			Home About us Contact

Difficult Management Problem (difficult + management_problem)

Distribution by Scientific Domains

Medical Sciences	100%

Selected Abstracts

Enterocutaneous fistula: a single-centre experience

ANZ JOURNAL OF SURGERY, Issue 3 2010
D. E. Gyorki
Abstract Background:, Enterocutaneous fistulae (ECFs) present a difficult management problem and can cause significant morbidity. The aim of the study was to assess the outcome of these patients. Methods:, A retrospective chart review of all patients with ECF managed at a tertiary centre between 1996 and 2006 was performed. Demographic, management and outcome data including ECF closure, morbidity and mortality were recorded. Results:, A total of 33 patients (17 male) were identified with ECF (median age: 63 years, range: 27,84). The primary aetiology was Crohn's (30%), anastomotic leak (24%), iatrogenic (18%), mesh (6%), neoplasia (6%) and other (16%). Definitive surgery was undertaken in 21 (64%) at a median of 6.4 months (0.4,72 range) following presentation. Twenty percent of patients required emergency surgical intervention and 5 patients required preoperative total parenteral nutrition (TPN). Surgical management was formal resection and reanastomosis in all patients, with a mean operative time of 4.75 h (standard deviation = 1.8). The median hospital stay for the operative group was 19 days (7,85). Four patients required post-operative TPN with one patient requiring home TPN. Fistula closure rate was 97% (operative group: 21 out of 21; non-operative group: 11 out of 12). Mean follow-up was 37.3 months (0.5,217). Six (19%) operative patients developed fistula recurrence. There were two deaths at 2 and 5 months (fistula aetiology malignant colonic fistula and radiation enteritis, respectively). Conclusion:, Patients with ECF can be treated with low morbidity and low recurrence rate in a multidisciplinary setting. We believe that patients with ECF should be referred to specialist units for management. [source]

CR12 ENTEROCUTANEOUS FISTULAE , ARE WE GETTING IT RIGHT?

ANZ JOURNAL OF SURGERY, Issue 2007
D. E. Gyorki
Purpose Enterocutaneous fistulae (ECF) present a difficult management problem and can cause significant morbidity. The aim of the study was to assess the outcome of these patients. Methodology A retrospective chart review of all patients with ECF managed at a tertiary centre between 1996 and 2006. Demographic, management and outcome data was recorded. Factors influencing ECF closure and outcome were assessed with Cox regression analysis. Results Thirty-three patients (17 male) were identified with ECF (median age 63, range 27,84). The primary aetiology was Crohn's (30%), anastomotic leak (24%), iatrogenic (18%), mesh (6%), neoplasia (6%) and other (16%). Definitive surgery was undertaken in 21 (64%) at a median of 6.4 months (0.4,72 range) following presentation. Twenty percent of patients required emergency surgical intervention and 5 patients required preoperative total parenteral nutrition (TPN). Surgical management was formal resection and reanastomosis in all patients, with a mean operative time of 4.75 hours (SD = 1.8). The median hospital stay for the operative group was 19 days (7,85). Four patients required post-operative TPN. Fistula closure rate was 97% (operative group 21/21, non-operative group 11/12). Mean follow up was 37.3 months (0.5,217). Six operative patients (19%) developed fistula recurrence. There were 2 deaths at 2 and 5 months (fistula aetiology malignant colonic fistula and radiation enteritis respectively). No factor was predictive of fistula recurrence. Conclusion Patients with enterocutaneous fistula can be treated with low morbidity and low recurrence rate in a multidisciplinary setting. Patients with ECF should be referred to specialist units for management. [source]

Usefulness of fluorine-18 fluorodeoxyglucose positron emission tomography in patients with a residual structural abnormality after definitive treatment for squamous cell carcinoma of the head and neck

HEAD & NECK: JOURNAL FOR THE SCIENCES & SPECIALTIES OF THE HEAD AND NECK, Issue 12 2004
Robert E. Ware MB
Abstract Background. Residual structural abnormalities after definitive treatment of head and neck squamous cell carcinoma (HNSCC) are common and pose difficult management problems. The usefulness of fluorine-18 fluorodeoxyglucose positron emission tomography (FDG PET) to supplement conventional evaluation with clinical and standard radiologic examination (CE) in such patients was assessed. Methods. Fifty-three eligible patients were identified with residual structural abnormalities on CE. True disease extent could be validated in 46 patients. Patients had a median potential follow-up of 55 months (range, 41,75 months) from the date of PET scan to the analysis closeout date. Results. PET had better diagnostic accuracy than CE (p = .0002) and induced management change in 21 patients (40%; 95% confidence interval [CI], 26%,54%), including avoidance of unnecessary planned surgery in 14 patients with negative PET. Appropriate management change was confirmed in 19 (95%) of 20 evaluable cases. Disease presence and extent assessment by PET were significant predictors of survival (p < .0001), whereas the extent of disease determined by CE was not. Conclusion. PET added significantly to the value of CE in restaging disease in patients with structural abnormalities after definitive treatment of HNSCC. Management decisions based on PET were appropriate in most patients. © 2004 Wiley Periodicals, Inc. Head Neck26: 1008,1017, 2004 [source]

Hepatitis C: Magnitude of the problem

LIVER TRANSPLANTATION, Issue 10B 2002
Jorge Rakela MD
1End-stage liver disease associated with hepatitis C virus (HCV) infection has become the leading indication for liver transplantation in the United States. 2Patients with end-stage liver disease caused by HCV may have such associated comorbidities as chronic alcoholism, steatosis, or coinfection with human immunodeficiency virus 1 or other hepatitis viruses. These comorbidities may accelerate disease progression. 3As chronic hepatitis C progresses to cirrhosis, the risk for the development of hepatocellular carcinoma increases; this poses difficult management problems. 4As patients who underwent transplantation for end-stage liver disease caused by HCV infection are followed up long term, it has become clear that patient and graft survival are decreased compared with HCV-negative patients or those with cholestatic liver disorders. 5Risk factors associated with a worse outcome after transplantation include host, viral, donor, and posttransplantation factors. 6Major challenges to be addressed in the future include delineation of the optimal antiviral therapy and how to handle the need to perform retransplantation on patients who develop graft dysfunction as a result of HCV recurrence. [source]