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    • Surgical intervention remains obligatory for hemodynamic ins

    2019-04-15

    Surgical intervention remains obligatory for hemodynamic instability, including shock secondary to renal bleeding, complex lacerations, renal pelvic, or ureteral injury, plus certain renovascular conditions. The prolonged warm ischemia that may occur when under renal neoplasty usually results in irreparable damage and loss. There have been only a few functional renal outcomes of surgical repairs for such situations. Renal exploration was more likely to result in the loss of the injured kidney than was nonoperative management. In conclusion, avoiding unnecessary nephrectomy is of utmost importance. At present, TAE for injured segmental renal middle-aged is a widely accepted therapeutic modality for most renal vascular injuries. It is considered the first-choice treatment to control ongoing renal hemorrhage in patients with iatrogenic as well as blunt and penetrating trauma. The clinical success of TAE in controlling severe hemorrhage is 57–100%. Intravascular contrast extravasation indicates direct radiographic evidence of ongoing bleeding. Thus, intravascular contrast extravasation should be a valuable predictor of the need for intervention to control renal bleeding. However, TAE requires specific techniques and working conditions. It is difficult to produce a marked effect in emergencies. Prior to the advent of the coaxial catheter, it was impossible to use extremely superselective technique to catheterize subsegmental artery, which resulted in significant infarction and loss of function. Some studies have reported the complications of embolization, including pyrexia, pain, intimal dissection, hypertension, and abscess. The infarct acts as a scar that has a tendency to shrink. It can induce renal atrophy, just as we found in our study. Patients with a solitary kidney had deleterious effects after TAE, in the form of elevated serum creatinine level. In renal trauma patients, the choice between surgery or TAE largely depends on the condition of the patient, skill level of surgeons, and the availability of interventional services in the institution. TTBR remains a damage control method. Multiorgan trauma injuries are addressed by angiography and temporal embolism. At that time, the patient becomes hemodynamically stable. Then, a laparotomy can be performed without any delay at the time of when or after evacuation. Urogenital systemic injury constitutes a small portion of battlefield injuries, ranging from 0.7% to 8%, but with renal injuries as high as 40%. The genitourinary organ system is well suited to this style of management. Complex genitourinary reconstructive surgery should be delayed until the patient is hemodynamically and metabolically stable. In emergencies, TAE is very difficult, because of the possible skill limitations of the surgeon (i.e., immediate vascular control, arteriography ability, plus experience in renal reconstructive techniques). TTBR should be used to localize hemorrhage sites and to guide angiographic or surgical intervention.
    Introduction Intrahepatic cholangiocarcinoma (ICC) originates from either the small intrahepatic ductules, or the large intrahepatic ducts proximal to the bifurcation of the right and left hepatic ducts. ICC accounts for 10–15% of all liver cancers, and is the second most common primary malignancy of the liver after hepatocellular carcinoma. Surgical resection remains the only potentially curative treatment for ICC. However, only 30–40% of patients present with resectable disease at the time of diagnosis. High recurrence rates have contributed to a poor 5-year survival, which ranges from 14% to 40%. Recently, a multicenter international study of ICC patients reported a median postoperative overall survival (OS) of only 14.8 months. Accurate staging may therefore be helpful to select suitable patients to undergo surgery or receive earlier chemotherapy. The 6th edition of the American Joint Committee on Cancer (AJCC) cancer staging system did not separate ICC from hepatocellular carcinoma, whereas the staging system referenced in the 7th edition of the AJCC introduced a separate TNM (tumor, node, metastasis) classification for ICC. The latest classification focuses on multiple tumors, vascular invasion, and lymph node metastases. However, several studies found additional prognostic factors, including age, positive surgical margins, tumor sizes, and tumor differentiation. Prognostic nomograms, including additional factors, might be more accurate than the conventional AJCC staging system for predicting outcomes. In this study, we analyzed 103 ICC patients who received surgical resection with curative intent at the Taipei Veterans General Hospital in Taiwan. We aimed to identify additional prognostic factors and evaluate the effect of lymph node dissection (LND) on prognosis in this cohort of ICC patients.