Pessimism concerning palliative bypass procedures for established malignant esophagorespiratory fistulas: a report of 18 patients

Eighteen patients with established malignant esophagorespiratory fistulas due to primary esophageal cancer were managed by substernal gastric bypass and isolation of the cancerous esophageal segment. Seven fistulas were esophagotracheal and 11 were esophagobronchial. Ten patients died in the hospital between two days and six weeks after operation. Eight patients left the hospital, surviving an average of 3 1/2 months, but 2 patients lived 5 and 7 months, respectively. Unrelenting respiratory infection and clinical inanition caused 7 hospital deaths in patients reestablished on oral alimentation with their fistulas disconnected. Anastomotic leaks occurred in 5 patients; three of these leaks closed. In the other 2 patients, cervicomediastinal sepsis and bilateral pneumonia with respiratory failure caused death. One patient died of anoxic cardiac arrest 48 hours postoperatively. Fifteen of the 18 patients resumed oral alimentation, but the overall results of palliative surgical therapy achieved in this series were not observably worthwhile for the majority.     

The spectrum of injuries resulting from posterior abdominal stab wounds: a South African experience

Introduction

The spectrum of injury associated with anterior abdominal stab wounds (SWs) is well established. The literature on the spectrum of organ injury associated with SWs to the posterior abdomen, however, is limited.

Methods

We reviewed our experience of 105 consecutive patients who had established indications for laparotomy managed over a 4-year period in a high volume trauma service in South Africa.

Results

Of the 105 patients, 97 (92%) were male and the overall mean age was 24 years. Fifty-seven patients (54%) had immediate indications for laparotomy. The remaining 48 patients (46%) initially underwent active clinical observation and the indications for laparotomy became apparent during the observation period. Of the 105 laparotomies performed, 94 (90%) were positive and 11 (10%) were negative. Of the 94 positive laparotomies, 92 were therapeutic and 2 were non-therapeutic. A total of 176 organ injuries were identified: 50 (53%) of the 94 patients sustained a single organ injury while the remaining 44 (47%) sustained multiple organ injuries. The most commonly injured organs were the colon (n=63), spleen (n=21) and kidney (n=19).

Conclusions

The pattern of intra-abdominal injuries secondary to SWs to the posterior abdomen is different to that seen with the anterior abdomen. Colonic injury is most commonly encountered, followed by injuries to the spleen and kidney. Clinicians must remain vigilant because of the potential for occult injuries.     

Laparotomy for organ evisceration from abdominal stab wounds: A South African experience

Introduction

Organ evisceration following abdominal stab wound (SW) is currently considered as an absolute indication for mandatory laparotomy due to the high incidence of associated intra-abdominal injuries, but literature describing the spectrum of organ injury encountered is limited.

Performance of glutaraldehyde-preserved porcine bioprosthesis as a mitral valve substitute in a young population group

Porcine bioprostheses were implanted in the mitral position in 289 patients. The mean age was 25.8 +/- 13.7 years. One hundred thirty-five patients (47%) were 20 years old or younger. Most patients had chronic rheumatic valvulitis (74%). Mitral regurgitation and mixed mitral valve disease were the dominant lesions. Hancock, Angell-Shiley, and Carpentier-Edwards prostheses were implanted in 84, 14, and 191 patients, respectively. There were 19 early and 64 late deaths. Mean follow-up was 5.04 +/- 1.03 patient-years. Fifty-eight patients (6.71% per patient-year) were reoperated on for degenerated prostheses, with 13 deaths. Twelve patients died without reoperation, and 17 await reoperation for degenerated valves. The rate of structural failure (total, 87 patients) was 21.07% and 3.04% per patient-year for patients less than and older than 20 years, respectively (p less than 0.001). The 6-year actuarial survival for these two groups was 50% and 68%, respectively. However, for patients 20 years old or younger, survival free from degeneration was only 20% at 6 years (p less than 0.001). Bioprostheses have a high failure rate and should not be implanted in young patients or in patients with a life expectancy exceeding 10 years.     

A prospective study of hyperamylasemia and pancreatitis after cardiopulmonary bypass

General surgical complications after cardiopulmonary bypass (CPB) are infrequent but serious. No prospective studies have evaluated their incidence. We analyzed in such a study 135 patients who were to undergo CPB. Among these 135 patients, an abdominal complication developed in 6.6%; it contributed to 2 of the 5 deaths. Postoperative hyperamylasemia was found in 36% of patients, but only 2 had overt pancreatitis. The hyperamylasemia was not due to the salivary component, pulmonary complications, or prolonged CPB (r = 0.22). A gastrointestinal hemorrhage occurred in 7 patients. No patients had acute cholecystitis. We conclude that abdominal complications are more frequent than reported in retrospective studies, and result in significant morbidity and mortality. Postoperative hyperamylasemia is common but usually is not associated with untoward morbidity or mortality.     

Diaphragmatic hernia as a long-term complication of stab wounds of the chest

The suggestion that early exploratory operation be performed in all patients with stab wounds of the left lower chest in whom the diaphragm is likely to be injured is examined in detail. The incidence of stabs in this situation is reported on an analysis of 1,000 consecutive cases of stab wounds of the chest. Thirteen cases of diaphragmatic hernia as a long-term complication of stab wounds of the chest are discussed.     

Penetrating injuries of the diaphragm

Thirty-two cases of penetrating injuries of the diaphragm are reviewed. The problems of clinical and radiological diagnosis are outlined and the pitfalls of barium contrast studies are illustrated. Thoracoscopy is advised in all cases seen within 24 hours of the injury. Surgical access via laparotomy is recommended in both acute and chronic cases and where additional thoracotomy is necessary, separate abdominal and thoracic incisions are advised. The presence of colonic injury is shown to increase the risk of both wound sepsis and empyema postoperatively, whilst other visceral injuries do not appear to affect postoperative morbidity.     

Emergency Heart Valve Replacement: An Analysis of 170 Patients

The results of 170 emergency heart valve procedures performed during a 4 1/2-year period were analyzed. Five pathological groups of patients were recognized: those with infective endocarditis (Group 1, 28 patients); acute rheumatic carditis (Group 2, 43 patients); previous valve operation (Group 3, 29 patients); acute-on-chronic cardiac disease (Group 4, 67 patients); and miscellaneous conditions (Group 5, 3 patients). Mitral, aortic, and multiple valve procedures were performed on 58, 65, and 44 patients, respectively. The most common functional lesion was regurgitation. Hospital mortality was highest in Groups 3 (34%) and 4 (31%). By contrast, among the hospital survivors, the highest rate of attrition was in Group 2. Myocardial failure was the predominant cause of death. In view of the hopeless prognosis without operation, the 52% overall 3-year actuarial survival is a gratifying salvage. Unnecessary procrastination can only jeopardize the prospects for surgical cure.     

Superior mesenteric artery injury: a case report.

A case of blunt trauma to the upper abdomen with multiple organ injury is described. The lesion involveing the superior mesenteric artery was undiagnosed at operation. The subsequent diagnosis and handling of the case is described with a review of the literature on blunt injury to this vessel.     

A decade of experience with laparoscopic ventral hernia repairs

Background

Few studies have evaluated surgical outcomes in long-term follow-up for patients undergoing Laparoscopic Ventral Hernia Repair (LVHR).

A conservative approach to penetrating injuries of the chest. Experience with 131 successive cases.

One hundred and thirty-one cases of penetrating injuries of the chest were reviewed prospectively. A policy of conservative management is advocated, based on the intercostal drainage of moderate or large collections of fluid and/or air. The site of the intercostal drain is not an important factor in the management.     

Comparison of 3D laparoscopic gastrectomy with a 2D procedure for gastric cancer: A phase 3 randomized controlled trial

Objective

To determine the relative safety and efficacy of 3D laparoscopic gastrectomy and 2D laparoscopic surgery in patients with gastric cancer.

The distal margin of the lateral malleolus visible under ankle arthroscopy (articular tip) from the anteromedial portal,is separate from the ATFL attachment site of the fibula: A cadaver study

Purpose

The purpose of this study was to evaluate the relationship between the lateral malleolus view under ankle arthroscopy and the anterior talofibular ligament (ATFL) attachment site.

Quality of life after single-incision laparoscopic cholecystectomy: A randomized,clinical trial

Background

Controversy continues as to whether single-incision laparoscopic cholecystectomy, with the somewhat larger incision at the umbilicus, may lead to a worse postoperative quality of life and more pain compared with the more classic 4-port laparoscopic cholecystectomy. The aim of this study was to compare single-incision and 4-port laparoscopic cholecystectomy from the perspective of quality of life.

Stride length of elderly patients with lumbar spinal stenosis: Multi-center study using the Two-Step test

BackgroundShort stride length is one of clinical symptoms associated with lumbar spinal stenosis (LSS). Short stride is a risk factor for falls; therefore, identification of factors associated with short stride is critical for fall prevention in LSS patients. Although the Two-Step test can conveniently assess maximal stride length, it has not become widely used; therefore, its data are limited. We identified the potential factors associated with short stride of elderly LSS patients using Two-Step test.MethodsClinical data of patients aged >65 years who planned to undergo surgery for LSS were prospectively collected at multiple institutions. Patients were assessed with the Two-Step test and Timed Up-and-Go Test prior to surgery; 357 consecutive patients were enrolled. We determined the cut-off value of the Two-Step test score for short stride, referring to the Timed Up-and-Go Test score of 13.5 s, used to indicate high risk of falls in elderly individuals. Logistic regression model was constructed to identify factors associated with short stride.ResultsThe Two-Step test score showed moderate-to-strong inverse correlation with that of Timed Up-and-Go Test (r = ?0.65, p < 0.001). Using the tentative Two-Step test cut-off value (0.93) for short stride, multivariable analysis showed that age ≥80 years (OR = 2.3, 95% CI:1.1–4.8), a score of <60 for lumbar function in Japanese Orthopedic Association Back Pain Evaluation Questionnaire (OR = 2.7, 95% CI:1.5–4.7), motor deficit (OR = 2.7, 95% CI:1.2–6.1), and sagittal vertical axis ≥50 mm (OR = 2.1, 95% CI:1.2–3.5) were factors significantly associated with short stride in elderly patients with LSS.ConclusionsUsing the Two-Step test, we found that 80 years old and over, lumbar dysfunction, motor deficit of the lower extremities, and forward-bent posture were associated with short stride in LSS patients. Therefore, elderly LSS patients with these conditions may have a higher risk for falls.