Hartmann's procedure has been widely accepted as a curative intervention in emergency cases (oncosurgically adequate R0 resection) for the carcinoma of the left colon. Because of the high postoperative morbidity and mortality in emergency situations with only palliative options (R0 resection not possible), alternative endoscopic treatment should be considered more frequently.
Acute appendicitis during pregnancy is a rare event, and large numbers of cases reported in the literature stem entirely from data stored in national registers. Between 1974 and 2000 relevant perioperative data on the treatment of appendicitis were collected consecutively and analyzed retrospectively. Surgical and obstetric data relating to the medical history, the clinical, intraoperative, and histologic findings, and the course of the pregnancy were recorded. Altogether, 9793 appendectomies were performed, 94 of which were in pregnant women (24.5% during the first trimester, 51% during the second trimester, and 24.5% during the third trimester). This represents 0.2% of the 46,960 deliveries during the period under observation. Fifty percent of the case histories during the second trimester were atypical. The overall perforation rate was 14.9%; it was 8.7%, 12.5%, and 26.1% during the three trimesters, respectively. Maternal mortality was 0%; the combined miscarriage/abortion rate was 8.5% (n = 8); and infant mortality was 3.2% (n = 3). The postoperative spontaneous abortion rate was 13.0% and the additional therapeutic/requested abortion rate 21.7% during the first trimester. In view of the elevated postoperative abortion rate and the facility of the clinical diagnosis during the first trimester, the indication for invasive diagnostic measures and surgery requires careful consideration. During the second and third trimesters the difficulty of establishing a clinical diagnosis makes it necessary to undertake exploratory surgery early.
Conflicting reports are found in the literature concerning whether to remove an incidentally discovered Meckel's diverticulum (MD). Between 1.1.1974 and 31.12.2000, at a single center, the perioperative data associated with appendectomy (AE) were recorded consecutively and analyzed retrospectively. All patients in whom an MD was discovered during an AE were included in the study. The clinical presentation, postoperative course, and follow-up in all MDs left in place were analyzed. During the course of 7927 AE, 233 MD (2.9%) were detected. Of these 80.7% (n = 188) were removed and 19.3% (n = 45) were left untouched. In 9% (n = 21) of all detected diverticula pathological changes were found. Ectopic tissue was seen in 12.2% (n = 23) of the MDs removed. The postoperative complication rates did not differ significantly between patients in whom the MD was removed (9.5%; n = 18) and those in whom it was not (17.7%; n = 8); in the latter group the appendicitis was of the more acute type (gangrenous or perforated) (24.4% vs. 4.3%). In 18 patients (40.0%) with non-removed MDs, a follow-up period of 14.1 5.8 years was achieved. Complications associated with a non-removed MD were not observed. If during the course of an AE a MD is detected, the present data, as well as those in the literature, suggest that an individualized approach should be taken. Meckel's diverticulum with obvious pathology should always be removed. In cases of gangrenous or perforated appendicitis, an incidentally discovered MD should be left in place, whereas in an only mildly inflamed appendix it should be removed.
For palliative treatment of malignancy-induced colorectal obstruction, SEMS is an efficient tool associated with low morbidity and minimal mortality. From a technical point of view, all tumor locations are accessible.
Palliative treatment of incurable obstructive colorectal carcinoma using stents is an effective and suitable alternative to palliative surgery with no negative impact on the survival but less peri-interventional morbidity and mortality as well as comparable overall morbidity.
Multiple treatment regimens have been used to successfully treat parotid hemangiomas. Although propranolol is a recent addition, it seems most promising. Further evaluation is warranted.
Kaposiform hemangioendothelioma (KHE) is a rare vascular tumor in children, which can be accompanied by life‐threatening thrombocytopenia, referred to as Kasabach‐Merritt phenomenon (KMP). The mTOR inhibitor sirolimus is emerging as targeted therapy in KHE. As the sirolimus effect on KHE occurs only after several weeks, we aimed to evaluate whether additional transarterial embolization is of benefit for children with KHE and KMP. Seventeen patients with KHE and KMP acquired from 11 hospitals in Germany were retrospectively divided into two cohorts. Children being treated with adjunct transarterial embolization and systemic sirolimus, and those being treated with sirolimus without additional embolization. Bleeding grade as defined by WHO was determined for all patients. Response of the primary tumor at 6 and 12 months assessed by magnetic resonance imaging (MRI), time to response of KMP defined as thrombocyte increase >150 × 103/μL, as well as rebound rates of both after cessation of sirolimus were compared. N = 8 patients had undergone additive embolization to systemic sirolimus therapy, sirolimus in this group was started after a mean of 6.5 ± 3 days following embolization. N = 9 patients were identified who had received sirolimus without additional embolization. Adjunct embolization induced a more rapid resolution of KMP within a median of 7 days vs 3 months; however, tumor response as well as rebound rates were similar between both groups. Additive embolization may be of value for a more rapid rescue of consumptive coagulopathy in children with KHE and KMP compared to systemic sirolimus only.
Dysphagia and gastric stenosis, which significantly influence the healing of esophagojejunal anastomosis after gastrectomy, are considered characteristics of an advanced tumor growth and a pretherapeutic lack of an adequate nutrition. This emphasizes the necessity of an early diagnosis of gastric cancer in order to lower perioperative morbidity. In addition, dysphagia is commonly associated with an obstruction of the upper gastrointestinal tract, which can lead to nutritional deficits, and thus deserves specific care during preventive management.
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