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The emergence of laparoscopic cholecystectomy has revolutionized the face of surgery and proved that in the appropriate circumstances the laparoscopic technique affords comparable surgical outcomes with improvements in parameters ...
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The emergence of laparoscopic cholecystectomy has revolutionized the face of surgery and proved that in the appropriate circumstances the laparoscopic technique affords comparable surgical outcomes with improvements in parameters such as blood loss, postoperative pain, and hospital length of stay. The first laparoscopic liver resection (LLR) was described in 1992, and since then LLRs have expanded from partial hepatectomies and wedge resections for benign peripheral lesions to left and right hepatectomies for malignant lesions, which are now being performed at large-volume tertiary care centers. Laparoscopic liver surgery technique can be divided into 3 main categories based on The Louisville Statement: pure laparoscopy, hand-assisted laparoscopy, and the hybrid technique. Pure laparoscopy involves performing the entire liver resection using only laparoscopic ports, with a small incision used for specimen extraction. Hand-assisted laparoscopy is defined as laparoscopy with the addition of a hand-port placed to facilitate the operation, and the hybrid technique refers to a procedure which is started as purely laparoscopic or hand-assisted, and the resection is performed through a smalliaparotomy incision.2 The majority of LLR reported in a 2000 case registry study were totally laparoscopic (75.1%), followed by hand-assisted (16.5%), and then the hybrid technique (2.1%).
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Acute cholecystitis is defined as inflammation of the gallbladder and is usually caused by obstruction of the cystic duct. Cholescintigraphy is the most sensitive imaging modality for cholecystitis. The gold standard treatment of ...
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Acute cholecystitis is defined as inflammation of the gallbladder and is usually caused by obstruction of the cystic duct. Cholescintigraphy is the most sensitive imaging modality for cholecystitis. The gold standard treatment of acute cholecystitis is laparoscopic cholecystectomy. Operating early in the disease course decreases overall hospital stay and avoids increased complications, conversion to open procedures, and mortality. Cholecystitis during pregnancy is a challenging problem for surgeons. Operative intervention is generally safe for both mother and fetus, given the improved morbidity of the laparoscopic approach compared with open, although increased caution should be exercised in women with gallstone pancreatitis.
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Background: Compartment syndrome of the thigh is a surgical emergency rarely reported in the literature. The most common etiologies include blunt trauma, vascular injuries from penetrating trauma, and hematoma formation. Thigh com...
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Background: Compartment syndrome of the thigh is a surgical emergency rarely reported in the literature. The most common etiologies include blunt trauma, vascular injuries from penetrating trauma, and hematoma formation. Thigh compartment syndrome (TCS) is important as it is often associated with concomitant severe injury with mortality rates as high as 47%. This study aims to identify mechanisms of injury, clinical presentation, and outcomes associated with TCS in the urban trauma patient population. Methods: Demographic and clinical information for all patients with a diagnosis of TCS at a level 1 urban trauma center over a 10.5-y period were reviewed. Collected data included age, sex, mechanism of injury, method of diagnosis, time taken for diagnosis and management, methods of decompression, wound management, lengths of stay in the intensive care unit and hospital, amputation rate, and hospital disposition. Results: Ten patients were identified with diagnosis of TCS. The mechanism of injury was penetrating in six patients and blunt in four. The mean time from injury to diagnosis was 23.4 h. Intensive care unit and hospital lengths of stay were significantly increased among patients sustaining penetrating injuries compared with blunt injuries. Two of the six penetrating injury patients underwent an amputation. Eight of 10 patients were ambulatory on discharge. There were no mortalities. Conclusions: Among urban trauma patients, penetrating injuries of the thigh and adjacent vascular structures and the need for decompressive fasciotomy of the lower leg are the major risk factors for TCS. Clinical diagnosis and early intervention with fasciotomy remain the mainstay of treatment.
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Hepatic malignancies are a major source of morbidity and mortality in the United States and worldwide. The liver not only harbors primary malignancies, most commonly hepatocellular carcinoma (HCC), but is also a common site of met...
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Hepatic malignancies are a major source of morbidity and mortality in the United States and worldwide. The liver not only harbors primary malignancies, most commonly hepatocellular carcinoma (HCC), but is also a common site of metastases for other types of cancer including colorectal cancer, breast cancer, lung cancer, pancreatic cancer, stomach cancer, melanoma, and neuroendocrine malignancies. The mainstay of curative treatment for primary and secondary hepatic malignancies is surgical resection, although unfortunately in the majority of cases resection is not possible due to the extent of the disease or patient comorbidities. Resection of primary and secondary hepatic malignancies has not been subjected to prospective randomized comparison vs nonsurgical therapy, but it has resulted in durable cure in many patients and is the standard of care. The need for treatment of hepatic malignancies in patients who are not amenable to surgical resection has led to the development of a variety of therapies and techniques in recent years. Newer surgical techniques have also focused on minimizing the morbidity of open liver resection. This review focuses on minimally invasive therapies used to treat both primary and secondary hepatic malignancies. The therapies covered range from surgical (laparoscopic and robotic), percutaneous ablative (radiofrequency ablation [RFA], microwave ablation [MWA], cryoabla-tion, ethanol ablation, and irreversible electroporation [IRE]), and transarterial (chemoembo-lization, radioembolization, and portal vein embolization [PVE]). Each of these treatment modalities has a role in treating hepatic malignancy, although the indications are different for each, as are the treatment goals. We have focused on studies that directly compare newer technologies with resection. In cases in which comparison has not been done, we have used the best available data to arrive at conclusions.
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Background Endoscopic resection is increasingly used to treat localized, early-stage esophageal cancer. We sought to assess its adoption, characterize the risks of nodal metastases, and define differences in procedural mortality a...
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Background Endoscopic resection is increasingly used to treat localized, early-stage esophageal cancer. We sought to assess its adoption, characterize the risks of nodal metastases, and define differences in procedural mortality and 5-year survival between endoscopic and surgical resection in the United States. Methods From the National Cancer Data Base, patients with T1a and T1b lesions were identified. Treatment patterns were characterized, and hierarchical regression methods were used to define predictors and evaluate outcomes. All statistical tests were two-sided. Results Five thousand three hundred ninety patients were identified and underwent endoscopic (26.5%) or surgical resection (73.5%). Endoscopic resection increased from 19.0% to 53.0% for T1a lesions (P <. 001) and from 6.6% to 20.9% for T1b cancers (P <. 001). The strongest predictors of endoscopic resection were depth of invasion (T1a vs T1b: odds ratio [OR] = 4.45; 95% confidence interval [CI] = 3.76 to 5.27) and patient age of 75 years or older (vs age less than 55 years: OR = 4.86; 95% CI = 3.60 to 6.57). Among patients undergoing surgery, lymph node metastasis was 5.0% for T1a and 16.6% for T1b lesions. Predictors of nodal metastases included tumor size greater than 2cm (vs. <2cm) and intermediate-/high-grade lesions (vs low grade). For example, 0.5% of patients with low-grade T1a lesions less than 2cm had lymph node involvement. The risk of 30-day mortality was less after endoscopic resection (hazard ratio [HR] = 0.33; 95% CI = 0.19 to 0.58) but greater for conditional 5-year survival (HR = 1.63; 95% CI = 1.07 to 2.47). Conclusions Endoscopic resection has become the most common treatment of T1a esophageal cancer and has increased for T1b cancers. It remains important to balance the risk of nodal metastases and procedural risk when counseling patients regarding their treatment options.
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