Videothoracoscopic drainage for esophageal perforation with mediastinitis in children

Background

Esophageal perforation remains a devastating event that is difficult to diagnose and manage. The overall mortality associated with esophageal perforation can approach 20%, and delay in treatment of more than 24 hours after perforation can result in a doubling of mortality. The treatment option for esophageal perforation with mediastinitis is not very clear and still controversial.

Methods

Between April 2000 and March 2004, 6 males and 2 females, with ages ranging from 2 to 6 years (mean, 3.8 years), underwent videothoracoscopic drainage for esophageal perforation with mediastinitis.

Results

The mean hospital length of stay for patients in our series was 34.1 days (range, 14-47 days). There was no perioperative mortality. All patients were discharged from hospital without major sequelae.

Conclusions

Minimally invasive videothoracoscopic drainage is a feasible and effective method for esophageal perforation with mediastinitis in children.     

Simplified treatment of postoperative mediastinitis

Background

Wound infection after median sternotomy for cardiac or thoracic surgery is a serious complication. A variety of treatment plans have been advocated, and there is lack of agreement regarding the best treatment method. We present our results in patients with mediastinitis who have been treated in a simple, consistent manner.

Methods

We reviewed our experience with 40 consecutive patients with mediastinitis who were treated between January 1995 and May 2003 with a single-stage treatment consisting of sternal and soft tissue debridement and wound closure over mediastinal tubes with continuous irrigation and drainage. Tubes were placed posterior to the sternum in all patients and were irrigated continuously for at least 7 days with antibiotic or antibacterial solution. Systemic antibiotics were selected based on culture and sensitivity data and were administered for 2 to 6 weeks.

Results

All patients with mediastinitis treated in this manner survived. Of the 40 patients, 38 achieved complete healing of the wound without further operative intervention or major complication. One patient had recurrent infection and required sternal resection and advancement of muscle flaps. One patient had a residual localized focus of chondritis and underwent limited resection of cartilage.

Conclusions

In this series of patients with postoperative mediastinitis, a simplified approach consisting of wound debridement, reclosure over drains, and anterior mediastinal irrigation has been an effective treatment. The results we have achieved suggest that this technique may be a suitable option for treating this condition.     

Follow-up of acute osteomyelitis in children: the possible role of PET/CT in selected cases

Background

Magnetic resonance imaging (MRI) and/or scintigraphy are commonly used for follow-up in children after treatment of acute osteomyelitis. Regularly, post-treatment imaging reveals pathological findings even if serum inflammatory parameters and clinical presentation are normal. We analyzed combined positron emission tomography and multislice computed tomography (PET/CT) for this condition.

Methods

Six children received PET/CT after treatment of acute osteomyelitis. Post-treatment MRI had revealed suspicious residual and/or additional findings. All patients had physiological serum infection parameters and no clinical symptoms.

Results

Median patient age was 59.5 months (range, 48-156). No increased 18-Fluor-2-deoxy-D-glucose uptake was observed in 3 patients. In 3 patients, there was minimal activity at the site of infection, which, however, did not reach the presumed range of osteomyelitis. All children were taken off antibiotic medication. No clinical symptoms reoccurred in any of them, and repeatedly controlled serum infection parameters were all normal. Median follow-up was 33 months (range, 4-65).

Conclusions

The PET/CT was superior to MRI in distinguishing between infection and reparative activity within the musculoskeletal system in selected children after acute osteomyelitis. The termination of antibiotic treatment for children after acute osteomyelitis seems justified when laboratory parameters as well as clinical presentation are normal, and PET/CT scan is unsuspicious.     

Is kyphoplasty reliable for osteoporotic vertebral compression fracture with vertebral wall deficiency?

Background

Vertebral compression fractures are a common clinical manifestation of osteoporosis. The introduction of kyphoplasty has allowed minimally invasive treatment of these fractures. However, in patients with loss of vertebral wall integrity, balloon kyphoplasty is contraindicated due to the possibility of extruding wall fragments into the canal and cement extravasation. We evaluated the efficacy and safety of kyphoplasty in the treatment of vertebral compression fractures in patients with compromised vertebral walls using individualised surgical techniques to avoid cement extravasation.

Methods

Symptomatic vertebral fractures (59 fractures in 55 patients) were treated by kyphoplasty. In levels with compromised anterior vertebral walls, two distinct sequential applications of cement were performed to avoid anterior leakage. In levels that demonstrated posterior or lateral wall deficiencies, the cement was injected under live fluoroscopy to monitor lateral or posterior extravasation. Radiographic outcomes were evaluated by comparing pre- and postoperative anterior/middle vertebral body height and local kyphotic angle. Clinical outcomes were evaluated by comparing Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) values preoperatively, postoperatively, and at 3-, 6- and 12-month follow-ups.

Results

Symptomatic cement extravasation and complications after kyphoplasty were not observed. Vertebral height was restored and the mean kyphotic angle was improved. The mean VAS decreased significantly from pre-surgery to post-surgery, as did the ODI (p < 0.05).

Conclusion

Kyphoplasty is a safe, clinically effective treatment for osteoporotic vertebral fracture with peripheral wall damage when using individualised surgical techniques to prevent bone cement leakage.     

Primary sternal osteomyelitis: a case series and review of the literature

Purpose

Primary sternal osteomyelitis is rare in the pediatric population.

Methods

We present 4 recent cases that demonstrate a wide range in age, presenting features, and clinical course, and we performed a literature review.

Result

A combination of diagnostic aspiration with prolonged appropriate antibiotic therapy led to successful resolution in all cases. Surgical debridement should be reserved for cases that do not respond to medical therapy.

Conclusion

Sternal osteomyelitis is a rare condition in children that usually resolves with aspiration and prolonged antibiotic therapy.     

Torsion of the primary epiploic appendagitis: a case series and review of the literature

Background

Differential diagnosis and appropriate treatment of epiploic appendagitis (EA) is a dilemma for general surgeons because of nonspecific signs and symptoms.

Methods

Twelve patients (3 women and 9 men, average age 40 years, range 18-82 years) who were diagnosed as having EA upon presenting to the emergency department or at the time of discharge between April 2002 and September 2008 were included.

Results

The major presenting symptom was abdominal pain. Physical examination revealed well-localized tenderness in all cases (n = 12); in addition, rebound tenderness and distention were also observed. Laboratory blood tests were normal except for 4 patients who had leukocytosis. Seven cases were diagnosed by an abdominal computed tomography scan. Five patients required surgical intervention, whereas the remaining did not.

Conclusions

Surgeons should be aware of this self-limiting disease that mimics many other intra-abdominal acute conditions. An abdominal computed tomography scan has a significant role in accurate diagnosis of EA before surgery to avoid unnecessary surgical interventions.     

Surgical outcomes of esophageal atresia without fistula for 24 years at a single institution

Purpose

The aim of the study was to evaluate the surgical outcome of esophageal atresia (EA) without fistula for 24 years at a single tertiary center for pediatric surgery.

Methods

The study used a retrospective chart review of infants diagnosed with EA without fistula between 1981 and 2005.

Results

Of 33 patients with EA without fistula, 31 charts were available. Mean birth weight was 2327 g (range, 905-3390 g), and 71% were male. Most common associated anomalies were cardiac (n = 6; 19%) and renal (n = 5; 16%), followed by vertebral (n = 4; 13%) and anorectal (n = 2; 7%). The median initial esophageal gap was 5 vertebral bodies. Six had a primary repair, and 25 patients had esophageal replacement at a median age of 7 months. This involved gastric transposition in 20 (1 followed failed jejunal interposition), colonic interposition in 5, jejunal interposition in 1 (after a failed colonic), and repair at another center in 1. With a median review of 9 years, 21 patients had long-term sequelae with the need for multiple further surgical procedures including an antireflux procedure in 5. One patient died.

Conclusions

Management of EA without fistula remains challenging. Most patients required staged treatment that included esophageal replacement. The frequency of late complications indicates the need for programmed long-term review.     

Utility of frozen-section analysis of sentinel lymph node biopsy specimens for melanoma in surgical decision making

Background

Debate exists whether frozen-section analysis of sentinel lymph nodes (SLNs) for melanoma is an accurate method to detect disease that has metastasized to the lymph nodes. The purpose of this study was to evaluate the utility of intraoperative frozen section for SLNs in melanoma.

Methods

We reviewed 133 patients (271 nodes) who underwent SLN biopsy with frozen section for melanoma between April 2003 and September 2007. Frozen-section diagnosis was compared with final diagnosis to determine concordance between intraoperative and postsurgical diagnosis.

Results

A total of 11 nodes (8% of patients) were found to have metastatic disease. All patients underwent lymph node dissections at the time of SLN biopsy. No false-positive SLNs were found on frozen section. The false-negative rate for SLN biopsy frozen section was 8% (1 of 133 patients).

Conclusions

Intraoperative frozen section can be an accurate and reliable tool in the right setting for analysis of sentinel nodes in cutaneous melanoma and deserves further study.     

Thoracoscopy using a substernal handport for palpation

Background

A substernal handport allows palpation of the lung and thus circumvents one of the major limitations of thoracoscopy.

Methods

This approach has been used in 24 consecutive patients, primarily during planned metastasectomy or when palpation was needed for deeper or smaller lesions that were difficult to find.

Results

No long-term complications from this procedure were noted, and the 3 early complications were either minor or unrelated to the procedure. This approach allowed adequate resection to be accomplished by a less invasive approach in 67% of patients, although conversion to an open procedure was necessary in 33% of patients for anatomic and technical reasons. Among the 16 patients who underwent this procedure alone, the median length of stay in the hospital was 3 days. The rate of incomplete resection and of recurrence after metastasectomy was comparable to that for an open approach.

Conclusions

Our experience documents that a substernal handport is safe, does not compromise the ability to perform an adequate metastasectomy, and allows biopsy of lesions that are otherwise not amenable to a minimally invasive approach. This technique should be included in the standard armamentarium of approaches for thoracic surgery.     

Pseudarthroses of the cornu of the thyroid cartilage

Objective

Injuries to the cartilaginous larynx are rare disorders that usually undergo good spontaneous healing and rarely require surgery.

Study Design

Case series with chart review from patients with pseudarthrosis of the cornu of the thyroid cartilage.

Setting

ENT department of a level I trauma center.

Subjects and Methods

We examined the medical records of seven patients treated for impaired healing of the cornu of the thyroid cartilage at a level I trauma center between 1997 and 2009.

Results

Seven patients were treated as a result of impaired healing of injuries to the cornu of the thyroid cartilage caused by trivial trauma (e.g., car accidents). The principal symptom was odynophagia. Computed tomography was used to confirm the diagnosis. Treatment involved resecting the cornu of the thyroid cartilage. Histology showed a hypertrophic pseudarthrosis at the base of the cornu. All patients were free of symptoms 10 days after resection.

Conclusion

Pseudarthrosis of the cornu of the thyroid cartilage is a previously undescribed condition. Pseudarthrosis of the laryngeal skeleton should be excluded in patients with odynophagia.     

Effects of tacrolimus on antioxidant status and oxidative stress in glioma cells

Objectives

After organ transplantation, some patients suffer from mild neurologic symptoms, ranging from tremor to severe complications, including seizures and encephalopathy. Among the immunosuppressants, tacrolimus can cause neurologic side effects. However, the mechanisms of encephalopathy by tacrolimus are not fully understood. We measured the antioxidant status, hydrogen peroxide level, and malondialdehyde level in glioma cells after tacrolimus treatment.

Methods

The production of hydrogen peroxide was determined by the modified xylenol orange method. The amount of malondialdehyde was measured by the thiobarbituric acid assay, which is based on malondialdehyde reaction with thiobarbituric acid to give a red species absorbing at 535 nm. Total antioxidant status (TAS) was measured using TAS kits (NX2332).

Results

Tacrolimus resulted in dose- and time-dependent increases in the production of hydrogen peroxide by glioma cells. The antioxidant status decreased in the glioma cells after tacrolimus treatment. Malondialdehyde level was unchanged in the glioma cells after tacrolimus treatment.

Conclusions

Increased production of reactive oxygen species and decreased antioxidant status by tacrolimus in glioma cells may contribute to neurologic side effects.     

Terlipressin as Rescue Therapy in Catecholamine-Resistant Hypotension in Solid Organ Donors: A Case Report

Objective

The objective of this study was to report the effects of Terlipressin treatment in 2 potential organ donors with intractable, catecholamine-resistant hypotension.

Design and Setting

This study was based on case reports in the intensive care unit of a general hospital.

Patients

Patients included 2 adult patients with cerebral death and catecholamine-resistant hypotension.

Interventions

A low dose of Terlipressin (3.5 μg/kg) by intravenous bolus was added to the standard treatment.

Measurement and Results

In both cases, Terlipressin induced a rapid improvement in arterial pressure with a consequent increase in urine output and the appearance of diabetes insipidus. In 1 patient it allowed for the withdrawal of norepinephrine infusion. No related adverse effects were detected in either patient. Organ removal was not possible in the second case due to lack of family consent.

Conclusions

Terlipressin might be considered as a rescue therapy for potential organ donors with intractable, catecholamine-resistant hypotension. In spite of the positive results obtained here and by other authors in the treatment of septic shock, its judicious use is recommended, and an optimal administration schedule must still be elucidated.     

Comparison of pharyngeal stenosis between hypopharyngeal patients undergoing primary versus salvage laryngopharyngectomy

Objective

To survey the risk factors of pharyngeal stenosis after laryngopharyngectomy in patients with advanced hypopharyngeal cancers.

Study Design

Case series with chart review.

Setting

Tertiary medical center.

Subjects and Methods

Pharyngeal stenosis rates and risk factors were compared between two groups of laryngopharyngectomy patients: a group that underwent concurrent chemoradiation therapy followed by surgical salvage, and a surgery initiated group with adjuvant chemoradiation.

Results

Of 160 patients, 25 developed pharyngeal stenosis, which was diagnosed by barium esophagography with a pooling of barium contrast above the neopharyngeal inlet. These patients required nasogastric tube feeding or gastrostomy feeding because an oral liquid diet could not meet their nutritional needs. Primary closure and old age were risk factors for pharyngeal stenosis. Pharyngeal stenosis did not affect survival in patients with advanced hypopharyngeal cancer who underwent laryngopharyngectomy.

Conclusion

Primary closure reconstruction is discouraged in patients over the age of 65 years.     

Laparoscopic diagnosis and treatment of postoperative complications

Background

There is no unequivocal attitude to a laparoscopy as to the means in the diagnosis and treatment of postoperative surgical complications. Our study sought to determine the role of laparoscopy in the management of suspected postoperative complications.

Methods

We performed a retrospective review of the patients who underwent laparoscopy for complications of previous surgery over a 6-year period.

Results

Sixty-four patients underwent laparoscopy for complications during the study period including 49 laparoscopies, 14 laparotomies, and 1 endoscopic procedure. The median delay between operations was 2 ± 4.5 days. In 18 (28.1%) patients, laparoscopy did not find intra-abdominal pathology. The conversion to open surgery was necessary in 9 (14.1%) patients. Seven patients underwent more than 1 relaparoscopy. No cases of misdiagnosis were observed. Morbidity was 12.5%. There was no laparoscopy-related death.

Conclusions

Laparoscopy is an effective tool for the management of postoperative complications after open and laparoscopic surgery. It avoids diagnostic delay and unnecessary laparotomy.     

Colonic Perforation After Renal Transplantation: Risk Factor Analysis

Introduction

The incidence of gastrointestinal (GI) complication in renal transplantation is relatively high. These complications may be severe, leading to graft loss and patient death.

Materials and Methods

We reviewed 1651 patients who underwent renal transplantation between 1976 and 2007, analyzing the incidence of colonic perforations and the clinical prognostic factors.

Results

Twenty-one patients (1.3%) developed colonic perforations with 7 subsequent deaths. Diverticulitis and ischemia were the most common causes of perforation. Eleven patients (52.3%) were diagnosed and treated within the first 24 hours; their mortality was 18.1%. The 10 patients (47.7%) who were diagnosed and treated 24 hours after the clinical event displayed an high mortality rate (50%). Diverting stoma procedures were performed in all cases.

Conclusions

The follow-up of the kidney transplant patients should include a careful evaluation for possible GI complications and colonic perforations. Early diagnosis and timely treatment were associated with improved outcomes, regardless of the surgical procedures, the cause of perforation or the clinical and laboratory parameters.     

Necrotizing enterocolitis is associated with neonatal intestinal injury

Purpose

We hypothesized that a subset of premature newborns has subclinical, intestinal mucosal compromise that predisposes to the development of necrotizing enterocolitis (NEC) days or weeks later.

Methods

Fifty-five newborns of 23 to 36 weeks' gestational age were identified, and urine was collected over the first 90 hours of life. The urinary concentration of intestinal fatty acid binding protein (iFABP_u), a sensitive marker for intestinal injury, was determined. The diagnosis of NEC was based upon clinical condition, pathology, and/or imaging findings.

Results

Neonatal iFABP_u exceeded 800 pg/mL in 27 subjects, including 9 of 9 who subsequently developed stage 2 or 3 NEC. This degree of iFABP_u elevation, but not asphyxia, was significantly associated with the development of NEC (P < .01).

Conclusion

In this population of premature newborns, there was a substantial incidence of intestinal mucosal compromise. All infants who subsequently developed stage 2 or 3 NEC had an elevated iFABP_u. This finding suggests a model for the pathogenesis of some cases of NEC, whereby perinatal mucosal injury predisposes to further damage when feedings are initiated. In addition, neonatal iFABP_u assessment may represent a tool to identify infants at the highest risk for NEC and allow for the institution of focused, preventive measures.     

Intestinal obstruction due to internal hernia following pancreas transplantation

Background

Simultaneous pancreas-kidney transplantation has evolved as the best treatment for type 1 diabetic patients at end-stage renal disease. The surgical complication rate is high, which is an important barrier to the success of this procedure. The frequent complications that require relaparotomies include fistulas, graft thromboses, and intra-abdominal abscesses. Intestinal obstructions after pancreas transplantation due to internal herniation are not common.

Purpose

The objective of this article was to review the literature about this problem and describe our personal experience in pancreas transplantation.

Methods

We examined the cases of small bowel obstruction secondary to an internal hernia after following 292 pancreas transplantations in our center from 2000 to 2009 as well as performed a Medline literature review.

Results

Only 2 articles described the diagnosis and treatment of internal hernias after pancreas transplantation. However, both contribution were from the same center reporting the same 3 cases, with surgical versus radiologic perspectives. We have described our 2 cases of young pancreas-kidney transplant patients who presented with acute intestinal obstruction due to internal hernia.

Conclusion

Although internal hernias are rare, they are potentially fatal and difficult to diagnose when they occur after pancreas transplantation. Detection with early surgery demands a high degree of clinical vigilance.     

Sclerotherapy for lymphatic malformations in children: a scoping review

Purpose

This scoping review assesses the literature and summarizes the current evidence on sclerotherapy for the treatment of lymphatic malformations in pediatric patients.

Methods

A comprehensive search of published and unpublished literature was conducted using multiple databases. Title, abstract, and full-text screening was conducted by 2 independent clinicians. All discrepancies were resolved during consensus meetings.

Results

A total of 182 articles were retrieved. Forty-four articles were removed as duplicates, and 11 articles were added after reviewing prominent studies. After full-text abstraction, 44 articles and 2 conference proceedings (N = 882 patients) were included in the final results. Twelve articles were classified as level II and 34 articles as level IV evidence. Picibanil (OK-432) was the primary agent used in most included studies. Postinjection symptoms with OK-432 were primarily fever, swelling, and erythema at the site. Life-threatening complications were uncommon and involved postinjection swelling of cervical lesions causing airway compromise.

Conclusions

The literature regarding sclerotherapy for lymphatic malformations is of a low level of evidence and suffers from a lack of standardization. Randomized clinical trials focused on OK-432, bleomycin, or alcoholic solution of zein; standardized dosing protocols; and consistent and reliable outcome reporting will be necessary for further development of treatment guidelines.