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PubMed1997

Capnometry as a tool to unmask silent pulmonary embolism.

Because pulmonary embolism is often silent, simple clinical procedures are desirable to identify patients with a low to intermediate probability of pulmonary embolism. Among 19,467 patients managed under general anesthesia, we had one bile tract surgery case and three neurosurgical cases whose silent pulmonary embolism was initially suggested by an increase in the arterial to end-tidal CO2 gradient (from 17 to 27 mmHg) after general anesthesia was induced or their trachea was intubated. During the preoperative assessment, the patients presented no clinical manifestations suggestive of pulmonary embolism. Our initial diagnosis was confirmed by scintigraphy and/or angiography done immediately after the operations. Because capnometry has been shown to be applicable to non-intubated, spontaneously breathing patients, we suggest that measuring the gradient may serve as an additional method for unmasking silent pulmonary embolism in patients at risk or with disturbed consciousness, whether they are scheduled for operations or not.

Aged↗
PubMedDate not supplied

Hepatic functional reserve in patients with biliary malignancies: an assessment by technetium 99m galactosyl human serum albumin hepatic scintigraphy.

PROBLEM: Technetium 99m galactosyl human serum albumin (99mTc-GSA) is a hepatic scintigraphy agent that binds to the asialoglycoprotein receptors. We evaluated the clinical use of the scintigraphy for the pre-operative assessment of biliary malignancies. PATIENTS AND METHODS: Scintigraphy was performed before operation in 56 patients with biliary malignancies. A hepatic uptake ratio of 99mTc-GSA (LHL15; the count ratio of the liver to the sum of the heart and liver 15 min after injection of 99mTc-GSA) was calculated. RESULTS: LHL15 was significantly associated with bilirubin half-life in patients treated before operation with percutaneous transhepatic biliary drainage (P = 0.007). After operation, 4 of 18 patients with LHL15 < 0.925 died within 30 days. The postoperative mortality was significantly greater in patients with LHL15 < 0.925 than in patients with LHL15 > or = 0.925 (P = 0.033). CONCLUSION: 99mTc-GSA scintigraphy is useful in evaluating the hepatic functional reserve in patients with biliary malignancies.

Adult↗
PubMedDate not supplied

Unilateral hepatic artery reconstruction is unnecessary in biliary tract carcinomas involving lobar hepatic artery: implications of interlobar hepatic artery and its preservation.

BACKGROUND/AIMS: The interruption of hepatic arterial flow when performing a bilioenteric anastomosis has been reported to usually bring about serious postoperative complications, such as anastomotic leakage, hepatic abscess and infarction. We aimed to evaluate the surgical implications of the interlobar hepatic artery when patients with advanced biliary tract carcinomas undergo surgical resection with a bilioenteric anastomosis. METHODOLOGY: In 7 patients with advanced biliary tract carcinomas, the combined resection of the liver (greater than hemihepatectomy in 2 and less than hemihepatectomy in 5), extrahepatic bile duct, hepatic artery (right hepatic artery in 5, right and left hepatic artery in 1, left hepatic artery in 1), and the portal vein was performed in 4 patients. The portal vein was reconstructed in all 4 patients. The hepatic artery was reconstructed in only one patient, with combined resection of both right and left hepatic arteries, but was not reconstructed in 2 other patients, even though they underwent resection greater than hemihepatectomy. RESULTS: The interlobar hepatic artery running into the Glissonian sheath around the hepatic duct confluence could be preserved in 5 patients, as shown by angiography, but could not be preserved in 2 patients who underwent greater than hemihepatectomy. Moderate and transient ischemic liver damage occurred, but no serious postoperative complications were induced in any of the 5 patients in the unilateral hepatic artery preserved group. However, both cases without preservation of the hepatic artery encountered liver failure, liver abscess and leakage of bilioenteric anastomosis, and one patient died of multiple organ failure. CONCLUSIONS: One major lobar branch of the hepatic artery involved by cancer invasion could be safely resected without reconstruction in patients with advanced biliary tract carcinomas when the interlobar hepatic artery running into the Glissonian sheath around the hepatic duct confluence is preserved.

Adult↗
PubMedDate not supplied

Right hepatic artery interruption and prostaglandin E1 in total or proximal pancreatectomy for pancreatobiliary malignancy.

BACKGROUND/AIMS: Advanced hepato-biliary-pancreatic malignancy can frequently involve the hepatic artery. We evaluated the use of prostaglandin E1 in total or proximal pancreatectomy with the right hepatic artery interruption. METHODOLOGY: A Consecutive seven of 117 patients (6.0%) in whom the right hepatic artery was interrupted and not reconstructed were reviewed retrospectively. Four of them received prostaglandin E1 (10-20 ng/kg/min) until the fifth postoperative day, while, the remaining three did not. The effect of prostaglandin E1 was compared concerning complication and hepatic function. RESULTS: The right hepatic artery was intentionally resected because of cancer invasion in five patients with biliary tract carcinoma, while, accidentally transected in two with pancreatic carcinoma. Operative deaths did not occur. The biliary leakage was identified in one patient treated without prostaglandin E1. Although a marked rise in glutamic oxaloacetic transaminase, glutamic pyruvic transaminase, and lactate dehydrogenase levels was observed, hepatic dysfunction was successfully treated conservatively in all patients. The glutamic oxaloacetic transaminase and lactate dehydrogenase values were significantly lower (P < 0.05) in patients treated with prostaglandin E1 compared with those without prostaglandin E1. CONCLUSIONS: The prostaglandin E1 infusion can be helpful for biliary anastomosis and hepatic function in radical hepato-biliary-pancreatic surgery with the right hepatic artery interruption.

Adult↗
PubMed2002

Asymptomatic gallstones in the laparoscopic era.

Recent introduction of new treatment options has significantly altered the approach towards gallstone management. There is now general agreement that cholecystectomy is the treatment of choice for symptomatic gallstones. Controversy, however, exists as to the management of asymptomatic gallstones. The ready availability of abdominal ultrasonography for the investigation of a wide range of abdominal symptoms has resulted in the increased diagnosis of asymptomatic gallstones. Management of such accidentally discovered gallstones poses a dilemma as conclusive evidence of the benefits of cholecystectomy is lacking. This is further complicated by the fact that the majority of asymptomatic gallstones remain so and patients rarely experience symptoms or complications. Furthermore, cholecystectomy is associated with a low but recognised morbidity. Recent introduction of laparoscopic cholecystectomy as the treatment of choice of symptomatic gallstones has further complicated the issue of asymptomatic gallstone management. This article reviews the current management of asymptomatic gallstones in the era of laparoscopic cholecystectomy

Anemia, Sickle Cell↗
PubMed1985

[Endoscopic palliative drainage of the bile ducts].

Initial results of palliative endoscopic retrograde drainage of the common bile duct are reported. In 12 out of 19 patients the treatment was successful (63% cases). In every case the serum bilirubin level quickly decreased to normal values. The life span of the endoprostheses lasted on average for 3 months. No fatal complications occurred in connexion with prosthesis implantation. Endoscopic drainage of the common bile duct in patients with an inoperable tumour of the biliary tract represents an alternative procedure to palliative surgery in the management of malignant occlusion icterus.

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