value for diagnosing stage T1-T2 disease of both 100%, sensitivity of 95.7% and negative predictive value of 90%. The optimum threshold of d was >3.05 mm, and Youden index was 0.957. Conclusions: High-resolution MRI can show the DF and accurately evaluate the relationship of DF with tumor in rectal cancer patients. Analysis on d value can provide an objective basis for the safe preservation of DF.
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Neoplasias Retais , Idoso , Estudos de Coortes , Fáscia/diagnóstico por imagem , Fáscia/patologia , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Neoplasias Retais/diagnóstico por imagem , Neoplasias Retais/patologia , Neoplasias Retais/cirurgia , Estudos RetrospectivosRESUMO
AIM: To investigate differences in the radiographic signs for left and right-sided blunt diaphragmatic rupture (BDR) in order to provide guidance to avoid missing these injuries. MATERIALS AND METHODS: A retrospective review of the computed tomography (CT) examinations of 43 patients with BDR treated at our hospital between January 1995 and 2007 was undertaken. The presence of diaphragmatic discontinuity, diaphragmatic thickening, herniation of abdominal organs into the thoracic cavity, collar/hump sign, dependent viscera sign, abnormally elevated 4 cm or more above the dome of the other-sided hemi-diaphragm, and of associated injuries was recorded and their relationship to each other and to BDR diagnosis examined. A comparison between the use of axial and sagittal/coronal reconstruction images in diagnosis was also performed in 15 patients. RESULTS: On axial imaging, left-sided diaphragmatic rupture occurred in 31 patients (72%) and right-sided in 12 (28%). Twenty-nine patients had associated injuries. More than 60% of the patients showed the "dependent viscera" sign, "abdominal organ herniation" sign, diaphragm thickening, or had a more than 4 cm elevation of one side of the diaphragm. "Diaphragmatic discontinuity" and "stomach herniation" were seen almost exclusively in left-sided rupture. Those with BDR and haemothorax had a significantly lower incidence of "diaphragm discontinuity" (p=0.034) than those without haemothorax. Sagittal/coronal reconstruction slightly increased the number of band signs, diaphragmatic discontinuities and diaphragmatic thickenings seen. CONCLUSIONS: Of the CT signs examined in this study, when herniation of abdominal organs was used as a diagnostic marker, only a very small fraction of trauma patients identifiable by CT would be missed. Further, CT signs differ for left-sided and right-sided BDR, thus the possibility of BDR should be considered when any of the reported CT signs are present.
Assuntos
Acidentes de Trânsito , Diafragma/lesões , Hérnia Abdominal/diagnóstico por imagem , Adulto , Idoso , Meios de Contraste , Diagnóstico Diferencial , Diafragma/diagnóstico por imagem , Feminino , Hemotórax/diagnóstico por imagem , Humanos , Hepatopatias/diagnóstico por imagem , Lesão Pulmonar/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Pneumotórax/diagnóstico por imagem , Valor Preditivo dos Testes , Estudos Retrospectivos , Ruptura/diagnóstico por imagem , Ruptura/patologia , Tomografia Computadorizada por Raios X/métodos , Ferimentos não Penetrantes/diagnóstico por imagemRESUMO
Total mesorectal excision (TME) has been advocated as the golden standard of mid-low rectal cancer surgery for nearly 30 years. However, the complication of postoperative urinary and sexual dysfunctions due to intraoperative nerve injury has yet to be improved. Based on the concept of membrane anatomy, we carried out a systematic study on the important membrane anatomical structure anterior to the rectum--Denonvilliers' fascia. From multiple aspects including anatomy, physiology, histochemistry and surgical practice, we verified the importance of Denonvilliers' fascia for TME surgery in prevention of intraoperative nerve injury and postoperative urogenital dysfunction. Moreover, based on anatomical study of the surgical marker line of Denonvilliers' fascia (Wei's line) and surgical plane, we proved that total mesorectal excision with preservation of Denonvilliers' fascia (iTME) was feasible and practical. Therefore, we conducted a large multicentric randomized controlled trial (RCT). The mid-term result demonstrated that compared with traditional TME surgery, iTME was more effective in reducing the incidence of postoperative urinary and sexual dysfunctions in male patients with mid-low rectal cancer, without sacrifice of short-term tumor radical outcome. We believe that the final RCT result of iTME, based on membrane anatomy, will provide solid evidence for the update of concepts of rectal cancer surgery.
Assuntos
Fáscia/anatomia & histologia , Mesentério/cirurgia , Protectomia/efeitos adversos , Protectomia/métodos , Neoplasias Retais/cirurgia , Reto/cirurgia , Humanos , Masculino , Mesentério/anatomia & histologia , Traumatismos dos Nervos Periféricos/etiologia , Traumatismos dos Nervos Periféricos/prevenção & controle , Peritônio/anatomia & histologia , Reto/anatomia & histologia , Disfunções Sexuais Fisiológicas/etiologia , Disfunções Sexuais Fisiológicas/prevenção & controle , Doenças Urológicas/etiologia , Doenças Urológicas/prevenção & controleRESUMO
AIMS: Observing the parameter-specific anti-hyperalgesic effects of EA with different stimulation times and frequencies on painful hyperalgesia mediated by the level of TRPV1 and P2X3 expression in DRG after CFA injection. MAIN METHODS: The model was induced by the injection of CFA in each rat's right hind paw. EA treatment was applied to the bilateral ST36 and BL60. Paw withdrawal threshold (PWT) and paw withdrawal latency (PWL) were tested with Von Frey filaments and the radiant heat source of the test instrument, respectively. TRPV1 and P2X3 expressions were measured by immunofluorescence and western blot. αß-meATP and capsaicine combined with EA were further utilized to investigate the change in PWL. KEY FINDINGS: Different stimulation times (20, 30, 45â¯min) combined with different frequencies (2â¯Hz, 100â¯Hz, 2/100â¯Hz) of EA have analgesic effects on the PWT and PWL; however, the level of the hypoalgesic efficacy of EA was primarily associated with EA frequency. The analgesic effect of EA was better at 100â¯Hz than at 2â¯Hz. The level of regulation of 100â¯Hz EA on TRPV1 and P2X3 in DRG was greater than that of 2â¯Hz. Furthermore, both TRPV1 agonist and P2X3 agonist may impair the level of EA analgesia. SIGNIFICANCE: EA has a parameter-specific effect on chronic inflammatory pain relief, which primarily depend on the stimulation frequency and not on the stimulation time at a certain stimulation time. The parameter-specific analgesic effect of EA is at least partially related to mediation of the protein level of TRPV1 and P2X3 expression in DRG of CFA rats.
Assuntos
Eletroacupuntura , Gânglios Espinais/metabolismo , Regulação da Expressão Gênica , Hiperalgesia/metabolismo , Hiperalgesia/terapia , Manejo da Dor , Dor/metabolismo , Receptores Purinérgicos P2X3/biossíntese , Canais de Cátion TRPV/biossíntese , Animais , Modelos Animais de Doenças , Gânglios Espinais/patologia , Gânglios Espinais/fisiopatologia , Hiperalgesia/induzido quimicamente , Hiperalgesia/fisiopatologia , Masculino , Dor/induzido quimicamente , Dor/patologia , Dor/fisiopatologia , Ratos , Ratos Sprague-DawleyRESUMO
BACKGROUND: Pancreatic stents can be used to treat a variety of acute and chronic pancreatic lesions. Sporadic successful trials in trauma patients have been reported. To our knowledge, however, a series with long-term follow-up has not previously been reported. We treated six patients in a 6-year period and report the long-term results. METHODS: From February 1999 to February 2005, six blunt-trauma patients with major pancreatic duct disruption were treated with pancreatic duct stent at a single trauma center. Assessment of injury severity and diagnosis were based on abdominal computed tomography (CT) and proved by endoscopic retrograde pancreatography (ERP), with chart review used to establish mechanism of injury, timing of ERP, and stent placement, as well as the long-term outcome. RESULTS: Three of the six injuries were classified AAST grade III and three were grade IV; the interval to ERP with stent placement ranged from 8 hours to 22 days after the injury. One patient developed sepsis and died. One patient's stent could be removed early (52 days post-stenting) with mild ductal stricture, whereas the other four were complicated by severe ductal stricture that required repeated and prolonged stenting treatment. Removal of the stents was only possible in three of these four cases (at 12, 19, and 39 months, respectively), with stent dislodgment in the pancreatic duct occurring in another. CONCLUSIONS: Stent therapy may avoid surgery in the acute trauma stage, and may be preserved as another choice for acute grade IV pancreatic injury. However, variant outcome and long-term ductal stricture reveal that the role of pancreatic duct stent is uncertain and may not be suitable for acute grade III pancreatic injury. However, it needs more clinical data to define the value in the acute blunt pancreatic duct injury.
Assuntos
Ductos Pancreáticos/lesões , Stents , Ferimentos não Penetrantes/cirurgia , Acidentes de Trânsito , Adolescente , Adulto , Colangiopancreatografia Retrógrada Endoscópica , Endoscopia do Sistema Digestório , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ductos Pancreáticos/diagnóstico por imagem , Ductos Pancreáticos/cirurgia , Stents/efeitos adversos , Tomografia Computadorizada por Raios X , Ferimentos não Penetrantes/diagnóstico , Ferimentos não Penetrantes/diagnóstico por imagemRESUMO
Post-surgical adhesion occurs when fibrous strands of scar tissue form, leading to the abnormal joining of anatomical structures. Patients undergoing abdominal surgery are at risk of the complications associated with intraperitoneal adhesions. Hyaluronic acid (HA) is a biocompatible, biodegradable and non-toxic natural polymer, which is gaining popularity as a barrier agent for preventing post-surgical adhesions. As HA is water-soluble and rapidly degraded in vivo, chemical modification is required to produce a non-soluble sheet that might be used to prevent tissue adhesion. We developed a range of biocompatible cross-linked HA-collagen composites and then evaluated them in a rat model of post-surgical adhesion. The results showed that cross-linked HA-collagen was almost totally resistant to hyaluronidase digestion. HA-collagen membranes induced minimal tissue reactions and were bioresorbed within 14 days post-surgery. These results suggest that cross-linked HA-collagen membrane may be a valuable anti-adhesion material to prevent post-surgical intraperitoneal adhesion.
Assuntos
Colágeno , Ácido Hialurônico , Aderências Teciduais/prevenção & controle , HumanosRESUMO
BACKGROUND: Nonoperative management of blunt hepatic injury is currently a widely accepted treatment modality. Computed tomography (CT) is an important imaging study both for diagnosis and follow-up of these patients. There is, however, no reliable predictor of failure of nonoperative treatment other than the ultimate development of hemodynamic instability. Previous reports mostly were based on the data obtained from low-speed dynamic incremental scanners. The purpose of this study is to evaluate the value of a high-speed helical scanner in predicting the outcome of patients managed nonoperatively. METHODS: During a 30-month period, 194 patients with blunt hepatic injury were treated, 150 of them were hemodynamically stable after initial resuscitation and underwent abdominal CT examination. All CT scans were performed with the High Speed Advantage Scanner. The CT scans and medical records were reviewed. RESULTS: Nonoperative management was successfully applied to all patients with grade I and II, 93% of grade III, 87% of grade IV, and 67% of grade V liver injuries. Twelve patients required liver-related celiotomy. Pooling of contrast material was detected on the CT scans of 8 patients. Six (75%) of these patients developed hemodynamic instability and required liver-related celiotomy later. Pooling of contrast material can be detected in 50% of the patients receiving liver-related celiotomy. CONCLUSION: The presence of pooling of contrast material within the hepatic parenchyma indicates free extravasation of blood as a result of active bleeding. In patients with blunt hepatic injury, if this sign is detected, nonoperative treatment should be terminated and angiography or celiotomy undertaken promptly. With the increasing use of high-speed spiral CT scanner and improvement in scanning technique, pooling of contrast material may become a sensitive sign for active bleeding and may be used as a guide for the selection of treatment modality.
Assuntos
Meios de Contraste/análise , Hemorragia Gastrointestinal/diagnóstico , Fígado/lesões , Tomografia Computadorizada por Raios X/métodos , Ferimentos não Penetrantes/diagnóstico por imagem , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Angiografia , Feminino , Humanos , Fígado/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Procedimentos Cirúrgicos OperatóriosRESUMO
PURPOSE: Although many reports advocate computed tomography (CT) as the initial surveillance tool for occult cervical spine injury (CSI) at the emergency department (ED), the role of a lateral cervical spine radiograph (LCSX) has still not been replaced. We hypothesized that the increased width of the prevertebral soft tissue on an LCSX provides helpful information for selecting the high-risk patients who need to be evaluated with more accurate diagnostic tools. METHODS: This was a retrospective and consecutive series of injured patients requiring cervical spine evaluation who were first imaged with three-view plain films at the ED. The prevertebral soft tissue thickness (PVST) and ratio of prevertebral soft tissue thickness to the cervical vertebrae diameter (PVST ratio) were calculated on the LCSX. Suspicion of CSI was confirmed by either CT or magnetic resonance imaging (MRI) scans. RESULTS: A total of 826 adult trauma patients requiring cervical spine evaluation were enrolled. The C3 PVST and PVST ratio were significantly different between patients with or without upper cervical area injury (UCAI, 8.64 vs. 5.49 mm, and 0.394 vs. 0.276, respectively), and, likewise, the C6 PVST and PVST ratio for patients with or without lower cervical area injury (LCAI, 16.89 vs. 14.66 mm, and 0.784 vs. 0.749, respectively). The specificity was greater than 90 % in predicting UCAI and LCAI when combining these two parameters. CONCLUSIONS: This method maximizes the usefulness of LCSX during the initial assessment of a conscious patient with blunt head and neck injury, especially for the identification of high-risk patients requiring prompt CT or MRI; on the other hand, it prevents the overuse of these high-cost imaging studies as initial diagnostic tools.
RESUMO
When there is no major pancreatic duct injury or the injury involves only the distal duct, percutaneous drainage should be considered the primary therapeutic procedure for traumatic pancreatic pseudocyst. If the pseudocyst does not then resolve, endoscopic retrograde pancreatography should be performed to prove proximal duct injury. When the major pancreatic duct is disrupted but not obstructed, pancreatic duct stenting may avert surgical resection. If the major duct is obstructed, surgical resection is required.
Assuntos
Ductos Pancreáticos/lesões , Pseudocisto Pancreático/terapia , Ferimentos não Penetrantes/terapia , Adolescente , Adulto , Colangiopancreatografia Retrógrada Endoscópica , Protocolos Clínicos , Drenagem/métodos , Feminino , Humanos , Masculino , Pseudocisto Pancreático/diagnóstico por imagem , Pseudocisto Pancreático/etiologia , Radiografia Intervencionista/métodos , Stents , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/diagnóstico por imagemRESUMO
We report two clinical experiences in the treatment of postoperative enterocutaneous fistula and stress ulcer bleeding with octreotide acetate (Sandostatin). In both patients, upper gastrointestinal bleeding occurred 7 days after operation, and the bleeding proved to be stress ulceration, by panendoscopic examination. Enterocutaneous fistulas also were found in both patients. One was high output (750 ml/day), and the other was low output (50 ml/day). Octreotide 50-100 micrograms was given subcutaneously every 8 h. After three doses of octreotide, a significant reduction in fistula output and control of the stress ulcer bleeding were noted. The fistulas closed promptly after nine doses of octreotide, but the first patient's fistula recurred 2 days later, with fluid losses of about 100-200 ml/day. This fistula closed spontaneously 1 month after discharge. Octreotide appears to be useful as an adjunct to the conventional treatment of enterocutaneous fistulas, especially those complicated by stress ulcer bleeding.
Assuntos
Fístula/tratamento farmacológico , Fístula Intestinal/tratamento farmacológico , Octreotida/uso terapêutico , Úlcera Péptica Hemorrágica/tratamento farmacológico , Complicações Pós-Operatórias/tratamento farmacológico , Dermatopatias/tratamento farmacológico , Idoso , Feminino , Fístula/complicações , Humanos , Fístula Intestinal/complicações , Masculino , Pessoa de Meia-Idade , Úlcera Péptica Hemorrágica/complicações , Dermatopatias/complicações , Estresse FisiológicoRESUMO
It is difficult to diagnose blunt abdominal trauma in unstable patients with pelvic fractures. In the United States the standard diagnostic procedures for these patients were the physical examinations and diagnostic peritoneal lavages. However, abdominal echograms were prevalent in Europe and Japan. We reviewed 60 patients suspected blunt abdominal trauma in 804 pelvic fractures in the past four years. Eighteen DPLs and twenty-five abdominal echograms were done separately. Sensitivity, specificity, and accuracy were 100%, 40%, 66% for DPL and 94.7%, 50%, 84% for abdominal echograms respectively. Besides the better correlation with the results for echogram, it provides easy availability, noninvasiveness, and imaging function. Thus we recommend that the echogram be the first-line screening test DPL acts as a complementary test, especially in the cases of bowel perforation.
Assuntos
Traumatismos Abdominais/diagnóstico , Fraturas Ósseas/complicações , Ossos Pélvicos/lesões , Ferimentos não Penetrantes/diagnóstico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
OBJECTIVES: Diagnostic peritoneal lavage (DPL) had been widely used in evaluating patients with suspected intraperitoneal injuries due to its high sensitivity. If the positive criteria are strictly followed, however, the incidence of nontherapeutic laparotomies will be unacceptably high. This realization has become more important recently with the popularization of nonoperative treatment for blunt solid organ injuries. For these patients, the early diagnosis of an associated hollow organ perforation is mandatory. METHODS: Three hundred and twenty patients undergoing DPL over an 18-month period were retrospectively reviewed to evaluate the usefulness of "cell count ratio" in diagnosing hollow organ perforation. The cell count ratio was defined as the ratio between white blood cell count and red blood cell count in the lavage fluid divided by the ratio of the same parameters in the peripheral blood. RESULTS: Two hundred twelve patients were diagnosed as having a positive DPL according to the classic criteria. Forty-four patients (21%) had a cell count ratio of greater than or equal to 1. The diagnosis at laparotomy was small bowel perforation in 31 patients, colon perforation in eight patients, diaphragmatic hernia in one patient, pancreatic transection in two patients, and liver laceration in two patients. None of the patients with a cell count ratio of less than I sustained hollow organ perforation. The average interval from injury to DPL was 5 hours, with the shortest being 1.5 hours. CONCLUSION: A cell count ratio of greater than or equal to 1 predicted hollow organ perforation with a specificity of 97% and a sensitivity of 100%. The selective use of the cell count ratio has improved the probability of early diagnosis of bowel perforation without increasing the cost of care. Nonoperative management can be applied more confidently to those patients sustaining a blunt solid viscus injury of the abdomen if the cell count ratio is low. We conclude that the cell count ratio of DPL effluent is a very sensitive and specific indicator of hollow organ perforation. In the treatment of blunt abdominal injuries, if the cell count ratio is positive, nonoperative treatment should be abandoned and a laparotomy undertaken.
Assuntos
Traumatismos Abdominais/sangue , Lavagem Peritoneal , Peritônio/lesões , Ferimentos não Penetrantes/sangue , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Colo/lesões , Contagem de Eritrócitos , Feminino , Hérnia Diafragmática/etiologia , Humanos , Perfuração Intestinal/etiologia , Contagem de Leucócitos , Fígado/lesões , Masculino , Pessoa de Meia-Idade , Pâncreas/lesões , Estudos Retrospectivos , Sensibilidade e EspecificidadeRESUMO
BACKGROUND: Pyloric exclusion had been widely used in the management of complicated duodenal injuries. The original concept of pyloric exclusion was that this technique would temporarily exclude the pylorus during the healing phase, but would subsequently allow resumption of normal gastrointestinal tract transit through the duodenum. The best method for pyloric exclusion has not been well established. Controversies exist regarding the need for a gastrojejunostomy and vagotomy as part of the procedure. None of these combinations can fulfill the original concept of pyloric exclusion and avoid late complications. METHODS: We developed a controlled reopen suture technique for pyloric exclusion. This technique was applied to nine patients (group II) with a complicated blunt duodenal injury over the past 5 years. The clinical courses and outcomes of these patients were compared with an eight-patient comparison group treated by pyloric exclusion and gastrojejunostomy (group I) over the same time period. RESULTS: All 17 patients survived. There were one early (duodenal wound leakage) and two late complications (marginal ulcers) in the group I patients. No delayed complications were found in the group II patients. The average hospital stay was about the same in both groups. CONCLUSION: The controlled reopen suture technique is a quick and simple procedure. In the treatment of a complicated blunt duodenal injury, if repair of the duodenal wound will not compromise the lumen, gastrojejunostomy and vagotomy can be omitted when using this technique. This technique offers the best combination of limited surgery in the severely injured patient, effective exclusion of the duodenum until after the healing has occurred, and allowance for the resumption of normal gastrointestinal tract transit through the duodenum. The late complications of gastrojejunostomy can also be avoided.
Assuntos
Duodeno/lesões , Duodeno/cirurgia , Técnicas de Sutura , Ferimentos não Penetrantes , Adolescente , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do TratamentoRESUMO
BACKGROUND: Nonoperative management has been validated as a standard of care for patients with blunt hepatic trauma. We herein study the correlation of intra-abdominal pressure (IAP) and other clinical parameters to predict the failure of nonoperative management, and attempt to use IAP to determine further therapeutic options. METHODS: During a 9-month period, 25 hemodynamically stable patients sustaining grades III to V blunt hepatic injuries were prospectively studied. They were admitted to the intensive care unit for clinical reevaluation, and hemodynamic and IAP monitoring. If the patient developed an IAP greater than 25 cm H(2)O, then an emergent laparotomy or laparoscopy was performed to achieve hemostasis and decompression of intra-abdominal hypertension (IAH). On the basis of an IAP of 25 cm H(2)O, the correlation between the IAP and an estimated amount of liver-related transfusion, the Pao(2)/Fio(2) ratio and peritoneal signs were analyzed. RESULTS: Of the 25 patients being studied, 20 (80%) had an IAP below 25 cm H(2)O, 1 of whom was found to have a pelvic abscess from an amputated segment of liver. On the other hand, five other patients with an IAP greater than 25 cm H(2)O received decompression and laparoscopic examinations, and one needed an open hepatorrhaphy. In general, though, 19 patients (76%) were successfully treated without operation. All recovered well after different therapeutic regimens; however, two developed liver abscesses, for a morbidity rate of 8% (2 of 25). This analysis revealed a strong association between the IAP value and the presence of peritoneal signs (Phi coefficient = 0.890, p < 0.001), but not in the estimated amount of liver-related transfusion and Pao(2)/Fio(2) ratio. CONCLUSION: This preliminary investigation suggests that IAH or abdominal compartment syndrome can develop while patients receive nonoperative management for grade III to V blunt hepatic injuries. There were no parameters that precisely reflected ongoing hepatic hemorrhage or predicted hemodynamic instability. Although the amount of hepatic hemorrhage was not accurately measured by the IAP, it could be reflected by an increased IAP. During nonoperative management, IAP monitoring may be a simple and objective guideline to suggest further intervention for patients with blunt hepatic trauma. Laparoscopic hepatic evaluation and abdominal decompression may be helpful in this situation.
Assuntos
Traumatismos Abdominais/cirurgia , Hemoperitônio/cirurgia , Fígado/lesões , Monitorização Fisiológica , Ferimentos não Penetrantes/cirurgia , Traumatismos Abdominais/diagnóstico , Adolescente , Adulto , Descompressão Cirúrgica , Feminino , Hemoperitônio/diagnóstico , Humanos , Pressão Hidrostática , Laparoscopia , Masculino , Manometria , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Ferimentos não Penetrantes/diagnósticoRESUMO
OBJECTIVE: To review our experience of 18 patients with duodenal injuries after blunt trauma, the diagnosis of which had been delayed for more than 24 hours. DESIGN: Retrospective study. SETTING: Teaching hospital, Taiwan, R.O.C. SUBJECTS: 18 patients who presented with duodenal injuries between January 1986 and December 1995. MAIN OUTCOME MEASURES: Morbidity and mortality. RESULTS: The reasons for the delay were: injuries not found during the first operation (n = 6), patients had not sought medical help (n = 6), and injuries treated conservatively at local hospitals (n = 5). There was one delay in our department because the patient lost consciousness. 12 patients were treated by pyloric exclusion with no deaths and four complications (one duodenal fistula and 3 retroperitoneal abscesses). The other 6 had various operations including pancreaticoduodenectomy, jejunostomy, and gastrostomy, with six complications and one death, giving an overall mortality of 6% and morbidity of 50%. Three patients developed delayed extensive retroperitoneal abscesses and all three were treated successfully by laparostomy. 16 of the 18 patients required enteral feeding through a jejunostomy. CONCLUSIONS: Though the complication rate was high, the use of pyloric exclusion and a feeding jejunostomy kept the mortality low. Enteral nutrition should be started early. Laparostomy is a good way to manage retroperitoneal abscesses. To avoid delay, patients at risk of duodenal injuries should be evaluated early by experienced trauma surgeons and any central retroperitoneal haematoma should be explored during the initial laparotomy.
Assuntos
Duodeno/lesões , Duodeno/cirurgia , Ferimentos não Penetrantes/cirurgia , Abscesso/etiologia , Adolescente , Adulto , Criança , Pré-Escolar , Nutrição Enteral , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Espaço Retroperitoneal , Estudos Retrospectivos , Fatores de Tempo , Resultado do TratamentoRESUMO
Abdominal compartment syndrome (ACS) can occur in a variety of surgical conditions, particularly those with major life-threatening hemorrhage, massive volume resuscitation, prolonged operation times, and coagulopathy. In severely traumatized patients, the incidence of ACS is reported to be as high as 14% to 15% after damage control laparotomies. Although favorable results have been achieved with nonsurgical management of adult blunt hepatic trauma, the failure rates still range from 0% to 19%. Exploratory laparotomy is considered the intervention of choice in patients with blunt hepatic trauma who fail nonsurgical treatment. Expedient abdominal decompression currently is the treatment of choice after ACS. Oliguria, tachypnea, and tachycardia developed in two blunt hepatic trauma patients with grade IV and V injuries while they were receiving nonsurgical treatment. The intra-abdominal pressures measured more than 35 and 25 cm H 2O, respectively. Two patients with grade II and III ACS received laparoscopic examination instead of laparotomy. Their ACS was decompressed effectively via laparoscopy without any adverse effects. Therefore, we suggest that laparoscopy can be used as a safe alternative for the decompression of ACS.
Assuntos
Traumatismos Abdominais/cirurgia , Síndromes Compartimentais/cirurgia , Humanos , Ferimentos não PenetrantesRESUMO
This is a case report of a 39-year-old male. Sudden onset of abdominal pain occurred 5 months after a successful cadaveric renal transplant. The immunousuppressants chosen were cyclosporin-A, prednisolone and azathioprine. A small bowel perforation was noted 100cm proximal to ileocecal area during emergent laparotomy. Mesentery lymphadenopathy was also noted. Segmental resection with end-to-end anastomosis was done. The pathology revealed a diffuse mixed small and large cell malignant lymphoma. The postoperative course was smooth and one course of acyclovir therapy was given 2 months after the emergency procedure. From this case and literature review, we know posttransplant lymphoma of the small intestine is very rare, but it should be considered in every posttransplant victim with abdominal symptoms.
Assuntos
Neoplasias Intestinais/etiologia , Perfuração Intestinal/etiologia , Transplante de Rim/efeitos adversos , Linfoma/etiologia , Adulto , Humanos , Imunossupressores/efeitos adversos , MasculinoRESUMO
BACKGROUND: Acute appendicitis is the most common non-obstetric reason for laparotomy during pregnancy. The purpose of this study was to analyze the characteristics of the clinical presentations and postoperative outcomes of these patients and their fetuses. METHODS: Patients who underwent appendectomies during pregnancy from July 1991 to June 1997 were retrospectively identified. Their ages, clinical presentations, the severity of the inflammatory change in the appendices, and the postoperative complications of these patients and fetuses were recorded and analyzed. Long-term outcomes were confirmed by telephone contact, when possible. RESULTS: Forty-five pregnant women who underwent appendectomies for suspected acute appendicitis were retrospectively reviewed. The histopathological inflammatory change in the appendix was proven in 35 patients (78%). Sixty-three percent of the patients were multiparous, and 86% were in the first 2 trimesters. In the clinical settings, pain and tenderness in the right lower abdominal quadrant were the most common symptoms and signs in presentation. Perioperative administration of ritodrine had no obvious advantage in the prevention of fetal loss. Appendectomy was performed beyond 36 hours of onset of symptoms in 28% of the patients, among whom one-half had gangrenous or perforated appendices. Only one fetus was spontaneously lost in 32 patients with diseased appendices (3%), excluding 3 patients choosing artificial abortion. There was no maternal death in our series. CONCLUSION: The rate of fetal loss due to surgery for acute appendicitis during pregnancy was low. Delay of operation was pertinent to the more-inflammatory changes of the appendix and to the higher maternal complication rate. Early surgical intervention is essential.