Multiple gastrointestinal stromal tumors (GISTs) of the small intestine is an uncommon finding but can be a marker for underlying neurofibromatosis type 1 (NF1). We present the case of the 38-year-old male without prior NF1 diagnosis who presented with a small bowel obstruction. His physical exam was notable for cutaneous nodules and café-au-lait spots. He progressed to peritonitis and underwent an exploratory laparotomy, which revealed a 6-cm hemorrhagic mass along the antimesenteric border of the jejunum, causing obstruction and perforation. Pathology was consistent with GISTs. NF1-associated GISTs differ from wild-type GISTs in that they are unlikely to have C-KIT and PDGFRA mutations and therefore do not respond to imatinib. Treatment is largely limited to surgical resection; however, there is evidence that MEK inhibitors may prove an additional treatment strategy.
Background Acute kidney injury (AKI) is a known postoperative complication of open ventral hernia repair contributing to increased costs, hospital length of stay, and mortality. The aim of this study was to identify whether the muscle injury that occurs in a posterior separation of components via transversus abdominis release (TAR) contributes to a higher incidence of postoperative AKI. Methods A retrospective cohort study of patients who underwent open retrorectus ventral hernia repair with and without TAR at a single institution between 2012 and 2019 was performed. Patients who underwent a separation of components via either unilateral or bilateral transversus abdominis release were compared to those who did not undergo TAR as part of their hernia repair (non-TAR). The outcome of interest was the development of postoperative AKI. Acute kidney injury was defined as an increase in creatinine of greater than 50% of the preoperative baseline. Univariate and multivariate analyses were performed to determine the influence of TAR on the development of AKI. Results There were 523 patients who met inclusion criteria, of which 159 (30.4%) had a TAR as part of their retrorectus hernia repair. No differences were found in preoperative characteristics between the TAR and non-TAR group including age, gender, history of kidney disease, or history of diabetes. By contrast, the TAR group had significantly greater median estimated blood loss (100 mL vs 75 mL, P < .01), mean positive intraoperative fluid balance (2255 mL vs 1887 mL, P < .01), and operative duration (321 min vs 269 min, P < .001). The rate of AKI in the TAR group was 11% (n = 18) vs 6% (n = 23, P = .0503) in the non-TAR group. On multivariate analysis controlling for patient characteristics and intraoperative factors, TAR was the only factor with a significantly increased odds of AKI (OR 1.97, 95% CI 0.994-3.905, P = .0521). Conclusions In patients with large ventral hernias requiring retrorectus repair, performing a TAR is associated with a nearly 2-fold increase in the development of postoperative AKI. These findings suggest that these patients should be optimized perioperatively with emphasis on fluid resuscitation, limiting nephrotoxic medications and monitoring urine output.
Die altbekannte mechanische Drainage hochgradiger Hautödeme gilt auch heute noch bei den meisten Ärzten als eine Maßnahme, die man nur lin äußersten Notfalle bei einer Herzinsuffizienz oder einer Nephrose anwenden soll. Als wesentlichster Nachteil gilt die Gefahr einer Infektion an den Einstichstellen. Dieser Einwand, das muß mit allem Nachdruck betont werden, besteht heute, nach der Einführung der Antibiotika nicht mehr zu Recht. Mit Penicillin und anderen Antibiotika usw. sowie mit strenger lokaler Aseptik läßt sich beim kardialen Ödem eine Infektion praktisch immer verhüten. Das gleiche gilt für das nephrotische Odem, obwohl die Neigung zu Infekten etwas größer sein dürfte. Deshalb haben namhafte Autoren [P. D. White (1), G. Nylin (2) und seine Schule (3)] in letzter Zeit wieder auf den Wert der mechanischen Odemdrainage hingewiesen.Viele Kranke mit einer chronischen Herzinsuffizienz erreichen nach oft jahrelanger Anwendung der Quecksilber-Diuretika ein Stadium, in dem diese Entwässerungsmaßnahmen versagen. Gelegentlich gelingt es, diesen Zustand nach der Aufklärung seiner Entstehungsursachen (z. B. Störungen im Elektrolyt-Haushalt) erfolgreich zu bekämpfen. In anderen Fällen bleibt die Drainage des Odems, abgesehen von einigen komplizierteren und nicht überall anwendbaren Methodén (Peritonaealdialyse u. â.), der einzige therapeutische Ausweg. In diesen Fällen erweist sie sich geradezu als lebensrettend und dies nicht nur in dem Sinne, daß sie dem Kranken noch-eine kurze Verlängerung seiner Lebensspanne verschafft. Vielmehr
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