COMPLICATIONS AFTER EXCISION OF CHOLEDOCHAL CYSTS

COMPLICATIONS AFTER EXCISION OF CHOLEDOCHAL CYSTS tài liệu, giáo án, bài giảng , luận văn, luận án, đồ án, bài tập lớn v...

Int. J. Med. Sci. 2009, 6 http://www.medsci.org 265IInntteerrnnaattiioonnaall JJoouurrnnaall ooff MMeeddiiccaall SScciieenncceess 2009; 6(5):265-273 © Ivyspring International Publisher. All rights reserved Research Paper Complications after spacer implantation in the treatment of hip joint in-fections Jochen Jung 1 , Nora Verena Schmid 1, Jens Kelm 1,2, Eduard Schmitt 1, Konstantinos Anagnostakos 1 1. Klinik für Orthopädie und Orthopädische Chirurgie, Universitätskliniken des Saarlandes, Homburg/Saar, Germany 2. Chirurgisch-Orthopädisches Zentrum Illingen/Saar, Germany  Correspondence to: Dr. Jochen Jung, Klinik für Orthopädie und Orthopädische Chirurgie, Universitätskliniken des Saar-landes, D-66421, Homburg/Saar. Tel.: 0049-6841-1624575; Fax: 0049-6841-1624516; email: dr.med.jung@gmx.de Received: 2009.08.01; Accepted: 2009.09.01; Published: 2009.09.02 Abstract The aim of this retrospective study was to identify and evaluate complications after hip spacer implantation other than reinfection and/or infection persistence. Between 1999 and 2008, 88 hip spacer implantations in 82 patients have been performed. There were 43 male and 39 female patients at a mean age of 70 [43 – 89] years. The mean spacer implantation time was 90 [14-1460] days. The mean follow-up was 54 [7-96] months. The most common identified organisms were S. aureus and S. epidermidis. In most cases, the spacers were impregnated with 1 g gentamicin and 4 g vancomycin / 80 g bone cement. The overall complication rate was 58.5 % (48/82 cases). A spacer dislocation occurred in 15 cases (17 %). Spacer fractures could be noticed in 9 cases (10.2 %). Femoral fractures oc-curred in 12 cases (13.6 %). After prosthesis reimplantation, 16 patients suffered from a prosthesis dislocation (23 %). 2 patients (2.4 %) showed allergic reactions against the intra-venous antibiotic therapy. An acute renal failure occurred in 5 cases (6 %). No cases of he-patic failure or ototoxicity could be observed in our collective. General complications (con-sisting mostly of draining sinus, pneumonia, cardiopulmonary decompensation, lower urinary tract infections) occurred in 38 patients (46.3 %). Despite the retrospective study design and the limited possibility of interpreting these find-ings and their causes, this rate indicates that patients suffering from late hip joint infections and being treated with a two-stage protocol are prone to having complications. Orthopaedic surgeons should be aware of these complications and their treatment options and focus on the early diagnosis for prevention of further complications. Between stages, an interdisci-plinary cooperation with other facilities (internal medicine, microbiologists) should be aimed for patients with several comorbidities for optimizing their general medical condition. Key words: hip joint infection, hip spacers, spacer dislocation, prosthesis dislocation Introduction Antibiotic-loaded cement spacers have become a popular procedure in the treatment of hip joint infec-tions over the past two decades. Depending on the definition of infection eradication and reinfection, hip spacers have reportedly a success rate of > 90 % [1]. Although hip spacers are established as an ade-quate treatment option in the management of these infections, several complications might occur between stages and, hence, endanger the functional outcome. Besides a reinfection and/or infection persistence, mechanical complications, such as spacer fracture, COMPLICATIONS AFTER EXCISION OF CHOLEDOCHAL CYSTS Trung Bui Hai MD Hung Le Hoang MD Tri Tran Thanh MD General surgery Deparment CHOLEDOCHAL CYSTS • Congenital dilatations of the extra and/or intrahepatic bile ducts • Most common site: choledochus • Significantly more common in Asia • Female dominance ( 3-4/1) CHOLEDOCHAL CYSTS CHOLEDOCHAL CYSTS • Etiology: – Pancreaticobiliary maljunction(PBM)->reflux of pancreatic fluid into the bile duct – Distal obstruction at the level duodenum CLASSIFICATION CLINICAL FEATURES DIAGNOSIS • Abdominal ultrasound: first imaging modality(sens modality( 71-97%), antenatal diagnosis • Technectium-99m HIDA scan • CT scan, CT cholangiography • ERCP, PTC, intraoperative cholangiogram: cholangiogram risk of pancreatitis, cholangitis • MRCP: now considered the gold standard SURGICAL MANAGEMENT • Laproscopic surgery • Open surgery SURGICAL MANAGEMENT Journal of pediatric surgery, Vol 32 , No (July), 1997: p 1097- 1102 J Hepatobiliary Pancreat Sur (1999) 6:207-212 CONCLUSION • Excellent prognosis with early total resection and reconstruction • Long-term term surveillance for the development of malignancy still essential THANK YOU FOR YOUR ATTENTION CASE REPO R T Open Access Robot-assisted complete excision of choledochal cyst type I, hepaticojejunostomy and extracorporeal Roux-en-y anastomosis: a case report and review literature Thawatchai Akaraviputh 1* , Atthaphorn Trakarnsanga 1 , Nutnicha Suksamanapun 2 Abstract For Choledochal cyst type I, complete excision of cyst with Roux-en-Y hepaticojejunostomy anastomosis is the treatment of choice. It has been performed laparoscopically with the advancement of laparoscopic skill. Recently, a telemanipulative robotic surgical system was introduced, providing laparoscopic instruments with wrist-arm tech- nology and 3-dimensional visualization of the operative field. We present a case of robot-assisted total excision of a choledochal cyst type I and biliary reconstruction in a 14-year-old girl. No intraoperative complications or technical problems were encountered. An intraabdominal collection occurred and was successfully treated with continuous percutaneous drainage. At one-year follow-up, she is doing well without evidence of recurrent cholangitis. Background Choledochal cyst is a rare congenital anomaly of the biliary system in the western countries, but has a higher rate of occurrence in Asia. This disorder is usually diag- nosed during childhood and is more common in females. After being described first by Vater in 1723 [1], choledochal cysts are now classifi ed using the Todani modification of the Alonzo-Lej classification s ystem [2]. The most common is type I consisting of cystic, fusi- form dilatation of the extrahepatic common bile duct. Untreated choledoc hal cysts are associated with compli- cations such as recurrent cholangitis, acute pancreatitis and cholangiocarcinoma. The standard procedure is complete resection of the cyst with a Roux-en-Y hepati- cojejunostomy anastomosis. Cystoenterostomy is no longer recommended [3]. Recently, many centers reported their experience with lapar osco pic resection of the cyst [ 4]. Although this approach has been shown to be feasible and safe, most repo rts emphasized the t ech- nical challenge of the procedure as well as the long operative times [5]. The use of da Vinci Robotic Surgical System (Intuitive Surgical, Sunnyvale, California) pro- vides the advantages of three-dimensional visualization through a stereoendoscope, tremor reduction, motion scaling, and wristed instrumentation with additional degrees of freedom compared to standard laparoscopic instruments [6,7]. We report the application of da Vinci Robotic Surgical System in type I chol edochal cyst exci- sion in a 14-year-old girl. Case presentation A 14-year-old, girl presented with recurrent abdominal dyspepsia and intermittent jaundice. Her b lood labora- tory examinations were within normal limits. Ser um CA 19-9 was normal. Ultrasonography demonstrated a large cystic dilatation of common bile duct. An abdominal computed tomography (CT) scan revealed a type I cho- ledochal cyst measuring > 4 cm in diameter (Figure 1). The patient underwent da Vinci robot-assisted excision of th e choledochal cyst, hepaticojejunostomy, and extra- corporeal jejuno-jejunostomy of Roux-en-Y limb. Surgical technique The patient was placed in supine position. The pneumo- peritoneum was created upto 12 mmHg using closed technique with Veress needle. Three 8-mm robotic * Correspondence: sitak@mahidol.ac.th 1 Minimally Invasive Surgery Center, Division of General Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand Full list of author information is available at the end of the article Akaraviputh et al. World Journal of Surgical Oncology 2010, 8:87 http://www.wjso.com/content/8/1/87 WORLD JOURNAL OF SURGICAL ONCOLOGY © 2010 Akaraviputh et al; licensee BioMed Central Ltd. This is an Open A ccess article distributed under the terms of the Creative Commons At tribution License (http://creativecommons.org/licenses/b y/2.0), which permits unrestricted use, distribution, and JOURNAL OF MEDICAL CASE REPORTS Successful pregnancy outcome after laparoscopic- assisted excision of a bizarre leiomyoma: a case report Takeda et al. Takeda et al. Journal of Medical Case Reports 2011, 5:344 http://www.jmedicalcasereports.com/content/5/1/344 (3 August 2011) CAS E REP O R T Open Access Successful pregnancy outcome after laparoscopic- assisted excision of a bizarre leiomyoma: acasereport Akihiro Takeda * , Sanae Imoto, Masahiko Mori and Hiromi Nakamura Abstract Introduction: Bizarre leiomyoma is a rare leiomyoma variant that requires a precise histopathological evaluation. Especially when diagnosed in a younger woman, this tumor leads to challenging treatment issues involving fertility preservation. Owing to the low incidence of bizarre leiomyoma, there is insufficient evidence to support myomectomy alone as an appropriate management option. Also, the impact of bizarre leiomyoma on fertility is not well known. Case presentation: A 30-year-old Japanese woman who had never given birth was referred to us because of a uterine tumor with an unusual diagnostic image and was treated by a gasless laparoscopic-assisted excision with a wound retractor. Owing to an unclear margin between her uterine tumor and myometrium, a concomitant excision of adjacent myometrial tissue was required to achieve the maximum resection of her tumor. The histopathological diagnosis was bizarre leiomyoma. Seven months later, she conceived spontaneously and her pregnancy course was uneventful. At 37 weeks of gestation, an elective cesarean secti on was performed. Although a slight omental adhesion was noted at the postexcisional scar, her uterine wall structure was well preserved and a recurrence of bizarre leiomyoma was not noted. Conclusions: A laparoscopic-assisted excision of bizarre leiomyoma is a feasible and minimally invasive conservative measure for a woman who wishes to preserve fertility. Introduction Smooth muscle tumors of the uterus encompass a variety of benign and malignant neoplasms [1]. Among uterine smooth muscle tumors, leiomyoma is the most common benign neoplasm in women of reproductive age [2]. Although most leiomyomas usually do not present a diagnostic problem, subt ypes of leiomyoma mimic malig- nancy in one or more aspects and so are of great interest [3]. Because of the rapidly growing availability of a more conservative set of measures for women who have benign uterine pathology and want to preserve fertility, differen- tiating benig n from malignant uterine smooth muscle tumors is b ecoming increasingly important when a treat- ment strategy is planned [1,4]. Bizarre leiomyoma, also referred to as a typical, pleo- morphic, or symplastic leiomyoma, is one of a group of rare leiomyoma variants that require precise histopatho- logical evaluation so that they are not misinterpreted as leiomyosarcomas [5,6]. Alt hough the pathology of this morphologic variant is well established [3,5], preopera- tive diagnostic image fi ndings of bizarre leiomyoma have not been described. If fertility preservation is not required, the standard surgical intervention for bizarre leiomyoma that shows a benign clinical course is a simple hyste rectomy [1,5,6]. However, owing to the low incidence of bizarre leio- myoma, there is insufficient evidence to support myo- mectomy alone as an appropriate management option [1,6]. Also, the impact of bizarre leiomyoma on fertility is not well known. In this report, preopera tive diagnostic image characteristics and minimally invasive conservative management of bizarre leiomyoma by a laparoscopic- assisted excision that resulted in a successful pregnancy outcome in a woman who had never given b irth are described. * Correspondence: gyendoscopy@gmail.com Department of Obstetrics & Gynecology, Gifu Prefectural Tajimi Hospital, Maebata-cho 5-161, Tajimi, Gifu, 507-8522, Japan Takeda et al. Journal of Medical Case Reports 2011, 5:344 http://www.jmedicalcasereports.com/content/5/1/344 JOURNAL OF CAS E REP O R T Open Access Remission of severe restless legs syndrome and periodic limb movements in sleep after bilateral excision of multiple foot neuromas: a case report Ludwig A Lettau 1* , Charles J Gudas 2 , Thomas D Kaelin 3 Abstract Introduction: Restless legs syndrome is a sensorimotor neurological disorder characterized by an urge to move the legs in response to uncomfortable leg sensations. While asleep, 70 to 90 percent of patients with restless legs syndrome have periodic limb movements in sleep. Frequent perio dic limb movements in sleep and related brain arousals as documented by polysomnography are associated with poorer quality of sleep and daytime fatigue. Restless legs syndrome in middle age is sometimes associated with neuropathic foot dysesthesias. The causes of restless legs syndrome and periodic limb movements in sleep are unknown, but the sensorimotor symptoms are hypothesized to originate in the central nervous system. We have previously determined that bilateral forefoot digital nerve impingement masses (neuromas) may be a cause of both neuropathic foot dysesthesias and the leg restlessness of restless legs syndrome. To the best of our knowledge, this case is the first report of bilateral foot neuromas as a cause of periodic limb movements in sleep. Case presentation: A 42-year-old Caucasian w oman with severe restless legs syndrome and periodic limb movements in sleep and bilateral neuropathic foot dysesthesias was diagnosed as having neuromas in the second, third, and fourth metatarsal head interspaces of both feet. The third interspace neuromas represented regrowth (or ‘stump’ ) neuromas that had developed since bilateral third interspace neuroma excision five years earlier. Because intensive conservative treatments including repeated neuroma injections and va rious restless legs syndrome medications had failed, radical surgery was recommended. All six neuromas were excised. Leg restlessness, foot dysesthesias and subjective sleep quality improved immediately. Assessment after 18 days showed an 84 to 100 percent reduction of visual analog scale scores for specific dysesthesias and marked reductions of pre-operative scores of the Pittsburgh s leep quality index, fatigue severity scale, and the international restless legs syndrome rating scale (36 to 4). Polysomnography six weeks post- operatively showed improved sleep efficiency, a marked increase in rapid eye movement sleep, and marked reductions in hourly rates of both periodic limb movements in sleep with arousal (135.3 to 3.3) and spontaneous arousals (17.3 to 0). Conclusion: The immediate and near complete remission of symptoms, the histopathology of the excised tissues, and the marked improvement in polysomnogra phic parameters documented six weeks after surgery together indicate that this patie nt’s severe restless legs syndrome and periodic limb movements in sleep was of peripheral nerve (foo t neuroma) origin . Further stu dy of foo t neuromas as a source of periodic limb movements in sleep and as a cause of sleep dysfunction in patients with or without concomitant restless legs syndrome, is warranted. * Correspondence: lettaul@comcast.net 1 Lowcountry Infectious Diseases, Charleston, SC, USA Full list of author information is available at the end of the article Lettau et al. Journal of Medical Case Reports 2010, 4:306 http://www.jmedicalcasereports.com/content/4/1/306 JOURNAL OF MEDICAL CASE REPORTS © 2010 Lettau et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, di stribution, and reproduction in any medium, provided the original work is properly cited. Introduction Restless legs sy ndrome (RLS) is a sensorimotor neurolo- gical disorder characterized by an urge to move the legs in response to uncomfortable leg sensations [1]. While asleep, 70% to 90% of patients with RLS Open Access Available online http://ccforum.com/content/9/6/R687 R687 Vol 9 No 6 Research Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. A randomised, controlled trial [ISRCTN38797445] Rupert Pearse, Deborah Dawson, Jayne Fawcett, Andrew Rhodes, R Michael Grounds and E David Bennett Adult Intensive Care Unit, 1st floor St James' Wing, St George's Hospital, Blackshaw Road, London SW17 0QT, UK Corresponding author: Rupert Pearse, rupert.pearse@doctors.net.uk Received: 8 Sep 2005 Accepted: 30 Sep 2005 Published: 8 Nov 2005 Critical Care 2005, 9:R687-R693 (DOI 10.1186/cc3887) This article is online at: http://ccforum.com/content/9/6/R687 © 2005 Pearse et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0 ), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Introduction Goal-directed therapy (GDT) has been shown to improve outcome when commenced before surgery. This requires pre-operative admission to the intensive care unit (ICU). In cardiac surgery, GDT has proved effective when commenced after surgery. The aim of this study was to evaluate the effect of post-operative GDT on the incidence of complications and duration of hospital stay in patients undergoing general surgery. Methods This was a randomised controlled trial with concealed allocation. High-risk general surgical patients were allocated to post-operative GDT to attain an oxygen delivery index of 600 ml min -1 m -2 or to conventional management. Cardiac output was measured by lithium indicator dilution and pulse power analysis. Patients were followed up for 60 days. Results Sixty-two patients were randomised to GDT and 60 patients to control treatment. The GDT group received more intravenous colloid (1,907 SD ± 878 ml versus 1,204 SD ± 898 ml; p < 0.0001) and dopexamine (55 patients (89%) versus 1 patient (2%); p < 0.0001). Fewer GDT patients developed complications (27 patients (44%) versus 41 patients (68%); p = 0.003, relative risk 0.63; 95% confidence intervals 0.46 to 0.87). The number of complications per patient was also reduced (0.7 SD ± 0.9 per patient versus 1.5 SD ± 1.5 per patient; p = 0.002). The median duration of hospital stay in the GDT group was significantly reduced (11 days (IQR 7 to 15) versus 14 days (IQR 11 to 27); p = 0.001). There was no significant difference in mortality (seven patients (11.3%) versus nine patients (15%); p = 0.59). Conclusion Post-operative GDT is associated with reductions in post-operative complications and duration of hospital stay. The beneficial effects of GDT may be achieved while avoiding the difficulties of pre-operative ICU admission. Introduction Goal-directed therapy (GDT) is a term used to describe the use of cardiac output or similar parameters to guide intrave- nous fluid and inotropic therapy. When commenced in the pre- operative period, this technique has been shown to improve outcome after major general surgery [1-3]. Although the number of post-operative deaths has changed little in recent years [4,5], pre-operative GDT has not been introduced into routine practice. The principal reason for this is likely to be the limited availability of intensive care unit (ICU) facilities, but there are also safety concerns regarding the use of the pulmo- nary artery catheter to measure cardiac output [6]. In cardiac surgery, these problems have been addressed suc- cessfully by commencing GDT in the immediate post-opera- tive period [7,8] and by using the oesophageal Doppler probe in place of the pulmonary artery catheter to measure cardiac output [8]. Use of the oesophageal Doppler probe to guide fluid administration during surgery is also associated with improved outcome [9-13] Unfortunately the Doppler probe is not readily tolerated by ... treated 97 choledochal cysts by surgical excision Biliary reconstruction consisted of 67 hepaticoduodenostomies nd 30 epaticojejunostomies The common hepatic duct was the site of anastomosis n of the... common in Asia • Female dominance ( 3-4/1) CHOLEDOCHAL CYSTS CHOLEDOCHAL CYSTS • Etiology: – Pancreaticobiliary maljunction(PBM)->reflux of pancreatic fluid into the bile duct – Distal obstruction.. .CHOLEDOCHAL CYSTS • Congenital dilatations of the extra and/or intrahepatic bile ducts • Most common site: choledochus • Significantly more common in Asia • Female dominance ( 3-4/1) CHOLEDOCHAL