Current opinion in general surgery最新文献

In the past 2 years, a revolution of unprecedented scope has occurred in biliary surgery. Laparoscopic cholecystectomy, first performed in 1987, has now become the procedure of choice to treat cholelithiasis. Because laparoscopic surgery proliferated in the absence of controlled clinical trials, concerns have been raised regarding its complications. This article reviews the technique of laparoscopic cholecystectomy, examines its feasibility and complications, and discusses the evolving role of intraoperative cholangiography and the approach to common bile duct stones. In a separate section, we review the year's literature on gallstone pancreatitis and on surgical treatment of benign biliary strictures.

The musculature of the anal sphincter is not involved in ulcerative colitis and is seldom invaded directly by rectal carcinoma. Because the sphincter is capable of preserving a good degree of continence, even after removal of the entire rectum for rectal carcinoma, or even of the entire rectum and colon in ulcerative colitis, it should be preserved in most patients who require surgical treatment for these conditions. This review is primarily concerned with what type of enteric substitute should be used for the excised rectum. It addresses the issues of whether retention of a few centimeters of distal rectum above the anal high pressure zone (when permissible) is of value in patients with rectal carcinoma; whether the entire anal sphincter complex, including the so-called "sampling zone" of anal mucosa, should be preserved in the course of rectal excision for ulcerative colitis; or whether, alternatively, all mucosa above the dentate line should be removed and continuity restored by means of an endoanal, pouch-anal anastomosis. For the patient, the eventual clinical result depends on the quality of the anal sphincter, the physiologic characteristics of the "neorectum," the degree to which anal and rectal function are coordinated, and finally, the judgment and technical skill of the surgeon.

Trauma is a major health and social problem. It is the leading cause of death for those under age 45, and is a major expense to society, in terms of direct medical expense and lost wages. Visceral injury continues to be a major cause of morbidity and mortality in the overall trauma picture. This article reviews the significant developments in the diagnosis and management in specific areas of visceral injury.

From more than 900 articles in the medical literature, published between August 1, 1991 and July 31, 1992, 46 were selected for review. During the year of review, major international symposiums were held on a new drug, FK506, and intestinal transplantation. In addition, at least one new attempt at a unifying hypothesis regarding graft adaptation was proposed. Other studies included living related donor transplantation, results with transplantation for alcoholics, and the controversy regarding the role of liver transplantation for the treatment of Budd-Chiari syndrome. Concerns regarding the recurrence of both hepatitis and primary hepatic malignancy following liver transplantation were also addressed. Two innovative approaches to the treatment of acute liver failure offer exciting promise for the future. Other subjects include histologic evaluation of renal dysfunction in patients with liver disease, quality of life after transplantation, and the proper distribution of precious donor livers.

The introduction of computed tomography has dramatically increased the detection and in turn the incidence of incidentally identified adrenal abnormalities; the current incidence rate is approximated at 2%. Improvements in technology can be expected to increase the reported incidence even further and magnify the clinical problem these abnormalities pose. Although most clinicians would agree that surgery is indicated in patients with primary adrenal malignancy and those with significant endocrine function, strategies for the management of patients with incidentally identified lesions remain controversial. One approach is to base the risk of primary adrenal malignancy on lesion size and undertake biochemical evaluation only for patients who, on clinical grounds, are likely to have endocrinopathy. Another approach is to assess endocrine function (biochemically and radiographically) in all patients and recommend surgery or additional evaluation (eg, needle biopsy) for those found to have abnormalities. Recent studies of patients with benign, incidentally discovered adrenal lesions suggest that these common lesions are almost all hormonally functional to some extent. The natural history of subclinical but functioning adrenal adenomas is not known.

For patients undergoing potentially curative surgery for cancer, the perioperative period is when they appear to be most vulnerable. The antitumor immune response is subjected to a number of iatrogenic insults at this time, not the least of which is the surgery itself. Any improvements that can be made by a further understanding of the pathophysiology of the events in the perioperative period, and the therapeutic interventions to control them, would obviously benefit the patient. Over the past 10 years, the desire for such benefits has led to the intense investigation of "the blood transfusion effect" in cancer surgery, which this article reviews.

Despite their availability since 1975, monoclonal antibodies (MAbs) have failed to make a significant impact in the clinical treatment of patients outside of diagnostic assays for the measurement of tumor markers. Recently, however, studies have appeared demonstrating that MAb-directed imaging techniques may have a meaningful role to play in the diagnosis and treatment of patients with solid tumors such as colorectal cancer and malignant melanoma. Furthermore, second generation MAbs are appearing that mediate more specific binding characteristics, and experimental studies have suggested that genuine antitumor activity may not be far away. Finally, the recent development of newer molecules, such as chimeric and human antibodies, may lead to significant advances in MAb use. Specifically, allergic reactions to murine antibodies can be reduced or avoided altogether, and repeated doses can be administered safely. These newer MAbs appear to mediate cell lysis more efficiently and have been combined with chemotherapeutic agents and cell toxins. Greater understanding of host responses to MAbs and the development of anti-idiotype and anti-anti-idiotype antibodies have led to clinical trials that, it is hoped, will confirm the place of MAb therapy in clinical oncology.

Strategies to evaluate patients with continence disorders continue to evolve at a rapid pace. These novel methods quantify physiologic events that, in turn, facilitate increasingly accurate discrimination among the causes of incontinence and constipation. This review discusses recent advances in the causes, diagnostic approaches, and management options available for patients with continence disorders.

The scope and importance of biliary infections from both a clinical and scientific perspective is rapidly changing. During this past year, considerable attention in the literature has focused on infections that are increasing in frequency in the United States and throughout the world, as a result of evolving demographics and continued spread of the acquired immunodeficiency syndrome epidemic. Pyogenic cholangitis remains a challenge for us to treat and significant controversy remains regarding optimal management. The myriad hepatobiliary manifestations of human immunodeficiency virus infection have led to a resurgence in the interest in parasitic and viral infections. Our understanding of infections and their pathogenesis and sequelae has progressed, although there are still many important questions that remain unanswered.