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PubMed1996

Nonoperative management for intra-abdominal abscesses.

Percutaneous drainage of an intra-abdominal abscess is utilized frequently. To evaluate its effectiveness at our institution over 16 months, 18 patients (mean age 49 years) who underwent radiologically directed percutaneous drainage of intra-abdominal abscesses were retrospectively reviewed. The abscesses were postoperative in 14 patients (laparotomy, 5; appendectomy, 4; colectomy, 3; hysterectomy, 2). Primary abscesses were due to diverticular disease (3), perforated appendicitis (3), perforated colon carcinoma (1), and perforated peptic ulcer (1). Percutaneous drainage was ultimately established in all patients with complete resolution of the abscesses occurring in 12 patients (67%). The average duration for drainage was 5.5 days (range 1-23). Average length of hospital stay after the establishment of drainage was 14.6 days (range 1-48). Six patients required surgical procedures because of inadequate abscess drainage (4) or continued clinical deterioration (2). There were no deaths. A major complication (colon perforation, enteric fistula) occurred in two patients (11%). Catheter-related problems were common (7/18 patients), and included drain migration (3), inadequate drainage, and catheter obstruction(2). Four patients required multiple percutaneous drainage procedures. Despite technical feasibility and clinical success in the majority of patients, percutaneous drainage of these intra-abdominal abscesses had frequent catheter-related complications. One-third of patients (31.8%) required surgical intervention despite a prolonged period (average 15 days) of percutaneous drainage. Patients demonstrated to have nonresolving abscesses by computer tomography (CT), abscesses associated with colonic diverticular disease of colon cancer, and abscesses localized to the left lower quadrant were noted to have less successful percutaneous abscess drainage. Patients with a persistent of rising leukocyte count and/or an elevated APACHE II score prior to drainage should be routinely reevaluated at 4 days. Earlier surgical intervention is felt to be warranted because these two factors in this study were indicative of a low nonoperative success rate. Post-appendectomy abscesses uniformly demonstrated prompt response to percutaneous drainage. CT-directed percutaneous drainage of intra-abdominal abscesses provides an alternative to immediate surgical intervention. The preliminary findings from this study suggest a limited application of this intervention in one-third of patients. Further detailed analysis of this patient group is required to delineate guidelines for identifying those patients where percutaneous drainage is unlikely to be successful.

APACHE↗
PubMed2005

Chronopharmacology and controlled drug release.

Circadian rhythms in the body are well established and are an important factor to consider when administering drugs. Many diseases display symptoms and onset characteristics that are not randomly distributed within 24 h (e.g., coronary infarction, angina pectoris, asthmatic attacks and peptic ulcer perforations); therefore, it is not surprising that the effects and/or pharmacokinetics of drugs can display significant daily variations. Recent data, primarily concerned with the chronopharmacokinetics of antiasthmatics, histamine H2-blockers and cardiovascular active drugs (e.g., propanolol, organic nitrate and nifedipine) are described as representative examples in this review. The data demonstrate that biological rhythms should have been taken into account when evaluating drug delivery systems, galenic formulations and pharmacokinetics as a basis for drug treatment.

Adrenergic beta-Antagonists↗
PubMed1991

Ultrasonography in the diagnosis of acute appendicitis.

Ultrasonography with graded compression was performed in 525 patients with clinical signs of acute appendicitis. Of 207 patients with surgically proven appendicitis the inflamed appendix (diameter greater than or equal to 6 mm) had been visualized sonographically in 177 (86 per cent). The score for non-perforated appendicitis (91 per cent) was higher than for perforated appendicitis (55 per cent). Twenty-four patients in whom an inflamed appendix was seen on ultrasonography did not undergo surgery because of rapidly subsiding symptoms ('abortive appendicitis'). Four of these 24 developed recurrent appendicitis warranting surgery. Two underwent elective appendectomy and 18 have remained symptom-free. Of 155 patients with a subsequently confirmed alternative condition, ultrasonography made the correct diagnosis in 140: bacterial ileocaecitis (69), mesenteric lymphadenitis (eight), gynaecological conditions (34), urological conditions (eight), caecal diverticulitis (six), perforated peptic ulcer (six), Crohn's disease (two) and miscellaneous conditions (seven). Of 139 patients in whom no definite diagnosis was made ultrasonography showed no abnormalities in 138. In four patients a false positive sonographic diagnosis of appendicitis was made and in two patients with appendicitis an alternative condition was incorrectly diagnosed. During the last 3 years of the study the negative appendicectomy rate was 7 per cent and delay beyond 6 h after admission occurred in only 2 per cent of patients with surgically proven appendicitis. When used to complement the clinical diagnosis ultrasonography improves the diagnostic accuracy and patient management in those suspected of having acute appendicitis.

Acute Disease↗
PubMed2006

Optimal injection volume of epinephrine for endoscopic treatment of peptic ulcer bleeding.

AIM: To define the optimal injection volume of epinephrine with high efficacy for hemostasis and low complication rate in patients with actively bleeding ulcers. METHODS: This prospective, randomized, comparative trial was conducted in a medical center. A total of 228 patients with actively bleeding ulcers (spurting or oozing) were randomly assigned to three groups with 20, 30 and 40 mL endoscopic injections of an 1:10000 solution of epinephrine. The hemostatic effects and clinical outcomes were compared between the three groups. RESULTS: There were no significant differences in all background variables between the three groups. Initial hemostasis was achieved in 97.4%, 98.7% and 100% of patients respectively in the 20, 30 and 40 mL epinephrine groups. There were no significant differences in the rate of initial hemostasis between the three groups. The rate of peptic ulcer perforation was significantly higher in the 40 mL epinephrine group than in the 20 and 30 mL epinephrine groups (P < 0.05). The rate of recurrent bleeding was significantly higher in the 20 mL epinephrine group (20.3%) than in the 30 (5.3%) and 40 mL (2.8%) epinephrine groups (P < 0.01). There were no significant differences in the rates of surgical intervention, the amount of transfusion requirements, the days of hospitalization, the deaths from bleeding and 30 d mortality between the three groups. The number of patients who developed epigastric pain due to endoscopic injection, was significantly higher in the 40 mL epinephrine group (51/76) than in the 20 (2/76) and 30 mL (5/76) epinephrine groups (P < 0.001). Significant elevation of systolic blood pressure after endoscopic injection was observed in the 40 mL epinephrine group (P < 0.01). Significant decreasing and normalization of pulse rates after endoscopic injections were observed in the 20 mL and 30 mL epinephrine groups (P < 0.01). CONCLUSION: Injection of 30 mL diluted epinephrine (1:10000) can effectively prevent recurrent bleeding with a low rate of complications. The optimal injection volume of epinephrine for endoscopic treatment of an actively bleeding ulcer (spurting or oozing) is 30 mL.

Aged↗
PubMed2000

[Perforated duodenal ulcer: laparoscopic treatment of perforation and ulcerous disease].

STUDY AIM: The aim of this retrospective study was to report a continuous series of 44 perforated duodenal peptic ulcers operated on through laparoscopic approach with curative treatment of the peptic ulcer disease for socioeconomic purpose. PATIENTS AND METHOD: From February 1995 to May 1996, 44 patients were operated on laparoscopically. There were 42 men and two women (mean age: 36 years). All patients had peritonitis with pneumoperitoneum in 68%. Duodenal peptic ulcer was known in 12 patients and antecedent of episodic epigastric pain were present in 27. Four trocads were used. The diagnosis was confirmed by abdominal exploration and peritoneal lavage was performed with physiological serum. RESULTS: The procedures were: suture of perforated ulcer associated with posterior vagotomy and anterior seromyotomy (n = 6), with troncular vagotomy and pyloroplasty (n = 24) and single suture (n = 1). A conversion into laparotomy was necessary in 13 patients (29.5%). There was no mediastinitis, no postoperative death. Peritonitis by leakage occurred in two patients who were reoperated by laparotomy; mean duration of hospital stay was 5.5 days. With a one-year follow-up, all patients were in good condition, free of pain. CONCLUSION: With laparoscopic surgery, diagnosis of peptic ulcer perforation was confirmed, peritoneal lavage was perfectly done, duodenal perforation was sutured and surgical treatment of the peptic ulcer disease was performed, which is important in poor countries.

Adult↗
PubMed1997

Improved treatment outcome in adult acute lymphoblastic leukemia using the intensive German protocol, a preliminary report.

Thirty-nine consecutive patients with acute lymphoblastic leukemia were treated with an intensive chemotherapy protocol. There were 23 males and 16 females with a median age of 37 years (range: 15-65). Eighteen patients had common ALL, seven had pre-B ALL, three early-precursor B ALL, seven T-ALL and four had aberrant expression of myeloid antigens (c-ALL in three and pre-B ALL in one). The median initial leukocyte count was 11.8 x 10(9)/l (range: 0.65-295). Cytogenetic result of the marrow was available in 16 of 39 patients (41 per cent) and showed Philadelphia positivity in six, a normal result in six and one each of t(4,11), t(1,19), hyperdiploidy and del 12p. Hepatosplenomegaly was present in about 20 per cent of the patients. L-Asparaginase-related hepatic toxicity was the commonest toxicity (48.7 per cent) during phase I of induction. Prolonged pancytopenia and hypoplastic death were common during phase II. With the use of growth factors during the neutropenic period of phase II induction, the rate of hypoplastic death was reduced from 40 per cent to 3 per cent. Common causes of treatment failure included early hypoplastic death (27.8 per cent) and leukemia relapses (50 per cent) while primary refractory leukemia, hepatic failure and perforated peptic ulcer contributed to 11.1, 5.5 and 5.5 per cent of the other deaths. A high complete remission (CR) rate (87.4 per cent) was achieved after phase I induction. The median event-free survival (EFS) was 8 months and the 3-year event-free survival was 43 per cent. This result compared favourably to the other regimens previously employed in our institution. In conclusion, satisfactory survival can be achieved with this intensive regimen. Good supportive care was however, essential to minimize toxicities.

Adolescent↗
PubMed1990

Modern aids to clinical decision-making in the acute abdomen.

Acute abdominal pain continues to provide not only a large workload for the general surgeon but also many diagnostic and management problems. Many different techniques have been introduced over the past two decades to help in the management of the acute abdomen and this review considers their relative claims to become incorporated into the process of clinical decision-making. The evidence in support of formally structured patient interview pathways with or without computer-aided diagnostic programs is now overwhelming and should become routine. Both laparoscopy and peritoneal cytology have an important role to play in the management of patients in whom the decision to operate is in doubt, and a combination of the two would be complementary. Ultrasonography has become increasingly popular for investigating the acute abdomen, and results from specialist centres are impressive. However, the problems of operator variation and the difficulties in providing a 24-h service will probably prevent it from becoming a first-line investigation in most hospitals. Although plain radiography has been available for many years, its routine use in the management of the acute abdomen remains controversial. Recent studies have confirmed that contrast radiography is an important adjunct to decision-making, particularly in the management of large bowel obstruction, and there is increasing evidence to support its use in suspected small bowel obstruction, perforated peptic ulcer and acute diverticular disease.

Abdomen, Acute↗
PubMed1993

Emergency laparoscopic surgery.

The acute abdomen continues to demand a large proportion of the general surgeon's workload. Recent studies have demonstrated that management errors can be significantly reduced using selective laparoscopy and this should now become routine practice. The continuing advances in laparoscopic surgery that permit many emergency procedures to be performed by this route provide increased impetus for a combined approach using diagnostic and therapeutic laparoscopy for the management of the acute abdomen. Results of current studies must be awaited before the exact role of emergency laparoscopic surgery can be defined, but early reports suggest several advantages in using laparoscopy to manage conditions such as acute appendicitis, perforated peptic ulcer and gynaecological emergencies.

Abdomen, Acute↗
PubMed2001

[Laparoscopic surgery of the upper gastrointestinal tract].

Laparoscopic surgery of the upper gastrointestinal tract is nowadays associated with little morbidity and mortality. Cardiomyotomy with semifundoplication for management of achalasia and the various forms of fundoplication for treatment of reflux syndrome have proved beneficial and have largely replaced conventional surgery. Independent of the operative approach, it has not yet been established with certainty whether gastroesophageal reflux can best be prevented by 360 degrees fundoplication or semifundoplication. A perforated peptic ulcer can be treated effectively by laparoscopic overstitching of omental patch-plasty, although the superiority of the laparoscopic method has yet to be proved. Benign lesions and early malignancies are currently resected laparoscopically, but the role of laparoscopy in the curative treatment of advanced gastric carcinoma remains to be clarified. Diagnostic laparoscopy is used to avoid unnecessary laparotomy in inoperable cancer and to ascertain whether neoadjuvant therapy is indicated in advanced gastric carcinoma.

Esophageal Diseases↗
PubMedDate not supplied

Gastrointestinal tract perforation: CT diagnosis of presence, site, and cause.

Gastrointestinal tract perforation is an emergent condition that requires prompt surgery. Diagnosis largely depends on imaging examinations, and correct diagnosis of the presence, level, and cause of perforation is essential for appropriate management and surgical planning. Plain radiography remains the first imaging study and may be followed by intraluminal contrast examination; however, the high clinical efficacy of computed tomographic examination in this field has been well recognized. The advent of spiral and multidetector-row computed tomographic scanners has enabled examination of the entire abdomen in a single breath-hold by using thin-slice sections that allow precise assessment of pathology in the alimentary tract. Extraluminal air that is too small to be detected by conventional radiography can be demonstrated by computed tomography. Indirect findings of bowel perforation such as phlegmon, abscess, peritoneal fluid, or an extraluminal foreign body can also be demonstrated. Gastrointestinal mural pathology and associated adjacent inflammation are precisely assessed with thin-section images and multiplanar reformations that aid in the assessment of the site and cause of perforation.

Barium Sulfate↗
PubMed2002

Nontraumatic abdominal emergencies: acute abdominal pain: diagnostic strategies.

Common causes of acute abdominal pain include appendicitis, cholecystitis, bowel obstruction, urinary colic, perforated peptic ulcer, pancreatitis, diverticulitis, and nonspecific, nonsurgical abdominal pain. The topographic classification of acute abdominal pain (pain in one of the four abdominal quadrants, diffuse abdominal pain, flank or epigastric pain) facilitates the choice of the imaging technique. The initial radiological evaluation often consists of plain abdominal radiography, despite significant diagnostic limitations. The traditional indications for plain films--bowel obstruction, pneumoperitoneum, and the search of ureteral calculi--are questioned by helical computed tomography (CT). Although ultrasonography (US) is in many centers the modality of choice for imaging the gallbladder and the pelvis in children and women of reproductive age, CT is considered to be one of the most valued tools for triaging patients with acute abdominal pain. CT is particularly beneficial in patients with marked obesity, unclear US findings, bowel obstruction, and multiple lesions. The introduction of multidetector row CT (MDCT) has further enhanced the utility of CT in imaging patients with acute abdominal pain.

Abdominal Pain↗
PubMed2003

Increased transperitoneal bacterial translocation in laparoscopic surgery.

BACKGROUND: The indications for laparoscopic surgery have expanded to include diseases possibly associated with peritonitis such as appendicitis, perforated peptic ulcers, and diverticulitis. The safety of carbon dioxide (CO2) pneumoperitoneum in the presence of peritonitis has not been proved. Our previous investigations demonstrated increased bacteremia associated with CO2 insufflation. In effort to clarify the relative effects of intraabdominal pressure and type of gas, this study was designed to measure bacterial translocation with different gases at different pressures of pneumoperitoneum. METHODS: For this study, 110 rats were given intraperitoneal bacterial innoculations with Escherichia coli and equally divided into five groups of 20 animals each. The study groups included a control group with no pneumoperitoneum administered (n = 30), insufflation at a commonly used pressure of 14 mmHg with helium (n = 20) and CO2 (n = 20), and low insufflation at 3 mmHg with helium (n = 20) and CO2 (n = 20) in an effort to minimize influences related to pressure. Blood cultures were checked at 15-min intervals for the first 45 min, then hourly thereafter for a total of 165 min after peritoneal inoculation with 2 x 10(7) E. coli. RESULTS: There is increased risk of bacterial translocation in comparing groups that underwent pneumoperitoneum with those that did not in the rat peritonitis model. Furthermore, these findings are dependent on the presence or absence of gas, but not necessarily on the type of gas used for insufflation. In the low-pressure groups of both gases (helium and CO2), bacterial translocation was significantly increased, as compared with the control group. Low pressure also was associated with increased bacterial translocation, as compared with high pressure, but beyond 30 min of insufflation, no significant differences were apparent. CONCLUSIONS: The risk of bacterial translocation in the E. coli rat peritonitis model is increased with insufflation using CO2 or helium, and this effect is more significant at lower pressures (3 mmHg) than at higher pressures (14 mmHg). However, no clinically applicable conclusions regarding the relative effects from type of gas or insufflation pressures could be confirmed.

Animals↗
PubMed2005

Laparoscopy for abdominal emergencies: evidence-based guidelines of the European Association for Endoscopic Surgery.

BACKGROUND: Emergency laparoscopic exploration can be used to identify the causative pathology of acute abdominal pain. Laparoscopic surgery also allows treatment of many intraabdominal disorders. This report was prepared to describe the effectiveness of laparoscopic surgery compared to laparotomy or nonoperative treatment. METHODS: A panel of European experts in abdominal and gynecological surgery was assembled and participated in a consensus conference using Delphi methods. The aim was to develop evidence-based recommendations for the most common diseases that may cause acute abdominal pain. RECOMMENDATIONS: Laparoscopic surgery was found to be clearly superior for patients with a presumable diagnosis of perforated peptic ulcer, acute cholecystitis, appendicitis, or pelvic inflammatory disease. In the emergency setting, laparoscopy is of unclear or limited value if adhesive bowel obstruction, acute diverticulitis, nonbiliary pancreatitis, hernia incarceration, or mesenteric ischemia are suspected. In stable patients with acute abdominal pain, noninvasive diagnostics should be fully exhausted before considering explorative surgery. However, diagnostic laparoscopy may be useful if no diagnosis can be found by conventional diagnostics. More clinical data are needed on the use of laparoscopy after blunt or penetrating trauma of the abdomen. CONCLUSIONS: Due to diagnostic and therapeutic advantages, laparoscopic surgery is useful for the majority of conditions underlying acute abdominal pain, but noninvasive diagnostic aids should be exhausted first. Depending on symptom severity, laparoscopy should be advocated if routine diagnostic procedures have failed to yield results.

Abdomen↗