Acute appendicitis after diaphragmatic hernia after pediatric liver transplant

Multiple complications in liver transplant have been described in the literature. However, appendicitis and diaphragmatic hernia have rarely been reported after solid-organ transplant. The clinical presentation of appendicitis is similar to that of nontransplant patients, but complications are more frequent, because the majority of the patients do not have leukocytosis. Diaphragmatic hernia can present with a variety of atypical clinical symptoms. In this report, 1 patient who developed a diaphragmatic hernia and appendicitis after liver transplant is presented. A 2-year-old boy with end-stage liver cirrhosis owing to progressive familial intrahepatic cholestasis type-2 received a living-donor liver transplant. The posttransplant course was complicated. The diagnosis of diaphragmatic hernia was confirmed by thoracoabdominal computed tomography, and we decided to proceed with surgical repair. The patient had evidence of perforation, and the appendix was removed. After repositioning the intestine in the abdomen, a chest tube was placed, and the defect repaired with interrupted polypropylene sutures. The patient recovered after surgery without untoward sequelae.     

Enhanced recovery after surgery programs hasten recovery after colorectal resections

Colorectal resection was traditionally associated with significant morbidity and prolonged stay in hospital.Laparoscopic colorectal resection was first described in 1991 as a minimally invasive form of colorectal surgery.It was later on assessed by multiple randomized controlled trials and meta-analysis and was found to be associated with a faster recovery,lower complication rates and a shorter stay in hospital compared with open resection.To assess the effect of enhanced recovery after surgery (ERAS) program on postoperative length of stay after elective colorectal resections,a literature review was conducted,supplemented by the results of 111 ERAS colorectal resections at regional NWS Hospital using a protocol based on the Fast Track approach described by Kehlet in 1999.ERAS has been shown to improve postoperative recovery,reduce length of stay and enhance early return to normal function when compared with traditional colorectal surgical protocols.The role of laparoscopic surgery in colorectal resections within a fast-track (ERAS) program is controversial.The current evidence suggests that within such a program,there is no difference between laparoscopic and open colorectal surgery in terms of postoperative recovery rates or length of hospital stay.     

Infection after arthroscopy

Infection of a peripheral joint following arthroscopic surgery is extremely rare, with an incidence of up to 0.42%. However, the consequences of delayed diagnosis can be dramatic. Besides taking an exact patient history, C-reactive protein determination and, especially, diagnostic arthrocentesis are required. For early-stage infections, arthroscopic therapy has been proven valuable. In addition, calculated and antibiogram-adjusted antibiotic therapy is essential. In the case of persisting signs of infection, re-arthroscopy should be considered quickly, with indications broad. The number of necessary revisions depends on the initial stage of infection. Postoperative immobilisation of the affected joint is occasionally essential for treating pain; otherwise, early mobilisation of the joint should be performed.     

Outcome after polytrauma

Background and aims: Outcome refers to the different facets of consequences resulting from an event or intervention. These consequences may be relevant for an individual patient, but also for society. There is a growing recognition that clinical research needs to define and focus on the outcomes of medical care. Outcome research should help health care professionals to better evaluate the effectiveness of specific interventions or a therapeutic concept. This broader base of evidence should then benefit the patients. Methods: The literature was reviewed with respect to concepts of outcome research as well as results of outcome research after major trauma. Results: Measuring outcome might be relevant for research purposes as well as in daily surgical practice. In the past, clinical research in trauma care has tended to focus on survival. Mortality rates are not out, complication rates are not out, but their value is limited and restricted to given scenarios with high mortality rates. New outcomes have to be added: such a functional status, emotional health, social interaction, cognitive function, degree of disability and other indicators of health. Conclusion: Despite differences in injury pattern and severity of injury, there is strong evidence from the literature that the quality of life is significantly impaired after major trauma. This is true for functional outcome as well as for psycho-social outcome in up to 70% of patients. Received: 22 February 1998     

Reoperation after cholecysto-enterostomy

Treated were 129 patients, who earlier underwent cholecysto-enterostomy in periampullary tumors. At the period of from 3.5 to 5 weeks after the first operation, these patients need thorough clinico-instrumental examination, they should be given aid at a specialized in-patient department.     

Complications after pancreaticoduodenectomy

The most frequent complications after pancreaticoduodenectomy are analysed in this review. These include, delayed gastric emptying, pancreatic fistula, post-operative bleeding, and the complications after vascular reconstruction in the cases of locally extended pancreatic cancer. For this, randomised prospective studies, systematic meta-analyses and clinical guidelines on the definition, clinical severity grade and treatment of these complications have been evaluated.     

Reconstruction after mastectomy

Advances in materials and techniques, especially those involving transposition of muscle and skin flaps, have made breast reconstruction possible for most women who undergo mastectomy for breast cancer. The availability of this option can alleviate the breast and chest wall deformity that results from virtually all local treatment of breast cancer. It is essential that the reconstruction surgeon be part of the breast cancer management team from the beginning of treatment planning and that this surgeon work closely with the general surgeon, medical oncologist, and radiation therapist as well as the adjunctive treatment team members. The patient's clinical status and the type of local treatment will be significant determinants of the reconstructive options. For women with stage I breast cancer, these decisions may be based largely on the oncologist's local and adjunctive therapy procedures and the woman's desire to proceed or delay. For women with systemic disease, all members of the breast management team may need to agree on the advisability and timing of reconstruction. Central to all of the numerous decisions described in this paper regarding the timing, type, and extent of breast reconstruction is the primary goal of the entire team: the best possible management of the breast cancer itself. The promise of attractive, symmetric, and natural appearing breasts, complete with a symmetric nipple-areolar complex, has eased somewhat the diminishment of self-esteem and the threat to femininity that can accompany the loss of a breast. By lowering fear, the widely recognized availability of breast reconstruction may encourage more women to monitor their breasts and seek diagnosis of changes and may influence selection of the type of local treatment if cancer is detected. Because of the psychological and cultural significance of the breast, the reconstructive surgeon must be particularly sensitive to the psychological and aesthetic expectations of the patient. Even in those patients with metastases and limited life expectancy, breast reconstruction can enhance the quality of life.     

Discitis after discography

Infection after intradiscal injections has been recognised as a distinct entity, but discitis after discography has often been attributed to an aseptic process or a chemical reaction to the contrast material. We examined the hypothesis that discitis after discography is always due to infection, and report a clinical review and an experimental study. Part I. We reviewed the case records and radiographs of 432 patients who had undergone lumbar discography. When an 18-gauge needle without a stilette had been used, discitis was diagnosed in 2.7% of 222 patients but stiletted needles and a two-needle technique at each level reduced the incidence to 0.7%. Seven patients with discitis after discography had undergone anterior discectomy and fusion; in them the histopathological findings were of a chronic inflammatory response. Bacteria were isolated from the discs of three of the four patients who had open biopsy less than six weeks from the time of discography. These findings suggest that bacteria were initiators rather than promoters of the response. Part II. Multiple level lumbar discography was carried out in mature sheep, injecting contrast material with or without various concentrations of bacteria. Radiographs were taken and the discs and end-plates were examined histologically and cultured for bacteria at intervals after injection. None of the controls showed any evidence of discitis but all sheep injected with bacteria had typical radiological and histopathological changes by six weeks, though cultures were almost all negative. However, at one and two weeks after injection, but usually not after three weeks, bacteria could be isolated. We suggest that all cases of discitis after discography are initiated by infection, and that a very strict aseptic technique should be used for all injections into intervertebral discs.