RESUMEN
Nearly 600 cases of laparoscopic adrenalectomy have been described in the world literature, documenting the safety and effectiveness of the procedure. Comparative studies have demonstrated the advantages of the laparoscopic approach when compared to traditional open approaches to adrenalectomy, documenting a more rapid and comfortable recovery, shorter hospitalization, and fewer complications. Several techniques of laparoscopic adrenalectomy have been described. We prefer the transabdominal approach in the lateral decubitus position. Herein we report our experience with 28 adrenalectomies using this approach. Indications for adrenalectomy have been hyperaldosteronism (9), hypercortisolism (4), pheochromocytoma (3), incidentaloma (6), metastasis (3), lymphoma (1), angiomyolipoma (1), other (1). Average tumor size was 3.3 cm (1. 4-8.3 cm). Average operative time was 152 minutes (110-210 minutes), with left adrenalectomy taking slightly longer to perform than on the right (156 vs. 145 minutes). There were no intraoperative complications and one conversion to open adrenalectomy for a large metastatic lung cancer found to be invading the liver. One patient experienced left rib pain from a cannula site immediately at the costal margin. There were no other complications. Average length of hospitalization was 2.3 days (1-6 days). With this and others' experience, laparoscopic adrenalectomy has become the gold standard for adrenalectomy. This manuscript reviews the literature on laparoscopic adrenalectomy and describes the transabdominal lateral approach.
Asunto(s)
Enfermedades de las Glándulas Suprarrenales/cirugía , Adrenalectomía/métodos , Laparoscopía/normas , Neoplasias de las Glándulas Suprarrenales/cirugía , Adrenalectomía/normas , Estudios de Seguimiento , Humanos , Tiempo de Internación , Pautas de la Práctica en Medicina , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Operative internal drainage has been standard treatment for chronic unresolved pancreatic pseudocysts (PPs). Recently, percutaneous external drainage (PED) has become the primary mode of treatment at many medical centers. STUDY DESIGN: A retrospective chart review was performed of 96 patients with PPs who were managed between 1987 and 1996. Longterm followup information was obtained by telephone and mail questionnaire. RESULTS: Twenty-seven patients underwent computed tomographic (CT)-guided PED. PP resolution occurred in 17 patients. Clinical deterioration or secondary infection mandated urgent pancreatic debridement in 7 (26%) patients and cystgastrostomy in 2 (7%) patients. There was one hospital death in this group. Thirty-two patients underwent cystgastrostomy or cystjejunostomy (n = 21), distal pancreatectomy (n = 8), pancreatic debridement and external drainage (n = 2), or cystectomy (n = 1). Two (6%) patients required postoperative pancreatic debridement for failure of resolution and peritonitis and two patients underwent PED of abscess. There was one hospital death in the expectantly managed group of 37 patients. Median followup of 3 years (range, 0.5-9.3 years) in 66 patients revealed that 6, 3, and 4 patients of PED, surgery, and expectantly managed groups, respectively, had radiologic evidence of recurrent PPs. CONCLUSIONS: Operative management for PPs appears to be superior to CT-guided PED. Although the later was often successful, it required major salvage procedures in one third of the patients. An expectant management protocol may be suitable for selected patients.
Asunto(s)
Drenaje/métodos , Seudoquiste Pancreático/terapia , Absceso/terapia , Adulto , Anciano , Anciano de 80 o más Años , Infecciones Bacterianas/cirugía , Causas de Muerte , Desbridamiento , Progresión de la Enfermedad , Femenino , Estudios de Seguimiento , Humanos , Yeyuno/cirugía , Tiempo de Internación , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Pancreatectomía , Seudoquiste Pancreático/fisiopatología , Seudoquiste Pancreático/cirugía , Peritonitis/etiología , Peritonitis/cirugía , Radiografía Intervencional , Recurrencia , Estudios Retrospectivos , Estómago/cirugía , Encuestas y Cuestionarios , Teléfono , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
OBJECTIVE: The authors report their experience with biliary tract stones in adult and pediatric heart transplant patients, and review the current literature relative to this problem. SUMMARY BACKGROUND DATA: Prior studies in adults have noted that heart transplant patients frequently have cholelithiasis, but offer no consensus about treatment strategy. Few studies exist for pediatric heart transplant patients. A higher rate of hemolysis and cyclosporine-induced changes in bile metabolism may contribute to lithogenesis in this population. METHODS: A chart review was conducted for 211 patients who had heart transplants between January 1988 and September 1994 to determine prevalence of biliary tract stones, management strategies used, and outcome. RESULTS: Of 175 long-term heart transplant survivors, 52 (29.7%) had stones detected: 32.8% of adults (47/143) and 15.6% of children (5/32). The majority of patients (31) were diagnosed 4 months (mean) after transplantation; cholelithiasis developed in 10 of these patients (32%) within 11 months (median) after a negative ultrasound. Symptoms developed in 45% of patients. All patients underwent either elective (36) or urgent (6) cholecystectomy via an open (32) or laparoscopic (10) approach, or endoscopy for common bile duct stones (2). There were no deaths or complications during a follow-up period of up to 7 years. CONCLUSION: Heart transplant patients have a high prevalence of symptomatic biliary tract stone disease. They can be treated safely via an open or laparoscopic approach after transplantation. The authors recommend routine gallbladder ultrasound screening and elective cholecystectomy in the post-transplant period if stones are detected.
Asunto(s)
Colelitiasis , Trasplante de Corazón , Adolescente , Adulto , Anciano , Niño , Preescolar , Colecistectomía , Colecistectomía Laparoscópica , Colelitiasis/etiología , Colelitiasis/cirugía , Femenino , Cálculos Biliares/etiología , Cálculos Biliares/cirugía , Trasplante de Corazón/efectos adversos , Humanos , Terapia de Inmunosupresión , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
We report an unusual case of fibrosing peritoneal cryptococcal granulomas in a 36-year-old human immunodeficiency virus-negative man with small-bowel obstruction who previously had been treated for cryptococcal meningitis. At laparotomy, multiple pinhead-sized granulomas studded the visceral peritoneum. Microscopic examination showed cryptococcal granulomas characterized by peripheral fibrosis and central caseous necrosis. On mucicarmine staining, the rare teardrop budding and prominent capsular staining were characteristic of Cryptococcus species. We surmise that this inflammatory reaction observed in the peritoneum represents a chronic tissue reaction that occurred during the previous cryptococcal infection.
Asunto(s)
Criptococosis/patología , Granuloma/patología , Enfermedades Peritoneales/patología , Adulto , Criptococosis/etiología , Humanos , Masculino , Registros Médicos , Meningitis Criptocócica/complicaciones , Enfermedades Peritoneales/etiología , Seminoma/complicaciones , Neoplasias Testiculares/complicacionesRESUMEN
Splenic metastasis is a late manifestation of disseminated disease. Focal metastatic splenic involvement, however, without evidence of additional systemic disease, is unique. Review of the literature yielded only one case of isolated splenic metastasis incidental to rectal carcinoma. We have reported an additional case of isolated solitary splenic metastasis from primary adenocarcinoma of the rectum. Theoretically, certain anatomic, histologic, and functional splenic attributes may limit splenic involvement from metastatic disease.
Asunto(s)
Adenocarcinoma/complicaciones , Neoplasias del Recto/complicaciones , Neoplasias del Bazo/diagnóstico por imagen , Adenocarcinoma/patología , Adenocarcinoma/cirugía , Antígeno Carcinoembrionario/sangre , Colostomía , Femenino , Humanos , Persona de Mediana Edad , Neoplasias del Recto/patología , Neoplasias del Recto/cirugía , Esplenectomía , Neoplasias del Bazo/secundario , Neoplasias del Bazo/cirugía , Tomografía Computarizada por Rayos XRESUMEN
The ileal pouch-anal anastomosis has become a practical alternative to proctocolectomy for the treatment of ulcerative colitis and polyposis coli. To evaluate its success, the Emory University Affiliated Hospital experience from February 1984 to March 1989 was retrospectively reviewed. There were a total of 50 patients identified; 84 per cent had ulcerative colitis, and 16 per cent had polyposis coli (familial polyposis and Gardner's syndrome). The majority of these patients underwent a two-stage operation, but one-third required a three-stage procedure due to difficulty in mucosal proctectomy or toxic megacolon. J-pouch construction was performed in 72 per cent of patients, S-pouch construction in 14 per cent, straight ileo-anal anastomosis in 8 per cent, and lateral isoperistaltic ileo-anal anastomosis in 6 per cent. Of the 50 patients, 36 (72%) have had closure of the temporary ileostomy. Fourteen patients have not had ileostomy closure due to change in diagnosis to Crohn's disease, operative complications, or ileostomy closure pending. The combined operative morbidity per patient for the ileal pouch-anal anastomosis and the closure of the ileostomy was 32 per cent. This included bowel obstruction, 16 per cent; pelvic abscess, 6 per cent; and ileo-anal separation, 4 per cent. Follow-up on patients with ileostomy closure ranged from 6 months to 4 years (mean, 1.3 years). Stool frequency was 5.9 stools per 24 hours at 6 months and improved with time. During the follow-up period, all patients were eventually completely continent of stool during the day, and most became completely continent of stool at night.(ABSTRACT TRUNCATED AT 250 WORDS)
Asunto(s)
Poliposis Adenomatosa del Colon/cirugía , Canal Anal/cirugía , Anastomosis Quirúrgica/normas , Colitis Ulcerosa/cirugía , Íleon/cirugía , Poliposis Adenomatosa del Colon/fisiopatología , Adulto , Anastomosis Quirúrgica/efectos adversos , Anastomosis Quirúrgica/métodos , Colectomía , Colitis Ulcerosa/fisiopatología , Colitis Ulcerosa/psicología , Comportamiento del Consumidor , Defecación , Incontinencia Fecal/tratamiento farmacológico , Incontinencia Fecal/epidemiología , Femenino , Estudios de Seguimiento , Humanos , Ileostomía , Obstrucción Intestinal/epidemiología , Masculino , Complicaciones Posoperatorias/epidemiología , Calidad de Vida , Estudios Retrospectivos , Técnicas de SuturaRESUMEN
Fragmentation of bile duct stones by mechanical, electrohydraulic, and laser intraluminal lithotripsy has greatly facilitated the ability to remove stones that are otherwise difficult to remove by standard manipulative techniques. Even these approaches fail when stones lack access or are impacted within the biliary tree. Extracorporeal shock-wave lithotripsy (ESWL) was evaluated in the United States in a multicenter trial with 56 patients. Stone fragmentation occurred in 91 percent of patients and duct clearance in 79 percent. Adjunctive procedures were used in 54 percent. Two ESWL treatments were required for fragmentation in 28 percent. Complications were mild and relatively infrequent. Hemobilia (8 percent), gross hematuria (6 percent), and biliary sepsis (4 percent) occurred less frequently than expected. There were no deaths during the 1 to 31 days of hospitalization (mean 9 days). We conclude that ESWL is a safe and effective adjunct to the treatment of difficult-to-remove bile duct stones under the conditions observed in this trial.
Asunto(s)
Colelitiasis/terapia , Litotricia , Enfermedades de los Conductos Biliares/terapia , Ensayos Clínicos como Asunto , Alemania Occidental , Humanos , Litotricia/instrumentación , Litotricia/métodos , Estudios Multicéntricos como Asunto , Ultrasonido , Estados UnidosRESUMEN
A multi-institutional study to evaluate the efficacy, clinical application, and safety of extracorporeal shock-wave lithotripsy (ESWL) with the Dornier HM-3 or HM-4 lithotripter for bile duct calculi (BDC) was initiated in September, 1987. Symptomatic patients who entered into this prospective trial had BDC in the common bile duct and/or the intrahepatic, cystic or lobar ducts of the liver that were inaccessible or untreatable by papillotomy or percutaneous stone extraction. The study excluded gallbladder stones. Nasobiliary (54.4%) or transhepatic catheters (10.5%) and T-tube or cholecystostomy tubes (17.5%) or combinations (14.0%) permitted access for radiographic contrast to allow fluoroscopic monitoring of stone position and fragmentation. Exclusion criteria included pregnancy, failure to localize the stone, disturbances of coagulation, pacemakers, or vascular aneurysms or large bones that lie in the focal axis of the shock waves. Eleven institutions treated 42 patients (23 male, 19 female) with BDC; age range was 25 to 95 years (mean +/- SD, 73.5 +/- 13.8) and ASA risk category was 1 to 4 (mean, 2.3 +/- 0.8). Fourteen patients (33.3%) had a single BDC; 28 had 2 to 8 stones (mean, 2.7 +/- 1.8) ranging in size from 6 mm to 30 mm (mean, 18.5 +/- 6.4). The majority (66.7%) of patients were postcholecystectomy. The 42 patients received 57 ESWL treatments consisting of 600 to 2400 shocks per treatment (mean, 1924 +/- 289) at 12 to 22 kV (mean, 18.5 +/- 1.9) administered over 20 to 125 minutes (mean, 52.9 +/- 20.8). General anesthesia was used in 32% of the treatments; the majority were treated with epidural or regional block (42.1%), local infiltration (28.1%), or intravenous sedation (38.6%). Fifteen patients (35.7%) required two ESWL treatments. Stone fragmentation occurred in 94.6% of evaluable patients and in 90.4% of ESWL treatments, respectively; however, BDC fragments remained in 59.5% of patients 24 hours after treatment (diameter less than or to 3 mm, 12%; 4 to 9 mm, 16%; greater than or equal to 10 mm, 68%). Some patients (50%) required adjunctive procedures to achieve stone removal that included endoscopic extraction (n = 10; 47.6%), biliary lavage (n = 8; 38.1%), endoscopic bile duct prosthesis (n = 1; 4.8%), and operation (n = 2; 9.5%). ESWL treatment complications during hospitalization were observed in 15 patients (35.7%) and were present in four (9.5%) at discharge. Complications included macrohematuria (5%), biliary pain (15%), biliary sepsis (5%), hemobilia (10%), ileus (2.5%), and adverse pulmonary changes (7.5%). One patient developed pancreatitis before ESWL at ERCP that resolved prior to discharge.(ABSTRACT TRUNCATED AT 400 WORDS)
Asunto(s)
Colelitiasis/terapia , Cálculos Biliares/terapia , Litotricia/métodos , Adulto , Anciano , Anciano de 80 o más Años , Antibacterianos/uso terapéutico , Conductos Biliares Intrahepáticos , Colelitiasis/complicaciones , Interpretación Estadística de Datos , Femenino , Cálculos Biliares/complicaciones , Humanos , Masculino , Persona de Mediana Edad , Estudios Multicéntricos como Asunto , Premedicación , Estudios Prospectivos , Esfínter de la Ampolla Hepatopancreática/cirugíaRESUMEN
Perianal infections in patients with acute leukemia and granulocytopenia are potentially lethal conditions. To evaluate the management of perianal infections in patients with granulocytopenia and acute leukemia, all such patients treated at Emory University Hospital between January 1, 1980, and December 31, 1985, were reviewed. Twenty patients were found to have severe granulocytopenia (fewer than 500 polymorphonuclear leukocytes/mm3) and perianal infection, representing 5.7 per cent of all hematology service admissions during that period. Eleven patients were managed conservatively with broad-spectrum antibiotics and supportive measures, and nine patients underwent operative drainage of the perianal infection in addition to conservative measures. The two groups were similar in respect to age, associated conditions, length of hospitalization, and degree of perianal infection, with the exception that operatively drained patients were more likely to have positive blood cultures (7/9 operatively drained; 4/11 conservatively managed). Mortality was higher in the operatively drained group (44.4% vs 9% in the conservatively managed), and three patients had progression of the local infection after drainage, two of whom required a diverting colostomy. The overall mortality attributed to perianal disease in these severely granulocytopenic patients was 25 per cent. From this review, operative drainage of perianal infection does not appear to increase survival or decrease morbidity in patients with severe granulocytopenia.
Asunto(s)
Agranulocitosis/complicaciones , Enfermedades del Ano/terapia , Infecciones Bacterianas/terapia , Leucemia/complicaciones , Enfermedad Aguda , Enfermedades del Ano/cirugía , Infecciones Bacterianas/cirugía , Drenaje , Femenino , Humanos , Masculino , Estudios Retrospectivos , Irrigación TerapéuticaRESUMEN
Primary hepatolithiasis, although rare, is a difficult condition requiring the combined management of radiology and surgery. Use of extracorporeal shock wave lithotripsy and percutaneous stone extraction, along with improved biliary drainage by choledochojejunostomy, should provide a safe effective approach to this unusual problem.
Asunto(s)
Cálculos/terapia , Litotricia , Hepatopatías/terapia , Anciano , Femenino , HumanosRESUMEN
Duodenocaval fistulae are rare but may well be the source of gastrointestinal hemorrhage with associated sepsis in patients undergoing surgery and subsequently receiving radiation to the right upper abdomen. Management of these fistulae may be challenging. Diagnosis usually requires a high index of suspicion, particularly in post irradiated patients.
Asunto(s)
Enfermedades Duodenales/etiología , Úlcera Duodenal/complicaciones , Fístula/etiología , Fístula Intestinal/etiología , Traumatismos por Radiación/complicaciones , Vena Cava Inferior , Adulto , Enfermedades Duodenales/diagnóstico por imagen , Fístula/diagnóstico por imagen , Humanos , Fístula Intestinal/diagnóstico por imagen , Masculino , Radiografía , Radioterapia/efectos adversosRESUMEN
We present a case of complete scrotal destruction secondary to acute necrotizing fasciitis. Full scrotal reconstruction utilizing bilateral gracilis musculocutaneous flaps was achieved with excellent results. This technique is described.
Asunto(s)
Fascitis/cirugía , Escroto/cirugía , Colgajos Quirúrgicos , Adulto , Desbridamiento , Fascitis/patología , Gangrena , Humanos , Masculino , Necrosis , Escroto/patologíaRESUMEN
Pyoderma gangrenosum is a rare idiopathic skin condition often associated with other diseases, including Crohn's disease. We believe this is the first report of cases in which pyoderma gangrenosum was identified at the parastomal site in patients with Crohn's disease. Four episodes of the condition occurred in three patients. In these patients, pyoderma gangrenosum first appeared after two to three surgical procedures and between ten months and five years after the initial surgery. The disease course varied from resolution within two months with corticosteroid therapy to resolution only after revision or relocation of the stoma with resection of recurrent disease segments. Parastomal pyoderma gangrenosum at the ileostomy site in patients with Crohn's disease may be more common than previously thought. Optimal treatment has not yet been established, and treatment needs to be tailored for each patient.