Nonoperative management of renal stab wounds

A prospective clinical study of 54 patients with stab wounds and hematuria was conducted to evaluate the safety of selective nonoperative management compared to mandatory surgical exploration of these patients. In the absence of signs of severe blood loss, associated intra-abdominal injury or major abnormality on the excretory urogram patients were randomized to undergo mandatory surgery (group 1) or nonoperative management (group 2). Patients with signs of severe blood loss, associated intra-abdominal injury or gross abnormality on excretory urography were selected for an operation (group 3). The rate of probably needless operations (defined as minor renal injury without associated intra-abdominal lacerations) was 78 per cent in group 1 and 0 per cent in group 3. Pulmonary complications occurred in 33 per cent of the patients in group 1, 4 per cent in group 2 and 38 per cent in group 3. Despite an operation delayed renal hemorrhage occurred in 1 patient (5 per cent) in group 1 and 2 (15 per cent) in group 3, and resulted in nephrectomy in 2 of these patients. No instance of secondary hemorrhage occurred in group 2 patients. The mean length of hospitalization was 9, 5 and 11 days in groups 1 to 3, respectively. Our results indicate that the selective nonoperative management of patients with renal stab wounds can lead to a decrease in the rate of unnecessary operations, postoperative complications and length of hospitalization compared to a policy of mandatory surgical intervention.     

Cholecystectomy concomitant with other intra-abdominal operations. Assessment of risk

In a retrospective study, 1,416 cholecystectomies performed during a three-year period were reviewed to define the risk of cholecystectomy when combined with another intra-abdominal procedure. Group 1, cholecystectomy alone (1,148 patients), with subsets of cholangiography and/or common bile duct exploration, had a complication rate of 14.29% and a mortality of 0.52%. Group 2, primary cholecystectomy combined with secondary intra-abdominal surgery (214 patients), had a complication rate of 19.63%. Group 3, primary intra-abdominal surgical procedure with incidental cholecystectomy (54 patients), had a complication rate of 20.37%. Mortality for groups 2 and 3 was 2.24%. The rate of nonfatal complications was increased slightly when a second surgical procedure was performed (14.29% v 19.78%). Pairing cholecystectomy with other intra-abdominal surgery is advised only when surgical exposure is adequate, the patient's condition is satisfactory, and operating time is not prolonged greatly.     

Value of intravenous urography before shockwave lithotripsy in the treatment of renal calculi: a randomized study

PURPOSE: To study the impact of preprocedure intravenous urography (IVU) on the outcome of SWL for renal stones. PATIENTS AND METHODS: Two hundred patients with radiopaque renal stones 相似文献   

A comparative study of intravenous urograms and radionuclide renal scans in diagnosis of renal trauma

We analyzed 31 patients who underwent intravenous urograms (IVU) and radionuclide renal scans (RNRS) in the investigation of blunt abdominal trauma, and compared the IVU to the RNRS in the definition of blunt renal injuries, and their correlation with patients' symptoms and signs. Thirteen patients had abnormal IVU and 12 had abnormal RNRS (42% of the 31 patients). In 8 patients findings on IVU correlated with those on RNRS (62%), and in 5 patients findings were different (38%). Only 2 patients (6.5%) had significant differences which may have influenced further treatment. Only 1 patient required operative management. Follow-up IVUs were performed on 6 of the 13 patients who had abnormal radiologic studies. The radionuclide renal scan was shown to be as accurate as the intravenous urogram in defining renal trauma. Patients who undergo liver-spleen scans for investigation of blunt abdominal trauma, and who may have renal trauma, may well undergo RNRS at the same time and obviate the need for an IVU, without any diagnostic compromise.     

Simultaneous vs. sequential laparoscopic bilateral native nephrectomy and renal transplantation

We reviewed our experience with simultaneous single incision bilateral native nephrectomy and renal transplantation in 11 patients (Group 1), compared to seven recipients who underwent staged laparoscopic bilateral nephrectomy followed by kidney transplantation (Group 2). Mean age, donor source, sex, cause of ESRD, and specimen size were similar in both groups (P=0.1). All Group 2 patients and 9 of 11 Group 1 patients had autosomal-dominant polycystic kidney disease. Perioperative Group 1 complications included: bowel injury, transplant urine leak, necrotic pancreatitis, delayed bowel movement, and severe shoulder pain secondary to diaphragmatic irritation. Seven (63.6%) Group 1 patients required an additional surgical procedure: midline incisional hernia, repair ureteral fistula, and repair enterocutaneous fistula. One Group 1 patient lost his graft secondary to bowel injury and intra-abdominal sepsis. No major complications, reoperations, or graft loss occurred in Group 2. For simultaneous bilateral native nephrectomy and kidney transplantation, over 60% of patients required an additional surgical procedure. Laparoscopic bilateral nephrectomy followed by kidney transplantation is a safe and feasible alternative.     

Is intravenous urography a prerequisite for renal shockwave lithotripsy?

PURPOSE: To determine whether intravenous urography (IVU) is a prerequisite for shockwave lithotripsy (SWL) of renal stones by addressing whether using non-contrast-enhanced CT (NCCT) instead of IVU for delineating urinary tract anatomy is associated with post-SWL complications. PATIENTS AND METHODS: Thirty-eight patients treated by SWL (Econolith 2000) for radiopaque renal stones underwent either IVU or NCCT. Twenty patients with normal urinary tracts or with mild hydronephrosis proximal to the stone on urography comprised the IVU group. Eighteen patients who underwent NCCT and plain abdominal (KUB) films and had urinary tract systems similar in appearance to the IVU group comprised the NCCT group. The two groups were of similar mean age (45.75 years, range 24-73 years; and 49.0 years, range 26-72 years, respectively) and had a similar mean stone size (10.1-10.2 mm). Patients with internal ureteral or nephrostomy catheters were excluded. Information on episodes of intractable renal colic, urinary tract infections, and hospitalization was recorded at follow-up 2 to 6 weeks post-SWL. RESULTS: The IVU and NCCT patients had similar mean stone fragmentation rates (80% and 74%, respectively) at 2 to 6 weeks post-SWL. Four IVU patients (20%) had intractable renal colic. One NCCT patient (5.5%) had a urinary infection. Complication and hospitalization rates in the two groups were not significantly different (P = 0.34; Fisher' exact test). CONCLUSIONS: Using only NCCT before SWL was not associated with higher complication rates. Thus, IVU is not a prerequisite for SWL of radiopaque renal stones in patients with a normal urinary tract anatomy as seen on NCCT.     

Renal trauma found during laparotomy for intra-abdominal injury

Whether renal injury found during a laparotomy for intra-abdominal injury should have surgical or nonsurgical management is controversial. Five hundred twenty-one renal injuries were found during laparotomy for such injury in 513 patients. Blunt external trauma was the cause in 88%. A modified operating room table enabled performance of immediate intravenous pyelogram during the laparotomy. More severe degrees of renal injury (laceration, rupture, pedicle injury) were present in 135 (26%) of the renal injuries. Immediate surgical management of 102 more severe renal injuries resulted in nephrectomies in 37 (36%), delayed renal surgery in one (0.9%), and renal salvage in five of 18 (27%) main renal artery and/or vein injuries. Nonsurgical management of the remaining 23 resulted in nephrectomies in three (13%), delayed renal surgery in six (26%), total renal loss in seven of seven (100%) main renal artery injuries and an overall nephrectomy/total renal loss rate of 39%. With immediate surgical management of the more severe degrees of renal injury there was a slight increase in the salvage of kidneys and a marked decrease in delayed renal surgery and morbidity.     

171例肾损伤的诊治体会

目的提高肾损伤的诊治效果。方法回顾性分析171例肾损伤患者的临床诊治资料。结果血尿147例(86.0%);B超检查132例,其中103例(78%)有异常表现;CT检查130例,阳性表现107例(82.3%);静脉肾盂造影(IVU)检查65例,其中肾穿透伤7例(占10.8%),肾钝挫伤2例(占3%)。本组患者手术治疗46例(26.9%),非手术治疗125例(73.1%)。死亡12例(7%),治愈159例(93%),93例(54.4%)随诊1～3年,尿常规及肾功能检查正常。结论尿液检查和B超检查快速安全,无损伤;对于有血尿的肾穿透伤患者,或虽无血尿,但高度怀疑肾损伤的患者,如生命体征平稳,IVU检查是必需的;CT检查明确率高,可同时了解其他脏器受损程度。如果损伤严重,尤其是合并腹腔内脏器受损者,宜适时探查肾脏,做出相应的外科处理。     

Stab wounds associated with hematuria--a review of 67 cases

The clinical records of 67 patients who underwent surgical exploration for stab wounds associated with hematuria were reviewed in an attempt to evaluate the need for mandatory operation and to define criteria for possible nonoperative of such cases. Minor renal injuries without associated intra-abdominal lacerations were found in 61 per cent of the patients. Delayed renal hemorrhage occurred in 15 per cent of the patients despite early exploration, suture and drainage of the kidney, and antibiotic prophylaxis. Of 7 nephrectomies 5 were performed for secondary hemorrhage. Postoperative pulmonary complications arose in 28 per cent of the patients. A policy of mandatory operation on all patients with stab wounds and hematuria led to apparently needless surgery in 61 per cent of the patients in this series. Retrospective analysis revealed that the rate of probably unnecessary operations could have been reduced to 24 per cent by selecting for operation only those patients with signs of severe hemorrhage, associated intra-abdominal injury or major extravasation of contrast material on excretory urography.     

Increasing role of angiography and segmental artery embolization in the management of renal stab wounds.

During a 5-year period 93 patients with stab wounds involving the upper urinary tract were treated. Of these patients 79 were treated initially at our department (group 1) and 14 were referred with complications after initial treatment elsewhere (group 2). In group 1, 26 patients (33%) were selected for surgery on the basis of signs of severe blood loss or associated intra-abdominal injury, or major abnormality on the excretory urogram. At operation a major renal injury and/or associated intra-abdominal laceration was found in 23 patients (88%) and nephrectomy was required in 7 (27%) of them. Nonoperative management was selected in 53 patients (67%) in group 1 and secondary hemorrhage occurred in 8 (15%). Of the patients in group 2, 4 had undergone an operation elsewhere and 10 had been managed nonoperatively. Renal arteriography was performed in 14 patients who had been managed nonoperatively (6 from group 1 and 8 from group 2) and demonstrated a traumatic pseudoaneurysm in 6, an arteriovenous fistula in 5 and no large vessel injury in 3. Selective embolization of the involved segmental artery was successful in 9 of 11 patients (82%) when angiography showed a vascular lesion. This study demonstrates the increasingly important role of renal angiography and selective embolization in the selective nonoperative management of patients with stab wounds of the kidney.     

Surgical diverticulitis: treatment options.

Acute diverticulitis requiring surgical intervention has conventionally been treated by resection with colostomy or delayed resection with primary anastomosis at a second admission. Our objective was to determine the outcome for treatment of diverticulitis with resection and primary anastomosis during the same hospitalization. We conducted a retrospective review of patients (n = 74) undergoing surgery for diverticulitis. Groups included: 1) resection with primary anastomosis (n = 33), 2) resection with colostomy followed by a takedown colostomy (n = 32), and 3) delayed resection with primary anastomosis at a second admission (n = 9). Despite local perforation primary anastomosis was often performed unless patients were clinically unstable or had fecal contamination. The operation was urgent in five (15%) patients in Group 1 as compared with 26 patients (88%) in Group 2. Serious intra-abdominal complications occurred in two patients (6%) in Group 1 as compared with nine patients (28%) in Group 2 and one patient (11%) in Group 3. Postoperative abscesses occurred in two patients in Group 1, five patients in Group 2, and one patient in Group 3. We have shown that resection with primary anastomosis for acute diverticulitis--even in selected patients requiring urgent operation--can be safely performed during the same hospital admission with a low complication rate.     

Exploration for hemorrhage following laparoscopic renal surgery: intraoperative findings

PURPOSE: Bleeding after surgery is a rare but potentially life threatening complication. We reviewed operative and postoperative clinical features in patients who required surgical exploration secondary to hemorrhage following laparoscopic renal procedures. MATERIALS AND METHODS: We retrospectively reviewed the records of patients undergoing laparoscopic renal surgery between January 1996 and September 2004. Nine of 1,123 patients (0.8%) underwent early exploration for bleeding within 5 days of surgery. RESULTS: Two groups were identified. Group 1 consisted of 4 patients who underwent early exploration at less than 10 hours after surgery and had arterial bleeding. Group 2 consisted of 5 patients who underwent exploration a mean 38 hours after surgery and in whom no bleeding source was identified. Group 1 patients had pronounced hypotension with systolic blood pressure 70 to 79 mmHg and hematocrit decreases (mean 10.5%) in a short time course before repeat exploration (mean 4.5 hours). Arterial bleeding was identified in the hilum and adrenal bed. Group 2 patients demonstrated a decrease in hematocrit from an initial mean of 28.3% to 22.5% with tachycardia and mild hypotension (systolic blood pressure 90 to 99 mmHg). On exploration group 2 patients had diffuse oozing. Mean hospital stay in group 1 was 8 days (range 4 to 9) vs 12 (range 6 to 24) in group 2. CONCLUSIONS: Early hemodynamic instability after laparoscopic renal surgery is likely to indicate a discrete arterial bleeding source from the hilum or adrenal bed, requiring surgical control. In patients who underwent exploration after a delayed bleeding presentation no discrete source was found intraoperatively. Therefore, it is unclear whether these patients benefited from surgical exploration.     

Tratamiento del traumatismo cerrado de hígado,indicaciones de cirugía y desenlaces

Introduction

The liver is the most frequently injured organ in blunt abdominal trauma. Patients that are hemodynamically unstable must undergo inmmediate surgical treatment. There are 2 surgical approaches for these patients; Anatomical Liver resection or non-anatomic liver resection. Around 80-90% of patients are candidates for non-operative management. -Several risk factors have been studied to select the patients most suited for a non operative management.

Materials and methods

We performed a retrospective study based on a prospective database. We searched for risk factors related to immediate surgical management and failed non-operative management. We also described the surgical procedures that were undertaken in this cohort of patients and their outcomes and complications.

Results

During the study period 117 patients presented with blunt liver trauma. 19 patients (16.2%) required a laparotomy during the initial 24 h after their admission. There were 11 deaths (58%) amongst these patients. Peri-hepatic packing and suturing were the most common procedures performed. A RTS Score < 7.8 (RR: 7.3; IC 95%: 1.8-30.1), and ISS Score > 20 (RR 2,5 IC 95%: 1.0-6.7), and associated intra-abdominal injuries (RR: 2.95; IC 95%: 1.25-6.92) were risk factors for immediate surgery. In 98 (83.7%) patients a non-operative management was performed. 7 patients had a failed non-operative management.

Conclusion

The need for immediate surgical management is related to the presence of associated intra-abdominal injuries, and the ISS and RTS scores. In this series the most frequently performed procedure for blunt liver trauma was peri-hepatic packing.     

DMSA renal scanning versus urography for detecting renal scars in vesicoureteral reflux

32 children admitted to Hacettepe University Hospital for surgical treatment of vesicoureteral reflux (VUR) between 1987 and 1988 were included in this prospective double-blind study. All patients underwent intravenous urography (IVU), voiding cystouretrography and 99mTc DMSA renal scanning. The sensitivity and specificity of the DMSA scan and IVU for detecting renal scarring were investigated. With regard to the presence of renal scarring, the sensitivity and specificity of IVU and DMSA were not found to be statistically different. But when the scars were scored, DMSA was found to have a higher scoring index compared to IVU. In patients who were candidates for surgical management of VUR, renal scars could be detected both by IVU and DMSA scan but, for the follow-up, the DMSA scan was found to be the investigation of choice.     

Renal scintigraphy in initial evaluation of renal colic.

To determine the role of renal scintigraphy (RS) in patients with suspected acute urinary tract obstruction, a prospective study was performed comparing RS with emergency intravenous excretory urography (IVU) in 36 examinations. Thirty patients were diagnosed as having renal colic: 28 had dilation of the urinary tracts with (89%) or without (11%) visualized stone; 2 patients with stones did not have stasis at the IVU. An abnormal RS was found in 28 patients with abnormal IVU, while it was normal in the 2 nonobstructed patients (sensitivity = 93%). The radiopaque stones in these 2 patients were seen on plain x-ray film of the abdomen. The results of this study support the use of RS combined with a plain film of the abdomen in the initial evaluation of renal colic.     

Diagnosis and treatment of patients with renal trauma

In this selective study, 59% of the patients had a renal injury (laceration, rupture or pedicle injury). A normal IVU excluded significant renal injury after blunt trauma. Renal angiography was more accurate than ultrasonography or computed tomography in determining the extent of the injury. A retroperitoneal haematoma found during laparotomy should be explored if significant renal trauma cannot be excluded. Renal salvage after rupture or pedicle injury should be attempted in stable patients.     

Color-coded duplex sonography study of arteriovenous fistulae and pseudoaneurysms complicating percutaneous renal allograft biopsy

BACKGROUND: The exact incidence and clinical impact of arteriovenous fistulae (AVF) and pseudoaneurysms as complications emerging from renal allograft biopsy are not well established. We therefore conducted a prospective study using color-coded duplex sonography (CCDS) to determine the frequency, clinical presentation and spontaneous occlusion rate of biopsy-related AVF and pseudoaneurysms in kidney transplant recipients. METHODS: We investigated 72 consecutive patients undergoing renal allograft biopsy using an automated biopsy technique. CCDS was performed before, immediately after and up to more than 6 months after biopsy. The diagnosis of AVF was based on the presence of perivascular vibration artifacts and detection of typical Doppler curves. Pseudoaneurysms were diagnosed based on the presence of"to-and-fro" signals. RESULTS: In 5 patients (6.9%), an AVF was detectable before biopsy. Post-biopsy AVF were found in 12 additional patients (16.7%) with a spontaneous occlusion rate of 50% within 48 hours and 75% after 4 weeks. Three (25%) AVF persisted longer than 1 year. Four patients (5.6%) were found to have pseudoaneurysms. All pseudoaneurysms were located closely to AVF and closed spontaneously. None of the post-biopsy AVF and pseudoaneurysms required specific therapy. In 2 patients (2.8%), allograft biopsy lead to significant hemorrhage independent of AVF or pseudoaneurysms. CONCLUSION: These results indicate that post-biopsy AVF and pseudoaneurysms are a frequent finding after automated renal allograft biopsy. The natural history of these lesions shows a high rate of early occlusion. The present data fail to demonstrate significant clinical impact of AVF and pseudoaneurysms after renal allograft biopsy.     

Immediate surgical management of severe renal injuries in multiple-injured patients

Between 1969 and 1980, 1,132 renal injuries were recorded in 1,120 patients. Of the 129 patients with a severe renal injury (laceration, rupture, pedicle injury), 118 (91%) had associated injuries and 101 (86%) required an immediate laparotomy by general surgeons for intra-abdominal injury. Immediate surgical management was performed on 90 severe renal injuries and resulted in a nephrectomy rate of 5 of 55 lacerations (9%), 16 of 17 ruptures (94%), and 10 of 18 pedicle injuries (56%). Seven of the 18 pedicle injuries (39%) had immediate repair with salvage of the kidney. Conservative management was done on 32 severe renal injuries. Autopsy revealed 10 severe renal injuries in 9 patients who died in the operating room or on admission. A delayed renal operation was required in 9 (28%), and total renal loss (nephrectomy plus main renal artery injury) occurred in 7 of the 32 cases (22%). The severe degrees of renal injury did not all resolve spontaneously. Immediate surgical management of the patient with a severe renal injury resulted in a nephrectomy rate comparable with that of conservatively managed renal injuries.     

Complications of arteriovenous fistula in dialysis patients

Repeated access to the circulation is essential to perform adequate maintenance hemodialysis (HD). Dysfunction of fistulae is the most common reason for a second intervention and recurrent hospitalization. The aim of this study was to evaluate the complications of HD fistulas seeking to evaluate the impact of age, site of arteriovenous fistula (AVF) (proximal or distal), side (left or right), and history of previous vascular access. We evaluated the clinical complications in 273 patients from the beginning of the use of the current access using the history and physical examination obtained at every dialysis session. We performed further investigations including doppler ultrasound or spiral computed tomography to confirm the clinical diagnosis. Of our patients, 40% had diabetes mellitus as the cause of end-stage renal disease. Almost half (49%) the patients dialyzed through an AVF and 13% with a catheter. One hundred eighty-four cases (67.6%) experienced complications. Of 145 cases that had elbow AVFs, 103 cases (71%) had complications; of 128 cases with wrist AVFs, 80 cases (62.5%) had complications. There were 115 (62.5%) complicated cases among 185 patients with left AVFs, and 69 (78%) among 88 patients with right AVFs. The rate of AVF complications increased with age. The 1-year survival rate was 94%. We did not observe any significant difference between AVF complications in patients with diabetes mellitus or hypertension as the underlying cause of renal failure. Mean cholesterol plasma level did not differ significantly between the patients with and without AVF complications. Mean hematocrit levels were not significantly different between the two groups. However, mean EPO weekly dose was significantly higher among the group of patients with AVF complications. We did find that rate of complications increased with age (P<.05). Our results showed that the frequency of complications was higher among patients with elbow and right-side AVFs, and also among patients with a history of a previous failed shunt but no significant relationship was observed between these variables (P>.05).     

Diagnostic laparoscopy decreases the rate of unnecessary laparotomies and reduces hospital costs in trauma patients

BACKGROUND AND PURPOSE: The use of laparoscopy for the treatment of various surgical diseases has been well described, and recently, it has gained popularity in the evaluation of abdominal trauma patients. The value of diagnostic laparoscopy (DL) in avoiding unnecessary laparotomies and its effects on hospital costs was evaluated in a prospective clinical trial. PATIENTS AND METHODS: In a 48-month period, 99 hemodynamically stable abdominal trauma patients (28 blunt and 71 penetrating injuries) among 428 patients admitted with abdominal trauma in whom the decision for surgical exploration was made were accepted for the study and underwent DL prior to laparotomy. RESULTS: The DL was negative in 60.7% of the patients with blunt abdominal trauma (BAT) and in 62.0% of the patients with penetrating abdominal trauma (PAT). Laparoscopy-positive patients (Group 1) underwent immediate laparotomy, whereas on DL-negative patients (Group 2), no laparotomies were performed. Hospitalization times and hospital costs of the two groups were recorded and compared. The difference between the hospitalization times of Group 1 and Group 2 was statistically significant (P < 0.001). The use of DL reduced the rate of unnecessary laparotomies from 60.7% to 0 in BAT and from 78.9% to 16.9% in PAT. The mean hospitalization time was 2.75 +/- 1.20 days in patients with negative DL, whereas it was 7.4 +/- 2.20 days and 5.2 +/- 1.42 days in DL-positive patients undergoing a therapeutic and nontherapeutic laparotomy, respectively. When the hospital costs of the Group 1 patients were compared with those of Group 2 patients, there was a 4.07-fold increase in patients undergoing therapeutic laparotomy and a 1.78-fold increase in patients undergoing nontherapeutic laparotomy. CONCLUSION: Diagnostic laparoscopy might be used in selected patients to exclude significant intra-abdominal injuries.