RESUMO
OBJECTIVE: Enhanced recovery has been utilized to decrease length of stay and cost in bariatric surgery. We have recently focused efforts on pre-operative education with regards to discharge on the first post-operative day. The aim of this study was to determine the effectiveness of pre-operative education on discharge timing and readmission rates. METHODS: A retrospective review was conducted after revising discharge expectation education. Patients undergoing first time bariatric operations were included. Early group education focused on average patient stay of 2 postoperative days. Revised education informed patients they could go home on the first post-operative day. RESULTS: A total of 125 patients met inclusion criteria. Implementation of preoperative education was associated with a decrease in mean LOS and greater percentage of patients discharged on post-operative day one. There was no difference in readmission and complication rates. CONCLUSION: Effective pre-operative education can decrease length of stay in first time laparoscopic bariatric surgery.
Assuntos
Cirurgia Bariátrica , Tempo de Internação/estatística & dados numéricos , Educação de Pacientes como Assunto/métodos , Cuidados Pré-Operatórios/métodos , Adulto , Feminino , Humanos , Laparoscopia , Masculino , Pessoa de Meia-Idade , Alta do Paciente , Readmissão do Paciente/estatística & dados numéricos , Estudos RetrospectivosRESUMO
Fourteen patients with lateral duodenal fistulas were treated over an 8-year period. Fistulas occurred after abdominal trauma (7) or as complications of operations for peptic ulcer (4) and biliary tract disease (3). Six patients with posttraumatic fistulas had had a delay of longer than 24 hours in recognition of the initial duodenal injury. Immediate correction of fluid and electrolyte imbalances, aggressive control of infection with surgical drainage and antibiotics, localization of the fistulous discharge, and early total parenteral nutrition were paramount in treatment. Ten patients had fistulas that persisted despite these measures; they required definitive operation. Surgical treatment consisted largely of diversion and decompression of the involved duodenum (8 patients); duodenorrhaphy reinforced with a jejunal serosal patch and resection of the involved bowel was done once each. Definitive operations performed in the presence of uncontrolled infection and with inadequate duodenal decompression were followed by fistula recurrence (3 patients). There was one fistula-related death (a 7% mortality rate). These results suggest that (1) lateral duodenal fistulas have a low rate of spontaneous closure; (2) when maximal nonoperative management fails, operative diversion and decompression of the duodenum can simplify management and reduce the mortality rate; and (3) definitive therapy is best reserved for situations in which infection is controlled.
Assuntos
Duodenopatias/terapia , Fístula Intestinal/terapia , Traumatismos Abdominais/complicações , Adulto , Idoso , Antibacterianos/uso terapêutico , Drenagem , Duodenopatias/etiologia , Duodeno/cirurgia , Feminino , Hidratação , Humanos , Fístula Intestinal/etiologia , Masculino , Pessoa de Meia-Idade , Nutrição Parenteral Total , Complicações Pós-Operatórias , Infecção dos Ferimentos/tratamento farmacológicoRESUMO
Axial computerized tomography is a useful tool in the evaluation of either primary or metastatic hepatic neoplasms. An adjunct to this technique is visceral arterial enhanced computerized tomography (AECT). To determine the effectiveness of this modality, bolus intravenous enhanced computerized tomography scans and AECT were compared and correlated to operative findings. Fifty-four consecutive patients were evaluated by AECT and bolus intravenous enhanced computerized tomography over a 30-month period (May 1986 to August 1989) for suspected primary or metastatic hepatic malignancies. Forty-four patients (81%) had hepatic lesions. Fifty-two percent (23 of 44 patients) of the metastatic tumors were from colonic or rectal primary lesions, and 20% were hepatocellular primary lesions. The remainder of the lesions were metastases from a variety of primary lesions. When studies were compared, 34% of the patients (15 of 44 patients) differed in either the location or total number of lesions noted. The lesions of three of the 15 patients (20%) were determined unresectable on the basis of AECT. Of the remaining patients, planned resections were revised in seven patients to either lesser or greater procedures. The number of lesions found at laparotomy equaled the number found by AECT in all but two cases. AECT caused no complications. AECT improved our ability to identify and localize primary and metastatic lesions of the liver. This technique offers the advantage of preoperative definition of the hepatic arterial and portal venous anatomy.
Assuntos
Aumento da Imagem , Neoplasias Hepáticas/diagnóstico por imagem , Tomografia Computadorizada por Raios X/métodos , Adenoma de Células das Ilhotas Pancreáticas/diagnóstico por imagem , Adenoma de Células das Ilhotas Pancreáticas/secundário , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma Hepatocelular/diagnóstico por imagem , Criança , Diagnóstico Diferencial , Feminino , Humanos , Hepatopatias/diagnóstico por imagem , Neoplasias Hepáticas/patologia , Neoplasias Hepáticas/secundário , Masculino , Pessoa de Meia-Idade , Neoplasias Pancreáticas/patologia , Teratoma/diagnóstico por imagem , Teratoma/secundárioRESUMO
Thrombofibrinous sheath occlusion of peritoneovenous shunts is described in two case presentations. In reviewing the literature, we found only 17 other such cases mentioned. Most patients were seen initially with recurrence of ascites and only one with superior vena cava syndrome. A shuntogram documented a characteristic sheath in 17 patients, and relocation was the preferred treatment. Relocation was successful in eight of 11 attempts, but long-term follow-up data were not available. Histologic examination of the sheath in our first case study revealed recent and organized thrombus. This would help explain why only one of three patients was successfully treated with fibrinolytic agents.
Assuntos
Derivação Peritoneovenosa , Complicações Pós-Operatórias/diagnóstico por imagem , Trombose/etiologia , Cateterismo , Falha de Equipamento , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/terapia , Radiografia , Trombose/diagnóstico por imagemRESUMO
Ninety percent jejunoileal bypass was performed in 20 growing (100 gram) male Sprague-Dawley (SD) and 15 male, genetically obese, growing (125 gram) Zucker "fat rats" (FR). Twenty SD and 15 FR unoperated rats of similar age and weight served as controls. Animals were evaluated for weight gain or loss, complications, and survival. At death (4 months), caliper measurements of long bones, vertebral column, pelvis, and skull were obtained, and brain, liver, spleen, and kidneys were excised and weighed. Liver and gonadal histology were obtained. The "fat fat" was more fragile, with a 20 percent anastomotic leak rate and a 33 percent mortality rate. The mortality rate was 5 percent (SD) and zero in controls. Bypassed animals showed growth retardation with weight of SD rats 31 percent (p less than 0.05) and FR's 19 percent of controls (p less than 0.05). Organ weights (liver, spleen, kidneys) were similar, except for a smaller brain in bypassed rats [SD 1.06 +/- 0.08 to 1.83 +/- 0.08 Gm. control (p less than 0.05), FR 1.2 +/- 0.12 to 1.68 +/- 0.09 control (p less than 0.025)]. Skeletal development was retarded significantly in bypassed rats [vertebral column, 125.9 +/- 3.5 to 138.3 +/- 3.9 mm. in controls (p less than .025); ilium, 39.4 +/- 1.1 to 46.2 +/- 1.5 mm. in controls (p less than 0.05); skull circumference, 20.2 +/- 0.03 to 22.5 +/- 0.05 mm. in controls (p less than 0.025)]. No increase in fatty infiltration of liver was observed. Spermatogenesis was diminished 30 percent (p less than 0.05) in bypassed (SD) animals. The data document significant morbidity and mortality rates, growth retardation, and diminished spermatogenesis in bypassed "adolescent" rats. These results imply that jejunoileal bypass may affect intellectual, skeletal, and reproductive development adversely and question the advisability of these procedures in growing subjects.
Assuntos
Transtornos do Crescimento/etiologia , Íleo/cirurgia , Jejuno/cirurgia , Obesidade/cirurgia , Complicações Pós-Operatórias , Animais , Peso Corporal , Encéfalo/patologia , Ratos , Ratos EndogâmicosRESUMO
Fatty infiltration of liver and formation of cholesterol stones are significant problems following jejunoileal bypass for morbid obesity. This report evaluates hepatic lipid metabolism and fat absorption in genetically obese, bypassed, and lean Zucker rats. Ninety percent jejunoileal bypass was performed in 12 (500 grams) obese rats (BP). Similar numbers of unoperated "fat rats" (FR) and lean litter mates (LR) were controls. Food consumption, weight gain or loss, and fecal fat were evaluated. At 4 weeks serum triglycerides, hepatic cholesterol, total lipids, triglycerides, and hepatic synthesis of fatty acids and cholesterol were measured in vivo. Food intake was excessive in FR's (23.8 +/- 0.7 gm/day), decreased in BP (18.3 +/- 2.3 gm/day), and lowest in LRss ( less than 0.05) and excessive fecal fat excretion (p less than 0.05). Serum triglycerides were elevated in FR's (284 +/- 32 mg/dl), reduced in BP rats (148 +/- 20 mg/dl) (p less than 0.05), and low in LR's (86 +/- 16 mg/dl). Total hepatic lipids, triglycerides, and hepatic synthesis of fatty acids were elevated in FR's (p less than 0.05) and were unchanged by bypass. Hepatic cholesterol was similar in all groups. Hepatic synthesis of cholesterol, however, was increased significantly in bypassed rats (p less than 0.05), (BP--102 +/- 22 micronnmole/"C2"/minute/gm, FR--39 +/- 6.0, LR--30 +/- 4.0). Jejunolileal bypass in FR's results in weight loss, decreased food intake, increased fecal fat, decreased serum triglycerides, and increased hepatic synthesis of cholesterol. Bypass had little effect on reducing elevated hepatic lipids, triglycerides, or fatty acid synthesis in FR's. These data suggest that following bypass increased hepatic cholesterol synthesis (as a precursor for bile acids) is related to interruption of the enterohepatic circulation and bile salt pool depletion. This implies that excess synthesis of hepatic cholesterol results in supersaturation of bile which is choletithocenic and may explein in part the increased incidence of gall stones observed following jejunoileal bypass.
Assuntos
Colesterol/biossíntese , Intestino Delgado/cirurgia , Fígado/metabolismo , Obesidade/terapia , Animais , Peso Corporal , Gorduras na Dieta/metabolismo , Ácidos Graxos/biossíntese , Fezes/análise , Absorção Intestinal , Lipídeos/sangue , Obesidade/genética , Ratos , Ratos Endogâmicos , Triglicerídeos/sangueRESUMO
BACKGROUND: Optimal treatment strategies for patients with external pancreatic fistulas have evolved with improved radiographic imaging and the development of transpapillary pancreatic duct stents. The aim of this study was to examine factors affecting fistula closure and develop a classification scheme to guide therapeutic interventions. METHODS: Retrospective chart review was made of all patients with external pancreatic fistulas treated at our institution from January 1991 to January 1997. Side (partial) fistulas maintained continuity with the gastrointestinal tract; end (complete) fistulas had no continuity with the gastrointestinal tract. RESULTS: Postoperative side fistulas resolved with medical treatment in 13 (86%) of 15 patients after a mean of 11 weeks of conservative management. Inflammatory side fistulas resolved with medical treatment in only 8 (53%) of 15 patients after a mean of 22 weeks; those that did not close initially did so with transpapillary stenting. End pancreatic fistulas never closed with medical treatment and were unable to be stented; therefore internal drainage or pancreatic resection was necessary to achieve closure. There were no differences in sepsis rates, Acute Physiology and Chronic Health Evaluation II scores, fistula site, total parenteral nutrition, somatostatin treatment, or initial fistula output between groups. CONCLUSIONS: Classifying external pancreatic fistulas as to their pancreatic duct relationship and cause provides important prognostic and therapeutic information.
Assuntos
Fístula Cutânea/terapia , Fístula Pancreática/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Fístula Cutânea/classificação , Fístula Cutânea/etiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fístula Pancreática/classificação , Fístula Pancreática/etiologia , Complicações Pós-Operatórias/terapia , Estudos RetrospectivosRESUMO
BACKGROUND: The management of perforations after endoscopic sphincterotomy (ES) is controversial. The purpose of this study was to analyze the treatments and outcome of patients with ES perforations. METHODS: Between January 1994 and July 1998, in a series of 6040 endoscopic retrograde cholangiopancreatographies, 2874 (48%) ESs were performed: 40 patients (0.6%) with perforation were identified and retrospectively reviewed. RESULTS: All patients (n = 14) with guidewire perforation (group I) were recognized early, managed medically, and discharged after a mean hospital stay of 3.5 days. Twenty of 22 patients with periampullary perforation (group II) were identified early; 18 patients (90%) had aggressive endoscopic drainage, and none required operation. Of the 2 patients identified late, 1 patient required operation and subsequently died. Mean hospital stay for this group was 8.5 days. Only 1 of 4 patients with duodenal perforations (group III) was identified early; all required operation; 1 patient died, and the mean hospital stay was 19.5 days. CONCLUSIONS: ES perforation has 3 distinct types: guidewire, periampullary, and duodenal. Guidewire perforations are recognized early and resolve with medical treatment. Periampullary perforations diagnosed early respond to aggressive endoscopic drainage and medical treatment. Postsphincterotomy perforations diagnosed late (particularly duodenal) require surgical drainage, which carries a high morbidity and mortality rate.
Assuntos
Perfuração Intestinal/etiologia , Complicações Pós-Operatórias/classificação , Complicações Pós-Operatórias/terapia , Esfinterotomia Endoscópica/efeitos adversos , Abscesso/etiologia , Adulto , Idoso , Fístula do Sistema Digestório/etiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pancreatite/etiologia , Complicações Pós-Operatórias/mortalidade , Síndrome do Desconforto Respiratório/etiologia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Unlike chronic calcific pancreatitis, obstructive pancreatitis occurs as a consequence of an obstruction or stricture in the main pancreatic duct. The purpose of this paper is to identify the best method of surgical treatment for patients with obstructive pancreatitis. METHODS: Retrospective analysis of 224 patients surgically treated for chronic pancreatitis during a 7-year period (1988 through 1994) identified 23 patients with obstructive pancreatitis. Patients were classified by surgical treatment into pancreaticoduodenectomy (five patients), side-to-side pancreaticojejunostomy (nine patients), or distal pancreatectomy (nine patients) groups and analyzed. RESULTS: Despite similar demographics, patients treated with distal pancreatectomy had significantly better outcomes (seven of nine) than those treated with either pancreaticoduodenectomy (zero of four) or side-to-side pancreaticojejunostomy (two of eight) at a mean follow-up of 26 months (chi-squared, p = 0.009). Multivariate analysis revealed stricture location, cause of pancreatitis, maximal duct dilatation, exocrine insufficiency, or continued alcohol intake had no influence on surgical outcome in this series (p = 0.698, logistic regression analysis). CONCLUSIONS: At 2 years of follow-up, distal pancreatectomy provided superior relief from pain and recurrent pancreatitis compared with pancreaticoduodenectomy or side-to-side pancreaticojejunostomy. Obstructive pancreatitis is best treated by distal rather than proximal pancreatic resection or drainage.
Assuntos
Pancreatectomia , Ductos Pancreáticos/patologia , Pancreaticoduodenectomia , Pancreaticojejunostomia , Pancreatite/cirurgia , Adulto , Consumo de Bebidas Alcoólicas/efeitos adversos , Colangiopancreatografia Retrógrada Endoscópica/efeitos adversos , Doença Crônica , Constrição Patológica/complicações , Constrição Patológica/patologia , Constrição Patológica/cirurgia , Feminino , Humanos , Hiperlipidemias/complicações , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Pancreatectomia/efeitos adversos , Pancreaticoduodenectomia/efeitos adversos , Pancreaticojejunostomia/efeitos adversos , Pancreatite/etiologia , Complicações Pós-Operatórias , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Muncin-hypersecreting intraductal pancreatic neoplasms were first described in 1982 and have been observed in increasing numbers since. They are observed primarily by endoscopic retrograde cholangiopancreatography (ERCP) and are characterized by an intraductal papillary neoplasm that secretes thick mucin, causing pancreatic duct dilatation and obstructive pancreatitis. METHODS: Twenty patients are presented, 14 male and six female, with an average age of 59 +/- 11 years. All patients presented with abdominal pain, and most had nausea and vomiting, weight loss, and documented pancreatitis. Of the preoperative studies, ERCP was positive in all patients. Computed tomography scan, endoscopic ultrasonogram, and cytologic findings were less sensitive. Tumor markers were only positive in one patient. All 20 patients were treated surgically. Nine underwent Whipple procedure, one patient had a total pancreatectomy, and nine had distal pancreatic resections. The first patient in the series did not have a pancreatic resection, and his disease evolved into a lethal cystadenocarcinoma causing his death 99 months later. RESULTS: Histopathologic findings were interpreted as borderline malignant in 17 of the 20 patients, and three patients had evidence of invasive adenocarcinoma. Two of these three patients had nodal or distant metastases at the time of diagnosis, and all three died of adenocarcinoma. Seventeen of the patients are alive and well, although two of three with positive pancreatic margins have had recurrent symptoms and have been successfully reresected. CONCLUSIONS: The mucin-producing intraductal papillary tumor of the pancreas is a newly described variant of pancreatic cancer. It presents with symptoms of pancreatitis and has a progressive but more indolent course than the more lethal invasive ductal cancers. Patients with unexplained pancreatitis should undergo ERCP investigation, and aggressive surgical therapy should be carried out because the prognosis for this lesion, when appropriately treated, is more favorable than the usual pancreatic cancer.
Assuntos
Adenocarcinoma Mucinoso/cirurgia , Carcinoma Intraductal não Infiltrante/cirurgia , Cisto Pancreático/complicações , Neoplasias Pancreáticas/cirurgia , Dor Abdominal , Adenocarcinoma Mucinoso/diagnóstico , Adenocarcinoma Mucinoso/diagnóstico por imagem , Adenocarcinoma Mucinoso/patologia , Carcinoma Intraductal não Infiltrante/diagnóstico , Carcinoma Intraductal não Infiltrante/diagnóstico por imagem , Carcinoma Intraductal não Infiltrante/patologia , Colangiopancreatografia Retrógrada Endoscópica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Mucinas/metabolismo , Náusea , Cisto Pancreático/diagnóstico por imagem , Cisto Pancreático/patologia , Neoplasias Pancreáticas/diagnóstico , Neoplasias Pancreáticas/diagnóstico por imagem , Neoplasias Pancreáticas/patologia , Pancreatite , Complicações Pós-Operatórias/classificação , Complicações Pós-Operatórias/epidemiologia , Tomografia Computadorizada por Raios X , Vômito , Redução de PesoRESUMO
A Jehovah's Witness presented with colon cancer and profound anemia. On admission, her hemoglobin level was 30 g/L (3.0 g/dL). She refused all transfusions and failed to respond to oral iron therapy. She was ultimately prepared for surgery using recombinant human erythropoietin, iron dextran, and total parenteral nutrition. It took nearly 1 month to increase her hemoglobin level to an acceptable preoperative level of 110 g/L (11.0 g/dL). During the postoperative period, erythropoietin and parenteral iron therapy were briefly continued and a follow-up hemoglobin level of greater than 120 g/L (12.0 g/dL) was observed. Recombinant human erythropoietin, along with parenteral iron and adequate nutrition, may be useful in patients who refuse transfusion or cannot be transfused because of difficult cross-reacting antibodies.
Assuntos
Adenocarcinoma/cirurgia , Anemia/terapia , Cristianismo , Eritropoetina/uso terapêutico , Complexo Ferro-Dextran/uso terapêutico , Nutrição Parenteral Total , Neoplasias do Colo Sigmoide/cirurgia , Adenocarcinoma/complicações , Anemia/sangue , Anemia/complicações , Feminino , Humanos , Pessoa de Meia-Idade , Cooperação do Paciente , Cuidados Pós-Operatórios , Cuidados Pré-Operatórios , Proteínas Recombinantes , Índice de Gravidade de Doença , Neoplasias do Colo Sigmoide/complicaçõesRESUMO
OBJECTIVE: To design an operation to prevent enterogastric reflux of bile that will not interfere with gastric or proximal intestinal motility and that will be applicable in patients with primary alkaline reflux gastritis, various prior ulcer operations, and previous corrective operations for enterogastric reflux. DESIGN: A nonrandomized, prospective review of 27 patients with enterogastric reflux operated on between 1991 and 1995. SETTING: A midwestern medical school and 400-bed tertiary referral center, adult hospital. PATIENTS: Twenty-seven patients with symptoms compatible with enterogastric reflux, primary or secondary to ulcer operations, or with Roux-en-Y limb stasis following attempts to correct alkaline reflux gastritis. INTERVENTIONS: An operation designed to reestablish gastroduodenal continuity by converting previous procedures such as Billroth II gastrectomy and Roux-en-Y gastrojejunostomy to a Billroth I gastroduodenostomy, and by diverting bile away from the stomach by end-to-side choledochojejunostomy by means of a Roux-en-Y limb of 35 to 40 cm. MAIN OUTCOME MEASURES: Resolution of the preoperative symptoms of pain, nausea, and bilious vomiting in patients with enterogastric reflux, and elimination of the Roux stasis syndrome as well as prevention of future enterogastric reflux in patients undergoing conversion from Roux-en-Y to Billroth I. Serial evaluation of gastric emptying after conversion to a Billroth I configuration to determine whether dysmotility is improved or eliminated. RESULTS: Symptoms were completely resolved in 22 of the 26 surviving patients, with follow-up of 6 months to 4 years. None of the 26 patients have had any bilious vomiting postoperatively. Roux-en-Y stasis has been corrected when due to a mechanical problem (eg, strictures, marginal ulcers), although thus far normal gastric emptying has not been observed in all of these multiply surgically treated patients. CONCLUSIONS: Enterogastric reflux is common following most ulcer operations. Attempted correction of this problem may result in other difficulties, including delayed emptying due to Roux-en-Y stasis. The fact that most patients with enterogastric reflux are female suggests that this condition is related to disordered motility; therefore, vagal interruption and major gastric resections should be carefully considered to avoid future disabling problems.
Assuntos
Refluxo Biliar/prevenção & controle , Desvio Biliopancreático/métodos , Adulto , Idoso , Anastomose em-Y de Roux/efeitos adversos , Feminino , Seguimentos , Gastrite/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos ProspectivosRESUMO
BACKGROUND: Duodenal anomalies are defects in embryologic development and usually present as gastric outlet obstruction in infancy or early childhood. Occasionally, they remain asymptomatic until adulthood and, because they are unusual, may not be diagnosed. HYPOTHESIS: Based on current experience and review of the literature, recognition of diagnosis and the preferred methods of treatment of duodenal anomalies can be recommended. DESIGN: Retrospective study of congenital duodenal anomalies in adults. SETTING: Tertiary care university medical center. PATIENTS: Twenty-nine patients were observed and treated between 1983 and 1999 (19 women and 10 men; mean +/- SD age, 52 +/- 16 years). Twenty patients had duodenal webs, 7 had annular pancreata, and 2 had both. Nausea, vomiting, abdominal pain, and weight loss were predominant symptoms in all groups. Peptic ulceration occurred in 13 of 20 patients with webs but in none of those with annular pancreata or combined anomaly. MAIN OUTCOME MEASURES: Surgical outcomes including postoperative complications, deaths, and resolution of preoperative symptoms. RESULTS: The treatment for patients with duodenal webs was transduodenal web excision and duodenoplasty in 19 of 22. Patients with annular pancreata were treated by transection of the annulus and duodenoplasty (n = 4) and proximal duodenal bypass (n = 3). There were no operative deaths, but 44% of patients had some complications. No pancreatic fistulas occurred in patients who had division of an annular pancreas. Outcome was considered excellent or good in 17 of 20 patients with duodenal webs, 4 of 7 with annular pancreata, and 2 of 2 with the combined anomaly. CONCLUSIONS: Duodenal anomalies are rare in adults. Duodenal webs are best managed by transduodenal excision and duodenoplasty. Annular pancreas is generally best treated by duodenal bypass to the distal duodenum or the jejunum. Annulus division can be carried out if the annulus is extramural, without duodenal stenosis, and if access to the pancreaticobiliary sphincters is necessary.
Assuntos
Duodeno/anormalidades , Adulto , Idoso , Duodeno/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
HYPOTHESIS: Adenosquamous carcinoma of the pancreas is a rare but particularly virulent variant of invasive ductal carcinoma. This review will demonstrate the aggressive biologic activity, histopathologic features, and DNA flow cytometric characteristics of this aggressive lesion. In addition, the outcome is less favorable than in other pancreatic neoplasms, in spite of aggressive surgical and postoperative adjuvant therapy. DESIGN: A retrospective review of 6 patients treated during an 8-year period. SETTING: A major urban university tertiary referral hospital. PATIENTS: There were 6 patients with this unusual tumor seen between 1990 and 1998. There were 4 men and 2 women, all white, with a mean+/-SD age of 63.5+/-14.7 years. Symptoms were similar to those in patients with more common pancreatic malignant neoplasms. RESULTS: Four patients with tumors in the head of the pancreas had pancreatoduodenectomy, and 2 with body and or tail lesions had distal pancreatectomy and splenectomy. Pathologically, all the tumors were poorly differentiated and aneuploid, and 5 of the 6 were locally metastatic. All but 1 patient had postoperative complications, but there were no operative deaths. One half of the patients received postoperative adjuvant chemotherapy and radiation therapy. Only 1 patient is still alive at 9 months after surgery, but has known residual cancer around his portal vein noted during palliative distal pancreatectomy. CONCLUSIONS: Adenosquamous carcinoma of the pancreas is an uncommon variant of exocrine pancreatic neoplasm. It is characterized by an admixture of adenomatous and squamous cell elements and demonstrates aggressive biologic behavior. This series of 6 patients is similar to the 134 cases reported since 1907, in that survival is short despite aggressive surgical therapy. Few patients with this disease live more than 1 year. Aggressive therapy should be tempered by the realization of the uniform poor prognosis associated with this malignant neoplasm.
Assuntos
Carcinoma Adenoescamoso/cirurgia , Neoplasias Pancreáticas/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
Fifty-six patients were treated surgically for alkaline reflux gastritis, in each a consequence of subtotal gastrectomy and vagotomy for ulcer disease. Of these, 41 available for follow-up, 18 of whom had had Henley loop jejunal interpositioning and the remaining 23 Roux-en-Y (long-loop) gastroenterostomy. The conditions of most patients improved with respect to reflux symptoms of pain, vomiting, and weight loss, but the patients with Roux-en-Y procedure had uniformly better results that did those with the Henley loop. Although the Henley loops in this series of patients may have been too short to be completely effective in preventing bile reflux into the stomach, we prefer the Roux-en-Y diversion because it is technically easier and safer.
Assuntos
Refluxo Biliar/cirurgia , Doenças Biliares/cirurgia , Gastrite/cirurgia , Adulto , Idoso , Refluxo Biliar/complicações , Duodeno/cirurgia , Feminino , Gastrite/etiologia , Gastroenterostomia , Humanos , Jejuno/cirurgia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Estômago/cirurgiaRESUMO
Massive pulmonary embolus usually leads to in-hospital mortality if not treated aggressively. Four patients were seen with severe cardiorespiratory compromise resulting from massive pulmonary emboli. Emergent pulmonary embolectomy was followed by marked clinical improvement, and 3 patients were subsequently discharged from the hospital. The clinical courses of these patients are described, and massive pulmonary embolus and its management are discussed.
Assuntos
Emergências , Embolia Pulmonar/cirurgia , Doença Aguda , Adolescente , Adulto , Idoso , Diagnóstico Diferencial , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Embolia Pulmonar/diagnósticoRESUMO
Urinary calculi, predominantly of oxalate composition, have been noted in 10 to 14% of a large series of morbidly obese patients after jejunoileal intestinal bypass at this institution. Physical and metabolic changes after bypass surgery, including the presence of hyderoxaluria, hyperuricemia, and fluid and electrolyte disturbances are reviewed in their possible relationship to this increased incidence of urolithiasis.
Assuntos
Íleo/cirurgia , Jejuno/cirurgia , Obesidade/terapia , Complicações Pós-Operatórias , Cálculos Urinários/etiologia , Adolescente , Adulto , Ácidos e Sais Biliares/metabolismo , Dieta , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Oxalatos/urina , Cálculos Urinários/prevenção & controleRESUMO
Pancreatic cancer presenting as acute pancreatitis is relatively uncommon. Pancreatic cancer should be included in the differential diagnosis of "idiopathic" acute pancreatitis, particularly in the elderly. The following case report describes a patient in whom pancreatic cancer presented as acute pancreatitis with pseudocyst formation and subsequent resolution with octreotide therapy. Various implications of this case are reviewed.
Assuntos
Octreotida/uso terapêutico , Neoplasias Pancreáticas/complicações , Neoplasias Pancreáticas/tratamento farmacológico , Pseudocisto Pancreático/tratamento farmacológico , Pancreatite/etiologia , Doença Aguda , Idoso , Seguimentos , Humanos , Masculino , Neoplasias Pancreáticas/diagnóstico por imagem , Pseudocisto Pancreático/etiologia , Tomografia Computadorizada por Raios XRESUMO
Complicated pancreatic pseudocysts, including multiple pseudocysts, those that have failed prior internal or external drainage, those with associated biliary or pancreatic duct strictures, and those where the diagnosis of cystic neoplasm cannot be excluded, pose unique problems in terms of treatment by standard internal or external drainage techniques. In the series reported herein, pancreatic resection (pylorus-sparing pancreaticoduodenectomy or distal pancreatectomy) was used to treat patients with these complicated pseudocysts resulting in a 59% morbidity rate, 3% mortality rate, and 6% recurrence rate. Results from a collective series of 152 patients from the literature support these findings. Although pancreatic resection has a limited role in the management of patients with uncomplicated pancreatic pseudocysts, it is the treatment of choice in patients with complicated pancreatic pseudocysts.
Assuntos
Pancreatectomia , Pseudocisto Pancreático/cirurgia , Pancreaticoduodenectomia , Adulto , Colangiopancreatografia Retrógrada Endoscópica , Drenagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pancreatectomia/efeitos adversos , Pseudocisto Pancreático/diagnóstico por imagem , Pseudocisto Pancreático/terapia , Pancreaticoduodenectomia/efeitos adversos , Complicações Pós-Operatórias , RecidivaRESUMO
Pancreas divisum is a congenital variant of pancreatic duct drainage in which the dorsal duct dominates, most likely due to the failure of the two independent pancreatic ductal systems to fuse embryologically. Although 5 to 10 percent of the population have this congenital variation, few demonstrate symptoms related to their pancreaticobiliary ductal systems. However, patients may present with symptoms referable to this system, and the diagnosis is difficult. In this series, endoscopic retrograde cholangiopancreatography with cannulation and radiographic injection of the dorsal duct demonstrated this abnormality in 30 of 32 patients, and results of morphine-prostigmine testing were positive for symptoms, chemical enzyme elevation, or both in three fourths of the patients tested, but other maneuvers were not as helpful. The surgical approach has been to perform a sphincteroplasty of both the main and accessory ampullas and to excise the gallbladder when it is present. Pathologic study of the gallbladders showed nearly all of them to have been diseased, whereas histologic study of the ampullas was not as conclusive. In general, this condition should be suspected as part of the postcholecystectomy syndrome or in patients who present with idiopathic pancreatitis and whose conditions cannot be identified by all other diagnostic methods. Preoperative screening may be carried out with noninvasive techniques such as the morphine-prostigmine test, or by use of the secretin-stimulated ultrasonographic visualization of the ductal system. The primary tool for making the diagnosis is endoscopic retrograde cholangiopancreatography. The goal of surgical treatment should be the opening of the main and accessory ducts, since this offers the best chance for long-term relief of the patient's symptoms.