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PubMed2000

[Timely management of bile duct complications after laparoscopic cholecystectomy].

INTRODUCTION: Bile duct complications after laparoscopic cholecystectomy occur twice to three times more frequently than after an open procedure. Four different types of lesions may be differentiated by the Siewert classification: postoperative bile fistulas (type I), late strictures (type II), tangential injuries of the bile duct (type III) and defect lesions (type IV). The diagnostic and therapeutic management is demonstrated in relation to our own experience and the literature. METHODS: Eleven patients (median age 43.8 +/- 17.2) with bile duct complications after laparoscopic cholecystectomy were operatively treated between November 1993 and December 1998. Nine patients (four type-II lesions, five type-IV lesions) were referred from another hospital; 2 defect lesions out of 410 laparoscopic cholecystectomies (0.5%) were documented in our own patient group. RESULTS: Four patients with late strictures were operatively treated with a hepaticocholedochostomy (n = 2) or hepaticojejunostomy (n = 2) after 14.3 +/- 8.4 months and were discharged from hospital after 10.6 +/- 3.8 days. In both cases with type-IV lesion and a short defect, an end-to-end anastomosis was successful (hospital stay 11.6 +/- 1.0 days). However, a retrocolic Roux-Y end-to-side hepaticojejunostomy was performed in all cases with a larger defect (n = 5; hospital stay 14.8 +/- 2.0 days). The two defect lesions in our own group were detected by intraoperative cholangiography and immediately treated after conversion either with hepaticocholedochostomy or hepaticojejunostomy (hospital stay 11.2 +/- 0.6 days). CONCLUSIONS: The incidence of bile duct complications after laparoscopic cholecystectomy might be kept down by anatomic preparation, selective intraoperative cholangiography and early consideration of conversion to open procedure. The clinical course after biliary tract injury can be positively influenced only by a standard diagnostic and operative procedure and by an early transfer to a specialized center.

Adult↗
PubMedDate not supplied

Undiagnosed retroperitoneal mass. Report of a case in which needle aspiration cytodiagnosis led to investigation and timely management.

Needle aspiration cytology of an undiagnosed retroperitoneal mass was performed on a 37-year-old male. The cytologic findings were highly consistent with a seminoma. In the differential diagnosis the possibility of non-Hodgkin's lymphoma, melanocarcinoma and metastatic adenocarcinoma was considered. The cytologic features in the aspirate included uniform, single to loose groups of malignant cells with round nuclei and prominent nucleoli and pale cytoplasm with occasional vacuoles. A variable number of lymphocytes were intermingled with the neoplastic cells. On immunostaining, the markers for lymphoma, melanoma and epithelial malignancy were negative, while alpha-1-antitrypsin was positive in malignant cells, and alkaline phosphatase activity was weakly positive in the cytoplasm. In view of the cytologic diagnosis, a clinical examination of the testes was undertaken and followed by an ultrasound examination, which demonstrated a well-demarcated tumor in the left testis. It was removed and diagnosed as a typical seminoma. This case is of interest since needle aspiration cytodiagnosis not only suggested the correct diagnosis in an otherwise-undiagnosed retroperitoneal mass but also led to a timely investigation and correct management.

Adult↗
PubMedDate not supplied

[Clinic structure and timely management of emergency cesarean section--reference values and recommendations].

GOAL: This retrospective clinical study was performed to analyze the relationship between the time course of an emergency Cesarean Section and the structural, logistic and circadian aspects of the clinical environment. METHODS: Statistical analysis was based on architectural and structural data from 132 Departments of Obstetrics in the region of Northrhine-Westfalia, Germany. Hospitals were compared in four groups of equal size defined by the number of deliveries per year. Data were available on 207 emergency C-Sections from 66 participating hospitals. The time of the day of each delivery was rounded to full hours. RESULTS: The size of the hospital was a highly significant predictor (p < 0.001) of the time elapsing between decision making and delivery (DD-interval) and of the preparation time required prior to the start of the operation: With increasing number of yearly deliveries the DD interval decreased from 31 minutes (SD = 15) to 19 minutes (SD = 7) with respective set-up times of 26 minutes (SD = 15) and 15 minutes (SD = 7) respectively. The time of the day had a significant influence on both variables (p < 0.05) with emergency C-Sections being slowest between 1:00 a.m. and 7:00 a.m. The mean time intervals observed may serve as a reference for the individual hospital situation: A preparation time of 15 minutes, time from start of surgery until delivery of 4 minutes and a DD interval of 19 minutes. CONCLUSIONS: The data presented in this study underline the importance of the immediate availability of a complete emergency team consisting of midwife, obstetrician, anesthesiologist, OR nursing staff and pediatrician. While not necessarily arguing in favor of a concentration of obstetrical practice in specialized centers, the following recommendations might be worth considering for any given clinical setting: 1. Immediate availability of a complete team is essential, especially during the night. 2. Well defined steps of urgency in agreement between all disciplines involved improve communication and save time. 3. The emergency C-Section in the delivery room may be a worthwhile alternative in the individual case. 4. Flexibility in the decision making process may increase efficiency. 5. Practice drills may help to identify weaknesses in the interaction and coordination of the team. 6. A functional hospital architecture is important to avoid unnecessary and uncontrollable delays. 7. Adequate training programs for the obstetrical team are essential with special emphasis on the early diagnosis of fetal distress and maternal complications.

Cesarean Section↗