RESUMEN
INTRODUCTION: Acute cholecystitis is among the most common general surgical presentations. There is a cohort of patients who develop systemic sepsis and complications of acute cholecystitis. These patients are often elderly and co-morbid. Conservative management with percutaneous cholecystostomy has been shown to be a safe and effective management option in the acute setting. However, there is currently no consensus for the further management of these patients. In particular, there is a paucity of data on readmission rates and subsequent operative or non-operative management. METHODS: A retrospective study was carried out of patients treated with a percutaneous cholecystostomy for biliary sepsis over a three-year period in a UK teaching hospital. Outcome measures were subsequent operative or conservative management, conversion rates, operative complications and readmission rates. RESULTS: Twenty-five patients had a percutaneous cholecystostomy for the treatment of acute biliary sepsis. The median follow-up duration was 35 months. Thirteen patients (52%) had operative treatment. In the operative group, 6/13 had a laparoscopic cholecystectomy, 2/13 had a planned open cholecystectomy, 2/13 had abandoned procedures and 3/13 had a converted procedure. Complications in the operative group included: postoperative mortality (1/13), common bile duct injury requiring drainage and endoscopic stenting (1/13) and one patient required readmission with recurrent pain. In the non-operative group, 5/12 patients were readmitted with biliary sepsis, 5/12 had no readmissions, 1/12 died in the community and 1/12 was readmitted with biliary colic. CONCLUSIONS: Percutaneous cholecystostomy is a recognised treatment modality for elderly, co-morbid patients with biliary sepsis. Nevertheless, the readmission rate in this group is relatively high at 5/12 (42%). Patients who undergo subsequent operative management have a conversion rate of 3/13 (23%) and a significant complication rate of 2/13 (15%). The further management of patients having undergone percutaneous cholecystostomy requires careful consideration on an individual case basis. The P-POSSUM (Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity) may aid decision making.
Asunto(s)
Colecistitis Aguda/cirugía , Colecistostomía/métodos , Sepsis/cirugía , Enfermedad Aguda , Adulto , Anciano , Anciano de 80 o más Años , Algoritmos , Colecistectomía Laparoscópica/métodos , Conversión a Cirugía Abierta/estadística & datos numéricos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Factores de Riesgo , Índice de Severidad de la Enfermedad , Tiempo de Tratamiento , Resultado del TratamientoRESUMEN
INTRODUCTION: Transanal endoscopic microsurgery (TEMS) is becoming more widespread due to the increasing body of evidence to support its role. Previous published data has reported recurrence rates in excess of 10% for benign polyps after TEMS. METHODS: Bradford Royal Infirmary is a tertiary referral centre for TEMS and early rectal cancer in the UK. Data for all TEMS operations were entered into a prospective database over a 7-year period. Demographic data, complications and recurrence rates were recorded. Both benign adenomas and malignant lesions were included. RESULTS: A total of 164 patients (65% male), with a mean age of 68 years were included; 114 (70%) of the lesions resected were benign adenomas, and 50 (30%) were malignant lesions. Median polyp size was 4 (range 0.6-14.5) cm. Mean length of operation was 55 (range 10-120) min. There were no recurrences in any patients with a benign adenoma resected; two patients with malignant lesions developed recurrences. Three intra-operative complications were recorded, two rectal perforations (repaired primarily, one requiring defunctioning stoma), and a further patient suffered a blood loss of >300 ml requiring transfusion. Six patients developed strictures requiring dilation either endoscopically or under anaesthetic in the post-operative period. CONCLUSIONS: We have demonstrated that TEMS procedures performed in a specialist centre provide low rates of both recurrence and complication. Within a specialist centre, TEMS surgery should be offered to all patients for rectal lesions, both benign and malignant, that are amenable to TEMS.
Asunto(s)
Adenocarcinoma/cirugía , Adenoma/cirugía , Pólipos del Colon/cirugía , Endoscopía/métodos , Microcirugia/métodos , Neoplasias del Recto/cirugía , Adenocarcinoma/patología , Adenoma/patología , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Estudios de Seguimiento , Humanos , Complicaciones Intraoperatorias/cirugía , Masculino , Recurrencia Local de Neoplasia/patología , Recurrencia Local de Neoplasia/cirugía , Estadificación de Neoplasias , Tempo Operativo , Cuidados Preoperatorios , Estudios Prospectivos , Neoplasias del Recto/patología , Estomas QuirúrgicosRESUMEN
Merkel cell carcinoma (MCC) is a rare but aggressive neuroendocrine tumour of the skin with high rate of local recurrence and distant metastatic potential leading to poor outcomes. Merkel cells are normally found as innervated clusters of cells around hair follicles in the basal layer of the epidermis and are thought to function as touch receptors. Here, we describe a case of MCC in a 71-year-old female and provide an up-to-date review of the literature pertinent to the management of MCC.
Asunto(s)
Carcinoma de Células de Merkel/patología , Carcinoma de Células de Merkel/cirugía , Neoplasias Cutáneas/patología , Neoplasias Cutáneas/cirugía , Anciano , Antineoplásicos/uso terapéutico , Carcinoma de Células de Merkel/tratamiento farmacológico , Carcinoma de Células de Merkel/radioterapia , Carcinoma de Células de Merkel/secundario , Femenino , Humanos , Metástasis Linfática , Neoplasias Cutáneas/tratamiento farmacológico , Neoplasias Cutáneas/radioterapiaRESUMEN
A rare case of pseudohernia of the abdominal wall following video-assisted thoracoscopy (VAT) and pleural biopsy in a 61-year-old male is presented. The patient presented with a recurrent pleural effusion following fractured ribs after a road traffic accident. Computerised tomography (CT) showed thickened pleura, which was biopsied using VAT. Access to the pleural cavity was obtained with two laparoscopic ports inserted at the 8th intercostal space on the posterior chest wall. Following the procedure, the patient experienced sharp pain over the right hypochondrium, which was followed by the development of a diffuse bulge associated with the loss of skin sensation. Ultrasound and CT disclosed no musculofascial defect. Electromyography showed denervation changes affecting the muscles innervated by the 8th intercostal nerve. With expectant treatment over a year, cutaneous sensation recovered partially; however, the size of the pseudohernia remained unchanged. To the authors' knowledge, this is the first report of a pseudohernia in the English literature following VAT and pleural biopsy.
Asunto(s)
Biopsia/efectos adversos , Hernia Abdominal/etiología , Cirugía Torácica Asistida por Video/efectos adversos , Diagnóstico Diferencial , Fracturas Óseas/complicaciones , Fracturas Óseas/diagnóstico , Fracturas Óseas/cirugía , Hernia Abdominal/diagnóstico , Hernia Abdominal/cirugía , Humanos , Masculino , Persona de Mediana Edad , Derrame Pleural/complicaciones , Derrame Pleural/diagnóstico , Derrame Pleural/cirugía , Complicaciones Posoperatorias , Costillas/lesiones , Traumatismos Torácicos/complicaciones , Traumatismos Torácicos/diagnóstico , Traumatismos Torácicos/cirugíaRESUMEN
Vaginal pessaries still have a role in the management of uterine prolapse, particularly in elderly patients. However, they are known to cause serious complications if proper care is not taken. We present a case of a rectovaginal fistula, developing secondary to a forgotten vaginal pessary. The shelf pessary was found to have eroded through into the rectum. A review of the relevant literature was undertaken and complications associated with vaginal pessaries are discussed.