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At least 1,369 records · Page 76Linked to original sources
PubMed1997

Complications of surgical endoscopy. A decade of experience from a surgical residency training program.

BACKGROUND: This study examines the notion that gastrointestinal endoscopy performed by supervised surgical residents is safe. METHODS: We reviewed all gastrointestinal endoscopic procedures performed by surgical residents with faculty supervision for complications and deaths occurring up to 30 days following the procedures. RESULTS: The overall complication rate for 9,201 upper and lower endoscopy procedures was 1.4% and 0.42%, respectively. Overall mortality rate was 0.76% for upper endoscopy and 0.6% for lower endoscopy. No mortality was a direct result of a procedure-related complication. Intestinal perforation, drug overdose, bleeding, and aspiration were the most common procedure-related complications. Each resident completed an average of 75 upper endoscopies and 79 lower endoscopies during their training period. CONCLUSIONS: Gastrointestinal endoscopy can be performed safely by surgical residents with appropriate supervision. The higher morbidity and mortality of upper endoscopy are most likely related to the underlying disease rather than the procedure. Awareness of common complications and application of appropriate precautions and instruction are critical for minimizing complications.

Adult↗
PubMed1997

Laparoscopic pancreaticoduodenectomy in the porcine model.

BACKGROUND: Minimally invasive techniques offer theoretical advantages for treating resectable periampullary neoplasms. Laparoscopic pancreaticoduodenectomy (LPD) was first reported in 1992 and has been performed clinically despite lack of animal data to support the operation. The purpose of this study was to develop LPD in an acute porcine model and to assess safety and efficacy before considering clinical trials. METHODS: LPD was initiated in six domestic pigs under general anesthesia. Once pneumoperitoneum was created, five 10-mm access ports were placed (one central and two in each flank). After cholecystectomy, the duodenum was mobilized and the proximal jejunum was divided distal to the ligament of Treitz. The neck of the pancreas was separated from the superior mesenteric vein, and the midstomach was divided by a stapler. Pancreaticojejunostomy (PJ), choledochojejunostomy (CDJ), and gastrojejunostomy (GJ) were performed using interrupted sutures. The animals were immediately sacrificed and the operative site was examined. RESULTS: LPD was aborted in three animals due to complications: intestinal perforation with fecal contamination (one) and prolonged resection time >/= 2.5 h (two). LPD was completed in three animals (operative time ranged from 5.0 to 7.5 h, blood loss < 200 cc); however, at sacrifice one PJ and two CDJs had small posterior leaks. The efferent loop of the GJ was narrowed by the staple line in one pig. All animals had extensive ecchymosis of the jejunal serosa due to excessive manipulation. CONCLUSION: Despite a significant number of anastomotic leaks in the immediate postoperative period, laparoscopic pancreaticoduodenectomy is feasible in a porcine model. Further studies and technical development are necessary before laparoscopic pancreatic resection can be performed on a more widespread basis.

Anastomosis, Surgical↗
PubMed2002

Clinical and genetic features of vascular Ehlers-Danlos syndrome.

Vascular Ehlers Danlos syndrome (EDS) is a rare autosomal dominant inherited disorder of connective tissue resulting from mutation of the COL3A1 gene encoding type III collagen. Affected individuals are prone to serious vascular, intestinal, and obstetrical complications. Complications are rare during infancy but occur in up to 25% of affected persons before the age of 20 and 80% before the age of 40. Median survival is 48 years. Arterial rupture accounts for most deaths. Intestinal perforation, usually involving the colon, are less fatal. Pregnancy is a high risk for women with EDS. As for many rare orphan diseases, delayed and/or improper diagnosis can lead to inadequate or inappropriate treatment and management. Diagnosis is based on clinical findings including specific facial features, thin translucent skin, propensity to bleeding, and rupture of vessels and/or viscera. Diagnosis can be confirmed either by biochemical assays showing qualitative or quantitative abnormalities in type III collagen secretion or by molecular biology studies demonstrating mutation of the COL3A1 gene. Varied molecular mechanisms have been observed with different mutations in each family. No correlation has been established between genotype and phenotype. Diagnosis should be suspected in any young person presenting with arterial or visceral rupture, carotid dissection, or colonic perforation. There are currently no specific treatments for EDS.

Collagen↗
PubMed2006

Prospective clinical study of laparoscopic treatment of incisional and ventral hernia using a composite mesh: indications, complications and results.

The aim of this study is to establish the indications, safety, efficacy, feasibility and reproducibility of the laparoscopic technique in treating defects in the abdominal wall, including those of large dimensions, to standardise the surgical technique and to confirm the performance of the composite prosthesis used (Parietex, Sofradim). The study encompassed the period from January 2001 to December 2004 and included 178 nonselected patients (108 women and 70 men), with an average age of 56 years (range: 26-77 years) and an average body mass index (BMI) of 30 (range: 26-40). These patients were treated for either abdominal hernia (156 patients; 89.7%) or a primary defect (22 patients; 10.3%). The dimensions of the abdominal hernias treated varied from 4 to 26 cm (average: 12.1 cm). All patients were treated using the laparoscopic technique, and all meshes were placed in the intraperitoneal position. Eleven (7%) postoperative complications arose after an average follow-up period of 29 months (range: 1-48 months): seven seromas (4.4%) lasting for 4 weeks, with one becoming infected after being punctured repeatedly; we removed the infected prosthesis by laparoscopy; three (1.9%) patients with persistent neuralgia, which were resolved after 2 months with a prescription for FANS; one patient with a haematoma at the trocar site. There were also four recurrences (2.5%), all of which occurred between 1 and 3 months postsurgery: one in the 'small' group of abdominal hernias (less than 9 cm) and three in the 'large' group of abdominal hernias. With the exclusion of any primary defects, an adhesiolysis was carried out in 99.3% of the patients. In seven cases (4.4%) we carried out a raphe for speritonealisations of loops in the small intestine; in four patients (2.5%), following tenacious adhesion (one patient) and loops fixed to the previous scar by stitches (three patients), we carried out an intestinal perforation (ileus) which was sutured by laparoscopy. The average operating time was 65.6 min (range: 28-130 min), with an average postoperative period in the hospital of 2.1 days (range: 1-5 days). No conversion was observed, and mortality was zero. The results obtained during the clinical trial demonstrate the safety and efficacy of the laparoscopic technique and of the mesh used as well as the reproducibility of the technique in the intraperitoneal treatment of congenital and postincision defects in the abdominal wall, including those of large dimensions.

Adult↗
PubMed2001

Small Intestinal Infections.

The differential diagnosis of small intestinal infections is broad, making the identification and management of these disorders challenging. The majority of cases of acute diarrhea are self-limited and do not require diagnostic evaluation or treatment. Most patients do not require specific therapy, and treatment should focus on fluid and electrolyte replacement. In patients with severe, persistent, or chronic diarrhea, a careful medical history and routine stool testing are helpful in determining the cause. Pathogen-specific therapy should be given in patients in whom a pathogen is identified. In those without an identifiable pathogen, antidiarrheal agents are helpful in reducing the number of bowel movements and preventing further dehydration. Endoscopy may be helpful in patients with severe diarrhea and a negative stool evaluation, particularly in HIV-infected patients with chronic diarrhea. Surgery has a limited role in the management of small intestinal infections, but may be lifesaving in patients with intestinal perforation or small bowel obstruction.

Journal Article↗
PubMed1976

Arteritis of the aged (giant cell arteritis) and fever of unexplained origin.

Arteritis of the aged (giant cell arteritis) masquerades as a degenerative, infectious, neoplastic or even functional disorder in the elderly. In the absence of obliterative vascular changes, the diagnosis is often overlooked when too rigid diagnostic criteria are employed. Four elderly women presented with fever of unexplained origin as the initial manifestation of this disease. The temporal arteries were conspicuously normal in all four, and other traditional clinical clues, such as visual disturbances, headache or manifestations of polymyalgia rheumatica were likewise infrequent of entirely absent. Influenza immunization and uncomplicated rectal surgery preceded the onset of illness in two. Anemia and an increased erythrocyte sedimentation rate are important diagnostic features, particularly in the face of spontaneous clinical improvement accompanied by defervescence and disappearance of nonspecific liver dysfunction. Occult intestinal perforation complicated steroid therapy in one case. Significant and sometimes hectic fever may be a common pattern for this arteritis in its earliest stages, when palpably abnormal temporal arteries, obliterative vascular changes and other traditional diagnostic clues are more likely to be absent.

Aged↗
PubMed1986

Combination antibiotic therapy in pediatrics.

Combinations of beta-lactam and aminoglycoside antibiotics are frequently used in the treatment of pediatric infections. At our institution, amikacin has been the sole aminoglycoside utilized for the past five years. Such regimens are used empirically in specific patient populations to treat the pathogens most likely to be responsible for a symptom complex, e.g., sepsis in the immunocompromised host, pneumonitis in patients with cystic fibrosis, neonatal infections such as sepsis or meningitis, and infections in patients with intestinal perforations. Beta-lactam and aminoglycoside combinations are employed as definitive therapy when synergistic interactions can be predicted, such as in systemic Pseudomonas infections, viridans streptococcal endocarditis, or enterococcal infections. In all of these circumstances, we have utilized amikacin extensively as the sole aminoglycoside, with highly satisfactory results. In vitro antibiotic synergy studies, including those employing aminoglycosides such as amikacin, may be used to predict in vivo antibiotic interactions. However, definitions of in vitro synergy vary with the laboratory method used to evaluate synergy. Furthermore, recent data from our laboratory suggest that the absence of demonstrated in vitro synergy between amikacin and imipenem may not correlate with improved survival of neutropenic rats with gram-negative sepsis that are treated with both agents. Thus, in vitro studies of synergy may underestimate the frequency of improved outcomes with combination antibiotics, especially with amikacin and imipenem. There are potential risks associated with the use of multiple, broad-spectrum antibiotics, including fungal or bacterial superinfection and increased drug toxicity. Although the former is common in pediatric patients, aminoglycoside (amikacin) toxicity has rarely been a problem. Combination antibiotic regimens that include an aminoglycoside such as amikacin continue to have an important role in pediatrics and should be used empirically or definitively for the specific indications discussed.

Amikacin↗
PubMed1975

Midgut nonrotation in adults. An aggressive approach.

Five adults with midgut nonrotation were treated at Tripler Army Medical Center between January 1, 1966 and January 1, 1974. These patients usually presented with vague epigastric or lower abdominal symptoms. Initial diagnosis was generally based on barium enema studies revealing an entirely left-sided colon. However, on upper gastrointestinal series the absence of a normal duodenal "c" loop with straightening is also seen. Duodenal obstructive bands are rarely documented radiographically. Surgical intervention is frequently delayed in these patients due to the "atypical" symptoms and lack of correlation of these symptoms with objective radiographic changes. The high incidence of associated duodenal ulcer disease, the frequent occurrence of bowel obstruction, the persistence of chronic abdominal pain in the untreated patients, and the resolution of symptoms after anatomic correction point to the need for an aggressive approach to treatment in those patients who have chronic recurrent symptoms secondary to midgut nonrotation.

Adult↗
PubMed1977

A hard look at colonoscopy.

The fiberoptic colonscope represents a significant diagnostic and therapeutic acheivement in the management of colonic disease. Despite some claims to the contrary, it is not universally simple, rapid, thorough, reliable, and inexpensive or without morbidity and mortality. Until these goals are achieved through future refinements, modifications, and new instrumentation, it is strongly recommended that the indications for colonscopy be sharply defined to include the following: (1) Investigation of colonic lesions seen on two successive or one air-contrast barium enema examination. Pedunculated polyps less than 1 cm in diameter can be observed. (2) Preoperative investigation of patients with demonstrable colorectal cancer (to rule out synchronous lesions). (3) Postoperative evaluation after colectomy for carcinoma where the anastomosis is above the reach of a sigmoidoscope. (4) Evaluation of patients with inflammatory bowel disease of the colon. (5) Investigation of persistent occult or gross rectal bleeding when anoscopy, sigmoidoscopy, and barium studies are negative. Patients who represent prohibitive surgical risks because of age or systemic disease should not be considered as candidates for colonoscopy without compelling indications. The decision to biopsy rather than remove or fulgerate a detected lesion must be left to the judgment and experience of the endoscopist. The morbidity that follows polypectomy or fulgeration of sessile lesions less than 0.5 cm in diameter probably exceeds the incidence of carcinoma.

Barium Sulfate↗
PubMed1977

The modern enigma of radiation enteropathy: sequelae and solutions.

With the extended indications for abdominal and pelvic radiation therapy, administered at higher dosage levels, an increased incidence of radiation injury to the intestine can be anticipated. Increased efforts are urgently needed to develop innovative methods in the detection, prevention, and management of radiation-induced intestinal injury. Fifty cases of radiation enteropathy have been reviewed to highlight problems in management and to suggest preventive and therapeutic measures, both surgical and nonsurgical.

Abdominal Neoplasms↗