ABSTRACT
Introduction: Renal injuries account for up to 1–5% of alltrauma related injuries. Over the years there has been a shifttowards non-operative treatment for blunt renal trauma. Theaim of our study was to assess outcomes of patients managedconservatively (non-operatively) for high grade blunt renalinjury at our centre.Material and methods: The study was conducted in aretrospective manner using hospital records of last 5 years. Allpatients with blunt renal injuries were included. These patientswere categorized based on AAST(1989) injury gradingand further subdivided into operative and non-operativemanagement groups. These management strategies wereanalyzed in terms of ‘failure of non- operative management’,complications and need for adjunctive procedures. Descriptiveanalysis was done using Microsoft Excel(2010, ver14)software.Results: Forty three patients were included in the study witha mean age of 44.6 years. Out of the total, 28 had grade I– III injuries, 11 had grade IV and 4 had grade V injuries.All the grade I-III patients were managed conservatively andrequired no adjunctive procedures. One (9%) of grade IV and2(50%) of grade V injuries underwent immediate exploration.Out of 10 cases of grade IV injuries which underwent nonoperative management, 3(30%) required delayed explorationand none of the grade V injuries required delayed exploration.Complications included urinary tract infection (UTI) (6 cases),persistent hematuria (3 cases), hypertension(2 cases), urinoma(2 cases) and ileus(2 cases) .All complications were Claviengrade 1-2 with no mortalities overall.Conclusion: If the patient is hemodynamically stable,even grade IV and V blunt renal injuries can be managedconservatively, as is seen in our study where failure of nonoperative management occured in only 30% of grade IV andnone of the Grade V injuries.
ABSTRACT
Introducción: el traumatismo cardíaco es una condición poco frecuente en edad pediátrica, ocurriendo en menos del 5 % de traumatismos torácicos. Afecta más frecuentemente los ventrículos que las aurículas. Según el mecanismo de injuria puede ser: cerrado (como las contusiones torácicas) o penetrante (como las heridas por arma blanca o armas de fuego). El siguiente documento tiene la intención de describir la presentación clínica y el manejo de un paciente pediátrico con traumatismo cardíaco penetrante; se pretendió realizar una revisión de literatura sobre otros casos de traumatismo cardíaco penetrante. Presentación del caso: se expone el caso clínico de un paciente masculino de 14 años de edad, quien es referido al centro por historia de herida de arma blanca en región precordial izquierda. Se recibe con inestabilidad hemodinámica y hemitórax izquierdo hipodinámico; luego de realizar estudios de imagen y laboratorio se decide realizar toracocentesis. Ante evidente deterioro clínico, se decide realizar exploración quirúrgica, donde se halla laceración del ventrículo izquierdo y hematoma pericárdico, y se procede a drenar hematoma y cardiorrafia de ventrículo izquierdo. Conclusión: luego de describir la presentación y manejo de nuestro paciente, llegamos a la conclusión de que la sospecha clínica y el diagnóstico y manejo precoz son imprescindibles para mejorar el pronóstico de estos traumatismos. Asimismo, entendemos pertinente la exploración quirúrgica temprana ante los casos de inestabilidad hemodinámica, evitando el retraso de un tratamiento oportuno
Introduction: Cardiac trauma is a rare condition in pediatrics, occurring in less than 5 % of thoracic trauma. It affects the ventricles more often than the atria. Depending on the mechanism of injury, it may be classified as closed (such as blunt chest traumas) or penetrating (such as wounds with a knife or guns). The following document has the intention to describe the clinical presentation and management of a pediatric patient with a penetrating cardiac trauma, and it was intended to conduct a literature review on other cases of penetrating cardiac trauma. Case presentation: We present the clinical case of a 14-year-old male, who is referred to the center with history of a knife wound in the left precordial region. He is received with hemodynamic instability and hypodynamic left hemithorax, and, after performing imaging and laboratory studies, it was decided to perform thoracentesis. In the presence of evident clinical deterioration, it was decided to perform surgical exploration, where laceration of the left ventricle and pericardial hematoma is evidenced, for which drainage of hematoma and left ventricle cardiorrhaphy were performed. Conclusion: After describing the presentation and management of our patient, we conclude that clinical suspicion and early diagnosis and management are essential to improve the prognosis of these injuries. Likewise, we recognize the pertinence of early surgical exploration in cases of hemodynamic instability, avoiding the delay of a timely treatment.
Subject(s)
Humans , Male , Adolescent , Myocardial Reperfusion Injury , Wounds and Injuries , Cardiology , Child HealthABSTRACT
Objective@#To summarize the diagnosis and treatment of biliary pancreatic duct dilatation.@*Methods@#The retrospective and descriptive study was conducted. The clinical data of 22 patients with biliary pancreatic duct dilatation who were admitted to Renji Hospital of Shanghai Jiaotong University School of Medicine between October 2013 to September 2017 were collected. There were 6 males and 16 females, aged from 33 to 82 years, with an average age of 66 years. Surgical exploration was decided according to clinical symptoms, results of laboratory test and imaging examinations. For patients with space occupying lesions, surgical procedure was selected based on results of pathological examination. Patients without surgical exploration or space occupying lesions were allocated into follow-up. Observation indicators: (1) surgical exploration; (2) relationship of clinical symptoms and preoperative examinations with surgical exploration positive for space occupying lesions; (3) surgical treatment; (4) follow-up. Follow-up using outpatient examination was performed on patients up to October 2018. Follow-up was performed on patients with positive surgical exploration to detect postoperative complications.For patients with positive results of imaging examinations, no jaundice, normal laboratory indicators or mild abnormality, liver function, tumor markers and B-ultrasound were re-examined each month, and computed tomography (CT) and magnetic resonance imaging (MRI) was performed once every 3 months. Surgical exploration was performed when total bilirubin (TBil) or tumor markers showed a progressive increase. Follow-up was performed on patients with negative results of imaging examination, jaundice, and mildly elevated CA19-9. TBil and CA19-9 were re-examined monthly, and if they were progressively elevated, patients were transferred to surgical exploration. For patients with negative results of imaging examination, no symptoms, and negative laboratory test, liver function, tumor markers, and B-ultrasound were re-examined once every 3 months, and enhanced CT and MRI were re-examined once every 6 months within one year. Follow-up was performed once every 6 months during the second year, and once a year after two years. Measurement data with normal distribution were represented as Mean±SD, and comparison between groups was analyzed using the t test. Count data were descibed as absolute numbers, and they were analyzed using the chi-square test under R×C chart or Fisher exact probability.@*Results@#(1) Surgical exploration: of 22 patients, 11 underwent surgical exploration, and 11 underwent follow-up. Of the 11 patients with surgical exploration, 4 were positive for space occupying lesions including 1 of false negative, and 7 were negative for space occupying lesions. (2) Relationship of clinical symptoms and preoperative examinations with surgical exploration positive for space occupying lesions. ① Relationship of clinical symptoms and laboratory test with surgical exploration positive for space occupying lesions: juandice was significantly associated with surgical exploration positive for space occupying lesions (P<0.05), and elevated TBil and DBil were significantly associated with surgical exploration positive for space occupying lesions (χ2=0, 0, P<0.05), with a sensitivity of 75.0% and specificity of 100.0%. ② Relationship between imaging examination and surgical exploration positive for space occupying lesions: results of CT, MRI, endoscopic retrograde cholangio-pancreatography, endoscopic ultrasonography, PET-CT, and combined imaging examinations had no significant association with surgical exploration positive for space occupying lesions (χ2=0, 0.77, 0, 0, 1.00, 0, 0, 0, 0, P>0.05). PET-CT had no significant association with surgical exploration positive for space occupying lesions (P>0.05). ③ Relationship of imaging examination and laboratory test with surgical exploration positive for space occupying lesions: positive imaging examination combined with elevated TBil and CA19-9 was significantly associated with surgical exploration positive for space occupying lesions (P<0.05), with a sensitivity of 50.0% and specificity of 100.0%. ④ Relationship of preoperative diameters of biliary ducts and pancreatic ducts with surgical exploration positive for space occupying lesions: of 22 patients, the diameters of biliary ducts and pancreatic ducts were (13.8±4.3)mm and (4.6±1.5)mm for patients with positive surgical exploration, (13.0±2.8)mm and (3.5±0.5)mm for patients with negative surgical exploration, (11.6±2.4)mm and (3.2±0.4)mm for patients with follow-up, respectively, showing no significant difference between them (t=0.22, 0.36, P>0.05). (3) Surgical treatment: 9 of 11 patients with surgical exploration followed the standard procedure. Of the 9 patients, 4 were found space-occupying lesions at the choledocho-pancreatico-duodenal junction (3 undergoing pancreaticoduodenectomy and 1 undergoing duodenal papilla partial resection), 5 with negative exploration underwent common bile duct incision and T-tube drainage (one patient was unable to pinch the T-tube one month after operation and detected obstruction at the lower end of the bile duct by radiography, and was confirmed pancreatic head cancer by reoperation 3 months after the first operation). Two patients didn′t follow the exploratory procedure, and underwent the child operation only based on the preoperative imaging findings, without intraoperative pathological examination. Postoperative pathological examination showed chronic ampulla and chronic pancreatitis, respectively. (4) Follow-up: 22 patients were followed up for 12-60 months, with a median follow-up time of 36 months. Two of 11 patients with surgical exploration had postoperative gastroplegia, 1 had bile leakage, 1 had incisional infection, and they were improved after symptomatic treatment. Four patients undergoing surgeries for positive exploration had no recurrence during follow-up. Of 5 patients with negative exploration undergoing common bile duct incision and T-tube drainage, 1 was confirmed pancreatic head cancer and underwent pancreaticoduodenectomy, 4 were removed T-tube after by T-tube cholangiography at 2 months after surgery. During the follow-up, no positive signs showed in laboratory test or imaging examination. No recurrence occurred in the two patients undergoing pancreaticoduodenectomy. Of 11 patients with follow-up, 10 had abdominal pain before surgery, including 3 with pain during follow-up and 7 with symptoms disappeared. There was no abnormalities in the laboratory test.@*Conclusions@#The positive imaging examinations combined with jaundice and elevated CA19-9 is an absolute indication for surgical exploration in patients with biliary duct dilatation. Those patients who do not meet this criteria should be distributed into the follow-up. If no positive pathological results were obtained during the operation, the surgery should be terminated and the patients should be transferred into follow-up. The reckless biliary anastomosis or biliary stents placement is opposed.
ABSTRACT
Objective To summarize the diagnosis and treatment of biliary pancreatic duct dilatation.Methods The retrospective and descriptive study was conducted.The clinical data of 22 patients with biliary pancreatic duct dilatation who were admitted to Renji Hospital of Shanghai Jiaotong University School of Medicine between October 2013 to September 2017 were collected.There were 6 males and 16 females,aged from 33 to 82years,with an average age of 66 years.Surgical exploration was decided according to clinical symptoms,results of laboratory test and imaging examinations.For patients with space occupying lesions,surgical procedure was selected based on results of pathological examination.Patients without surgical exploration or space occupying lesions were allocated into follow-up.Observation indicators:(1) surgical exploration;(2) relationship of clinical symptoms and preoperative examinations with surgical exploration positive for space occupying lesions;(3) surgical treatment;(4) follow-up.Follow-up using outpatient examination was performed on patients up to October 2018.Follow-up was performed on patients with positive surgical exploration to detect postoperative complications.For patients with positive results of imaging examinations,no jaundice,normal laboratory indicators or mild abnormality,liver function,tumor markers and B-ultrasound were re-examined each month,and computed tomography (CT) and magnetic resonance imaging (MRI) was performed once every 3 months.Surgical exploration was performed when total bilirubin (TBil) or tumor markers showed a progressive increase.Follow-up was performed on patients with negative results of imaging examination,jaundice,and mildly elevated CA19-9.TBil and CA19-9 were re-examined monthly,and if they were progressively elevated,patients were transferred to surgical exploration.For patients with negative results of imaging examination,no symptoms,and negative laboratory test,liver function,tumor markers,and B-ultrasound were re-examined once every 3 months,and enhanced CT and MRI were re-examined once every 6 months within one year.Follow-up was performed once every 6 months during the second year,and once a year after two years.Measurement data with normal distribution were represented as Mean±SD,and comparison between groups was analyzed using the t test.Count data were descibed as absolute numbers,and they were analyzed using the chi-square test under R×C chart or Fisher exact probability.Results (1) Surgical exploration:of 22 patients,11 underwent surgical exploration,and 11 underwent followup.Of the 11 patients with surgical exploration,4 were positive for space occupying lesions including 1 of false negative,and 7 were negative for space occupying lesions.(2) Relationship of clinical symptoms and preoperative examinations with surgical exploration positive for space occupying lesions.① Relationship of clinical symptoms and laboratory test with surgical exploration positive for space occupying lesions:juandice was significantly associated with surgical exploration positive for space occupying lesions (P＜0.05),and elevated TBil and DBil were significantly associated with surgical exploration positive for space occupying lesions (x2 =0,0,P＜0.05),with a sensitivity of 75.0％ and specificity of 100.0％.(② Relationship between imaging examination and surgical exploration positive for space occupying lesions:results of CT,MRI,endoscopic retrograde cholangiopancreatography,endoscopic ultrasonography,PET-CT,and combined imaging examinations had no significant association with surgical exploration positive for space occupying lesions (x2 =0,0.77,0,0,1.00,0,0,0,0,P＞0.05).PET-CT had no significant association with surgical exploration positive for space occupying lesions (P＞0.05).③ Relationship of imaging examination and laboratory test with surgical exploration positive for space occupying lesions:positive imaging examination combined with elevated TBil and CA19-9 was significantly associated with surgical exploration positive for space occupying lesions (P＜0.05),with a sensitivity of 50.0％ and specificity of 100.0％.④ Relationship of preoperative diameters of biliary ducts and pancreatic ducts with surgical exploration positive for space occupying lesions:of 22 patients,the diameters of biliary ducts and pancreatic ducts were (13.8±4.3)mm and (4.6±1.5)mm for patients with positive surgical exploration,(13.0±2.8)mm and (3.5±0.5) mm for patients with negative surgical exploration,(11.6±2.4) mm and (3.2±0.4) mm for patients with follow-up,respectively,showing no significant difference between them (t =0.22,0.36,P＞0.05).(3) Surgical treatment:9 of 11 patients with surgical exploration followed the standard procedure.Of the 9 patients,4 were found space-occupying lesions at the choledocho-pancreatico-duodenal junction (3 undergoing pancreaticoduodenectomy and 1 undergoing duodenal papilla partial resection),5 with negative exploration underwent common bile duct incision and T-tube drainage (one patient was unable to pinch the T-tube one month after operation and detected obstruction at the lower end of the bile duct by radiography,and was confirmed pancreatic head cancer by reoperation 3 months after the first operation).Two patients didn't follow the exploratory procedure,and underwent the child operation only based on the preoperative imaging findings,without intraoperative pathological examination.Postoperative pathological examination showed chronic ampulla and chronic pancreatitis,respectively.(4) Follow-up:22 patients were followed up for 12-60 months,with a median followup time of 36 months.Two of 11 patients with surgical exploration had postoperative gastroplegia,1 had bile leakage,1 had incisional infection,and they were improved after symptomatic treatment.Four patients undergoing surgeries for positive exploration had no recurrence during follow-up.Of 5 patients with negative exploration undergoing common bile duct incision and T-tube drainage,1 was confirmed pancreatic head cancer and underwent pancreaticoduodenectomy,4 were removed T-tube after by T-tube cholangiography at 2 months after surgery.During the follow-up,no positive signs showed in laboratory test or imaging examination.No recurrence occurred in the two patients undergoing pancreaticoduodenectomy.Of 11 patients with follow-up,10 had abdominal pain before surgery,including 3 with pain during follow-up and 7 with symptoms disappeared.There was no abnormalities in the laboratory test.Conclusions The positive imaging examinations combined with jaundice and elevated CA19-9 is an absolute indication for surgical exploration in patients with biliary duct dilatation.Those patients who do not meet this criteria should be distributed into the follow-up.If no positive pathological results were obtained during the operation,the surgery should be terminated and the patients should be transferred into follow-up.The reckless biliary anastomosis or biliary stents placement is opposed.
ABSTRACT
Anterior interosseous nerve is purely a motor nerve and supplies flexor pollicis longus, flexor digitorum profundus to the index finger, and pronator quadratus. The etiology and treatment option of anterior interosseous nerve syndrome remain controversial. Bilateral involvement of the anterior interosseous nerve have been described rarely; however, we found no reported case of nonsimultaneous bilateral anterior interosseous nerve palsy associated with the entrapment neuropathy. We present the unique case of delayed anterior interosseous nerve syndrome, 3 years 5 months following an identical event in the opposite extremity and literature review.
Subject(s)
Equipment and Supplies , Extremities , Fingers , ParalysisABSTRACT
PURPOSE: The etiology and treatment strategy of the anterior interosseous nerve (AIN) syndrome are still controversial. Seven patients with the AIN syndrome who were treated by surgical exploration and neurolysis were reviewed at a mean of 35.9 months follow up period. MATERIALS & METHODS: There were six men and one woman. The mean age was 37.3 years, ranging from 26 to 59. No patient was related to trauma and associated neurological lesion. Surgical exploration was performed at 7.7 months after onset of paralysis. RESULTS: All except one patients experienced pain around the elbow region before the onset of the palsy. On 7 patients, only the flexor pollicis longus was paralysed in 1, only the index flexor digitorum profundus in 2, and none had paralysis of the middle. The most common compression structures were fibrous bands within flexor digitorum sublimis arcade. However there was no demonstrable abnormality in three. Recovery was complete in all cases within 12 months after surgery. CONCLUSION: We recommended surgical exploration and neurolysis in patients who have shown no improvement after 6 months of conservative treatment. And careful preoperative examination is essential to avoid misdiagnosis and inappropriate surgery, especially in incomplete AIN syndrome.
Subject(s)
Female , Humans , Male , Diagnostic Errors , Elbow , Follow-Up Studies , ParalysisABSTRACT
Objective To analyse the diagnosis and treatment of testicular torsion. Methods The clinical data of 66 cases of testicular torsion were retrospectively analysed. Results Among the 66 cases,32(48.5%) paid the first medical visit within 10 h,and 24(36.4%)were confirmed diagnosis at the first visit.False negative results occurred with color Doppler flow imaging(CDFI),and 8 testicles were damaged due to the false negative diagnosis.Thirty-three patients without prophylactic contralateral orchidopexy were followed up for 6 months to 20 years,and one experienced recurrent torsion. Conclusion The testicular torsion must be considered when a sudden acute scrotum pain is occurred.Testicular damage is closely related to the torsion time,and delayed medical intervention contributes to the testicular damage.Highly suspected cases should be performed surgical exploration timely due to the false negative results with CDFI.Prophylactic contralateral orchidopexy is recommended.
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Objective To evaluate the significance of surgical exploration for the refractory arterial crisis daring the hypersensitive period (48 h to 96 h) after replantation of severed fingers.Methods One hundred and seventy-one patients experienced refractory arterial crisis during the hypersensitive period after replantation of the proximal thumb from February 1995 to February,2005 in our department.Eighty-seven of them were managed with surgical exploration,including incision injury (n=6),saw injury (n=17),rotation and avulsion injury (n=30), and crush injury (n=34).Eighty-four cases received conservative treatment,including incision injury (n=6),saw injury (n=16).rotation and avulsion injury (n=29),and crush injury (n=33).In the surgery group,the e- mergent explorations were performed as soon as the refractory arterial crisis arose,If arterial spasm or/and thrombosis were found,the involved parts were resected before the artery ends were anastomosed or the finger artery was repaired by cubital vein graft.In the other group,conservative managements were carried out by using intramuscular injection of 30 mg Papaverine and intravenous injection of 20,000-unit Urokinase in 20 mL normal saline.If symptums were not alleviated after half an hour,the procedures were repeated.The conservative managements also included abirritative antipsychotics and analgesia of anodyne.Meanwhile,the survival state of all the digital replants was observed. Results In the surgery group,78 fingers survived,the surviving rate being 89.7%.In the conservative group,41 fingers survived with a surviving rate of 48.8%.The difference was statistically significant (P＜0.01).No obvious complications happened in the two groups.Conclusion Since surgical exploration is crucial to management of refractory arterial crisis during the hypersensitive period after replantation of severed fingers,it should not be readily abandoned.
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Contralateral exploration has become standard treatment of the unilateral Wilms' tumor. The current preoperative imaging modalities including CT and ultrasonography are far superior to the IVP at detecting contralateral disease in unilateral Wilms' tumor. The question must then be posed whether contralateral exploration is still indicated in patient with negative preoperative imaging studies. We reviewed 18 patients of Wilms' tumor seen at our hospital from 1980 to 1995. All 18 patients had unilateral disease in the preoperative CT and/or ultrasonography. Contralateral exploration was done in the early 3 patients (1980-1985). The results of imaging studies were confirmed on surgical exploration. The remaining 15 patients were not explored because the contralateral tumor was not found in the preoperative CT and ultrasonography. During the periodic follow-up with CT, 5 patients with high stage (III,IV) and/or unfavorable histology were early expired. Two patients were not evaluable owingto short follow-up duration. The remnant 8 patients were free of disease clinically and radiologically during follow-up (mean duration 51.5 months). The current, accurate preoperative imaging modalities and effective chemotherapy suggest that contralateral surgical exploration may no longer be mandatory in patients with unilateral Wilms' tumor despite of short follow-up duration and small number of patients.
Subject(s)
Humans , Drug Therapy , Follow-Up Studies , Ultrasonography , Wilms TumorABSTRACT
The authors describe a case of pituitary tuberculoma in 45 year old female patient with previous history of tuberculous meningitis. Her clinical complaints were headache, visual field defects and amenorrhea. Endocrinological studies showed hypopitutitarism. Radiological studies including CT showed tumor mass in the sella turcica and suprasella area & paietal lobe. Ramamurthi and Varadarajan described the two types of the intracranial tuberculoma ; 1) A superficial and vascular type requires operation only in selected cases and it responds favoratly to treatment. 2) A deep and avascular type accompanied by increased intracranial tension and a spaecoccupying lesion, which does not respond to medical treatment and requires operation. Removal of the pituitary tuberculoma by T.S.A. followed by antituberculous treatment resulted in resolution of her neurological symptoms and signs.
Subject(s)
Female , Humans , Middle Aged , Amenorrhea , Headache , Sella Turcica , Tuberculoma , Tuberculoma, Intracranial , Tuberculosis, Meningeal , Visual FieldsABSTRACT
We have experienced 10 cases of intracranial tuberculoma which were confirmed by CT scan in National Medical Center from Jan. '79 to Aug. '82. The analysis is based on 10 cases with intracranial tuberculoma on whom operation was performed in 7 cases and conservative treatment was done in 3 cases. Extracranial disease or a past history of tuberculosis are evident in half of patients. The common presenting features are intracranial hypertension and papilledema. These are usually located in the supratentorial region. The use of CT brain scanning can be of great help in diagnosis and follow up more than others. The current treatment consists of medical therapy such as combined antituberculous agents, but surgical exploration may be reserved for intractable seizure, suspected brain tumor and medical failure or severe intracranial hypertension.