ISSN:0004-8682    

DOI:10.1111/j.1445-2197.1996.tb01205.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY

ISSN:0004-8682    

DOI:10.1111/j.1445-2197.1996.tb01206.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY

摘要:

Background: Penetrating injuries of the colon have been managed traditionally by diverting colostomy. Recently, a trend towards primary repair has been observed, particularly for knife injuries. The purpose of this study is to evaluate the safety of primary repair for colonic gunshot wounds in the presence of certain clinical risk factors.Methods: A retrospective analysis of 223 patients with colonic bullet injuries in a period of 3 years (1990–93) was performed.Results: Of 223 patients with colonic trauma, 168 were primarily repaired (group A) and 55 underwent a colostomy (group B). Intra‐abdominal septic complications occurred in 5.9% of group A patients and 10.9% of group B patients (P>0.05, NS). These patients were, furthermore, stratified according to well‐known risk factors for the development of complications, namely, site of injury, presence of shock on admission, degree of faecal contamination and number of associated injuries. We were unable to find any statistically significant differences in intra‐abdominal septic complication rates between patients treated with primary repair and patients treated with colostomy.Conclusions: Primary repair seems to be a safe therapeutic option for gunshot wounds of the colon. Even in the presence of the abovementioned risk factors, colostomy may be avoided in most cases as primary repair does not appear to be associated with higher complicatio

ISSN:0004-8682    

DOI:10.1111/j.1445-2197.1996.tb01207.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY

摘要:

Background: The chief danger of colonic injury is sepsis resulting from faecal spill. Primary repair is now well established in the USA, particularly for penetrating injuries, in up to 81% of patients. However, in Australia, highly destructive blunt trauma forms a larger proportion of injuries, and the purpose of this study was to determine if there are any contrasts in the management of these patients.Method: A retrospective survey was undertaken over the past 20 years of all of the patients with full‐thickness colorectal injuries presenting at the three major hospitals which receive multi‐trauma patients in Brisbane.Results: Of 112 patients 114 sustained full‐thickness colorectal injuries. Forty patients had penetrating injuries, 41 had blunt injuries and 33 had iatrogenic injuries. Primary repair or resection and anastomosis was performed in 39% of patients with colonic injuries and the leak rate was 8%. Exteriorized repairs had a 67% leak rate. A colostomy was used in 58% of patients. The mortality for penetrating injuries was zero. The mortality for blunt colonic injuries was 17% and for iatrogenic injuries was 7% but for blunt rectal injuries was 50%. The overall mortality was 10%. Colostomy closure had a 20% morbidity but no mortality.Conclusions: In the absence of shock, associated injuries, or gross faecal soiling primary repair or resection with anastomosis may be considered. For blunt injury, colostomy is still usually indicated, often with resection. For iatrogenic injury, when seen early, primary repair can be performed. We do not recommend exteriorized repair. Extraperitoneal rectal injuries require proximal colostomy and distal washout, with drainage where appropriate. Blunt devitalizing injury is relatively more common in Australia than in the USA and therefore there is less indication here for primary repair. Colostomy remains an important consideration in operative manag

ISSN:0004-8682    

DOI:10.1111/j.1445-2197.1996.tb01208.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY

摘要:

Background: The gracilis muscle has been used previously to construct an anal neosphincter, but this was not successful since a short‐lived muscle contraction was insufficient to restore continence. Recently, a procedure was described in which conversion to a fatigue‐resistant muscle was achieved by chronic low frequency electrical stimulation, and the resultant ability to sustain a constant contraction was associated with improved continence. Our initial results with this procedure, using a standardized operation and treatment protocol in 12 consecutive patients. is reported.Methods: Seven women (mean age 50 years, range 22–71 years) had faecal incontinence, and five patients (F:M. 3:2; aged 53–72 years) underwent reconstruction after abdominoperineal excision of the rectum for cancer. A detailed questionnaire including continence score was completed pre‐operatively. Eight patients have been assessed after ileostomy closure at a mean time of 10 months.Results: Slow‐twitch muscle conversion was achieved in each case and all patients have a functional neosphincter. Mean continence score was 6.8 (range 4–12), and seven patients were continent. There was significant improvement in continence in the non‐cancer group (p= 0.03). Mean pre‐operative resting anal pressure, functional neosphincter pressure (NPfunc), and maximal neosphincter pressure (NPmax) were 36, 102 and 207 cmH2O, respectively. There was a significant improvement in pressure comparing NPfunc (P= 0.03) and NPmax (P= 0.03) with pre‐operative pressure. Complications included deep vein thrombosis. pulmonary embolism, saphenous nerve injury, leg wound haematoma, and late pacemaker infection.Conclusion: The stimulated gracilis neosphincter achieves satisfactory continence in a m

ISSN:0004-8682    

DOI:10.1111/j.1445-2197.1996.tb01209.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY

摘要:

Background: Completion thyroidectomy is the removal of any thyroid tissue that remains after a less than total thyroidectomy. This procedure has been commonly performed when the final histopathology of the excised ipsilateral thyroid lobe reveals papillary or follicular carcinoma of the thyroid. Complete thyroidectomy carries little morbidity if performed by experienced surgeons using a lateral approach. The purpose of this study is to reinforce the usefulness of a lateral approach.Methods: A retrospective analysis over a 5 year period at the Department of Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS) yielded 19 patients who underwent completion thyroidectomy. This group represents 23% of 82 patients who underwent total thyroidectomy for differentiated thyroid cancer (DTC) during that period. The residual thyroid tissue was excised through a lateral approach and could be resected safely, preserving the recurrent laryngeal nerve (RLN) and the parathyroid glands.Results: A lateral approach dissection could be performed with ease in a virgin area. Excision of residual thyroid tissue could be performed safely even in cases with prior partial lobectomy or bilateral subtotal resection. Tumour was found in 52% of the re‐operative specimens: in three out of four of those after a previous partial lobectomy, in six out of 12 of those after a total lobectomy, and in one out of three of those after a prior bilateral (although incomplete) thyroid resection. Postoperative complications included transient RLN palsy (n =2) and transient hypoparathyroidism (n =4).Conclusions: Completion thyroidectomy using a lateral approach is safe in re‐operative thyroid surg

ISSN:0004-8682    

DOI:10.1111/j.1445-2197.1996.tb01210.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY

摘要:

Background: There is increasing pressure on surgeons to minimize the time patients stay in hospital, and there is therefore a need to establish guidelines for reasonable lengths of stay for common operations. This study was conducted to test the feasibility and safety of early discharge after open appendicectomy. In addition, this study was performed to provide standards for open appendicectomy against which the results of laparoscopic appendicectomy can be compared.Methods: A prospective study of all patients having open appendicectomy for suspected acute appendicitis at Liverpool Hospital, Sydney during a 4 month period was undertaken. An early discharge programme was established, with the aim of discharging patients within 48 h of operation in uncomplicated cases. Discharge was allowed when the patient was eating, walking, and had passed flatus. Follow up was with the consultant surgeon at I week postoperatively, and with a community nurse at 2 weeks. Multivariate linear regression, using the number of postoperative hours to discharge as the outcome, was used to analyse the data for the following four factors: age, gender, incision type, and pathology.Results: One hundred and sixteen consecutive patients were enrolled in the study. The median postoperative stay for all patients was 46 h. Perforation of the appendix, use of a midline laparotomy for appendicectomy, and age significantly prolonged hospital stay, but gender had no effect. The main complication was wound infection, which was seen in 7.5% of patients. No patient had a problem directly related to early discharge. A community nurse saw 81% of patients 2 weeks after discharge. Over three‐quarters of the patients seen had returned to full normal activities by 2 weeks, including work or school. Eighty‐eight per cent of patients considered the timing of their discharge ‘good’ or ‘excellent’.Conclusions: Discharge at 2 days after open appendicectomy is both feasible and safe for patients having an unperforated appendix removed through a right iliac fossa incision. Passage of stool is not required prior to discharge. Early discharge is well accepted by patients and may result in financial savings for hospitals where payment is according to Diagnosis‐Related Groups. On the basis of the results of the six randomized controlled trials comparing laparoscopic and conventional open appendicectomy published to date, and on the results of this study, the authors conclude that laparoscopic appendicectomy should not yet be considered the ‘procedure of choice’, and surgeons are justified in performing appendicectomy

ISSN:0004-8682    

DOI:10.1111/j.1445-2197.1996.tb01211.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY

摘要:

Background: Gastroschisis is an uncommon condition in which viscera protrude at the base of the umbilical cord. To investigate the possible relationships between antenatal ultrasound findings, patient demographics, smoking, alcohol consumption and this condition, 21 causes are reviewed.Methods: The medical records and antenatal ultrasounds of 21 children diagnosed with gastroschisis at the Adelaide Children's Hospital between 1 January 1985 and 31 December 1992 were reviewed.Results: Antenatal ultrasound was employed in 15 cases, and the diagnosis was accurately made in 13 (86.7%) of these. There were 17 live births, two elective terminations and two pre‐term abortions. Seven of the 21 cases had associated anomalies. The anomalies included five atresias, a ventricular septal defect (VSD), and a dislocated gall‐bladder. Postoperative complications (which included one death) occurred in seven of the 17 patients. Bowel dilatation or thickening was first detected on five ultrasound examinations performed before 21 weeks' gestation, and four ultrasounds after 21 weeks. The nine cases with bowel changes on ultrasound were associated with a high atresia rate and a longer hospital stay, but not with an increased complication rate. Maternal race, parity, and alcohol consumption were not associated with increased risk of fetal gastroschisis. All mothers were under 27 years of age. There were nine mothers who smoked during pregnancy and a disproportionate number of mothers who lived outside the metropolitan area with gastroschisis‐affected offspring.Conclusions: Bowel changes seen on antenatal ultrasound increase the chances of intestinal atresia and longer hospitalization. Smoking during pregnancy may be associated with an increased risk of gastrosc

ISSN:0004-8682    

DOI:10.1111/j.1445-2197.1996.tb01212.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY

摘要:

Background: The role of pre‐operative white blood cell counts (WBCC) in patients with an acute abdomen is contentious.Methods: This study documents the association between pre‐operative WBCC and the extent of intraperitoneal inflammation at the time of surgery in a heterogeneous group of 1166 patients undergoing abdominal surgery.Results: WBCC failed to adequately discriminate between groups of patients with varying degrees of intraperitoneal inflammation. For example, only 31% (37/118) of the patients with either free pus or an abscess within the peritoneal cavity had a WBCC>15.0 × 109/L.Conclusions: There is a need to replace the WBCC with more powerful predictors of inflammation within the peritoneal ca

ISSN:0004-8682    

DOI:10.1111/j.1445-2197.1996.tb01213.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY

摘要:

Background: Buerger's disease is a specific, idiopathic, recurrent, segmental, inflammatory, obliterative vascular disease involving medium‐sized arteries and veins of the limbs. We performed omental transfer on a group of patients with Buerger's disease that had previously undergone lumbar sympathectomy and the results are described.Methods: Between January 1988 and December 1993, 100 cases of peripheral vascular disease (PVD) diagnosed as Buerger's Disease were subjected to femoral angiography. Fifty cases of angiographic intermediateldistal type blocks underwent omental transposition.Results: Of 50 patients subjected to omental transfer all had intermittent claudication, 40 had rest pain of whom 36 had non‐healing ulcers, 8 had gangrene and 32 had bilateral lower limb involvement. Fifteen patients underwent bilateral omental transfer and posterior tibial artery biopsy was performed in 40. All patients showed improved skin temperature, rest pain decreased in 36 and claudication distance increased in 48. Ulcers healed in 32 of 36 patients and the line of demarcation receded in six of eight patients with gangrene.Conclusions: Omental transfer improved skin and muscle microcirculation and forestalled the need for amputation by providing symptomatic relief and clinically arresting the progress of Buerger's disease. Omental transfer should be considered seriously as an alternative to other modalities of therapy to delay the ischaemic complications of Buerger's dise

ISSN:0004-8682    

DOI:10.1111/j.1445-2197.1996.tb01214.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY