RESUMEN
OBJECTIVES: This systematic review assessed the efficacy of centralisation for the treatment of unruptured and ruptured abdominal aortic aneurysms. Patient outcomes achieved by low and high volume hospitals/surgeons, including morbidity, mortality and length of hospital stay, were used as proxy measures of efficacy. DESIGN: Systematic review was designed to identify, assess and report on peer-reviewed articles reporting outcomes from unruptured and ruptured abdominal aortic aneurysms. No language restriction was placed on the databases searched. MATERIALS: Only peer-reviewed journals articles were included. METHODS: To ensure the contemporary nature of this review, only studies published between January 1997 and June 2007 were sought. Studies were included if they reported on at least one volume type and patient outcome. RESULTS: Twenty two studies were included in this review. In the majority of group assessments, the number of studies reporting statistical significance was similar to the number of studies reporting no statistical significance. CONCLUSION: The paucity of studies reporting statistically significant results demonstrates that although this evidence exists, its potential to be overstated must also be taken into account when drawing conclusions as to its efficacy for twenty first century healthcare systems.
Asunto(s)
Aneurisma de la Aorta Abdominal/epidemiología , Aneurisma de la Aorta Abdominal/cirugía , Procedimientos Quirúrgicos Vasculares/estadística & datos numéricos , Hospitales/estadística & datos numéricos , Humanos , Médicos/estadística & datos numéricos , Resultado del TratamientoRESUMEN
BACKGROUND: Pancreatic trauma is uncommon, but carries high morbidity and mortality rates, especially when diagnosis is delayed or inappropriate surgery is attempted. Although the retroperitoneal position of the pancreas confers it some immunity to injury, the force required to do so often results in severe associated injuries to other organs, which may be life threatening. Diagnosis may be difficult and surgery can be a considerable technical challenge. METHODS: All patients with pancreatic trauma who attended one of three Melbourne teaching hospitals from 1977 to 1998 were identified. Injuries were graded and the method of diagnosis and treatment studied. The incidence and causation of postoperative morbidity and mortality was identified. RESULTS: Thirty-eight patients (26 men and 12 women) were studied. Blunt trauma was responsible in 30 patients, stab wounds in five, gunshot wounds in two and iatrogenic injury in one. Injuries to other organs occurred in 30 patients. Surgical procedures were undertaken in 34 patients, resulting in the death of five and complications in 25. CONCLUSION: Complications and death are related to the associated injuries, as much as to the pancreatic injury itself. In this study, we review the experience of the management of pancreatic trauma in three large teaching hospitals in Melbourne over a 21-year period, and suggest a strategy for dealing with these difficult patients. Adherence to the basic concepts of control of bleeding from associated vascular injury, minimization of contamination, accurate pancreatic assessment, judicious resection and adequate drainage can diminish the risk. By approaching the problem in a systematic way and adopting a generally conservative management plan, complications and deaths can be minimized in these complex cases.
Asunto(s)
Páncreas/lesiones , Páncreas/cirugía , Heridas no Penetrantes/clasificación , Traumatismos Abdominales/complicaciones , Adolescente , Adulto , Anciano , Australia/epidemiología , Colangiopancreatografia Retrógrada Endoscópica , Traumatismos Craneocerebrales/complicaciones , Femenino , Humanos , Masculino , Persona de Mediana Edad , Morbilidad , Pancreatectomía/mortalidad , Traumatismos Torácicos/complicaciones , Tomografía Computarizada por Rayos X , Heridas no Penetrantes/epidemiología , Heridas no Penetrantes/cirugíaRESUMEN
Ideally antibiotics should be administered preoperatively within 2 hours of skin incision to ensure adequate tissue concentrations, especially when a vascular prosthesis is used. The quality of patient outcomes may be adversely affected when key processes, by degrees, fail to meet patient care objectives. This study was designed to incorporate the concepts of total quality management to determine how effectively this goal was achieved, and, after review of those measured results, what process improvements could be instituted to meet the established requirements for the administration of antibiotics. The study was then repeated on a yearly basis to determine what effect these improvement measures had on antibiotic administration. Three time periods were established for determining when antibiotics were administered. The "early" period was more than 2 hr preoperatively. "Preoperative" was from 2 hr before surgery until the time of incision and "perioperative" was after the time of incision. Group 1 consisted of the first 100 patients undergoing vascular procedures in 1992. After the data were collected, a multidisciplinary team of nurses, pharmacists, and surgeons was assembled to determine the step by step desired process flow from order received to actual medication administration. The team then reviewed each step of the process to identify variations relative to data obtained. An action plan was developed to implement the agreed upon improvement plan. After improvements were implemented, groups 2, 3, 4, and 5 consisted of the first 100 vascular procedures of 1993, 1994, 1995, and 1996. Group 1 had only 26% of antibiotics administered during the preoperative period and 74% during the perioperative period. Problems identified were: surgeons ordered the antibiotics when the patient was in the operating room, cefamandole and vancomycin required at least 1 hr to infuse, nurses were not aware of the need for preoperative infusion, and the pharmacy did not supply the antibiotics in a timely fashion. Educational inservices were held for all parties involved, and cefazolin was used in place of cefamandole because it could be given as a bolus. Results were: group 1, early, 0%; preoperative, 26%; perioperative, 74%; P = N/A; group 2, early, 0%, preoperative, 90%; perioperative, 10%; group 3, early, 7%; preoperative, 93%; perioperative, 0%; group 4, early 0%; preoperative, 100%; perioperative, 0%; and group 5, early, 0%; preoperative, 100%; perioperative, 0%; P = 0.0001 for groups 2-5 (versus group 1). It was surprising how often antibiotics were administered incorrectly in a busy vascular practice. By focusing on the process of care delivery, a continuous quality improvement team implemented simple changes that resulted in significant improvements. We are now conducting a study to determine what effect these process improvements had on our infection rate.
Asunto(s)
Profilaxis Antibiótica/estadística & datos numéricos , Cuidados Preoperatorios/normas , Gestión de la Calidad Total/estadística & datos numéricos , Procedimientos Quirúrgicos Vasculares/normas , Adhesión a Directriz , Hospitales Comunitarios/normas , Humanos , Cuidados Preoperatorios/estadística & datos numéricos , Estudios Prospectivos , Factores de Tiempo , Estados Unidos , Procedimientos Quirúrgicos Vasculares/métodosRESUMEN
PURPOSE: To assess the safety and efficacy of percutaneous retrograde transjejunal cholangiography and biliary intervention for benign and malignant disease. MATERIALS AND METHODS: The clinical and radiographic records of 43 patients (31 with benign and 12 with malignant disease) who had undergone percutaneous retrograde transjejunal biliary intervention over a 10-year period at a single institution were reviewed. One hundred eighty-one procedures were performed via a fixed Roux-en-Y loop and 15 via an unfixed loop. RESULTS: Percutaneous retrograde transjejunal cholangiography was attempted on 196 occasions (143 for benign and 53 for malignant disease). Primary successful access was obtained in 181 (92.3%). Adjunctive percutaneous transhepatic cholangiography improved successful access in an additional seven procedures, to 188 (95.9%). Interventions included stricture dilation, stone extraction, stent insertion, and brachytherapy. The mean number of biliary interventions and the mean interval between them were 3.1 interventions and 5.9 months in the benign group and 3.6 interventions and 3.8 months in the malignant group. The complication rate was 4.1%, with no deaths or episodes of biliary sepsis. CONCLUSION: Percutaneous transjejunal biliary access allows repeated interventions over many years with a low morbidity. Routine superficial fixation of Roux-en-Y loops is recommended for all biliary-enteric anastomoses to allow use of this safe and effective approach for any subsequent biliary intervention.
Asunto(s)
Anastomosis en-Y de Roux , Enfermedades de los Conductos Biliares/terapia , Colangiografía/métodos , Radiografía Intervencional/métodos , Enfermedades de los Conductos Biliares/diagnóstico por imagen , Neoplasias del Sistema Biliar/diagnóstico por imagen , Neoplasias del Sistema Biliar/terapia , Braquiterapia , Colangiografía/estadística & datos numéricos , Coledocostomía , Colelitiasis/diagnóstico por imagen , Colelitiasis/terapia , Dilatación , Femenino , Conducto Hepático Común/cirugía , Humanos , Yeyuno/cirugía , Masculino , Persona de Mediana Edad , Radiografía Intervencional/estadística & datos numéricos , Estudios Retrospectivos , Stents , Factores de TiempoRESUMEN
Trauma to the right hepatic artery during biliary surgery can lead to false aneurysm formation. Subsequent rupture into the biliary system, which may occur after a considerable delay, will then result in major haemobilia. This report details five cases referred to the Royal Melbourne Hospital over a 12 month period, four of which followed initial laparoscopic procedures, and emphasizes important management procedures to prevent and treat this previously rare complication.
Asunto(s)
Colecistectomía Laparoscópica/efectos adversos , Hemobilia/etiología , Anciano , Aneurisma Falso/diagnóstico por imagen , Aneurisma Falso/etiología , Angiografía de Substracción Digital , Femenino , Arteria Hepática/diagnóstico por imagen , Arteria Hepática/lesiones , Humanos , Masculino , Persona de Mediana EdadAsunto(s)
Protocolos Clínicos , Endarterectomía Carotidea/normas , Garantía de la Calidad de Atención de Salud , Adulto , Anciano , Endarterectomía Carotidea/economía , Femenino , Control de Formularios y Registros , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Satisfacción del Paciente , Pennsylvania , Servicio de Cirugía en Hospital/normasRESUMEN
Debate continues as to the appropriateness of the Whipple procedure. This retrospective review confirms that it is a worthwhile operation when done by experienced surgeons on suitable patients. Meticulous intra-operative technique must be followed by judicious postoperative care. In this series of 27 Whipple operations major morbidity occurred in 26% of cases. Leakage from the pancreatic anastomosis was infrequent (11%). Various anastomotic techniques were used, depending on the findings at operation. There were no peri-operative deaths and five-year actuarial survival is 63%.
Asunto(s)
Pancreatectomía , Neoplasias Pancreáticas/cirugía , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Neoplasias Pancreáticas/mortalidad , Neoplasias Pancreáticas/patología , Complicaciones Posoperatorias , Estudios RetrospectivosRESUMEN
The multiple endocrine neoplasia syndromes are an association of tumours of 2 or more endocrine glands. Multiple endocrine neoplasia type 2b (MEN 2b) patients develop medullary thyroid carcinoma and pheochromocytomas as well as unique physical characteristics. Most commonly, MEN2b is inherited with an autosomal dominant pattern although sporadic cases are not uncommon. If untreated the disease may be lethal. The facial, oral and ocular characteristics are reliable markers of the disease. These patients give a history most commonly of slipped capital femoral epiphysis, hypertension and life-long diarrhoea and/or constipation. MEN2b is most commonly characterised by nodules on the anterior aspect of the tongue, thickened lips with nodules, thickened upper eyelids, broadened nasal bridge, thickened corneal nerves and dilated, symmetrical, pedunculated nodules on the cheek mucosa. The patient described has most of these characteristics. Radiographic features of the jaws which have not been previously described are reported. These include a markedly enlarged and bifurcated inferior alveolar canal and shortened roots of the lower incisor teeth. Due to the lethality of the disease, patients who present with the above physical characteristics must be further investigated to exclude MEN2b.
Asunto(s)
Neoplasias de las Glándulas Suprarrenales , Carcinoma , Neoplasia Endocrina Múltiple , Feocromocitoma , Neoplasias de la Tiroides , Neoplasias de las Glándulas Suprarrenales/patología , Adulto , Carcinoma/patología , Neoplasias del Ojo/patología , Humanos , Masculino , Neoplasia Endocrina Múltiple/patología , Neuroma/patología , Feocromocitoma/patología , Neoplasias de la Tiroides/patologíaRESUMEN
Five unusual cases of bile-duct obstruction are presented. There were three cases of intrabiliary hepatoma, one of intrabiliary colon cancer metastasis, and one cystadenoma of the bile-duct. The importance of an accurate diagnosis is emphasized, as these tumours can be treated by surgery or by biliary stenting, sometimes with prolonged survival.
Asunto(s)
Neoplasias de los Conductos Biliares/complicaciones , Carcinoma Hepatocelular/complicaciones , Colestasis/etiología , Conducto Colédoco , Anciano , Neoplasias de los Conductos Biliares/diagnóstico por imagen , Neoplasias de los Conductos Biliares/cirugía , Carcinoma Hepatocelular/diagnóstico por imagen , Carcinoma Hepatocelular/cirugía , Colestasis/diagnóstico por imagen , Colestasis/cirugía , Conducto Colédoco/diagnóstico por imagen , Conducto Colédoco/cirugía , Cistoadenoma/complicaciones , Cistoadenoma/diagnóstico por imagen , Cistoadenoma/cirugía , Femenino , Humanos , Neoplasias Hepáticas , Masculino , Persona de Mediana Edad , RadiografíaRESUMEN
Visceral artery aneurysms are uncommon. During the period 1975-88, 32 patients were treated at the Royal Melbourne Hospital for true and false visceral artery aneurysms. There were 18 males and 14 females, with an age range of 12-86 years. Of the 32 patients, 26 were symptomatic and six were asymptomatic. True aneurysms were found in 20 patients and false aneurysms in 10. A further two were dissecting aneurysms. Of the arteries involved, 17 were renal, six were hepatic, five were splenic, one was superior mesenteric, one was left colic and there were two patients with aneurysms at multiple sites. Aetiological factors included atherosclerosis, fibromuscular dysplasia, pancreatitis, and trauma. Only one patient presented in pregnancy. Rupture occurred in 12 patients and two died as a result of this complication. All the true hepatic artery aneurysms presented in this way. Pre-operative investigations included plain radiology, computerized tomography with contrast, nuclear scanning and selective angiography. Operative treatment was required in 22 cases, 12 as an emergency and 10 as an elective procedure. Surgical options included aneurysm excision with or without arterial reconstruction, aneurysmorrhaphy with flap arterioplasty, or ligation of the aneurysm. Embolization was successfully employed in two patients and eight were merely observed without complications. Surgical therapy is recommended for any patient with symptoms, for any woman of child-bearing age and for all hepatic artery aneurysms.
Asunto(s)
Aneurisma , Vísceras/irrigación sanguínea , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Aneurisma/diagnóstico , Aneurisma/diagnóstico por imagen , Aneurisma/cirugía , Niño , Femenino , Arteria Hepática/diagnóstico por imagen , Humanos , Masculino , Persona de Mediana Edad , Radiografía , Arteria Renal/diagnóstico por imagen , Arteria Esplénica/diagnóstico por imagenRESUMEN
Endoscopic sphincterotomy is the treatment of first choice for stones that remain in the bile duct after cholecystectomy. There is a small group of patients in whom this technique is not successful; many of these patients carry a high risk for surgery because of their age or associated medical conditions. A variety of non-surgical techniques is available; however, none is well established. We have used an in-vitro model to show that human gallstones are fragmented readily by shock-wave lithotripsy. Two elderly frail patients with difficult bile-duct stones have been treated successfully by extracorporeal shock-wave lithotripsy. The bile ducts were cleared of stones and the patients suffered no adverse effects. Extracorporeal shock-wave lithotripsy is a new and promising alternative to the current non-surgical techniques for the management of bile-duct stones.
Asunto(s)
Cálculos Biliares/terapia , Litotricia/métodos , Anciano , Anciano de 80 o más Años , Femenino , Cálculos Biliares/diagnóstico por imagen , Humanos , RadiografíaRESUMEN
Primary sclerosing cholangitis is an uncommon condition, generally considered to carry a poor prognosis. Based on the distribution of the biliary strictures, treatment groups can be defined. Those patients with localized hilar or predominantly extrahepatic strictures are most likely to be suitable for biliary-enteric bypass and the use of surgical techniques developed for the management of high bile duct strictures are allowing improvement in the results of surgery in this form of the disease. After 3 months to 3 years follow-up (median 16 months) nine of 12 patients treated by surgical biliary decompression are asymptomatic.
Asunto(s)
Colangitis/cirugía , Adolescente , Adulto , Anciano , Conductos Biliares/patología , Conductos Biliares Intrahepáticos/diagnóstico por imagen , Conductos Biliares Intrahepáticos/patología , Colangiografía , Colangitis/diagnóstico por imagen , Colangitis/patología , Femenino , Humanos , Masculino , Métodos , Persona de Mediana Edad , EsclerosisRESUMEN
Eight patients with biliary obstruction and a pre-operative diagnosis of a neoplastic lesion at the confluence of the hepatic ducts were found postoperatively to have benign disease. Cholangiography was highly suggestive of a malignant stricture in all patients. Angiography performed in six patients indicated that the lesions were potentially resectable. Seven patients underwent elective surgery; in six the ductal confluence including the lesion was removed, without mortality. Six patients are alive, five of them totally asymptomatic, in a median follow-up of 32 months. Many patients with hilar strictures are treated for what appears radiologically to be a neoplastic lesion. Since treatment often involves the placement of an endoprosthesis or palliative surgery, without histological diagnosis, some of these patients with benign disease are likely to be treated inappropriately, unless they are considered for a curative resection.
Asunto(s)
Neoplasias de los Conductos Biliares/diagnóstico , Colestasis/diagnóstico , Conducto Hepático Común/cirugía , Adulto , Anciano , Colestasis/cirugía , Constricción Patológica/diagnóstico , Constricción Patológica/cirugía , Diagnóstico Diferencial , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
In 19 patients with carcinoma of the gallbladder treated over a four year period, several features of percutaneous transhepatic cholangiography have been recognized which have increasingly provided an accurate diagnosis preoperatively. These features are due to intrahepatic invasion of the bile duct and by providing a diagnosis preoperatively can have a large bearing on the choice of therapy for a particular patient. The relative roles of surgical bypass and endoscopically or percutaneously placed prostheses are discussed.
Asunto(s)
Neoplasias de la Vesícula Biliar/diagnóstico , Adulto , Anciano , Colangiografía , Colecistografía , Endoscopía , Femenino , Neoplasias de la Vesícula Biliar/diagnóstico por imagen , Neoplasias de la Vesícula Biliar/cirugía , Humanos , Hígado/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Cuidados Paliativos , Cuidados Preoperatorios , Estudios Retrospectivos , Factores de Tiempo , UltrasonografíaRESUMEN
Four patients with large right upper quadrant tumour masses of non-hepatic origin are presented. On initial clinical and radiological assessment, all cases were misinterpreted as either having a primary liver tumour or extensive invasion of the liver by an extrinsic tumour. Although angiography and CT scanning are most likely to yield an accurate diagnosis, they can be misleading. Vena cavography also gives important information in determining operability and at operation guides the retroperitoneal dissection. After thorough investigation an aggressive surgical approach to these tumours, with hepatic resection when necessary, provides the best chance of good palliation and possible cure.