Current opinion in general surgery最新文献

Traditional open hernia repairs are usually performed as outpatient procedures under local anesthesia, with minimal morbidity and low recurrence rates. To be widely accepted, any new procedure must at least match current standards of performance. This review summarizes the most widely used techniques for laparoscopic inguinal herniorrhaphy. Early results of over 1700 cases using these techniques are reported. Recurrence was lowest using the total extraperitoneal repair. In selected patients, laparoscopic inguinal herniorrhaphy is a safe and comparable alternative to standard open repairs.

Advances in diagnostic and therapeutic interventions originally intended for use under elective circumstances have been applied to the trauma victim. This review examines the use of three of these techniques--transesophageal echocardiography (TEE), laparoscopy, and thoracoscopy--in the evaluation and treatment of the trauma patient. Initial experiences with TEE show it to be superior to transthoracic echocardiography in the evaluation of the heart. In limited studies, TEE appears to have the sensitivity to use as a screening tool for aortic disruption; however, it is severely limited by its ability to evaluate the distal aorta only. TEE cannot be used to visualize the ascending aorta or brachiocephalic vessels, which may account for 15% to 20% of injuries. Use of laparoscopy has been reported in more than 350 patients. Its primary use appears to be in decreasing negative and nontherapeutic laparotomies associated with penetrating trauma. The ability to operate through the scope continues to increase as additional improvements in instrumentation are introduced. Thoracoscopy has recently been shown to be able to evacuate retained hemothoraces and even drain empyemas and decorticate the pleural cavity.

Randomized clinical trials on the efficacy of carotid endarterectomy have assisted in the selection of patients for operative intervention. Three such trials involving symptomatic carotid stenosis have confirmed the value of endarterectomy in patients with stenoses 70% or greater. Patients with recent transient ischemic attack or nondisabling stroke should be referred for noninvasive testing. If the patient's stenosis exceeds a threshold level (50% to 70% diameter-reducing lesion), arteriography should be performed and prompt endarterectomy scheduled, rather than antiplatelet therapy, as the primary means of treatment. Furthermore, the results of one clinical trial on asymptomatic stenosis have demonstrated benefits for operative intervention in reducing neurologic events (transient ischemic attack plus stroke). These data require additional confirmation in the analysis of stroke alone, which should be available within the next year from another clinical trial. These trials help to define indications for operation, and the thorough knowledge of their results has become essential to our practices.

Severe acute pancreatitis remains a disease with high hospital mortality. In the period from 1991 to 1992, several articles dealt with the complicated form of acute pancreatitis. There is no question that necrosis of the pancreas and fatty tissue in the peripancreatic spaces and particularly secondary infection of necrosis are the most important prognostic factors for these patients. Indications for surgery and the efficacy of conservative treatment of acute pancreatitis (including interventional measures) have not been clearly determined. Most surgeons would elect to operate on a patient with multiorgan failure caused by infected necrosis, however. Another major question is the type of surgery to be performed: closed continuous lavage of the lesser sac and retroperitoneal cavities, staged relaparotomy, or open packing. This review concentrates on articles pertaining to complicated acute pancreatitis in humans.

Perioperative cardiac morbidity is the leading cause of death following the administration of general anesthesia. With the aging of the population, the number of patients at significant cardiac risk for noncardiac surgical procedures is expected approximately to double over the next 30 years. Assessing cardiac risk will assume increasing importance in surgical decisions. Historical predictors, diagnostic testing predictors, and recent data concerning preoperative cardiac physiology assessment and optimization are discussed.

Neurotrauma advances in 1992 include further elucidation and understanding of the pathophysiologic processes involved in head and spine trauma, major contributions from multicenter clinical pharmacologic trials, and significant refinement of acute management principles. This article integrates the neurotrauma advances of 1992 in the context of the daily treatment of patients with head and spinal cord injuries.

A new stimulus for research into the etiology and pathogenesis of Barrett's columnar-lined lower esophagus has been provided by the discovery that Barrett's esophagus has a very high prevalence in the general population and that adenocarcinoma of the esophagus and cardia is the fastest-growing cancer in the United States. Gastroesophageal reflux disease is the single most important factor in the pathogenesis of Barrett's esophagus, and duodenal juices may play a key role in the development of complications of stricture, ulceration, and possibly even malignant degeneration. Treatment is, therefore, aimed at abolishing all forms of reflux. Acid suppression, if used, needs to be given in massive doses to be effective in gastric hypersecretion and has no effect on other constituents of the refluxed material. Antireflux surgery has been shown to be superior to all forms of medical treatment. Regression is rare after any therapy, but continued surveillance is essential, with increased vigilance in patients with dysplasia or DNA abnormalities on flow cytometry. The role of cigarettes and alcohol in malignant degeneration is refuted.

Endocrine tumors commonly produce characteristic clinical signs, and laboratory tests lead to accurate diagnosis in a high percentage of cases. The successful management of these tumors usually requires complete surgical resection. A large number of preoperative localization procedures to facilitate the operative management of these tumors have been developed. This report reviews the recent contributions to this literature, with a particular emphasis on cost-effective use of these procedures.

Chronic pancreatitis should be treated medically until a surgically correctable complication develops. Incapacitating abdominal pain refractory to medical therapy is the most common indication for operation. Preoperative evaluation of chronic pancreatitis should include a dynamic computed tomography scan to evaluate the pancreas and pancreatic duct. If the pancreatic duct is not seen or is not dilated on computed tomography, an endoscopic retrograde cholangiopancreatogram should be performed. If the pancreatic duct is dilated more than 5 mm, a side-to-side pancreaticojejunostomy should be performed in symptomatic patients. If the pancreatic duct is not dilated and all other causes of pain have been ruled out, a pylorus-preserving Whipple resection or duodenum-preserving pancreatic head resection should be performed. Distal pancreatectomy is reserved for disease isolated to the tail. Total pancreatectomy is used only as a salvage procedure and, whenever possible, should be accompanied by autotransplantation of the residual gland or islet cells.