两例表现为急腹症的腹主动脉夹层动脉瘤破裂早期诊断

目的总结腹主动脉夹层动脉瘤破裂早期诊断体会。方法回顾分析2例腹主动脉夹层动脉瘤破裂的临床资料。结果2例曾被误诊为急性阑尾炎和急性胰腺炎,分别在就诊后6 h和80 h经急诊CT和超声检查得到确诊。结论腹主动脉夹层动脉瘤破裂临床表现复杂多样,早期诊断困难,易于漏诊误诊;对出现突发的、剧烈的、顽固的、一般治疗不能缓解的、症状与体征不符的、排除其他急腹症(如急性肠绞窄、重症胰腺炎、急性阑尾炎等)的腹胀腹痛,要想到腹主动脉夹层动脉瘤破裂的可能,结合急诊CT和超声检查可确诊,必要时要复查腹部CT。

腹壁切口裂开防治体会

目的 探讨腹壁手术切口裂开的防治方法。方法 对我院近 5年收治的腹壁切口裂开患者 16例临床资料进行回顾性分析。结果 16例腹壁切口裂开患者 ,行再次缝合 10例 ,单纯伤口换药 6例 ,均全部治愈 ,未发生死亡及再裂开病例。结论 注意缝合技术和增加组织抗张力的强度。降低腹压 ,避免危险因素和对危险因素的围手术期处理 ,能有效地预防腹壁手术的切口裂开。

剖宫产术后腹内疝并发肠梗阻18例超声检查分析

目的探讨超声检查在诊断剖宫产术后腹内疝并发肠梗阻的临床价值。方法对1998-01-2010-12回顾性分析18例经手术证实的剖宫产术后腹内疝并发肠梗阻的声像图特征。结果 18例超声均提示肠梗阻,其中12例提示肠绞窄均得到手术证实,剖宫产术后腹内疝并发肠梗阻超声主要表现为膀胱与子宫之间局限性肠管突入,突入肠管扩张充液;绞窄处肠管变窄,肠内容物通过受阻;不同程度腹腔积液;梗阻部位肠壁水肿增厚,肠管蠕动减弱或消失。结论超声检查是剖宫产术后腹内疝并发肠梗阻的可靠的方法,为临床提供了准确的诊断依据。

Clostridium difficile causing acute renal failure: Case presentation and review

AIM: Clostridium difficile infection is primarily a nosocomial infection but asymptomatic carriers of Clostridium difficile can be found in up to 5% of the general population. Ampicillin, cephalosporins and clindamycin are the antibiotics that are most frequently associated with Clostridium difficile-associated diarrhea or colitis. Little is known about acute renal failure as a consequence of Clostridium difficile-associated diarrhea. METHODS: In this case report, we describe the course of Clostridium difficile-associated diarrhea in an 82-year-old patient developing acute renal failure. Stopping the offending agent and symptomatic therapy brought a rapid improvement of diarrhea and acute renal failure, full recovery was gained 18 d after admission. In a systematic review we looked for links between the two conditions. RESULTS: The link between Clostridium difficile-assoaated diarrhea and acute renal failure in our patient was most likely volume depletion. However, in experimental studies a direct influence of Clostridium difficile toxins on renal duct cells could be shown. CONCLUSION: Rapid diagnosis, nonspecific supportive treatment and specific antibiotic treatment, especially in the elderly, may lower excess mortality Clostridium difficile-associated diarrhea and renal failure being possible complications.

Capsule endoscopy in celiac disease

Video capsule endoscopy is an attractive and patient- friendly tool that provides high quality images of the small bowel. Obscure gastrointestinal bleeding is the primary and most evaluated indication to capsule endoscopy;however,indications are expanding and a small number of preliminary reports have been presented concerning the role of video capsule endoscopy in the diagnosis of celiac disease. The purpose of this review is to update the current knowledge and to hypothesize on future perspectives of the use of video capsule endoscopy in patients with celiac disease.

Natural orifice transluminal endoscopic surgeryvs laparoscopic ovariectomy:Complications and inflammatory response

AIM:To compare natural orifice transluminal endoscopic surgery (NOTES) vs standard laparoscopic ovariectomy in mini pigs with respect to technical aspects,complications and parameters of systemic inflammatory response.METHODS:This was a randomized,experimental,survival study.Ten female mini pigs underwent NOTES transgastric ovariectomy (NOTES group) and ten female mini pigs underwent laparoscopic ovariectomy (LAP group).A "percutaneous endoscopic gastrostomy" approach with guidewire and sphincterotome was used for gastrotomy creation.The ovary was resected using standard biopsy forceps and a snare.The access site was closed using a "KING" closure with a single endoloop and several clips.In the laparoscopic group,a three-port laparoscopy and an ovariectomy were performed with the use of standard laparoscopic devices.C-reactive protein (CRP),white blood count and interleukin (IL)-6 plasma levels were used as indicators of systemic inflammatory response.All animals were euthanized 28 d after surgery.RESULTS:All animals survived without complications.The mean procedure time was 41.3 min ± 17.6 min (NOTES group) and 25.7 min ± 5.25 min (LAP group,P < 0.02).Postmortem examinations demonstrated that 50% and 70% of animals were free of any complications in the NOTES and LAP groups,respectively.The remaining animals developed minor complications (adhesions) in a comparable frequency between the two groups.In the NOTES group,one animal developed a small intramural gastric abscess close to the gastrotomy site.A minor serous exudate that was present in 50% and 40% of the animals in the NOTES and laparoscopy groups,respectively,was not considered a complication.In both groups CRP levels increased significantly on the 2nd and 7th postoperative days (POD) and returned to normal after 28 d.On POD 2,an increase of CRP level was significantly higher in the NOTES group compared to the LAP group.Values of IL-6 did not differ from baseline values in either of the groups postoperatively.Interestingly,the platelet count decreased significantly on POD 2,but returned close to baseline values on POD 7 and PODs 28-30.CONCLUSION:Both NOTES and laparoscopic ovariectomies had a similar frequency of minor complications.However,the NOTES technique produced an increased systemic inflammatory response on POD 2.

Evidence-based medicine: An update on treatments for peritoneal dialysis-related peritonitis

Peritonitis continues to be a major complication of peritoneal dialysis （PD）, and adequate treatment is crucial for a favorable outcome. There is no consensus regarding the optimal therapeutic regimen, and few prospective controlled studies have been published. The objectiveof this manuscript is to review the results of PD peritonitis treatment reported in narrative reviews, systematic reviews, and proportional meta-analyses. Two narrative reviews, the only existing systematic review and its update published between 1991 and 2014 were included. In addition, we reported the results of a proportional meta-analysis published by our group. Results from systematic reviews of randomized control trials （RCT） and quasi-RCT were not able to identify any optimal antimicrobial treatment, but glycopeptide regimens were more likely to achieve a complete cure than a first generationcephalosporin. Compared to urokinase, simultaneous catheter removal and replacement resulted in better outcomes. Continuous and intermittent IP antibiotic use had similar outcomes. Intraperitoneal antibiotics were superior to intravenous antibiotics in reducing treatment failure. In the proportional meta-analysis of RCTs and the case series, the resolution rate （86%） of ceftazidime plus glycopeptide as initial treatment was signifcantly higher than frst generation cephalosporin plus aminoglycosides （66%） and glycopeptides plus aminoglycosides （75%）. Other comparisons of regimens used for either initial treatment or treatment of gram-positive rods or gram-negative rods did not show statistically significant differences. The superiority of a combination of a glycopeptide and a third generation cephalosporin was also reported by a narrative review study published in 1991, which reported an 88% resolution rate.

Cancer-derived VEGF plays no role in malignant ascites formation in the mouse

AIM: Vascular endothelial growth factor (VEGF) is a potent mediator of peritoneal fluid accumulation following tumor progression. This study investigated the role of VEGF secreted by cancerous cells in the formation of malignant ascites.METHODS: VEGF expression was eliminated byknockdown in the pancreas cancer cell-line PancO2 using vector-based short-hairpin type RNA interference (RNAi).Malignant ascites formation in the mouse was analyzed by intraperitoneal injection of PancO2 cells expressing VEGF or with expression knockdown.RESULTS: The VEGF knockdown PancO2 cell was successfully established. Knockdown of VEGF did not affect cancer cell proliferation in vitro or in vivo. The volume of ascites following peritoneal expansion of the tumor in VEGF knockdown cells and control cells did not differ statistically in this in vivo study. Moreover, the VEGF concentration in the ascites did not differ statistically.CONCLUSION: Malignant ascites formation might be mediated by VEGF production in noncancerous tissues,such as stromal compartments. An anti-VEGF strategy against malignant ascites could be applied to various tumors regardless of whether they secrete VEGF.

Trocar-related abdominal wall bleeding in 200 patients after laparoscopic cholecistectomy: Personal experience

AIM: To determine the complications and incidence of the first and second access-related vascular injuries induced by videolaparoscopic cholecistectomy. METHODS: We retrospectively reviewed vascular injuries in 200 consecutive patients who underwent videolaparoscopic cholecistectomy from 2003 to 2005. One hundred and one patients with placement of radial expanding trocars were assigned into group A and 99 patients with placement of pyramidal tipped trocars into group B. All the patients were submitted to open access according to Hasson for the first trocar. RESULTS: Bleeding did not occur at the intraoperative cannula-site in group A. However, it occurred at the intraoperative cannula-site of 7 patients (7.1%) in group B, with a statistically significant difference (P < 0.01). No mortality was registered. More vascular lesions were found in group B. CONCLUSION: The advantage of Hasson technique is that peritoneal cavity access is gained under direct vision, preventing most severe injuries. The open technique with radial expanding trocars is recommended for secure access to the abdominal cavity in videolaparoscopy. Great care should be taken to avoid major complications and understanding the abdominal wall anatomy is important for reducing bleeding during or after s placement of trocars.

Extensive retroperitoneal and right thigh abscess in a patient with ruptured retrocecal appendicitis:An extremely fulminant form of a common disease

As a disease commonly encountered in daily practice, acute appendicitis is usually diagnosed and managed easily with a low mortality and morbidity rate. However, acute appendicitis may occasionally become extraordinarily complicated and life threatening. A 56-year-old man, healthy prior to this admission, was brought to the hospital due to spiking high fever, poor appetite, dysuria, progressive right flank and painful swelling of the thigh for 3 d. Significant inflammatory change of soft tissue was noted, involving the entire right trunk from the subcostal margin to the knee joint. Painful disability of the right lower extremity and apparent signs of peritonitis at the right lower abdomen were disclosed. Laboratory results revealed leukocytosis and an elevated C-reactive protein level. Abdominal CT revealed several communicated gas-containing abscesses at the right retroperitoneal region with mass effect, pushing the duodenum and the pancreatic head upward, compressing and encasing inferior vena cava, destroying psoas muscle and dissecting downward into the right thigh. Laparotomy and right thigh exploration were performed immediately and about 500 mL of frank pus was drained. A ruptured retrocecal appendix was the cause of the abscess. The patient fully recovered at the end of the third post-operation week. This case reminds us that acute appendicitis should be treated carefully on an emergency basis to avoid serious complications. CT scan is the diagnostic tool of choice, with rapid evaluation followed by adequate drainage as the key to the survival of the patient.

Appendiceal mass:Is interval appendicectomy “something of the past” ?

The need for interval appendicectomy (I.A) after successful conservative management of appendiceal mass has recently been questioned.Furthermore,emergency appendicectomy for appendiceal mass is increasingly performed with equal success and safety to that performed in non-mass forming acute appendicitis.There is an increasing volume of evidence-although mostly retrospective-that if traditional conservative management is adopted,there is no need for routine I.A except for a small number of patients who continue to develop recurrent symptoms.On the other hand,the routine adoption of emergency laparoscopic appendicectomy (LA) in patients presenting with appendiceal mass obviates the need for a second admission and an operation for I.A with a considerable complication rate.It also abolishes misdiagnoses and deals promptly with any unexpected ileo-cecal pathology.Moreover,it may prove to be more cost-effective than conservative treatment even without I.A due to a much shorter hospital stay and a shorter period of intravenous antibiotic administration.If emergency LA is to become the standard of care for appendiceal mass,I.A will certainly become 'something' of the past.

Duplicated appendix complicated by appendiceal cancer

A 37-year old male presented with an acute abdomen suggestive of an appendiceal perforation.Urgent laparotomy showed a duplicated appendix with one of the lumens involved with appendicitis and a focal periappendicular abscess while the other lumen had a localized appendiceal cancer.Recognition of congenital intestinal duplications in adults is important to avoid serious clinical consequences.