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1.
Surgical treatment of patients with acute cholecystitis: Tokyo Guidelines   总被引:7,自引:0,他引:7  
Cholecystectomy has been widely performed in the treatment of acute cholecystitis, and laparoscopic cholecystectomy has been increasingly adopted as the method of surgery over the past 15 years. Despite the success of laparoscopic cholecystectomy as an elective treatment for symptomatic gallstones, acute cholecystitis was initially considered a contraindication for laparoscopic cholecystectomy. The reasons for it being considered a contraindication were the technical difficulty of performing it in acute cholecystitis and the development of complications, including bile duct injury, bowel injury, and hepatic injury. However, laparoscopic cholecystectomy is now accepted as being safe for acute cholecystitis, when surgeons who are expert at the laparoscopic technique perform it. Laparoscopic cholecystectomy has been found to be superior to open cholecystectomy as a treatment for acute cholecystitis because of a lower incidence of complications, shorter length of postoperative hospital stay, quicker recuperation, and earlier return to work. However, laparoscopic cholecystectomy for acute cholecystitis has not become routine, because the timing and approach to the surgical management in patients with acute cholecystitis is still a matter of controversy. These Guidelines describe the timing of and the optimal surgical treatment of acute cholecystitis in a question-and-answer format.  相似文献
2.
Background/Purpose: To provide a framework for clinicians to manage acute pancreatitis, evidence-based guidelines have been developed by the Japanese Society of Abdominal Emergency Medicine. Methods: Evidence was collected by a systematic search of MEDLINE and Japana Centra Revuo Medicina. A total of 1348 papers were reviewed and levels of evidence were assessed. Practical recommendations were also graded. Results: The present guidelines consist of introductions, a summary of recommendations, practice algorithms, definitions, epidemiology, diagnosis, severity assessment, and therapy. The main points of recommendation in these guidelines are: (1) measuring lipase for the diagnosis of acute pancreatitis (recommendation grade [RG], A). (2) The Severity of acute pancreatitis should be assessed using a scoring system, such as that of the Japanese Ministry of Health and Welfare or Acute Physiology and Chronic Health Evaluation (APACHE) II (RG, A). (3) Enhanced computed tomography (CT) should be used for assessment of degree of pancreatic necrosis and inflammation (RG, B). (4) Prophylactic antibiotic administration should be used for severe pancreatitis (RG, A), but not for mild to moderate pancreatitis (RG, D). (5) Gabexate mesilate should be used for severe pancreatitis (RG, B). (6) Enteral feeding should be used for all pancreatitis (RG, B). (7) Continuous hemodiafiltration and continuous arterial infusion of proteinase inhibitor and antibiotics may be of benefit (RG, C). (8) Fine-needle aspiration should be done for the diagnosis of infectious pancreatic necrosis, and if positive, necrosectomy is indicated (RG, A). Conclusions: These guidelines provide useful information for physicians to manage this troublesome disease. Received: May 6, 2002 / Accepted: May 17, 2002 RID="*" ID="*"  Working Group for the Practical Guidelines for Acute Pancreatitis of the Japanese Society of Emergency Abdominal Medicine RID="*" RID="*" RID="*" RID="*" RID="*" RID="*" RID="*" RID="*" RID="*" RID="*" RID="*" RID="**" ID="**"  President of the Japanese Society of Emergency Abdominal Medicine, Tokyo, Japan Offprint requests to: T. Mayumi  相似文献
3.
Background. Propacetamol is widely used in the management ofpostoperative pain. It decreases morphine requirements but itseffect on the incidence of morphine-related adverse effectsremains unknown. Methods. Patients (550) were randomly assigned to receive propacetamolor a placebo over the first 24 h after operation in a blindedstudy. Intravenous morphine titration was performed, after whichmorphine was administered s.c. every 4 h according to theirpain score. Pain was assessed using a visual analogue scale(VAS). The primary end-point was the incidence of morphine-relatedadverse effects. The main secondary end-points were morphinerequirements and VAS score. Results. After morphine titration, the VAS score and the numberof patients with pain relief did not differ between groups.Morphine requirements were decreased in the propacetamol group(21 vs 14.5 mg, P<0.001) but the incidence of morphine-relatedadverse effects did not differ between groups (42 vs 46%, notsignificant). In patients with moderate pain (n=395), morphinerequirements decreased by 37% (P<0.001) and the percentageof patients requiring no morphine was greater (21 vs 8%, P=0.002)in the propacetamol group. In patients with severe pain (n=155),morphine requirements decreased by 18% (P=0.04) in the propacetamolgroup and the number of patients who did not require morphine(3 vs 8%) did not differ significantly. Conclusions. Although propacetamol induced a small morphine-sparingeffect, it did not change the incidence of morphine-relatedadverse effects in the postoperative period. Moreover, no benefitcould be demonstrated in patients with severe postoperativepain. Br J Anaesth 2003; 90: 314–19  相似文献
4.
The goal of the current investigation was to detect clinically important axonal damage in cerebral white matter after mild traumatic brain injury (TBI) using diffusion tensor imaging (DTI). To this end, we evaluated a prospective, pilot study of six subjects with isolated mild TBI and six matched orthopedic controls. All subjects underwent DTI scanning, post-concussive symptom (PCS) assessment, and neurobehavioral testing within 72 h of injury. Fractional anisotropy (FA) and trace values in white matter voxels of whole brain and five preselected regions of interest (ROI) were compared in mild TBI and control subjects using a quantile approach. In addition, whole brain images were analyzed using voxel-based morphometry. All subjects underwent quality of life and repeat PCS assessment at 1 month. Whole brain images revealed significantly lower 1(st) percentile trace values (mean 0.465 vs. 0.488, p = 0.049) among mild TBI subjects. These trace values correlated with PCS scores at both 72 h (r = -0.57, p = 0.05) and 1 month (r = -0.61, p = 0.04). Analysis of ROIs showed mild TBI subjects to have significantly lower mean trace in the left anterior internal capsule (0.536 vs. 0.574, p = 0.007) and higher maximum ROI-specific median FA values (mean 0.801 vs. 0.756, p = 0.035) in the posterior corpus callosum. These FA values correlated with 72-h PCS score (r = -0.63, p = 0.03), and two neurobehavioral tests (visual motor speed [r = 0.63, p = 0.03] and impulse control [r = 0.59, p = 0.04]). Collectively, DTI detected significantly lower trace and elevated FA values in mild TBI subjects compared to controls. These abnormalities correlated to poor clinical outcome. We believe these findings represent axonal swelling, an early step in the process of axonal injury.  相似文献
5.
A new minimally invasive experimental spinal cord injury model in rabbits.   总被引:3,自引:0,他引:3  
The aim of this experimental study was to evaluate the effectivity of epidural microballoon inflation into the unroofed spinal column for the creation of a new experimental spinal cord injury model in rabbits. 10 New Zealand white rabbits were used for this study. Before operation and after anasthesia with 50 mg/kg ketamine and 8 mg/kg xylazine, spinal evoked potentials (SEP) were recorded in all rabbits. A midline skin incision was done on the lomber skin at the level of L1-L4. Paravertebral muscles were dissected bilaterally. A microhemilaminotomy was done in the right L3 lamina close to the midline by using Midas-rex micro-diamond drill instruments. The ligamentum flavum was opened and removed with microscissors. A microballoon was inserted into the spinal column between the bone and dura mater to the level of T12. The microballoon was inflated by using a pressure- and volume-controlled microballoon inflation device. Pre-injury and post-injury SEPs were recorded. The microballoon was deflated 15 minutes later and removed completely from the epidural space. 24 hours later the SEP study was repeated. Following microballoon inflation the SEP waves dropped to the basal level. All rabbits were paraplegic after the operation. In conclusion, this experimental study demonstrated that the microballoon inflation technique is a very successful method for the evaluation of spinal cord injury in rabbits. Unroofing of the spinal column is extremely important because decompression may be an effective treatment in spinal cord injury. Also the traumatic effect of aneurysm clips represents a different type of injury to the spinal cord. This new model may be used in experimental studies of spinal cord injury in rabbits.  相似文献
6.
Background. Postoperative morphine titration frequently inducessedation. The assumption is made that patients sleep when theirpain is relieved. Some patients complain of persistent painwhen they awake. We studied the time-course of sedation andanalgesia to understand the determinants of patients’sleep during morphine titration. Methods. Seventy-three patients requiring morphine titrationin a post-anaesthetic care unit after major surgery, were studied.Fifty-two patients slept (Sleep group) and 21 did not (Awakegroup). When a patient slept during titration, morphine wasdiscontinued. Visual analogue pain scale (VAS), Ramsay score(RS), and the bispectral index (BIS) were recorded at the beginningof titration (STonset), at sleep onset (STsleep), then 5, 10,20, and 30 min afterwards (ST4). Results. In the Sleep group, mean (SD) RS increased from 1.7(0.4) to 2.4 (0.6) (P<0.05 vs STonset) and BIS decreasedfrom 95 (5.0) to 89.8 (10.2) between STonset and STsleep (P<0.05),RS remained stable thereafter. Conversely, RS and BIS remainedunaltered in the Awake group. The reduction in VAS was comparablebetween groups (from 78 (17) to 39 (21), and from 64 (16) to30.4 (11), respectively). Even though mean (SD) VAS was 39 (21)at ST4 in the Sleep group, 13 patients (25%) maintained a VASabove 50 mm. Conclusion. We observed dissociated effects of morphine on thetime-course of sedation and analgesia with sedation occurringfirst, followed by analgesia. Therefore, morphine-induced sedationshould not be considered as an indicator of an appropriate correctlevel of analgesia during i.v. morphine titration. Br J Anaesth 2002; 89: 697–701  相似文献
7.
Inguinal hernia (IH) surgery has changed substantially in the past decade. Conventional (nonmesh) techniques have largely given way to prostheses. This studys aim was to analyse whether changes in technique used for IH repair influenced the operation rate for recurrence. A retrospective study was performed on all adult males who had undergone IH surgery in the Amsterdam region during the calendar years of 1994, 1996, 1999, and 2001. Data were obtained for 3,649 subjects and included patient demographics, hernia type, and surgical technique. We observed a decrease in the use of conventional techniques and a significant increase (P<0.05) in the use of prosthetic materials. The number of operations performed for recurrent hernia decreased from 19.5% (216/1,108) in 1994, to 16.8% 197/1,170) in 1996, to 14.0% (152/1,088) in 1999, and to 14.1% (40/283) in 2001. When comparing 1999 and 2001 with 1994, there was a significant decrease in operations performed for recurrent hernia (P=0.005). There was also a significant increase in supervision of the surgical resident by a surgeon.  相似文献
8.
Image-guided endoscopic evacuation of spontaneous intracerebral hemorrhage   总被引:2,自引:0,他引:2  
BACKGROUND: Spontaneous ICH is a devastating disease with high morbidity and mortality. Intracerebral hemorrhage lacks an effective medical or surgical treatment despite the acknowledged pathophysiologic benefits of achieved hemostasis and clot removal. Image-guided stereotactic endoscopic hematoma evacuation is a promising minimally invasive approach designed to limit operative injury and maximize hematoma removal. METHODS: A single-center randomized controlled trial was designed to assess the safety and efficacy of stereotactic hematoma evacuation compared to best medical management. Patients were randomized within 24 hours of hemorrhage in a 3:2 fashion to best medical management plus endoscopic hematoma evacuation or best medical management alone. Data were collected to assess efficacy and safety of hematoma evacuation and to identify procedural components requiring technical improvement. RESULTS: Ten patients have been enrolled and randomized to treatment. Six patients underwent endoscopic evacuation with a hematoma volume reduction of 80% +/- 13% at 24 hours post procedure. The medical arm demonstrated a hematoma enlargement of 78% +/- 142% during this same period. Rehemorrhage rates and deterioration rates were similar in the 2 groups. Mortality was 20% in the endoscopic group and 50% in the medical treatment cohort. The endoscopic technique was shown to be effective in identification and evacuation of hematomas, whereas reduction in the number of endoscopic passes and maintenance of hemostasis require further study. CONCLUSION: Image-guided stereotactic endoscopic hematoma removal is a promising minimally invasive technique that is effective in immediate hematoma evacuation. This technique deserves further investigation to determine its role in ICH management.  相似文献
9.
OBJECT: Experimental evidence suggests that hemoglobin degradation products contribute to cellular injury after intracerebal hemorrhage (ICH). Hemoglobin breakdown is catalyzed in part by the heme oxygenase (HO) enzymes. In the present study, the authors tested the hypothesis that HO-2 gene deletion is cytoprotective in an experimental ICH model. METHODS: After anesthesia was induced with isoflurane, 3- to 6-month-old HO-2 knockout and wild-type mice were stereotactically injected with 15 microl autologous blood and a group of control mice were injected with an equal volume of sterile saline. Striatal protein and lipid oxidation were quantified 72 hours later using carbonyl and malondialdehyde assays. Cell viability was determined by performing a 3(4,5-dimethylthiazol-2-yl)2,5-diphenyltetrazolium bromide (MTT) assay. Following blood injection, the investigators found a 3.4-fold increase in protein carbonylation compared with that in the contralateral striatum in wild-type mice; in knockout mice, the investigators found a twofold increase. The mean malondialdehyde concentration in injected striata was increased twofold in wild-type mice at this time, compared with 1.5-fold in knockout mice. Cell viability, as determined by MTT reduction, was reduced in injected striata to 38 +/- 4% of that in the contralateral striata in wild-type mice, compared with 66 +/- 5% in HO-2 knockout mice. Baseline striatal HO-1 protein expression was similar in wild-type and HO-2 knockout mice, but was induced more rapidly in the former after blood injection. CONCLUSIONS: Deletion of HO-2 attenuates oxidative cell injury after whole-blood injection into the mouse striatum. Therapies that specifically target HO-2 may improve outcome after ICH.  相似文献
10.
Antimicrobial therapy for acute cholangitis: Tokyo Guidelines   总被引:2,自引:0,他引:2  
Antimicrobial agents should be administered to all patients with suspected acute cholangitis as a priority as soon as possible. Bile cultures should be performed at the earliest opportunity. The important factors which should be considered in selecting antimicrobial therapy include the agent's activity against potentially infecting bacteria, the severity of the cholangitis, the presence or absence of renal and hepatic diseases, the patient's recent history of antimicrobial therapy, and any recent culture results, if available. Biliary penetration of the microbial agents should also be considered in the selection of antimicrobials, but activity against the infecting isolates is of greatest importance. If the causative organisms are identified, empirically chosen antimicrobial drugs should be replaced by narrower-spectrum antimicrobial agents, the most appropriate for the species and the site of the infection.  相似文献
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