This study retrospectively reviewed 29 patients over 10 years with penetrating duodenal or pancreaticoduodenal injuries to compare outcomes of repairs with or without pyloric exclusion. It found that the two groups were similar in demographics and injury severity. There was a non-significant trend toward higher complication rates, pancreatic fistulas, and longer hospital stays with pyloric exclusion. Neither group experienced duodenal fistulas. The study concludes pyloric exclusion did not improve outcomes for these injuries and simple repair may be adequate and safer.
This 12-month study evaluated the safety and efficacy of the transoral incisionless fundoplication (TIF) procedure using the EsophyX system. 86 patients with gastroesophageal reflux disease underwent the TIF procedure. At 12 months, 73% of patients reported at least a 50% improvement in quality of life scores, 85% discontinued daily PPI use, and 81% had complete cessation of PPIs. The TIF procedure was found to be safe and effective in improving symptoms for most patients with GERD.
This study analyzed 44 cases of penetrating pelvic injury (PPI) that underwent laparotomy at a hospital in Juarez, Mexico over one year. Most injuries were from gunshots. The small bowel was the most commonly injured organ. Therapeutic laparotomies were performed in 61.4% of cases where injuries required intervention. Major complications included surgical site infections. The mortality rate was 20%, primarily due to hypovolemic shock. Despite the safety of non-operative management of PPI in other settings, the lack of advanced imaging technology in this developing world hospital meant laparotomy remained the standard of care for penetrating pelvic trauma.
Isolated traumatic rupture of the duodenum: Case report - Perforations, prefe...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Hirschsprung’s disease in adults: Clinical and therapeutic featuresPremier Publishers
Hirschsprung’s disease (HD) is rare in adults and it is thus often undiagnosed or misdiagnosed. Through this series of 12 patients we try to study the clinical characteristics of this pathology, to define its diagnostic clues and to assess the different therapeutic approaches.
Definitive diagnosis is established on histology of specimens from the rectum and colon. The disease involved the rectum and the sigmoid colon in 2 patients and was confined to the rectum, in the 10 others.
Treatment was in all cases surgical consisting of recto-colic resection associated with coloanal anastomosis and a protective right lateral ileostomy.
We conclude that Hirschsprung’s disease is rare in adults but by no means exceptional. It should be considered in young adults with a history of chronic constipation. Diagnosis is first of all clinical. When barium enema appearances are pathognomonic we needn’t resort to histology to confirm the diagnosis. Anorectal manometry does not usually show RAIR. Current primary treatment of HD diagnosed in adults consists mainly of surgical resection.
Laparoscopy-assisted distal gastrectomy with D1+β compared with D1+α lymph no...Goto Pablo
This study compared outcomes of laparoscopy-assisted distal gastrectomy (LADG) with D1+a lymph node dissection versus D1+b lymph node dissection for early gastric cancer. D1+b dissection removed more lymph nodes along the common hepatic artery and celiac artery compared to D1+a. However, there were no significant differences in short-term outcomes such as complications, recovery times, or length of stay between the two procedures. The study concluded that LADG with D1+b dissection is as minimally invasive as D1+a dissection while providing the oncological benefits of more extensive lymph node removal.
1) A randomized controlled trial compared gastric bypass (GB) and sleeve gastrectomy (SG) for treating type 2 diabetes mellitus (T2DM) in 60 moderately obese patients.
2) At 12 months, remission of T2DM was achieved by 93% in the GB group and 47% in the SG group, indicating GB was more effective at treating T2DM.
3) Participants who received GB had greater weight loss and better control of glucose, HbA1c, and blood lipid levels compared to those who received SG. No serious complications occurred in either group.
The document discusses a prospective study that compares the incidence of incisional hernia in 134 patients undergoing gastric bypass surgery who received either primary fascial closure or closure with a prophylactic biological mesh. The results showed a significantly lower incidence of incisional hernia in patients who received the biological mesh (2.3% vs 17.7%), though these patients experienced a higher rate of seroma formation. After adjusting for risk factors, prophylactic mesh placement was found to be protective against hernia development while smoking increased hernia risk. The study provides evidence that prophylactic biological mesh may reduce incisional hernia rates in high-risk patients.
This document reports a case study of a 64-year-old female patient who developed late onset tracheal stenosis after receiving an 125Iodine seed esophageal stent to treat advanced esophageal carcinoma. The patient experienced progressive stenosis of the lower trachea at 6, 26, and 47 days post-operatively. The causes of stenosis are believed to include direct pressure from the stent, tumor proliferation, pressure from the aortic arch, and complications from other therapies such as radiation treatment. Due to its short clinical use, 125Iodine seed stents may present some fatal complications, and more study is needed on their long-term efficacy.
This 12-month study evaluated the safety and efficacy of the transoral incisionless fundoplication (TIF) procedure using the EsophyX system. 86 patients with gastroesophageal reflux disease underwent the TIF procedure. At 12 months, 73% of patients reported at least a 50% improvement in quality of life scores, 85% discontinued daily PPI use, and 81% had complete cessation of PPIs. The TIF procedure was found to be safe and effective in improving symptoms for most patients with GERD.
This study analyzed 44 cases of penetrating pelvic injury (PPI) that underwent laparotomy at a hospital in Juarez, Mexico over one year. Most injuries were from gunshots. The small bowel was the most commonly injured organ. Therapeutic laparotomies were performed in 61.4% of cases where injuries required intervention. Major complications included surgical site infections. The mortality rate was 20%, primarily due to hypovolemic shock. Despite the safety of non-operative management of PPI in other settings, the lack of advanced imaging technology in this developing world hospital meant laparotomy remained the standard of care for penetrating pelvic trauma.
Isolated traumatic rupture of the duodenum: Case report - Perforations, prefe...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Hirschsprung’s disease in adults: Clinical and therapeutic featuresPremier Publishers
Hirschsprung’s disease (HD) is rare in adults and it is thus often undiagnosed or misdiagnosed. Through this series of 12 patients we try to study the clinical characteristics of this pathology, to define its diagnostic clues and to assess the different therapeutic approaches.
Definitive diagnosis is established on histology of specimens from the rectum and colon. The disease involved the rectum and the sigmoid colon in 2 patients and was confined to the rectum, in the 10 others.
Treatment was in all cases surgical consisting of recto-colic resection associated with coloanal anastomosis and a protective right lateral ileostomy.
We conclude that Hirschsprung’s disease is rare in adults but by no means exceptional. It should be considered in young adults with a history of chronic constipation. Diagnosis is first of all clinical. When barium enema appearances are pathognomonic we needn’t resort to histology to confirm the diagnosis. Anorectal manometry does not usually show RAIR. Current primary treatment of HD diagnosed in adults consists mainly of surgical resection.
Laparoscopy-assisted distal gastrectomy with D1+β compared with D1+α lymph no...Goto Pablo
This study compared outcomes of laparoscopy-assisted distal gastrectomy (LADG) with D1+a lymph node dissection versus D1+b lymph node dissection for early gastric cancer. D1+b dissection removed more lymph nodes along the common hepatic artery and celiac artery compared to D1+a. However, there were no significant differences in short-term outcomes such as complications, recovery times, or length of stay between the two procedures. The study concluded that LADG with D1+b dissection is as minimally invasive as D1+a dissection while providing the oncological benefits of more extensive lymph node removal.
1) A randomized controlled trial compared gastric bypass (GB) and sleeve gastrectomy (SG) for treating type 2 diabetes mellitus (T2DM) in 60 moderately obese patients.
2) At 12 months, remission of T2DM was achieved by 93% in the GB group and 47% in the SG group, indicating GB was more effective at treating T2DM.
3) Participants who received GB had greater weight loss and better control of glucose, HbA1c, and blood lipid levels compared to those who received SG. No serious complications occurred in either group.
The document discusses a prospective study that compares the incidence of incisional hernia in 134 patients undergoing gastric bypass surgery who received either primary fascial closure or closure with a prophylactic biological mesh. The results showed a significantly lower incidence of incisional hernia in patients who received the biological mesh (2.3% vs 17.7%), though these patients experienced a higher rate of seroma formation. After adjusting for risk factors, prophylactic mesh placement was found to be protective against hernia development while smoking increased hernia risk. The study provides evidence that prophylactic biological mesh may reduce incisional hernia rates in high-risk patients.
This document reports a case study of a 64-year-old female patient who developed late onset tracheal stenosis after receiving an 125Iodine seed esophageal stent to treat advanced esophageal carcinoma. The patient experienced progressive stenosis of the lower trachea at 6, 26, and 47 days post-operatively. The causes of stenosis are believed to include direct pressure from the stent, tumor proliferation, pressure from the aortic arch, and complications from other therapies such as radiation treatment. Due to its short clinical use, 125Iodine seed stents may present some fatal complications, and more study is needed on their long-term efficacy.
This document summarizes a study on using an endoluminal device called the StomaphyX to reduce gastric pouches after Roux-en-Y gastric bypass surgery in patients experiencing weight regain. Thirty-nine patients underwent the procedure, with an average excess weight loss of 7.4% at 2 weeks, 10.6% at 1 month, and 19.5% at 1 year. Minor complications included sore throat and epigastric pain. The procedure may offer an alternative to open or laparoscopic revisional surgery for weight regain with no major complications observed.
Current concepts in the management of esophagueal perforationsFerstman Duran
This study analyzed 119 patients with esophageal perforations treated at a hospital in Canada between 1981-2007 to identify factors associated with mortality. The researchers found that malignant perforations, pre-operative respiratory failure requiring mechanical ventilation, higher comorbidity burdens, and sepsis were associated with significantly higher mortality based on multivariate analysis. However, time to treatment was not associated with increased mortality. Primary repair or resection with reanastomosis can be attempted even in patients treated after longer time periods from perforation.
This document discusses the diagnosis and management of caustic esophageal strictures. It begins by outlining the clinical symptoms of dysphagia that result from caustic ingestion and lead to stricture formation. Diagnosis involves esophagogram or esophagoscopy at least 6 weeks after injury to identify strictures. Treatment involves endoscopic dilatation using wire-guided dilators, with multiple sessions often needed for complex strictures. Advanced endoscopic techniques have reduced the need for esophageal replacement surgery. The document concludes that caustic esophageal strictures can be successfully managed through endoscopic dilatation.
Diagnostic Laparoscopy for ITU patientsArshad Hayat
Diagnostic laparoscopy can be used safely in the ICU to diagnose intra-abdominal pathology in critically ill patients without moving them to the operating room. It has a high diagnostic accuracy of 90-100% and can help avoid unnecessary laparotomies in 36-95% of cases. While it has some limitations for retroperitoneal processes, diagnostic laparoscopy is recommended for use in the ICU when an intra-abdominal catastrophe is suspected but cannot be ruled out noninvasively, or to evaluate for conditions like acalculous cholecystitis or ischemic bowel. Any complications are typically minor and it does not increase mortality, which remains high for the critically ill ICU patient population.
Bouveret's syndrome as an unusual cause of gastric outletFerstman Duran
This case report describes an 83-year-old man who presented with vomiting and abdominal pain and was found to have Bouveret's syndrome. Endoscopy revealed a large mass obstructing the duodenum, which was discovered to be a gallstone during surgery. The gallstone had caused a cholecysto-duodenal fistula. Initial surgery removed the fistula but the gallstone remained, requiring a second surgery to remove it from the duodenum. Bouveret's syndrome is a rare complication of gallstones that can cause gastric outlet obstruction.
Right side diverticulitis, differential diagnosis of complicated appendicitis...Juan de Dios Díaz Rosales
A 23-year-old female presented with abdominal pain suggestive of appendicitis. During an emergency appendectomy, a perforated cecal diverticulitis was discovered instead. A segment of the cecum and distal ileum were resected. Histopathological analysis confirmed a diverticulum with chronic inflammation and acute exacerbation. Right-sided diverticulitis can mimic appendicitis and should be considered as a differential diagnosis during abdominal surgeries initially intended to be an appendectomy.
The Mini-Gastric Bypass:Best Treatment Type 2 Diabetes MellitusDr. Robert Rutledge
The Mini-Gastric Bypass:Best Treatment Type 2 Diabetes Mellitus
Dr K S Kular
Kular Medical Education & Research Society ,
Kular Group of Institutes ,
drkskular@gmail.com
www.kularhospital.com
The IOSR Journal of Pharmacy (IOSRPHR) is an open access online & offline peer reviewed international journal, which publishes innovative research papers, reviews, mini-reviews, short communications and notes dealing with Pharmaceutical Sciences( Pharmaceutical Technology, Pharmaceutics, Biopharmaceutics, Pharmacokinetics, Pharmaceutical/Medicinal Chemistry, Computational Chemistry and Molecular Drug Design, Pharmacognosy & Phytochemistry, Pharmacology, Pharmaceutical Analysis, Pharmacy Practice, Clinical and Hospital Pharmacy, Cell Biology, Genomics and Proteomics, Pharmacogenomics, Bioinformatics and Biotechnology of Pharmaceutical Interest........more details on Aim & Scope).
All manuscripts are subject to rapid peer review. Those of high quality (not previously published and not under consideration for publication in another journal) will be published without delay
This study assessed the efficacy of different surgical techniques (open surgery, percutaneous nephrolithotomy [PNL], and retrograde intrarenal surgery [RIRS]) for treating kidney stones. 102 patients undergoing kidney stone surgery were divided into the three treatment groups. The mean stone burden, operative time, length of hospital stay, and residual stone rates were compared between groups. Complications like fever, infection, urine leakage and persistent pain were also assessed. PNL and RIRS had lower stone burdens, shorter operative times, shorter hospital stays, and fewer complications compared to open surgery. PNL and RIRS were found to be safer and more effective treatments for kidney stones than open surgery.
Preoperative leukocytosis as predictor of intraabdominal injury in penetratin...Juan de Dios Díaz Rosales
This document summarizes a study on using preoperative leukocytosis as a predictor of intraabdominal injury in patients with penetrating abdominal trauma. The study included 231 patients who underwent exploratory laparotomy for abdominal trauma. Patients were divided into two groups: those with therapeutic laparotomy who had intraabdominal injuries (Group I), and those with non-therapeutic laparotomy who did not have intraabdominal injuries (Group II). The study found that 74.2% of patients in Group I had leukocytosis levels over 12,500/mm3, compared to only 27.7% of patients in Group II, indicating leukocytosis over 12,500/mm3 may help predict which patients have intra
This study compared outcomes of laparoscopic appendectomy versus open appendectomy in 68 patients with acute appendicitis. Patients were divided into two groups - Group I underwent laparoscopic appendectomy while Group II underwent open appendectomy. The time to start oral feeding and average hospital stay were shorter in the laparoscopic group compared to the open group. Post-operative wound infections and abscesses were also less common in the laparoscopic group. The study concluded that laparoscopic appendectomy is an effective treatment for acute appendicitis compared to open appendectomy.
A 40-year-old male presented to the emergency department with acute abdominal pain and distension after eating a heavy meal two days prior. Imaging showed massive gastric dilatation. Conservative management failed, so the patient underwent surgery. In surgery, the stomach was found to be hugely distended with thinned walls but no perforation. A gastrojejunostomy was performed to decompress the stomach. The patient recovered well post-operatively.
This document summarizes an article about evolving definitions, preventive strategies, and management of pancreatic fistula after pancreatectomy. It discusses how pancreatic resection is the standard treatment for pancreatic malignancy and certain benign disorders, but is a technically demanding procedure. While mortality after pancreaticoduodenectomy is now <3-5% in experienced centers, post-operative morbidity is around 30-50%, with pancreatic leakage and fistula being the most significant cause. The development of a pancreatic fistula increases hospital stay, costs, and can lead to life-threatening complications. The article reviews strategies to decrease fistula rates and emphasizes the importance of early recognition and treatment. It also discusses how there is no universally accepted definition of pancreatic fistula
Bouveret’s syndrome case report and review of the literatureFerstman Duran
This case report describes a patient with Bouveret's syndrome who presented with nausea, vomiting, abdominal pain and melena. Imaging revealed a gallstone obstructing the duodenum. The stone was successfully removed during an endoscopy using various extraction devices and mechanical lithotripsy. Bouveret's syndrome is a rare complication of gallstones that occurs when a gallstone passes through a cholecystoduodenal fistula and becomes lodged in the duodenum, causing gastric outlet obstruction. Endoscopic extraction is recommended as first-line treatment when possible due to its lower risk compared to surgery. The literature on Bouveret's syndrome and approaches to treatment, including endoscopic, lithotripsy and surgical
Open Versus Laparoscopic Repair for Perforated Peptic Ulcer: from personal ex...Raimundas Lunevicius
This document compares open versus laparoscopic repair for perforated peptic ulcers through a retrospective study and systematic review. The study analyzed 222 patients treated for perforated peptic ulcers, comparing 60 patients who underwent laparoscopic repair to 162 who had open repair. Results found that for low risk patients, laparoscopic repair had similar rates of wound infection and mortality as open repair, with shorter hospital stays. The systematic review concluded laparoscopic repair is at least as safe and effective as open repair for low risk patients with no Boey risk factors.
The document discusses traumatic injuries to the gallbladder and biliary ducts. It notes that 95% of biliary tree injuries are iatrogenic, while 5% are due to trauma. Trauma to the gallbladder occurs in 3-5% of abdominal trauma cases, while injuries to the biliary ducts occur in 0.5% of cases. Diagnosis is often intraoperative when associated injuries like liver, vascular, duodenal or splenic injuries are found. Imaging like CT may show duct dilation or periportal collections but do not always locate the injury site. ERCP is useful for diagnosing the location and type of biliary duct injury. Management depends on the specific injury but may include cholecystectomy
This study examined whether hip involvement negatively impacts radiographic outcomes after lumbar pedicle subtraction osteotomy (PSO) in ankylosing spondylitis patients with thoracolumbar kyphosis. 44 patients underwent one-level lumbar PSO and were divided into two groups based on their hip involvement scores. Both groups had similar corrections of local kyphosis, but the group with hip involvement had significantly larger sagittal vertical axis and pelvic tilt postoperatively, indicating hip involvement can negatively impact radiographic outcomes after lumbar PSO. Additional osteotomies may be needed for patients with hip involvement to achieve satisfactory correction.
This document discusses the management of duodenal injuries, which are challenging to diagnose and treat due to the duodenum's retroperitoneal location and proximity to major blood vessels. It provides an overview of the historical understanding and surgical techniques for duodenal injuries, and reviews considerations for diagnosis and various surgical repair methods used to treat these injuries. Successful management of duodenal trauma requires a high index of suspicion, prompt surgical exploration and treatment, and the skill to employ different repair techniques depending on the severity and location of the injury.
This document discusses the management of duodenal injuries. It notes that while duodenal injuries are uncommon, accounting for about 4% of abdominal injuries, they can have high morbidity and mortality rates of 65% and 20% respectively due to difficulties in diagnosis and management. It outlines the history of treatment for duodenal injuries and factors that influence incidence rates. It then discusses techniques for diagnosis, including physical exam, imaging studies, and exploratory laparotomy. Finally, it reviews surgical management strategies and repairs that can be used to treat duodenal injuries.
Practice management guidelines for selective nonoperative manegement of penet...precirujanos
This document provides practice management guidelines for the selective nonoperative management of penetrating abdominal trauma developed by the Eastern Association for the Surgery of Trauma Practice Management Guidelines Committee. The committee conducted a literature review to develop recommendations on which patients can be safely managed without mandatory laparotomy after penetrating abdominal injury. The guidelines conclude that stable patients without peritonitis or diffuse abdominal tenderness from stab wounds or tangential gunshot wounds do not require routine laparotomy. Abdominal CT and serial examinations can help determine the need for surgery. The guidelines are intended to minimize unnecessary laparotomies while ensuring timely treatment of injuries.
This document summarizes a study on using an endoluminal device called the StomaphyX to reduce gastric pouches after Roux-en-Y gastric bypass surgery in patients experiencing weight regain. Thirty-nine patients underwent the procedure, with an average excess weight loss of 7.4% at 2 weeks, 10.6% at 1 month, and 19.5% at 1 year. Minor complications included sore throat and epigastric pain. The procedure may offer an alternative to open or laparoscopic revisional surgery for weight regain with no major complications observed.
Current concepts in the management of esophagueal perforationsFerstman Duran
This study analyzed 119 patients with esophageal perforations treated at a hospital in Canada between 1981-2007 to identify factors associated with mortality. The researchers found that malignant perforations, pre-operative respiratory failure requiring mechanical ventilation, higher comorbidity burdens, and sepsis were associated with significantly higher mortality based on multivariate analysis. However, time to treatment was not associated with increased mortality. Primary repair or resection with reanastomosis can be attempted even in patients treated after longer time periods from perforation.
This document discusses the diagnosis and management of caustic esophageal strictures. It begins by outlining the clinical symptoms of dysphagia that result from caustic ingestion and lead to stricture formation. Diagnosis involves esophagogram or esophagoscopy at least 6 weeks after injury to identify strictures. Treatment involves endoscopic dilatation using wire-guided dilators, with multiple sessions often needed for complex strictures. Advanced endoscopic techniques have reduced the need for esophageal replacement surgery. The document concludes that caustic esophageal strictures can be successfully managed through endoscopic dilatation.
Diagnostic Laparoscopy for ITU patientsArshad Hayat
Diagnostic laparoscopy can be used safely in the ICU to diagnose intra-abdominal pathology in critically ill patients without moving them to the operating room. It has a high diagnostic accuracy of 90-100% and can help avoid unnecessary laparotomies in 36-95% of cases. While it has some limitations for retroperitoneal processes, diagnostic laparoscopy is recommended for use in the ICU when an intra-abdominal catastrophe is suspected but cannot be ruled out noninvasively, or to evaluate for conditions like acalculous cholecystitis or ischemic bowel. Any complications are typically minor and it does not increase mortality, which remains high for the critically ill ICU patient population.
Bouveret's syndrome as an unusual cause of gastric outletFerstman Duran
This case report describes an 83-year-old man who presented with vomiting and abdominal pain and was found to have Bouveret's syndrome. Endoscopy revealed a large mass obstructing the duodenum, which was discovered to be a gallstone during surgery. The gallstone had caused a cholecysto-duodenal fistula. Initial surgery removed the fistula but the gallstone remained, requiring a second surgery to remove it from the duodenum. Bouveret's syndrome is a rare complication of gallstones that can cause gastric outlet obstruction.
Right side diverticulitis, differential diagnosis of complicated appendicitis...Juan de Dios Díaz Rosales
A 23-year-old female presented with abdominal pain suggestive of appendicitis. During an emergency appendectomy, a perforated cecal diverticulitis was discovered instead. A segment of the cecum and distal ileum were resected. Histopathological analysis confirmed a diverticulum with chronic inflammation and acute exacerbation. Right-sided diverticulitis can mimic appendicitis and should be considered as a differential diagnosis during abdominal surgeries initially intended to be an appendectomy.
The Mini-Gastric Bypass:Best Treatment Type 2 Diabetes MellitusDr. Robert Rutledge
The Mini-Gastric Bypass:Best Treatment Type 2 Diabetes Mellitus
Dr K S Kular
Kular Medical Education & Research Society ,
Kular Group of Institutes ,
drkskular@gmail.com
www.kularhospital.com
The IOSR Journal of Pharmacy (IOSRPHR) is an open access online & offline peer reviewed international journal, which publishes innovative research papers, reviews, mini-reviews, short communications and notes dealing with Pharmaceutical Sciences( Pharmaceutical Technology, Pharmaceutics, Biopharmaceutics, Pharmacokinetics, Pharmaceutical/Medicinal Chemistry, Computational Chemistry and Molecular Drug Design, Pharmacognosy & Phytochemistry, Pharmacology, Pharmaceutical Analysis, Pharmacy Practice, Clinical and Hospital Pharmacy, Cell Biology, Genomics and Proteomics, Pharmacogenomics, Bioinformatics and Biotechnology of Pharmaceutical Interest........more details on Aim & Scope).
All manuscripts are subject to rapid peer review. Those of high quality (not previously published and not under consideration for publication in another journal) will be published without delay
This study assessed the efficacy of different surgical techniques (open surgery, percutaneous nephrolithotomy [PNL], and retrograde intrarenal surgery [RIRS]) for treating kidney stones. 102 patients undergoing kidney stone surgery were divided into the three treatment groups. The mean stone burden, operative time, length of hospital stay, and residual stone rates were compared between groups. Complications like fever, infection, urine leakage and persistent pain were also assessed. PNL and RIRS had lower stone burdens, shorter operative times, shorter hospital stays, and fewer complications compared to open surgery. PNL and RIRS were found to be safer and more effective treatments for kidney stones than open surgery.
Preoperative leukocytosis as predictor of intraabdominal injury in penetratin...Juan de Dios Díaz Rosales
This document summarizes a study on using preoperative leukocytosis as a predictor of intraabdominal injury in patients with penetrating abdominal trauma. The study included 231 patients who underwent exploratory laparotomy for abdominal trauma. Patients were divided into two groups: those with therapeutic laparotomy who had intraabdominal injuries (Group I), and those with non-therapeutic laparotomy who did not have intraabdominal injuries (Group II). The study found that 74.2% of patients in Group I had leukocytosis levels over 12,500/mm3, compared to only 27.7% of patients in Group II, indicating leukocytosis over 12,500/mm3 may help predict which patients have intra
This study compared outcomes of laparoscopic appendectomy versus open appendectomy in 68 patients with acute appendicitis. Patients were divided into two groups - Group I underwent laparoscopic appendectomy while Group II underwent open appendectomy. The time to start oral feeding and average hospital stay were shorter in the laparoscopic group compared to the open group. Post-operative wound infections and abscesses were also less common in the laparoscopic group. The study concluded that laparoscopic appendectomy is an effective treatment for acute appendicitis compared to open appendectomy.
A 40-year-old male presented to the emergency department with acute abdominal pain and distension after eating a heavy meal two days prior. Imaging showed massive gastric dilatation. Conservative management failed, so the patient underwent surgery. In surgery, the stomach was found to be hugely distended with thinned walls but no perforation. A gastrojejunostomy was performed to decompress the stomach. The patient recovered well post-operatively.
This document summarizes an article about evolving definitions, preventive strategies, and management of pancreatic fistula after pancreatectomy. It discusses how pancreatic resection is the standard treatment for pancreatic malignancy and certain benign disorders, but is a technically demanding procedure. While mortality after pancreaticoduodenectomy is now <3-5% in experienced centers, post-operative morbidity is around 30-50%, with pancreatic leakage and fistula being the most significant cause. The development of a pancreatic fistula increases hospital stay, costs, and can lead to life-threatening complications. The article reviews strategies to decrease fistula rates and emphasizes the importance of early recognition and treatment. It also discusses how there is no universally accepted definition of pancreatic fistula
Bouveret’s syndrome case report and review of the literatureFerstman Duran
This case report describes a patient with Bouveret's syndrome who presented with nausea, vomiting, abdominal pain and melena. Imaging revealed a gallstone obstructing the duodenum. The stone was successfully removed during an endoscopy using various extraction devices and mechanical lithotripsy. Bouveret's syndrome is a rare complication of gallstones that occurs when a gallstone passes through a cholecystoduodenal fistula and becomes lodged in the duodenum, causing gastric outlet obstruction. Endoscopic extraction is recommended as first-line treatment when possible due to its lower risk compared to surgery. The literature on Bouveret's syndrome and approaches to treatment, including endoscopic, lithotripsy and surgical
Open Versus Laparoscopic Repair for Perforated Peptic Ulcer: from personal ex...Raimundas Lunevicius
This document compares open versus laparoscopic repair for perforated peptic ulcers through a retrospective study and systematic review. The study analyzed 222 patients treated for perforated peptic ulcers, comparing 60 patients who underwent laparoscopic repair to 162 who had open repair. Results found that for low risk patients, laparoscopic repair had similar rates of wound infection and mortality as open repair, with shorter hospital stays. The systematic review concluded laparoscopic repair is at least as safe and effective as open repair for low risk patients with no Boey risk factors.
The document discusses traumatic injuries to the gallbladder and biliary ducts. It notes that 95% of biliary tree injuries are iatrogenic, while 5% are due to trauma. Trauma to the gallbladder occurs in 3-5% of abdominal trauma cases, while injuries to the biliary ducts occur in 0.5% of cases. Diagnosis is often intraoperative when associated injuries like liver, vascular, duodenal or splenic injuries are found. Imaging like CT may show duct dilation or periportal collections but do not always locate the injury site. ERCP is useful for diagnosing the location and type of biliary duct injury. Management depends on the specific injury but may include cholecystectomy
This study examined whether hip involvement negatively impacts radiographic outcomes after lumbar pedicle subtraction osteotomy (PSO) in ankylosing spondylitis patients with thoracolumbar kyphosis. 44 patients underwent one-level lumbar PSO and were divided into two groups based on their hip involvement scores. Both groups had similar corrections of local kyphosis, but the group with hip involvement had significantly larger sagittal vertical axis and pelvic tilt postoperatively, indicating hip involvement can negatively impact radiographic outcomes after lumbar PSO. Additional osteotomies may be needed for patients with hip involvement to achieve satisfactory correction.
This document discusses the management of duodenal injuries, which are challenging to diagnose and treat due to the duodenum's retroperitoneal location and proximity to major blood vessels. It provides an overview of the historical understanding and surgical techniques for duodenal injuries, and reviews considerations for diagnosis and various surgical repair methods used to treat these injuries. Successful management of duodenal trauma requires a high index of suspicion, prompt surgical exploration and treatment, and the skill to employ different repair techniques depending on the severity and location of the injury.
This document discusses the management of duodenal injuries. It notes that while duodenal injuries are uncommon, accounting for about 4% of abdominal injuries, they can have high morbidity and mortality rates of 65% and 20% respectively due to difficulties in diagnosis and management. It outlines the history of treatment for duodenal injuries and factors that influence incidence rates. It then discusses techniques for diagnosis, including physical exam, imaging studies, and exploratory laparotomy. Finally, it reviews surgical management strategies and repairs that can be used to treat duodenal injuries.
Practice management guidelines for selective nonoperative manegement of penet...precirujanos
This document provides practice management guidelines for the selective nonoperative management of penetrating abdominal trauma developed by the Eastern Association for the Surgery of Trauma Practice Management Guidelines Committee. The committee conducted a literature review to develop recommendations on which patients can be safely managed without mandatory laparotomy after penetrating abdominal injury. The guidelines conclude that stable patients without peritonitis or diffuse abdominal tenderness from stab wounds or tangential gunshot wounds do not require routine laparotomy. Abdominal CT and serial examinations can help determine the need for surgery. The guidelines are intended to minimize unnecessary laparotomies while ensuring timely treatment of injuries.
1) The authors reviewed outcomes of 104 consecutive minimally invasive esophagectomies (MIEs) performed between 1998-2007.
2) Surgical approaches included thoracoscopic/laparoscopic esophagectomy with cervical anastomosis (n=47), minimally invasive Ivor Lewis esophagectomy (n=51), and others.
3) Complications included anastomotic leak in 9.6% of patients and stricture in 26%. Mortality was 1.9% at 30 days and 2.9% in-hospital. Mean lymph nodes retrieved was 13.8.
Changing pattern of mechanical bowel obstruction and management outcome in no...BRNSSPublicationHubI
This study reviewed 94 patients treated for mechanical bowel obstruction over 5 years in North-Eastern Nigeria. Tumor was the most common cause of obstruction (27.66%), surpassing hernias which had previously been most common. Bowel resection was the most common procedure (54.26%). Post-operative complications included surgical site infections (22.34%) and enterocutaneous fistulas (3.19%). Mortality was 15.96%, primarily due to metastatic colon tumors. The rising incidence of colon tumors and availability of elective hernia repair have led to tumors becoming the predominant cause of mechanical bowel obstruction.
Component seperation technique for the repair of very large ventral hernias nikhilameerchetty
Includes all the ventral hernia repairs with the loss of domain and the various methods of component separation technique with their success rate for their repair ,few videos showing the methods of repair in addition to the latest techniques of repair .
This document discusses the application of damage control surgery principles from trauma surgery to non-traumatic abdominal emergencies. Damage control surgery involves abbreviated laparotomy to control hemorrhage or contamination, followed by physiological resuscitation and delayed definitive repair. While evidence is limited to retrospective case series, damage control surgery is increasingly used for conditions like uncontrolled bleeding, sepsis, and mesenteric ischemia. It facilitates life-saving intervention for critically ill patients and allows physiological restoration before definitive repair. The benefits depend on careful patient selection and application of a staged surgical approach when patients present with physiological derangement from hemorrhagic or septic shock.
Damage control surgery is a strategy used for critically ill patients with abdominal emergencies to control bleeding or contamination through an abbreviated initial surgery, allow physiological recovery, and perform definitive repair later. It has been applied to non-trauma emergencies like hemorrhage and sepsis. While evidence is limited to retrospective case series, damage control surgery appears to be a logical approach for severely ill general surgery patients based on its success in trauma. It facilitates life-saving intervention and stabilization before complete repair.
Liver trauma is an important cause of morbidity and mortality in Pakistan. This study analyzed 113 patients who underwent surgery for liver trauma at a teaching hospital from 2003-2010. Most patients were young males injured in road traffic accidents. Over 80% presented with low blood pressure and over half had other organ injuries as well. The majority had grade I or II liver injuries. The most common surgery was packing the liver with abdominal packing. Post-operative complications occurred in nearly a quarter of patients, with an in-hospital mortality rate of 9.7%. Liver trauma predominantly affects young males and improved emergency response is needed to reduce complications.
The document discusses several studies on the use of laparoscopic (TEP) and open preperitoneal (OPM) approaches for repairing recurrent inguinal hernias. The studies found that both approaches had low recurrence rates of around 2%, with the TEP approach having shorter operating times and hospital stays compared to OPM. Overall, the studies concluded that the preperitoneal approaches, whether open or laparoscopic, are good options for repairing recurrent inguinal hernias when performed by experienced surgeons.
Endoscopic submucosal dissection of gastric neoplastic12Taisir Shahriar
1) A systematic review was conducted of studies reporting on ESD of gastric neoplastic lesions in patients with liver cirrhosis. The review identified 68 ESD procedures in 61 cirrhotic patients reported in 3 studies.
2) En bloc resection was successful in 88.2% of cases and complete (R0) resection in 89.7% of cases. Post-procedure bleeding occurred in 13.1% of patients and was managed endoscopically.
3) Patients with more advanced cirrhosis (Child-Pugh class B/C) had a higher risk of bleeding compared to those with less severe disease (Child-Pugh class A). No procedure-related deaths occurred.
This study examined factors associated with the timing of death due to cancer recurrence after esophagectomy for adenocarcinoma. The study found:
- Of 351 patients who underwent esophagectomy, 191 (54%) died of cancer recurrence. The majority (97%) of these patients died within 5 years.
- Factors independently associated with earlier death due to recurrence included higher T-stage, lymph node ratio over 0.2, and presence of extracapsular lymph node involvement.
- Among patients who died of recurrence, earlier death was also associated with experiencing postoperative complications. This suggests complications may disturb the immune system and allow faster growth of residual cancer.
- The occurrence of complications was not directly
This case series describes 8 patients who presented with acute mesenteric ischemia and bowel gangrene. The most common presenting symptom was abdominal pain. Four patients had pre-existing cardiac conditions that increased their risk. All patients underwent exploratory laparotomy where gangrenous bowel segments were resected. Post-operative complications occurred in 4 patients, and the mortality rate in the series was 37.5%. Acute mesenteric ischemia can be difficult to diagnose due to non-specific symptoms, but prompt surgical treatment is needed to prevent high mortality from bowel necrosis.
This document discusses the principles of surgical treatment for Zenker diverticulum. It begins with an introduction that discusses the etiology and pathogenesis of Zenker diverticulum. It then describes a study of 11 patients who underwent surgical treatment for Zenker diverticulum between 2001-2011. The surgical approach involved resection of the diverticular pouch and esophageal myotomy. Complications included postoperative hematoma in two patients and esophageal leak in two patients. Early postoperative results showed relief of dysphagia symptoms. Long term follow up was limited due to the short monitoring period for many patients.
Non-Operative Management in Oesophagic Tear Due to Sengstaken Tubesuppubs1pubs1
This case report describes the non-operative management of a large oesophageal tear in a 79-year-old man. After a Sengstaken tube was inserted to treat upper gastrointestinal bleeding, a CT scan showed the gastric balloon inflated in the oesophagus. Endoscopy then revealed a 10 cm oesophageal tear. Due to the early diagnosis, the patient's general condition, and limited contamination, endoscopic stenting was used instead of surgery. Two metal stents were placed and removed after two weeks with complete healing of the tear. The patient was discharged four days later with no signs of perforation, demonstrating that selected cases of large oesophageal tears can be successfully treated with non-operative management including endoscopic
Uretero-Enteric Anastomosis Stricture after Urinary Diversion; Detailed Analy...JohnJulie1
To report the lessons we have learned in the management of uretero-enteric anastomosis stricture (UEAS) in a tertiary urology center over a decade of experience.
Uretero-Enteric Anastomosis Stricture after Urinary Diversion; Detailed Analy...NainaAnon
To report the lessons we have learned in the management of uretero-enteric anastomosis stricture (UEAS) in a tertiary urology center over a decade of experience.
Frequency of Anastomotic Leak in Early Versus Dealyed Oral Feeding after Elec...semualkaira
Intestinal stoma is usually performed as component of other surgical intervention for small and large bowel
pathologies. Of these temporary colostomy are commonest stomas
created for de-functioning of the distal anastomotic site to minimise the chances of leak. Colostomy is usually reversed at 8 to 12
weeks and Ileostomy closure is often considered a minor procedure but it is associated with significant morbidity and mortality
Este documento describe la hemicorporectomía, que implica la amputación de la mitad inferior del cuerpo por debajo de la columna lumbar. Las indicaciones incluyen cáncer confinado a la pelvis, traumatismos severos de la pelvis y extremidades inferiores, y osteomielitis pélvica terminal. La técnica quirúrgica ha evolucionado de un solo tiempo quirúrgico a un enfoque de múltiples etapas que incluye una colostomía terminal y el cierre de la herida con un colgajo mi
Este documento resume la anatomía del hígado y las vías biliares. Describe que el hígado pesa alrededor de 1.5 kg y se encuentra en el cuadrante superior derecho del abdomen. Explica sus ligamentos de soporte y relaciones con otros órganos. También describe la irrigación sanguínea del hígado, incluida la vena porta y las arterias hepáticas. Finalmente, resume brevemente la histología del hígado, incluida la organización de los hepatocitos en lobulillos hepátic
Este documento resume los conceptos básicos, técnicas quirúrgicas, niveles, complicaciones y resultados funcionales de las amputaciones de las extremidades inferiores. La amputación es un procedimiento común para eliminar tejidos no viables, principalmente debido a causas vasculares o traumáticas. Existen diferentes tipos de amputaciones según el nivel anatómico, desde dedos del pie hasta la rodilla o muslo. El éxito depende de una adecuada selección preoperatoria y rehabilitación posterior para lograr la
Hastened Attachment Of A Superficial Inf Epigastric Flapguest1c9ac82
This case report describes using the vacuum-assisted closure (VAC) device to hasten the attachment of a superficial inferior-epigastric artery flap used to reconstruct a third-degree burn injury on the hand of a 33-year-old patient. The VAC system was applied in a glove-like shape beneath the flap. After 4 days, hastened attachment of the flap to the exposed fingers was observed. The author reports that using the VAC system may decrease the typical 2-3 week attachment period for such flaps by promoting wound granulation and vascularization.
The document summarizes the pedicled transverse rectus abdominis myocutaneous (TRAM) flap procedure for breast reconstruction. It describes the indications, techniques, and outcomes of the procedure. The pedicled TRAM flap provides natural breast reconstruction with limited morbidity and good patient satisfaction. The document outlines the surgical steps including flap harvest, tunneling, and abdominal closure to properly perform the procedure and minimize complications.
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1) N-acetylcysteine (NAC) was used as a mucolytic agent to treat peripancreatic collections in a patient with severe acute pancreatitis after necrosectomy.
2) Administration of NAC into drainage tubes increased daily drain output from 50-120 mL to over 500 mL, indicating it helped break down the highly viscous fluid.
3) A follow up CT scan after treatment with NAC for 4.5 weeks showed reduction in size of the peripancreatic collection, and the patient made a full recovery with NAC treatment continued for 7 months.
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The document summarizes the pedicled transverse rectus abdominis myocutaneous (TRAM) flap procedure for breast reconstruction. It describes the indications, techniques, and outcomes of the procedure. The pedicled TRAM flap provides natural breast reconstruction with limited morbidity and good patient satisfaction. The document outlines the surgical steps including flap harvest, tunneling, and abdominal closure to properly perform the procedure and minimize complications.
Formacion De Especialistas Responsabilidad Compartidaguest1c9ac82
This document summarizes the pedicled transverse rectus abdominis myocutaneous (TRAM) flap procedure for breast reconstruction. It indicates that the pedicled TRAM flap has become a common autologous reconstructive procedure due to its ability to create a natural breast mound with limited morbidity. The document describes the indications, techniques, and risks of the pedicled TRAM flap procedure.
Formacion De Especialistas Responsabilidad Compartidaguest1c9ac82
El documento discute la necesidad de mejorar la formación de médicos especialistas en México a través de un enfoque basado en competencias. Actualmente, los médicos reciben formación en instituciones diferentes con planes de estudio no unificados, lo que resulta en calidades y habilidades desiguales entre los egresados. Se propone la creación de un modelo educativo nacional estandarizado para garantizar una formación de alta calidad y uniforme. También es necesario mejorar la integración entre la educación teórica y la práctica clínica para
El documento discute la necesidad de mejorar la formación de médicos especialistas en México a través de un enfoque basado en competencias. Actualmente, los planes de estudio varían entre universidades y no garantizan la calidad uniforme de los egresados. Se propone integrar mejor la educación teórica con la práctica clínica y coordinar al sector salud y educación para establecer modelos educativos alineados a las necesidades de la población.
El documento describe los elementos clave de una investigación y la elaboración de un informe de investigación. Explica que un informe de investigación describe el estudio realizado, incluyendo el objetivo, la metodología, los resultados y las conclusiones. También destaca que el formato del informe depende del usuario final, ya sea en un contexto académico donde se enfatiza la metodología científica, o en un contexto no académico donde se enfatizan las conclusiones y su aplicabilidad. Además, enumera los elementos típicos de
Este documento trata sobre conceptos estadísticos fundamentales como distribuciones muestrales, estadística inferencial y nivel de significancia. Explica que una distribución muestral es un conjunto de valores sobre una estadística calculada de todas las muestras posibles de determinado tamaño, y que la estadística inferencial permite generalizar los resultados obtenidos en una muestra a la población completa. También presenta un esquema del procedimiento de la estadística inferencial que involucra la recolección de datos, cál
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Este documento resume los pasos para formular hipótesis en una investigación. Explica que las hipótesis son explicaciones tentativas del fenómeno investigado y que deben definir las variables conceptual y operacionalmente. También describe las características que deben tener las hipótesis, como referirse a situaciones reales y tener términos comprensibles, precisos y concretos con una relación clara entre las variables.
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Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
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Travel Clinic Cardiff: Health Advice for International TravelersNX Healthcare
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2. The Journal of TRAUMA Injury, Infection, and Critical Care
Injuries were diagnosed and graded during laparotomy.
Operative repair was dictated by surgeon preference. Duode-
nal wound repairs were hand-sewn, one or two layer closures.
Pyloric exclusions were stapled distal to the pylorus and
included decompressive retrograde duodenostomy tubes.
Gastrojejunostomies were either hand-sewn or stapled.
Patients repaired without pyloric exclusion were com-
pared with patients repaired with pyloric exclusion and de-
scriptive statistics with the appropriate post hoc analysis
applied ( 2, Fisher exact test, t test). A p value less than 0.05
was considered statistically significant. Recorded and ana-
lyzed data included age, sex, mechanism of injury, grade of
injury, Injury Severity Score (ISS; calculated using Abbrevi-
ated Injury Scales [AIS] for head, face, chest, abdomen,
Fig. 1. Eighty-one associated injuries were found in 29 patients
extremities, and external; the three most severely injured
(mean 2.8/patient). The liver was the most frequently associated
body regions were each squared (x2) and then summed to
organ injured (19/29, 66%), but vascular (14/29, 48%), pancreatic
yield the ISS), evidence of hypovolemic shock (systolic pressure
(13/29, 45%), colon (10/29, 34%), small bowel (7/29, 24%), and
90 mm Hg), major vascular injuries, associated abdominal
stomach (7/29, 24%) injuries were still common. Gallbladder (6/29,
injuries, postoperative complications, fistula formation, length of
21%), kidney (4/29, 14%), and spleen (1/29, 3%) were also injured.
hospital stay, and mortality (survival 48 h).
RESULTS marily comprised gun shot victims (no PE, 67% vs. PE, 87%,
The study population was 100% male with a mean age of p 0.169). Although a statistical difference in duodenal
29 years (range, 19 – 69 years). All had penetrating injuries, injury grade between groups was not identified, a trend to-
of which 23 of 29 (79%) suffered gun shot wounds, and 6 of ward greater injury severity was noted in the pyloric exclu-
29 (21%) were stabbed. Seventeen of 29 (59%) patients had sion group (no PE, 2.5 0.7 vs. PE, 3.0 0.6, p 0.064).
multiple duodenal injuries— 46 duodenal wounds were dis- The single patient in the study population with a grade I
covered in total. The majority of wounds sustained (30 of 46, duodenal injury had an associated pancreatic injury and was
65%) were to the second portion of the duodenum (Table 1). repaired without the protection of a pyloric exclusion. Nine
The remaining injuries were distributed anatomically as fol- patients (31%) suffered grade II duodenal injuries, of which
lows: first portion, 4 injuries (9%); third portion, 9 injuries six were repaired without pyloric exclusion and three repaired
(20%); fourth portion, 3 injuries (7%). None of these wounds with pyloric exclusion. Sixteen of the 29 patients (55%) had
involved the ampullary complex. All patients in this study grade III injuries. Eight of this group of 16 with grade III
suffered injuries to abdominal organs other than the duode- injuries were primarily repaired without exclusion, and an-
num. In total, 81 associated injuries were identified in these other eight were treated with pyloric exclusion. Three suf-
29 patients (mean 2.8 associated injuries per patient). The fered severe grade IV duodenal trauma, all of which were
liver was the most frequently injured associated organ (19 of combined pancreaticoduodenal injuries and all treated with
29, 66%), but major vascular (14 of 29, 48%), pancreatic (13 pyloric exclusion (Table 2).
of 29, 45%), colon (10 of 29, 34%), small bowel (7 of 29, Thirteen of the 29 patients suffered combined pancreati-
24%), stomach (7 of 29, 24%), and gallbladder (6 of 29, 21%) coduodenal injuries. Ten of these 13 (77%) patients underwent
injuries were also common. Kidney and splenic injuries were pyloric exclusion, whereas 3 (23%) patients had primary repair
less frequent (Fig. 1). alone. Patients suffering combined pancreaticoduodenal injuries
Patients repaired without pyloric exclusion (no PE, n (n 13) had similar pancreatic injury grades between compar-
15) and with pyloric exclusion (PE, n 14) were similar with ison groups (no PE 2.7 2.1 vs. PE 2.0 0.9, p 0.799). ISS
respect to age, sex, and injury mechanism. Both groups pri- scores, a global indicator of injury severity in patients with
multiple injuries, were also similar between groups (no PE,
18.4 8.3 vs. PE, 23.2 17.5, p 0.631). Shock (no PE, 33%
Table 1 Duodenal Injury Location (n 46) vs. PE, 21%, p 0.682) and vascular injury (no PE, 53% vs. PE,
Location No. Wounds (%) 43%, p 0.847) were similarly present in both patient groups.
After confirming that our two surgical treatment groups
D1 4 (9)
D2 30 (65) had similar demographics and clinical characteristics, clinical
D3 9 (20) outcomes were compared (Table 3). Measured parameters
D4 3 (7) included overall complication rate, the development of duo-
Forty-six wounds were discovered in 29 patients. The majority of denal and pancreatic fistulas, length of hospital stay, and
these (65%) were contained in the second portion of the duodenum. mortality. Five of 15 (33%) patients who were repaired with-
830 April 2007
3. Pyloric Exclusion for Penetrating Duodenal Injuries
Table 2 Demographics and Clinical Characteristics
No Exclusion Exclusion
p
(n 15) (n 14)
Age (yr) 29.9 7.7* 28.5 12.9 0.280†
Sex (male) 15 (100%) 14 (100%) 1.0‡
Gun shot wounds 10 (67%) 13 (87%) 0.169§
Duodenal Injury Grade 2.5 0.6 3.0 0.7 0.064†
I 1 (7%) 0%
II 6 (40%) 3 (21%)
III 8 (53%) 8 (57%)
IV 0% 3 (21%)
Pancreatic Injury Grade 2.7 2.1 (n 3) 2.0 0.9 (n 10) 0.799†
Injury Severity Score 18.4 8.3 23.2 17.5 0.631†
Shock 5 (33%) 3 (21%) 0.682§
Vascular injury 8 (53%) 6 (43%) 0.847‡
Associated injury 15 (100%) 14 (100%) 1.0§
Patients were statistically similar with respect to age, sex, mechanism, injury grade, injury severity, the presence of shock, vascular injury,
and other associated injuries.
* Mean SD.
†
Mann-Whitney ranked sum test.
‡ 2
test
§
Fisher exact test.
out exclusion had postoperative complications during their with pancreatic injuries (40%, p 0.497) developed pancreatic
hospital course. Of these five patients with postoperative com- fistulas. Length of hospital stay was greater in the PE group (no
plications, four (80%) had evidence of hemorrhagic shock at PE, 13.5 7.7 days vs. PE, 24.3 19.7 days, p 0.087).
admission. Complications included pneumonia (3), adult respi- In-hospital mortality rates were similar in both populations [no
ratory distress syndrome (ARDS; 1), acute renal failure (1), PE, 1/15 (7%) vs. PE, 3/14 (21%), p 0.273].
intra-abdominal abscess (1), and urosepsis (1). None of these 15
(0%) patients suffered a duodenal or pancreatic fistula. Ten of 14
(71%) patients with pyloric exclusion had postoperative com- DISCUSSION
plications consisting of sepsis (5), ARDS (4), pancreatic fistulas Significant controversy exists regarding the best opera-
(4), ventilator dependent respiratory failure (3), acute renal fail- tive treatment for duodenal injuries. Throughout the years,
ure (3), small bowel obstruction (2), wound infections (2), pneu- surgeons have developed several innovative procedures to
monia (2), and intra-abdominal abscesses (1). Only three of both repair the wounded duodenum and prevent fistulization
these 10 (30%) patients with postoperative complications had from repair breakdown. The first method of suture line pro-
evidence of hemorrhagic shock at arrival. Although none of tection was the “triple tube ostomy” described by Stone.6,7 In
these 14 (0%) patients suffered a duodenal fistula, four patients this straightforward surgical technique, a gastrostomy tube
and two separate jejunal tubes are placed. The proximal
jejunal tube is threaded in a retrograde fashion into the duo-
Table 3 Postoperative Complications and Outcome denum to decompress the suture line, whereas the distal tube
No Exclusion Exclusion is placed as standard jejunal feeding access. Despite its tech-
p
(n 15) (n 14) nical simplicity and encouraging initial results, reports from
Complications (5/15) 33% (10/14) 71% 0.093‡ others have failed to show improved outcomes with the
Duodenal fistula (0/15) 0% (0/14) 0% 1.0§ technique.8,9 Procedures for complete diversion of the gas-
Pancreatic fistula (0/3) 0% (4/10) 40% 0.497§ trointestinal stream were soon developed. Berne and Dono-
Length of stay (d) 13.5 7.7* 24.3 19.7 0.087†
van excluded repairs by “diverticulizing” the duodenum.10,11
Mortality (1/15) 7% (3/14) 21% 0.273§
This procedure originally consisted of a duodenal repair, vagot-
A trend toward a higher overall complication rate (71%) and omy, antrectomy, gastrojejunostomy, tube duodenostomy, and T
hospital length of stay (24.3 d) was evident in the pyloric exclusion
group. Although no patient repaired without pyloric exclusion devel- tube biliary drainage. Although effective in diverting enzymatic
oped a pancreatic fistula, 40% (4 of 10) of patients with pyloric secretions, the procedure is complex, time consuming, and re-
exclusion later formed pancreatic fistulas. No patient in either group sects normal tissue in young, often healthy patients. Today
leaked from their duodenal repair. Mortality rates were statistically diverticulization is seldom performed and has largely been re-
similar between groups. placed by the simpler pyloric exclusion.
* Mean SD.
†
Mann-Whitney ranked sum test. First described by Vaughan in 1977, the pyloric exclu-
‡ 2
test. sion consists of a duodenal repair, over-sewing the pylorus
§
Fisher exact test. through a gastrotomy, and gastrojejunostomy.12,13 At present,
Volume 62 • Number 4 831
4. The Journal of TRAUMA Injury, Infection, and Critical Care
the pyloric exclusion is often performed by applying a non- sumption that the pyloric exclusion adjunct prevents
cutting stapler immediately distal to the pylorus, further sim- fistulas.12–15,21 With a trend toward a greater complication
plifying the procedure. Despite its technical simplicity and rate and length of hospital stay in the pyloric exclusion group,
swiftness, the procedure permanently alters the gastrointesti- we have shown that patients repaired without pyloric exclu-
nal tract with the construction of the gastrojejunostomy. Al- sion have similar clinical outcomes when compared with
though most reports indicate that the pylorus reopens within those repaired with pyloric exclusion. Although no compli-
3 weeks in most of patients, the pyloric exclusion remains an cation was directly attributable to the procedure itself, two
ulcerogenic operation. Postpyloric exclusion marginal ulcer- early postoperative partial small bowel obstructions were
ation incidence ranges from 0% to 33% in numerous reports, observed in the pyloric exclusion group. Both resolved with
with most studies demonstrating marginal ulcers in approxi- conservative management. Furthermore, four pancreatic fis-
mately 10% of patients who underwent surveillance tulas were observed after pyloric exclusion in those with
endoscopy.12–15 Postoperative anastomotic leaks and small combined injury. This 40% pancreatic fistula rate is similar to
bowel obstructions have also been described.3,14,15 previous reports describing fistula rates of 33% to 45% after
Concern for these potential morbidities has led several pancreatic injury.14 –17,21,22
authors to attempt to define which duodenal injuries may be Despite our findings, we acknowledge several limitations
repaired with simple suture techniques and which injuries of this study. This was an inpatient study, and thus no long-
may require more sophisticated procedures such as the pylo- term follow-up data were reviewed. As a result, many of the
ric exclusion.2– 4,8 –9,12–14,16 –19 Snyder classified duodenal in- reported complications of the pyloric exclusion procedure
juries as either mild or severe (missile injury, damage to such as marginal ulceration or bowel obstruction may have
75% of the wall circumference, involvement of the first or been overlooked. Furthermore, without a single duodenal
second portion of the duodenum, injury to repair interval 24 fistula, we were unable to examine the clinical outcomes of
h, and common bile duct injury) and advocated complex patients with duodenal fistulas when repaired without and
repairs for these advanced injuries.4 Adhering to these crite- with pyloric exclusion. We postulate that the protection of the
ria, 93% of our population had severe injuries, though pa- pyloric exclusion may benefit those patients with breakdown
tients repaired without pyloric exclusion fared equally or of the duodenal repair because of increased spontaneous
better than those with pyloric exclusion in each of our mea- closure rates, decreased fistula output, and improved nutri-
sured clinical parameters. tion. Lastly, the small sample size, despite a 10-year retro-
AAST grading may be employed to classify duodenal in- spective review of a busy, Level I trauma center, is a result of
jury severity, but injury grade alone may not be an important the infrequency of injury to the well protected duodenum.
factor when deciding to perform a pyloric exclusion.5,20 In our Although the study population is small, the population is
study population, a trend toward greater duodenal injury severity homogeneous, consisting of only penetrating, advanced duo-
was evident in the pyloric exclusion group although statistical denal or combined pancreaticoduodenal injuries. Only a
significance was not reached. Although numerous authors have large, randomized, prospective trial comparing patients with
described the use of the pyloric exclusion for more “severe” duodenal injuries repaired without and with pyloric exclusion
duodenal injuries, Timaran reported that duodenal injury grade will be able to demonstrate the superiority of one technique
is not predictive of either duodenal fistula or mortality. After over the other. Given the rarity of the penetrating duodenal
analyzing several risk factors including shock (SBP 90 mm injury and the innumerable clinical variables, a randomized
Hg), mechanism of injury, Abdominal Trauma Index, and Du- prospective study seems unlikely.
odenal Injury Score, preoperative or intraoperative hypotension In conclusion, the performance of pyloric exclusion for
proved to be the most important predictor of overall complica- penetrating advanced duodenal injury and combined pancre-
tions, duodenal fistulae, and mortality.20 In our series, shock was atic and duodenal injuries was not associated with either
more common in the group without pyloric exclusion, although duodenal fistula formation or improved clinical outcomes in
statistical significance was not reached. Despite the preponder- our study patient population. The observed trend toward
ance of shock in the primary repair-alone group, clinical out- increased rate of pancreatic fistula, overall complications, and
come was equivalent to those who underwent pyloric exclusion. length of hospitalization suggests that the addition of pyloric
In a meta-analysis, Asensio reviewed 15 clinical series exclusion to the repair of duodenal injuries provides no added
containing 1,408 patients with duodenal injuries who under- benefit. On the basis of our findings and those of others, we
went various surgical repairs and found an overall duodenal recommend primary repair without pyloric exclusion for most
fistula rate of 6.6%.1 In our study population, no patient of the penetrating duodenal injuries in hemodynamically sta-
developed a duodenal fistula regardless of surgical treatment. ble patients.
To our knowledge, no previous study has compared patients
repaired without pyloric exclusion to those compared with the
adjunctive procedure. Prior reports have argued in favor of REFERENCES
pyloric exclusion based on low overall duodenal fistulization 1. Asensio JA, Feliciano DV, Britt LD, et al. Management of duodenal
rates in heterogeneous study groups and the unproven as- injuries. Curr Probl Surg. 1993;30:1023–1093.
832 April 2007
5. Pyloric Exclusion for Penetrating Duodenal Injuries
2. Ivatury RR, Nassoura ZE, Simon RJ, et al. Complex duodenal 13. Martin TD, Feliciano DV, Mattox KL, et al. Severe duodenal
injuries. Surg Clin North Am. 1996;76:797– 812. injuries: treatment with pyloric exclusion and gastrojejunostomy.
3. Carrillo EH, Richardson DJ, Miller FB. Evolution in the Arch Surg. 1983;118:631– 635.
management of duodenal injuries. J Trauma. 1996;40:1037–1046. 14. Feliciano DV, Martin TD, Cruse PA, et al. Management of
4. Snyder WH III, Weigelt JA, Watkins WL, et al. The surgical combined pancreaticoduodenal injuries. Ann Surg. 1987;205:673–
management of duodenal trauma. Arch Surg. 1980;115:422– 429. 680.
5. Moore EE, Cogbill TH, Malangoni MA, et al. Organ injury scaling. 15. Buck JR, Sorensen VJ, Fath JJ, et al. Severe pancreatico-duodenal
II. Pancreas, duodenum, small bowel, colon and rectum. J Trauma. injuries: the effectiveness of pyloric exclusion with vagotomy. Am
1990;30:1427–1429. Surg. 1992;58:557–561.
6. Stone HH, Garoni WJ. Experiences in the management of duodenal 16. Mansour MA, Moore JB, Moore EE, et al. Conservative management
wounds. South Med J. 1966;59:864 – 867. of combined pancreaticoduodenal injuries. Am J Surg. 1989;158:531–
7. Stone HH, Fabian TC. Management of duodenal wounds. J Trauma. 535.
1979;19:334 –339. 17. Flynn WJ, Cryer HG, Richardson JD. Reappraisal of pancreatic and
8. Ivatury RR, Nallathambi M, Gaudino J, et al. Penetrating duodenal duodenal injury management based on injury severity. Arch Surg.
injuries: analysis of 100 consecutive cases. Am J Surg. 1985;2:153– 1990;125:1539 –1541.
158. 18. Nassoura ZE, Ivatury RR, Simon RJ, et al. A prospective reappraisal
9. Cogbill TH, Moore EE, Feliciano DV, et al. Conservative of primary repair of penetrating duodenal injuries. Am Surg. 1994;
management of duodenal trauma: a multicenter perspective. 60:35–39.
J Trauma. 1990;30:1469 –1475. 19. Velmahos GC, Kamel E, Chan LS, et al. Complex repair for the
10. Berne CJ, Donovan AJ, White EJ, et al. Duodenal “diverticulization” management of duodenal injuries. Am Surg. 1999;65:972–975.
for duodenal and pancreatic injury. Am J Surg. 1974;127:503–507. 20. Timaran CH, Martinez O, Ospina JA. Prognostic factors and
11. Berne CJ, Donovan AJ, Hagen WE. Combined duodenal pancreatic management of civilian penetrating duodenal trauma. J Trauma.
trauma: the role of end-to-side gastrojejunostomy. Arch Surg. 1968; 1999;47:330 –335.
96:712–722. 21. Graham JM, Mattox KL, Vaughan GD III, et al. Combined
12. Vaughan GD III, Frazier OH, Graham DY, et al. The use of pyloric pancreaticoduodenal injuries. J trauma. 1979;19:340 –346.
exclusion in the management of severe duodenal injuries. Am J Surg. 22. Wynn M, Hill DM, Miller DR, et al. Management of pancreatic and
1977;134:785–790. duodenal trauma. Am J Surg. 1985;150:327–332.
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