Upper gastrointestinal emergencies

Upper gastrointestinal emergencies form the majority (in some centres 60–70%) of an unselected general surgical emergency take and non-specialist general surgeons need to have a thorough knowledge of the presentation and initial management of these conditions. Recent developments in the management of gallstone disease, pancreatitis and liver trauma in particular are covered in this article.     

Perineal burn care: French working group recommendations

Objectives

Burns to the perineum are frequently exposed to faeces. Diverting colostomy is often described to prevent faecal soiling. Because this technique is invasive with frequent complications, use of non-surgical devices including specifically designed faecal management systems has been reported in perineal burns.

Methods

In order to standardise the faecal management strategy in patients with perineal burns, a group of French experts was assembled. This group first evaluated the ongoing practice in France by analysing a questionnaire sent to every French burn centre. Based on the results of this study and on literature data, the experts proposed recommendations on the management of perineal burns in adults.

Results

Specifically designed faecal management systems are the first-line method to divert faeces in perineal burns. The working group proposed recommendations and an algorithm to assist in decisions in the management of perineal burns in four categories of patients, depending on total burn skin area, depth and extent of the perineal burn.

Conclusion

In France, non-surgical devices are the leading means of faecal diversion in perineal burns. The proposed algorithm may assist in decisions in the management of perineal burns. The expert group emphasises that large clinical studies are needed to better evaluate these devices.     

The morphology and clinical significance of the dorsal meningovertebra ligaments in the cervical epidural space

Background contextThe dural sac is anchored within the vertebral canal by connective tissue called meningovertebral ligaments in the epidural space. During flavectomy and laminectomy, inadvertent disruption of the dorsal meningovertebral ligaments may lead to dura laceration and cerebrospinal fluid (CSF) leaks. All the described dorsal meningovertebral ligaments were located in the lumbar region. A rare study is available about dorsal meningovertebral ligaments of the cervical spinal dura to the adjacent vertebrae.PurposeTo identify and describe the dorsal meningovertebral ligaments at each cervical level and discuss their clinical significance.Study designA dissection-based study of 22 embalmed cadavers.MethodsThe anatomy was studied in 22 whole cervical cadavers (11 females, 11males), prepared with formaldehyde, whose ages at the time of death ranged from 55 to 78 years. The vertebral canal was divided to expose the dural sac and the spinal nerve roots. At all levels of the cervical vertebra, the morphology, quantity, origin, insertion, and spatial orientation of the dorsal meningovertebral ligaments were determined and the length, width or diameter, and thickness of the ligaments were measured with vernier calipers.ResultsThe dorsal meningovertebral ligaments in the cervical region anchored the posterior dural sac to the ligamentum flavum or laminae. The number of attachment points on the ligamentum flavum was relatively larger than that on the lamina, and the occurrence rate of dorsal meningovertebral ligaments was 100% at C1–C2 and C4––C5. The thickest ligaments were observed at the C1 and C2 vertebrae. The length of the ligaments varied from 1.50 to 35.22 mm, and the orientation of the ligaments mostly was craniocaudal. The morphology of the dorsal meningovertebral ligaments was divided into four types: strip type, cord type, grid type, and thin slice type.ConclusionsIn the cervical spine, the dorsal meningovertebral ligaments exist between the posterior dural sac and the ligamentum flavum or lamina. The dorsal meningovertebral ligaments may be of clinical importance to surgeons. Dissecting the dorsal meningovertebral ligaments before the cervical flavectomy and laminectomy may be an important step in reducing postoperative dura laceration and CSF leaks, which may result in significant benefits for patients and health-care organizations.     

腹腔镜超低位直肠癌经腹会阴联合切除会阴人工肛门重建术的疗效观察

目的探讨腹腔镜超低位直肠癌经腹会阴联合切除会阴人工肛门重建术的安全性和临床疗效。方法回顾性分析2006年4月至2010年2月期间解放军第150中心医院全军肛肠外科研究所收治的102例超低位直肠癌行经腹会阴联合切除会阴人工肛门重建术的患者,其中腹腔镜手术58例（腹腔镜组）,开腹手术44例（开腹组）。观察指标包括手术时间、术中失血量、检出淋巴结数目、术后恢复流质饮食时间、术后首次肛门排气时间、术后住院时间、术后并发症等;采用Kaplan-Meier法计算生存率并经log-rank检验,计量资料采用t检验,计数资料采用χ2检验。结果腹腔镜组和开腹组的一般临床病理资料比较差异均无统计学意义（P〉0.05）。2组均顺利完成手术,无与手术相关的死亡病例。腹腔镜组的手术时间略长于开腹组,但差异无统计学意义（P〉0.05）;腹腔镜组的术中失血量明显少于开腹组,差异有统计学意义（P〈0.05）;腹腔镜组的术后首次肛门排气时间、术后恢复流质饮食时间及术后住院时间均明显短于开腹组,差异均有统计学意义（P〈0.05）;腹腔镜组检出淋巴结枚数明显多于开腹组,差异有统计学意义（P〈0.05）。2组并发症发生率比较,差异无统计学意义（P〉0.05）。2组患者的生存曲线比较,差异无统计学意义（P=0.897）。结论腹腔镜超低位直肠癌经腹会阴联合切除会阴人工肛门重建手术与开腹直肠癌手术能达到同样的疗效,且其创伤小、术后恢复快、安全可行。     

单手保护会阴法对自由体位分娩产妇分娩结局的影响

目的:探讨单手保护会阴法对自由体位分娩产妇分娩结局的影响。方法:选取2016年5月1日~2017年5月31日给予常规助产方式分娩的产妇78例作为对照组,选取2017年6月1日~2018年6月30日给予自由体位单手保护会阴法分娩的产妇78例作为观察组。比较两组会阴裂伤程度、产后出血率、新生儿窒息率及临床满意度。结果:观察组干预后会阴裂伤程度轻于对照组(P<0.05),产后出血率、新生儿窒息率均低于对照组(P<0.05),临床满意度高于对照组(P<0.05)。结论:单手保护会阴法在自由体位分娩中可减轻产妇会阴裂伤程度,降低产后出血率和新生儿窒息率,提高临床满意度。     

Are Asian American women at higher risk of severe perineal lacerations?

Objective: To evaluate whether Asian race is an independent risk factor for severe perineal lacerations.

Methods: We performed a nationwide population-based retrospective cohort study examining the relationship between Asian race and severe perineal lacerations (third and fourth degree). The data were collected from the 2012 Healthcare Cost and Utilization Project National Inpatient Sample (HCUP-NIS). Characteristics of Asian American women were compared with those of non-Asian women. The primary outcome of interest was severe perineal lacerations. Multivariable logistic regression was used to refine the associations between Asian race and severe perineal lacerations while adjusting for confounding effects. Results were compared with previously published data using a pooled odds ratio.

Results: 2,270,044 Women with singleton vaginal deliveries were identified, and 120,452 (5.3%) were Asian. After adjusting for confounders, Asian women were more likely to experience severe perineal lacerations than any other racial group (3.5% versus 6.3%, adjusted odds ratio [aOR] 1.50, 99% CI 1.29–1.74, p?p?Conclusion: Asian race is an independent risk factor for severe perineal lacerations in the United States.     

额叶挫裂伤致脑中心疝手术时机探讨

目的探讨额叶挫裂伤致脑中心疝手术时机,提高手术效果,改善患者预后。方法回顾性分析我院收治的额叶挫裂伤导致脑中心疝33例患者的临床资料,根据患者的临床表现及影像学检查结果进行病理分期,并探讨不同手术时机的效果。结果间脑期14例患者优良率71.43%,中脑-脑桥上部、脑桥下部-延髓上部期、延髓期无优良患者,3组预后比较差异有统计学意义(P0.01)。恢复良好患者中,部分患者记忆力、注意力下降,中残、重残患者均有智能障碍和情感障碍。结论额叶挫裂伤致脑中心疝患者入院后尽快抢救,尽可能在间脑期,即疾病早期进行手术可显著提高抢救成功率,避免遗留严重的后遗症。