Current opinion in general surgery最新文献

The survival of infants with biliary atresia has improved significantly during the past two decades as a result of modification of the Kasai hepatoportoenterostomy procedure complemented by advances in liver transplantation. Recent reports suggest that the long-term success rate of the Kasai procedure is 40%. Failures are salvaged by liver transplantation. Advances in organ preservation, the use of reduced-sized grafts, and newer immunosuppressive agents (cyclosporine, FK 506) have strongly influenced these improved results. Unfortunately, liver transplantation is associated with a high complication rate, the risk of opportunistic infection, and an increased rate of malignancy due to immunosuppression. Until immunotolerance can be achieved, the Kasai procedure remains the procedure of choice for infants with biliary atresia. Liver transplantation is a life-saving complementary procedure for patients who fail to drain bile following the Kasai procedure, who are older than 3 to 4 months of age at diagnosis, or who have advanced cirrhosis. In the current era, the overall survival should exceed 80%.

The surgical treatment of patients with the Zollinger-Ellison syndrome has undergone a dramatic evolution since the syndrome was originally described. It is now recognized that an aggressive surgical approach is mandatory because of the malignant potential of gastrinomas in both the sporadic and the familial forms of the syndrome. Although initially regarded as an incurable neoplasm, it is now known that complete surgical resection of gastrinomas can result in eugastrinemia even in the presence of lymph node metastases. It is now recognized that extrapancreatic gastrinomas are more common than pancreatic gastrinomas, and the most common location for an extrapancreatic gastrinoma is the duodenal wall. Major improvements in preoperative imaging and intraoperative localization techniques combined with an increased awareness of the anatomic distribution of gastrinomas have markedly increased the surgeon's ability to care for and cure patients with the Zollinger-Ellison syndrome.

The mortality rate of severe respiratory failure in most centers remains 60% to 90% with conventional pulmonary support techniques. Recent advances in the physiologic management of patients with acute respiratory failure include optimizing systemic oxygen delivery as reflected by continuous mixed-venous saturation monitoring, avoidance of the damaging effects of high inflation pressures and volumes during mechanical ventilation, and the increasing application of extracorporeal life support techniques for refractory respiratory failure. The future promises the routine clinical application of novel support techniques including implantable intracorporeal gas exchange devices and perfluorocarbon liquid ventilation.

This review outlines the progress made in recently reported trials to establish an effective adjuvant treatment for the surgical management of rectal cancer. Many of the trials of preoperative and postoperative radiation conducted over the past two decades are now mature. Moderate-to-high doses of radiation given prior to or following surgery reduce pelvic tumor recurrence rates but have little effect on survival. The coupling of radiation with cytotoxic chemotherapy, particularly 5-fluorouracil-based protocols, has been reported to improve survival as well as reduce the risk of recurrence in the pelvis and elsewhere. The status of ongoing trials is outlined.

Over the past 20 years, the predominant trend in the care of the civilian trauma patient has been toward less invasive therapy. Splenic injuries that are now being identified with computed tomography scan or ultrasound are managed without laparotomy. Similarly, in caring for the patient with potential vascular injury of the extremity, the trend has been toward less invasive means of diagnosis and therapy. Defining which patients need angiography and how to use duplex scanning and pressure indices are still evolving issues.

The closely related processes of healing and adaptation in the intestinal mucosa are of substantial clinical significance in patients after injury, intestinal surgery, and inflammatory or infectious ulceration, as well as all patients who are fasting. Recent investigations demonstrate that mucosal healing and adaptation are complex processes that seem likely to be regulated by a variety of autocrine and juxtacrine growth factors as well as conventional gut peptides. Further studies of the biology of mucosal healing may permit pharmacological intervention to promote healing and adaptation in the future.

The standard treatment of peripheral arterial occlusion has been operative, employing embolectomy, thrombectomy, or bypass grafting to restore blood flow to the compromised extremity. Intra-arterial thrombolysis has been advocated as an initial intervention designed to unmask the anatomic lesion responsible for the occlusive event, with a directed or endovascular modality thereafter. Four thrombolytic agents are in clinical use: streptokinase, urokinase, recombinant tissue plasminogen activator, and acylated plasminogen streptokinase activator complex. The agents differ with respect to efficacy of thrombolysis, fibrin specificity, and cost. At present, urokinase is the most widely used. Recent randomized clinical trials suggest a benefit of thrombolytic therapy in the initial management of acute peripheral arterial occlusion, with improved patient survival and similar amputation rates compared with immediate open intervention. Each modality has its place in specific patient subcategories; the determination of which patients are best served by a specific modality awaits the results of large clinical trials.