CT引导下经皮穿刺置管引流在胰腺术后腹腔感染患者中的应用疗效

目的 探讨CT引导下经皮穿刺置管引流应用于胰腺术后腹腔感染的可行性、安全性及疗效。方法 回顾性纳入胰腺术后腹腔积液合并感染并接受CT引导下经皮穿刺置管引流的患者,分析穿刺置管对患者腹腔积液感染的治疗效果。结果 纳入8例胰腺术后患者,术后均出现腹腔积液合并腹腔感染。共完成10次CT引导下穿刺置管引流,置管13根,穿刺成功率100%。穿刺管引流液淀粉酶含量较高者达92.3%(12/13),细菌培养阳性率达100%,联合应用抗生素治疗后均治愈。结论 CT引导下经皮穿刺置管引流是胰腺术后腹腔积液感染治疗的重要手段,安全有效、创伤小。     

Transvaginal endoscopic cholecystectomy using a simple magnetic traction system

Abstract

Natural orifice transluminal endoscopic surgery (NOTES) is still at an early stage of clinical development. The development of new instruments is required to overcome some of the current limitations of NOTES. We thus performed transvaginal endoscopic cholecystectomies to determine the feasibility of using a magnetic traction system. Experiments were performed in a non-survival porcine model (n = 4). The magnet-fixed endoscopic clip was attached to the apex of the gallbladder fundus and held together with the external handheld magnet across the abdominal wall. The gallbladder fundus was then retracted to the cephalic direction by moving the external handheld magnet and the gallbladder was dissected from the liver bed. The gallbladder was placed in the endocatch material and delivered through the vagina. NOTES cholecystectomies via the transvaginal approach were successfully performed in a porcine model. The magnetic traction system was effective in achieving adequate exposure in all pigs. The magnetic traction system provides vigorous, multi-axial traction as required for the cholecystectomy procedure. There were no complications during the procedure other than minor bleeding from the liver bed. The mean procedure time was 133.8 minutes (range, 105 to 175 minutes). Our study successfully demonstrated the feasibility of the magnetic traction system in NOTES.     

Therapeutic options in acute diverticulitis

Diverticulitis is a serious intra-abdominal infection that ultimately afflicts about one in four patients having colonic diverticulosis. The illness may be indolent or fulminant, depending on the degree of colonic spillage and its containment. Most patients require hospitalization, and medical therapy suffices in about three fourths. Those who fail aggressive medical management and those with recurrent acute attacks, diffuse peritonitis, abscess, persistent obstruction, or fistulization require surgical intervention. Abdominal CT scanning has supplanted the contrast enema as the acute diagnostic procedure of choice and allows guided percutaneous drainage of large abscesses in selected cases. This approach helps realize the surgical ideal of a single elective operation without a temporary colostomy. For those patients still requiring emergency surgery, the two-stage approach employing resection of the diseased colon at the initial operation is far superior to the older three-stage approach.     

Urgent tracheostomy: four-year experience in a tertiary hospital

BACKGROUND: Urgent airway management is one of the most important responsibilities of otolaryngologists, often requiring a multidisciplinary approach. Urgent surgical airway intervention is indicated when an acute airway obstruction occurs or there are intubation difficulties. In these situations, surgical tracheostomy becomes extremely important.METHODS: We retrospectively studied the patients who underwent surgical tracheostomy from 2011 to 2014 by an otolaryngologist team at the operating theater of the emergency department of a tertiary hospital. Indications, complications and clinical evolution of the patients were reviewed.RESULTS: The study included 56 patients (44 men and 12 women) with a median age of 55 years. The procedure was performed under local anesthesia in 21.4% of the patients. Two (3.6%) patients were subjected to conversion from cricothyrostomy to tracheostomy. Head and neck neoplasm was indicated in 44.6% of the patients, deep neck infection in 19.6%, and bilateral vocal fold paralysis in 10.7%. Stridor was the most frequent signal (51.8%). Of the 56 patients, 15 were transferred to another hospital. Among the other 41 patients, 21 were decannulated (average time: 4 months), and none of them were cancer patients. Complications occurred in 5 (12.2%) patients: hemorrhage in 3, surgical wound infection in 1, and cervico-thoracic subcutaneous emphysema in 1. No death was related to the procedure.CONCLUSION: Urgent tracheostomy is a life-saving procedure for patients with acute airway obstruction or with difficult intubation. It is a safe and effective procedure, with a low complication rate, and should be performed before the patient's clinical status turns into a surgical emergency situation.     

NOTES: past,present and future

Once in a few decades in science or medicine, an idea emerges that is so powerful that it changes forever how we think about that field. Natural Orifices Translumenal Endoscopic Surgery (NOTES) has the potential to break the physical barrier between bodily trauma and surgery. At the dawn of surgery, excellence was associated with big incisions: “big scar ‐ big surgeon”. In the 80s, minimally invasive surgery was born representing one of the greatest surgical evolutions of the 20th century. After Kalloo's first report in 2004 on transgastric peritoneoscopy in a porcine model, the interest in natural orifice transluminal endoscopic surgery (NOTES) has blossomed. Theoretically the same operation performed laparoscopically could be carried out through natural orifices without any abdominal incision avoiding pain and scarring. The lesson learned from the advent of laparoscopic surgery, thought us that we could be witnessing the birth of another surgical revolution. Since 2004 many abdominal procedures that use a NOTES approach have been successfully performed in animal models. However, the initial excitement for NOTES has been somewhat tempered by the reality that a NOTES procedure in human without laparoscopic assistance has not been performed by most groups. Indeed, a major issue is the lack of stable operative platform and flexible instruments that allow retraction and exposure of the organs, such as appendix or gallbladder. Will this issue change the future of NOTES?     

Treatment of polymicrobial infections: post hoc analysis of three trials comparing ertapenem and piperacillin-tazobactam

The efficacy of ertapenem 1 g once a day for the treatment of polymicrobial complicated intra-abdominal, complicated skin/skin-structure and acute pelvic infections was compared with piperacillin-tazobactam 3.375 g every 6 h in a post hoc analysis of data from three large randomized double-blind trials. Of the 1,558 treated patients in the three trials, no pathogen was identified in 345 (22.1%), 423 (27.2%) had a monomicrobial infection and 790 (50.7%) had a polymicrobial infection. At the test-of-cure assessment, there were no significant differences in outcome between the two treatment groups for any of the three infections. Cure rates (clinical and microbiological for intra-abdominal infection, clinical for skin/skin-structure and pelvic infections) in microbiologically evaluable patients for ertapenem and piperacillin-tazobactam, respectively, were 85.6% (154/180 evaluable patients) and 82.5% (127/154) for polymicrobial intra-abdominal infection, 80.3% (53/66) and 78.7% (48/61) for polymicrobial skin/skin-structure infection, and 95.7% (88/92) and 92.6% (88/95) for polymicrobial pelvic infection. Respective cure rates for all evaluable patients in the original trials were: 83.6% and 80.4% for intra-abdominal, 83.9% and 85.3% for skin/skin-structure, and 93.9% and 91.5% for pelvic infections. These data show that in the three trials, ertapenem 1 g once a day was highly effective for the treatment of polymicrobial infections and as effective as piperacillin-tazobactam 3.375 g every 6 h.     

Laparoscopic management of adhesive acute postoperative small bowel obstruction

Laparoscopic management of postoperative acute adhesive small bowel obstruction (SBO) may often have clinical advantages. This prospective study included patients with postoperative acute SBO in whom sufficient intestinal decompression was achieved using a nasoenteric ileus tube preoperatively, but pass disorder was not improved. This study describes our experience with the laparoscopic procedure for patients with adhesive acute SBO. The laparoscopic approach was undertaken in 24 of 51 patients admitted for acute postoperative SBO from July 1994 through June 2000; it was performed successfully in 20 patients (83%), and four cases were converted to open surgery (17%) because of strong adhesions. In four patients with gallstones and inguinal hernia, laparoscopic surgery (cholecystectomy, hernioplasty) was performed simultaneously. There was no mortality and low morbidity (4.1%). The group of patients treated laparoscopically had a shorter hospital stay than the conventional open group (12 versus 21 days; p < 0.05). At the median follow-up of 84 months, 21 of the 22 patients who had received laparoscopic procedure remained asymptomatic. Laparoscopic treatment was effective, involved a shorter hospital stay and has shown good long-term results for most patients with adhesive acute SBO.     

Early nosocomial infections in pediatric cardiovascular surgery patients

All patients undergoing cardiovascular surgery between July 1, 1987 and February 29, 1988 were followed from admission to the pediatric ICU (PICU) daily by an intensivist/anesthetist. Patients were characterized by surgical procedure and PRISM score on ICU admission. Of 310 patients, 40 patients (nosocomially infected patient ratio 12.9) developed 78 infections (nosocomial infection ratio 25.2), of which 28% (n = 22) were wounds, within 2 months of surgery. Early wound infection followed 8% of closed, nonpump cases and 6.7% of open, pump cases. Wound infection was more likely if the sternum was open on the ward (elective or emergency) (27.6% open vs. 5.0% closed, p less than .001) or if the PRISM score was greater than or equal to 10 on PICU admission (10.7% greater than or equal to 10 vs. 2.3% less than 10, p less than .01). The causative agents in wound infections in closed cases were Staphylococcus aureus (70%) and coagulase negative staphylococci (CONS) (30%) while in open, pump cases the agents were CONS (33%), Pseudomonas aeruginosa (27%), Candida spp. (27%), and S. aureus (20%). Nonwound infections accounted for 72% of infections (n = 56). The number of bacteremias and other central and arterial line-related infections approximated wound infection in incidence at 6.8/100 patients. Wound infections are more likely if the sternum has been left open on the ward, if the patient has a high PRISM score on PICU admission, and after specific surgical procedures.     

Conservative treatment versus endoscopic sphincterotomy in the initial management of acute cholecystitis in elderly patients at high surgical risk

BACKGROUND AND STUDY AIMS: Surgery in elderly patients with acute cholecystitis is quite a high-risk procedure. The recent finding that activated pancreatic enzyme is present in sterile bile from the acutely inflamed gallbladder suggests that obstruction at the level of the common channel is a possible precipitating factor. It was therefore hypothesized that an initial endoscopic sphincterotomy in patients with acute cholecystitis might improve the clinical course. PATIENTS AND METHODS: A prospective unselected series of 105 patients over 65 years of age (52 men, 53 women; mean age 78) suffering from acute cholecystitis were initially treated on a random basis with either conservative methods or endoscopic sphincterotomy. Within the first 72 h after the onset of symptoms, all 52 patients in the endoscopic sphincterotomy group were managed by endoscopic retrograde cholangiopancreatography (ERCP), combined with endoscopic sphincterotomy in 50 cases. The main study parameter was the need for emergency cholecystectomy within the first week after admission. RESULTS: Biliary sepsis requiring emergency surgery occurred in 15 patients in the conservatively treated group, in contrast with none of the 52 patients in the endoscopic sphincterotomy group ( P < 0.001). Iatrogenic complications after endoscopic sphincterotomy occurred in three patients, one of whom required surgery, while two were managed by conservative means. The clinical course improved, avoiding the need for emergency cholecystectomy and other interventions, in 48 patients in the endoscopic sphincterotomy group and in 36 patients in the conservatively treated group ( P < 0.01). CONCLUSIONS: The clinical course after endoscopic sphincterotomy improved in the majority of elderly patients suffering from acute cholecystitis, suggesting that early relief of obstruction at the level of the common channel reduces the risk of developing biliary sepsis. The majority of these patients can undergo surgery electively or can receive further conservative treatment.     

Endoscopic ultrasound-guided fine-needle aspiration biopsy for lymphadenopathy of unknown origin

BACKGROUND AND STUDY AIMS: The diagnosis of mediastinal and intra-abdominal lymphadenopathy is sometimes difficult, especially in patients who have no other primary lesions. Lymphoma is one of the main causes of this condition. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a safe and accurate diagnostic procedure for lesions surrounding the gastrointestinal tract. However, diagnosing lymphoma using the EUS-FNA technique remains a diagnostic challenge, due to limitations in the amount of material sampled. The aim of the present study was to evaluate the yield of EUS-FNA biopsy (EUS-FNAB) using a large-gauge needle in patients with mediastinal and intra-abdominal lymphadenopathy of unknown origin, especially in relation to subclassification of the lymphomas. PATIENTS AND METHODS: Consecutive patients with mediastinal and intra-abdominal lymphadenopathy of unknown origin who were referred between October 2003 and March 2005 were enrolled in the study. EUS-FNAB was carried out using a 19-gauge needle, passing through the esophageal, gastric, and duodenal walls. Pathological diagnoses were made on the basis of histological findings, including immunopathological staining. RESULTS: A total of 104 patients were included in the study. The locations of the lymph nodes were mediastinal in 50 patients, intra-abdominal in 48 patients, and both mediastinal and intra-abdominal in six patients. The diagnoses made using EUS-FNAB were lymphoma (n = 48), metastasis (n = 16), and benign/reactive (n = 40). The overall accuracy of EUS-FNAB for unknown lymphadenopathy was 98 %, and it was possible to classify the lymphomas in accordance with the World Health Organization classifications in 88 % of cases. No serious complications occurred with the procedure. CONCLUSIONS: Open thoracic surgery, laparotomy, and other invasive diagnostic procedures such as mediastinoscopy and laparoscopy can now be avoided, as EUS-FNAB is potentially a safe and accurate tool for diagnosing unknown lymphadenopathy, including lymphoma.     

Laparoscopic appendectomies: Experience of a surgical unit

Appendicitis is one of the most common causes of acute abdomen in adults and appendectomy is the most common emergency abdominal procedure. Laparoscopic appendectomy has gained popularity only in recent years and the optimal approach for the treatment of acute appendicitis is still under debate. This retrospective study aimed at examining the current indications for laparoscopic appendectomy. 1024 patients undergoing laparoscopic appendectomy between February 1992 and December 2007 were retrospectively reviewed. 39.9% of patients (n=408) underwent emergency surgery. In 616 cases (60.1%) conservative management was performed in vain and these patients underwent an elective operation. In the 36 patients with an intraoperative normal appendix, other pathological findings were laparoscopically detected and treated. Conversion to an open procedure was required for 13 (1.3%) cases. The mean operative time was 38 min and the average length of postoperative hospitalization was 2.5 days. The overall morbidity rate was 2.6%. Laparoscopic appendectomy should be considered a procedure of choice for the treatment of non-complicated appendicitis. We stress the possibility to laparoscopically treat even complicated appendicitis in the surgical setting with substantial experience in minimally invasive surgery.     

Safety and Efficacy of Long-Term Outpatient Ertapenem Therapy

Ertapenem is increasingly utilized in outpatient parenteral antimicrobial therapy (OPAT), but data regarding the efficacy and safety of long-term ertapenem therapy have been limited. We conducted a retrospective cohort study of adult patients who received outpatient ertapenem therapy at our center between 2010 and 2013. Among 306 unique patients who were discharged on ertapenem therapy, the most common indications were intra-abdominal infections (38%), followed by pneumonia (12%), bone and joint infections (11%), bloodstream infections (10%), urinary tract infections (10%), surgical site infections (5%), and skin and soft-tissue infections (4%). Of these 306 patients, 68 received regular outpatient follow-up visits at our infectious disease clinic, where the majority of patients (91%) were successfully treated with ertapenem by the end of therapy. Of the 6 patients who experienced clinical failure, 2 had adverse events leading to discontinuation of therapy and 4 required additional source control for clinical success. In addition, 2 patients had recurrent infection at 6 months.     

Evaluation of tigecycline penetration into colon wall tissue and epithelial lining fluid using a population pharmacokinetic model and Monte Carlo simulation

The objective of these analyses was to assess the penetration of tigecycline into colon wall tissue and epithelial lining fluid (ELF). The analyses included data from subjects without infection (phase 1) and patients with intra-abdominal infections (phase 2/3). Steady-state serum samples were collected from all subjects/patients (n = 577), while colon wall specimens (n = 23) and ELF specimens (n = 30) were obtained from subjects without infection. Tissue and serum data were simultaneously comodeled by using the BigNPAG program, and a four-compartment, open model with zero-order intravenous input and first-order elimination was employed. To examine the full range of tissue penetration and the associated probabilities of occurrence, a 9,999-subject Monte Carlo simulation was performed with two outputs, one for ELF penetration and one for colon wall tissue penetration. Data were well fit using models described above, with all r(2) values above 0.95. For subjects without infection, the median (5th and 95th percentiles) colon wall and ELF penetration ratios were 1.73 (0.160 and 199) and 1.15 (0.561 and 5.23), respectively. Simulation results predict that tissue penetration varies considerably and likely explain unexpected clinical outcomes for those patients infected with strains at margins of the MIC distribution.     

Establishing transvaginal NOTES for gynecological and surgical indications: benefits, limits, and patient experience

Gynecologists have been performing transvaginal surgery for over a century and consequently the transvaginal approach was advocated for establishing natural orifice transluminal endoscopic surgery (NOTES) in gynecological and surgical practice. From 2008 the NOTES alternative has been offered to selected patients. Transvaginal cholecystectomies were intended in 13 patients and completed in 12. Various additional procedures were performed. All surgical procedures and postoperative courses were uneventful. The mean operating time for transvaginal cholecystectomy only was 88.4 minutes (standard deviation [SD] 17.3). A questionnaire was posted to the patients after a mean follow-up of 8.5 months. Patients primarily chose transvaginal NOTES because of the lack of scarring. Vaginal sensation was not affected. Patients perceived transgastric, transvesical, and transrectal surgery to be less acceptable approaches. The feasibility of transvaginal NOTES was proven for different indications. Patients' experiences and perceptions concerning transvaginal NOTES were excellent.     

小儿外科手术切口感染调查

目的了解儿童手术切口感染情况及其特点,为预防和控制切口感染提供依据。方法通过回顾性分析方法,对某院小儿外科患者手术后切口感染情况进行调查与分析。结果 2008-2011年,该医院小儿外科共进行儿童手术3 419例,发生切口感染75例,感染率为2.19%。手术切口感染患儿≤3岁、Ⅲ类手术切口、颅脑手术、急诊手术和手术时间超过3 h的患者手术切口感染率较高。结论儿童手术切口感染主要危险因素是低龄、切口类型、脑部和急诊手术以及手术持续时间过长等,应针对高危因素采取防控措施。     

Transvesical peritoneoscopy: initial clinical evaluation of the bladder as a portal for natural orifice translumenal endoscopic surgery

Abdominal surgery has traditionally been performed through large incisions into the peritoneal cavity. In the past decade, traditional open surgery has been increasingly replaced by minimally invasive laparoscopic and robotic techniques. In comparison to open surgery, these approaches can decrease postoperative pain, shorten the convalescence period, and improve cosmesis. Nonetheless, these techniques require multiple small entry incisions and are therefore associated with risk of wound infection and incisional hernia. The latest surgical advance is performance of procedures via natural body openings such as the mouth, anus, vagina, and bladder. To date, clinical experience with natural orifice translumenal endoscopic surgery (NOTES) is extremely limited. Herein, we describe the initial clinical case in which we evaluated the bladder as a portal for NOTES. Our experience indicates clinical feasibility of transvesical peritoneoscopy with existing clinical equipment, but additional refinements of the technique and associated instrumentation appear warranted. In comparison to other portals, the urinary tract seems to have distinct clinical advantages for NOTES.     

Impact of respiratory syncytial virus infection on surgery for congenital heart disease: postoperative course and outcome.

OBJECTIVES: a) To describe the postoperative course and outcome of cardiac surgery in children with recent respiratory syncytial virus (RSV) infection; and b) to evaluate whether timing of surgery has any impact on the outcome. DESIGN: Retrospective case series. SETTING: Intensive care unit and medical and surgical wards of a teaching pediatric hospital. PATIENTS: Twenty-five children (aged 25 days to 3.5 yrs; median, 4 months) with congenital heart disease who had cardiac surgery within 6 months after RSV infection. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We reviewed the clinical course and outcome of all patients. The cardiac diagnoses included ventricular septal defect (n = 11), tetralogy of Fallot (n = 3), atrioventricular canal (n = 3), and others (n = 8). Thirteen patients had surgery during the same admission as RSV infection (group I), and 12 patients had surgery electively after being discharged to home after RSV infection (group II). Two patients in group I died; both of these patients had undergone total repair of tetralogy of Fallot within 2 wks after admission for RSV infection. Postoperative complications in group I patients included pulmonary hypertension (n = 5), adult respiratory distress syndrome (n = 1), tracheal stenosis (n = 1), left ventricular dysfunction (n = 1), pericardial effusion (n = 1), secondary bacterial or fungal infection (n = 7), and deep venous thrombosis (n = 1). Of all group I patients, the ones who were operated on early appeared to be at higher risk for complications, especially for postoperative pulmonary hypertension. No patient in group II died, and only two patients had minor complications (one had reactive airway disease, and the other had a transient superior vena cava syndrome after a bidirectional Glenn operation). CONCLUSIONS: Cardiac surgery performed during the symptomatic period of RSV infection is associated with a high risk of postoperative complications, especially postoperative pulmonary hypertension. These complications appeared to be more frequent and of greater severity in patients who had earlier surgery compared with those who had later surgery. More studies are needed regarding the proper timing of cardiac surgery in patients with congenital heart disease and RSV infection.     

Efficacy of ertapenem in the treatment of serious infections caused by Enterobacteriaceae: analysis of pooled clinical trial data

OBJECTIVE: The efficacy of ertapenem, 1 g once a day, for treatment of adults with serious infections caused by Enterobacteriaceae was compared with ceftriaxone 1 g once a day [complicated urinary tract infection (CUTI) and community-acquired pneumonia (CAP)] or piperacillin-tazobactam, 3.375 g every 6 h (complicated intra-abdominal, complicated skin/skin structure and acute pelvic infections). PATIENTS AND METHODS: This combined analysis included the subgroup of all 1167 treated patients infected with Enterobacteriaceae from seven randomized double-blind studies. RESULTS: Escherichia coli was the most common pathogen, accounting for 65.3% of all Enterobacteriaceae. Among evaluable patients with deep tissue (intra-abdominal, skin and pelvic) infections, the combined clinical cure rates were 84.8% (223 of 263) for ertapenem and 82.9% (194 of 234) for piperacillin-tazobactam [95% confidence interval (CI) for the difference, adjusting for infection, -4.9% to 8.9%]. Cure rates by infection for ertapenem and piperacillin-tazobactam, respectively, were: intra-abdominal, 85.1% (143 of 168) and 79.9% (119 of 149); pelvic, 86.8% (46 of 53) and 94% (47 of 50); skin/skin structure, 81% (34 of 42) and 80% (28 of 35). Among patients with CUTI, microbiological cure rates were 90.5% (220 of 243) for ertapenem and 92% (196 of 213) for ceftriaxone (95% CI for the difference, -7.1% to 4.1%). In patients with CAP, clinical cure rates were 95% (19 of 20) for ertapenem and 88.9% (16 of 18) for ceftriaxone. CONCLUSION: Ertapenem therapy was as effective as either piperacillin-tazobactam or ceftriaxone for serious infections caused by Enterobacteriaceae.     

腹膜透析患者并发腹腔感染的原因分析及护理对策

目的分析腹膜透析患者发生腹腔感染的环节及其发生的相关影响因素,为临床预防和减少腹腔感染的发生提供依据,并提出相应的护理干预措施。方法回顾性调查第二军医大学长征医院自2011年1-12月共300例腹膜透析患者(共腹透3368个月)腹腔感染发生的原因。结果 300例维持性腹膜透析患者共发生腹腔感染55例次,感染发生率为18.3%。结论腹膜透析患者腹腔感染发生率高,应针对腹腔感染发生的原因加以预防,采取提高患者依从性、积极治疗原发病、预防呼吸道及肠道感染、加强宣教和随访等措施,以提高透析疗效,改善患者的生活质量。     

Palliative surgery for acute bowel obstruction caused by Kaposi's sarcoma in a patient with AIDS

Patients with human immunodeficiency virus (HIV) infection or acquired immune deficiency syndrome (AIDS) can present with acute abdominal surgical problems, either with intra-abdominal opportunistic infection as a result of their immunosuppression, or with associated malignancies. We report a 39-year-old man who developed intermittent nausea and vomiting, which was originally thought to be a side-effect of the chemotherapy he was receiving for facial Kaposi's sarcoma. However, he was found to have intraperitoneal Kaposi's sarcoma causing small bowel obstruction, which was successfully excised at laparotomy. There were no perioperative complications despite AIDS-related respiratory disease. The patient remained free of abdominal symptoms until his death. HIV infections or AIDS alone should not be contraindications to surgery for such problems, as careful patient selection can yield good results and significantly improve quality of life.