羟氨苄青霉素引起大疱性类天疱疮样疹

Epidemiology and Natural History of Inflammatory Bowel Diseases

Principal changes with respect to the 2004 ECCO guidelines 

Ileocolonoscopy is recommended within the first year after surgery where treatment decisions may be affected (Statement 8C).

Thiopurines are more effective than mesalazine or imidazole antibiotics alone in post-operative prophylaxis (Statement 8F).

### 8.1 Epidemiology of post-operative Crohn's disease

In the natural history of CD, intestinal resection is almost unavoidable since about 80% of patients require surgery at some stage. Surgery is unfortunately not curative as the disease inexorably recurs in many patients. The post-operative recurrence rate varies according to the definition used: clinical, endoscopic, radiological, or surgical. It is lowest when the repeat resection rate is considered, intermediate when clinical indices are used and highest when endoscopy is employed as the diagnostic tool.1–10

Data from endoscopic follow-up of patients after resection of ileo-caecal disease have shown that in the absence of treatment, the post-operative recurrence rate is around 65–90% within 12 months and 80–100% within 3 years of the operation. The clinical recurrence without therapy is about 20–25%/year.1,10 It has been demonstrated that the post-operative clinical course of CD is best predicted by the severity of endoscopic lesions. Symptoms, in fact, appear only when severe lesions are present and it is not uncommon to observe patients with fairly advanced recurrent lesions at endoscopy who remain asymptomatic.1 For these reasons, clinical indices such as the CDAI have low sensitivity at discriminating between patients with or without post-operative recurrence.11

These data mandate strategies aimed at interrupting or delaying the natural course of post-operative recurrence. Several medications have been tried in an attempt to prevent post-operative recurrence, mostly with disappointing results. The aim of this Consensus was therefore critically to evaluate the optimal strategies for the management of post-operative recurrence in CD. Most, if not all, of the evidence available deals with …

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The second European evidence-based Consensus on the diagnosis and management of Crohn's disease: Special situations

Currently, adrenal masses are discovered incidentally in 0.35–5% of patients imaged with computed tomography (CT) and are referred to as adrenal incidentalomas [1,2]. As a result, the diagnostic dilemma of separating the small fraction of hypersecretory and/or malignant masses from the majority that are nonhypersecretory adrenal adenomas has become common. Given the fourfold greater autopsy incidence of adrenal adenomas compared with the radiographic incidence, and the oncology data that only 20–41% of adrenal metastases are detected by CT [1,3], it is likely that an increase in prevalence will occur if the spatial resolving capacity of abdominal imaging improves, if abdominal imaging occurs more frequently, and if routine abdominal imaging slice thickness is decreased.

Incidentally discovered adrenal masses

Hepatocellular carcinoma (HCC) is a common cause of death in patients with cirrhosis. Cirrhosis develops as a result of chronic liver injury secondary to extrinsic environmental factors in the vast majority of affected individuals. Hepatitis B or C virus infection, aflatoxin B1 or other mycotoxin ingestion, and prolonged ethanol abuse are the major causes of cirrhosis. 1 The worldwide population at risk for developing HCC because of one or more of these etiologic factors numbers in the tens of millions: in the United States and Italy, for example, there are an estimated 7.5 million persons with chronic hepatitis C virus infection. 2,3

In most patients with HCC, treatment options are limited by the liver dysfunction caused by chronic inflammation and cirrhosis. Although complete surgical resection of HCC offers the best chance of long-term survival, cirrhosis may limit the amount of parenchymal resection that will be tolerated and increases the risk of postoperative liver failure and death. 4–6 Systemic or regional chemotherapy is at best palliative in a small subset of patients (although rarely patients have sufficient tumor downstaging to convert an unresectable to a resectable lesion), but at the cost of significant side effects and a reduced quality of life. 1 In most patients with cirrhosis and HCC confined to the liver, resection is not safe, and local tumor-ablation therapies are considered as alternative treatment options.

Radiofrequency ablation (RFA) is a thermal treatment technique designed to produce localized tumor destruction by heating tumor tissue to temperatures that exceed 50°C. When tumor cells are heated to temperatures above 45° to 50°C for more than 3 minutes, intracellular protein denaturation and melting of lipid bilayers results in direct tumor cell death. 7–10 RFA uses alternating current passed across needle electrode arrays placed directly into the tumor. Ionic stimulation induced by the alternating current in tissue surrounding the electrode array produces gradual frictional heating, and the tissue temperatures rise to 80° to 110°C, which results in coagulative necrosis of the tissue in proximity to the electrode. The basic principle is similar to that of the surgical electrocautery units used to achieve intraoperative hemostasis.

We performed this prospective study using RFA to treat HCC in patients with cirrhosis to determine treatment efficacy, safety, local tumor control, patterns of failure, and treatment-related complications.

Radiofrequency ablation of hepatocellular cancer in 110 patients with cirrhosis.

Published results of hepatic cryotherapy are now available for almost 900 patients. Its safety is well established and its clinical role in treating patients with unresectable hepatoma or liver metastases from colorectal carcinoma is well supported by tumour marker and survival data; the results in the treatment of neuroendocrine liver metastases are promising. Its role as an alternative to liver resection is not yet well supported by long-term data. Although different adjuvant treatment protocols have been used following the cryotherapy of colorectal liver metastases, the effect of adjuvant treatment on recurrence or survival has not been assessed in prospective studies. Laparoscopic hepatic cryotherapy is feasible in selected patients with suitable tumour locations. However, the proportion of patients who might be usefully treated with this technique is not yet well established. The mechanisms of tissue destruction by freezing are reviewed.

A collective review of the world literature on hepatic cryotherapy.

Incidence and clinical importance of perioperative histamine release: randomised study of volume loading and antihistamines after induction of anaesthesia

Background The aim of this study was to report the frequency of post-operative recurrent laryngeal nerve paralysis (RLNP) following resection for esophageal carcinoma. Patients and methods Four hundred and four patients were studied. Diagnosis of post-operative RLNP was performed by indirect laryngoscopy. Tumour characteristics, surgical approach and perioperative morbidity and mortality following esophageal resection were recorded. Results Sixty patients were diagnosed with post-operative RLNP, of whom 47 had a unilateral and 16 a bilateral lesion. RLNP was more frequently diagnosed after transhiatal resection with cervical esophagogastrostomy as compared to abdomino-thoracic resection ( p =0.06). A higher rate of post-operative pneumonia was evident in patients with RLNP (33 of 63 as opposed to 90 of 341; p =0.027). Conclusion RLNP is associated with a significant morbidity, especially pulmonary complications after resection of esophageal cancer.

Recurrent laryngeal nerve paralysis (RLNP) following esophagectomy for carcinoma

Subfascial elimination of incompetent perforating veins is the most effective therapeutic principle in the treatment of trophic skin disorders associated with varicosis. A recently developed endoscopic technique allows accurate sectioning of perforating veins with direct observation of the veins and minor trauma. From November 1986 to July 1991 endoscopic sectioning of perforating veins was performed in 72 patients (103 legs). The most frequently transected perforating veins were Cockett's veins (n=219), 24 cm perforating veins (n=83), and Boyd's perforating veins (n=82). Postoperative delayed wound healing was observed in 3 (2.9%) legs with pronounced trophic skin disorders in the lower extremities. Two patients complained of dysesthesia in the area of distribution of the sural nerve. Further complications recorded were extended subcutaneous hematoma in 6 (5.8%) legs and postoperative dysesthesia in the area of distribution of the saphenous nerve in 10 (9.7%) legs. At follow-up examination (mean 27 months postoperatively) clinical investigation and Doppler sonography showed newly formed incompetent perforating veins in only 2 lower legs. Radiography at follow-up revealed one incompetent Dodd's perforating vein in 1 leg, which was the starting point of pronounced recurrent varicosis in the lower leg. After an average follow-up of >2 years, we recorded the occurrence of new varices in 9 lower legs. Staging of chronic venous incompetence showed an upward trend ranging from change to a more favorable stage to complete cure. Findings were unchanged in only 10% of the patients. There was no case of postoperative aggravation.

Endoscopic subfascial sectioning of incompetent perforating veins in treatment of primary varicosis.

Controversy exists with regard to the most optimal therapy for achalasia. None of the available therapeutic methods can reverse the neurologic abnormalities, consisting of a marked reduction or lack of ganglionic cells in Auerbach's plexus, a Wallerian degeneration of extraesophageal nerve fibers and perhaps fewer neurones in the dorsal vagal nucleus.1–5 Therefore, any type of therapy for these patients is strictly palliative. Currently, only 2 treatment modalities promise a long-term relief from dysphagia and regurgitation, namely pneumatic dilation and Heller myotomy. Both methods have different characteristics: pneumatic dilation may cause a too low reduction of lower esophageal sphincter (LES) pressure and only little improvement in symptoms, and myotomy may have the opposite effect, leading to a higher frequency of gastroesophageal reflux. The results of a single randomized controlled study6 suggest that surgery may be more effective than myotomy in the long-term management of patients with achalasia. However, this study has been criticized for its less than optimal method of pneumatic dilation.7 Thus, at the present time, the optimal therapy for patients with achalasia remains to be determined.

An even greater therapeutic challenge arises in patients who fail to respond to either one of these treatment modalities. There is no prospective controlled study that investigates the effect of surgical myotomy in patients not responding to repeated pneumatic dilation. In fact, it remains unclear whether patients who had previously undergone pneumatic dilation are more difficult to treat surgically. While Patti et al8 encountered no difficulties when dissecting the different anatomic planes in patients who had previously been treated by pneumatic dilation, others9,10 emphasized that surgery is technically more demanding in this situation and occasionally leads to mucosal perforation. Furthermore, there is almost no information on the long-term outcome in patients who have been treated by dilation and subsequently required surgery.

In 1980, we began a prospective long-term observation in patients with achalasia with the aim to determine their long-term clinical course.11 The current analysis is aimed at answering the following questions. (1) What is the long-term clinical course in patients undergoing surgery after failed pneumatic dilations in comparison with that of patients showing an “optimal response” to a single dilation therapy? (2) Does a preceding pneumatic dilation adversely affect the performance of a Heller myotomy and does it increase perioperative morbidity? (3) Does clinical information obtained at initial presentation allow one to predict the eventual requirement of surgery?

Th. Junginger

Papers

A collective review of the world literature on hepatic cryotherapy.

Incidence and clinical importance of perioperative histamine release: randomised study of volume loading and antihistamines after induction of anaesthesia

Recurrent laryngeal nerve paralysis (RLNP) following esophagectomy for carcinoma

Endoscopic subfascial sectioning of incompetent perforating veins in treatment of primary varicosis.

Heller Myotomy for Failed Pneumatic Dilation in Achalasia: How Effective Is It?