RESUMO
BACKGROUND: Surgical disease is inadequately addressed globally, and emergency conditions requiring surgery contribute substantially to the global disease burden. METHODS: This was a review of studies that contributed to define the population-based health burden of emergency surgical conditions (excluding trauma and obstetrics) and the status of available capacity to address this burden. Further data were retrieved from the Global Burden of Disease Study 2010 and the University of Washington's Institute for Health Metrics and Evaluation online data. RESULTS: In the index year of 2010, there were 896,000 deaths, 20 million years of life lost and 25 million disability-adjusted life-years from 11 emergency general surgical conditions reported individually in the Global Burden of Disease Study. The most common cause of death was complicated peptic ulcer disease, followed by aortic aneurysm, bowel obstruction, biliary disease, mesenteric ischaemia, peripheral vascular disease, abscess and soft tissue infections, and appendicitis. The mortality rate was higher in high-income countries (HICs) than in low- and middle-income countries (LMICs) (24.3 versus 10.6 deaths per 100,000 inhabitants respectively), primarily owing to a higher rate of vascular disease in HICs. However, because of the much larger population, 70 per cent of deaths occurred in LMICs. Deaths from vascular disease rose from 15 to 25 per cent of surgical emergency-related deaths in LMICs (from 1990 to 2010). Surgical capacity to address this burden is suboptimal in LMICs, with fewer than one operating theatre per 100,000 inhabitants in many LMICs, whereas some HICs have more than 14 per 100,000 inhabitants. CONCLUSION: The global burden of surgical emergencies is described insufficiently. The bare estimates indicate a tremendous health burden. LMICs carry the majority of emergency conditions; in these countries the pattern of surgical disease is changing and capacity to deal with the problem is inadequate. The data presented in this study will be useful for both the surgical and public health communities to plan a more adequate response.
Assuntos
Tratamento de Emergência/mortalidade , Procedimentos Cirúrgicos Operatórios/mortalidade , Efeitos Psicossociais da Doença , Emergências/epidemiologia , Tratamento de Emergência/economia , Tratamento de Emergência/estatística & dados numéricos , Saúde Global , Gastos em Saúde , Humanos , Mortalidade Prematura , Anos de Vida Ajustados por Qualidade de Vida , Procedimentos Cirúrgicos Operatórios/economia , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricosRESUMO
Analysis of amino-terminus mutants of c-Myc has allowed a systematic study of the interrelationship between Myc's ability to regulate transcription and its apoptotic, proliferative, and transforming functions. First, we have found that c-Myc-accelerated apoptosis does not directly correlate with its ability to transactivate transcription using the endogenous ornithine decarboxylase (ODC) gene as readout for transactivation. Furthermore, deletion of the conserved c-Myc box I domain implicated in transactivation does not inhibit apoptosis. Second, the ability of c-Myc to repress transcription, using the gadd45 gene as a readout, correlates with its ability to accelerate apoptosis. A conserved region of c-Myc implicated in mediating transrepression is absolutely required for c-Myc-accelerated apoptosis. Third, a lymphoma-derived Thr58Ala mutation diminishes c-Myc-accelerated apoptosis through a decreased ability to induce the release of cytochrome c from mitochondria. This mutation in a potential phosphorylation site does not affect cell cycle progression, providing genetic evidence that induction of cell cycle progression and acceleration of apoptosis are two separable functions of c-Myc. Finally, we show that the increased ability of Thr58Ala mutant to elicit cellular transformation correlates with its diminished ability to accelerate apoptosis. Bcl-2 overexpression blocked and the lymphoma-associated Thr58Ala mutation decreased c-Myc-accelerated apoptosis, and both led to a significant increase in the ability of Rat1a cells to form colonies in soft agar. This enhanced transformation was greater in soft agar containing a low concentration of serum, suggesting that protection from apoptosis is a mechanism contributing to the increased ability of these cells to proliferate in suspension. Thus, we show here for the first time that, in addition to mutations in complementary antiapoptotic genes, c-Myc itself can acquire mutations that potentiate neoplastic transformation by affecting apoptosis independently of cell cycle progression.
Assuntos
Apoptose/genética , Ciclo Celular/genética , Regulação da Expressão Gênica , Genes myc , Animais , Linhagem Celular , Fibroblastos , Mutação , RatosRESUMO
Forty three patients were diagnosed to have obscure gastrointestinal hemorrhage (OGH) between January 1987 and April 1996. Pre-operative diagnostic investigations were useful in localizing the site of bleeding in 28 patients (65.1%). These included small bowel enema (n = 12), erythrocyte tagged scan (n = 8), Meckel's scan (n = 2) and selective visceral angiography (n = 7). Following complete evaluation all patients underwent exploratory laparotomy. At laparotomy 31 patients were found to have gross lesions. Intraoperative enteroscopy (IOE) could detect lesions in 9 of the remaining 12 patients.
Assuntos
Endoscopia Gastrointestinal , Hemorragia Gastrointestinal/cirurgia , Adulto , Algoritmos , Feminino , Gastroenteropatias/complicações , Gastroenteropatias/diagnóstico , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/etiologia , Neoplasias Gastrointestinais/complicações , Neoplasias Gastrointestinais/diagnóstico , Humanos , Cuidados Intraoperatórios , Laparotomia , Masculino , Estudos RetrospectivosRESUMO
BACKGROUND: Portal hypertension develops in 15-20% of patients with benign bile duct stricture. Hepaticojejunostomy in such patients is associated with considerable morbidity and mortality. Preliminary portosystemic shunting has been suggested to reduce intra-operative bleeding. We present our experience without preliminary shunting in such patients. PATIENTS AND METHODS: Fourteen consecutive cases of biliary stricture with portal hypertension over a 13-year period (1989-2001) were retrospectively analysed. RESULTS: Thirteen patients were operated upon. One patient had a preliminary portosystemic shunt. In another patient, shunt was attempted. One stage hepaticojejunostomy was possible in 11 patients. There were no intra-operative deaths. Nine of the 13 survived and were available for follow-up. One patient had cholangitis. Another had jaundice related both to chronic liver disease and a strictured hepaticojejunostomy. The remaining 7 patients are asymptomatic and anicteric although alkaline phosphatase levels remain elevated in 5 of them. CONCLUSIONS: Hepaticojejunostomy without preliminary portosystemic shunting is possible in patients with portal hypertension and benign biliary stricture with acceptable morbidity and mortality rates.
Assuntos
Colecistectomia/efeitos adversos , Colestase/cirurgia , Hipertensão Portal/cirurgia , Derivação Portossistêmica Cirúrgica/métodos , Adolescente , Adulto , Colecistectomia/métodos , Colestase/etiologia , Feminino , Humanos , Hipertensão Portal/etiologia , Jejuno/cirurgia , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Estomia/métodos , Estudos Retrospectivos , Resultado do TratamentoRESUMO
This report examines the characteristics of 124 patients with typhoid ileal perforation treated over a 17-year period ending in 1986. Three adverse prognostic determinants were identified: prolonged fever/perforation interval, prolonged perforation/operation interval and multiple perforations. Simple closure was performed in 74 patients with a mortality of 31.1%, and trimming of the ulcer with closure in 38 patients with a 7.9% mortality.
Assuntos
Doenças do Íleo/cirurgia , Perfuração Intestinal/cirurgia , Febre Tifoide/complicações , Adolescente , Adulto , Idoso , Feminino , Humanos , Doenças do Íleo/etiologia , Perfuração Intestinal/etiologia , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos RetrospectivosRESUMO
Elective surgery for peptic ulcer is becoming rare with the use of more effective medical therapy. However, life threatening complications have not reduced in number. A retrospective study was carried out to compare perforation rates per 10,000 admissions, mortality rates from perforated duodenal ulcers per 10,000 admission and the proportion of patients with perforated duodenal ulcer who died, before and after the introduction of H2 receptor blockers in a large teaching hospital in South India. Perforation rates were not significantly different between the two periods under study. There was a small, but statistically significant (p = 0.047) drop in mortality per 10,000 admissions and a significant drop in proportion of patients with perforated ulcer who died (p = 0.028). Inspite of effective medical therapy, there is a subset of patients with duodenal ulcer who continue to perforate. Efforts should be directed towards identifying this subset and offering them early surgery. Mortality rates have not changed significantly.
Assuntos
Úlcera Duodenal/tratamento farmacológico , Úlcera Duodenal/mortalidade , Antagonistas dos Receptores H2 da Histamina/uso terapêutico , Úlcera Péptica Perfurada/mortalidade , Humanos , Índia/epidemiologia , Úlcera Péptica Perfurada/prevenção & controle , Estudos RetrospectivosRESUMO
Eighteen patients with gastrointestinal angiodysplasia were seen in a single surgical unit over a period of 8 years. The mean age at onset of symptoms was 33 years. The average duration of symptoms was 54 months (range 2 days-16 years). Three patients had gastric angiodysplasia, two had colonic angiodysplasia, both diagnosed endoscopically preoperatively. The remaining patients required further investigation, which included small bowel enema (SBE), erythrocyte tagged scan (ETC), selective visceral angiography and intraoperative enteroscopy (IOE). SBE was useful but not diagnostic in 3, ETC in 3 and angiography in 5. Four patients required IOE for a diagnosis. Follow up of 17 months is available on all patients. Four had recurrence of symptoms. One required re-exploration and resection of 3 feet of small bowel and right hemicolectomy, another is on hormonal therapy and maintaining normal haemoglobin. Two others are asymptomatic on oral iron therapy.
Assuntos
Angiodisplasia/diagnóstico , Angiodisplasia/cirurgia , Gastroenteropatias/diagnóstico , Gastroenteropatias/cirurgia , Adolescente , Adulto , Idoso , Diagnóstico Diferencial , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
Natural disasters occur frequently in the country and civic authorities requisition medical aid from the Armed Forces for the succour of populations, with increasing regularity. The recent Orissa floods (2001) saw deployment of a Medical Team and the experiences of the team are discussed. Over a nine day period, 7450 cases were treated on site in medical aid posts established in flood affected areas. Of these patients, 4038 (54.20%) were affected by gastrointestinal illnesses (diarrhoea/acute gastroenteritis); 976 (13.10%) had suffered injuries and were treated accordingly; 2007 (26.94%) cases of respiratory infection were managed. 210 (2.82%) cases of undiagnosed fever were treated, and 18 (0.24%) cases of clinical malaria were diagnosed additionally. Skin and other infections comprised 186 (2.50%) cases of the total. Thus, this study provides a brief outline of the spectrum of illnesses that may be encountered in dealing with flood affected populations, for the benefit of planning for future humanitarian operations. The various stages of a disaster have been brought out, for an insight into the morbidity pattern in such deployments. The concept of "Health Emergencies in Large Populations" is introduced in the discussion, for policy to be evolved. Public health is closely interlinked with disaster management, and the Army with its resource of trained specialists is geared for response in the face of disaster in a professional manner. Recommendations on dealing with future situations under such conditions of deployment have also been made.
RESUMO
A case of primary mesenteric fibromatosis is reported and the current modalities of therapy are discussed. Surgery is the primary mode of treatment. Other modalities should be reserved for gross local residual disease and for unresectable recurrence.
Assuntos
Fibroma/patologia , Mesentério/patologia , Neoplasias Peritoneais/patologia , Adulto , Humanos , Masculino , Artéria Mesentérica Superior/patologiaRESUMO
Angiodysplasia of the intestine was diagnosed by selective visceral angiography in ten of 30 patients from India with unexplained recurrent hemorrhage of the gastrointestinal tract. In contrast with the reports from the western literature, most of the instances involved the small intestine and occurred in the third decade of life.
Assuntos
Hemorragia Gastrointestinal/etiologia , Enteropatias/diagnóstico por imagem , Intestinos/irrigação sanguínea , Jejuno/irrigação sanguínea , Clima Tropical , Capilares/patologia , Capilares/ultraestrutura , Extravasamento de Materiais Terapêuticos e Diagnósticos , Hemorragia Gastrointestinal/cirurgia , Humanos , Índia , Enteropatias/patologia , Enteropatias/cirurgia , Mucosa Intestinal/patologia , Mucosa Intestinal/ultraestrutura , Intestinos/diagnóstico por imagem , Masculino , RadiografiaRESUMO
Three patients with idiopathic Budd-Chiari syndrome with occlusion of the hepatic veins and significant obstruction of the hepatic segment of the inferior vena cava are presented. The inferior vena caval obstruction precluded the use of conventional side-to-side portacaval or mesocaval shunts. Dramatic regression in liver size and resolution of ascites occurred in all three patients following the construction of meso-atrial shunts using wide-lumen woven Dacron grafts. Shunt patency was confirmed by angiography in two patients and Doppler studies in one. One patient died five months after surgery and another after 16 months. The shunts were widely patent at autopsy and the full length of the grafts were lined by neo-intima. The third patient is asymptomatic 20 months after surgery and is free of ascites. Our experience in these three cases suggests that patency can be expected in long synthetic grafts between the portal and systemic venous system provided the shunt is of adequate diameter and there is a pressure gradient between the two ends.
Assuntos
Síndrome de Budd-Chiari/cirurgia , Átrios do Coração/cirurgia , Veias Mesentéricas/cirurgia , Adulto , Ascite/cirurgia , Prótese Vascular , Feminino , Sobrevivência de Enxerto , Humanos , Masculino , Trombose/cirurgia , Veia Cava InferiorRESUMO
A case of a 17-year-old Indian male with disseminated tuberculosis is reported. While on chemotherapy, he was detected to have splenic abscesses. The patient remained unresponsive to antituberculous drugs until a splenectomy was performed.