Current opinion in general surgery最新文献

This review summarizes the recent literature on alternative surgical procedures for treating rectal carcinoma. After a brief examination of publications on preoperative staging, current reports on alternative surgical procedures, from local excision to anterior resection and extended resection, are discussed. Although radiotherapy and chemotherapy are assuming increasingly prominent roles in the management of rectal carcinoma, detailed examination of these therapies is beyond the scope of this review.

Many recent clinical studies focus on the critically ill or injured hypermetabolic patient and investigate nutritional factors and regimens that can potentially reduce septic complications and improve clinical outcome. In addition to better defining the amount and type of nutrients appropriate for this population, these studies provide insight into important variables such as route of nutrient administration, supplementation of formulas with immune-enhancing (or nonimmunosuppressive) nutrients, and anabolic agents that promote increased nitrogen retention and lean body mass accumulation.

The rapid evolution and acceptance of laparoscopic cholecystectomy for the management of symptomatic cholelithiasis and acute and chronic cholecystitis are unprecedented in modern surgical practice. With rapid advances in laparoscopic and endoscopic instrumentation and surgical skills, many surgeons are developing minimally invasive techniques and strategies for treating the patient with known, suspected, or unsuspected choledocholithiasis. Recent articles describing the current status, complications, results, and future directions of laparoscopic and endoscopic management of common bile duct stones are reviewed. The role of endoscopic retrograde cholangiopancreatography and sphincterotomy, laparoscopic exploration of the common bile duct, choledochoscopy, and percutaneous transhepatic extraction techniques are discussed.

Injury is the leading cause of death among US children over 1 year of age. The financial burden of acute care is over $15 billion annually. The unique anatomic and physiologic differences of children predispose them to certain types of injuries and require a specialized approach to pediatric trauma care. This article reviews the common etiologies of injuries to children and identifies injury subgroups at increased risk of mortality. Resuscitation and assessment are discussed, emphasizing fluid management, rapid intravenous access, and the physiologic evaluation of the child in shock. Protocols for evaluating head, thoracic, abdominal, and pelvic injuries are presented in light of recent advances in the diagnosis, treatment, and rehabilitation of children sustaining these injuries.

There have been several new developments in breast cancer research. Investigators are closer to identifying the breast cancer gene, which may aid in the diagnosis and treatment of the disease. The more established routine of screening mammography has been questioned by the results of the Canadian National Breast Screening Study. Many authors challenge this study's validity. Largely because of screening mammography, noninvasive breast cancer is one of the most frequently diagnosed types of breast cancer. The treatment options for noninvasive breast cancers are discussed along with recent publications. The option of breast-conserving therapy for early stage cancers is also reviewed. Recent investigators have sought to identify the most appropriate patients for breast conservation. This overview also discusses treatment options for advanced cancers and the use of hormonal therapy for all patients with breast cancer.

Surgical investigators have shown that a hemicolectomy can be done laparoscopically. This minimally invasive approach to treat colon cancer potentially reduces hospitalization time, hastens return to normal activity, and reduces health care costs. Hopefully, all of these favorable outcomes can be achieved without compromising cancer control. At present, however, the issues regarding laparoscopic colectomy are not clear, and prospective studies are necessary to validate that this new procedure is superior to open colectomy. Because cancer control might be compromised by this new procedure, laparoscopic colectomy should not be accepted by the surgical community because of the allure of new technology or the hope that it is equivalent to open colectomy in controlling a curable disease. Rather, a randomized trial of laparoscopic colectomy compared with open colectomy is needed to prove that cancer control is not different and that laparoscopic colectomy is cost-effective.

Multiple endocrine neoplasia (MEN) type 1 is an autosomal, dominantly inherited predisposition to develop neoplastic lesions of the parathyroid glands, the neuroendocrine pancreas-duodenum, and the anterior pituitary. The genetic defect was mapped to the centromeric part of the long arm of chromosome 11 based on studies of somatic deletions in MEN-1-associated tumors and linkage analysis in families in whom the disease is segregated. Combined family and tumor analysis has shown that tumorigenesis in MEN-1 involves loss of the wild-type chromosome, indicating that the putative MEN-1 gene is a tumor suppressor gene. Similar deletions are also seen in a proportion of sporadic parathyroid and pancreatic tumors, suggesting that tumorigenesis involves related mechanisms in both sporadic and familial cases. Based on results from linkage analysis in more than 40 MEN-1 families, predictive testing for MEN-1 using DNA polymorphisms can now be performed with high accuracy. Hence, biochemical screening programs can focus on individuals at risk to identify early signs of tumor development. MEN-2, an autosomal dominant cancer syndrome of variable expressivity, has previously been localized to chromosome 10q11.2 by positional cloning tactics. The RET protooncogene mapping to the MEN2 susceptibility locus has recently emerged as a candidate gene for MEN-2A. RET, a transmembrane receptor protein, has a large glycosylated extracellular domain containing clustered cysteine residues and calcium-binding motifs, a single hydrophobic transmembrane domain, and a cytoplasmic domain with tyrosine kinase catalytic activity. Several germline missense mutations in a codon specifying one of these highly conserved cysteine residues have been detected in patients affected with MEN-2A.(ABSTRACT TRUNCATED AT 250 WORDS)

The diagnosis of primary sclerosing cholangitis is made radiologically in patients with extrahepatic obstructive jaundice. This condition lacks a known cause and another method of diagnosis, and its treatment is palliative-mechanical, with bypasses, dilation, or orthotopic liver transplantation. Recent progress has been seen in stratifying patients with respect to prognosis. Stratification is important for conducting clinical trials and for predicting which patients should receive a transplant at an earlier, less risky stage in the course of the disease. Expandable metal stents are on trial in patients with benign or malignant strictures. These newer stents seem to be better than polyethylene stents, although their use has not been reported in sclerosing cholangitis. With survival data used as a measuring point, relief of jaundice does not appear to correlate with increased survival. Of concern has been the association of cholangiocarcinoma with sclerosing cholangitis. Cholangiocarcinoma is difficult to recognize clinically and has a negative impact on the results of transplantation.

Klatskin tumors, or hilar cholangiocarcinomas, are an uncommon cause of obstructive jaundice. With the advent of sophisticated imaging studies and cholangiography, these tumors can be preoperatively identified in most patients, and a treatment plan can be outlined before operative exploration. Surgical resection of the hepatic bifurcation with the addition of a hepatic lobectomy as indicated by tumor extension is the treatment of choice. Although complete surgical resection improves survival over that achieved with palliative procedures, the 5-year survival rate remains less than 20%. Postoperative radiation therapy may increase long-term survival.

Among the rare anorectal pathologic conditions published in the literature since 1992, except for malignant pathology, we have taken an interest in anal dermatology with Hailey-Hailey disease; infectious diseases, including tuberculosis, gangrene, actinomycosis, and cytomegalovirus ulcerations; vascular pathology with rectal varices and tumoral pathology with leiomyomas and lipomas; embryologic disorders, including gastric and salivary heterotopia; and a few exceptional lesions, such as spontaneous hematomas and certain traumatic lesions.