[Obstructive jaundice: diagnostic and therapeutic approaches].
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Biomedical subjects
Publications and source records attributed to M Schein.
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A patient with Budd-Chiari syndrome caused by large-vein, thrombotic, hepatic venous outflow obstruction, who was initially treated conservatively, is presented. The hazards of this approach are emphasised. Accurate classification of Budd-Chiari syndrome and active treatment tailored to the site and nature of the hepatic venous outflow obstruction are indicated to prevent progressive hepatic damage leading to chronic liver failure, portal hypertension and eventual death.
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Primary palmar hyperhidrosis is a functionally and socially disabling condition. Upper thoracic sympathectomy is the best curative treatment. Several surgical approaches have been suggested and, recently, less invasive techniques have been communicated. To evaluate which method is the best, the short- and particularly the long-term results must be compared. A series is presented of 170 upper thoracic sympathectomies by the supraclavicular approach performed on 85 patients with palmar hyperhidrosis. Follow-up for a mean of 8.3 years was obtained on 124 operated limbs. The immediate failure rate for relief from hyperhidrosis was 2.4 per cent and hyperhidrosis recurred in another 4.1 per cent of limbs after a period of between 2 and 18 months. Thirteen per cent of patients were dissatisfied with the results of operation, one because of persisting vasomotor rhinitis, two because of Horner's syndrome and five because of persisting or recurrent hyperhidrosis. Satisfactory results in approximately 87 per cent of cases make the operation rewarding. This outcome should be compared with the long-term results of other methods, such as percutaneous phenol injection and the transthoracoscopic approach, when such data are compiled and published.
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Hepatico-jejunostomy bypass is technically very demanding when used for proximal malignant biliary obstruction. The use of synthetic vascular grafts may simplify these operations. Our recent clinical experience and published reports support the selective use of synthetic grafts in the operative treatment of malignant obstructive jaundice.
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The use of the linear stapling device (LSD) is well-established in hollow-organ gastro-intestinal surgery. Its use in operations performed on parenchymatous viscera is less common. We present our experiences with the LSD in partial resection of the spleen (2 cases), pancreas (5 cases), liver (2 cases) and kidney (2 cases). To the best of our knowledge the use of the LSD for partial nephrectomy and resectional debridement of the liver has not been previously described. We suggest that LSDs are useful aids in the resection of parenchymatous organs, and allow rapid resection if applied to healthy tissues and in regions with an intact capsule.
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Classically, penetrating injuries of the heart present with clinical signs of an ongoing massive haemorrhage or cardiac tamponade. In a few patients, however, none of these signs are present and the diagnosis is overlooked. Diagnostic aids, such as ultrasonography or angiography, are occasionally misleading. Four cases of penetrating cardiac injuries that were not diagnosed on initial presentation, but which subsequently manifested with a secondary and sometimes fatal haemorrhage, are presented. Recommendations are made for preventing diagnostic delays.
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