Surgical treatment of patients with obstructive jaundice]

The results of treatment of 481 patient operated on for obstructive jaundice have been analysed. In 388 (80.7%) patients, jaundice was caused by non-tumor lesion of the bile ducts. At the peak of jaundice, operated on were 312 (64.9%) patients, who experienced no benefit from conservative therapy. The tactics for operative intervention was chosen individually with regard for the cause of jaundice, concomitant pathology and age of a patient. The main cause of death was the aggravating hepato-renal failure due to prolonged jaundice and late hospitalization.     

Influence of diabetes on mortality and morbidity following operations for obstructive jaundice

The influence of diabetes on mortality and morbidity following operations for obstructive jaundice has been assessed in 118 consecutive patients, all of whom received antibiotic cover, subcutaneous heparin and intravenous mannitol. 44 patients had diabetes mellitus (37%). There were 12 post operative deaths (10%). Factors which significantly contributed to mortality included; admission values for alkaline phosphatase, creatinine, haematocrit, bilirubin and age of patient over 70 years. Although mortality was not increased in diabetics, wound sepsis was significantly more common (20% and 4% respectively; p less than 0.02). The majority of infections were due to antibiotic sensitive Staphylococcus aureus. Diabetes did not influence survival after operation for malignant disease.     

Preoperative percutaneous transhepatic biliary decompression lowers operative morbidity in patients with obstructive jaundice

Percutaneous transhepatic biliary decompression is a safe and potentially helpful procedure. If done correctly, it will accomplish adequate decompression of the biliary tree and permit hepatic function to return to a more normal state preoperatively. The time gained while waiting for the bilirubin level to decrease can be used for adequate preoperative preparation of the patient. Use of this technique may make it possible for operative treatment of obstructive jaundice to return to a two-stage procedure, the first stage being percutaneous transhepatic biliary decompression.     

Dose standardized management of patients with occlusive jaundice reduce morbidity and mortality?]

Patients with obstructive jaundice have a high incidence of complications. Invasive techniques required for definitive diagnosis and treatment compound the situation. In a prospective randomised trial we studied 54 patients over a 12-month period. All had obstructive jaundice (bilirubin greater than 100 mg/%). Prior to treatment, the trial protocol required correction of fluid balance (CVP), administration of albumin and vitamin K and an adequate urine output. Antibiotics were administered in accordance with a strict regime. The overall mortality was 7.5%, in elective cases with a mortality of 4%, in emergency cases with a mortality of 100%. The surgical treated patients had a higher incidence of complications than patients with interventional procedure, but not a higher mortality. Patients with obstructive jaundice will benefit from an adequate pre-treatment resuscitation and a standardised treatment policy after elimination of the obstruction.     

术前减黄对低位胆道恶性梗阻性黄疸患者行胰十二指肠切除术的影响

目的探讨术前减黄对低位胆道恶性梗阻性黄疸患者行胰十二指肠切除术的影响。方法回顾1999年1月至2005年12月98例总胆红素>85μmol/L行胰十二指肠切除术的低位胆道恶性梗阻性黄疸的临床资料。结果术前减黄34例(35%,34/98),减黄前的胆红素水平为(266±119)μmoL/L,减黄后下降为(184±115)μmoL/L(t=2.66,P=0.010)。减黄组术中红细胞输注量为(276±419)ml,未减黄组为(397±344)ml(P=0.016);术后总的并发症发生率为39%(38/98);减黄组为35%(12/34),未减黄组为40%(26/64),差异无显著性(P=0.053),感染性并发症和单个并发症发生率两组之间亦无显著性差异(P=0.513)。单变量分析显示术前胆红素>340μmol/L(P=0.042)、手术出血量>600 ml(P=0.001)和术中红细胞输注量>600 ml(P=0.003)时,术后并发症的发生率显著性上升。多变量Logistic回归分析表明影响术后并发症的危险因素为手术出血量>600 ml(OR=2.77,P=0.036)和术中红细胞输注量>600 ml(OR=3.78,P=0.048)。结论低位恶性胆道梗阻患者,术前胆红素>340μmol/L时术后并发症的发生率显著增加,但术前减黄并未降低术后并发症的发生率,术者的技术和操作熟练程度可能影响术后并发症的发生。     

Surgical risk factors, morbidity, and mortality in elderly patients

BACKGROUND: The aging population of the United States results in increasing numbers of surgical operations on elderly patients. This study observed aging related to morbidity, mortality, and their risk factors in patients undergoing major operations. STUDY DESIGN: We reviewed our institution's American College of Surgeons National Surgical Quality Improvement Program database from February 24, 2002, through June 30, 2005, including standardized preoperative, intraoperative, and 30-day postoperative data points. This required review and analysis of the prospectively collected data. We examined patient demographics, preoperative risk factors, intraoperative risk factors, and 30-day outcomes with a focus on those aged 80 years and older. RESULTS: A total of 7,696 surgical procedures incurred a 28% morbidity rate and 2.3% mortality rate, although those older than 80 years of age had a morbidity of 51% and mortality of 7%. Hypertension and dyspnea were the most frequent risk factors in those aged 80 years and older. Preoperative transfusion, emergency operation, and weight loss best predicted morbidity for those 80 years of age and older. Operative duration predicted "other" postoperative occurrences and emergent case status predicted respiratory occurrences across all age groups. Preoperative impairment of activities of daily living, emergency operation, and increased American Society of Anesthesiology classification predicted mortality across all age groups. A 30-minute increment of operative duration increased the odds of mortality by 17% in patients older than 80 years. Postoperative morbidity and mortality increased progressively with increasing age. Age was statistically significantly associated with morbidity (wound, p = 0.021; renal, p = 0.001; cardiovascular, p = 0.0004; respiratory, p < 0.0001) and mortality (p = 0.001). CONCLUSIONS: Although several risk factors for postoperative morbidity and mortality increase with age, increasing age itself remains an important risk factor for postoperative morbidity and mortality.     

Surgical morbidity and mortality meetings.

Morbidity and mortality meetings aim to improve the standards of surgical care, and are now required in all hospitals responsible for training junior surgical staff. If they are to receive support and achieve their aim, they must be carefully planned and well organised. This paper outlines considerations in setting up morbidity meetings and in making them a success.     

Respiratory morbidity and mortality following transhiatal esophagectomy in patients with severe chronic obstructive pulmonary disease

In order to assess the influence of severe chronic obstructive pulmonary disease on the pulmonary morbidity and mortality following transhiatal oesophagectomy, the authors reviewed 136 consecutive patients who underwent oesophageal cancer resection by a transhiatal approach. Nineteen patients had a forced expiratory volume in one second (FEV) lower than 60% of the theoretical value, indicating severe chronic obstructive pulmonary disease. The other group of 117 patients had a FEV higher than 60% of the theoretical value. Pulmonary complications occurred in 36 patients: 23 (64%) were minor and 13 (36%) were major. Severe chronic obstructive pulmonary disease did not significantly increase pulmonary morbidity. However, pulmonary complications occurring in this group of patients appeared more severe with a significant increase in major pulmonary complications (21% versus 8%, p = 0.05) and respiratory mortality rates (10% versus 1.6%, p = 0.04). One factor was significantly correlated to respiratory mortality: age higher than 75 years (p = 0.006). Severe chronic obstructive pulmonary disease does not constitute a contraindication for transhiatal oesophagectomy. However, this approach should be reserved for patients under 75 years of age, in order to obtain respiratory morbidity and mortality rates comparable to those of patients with normal spirometry.     

梗阻性黄疸患者免疫功能的变化

梗阻性黄疸患者由于机体免疫功能障碍而有较高的并发症、病死率。笔者结合近年文献资料初步综述了梗阻性黄疸患者机体免疫功能各个方面的变化及其相关的临床意义。     

原发性肝癌并阻塞性黄疸的外科治疗

目的 总结原发性肝癌并阻塞性黄疸的临床特征、原因、治疗方法及疗效。方法 4例病人术前应用B超、CT、PTC等影像学检查均明确诊断,除1例为肿瘤压迫外,其余3例均为肿瘤侵入胆管引起黄疸。采用肝癌切除取尽癌栓,解除胆管梗阻的方法,术后行HAE等治疗。结果 4例均得到随访,平均生存时间为8.5个月。结论 对肝癌并阻塞性黄疸者应及时诊断,尽早切除肿瘤、清除癌栓、解除胆管梗阻是一种积极有效的治疗方法。     

Surgical morbidity in patients with neurologic dysfunction

Mortality and morbidity data were collected on 388 patients treated by operations to correct extremity deformities caused by stroke, head trauma and neurologic disease. A total of 613 procedures were performed, requiring 524 general, 2 spinal and 16 regional anesthesias. There were no postoperative deaths. None of the patients showed further neurologic deterioration. The incidence of medical complications was 6.4% and all patients responded to medical treatment. Sixteen wound complications responded to routine care. Age appeared to be the primary risk factor to postoperative morbidity. It is generally safe to perform elective orthopedic surgery to correct extremity deformities in the neurologically involved patient.     

Surgical strategy in the management of benign obstructive jaundice

623 patients with benign biliary obstructions of extrahepatic biliary ducts were treated in surgical clinic number 2 during the period of 1990-2002 years. Surgical treatment included 3 stages: (1) diagnosis of benign biliary obstructions; (2) preoperative biliary tree decompression; (3) definitive surgical resolve. Definitive diagnosis was established in 90% of cases after cholangiopancreatography retrograde endoscopic (CPGRE), in 7% of cases was used cholangiography transhepatic percutaneous with using ultrasonography, which was the method of choice in cases with high obstructions, and with gastric resections in anamnesis. In 22 cases with negative results of applied methods was used MRI of biliary tract, with permitted positive solution of problem. Surgical tactics was in direct dependency from pathology, level of obstruction, grade of clinical manifestation of the disease. In all cases was applied staged treatment, with permitted in pre-operative period to resolve the jaundice, biliary infection and correction of hepatic function with following surgical definitive correction with minimal risk of postoperative complications. The total lethality was 9 (1.44 %) patients.     

肝癌胆管内转移致阻塞性黄疸的外科治疗

目的: 探讨外科手术治疗原发性肝癌胆管内转移致阻塞性黄疸的疗效.方法: 自1944年1月至1997年10月间对21例原发性肝癌胆管内转移致阻塞性黄疸的患者进行了外科手术治疗.其中行总胆管切开取癌栓者19例,行肝动脉插管化疗者4例,行肝动脉结扎者10例,行肝叶切除者2例.结果: 患者平均生存时间为8.5个月,最长存活时间为18个月.结论: 外科治疗明显改善了患者生活质量,提高了生存时间.     

Surgical treatment of atrial fibrillation with bipolar radiofrequency ablation: mid-term results in one hundred consecutive patients

AIM: The Cox-Maze procedure was introduced nearly two decades ago for the surgical treatment of atrial fibrillation (AF). Recently, our group has replaced most of the incisions of the Cox-Maze procedure with bipolar radiofrequency (RF) ablations (Cox-Maze IV procedure). The purpose of this study was to examine our midterm results with the Cox-Maze procedure using bipolar RF ablation. METHODS: From January 2002 to October 2005, 100 consecutive patients underwent a modified Cox-Maze procedure with bipolar RF ablation for AF; 32 were lone operations, and 68 were concomitant procedures. Follow-up was performed at 1, 3, 6, and 12 months, and then annually thereafter. Heart rhythm was confirmed by electrocardiography. RESULTS: The mean age of patients was 62+/-13 years; 57% were male. Duration of AF was 6.3+/-7.6 years (0.1 to 40 years), 59% had paroxysmal AF, and 34% had permanent AF. Follow-up was complete for all patients with a mean follow-up of 13+/-10 months. At 12-month follow-up, 91% (49/54) of patients were free of AF. Cross-clamp time in the lone Cox-Maze IV procedure patients was 42+/-15 minutes, while it was 101+/-29 minutes for the Cox-Maze IV with a concomitant procedure (compared to 93+/-34 minutes and 122+/-37 minutes for the traditional procedure, P<0.05). There were four operative deaths. CONCLUSIONS: The Cox-Maze IV procedure had good mid-term efficacy. The use of bipolar RF energy significantly decreased operative time and simplified the procedure compared to the traditional Cox-Maze procedure, potentially increasing utilization of the procedure among cardiac surgeons.