British Journal of Surgery

Các bệnh nhân bị cơn tấn công viêm đường mật nguy hiểm đến tính mạng do sỏi gan nguyên phát hai bên với tình trạng teo gan chính và phình đại thùy đuôi đã được đánh giá để thực hiện cắt gan một phần bảo tồn thùy đuôi.

Đây là một nghiên cứu hồi cứu dựa trên dữ liệu thu thập tiến hành từ trước của các bệnh nhân đã trải qua phẫu thuật cắt gan một phần bảo tồn thùy đuôi (cắt bỏ 7 phân khúc gan, chỉ để lại thùy đuôi) từ tháng 3 năm 2003 đến tháng 12 năm 2009. Tất cả bệnh nhân đã thực hiện kiểm tra đường mật đồng thời và soi đường mật. Các kết quả trong và sau phẫu thuật đã được phân tích.

Đã đạt được loại bỏ sỏi ngay lập tức ở cả 12 bệnh nhân tham gia nghiên cứu. Hai bệnh nhân đã trải qua phẫu thuật giãn mạch cho ống mật đuôi bị hẹp. Không có trường hợp tử vong tại bệnh viện và có sáu biến chứng xảy ra ở ba bệnh nhân. Tại thời điểm theo dõi trung bình là 51 tháng, một bệnh nhân đã bị sỏi tái phát ở ống mật thùy đuôi sau 8 tháng và chết do viêm đường mật purulent cấp tính, 17 tháng sau phẫu thuật. 11 bệnh nhân còn lại không có triệu chứng và không còn cơn tấn công viêm đường mật cấp tính nào khác.

Postoperative adhesion formation has been associated with a decreased capacity to degrade intra-abdominally deposited fibrin. Adhesions, once lysed, have a high propensity for reformation. This study tested the hypothesis that patients with a high propensity for adhesion formation as well as adhesion tissue had a reduced fibrinolytic capacity.

Peritoneal biopsies were taken during abdominal surgery from 21 patients who had previously undergone operation; previously formed adhesion tissue was sampled from ten of these patients. Adhesion formation was scored. The fibrinolytic capacity of peritoneum was determined in tissue extracts.

At the time of opening of the abdominal cavity, levels of plasminogen activator inhibitor (PAI) type 1 (P = 0·009) and tissue-type plasminogen activator (tPA)/PAI complex (P = 0·008) were increased in peritoneal samples from patients with severe adhesions compared with those in samples from patients with less severe adhesions. Adhesion tissue similarly had reduced fibrinolytic capacity as judged by a decrease in tPA activity (P = 0·005) and an increase in PAI-1 level (P = 0·01), reflected in an increased level of tPA/PAI complex (P = 0·008) compared with unaffected peritoneum.

These observations demonstrate reduced fibrinolytic capacity in peritoneal tissue in patients with a greater propensity for development of adhesions and likewise in adhesion tissue. This suggests that components of the fibrinolytic system may be used as markers of an increased risk of adhesion development.

Intra-abdominal adhesions and abscesses cause significant morbidity and mortality. The formation of fibrin in the abdominal cavity is a common pathophysiological pathway for both. The aim of this review was to investigate the pathophysiology of intra-abdominal adhesions and abscesses, and to explore the possible sites of action of hyaluronan.

Data were reviewed from the literature using the Medline database.

Both surgery and peritonitis disturb the equilibrium between coagulation and fibrinolysis in the abdominal cavity in favour of the coagulation system. Hyaluronan-based agents reduce adhesion formation after surgery. Moreover, hyaluronan solution reduces abscess formation in experimental peritonitis. Possible mechanisms of action include mechanical separation of wound surfaces, improvement of peritoneal healing, modulation of the inflammatory response and enhanced fibrinolysis.

Diminished fibrin degradation is a common pathway for the formation of adhesions and abscesses. The potential of hyaluronan-based agents to reduce intra-abdominal adhesions and abscesses in abdominal surgery and sepsis is a promising new concept. Elucidating the mechanisms involved and the clinical application of hyaluronan in peritonitis are challenges for future research.

Laparoscopic cholecystectomy is frequently complicated by gallbladder perforation and loss of bile or stones into the peritoneal cavity. The aim of this study was to compare the use of ultrasonic dissection and electrocautery with respect to the incidence of gallbladder perforation and intraoperative consequences.

Between January 1998 and January 2000, 200 patients undergoing elective laparoscopic cholecystectomy were randomized to electrocautery or ultrasonic dissection of the gallbladder. The main outcome measures were gallbladder perforation, operating time and the number of times the lens was cleaned. Univariate and multivariate analyses were performed.

The perforation rate differed significantly: 16 per cent for ultrasonic dissection (n = 96) and 50 per cent for electrocautery (n = 103) (P < 0·001). The operating time of the least experienced surgeons, who had performed fewer than ten laparoscopic cholecystectomies, was significantly shorter when ultrasonic dissection was used, compared with electrocautery. The number of times the lens needed to be cleaned was significantly lower when ultrasonic dissection was used in complicated gallbladders (P < 0·035). At logistic regression analysis, the risk of perforation in the electrocautery group was about four times higher (odds ratio 0·26, P < 0·001) than that in the ultrasonic group. When the groups were matched for prognostic factors, including body mass index and surgical experience, the results were similar to those obtained with univariate and multivariate analysis.

The use of ultrasonic dissection in laparoscopic cholecystectomy reduces the incidence of gallbladder perforation and helps the operation to progress. Less experienced surgeons benefit most from ultrasonic dissection, particularly in complicated intraoperative circumstances.

Các đặc điểm của tăng cận giáp nguyên phát (PHPT) ở các nước đang phát triển ít khi được khảo sát. Nghiên cứu này khám phá các đặc điểm lâm sàng của PHPT tại Ấn Độ với giả thuyết rằng điều này có thể nâng cao nhận thức về cơ chế bệnh sinh của căn bệnh trên toàn thế giới.

Các bệnh nhân liên tiếp mắc PHPT (24 phụ nữ, năm nam giới) đã được kiểm tra theo cách thuần tập trước và sau phẫu thuật cắt tuyến cận giáp.

Tất cả bệnh nhân đều mắc bệnh viêm xương xơ nang với thời gian có triệu chứng trung bình là 2,5 (phạm vi 1–26) năm. 14 bệnh nhân có gãy xương do yếu tố nguy cơ, trong đó tám người phải nằm giường; 20 người có khối u nâu. Mức canxi huyết thanh trước phẫu thuật trung bình là 3,1 mmol/l, trong khi mức hormone cận giáp intact (iPTH) và phosphatase kiềm tổng số (ALP) lần lượt cao gấp 17 lần và 12 lần so với bình thường. Chín bệnh nhân có tổn thương thận rõ ràng, chủ yếu là bệnh thận do canxi. Phẫu thuật cắt tuyến cận giáp luôn dẫn đến hạ canxi huyết nghiêm trọng, cần điều trị vitamin D lâu dài. Trọng lượng tuyến cận giáp trung bình là 8,6 (phạm vi 2,0–36,6) g và đặc điểm của ung thư được phát hiện ở bốn bệnh nhân. Mức calcidiol huyết thanh có tương quan nghịch (P < 0,05) với iPTH huyết thanh và ALP, cũng như trọng lượng tuyến cận giáp.

PHPT ở người Ấn Độ là một rối loạn nghiêm trọng, có triệu chứng với các biểu hiện về xương, cơ bắp và thận ở độ tuổi trẻ. Sự hiện diện của biến thể nặng này của PHPT ở những người Ấn Độ có đủ vitamin D, và sự thiếu hụt bệnh xương ở các quần thể thiếu vitamin D khác, đặt ra khả năng về các yếu tố bệnh sinh bổ sung.

Recent evidence suggests that depletion of skeletal muscle mass (sarcopenia) and an increased amount of intra-abdominal fat (central obesity) influence cancer statistics. This study investigated the impact of sarcopenia and central obesity on survival in patients undergoing liver resection for colorectal liver metastases (CLM).

Diagnostic imaging from patients who had hepatic resection for CLM in one centre between 2001 and 2009, and who had assessable perioperative computed tomograms, was analysed retrospectively. Total cross-sectional areas of skeletal muscle and intra-abdominal fat, and their influence on outcome, were analysed.

Of the 196 patients included in the study, 38 (19·4 per cent) were classified as having sarcopenia. Five-year disease-free (15 per cent versus 28·5 per cent in patients without sarcopenia; P = 0·002) and overall (20 per cent versus 49·9 per cent respectively; P &lt; 0·001) survival rates were lower for patients with sarcopenia at a median follow-up of 29 (range 1–97) months. Sarcopenia was an independent predictor of worse recurrence-free (hazard ratio (HR) 1·88, 95 per cent confidence interval 1·25 to 2·82; P = 0·002) and overall (HR 2·53, 1·60 to 4·01; P &lt; 0·001) survival. Central obesity was associated with an increased risk of recurrence in men (P = 0·032), but not in women (P = 0·712).

Sarcopenia has a negative impact on cancer outcomes following resection of CLM.

Concern has been raised regarding international discrepancies in perioperative mortality after repair of ruptured abdominal aortic aneurysm (rAAA). The variation in in-hospital mortality is difficult to interpret, owing to international differences in discharge strategies. This study compared 90-day and 5-year mortality in patients who had a rAAA in England and Sweden.

Patients undergoing rAAA repair were identified from English Hospital Episode Statistics and the Swedish Vascular Registry (Swedvasc) between 2003 and 2012. Ninety-day and 5-year mortality were compared after matching for age and sex. Within-country analyses examined the impact of co-morbidity, teaching hospital status or hospital annual caseload, adjusted with causal inference techniques.

Some 12 467 patients underwent rAAA repair in England, of whom 83·2 per cent were men; the median (i.q.r.) age was 75 (70–80) years. A total of 2829 Swedish patients underwent rAAA repair, of whom 81·3 per cent were men; their median (i.q.r.) age was 75 (69–80) years. The 90-day mortality rate was worse in England (44·0 per cent versus 33·4 per cent in Sweden; P &lt; 0·001), as was 5-year mortality (freedom from mortality 38·6 versus 46·3 per cent respectively; P &lt; 0·001). In England, lower mortality was seen in teaching hospitals with larger bed capacity, higher annual caseloads and greater use of endovascular aneurysm repair (EVAR). In Sweden, lower mortality was associated with EVAR, high annual caseload, or surgery on weekdays compared with weekends.

Short- and long-term mortality after rAAA repair was higher in England. In both countries, mortality was lowest in centres performing greater numbers of AAA repairs per annum, and more EVAR procedures.

No effective treatment is currently available to prevent progression of small and medium-sized abdominal aortic aneurysms (AAAs). Identification of drugs with sufficient promise to justify large expensive randomized trials remains challenging. One potentially useful strategy is to look for associations between commonly used drugs and AAA enlargement in appropriately adjusted observational studies.

Potential AAA measurements were identified from abdominal imaging reports in the electronic data files of three medical centres from 1995 to 2010. AAA measurements were extracted manually and patients with an aneurysm of 3 cm or larger, who had at least two measurements over an interval of at least 6 months, were identified. Other data were obtained from the electronic data files (demographics, co-morbidities, smoking status, drug use) to conduct a propensity analysis of the associations of drugs and other factors with AAA enlargement.

From 52 962 abdominal imaging studies, 5362 patients with an AAA of 3 cm or more were identified, of whom 2428 had at least two measurements over at least 6 months. Mean AAA follow-up was 3·4 years and the mean AAA enlargement rate was 2·0 mm per year. Propensity analysis demonstrated no significant association of AAA enlargement with statins, beta-blockers, angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers. Diabetes was associated with a reduction in AAA enlargement of 1·2 mm per year (P = 0·008), and chronic obstructive pulmonary disease was associated with increased enlargement (0·5 mm per year; P = 0·050). Moderate AAA measurement variation and substantial terminal digit preference were also observed, but the digit preference became less pronounced after 2000.

This study confirms the negative association of diabetes with AAA progression. There was no evidence that commonly used cardiovascular drugs affect AAA enlargement.