RESUMEN
BACKGROUND: Which type of closure after carotid endarterectomy (CEA), whether primary, patching, or eversion, will provide the optimal results has remained controversial. In the present study, we compared the results of randomized controlled trials (RCTs) and systematic meta-analyses of the various types of closure. METHODS: We conducted a PubMed literature review search to find studies that had compared CEA with primary closure, CEA with patching, and/or eversion CEA (ECEA) during the previous three decades with an emphasis on RCTs, previously reported systematic meta-analyses, large multicenter observational studies (Vascular Quality Initiative data), and recent single-center large studies. RESULTS: The results from RCTs comparing primary patching vs primary closure were as follows. Most of the randomized trials showed CEA with patching was superior to CEA with primary closure in lowering the perioperative stroke rates, stroke and death rates, carotid thrombosis rates, and late restenosis rates. These studies also showed no significant differences between the preferential use of several patch materials, including synthetic patches (polyethylene terephthalate [Dacron; DuPont, Wilmington, Del], Acuseal [Gore Medical, Flagstaff, Ariz], polytetrafluoroethylene, or pericardial patches) and vein patches (saphenous or jugular). The results from observational studies comparing patching vs primary closure were as follows. The Vascular Study Group of New England data showed that the use of patching increased from 71% to 91% (P < .001). Also, the 1-year restenosis and occlusion (P < .01) and 1-year stroke and transient ischemic attack (P < .03) rates were significantly lower statistically with patch closure. The results from the RCTs comparing ECEA vs conventional CEA (CCEA) were as follows. Several RCTs that had compared ECEA with CCEA showed equivalency of CCEA vs ECEA (level 1 evidence) with patching in the perioperative carotid thrombosis and stroke rates. At 4 years after treatment, the incidence of carotid stenosis was lower for ECEA than for primary closure (3.6% vs 9.2%; P = .01) but was comparable between patching and eversion (1.5% for patching vs 2.8% for eversion). CONCLUSIONS: Routine carotid patching or ECEA was superior to primary closure (level 1 evidence). We found no significant differences between the preferential use of several patch materials. The rates of significant post-CEA stenosis for CEA with patching was similar to that with ECEA, and both were superior to primary closure.
Asunto(s)
Enfermedades de las Arterias Carótidas/cirugía , Endarterectomía Carotidea , Hemostasis Quirúrgica , Enfermedades de las Arterias Carótidas/diagnóstico por imagen , Enfermedades de las Arterias Carótidas/mortalidad , Endarterectomía Carotidea/efectos adversos , Endarterectomía Carotidea/mortalidad , Hemostasis Quirúrgica/efectos adversos , Hemostasis Quirúrgica/instrumentación , Hemostasis Quirúrgica/mortalidad , Humanos , Complicaciones Posoperatorias/etiología , Ensayos Clínicos Controlados Aleatorios como Asunto , Recurrencia , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
All health care providers should be aware of the impact of bleeding disorders on their patients during any surgical procedures. The knowledge of the mechanisms of hemostasis and optimized management are very important. Initial recognition of a bleeding disorder, in such patients with a systemic pathologic process, may occur in surgical practice. The surgical treatment of those patients might be complicated during the surgery due to the use of anticoagulant and/or antiplatelet medications raises a challenge in the daily practice of surgical professionals. Adequate hemostasis is critical for the success of any surgical procedure because bleeding problems can give rise to complications associated with important morbidity-mortality. Besides, prophylactic, restorative, and surgical care of patients with any bleeding disorders is handled skillfully by practitioners who are well educated regarding the pathology, complications which could arise, and surgical options associated with these conditions. The purpose of this paper is to review common bleeding disorders and their effects on the surgical aspect. Many authors consider that patient medication indicated for the treatment of background disease should not be altered or suspended unless so indicated by the prescribing physician. Local hemostatic measures have been shown to suffice for controlling possible bleeding problems resulting from surgery.
Asunto(s)
Humanos , Procedimientos Quirúrgicos Operativos , Inhibidores de Agregación Plaquetaria/administración & dosificación , Hemorragia/cirugía , Trastornos Hemorrágicos/complicaciones , Hemostasis Quirúrgica/mortalidad , Anticoagulantes/administración & dosificaciónRESUMEN
PURPOSE: To identify the treatment options and prognostic factors for patients with initially unresectable ruptured hepatocellular carcinoma (HCC). METHODS: Between June 2012 to December 2016, 94 consecutive patients with initially unresectable ruptured HCC were analyzed retrospectively in this study. Patients were followed until December 2017. Predictors of short-term (≤30 days) and long-term (>30 days) survival were identified by using logistic regression model and Cox proportional hazard model, respectively. RESULTS: Of the 94 patients, initial hemostasis treatment was achieved by transarterial embolization (TAE) in 59 patients, surgical hemostasis in 14, and conservative treatment in 21. Twenty-five (26.6%) patients died within 30 d after tumor rupture. In the multivariate analysis, patients treated with aggressive initial treatment strategies (TAE or surgical hemostasis) (P < 0.001) or those with better Child-Pugh class (P = 0.003) and absence of shock on admission (P = 0.001) had a better chance of short-term survival. Of the 69 patients who survived more than 30 days after initial treatment, the median survival time was 268 d. In the multivariate analysis, among the 69 who survived, early modified LCSGJ stage (P = 0.003) and staged hepatectomy as definitive treatment (P < 0.001) were significant predictors of increased long-term survival. CONCLUSION: Short-term survival of patients with initially unresectable ruptured HCC could achieve with better Child-Pugh class, absence of shock and aggressive initial treatment strategies. After survived the emergency phase of tumor rupture, long-term survival was significantly increased with early modified LCSGJ stage and staged hepatectomy therapy.
Asunto(s)
Carcinoma Hepatocelular/complicaciones , Carcinoma Hepatocelular/terapia , Embolización Terapéutica/métodos , Neoplasias Hepáticas/patología , Rotura/etiología , Adulto , Anciano , Carcinoma Hepatocelular/irrigación sanguínea , Carcinoma Hepatocelular/diagnóstico por imagen , Embolización Terapéutica/efectos adversos , Embolización Terapéutica/mortalidad , Femenino , Hemostasis Quirúrgica/efectos adversos , Hemostasis Quirúrgica/métodos , Hemostasis Quirúrgica/mortalidad , Hepatectomía/efectos adversos , Humanos , Imagen por Resonancia Magnética/métodos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Pronóstico , Estudios Retrospectivos , Rotura/mortalidad , Rotura/terapia , Análisis de Supervivencia , Tomografía Computarizada por Rayos X/métodos , Resultado del TratamientoRESUMEN
INTRODUCTION: Managing patients with open pelvic fractures continues to be challenging and requires a multidisciplinary approach. In this study, we examined the characteristics of patients with open pelvic fractures and strategies for managing such patients. MATERIALS AND METHODS: The records of patients with open pelvic fractures from January 2010 to August 2016 were retrospectively reviewed. Emergency surgery was performed to control hemorrhaging in patients with an active external hemorrhage. Transcatheter arterial embolization (TAE) was used for definitive hemostasis. The relation between cause of death and timing of death was examined. We also compared the characteristics of surviving and non-surviving patients. Furthermore, patients who received both surgery and post-operative TAE were analyzed in detail. RESULTS: In total, 42 patients with open pelvic fractures were enrolled in the study. The overall mortality rate among patients with open pelvic fractures was 26.2%. Patients whose deaths were related to hemorrhaging and associated injuries died significantly earlier than patients whose deaths were related to sepsis and multiple organ failure (1.3days vs. 12.3days, p<0.001). Sixteen patients (38.1%) received TAE for hemostasis, and their systolic blood pressure (SBP) improved significantly following TAE (from 88.4mmHg to 111.6mmHg, p<0.05). In the patients who received both surgery and post-operative TAE (n=8), the SBP increased significantly after surgery (from 58.8mmHg to 81.1mmHg, p<0.05). Similarly, the patients' SBP after TAE was significantly higher than their post-operative SBP (110.5mmHg vs. 81.1mmHg, p<0.05). CONCLUSION: Active external hemorrhaging was initially controlled when managing patients with open pelvic fractures; however, most patients also required TAE for definitive hemorrhage control. Early TAE should be considered due to the high probability of concomitant internal and external hemorrhage. Close observation and further infection control are important following the hemostatic procedure.
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Embolización Terapéutica/métodos , Fracturas Óseas/terapia , Hemorragia/prevención & control , Huesos Pélvicos/lesiones , Accidentes por Caídas/estadística & datos numéricos , Accidentes de Tránsito/estadística & datos numéricos , Adulto , Terapia Combinada , Tratamiento de Urgencia/métodos , Femenino , Fracturas Óseas/mortalidad , Hemorragia/mortalidad , Hemostasis Quirúrgica/métodos , Hemostasis Quirúrgica/mortalidad , Humanos , Masculino , Resultado del TratamientoRESUMEN
AIM: To present treatment of 52 149 patients with ulcerative gastroduodenal bleeding (UGDB) who were treated in different regions of Central Federal District (CFD) for the period 2011-2014. It is noted that UGDB incidence per 100 thousands is increased proportionally from 32.9 to 77.8 according to population less than 20 and over 100 thousands, respectively. In hospitals of small and medium settlements the number of UGDB patients without surgery reaches 81.6 and 81.1%, the number of operated patients - 18.4 and 18.9% respectively. In hospitals of large settlements this ratio is 90.1 and 90.6%, the number of operated patients - 9.9 and 9.4%, respectively. In areas of Central Federal District the mortality rate in patients without surgery is 3.9-8.2%, in operated patients - 17.4-36.9%. RESULTS: Structured analysis of the organization of surgical care in Central Federal District revealed the relationship between outcomes and efficient use of endoscopic diagnostics and haemostasis. In municipal hospitals of Central District endoscopic technologies are insufficiently used for final elimination of ulcerative bleeding.
Asunto(s)
Hemostasis Quirúrgica , Hospitales , Úlcera Péptica Hemorrágica , Endoscopía Gastrointestinal/métodos , Necesidades y Demandas de Servicios de Salud , Hemostasis Quirúrgica/métodos , Hemostasis Quirúrgica/mortalidad , Hemostasis Quirúrgica/estadística & datos numéricos , Hospitales/clasificación , Hospitales/estadística & datos numéricos , Humanos , Mortalidad , Úlcera Péptica Hemorrágica/epidemiología , Úlcera Péptica Hemorrágica/cirugía , Federación de Rusia/epidemiologíaRESUMEN
BACKGROUND: In the treatment of complex pelvic fractures hemorrhage control is of primary importance; however, studies regarding the localization of bleeding are contradictory so that various treatment approaches are recommended. The primary aim of external pelvic compression applied in the trauma room is to reduce the pelvic volume and counteract blood loss through self-induced tamponade. This study examined the influence of external pelvic compression on mortality and outcome in cases of hemodynamically unstable pelvic fractures in a larger number of cases. MATERIAL AND METHODS: The current study used the TraumaRegister DGU® (TR-DGU) to retrospectively evaluate the records of 104 patients treated between 2002 and 2011. All patients suffered severe injury with an injury severity score (ISS) of at least 16 points. In addition, the patients were hemodynamically unstable with confirmed relevant isolated pelvic injuries. To evaluate the effectiveness of external pelvic compression, patients with and without external pelvic stabilization were compared. RESULTS: Of the investigated patients 26.9 % died of their injuries and of these the mortality was 78.6 % within the first 6 h of admission to the trauma room. External pelvic stabilization was performed in 45.2 % of patients. The mortality was 19.1 % in patients with external pelvic stabilization and in contrast, the mortality in the group of patients without external pelvic stabilization was 33.3 %. During the course of hospitalization, surviving patients with external pelvic stabilization were significantly more likely to develop sepsis or multiple organ failure and required longer periods of intensive care. CONCLUSION: External pelvic stabilization seems to be an important instrument for the initial treatment of hemodynamically unstable pelvic fractures and showed a positive effect on patient mortality.
Asunto(s)
Fracturas Óseas/mortalidad , Fracturas Óseas/cirugía , Hemorragia/mortalidad , Hemorragia/prevención & control , Hemostasis Quirúrgica/estadística & datos numéricos , Huesos Pélvicos/lesiones , Huesos Pélvicos/cirugía , Adulto , Causalidad , Comorbilidad , Femenino , Alemania/epidemiología , Hemostasis Quirúrgica/mortalidad , Humanos , Masculino , Persona de Mediana Edad , Mortalidad , Prevalencia , Estudios Retrospectivos , Factores de Riesgo , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
PURPOSE: This study investigated the advantages of performing urgent resuscitative surgery (URS) in the emergency department (ED); namely, our URS policy, to avoid a delay in hemorrhage control for patients with severe torso trauma and unstable vital signs. METHODS: We divided 264 eligible cases into a URS group (n = 97) and a non-URS group (n = 167) to compare, retrospectively, the observed survival rate with the predicted survival using the Trauma and Injury Severity Score (TRISS). RESULTS: While the revised trauma score and the injury severity score were significantly lower in the URS group than in the non-URS group, the observed survival rate was significantly higher than the predicted rate in the URS (48.5 vs. 40.2%; p = 0.038). URS group patients with a systolic blood pressure (SBP) <90 mmHg and a Glasgow coma scale (GCS) score of ≥9 had significantly higher observed survival rates than predicted survival rates (0.433 vs. 0.309, p = 0.008), (0.795 vs. 0.681, p = 0.004). The implementation of damage control surgery (DCS) was found to be a significant predictor of survival (OR 5.23, 95% CI 0.113-0.526, p < 0.010). CONCLUSION: The best indications for the URS policy are an SBP <90 mmHg, a GCS ≥9 on ED arrival, and/or the need for DCS. By implementing our URS policy, satisfactory survival of patients requiring immediate hemostatic surgery was achieved.
Asunto(s)
Atención Ambulatoria , Hemorragia/prevención & control , Hemorragia/cirugía , Hemostasis Quirúrgica , Resucitación/métodos , Torso/lesiones , Torso/cirugía , Adulto , Anciano , Femenino , Escala de Coma de Glasgow , Hemorragia/mortalidad , Hemostasis Quirúrgica/mortalidad , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Tasa de Supervivencia , Sístole , Índices de Gravedad del Trauma , Signos VitalesRESUMEN
AIM: To define the role of endoscopic hemostasis in treatment of gastroduodenal ulcers complicated by bleeding. MATERIAL AND METHODS: The results of endoscopic hemostasis in 770 patients with peptic ulcers were analyzed. RESULTS: Injection hemostasis had the highest efficacy in case of recurrent bleeding. No other method showed significant advantage in its efficiency. The efficacy of injection method was 52%, argon-plasma coagulation - 83.3%, radiowave technique - 78%, combined endoscopic method - 96%. In case of recurrent bleeding endoscopic hemostasis is effective alternative to surgery especially in high-risk patients. Repeated endoscopic hemostasis significantly decreases mortality from 45% to 23% in case of recurrent bleeding.
Asunto(s)
Endoscopía Gastrointestinal , Hemostasis Quirúrgica , Úlcera Péptica Hemorrágica , Hemorragia Posoperatoria , Úlcera Gástrica/complicaciones , Adulto , Coagulación con Plasma de Argón/métodos , Investigación sobre la Eficacia Comparativa , Electrocoagulación/métodos , Endoscopía Gastrointestinal/efectos adversos , Endoscopía Gastrointestinal/métodos , Femenino , Hemostasis Quirúrgica/efectos adversos , Hemostasis Quirúrgica/métodos , Hemostasis Quirúrgica/mortalidad , Humanos , Masculino , Persona de Mediana Edad , Moscú , Evaluación de Resultado en la Atención de Salud , Úlcera Péptica Hemorrágica/diagnóstico , Úlcera Péptica Hemorrágica/etiología , Úlcera Péptica Hemorrágica/cirugía , Hemorragia Posoperatoria/diagnóstico , Hemorragia Posoperatoria/cirugía , Recurrencia , Reoperación/métodos , Reoperación/estadística & datos numéricos , Ajuste de Riesgo , Análisis de SupervivenciaRESUMEN
Small-bowel bleeding comprises a majority of obscure gastrointestinal bleeding, but is caused by various kinds of diseases. For its diagnosis, history-taking and physical examination is requisite, leading to a suspicion of what diseases are involved. Next, cross-sectional imaging such as computed tomography should be done, followed by the latest enteroscopy, videocapsule endoscopy and deep enteroscopy according to the severity of hemorrhage and patient conditions. After comprehensive diagnosis, medical, enteroscopic, or surgical treatment should be selected.
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Endoscopía Capsular/métodos , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/cirugía , Hemostasis Quirúrgica/métodos , Imagen Multimodal/métodos , Endoscopía Gastrointestinal/métodos , Femenino , Hemorragia Gastrointestinal/etiología , Hemorragia Gastrointestinal/mortalidad , Hemostasis Quirúrgica/mortalidad , Humanos , Laparoscopía/métodos , Masculino , Sangre Oculta , Pronóstico , Medición de Riesgo , Índice de Severidad de la Enfermedad , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
OBJECTIVE: To compare radical surgery with a minimal approach for peptic ulcer bleeding in relation to survival. DESIGN: A Swedish nationwide population-based cohort study from 1987-2008 compared survival after minimal surgery and definitive surgery. The cohort was also stratified into calendar year before and after the year 2000 for subgroup analyses. Data were collected from the Swedish Patient Register. The two surgical groups were matched based on the propensity score to mimic a randomized trial design. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using Cox regression models adjusted for potential confounders. RESULTS: 4,163 patients were included. There were no differences in survival in patients who underwent definitive surgical procedures compared to those who underwent minimal surgery for a bleeding peptic ulcer during the full study period. Using minimal surgery group as the reference, the HRs for death in the definitive surgery group within 30 days, 90 days, 1 year, and 5 years were 0.87 (95% CI 0.72-1.05), 0.93 (0.80-1.09), 1.00 (95% CI 0.87-1.14), and 1.05 (95% CI 0.95-1.16), respectively. The corresponding HRs during the calendar period after the year 2000 were 1.05 (95% CI 0.65-1.69), 1.18 (95% CI 0.81-1.73), 1.17 (0.84-1.62), and 1.27 (95% CI 0.99-1.63), respectively. CONCLUSION: This study found no worse overall survival after minimal surgery compared to more extensive surgery for refractory peptic ulcer bleeding, and indicated better long-term survival in the minimal surgery group during the more recent study period. A minimal approach is probably sufficient in most cases.
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Causas de Muerte , Gastrectomía/métodos , Hemostasis Quirúrgica/métodos , Úlcera Péptica Hemorrágica/mortalidad , Úlcera Péptica Hemorrágica/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Intervalos de Confianza , Femenino , Estudios de Seguimiento , Gastrectomía/mortalidad , Hemostasis Quirúrgica/mortalidad , Mortalidad Hospitalaria , Humanos , Ligadura/métodos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Procedimientos Quirúrgicos Mínimamente Invasivos/mortalidad , Análisis Multivariante , Úlcera Péptica Hemorrágica/diagnóstico , Modelos de Riesgos Proporcionales , Sistema de Registros , Estudios Retrospectivos , Medición de Riesgo , Índice de Severidad de la Enfermedad , Análisis de Supervivencia , Suecia , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Liver transection is considered a critical factor influencing intra-operative blood loss. A increase in the number of complex liver resections has determined a growing interest in new devices able to 'optimize' the liver transection. The aim of this randomized controlled study was to compare a radiofrequency vessel-sealing system with the 'gold-standard' clamp-crushing technique. METHODS: From January to December 2012, 100 consecutive patients undergoing a liver resection were randomized to the radiofrequency vessel-sealing system (LF1212 group; N = 50) or to the clamp-crushing technique (Kelly group, N = 50). RESULTS: Background characteristics of the two groups were similar. There were not significant differences between the two groups in terms of blood loss, transection time and transection speed. In spite of a not-significant larger transection area in the LF1212 group compared with the Kelly group (51.5 versus 39 cm(2) , P = 0.116), the overall and 'per cm(2) ' blood losses were similar whereas the transection speed was better (even if not significantly) in the LF1212 group compared with the Kelly group (1.1 cm(2) /min versus 0.8, P = 0.089). Mortality, morbidity and bile leak rates were similar in both groups. CONCLUSIONS: The radiofrequency vessel-sealing system allows a quick and safe liver transection similar to the gold-standard clamp-crushing technique.
Asunto(s)
Pérdida de Sangre Quirúrgica/prevención & control , Ablación por Catéter/instrumentación , Hemostasis Quirúrgica/instrumentación , Hepatectomía/instrumentación , Adulto , Anciano , Anciano de 80 o más Años , Ablación por Catéter/efectos adversos , Ablación por Catéter/mortalidad , Constricción , Diseño de Equipo , Femenino , Hemostasis Quirúrgica/efectos adversos , Hemostasis Quirúrgica/métodos , Hemostasis Quirúrgica/mortalidad , Hepatectomía/efectos adversos , Hepatectomía/métodos , Hepatectomía/mortalidad , Humanos , Italia , Masculino , Persona de Mediana Edad , Tempo Operativo , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/mortalidad , Estudios Prospectivos , Factores de Tiempo , Resultado del TratamientoRESUMEN
AIM: The aims of this study were to determine the early mortality rate in low-risk coronary artery bypass graft (CABG) patients and examine the causes of death, to identify problems that could be avoided in future surgeries. METHODS: All low-risk patients (EuroSCORE ≤ 2) who died after CABG were included. Their peri-operative information was meticulously studied by internal and independent external reviewers to identify causes of death, which were classified as: cardiac or non-cardiac; and a further division as: (1) non-preventable, (2) preventable (technical error), and (3) preventable (system error). RESULTS: Early mortality was 0.93% (24/2570). Eleven patients (45.8%) were classified as preventable deaths. In six of them the main problem was identified as graft thrombosis, which was secondary to a technical error of either the harvesting or anastomosis of the left internal mammarian artery. There were also five system errors identified as delays in the treatment of an identified and potentially reversible problem. CONCLUSION: Correction of technical and system errors, such as harvesting of the left internal mammarian artery, haemostasis during surgery, and establishing standard protocols for the transfer of patients from ward to intensive care units will eventually lead to improvement in both the quality of care and patient outcomes, even in low-risk groups.
Asunto(s)
Puente de Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/cirugía , Complicaciones Posoperatorias/mortalidad , Anciano , Causas de Muerte , Puente de Arteria Coronaria/efectos adversos , Enfermedad de la Arteria Coronaria/mortalidad , Femenino , Hemostasis Quirúrgica/mortalidad , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/prevención & control , Estudios Prospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Tiempo de Tratamiento , Recolección de Tejidos y Órganos/mortalidad , Resultado del Tratamiento , Turquía/epidemiologíaRESUMEN
BACKGROUND: Excessive intraoperative blood loss and the possible requirement for blood transfusion are major problems in hepatic resection for liver tumors. The decrease of blood loss is a goal in liver surgery, and several technical developments have been introduced for this purpose. The aim of this prospective randomized study was to compare the use of the Cavitron Ultrasonic Surgical Aspirator (CUSA) with a radiofrequency-based bipolar hemostatic sealer versus CUSA with standard bipolar cautery (BC) in patients undergoing hepatic resection. METHODS: One hundred nine patients with liver tumors were randomized to undergo hepatic transection via CUSA with a bipolar sealer (Aquamantys 2.3 Bipolar Sealer; n = 55) or BC (n = 54). Blood loss during parenchymal transection and speed of transection were the primary end points, whereas the degree of postoperative liver injury and morbidity were secondary end points. RESULTS: Compared with the BC group, the bipolar sealer showed lesser blood loss during transection and blood loss divided by resection area (P = .0079 and .0008, respectively), shorter transection time (P = .0025), faster speed of transection (P < .0001), and fewer ties and ties divided by resection area required during transection (P < .0001). CONCLUSION: CUSA with a bipolar sealer is superior to CUSA with standard BC for various hepatectomy in terms of less blood loss and faster speed of transection, with no increase in morbidity.
Asunto(s)
Cauterización/instrumentación , Hemostasis Quirúrgica/instrumentación , Hepatectomía/instrumentación , Neoplasias Hepáticas/cirugía , Anciano , Anciano de 80 o más Años , Femenino , Hemostasis Quirúrgica/mortalidad , Hepatectomía/mortalidad , Hepatectomía/estadística & datos numéricos , Humanos , Neoplasias Hepáticas/mortalidad , Neoplasias Hepáticas/patología , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Succión/instrumentaciónRESUMEN
AIM: To determine the clinical value of a splenorenal shunt plus pericardial devascularization (PCVD) in portal hypertension (PHT) patients with variceal bleeding. METHODS: From January 2008 to November 2012, 290 patients with cirrhotic portal hypertension were treated surgically in our department for the prevention of gastroesophageal variceal bleeding: 207 patients received a routine PCVD procedure (PCVD group), and 83 patients received a PCVD plus a splenorenal shunt procedure (combined group). Changes in hemodynamic parameters, rebleeding, encephalopathy, portal vein thrombosis, and mortality were analyzed. RESULTS: The free portal pressure decreased to 21.43 ± 4.35 mmHg in the combined group compared with 24.61 ± 5.42 mmHg in the PCVD group (P < 0.05). The changes in hemodynamic parameters were more significant in the combined group (P < 0.05). The long-term rebleeding rate was 7.22% in the combined group, which was lower than that in the PCVD group (14.93%), (P < 0.05). CONCLUSION: Devascularization plus splenorenal shunt is an effective and safe strategy to control esophagogastric variceal bleeding in PHT. It should be recommended as a first-line treatment for preventing bleeding in PHT patients when surgical interventions are considered.
Asunto(s)
Várices Esofágicas y Gástricas/cirugía , Hemorragia Gastrointestinal/cirugía , Hemostasis Quirúrgica/métodos , Hipertensión Portal/etiología , Adolescente , Adulto , Anciano , Várices Esofágicas y Gástricas/diagnóstico , Várices Esofágicas y Gástricas/etiología , Várices Esofágicas y Gástricas/mortalidad , Várices Esofágicas y Gástricas/fisiopatología , Femenino , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/etiología , Hemorragia Gastrointestinal/mortalidad , Hemorragia Gastrointestinal/fisiopatología , Hemostasis Quirúrgica/efectos adversos , Hemostasis Quirúrgica/mortalidad , Humanos , Hipertensión Portal/diagnóstico , Hipertensión Portal/mortalidad , Hipertensión Portal/fisiopatología , Cirrosis Hepática/complicaciones , Masculino , Persona de Mediana Edad , Tempo Operativo , Presión Portal , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: Hemorrhage caused by inflammatory vessel erosion represents a life-threatening complication after upper abdominal surgery such as pancreatic head resection. The gold standard therapeutic choice is an endovascular minimally invasive technique such as embolization or stent placement. Hepatic arterial hemorrhage in presence of pancreatitis and peritonitis is a particular challenge is if a standard therapeutic option is not possible. METHODS: The management of five patients with massive bleeding from the common hepatic artery is described. All patients underwent a splenic artery switch. The splenic artery was dissected close to the splenic hilum and transposed end-to-end to the common hepatic artery after resection of the eroded part. Patients' medical records, radiology reports, and images were reviewed retrospectively. Technical success was defined as immediate cessation of hemorrhage and preserved liver vascularization. Clinical success was defined as hemodynamic stability and adequate long-term liver function. RESULTS: Total pancreatectomy and splenectomy were performed in four of the five cases. Hemodynamic stability and good liver perfusion was achieved in these patients. CONCLUSIONS: Splenic artery switch is an effective, safe procedure for revascularization of the liver in case of hepatic arterial hemorrhage following pancreatic surgery, pancreatitis, and/or peritonitis. The technique is a promising option if a standard procedure-e.g., stent implantation, embolization and surgical repair with alloplastic prosthesis or autologous venous interposition graft-is not possible.
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Hemostasis Quirúrgica/métodos , Hígado/irrigación sanguínea , Hemorragia Posoperatoria/mortalidad , Hemorragia Posoperatoria/cirugía , Terapia Recuperativa , Arteria Esplénica/cirugía , Anciano , Angiografía de Substracción Digital/métodos , Arteritis/complicaciones , Arteritis/diagnóstico por imagen , Estudios de Cohortes , Bases de Datos Factuales , Femenino , Estudios de Seguimiento , Neoplasias Gastrointestinales/patología , Neoplasias Gastrointestinales/cirugía , Hemostasis Quirúrgica/mortalidad , Arteria Hepática , Humanos , Laparotomía/efectos adversos , Laparotomía/métodos , Masculino , Persona de Mediana Edad , Neoplasias Pancreáticas/patología , Neoplasias Pancreáticas/cirugía , Hemorragia Posoperatoria/diagnóstico por imagen , Estudios Retrospectivos , Medición de Riesgo , Índice de Severidad de la Enfermedad , Análisis de Supervivencia , Factores de Tiempo , Resultado del TratamientoAsunto(s)
Procedimientos Quirúrgicos Cardíacos/métodos , Fibrinógeno/uso terapéutico , Rotura Cardíaca Posinfarto/cirugía , Hemostasis Quirúrgica , Hemostáticos/uso terapéutico , Trombina/uso terapéutico , Anciano , Anciano de 80 o más Años , Gasto Cardíaco Bajo/etiología , Gasto Cardíaco Bajo/mortalidad , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Procedimientos Quirúrgicos Cardíacos/mortalidad , Puente Cardiopulmonar , Combinación de Medicamentos , Femenino , Fibrinógeno/efectos adversos , Rotura Cardíaca Posinfarto/mortalidad , Hemostasis Quirúrgica/efectos adversos , Hemostasis Quirúrgica/mortalidad , Hemostáticos/efectos adversos , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Esternotomía , Técnicas de Sutura , Trombina/efectos adversos , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND/AIMS: Liver resection is the most effective treatment for selected patients with primary or metastatic hepatic tumor and many liver resection techniques have tried to minimize blood loss. The objective of the present study was to examine whether TissueLink dissection sealer (DS) was superior to clamp-crushing (CC) technique for liver transection or not. METHODOLOGY: MEDLINE, Pubmed, Ovid and Cochrane Library electronic databases were used to search for studies without language and time period restrictions. RESULTS: Four clinical trials with 276 patients were involved. We evaluated intraoperative blood loss, postoperative morbidity, postoperative biliary leakage, transfusion rate, operation time,hospital stay duration, postoperative mortality,transection time, blood loss in liver transection and pertran section area, transection speed, AST and TBIL and found no statistical differences between the DS and CC groups. Sensitive analysis showed transection time was longer in the former group. In addition, there was no apparent publication bias concerning intraoperative blood loss. CONCLUSIONS: In summary, we could not draw a firm conclusion that DS is superior to CC in liver resection of transection and the advantage of TissueLink dissecting sealer should be evaluated
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Pérdida de Sangre Quirúrgica/prevención & control , Hemostasis Quirúrgica/instrumentación , Hepatectomía/instrumentación , Hemorragia Posoperatoria/prevención & control , Equipo Quirúrgico , Adulto , Anciano , Aspartato Aminotransferasas/sangre , Bilirrubina/sangre , Biomarcadores/sangre , Pérdida de Sangre Quirúrgica/mortalidad , Transfusión Sanguínea , Distribución de Chi-Cuadrado , Constricción , Diseño de Equipo , Femenino , Hemostasis Quirúrgica/efectos adversos , Hemostasis Quirúrgica/mortalidad , Hepatectomía/efectos adversos , Hepatectomía/mortalidad , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Hemorragia Posoperatoria/sangre , Hemorragia Posoperatoria/mortalidad , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: The purpose of this original article was to evaluate the impact of the Pringle maneuver on the survival of patients with colorectal liver metastases. METHODS: Eighty patients with colorectal liver metastases were randomized to undergo hepatectomy with (39 patients, HPC group) or without (41 patients, NHPC group) pedicle clamping. RESULTS: The two groups were homogeneous. Mortality and morbidity rates were similar. Blood transfusions rates were higher in HPC group (p = 0.010). Median follow-up was 67.1 +/- 20 months in the HPC group and 77.5 +/- 16.6 months in the other group (p = 0.07). Overall survival at 1, 3, and 5 years was 100%, 86.1%, and 49.4% in HPC group vs. 92.6%, 65.8%, and 48.2% in NHPC group (p = 0.704). Disease-free survival was similar between the two groups: 1-, 3- and 5-year survival rates were 85.7%, 51.4%, and 34.3% in the HPC group vs. 84%, 51.5%, and 37.9% in NHPC group (p = 0.943). The incidence of hepatic recurrence was similar in the two groups (p = 0.506). Median time to hepatic recurrence was similar in the two groups (p = 0.482). Overall and disease-free survival rates were similar even when the Pringle maneuver was longer than 45 min (p = 0.571 and 0.948) and in patients with liver steatosis (p = 0.779 and 0.412). CONCLUSIONS: The Pringle maneuver does not seem to affect the survival of patients with liver metastases.
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Neoplasias Colorrectales/mortalidad , Neoplasias Colorrectales/patología , Hemostasis Quirúrgica/mortalidad , Hepatectomía/mortalidad , Neoplasias Hepáticas/mortalidad , Neoplasias Hepáticas/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Hepatectomía/métodos , Humanos , Neoplasias Hepáticas/secundario , Masculino , Persona de Mediana Edad , Análisis de Supervivencia , Adulto JovenRESUMEN
OBJECTIVE: To determine whether interventional radiology (IR) or laparotomy (LAP) is the best management of delayed postoperative hemorrhage (DPH) after pancreaticoduodenectomy. Data Source We undertook an electronic search of MEDLINE and selected for analysis only original articles published between January 1, 1990, and December 31, 2007. STUDY SELECTION: Two of us independently selected studies reporting on clinical presentation and incidence of postoperative DPH and the following outcomes: complete hemostasis, morbidity, and mortality. DATA EXTRACTION: Two of us independently performed data extraction. Data were entered and analyzed by means of dedicated software from The Cochrane Collaboration. A random-effects meta-analytical technique was used for analysis. DATA SYNTHESIS: One hundred sixty-three cases of DPH after pancreaticoduodenectomy were identified from the literature. The incidence of DPH after pancreaticoduodenectomy was 3.9%. Seventy-seven patients (47.2%) underwent LAP; 73 (44.8%), IR; and 13 (8%), conservative treatment. On meta-analysis comparing LAP vs IR for DPH, no significant difference was found between the 2 treatment options for complete hemostasis (73% vs 76%; P = .23), mortality (43% vs 20%; P = .14), or morbidity (77% vs 35%; P = .06). CONCLUSIONS: This meta-analysis, although based on data from small case series, is unable to demonstrate any significant difference between LAP and IR in the management of DPH after pancreaticoduodenectomy. The management of this life-threatening complication is difficult, and the appropriate treatment pathway ultimately will be decided by the clinical status of the patient and the institution preference.