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Decreasing morbidity after liver trauma.
Fifty-one patients with significant recognized hepatic trauma were treated at Hartford Hospital during a four year period ending May 1973. Seventy-five per cent of the injuries were the result of blunt trauma. Many patients had severe associated injuries and three died in the emergency room before operation could be undertaken. Forty-eight patients underwent laparotomy and various types of repair including sixteen resections of significant volumes of nonviable liver. Three patients died in the operating room, but no patient who left the operating room alive after resection diet. Hematologic, pulmonary, renal, and gastrointestinal complications are analyzed in detail. There were no postoperative intrahepatic or subphrenic abscesses in patients undergoing resection and we believe that this is attributable to changes in technic. This review stresses the technical details of the operations as they may relate to the apparent improvement in morbidity and mortality.
Gunshot wounds of the left upper abdominal quadrant associated with multiple intraabdominal injuries.
This study reviews low velocity gunshot wounds of the left upper quadrant of the abdomen and presents four cases recently treated at Boston City Hospital. All patients sustained multiple intraabdominal organ injuries and underwent prompt exploration. Hypotension on admission seemed to be the most reliable sign for a prolonged and complicated hospital course. The essential preoperative studies in stable patients should include a chest x-ray and intravenous pyelogram. Intraoperatively, injury to the body or tail or the pancreas is best managed by distal pancreatectomy and sump drainage. Exploration of the retroperitoneum is warranted for bleeding from the kidney. Initial maneuvers should be designed to control hemorrhage from the renal pedicle. If this is unsuccessful or the renal parenchyma is badly fragmented, nephrectomy should be performed. The complications noted in our patients, infection (pneumonia and left subphrenic abscess) and hemorrhage, are comparable to those reported in most large series. Pancreatic complications (fistulas, pseudocysts, and pancreatitis) were not noted.
Risk of splenic salvage after trauma. Analysis of 200 adults.
This review was undertaken to analyze critically the complications resulting from operative splenic salvage. Over a 6 year period, 200 adults who sustained splenic trauma underwent laparotomy. The mechanism of injury was blunt in 138 patients (69 percent), a stab wound in 32 patients (16 percent), and a gunshot wound in 30 patients (15 percent). Splenorrhaphy was accomplished in 85 patients (42 percent). Methods of repair included cautery and hemostatic agents in 24 patients (28 percent), debridement and suturing in 42 patients (50 percent), and partial resection in 19 patients (22 percent). Six patients died, four from head trauma and two from multiple organ failure. Postoperative complications occurred in 14 patients. Four were intraabdominal. Three patients required reoperation for splenic hemorrhage; one (2 percent) after suture repair and two (11 percent) after partial resection. A left subphrenic abscess developed in another patient. Splenic reimplantation was performed in 43 patients (22 percent). Five deaths occurred. One was due to head trauma, three to multiple organ failure, and one to overwhelming pneumococcal infection. Eleven postoperative complications occurred, but none was related to splenic autotransplantation. Despite the enthusiasm for splenic salvage, the number of patients suitable for splenorrhaphy plateaued at 56 percent. Complications of splenorrhaphy are infrequent, and the risk increases with more complex salvage attempts. We believe that splenic reimplantation remains a safe procedure.
Transhiatal esophagectomy.
Thirty-six patients underwent resection of the thoracic esophagus without a thoracotomy for the management of cancer of the cervical esophagus (2 patients), middle third and lower third of the esophagus (4 patients and 23 patients, respectively), and the gastroesophageal junction (17 patients). In addition to a total esophagectomy, two patients required a laryngectomy and seven patients had a total gastrectomy. Intraoperative bleeding occurred in three patients. Postoperative complications included subphrenic abscess (Candida) (2 patients), diaphragmatic hernia (1 patient), and salivary fistula (11 patients). Three patients died in the postoperative period from necrosis of interposed colon, pneumonia, and liver failure due to liver metastasis. The average blood loss was 1,300 ml, the duration of surgical procedure was 5.3 hours, and the hospital stay was 21 days. The survival rates at 1, 2, and 3 years were 80 percent, 50 percent, and 33 percent, respectively. Transhiatal esophagectomy can be considered a sound alternative to transthoracic esophagectomy in the management of tumors involving the cervical and lower esophagus. Small lesions of the middle third should also be considered for this procedure, however, bulky lesions of the upper esophagus are better removed by thoracotomy.
Management of cavernous hemangioma of the liver.
Cavernous hemangioma of the liver was diagnosed in 12 of 60 patients (20 percent) evaluated for surgery of neoplastic liver disease. All were female, from 29 to 77 years old. Six patients presented with abdominal pain and seven had taken estrogens. Indications for surgery included uncertain diagnosis, symptoms, large lesion greater than or equal to 6 cm, and hypoproliferative anemia. Three right lobectomies, one left lateral segmentectomy, one open biopsy, and one right trisegmentectomy were performed. There were no deaths, one subphrenic abscess, and one bile leak. The remaining seven patients were observed and at 2 to 6 years post operatively had followed a benign course. Resectional therapy may be considered for superficial large or symptomatic lesions in the appropriate patient, but most hepatic hemangiomas follow a benign course.
Solitary infected renal cyst: report of 2 cases and review of literature.
Two cases of suppuration in solitary renal cyst are reported. The clinical history of acute pyelonephritis, avascular mass lesion of the kidney with ipsilateral pleural effusion (triad) seen in a female patient of child-bearing age is characteristic of this condition. Surgical management is satisfactory. Our Case 1 is the first reported case of solitary infected cyst that ruptured retroperitoneally, clinically mimicking a subphrenic abscess.
Neoadjuvant chemotherapy in locally advanced gastric carcinoma--a phase II trial with combined continuous intravenous 5-fluorouracil and bolus cisplatinum.
Locally advanced gastric adenocarcinomas (LAGC) have a poor prognosis, particularly when tumours are bulky, located in the cardia or in the event of locoregional lymph node involvement. Patients bearing these tumours were entered in a phase II trial of neoadjuvant chemotherapy, combining continuous intravenous 5-fluorouracil (5FU) (1000 mg/m2 for 5 days) and cisplatinum (CDDP) (100 mg/m2 on day 2) repeated every 4 weeks, for one to six cycles according to response and tolerance. 30 patients have been entered, 26 after clinical evaluation (CAT scan and upper gastrointestinal endoscopy) and 4 with unresectable tumours at prior laparotomy. Median age was 60 years, 15/30 patients had a tumour of the cardia, 15/30 had enlarged lymph nodes and 7/30 had linitis plastica (diffuse type). A mean number of three cycles was administered (range 1-6). 27 of the 30 patients were evaluable for response. One patient achieved a complete response (CR) and 14 a partial response (56%; 95% confidence interval 38-74%). No patient had tumour progression, and only 1/6 with linitis plastica responded. 28 patients underwent surgery, and 23 had a macroscopically complete resection (77% of the 30 entered patients); RO resections were performed in 60% of the cases, mainly after an objective response (13/15 versus 4/12 in nonresponders). No pathological CR were seen. Grade 4 neutropenia was observed in eight cycles (5 patients), with five septic complications and one death due to toxicity. Four postoperative complications were observed: 2 cases of severe pneumonia and 2 subphrenic abscesses. One postoperative death, due to intravascular disseminated coagulation, was observed at day 30. Median survival was 16 months and the 1-, 2- and 3-year survival was 67, 42 and 38%, respectively. Patients with linitis plastica had a significantly shorter survival (P < 0.002). We conclude that neodjuvant chemotherapy is feasible in LAGC, although randomised trials are warranted to demonstrate its efficacy on survival and resection rates.
Outcome and complications after resection of hepatoblastoma.
PURPOSE: The aim of this study was to review the outcome and complications after resection of hepatoblastoma treated over 2 decades in our institution. METHODS: Clinical, radiologic, and pathologic data were reviewed retrospectively, focusing on the outcome and complications. RESULTS: Between January 1978 and December 2002, 56 children were treated for hepatoblastoma. The age range was 0.08 to 8.74 years (median, 1 year). The right lobe was involved in 48%, the left lobe in 22%, and in 29% the main bulk of the tumour was centrally located. Surgical procedures included the following: hemihepatectomy in 62%, trisegmentectomy in 18%, extended hemihepatectomy in 16%, and liver transplantation and laparotomy in one patient each. Intraoperative complications occurred in 5(9%)--rupture of the tumour (1), haemorrhage from the contralateral lobe (1), a defect in the left hepatic duct (1), cardiac arrest from tumour embolus (1), and bleeding from the inferior vena cava (1). The mean blood loss was 280 mL (50 to 2,000 mL). Postoperative complications occurred in 12 patients (22%) including subphrenic abscess (3), adhesion obstruction (2), ischaemic stenosis of the bile duct (1), abdominal wound dehiscence (1), pyloric obstruction (1), and pleural effusion (2). Fifteen patients died, 14 as a result of tumour recurrence (mortality rate, 27%).
Gastrobronchial fistula after toothbrush ingestion.
Gastrobronchial fistulous communications are uncommon complications of disease processes with only 36 previously reported cases. Described as complication of a number of conditions, such as previous gastroesophageal surgery, subphrenic abscess, and gastric ulcers (Jha P, Deiraniya A, Keeling-Robert C, et al. Gastrobronchial fistula--a recent series. Interact Cardiovasc Thorac Sur 2003;2:6-8), we report a case of fistulization caused by ingestion of a foreign body. A patient with mental retardation, admitted for the treatment of osteomyelitis, presented during hospitalization symptoms of high fever, vomiting, and respiratory distress. Endoscopy showed the presence of a gastrobronchial fistula, which developed after ingestion of a toothbrush. The toothbrush was extracted endoscopically, and the fistula was subsequently closed by surgery. The patient recovered completely. We report the first case of a gastrobronchial fistula as a complication of foreign body ingestion.
Diaphragm resection for ovarian cancer: technique and short-term complications.
OBJECTIVE: Diaphragm resection (DR) is occasionally necessary to achieve optimal cytoreductive surgery in ovarian carcinoma (OC). In a recent survey of the SGO membership, bulky diaphragm disease was one of the most common justifications for suboptimal debulking (Gynecol. Oncol. 82 (2001) 489). The aim of this study was to assess postoperative complications of DR in OC. METHODS: Retrospective chart review of all patients with OC who underwent DR from January 1988 through December 2001 at Mayo Clinic. RESULTS: We identified 41 women who underwent DR for OC. DR was performed during debulking for recurrent disease in 85%. Most patients (95%) underwent associated radical debulking procedures including bowel resection (51%), hepatic resection (27%), and splenectomy (17%). Full-thickness diaphragmatic lesions were present in 85% of specimens. Residual disease was classified as no gross residual in 80% of cases and <1 cm in 10%. Postoperative complications requiring treatment occurred in eight cases: pneumothorax (two cases, definitely attributable to DR); symptomatic pleural effusion (four cases, possibly attributable to DR); one case each of subphrenic abscess and gastro-pleural fistula (most likely unrelated to DR). CONCLUSIONS: (1) DR as part of cytoreductive surgery for ovarian cancer carries comparable risks to other radical debulking procedures. (2) The majority of complications are expected outcomes after entrance into the pleural cavity and generally manageable with chest tube. (3) DR is a useful adjunct to other radical debulking procedures and can eliminate isolated bulky diaphragmatic disease as an obstacle to optimal cytoreductive surgery for patients with ovarian cancer.
Gallium-67 imaging in abdominal disease.
Gallium-67 imaging is useful for detecting sites of intra-abdominal inflammation, including subphrenic abscesses, postoperative infection, pyelonephritis or perinephric abscesses, and peritonitis. Positive images may be obtained within several hours of injection, but are more reliable at 24 hr. The results may be used to guide ultrasound or computed tomography studies, which give a detailed anatomic picture of the abscess. Gallium-67 imaging has also been used to detect abdominal neoplasms, but results are less impressive. Abdominal lymphoma is detected in just over 50% of sites. Gastrointestinal, renal, and gynecologic neoplasms are detected even less frequently. However, 67Ga is useful for detecting recurrence of 67Ga-avid neoplasms, and has been reliable in detecting hepatomas and nodal spread of seminoma. When used selectively in patients with neoplastic disease and suspected abscesses, 67Ga is an effective method for diagnosing abdominal disease.
[Current treatment of closed injuries of the liver: benefits and pitfalls].
STUDY AIM: The management of blunt hepatic trauma has been modified by the development of conservative methods. Risks and pitfalls of this new approach must be determined. PATIENTS AND METHODS: From January 1985 to September, 1998, 130 patients with blunt hepatic trauma were treated by the same team. Among them, 38 patients were referred from another centre (21 already having undergone operations). Eighty patients (61%) had an initial non operative management and 50 patients (39%) underwent emergency laparotomy. Perihepatic packing was performed in 24 patients, hepatic sutures in 22, limited hepatic resection in six, and major hepatectomy in two patients only. RESULTS: There were three deaths in the non operative management group (mortality rate: 3.5%) and 11 patients required a secondary laparotomy: four for haemorrhage, one for enteric injury, two for acute pancreatitis, one for bile leakage, one for subphrenic abscess, one for acute cholecystitis. There were 14 deaths in the emergency laparotomy group (mortality rate: 28%), including four intraoperative deaths due to haemorrhage and two due to abdominal compartment syndrome. CONCLUSIONS: In the nonoperative management group a close clinical survey of the patient is necessary and a secondary laparotomy often indicated. In the operative management group, early packing requires reintervention if the patient is unstable. Alternative means of temporary closure may allow coverage without tension in order to avoid the abdominal compartment syndrome.
Near-total gastrectomy for gastric cancer.
Fifty-nine consecutive patients (95 percent) with gastric cancer of the distal portion of the stomach were operated on with 95 percent subtotal gastrectomy between 1975 and 1980. The operations were for cure in all cases. Twenty-five patients were alive after 5 years, for a crude 5 year survival rate of 42 percent. The operative mortality rate was 5 percent (three patients). Twenty-four patients (41 percent) had complications, which consisted of postoperative respiratory infection in 11 patients (19 percent), postoperative ileus in 4 patients (7 percent), and subphrenic abscess in 2 patients (3.4 percent). In addition, there was one wound dehiscence and one liver rupture (with fatal outcome), one deep venous thrombosis, one urinary infection, and one wound infection. Only one patient (1.7 percent) had an anastomotic leak at the gastrojejunostomy site. Seven relaparotomies (12 percent) had to be performed for complications. We have concluded that, in patients with distal gastric cancer, 95 percent subtotal gastrectomy can result in a 5 year survival rate that is comparable to that reported in the literature for total gastrectomy, and it has the advantage of a very low rate of anastomotic leakage between the minute gastric remnant and the jejunum. Therefore, 95 percent subtotal gastrectomy is recommended over total gastrectomy in the treatment of distal gastric cancer.
Hepatic resection for primary and metastatic tumors.
Thirty-four hepatic resections were performed on 33 patients. These included 4 trisegmentectomies, 14 lobectomies, 7 segmentectomies, and 9 wedge resections. Twenty patients had metastatic colorectal cancer, 4 had a primary liver tumor, 2 had giant cavernous hemangioma, 1 had metastatic leiomyosarcoma, 5 had various benign lesions including focal nodular hyperplasia, and 1 patient had resection for trauma. Operative morbidity included four subphrenic abscesses, one bile leak, one bile duct injury, one case of cholestasis, and one case of phlebitis. There were no operative deaths. The median survival of the patients with metastatic colorectal cancer was 40 months, and the 5-year actuarial survival rate was 35 percent. Survival rates were not significantly different between patients with a solitary metastasis and those with multiple lesions and was not influenced by size of the metastases. However, survival was significantly better in patients whose primary colorectal lesion was Dukes' B as compared with those whose lesion was Dukes' C. The results indicate that liver resection can be performed safely with acceptable morbidity and improved long-term survival.
Raising the outcome standards for conventional open cholecystectomy.
BACKGROUND: Postcholecystectomy length of stay declined after the introduction of laparoscopy in 1987. Technology deserves some credit for reducing iatrogenic trauma. However, the improved outcome primarily resulted from setting higher surgical standards. What goals were (and are) achievable with the conventional "open" technique? METHODS: One surgeon performed 160 consecutive open cholecystectomies from 1983 to 1987. The patients averaged 46 years of age (range 13 to 100), 62% were female, and 20% presented acutely. Five (3.1%) had common bile duct exploration. Each patient was prepared to accept early discharge. Prompt ambulation followed minimal tissue handling and use of long-acting local anesthesia. Enteral feeding at 300 kcal plus 12 g AAs/ hour began immediately, with swallowed air and potential excess removed automatically by efficient more proximal aspiration. RESULTS: 160 patients were discharged the next day, 158 of 160 (99%) without receiving any narcotics. They absorbed (on average) 3,350 kcal plus 130 g AAs the initial 8 to 16 hours. Serum branched-chain amino acids (BCAA) levels rose above basal within 4 hours. Three patients (1.9%) were readmitted. One (0.6%) had a sterile biloma drained percutaneously. A single acute cholecystitis patient developed sepsis (0.6%), a subphrenic abscess that resolved after drainage. The sole mortality (0.6%) was caused suddenly 27 days postoperatively by a pulmonary embolus. CONCLUSIONS: Laparoscopy is a valuable surgical tool whose actual incremental benefits are yet to be determined. Shorter length of stay after cholecystectomy may primarily reflect the altered expectations and overall improved surgical performance associated with this innovation.
Is radical hepatic surgery safe?
BACKGROUND: A prospective review of 200 consecutive liver resections performed for benign and malignant disease, between 1989 and 1995 at the Hammersmith Hospital, was undertaken to evaluate the safety of radical hepatic resection. METHODS: The indications for operation were: hepatocellular carcinoma (n = 39), cholangiocarcinoma (n = 21), gall bladder carcinoma (n = 8), colorectal secondaries (n = 75), noncolorectal secondaries (n = 35), and benign disease (n = 26). Twenty patients were cirrhotic and 36 were jaundiced. Major resections were performed in 74% of cases and included 63 extended hepatectomies, 17 repeated resections for recurrent colorectal metastases, and 17 resections combined with vascular reconstruction. Total vascular exclusion of the liver was used in the majority of cases. RESULTS: The overall mortality rate was 5%. Thirty-day mortality was 2.5%. Sepsis and not hemorrhage was the most common cause of death. There were 101 complications that occurred in 37% of the patients. The main complications were subphrenic abscess and biliary leak. The extent of liver resection (major versus minor) significantly increased the risk of morbidity (46% versus 16%). Blood loss greater than 100 mL increased the risk of morbidity from 12% to 25%. CONCLUSIONS: Major hepatic resection can be achieved with acceptable mortality but high morbidity rates.
Resectional gastric bypass is a new alternative in morbid obesity.
BACKGROUND: Severe obesity is a common serious health problem in the United States. Medical therapy is often ineffective. A variety of surgical procedures have been employed for treatment of morbid obesity. Surgical therapy continues to evolve. METHODS: Eighty-five patients have undergone subtotal gastrectomy and retrocolic Roux-en-Y gastrojejunostomy for weight control at our institution. We refer to this procedure as resectional gastric bypass (RGB). Thirty-eight patients have undergone RGB as conversion from failed or problematic prior bariatric procedures. Forty-seven patients have had RGB as their primary bariatric procedure. RESULTS: Twenty-six patients undergoing RGB for conversion of an anatomically or functionally failed prior bariatric procedure have had mean additional weight loss of 37% excess body weight (EBWL) in 18 months follow-up. Twelve patients undergoing RGB for intractable side effects of prior bariatric procedures have all had clinical improvement. Forty-seven patients undergoing RGB as a primary procedure have had EBWL of 53%, in mean follow-up of 11 months. For the entire series, major complications were one anastomotic leak, one reexploration for suspected subphrenic abscess, and one major pulmonary embolus. These patients recovered. There was no mortality in the series. CONCLUSIONS: Resectional gastric bypass is a new alternative for salvage of a failed or problematic prior bariatric procedure. It is also effective as a primary weight control operation.