Colon Interposition Graft for Corrosive Esophageal Stricture: Midterm Functional Outcome

Background

Corrosive esophageal stricture is a major cause of morbidity among Nigerians. In most cases, this follows accidental or parasuicidal ingestion of caustic sodium hydroxide solution (NaOH) often used in the local production of soaps. Various treatment modalities have been advocated for the treatment of esophageal stricture. In this study, we review the results of our adopted technique in the past 10 years for pedicled colonic interposition.

Methods

This is a retrospective study of 21 patients who underwent substernal isoperistaltic pedicled colonic interposition graft for management of corrosive esophageal stricture. The right colon was pulled up into the neck in all the patients without resecting the strictured esophagus.

Results

Long segment strictures and multiple strictures were the main indications for the procedure. The mean duration of the procedure was 339.6 ± 71.1 min. The average intraoperative blood loss was 673.1 ± 398.1 mL. There were two (9.5 %) hospital mortalities. Graft infarction (9.5 %), cervical fistulae (19.0 %), and reflux neo-esophagitis (14.3 %) were the main non-fatal complications. In the mid-term, dysphagia was completely relieved in a little over 84 % (16/19) of patients, while one patient (4.8 %) still experienced reflux neo-esophagitis requiring treatment. There was no case of gross regurgitation or nocturnal aspiration in the mid-term.

Conclusions

Although the use of pedicled colonic interposition graft offers a good mid-term functional outcome with relief of dysphagia, early postoperative morbidity is high. Graft infarction is the single most important factor for poor functional outcome and every effort must be made to prevent its occurrence.     

Sternocleidomastoid Muscle Myocutaneous Flap for Corrosive Pharyngoesophageal Strictures

Background Strictures at the pharyngoesophageal junction represent a subgroup of corrosive esophageal strictures requiring a specialized management approach. Non-dilatable cricopharyngeal strictures need surgical intervention. We report the use of the sternocleidomastoid muscle myocutaneous inlay flap (SCMMIF) for reconstruction of the cervical esophagus in patients with corrosive strictures. Methods A SCMMIF was used in four patients with cricopharyngeal strictures. The surgical technique is described. All patients had complete dilatation of the stenosed cricopharyngeal segment as seen on postoperative endoscopy and contrast studies. One patient was managed successfully for a short midesophageal stricture by serial endoscopic dilatations. Another patient underwent an esophagocoloplasty subsequently for bypass of the long distal esophageal stricture The last two patients await esophagocoloplasty. Conclusions This is the first report on the use of sternocleidomastoid muscle myocutaneous inlay flap for corrosive cricopharyngeal strictures. The flap is simple to construct, is effective and can be performed in a short time, and yields good cosmetic results.     

Therapeutic Options for Management of Pharyngoesophageal Corrosive Strictures

Introduction  

Pharyngoesophageal strictures due to corrosive injury raise difficult therapeutic problems due to the site of stricture, the possible association with laryngeal injury and the presence of downstream esophageal strictures. We present here our approach to management of 51 consecutive patients with pharyngoesophageal strictures seen over a 30-year period.     

Antesternal Colonic Interposition for Corrosive Esophageal Stricture

Restoration of swallowing in a patient with dysphagia due to nondilatable corrosive stricture of esophagus remains a surgical challenge. Organs available for replacement are stomach, jejunum, or colon. Jejunum is useful to replace a small segment, whereas stomach and colon are required for a long-segment replacement. In cases where the stomach is also injured, colon remains the only option. The route of colonic interposition has also been a subject of debate over the years. Antesternal, retrosternal, or esophageal bed passage are the routes described. In the present series, the data of antesternal colonic interposition (ACI) performed for nondilatable benign esophageal strictures in 32 patients (1988–2011) have been retrospectively analyzed. The results indicate that ACI for corrosive strictures is a quick and simple procedure. Thoracotomy is avoided and anastomosis is easily performed in the neck, and mortality rate due to anastomotic failure or graft failure is diminished. This retrospective analysis discusses the ease, effectiveness, quality of life, morbidity, and mortality of ACI and compares the pros and cons of ACI with other procedures described in the literature.     

Binasal Endoscopic Approach to the Sellar Region: Experience and Outcome Analysis of 80 Cases

A prospective study was performed on 80 cases of different types of sellar lesions during the period between January 2007 and December 2010. The binasal approach was used in all patients. Functioning lesions were diagnosed in 59 patients. The most common secretory tumors were prolactinomas (37 patients) followed by adrenocorticotropic hormone producing tumors (11 patients) and growth hormone producing tumors (11 patients). Nonfunctioning lesions included: 14 pituitary adenomas, 2 chordomas, 2 metastatic lesions (ovarian carcinoma and thyroid carcinoma), and 1 case of sarcoidosis, Rathke''s cleft cyst, and craniopharyngioma. Seven nonfunctioning cases developed apoplexy. Among the 59 patients with functioning pituitary lesions, postoperative endocrinological control was achieved in 51 of them (86.5%) 3 months postoperatively with normalization of pituitary functions and complete tumor resection as proved by postoperative magnetic resonance imaging. Postoperative visual field defect improvement was achieved in 15 out of 23 patients (65.2%), including the cases with apoplexy, with complete tumor resection. Postoperative discomfort such as headache, vomiting, or dizziness was minimal and hospitalization period was 2 to 3 days. Postoperative leak continued in one patient in whom revision surgical repair was performed 7 days later. The merits, outcome, and limitations of the approach were discussed.     

Endoscopic Management of Urethral Stricture: Review and Practice Algorithm for Management of Male Urethral Stricture Disease

Purpose of Review

Male urethral stricture disease is characterized by the formation of scar tissue within the urethra resulting in lower urinary tract symptoms, infection, and potentially kidney dysfunction. There is significant variability in clinical practice for the treatment of urethral stricture. We sought to summarize the known data on endoscopic management of urethral stricture disease as part of this larger edition on urethral stricture management.

Recent Findings

Older studies quoted high rates of success with endoscopic management of urethral stricture, including repeated DVIU. There is now evidence to support a limited role of endoscopic intervention in the management of urethral stricture, and especially strong evidence that repeated endoscopic procedures are not effective.

Summary

There is poor evidence to support the long-term efficacy of endoscopic urethral stricture management. Furthermore, novel advances in adjunctive therapies have not yet demonstrated durable patency. We discuss the limited role of endoscopic management and suggest an algorithm for its use in stricture management.

     

Outcome from Complex Neurosurgery: An Evidence Based Approach

Summary ? Background. The aim of this study was to determine outcome, including quality of life, after surgery for petroclival meningioma using a standard skull base approach and to carry out an evidence based appraisal of the relevant literature.  Method. Pre- and post-operative data including adverse events were prospectively recorded in 19 patients (15 females, age range 29–63) undergoing a transpetrous approach for a petroclival meningioma. Patients were assessed using the GOS and SF-36 post operatively.  Findings. 24 operations were done. 6 patients developed a new permanent neurological deficit and 10 experienced a temporary deficit or exacerbation of existing deficits. At 1 year 15 patients had made a good/moderate recovery, 3 were severely disabled and 1 died – in keeping with other studies. By contrast the SF-36 showed that in all 8 categories of the SF-36 between 39–72% of surviving patients were functioning below the accepted norms.  Interpretation. After transpetrous excision of a petroclival meningioma the quality of life for the patient is worse than that indicated in surgeons' reported results. This paper represents an attempt to address the issue of evidence-based medicine and finds that such an approach is not apparent in the medical literature on this pathology. While we argue that methods for measuring outcome should be refined and carers input recognised it does raise certain philosophical considerations. It is the counsel of perfection and if achieved may lead to surgeons operating on fewer patients, more petroclival cases being viewed as inoperable because of the higher morbidity, despite there being an inescapable pathway to surgical intervention.     

脊髓型颈椎病前后路减压的比较

目的　比较脊髓型颈椎病前路和后路外科手术的疗效 ,分析影响疗效的预后因素。方法　对 1 0 6例前后路减压后脊髓型颈椎病患者通过信函、电话采访和复诊等方式进行了随访 ,平均随访时间为 38个月 (5～ 84个月 ) ,平均术前症状时间为 2 6个月 (5～ 79个月 ) ,年龄分组为大于 55岁组和小于 55岁组 ;按照JOA评分系统评价术前和术后神经功能状态。结果　术前症状时间与恢复率有显著相关性 (R =0 . 544) ,术后 1个月 76例前路手术患者 ,61例有改善 ;30例后路手术患者 2 7例有改善 ,最后 1次随访前路 57例有改善 ,后路 2 1例有改善 ,年龄组间的症状时间、下肢症状时间和术后JOA评分有显著差异。结论　前、后路手术在早期均有好的疗效 ,其疗效在晚期呈进行性下降 ,脊髓型颈椎病需要手术治疗。     

Pharyngolaryngo-Esophagectomy with Laparoscopic Gastric Pull-Up: A Reappraisal for the Pharyngoesophageal Junction Cancer

Background

Surgical treatment of advanced hypopharyngeal tumors is still a surgical challenge. We report a case of a hypopharyngeal tumor treated with a pharyngolaryngo-esophagectomy (PLE) and laparoscopic gastric tubulization and interposition.

Methods

A 56-year-old man presented with a relapsing hypopharynx carcinoma, after primary chemoradiation therapy. Preoperative workup showed a stage IV cancer with esophageal invasion and multiple cervical lymph node metastases. Surgical treatment consisted of a cervical phase, with larynx, pharynx, and esophagus dissection, radical lymph node dissection, homolateral hemithyroidectomy and definitive tracheostomy, and an abdominal phase with a 4-trocar laparoscopy. The gastrocolic ligament was opened, and short gastric and left gastric vessels were divided preserving an accessory left hepatic artery. Gastric tailoring was carried out with 45-mm linear staplers. The hiatus was opened and the esophagus dissected free with Ultracision (Ethicon Endo-Surgery, Cincinnati, OH) to the tracheal bifurcation. The upper esophagus was bluntly mobilized by finger and sponge stick dissection. The gastric tube was pulled up, and the anastomosis between the stomach and the tongue base was performed with a 2-layer interrupted hand-sewn technique.

Results

Total operative time was 390?min (abdominal time 180?min). Estimated blood loss was 400?cc. The number of dissected cervical lymph nodes was 32. Oral feeding was started after 10?days, and the patient was discharged after 14?days. Stage of disease was pT4N1M0 G3 R0.

Conclusions

Laparoscopic surgery allows a minimally invasive gastric tailoring and tubulization and transhiatal esophageal dissection and represents a valuable alternative for intestinal reconstruction after PLE.

Refractory Urethral Stricture Management: Indications for Alternative Grafts and Flaps

Purpose of Review

Urethral strictures that are refractory to initial management present unique challenges to the reconstructive surgeon. Treatment trends have shifted as new tissue resources are becoming available. There is renewed interest in old methods as skill and technique have improved. We describe the scope of the surgical armamentarium available to develop creative approaches and successful outcomes.

Recent findings

We discuss techniques to maximize the availability of oral mucosa, harvest and use of rectal mucosa, and developments in tissue engineering. Evolving methods to assess success of repair are also described.

Summary

Urethral reconstruction for refractory urethral strictures requires proficiency with multiple methods as these strictures often require combining techniques for successful treatment.

     

前,后入路腰间盘摘除术远期疗效对比分析

目的：对比分析前、后入路腰椎间盘摘除术远期疗效，为临床腰椎间盘摘除术术式选择提供一定的理论基础。方法：应用Ｒｏｌａｎｄ，Ｇｒｅｅｎｏｕｇｈ标准及疗效评定相关指标随访１９８４～１９９１年底间于我院行首次腰椎间盘摘除术的患者。有效随访前路６７例，后路１３６例，随访时间３～１１年。应用ＦｏｘＢＡＳＥ＋２．１０建立数据库，ＰＣＳＡＳ６．０３进行各种统计分析。结果：前路手术有手术时间短，术中出血少，术中并发症少，术后恢复快的优点，其远期疗效亦稍优于后路组。按病程及年龄分层分析结果显示它们对术后疗效无显著影响。结论：对有手术指征而无前路手术禁忌证的患者，特别是术后要求从事体力劳动者，前路手术是较好的选择。     

Early Outcome Comparison Between the Direct Anterior Approach and the Mini-Incision Posterior Approach for Primary Total Hip Arthroplasty: 150 Consecutive Cases

This study evaluated early postoperative results of 150 consecutive primary total hip arthroplasties performed by a single surgeon; 50 from mini-incision posterior approach, 50 during the learning curve for the direct anterior approach, and 50 subsequent cases when the approach was routine. The anterior approach groups had significantly reduced hospital length of stays (2.9 and 2.7 days versus 3.9 days for the posterior group; P < 0.0001) and discharge to home versus rehab was more likely (80% and 84% in anterior groups, 56% in posterior group; P = 0.0028). In the anterior groups, there was significantly less use of assistive devices and narcotics at 6 weeks, and pain was significantly lower. Primary total hip arthroplasty using the anterior approach allows for superior recovery in a matched cohort of patients.