重症急性胰腺炎112例治疗体会

目的: 探讨重症急性胰腺炎(SAP)的合理有效的个体化治疗方案.方法: 对112例SAP临床资料进行回顾分析.结果: 以非手术治疗为主的综合治疗组并发症发生率为26.7%,病死率为10.7%,而手术组并发症发生率为67.9%,病死率为28.6%,其明显高于非手术组.结论: SAP早期宜行非手术治疗,一旦有手术指征,应及时手术治疗.     

22例严重肝外伤的外科诊治体会

目的 探讨严重肝外伤的手术探查、快速止血方法及围手术期处理措施.方法 回顾性分析22例严重肝破裂患者的诊断和治疗方法,其中Ⅲ级16例,Ⅳ级5例,Ⅴ1例.结果 22例患者中,治愈18例,治愈率81.8%;死亡4例,病死率18.2%,死亡原因为不适当的止血方法、出血性休克、多器官功能衰竭和合并伤.术后出现并发症11例,均临床治愈.结论 遵循损伤控制性原则,正确的探查方法和快速有效止血是治疗的关键措施;加强围手术期脏器功能保护和凝血机制维护是决定抢救成功与否的重要环节.     

介入疗法在严重肝破裂术后再出血中的应用

目的: 探讨介入疗法在严重肝破裂术后再出血中的应用价值.方法: 对严重肝破裂术后早期继续出血,经保守治疗血流动力学仍不稳定的5例患者行介入治疗.5例患者均于术后9~12 h行血管造影及经导管栓塞止血.结果: 3例造影显示肝脏表面不规则渗血明显,2例造影显示肝动脉分支有活动性出血.介入治疗后24~48 h出血明显减少,显示效果明显.其中4例最后痊愈出院,1例于术后2 w死于应激性溃疡大出血.结论: 介入治疗具有创伤小,见效快,相对简单安全等优点,是严重肝破裂术后再出血的又一有效的治疗手段.     

重症急性胰腺炎早期非手术治疗的再认识

目的: 探讨重症急性胰腺炎的早期治疗方法. 方法: 对80例急性重症胰腺炎资料分别采用早期手术治疗和早期非手术治疗的两种方法进行回顾分析,并对病死率及主要并发症进行总结. 结果: 1992年1月~1994年12月的29例患者经早期手术治疗,病死率和并发症发生率分别为55.2%和93.1%,1995年1月~2000年12月的51例经早期非手术治疗,病死率和并发症发生率分别为23.5%和51.0%.两组比较差异有显著性(P<0.01). 结论: 对急性重症胰腺炎患者采用早期非手术治疗能降低病死率和并发症发生率.     

重症急性胰腺炎11例后期治疗研究

目的 总结重症急性胰腺炎(SAP)后期治疗经验.方法 回顾性分析我院2009年1月至2012年1月收治的发病超过1个月的11例SAP患者治疗方法及效果.结果 11例患者中,4例有确切病因得到去除,10例有针对性选择抗生素,5例行手术治疗.所有患者均启动肠内营养.11例获得痊愈.结论 SAP病程迁延,后期治疗仍应积极,措施应个体化.     

53例重型肝破裂的治疗体会

目的 分析53例重型肝破裂手术治疗的效果.方法 回顾性分析2002-2009年本院收治的53例重型肝破裂的临床资料.结果 肝破裂Ⅲ级23例,Ⅳ级22例,Ⅴ级7例,Ⅵ级1例.单纯缝合修补13例,大网膜填塞加缝合11例,不规则肝段切除28例,术中探查死亡1例.在不规则肝切除的基础上,加用大网膜填塞压迫止血25例,消毒绷带填塞压迫止血3例.痊愈47例,死亡6例.结论 对于重型肝破裂,尤其是Ⅳ~Ⅵ级肝破裂,外科手术治疗是需要的,不规则肝切除加带蒂大网膜肝周填塞是治疗重型肝破裂的有效术式.在重型肝破裂患者的救治过程中,应贯彻损伤控制性手术理念.     

复杂肝外伤46例救治体会

目的 总结复杂肝外伤的临床诊断和治疗的经验,提高对复杂肝外伤的救治水平.方法 对46例复杂肝外伤患者的临床资料进行回顾性分析.结果 46例中,2例行非手术治疗,44例行手术治疗,其中5例采用损伤控制性手术治疗.治愈37例;死亡9例,其中死于大血管破裂失血性休克2例,严重颅脑外伤2例,呼吸衰竭1例,肝创面再出血1例,多器官功能衰竭3例.结论 根据患者的局部和全身情况选择合适的治疗方案,手术是治疗复杂肝外伤的有效方法,损伤控制性手术治疗对降低复杂肝外伤的病死率有重要意义.     

老年人胆汁性腹膜炎29例分析

目的:探讨老年人胆汁性腹膜炎的急诊处理.临床资料:分析我院6年来29例老年胆道疾病并发胆汁性腹膜炎治疗的临床资料.29例均经手术治疗,治愈27例,死亡2例.结论:老年人胆汁性腹膜炎早斯诊断较困难,合并疾病多,宜在加强围手术期处理的同时行急诊手术,手术方案应个体化.     

超高龄老人重症急性胰腺炎的临床特点及诊治策略

目的 总结老年重症急性胰腺炎临床特点及治疗经验.方法 回顾性分析57例老年重症急性胰腺炎的病史特点、诊断及治疗结果.结果 老年重症急性胰腺炎以胆源性胰腺炎最多见,本组38例,占66.7%,高脂血症及药物引起的胰腺炎占14%.非手术治疗42例,治愈率88.1%;手术干预15例,治愈率86.7%.结论 老年重症急性胰腺炎临床表现不典型,伴发病比较多,病情较重且发展较快,治疗上采取以非手术为主的"个体化"综合治疗,对于需要外科干预的患者,应尽量采用创伤小、比较安全的手段,手术方式宜简不宜繁.     

十二指肠镜和腹腔镜联合治疗伴发MODS急性胆源性胰腺炎疗效分析

目的 探讨十二指肠镜和腹腔镜联合治疗危重、治疗前即发生多器官功能不全综合征(MODS)的急性胆源性胰腺炎(ABP)患者的临床应用价值.方法 将1992年1月至2011年1月我院收治的75例患者,分为外科手术组(n=32)和内镜治疗组(n=43),对比分析治疗效果.结果 本组75例患者临床治愈67例,围手术期死亡8例,总治愈率89.3％,总病死率10.7％.其中内镜治疗组治愈率(95.3％)明显高于手术治疗组(81.3％,P<0.05).与手术治疗组此较,内镜治疗组病死率由18.8％降至4.6％(P<0.05),并发症发生率由34.4％降至9.3％(P<0.01),总治疗时间由32.2天缩短至16.5 d(P<0.01).结论 两镜联合治疗伴发MODS的ABP具有安全有效、并发症少、治疗时间短特点,是首选的治疗方法.     

Adverse effects of preoperative hepatic artery chemoembolization for resectable hepatocellular carcinoma: a retrospective comparison of 138 liver resections

During the past 8 years we have treated 268 patients with primary hepatocellular carcinoma (HCC); total extirpation of the tumor was carried out in 138. Thirty-one of the patients with resectable HCCs had already been treated with transcatheter arterial embolization (TAE) of the liver before they were referred to us. The clinical values of preoperative TAE were retrospectively evaluated for those 31 patients and for the remaining 107 patients without TAE. There were no substantial differences between the two study groups in the clinical and histopathologic backgrounds. No differences were observed in the extent of liver resection, estimated blood loss during surgery, and operation time. During surgery, however, troublesome intra-abdominal complications relevant to TAE were encountered in 15 patients, and detection of tumors was impossible, even with intraoperative ultrasonography, in five patients in the group with TAE. Such findings were not present in any of the patients without TAE. Postoperative morbidity and mortality rates were similar in the two groups. There was no significant difference in the rate of recurrence of tumor in the liver, but the recurrence time was significantly shorter in the group with TAE. TAE did not improve the long-term survival rates in patients either with or without cirrhosis. Results of our study seem to indicate that preoperative TAE is meaningless in the treatment of resectable HCCs and therefore should be avoided, particularly in patients with advanced cirrhosis of the liver.     

Management of spontaneous bleeding due to hepatocellular carcinoma

BACKGROUND: Spontaneous rupture is a life-threatening complication of HCC, occurring in 4.8-26% of cases. Liver failure is the main cause of death. Debates still remain on the most appropriate treatment in such patients because of the high operative mortality of emergency surgery and the high risk of rebleeding and less satisfying mid- and long-term results of nonoperative procedures like angiographic embolization. Early and long-term results of a surgically oriented treatment, based on prompt evaluation of the functional liver reserve and tumor resectability was retrospectively review-ed. METHODS: From January 1994 to December 2000, 11 patients (7 males and 4 female, mean age 66.2 (11.86 years) were treated for ruptured HCC, in 10 cases involving a cirrhotic liver. Seven patients underwent emergency surgery and 4 patients transcutaneous arterial embolization (TAE). Liver resection was performed in patients with preserved liver function, after ultrasonography and/or CT scan demonstrated hemoperitoneum and a single resectable liver tumour (5 cases). In one patient with cirrhosis, ultrasonography showed only hemoperitoneum. A bleeding nodule was discovered intraoperatively and resected in a liver with a multinodular HCC. Another patient under-went emergency resection after referral at our Unit with a surgical packing. In 4 cases with poor liver function and/or unresectable tumour TAE of the neoplasm was performed, in one case after surgical packing. Mortality, morbidity and patients survival after treatment were analyzed. All patients had at least 1 year follow-up. RESULTS: All patients underwent minor resection; 2 left lobectomies, 1 segmentectomy (VII), 1 bisegmentectomy (VII-VIII), and 3 wedge resections. Postoperative course was complicated by ascites in 5 cases and subphrenic abscess in one case. Four patients died 3, 4, 6 and 62 months after surgery; 3 patients are actually alive 22, 25, and 89 months after surgery. Four patients were submitted to TAE: all patients died within 6 months. CONCLUSIONS: When ruptured HCC is suspected, preserved liver function (Child A-B7) and a resectable hepatic tumour are considered clear indications to surgery. Emergency liver resection achieved good early and long-term results. In cases of advanced liver disease or multinodular HCC a non-operative approach, like TAE, must be attempted. Surgical direct hemostasis or hepatic artery ligation must be reserved for patients with uncontrollable o recurrent bleeding after TAE.     

Time to intervention in patients with splenic injury in a Dutch level 1 trauma centre

Background

Timely intervention in patients with splenic injury is essential, since delay to treatment is associated with an increased risk of mortality. Transcatheter Arterial Embolisation (TAE) is increasingly used as an adjunct to non-operative management. The aim of this study was to report time intervals between admission to the trauma room and start of intervention (TAE or splenic surgery) in patients with splenic injury.

Methods

Consecutive patients with splenic injury aged ≥16 years admitted between January 2006 and January 2012 were included. Data were reported according to haemodynamic status (stable versus unstable). In haemodynamically (HD) unstable patients, transfusion requirement, intervention-related complications and the need for a re-intervention were compared between the TAE and splenic surgery group.

Results

The cohort consisted of 96 adults of whom 16 were HD unstable on admission. In HD stable patients, median time to intervention was 105 (IQR 77–188) min: 117 (IQR 78–233) min for TAE compared to 95 (IQR 69–188) for splenic surgery (p = 0.58). In HD unstable patients, median time to intervention was 58 (IQR 41–99) min: 46 (IQR 27–107) min for TAE compared to 64 (IQR 45–80) min for splenic surgery (p = 0.76). The median number of transfused packed red blood cells was 8 (3–22) in HD unstable patients treated with TAE versus 24 (9–55) in the surgery group (p = 0.09). No intervention-related complications occurred in the TAE group and one in the splenic surgery group (p = 0.88). Two spleen related re-interventions were performed in the TAE group versus 3 in the splenic surgery group (p = 0.73).

Conclusions

Time to intervention did not differ significantly between HD unstable patients treated with TAE and patients treated with splenic surgery. Although no difference was observed with regard to intervention-related complications and the need for a re-intervention, a trend towards lower transfusion requirement was observed in patients treated with TAE compared to patients treated with splenic surgery. We conclude that if 24/7 interventional radiology facilities are available, TAE is not associated with time loss compared to splenic surgery, even in HD unstable patients.     

Transcatheter embolization as the new reference standard for endoscopically unmanageable upper gastrointestinal bleeding

Acute nonvariceal upper gastrointestinal bleeding(UGIB) is a major medical emergency problem associated with significant morbidity and mortality.Endoscopy is considered the first method of choice to detect and treat UGIB.Endoscopic therapy usually achieves primary hemostasis,but 10%-30% of these patients have repeat bleeding.In patients in whom hemostasis is not achieved with endoscopic techniques,treatment with transcatheter angiographic embolization(TAE) or surgery is needed.Surgical intervention is usually an expeditious and gratifying endeavor,but it can be associated with high operative mortality rates.A large number of studies support the use of TAE as salvage therapy as an alternative to surgery.However,few studies have compared the results of TAE with that of emergency surgery in terms of efficiency,the frequency of repeat bleeding,and complications.Recently,Ang et al retrospectively compared the outcome of TAE and surgery as salvage therapy of UGIB after failed endoscopic treatment.There were no significant differences in 30 d mortality,complication rates and length of stay although higher rebleeding rates were observed after TAE compared with surgery.In this commentary,we discuss the advantages and drawbacks of these two therapeutic strategies for UGIB.We also attempt to define the exact role of TAE for acute nonvariceal UGIB.     

Pelvic packing and angio-embolization after blunt pelvic trauma: a retrospective 18-year analysis

IntroductionTreatment of pelvic trauma related hemorrhage is challenging and remains controversial. In hemodynamically unstable patients suspected for massive bleeding, pre-peritoneal packing (PPP) with temporary external fixation (EF) and subsequent trans-arterial embolization (TAE) can be performed in order to control bleeding. In hemodynamically stable patients suspected for minor to moderate bleeding, primary TAE with EF may be performed. The goal of this study was to determine effectiveness and safety of both strategies.MethodsRetrospectively, patients that received treatment for pelvic trauma-related hemorrhage at two level 1 trauma centers located in the United States between January 2001 and January 2019 were evaluated. Both centers advocate subsequent TAE in addition to PPP and EF in hemodynamically unstable patients, and primary TAE in stable patients. Demographic and clinical data was collected and mortality, ischemic and infectious complications were determined.ResultsIn total, 135 patients met the inclusion criteria. Of these, 61 hemodynamically unstable patients suspected for massive pelvic bleeding underwent primary PPP (45%) and 74 stable patients suspected for minor/moderate bleeding underwent primary TAE (55%). In total, 37/61 primary PPP patients underwent EF (61%) and 48 underwent adjunct TAE (79%), performed bilaterally in 77% and unselective by use of gelfoam in 72% of cases. Primary TAE patients received embolization bilaterally in 49% and unselective in 35% of cases. Exsanguination-related deaths were found in 7/61 primary PPP patients (11%). There were none among the primary TAE patients. Potentially ischemic in-hospital complications, of which one could be considered severe (gluteal necrosis), occurred more in patients that received bilateral unselective TAE compared to all other TAE patients (p=0.02).ConclusionPrimary TAE appears to be an effective and safe adjunct for (minor) pelvic hemorrhage in hemodynamically stable patients. Primary PPP followed by EF and adjunct bilateral unselective TAE with gelfoam appears effective for those suspected of massive pelvic bleeding. This unselective embolization approach using gelfoam might be related to (ischemic) complications. When considering the amount and severity of complications and the severity of pelvic trauma, these might not outweigh the benefit of fast hemorrhage control.     

Spontaneous rupture of hepatocellular carcinoma: conservative management and selective intervention.

HYPOTHESIS: A conservative approach using selective intervention is better than an aggressive approach using nonselective intervention for ruptured hepatocellular carcinoma. DESIGN: Nonrandomized controlled trial. SETTING: A university hospital. PATIENTS AND INTERVENTIONS: From 1984 to 1990, an aggressive approach was adopted in which 29 and 8 of a total of 40 patients underwent surgical intervention or attempted transarterial embolization (TAE), respectively. From 1991 to 1997, a more conservative approach was used. The initial treatment for 72 patients was conservative with close monitoring. Additional hemostatic procedures consisting of TAE (n = 13) or surgical intervention (n = 9) were given, depending on the clinical progress, disease status, and liver function of the patients. MAIN OUTCOME MEASURES: In-hospital mortality, survival. RESULTS: In-hospital mortality rate was 62% (25 of 40 patients) in the first period and 51% (37 of 72 patients) in the second period. The respective median survival times were 7 and 12 days. If 36 patients with end-stage malignant neoplasms were excluded, the in-hospital mortality rate became 60% (18 of 30 patients) in the first period and 35% (16 of 46 patients) in the second period (P = .03, chi2 test). The respective median survival times became 8 and 72 days (P = .02, log rank test). In the second period, 7 (54%) of 13 patients who underwent TAE and 1 (11%) of 9 patients who underwent surgical intervention died within the same hospital admission (P = .07, Fisher exact test). CONCLUSIONS: Selective intervention was cost-effective and gave better results than an aggressive approach. When intervention was indicated for hemostasis, surgery seemed better than TAE although the difference was not statistically significant.     

Nonoperative treatment for a ruptured pseudoaneurysm of the celiac trunk: Report of a case

We report the case of a 67-year-old man in whom hemorrhage from a ruptured celiac trunk pseudoaneurysm, which occurred as a consequence of leakage at the site of gastroduodenostomy, was successfully controlled by transcatheter arterial embolization (TAE) with stainless steel coils and N-butyl cyanoacrylate (NBCA). The occurrence of a pseudoaneurysm of the celiac trunk associated with anastomotic leakage is etiologically rare. We compiled reports from the literature on TAE for ruptured aneurysms of the celiac trunk, and compared its therapeutic value with that of surgical treatment. Operative death occurred in 4 of a series of 43 patients with aneurysms of the celiac trunk that were surgically treated (9.3%). In 5 patients with ruptured aneurysms, the operative mortality rate was 40% (2/5). Conversely, while the unsuccessful rate of TAE therapy was 17% (1/6), the mortality rate was nil. The patient whose case is presented here was affected by methicillin-resistant staphylococcus aureus (MRSA) at the site of leakage and in the lung. Under septic conditions such as hemorrhage secondary to pancreatitis, the mortality rate of surgical therapy was 23%–29%, whereas the success rate of TAE therapy was 79% and the mortality rate was 4%. Based on these findings, it is suggested that TAE therapy is a viable alternative to surgery for patients even with ruptured pseudoaneurysms of the celiac trunk.     

Management of Massive Arterial Hemorrhage After Pancreatobiliary Surgery: Does Embolotherapy Contribute to Successful Outcome?

Massive arterial hemorrhage is, although unusual, a life-threatening complication of major pancreatobiliary surgery. Records of 351 patients who underwent major surgery for malignant pancreatobiliary disease were reviewed in this series. Thirteen patients (3.7%) experienced massive hemorrhage after surgery. Complete hemostasis by transcatheter arterial embolization (TAE) or re-laparotomy was achieved in five patients and one patient, respectively. However, 7 of 13 cases ended in fatality, which is a 54% mortality rate. Among six survivors, one underwent selective TAE for a pseudoaneurysm of the right hepatic artery (RHA). Three patients underwent TAE proximal to the proper hepatic artery (PHA): hepatic inflow was maintained by successful TAE of the gastroduodenal artery in two and via a well-developed subphrenic artery in one. One patient had TAE of the celiac axis for a pseudoaneurysm of the splenic artery (SPA), and hepatic inflow was maintained by the arcades around the pancreatic head. One patient who experienced a pseudoaneurysm of the RHA after left hemihepatectomy successfully underwent re-laparotomy, ligation of RHA, and creation of an ileocolic arterioportal shunt. In contrast, four of seven patients with fatal outcomes experienced hepatic infarction following TAE proximal to the PHA or injury of the common hepatic artery during angiography. One patient who underwent a major hepatectomy for hilar bile duct cancer had a recurrent hemorrhage after TAE of the gastroduodenal artery and experienced hepatic failure. In the two patients with a pseudoaneurysm of the SPA or the superior mesenteric artery, an emergency re-laparotomy was required to obtain hemostasis because of worsening clinical status. Selective TAE distal to PHA or in the SPA is usually successful. TAE proximal to PHA must be restricted to cases where collateral hepatic blood flow exists. Otherwise or for a pseudoaneurysm of the superior mesenteric artery, endovascular stenting, temporary creation of an ileocolic arterioportal shunt, or vascular reconstruction by re-laparotomy is an alternative.     

Management of Spontaneously Ruptured Hepatocellular Carcinoma and Hemoperitoneum Manifested as Acute Abdomen in the Emergency Room

Background

Spontaneously ruptured hepatocellular carcinoma (HCC) with hemoperitoneum has a poor prognosis, especially in cases of cirrhosis. Patients usually present to emergency rooms (ERs) with acute abdomen. The aim of the present study was to determine the factors affecting mortality and to compare the prognosis of conservative treatment, transcatheter arterial embolization (TAE), or hepatectomy in these situations.

Methods

Fifty-four patients with spontaneously ruptured HCC diagnosed between January 2004 and August 2010 were enrolled in this retrospective review of clinical data. Grouping by survival or mortality, univariate and multivariate analyses of factors affecting 30-day mortality, and long-term survival were conducted. The outcomes of the various treatments were analyzed.

Results

After primary fluid resuscitation in the ER, 6 of 54 patients underwent conservative treatment. Emergency hepatectomy was performed on 19 patients; TAE was used for 29 patients, 18 of whom received staged hepatectomy thereafter. Poor liver function, prolonged international normalized ratio (INR), and conservative treatment were associated with increased 30-day mortality. Logistic regression analysis of cumulative survival revealed that INR?≥?1.4, multiple intrahepatic HCC, and conservative treatment were related to poorer long-term survival. The patients who received hepatectomy, either immediate or staged after TAE, had higher survival rates of 85.2?% at 30?days and 62.2?% at 1?year.

Conclusions

The treatment of ruptured HCC should be tailored to the individual case. Prolonged survival is possible in patients with preserved liver function through curative liver resection. Emergency physicians, radiologists, and surgeons play essential roles in managing these patients.     

Spontaneous rupture of hepatocellular carcinoma: a Western experience

BACKGROUND: Spontaneous rupture of hepatocellular carcinoma (HCC) is a life-threatening presentation, with an incidence of <3% of HCC patients in Western countries. The reported overall mortality is < or =50% in Asian countries, where the incidence is 12% to 14%. The aim of this study was to report a single center's experience of patients with ruptured HCC during a 11-year period. METHODS: A retrospective review was performed of all patients who presented with ruptured HCC between 1995 and 2005. Data on clinical features, treatment strategies, and survival outcomes were collected. Statistical methods included univariate analysis and Kaplan-Meier survival estimates with log-rank test. RESULTS: A cohort of 21 patients (15 male and 6 female) was identified. Fourteen (66.6%) patients had histologic evidence of underlying cirrhosis, ad the median age at presentation was 68 years (interquartile range [IQR] 61 to 69). Ten of these patients (71.4%) were hemodynamically unstable at presentation. The mean tumor size was 8.5 cm (range 3 to 13), and there was multifocal disease in 6 (42.8%) patients. The etiology of cirrhosis was hepatitis B infection in 3, hepatitis C in 3, alcohol in 4, and cryptogenic in 4 patients. Initial bleeding control was attempted by transarterial embolization (TAE) in 7 (50%) and by emergency surgery in 7 patients (50%). Four of the operations were performed at referring hospitals, and 3 were performed at our institution. Two patients (14.2%) underwent palliative treatment only. Definitive treatment included resection at emergency surgery in 1, staged hepatectomy in 1, and transarterial chemoembolization in 2 patients. There were 7 patients who were noncirrhotic and had a median age of 51 years (IQR 42 to 60). Of these, 6 (87.5%) were hemodynamically unstable at presentation. Mean tumor size was 9 cm (range 6 to 18) and confined to right lobe in all patients. Primary hemostasis was successfully achieved by TAE in 2 and perihepatic packing in 1 patient. Definitive treatment was provided by emergency hepatectomy in 4 and staged hepatectomy in 3 patients. Patients with cirrhosis (n = 14) had a median survival rate of <30 days. Child-Pugh score at presentation (median 7, IQR 5 to 8) correlated strongly with overall survival (P <.0001). Median survival for noncirrhotic patients was 20 months (IQR 2 to 31). One patient without cirrhosis survived for 122 months without disease recurrence. CONCLUSIONS: Spontaneous rupture of HCC is an uncommon presentation in Western countries. Primary hemostasis, followed by emergency or staged hepatic resection, is the treatment of choice. Median survival in patients initially treated with surgery was better than that observed in patients who underwent initial TAE, although this was not statistically significant. Patients who had no underlying liver disease had better prognosis than those who had cirrhosis.