Current opinion in general surgery最新文献

In diabetic patients, nonhealing cutaneous ulcers are a significant clinical, social, and healthcare problem. Based on more than 10 million diabetic patients in the United States and an estimated prevalence of 15% for chronic cutaneous ulcers, there are approximately 1.5 million patients with this problem. These nonhealing cutaneous ulcers result in a high rate of lower extremity amputations in the diabetic population. Patients with diabetes have many complications that cause chronic cutaneous ulcers. These include peripheral vascular disease, autonomic and sensory neuropathy, impaired host defense against infection, and delayed wound repair. To treat diabetic patients with chronic cutaneous ulcers effectively all the complicating factors must be addressed. In this review we discuss the surgical care of these patients and the use of growth factors in combination with a comprehensive treatment algorithm.

This review of early care covers issues pertaining to the analysis of system function, prehospital intravascular volume replacement, diagnosis of proximity vascular injury, the role of emergency thoracotomy, and the value of transesophageal echocardiography. The first six articles deal with various aspects of system function, from triage to analysis of outcome. The next series of articles reviews work in progress evaluating optimal fluid for resuscitation. Hypertonic saline and dextran combinations have been shown to restore vital signs better than isotonic solutions; they are safe, require smaller volumes, and may improve head injury outcome. Danger lies in the restoration of perfusion without hemorrhage control. Two articles on emergency thoracotomy review the indications and outcome in blunt and penetrating trauma. Survival in blunt trauma is virtually zero. An article and two editorials summarize state of the art for diagnosis and treatment of proximity vascular injury. Two articles describe the potential use of the new technique of transesophageal echocardiography. This new modality has not formed a solid indication at present and can be considered investigational in trauma care.

Some aspects of the surgical treatment of cutaneous melanoma are still currently debated. There is presently a general agreement in favor of a less wide excision of primary lesions. Specifically, data coming from a randomized study of the World Health Organization (WHO) Melanoma Programme indicates that the width of resection has no impact on either disease-free and overall survival of 612 stage I entered patients. Opportunity of an elective (ELND) or delayed (DLND) lymph node dissection remains much more controversial. Complications, including lymphedema, associated with this type of surgery, and no evidence of regional lymph node disease in at least 70% of clinical stage I patients submitted to node dissection, argue for avoiding ELND. Some studies show a positive value for ELND, but they are flawed by biased entry of patients into the ELND group, and conclusions are not derived from randomized studies. Two prospective trials show that ELND does not improve the prognosis of patients with stage I cutaneous melanoma. The results of the WHO study of 553 cases will be evaluable at 20 years. So far, on the basis of many biologic, clinical, and statistical findings, there is no evidence, in our opinion, of a substantial benefit related to ELND.

Among the vascular disorders of the small intestine, two major categories are mesenteric ischemia and occult gastrointestinal bleeding secondary to a mucosal or muscular lesion. Mesenteric ischemia remains a clinical entity with a high mortality. Recent advances in the understanding of the pathogenesis of mesenteric ischemia have focused on the role of the neutrophil in modulating reperfusion injury. The advent of duplex scanning has provided a noninvasive method to detect hemodynamically significant stenoses in the mesenteric vessels. Effective small bowel endoscopy remains a critical requirement for endoluminal intestinal enteroscopy, and its application has proved of increasing advantage in the localization of small intestinal lesions that may be the source of occult gastrointestinal bleeding.

Pharyngoesophageal dysphagia is chiefly a disorder of the elderly. This review examines recent advances in the understanding of the normal physiology of oropharyngeal bolus transport. Techniques for the evaluation of symptomatic patients are discussed with an emphasis on the complementary nature of manometry and videoradiography. The technical limitations of manometry are detailed. Therapy for the condition is aimed at the underlying cause, and patients with neurologic deficits (largest subgroup of patients) should have a good response to myotomy provided they fulfill basic criteria. Surgery for Zenker's diverticulum is always necessary, and a short discussion of technique has been included.

Evidence continues to accrue that proximal gastric vagotomy is a safe and effective elective operation for duodenal ulcer. Recurrent ulceration remains the major shortcoming of the procedure but reoperation is rarely required. Laparoscopic surgery for peptic ulcer disease is rapidly evolving with anterior seromyotomy and posterior truncal vagotomy emerging as the elective procedure of choice. Perforated ulcer can also be treated by laparoscopic techniques in some cases. Hemorrhage is often amenable to initial endoscopic control measures, but when surgery is required, a definitive acid-reducing operation should be employed. Ulcerogenic drug use appears to be responsible for an increasing number of emergency interventions for life-threatening peptic ulcer complications, although simple closure of perforation due to such drugs may be sufficient surgical treatment. Long-term follow-up data suggest that there is a real risk increase for gastric remnant cancer development 20 years after partial gastrectomy for peptic ulcer but the value of regular endoscopic screening of patients at risk has not been demonstrated. The long-acting somatostatin analogue, octreotide acetate, has been shown to ameliorate the symptoms of the postoperative dumping syndrome markedly, although the mechanism of action remains largely unknown.

Multiple organ failure remains a leading cause of death in surgical intensive care units. This review of multiple organ failure focuses on recent (1990 to 1992) laboratory and clinical advances related to diagnosis, prognosis, and therapy of multiple organ failure and is divided into three parts. First, it recasts multiple organ failure into the currently accepted terminology, ie, the multiple organ dysfunction syndrome. Second, it examines the strengths and weaknesses of three mechanistic hypotheses proposed for the clinical syndrome. The three hypotheses focus on the gut, molecular mediators, and the microvasculature. Third, it synthesizes those three mechanisms into a single paradigm; this unifying paradigm can serve as a framework in which to interpret subsequent laboratory and clinical advances.

Since 1991, the techniques of endosurgical antireflux repair and myotomy have been developed for the treatment of gastroesophageal reflux disease and esophageal motility disorders. The principles of open surgery for the treatment of these conditions learned over several decades should be incorporated into minimally invasive approaches. Moreover, proper patient evaluation and selection are critical to the success of these procedures. This paper describes the technical aspects of endosurgical antireflux repair and myotomy.

Pancreatic carcinoma remains a significant cause of cancer death worldwide. In spite of more effective diagnostic techniques, most patients still have advanced and incurable disease when the diagnosis is made. Treatments differ depending on the extent of the disease at presentation, but accurate staging preoperatively is difficult. The Whipple procedure is now done with an operative mortality of 5% or less. More effective means of nonoperative palliation are being developed. Adjuvant therapy is still largely ineffective.

This paper presents a brief description of current uses of the carbon dioxide, neodymium:yttrium aluminum garnet, and other lasers in common general surgical procedures. It focuses on the author's own experiences and includes a review of the current literature.