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Although outcomes after liver resection have improved, there remains considerable perioperative morbidity and mortality with these procedures. Studies suggest a primary liver cancer diagnosis is associated with poorer outcomes, bu...
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Although outcomes after liver resection have improved, there remains considerable perioperative morbidity and mortality with these procedures. Studies suggest a primary liver cancer diagnosis is associated with poorer outcomes, but the extent to which this is attributable to a higher degree of hepatic dysfunction is unclear. To better delineate this, we performed a matched pair analysis of primary versus metastatic malignancies using a national database. The American College of Surgeons National Surgical Quality Improvement Program (2005-2013) was analyzed to select elective liver resections. Diagnoses were sorted as follows: 1) primary liver cancers and 2) metastatic neoplasms. A literature review identified factors known to impact hepatectomy outcomes; these variables were evaluated by a univariate analysis. The most predictive factors were used to create similar groups from each diagnosis category via propensity matching. Multivariate regression was used to validate results in the wider study population. Outcomes were compared using chi-squared test and Fisher exact test. Matched groups of 4838 patients were similar by all variables, including indicators of liver function. A number of major complications were significantly more prevalent with a primary diagnosis; overall major morbidity rates in the metastatic and primary groups were 29.3 versus 41.6 per cent, respectively. The mortality rate for primary neoplasms was 4.6 per cent (vs 1.6%); this represents a risk of death nearly three-times greater (95% confidence interval 5 2.20-3.81, P < 0.0001) in cancers of hepatic origin. Hepatectomy carries substantially higher perioperative risk when performed for primary liver cancers, independent of hepatic function and resection extent. This knowledge will help to improve treatment planning, patient education, and resource allocation in oncologic liver resection.
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Splenosis, the autotransplantation of splenic tissue, is most commonly seen after traumatic splenic rupture and splenectomy. It also can occur during embryonic development. Intraperitoneal, intrathoracic, and retroperitoneal sites...
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Splenosis, the autotransplantation of splenic tissue, is most commonly seen after traumatic splenic rupture and splenectomy. It also can occur during embryonic development. Intraperitoneal, intrathoracic, and retroperitoneal sites have been reported. Although the presence of the splenic tissue often is asymptomatic and an incidental finding, it may present with pain or be confused with various pathologies including neoplasia. Because most pediatric splenectomies are performed for hemolytic disorders, parenchymal disruption must be contained to avoid recurrent disease. We present a case in which the devascularized spleen was contained in a bag and fragmented in situ. Splenosis developed in the retrieval port site after laparoscopic splenectomy and cholecystectomy. Port-site splenosis needs to be considered in the differential diagnosis of port-site pain and a palpable nodule postsplenectomy.
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The case of a 37-year-old man in whom a massive hemoperitoneum developed a few hours after running is described. The patient disclaimed any trauma and clearly noted that symptoms appeared after running. Findings at laparoscopy sho...
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The case of a 37-year-old man in whom a massive hemoperitoneum developed a few hours after running is described. The patient disclaimed any trauma and clearly noted that symptoms appeared after running. Findings at laparoscopy showed that the bleeding was caused by the rupture of adhesions between the omentum and left inguinal abdominal wall. These adhesions, which had resulted from a previous laparoscopic transperitoneal bilateral inguinal hernia cure, were resected. Recovery was simple and follow-up assessment was uneventful. Hemoperitoneum secondary to the rupture of intraperitoneal adhesions is very rare in the absence of precipitating trauma. However, the trauma can be trivial. Rupture of intra-abdominal adhesions has been described after sexual intercourse or mobilization of the patient under general anesthesia. Disruption of adhesions by insufflation or mobilization of organs under laparoscopy also is reported. The transperitoneal approach to laparoscopic treatment of inguinal hernia can be responsible for late intestinal obstruction caused by intra-abdominal adhesions, but late hemorrhagic complication has not yet been reported.
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Wandering spleen is an extremely rare anatomic variant with potentially serious clinical implications. Usually, splenectomy is advocated for treatment of this disease. Various methods for preserving the wandering spleen by means o...
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Wandering spleen is an extremely rare anatomic variant with potentially serious clinical implications. Usually, splenectomy is advocated for treatment of this disease. Various methods for preserving the wandering spleen by means of splenopexy have been described, including two reports on laparoscopic splenic refixation. We describe the third case in which laparoscopic splenopexy was used to manage chronic intermittent splenic torsion. In a 25-year-old woman, splenopexy was successfully performed by laparoscopic reposition and fixation of the spleen by omental pouch creation. At laparoscopy with a normal operating room setup and four trocars, a free-floating, macroscopically normal spleen attached to an abnormally long vascular pedicle with no gastrosplenic or phrenicosplenic ligaments was detected in the lower right quadrant. The spleen was repositioned and placed in the left phrenorenal angle. Splenopexy was achieved by suturing the left colophrenic ligament to the lateral diaphragm, thus creating a pouch for the inferior part of the spleen, and by suturing the gastrocolic ligament to the anterior diaphragm to create a pouch for the upper splenic pole. The postoperative course was uneventful. At a follow-up examination 3 months after the operation, the patient was well, with no further episode of recurrent abdominal pain. Ultrasonographically, the spleen was seen easily in the left hypochondrium in its normal physiologic position. Laparoscopic splenopexy is a useful option for organ-preserving therapy of the wandering spleen.
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As most readers are aware, permanently implanted devices (PMs and implantable cardioverter-defibrillators [ICDs]) can provide therapy for ventricular bradycardia regardless of cause (sinoatrial node disease, atrial tissue disease,...
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As most readers are aware, permanently implanted devices (PMs and implantable cardioverter-defibrillators [ICDs]) can provide therapy for ventricular bradycardia regardless of cause (sinoatrial node disease, atrial tissue disease, or conduction system disease), significant cardiomyopathy (modalities currently identified as cardiac resynchronization therapy, biven-tricular pacing, or heart failure pacing), hypertrophic cardiomyopathy (the left bundle-branch block activation pattern results in late depolarization of the septum, with emptying of the ventricle prior to septal movement), neurogenic syncope, carotid sinus syndrome, and long QT syndrome (pacing prevents the long-short-long RR cycles that can precipitate untoward tachyarrhythmias). ICDs also provide therapy for tachy-arrbythmias.
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A retrospective survey of 152 patients undergoing emergency abdominal surgery was carried out to examine factors which may have affected the outcome of surgery. The operative diagnosis and procedure carried out, pre-operative heal...
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A retrospective survey of 152 patients undergoing emergency abdominal surgery was carried out to examine factors which may have affected the outcome of surgery. The operative diagnosis and procedure carried out, pre-operative health of the patient, duration of surgery and grade of surgeon were studied to assess whether these factors had any bearing on the eventual outcome. A large variety of surgical emergencies were treated but none of the factor under study were related to the eventual morbidity or mortality recorded.
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