Refractory Gastroparesis After Roux-en-Y Gastric Bypass: Surgical Treatment with Implantable Pacemaker

Abstract Background Gastroparesis is a rare complication of Roux-en-Y gastric bypass. We evaluate the role of gastric electrical stimulation in medically refractory gastroparesis. Methods Patients with refractory gastroparesis after gastric bypass for morbid obesity were studied. After behavioral and anatomic problems were ruled out, the diagnosis of disordered gastric emptying was confirmed by radionuclide gastric emptying. Temporary endoscopic stimulation was used first to assess response before implanting a permanent device. Results Six patients, all women with mean age of 42 years, were identified. Two patients ultimately had reversal of their surgery with gastro-gastrostomy, while another had a total gastrectomy with persistence of symptoms in all three. Five of the patients evaluated had insertion of a permanent gastric pacemaker, with pacing lead implanted on the gastric pouch (2), the antrum of the reconstructed stomach (1), or the proximal Roux limb (2). Nausea and emesis improved significantly postoperatively; mean total symptom score decreased from 15 to 11 out of 20. There was also a persistent improvement in gastric emptying postoperatively based on radionuclide testing. Conclusion If medical therapy fails, electrical stimulation is a viable option in selected patients with gastroparesis symptoms complicating gastric bypass and should be considered in lieu of reversal surgery or gastrectomy. Presented at SSAT meeting, Washington, DC, May 2007.     

Pacemaker Implantation in a toddler: A case report

An 18-month-old child who had recurrent Stokes-Adams episodes due to congenital complete heart block underwent permanent programmable myocardial pacemaker implantation. To the best of our knowledge this is the youngest patient reported to have received a pacemaker in this country.     

Treating osteomyelitis of major limb amputations with a modified Lautenbach technique

IntroductionMajor lower limb amputation significantly increases the energy cost of walking for patients. Complications such as osteomyelitis may require further surgery, and can lead to shortening of the stump. In these cases, the aim should be to treat infection without shortening the limb further. We present a series of patients with established osteomyelitis of the amputation stump, managed using a modified Lautenbach technique.MethodSix patients with either above or below knee amputations, in the practice of a single orthopaedic surgeon, were studied. Ages range from 39 to 64 years, and reasons for amputation included infection, pain, and necrosis. All patients had osteomyelitis in the amputation stump confirmed on MRI.ResultsAt a mean follow-up of 3.75 years (range 7 months to 6 years) all six patients had no clinical or haematological evidence of infection, and had returned to independent living. Stump length was preserved in all cases, including in one patient who underwent two procedures to ensure complete debridement.ConclusionsWe believe that this case series is the largest so far published regarding this modification of the Lautenbach Procedure. This operation treats infection effectively without further loss of bone length, and no patients so far have developed significant complications.     

A new dorsal modular fixation device allows a modified approach in cervical and cervico-thoracic neoplastic lesions

Introduction The aim of this study was to improve the management of cervical tumor osteolysis. A new modular rod-screw implant system for the posterior instrumentation of the occipito-cervical, cervical and cervico-thoracic spine (neon occipito cervical system, Ulrich, Germany) is available since 2000. K-wire guided pedicle screws are used, CT-guided instrumentation is possible. Previous studies have demonstrated increased biomechanical stability compared to established posterior cervical systems.Methods The cervical and cervico-thoracic spine of 8 patients (6 males, 2 females, mean age 62 years, range 48–77 years) with osteolysis due to plasmocytoma (n=2), bronchial (n=2), mammary (n=2), esophageal (n=1) and pancreatic (n=1) carcinoma were instrumentated since June 2001.Results A stable fixation without loosening or failure of the fixation system was achieved in all cases. No impairment of the neurogical status was observed.Conclusion Posterior instrumentation of the cervical spine including the occipito-cervical and the cervico-thoracic region with a new modular angle-stable rod-screw implant system offers good stabilization and allows simultaneous decompression. Since tumor masses are predominantly located in the anterior portion of the spine blood loss can be reduced.     

安置心脏起搏器患者行腹腔镜胆囊切除术应注意的问题(附7例报告)

目的:确定安置心脏起搏器患者行腹腔镜胆囊切除术(LC)的可行性及注意问题。方法:采用常规腹腔镜手术设备,术中使用的高频电切器为主要分离切割止血工具,若高频电磁波对起搏器功能影响过大,可采取非电切、电凝法分离、结扎胆囊管及动脉。结果: 7例患者均使用高频电切器顺利完成LC术, 3例患者在使用高频电切器时对起搏器有轻度干扰,停用后很快恢复正常。结论:安置心脏起搏器患者行LC术是安全、可行的方法,但术前、术中应注意以下几点: (1)了解起搏器性能及抗电磁波干扰能力; (2)术中全面监测心电功能; (3)使用高频电切器持续时间应短; ( 4 )术者应具备娴熟的LC技能,并能在不使用电切器的情况下完成LC。     

A novel approach to delivery of extracorporeal support using a modified continuous flow ventricular assist device in a mid‐volume congenital heart program

Extracorporeal life support (ECLS) is an essential component of a modern congenital cardiac surgery program. The circuit components and bedside management team may, however, vary among institutions. Here, we evaluate our initial experience with a modified ventricular assist device—based ECLS circuit primarily managed by the bedside nurse. We hypothesize that our outcomes are comparable to Extracorporeal Life Support Organization (ELSO) registry data. All patients who received ECLS from January 1, 2016 to December 31, 2019 at a single institution were included. Primary outcomes were survival to ECLS decannulation and discharge or transfer. Secondary outcomes included complications from ECLS. Data were compared to available ELSO registry data. Thirty‐seven patients underwent 44 ECLS runs during the study period. Forty percent of patients had single ventricle physiology. Nearly 46% of patients received ECLS as part of extracorporeal cardiopulmonary resuscitation (eCPR). Survival to ECLS decannulation (68.2%) and survival to discharge or transfer (61.4%) did not differ from overall ELSO outcomes (69.7%, P = .870 and 50.7%, P = .136), as well as survival to discharge or transfer in a comparable cohort of ELSO centers (53.1%, P = .081). Patients with complications had a lower rate of survival to discharge or transfer but this did not reach statistical significance (47.7% vs. 75.0%, P = .455). Neurologic (50.0%), hemorrhagic (45.5%), and renal complications (31.8%) were most common in this cohort. A modified ventricular assist device‐based ECLS circuit with primary management by the bedside nurse can provide comparable support in a neonatal and pediatric cardiac surgery population. Cost analyses and further delineation of the complication profile are necessary for a complete characterization of this system.     

Shoulder arthroscopy: a modified approach

This paper proposes a modification of the classical position for shoulder arthroscopy. Two changes are proposed to improve visualization, accentuate pathology, and give better access to the inferior one half to one third of the shoulder joint. The direct lateral position is changed to a semilateral position in which the patient is allowed to rotate 30 to 40 degrees posteriorly, thus putting the shoulder joint on a horizontal plane. This allows for more comfortable arthroscopy and instrumentation. Also, if capsulorrhaphy is desired, better penetration of the scapula is possible since the scapula is vertical; thus, the angle of the approaching staple is less severe. The second change is to apply traction in a plane perpendicular to the long axis of the humerus rather than parallel to it. This modification elevates the humerus out of the glenoid rather than distracts the humerus into a subluxed position. The result accentuates labral pathology and gives a significantly improved view of the inferior one half to one third of the glenoid capsule. This new plane of traction allows excellent visualization with very little traction; thus, the problem of traction neuropraxia has been eliminated.     

Long-term outcome of lung transplantation for cystic fibrosis — Danish results

Objective: Over the last decades improvements in medical therapies have delayed the progression of lung disease in cystic fibrosis (CF). However, lung disease is still the most common cause of premature death, and lung transplantation today is the only treatment for end-stage lung disease in patients with CF. We present a retrospective review of the outcome of CF patients transplanted in Denmark since start of the national lung transplantation programme in 1992. Methods: In a 10-year period, 47 patients with CF were listed for lung transplantation; 29 patients underwent transplantation and 18 patients died while waiting for donor organs. Eleven patients received en block double lung transplantation with direct bronchial artery revascularization and 18 patients received bilateral sequential lung transplantation. Median age at transplantation was 29 years (range 11–50). Results: The perioperative mortality (≤30 days) was 3.5% (1/29 patients). Actuarial survival of transplanted patients at 1, 3, 5 and 8 years was 89, 80, 80 and 70%, respectively. Actuarial survival of non-transplanted patients on the waiting list at 1 and 2 years was 28 and 11% (P<0.0001). Causes of death of transplanted patients were: respiratory failure on day 7 (n=1), bronchiolitis obliterans syndrome (n=2), infection (Cytomegalovirus, Aspergillus fumigatus) (n=2), bronchial anastomosis dehiscence (n=1). Pulmonary function (FEV₁% predicted) improved from median 20% (range 13–31) pre-transplant to 71% (range 19–118) after 5 years (P<0.0001). Renal function (⁵¹Cr-EDTA clearance) decreased from median 97 ml/min (range 45–190) pre-transplant to 32 ml/min (range 8–84) 6 months after transplantation (P<0.001). Three patients (11%) received dialysis post-transplant of whom two underwent kidney transplantation. Immunosuppressive induction therapy with rabbit-antithymocyte-globulin compared to daclizumab resulted in fewer treatments for acute rejection within the first 3 months post-transplant (P=0.05 at 5–8 weeks). Burkholderia multivorans was present in three patients pre-transplant with satisfying long-term outcome in one patient. Conclusions: Lung transplantation is a well-established life-extending treatment for patients with CF and end-stage lung disease. The operative mortality is low and CF patients have a significant early survival benefit after lung transplantation. Satisfying long-term results can be achieved in this young and severely ill group of patients.     

Temporary right heart assist: a minimally invasive approach

A surgical method for the implantation of a mechanical right ventricular assist device which avoids resternotomy/thoracotomy and related complications at the time of explantation is presented. In order to support the failing right heart, a Dacron vascular graft was sewn to the pulmonary artery. For venous drainage, a cannula was inserted into the right atrium via the femoral vein. Explantation of the system, after the right heart resumed its function, was accomplished by retracting and compressing the venous cannula in the groin as well as by retracting the arterial cannula from the Dacron vascular graft followed by suturing without opening the chest. Between 2006 and 2011, this system was used in 12 patients. The median duration of right heart support was 10.5 days. Seven patients were successfully weaned from the system, six patients survived. In all cases, explantation was free of complications. The technique described is a safe method to support the right heart and allows explantation without the risks and complications of reopening the thorax.     

Injuries sustained at a temporary ice-skating rink: Prospective study of the Winchester experience 2007–2008

Anecdotal reports when a temporary ice-rink opened in Winchester, suggested a burden on the Emergency Department (ED) and Trauma & Orthopaedic (T&O) services. This study was undertaken to assess, prospectively, the workload created as a consequence of ice-rink injuries, when the facility was reopened over Christmas 2007.All patients attending from the ice-rink were included and their injuries reviewed. Costs of care were calculated based on ED attendance, out-patient appointments (OPA's), radiography, plaster immobilisation and government tariffs for surgical procedures.The ice-rink was open for 39 days welcoming 43,000 skaters. Sixty-two accidents were recorded in the accident book, 43 attended the ED. Radiographic investigation was necessary for 31 patients. Nineteen had diagnoses of soft tissue injury, 3 of head/facial injuries. T&O received 23 referrals; all fractures were in the upper limb, 6 requiring admission and surgery. Fifty-eight ED, fracture clinic and physiotherapy OPA's were required. Additional costs to The Royal Hampshire County Hospital (RHCH) were calculated as £33,718.50.This temporary facility created a smaller than predicted burden for the ED and T&O service, however, sufficient consideration of OPA requirements should be made when planning service provision whilst temporary recreational facilities, such as this, are open.     

Performance of an oxygen delivery device for weaning potentially infectious critically ill patients

Oxygen delivery via a heat and moisture exchange filter with an attached T-shaped reservoir satisfies infection control requirements of high efficiency bacterial and viral filtration and low gas flows. In order to assess the performance of such a device in critically ill patients being weaned from mechanical ventilation, we simulated 16 patients using a human patient simulator, measuring fractional inspired oxygen and carbon dioxide concentrations and work of breathing at three oxygen flow rates. Oxygen concentration was dependent on peak inspiratory flow rate, tidal volume and oxygen flow rate. Rebreathing, as indicated by inspired carbon dioxide concentration, was greatest at high respiratory rates and low tidal volumes. Imposed inspiratory work of breathing was relatively high (mean 0.88 J.l(-1)[SD 0.30]). We conclude that this method of oxygen delivery is only suitable for patients in whom rapid extubation is anticipated.