Second-look laparotomy for Wilms' tumor: indications and results in 19 patients

Nineteen of 74 children with Wilms' tumor underwent second-look laparotomy. Transperitoneal operation was done in five cases referred after flank operation elsewhere. Four had a change in stage from I to II or III, while one considered "inoperable" was resected (4/5 survived). Reoperation was done in two late referrals after operations with tumor spill. One had recurrent flank disease; the other had a flank mass with unrecognized diaphragmatic and intracaval extension (1/2 survived). Three children with giant tumors initially considered unresectable were successfully resected after cytoreduction with chemotherapy (3/3 survived). Two of three patients with bilateral Wilms' tumor survived reoperative procedures (partial or total nephrectomy). Five children with late intraabdominal recurrence (3 liver: 2 flank) eventually died despite reoperation and adjunctive therapy. All five had unfavorable histology. One child with en bloc hepatic resection had successful reoperation for suprahepatic vena caval obstruction due to regeneration of liver, but subsequently died. Ten of the 19 patients survived (52.6%) following reoperation and adjunctive therapy. Second-look laparotomy is quite useful in patients inadequately staged with flank operations, in cases of bilateral Wilms' tumor, and in children with initially unresectable tumors following cytoreduction. Patients with extensive tumor spill at a previous procedure may benefit from early reoperation. Late recurrence of tumor (especially with unfavorable histology) and/or liver metastases carried an ominous prognosis.     

Acetabular osteotomy: indications and results

Acetabular osteotomy is the treatment of choice for young patients with symptomatic structural abnormalities of the acetabulum in the absence of severe secondary degenerative changes. These disorders can include hip instability from classic developmental dysplasia or posttraumatic acetabular dysplasia, hip impingement from retrotorsional acetabular deformities, or rarely, posttraumatic problems. During the last 15 years, various techniques of acetabular reorientation have evolved, making the procedure reliable, reproducible, and durable. In this report, the current indications and results of acetabular osteotomy in patients with symptomatic acetabular structural problems will be discussed.     

Video-assisted thyroidectomy: indications and results

Background and aims Minimally invasive video-assisted thyroidectomy (MIVAT) was set up and introduced in our department in 1998. Its results, after an acceptable relapse, can now be evaluated, also speculating on new possible indications. Patients and methods The procedure is based on a unique incision in the central neck, 2 cm above the sternal notch, using small conventional retractors and needlescopic (2 mm) reusable instruments. Haemostasis is achieved by a harmonic scalpel. Patients, 833, underwent MIVAT since June 1998. There were 715 females and 118 males (ratio 4:1). Lobectomy was carried out in 323 (38.7%) patients, total thyroidectomy in 510 (61.2%) patients. Results Mean operative time of lobectomy was 36.2 min (range: 20–120); for total thyroidectomy, 46.1 min (30–130). Conversion to standard cervicotomy was required in 16 cases (1.9%); Operative complications were represented by transient monolateral recurrent nerve palsy in eight cases (0.9%), definitive monolateral recurrent nerve palsy in seven cases (0.8%). Twenty patients exhibited a hypoparathyroidism, which corresponds to 3.9% of total thyroidectomies performed, but only two showed permanent hypoparathyroidism (0.3%). Conclusion MIVAT can be considered a safe operation offering significant cosmetic advantages with possible new promising indications such as prophylactic thyroidectomy in rearranged during transfection (RET) gene mutation carriers. It is still limited to a minority of patients, in particular, in endemic goitre countries. Electronic Supplementary Materials Supplementary material is available for this article at Presented at the International Symposium, Modern Technologies in Thyroid Surgery”, 10–11 February 2006, Halle/Saale, Germany.     

Surgical treatment of renal artery dissection in 25 patients: indications and results

OBJECTIVE: Results of surgical revascularization in 25 patients with renal artery dissection (RAD) over 14 years, with mean follow-up of 55.3 months (range, 10-111 months), were analyzed. Indications for surgery were renovascular hypertension and preservation or improvement of kidney function. PATIENTS AND METHODS: Two patients (both 20 years of age) underwent emergency surgery after severe trauma; 23 patients (mean age, 41 years) underwent elective surgery in a chronic stage of disease. Preoperative, postoperative, and follow-up examinations included duplex ultrasound scanning, determination of serum creatinine and urea concentrations, and evaluation of blood pressure control. All long-term patients underwent digital subtraction angiography preoperatively and postoperatively. All histologic specimens of resected renal arteries were re-evaluated by two independent pathologists. RESULTS: Histologic re-evaluation confirmed the traumatic origin in 2 patients who underwent emergency surgery and 1 who underwent elective surgery. Renal artery dissection developed spontaneously, with no histologic signs of trauma or fibromuscular dysplasia, in 22 patients. In 17 revascularized kidneys (61%) a kidney infarction had already developed preoperatively, and the kidneys were diminished in size or function. Results of revascularization and improvement of hypertension depended on preoperative extent of renal infarction. Hypertension resolved or improved in 86% of patients without preoperative kidney damage, but in only 38% with preoperatively damaged kidneys. Kidney function was preserved in 23 of 28 revascularized kidneys (82%). During follow-up, late renal artery occlusion developed in 3 kidneys. CONCLUSIONS: Renal artery dissection can be effectively treated with surgical revascularization. Primary nephrectomy should be considered only in patients with a large ischemic kidney infarction, with significant deterioration of kidney function, to effectively cure or improve severe renovascular hypertension.     

Ampullectomy in benign lesion: indications and results

BACKGROUND: Surgical resection remains today the standard treatment of ampullary and papilla tumours. Whether pancreaticoduodenectomy (PD) or ampullectomy is indicated for presumed benign lesions remains debated. The feared potential post-operative morbidity of ampullectomies is balanced by the functional sequelae of PD. AIM OF THE STUDY: This work reports our experience of ampullectomies for presumed benign lesion of the ampulla and papilla and analyses the indications and results of ampullectomies, considering both our series and published series of the literature. METHODS: Since 1997, eight ampullectomies with frozen section have been performed for presumed benign lesions, taking account of morphologic criteria and pre-operative endoscopic biopsies. RESULTS: Post-operative mortality was nil. Post-operative morbidity included one bilio-enteric fistula and four acute pancreatitis, all treated conservatively. Final pathological examination showed one benign and one malignant ampullomas, one benign fibrous stenosis of the papilla, one duodenal duplication and one choledococele, two adenomas and one adenomyomatosis of the papilla in patients with familial adenomatous polyposis (FAP). During follow-up, one de novo duodenal adenoma in FAP and one benign stenosis of the papilla were observed and treated endoscopically. All other patients remain asymptomatic. CONCLUSION: Ampullectomy with accurate intra-operative frozen section appears adequate for presumed benign lesion of the papilla and ampulla.     

Open and laparoscopic cholecystectomy in acquired immunodeficiency syndrome: indications and results in fifty-three patients

BACKGROUND: Although acute cholecystitis is one of the most common indications for abdominal surgery in patients with acquired immunodeficiency syndrome (AIDS), previous studies have reported disappointingly high morbidity and mortality among those patients who have undergone cholecystectomy. The aims of this study were to analyze the indications for and the outcome of cholecystectomy performed for acute cholecystitis in patients with AIDS. METHODS: We retrospectively reviewed the hospital charts of 53 patients with AIDS who underwent open or laparoscopic cholecystectomy from 1992 to 1997. Statistical analysis using the chi-square, Student's t, and Fisher exact tests was conducted to determine whether cause of cholecystitis, type of surgical approach, and CD4+ T-lymphocyte count influenced outcome. RESULTS: The clinical findings and imaging by ultrasonography were always reliable in establishing diagnosis and guiding treatment of acute cholecystitis. Open cholecystectomy was performed in 24 patients (45%). The procedure was begun laparoscopically in 29 patients (55%) and converted to open in 4 (14%). The pathologic findings showed acalculous cholecystitis in 19 patients (36%) and cholelithiasis in 32 (60%). Morbidity was 34% and mortality was 2%. Type of operative approach, cause of cholecystitis, and CD4+ T-lymphocyte count (greater or less than 50 cells/mm3) did not significantly affect morbidity and mortality. The length of hospital stay was significantly influenced by the CD4+ T-lymphocyte count. CONCLUSIONS: These findings suggest that in most patients with AIDS, laparoscopic or open cholecystectomy may be performed with significant but acceptable morbidity and low mortality.     

Percutaneous endoscopic gastrostomy: indications and results

Patients requiring feeding gastrostomies are often poor risks for either laparotomy or general anesthesia. Percutaneous endoscopic gastrostomy can be performed at the bedside by a surgeon-endoscopist and with minimal sedation. The authors performed this procedure on 45 patients ranging in age from 17 to 88 years. The procedure was indicated for neurologic disorders in 34 patients, head and neck tumours in 2, failure to thrive in 4, esophageal obstruction from lung cancer in 1 and tracheostomy for multisystem failure or trauma and sepsis in 4. In three cases the procedure could not be performed because the stomach could not be intubated. In 29 cases local anesthesia and sedation (diazepam and meperidine) were used, but in 16 cases general anesthesia with hyperventilation was preferred. The mean operative time was 32 minutes, decreasing with experience so that the current mean operative time for the last nine cases was 23 minutes. Feeding was begun on day 1 after operation in most patients and on day 2 in others. Complications included tube displacement in three patients, superficial infection at the site of the tube insertion in three (not requiring drainage or tube removal) and asymptomatic pneumoperitoneum in one patient. These complications all occurred early in the series. No patient suffered paralytic ileus, vomiting, aspiration or significant leaking around the tube. In the authors' opinion percutaneous endoscopic gastrostomy is the preferred method for placement of a feeding gastrostomy. It can be performed rapidly with minimal stress in high-risk patients.     

Neurosurgery without shaving: indications and results

The objective of the investigation was to prevent the stigmatizing effect of a totally or partially shaved head with openly visible signs of a head operation, easing the reintegration of the patient into his daily life. After extended surface cleaning with a colourless, regular skin disinfection liquid (undyed isopropanol/dibrom/propylenglycol solution) the hair was combed apart from the incision line before draping. Wound closure was performed as usual, taking care to remove meticulously hair from the wound. To aid closure we made use of a 20% chlorhexidine jelly that holds the hair away from the incision. A neomycin ointment served for sealing the wound surface, no further dressing being used. After 215 cranial neurosurgical operations, among them 63 for tumours, 33 stereotactic procedures 18 shunt, 55 for torticollis and 46 other operations performed without shaving the hair, we saw one wound infection (0.5%). This percentage corresponds very well to our general infection rate of 0.6%. All patients very much appreciated the offered opportunity and the result. If the objective is to give patients a psychological advantage by preventing a partially bald head we think one can safely refrain from the shaving procedure without risking a higher infection rate.     

Axillo-femoral bypass: indications and results]

Axillofemoral bypass grafting is an accepted method for the treatment of vascular insufficiency of the lower limb. It is especially useful in high risk patients whose conditions preclude aortofemoral bypass grafting. The goal of our study is to evaluate whether the benefit of this operation outweigh the potential risks in the age group "sixty-plus". We performed 23 axillofemoral bypass grafting procedures (axillofemoral in 20, axillobifemoral in 3 cases) mainly be mean of 8 mm Dacrom prosthesis. The 30-day operative mortality rate was 8.7% and the cumulative 5-year patient survival rate was 52.2%. Overall the 1- and 5-year life table patency rate were 80% and 64%, respectively. The cumulative limb salvage was 90% and 72% at 1 and 5 years. We obtained an average reduction in Fontaine classification of 2 stages in the first year and 1.3 stages after 5 years. The comparison of the cumulative survival rate with the limb salvage rate indicates that advanced age should not be considered a contraindication to performing an axillofemoral bypass graft. The reduction in Fontaine stage means a remarkable improvement in quality of life.     

Wrist arthroscopy: indications and results.

The results of 84 wrist arthroscopies in 74 patients (performed by the same surgeon) were reviewed retrospectively. Arthroscopies were categorized as "diagnostic"--to identify unknown pathology, "staging"--to assess the severity of known pathology, and "operative"--to treat known pathology. Ninety-eight percent of diagnostic arthroscopies accurately established details of the pathology in question. Ninety-six percent of staging arthroscopies helped guide future clinical management. Of the patients in the operative category, 35% improved after treatment with arthroscopy alone, requiring no further surgical intervention. This study shows that wrist arthroscopy is a powerful diagnostic and staging tool and suggests that it may also develop into a valuable treatment modality.     

Femorofemoral grafting: indications and late results

Experience with fifty-three femorofemoral grafts performed as the initial operation for iliac occlusive disease over a ten year period is reviewed. There was one operative death (2 per cent). There were two early and three late graft failures, for a five year cumulative graft patency rate of 80 per cent. Of the twenty-eight patients in whom the femorofemoral graft was performed for limb salvage, the five year cumulative limb salvage rate was 91 per cent. During the follow-up period, two grafts were converted to axillobilateral femoral grafts because of recurrent symptoms of claudication caused by progression of disease in the iliac system from which the femorofemoral graft originated. All other patients with patent grafts have had satisfactory relief of symptoms throughout the follow-up period.