A critical evaluation of a percutaneous diagnostic and treatment strategy for chylothorax after thoracic surgery.

OBJECTIVE: Because chylothorax complicating thoracic surgery is difficult to diagnose and failure of nonoperative management necessitates further surgery, we critically evaluated an evolving percutaneous strategy for diagnosing and treating chylothorax. METHODS: After thoracic surgery, 37 patients with a clinical diagnosis of chylothorax were referred for lymphangiography for definitive diagnosis and percutaneous treatment. Successful localization of the cisterna chyli by lymphangiogram facilitated percutaneous cannulation of the thoracic duct and its embolization. In patients in whom cannulation was not possible, the thoracic duct was percutaneously disrupted. RESULTS: Diagnosis: Lymphangiography was successful in 36 of the 37 patients (97%). Contrast extravasation, confirming clinical diagnosis, was present in 21 of the 36 (58%). Management: Twenty-one of 36 patients underwent 22 lymphangiographically directed percutaneous interventions: 12 embolizations and 10 disruptions. Mortality was zero, with two manageable complications. Patients without percutaneous intervention were discharged a median of 7 days (range 4-58) after first lymphangiography, 8 days (range 2-19) after percutaneous embolization, and 19 days (range 6-48) after first disruption. Eight patients had nine subsequent reoperations for chylothorax, two with negative lymphangiograms; no embolization patient required reoperation. CONCLUSIONS: There is a discrepancy between the clinical diagnosis of chylothorax after thoracic surgery and the presumed gold standard of diagnosis, contrast extravasation at lymphangiogram. Percutaneous treatment by thoracic duct embolization or disruption is safe and may obviate reoperation, but embolization of the thoracic duct is preferable to its disruption.     

Chylothorax: an assessment of current surgical management

The development of chylothorax is a serious and often life-threatening clinical entity. Optimal management of this problem has not been well defined to date. We reviewed our experience with chylothorax in patients of all ages during the past 10 years. Ages ranged from 2 days to 69 years. The etiologies were traumatic in 17 and congenital or idiopathic in three. Six patients (five infants) were treated nonoperatively with either repeated thoracenteses or chest tube drainage. Fourteen patients (11 infants) underwent operative treatment: transthoracic thoracic duct ligation (five patients), pleuroperitoneal shunting (seven), pleuroperitoneal shunting combined with reoperation on a patient with congenital heart disease (one), and reoperation alone on a patient with congenital heart disease (one). Duration of preoperative therapy ranged from 9 days to 2 months (average 3.3 weeks). Five of six (83.3%) patients treated nonoperatively died. Of the surgically treated group, only two of 14 (14.3%) died, and 11 of the 12 survivors had resolution of the chylothorax and immediate clinical improvement. Our experience suggests that both pediatric and adult patients respond poorly to nonoperative treatment of chylothorax and that this treatment has a high mortality rate. Post-traumatic and congenital chylothorax should be treated operatively after a limited trial (1 to 2 weeks) of nonoperative therapy. Pleuroperitoneal shunting may offer a reasonable and effective alternative to thoracotomy and thoracic duct ligation.     

Readmission for small-bowel obstruction in the early postoperative period: etiology and outcome.

OBJECTIVES: To determine the frequency of readmission for early postoperative small-bowel obstruction (SBO), to highlight factors that may predispose to this condition, to define the risks of strangulation and to compare the immediate and long-term risks and benefits of operative versus nonoperative treatment. DESIGN: A chart review. SETTING: The Sir Mortimer B. Davis-Jewish General Hospital, a university-affiliated teaching hospital in Montreal. PATIENTS: Out of a total of 1001 cases of SBO in 552 patients, 30 patients were readmitted within 50 days of a previous laparotomy with the diagnosis of SBO. INTERVENTION: Selective nonoperative management and exploratory laparotomy. MAIN OUTCOME MEASURES: The value of nonoperative management and need for operation. RESULTS: Adhesions were the cause of the obstruction in most cases (24); other causes were Crohn's disease (2), hernia (1), malignant neoplasm (1) and a combination of adhesions and malignant disease (2). Thirteen (43%) of the procedures preceding the obstruction were primary small-bowel operations. There was only 1 episode of strangulated bowel. Of the patients readmitted for SBO, 7 (23%) were treated operatively with a long-term recurrence rate of 57% compared with 63% for those treated nonoperatively for the SBO. The median time to recurrence was 0.1 years (range from 0.02-6 yr) for those whose SBO was managed operatively, compared with 0.7 years (range from 0.08-5 yr) for those managed nonoperatively for the SBO. The median length of stay for patients managed operatively for SBO was 12 days (range from 9-17 d) compared with 6 days (range from 2-33 d) for those managed nonoperatively. CONCLUSIONS: Readmission for SBO within 50 days of a previous laparotomy represents a small percentage of all cases of SBO. They frequently follow small-bowel operations. Cases of strangulation are no more common than in general cases of SBO. Patients treated nonoperatively for SBO did not experience less favourable outcomes with respect to resolution of symptoms, length of stay, risk of recurrence and reoperation. Thus, operative intervention is not necessary in an otherwise stable patient.     

Immediate postlaparotomy small bowel obstruction: a 16-year retrospective analysis

Small bowel obstruction (SBO) is a particularly vexing problem in the postoperative period. The goal of this study was to compare the results of operative versus nonoperative treatment. A secondary goal was to explore risk factors for necessitating reoperation in the immediate postoperative period. We conducted a historical cohort retrospective chart review at a university-affiliated hospital. The medical records of patients treated between 1985 and 2000 at the Sir Mortimer B. Davis Jewish General Hospital (Montreal, Quebec, Canada) who developed SBO after undergoing a laparotomy during that admission were reviewed. Postoperative SBO was defined as cessation of flatus or bowel movements after their resumption following operation. To compare operative versus nonoperative management of early postoperative mechanical SBO we used the following outcome measures: Reoperation rate, time to return of function, length of stay, and mortality. Of 52 patients who developed SBO in the immediate postoperative period 37 were male, 25 had colorectal surgery, and nine had a gastrectomy as the initial operation on admission; five had inflammatory bowel disease, six had a previous SBO, 22 had virgin abdomens before the current operation, and 11 had adhesions noted at the initial operation. The median time to the development of obstructive symptoms was 8 days (range 1-33). The reoperation rate was 42 per cent overall (67% in women and 32% in men, P = 0.02). For operatively treated patients the median time between onset of symptoms and surgery was 5 days [range 1-23, interquartile range (IQR) = 5]. The median time to the return of bowel function was greater in the operatively treated patients compared with nonoperatively treated patients [11.5 days (range 4-37, IQR = 11) vs 6 days (range 1-28, IQR = 7), P < 0.0001] as was median length of stay from onset of obstruction [23 days (range 6-60, IQR = 14) vs 12 days (range 2-45, IQR = 16), P < 0.009]. Operatively treated patients also stayed longer after their obstruction was relieved although not significantly longer [8 days (range 1-35, IQR = 11) vs 4.5 days (range 0-40, IQR = 10), P = 0.15]. There were 11 complications in nine of 22 patients who underwent operative treatment of their SBO. Immediate postoperative SBO can be treated nonoperatively in stable patients resulting in significantly quicker return of bowel function and shorter lengths of hospital stay. Definitive risk factors for immediate SBO could not be identified.     

Selective management of intrathoracic anastomotic leak after esophagectomy

OBJECTIVE: We sought to analyze our experience with management of intrathoracic anastomotic leak after esophagectomy. METHODS: All patients who had intrathoracic anastomotic leaks after esophagectomy were reviewed. Management and factors affecting outcome were analyzed. RESULTS: From March 1993 through February 2003, 761 patients had esophagectomy with intrathoracic anastomosis at our institution. Forty-eight (6.3%) patients had an anastomotic leak; one refused authorization to review his medical record and was excluded from further analysis. Twenty-four (51.1%) patients had a contained leak. Twenty-seven (57.4%) patients were managed nonoperatively. Twenty (42.6%) patients required surgical intervention that included primary anastomotic repair in 14 patients, reinforcement of the anastomosis with viable tissue in 6 patients, and esophageal diversion in 2 patients. A single reoperation was done in 15 patients, and 5 patients had 2 reoperations. Median hospitalization in the reoperative group was 31 days (range, 15-97 days) and 20 days (range, 10-42 days) in the nonoperative group ( P = .0037). Four (8.5%) patients died. Cause of death was sepsis in 2 patients and multiorgan failure and myocardial infarction in 1 patient each. At follow-up (median, 8 months; range, 1-120 months), 10 (58.8%) patients in the reoperative group were eating a normal diet and 5 (29.4%) patients required at least one dilatation compared with 20 (76.9%) patients in the nonoperative group who were eating a normal diet and 9 (34.6%) who required at least one dilatation. A noncontained leak had an adverse effect on long-term survival ( P = .04). CONCLUSION: Intrathoracic anastomotic leak after esophagectomy is associated with significant morbidity and mortality. Contained leaks often can be managed nonoperatively. When surgical management is required, esophagogastric continuity can often be maintained in the majority of patients. Long-term functional results are satisfactory and similar in both the reoperative and nonoperative groups. However, a noncontained leak adversely affected long-term survival.     

Treatment strategy for chylothorax after pulmonary resection and lymph node dissection for lung cancer

OBJECTIVE: We reviewed our experience with iatrogenic chylothorax after pulmonary resections for lung cancer to evaluate our treatment strategy and to identify factors that predict the need for reoperation. METHODS: From July 1992 through February 2000, a total of 1110 patients underwent pulmonary resection (at least lobectomy) and systematic mediastinal lymph node dissection for lung cancer at our division. Twenty-seven patients (2.4%) had postoperative chylothorax develop. We initially treated 26 of these patients conservatively with complete oral intake cessation and total parenteral nutrition, and these patients constituted the subjects in this study. RESULTS: There were 21 men and 5 women with a median age of 62 years (range 44 to 80 years). The initial procedures were pneumonectomy in 2 cases, bilobectomy in 1 case, and lobectomy in 23 cases. Twenty-one patients (81%) had the condition cured with conservative treatment. These patients resumed a normal diet at a median of 8 days after chylothorax diagnosis (range 4-35 days). The remaining 5 patients (19%) underwent reoperation at a median of 14 days after diagnosis (range 5-35 days). Chest tube drainage of less than 500 mL during the first 24 hours after complete oral intake cessation and total parenteral nutrition predicted a cure with conservative treatment. CONCLUSION: Although most cases of chylothorax after pulmonary resection with systematic mediastinal lymph node dissection can be cured with a conservative strategy, early surgical intervention may be indicated if chest tube drainage is more than 500 mL during the first 24 hours after complete oral intake cessation and total parenteral nutrition.     

Postoperative chylothorax: differences between patients who received median sternotomy or lateral thoracotomy for congenital heart disease

BACKGROUND: Chylothorax after surgery for congenital heart disease is rare. We wanted to compare the different presentations of chylothorax in patients who received median sternotomy or lateral thoracotomy. PATIENTS AND METHODS: We retrospectively studied pediatric patients with congenital heart disease who received palliative or corrective surgeries and developed postoperative chylothorax between January 1992 and July 2003. Patients were divided into two groups by the type of surgery: median sternotomy and lateral thoracotomy. The average daily fluid amount (mL/kg/24 hours), latency period, duration of chylothorax, and requirement for surgery were compared. RESULTS: Seventeen patients (11 boys, 6 girls; mean age, 14.0 +/- 12.8-month-old) were enrolled. Diagnoses were tetralogy of Fallot (n = 8), right isomerism with complex heart defects (n = 3), patent ductus arteriosus (n = 2), transposition of the great artery (n = 1), ventricular septal defect (n = 1), and endocardial cushion defect (n = 2). There were 9 in the lateral thoracotomy group and 8 in the median sternotomy group. Only one patient required surgery because of the failure of conservative treatment. The lateral thoracotomy group had a significantly lower average body weight (6.9 +/- 2.9 kg vs. 11.0 +/- 3.8 kg) and longer average latency period before postoperative chylothorax (15.1 +/- 9.2 days vs. 7.2 +/- 4.7 days). CONCLUSION: The majority of pediatric patients who develop chylothorax after cardiac surgery can be successfully managed by medical treatment only. To avoid complications in pediatric patients after cardiac surgery, chylothorax should be suspected for patients with unexplainable, prolonged, and abundant pleural effusion.     

Intraoperative use of isosulfan blue in the treatment of persistent lymphatic leaks

BACKGROUND: Lymphatic leaks are a major source of morbidity after lower extremity vascular surgery. We determined the ability of isosulfan blue (Lymphazurin) use to identify and help ligate offending lymphatics, and compared postoperative complication rates and length of stay versus nonoperative therapy alone. METHODS: From January 1993 through March 2002, we identified 15 patients with lymphatic leaks. The first group consisted of 5 patients treated nonoperatively. The second group was 10 patients (11 explorations) treated operatively aided by isosulfan blue, after a trial of nonoperative therapy. RESULTS: Isosulfan blue identified the leak in 10 of 11 cases. Mean drainage time for the nonoperative group was 47.6 days versus 1.8 days for the operative group (P = 0.036). Within the operative group, the mean drainage time during their initial conservative treatment phase was 15 days versus 1.8 days after surgery (P < 0.01). Complications were significantly less in the operative group (P < 0.05). Postoperative length of stay was a mean of 4.7 days versus 8.1 days for nonoperative patients (P = not significant). CONCLUSIONS: Intraoperative isosulfan blue use accurately identifies disrupted lymphatic channels and helps ensure definitive ligation. This simple procedure is associated with fewer complications, and a trend toward shorter hospital stay.     

Surgical intervention strategy for postoperative chylothorax after lung resection

Purpose

The optimal surgical management of postoperative chylothorax has not been established. Thus, we evaluated the treatment strategy for postoperative chylothorax and identified associated predictors of surgical intervention.

Methods

The subjects of this retrospective study were 50 patients who suffered postoperative chylothorax, representing 4 % of 1235 patients who underwent pulmonary resection between 2008 and 2012. The chylothorax patients were classified into two groups based on their postoperative management: a conservative group and a surgical group. The following parameters were investigated to establish the predictors of surgical intervention for chylothorax: mode of surgery, preoperative complications, intraoperative management, and postoperative clinical status.

Results

Forty-one (82 %) patients were treated conservatively and 9 (18 %) underwent reoperation, as direct or concomitant ligation of the thoracic duct at the point of leakage. The frequency of postoperative chest tube drainage just after initial surgery was significantly greater in the surgical group than the conservative group before oral intake was restarted (448 ± 189 vs. 296 ± 117 ml/12 h, respectively; p = 0.003). Furthermore, it was a significant predictor of reoperation based on a multivariate analysis (p = 0.010).

Conclusions

The amount of chest tube drainage just after surgery and before oral intake was a useful predictor to help us decide on the need for early surgical intervention for postoperative chylothorax.

     

Percutaneous Transhepatic Duodenal Diversion for the Management of Duodenal Fistulae

Purpose The aim of this study was to determine the success of the nonoperative management of persistent duodenal fistulae (DF) with percutaneous transhepatic duodenal diversion (PTDD). Methods Retrospective chart review identified six patients with DF managed by PTDD from 2006 to 2007. Patient outcomes and complications were assessed. Results The etiology of DF included pancreatic surgery (three patients), gastrectomy (two patients), and Crohn’s disease (one patient). PTDD was performed by interventional radiology at a median time of 37 days after fistula recognition. After PTDD, fistula drainage decreased from 775 cc/day (range 200 to 2,525 cc/day) to <50 cc/day at a median of 8 days. Patients were discharged 32 days (median) after PTDD. One patient with Crohn’s disease required definitive surgical treatment. Of the remaining five patients, the PTDD tube was capped at 27 days (median) after placement and was removed on an outpatient basis at 79 days (median) after placement. There was no mortality, no fistula recurrence, or complications associated with PTDD placement. Conclusions We present an algorithm for the nonoperative management of persistent postoperative DF. In this limited series, PTDD was highly effective at definitively treating DF, especially in the acute setting. PTDD should be considered by surgeons facing the management of postoperative DF.     

Complications following pancreaticoduodenectomy. Current management.

From 1980 to 1989, 279 patients underwent pancreaticoduodenectomy at a single institution with a postoperative mortality of 4%. The aim of this study was to determine incidence, origin, and present management strategy of early complications following this operation. Significant morbidity occurred in 46% of the patients, including delayed gastric emptying (23%), pancreaticojejunal anastomotic leak (17%), intra-abdominal sepsis (10%), biliary-enteric anastomotic leak (9%), gastrointestinal tract bleeding (5%), and intra-abdominal hemorrhage (3%). Complications were associated with advanced age, prolonged operations, and increased operative blood loss. Most complications were managed nonoperatively. Mortality was increased when a reoperation was required, a biliary-enteric leak occurred, or an intra-abdominal abscess developed. Pancreaticoduodenectomy continues to carry a high postoperative morbidity; however, operative mortality is low, and management of complications has been made simpler with more sophisticated, nonoperative therapeutic options.     

Nonsurgical management of solid abdominal organ injury in patients over 55 years of age

Age greater than 55 is often stated to be a contraindication to nonoperative management of intraperitoneal solid organ injury, based upon failures in early experiences of nonoperative therapy. Refinements in the criteria for nonoperative management of hepatic and splenic injuries have yielded improved success rates compared with those in initial reports, raising questions as to the validity of an age-related contraindication. A retrospective chart review of patients more than 55 years of age sustaining blunt hepatic and/or splenic injury at two urban Level I trauma centers was performed. Patients were stratified into three groups in which selection criteria could not consistently be determined: those managed nonoperatively, those managed operatively, and those who died within 24 hours. The purpose of this review is to identify whether age is a determinant for nonoperative management of abdominal solid organ injury. Eighty-eight patients were identified (mean age, 68.7 +/- 9.8), 17 of whom died in the emergency department or after operative intervention. Of the remaining 71 patients, 37 were originally managed nonoperatively (mean age 69.9 +/- 9.1, mean Injury Severity Score 19.9), 24 sustained hepatic injuries (grades I-IV), 12 sustained splenic injuries (grades I-III), and one patient sustained both organ injuries. Three patients with multisystem trauma died from complications unrelated to their solid organ injury (one brain death, one septic death, and one respiratory arrest). A single patient, with a grade I liver injury, required delayed exploration (for a persistent, unexplained metabolic acidosis) and underwent a nontherapeutic celiotomy. All but one of the 37 patients were successfully treated nonoperatively, for a 97 per cent success rate. We conclude that hemodynamically stable patients more than 55 years of age sustaining intra-abdominal injury can be observed safely. Age alone should no longer be considered an exclusion criterion for nonoperative management of intra-abdominal solid organ injury.     

Management and outcomes of small bowel obstruction in older adult patients: a prospective cohort study

Background

The purpose of this research was to examine the morbidity, mortality and rate of recurrent bowel obstruction associated with the treatment of small bowel obstruction (SBO) in older adults.

Methods

We prospectively enrolled all patients 70 years or older with an SBO who were admitted to a tertiary care teaching centre between Jul. 1, 2011, and Sept. 30, 2012. Data regarding presentation, investigations, treatment and outcomes were collected.

Results

Of the 104 patients admitted with an SBO, 49% were managed nonoperatively and 51% underwent surgery. Patients who underwent surgery experienced more complications (64% v. 27%, p = 0.002) and stayed in hospital longer (10 v. 3 d, p < 0.001) than patients managed nonoperatively. Nonoperative management was associated with a high rate of recurrent SBO: 31% after a median follow-up of 17 months. Of the patients managed operatively, 60% underwent immediate surgery and 40% underwent surgery after attempted nonoperative management. Patients in whom nonoperative management failed underwent surgery after a median of 2 days, and 89% underwent surgery within 5 days. The rate of bowel resection was high (29%) among those who underwent delayed surgery. Surgery after failed nonoperative management was associated with a mortality of 14% versus 3% for those who underwent immediate surgery; however, this difference was not significant.

Conclusion

These data suggest that some elderly patients with SBO may be waiting too long for surgery.     

Nonoperative management of acute epidural hematomas: a "no-brainer"

BACKGROUND: Acute epidural hematomas are generally considered to require urgent operation for clot evacuation and bleeding control. It has become increasingly apparent, however, that many epidural hematomas will resolve with nonoperative management. The purpose of the current study was to review our experience with nonoperative management of acute epidural hematomas. METHODS: Patients admitted to our busy urban level I trauma center with an epidural hematoma were identified using our trauma registry. Patients were excluded if they suffered other significant intracranial injury mandating operative intervention. Patient records were reviewed and relevant data collected. Patients who required subsequent craniotomy were compared to those who did not in order to identify risk factors for failure of nonoperative treatment. RESULTS: Between January 1995 and June 2004, 84 patients were identified. The mean age was 27 +/- 1.6 years and 68 (81%) were male. Mean Glasgow Coma Scale in the emergency department was 13.7 +/- 0.3. The most common mechanism of injury was a fall. Fifty-four (64%) patients were initially managed nonoperatively and 30 (36%) were taken directly to the operating room for craniotomy. Nonoperative management was successful in 47/54 (87%) patients. Failure of initial nonoperative management was not associated with adverse outcome. There were no deaths in patients managed operatively or nonoperatively. Seventy-two (86%) patients were discharged to home with excellent neurologic outcome. CONCLUSIONS: Epidural hematomas can be successfully managed nonoperatively in an appropriately selected group of patients. Moreover, failure of initial nonoperative management has no adverse effect on outcome.     

Laparoscopic surgery for recurrent Crohn's disease

BACKGROUND: The aim of this study was to assess the feasibility of laparoscopic surgery for recurrent Crohn's disease, and the role of repeated laparoscopy in reoperation. METHODS: Between January 1994 and May 2002, 61 laparoscopic operations were attempted in 52 patients with ileal or ileocolonic Crohn's disease. Of these, 16 procedures were performed for recurrence at the anastomotic site (recurrent group). The remaining 45 operations were performed as primary procedures (control group). The median follow-up was 48 (range 3-90) months. RESULTS: The median time to reoperation was 46 months. The incidence of enteric fistula and the conversion rate did not differ significantly between the two groups. Although the operating time was significantly longer in the recurrent group, there were no differences in the rate of postoperative complications (three in the recurrent group and six in the control group) and hospital stay (both median 8 days). CONCLUSION: Laparoscopic surgery for recurrent Crohn's disease is feasible in selected patients without an increase in conversion rate or postoperative complications.     

Contusions of the liver in adults. Initial non-operative management with computerized tomography follow-up is a reasonable therapeutic option. Report of 16 cases

Nonoperative management of blunt liver injury in adults still remains controversial. From February 1985 through September 1989, 27 patients were treated for blunt hepatic trauma: 11 required immediate operation and 16 (59%) were initially managed nonoperatively after evaluation of intraabdominal injury by computerized tomography. All of these 16 patients were hemodynamically stable and had no significant peritoneal signs. CT criteria for nonoperative management included subcapsular and intrahepatic hematoma, capsular tear or unilobar fracture, absence of large hemoperitoneum, absence of large devitalized liver and absence of other intraabdominal organ injuries. Clinical follow-up, repeated radiologic examinations and surgery confirmed the accuracy of CT. Only 2 patients required delayed operation (12.5%). Serial abdominal CT studies are an integral part of the conservative treatment of blunt hepatic injuries and showed complete resolution of hepatic injuries in the fourteen nonoperated patients in less than six months. No death and no delayed septic or biliary complications were noted. Mean hospital stay was seventeen days for all of the patients (multiple injuries or not) and only ten days for isolated blunt liver injury. These good results depend on identification of candidates for nonoperative management on strict clinical and CT criteria. Nonoperative management of adult blunt liver injury based on these findings is a useful alternative in a selected group of hemodynamically stable patients and decreases the rate of non-therapeutic coeliotomy.     

Selective Nonoperative Management of Abdominal Stab Wounds: Prospective,Randomized Study

p = 0.26). Four patients (17%) managed nonoperatively required delayed laparotomy. The hospital stay was shorter in the observation group (median 2 days versus 5 days; p = 0.002). About $2800 (US) was saved for every patient who underwent successful nonoperative management. It is concluded that selective nonoperative management of abdominal stab wounds, although resulting in delayed laparotomy in some patients, is safe and the preferred strategy for minimizing the days in hospital with concomitant savings in hospital costs. Mandatory laparotomy detects some unexpected organ injuries earlier and more accurately but results in a high nontherapeutic laparotomy rate and surgical management of minor injuries that in many cases could be managed nonoperatively.     

食管癌二次手术19例原因分析

目的：探讨食管癌行二次手术的原因及防治措施。方法回顾性分析2000年1月至2012年12月间北京大学肿瘤医院单一手术组施行的946例食管癌手术患者的临床资料,其中19例因术后严重并发症需行二次手术,总结该19例患者的临床特点及治疗经过。结果19例二次手术的患者中因术后胸腔内出血行开胸止血术4例,因膈疝行膈疝还纳、膈肌修补术4例,因乳糜胸行胸导管结扎术4例,因腹部切口裂开行切口缝合术4例,因创伤性胰腺炎行胸腹腔探查、腹腔置管引流术1例,因肠梗阻行回盲部切除、回肠造瘘术1例,因双侧喉返神经麻痹行气管切开术1例。19例二次手术患者全部治愈,无围手术期死亡和再次并发症发生。结论食管癌术后再次手术常见原因主要为术后出血、膈疝、乳糜胸和腹部切口裂开。     

Changing patterns in the management of splenic trauma: the impact of nonoperative management.

OBJECTIVE: The recognition that splenectomy renders patients susceptible to lifelong risks of septic complications has led to routine attempts at splenic conservation after trauma. In 1990, the authors reported that over an 11-year study period involving 193 patients, splenorrhaphy was the most common splenic salvage method (66% overall) noted, with nonoperative management employed in only 13% of blunt splenic injuries. This report describes changing patterns of therapy in 190 consecutive patients with splenic injuries seen during a subsequent 6-year period (1990 to 1996). An algorithmic approach for patient management and pitfalls to be avoided to ensure safe nonoperative management are detailed. METHODS: Nonoperative management criteria included hemodynamic stability and computed tomographic examination without shattered spleen or other injuries requiring celiotomy. RESULTS: Of 190 consecutive patients, 102 (54%) were managed nonoperatively: 96 (65%) of 147 patients with blunt splenic injuries, which included 15 patients with intrinsic splenic pathology, and 6 hemodynamically stable patients with isolated stab wounds (24% of all splenic stab wounds). Fifty-six patients underwent splenectomy (29%) and 32 splenorrhaphy (17%). The mean transfusion requirement was 6 units for splenectomy survivors and 0.8 units for nonoperative therapy (85% received no transfusions). Fifteen of the 16 major infectious complications that occurred followed splenectomy. Two patients failed nonoperative therapy (2%) and underwent splenectomy, and one patient required splenectomy after partial splenic resection. There no missed enteric injuries in patients managed nonoperatively. The overall mortality rate was 5.2%, with no deaths following nonoperative management. CONCLUSIONS: Nonoperative management of blunt splenic injuries has replaced splenorrhaphy as the most common method of splenic conservation. The criteria have been extended to include patients previously excluded from this form of therapy. As a result, 65% of all blunt splenic injuries and select stab wounds can be managed with minimal transfusions, morbidity, or mortality, with a success rate of 98%. Splenectomy, when necessary, continues to be associated with excessive transfusion and an inordinately high postoperative sepsis rate.     

Evaluation of treatment options for postoperative and spontaneous chylothorax in adults

Open in a separate window OBJECTIVESBoth postoperative and spontaneous chylothorax remain therapeutic challenges without recommendations for a standardized treatment approach. Regardless of its aetiology, patients with chylothorax experience prolonged hospitalization and suffer from the associated complications or the invasive therapy administered.METHODSWe conducted a retrospective, observational review of adult patients with chylothorax treated between January 2010 and September 2019. The primary end point was successful management with sustained cessation and/or controlled chylous output. Therapy duration, inpatient stay and the incidence of complications were evaluated as secondary end points.RESULTSOf the 36 patients included (22 men; median age 63 years), 24 patients (67%) suffered from a postoperative accumulation of chylous fluid in the pleural space; in the remaining 12 (33%) patients, chylothoraces occurred spontaneously. Initial conservative treatment was successful in 42% (n = 15); in the other 20 cases (56%) additional invasive therapeutic strategies were followed. A complicated course requiring more than 1 treatment was seen in 54% (n = 13) of the postoperative and in 58% (n = 7) of the spontaneous cases. The median length of hospitalization was significantly longer in the postoperative group (37.5 vs 15.5 days; P = 0.016). Serious complications were observed only in the postoperative group (P = 0.28). There were no in-hospital deaths.CONCLUSIONSBasic treatment of both postoperative and spontaneous chylothorax should include dietary measures in all patients. Additional sclerosing radiotherapy and interventional or surgical therapy are often necessary. The choice of therapeutic approach should be indicated, depending on the aetiology and development of the chylothorax. Early, multimodal treatment is recommended.