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PubMed1987

The effect of thoracic epidural analgesia on postoperative stress and morbidity.

A hundred patients scheduled for cholecystectomy were randomized to either thoracic epidural anaesthesia and analgesia for 24 h with bupivacaine intraoperatively about 100 mg and 15 mg/h thereafter (TEA) for postoperative analgesia, TEA combined with general anaesthesia (low dose fentanyl) (TEA + GA) and general anaesthesia (GA) (low dose fentanyl). During TEA and TEA + GA the arterial pressure was significantly decreased as compared with GA. TEA was associated by an intense haemodilution in comparison with GA. Blood glucose and plasma cortisol responses were significantly suppressed by TEA. The decreases in peripheral blood lymphocyte and eosinophilic counts observed after operation under GA was significantly reduced by TEA. The increase in the neutrophil count was inhibited by TEA but the increase in non-filamented neutrophils was significantly augmented by TEA. The postoperative alleviation of the alteration of the above mentioned parameters by TEA was slightly diminished in the TEA + GA group. However, we found no significant reduction in cardiac dysrhythmias (TEA 7%, TEA + GA 7% and GA 10%), ST-segment depression (TEA 17%), TEA + GA 3.3% and GA 12.5%), wound complication (TEA 3%, TEA + GA 0%, GA 0%), pneumonia (TEA 3%, TEA + GA 3% and GA 0%), subphrenic abscess (TEA 6%, TEA + GA 0%, GA 3%), mortality (TEA 0%, TEA + GA 3%, GA 0%), and urinary tract infect (TEA 17%, TEA + GA 7% and GA 2.5%). Since an equal number of patients in each group, about 30%, suffered one or more of the postoperative complications this epidural analgesia was not effective in reducing postoperative morbidity albeit the significant alleviation of the postoperative stress response.

Anesthesia, Epidural↗
PubMedDate not supplied

Bronchobiliary fistula in chronic pancreatitis. Case report.

Bronchobiliary fistulas are rare. One aetiological cause is biliary obstruction with secondary suppuration and subsequent hepatic and subphrenic abscesses. Only a few cases of bronchobiliary fistulas in patients with chronic pancreatitis have been reported and we record another case. A 47-year-old white male, with chronic alcohol-induced pancreatitis who had earlier undergone several laparotomies related to this disease, was admitted with a hepatic abscess. Drainage was not successful. The patient developed bilioptysis and a bronchobiliary fistula was diagnosed. The fistulous tract was demonstrated using PTC as well as bronchography. Laparotomy was performed and the fistulous tract was excised. The hepaticoduodenal ligament was completely obstructed by the inflamed pancreatic gland. An earlier but now obstructed cholecystojejunostomy was revised. This case was complicated by episodes of severe gastrointestinal bleeding probably caused by thrombosis of the portal vein and local varices around the gallbladder and common duct.

Alcoholism↗
PubMed1987

Choledochoduodenostomy for benign biliary tract disease in the elderly.

Endoscopic sphincterotomy is an available nonoperative alternative treatment for recurrent or residual common bile duct stones. Nevertheless, immediate, intraoperative and definitive treatment is needed in patients with common duct stones and other pathologies that are prone to develop into such complications, which is important especially in aged high-risk patients during recurrent operations and nonoperative instrumental interventions. To evaluate the safety of choledochoduodenostomy in elderly patients, we reviewed our experience with 55 patients over the age of 70 years with benign biliary tract diseases. Even though the majority of patients (69%) had obstructive jaundice and were operated on urgently, there was one death (1.8%) due to cardiac failure, and nine (16.3%) early postoperative complications including subphrenic abscess, disruption of wound and pneumonia (one case of each), wound infection (three cases) and urinary tract infections (three cases). There were no complications related to the procedure itself. In a follow-up period of one to 12 years, neither cholangitis nor sump syndrome were documented.

Aged↗
PubMed1979

Simplified distal pancreatectomy with the Auto Suture stapler: preliminary clinical observations.

The most serious complication following distal pancreatectomy is the development of a pancreatic fistula or subphrenic abscess. These complications are particularly prone to occur following distal pancreatectomy for trauma. The injured pancreas is divided in a contaminated field, often in the presence of hemorrhage and partly devitalized tissues, in which identification and secure closure of the transected pancreatic duct may be difficult. A review of 12 surgical publications describing experience with 234 distal pancreatectomies performed for trauma found the average pancreatic fistula rate to be 13% an in some reports as high as 25% to 30%. In an attempt to decrease the high postoperative fistula rate after distal pancreatectomy, transection of the gland with the autosuture has been investigated. There are at least three theoretical advantages of this technique. The pancreas is transected through healthy tissue, the pancreatic duct is closed securely, and stainless steel sutures are used, which probably are more resistant to the development of infection than other suture material. This report describes a technique of distal pancreatectomy for both trauma surgery and elective surgery with the TA-55 Auto Suture stapler. TA-55 Auto Suture stapler, with 3.5 mm staples, is placed across the mobilized pancreas, and two rows of staggered stainless steel staples are laid down. The gland distal to the stapler then is amputated. At present this technique has been used in a total of 12 cases--four for trauma and eight during elective procedures. One fistula related to pancreatectomy performed with the Auto Suture stapler developed, for a complication rate of 8.3%. This preliminary experience indicates that a more widespread evaluation of this technique is indicated.

Adult↗
PubMed1986

Adrenal gland surgery. Preoperative location of lesions, histologic findings and outcome of surgery.

The accuracy of various techniques for preoperative location of adrenal lesions was studied in 55 consecutive cases, and the perioperative course and outcome of surgery were analyzed. CT correctly located 94% of all adrenal tumours, was less accurate (42%) in hyperplasia and gave no false-positive results. Selective angiography revealed 75% of the tumours, but was likewise diagnostically inadequate in adrenal hyperplasia. Adrenal venous sampling correctly located 80% of tumours and of hyperplasia. In hyperplasia it was the single most successful procedure for detecting the site of adrenal hyperfunction. Phlebography gave misleading information in almost 45% of cases. The perioperative complications included splenic rupture necessitating splenectomy (3 cases), superficial wound infection (2), pneumonia (4) and subphrenic abscess (1). There were no perioperative deaths. The study indicated CT to be the principal procedure for preoperative location of adrenal disorders. In some cases with adrenal hyperfunction, venous sampling should be added. Adrenal surgery can be performed with low morbidity and no mortality and with favourable long-term outlook in cases of benign lesion.

Adolescent↗
PubMed1985

Prospective randomized controlled study of prophylaxis with cefamandole in high risk patients undergoing operations upon the biliary tract.

In this study, 52 high risk patients who underwent operations upon the biliary tract were assigned to receive either antibiotic prophylaxis or no treatment with antibiotics. Twenty-seven patients were given 2 grams of cefamandole intramuscularly 30 minutes before operation and 2 grams every eight hours for two days postoperatively. The remaining patients were in the control group and did not receive antibiotics. Surgical wounds were inspected daily by a surgeon while the patients were in the hospital and a follow-up revision was done four weeks after discharge from the hospital. Samples of exudate or pus were taken when the wound appeared infected and cultures of aerobic and anaerobic organism done. Chi-square affinity test with Yate's correction was used for statistical results; only p values more than or equal to 0.5 were considered significant. Seven patients (28 per cent) in the control group had complications develop postoperatively; seven surgical wound infections, one of which included a subphrenic abscess. Postoperatively, there were no septic complications in the group who received cefamandole as a prophylaxis. The incidence of infection was higher for females than males. The organisms most frequently isolated were Escherichia coli and Klebsiella; only in one instance was Clostridum sporogenes found. Polymicrobial infections accounted for 42.8 per cent of the infections. No incidences were reported with the use of cefamandole in those patients who were treated prophylactically. In view of these results, we believe that cefamandole is an ideal antibiotic to be used in the prophylactic treatment of infections of high risk patients who undergo operations upon the biliary tract.

Age Factors↗
PubMed1985

Greater curvature gastroplasty. Follow-up at 34 months.

This retrospective study analyzes the results of 198 consecutive greater curvature gastroplasties performed in 23 male and 175 female patients with morbid obesity. The gastroplasty consisted of the creation of a 30-50 cm3 proximal gastric pouch by a double application of the TA-90 stapler, modified by removing three staples near the pin and trimming the cartridge to prevent crushing of the stomach at the outlet. The outlet was calibrated to a diameter of 1 cm and reinforced with a polypropylene seromuscular suture. No deaths occurred; postoperative complications included 32 superficial wound infections (16.2%), 24 incisional hernias (12.0%), 15 staple-line disruptions (7.6%), seven gastric outlet obstructions (3.5%), five subphrenic abscesses (2.5%), three perforations (1.5%), one splenic infarction, and one enterocutaneous fistula. One hundred sixty-one (81%) patients have been followed for a mean of 34 months (range 24 to 56 months); their mean weight loss is 36.4 per cent +/- 32.9 per cent of excess body weight. Only 45.5 per cent of these patients can be considered to have had satisfactory weight loss. Because this is not as effective as other forms of surgical therapy, the authors do not recommend greater curvature gastroplasty for the treatment of morbid obesity.

Adolescent↗
PubMed1985

[An experience in the treatment of severe surgical infectious diseases with combination of antibiotics and human gammaglobulin (SM-4300)].

The human immunoglobulin (SM-4300), which was developed by Travenol Laboratories, Inc. U.S.A., was used with antibiotics on 12 cases of severe surgical infectious disease. The method of administration and the evaluation of clinical effect of gammaglobulin (SM-4300) were made based upon the criteria of the SM-4300 study group. The clinical evaluation of the effect was classified in 5 grades; excellent, good, fair, poor and unknown. Three types of administration dose schedules were employed. Severe surgical infections were 3 cases of postoperative pneumonia, 3 cases of sepsis with pneumonia, 3 cases of peritonitis, 1 case of cholangitis, 1 case of sepsis with perinephritis and 1 case of subphrenic abscess. Bacterial and immunological examination were also performed before and after the administration of SM-4300. Evaluable cases were 10 cases out of 12 cases. Clinical effects of the administration of SM-4300 were evaluated as excellent in 1 case, good in 3, fair in 2 and poor in 4.

Adult↗
PubMed1979

Causes for 340 reoperations on the extrahepatic bile ducts.

Three hundred forty of 5,086 patients undergoing operations on the extrahepatic biliary trees at the Swedish and University of Washington Hospitals in Seattle between 1956 and 1970 required reoperation on this system. This figure for reoperations did not include procedures for subhepatic or subphrenic abscess and/or wound complications. The most common cause for reoperation was an attempt to retrieve a residual or recurrent common duct stone (26.8% of the cases). The second most common cause for re-exploration was a tumor obstructing the common bile duct (18.9%). Less frequent causes for secondary surgery were stenosis of the ampulla of Vater (10.3%), bile duct injury (12.1%), pancreatitis (10.3%), inflammatory stricture (1.5%), cystic duct remnant (5%), and many other less important problems. Thus 4.7% or almost one in 20 of all our biliary operations were secondary. We feel that operative cholangiograms supplemented by manometry are the useful adjunct towards finding otherwise undetectable biliary pathology, whether on the basis of stones, tumors, or structures. We also feel that placement of T-tubes with a large arm going to the surface will allow the removal of most stones left behind after common bile duct explorations with the assistance of directable stone baskets.

Adolescent↗
PubMed1978

Practical approach to laparotomy for staging in the management of lymphomas.

This study was designed to delineate the role of laparotomy for staging in the management of lymphomas and to determine the accuracy of nonsurgical staging procedures. Fifty-four untreated patients with diagnoses of Hodgkin's disease or non-Hodgkin's lymphoma had extensive physical, laboratory, roentgenologic, scintigraphic, nonsurgical and surgical staging evaluation. Forty-five out of 54 patients had clinical Stage I and II disease; clinical Stage IV patients were excluded. One out of eight enlarged spleens, 12 out of 46 normal spleens, none of four enlarged livers and four out of 50 normal livers were positive at laparotomy. None of the preoperative needle biopsies of the liver and iliac crest was positive for lymphoma. The pathologic stage was advanced in six out of 25 of clinical Stage I, six out of 20 Stage II and two out of nine of Stage III. 67Ga scanning and lymphography were accurate in 16 out of 30 and 24 out of 45 patients, respectively. There was no mortality, but morbidity was limited to atelectasis, thrombophlebitis and subphrenic abscess in three patients, respectively. Only when treatment regimen is stage-dependent and only if nonsurgical staging procedures have reliably failed to rule out disseminated disease, then laparotomy for staging indicated in localized lymphomas. Laparotomy for staging should not be done when the treatment plan is not altered by staging data or when there is a medical contraindication or when evidence of disseminated disease has been reliably and consistently obtained by nonsurgical methods as needle biopsies of the liver and bone, lymphography, scintigraphic studies and laparoscopy.

Female↗
PubMed1982

[Spontaneous pneumopericardium. Apropos of a case report].

A patient operated for carcinoma of the bladder complicated by infection by anaerobic organisms developed pneumopericardium. Spontaneous pneumopericardium may or may not follow effraction of the pericardium. The following causes have been described: fistula with a tuberculous cavernoma, parenchymatous or pleural infection, carcinoma of the bronchus; oesophageal or gastro-pericardial fistulae arising from carcinoma or ulceration of the stomach or oesophagus; rupture of a mediastinal, hepatic or subphrenic abscess and, exceptionally, pericarditis complicated by fistulisation to the tracheo-bronchial tree. Pneumopericardium without effraction is caused by in situ gas production, a complication of pericarditis caused by anaerobic organisms; this may be a primary or a metastatic infection. Idiopathic pneumopericardium is included in this variety whilst "alveolar rupture" is usually considered in the group of pneumopericardial fistulae: air under pressure passes from the mediastinum into the pericardium by microscopic dissection (bronchitis, asthma, obstructive laryngitis, childbirth). The outcome and prognosis depends on the cause and type of effusion: pneumopericardium rarely contains air alone; serous fluid, blood or pus, are usually associated.

Humans↗
PubMed1978

Esophagectomy without thoracotomy.

Blunt esophagectomy without thoracotomy has been performed in 26 patients: four with benign disease and 22 with carcinomas involving various levels of the esophagus (10 cervicothoracic, one upper third, five middle third, and six distal third). Continuity of the alimentary tract was restored by anastomosing the pharynx or cervical esophagus either to stomach (19 patients) or to a colonic graft (seven patients). Esophageal resection and reconstruction were performed in a single stage in 25 patients, and the esophageal substitute was positioned in the posterior mediastinum in the original esophageal bed in 24 patients. There were no deaths directly related to the technique of blunt esophagectomy. Average intraoperative blood loss was 1,350 ml. for the entire group, 1,650 ml. for those requiring concomitant laryngectomy and 1,050 ml. for those undergoing esophagectomy without laryngectomy. Complications in these patients included pneumothorax (eight), transient hoarseness (five), pleural effusion (five), anastomotic leak (four), subphrenic abscess (one), and cerebrovascular accident (one). The five deaths were due to pheumonia (two), innominate artery rupture (two), and pulmonary embolus (one). Blunt esophagectomy without thoracotomy is safe and is far better tolerated physiologically than the combined transthoracic and abdominal operations more traditionally used for exophageal resection and reconstruction.

Adenocarcinoma↗
PubMed1982

Symptomatic maternal intraperitoneal meconium granulomata: report of two cases.

We present two cases of histologically proven maternal intraperitoneal granulomata following cesarean section delivery. One patient presented during the immediate postpartum period with clinical symptoms consistent with subphrenic abscess. The other patient required operative intervention for a suspected ruptured tubo-ovarian abscess. In both cases, microscopic examination of the tissue obtained at the time of reoperation showed granuloma reaction, lanugo hair, and fetal squamous cells consistent with meconium deposition. The authors conclude that meconium granuloma should enter the differential diagnosis in cesarean section patients with unexplained postoperative pain.

Adult↗
PubMed1994

Laparoscopic cholecystectomy: results of first 300 cases in Hong Kong.

Prospective analysis of the first three hundred patients who underwent laparoscopic cholecystectomy was carried out in three surgical centres of Hong Kong. Over a 20-month period, 300 consecutive patients were recruited, including elective and emergency cases. The indications for laparoscopic cholecystectomy were symptomatic gallstones (78%), cholangitis (6%), pancreatitis (5%) and cholecystitis (11%). Patients with common duct stones (12) had preoperative endoscopic sphincterotomy and stone extraction prior to cholecystectomy. Laparoscopic cholecystectomy was accomplished successfully in 287 patients. Thirteen patients (4.3%) required conversion to open cholecystectomy. The reasons for conversion were: inability to identify cystic duct and common bile duct clearly (6); bleeding (5); Mirizzi syndrome (1); and slippage of cystic duct clip (1). The median operation time was 80 min with a range of 28-270 min. The median hospital stay was 3 days. Seventy-five per cent of patients required only a single dose of pethidine injection. None of the patients required blood transfusion. The overall complication rate was 7%. These included mild cellulitis of the subumbilical wound (3%) and postoperative chest infection (3%). One patient developed subphrenic abscess which resolved on percutaneous drainage under ultrasound guidance. Iatrogenic injury to the common bile duct was seen in one patient who had an impacted stone at Hartmann's pouch. With adequate training laparoscopic cholecystectomy can be performed safely. The advantages over open cholecystectomy are less wound pain, better cosmesis and shorter convalescence.

Cholecystectomy↗
PubMedDate not supplied

[Acute appendicitis in children].

From January 1st, 1987 to December 31st, 1989, 267 patients were operated upon for acute appendicitis representing 97% of emergency laparotomies at the Pediatric Surgery Department of Santa Maria Hospital (HSM); of these, 207 records were analysed using a retrospective protocol and the results were as follows: most frequent symptoms were abdominal pain (99% of cases) and anorexia (86%). Referral for surgical evaluation was made in 35.8% of cases 48 hours after the onset of symptoms; surgery was performed in 129 patients (62.4%) in advanced stages of disease, with histopathological examinations of necrotic, perforated and gangrenous appendices. 15 patients (7.2%) had no appendicitis-11 were found to have follicular hyperplasia and 4 normal histology; of these, luminal distention by parasitic eggs was found in 4. Antibiotic therapy was used in 89 patients preoperatively and in 200 patients postoperatively; cefoxitin was the most commonly used in 89.9% and 83.0% respectively. There were 19 complications (9.2%): 8 parietal, 5 pelvic and 1 subphrenic abscesses, 4 total or partial obstructions and 1 lost drain; 4 patients (1.9%) were reoperated and there was no mortality.

Acute Disease↗
PubMed1995

[Perforated duodenal ulcer: subtotal anterior linear and posterior tuberous gastrectomy].

OBJECTIVE: To evaluate emergency surgery procedures for perforated duodenal ulcers. METHODS: Emergency surgery was performed for perforated duodenal ulcers in 25 patients (19 males and 6 females) with a mean age of 36 +/- 15 years. The procedure consisted of simple closure followed by anterior and partial posterior linear gastrectomy using a stapling device. There were 16 patients who smoked, 11 who drank and smoked, 3 who were under treatment with non-corticosteroid anti-inflammatory agents, 2 who had a history of other disease (myocardial infarction and arteritis) and 4 who were in septic shock. RESULTS: The delay in closure of perforation was less than 6 hours in 17 cases. Peritoneal leakage was confined to the supramesocolic level in 19 cases. The mean follow-up was 14 +/- 2 months with endoscopic control at 12 months. One recurrence (4%) was observed at 8 months. One patient died. Morbidity occurred in 7 patients (28%); epigastric bloating in 5 cases, subphrenic abscess in 1, abscess of the stomach wall in 1 and oesophageal reflux treated without surgery in 1. The mean duration of hospitalization was 13 +/- 3 days.

Adult↗