重症急性胰腺炎的手术与非手术治疗

为提高重症急性胰腺炎（ＳＡＰ）的疗效，作者总结了９３例ＳＡＰ患者的治疗经验。９３例中，治愈７３例（７８．５％）、死亡２０例（２１．５％）。手术治疗组５３例，死亡１５例（２８．３％）；非手术治疗组４０例，死亡５例（１２．５％）。１９９２年以前早期手术为主，死亡率２３％；１９９２年以后非手术或延期手术为主，死亡率１９．５％。作者认为本病的死亡原因与病情、胰腺坏死范围、有无继发感染及器官衰竭的处理方法有关。早期手术未能改善初期休克、胰腺广泛坏死、器官衰竭等并发症的预后，而非手术方法可以治愈大多数ＳＡＰ病例。胰腺组织坏死继发严重感染者应行手术治疗。手术方法以坏死组织清除和充分引流为主。     

急性出血坏死性胰腺炎非手术治疗的关键环节

作者１９７０年１月至１９９６年８月共收治急性出血坏死性胰腺炎（ＡＨＮＰ）１６６例。１９８０年以前以简化手术为主，１９８０～１９９０年以经典手术为主，１９９０年以后以非手术治疗为主。在当今ＩＣＵ条件下，多数ＡＨＮＰ患者可以经积极的非手术治愈，但不是所有的患者所有的时候都要坚持非手术治疗。非手术治疗组的各种并发症及死亡率均低于手术治疗组（Ｐ＜０．０５）。并发症急性呼吸窘迫综合征（ＡＲＤＳ）、胰腺脓肿、腹腔出血可能和手术打击有关。因此非手术治疗值得提倡和推广。总结非手术治疗的经验，我们认为采用非手术治疗前，ＡＨＮＰ的诊断必须明确，病程的不同时期有不同的治疗重点：病程早期（发病１周内）以纠正内环境紊乱及减轻胰外器官损害为主；中期（发病２～４周内）以防治胰腺坏死组织继发感染为主；后期（发病４周后）以处理胰腺坏死组织引起的并发症为主。     

非手术治疗重症急性胰腺炎43例体会

目的 探讨重症急性胰腺炎的治疗效果。方法 对比研究了以早期非手术治疗为主的A组（1993－2000年43例）和以早期手术为主的B组（1993年以前21例）患者的并发症和病死率。结果 A组并发症的发生率和病死率明显低于B组（P＜0.01）。结论 重症急生胰腺炎的早期非手术治疗明显优地早期手术治疗。在非手术治疗中需注意CT监测胰腺坏死范围的变化和中转手术指征。     

重症急性胰腺炎102例临床分析

目的探讨重症急性胰腺炎的合理治疗方案。方法以1985年1月～2005年8月间收治的102例重症急性胰腺炎作研究对象，比较手术组与非手术组的主要并发症和死亡率。A组：1985年1月～1993年12月以手术治疗为主41例；B组：1994年1月～2005年8月以早期非手术治疗为主61例。结果手术组死亡率和并发症发生率明显高于非手术组，两组病死率及并发症发生率比较差异有显著性（P〈0．05）。结论重症急性胰腺炎采用早期非手术治疗能有效降低病死率和并发症发生率。大多数重症急性胰腺炎可经非手术治愈。     

重症胰腺炎治疗方式及并发症98例分析

目的: 探讨重症胰腺炎(SAP)的有效治疗方法 。方法: 1983~1992年的42例以早期手术治疗为主（A组）,1992~1999年的56例以早期非手术治疗为主（B组）。比较两组的主要并发症及死亡率 。结果: 比较休克、胰腺坏死并发感染和器官功能衰竭等主要并发症的发生率及病死率,A组均高于B组（P<0.001) 。结论: 早期非手术治疗SAP明显优于早期手术治疗。     

急性坏死性胰腺炎的手术时机及手术指征

急性坏死性胰腺炎（ＡＮＰ）的手术时机及手术指征仍存争议。作者对该院１９８５年以来手术治疗的１１９例ＡＮＰ患者进行分析。将发病２周以内手术者定为早期手术，２周以后手术者为晚期手术。发现早期手术病例术中病理所见多为局灶性坏死（占７５．６％），术后并发症以循环及胰外脏器功能紊乱为主，术后死亡率达２８．２％；而晚期手术者多系全胰坏死型（占５３．７％），术后并发症以胰周局部脏器病变为主，死亡率降至１２．３％。因此作者认为ＡＮＰ应尽可能采用晚期手术，并对早期及晚期手术的指征进行了讨论。     

重症急性胰腺炎的治疗方案探讨

目的:确立重症急性胰腺炎(ASP)的治疗方案.方法:对比研究了以早期手术治疗为主的A组(125例)和以早期非手术治疗为主的B组(108例)的并发症发生率和死亡率.结果:B组的并发症(ARDS、肾衰、心衰、胰腺脓肿)发生率和死亡率均明显低于A组(P<0.001).早期手术治疗未能降低发生休克、胰腺广泛坏死感染及多器官功能衰竭的危险.结论:ASP宜首先进行非手术治疗.     

重症胰腺炎营养支持方法的改进和疗效观察

作者报告，自１９８８年以来，重症胰腺炎营养支持方法的改进主要是使用低热卡（＜１４６ｋＪ／ｋｇ．ｄ）高氮（０．２５－０．４ｇ／ｋｇ．ｄ），术后２周内采用白蛋白或血浆强化的ＴＰＮ支持方法。将按这种改进方法进行治疗的２３例（Ｂ组）与１９８８年以前的２０例（Ａ组）进行比较。结果发现，尽管Ｂ组的病情明显重于Ａ组，但两组术后并发症的发生率和手术死亡率均无明显差异。Ｂ纠正低蛋白血症所需的时间明显短于Ａ组。作为认     

急性坏死性胰腺炎的手术时机及手术指征

目的：探讨急性坏死性胰腺炎（ＮＡＰ）的手术时机及手术指征。方法：对１９８５年以来手术治疗ＡＮＰ１１９例进行了回顾性分析。结果：将发病２周的以内手术者定为早期手术，２周以后手术者为晚期手术。发现早期手术病例中病理所见多为忆灶性坏死（占７５．６％），术后并发症以循环及胰外脏器功能紊乱为主，术后死亡率达２８．２％；而晚期手术者系全胰坏死型（占５３．７％），术后并发症以胰周局部脏器病变为主，死亡率降至１２     

重症急性胰腺炎的中西医结合治疗

目的探讨中西医结合治疗重症急性胰腺炎（Severe acute pancreatitis，SAP）的疗效。方法对186例重症急性胰腺炎患者。其中早期手术治疗组84例，西医非手术治疗组41例，中西医结合非手术治疗组61例进行回顾性分析。并对其主要并发症、平均住院时间和病死率进行总结。结果中西医结合非手术治疗组的并发症发生率（19．7％）、平均住院时间为（22．5±8．3）d及病死率（8．2％）明显低于早期手术治疗组（P〈0．01）。中西医结合非手术治疗组的主要并发症、平均住院时间低于西医非手术治疗组（P〈0．05）。结论中西医结合非手术治疗能降低重症急性胰腺炎的并发症和提高治愈率．可作为SAP综合治疗的重要部分。     

Selective management of blunt splenic trauma

During a recent 8-year period, 235 patients with documented blunt splenic trauma were treated. After exclusion of 39 patients with early deaths (19 dead on arrival, nine died in emergency room, and 11 died in operating room), the 196 remaining patients were treated in accordance with an evolving selective management program. Definitive management included splenectomy in 117 patients (59.7%), repair in 32 (16.3%), and nonoperative treatment in 47 (24%). A spectrum of blunt splenic trauma, as manifested by the degree of associated injuries (Injury Severity Scores), hemodynamic status, and blood transfusion requirements, was identified and permitted application of a rational selective management program that proved safe and effective for all age groups. Comparative analysis of the three methods of treatment demonstrated differences that were more a reflection of the overall magnitude of total bodily injury sustained rather than the specific manner in which any injured spleen was managed. Retrospective analysis of 19 nonoperative management failures enabled establishment of the following selection criteria for nonoperative management: absolute hemodynamic stability; minimal or lack of peritoneal findings; and maximal transfusion requirement of 2 units for the splenic injury. With operative management, splenorrhaphy is preferred, but it was often precluded by associated life-threatening injuries or by technical limitations. Of 42 attempted splenic repairs, ten (24%) were abandoned intraoperatively. There were no late failures of repair. In many cases of blunt splenic trauma, splenectomy still remains the most appropriate course of action.     

The ability of MRI to predict failure of nonoperative treatment of pyogenic vertebral osteomyelitis

Pyogenic vertebral osteomyelitis (PVO) can be treated most often by medical management. For those failing with medical management, surgical delay can result in increased morbidity. Therefore, the ability to predict failure of medical management on presentation would greatly improve the outcome. This study determines the ability of the presenting magnetic resonance imaging scan to predict failure of nonoperative management at the onset of treatment. A cohort of patients with PVO, initially treated medically, was reviewed. Imaging, demographics, and clinical data of patients successfully treated medically were compared with those ultimately requiring surgical treatment. The extent of signal change on the T1-weighted sagittal images of the affected motion segment was determined for each group. Twenty-two patients were included in the study. Patients successfully treated medically averaged 57%+/-19% of motion segment involvement, whereas those failing conservative treatment averaged 89%+/-18%. Using 90% involvement as an indication for initial surgery would have a sensitivity of 78% and specificity of 93%. Patients with thoracolumbar PVO who have 90% or higher involvement of an affected motion segment should be considered for early operative management.     

Bleeding manifestations after early use of low-molecular-weight heparins in blunt splenic injuries

Low-molecular-weight heparins (LMWHs) have emerged as an effective method for deep venous thrombosis (DVT) prophylaxis after major trauma. The early use of LMWH in patients with splenic injuries may result in increased rates of blood transfusions and failure of nonoperative management. A retrospective review of the records of all patients > or = 18 years old that sustained blunt splenic injuries from April 2000 to July 2002 was performed. Patients were divided in two groups based on whether they received LMWH during the first 48 hours (early group) or not (late group). A total of 188 patients were evaluated. One hundred fourteen patients had their splenic injuries managed nonoperatively and were included in the study. Fifty patients were assigned to the early group and 64 to the late group. There was no statistical difference between groups regarding basic demographic data, initial laboratory results, and severity of their splenic injuries. In the early group, two (4%) patients failed nonoperative management compared with four (6%) patients in the late group (P = 0.593). The number of patients requiring blood transfusions within the first 5 days after admission was 25 (50.0%) in the early group and 36 (56.2%) in the late group (P = 0.507). The average number of blood units given per patient within the first 5 days after admission were 3.2 +/- 1.5 in the early group and 3.0 +/- 1.8 in the late group (P = 0.782). This study suggests that the early use of LMWH in trauma patients with splenic injuries is not associated with an increased rate of blood transfusion requirements or an increased rate of failure of nonoperative management.     

Early decisions in perforated appendicitis in children: lessons from a study of nonoperative management

Background

In nonoperative management of perforated appendicitis, some children do not respond to treatment. This study sought early identifiers of failure to help in surgical decision making.

Methods

Fifty-eight patients with computed tomographic (CT)-proven perforated appendicitis were treated according to a nonoperative protocol. Patients who recovered were considered “successes;” those who did not improve underwent appendectomy and were scored as “failures” of nonoperative treatment.

Results

Thirty-six (62%) of 58 patients responded to treatment and 22 (38%) failed. Three parameters distinguished the 2 groups: the number of band forms on the admission white blood cell count, the body temperature response after 24 hours of treatment, and the areas of the abdomen involved in the CT scan. Patients in whom nonoperative treatment failed stayed in the hospital longer (17 vs 9 days) and had more complications (46% vs 0%).

Conclusions

Because failure of nonoperative management is associated with a high complication rate, it is important to make an early decision about appendectomy. Persistence of fever after 24 hours of treatment, bandemia on admission, and multisector involvement on CT scan identify most patients who fail nonoperative management. When combined with clinical judgment, these are useful indicators to guide early decisions.     

Chylothorax complicating esophagectomy for cancer: a plea for early thoracic duct ligation

OBJECTIVE: Postoperative chylothorax remains an uncommon but potentially life-threatening complication of esophagectomy for cancer, and the ideal management is still controversial. The aim of the study was to compare the outcomes of patients treated nonoperatively with those of patients promptly undergoing reoperation. METHODS: From 1980 to 1998, 1787 esophagectomies for esophageal or cardia cancer were performed, and 19 (1.1%) patients had postoperative chylothorax. We analyzed type of operation, surgical approach, delay of diagnosis of chylothorax, daily chest tube output, type of management, major complications, death, hospital stay, and final outcome. RESULTS: Of the 19 patients with chylothorax, 11 were initially managed nonoperatively (group A): 4 (36%) patients had spontaneous resolution of chylothorax, and the other 7 required reoperation for the persistence of a high-volume output. There were three infectious complications and one postoperative death in this group. No reliable predictive criteria of successful versus unsuccessful nonoperative management could be found. The 8 most recent patients underwent early reoperation (group B). All patients recovered, and no major complications possibly related to chylothorax or hospital deaths were observed. They were discharged after a median of 22 days (range, 12-85 days) compared with a median of 36 days (range, 21-64 days) for patients of group A. CONCLUSIONS: Early thoracic duct ligation is the treatment of choice for chylothorax occurring after esophagectomy. Reoperation should be performed immediately after the diagnosis is made to avoid the complications related to nutritional and immunologic depletion caused by prolonged nonoperative treatment.     

Limitations of splenic angioembolization in treating blunt splenic injury

BACKGROUND: When angiography is performed in all hemodynamically normal patients with splenic injury, only 30% require embolization. This study examines the use of selective splenic angioembolization (SAE) as part of a management algorithm for adult splenic injury. METHODS: Criteria for selective SAE were added to our adult splenic injury protocol in July 1999. SAE was performed in hemodynamically stable patients if computed tomographic (CT) scan revealed injury to the hilum or vascular blush and when nonoperative patients had a gradual decrease in hematocrit. Patients were grouped by management strategy: nonoperative; operative; or SAE. Demographics, injury severity, and outcomes of the different groups were compared. Medical records, CT scans, and registry data were reviewed for all SAE cases, deaths, and treatment failures. Data are means +/- SE. p < 0.05 versus nonoperative management by analysis of variance. RESULTS: From July 1999 to August 2003, 194 adults were treated for splenic injury. Nine patients underwent SAE, six for CT findings (1 vascular blush) and three for decreasing hematocrit. Three patients failed SAE (33%), one for bleeding and two for delayed splenic infarction. Eleven patients failed nonoperative therapy (8%); splenorrhaphy was performed in three and splenectomy in eight. Operative patients were more seriously injured and had higher Injury Severity Scores and mortality; splenectomy (39 of 48) was more commonly performed than splenorrhaphy (9 of 48) in this group. CONCLUSION: Use of a splenic injury algorithm is associated with a high success rate for nonoperative management of splenic trauma. Using selective criteria, only 5% of patients were treated with SAE. SAE salvaged six patients with high-grade splenic injury or decreasing hematocrit but had a 33% failure rate. Failure of nonoperative management was most commonly caused by errors in judgment, primarily recognition of "high-risk" injury patterns on CT scan or attempting nonoperative management in anticoagulated or coagulopathic patients.     

Stage I and II posterior tibial tendon dysfunction treated by a structured nonoperative management protocol: an orthosis and exercise program

BACKGROUND: Posterior tibial tendon dysfunction (PTTD) is a relatively common problem of middle-aged adults that usually is treated operatively. The purpose of this study was to identify strength deficits with early stage PTTD and to assess the efficacy of a focused nonoperative treatment protocol. METHODS: Forty-seven consecutive patients with stage I or II posterior tibial tendon dysfunction were treated by a structured nonoperative protocol. Criteria for inclusion were the presence of a palpable and painful posterior tibial tendon, with or without swelling and 2) movement of the tendon with passive and active nonweightbearing clinical examination. The rehabilitation protocol included the use of a short, articulated ankle foot orthosis or foot orthosis, high-repetition exercises, aggressive plantarflexion activities, and an aggressive high-repetition home exercise program that included gastrocsoleus tendon stretching. Isokinetic evaluations were done before and after therapy to compare inversion, eversion, plantarflexion, and dorsiflexion strength in the involved and uninvolved extremities. Criteria for successful rehabilitation were no more than 10% strength deficit, ability to perform 50 single-support heel rises with minimal or no pain, ability to ambulate 100 feet on the toes with minimal or no pain, and ability to tolerate 200 repetitions of the home exercises for each muscle group. RESULTS: Before therapy weakness for concentric and eccentric contractures of all muscle groups of the involved ankle was significant (p<0.001). After a median of 10 physical therapy visits over a median period of 4 months, 39 (83%) of the 47 patients had successful subjective and functional outcomes, and 42 patients (89%) were satisfied. Five patients (11%) required surgery after failure of nonoperative treatment. CONCLUSION: This study suggests that many patients with stage I and II posterior tibial tendon dysfunction can be effectively treated nonoperatively with an orthosis and structured exercises.     

Small-bowel obstruction secondary to malignant disease: an 11-year audit.

OBJECTIVE: To determine the efficacy and long-term prognosis for operative versus nonoperative treatment of small-bowel obstruction (SBO) secondary to malignant disease. DESIGN: A chart review. SETTING: A university-affiliated teaching hospital. PATIENTS: The medical records of all patients with malignant disease as the established etiology of their obstruction who presented to the Sir Mortimer B. Davis-Jewish General Hospital, Montreal, between 1986 and 1996 were reviewed. There were 32 patients accounting for 74 admissions. INTERVENTIONS: Selective nonoperative management and exploratory laparotomy, immediate or delayed. MAIN OUTCOME MEASURES: The value of nonoperative management and need for operation. RESULTS: Colorectal and ovarian neoplasms were the principal primary malignant diseases that led to SBO. The median time between diagnosis of the malignant disease and SBO was 1.1 years. At their initial presentation, 80% of patients were treated by operation, but 47% of these patients had an initial trial of nonoperative treatment. Reobstruction occurred in 57% of patients who were operated on compared with 72% of patients who were not. The median time to reobstruction was 17 months for patients who underwent operation compared with 2.5 months for patients who did not. Also, 71% of patients were alive and symptom free 30 days after discharge from operative treatment compared with 52% after nonoperative treatment. Postoperative morbidity was 67%. Mortality was 13%, and 94% of patients eventually died from complications of their primary disease. CONCLUSIONS: SBO secondary to malignant disease usually indicates a grim prognosis. Operative treatment has better outcome than nonoperative management in terms of symptom free interval and reobstruction rates. However, it is marked by high postoperative morbidity. We recommend that, after short trial of nasogastric decompression, patients with obstruction secondary to malignant disease be operated on if clinical factors indicate they they will survive the operation.