The European journal of surgery. Supplement. : = Acta chirurgica. Supplement最新文献

Objective: To review the physiology, indications, technical aspects, morbidity, and mortality of damage control surgery.

Design: Retrospective study of published papers.

Setting: Teaching hospital, United Arab Emirates.

Interventions: A MEDLINE search on damage control surgery for the years 1981-2001. Further articles were retrieved from the references of the original articles.

Results: The indications for damage control surgery are: the need to terminate a laparotomy rapidly in an exsanguinating, hypothermic patient who had developed a coagulopathy and who is about to die on the operating table; inability to control bleeding by direct haemostasis; and inability to close the abdomen without tension because of massive visceral oedema and a tense abdominal wall. The principles of damage control surgery are: Phase I: laparotomy to control haemorrhage by packing; shunting, or balloon tamponade, or both; control of intestinal spillage by resection or ligation of damaged bowel, or both. Phase II: physiological resuscitation to correct hypothermia, metabolic acidosis, and coagulopathy. Phase III: planned reoperation for definitive repair. Damage control surgery is appropriate in a small number of critically ill patients who are likely to require substantial hospital resources; it has a high mortality (mean 45%, range (10%-69%).

Conclusion: Damage control surgery offers a simple effective alternative to the traditional surgical management of complex or multiple injuries in critically injured patients. Phases I and II can be done at a rural hospital before transfer to a major trauma centre for definitive repair.

Objective: To evaluate the effect of locally applied tranexamic acid on postoperative blood loss and measures of fibrinolysis in drained blood.

Design: Prospective study.

Setting: University hospital, Norway.

Patients: 30 patients operated on for low back pain by screw fixation of the lumbar spine, 16 of who were randomised to be given topical tranexamic acid.

Main outcome measures: Postoperative blood loss after 18 hours. Concentrations of plasmin/alpha2-antiplasmin (PAP) and D-dimer in arterial and drained blood at the time of wound closure and in drained blood after 1 hour.

Results: In the tranexamic group median (interquartile) blood loss was reduced by half from 525 (325-750) ml to 252 (127-465) ml, p = 0.02. In drained blood after one hour the increase in the concentration of PAP was 150 (109-170)% and D-dimer 150 (107-272)% in the tranexamic group compared with the control group where the increase in PAP was 320 (140-540)% and D-dimer 260 (161-670)%.

Conclusion: Tranexamic acid applied in the wound inhibits blood loss by up to a half in major orthopaedic surgery probably because it prevents excessive fibrinolysis.

Objective: To describe our experience of treating recurrent thyroid carcinoma.

Design: Retrospective study of casenotes.

Setting: Teaching hospital, Mexico.

Subjects: 20 patients who developed recurrences of 273 who presented with well-differentiated thyroid carcinoma between 1991 and 1999.

Main outcome measures: Presentation, management, morbidity, and mortality.

Results: There were 18 men and 2 women, median age 51 years (range 28-75). 13 were treated initially by total thyroidectomy and 7 with less than total resection. 16 were given ablative doses of 311I. The median time between initial resection and recurrence was 3 years (range 1-6). The sites of recurrence were cervical lymph nodes (n = 12), thyroid bed (n = 3), or both (n = 5). During a median of 3 years 10 patients were free of disease and 2 had died.

Conclusions: Well-differentiated thyroid cancer usually recurs in the cervical lymph nodes. Further resection offers a high cure rate.

Objective: To describe the demographics, mechanisms, pattern, and severity of injury, the prehospital and hospital care during the first 24 hours, and the outcome in the most severely injured children in a paediatric intensive care unit (PICU).

Design: Retrospective review.

Setting: Paediatric intensive care unit (PICU), Sweden.

Subjects: 45 children (0-16 years of age) with multiple injuries admitted to the PICU in Gothenburg from January 1990 to October 2000, inclusive.

Main outcome measure: Mortality within 30 days after injury.

Results: About 2/100000 children with multiple injuries were admitted to the PICU from the greater Gothenburg area each year from 1990-2000 inclusive. Injuries were more common in boys (n = 29, 64%). The mean age was 7 years (SD 5). Traffic related events (n = 29, 64%) and falls (n = 11, 24%) were the leading causes of injury. Thoracic and abdominal injuries were the most common (17% and 16% respectively). Three children died.

Conclusion: Major trauma with multiple injuries is rare in Swedish children. When they are cared for at a centre with the necessary facilities and trained personnel they have a good chance of survival.

Maslow's theory of the structure of basic needs and how unmet needs relate to anxiety and stress can be used as an underlying framework for clinical practice. The application of this theory is particularly pertinent to symptomatic conditions. In this paper patients with gastro-oesophageal reflux disease are used as an illustration of how better understanding of patient needs may promote well-being and improve delivery of health care.

A true comparison of long-term medical and surgical treatment in gastro-oesophageal reflux disease (GORD) is impossible as few studies have been carried out with adequate randomisation of the patients and long-term evaluation of quality of life. In general the control of the reflux symptoms is roughly equal with medical and surgical treatment. However, surgery can cause other symptoms such as dysphagia or non-specific epigastric discomfort or pain in some patients, which reduces the overall efficacy in controlling the symptoms. Based on a cost utility analysis, Heudebert et al. came to the conclusion that medical treatment was their preferred strategy for most patients with severe erosive oesophagitis.

The term "gastropathy", and discussion surrounding the adverse effects of non-steroidal anti-inflammatory drugs (NSAIDs) on the gastrointestinal (GI) tract, suggests that most of the complications arise from injury to the gastric mucosa, resulting in gastric ulcers that develop complications. The commonest GI complication is bleeding, which results principally from thrombocytopathy or impaired platelet function in the presence of various underlying GI conditions, including but not confined to antecedent peptic ulcer disease, and in some cases ulcers caused by NSAIDs. In unselected cases, bleeding as a result of aspirin or NSAID may occur early in the course of treatment, much of it predictable from a careful history, taken to identify well-defined risk factors, including previous peptic ulcer disease, GI bleeding, or concomitant treatment with steroids, anticoagulants, or anti-platelet drugs. Only in the presence of such risk factors is NSAID use likely to be associated with a serious GI complication. Although GI complications are common in such cases, attributability of the event solely to NSAIDs is low. Attributability of the complication to the drug is highest when NSAID use is the sole risk factor: the estimated incidence of complications in this setting is only about 10% of all NSAID-associated GI complications. In estimating the likely outcome of therapy, the risk factors identifiable from the history in each case before treatment are more important than the choice of NSAID. Independently analysed, the VIGOR and CLASS trials showed that use of rofecoxib or celecoxib caused fewer clinical ulcers and bleeding, but much of the bleeding observed did not arise from ulcers or from sites proximal to the ligament of Treitz. This suggests that the main value of these drugs is the absence of thrombocytopathy: their safety is substantially reduced by concomitant treatment with low doses of aspirin. This paper analyses the separate roles of COX 2-selective agents, H. pylori eradication, and concomitant aspirin prophylaxis or treatment with acid-suppressant drugs.

The physiological effects of psychological and physical stressors on gut function and brain-gut interactions are mediated by outputs of the emotional motor system in terms of autonomic, neuroendocrine, attentional, and pain modulatory responses. IBS patients with irritable bowel syndroms show an exaggerated responsiveness of this system manifesting itself in altered modulation of gastrointestinal motility and epithelial function, in alterations in the perception of visceral events, and in the associated conscious emotional responses. Animal models are being developed with high face and construct validity for functional visceral disorders that affect the gastrointestinal and urogenital tracts. These animal models suggest plausible targets for future drug development both in the periphery and in the central nervous system.

The identification of the various elements of the Corticotropin Releasing Factor (CRF) system including the characterisation of four mammalian CRF-related peptides, the cloning of two CRF receptor subtypes 1 and 2 (CRF1; CRF2) and the development of selective CRF1 receptor antagonists has allowed investigators to establish an important role for the CRF signalling pathways in coordinating the physiological and behavioural components of the stress response. In particular, compelling preclinical evidence showed that both central and peripheral injection of CRF mimicked stress-induced stimulation of colonic motility, transit, defaecation, and occurrence of diarrhoea along with degranulation of mast cells, and increased secretion of prostaglandin E2, mucus, and ionic permeability. Central CRF also increased abdominal pain from colorectal distention in rats and peripheral CRF reduced pain threshold to colonic distention and increased colonic motility in humans. Non-selective CRF antagonists for receptors 1 and 2 and selective CRF, antagonists inhibit exogenous (central or peripheral) CRF, and acute stress-induced stimulation of colonic motor and secretory function and visceral hyperalgesia. CRF1 receptors mediate stress-related anxiogenic and depression-like behaviours in rodents and CRF, antagonist reduced depression in a phase II clinical trial. These findings lend support to the hypothesis that hyperactivation of CRF1 receptors may contribute to the co-morbidity of anxiety and depression and irritable bowel syndrome. Targeting these pathways with selective CRF1 antagonists may be a novel therapeutic venue for diarrhoea-predominant IBS patients.

Considerable advances have been made in the treatment of inflammatory bowel disease (IBD) mainly in that of Crohn's disease, but many questions still remain. We need to develop treatments that modify the disease. The use of immunomodulation using cytokines and anti-cytokines is an important step to achieve this goal. The standard is now the chimeric monoclonal antibody against tumour necrosis factor (TNF) in Crohn's disease. These treatments, however, are associated with problems of immunogenicity and autoimmunity. Moreover a proportion of patients do not respond to treatment and we do not have measurements that predict response. The optimal use and the combined treatment with immunosuppression are under investigation. The safety of this treatment in the long-term is also not established. These costly drugs are not suitable for the management of mild to moderate Crohn's disease and ulcerative colitis (UC). If it turns out that the antigenic drive of the inappropriate immune reaction is in the lumen of the gut changing the gut flora by using probiotics may be the way to go.