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PubMed1984

Multiple pancreatic pseudocyst disease.

In an effort to determine the incidence of multiple pseudocyst disease and establish the optimal approach to this problem, the records of 91 consecutive patients diagnosed during a 36-month period as having pancreatic pseudocyst disease by sonography or computerized tomographic scanning were reviewed. Thirteen patients (14.3%) had multiple cysts; all received sonograms and six had CT scans. The combined false negative and false positive rate with sonography was 9%. Spontaneous resolution occurred involving five cysts (18%) up to 6.5 cm in size. The diagnosis of cyst multiplicity was confirmed at operation in seven cases; two of the seven operations were excisional and the remaining patients received drainage procedures. There were no operative deaths; complications included one patient who required chronic enzyme replacement therapy after excision and another patient who developed a subphrenic abscess after attempted percutaneous drainage. The incidence of multiple pseudocyst disease in our series is just over 14%. The possibility of multiplicity should be carefully investigated in each patient with pseudocyst disease. In light of the rate of spontaneous resolution, not all patients with multiple pseudocysts may require operative therapy. Because of the 7.7% false negative diagnoses with sonography, CT scanning is especially helpful when the diagnosis of multiple pseudocysts is suspected or in preoperative preparation of pseudocyst drainage. If an operation becomes necessary, a drainage procedure rather than excision should be used whenever possible to maximize gland salvage.

Adult↗
PubMed1989

Hepatectomy without abdominal drainage. Results of a prospective study in 61 patients.

The increasingly simple postoperative course of major surgery has challenged the routine use of drainage after most abdominal surgical procedures. Therefore a prospective study was designed to determine if abdominal drainage could be safely avoided after liver resection and was evaluated in 61 consecutive patients. There was one postoperative death (1.7%) from variceal bleeding. Four other patients (6.7%) developed an abdominal complication: two right subphrenic hematomas requiring reoperation in one case and two incisional ascitic leaks requiring incisional repair in one patient. There was neither a subphrenic abscess nor bile peritonitis. Postoperative hospitalization was 11.5 +/- 3 days in the entire group and 8.5 +/- 1 days in patients without complications. These results suggest that liver resection can be performed safely without abdominal drainage and that the routine use of drains is unnecessary.

Abdomen↗
PubMed1990

Splenorrhaphy. The alternative.

From 1980 to 1989, 240 adult patients underwent splenorrhaphy at one urban trauma center. This represents 43.4% of all splenic injuries seen during this time interval. Splenic injuries were graded I to V, and splenorrhaphy was attempted except when the spleen was shattered or when multiple injuries with associated hypotension were present. Penetrating wounds, blunt trauma, or iatrogenic/unknown etiologies were present in 54.2%, 41.6%, and 4.2% of patients, respectively. Grade I or II injuries were present in 51.7% of patients, grade III in 34.6%, grade IV or V in 9.6%, and unknown grade in 4.1%. The technique of splenorrhaphy was simple suture (usually chromic) with or without the addition of topical hemostatic agents in 200 patients (83.3%), topical agents alone in 12 (5%), unknown type of repair in 12 (5%), compression, cautery, or nonbleeding injury in 9 (3.8%), and partial or hemisplenectomy in 7 (2.9%). Postoperative rebleeding occurred in three patients (1.3%) with grade II, III, and IV injuries, respectively, and led to splenectomy at reoperation. In another patient who had a hemisplenectomy performed for a grade IV injury, subphrenic abscesses and septic shock led to the death of the patient. Splenorrhaphy can be safely performed in properly selected adult patients after a variety of injuries. The risk of rebleeding is practically nil when the spleen is fully mobilized and visualized during repair.

Adult↗
PubMed1994

Proximal splenorenal shunts for extrahepatic portal venous obstruction in children.

OBJECTIVE: The results of proximal splenorenal shunts done in children with extrahepatic portal venous obstruction were evaluated. SUMMARY BACKGROUND DATA: Extrahepatic portal venous obstruction, a common cause of portal hypertension in children in India, is being treated increasingly by endoscopic sclerotherapy instead of by proximal splenorenal shunt. It is believed that surgery (or the operation) carries high mortality and rebleeding rates and is followed by portosystemic encephalopathy and postsplenectomy sepsis. However, a proximal splenorenal shunt is a definitive procedure that may be more suitable for children, particularly those who have limited access to medical facilities and safe blood transfusion. METHODS: Between 1976 and 1992, the authors performed 160 splenorenal shunts in children. Twenty were emergency procedures for uncontrollable bleeding and 140 were elective procedures--102 for recurrent bleeding and 38 for hypersplenism. RESULTS: The overall operative mortality rate was 1.9%--10% (3/160-2/20) after emergency operations and 0.7% (1/140) after elective operations. Rebleeding occurred in 17 patients (11%), and pneumococcal meningitis developed in 1 patient who recovered later. Encephalopathy did not develop in any patient. Four patients died in the follow-up period--two of rebleeding, one of chronic renal failure and a subphrenic abscess, and one of unknown causes. The 15-year survival rate by life table analysis was 95%. CONCLUSIONS: A proximal splenorenal shunt, a one-time procedure with a low mortality rate and good long-term results, is an effective treatment for children in India with extrahepatic portal venous obstruction.

Adolescent↗
PubMed1994

A prospective randomized trial comparing R1 subtotal gastrectomy with R3 total gastrectomy for antral cancer.

OBJECTIVE: The authors determined if more radical surgery with extended lymphadenectomy improves the results of gastrectomy in patients with adenocarcinoma of the gastric antrum. SUMMARY BACKGROUND DATA: The overall survival in patients with gastric cancer is disappointing. Improved survival has been reported by Japanese authors. Whether this is because of a higher number of early gastric cancers in the Japanese series, different biologic behavior in Asians, or the adoption of radical surgery with lymphadenectomy remains unclear. METHODS: R1 subtotal gastrectomy with omentectomy and R3 total gastrectomy (omentectomy, splenectomy, distal pancreatectomy, lymphatic clearance of the celiac axis, and skeletonization of vessels in the porta hepatis) were evaluated in a prospective, randomized comparison. RESULTS: Fifty-five patients were randomized--25 to the R1 group and 30 to the R3 group. The two groups were comparable for age, sex, tumor size, TNM stage, and length of follow-up. The R3 group had a longer operating time (140 vs. 260 min; p < 0.05), a greater transfusion requirement (0 vs. 2 units, p < 0.05) and a longer hospital stay (8 vs. 16 days; p < 0.05) (medians; Mann-Whitney U test). The only postoperative death was in the R3 group and was caused by intra-abdominal sepsis. Fourteen patients in the R3 group developed left subphrenic abscesses. There were no major complications in the R1 group. Overall survival was significantly better in the R1 group (median survival estimated by Kaplan-Meier method, 1511 vs. 922 days, p < 0.05, log-rank test). CONCLUSIONS: R3 total gastrectomy can be performed with a low mortality, but it has a high morbidity because of intra-abdominal sepsis. The data do not support the routine use of R3 total gastrectomy for treatment of patients with antral cancer.

Adenocarcinoma↗
PubMed1994

Trends in morbidity and mortality of hepatic resection for malignancy. A matched comparative analysis.

OBJECTIVE: The authors define more clearly the trends in morbidity and mortality after hepatic resection for malignant disease in matched patient groups during two discrete time periods. SUMMARY BACKGROUND DATA: Recent reports have shown improvement in operative morbidity and mortality associated with hepatic resection; however, results often included resections for benign disease and trauma. Furthermore, specific factors contributing to the improvement in operative risks between the last two decades have not been defined. METHODS: A retrospective matched comparative analysis was conducted of patients with primary and metastatic hepatic malignancy resected with curative intent between two periods (1976 to 1980 and 1986 to 1990). Eighty-one patients met our inclusion criteria in the early period; this group was matched with 81 patients from the latter period by the following four parameters: age, gender, type of malignant disease, and extent of resection. Records of these two patient groups were abstracted for clinical presentation, co-morbid factors, operative techniques, and perioperative morbidity and mortality. RESULTS: The authors found a significant decrease in operative morbidity, median perioperative transfusion, and length of hospital stay in the latter period (1986 to 1990). The incidence of postoperative subphrenic abscess and intra-abdominal hemorrhage was significantly lower during this period. Operative mortality rate was similar for both periods, 4.9% and 1.2%, respectively (p > 0.05). CONCLUSION: Hepatic resection for malignant disease currently can be performed with a low morbidity and mortality in the hands of trained and experienced hepatic surgeons; operative risks of hepatic resection should not deter its application in the treatment of primary and metastatic malignant disease of the liver.

Adolescent↗
PubMed1995

Gastrogastric fistulas. A complication of divided gastric bypass surgery.

OBJECTIVE: This report warns that gastrogastric fistulas may follow the division of the stomach in bariatric surgery. SUMMARY BACKGROUND DATA: Although surgery is the most effective therapy for morbid obesity, the procedures are still undergoing evolution. One of the key elements in bariatric surgery is the partition of the stomach to develop a much smaller reservoir. The partition has been done with single layers of staples with almost universal failure and with double layers of staples with a failure rate of 11.8% when observed for a 12-year follow-up. METHODS: This report details the experience with a series of 100 consecutive patients in whom the partition was created by dividing the stomach. RESULTS: The course of six patients was complicated by gastrogastric fistulas. One of the patients had the gastric bypass as the initial bariatric operation; in the other five, the gastric bypasses were carried out to revise failed staple lines. Although one of the patients required drainage for a subphrenic abscess, two had only self-limited signs of infection. In the remaining three patients, there was no evidence of any complication. CONCLUSION: Gastrogastric fistulas followed division of the stomach in 6% of our gastric bypass operations. Methods for avoiding this complication include oversewing staple lines, using strong bites of tissue during the anastomosis, avoiding obstruction of the Roux-en-Y jejunal segment, and testing of the integrity of the anastomosis with methylene blue dyes. The ideal method for partition of the stomach remains to be developed.

Gastric Bypass↗
PubMedDate not supplied

Embolization of the spleen for treatment of splenomegaly and hypersplenism in patients with portal hypertension.

Splenectomy in cases of hypersplenism involves significant risk of serious complications, including infection, hemorrhage, portal systemic thrombosis, and necrosis of the stomach or small bowel. Alternative procedures such as transcatheter embolization have been associated with a high frequency of splenic or subphrenic abscess, preventing clinical use. We used partial splenic embolization under careful antibiotic protection to successfully treat thrombocytopenia in 18 patients, most of whom had hypersplenism and splenomegaly secondary to portal hypertension. Of the 30 embolizations performed, the only serious complications encountered were abscess in two patients (who had almost total infarction) and four cases of splenic vein thrombosis. We investigated the possible effect of splenic embolization on portal venous pressure in three patients and found no pressure change.

Abscess↗
PubMed1982

Splenic preservation following splenic trauma.

Increased awareness of the problem of overwhelming post-splenectomy sepsis has aroused interest in methods of splenic preservation in patients with abdominal trauma. In the past 6 years, we have treated 272 patients for splenic trauma at our institution, 41 of whom underwent splenic preservation. Mortality rates in those undergoing splenectomy vs. preservation were 23.4% and 4.9%, respectively, severe head injuries constituting cause of death in the latter. Overall morbidity in the two groups was not significantly different (40.7% vs. 39%). Pulmonary complications were predominant in both groups (splenectomy, 27.7%; splenic preservation, 23.1%) with atelectasis more common in the latter. Three subphrenic abscesses occurred in the splenectomy group, none in the repair group. Sepsis was twice as frequent in the splenectomy group (8.7% vs. 4.9%). Mode of injury was slightly more severe in the splenectomy group with these patients sustaining mor chest, spine, associated intra-abdominal, and vascular injuries, thus accounting for the high mortality. Average operative time was not increased by addition of repair (2 hr 54 min vs. 2 hr 33 min). Only on repair required return to the operating room, because of a missed hilar laceration at the original laparotomy, emphasizing the importance of care in technique. Postoperative scans in selected patients showed good functional activity. We conclude that splenic preservation is a technically safe procedure in patients exhibiting hemodynamic stability.

Adolescent↗
PubMed1990

The morbidity and financial impact of colostomy closure in trauma patients.

During a 10-year period, 87 patients who had undergone elective colostomy closure at Bellevue Hospital were retrospectively reviewed in order to evaluate the morbidity of colostomy closure after traumatic injury and its financial impact. Sixty-two per cent of the colostomies were in the left colon and 38% were right sided. The interval from the original injury to colostomy takedown varied from 20 to 465 days, with a mean of 144 days. The mean postoperative hospital stay for the entire group was 15.13 days at a cost of $13,995. There were no deaths and no anastomotic leaks in the entire series, but a morbidity rate of 25% ensued. Small bowel obstruction was the most frequent significant complication, occurring in ten patients (11.5%) and resulting in a prolongation of hospital stay by 7 days at an additional cost of $6,500 per patient. One additional patient developed a subphrenic abscess which required operative drainage, necessitating an additional 24 days in the hospital at an increased cost of $22,200. Other complications which did not prolong hospital stay included eight superficial wound infections, one transient respiratory failure, and two patients who returned at a later date with incisional hernias at the stoma site. The 25% morbidity encountered in this series suggests that colostomy closure is not a low-morbidity procedure and should be considered as an important factor favoring primary repair. Coupled with the significant financial impact of both colostomy formation and takedown, ample justification exists for greater efforts in avoiding colostomy formation whenever feasible.

Adolescent↗
PubMed1997

Effects of hypoxemia on early postoperative course of liver transplantation in pediatric patients with intrapulmonary shunting.

Nine pediatric patients (mean age, 10 years) with biliary atresia, who had hypoxemia related to intrapulmonary shunting, underwent living related liver transplantation. The effects of hypoxemia during the early postoperative period after liver transplantation on cardiopulmonary and renal function, as well as on transplanted liver, were analyzed. Based on the degree of shunt ratio calculated by technetium-99m macroaggregated albumin scintigraphy, the nine patients were included in the moderate group (shunt ratio under 40%, n=4) or the severe group (shunt ratio over 40%, n=5). Partial pressure of arterial oxygen was maintained at normal range in the moderate group, while that in the severe group persistently had very low values (<50 mmHg), in spite of a high degree of oxygen supply. However, all patients in the severe group maintained stable cardiopulmonary vital signs, including systemic blood pressure, heart rate, respiratory rate, and cardiac index. They also demonstrated stable renal function. None of the patients died of cardiopulmonary or renal insufficiency after transplantation, but three patients died of portal vein thrombosis, sepsis, and intracranial hemorrhage (one each). The minimal adverse effect of hypoxemia on the transplanted liver was confirmed by a rapid increase of arterial ketone body ratio, low peak values (under 200 IU/L) of aspartate aminotransferase, and a steady decrease of serum total bilirubin. Four patients encountered surgical complications, including two bile leaks from the cut liver surface, two leaks from bilioenteric anastomosis, and one intestinal perforation. Six patients suffered from bacterial infections, including four wound infections, three right subphrenic abscesses, one cholangitis, and two systemic sepses. All patients in the moderate group recovered from hypoxemia, but four of five patients in the severe group have not recovered during the follow-up period between 4 and 9 months. It was concluded that the adverse effects of hypoxemia on cardiopulmonary and renal function and transplanted liver were minimal, so that patients with severe hypoxemia could tolerate the stress of liver transplantation without special management. However, the high incidence of surgical complication and infection suggested the adverse effects of hypoxemia on wound healing and resistance to bacteria infection.

Adolescent↗
PubMed1993

Bilateral adrenalectomy: low mortality and morbidity in Cushing's disease.

OBJECTIVE: We assessed the current role of bilateral adrenalectomy in the overall management strategy of hypercortisolism. DESIGN: Retrospective review of case notes. PATIENTS: Twenty-six patients (20F/6M); mean age 46 years (range 15-70 years), median duration of follow-up 5.25 years (0.6-19.1 years) who had undergone bilateral adrenalectomy at the Royal Victoria Hospital since 1972. Eighteen had had prior transsphenoidal surgery which did not control the hypercortisolism. MEASUREMENTS: Morbidity, mortality, incidence of Nelson's syndrome. RESULTS: Surgery was performed through bilateral postero-lateral incisions (20 patients) or a long epigastric incision (six patients). The mean combined weight of the adrenals at surgery was 11.2 g. Twenty patients received subcutaneous heparin and 18 antibiotic prophylaxis peri and post-operatively. There was no operative mortality. Minor complications included one post-operative wound infection and a small pneumothorax requiring drainage. Major complications occurred in two other patients, both with pre-existing invasive pituitary tumours and considered at high risk because of age and general debility. One patient had a massive pulmonary embolus and the other a subphrenic abscess post-operatively. This latter patient, the only mortality, died from an unrelated cause three years post-operatively. Six patients have subsequently undergone pituitary surgery and three have received external pituitary irradiation therapy for expanding tumours. CONCLUSIONS: Bilateral adrenalectomy, in experienced hands, is a relatively safe and useful management option in patients with hypercortisolism. Growth of a pituitary adenoma post-operatively is now the most worrying complication.

Adolescent↗
PubMed1993

Persistent postoperative hiccups: a review.

The pathogenesis of persistent postoperative hiccups is not known. Hiccups can present as a symptom of a subphrenic abscess of gastric distention, and metabolic alterations may also cause hiccups. The hiccups may develop because of increased activity in neural reflex pathways not yet fully defined. Numerous treatment modalities have been tried but with questionable success. Valproate has proven effective in two trials investigating persistent non-surgical hiccups. The simple application of a nasogastric tube may successfully treat the hiccups, possibly because of an alteration of the activity in the reflex neural pathways involved. The available literature on the treatment of persistent hiccups is reviewed, and a treatment protocol for persistent postoperative hiccups is provided.

Hiccup↗
PubMed1988

Conservative treatment of traumatic closed hepatic haematoma.

A retrospective review was performed of nine patients with closed hepatic haematoma admitted to the Department of Surgery, Auckland Hospital, between 1980 and 1985. All resulted from blunt abdominal trauma due to motor vehicle accidents. Four haematomas were diagnosed at the time of laparotomy and were left undisturbed; four haematomas were diagnosed radiologically were also treated conservatively. One patient underwent partial right hepatic lobectomy, required a significant blood transfusion and developed a subphrenic abscess postoperatively. A further patient died from associated head injuries. The peri-operative mortality for urgent hepatic resection in multiply-traumatized patients is greater than 50%, even in experienced trauma units, and this review suggests that in haemodynamically stable patients with closed hepatic haematomas where the diagnosis can be radiologically ascertained, conservative treatment is a safe and reasonable option.

Adult↗
PubMed1990

Systemic antibiotic regimens for acute cholecystitis treated by early cholecystectomy.

A total of 203 patients were randomized into a prospective trial to compare short (SC) versus long courses (LC) of systemic antibiotic for acute cholecystitis treated by early cholecystectomy. The initial pre-operative management was the same and all patients received 2 g of cefamandole intravenously just before operation. Two further doses of cefamandole 500 mg were given 6 and 12 h later for patients on SC while the antibiotic was continued at 500 mg at 6 h intervals for 7 days for patients on LC. Seven patients developed wound infection on SC compared with five patients with wound infection and an additional patient with a subphrenic abscess on LC (P greater than 0.05). Thrombophlebitis related to intravenous antibiotic injections was more common in patients on LC (P less than 0.05). Also, patients on LC had to stay statistically longer in hospital in order to complete the course of antibiotic (P less than 0.05). We therefore recommend a SC to be used, as it is more cost-effective and causes fewer complications.

Acute Disease↗
PubMed2001

Short report: Hyperammonaemia in critically ill septic infants.

Three infants with subphrenic abscess, pyonephrosis, and obstructive ureterocoele respectively had grossly increased concentrations of plasma ammonia. This was considered to be a result of infections with urea splitting organisms. All died in spite of intensive care support, including specific measures to reduce plasma ammonia.

Ammonia↗
PubMed1987

Xanthogranulomatous cholecystitis: clinicopathological study of 13 cases.

In a retrospective three year study 13 cases of xanthogranulomatous cholecystitis (XGC) (seven female, six male) were found in 724 gallbladders (1.8%), an estimated incidence of 1.7 cases per 100,000 population per annum. Symptoms often began with an episode of acute cholecystitis and persisted for up to five years. There was extension of xanthogranulomatous tissue into adjacent organs in nine cases. Three patients had fistulae from the gallbladder, one to skin, and two to the duodenum; this is the first report of this complication in XGC. In two patients XGC sufficiently resembled carcinoma for the surgeon to request intraoperative frozen section diagnosis. There was a high rate of postoperative infective complication, with one subphrenic abscess and three wound infections (one fatal), two in patients with fistulae.

Adult↗