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PubMed1995

Early mortality in 100 consecutive liver resections in 96 patients with benign and malignant liver tumours.

This report describes the mortality in 100 liver resections performed in 96 patients for seven benign and 93 malignant liver tumours. Repeat hepatectomy was performed in four patients who developed recurrences after the first liver resection. Two patients died within 30 days. The first was a 67-year-old man who died on the 2nd postoperative day from cardiac failure. The second was a 69-year-old man who died on the 4th postoperative day with liver failure caused by hepatic vascular ischaemia. There were four other hospital deaths at days 33, 40, 45 and 50. A 65-year-old lady died on day 40 from sepsis caused by small bowel infarction. A 30-year-old man died on the 33rd postoperative day owing to liver failure from accelerated hepatic lymphoma spread. A 71-year-old diabetic lady died on the 45th postoperative day from sepsis caused by an untreated subphrenic abscess. A 65-year-old lady died on day 50 from systemic candidiasis after adult respiratory distress syndrome (ARDS). Further reduction in operative mortality could be achieved by better patient selection. Liver resection still remains a major operation, but has become a safe surgical procedure.

Adolescent↗
PubMed1994

Use of microwave tissue coagulator in hepatocellular carcinoma resection: compared with Lin's hepatic clamp.

Fifty-nine patients with hepatocellular carcinoma (HCC) underwent resection with the aid of a microwave tissue coagulator at the Department of Surgery, National Taiwan University Hospital from July 1987 to December 1992. There were 41 men and 18 women with an average age of 59.2 years (range, 32-79 years). The intraoperative blood transfusion included packed RBC 1.53 +/- 1.34 U, fresh frozen plasma 3.85 +/- 1.69 U and/or platelet 1.58 +/- 3.07 U. The operation time from skin incision to skin closure was 250 +/- 74.9 minutes (range, 125 range, 495 minutes) and the average hospital stay was 20 +/- 9.7 days (nine to 50 days, median 17 days). The complication rate was 16.9% (10/59), including two with biliary fistula, prolonged impaired liver function and pleural effusion. Subphrenic abscess was seen in one patient and ascites in three. There was no operative mortality. Compared to 34 patients who underwent similar hepatic resections for HCC carcinoma with the aid of Lin's hepatic clamp, there was no statistical difference between the operation time, and intraoperative blood transfusion. However, the hospital stay was shorter in the microwave group. The change in liver function was also less remarkable in the microwave group and the postoperative complication rate was lower. We conclude that the application of microwave tissue coagulator is useful and safe in the resection of HCC.

Adult↗
PubMed1994

[Neurogenic appendicitis. A case].

Laparoscopic procedures have changed the indications for appendectomy. Routine exeresis should not be performed if a normal organ is observed during an exploratory procedure, but should be in cases with clinical manifestations of right flank pain since neurogenic appendicitis is not rare. We report a recent case observed in a 76-year-old woman. The patient was initially hospitalized for right flank pain with nausea and irregular episodes of diarrhoea. Clinical examination and complementary exploration led to cholecystectomy via subcostal access. On per-operative cholangiography the common bile duct appeared normal. Immediate follow-up was uneventful and the patient was discharged. Twelve days later, the patient complained of the same type of abdominal pain and was hospitalized with a fever at 38 degrees C and shivers. The right flank was very painful at palpation. Echography and computed tomography eliminated a subphrenic abscess or secondary pancreatitis. Pain localized at MacBurney's point 8 days later. Barium study showed a normal colon with the exception of uncomplicated diverticulosis. Subjective pain persisted and appendectomy was decided. Pathological examination revealed neurogenic appendicitis. First described in 1924, neurogenic appendicitis is relatively frequent. Macroscopically, a sclerous fibromyxomatous nodule obliterates the lumen. Microscopically, the central obliterating lesion is composed of hyperplastic nervous tissue in a fibromyxoid matrix, particularly important at the point of the appendix. Clinically neurogenic appendicitis is usually chronic and the appendix appears healthy in situ. Cure is always achieved with resection. Laparoscopic procedures can identify para-appendicular causes of painful abdominal syndromes and sclero-atrophic appendicitis, but in the absence of another explanation exeresis appears to be justified due to the possibility of neurogenic appendicitis.

Aged↗
PubMedDate not supplied

Laparoscopic liver resection in the Large White pig--a comparison between waterjet dissector and ultrasound dissector.

Resection of 16 liver lobes was successfully undertaken laparoscopically in anaesthetised Large White pigs. These animals proved to be suitable for the instruments used in human laparoscopic procedures. It was planned to undertake a comparison between the waterjet and ultrasound dissectors, but this proved impossible because of the development of a thick intraabdominal mist during dissection with the waterjet dissector. The ultrasound dissector was effective in dissecting the intraparenchymal hepatic structures, especially the portal vein and the hepatic vein. These blood vessels were safely secured with endoclips, while bleeding points on the resection surface were coagulated with an argon beam coagulator. The liver specimens removed were approximately 75 g in weight. All ultrasound-dissected animals survived for 10 days. Post-mortem evaluation showed two cases of wound infection, one case of subphrenic abscess and two cases of biloma. Our results emphasise the potential of laparoscopic resection techniques for formal or at least peripheral liver resections in humans.

Animals↗
PubMed1994

[Computed tomographic detection of air in the portal vein--a case report].

Two cases of portal venous gas (PVG) are presented. One case due to bowel infarction and another due to duodenal ulcer perforation complicated by a subphrenic abscess. The diagnosis was suggested from plain abdominal radiographs and confirmed by unenhanced computed tomography (CT) of the abdomen which is superior to demonstrate gas in the portal venous system. The distinction between PVG and biliary gas is briefly discussed.

Aged↗
PubMed1993

[The surgical correction of iatrogenic damage to and cicatricial stricture of the extrahepatic bile ducts].

In treatment of 86 patients with a iatrogenic injury, or cicatricial stricture of the extrahepatic bile ducts, the Prader-Smith, Saypole-Kurian transhepatic drainage of hepatico-digestive anastomosis and that with the use of the method suggested by the authors have been used. The technique for performance of the operations is described, the special instruments are offered. After the operation, only one female patient has developed a subphrenic abscess.

Anastomosis, Surgical↗
PubMed1993

[Hydatid cyst of the liver. Treatment by resection of the cyst wall. Our experience apropos of a series of 495 cases].

From January 1976 to December 1990, 495 cases of hydatid cyst of the liver were treated by resection of the cyst wall. The mean age of the patients was 42 years with a female predominance (71% of cases). Confirmation of the diagnosis was essentially based on ultrasonography. At operation, the hydatid cysts were located in the right lobe of the liver in 83% of cases. The hepatic dome (segments VII + VIII) was involved in 52% of cases. After resection of the cyst wall, biliary tract lesions required common bile duct drainage with a Kehr drain in 50 cases, transcystic drainage in 22 cases and cysto-biliary disconnection in 22 cases. In every case, drainage of the residual cyst cavity was performed by a two-way catheter. Seven deaths were recorded in this series, including one from anaphylactic shock associated with intracystic injection of formalin, 3 from bronchopulmonary complications, 2 from subphrenic abscesses and 1 after surgical revision for evisceration on the 5th day. The postoperative morbidity and, consequently, the hospital stay depended on the condition of the pericystic tissues. The mean hospital stay was 12 days in the case of soft pericystic tissues and 32 days in the case of fibrotic and calcified pericystic tissues. Due to the benign nature of hydatid cysts of the liver, the authors emphasise the value of resection of the cyst wall which carries a lower operative risk and which can be performed by most surgeons.

Adolescent↗
PubMed1993

The use of fibrin adhesive for hemostasis after liver resection.

Bleeding, biliary fistula and subphrenic abscess represent the major postoperative complications after liver surgery. Many different adjuvant methods have been developed for control of hemorrhage from the raw surface of liver, but the superiority of any single method remains to be proved. The use of a two-component fibrin adhesive for the control of solid organ bleeding seems to be promising. This study was to evaluate the efficacy of this fibrin adhesive for control of postoperative bleeding in liver surgery. Forty patients were randomized into two groups, similar in all demographic and clinical conditions. Fibrin adhesive was applied to the raw surface of liver resections at the end of operations for 20 patients. Nothing was applied for the control group. Postoperative bleeding was estimated by multiplying the drain amount by the free hemoglobin concentration, every day. Estimated postoperative bleeding was 8.12 +/- 5.65 gm for patients with fibrin adhesive, 15.57 +/- 14.43 gm for control group. Fibrin adhesive has been used in the treatment of injury to the liver and spleen. In this study, it proved to be useful in the control of postoperative bleeding in liver resection, and hopefully decreasing morbidity.

Adult↗
PubMed1993

Combined penetrating rectal and genitourinary injuries: a challenge in management.

The standard management of penetrating rectal trauma consists of perioperative antibiotics, a diverting colostomy, and presacral drainage. While providing optimal results in isolated rectal trauma, this management scheme is inadequate in combined penetrating rectal and genitourinary (GU) tract injuries. A review of more than 200 cases of penetrating rectal trauma from our institution over a 13-year period identified 17 concomitant GU tract injuries (13 bladder, three urethral, and one ureteral injury). Complications consisted of pelvic, suprapubic, or subphrenic abscesses in 3 of 17 cases (18%), rectovesical or rectourethral fistulae in 24%, chronic urinary tract infections in 18%, bladder stones in 12%, and the development of urethral strictures in 12% of patients. Factors implicated in their pathogenesis included failure to perform presacral drainage, distal rectal washout, and rectal wound repair; prolonged suprapubic drainage; and failure to separate the rectal and GU tract wounds. Careful debridement of all necrotic tissue, urinary and fecal diversion, tension-free wound closure with well-vascularized tissue, and adequate drainage and separation of the injured sites with well-vascularized tissue such as omentum should reduce the high incidence of rectourethral and rectovesical fistulae from combined rectal-GU tract trauma. Therapeutic recommendations for individualized treatment are presented.

Adolescent↗
PubMed1995

[Treatment of esophageal fistulas after gastrectomy. Apropos of 4 cases].

The authors report 4 cases of esophageal fistula following a total gastrectomy. One patient died after a reoperation for a subphrenic abscess, another just before a coloplasty 3 months after an esophageal exclusion. Two patients have been successfully treated by an operation which comprised the removal of the fistula and an intra-thoracic esophago-jejunal anastomosis. This procedure, albeit risked, is probably a better option than the esophageal exclusion usually recommended, particularly in the patients with a malignant disease who have a short life expectancy.

Adenocarcinoma↗
PubMedDate not supplied

[Video-assisted surgery in the management of thoracic problems].

OBJECTIVE: To review the experience in minimally invasive videoassisted surgery for the diagnosis and treatment of thoracopulmonary problems. METHOD: Retrospective review of the clinical charts of patients submitted to thoracic videoassisted surgical procedures at the Instituto Nacional de Nutrición Salvador Zubiran from February 1993 to March 1995. RESULTS: A total of 102 patients were submitted to videoassisted thoracic surgery. There were three main indications for the procedure: 1) pleural disease (n = 30); 2) pulmonary disease (n = 66); and 3) various (n = 6). A total of 129 procedures were performed: 38 pleural procedures (biopsy 15, decortication 8, talc poudrage 7, revision/lavage 6, section of adhesions 1, and pleural abrasion 1), 75 pulmonary procedures (lung biopsy 32, pulmonary nodule wedge resection 30, large core needle biopsy 8, bullae resection 3, videoassisted lobectomy with minithoracotomy 2), and 16 various procedures (biopsy of mediastinal adenopathy 6, pericardial window 4, pericardial biopsy 4, subphrenic abscess 1, intercostal artery clippage 1). Morbidity appeared in three patients (two prolonged air leaks and one empiema) and two patients died (one cirrhotic patient who developed postoperative acute hepatic failure and a patient with lupus erythematosus who developed sepsis). All other patients had an uneventfull postoperative course with a mean pleural drainage of 1.76 days for pulmonary procedures (range 0.5-3 days) and 4.6 days for pleural procedures (range 2-15 days). CONCLUSIONS: The use of the videothorascope as an adjuvant in thoracic surgery allows the surgeon to perform different procedures using minimally invasive techniques. Indications are the same as for any thoracic surgical procedure and the general philosophy must be to establish a compromise between minimal invasion of the patient and the correct solution for the particular problem being treated.

Adolescent↗
PubMedDate not supplied

[Emergency surgical treatment in cancer of the colon].

The diagnostic delay which accompanies the colon-rectum neoplastic desease makes that complications are often the first signal. This work means to prove, according to our experience, that the incidence of these complications is high and that only in a few patients undergoing emergency treatment is possible a one-stage procedure with radical purpose. In our survey, since Genuary 1975 to December 1993, 473 patients (255 males and 218 females) affected of colon-rectum cancer were treated: among these 54 (11.5%) underwent emergency surgery. The neoplasm was located: in the rectosigmoid junction in 25 cases (46.3%) in the caecum or in the right colon in 10 cases (18.6%), in the left colon and in the hepatic flexure in 6 cases (11.1%), in splenic flexure in 4 cases (7.4%), and in the trasversum colon in 3 cases (5.5%). According to Astler & Coller classification 22 patients (40.8%) were C2, 17 (31.5%) were D, 11 (20.4%) were B2, 3 (5.5%) were A, and only 1 patient (1.8%) was C1. 16 patients (29.7%) underwent a one-stage procedure, 8 (14.9%) had a first stage with a colostomy added together with resective procedure, and 3 (5.5%) patients had a Hartmann procedure. In 27 (50%) patients was possible only a palliative procedure. Finally, 10 patients (18.5%) had post-operative complications such as anastomotic fistula, wound's leakage or subphrenic abscess, and 11 patients (20.4%) died for cardiac insufficiency, ARDS, renal failure or cerebral stroke.

Adolescent↗
PubMed1995

[The use of low-frequency ultrasound in surgical practice in thoracic surgery].

To gain better insight into the intimate mechanisms of action of low-frequency ultrasound in surgical practice, and to establish the indications for its practical implementation in concrete cases, the preliminary results in patients operated in the clinic of thoracic surgery of the State Institute Hospital of Pulmonary Diseases "St. Sofia"--Higher Medical Institute, Sofia, are reported. For the purpose the Russian ultrasound apparatus URSK-7N-18 is successfully employed. Following a concise technical characterization of the URSK-7N-18 parameters of action, clinical cases are described where ultrasound treatment with the apparatus is successfully used for the purpose of prophylaxis against pulmonary carcinoma recurrences, and serious purulent complications (mediastinitis, pleural empyema, subphrenic abscess). The method of intraoperative ultrasound treatment with the apparatus does not imply special qualification of the surgeon. The only requirement is to secure gradual filling of the respective cavity with normal serum, simultaneously with the ultrasound treatment, effected from the cavity bottom to its borders over a 10-minute period.

Adult↗
PubMed1995

[Complications of elective hepatic resections. Analysis of risk factors].

In the last decades the hepatic surgery has been more and more employed thanks to improvement of the surgical technique and of the post-operative assistance which have brought the peroperative mortality of principal specialistic centres to less of 5%. The main post-operative complications which trouble the hepatic surgery, forming in same cases the cause of the death, are: hepatic insufficiency, haemorrhage, subphrenic abscess and the appearance of biliary fistulas. These complications are often connected and linked to the devitalization of a part of the residual parenchyma. We have made a retrospective study on a series of 214 hepatic resections, executed in election, to estimate the main pre and intra-operative risk factors. The operative mortality has been zero whereas the post-operative one is occurred in 4.2% of the cases with a morbidity of 27.5%. In our experience the meaning full factors to prefigure an operative risk are resulted: the associated pathologies like diabetes, cardiopathies, ipertension and bronchopathies; the length of the operation; the entity of the peroperative haematic loss and of the consequent transfusional therapy and eventually quality the residual parenchyma.

Adolescent↗
PubMedDate not supplied

Esophageal fistulae. Results of conservative treatment.

Twenty-one consecutive cases of esophageal fistulae (EF), were studied to assess their etiology, the associated thoracopulmonary pathology and evaluate the usefulness of simultaneous partial exclusion of the esophagus and treatment of the present thoracopulmonary complications. EF were 6 cervical, 13 thoracic and 2 abdominal. The different types were: esophagopleural 8, esophagotracheal 7, esophagobronchial 1, congenital 1 and diverse type 4. Tracheal manipulation was the cause in 6, mistaken surgical procedures were an important etiologic factor in 9, improper use of dilators in 3 and different causes in 3. Esophageal reflux was the common antecedent, but 9 cases had normal esophagus before the EF. Pleural empyema, mediastinitis and aspiration pneumonia were major complications, two cases had subphrenic abscess. Treatment was based on partial exclusion of the esophagus, drainage of pleural and mediastinal infections, proper antimicrobial therapy and nutritional support. Four required thoracotomy. Eighteen patients were cured and 3 died.

Adolescent↗
PubMed1996

Major extended hepatic resections in diseased livers using hypothermic protection: preliminary results from the first 12 patients treated with this new technique.

BACKGROUND: Hepatic vascular exclusion allows the performance of major hepatic resections with minimal intraoperative blood loss. We have previously shown that normothermic ischemia can be tolerated by a healthy liver for up to 90 minutes, and this period is increased to 4 hours if the liver is cooled to 4 degrees C using University of Wisconsin solution. STUDY DESIGN: This study assessed whether these techniques could be successfully applied for patients requiring resection of a diseased liver, which is more sensitive to ischemic damage. Between July 1990 and May 1994, 12 patients (6 men, 6 women; mean age, 57.8 years) in whom the planned hepatic resection was believed to require hepatic vascular exclusion for more than 1 hour were treated with perfusion with the University of Wisconsin solution. The surgical procedures were right hepatectomy (one patient), extended right hepatectomy (seven patients), and extended left hepatectomy (four patients). The underlying hepatic disease was cirrhosis or severe fibrosis with hepatocellular carcinoma (four patients), cholestasis (due to cholangiocarcinoma and biliary stricture, one patient each), and more than 30 percent steatosis after treatment of hepatic metastases with chemotherapy (six patients). The University of Wisconsin solution that had been cooled to 4 degrees C was perfused through a cannula placed in the portal vein or the hepatic arterial branch of the segment to be resected, but with flow directed toward the liver that should be retained and effluent fluid drained through a cavotomy. Before reperfusion, the liver was rinsed with Ringer's lactate solution, which was also 4 degrees C. RESULTS: The mean duration of hepatic ischemia was 121 minutes (range, 65 to 250 minutes), and venovenous bypass was used in three cases. The mean amount of blood transfused intraoperatively was 4.3 +/- 4 U; four cases required no transfusion. One patient died on postoperative day seven of portal vein thrombosis. The median hospital stay was 21 days (range, 12 to 56 days). Postoperative complications consisted of pneumonia (one patient), liver insufficiency (one patient, who recovered spontaneously), and subphrenic abscess (one patient). The postoperative tests of hepatic function were altered to the same degree as that seen after hepatic vascular exclusion of less than 1-hour duration in healthy livers. All patients who left the hospital were alive at 1 year. CONCLUSIONS: Cooling of the hepatic parenchyma allowed us to perform major hepatic resection in patients with diseased livers using hepatic vascular exclusion for longer than 1 hour without increased morbidity or mortality. However, because of particular difficulties due to the size or location of the lesions, the application of these new techniques should only be considered for the largest and most complex hepatic resections for which hepatic vascular exclusions longer than 1 hour are foreseen.

Adenosine↗
PubMed1977

Advanced hyperbilirubinemia simulating obstructive jaundice after choledocholithotomy. Report of a case.

A case of intrahepatic cholestatic jaundice of unclear etiology and unusual course is described. A male patient underwent choledocholithotomy after PTC, showing a normal immediate postoperative recovery, but after a few days developed a severe cholestatic jaundice despite normal postoperative cholangiograms. The liver function tests showed a biphasic picture. Bilirubin was maximally 770 mumol/l and a lower level was obtained after blood exchange and subphrenic abscess drainage. It was, however, not until prednisolone treatment was induced that a slow continuous decrease of bilirubin was seen.

Aged↗
PubMed1997

Complications following cholecystectomy.

Laparoscopic cholecystectomy is considered the gold standard for cholelithiasis. Nevertheless possible complications must not be underestimated. In this department, from 1 July 1991 to 30 November 1995, 1005 patients with cholelithiasis underwent videocholecystectomy. There was no peri-operative mortality. In 36 cases (3.6%) the procedure was changed to laparotomy. In four cases (0.4%) conversion was mandatory due to severe complications: in three patients while introducing a trocar (one aortic lesion, one middle colic vein injury and one visceral perforation) and in one patient due to bleeding in the hepatic hilar region. In 32 cases (3.2%) conversion was carried out electively. This was due to technical difficulties or to choledocholithiasis (22 patients), anaesthesiological problems (three cases), biliodigestive fistula (one), bile spillage from accessory hepatic ducts (three), unexpected colonic cancer (one), instrument malfunction (two cases). Twenty-four patients (2.4%) experienced post-operative complications: one with pneumothorax, two with bile leakage (one bile duct damage, and one cystic duct leakage), eight with haemoperitoneum, five with subphrenic abscess, three with anaemia, three with intraparietal collections, one with bilateral basal bronchopneumonia, one with perforated duodenal stress ulcer. Of these, 11 patients (1%) underwent reintervention: five re-laparoscopies, three conversions, and three open laparotomies. This study demonstrates the safety of videolaparocholecystectomy. Complications are relatively rare and can be often dealt with conservative treatment or re-laparoscopy. Complications are often linked to insertion of a blind trocar or to the induction of a closed pneumoperitoneum. Meticulous technique or open laparoscopy minimize these risks. Conversion must not be considered a defeat but a wise decision in the face of major difficulties. Under these principles, videocholecystectomy is safe and represents the best treatment of gallbladder stones.

Adult↗