RESUMEN
BACKGROUND/AIMS: The approach to small bowel obstruction, when unrelieved with medical management, is open or laparoscopic exploration, often necessitating lysis of adhesions and the resection of any compromised bowel. In patients with prior bowel resections, the surgeon must tread a fine line, so as not to precipitate the clinical derangement known as short bowel syndrome (SBS). Techniques have been described that curtail the extent of intestinal resection, but these are primarily limited to the pediatric literature and are not commonly practiced in the general surgical population. METHODS: We report a case of a complicated small bowel obstruction in a patient with pre-existing short bowel length, in which a tapering enteroplasty was performed. RESULTS: Antimesenteric tapering successfully achieved a return of bowel function, avoiding the morbidity of an extended small bowel resection and the possibility of developing SBS. CONCLUSION: In such patients who are at high risk of developing SBS, in whom a segment of dilated small bowel has become defunctionalized, leading to significant and life-threatening symptoms, this procedure has the potential to help prevent SBS and its lifelong complications and associated mortality.
Asunto(s)
Procedimientos Quirúrgicos del Sistema Digestivo/métodos , Obstrucción Intestinal/cirugía , Enfermedades del Yeyuno/cirugía , Adulto , Dilatación Patológica , Femenino , Humanos , Obstrucción Intestinal/diagnóstico por imagen , Enfermedades del Yeyuno/diagnóstico por imagen , Enfermedades del Yeyuno/patología , Mesenterio/cirugía , Radiografía , Síndrome del Intestino Corto/prevención & controlRESUMEN
The purpose of this study was to identify the recurrence rate, the salvage rate after recurrence, and the overall survival after local excision of rectal adenocarcinomas. A retrospective medical chart review was performed in 31 consecutive patients with rectal adenocarcinoma who underwent local excision at Roswell Park Cancer Institute from January 1990 through December 1999. After excision nine patients were excluded from further analysis because they were found to have advanced stage on pathologic examination (T2 primary tumors with vascular invasion or T3 tumors). Eight of the nine patients underwent abdominoperineal resection as definitive therapy. In the remaining 22 patients who underwent transanal excision as definitive surgical therapy there were 13 patients with T1 tumors and nine patients with T2 tumors. Overall seven patients (32%) developed local recurrences after local excision. This included four patients with T1 and three patients with T2 primary tumors. All recurrences occurred in the seven patients who did not receive adjuvant chemoradiation. All patients underwent salvage resection of the recurrence. Four patients who underwent salvage resection of the recurrence remain without evidence of disease at a median follow-up of 19.5 months. Local excision without adjuvant therapy has an unacceptably high rate of local recurrence. Although most patients who recur locally are salvaged by radical resection the long-term results after resection remain unknown. The use of adjuvant chemoradiation appears to reduce this high recurrence rate and may eventually become a standard adjunct to local excision of rectal cancer.
Asunto(s)
Adenocarcinoma/cirugía , Recurrencia Local de Neoplasia , Neoplasias del Recto/cirugía , Adenocarcinoma/mortalidad , Adenocarcinoma/patología , Adenocarcinoma/terapia , Adulto , Anciano , Anciano de 80 o más Años , Quimioterapia Adyuvante , Femenino , Humanos , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia/prevención & control , Estadificación de Neoplasias , Radioterapia Adyuvante , Neoplasias del Recto/mortalidad , Neoplasias del Recto/patología , Neoplasias del Recto/terapia , Estudios RetrospectivosAsunto(s)
Neoplasias Primarias Desconocidas/cirugía , Adenocarcinoma/diagnóstico , Adenocarcinoma/secundario , Algoritmos , Axila , Carcinoma de Células Escamosas/diagnóstico , Carcinoma de Células Escamosas/secundario , Carcinoma de Células Escamosas/terapia , Análisis Citogenético , Humanos , Técnicas para Inmunoenzimas , Inmunohistoquímica , Metástasis Linfática , Melanoma/diagnóstico , Melanoma/secundario , Melanoma/terapia , Neoplasias Primarias Desconocidas/genética , Neoplasias Primarias Desconocidas/patología , Neoplasias Peritoneales/patología , PronósticoRESUMEN
BACKGROUND: This study assessed the presurgical and preradiation discussion of the risk of posttherapy sexual dysfunction among patients who underwent potentially curative therapy for rectal cancer. The incidence of sexual dysfunction after treatment for rectal cancer was then determined. METHODS: A retrospective review of the medical records of 52 consecutive patients who underwent potentially curative procedures for rectal cancer within 15 cm from the anal verge was performed. RESULTS: Presurgical discussion of the risk of sexual dysfunction was not documented in the consent in 37 of 52 patients (71%). Among the 5 males who underwent local excision, none reported posttherapy sexual dysfunction. Of the 6 males who were treated by low anterior resection, only 1 had a postoperative complaint of sexual dysfunction. Five of 15 males (33%) treated with abdominoperineal resection (APR) alone reported postprocedure sexual dysfunction, whereas 6 of 8 males (75%) treated with APR and radiation reported dysfunction. Of the entire female cohort, only 1 of the 16 reported sexual dysfunction posttherapy. CONCLUSION: A discussion of the risks of posttherapy sexual dysfunction was documented for fewer than one third of the patients. Among males after APR, the use of postoperative radiation showed a trend toward an increase in sexual dysfunction. Surgery and/or radiation therapy did not impact on sexual dysfunction in females.
Asunto(s)
Consentimiento Informado , Complicaciones Posoperatorias/epidemiología , Neoplasias del Recto/complicaciones , Disfunciones Sexuales Fisiológicas/epidemiología , Adulto , Anciano , Anciano de 80 o más Años , Terapia Combinada/efectos adversos , Femenino , Humanos , Incidencia , Modelos Logísticos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Neoplasias del Recto/terapia , Estudios Retrospectivos , Factores de Riesgo , Disfunciones Sexuales Fisiológicas/etiología , Encuestas y CuestionariosRESUMEN
Twenty-four patients who underwent surgery for pararenal aortic aneurysms between January 1992 and April 1997 are reviewed. Eighteen patients had primary atherosclerotic aneurysms, three patients had symptomatic infected aneurysms, two patients had an aneurysm proximal to a prior aortic repair, and one patient had a pseudoaneurysm of a proximal aortic graft anastomosis. Thirteen patients underwent elective operation, five had an urgent operation, and six patients underwent an emergency procedure. Five patients had the proximal aortic clamp placed between the renal arteries (Group I), three patients had it placed between the superior mesenteric and the renal arteries (Group II), and 16 patients had it placed in a supraceliac location (Group III). Aneurysm size, age, sex, preoperative blood chemistries (including hemoglobin, hematocrit, liver function studies, and coagulation studies) were similar in all groups. Two patients in Group III were on hemodialysis preoperatively. Preoperative renal function (blood urea nitrogen and creatinine) was the same in all groups. Visceral ischemic time was 43.4 +/- 9.37 min to the distal kidney in Group I, 26.6 +/- 7.63 min in Group II, and 24.5 +/- 6.22 min in Group III. Mean transfusion requirements were similar in all groups. Two patients in Group I required postoperative hemodialysis. No patient in either Group II or III developed renal insufficiency. Mortality was the same in each group but was related to the urgency of operation (elective 7.6%, urgent 40%, emergent 50%). Intrarenal clamping (Group I) was associated with more renal and gastrointestinal complications than either suprarenal or supraceliac clamping. Although suprarenal and supraceliac clamping had similar results, our preference is supraceliac clamping because it is technically easy to achieve and is associated with few end-organ complications.
Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Arteria Celíaca/cirugía , Urgencias Médicas , Isquemia/etiología , Riñón/irrigación sanguínea , Complicaciones Posoperatorias/cirugía , Anciano , Aneurisma Falso/mortalidad , Aneurisma Falso/cirugía , Aneurisma Infectado/mortalidad , Aneurisma Infectado/cirugía , Aneurisma de la Aorta Abdominal/mortalidad , Arteriosclerosis/mortalidad , Arteriosclerosis/cirugía , Femenino , Oclusión de Injerto Vascular/mortalidad , Oclusión de Injerto Vascular/cirugía , Humanos , Isquemia/mortalidad , Fallo Renal Crónico/etiología , Fallo Renal Crónico/mortalidad , Pruebas de Función Renal , Masculino , Arteria Mesentérica Superior/cirugía , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/mortalidad , Recurrencia , Arteria Renal/cirugía , Reoperación , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
OBJECTIVE: To evaluate the accuracy of fingerstick glucose measurements in severely hypotensive patients. DESIGN: Prospective, nonrandomized comparison study. SETTING: Emergency department in a university hospital. PATIENTS: Twenty-five severely hypotensive patients (systolic blood pressure less than or equal to 80 mm Hg) and 39 normotensive patients. MEASUREMENTS: Simultaneous fingerstick reagent strip glucose, venous reagent strip glucose, and laboratory glucose values were compared. Data were analyzed using error-grid analysis. RESULTS: In hypotensive patients, the mean fingerstick glucose values were significantly lower than the values obtained either by venous reagent strip or laboratory glucose measurements. Fingerstick glucose values in the hypotensive group were 67.5% of laboratory glucose values, and were significantly lower than the values obtained in the normotensive group (91.8%, P less than 0.001). Only 36% of the hypotensive patients had fingerstick glucose values within the acceptable range of 20% of the laboratory glucose value. Thirty-two percent of hypotensive patients were incorrectly diagnosed as hypoglycemic (glucose less than 3.89 mmol/L [70 mg/dL]); 2 of these patients were actually hyperglycemic (glucose greater than 11.10 mmol/L [200 mg/dL]). Venous reagent strip measurements accurately reflected laboratory glucose values in both hypotensive and normotensive patients. CONCLUSIONS: Fingerstick glucose testing does not accurately represent venous glucose levels in severely hypotensive patients. If fingerstick glucose testing is relied on for these patients, errors in clinical management may be made. Venous reagent strip glucose testing correlates well with laboratory glucose measurements and should be the preferred method for rapid assessment of glucose level in critically ill patients with severe hypotension.