Routine Repeat Imaging Is Unnecessary for Coagulopathic Patients Sustaining Head Trauma.

INTRODUCTION: In trauma patients using warfarin, current guidelines recommend computed tomography of the brain (CTH), 24-hour observation, and repeat CTH to monitor for stability. Despite growing evidence of uncommon delayed hemorrhage, this remains standard practice even in mild traumatic brain injury without intracranial hemorrhage (ICH). Our study sought to determine the incidence and outcomes of delayed ICH (DICH) in trauma patients on supra-therapeutic warfarin without initial ICH. METHODS: A retrospective, single institutional study was performed of all adult trauma patients (>18 years old) who presented on prehospital warfarin with an international normalized ratio (INR) >3 and initial CTH that did not demonstrate ICH. Each of these patients underwent subsequent CTH within 24 hours and any DICH was identified. Those who demonstrated DICH were further examined to identify potential risk factors and outcomes such as need for further imaging or surgical intervention. Analyses were performed using Fisher's exact tests and Student's t-tests. RESULTS: 225 patients were identified from January 2015 to April 2021 that met inclusion criteria. Of those identified, only 3 (1.33%) were found to develop any DICH on routine repeat CTH. Identified characteristics did not reach statistical significance due to the low number of DICH. None of the patients with DICH went on to require intervention. CONCLUSION: In patients with identified traumatic injury on supra-therapeutic warfarin, an initial CTH without identified ICH alone is an adequate survey. DICH in these patients is uncommon and routine reimaging within 24 hours is unlikely to change clinical management in patients with intact neurologic status.

Differentiation of metastatic follicular thyroid cancer from hepatocellular carcinoma using Hep Par 1.

Hepatocellular carcinoma usually arises in a cirrhotic liver. Multiple hepatic nodules in a non-cirrhotic liver are more likely to be metastatic. The primary focus commonly arises from the gastrointestinal tract, breast or lung, but in the absence of these a primary liver pathology must be considered. The case is reported of a middle-aged woman presenting with multiple nodules on computed tomography with no clinically apparent primary for whom results of initial diagnostic investigations were potentially misleading.

Hepatectomy for metastatic noncolorectal gastrointestinal, breast and testicular tumours.

BACKGROUND: The indications for hepatectomy for colorectal or neuroendocrine metastases are becoming clear with increasing experience reported. For other primary diseases, however, the overall number of cases is relatively small, and it is more difficult to derive clear guidelines. This paper reviews the reported experience of hepatectomy for metastases from non-colorectal gastrointestinal primary cancers, breast cancer and testicular teratoma. The aim is to determine for each whether and under what circumstances hepatectomy is indicated. METHODS: A Medline search was used to identify papers reporting hepatectomy for metastases from non-colorectal gastrointestinal carcinomas, breast carcinomas and testicular teratomas. The data collected included the primary disease, the number of cases reported, the survival post-hepatectomy and any prognostic factors associated with outcome. RESULTS: Of the gastrointestinal malignancies, hepatectomy for gastric metastases yields a 5-year survival, roughly half that reported for colorectal disease, and further elucidation of prognostic factors would be desirable. Results were poor for other gastrointestinal malignancies. Good results were reported for breast and testicular teratoma. CONCLUSION: Of the non-colorectal gastrointestinal primaries, at present only hepatectomy for gastric metastases can be cautiously recommended. For nongastrointestinal primaries, hepatic metastases probably represent widespread dissemination even if occult, and therefore, hepatectomy may only be of use when effective adjuvant treatments are available.

Relaxation of the criteria for day surgery laparoscopic cholecystectomy.

BACKGROUND: For day case laparoscopic cholecystectomy programmes, studies suggest that overnight admission may be predicted by the following factors: gall bladder wall thickness, patient age over 55 years and previous sphincterotomy. This study investigated the effect of relaxing selection for a day surgery laparoscopic cholecystectomy programme, by removing these factors from the exclusion criteria. METHODS: Between September 2002 and April 2003, patients for elective laparoscopic cholecystectomy were considered for day surgery subject to standard criteria. For the initial part of the programme, patients were additionally excluded according to the risk factors mentioned above. RESULTS: Thirty-three patients underwent intended day case procedures. The first 16 were selected according to the more rigorous criteria. The latter 17 were significantly older, with a significantly higher incidence of gall bladder wall thickening. There were seven admissions, three in the former part of the study and four in the latter. CONCLUSION: The exclusion criteria described are not necessary for a good same-day discharge rate.

Detecting curable disease following hepatectomy for colorectal metastases.

INTRODUCTION: Although resection may be curative for patients with hepatic colorectal metastases, recurrence occurs in the majority. Recurrence is occasionally amenable to repeated resection. The aim of the present study was to evaluate which modalities, at what intervals, detected potentially curable resection. METHODS: The records of patients undergoing hepatectomy for colorectal metastases over 10 years in one centre were retrospectively reviewed to determine when and how recurrence was diagnosed. Specific attention was paid to the detection of potentially curable disease. RESULTS: Of 41 recurrences, 22 occurred in the first year postoperatively, 21 of which were suitable for palliative treatment only. Ten of 19 recurrences occurring after 1 year underwent potentially curative intervention, 10 were diagnosed by computed tomography (CT). Carcinoembryonic antigen did not diagnose any curable recurrence. CONCLUSIONS: A follow-up protocol is proposed, based on annual CT.

How much liver resection is too much?

BACKGROUND: Hepatic failure occurring after liver resection carries a poor prognosis and is a complication dreaded by surgeons. Inadequate reserve in the remaining parenchyma leads to a steady decrease in liver function, inability to regenerate, and progression to liver failure. For this reason, many methods to quantify functional hepatic reserve have been developed. METHODS: This article reviews the main methods used in the assessment of hepatic reserve in patients undergoing hepatectomy and their use in operative decision making. RESULTS: A range of methods to categorically quantify the functional reserve of the liver have been developed, ranging from scoring systems (such as the Child-Pugh classification) to tests assessing complex hepatic metabolic pathways to radiological methods to assess functional reserve. However, no one method has or is ever likely to emerge as a single measure with which to dictate safe limits of resectability. CONCLUSIONS: In the future, the role of residual liver function assessment may be of most benefit in the routine stratification of risk, thus enabling both patient consent to be obtained and surgical procedure to be performed, with full information and facts regarding operative risks. However, there is no one single test that remains conclusively superior.

Systematic review of day-case laparoscopic Nissen fundoplication.

BACKGROUND: Laparoscopic Nissen fundoplication is increasingly being performed on a day-case basis. The aim of the present paper was to systematically review published data on day-case or ambulatory laparoscopic fundoplication and discuss the differing criteria for patient selection, postoperative management and patient outcomes presented in each series. METHODS: An optimally sensitive search strategy of subject headings and text words were used and the databases used included MEDLINE, PubMed and the Cochrane Library. All databases were searched from 1 January 1994 onwards. RESULTS: A total of seven papers were included in the present review, of which six were prospective single-cohort studies. Overall, there was large heterogeneity among the studies but with similar complication and readmission rates. CONCLUSIONS: Short-term outcomes for laparoscopic Nissen fundoplication in terms of complications and readmission rates are comparable to inpatient procedures. However there is a paucity of published data.

Choice of surveillance after hepatectomy for colorectal metastases.

HYPOTHESIS: By review of a reported series, is outcome related to surveillance after hepatectomy? DESIGN: We reviewed English-language literature indexed on MEDLINE from January 1, 1990, through December 31, 2002. Indexing terms were combinations of hepatectomy, colorectal metastases, and recurrence with prognostic, repeat, follow-up, or surveillance. STUDY SELECTION: Studies containing any of the following data fields were included: recurrence after hepatectomy, rates of repeat hepatectomy, 5-year survival (overall or disease free) after hepatectomy (initial or repeat), posthepatectomy surveillance protocol, and detection of recurrence by surveillance modality. DATA EXTRACTION: Data were taken directly from a small number of articles and pooled across studies for analysis. We highlighted difficulties in assessing data quality and validity as a caveat to the interpretation of the results. RESULTS: The rate of recurrence after hepatectomy was 58%, and the rate of hepatic recurrence was 30%. Repeat hepatectomy was performed in 9.6% of cases. Five-year survivals after initial and repeat hepatectomy were 29% and 38%, respectively. Many studies did not report their surveillance protocols. For those that did, computed tomography or ultrasonography with carcinoembryonic antigen measurement most commonly formed the basis of surveillance. No data related surveillance techniques to the outcomes of recurrence detection, repeat hepatectomy, or survival. CONCLUSIONS: This review confirmed the value of repeat hepatectomy for recurrent disease, but uncovered no direct evidence supporting any surveillance modalities. Further studies are clearly needed, and approaches to these are discussed.

Artificial liver support: potential to retard regeneration?

HYPOTHESIS: The concept of an "artificial liver" has been in development for over 40 years. Such devices aim to temporarily assume metabolic and excretory functions of the liver, with removal of potentially hepatotoxic substances, thereby clinically stabilizing patients and preventing deterioration while awaiting transplantation. If sufficient numbers of viable hepatocytes remain, regeneration and subsequent recovery of innate liver function may occur. However, these devices have not yet become part of routine clinical use. Much less is known regarding the effect such devices have, if any, on circulating cytokines and growth factors and the subsequent effects on the regenerating liver. If these devices remove or reduce factors known to promote regeneration, is the rate of regeneration retarded? Conversely, does the incorporation of hepatocytes into bioartificial support systems confer an advantage through the production of growth-promoting factors from these cultured hepatocytes?Data Sources, Extraction, and STUDY SELECTION: Data were obtained using PubMed search for reports involving liver support, extracorporeal circuits, dialysis, growth factors, and cytokines. Those reports specifically looking at the effect of artificial liver support on cytokines and growth factors are discussed. CONCLUSIONS: There is a paucity of information on the key events and substances involved in hepatic regeneration. In addition, there is a potential impact of liver support devices on the regeneration of substances associated with hepatic regeneration. Further study is needed.