Acute appendicitis after diaphragmatic hernia after pediatric liver transplant

Multiple complications in liver transplant have been described in the literature. However, appendicitis and diaphragmatic hernia have rarely been reported after solid-organ transplant. The clinical presentation of appendicitis is similar to that of nontransplant patients, but complications are more frequent, because the majority of the patients do not have leukocytosis. Diaphragmatic hernia can present with a variety of atypical clinical symptoms. In this report, 1 patient who developed a diaphragmatic hernia and appendicitis after liver transplant is presented. A 2-year-old boy with end-stage liver cirrhosis owing to progressive familial intrahepatic cholestasis type-2 received a living-donor liver transplant. The posttransplant course was complicated. The diagnosis of diaphragmatic hernia was confirmed by thoracoabdominal computed tomography, and we decided to proceed with surgical repair. The patient had evidence of perforation, and the appendix was removed. After repositioning the intestine in the abdomen, a chest tube was placed, and the defect repaired with interrupted polypropylene sutures. The patient recovered after surgery without untoward sequelae.     

Enhanced recovery after surgery programs hasten recovery after colorectal resections

Colorectal resection was traditionally associated with significant morbidity and prolonged stay in hospital.Laparoscopic colorectal resection was first described in 1991 as a minimally invasive form of colorectal surgery.It was later on assessed by multiple randomized controlled trials and meta-analysis and was found to be associated with a faster recovery,lower complication rates and a shorter stay in hospital compared with open resection.To assess the effect of enhanced recovery after surgery (ERAS) program on postoperative length of stay after elective colorectal resections,a literature review was conducted,supplemented by the results of 111 ERAS colorectal resections at regional NWS Hospital using a protocol based on the Fast Track approach described by Kehlet in 1999.ERAS has been shown to improve postoperative recovery,reduce length of stay and enhance early return to normal function when compared with traditional colorectal surgical protocols.The role of laparoscopic surgery in colorectal resections within a fast-track (ERAS) program is controversial.The current evidence suggests that within such a program,there is no difference between laparoscopic and open colorectal surgery in terms of postoperative recovery rates or length of hospital stay.     

Reflux after oesophagectomy

BACKGROUND: Reflux of gastric and duodenal content after oesophagectomy with gastric conduit reconstruction is a common problem and largely considered an inevitable consequence of surgery. Cervical burning and regurgitation, often more pronounced when supine, can be troublesome and even disabling, interfering substantially with quality of life. The aim of this study was to identify the factors contributing to reflux after oesophagectomy and evaluate measures to prevent or control it. METHODS: A Medline search using the terms 'gastro-oesophageal reflux', 'oesophagectomy' and 'antireflux surgery' was conducted. Additional references and search pathways were sourced from the bibliographies of articles located. RESULTS AND CONCLUSION: Reflux after oesophagectomy is a significant problem, with both clinical and pathological consequences. Simple measures to facilitate gastric emptying, such as creating a gastric tube, performing a pyloric drainage procedure and using gastric motility agents, may produce a reduction in symptoms but do not alone control reflux itself. A variety of surgical reconstructions have been used, many of which are either difficult to fashion or not suitable when a radical resection has been performed. A modified fundoplication at the anastomosis seems to be the simplest technique and may be relatively effective in controlling symptoms. The impact of strategies to reduce reflux on quality of life and on pathological sequelae of reflux in the oesophageal remnant remains to be evaluated.     

Beriberi after esophagectomy

A 55-years-old man with a history of alcoholism, hypertension and obesity was diagnosed of epidermoid carcinoma of the middle third portion of the esophagus. He was treated with two cycles of cytostatics with cisplatin and 5-fluorouracil. Due to his poor general health an inability to swallow solids and liquids, he received parenteral nutrition for 20 days using a commercial formula lacking in vitamins and minerals. During distal esophagectomy we observed a tendency to hypotension and severe metabolic acidosis that was unexplained by the hemodynamic profile and that persisted throughout the first 24 hours after surgery. Once these complications were corrected, he was weaned from mechanical ventilation and the following neurological signs were observed: temporal and spacial disorientation, aphasia, ophthalmoplegia with divergent strabismus and later conduction aphasia, amnesia and confabulation. Circulation was hyperdynamic, requiring inotropics and vasoconstrictors. Korsakoff syndrome secondary to Wernicke's encephalopathy was diagnosed, and the response to thiamine treatment was favorable. Beriberi can be found in hospitalized patients and the anesthesiologist may be involved in their perioperative care. Symptoms resolve easily with vitamin B1 treatment, which is ideally provided along with other hydrosoluble vitamins. Treatment should be prompt because delay leads to greater morbiomortality.     

Follow-up after polypectomy

Progress in understanding the biology, natural history, and relationship to colorectal cancer has provided the basis for a rational approach to patients with adenomas. Pathological assessment of polyps is essential for initial management; only adenomas require search for synchronous neoplasia. A finding of a 30%–50% synchronous rate has been observed. After clearing of the colon of all adenomas, follow-up examination will reveal a 30%–50% rate of metachronous adenomas, but usually with unimportant pathology. Patients with no special concerns at initial polypectomy can have surveillance at intervals of approximately 3 years, while those with an incompletely cleared colon, numerous polyps, or large sessile or malignant adenomas need individualized surveillance. Working guidelines can be provided at this time pending observations in ongoing trials. It is expected but not yet proven that control of colonic adenomas will reduce the incidence and mortality from colorectal cancer. Further research into the biology of adenomas and cancer will undoubtedly provide a clear understanding of susceptibility for colorectal adenomas and more selective control strategies.

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Resumen El progreso en la comprensión de la biología, la historia natural, y la relación con el cáncer colorrectal provee el fundamento para un enfoque racional del paciente con adenoma. La valoración histopatológica de los pólipos es esencial en la primera fase de su manejo; sólo los pacientes con adenomas requieren ser investigados para neoplasia sincrónica. Se ha encontrado una tasa de incidencia sincrónica de 30%–50%. Después de limpiar el colon de la totalidad de los adenomas, el examen de seguimiento revela una tasa de adenomas metácronos de 30%–50%, pero usualmente con patología no importante. Pacientes libres de riesgos especiales en el momento de la polipectomía pueden ser controlados a intervalos de 3 anos, mientras que aquellos con un colon no totalmente limpio de adenomas, o con pólipos numerosos, o con adenoma malignos requieren seguimiento individualizado. Es posible plantear pautas de trabajo, pendientes de las observaciones que se deriven de estudios actualmente en progreso. Se espera, aunque aun no está probado, que la resección de los adenomas del colon habrá de disminuir la incidencia y la mortalidad del cáncer colorrectal. Futuros estudios sobre la biología de los adenomas seguramente aportará una más clara comprensión de la susceptibilidad de los adenomas colorrectales y permitirá delinear estrategias de control más selectivas.

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Résumé Les progrès dans la compréhension de la biologie, de l'histoire naturelle, et de la relation avec le cancer colorectal constituent la base d'une approche rationnelle des patients ayant des adénomes. Un examen histologique des polypes est indispensable avant tout traitement; seuls les adénomes demandent la recherche d'une néoplasie synchrone. On a observé un taux de néoplasie synchrone de 30% à 50%. Après avoir débarassé le côlon de tous les adénomes, le suivi révélera un taux de 30% à 50% d'adénomes métachrones, mais généralement bénins. Les patients n'ayant pas eu de problème particulier à la première polypectomie doivent Être surveillés à des intervalles de 3 ans environ tandis que ceux qui ont un côlon incomplètement nettoyé, des polypes nombreux, des grands polypes sessiles, ou des adénocarcinomes ont besoin d'une surveillance particulière. On peut tracer quelques recommandations à l'heure actuelle en attendant les résultats des études en cours. Il est probable mais cependant pas encore démontré que l'ablation des adénomes coliques réduira l'incidence et la mortalité du cancer colorectal. De plus amples recherches dans la biologie des adénomes et du cancer apporteront sûrement des éclaircissements sur la survenue des cancers colorectaux et sur les méthodes de contrôles plus sélectives.

     

Rehabilitation after replantation

Limb replantation represents a particular surgical challenge.Rehabilitation and functional integration of the patient into everyday life has proven to be as equally important as the operation itself.This requires intensive and long-term cooperation between surgeon, therapist, and patient since replanted limbs without restoration of function are of no use. Besides physiotherapy, ergotherapy is highly important for this since it helps to reactivate daily activities.Also, tactile gnosis and protecting nervous sensibility and motor function can be improved by ergotherapy.With the help of special devices, adjustments,and psychological care, ergotherapy also supports the patient's reintegration into his former social environment.