ISSN:0004-8682    

DOI:10.1111/j.1445-2197.1994.tb04551.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

ISSN:0004-8682    

DOI:10.1111/j.1445-2197.1994.tb04552.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

ISSN:0004-8682    

DOI:10.1111/j.1445-2197.1994.tb04553.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

ISSN:0004-8682    

DOI:10.1111/j.1445-2197.1994.tb04554.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

The surgical management of portal hypertension depends on the location of the obstruction. Suprahepatic obstruction is usually optimally treated by a surgical portacaval shunt. In extrahepatic obstruction the treatment should be sclerotherapy. For intrahepatic obstruction in emergency situations, sclerotherapy is the first choice, with portacaval systemic shunts or transjugular intrahepatic portal systemic stent shunt the second option. Liver transplantation in other situations should, if possible, be considered ahead of a portal diversion.

ISSN:0004-8682    

DOI:10.1111/j.1445-2197.1994.tb04555.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

T‐tube drainage of the common bile duct (CBD) following duct exploration has become standard surgical practice. This randomized prospective study has compared primary closure versus T‐tube drainage of the CBD following exploration for calculous disease.Thirty‐seven patients underwent primary closure and 26 underwent closure over T‐tube. Both groups were comparable in terms of age, indications for surgery, associated illnesses, pre‐operative bilirubin, amylase and white cell count. Forty‐three per cent of operations were performed by a consultant in the primary closure group and 65% in the T‐tube group. There was no significant difference in the duration of operation, incidence of wound infection, surgical or other complications following operation between the two groups. However, the postoperative stay was significantly prolonged in the T‐tube group, to a median of 11 days, compared to 8 days in the primary closure group (P= 0.0001). This prolongation in stay was unrelated to whether admission was as an emergency or elective. T‐tube drainage of the bile continued for a median of 7 days postoperative, whereas the bile drained via a wound drain in only 13 (35%) of the primary closure group, for a median of 5 days in these 13 patients. Long‐term follow up was achieved in 48 patients, by a questionnaire sent at a median of 2.8 years following operation. Abdominal pains following recovery from the operation were experienced by 18% of the primary closure group and 20% of the T‐tube group. No patient developed jaundice or pancreatitis, nor needed further biliary surgery following operation. Primary closure of the CBD following exploration for calculous disease significantly reduces hospital stay, and is as safe as closure with T‐tube, in both

ISSN:0004-8682    

DOI:10.1111/j.1445-2197.1994.tb04556.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

Laparoscopic cholecystectomy has rapidly become the treatment of choice for symptomatic cholelithiasis. Although published morbidity and mortality rates compare favourably with open cholecystectomy, bile duct injuries occur far more frequently and technical complications unique to the laparoscopic approach account for a significant number of postoperative deaths. The majority of these complications are dealt with by laparotomy. Two technical complications encountered in a series of 170 patients undergoing laparoscopic cholecystectomy and their subsequent management are presented. One patient suffered a diathermy injury to the common hepatic duct and postoperative bile leak. This was managed successfully by repeat laparoscopy and peritoneal lavage combined with endoscopic retrograde cholangiopancreatography (ERCP) and stenting of the hepatic duct. Another patient sustained a perforated duodenum complicated by peritonitis, subcutaneous wound infection and generalized sepsis. The perforation was repaired at a second laparoscopy using intracorporeal suturing and Tissucol. It is demonstrated that it is possible to deal with some of the technical complications of laparoscopic cholecystectomy with a combination of minimally invasive techniques, sparing the patient from the additional risk of laparotomy.

ISSN:0004-8682    

DOI:10.1111/j.1445-2197.1994.tb04557.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

Despite recent advances in minimally invasive surgery, laparoscopic appendicectomy has been questioned as a feasible method of treating patients with suspected appendicitis because open appendicectomy carries few risks and complications. Between February 1992 and January 1993 a non‐randomized prospective study comparing open and laparoscopic appendicectomy was designed to assess differences in postoperative morbidity, pain, inpatient hospital stay and a return to normal lifestyle. One hundred and sixty‐seven patients with suspected clinical appendicitis were assigned to open (n= 74) or laparoscopic (n= 93) appendicectomy. Six patients were excluded due to the presence of other significant pathology such that the appendix was not removed. Eighty‐seven patients underwent attempted laparoscopic appendicectomy, of which 81 were completed. The diagnosis of appendicitis was confirmed histologically in 63.5% of patients undergoing open appendicectomy and 63% of patients undergoing laparoscopic appendicectomy. There were no significant differences in anaesthetic times, postoperative morbidity and analgesic requirements. There was a significant reduction in both postoperative inpatient stay (P<0.0001) and time taken to return to work or normal activities (P<0.0001) for the laparoscopic group. The use of laparoscopy for patients with suspected appendicitis aids definitive diagnosis and should reduce the negative appendicectomy rate to an acceptable figure. The results suggest that laparoscopic appendicectomy is safe and offers advantages over open appendicectomy in the management of patients with suspected appendi

ISSN:0004-8682    

DOI:10.1111/j.1445-2197.1994.tb04558.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

Eighteen expandable metallic biliary stents were inserted in patients with malignant (16 patients) or benign (two patients) biliary strictures. Four were the Gianturco‐Rosch biliary Z‐stents and the remaining 14 were the Wallstent. The stents were delivered through either the endoscopic transpapillary (10 patients), percutaneous transhepatic (five patients) or combined percutaneous‐endoscopic (three patients) route. No failure in implantation was encountered. Bile drainage was successful in all patients. Stent occlusions were observed in four patients with hilar obstruction due to tumour overgrowth above the stents at 30–67 days (mean 47.75 days) after insertion. The occlusions were drained percutaneously (two patients) or endoscopically (two patients). Migration of stent did not occur. After a median follow‐up period of 170.5 days (range 57–731 days), 11 patients were still alive and free of jaundice. The median patency period of the stents for common bile duct and hilar obstruction was 288.5 days (range 117–731 days) and 61.5 days (range 30–188 days), respectively. The overall median patency period was 165 days. It is concluded that expandable metallic biliary stent is a useful adjunct to the treatment of malignant biliary obstructions with a better result in dis

ISSN:0004-8682    

DOI:10.1111/j.1445-2197.1994.tb04559.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

Management of large common bile duct (CBD) calculi is controversial. Endoscopic treatment is fraught with difficulty, particularly when stones are over one centimetre in diameter and the patient's coagulation is deranged. Between 1988 and 1993, 56 patients have been managed by endoscopic retrograde cholangiopancreatography (ERCP) and stent placement as the initial treatment for large CBD calculi. Complete follow up has been possible in 50 cases (89.3%). The median age was 73.5 years (range 29–92) and primary presenting symptoms were jaundice (n= 39), cholangitis (n= 6) or abdominal pain (n= 5). Median bilirubin was 99 μmol/L (range 7–926) and 60% of the patients had deranged clotting with a median thrombotest of 61%. Stones ranged in size from 0.9 to 4.5 cm (median 1.6 cm). Treatment was with a 7F 'pigtail' stent in 39 cases and a 10F straight stent in 11 patients. Morbidity occurred in 12% of cases with two deaths (4%).Stents remained in place for a median of 1 month (range 0.2–59). Definitive treatment of CBD stones, once the jaundice and sepsis had settled, involved surgery in 24 patients and repeat ERCP with sphincterotomy +/‐ mechanical lithotripsy in 17 cases. Nine patients remain alive and well with their stents still in place. Initial management of large CBD calculi by ERCP and stent placement carries a low morbidity and mortality and is a useful adjunct in the management of a difficult clinical

ISSN:0004-8682    

DOI:10.1111/j.1445-2197.1994.tb04560.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY