Factors Predictive of Recurrence and Mortality after Surgical Repair of Enterocutaneous Fistula

Many enterocutaneous fistulas (ECF) require operative treatment. Despite recent advances, rates of recurrence have not changed substantially. This study aims to determine factors associated with recurrence and mortality in patients submitted to surgical repair of ECF. Consecutive patients submitted to surgical repair of ECF during a 5-year period were studied. Several patient, disease, and operative variables were assessed as factors related to recurrence and mortality through univariate and multivariate analysis. There were 35 male and 36 female patients. Median age was 52 years (range, 17–81). ECF recurred in 22 patients (31%), 18 of them (82%) eventually closed with medical and/or surgical treatment. Univariate analyses disclosed noncolonic ECF origin (p = 0.04), high output (p = 0.001), and nonresective surgical options (p = 0.02) as risk factors for recurrence; the latter two remained significant after multivariate analyses. A total of 14 patients died (20%). Univariate analyses revealed risk factors for mortality at diagnosis or referral including malnutrition (p = 0.03), sepsis (p = 0.004), fluid and electrolyte imbalance (p = 0.001), and serum albumin <3 g/dl (p = 0.02). Other significant variables were interval from last abdominal operation to ECF operative treatment ≤20 weeks (p = 0.03), preoperative serum albumin <3 g/dl (p = 0.001), and age ≥55 years (p = 0.03); the latter two remained significant after multivariate analyses. Interestingly, recurrence after surgical treatment was not associated with mortality (p = 0.75). Among several studied variables, recurrence was only independently associated with high output and type of surgical treatment (operations not involving resection of ECF). Interestingly, once ECF recurred its management was as successful as non-recurrent fistulas in our series. Mortality was associated to previously-reported bad prognostic factors at diagnosis or referral.     

Female Gender and Diabetes Mellitus Increase the Risk of Recurrence after Laparoscopic Incisional Hernia Repair

Background

Laparoscopic hernia repair is used widely for the repair of incisional hernias. Few case studies have focussed on purely ‘incisional’ hernias. This multicentre series represents a collaborative effort and employed statistical analyses to provide insight into the factors predisposing to recurrence of incisional hernia after laparoscopic repair. A specific hypothesis (ie, laterality of hernias as well as proximity to the xyphoid process and pubic symphysis predisposes to recurrence) was also tested.

Methods

This was a retrospective study of all laparoscopic incisional hernias undertaken in six centres from 1 January 2004 to 31 December 2010. It comprised a comprehensive review of case notes and a follow-up using a structured telephone questionnaire. Patient demographics, previous medical/surgical history, surgical procedure, postoperative recovery, and perceived effect on quality of life were recorded. Repairs undertaken for primary ventral hernias were excluded. A logistic regression analysis was then fitted with recurrence as the primary outcome.

Results

A total of 186 cases (91 females) were identified. Median follow-up was 42 months. Telephone interviews were answered by 115/186 (62%) of subjects. Logistic regression analyses suggested that only female sex (odds ratio (OR) 3.53; 95% confidence interval (CI) 1.39–8.97) and diabetes mellitus (3.54; 1–12.56) significantly increased the risk of recurrence. Position of the defect had no statistical effect.

Conclusions

These data suggest an increased risk of recurrence after laparoscopic incisional hernia repair in females and subjects with diabetes mellitus. These data will help inform surgeons and patients when considering laparoscopic management of incisional hernias. We recommend a centrally hosted, prospectively maintained national/international database to carry out additional research.     

胰十二指肠切除术后发生胰瘘的危险因素

目的探讨胰十二指肠切除术后胰瘘发生的危险因素。方法回顾性分析我院1994年12月至2003年12月期间接受胰十二指肠切除术的连续123例患者的临床资料。结果本组胰瘘的发生率为11.4%(14/123)。单变量分析结果表明:上腹部手术史、胰腺质地、术后血红蛋白、胰肠吻合方式及胰管直径为有意义的相关因素;经Logistic回归多变量分析确定了4个独立与胰瘘相关的变量,即上腹部手术史、胰腺质地、术后血红蛋白及胰肠吻合方式。结论上腹部手术史、胰腺质地软、术后血红蛋白<90g/L及常规套入式胰肠吻合为胰十二指肠切除术后胰瘘发生的主要危险因素。     

A Novel Technique for Risk Calculation of Anastomotic Leakage after Thoracoscopic Repair for Esophageal Atresia with Distal Fistula

PURPOSE: This study was designed to determine the risk of anastomotic leakage after thoracoscopic repair for esophageal atresia by digitally measuring the length of the proximal esophagus and distance of carina to proximal esophagus. METHODS: With the use of Picture Archiving and Communication System (PACS), the length of the proximal esophagus from the top of the first thoracic vertebra was measured on the preoperative chest x-ray, as well as the distance from the carina to the proximal esophagus. The chest x-rays of 27 neonates, born with esophageal atresia with distal fistula, were examined. Furthermore, the tapes from the procedures were reviewed. Statistical analysis was performed with the t test for equality of means by using SPSS 12.0.1 for Windows. RESULTS: Both groups were comparable, and there was a statistical significant difference in both length of the proximal esophagus (p < 0.023) and distance of carina to proximal esophagus (p < 0.022) in patients who did and did not leak postoperatively. There seems to be a tendency toward a shorter proximal esophagus in recent years that was not obvious earlier. CONCLUSIONS: The digital measurement of the length of the proximal esophagus (M < 7 mm) and distance of carina to proximal esophagus (M > 13.5 mm) with the use of PACS gives a good risk calculation for postoperative leakage.     

Laryngotracheo-Esophageal Cleft in a Neonate with Esophageal Atresia and Tracheo-Esophageal Fistula: Report of a Case

Laryngotracheo-esophageal cleft (LTEC) is a congenital anomaly, rarely found in neonates with esophageal atresia (EA) and tracheo-esophageal fistula (TEF), that poses diagnostic and treatment dilemmas for the attending surgeon. In most cases previously reported, the diagnosis of this association was made either at surgery or at autopsy. We present herein the case of a neonate with EA and distal pouch (type C) TEF who was also found to have a LTEC (Evans type III) at the time of surgery. The salient clinical and radiological features of this association are highlighted to increase awareness of the possibility of this rare association and to help promote its early detection. Received: September 3, 1999 / Accepted: July 25, 2000     

腹股沟疝无张力修补术后复发的外科治疗

目的探讨无张力疝修补术后复发性腹股沟疝的外科手术治疗方法。方法67例复发性腹股沟疝中,使用人工材料行无张力疝修补手术后复发者有13例(19.4%),均再次手术治疗,采用Kugel补片1例、PHS补片修补3例和疝环充填式无张力修补9例。结果术后发生伤口积液1例,阴囊水肿1例,无切口感染,术后随防3～63个月,未见复发。结论无张力疝修补术后亦难免复发,再手术时宜根据术中所见选用不同的疝修补方式,但网塞疝环充填法仍然是一种简单、有效的治疗方法。     

Repair of Inflammatory Tracheoesophageal Fistula

Benign acquired tracheoesophageal fistula is uncommon. Erosion of the membranous wall of the trachea and the anterior esophageal wall by the high-pressure cuff on a tracheostomy tube, often against the anvil of a nasogastric tube, may produce such fistulas. Techniques for closure have included patching the tracheal defect with muscle and, often, multiple staged procedures, planned or unplanned.Since any cuff lesion severe enough to cause a fistula necessarily damages the trachea circumferentially at the same level, definitive correction must include circumferential tracheal resection as well as closure of the fistula. Five patients with tracheoesophageal fistula due to cuff perforation had repair by such a single-stage procedure. Through an anterior approach the involved trachea was resected, primary anastomosis was done, and the esophagus was closed in layers. In 3 of these 5 patients muscle was interposed for added security. One patient had undergone a prior attempt at repair elsewhere. One required a second resection of trachea for subsequent stomal stenosis. Repair in 2 additional patients with fistulas of complex origin related to direct trauma, sepsis, and foreign body involved adaptation of the basic technique to the special problem; 1 of these procedures was necessarily staged. Results in all 7 patients have been good.     

体外冲击波碎石术后胆囊结石复发危险因素的探讨

探讨体外冲击波碎石术(ESWL)后胆囊结石复发的危险因素。方法:对454例经ESWL治疗后结石已消失的病人进行多因素分析。对85例病人检测血清胰岛素和总胆汁酸值。结果:经1～8.8年随访,胆囊结石的复发率分别为,1年11.9％,2年20.2％,3年23.1％,4年34.8％,5年35.7％和5年以上37.2％。胆囊结石复发的危险因素包括:(1)有胆囊结石的家属史(P<0.05);(2)患者肥胖(P<0.05);(3)胆囊壁增厚(P<0.01);(4)血清胰岛素平均值较低(P<0.05);(5)血清总胆汁酸平均值较高(P<0.05)。结论:有胆囊结石家属史、患者肥胖、胆囊壁增厚及血清胰岛素相对不足等均为促使胆囊结石复发的危险因素,对ESWL的治疗对象应予更严格地挑选。     

腹膜透析在儿童心脏病术后急性肾衰竭中的治疗体会

目的探讨腹膜透析（PD）治疗儿童先天性心脏病术后并发急性肾衰竭的疗效。方法对22例先心病术后ARF行PD治疗患儿的临床资料进行回顾性分析,观察肾功能指标变化情况。结果 22例患儿中治愈6例,占27.3%,死亡16例,占72.7%,本组病例K＋和HC03-指标在PD治疗48h后明显好转（P〈0.05）。治愈患儿平均动脉压、中心静脉指标呈好转趋势（P〈0.05）;死亡患儿无改善。结论小儿心脏手术后ARF应用PD治疗能够纠正电解质代谢紊乱和酸碱失衡,可降低死亡率。     

磁共振成像在复发性肛瘘中的应用价值

为探讨磁共振成像（magneticresonanceimaging,MRI）在复发性肛瘘中的应用价值,回顾40例复发性肛瘘患者的MRI表现,总结分析其内口位置特点、瘘管走行形态以及肛提肌侵犯范围等。MRI采用Philips1．5T超导型磁共振扫描机,软体线圈,检查体位为仰卧位。采用横断：TIWI自旋回波（SE）序列,T2WI快速自旋回波（FSE）序列,T2WI脂肪抑制（FAT—SAT）序列。冠状及斜冠状位：T2WIFSE序列。层厚5ram,间隔lmm。结果显示,40例复发性肛瘘患者均为高位肛瘘,手术证实均存在内口,其中38例术中所见与MRI表现一致,该38例患者内口均位于肛窦附近（32例存在1个内口,6例存在2个内口）;另2例MRI检查各序列及断面均未显示内口。瘘管长度7．0～16．0cm（其中走行平直23例,走行迂曲17例）;瘘管宽度0．8～3．0cm。瘘管走行于肌间者32例,走行于肛提肌内者8例。本组患者瘘管壁均不规则,其厚度为0．3～1．0cm。瘘管存在支管者11例;内盲瘘1例。瘘管仅侵犯耻骨直肠肌者4例,仅侵犯髂骨尾骨肌者9例,耻骨直肠肌及髂骨尾骨肌同时受侵27例;并发瘘管组织癌变1例。结果表明,MRI能准确显示内口的位置、瘘管走行及肛提肌受侵范围、程度,在复发性肛瘘术前检查中具有重要作用。     

腹壁切口疝补片修补术后复发的再手术治疗

目的总结腹壁切口疝补片修补术后复发再次手术治疗的经验。方法回顾性分析我院2007年1月至2010年12月期间收治的16例腹壁切口疝补片修补术后复发再次手术患者的资料。结果所有患者均再次采用补片进行修补,其中13例除去旧补片置入新补片修补,2例新补片与原补片重叠并扩大范围修补,1例在原补片上直接重叠新补片修补。术后所有患者切口均Ⅰ期愈合,3例发生补片上方积液,经穿刺加压后治愈。术后住院时间7～16 d,平均9 d。术后引流管拔除时间2～7 d,平均4 d。所有患者均获随访,随访时间5～36个月,平均20个月,1例有轻微腹壁异物感,无修补区慢性疼痛,无疝复发。结论补片修补术后复发性切口疝再次手术时需综合考虑复发疝的位置以及既往选用的补片类型和修补方法,再次手术需选用合适的补片及修补方法方可取得满意效果。     

可见光固化材料对后牙牙体病损修复的临床疗效

探究可见光固化材料对后牙牙体病损修复的临床疗效。方法 选取2022年11月-2023年8月 我院收治的80例后牙牙体病损患者为研究对象,采用随机数字表法分为对照组和观察组,各40例。对照 组采用普通树脂材料进行后牙牙体病损修复,观察组采用可见光固化材料进行后牙牙体病损修复,比 较两组临床疗效、治疗满意度及不良反应发生率。结果 观察组临床总有效率为90.00%,高于对照组的 70.00%（P＜0.05）;观察组治疗总满意度为92.50%,高于对照组的70.00%（P＜0.05）;观察组不良反应发 生率为7.50%,低于对照组的25.00%（P＜0.05）。结论 在后牙牙体病损修复中,可见光固化材料具有临床 疗效好、患者满意度高、不良反应少的优势,值得临床应用。     

Partial Excision of Infected Fistula Results in Increased Patency at the Cost of Increased Risk of Recurrent Infection

Reliable vascular access is often an issue of ongoing frustration for those requiring dialysis. Synthetic arteriovenous fistulae (SAVF) have been widely used to provide vascular access; however, the risk of infection at the SAVF site is significant, especially because the SAVF is potentially exposed to pathogens on a regular basis due to the cannulation required for dialysis. Between 11 and 35% of all SAVF become infected and require surgical removal. The purpose of this investigation was to: (1) compare the risk of recurrent infection with complete versus partial excision of the infected SAVF (ISAVF) and (2) explore the risks and benefits of attempting to preserve patency of noninfected portions of ISAVF. In a retrospective review to determine the risk of recurrent infection after removal of ISAVF, charts of 77 patients undergoing surgery for the removal of an ISAVF from the arm were identified with 84 instances of excision of an ISAVF. Of the 84 ISAVF, 26 (31 %) were treated with complete excision (CE), 30 (35.7%) grafts were partially excised with blood flow restoration through a new interposed PTFE segment (PERF), and 28 (33.3%) grafts were partially excised with no flow restoration (PENF), leaving portions that were not grossly infected. Fourteen of 30 (46.7%) PERF grafts, 4/28 (14.3%) PENF, and 0/26 CE grafts developed further infection at the excision site. These differences were significant when comparing PERF to CE (p < 0.001) and PERF to PENF (p < 0.025), but no significance was found when comparing CE to PENF. Patency was significantly greater for the PERF group at 1 and 2 years than for both CE (p < 0.001) and PENF (p < 0.001). In conclusion, the data suggest that restoring blood flow to the remainder of a partially excised ISAVF significantly increases patency without necessitating catherer placement and a new hemoaccess site, but at the cost of significantly increased risk of recurrent infection.