Long-term health-related quality of life following robot-assisted radical transmediastinal esophagectomy

Surgical Endoscopy - The good short-term and oncological outcomes of robot-assisted radical esophagectomy have been demonstrated, although its impact on long-term health-related quality of life...     

Long-term results of major bile duct injury associated with laparoscopic cholecystectomy

Background: Major bile duct injury (MBDI) is the most serious complication associated with laparoscopic cholecystectomy (LC). This study reports on long-term outcomes and clinical factors which predicted the outcome of 25 patients with LC-associated MBDI. Methods: Twenty-five consecutive patients receiving either primary (n = 11) or redo (n = 14) biliary reconstructive surgery at Cathay General Hospital for LC-associated MBDI were prospectively followed for 2 to 10 (mean, 4.5) years to assess their long-term outcomes. Twelve clinical factors relevant to their outcomes were analyzed. Results: There was no mortality. Although the 1-year postoperative results were successful in 23 patients (92%), the mid- to long-term outcomes were successful in only 17 patients (68%). Eight patients (32%) developed biliary strictures at an average of 3.3 years postoperatively and required subsequent reoperation or biliary stenting. Statistical comparison of 12 risk factors between the successful and unsuccessful groups revealed that two were significant, namely, repair performed by a nonreferral surgeon (p = 0.02) and repair at a stage with recent active inflammation (p = 0.04). A serum alkaline phosphatase level greater than 400 IU in the sixth postoperative month was highly correlated with long-term nonsuccess (p = 0.01). Conclusions: Only 68% of patients with LC-associated MBDI who underwent reconstructive surgery at our institution had long-term success. A serum alkaline phosphatase level above 400 IU in the sixth postoperative month was predictive of nonsuccess. For better long-term results, repair should be performed by the referral surgeon at a stage without coexisting active inflammation.     

Major bile duct injuries associated with laparoscopic cholecystectomy: effect of surgical repair on quality of life

OBJECTIVE: To assess the quality of life (QOL) of patients after surgical reconstruction of a major bile duct injury from laparoscopic cholecystectomy (LC). SUMMARY BACKGROUND DATA: The incidence of bile duct injuries has increased dramatically since the introduction and widespread use of LC. Previous reports show that at long-term follow-up, most patients surgically repaired will have a successful outcome as measured by standard clinical parameters. However, there is a general impression that these patients have an impaired QOL. Data addressing QOL of these patients are limited. METHODS: A standard QOL questionnaire was sent to 89 patients after successful surgical repair of a major bile duct injury from a LC treated at the Johns Hopkins Hospital between 1990 and 2000. The instrument consisted of 30 items on a visual analog scale categorized into physical (15 items), psychological (10 items), and social (5 items) domains. The same questionnaire was sent to age- and sex-matched healthy controls (n = 100) and to patients who underwent uncomplicated LC (n = 100). An additional portion of the questionnaire inquired about outcome measures and legal action undertaken by patients. RESULTS: Overall QOL scores for bile duct injury patients in the three domains (physical, psychological, and social) were 76%, 77%, and 75%, respectively. QOL scores were comparable to those of patients undergoing uncomplicated LC and healthy controls in the physical and social domains but were significantly different in the psychological domain. Presenting symptoms, prior repair, level of injury, number of stents, length of postoperative stenting, and length of follow-up did not influence QOL scores. Repaired patients reported similar rates of abdominal pain, change in bowel habits, use of pain medications, and recent symptoms of fever or chills as LC controls. Thirty-one percent of responding bile duct injury patients reported having sought legal recourse for their injury. All QOL domain scores were significantly lower in the patients who pursued a lawsuit versus those who did not. CONCLUSIONS: This study provides formal data evaluating QOL after surgical repair of major bile duct injuries from LC. Although there was a significant difference in the QOL as evaluated from a psychological dimension, bile duct injury patients reported QOL scores in the physical and social domains comparable to those of control patients. The decreased QOL assessment in the psychological dimension may be attributable to the prolonged, complicated, and unexpected nature of these injuries. The presence of a lawsuit appears to be associated with a poorer QOL assessment.     

经验值得注意——再论胆管损伤与损伤性胆管狭窄

自腹腔镜胆囊切除术普遍开展之后,胆囊切除的病例很快增多,而胆管损伤发生率也随之升高,胆管损伤与胆管狭窄又重新成为本世纪的热门话题。医源性胆管损伤重在预防,预防手术中胆管损伤的基本点仍然是强调外科手术的基本要求,认真细致地施行手术,必要时中转开放手术。在专科中心及有经验的外科医生手中,修复手术结果优良者一般可达到90％,初期修复的效果优于再次修复。恢复胆道生理功能是修复手术的最终目的,当前广泛应用的仍然是肝管Roux-en-Y空肠吻合术。     

医源性胆管损伤

目的　目的 :探讨医源性胆道损伤的预防和诊治方法。方法　对 91例医源性胆道损伤的临床资料进行回顾性分析。结果　 91例共施行手术 10 3次。其中 2次手术者 8例 ,3次手术者 2例。最后 1次手术方式为胆管端端吻合 18例 ,胆总管十二指肠吻合术 3例 ,胆管壁缺损修补 4例 ,单纯缝线拆除 1例 ,胆管空肠Roux en Y吻合 6 5例。 70例随访 1～ 10年 ,优良率 90 %。结论　胆囊切除术是医源性胆道损伤的主要原因 ,是可以避免的。肝管空肠Roux en Y吻合术是医源性胆道损伤或损伤性狭窄修复重建的首选方法。     

Acute bile duct injury

Background: An immediate repair is considered optimal in acute biliary duct injuries; however, it may prove to be a challenge, because such repairs are usually performed on small ducts whose viability cannot always be determined. Methods: We performed a retrospective review of the charts of patients with acute bile duct injury who underwent repair at a tertiary care academic university hospital. A total of 204 patients with acute bile duct injury were seen between 1989 and 2002. Of these, 30 were repaired within minutes to hours after the injury. These patients were divided into two groups. Group I patients had a Roux-en-Y hepatojejunostomy below the hepatic junction; Group II patients had a Roux-en-Y hepatojejunostomy at the junction level. We then performed a long-term evaluation of anastomosis function in these patients, using clinical, radiological, and laboratory. Results: Twenty-eight injuries were secondary to a laparoscopy; the other two resulted from open cholecystectomies. All of the patients suffered complex injuries with complete section of the duct and substance loss (Strasberg E). There were 12 patients in group I and 18 in group II. Three cases in group I (25%) and one in group II (5%) developed anastomosis dysfunction. Mean follow-up was 56 months (range, 12–80) in group I and 52 months (range, 10–76) in group II. Two cases in group I (16%) and none in group II (0) required reoperation (p < 0.05). Conclusions: In the acute setting, complex lesions should be treated with a high bilioenteric anastomosis (at the junction level) in the first attempt at repair. Lower-level anastomoses are associated with a higher dysfunction rate and the need for radiological manipulation and reoperation. Also, stenosis of the anastomosis secondary to undetected duct ischemia in the acute repair is more frequent in low bilioenteric anastomoses.     

Long-term outcomes of patients with common bile duct injury following laparoscopic cholecystectomy

Introduction

Common bile duct (CBD) injury is a serious and dreaded complication of cholecystectomy. A paucity of data assessing long-term outcomes exists. This study aimed to determine long-term mortality and liver transplantation rates following CBD injury requiring operative intervention.

Methods

Patients were identified via the New York State (NYS) Planning and Research Cooperative System longitudinal administrative database which captures patient-level data from every inpatient and outpatient hospital discharge in NYS. In total, 125 patients with CBD injuries were identified following 156,958 laparoscopic cholecystectomies for cholelithiasis performed in NYS from 2005 to 2010. Patients were then tracked by unique identifier to obtain rate of liver transplantation. Follow-up ranged from 4 to 9 years from surgery.

Results

There were 125 patients with CBD injuries detected. No mortalities occurred within 30 days. All-cause mortality was 20.8 % (n = 26) with mean time to death 1.64 ± 1.08 years. One patient who underwent hepaticoenterostomy required a liver transplant 4.3 years after surgery. Significant factors predictive of all-cause mortality included: age >61, Medicare insurance, male gender, White race, diabetes, hypertension and pulmonary complications following surgery. Overall 30-day morbidity, timing to and type of operative intervention did not influence mortality.

Conclusion

Considerable long-term mortality, 20.8 %, is associated with common bile duct injury requiring operative intervention. This was an increase of 8.8 % above the cohort’s expected age-adjusted rate of death. The mortality rate is appreciably higher than quoted previously. No difference was demonstrated by type of repair required. Liver transplant rate was 0.8 %. These data have significant implications for patient and family counseling both prior to cholecystectomy and following CBD injury.

     

Long-term health-related quality of life after minimally invasive surgery for diverticular disease

Background and aims  

The aim of this multicentric study was to evaluate the disease specific and the generic quality of life in patients affected by colonic diverticular disease (DD) who had undergone minimally invasive or open colonic resection or who had been treated with medical therapy in the long-term follow-up.     

腹腔镜胆囊切除术胆管损伤修复术后的远期效果观察

目的探讨LC胆道损伤修复术后的远期效果。方法回顾我院1993至2002年收治的27例LC胆管损伤病人的临床资料，结合部分病人随访结果进行分析总结。结果27例病人中，6例经介入方法治愈；21例行手术治疗，其中16例同时进行肝穿刺组织活检；术后1例在20个月时出现轻度吻合口狭窄并发胆管炎，1例在T管拔除之前吻合口近端节段性狭窄，均经气囊扩张治愈；16例行肝穿刺活检的病人中，5例肝组织显著纤维化，其中4例已发展为肝硬化。结论本组平均46个月的随访的病例中，胆肠吻合术的近期有效率为90．5％，远期有效率达100％。反复的盲目修复手术使延误收治的时间平均在16个月后，将导致肝组织损害。     

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开放法胆囊切除术(OC)和腹腔镜胆囊切除术(LC)均为当前治疗良性胆囊疾病的临床常用手术。小切口胆囊切除术(MC)亦屡有报道。无论何种方法,最严重的医源性损伤均为肝外胆管损伤。自1905年美国Mayo报告2例OC术后胆管狭窄的治疗以后,引起人们对OC致胆管损伤的认识和关注。随着胆囊     

重症急性胰腺炎远期疗效及健康相关生命质量分析

目的评估重症急性胰腺炎（severe acute pancreatitis,SAP）患者的远期疗效及健康相关生命质量,分析其影响因素。方法回顾性分析2003年1月至12月出院的98例SAP患者相关病历资料,应用SF-36量表及自制问卷表进行自评式调查,观察其健康相关生命质量及远期疗效。并与普通人群健康相关生命质量进行比较,作相关影响因素的单因素方差分析。自制问卷表单独分析。结果98例SAP患者中,病历资料完整59例,死亡2例,不能完成量表1例,无应答6例,收回有效问卷50例,应答率89．8％。SF-36量表生理功能、生理职能、情感职能、身体疼痛、活力、精神健康、社会功能和总体健康8个维度的得分分别为：（83±15）分、（62±42）分、（69±36）分、（80．4-15）分、（69±19）分、（72±15）分、（75±18）分和（65±18）分。与普通人群比较,生理职能和社会功能两项与普通人群间差异有统计学意义（P〈0．05）。其余6项与普通人群差异无统计学意义（P〉0．05）。影响生理健康总分的变量有治疗方式、住院时间、住院费用造成的经济负担。影响心理健康总分的变量有性别和住院费用造成的经济负担。结论SAP患者的健康相关生命质量与普通人群相近,远期疗效及生命质量良好,其影响因素主要有性别、治疗方法、住院时间及经济状况。