Diagnosis and management of 528 abdominal aortic aneurysms.

Between 1960 and 1979 528 patients with abdominal aortic aneurysms presented to the university department of surgery. Of these, 222 (42%) were elective cases, 72 acute (14%), 174 had ruptured (33%), and four had had a spontaneous aortoduodenal fistula (1%). In all these patients resections were undertaken, but in another 56 patients (11%) the aneurysm was not resected. A review of these cases showed that 91% had symptoms at their first presentation; abdominal pain and backache being most common. The diagnosis could be established in 91% by the presence of pulsatile abdominal mass on clinical examination. The operative mortality for elective resection was 8%, for acute 19%, for ruptured cases 42%, and for spontaneous aortoduodenal fistula 50%. After successful resection the overall five-year survival was 65% by the life table method, and there was no significant difference between elective, acute, and ruptured cases. This five-year survival after resection compares favourably with the expected 76% survival of a similar normal population, and was considerably better than that for conservatively treated patients. As most cases have symptoms, and diagnosis may be established easily by routine physical examination in 91%, the prognosis for this condition could be considerably improved by increased awareness of its existence and early referral for treatment as an elective surgical procedure.     

Long term relative survival after surgery for abdominal aortic aneurysm in Western Australia: population based study

Objective: To determine the long term relative survival of all patients who had surgery for abdominal aortic aneurysm in Western Australia during 1985-94. Design: Population based study. Setting: Western Australia. Subjects: All patients who had had surgery for abdominal aortic aneurysm in Western Australia during 1985-94. Main outcome measures: Morbidity and mortality data of patients admitted and surgically treated for abdominal aortic aneurysm in Western Australia during 1985-94. Elective, ruptured, and acute non-ruptured cases were analysed separately. Independent analyses for sex and patients aged 80 years or more were also undertaken. Postoperative (>30 days) relative survival was assessed against age and sex matched controls. Results: Overall, 1475 (1257 men, 218 women) cases were identified. The crude five year survival after elective surgery, including deaths within 30 days of surgery, was 79% for both men and women. When compared with a matched population the five year relative survival after elective surgery was 94.9% (95% confidence interval 89.9% to 99.9%) for men but only 88.0% (76.3% to 99.7%) for women. The five year relative survival of those aged 80 years and over was good: 116.6% (89.1% to 144.0%) compared with 92.4% (87.7% to 97.0%) for those under 80 years of age (men and women combined). Cardiovascular disease caused 57.8% of the 341 deaths after 30 days. Conclusion: In a condition such as abdominal aortic aneurysm, which occurs in elderly patients, relative survival is more clinically meaningful than crude survival. The five year relative survival in cases of elective and ruptured abdominal aortic aneurysm was better in men than in women. This is probably because of greater comorbidity in women with abdominal aortic aneurysm and this deserves more attention in the future. The long term survival outcome in octogenarians supports surgery in selected cases.

Key messages

• Background mortality for conditions such as abdominal aortic aneurysm in elderly patients needs to be taken into account when assessing long term survival after surgery
• Relative survival methodology can correct for background mortality
• The five year relative survival for patients surviving beyond 30 days of elective surgery for abdominal aortic aneurysm was 95% for men and 88% for women
• For octogenarians, five year survival after elective surgery was greater than that expected of an age matched population
• Age over 80 years should not preclude consideration for elective surgery for abdominal aortic aneurysm

     

Serum complex of trypsin 2 and alpha 1 antitrypsin as diagnostic and prognostic marker of acute pancreatitis: clinical study in consecutive patients.

OBJECTIVE--To estimate the usefulness of serum concentrations of the complex of trypsin 2 and alpha 1 antitrypsin in diagnosing and assessing the severity of acute pancreatitis in comparison with serum C reactive protein, amylase, and trypsinogen 2 concentrations (reference markers). DESIGN--Markers were measured in consecutive patients admitted with acute abdominal pain that was either due to pancreatitis or to other disease unrelated to the pancreas (controls). SETTING--Department of surgery of a teaching hospital in Helsinki. SUBJECTS--110 patients with acute pancreatitis and 66 with acute abdominal diseases of extrapancreatic origin. On the basis of the clinical course, acute pancreatitis was classified as mild (82 patients) or severe (28 patients). MAIN OUTCOME MEASURES--Clinical diagnosis of acute pancreatitis and severity of the disease. RESULTS--At admission all patients with acute pancreatitis had clearly raised concentrations of trypsin 2-alpha 1 antitrypsin complex (32 micrograms/l), whereas only three of the controls had such values. Of the markers studied, trypsin 2-alpha 1 antitrypsin complex had the largest area under the receiver operating curve, both in differentiating acute pancreatitis from extrapancreatic disease and in differentiating mild from severe disease. CONCLUSIONS--Of the markers studied, trypsin 2-alpha 1 antitrypsin complex was the most accurate in differentiating between acute pancreatitis and extrapancreatic disease and in predicting a severe course for acute pancreatitis.     

Recurrent ventral herniation in Ehlers-Danlos syndrome

Ehlers-Danlos syndrome is an inherited collagen disorder characterized by skin hyperextensibility, joint laxity, and tissue friability. In this study, it was hypothesized that Ehlers-Danlos syndrome is frequently undiagnosed in patients who present for repair of ventral abdominal wall hernias. A retrospective chart review was conducted, and patients who had presented for elective repair of recurrent abdominal wall herniation were identified. In all patients, one or more prior attempts at repair with either mesh or autologous tissues had failed. Patients in whom abdominal wall components were lost secondary to extirpation or trauma, patients who had required acute closure, and patients with less than 2 months of follow-up were excluded. Twenty patients met these criteria. Twenty cases of recurrent ventral hernia repairs were reviewed, with special attention to identification of the preoperative diagnosis of Ehlers-Danlos syndrome. Patients ranged in age from 29 to 75 years, with a mean age of 54 years. Five patients were male (25 percent), and 15 were female (75 percent). The majority (95 percent) were Caucasian. The most common initial procedures were gynecologic in origin (35 percent). A precise closure technique that minimizes recurrence after ventral hernia repairs was used. With use of this technique, there was only one recurrence over a follow-up period that ranged from 2 to 60 months (mean follow-up duration, 25.7 months). Two patients with Ehlers-Danlos syndrome were identified, and their cases are presented in this article. The "components separation" technique with primary component approximation and mesh overlay was used for defect closure in the two cases presented. The identification of these two patients suggests the possibility of underdiagnosis of Ehlers-Danlos syndrome among patients who undergo repeated ventral hernia repair and who have had previous adverse postoperative outcomes. There are no previous reports in the literature that address recurrent ventral abdominal herniation in patients with Ehlers-Danlos syndrome.     

两种肠内营养方案对重症急性胰腺炎患者 肠道菌群及预后的影响

目的探讨肠内免疫微生态营养和免疫增强型肠内营养方案对重症急性胰腺炎患者肠道菌群及远期预后的影响。方法选择2014年1月至2017年6月在我院就诊的重症急性胰腺炎患者156例。按照随机数字表法将患者分为A组(肠内免疫微生态营养方案组)、B组(免疫增强型肠内营养方案组)和对照组(常规肠内营养方案组),各52例。检测患者治疗前后T淋巴细胞及其亚群NK细胞、B淋巴细胞,血清免疫球蛋白及ALB、TF、PA等营养指标。同时检测患者肠道菌群,判定3组患者肠道菌失调症发生率。治疗后对患者随访6个月,记录并发症及不良预后。结果治疗后A组和B组患者患者CD+4细胞、CD+8细胞、CD+4/CD+8、NK细胞、B淋巴细胞水平显著高于治疗前,对照组患者除CD+8细胞和NK细胞外,其余各细胞水平亦显著高于治疗前(P0.05),且A组和B组患者治疗后各细胞水平高于对照组(P0.05)。治疗后A组和B组患者IgA、IgG、IgM水平显著升高,且A组和B组高于对照组(P0.05),同时3组患者治疗后ALB水平显著高于治疗前,且A、B组高于对照组,但A组和B组治疗后ALB水平比较差异无统计学意义(P0.05)。发病7～10d后,A组患者菌群失调发生率为5.77%,低于B组(19.23%)和对照组(36.54%),两两比较差异均有统计学意义(P0.05)。治疗6个月后,A组患者出现1例胰腺及胰周感染,1例MODS,0例病死;B组出现1例胰腺及胰周感染,2例MODS,3例菌血症,1例腹腔感染,2例病死;对照组出现6例胰周胰腺感染,7例MODS,5例菌血症,3例腹腔感染,3例病死。A组和B组预后显著优于对照组,且A组预后优于B组(P0.05)。结论肠内免疫微生态营养与免疫增强型肠内营养均能显著提高重症急性胰腺炎患者营养状况,提高免疫水平,且肠内免疫微生态营养在改善肠道菌群及预后方面具有更好的效果,值得临床推广。     

Secondary abdominal contour surgery: a review of early and late reoperative surgery

A retrospective chart review of 400 abdominal contour operations produced a series of 24 patients who underwent both their primary and then their secondary abdominal contour surgeries with the senior author (Matarasso). The majority of patients were classified and treated according to the abdominoplasty classification system previously described; however, a subgroup could not be categorized according to this system. In this study, the authors identified the secondary abdominal contour surgical experience of one surgeon. A comparison was made between two groups of patients treated for both primary and secondary operations: group I, considered early, less than 18 months after the previous operation; and group II, considered late, 18 or more months after the previous operation. There was a significant difference between groups I and II (chi2 = 4.12, p = 0.05); most patients had their surgical procedures before 18 months. For patients who underwent either a miniabdominoplasty or a full primary abdominoplasty, there was a statistically significant difference between the number of patients treated in group I and the number in group II (Fisher's exact test, D = 0, p = 0.05). Next, the nature of the secondary procedure was determined to be either a revisional procedure or a completely new reoperative procedure. The majority of patients underwent revision or "touch-ups," accomplished with either liposuction alone or in combination with scar revision. There was no significant difference between types of primary and secondary procedures performed in group I or group II. Secondary abdominal contour surgery accounted for 6 percent (24 of 400) of all abdominal contour procedures performed by one surgeon. Complete secondary surgery, performing an additional open procedure, occurred in 21 percent of cases (five of 24). Revision surgery (scar revision or removal of dog-ears) was performed in 29 percent of all cases (seven of 24). There was a 4 percent (one of 24) complication rate requiring operative intervention. This rate is consistent with that reported in the literature for primary abdominal contour surgery. With the overall acceptance of aesthetic surgery increasing, the number of patients undergoing abdominoplasty increasing, an aging population, and the safety of secondary abdominal contour surgery suggested from this review, it is likely that plastic surgeons will see more patients requesting secondary abdominal contour surgery in the future.     

Computer-aided Diagnosis of Acute Abdominal Pain

This paper reports a controlled prospective unselected real-time comparison of human and computer-aided diagnosis in a series of 304 patients suffering from abdominal pain of acute onset.The computing system''s overall diagnostic accuracy (91·8%) was significantly higher than that of the most senior member of the clinical team to see each case (79·6%). It is suggested as a result of these studies that the provision of such a system to aid the clinician is both feasible in a real-time clinical setting, and likely to be of practical value, albeit in a small percentage of cases.     

腹内压值对外科急腹症患者的检测价值研究

目的:评估膀胱压力(BP)测量作为急腹症诊断工具的临床价值。方法:选取在我院外科治疗的患者,根据病情分为两组:一组为325例急腹症患者,对照组为50例进行腹腔镜手术的患者。在治疗前测量患者腹内压力。患者采用仰卧位,将50 m L无菌生理盐水缓慢注射到膀胱中,待排光后检测BP。将导管同水压计连接,以耻骨联合处为参考点。将BP值大于10 cm H2O,作为诊断急腹症的标准。结果:BP诊断急腹症的灵敏度为94.4%,特异性为79%,阳性预测值为95.9%,阴性预测值为71.7%,精确度为92.3%。结论:腹内压(IAP)升高可以作为急性腹痛的诊断工具。BP检测有助于临床医生在试验室检查或影像学检查结果有限时对患者病情进行评估。     

Continuous narcotic infusions for relief of postoperative pain.

Relief of acute pain after surgery or trauma is still inadequate in many centres, most patients being treated with intermittent intramuscular injections of narcotic analgesics. Over the past three years continuous intravenous narcotic infusions have been used at this hospital to treat postoperative pain; recently a system has been devised whereby an hourly dose is given and the dispenser recharged every hour. The method used is cheap and reliable, and signs of overdosage may be easily checked by nursing staff. Side effects rarely occur. Fifty patients who had received intravenous infusions after undergoing major abdominal surgery were sent a questionnaire to assess postoperative pain, and the results were compared with those from 50 matched controls who had received intramuscular injections. Of those who replied, only four patients who had received the infusion had found the pain distressing compared with 13 controls. Continuous narcotic infusions are most effective in relieving postoperative pain and may be given cheaply and reliably.     

腹腔镜腹壁切口疝修补术的临床疗效分析

目的探讨腹腔镜腹壁切口疝修补术的临床疗效。方法选取2015年6月~2016年5月我院收治的腹壁切口疝患者89例,根据治疗方式的不同将患者分为开放组44例和腹腔镜组45例。开放组44例患者采用开放式腹壁切口疝修补术,腹腔镜组45例患者行腹腔镜腹壁切口疝修补术,并对两组患者的手术时间、术中出血量、术后疼痛评分、并发症及复发情况、住院时间进行比较。结果腹腔镜组患者的手术时间长于开放组(P0.05),而术中出血量、术后疼痛评分和住院时间均低于开放组(P0.05),并发症发生率和复发率低于开放组(P0.05)。结论腹腔镜腹壁切口疝修补术是一种安全、有效、可行的治疗手段,值得临床推广应用。     

经皮冠脉介入手术时机的选择对急性心肌梗死患者左室重构及心功能的影响

目的:探讨手术时机的选择对急性心肌梗死患者行经皮冠脉介入手术后左室重构及心功能的影响。方法:选择2014年10月-2015年10月在我院接受经皮冠脉介入手术治疗的97例急性心肌梗死患者为研究对象,根据手术时间不同将患者分为急诊手术组(49例)和择期手术组(48例)。观察并比较两组患者手术前后平均二尖瓣压力差(mMPG)、肺动脉平均压(mPAP)、左室舒张末径(LVDEd)、左室收缩末径(LVSEd)、左房内径(LAd)以及半年内心衰再住院率。结果:手术前,两组患者心功能及血流动力学各指标比较,差异均无统计学意义(P0.05);手术后,两组患者LVDEd,LVSEd及LAd均低于手术前,且急诊手术组患者LVDEd,LVSEd及LAd均低于择期手术组,差异具有统计学意义(P0.05);手术后,两组患者mMPG及mPAP均低于手术前,且急诊手术组患者mMPG及mPAP均低于择期手术组,差异具有统计学意义(P0.05);急诊手术组患者术后6个月心衰再住院率(2.04%)低于择期手术组(6.25%),差异具有统计学意义(P0.05)。结论:手术时机的选择对于行经皮冠脉介入手术的急性心肌梗死患者具有重要意义。与择期手术效果相比,急诊手术能够更好地改善患者的心功能及左室重构,减少心衰再住院率,值得在临床推广应用。     

Earliest Symptoms of Coronary Heart Disease and their Recognition

We have reviewed the histories of 320 patients in whom a diagnosis of coronary heart disease was ultimately established and traced the symptoms back to their first appearance. In 51% the first symptom was effort angina. Difficulties in recognition arose when the symptom was localized to an unusual site, when its occurrence was dependent on a combination of exercise with cold or a recent meal, or when it was induced by excitement rather than by effort. In a quarter of the cases the onset of angina was abrupt, and in these there was usually evidence of acute infarction.In 43% of cases the first symptom was an attack of pain or discomfort in the torso occurring without any discernable precipitating factor. Again, diagnosis was difficult when the pain was in an atypical site and also when it was of brief duration associated with skeletal or abdominal disease which could cause pain at the same site, or if the patient was able to undertake strenuous exertion. In four patients cardiac pain was first experienced during a paroxysm of tachycardia. In 6% of cases the onset was marked by a symptom other than pain—most frequently dyspnoea, tiredness, faintness, or syncope.Clinical examination was of no direct value in diagnosis. Its importance lay in disclosing factors which had to be taken into account in interpreting the electrocardiogram. The electrocardiogram was invaluable, though by no means infallible. In over half of the patients the first tracing showed major abnormalities of coronary type, and nearly a quarter more showed minor S-T/T depression consistent with coronary disease. Ten per cent. showed miscellaneous abnormalities, such as left ventricular hypertrophy or bundle-branch block, and 15% no definite abnormality.There is as yet no completely reliable objective method of diagnosing early coronary heart disease, so that the recognition of symptoms remains of paramount importance.     

腹腔镜胆囊切除术治疗高龄患者急性胆囊炎的临床观察

目的：探讨腹腔镜胆囊切除术治疗高龄患者急性胆囊炎的应用价值。方法：回顾性分析2005年1月．2011年12月我院收治的210例65岁以上因急性胆囊炎实施胆囊切除术的老年患者的临床资料,按手术方式分为腹腔镜组（LC组）和剖腹胆囊切除术组（OC组）,分析和比较两组患者的手术时间、术后肠功能恢复时间及住院时间,术中出血、腹腔引流量和术后并发症的发生情况。结果：与OC组比较,LC组的手术时间、术后肠功能恢复时间及住院时间均显著缩短,差异有统计学意义（P〈0．01）;但两组之间术中出血、腹腔引流量和术后并发症的发生率差异均无统计学意义（P〉0．05）。LC组中转开腹10例,占7_35％;其中粘连严重导致胆囊三角解剖不清6例,无法控制的出血2例,结石嵌顿胆囊管2例。结论：老年急性胆囊炎患者在条件合适的情况下行腹腔镜胆囊切除术治疗有助于患者更快地恢复．具有较强的临床应用价值。     

SPORADIC ACUTE GLOMERULONEPHRITIS IN ADULTS

Nineteen adults who had acute glomerulonephritis were reviewed with respect to the clinical course and long-term follow-up. The age range was from 17 to 55 years. Only one patient died during the acute episode. In 11 cases, onset occurred between November and January and 15 of the patients had a known respiratory tract infection three to 30 days before the onset. The most important symptoms noted were weight gain, edema, dyspnea, oliguria and red or smoky urine. The most prominent physical signs were elevated blood pressure, edema, abnormalities in the chest and fever of over 100° F. Fifteen patients showed roentgen evidence of pulmonary vascular congestion, pleural effusion, cardiomegaly, pneumonia or a combination of these abnormalities. All the patients had proteinuria and red blood cells in the urine, and half of them had red blood cell casts. Azotemia, when present, subsided in 9.4 days. The average diastolic pressure was 105 mm. of mercury and the mean fall was 26 mm. in 23.5 days. At six months, nine of the 13 patients still being observed continued to show proteinuria or microscopic hematuria (seven showed both). A late follow-up of ten patients showed one to have significant hypertension and one to have early functional impairment and inconstant proteinuria. In these cases the average blood pressure was 140/91 mm. as compared with 119/74 mm. at the time of discharge.Sporadic glomerulonephritis in adults presents essentially the same pattern as it does in children. Urinary abnormalities may persist for months or even years, and neither the present series nor those reported by others clearly reveal the ultimate prognosis.     

经脐单孔腹腔镜辅助整形术治疗急性胆囊炎的临床效果

目的:探讨单孔腹腔镜辅助整形术(TUES)对急性胆囊炎患者腹壁美观及其肝功能的影响。方法:选取我院急性胆囊炎择期手术患者130例,随机分为观察组和对照组。观察组采用经脐单孔腹腔镜胆囊切除术联合整形术,对照组采用三孔腹腔镜胆囊切除术。观察并比较两组手术时间、术后疼痛评分、切口满意度及肝功能指标的变化情况。结果:与对照组比较,观察组患者手术时间长,术后疼痛评分低,患者对切口美观满意度高,差异具有统计学意义(P0.05)。两组住院日无显著差异(P0.05)。两组患者术前ALT、AST和ALP水平无显著差异(P0.05)。两组患者术后ALT、AST和ALP水平均高于术前,组内比较差异具有统计学意义(P0.05)。观察组患者术后ALT、AST和ALP水平低于对照组,组间比较差异具有统计学意义(P0.05)。结论:单孔腹腔镜辅助整形术能够改善急性胆囊炎患者病情,提高腹壁美观效果,而且对肝功能影响较小,值得临床推广。     

Diagnosis of pseudomembranous colitis.

Twenty-eight patients with histologically proved pseudomembranous colitis have been seen in one hospital since July 1975. All patients with the disease had received antibiotics, six for infections not requiring operations; the other 22 cases all occurred after major surgery. All the patients had diarrhoea; six patients also had fever with clinical signs of sepsis, and three had abdominal pain thought to be due to anastomotic dehiscence after colonic resection. Pseudomembranous colitis was associated with white blood counts over 15 000/mm3 in 17 patients and albumin concentrations of less than 30 g/1 in 18. Pseudomembranous colitis was an incidental finding at necropsy in two of six patients who had not had an operation. Of the 22 patients who had had major surgery, nine died from this complication; in all except two of these cases the diagnosis was made only at necropsy. If pseudomembranous colitis is suspected on clinical grounds or if there is an unexplained complication after colorectal surgery repeat sigmoidoscopy and testing for faecal toxins should be carried out to establish the diagnosis so that prompt supportive treatment can be given.     

腹部手术伴COPD病人围手术期处理体会（附35例临床报告）

目的：探讨伴有COPD病人行腹部手术时的危险性、手术耐受力评估以及围手术期的处理。方法：主要分析35例COPD病人行上腹部手术的临床资料。结果：35例病人中术后有发生肺部感染、腹部创口破裂等并发症,无一例发生呼衰,术后均治愈出院。结论：COPD病人手术有一定危险性,主要在术后,但术前与术中应进行适当的准备与处理,能降低术后并发症发生。不能过分强调其危险性而丧失手术时机。     

Neonatal Necrotizing Enterocolitis: Clinical and Radiological Features

Necrotizing enterocolitis is an uncommon but dangerous disease in premature infants. Ten cases, seen over a three-year period at the Stanford University Medical Center, represented an incidence of 0.4 percent. The patients, six of whom died, derived from a general population, in contrast to the large series of patients reported in the literature in which the incidence was from 0.9 percent to 3.7 percent.^3-6The initial symptoms—rapid respiration, periodic breathing, lethargy and irritability—were identical to those which occurred in numerous infants who had respiratory disease. Subsequent symptoms (abdominal distension, in 100 percent; vomiting, 80 percent; apneic spells, 70 percent; jaundice, 70 percent; guaic-positive stools, 60 percent) were those of nonspecific acute abdominal disease.The radiologist first made the diagnosis in 90 percent of cases. Interstitial air in the wall of the gut and the retroperitoneum, and portal vein gas were the most diagnostic radiographic features. Barium contrast studies were not helpful, and in one case led to the erroneous diagnosis of small bowel volvulus.Plain abdominal radiographs must be taken of all premature infants with symptoms of nonspecific acute abdominal disease. If the radiographs are negative, but symptoms continue, they should be repeated at frequent intervals, for early diagnosis is critical to institution of proper therapy.     

腹部手术前后血气分析及肠道菌群变化

目的:探讨围手术期腹部外科病人血气和酸碱平衡、肠道菌群变化及临床意义.方法:随机检测100例腹部外科择期手术患者术前和术后血气分析.同时对术后发生腹泻的13例患者行粪便菌群分析.结果:手术后低血氧27例,而胃癌根治、直肠癌根治、肝叶切除等大手术者均有不同程度酸碱失衡,且发生酸碱失衡者中9例合并菌群失调.结论:具有高危因素的腹部手术患者,术前及术后检测血气,监测肺功能及酸碱平衡,并积极诊治肠道菌群失调.     

Postoperative death in sows as a result of gastric mucosal de-gloving at the pars oesophagea

It is well documented that pigs frequently die from postoperative acute gastric dilatation, and proximal gastric 'stress' ulceration. Three cases of gastric mucosal 'de-gloving' are reported. This was secondary to acute gastric dilatation and resulted in death from acute haemorrhage. All animals had undergone major abdominal surgery. Histology confirmed that the proximal gastric mucosa had been 'de-gloved', or torn from the gastro-oesophageal junction, leaving exposed muscle fibres. This syndrome has not been reported previously. The postmortem appearances of this mechanical injury could easily be mistaken for extensive oesophago-gastric peptic ulceration. This has major implications for prevention.