Case report: multidisciplinary treatment of a patient with gas-producing phlegmone

The authors present a 51-year-old patient with a severe case of gas-producing phlegmone following incision of a perianal abscess. Early diagnosis and extensive surgical excision during the first 12 hours from the onset of symptoms are crucial. Treatment of sepsis complicated by multiple organ failure: lung insufficiency (respiratory distress requiring mechanical ventilation), kidney insufficiency (requiring rehydration, furosemid, manitol), circulation (blood derivatives, saline, colloid solutions, cardio tonics, anti-arrhythmic drugs) and liver must be aggressive. Hyperbaric oxygen therapy is essential with repeated identification of aerobic and anaerobic bacteria (hemoculture, tissue sample, wound swab), their sensitivity to antibiotics and repeated surgical debridement of the wound. Following this treatment the patient was transferred to plastic surgery where Thiersh transplants covered skin defects. He survived with an abdominal wall hernia due to a team effort and aggressive multidisciplinary treatment by the general surgeon, anesthesiologist, hyperbaric medicine specialist, microbiologist and plastic surgeon. He refused hernia repair.     

Pierre Petit (1905-2002), pioneer of pediatric surgery and academic in spite of himself

Initially a general surgeon for children, like his predecessors such as Louis Ombredanne, Pierre Petit devoted all his time to his young patients in Saint Raphael Clinic and Saint Vincent de Paul Hospital where, in 1943, he succeeded Victor Veau, famous specialist of hare lip surgery. Each of the children who entered his hospital was his own patient. He did everything by himself, especially when it concerned babies who would bear the marks of his operation for the rest of their life. He performed the first successful operation for esophageal atresia. He greatly valued independence, declined honors and never participated in academic competition. However, he was among the first ones to understand the necessity of specific knowledge, and encouraged his collaborators to acquire a large specialization in the different fields which were complementary within a closely knit team. In 1957, he came out of his isolation and associated with the birth of the French Society for pediatric surgery, which greatly contributed to the unification, development and renown of french pediatric surgery.     

A not‐so‐sweet diagnosis – leukocytoclastic vasculitis masquerading as squamous cell carcinoma

Leukocytoclastic vasculitis (LCV) is a rare small‐vessel vasculitis characterised by neutrophilic inflammation of post‐capillary venules. Incidence varies from 3 to 4.5 per 100 000 people per year. Patients typically present with painful, itchy purpura and erythema, although clinical manifestations can vary making diagnosis a challenge. We report the case of a 75‐year‐old man with a history of a previously completely excised and grafted squamous cell carcinoma (SCC) on the dorsum of his hand, who presented with an acutely swollen, erythematous and ulcerated lesion adjacent to the graft site. A shave biopsy failed to definitively exclude SCC recurrence. He was referred to the Plastics team who initially suspected Sweet's syndrome but could not rule out SCC recurrence. The patient underwent formal mapping incisional biopsies that later diagnosed LCV. He was managed conservatively and made an excellent recovery. We present clinical photographs and histology to illustrate disease progression. LCV is typically self‐limiting with a good overall prognosis, but a minority of patients follow a protracted course, which may require treatment in the form of systemic corticosteroids or colchicine. LCV can only be confirmed histologically. We present this case in order to highlight the importance of adequate tissue biopsy when there is diagnostic uncertainty with an acute dermatosis, particularly in the context of previous skin malignancy.     

Ureteral and bladder metastases of renal cell carcinoma following synchronous renal cell carcinoma and bladder cancer; a case report

A 73-year-old man presented with gross hematuria. Ultrasonography and computerized tomography showed small bladder tumors and a left renal mass protruding to renal pelvis. Transurethral resection of bladder tumor and ureteroscopic tumor biopsy were performed, and pathological examinations revealed transitional cell carcinoma in the bladder and renal cell carcinoma in the kidney. He underwent left radical nephrectomy. A 4-month postoperative cystoscopy revealed a solitaly non-papillary tumor in the bladder. Transurethral resection was performed and pathological diagnosis was metastasis from renal cell carcinoma. At that time, multiple metastases to ureteral stump and lung were found. He had undergone palliative treatment because of his poor general condition until he died 26 months postoperatively. Care should be taken for management of ureteral stump when diagnostic ureteroscopy was done for renal cell carcinoma invading the renal pelvis.     

Factors influencing the diagnostic accuracy and management in acute surgical patients

AIM:To evaluate the diagnostic accuracy(DA) in acute surgical patients admitted to a District General Hospital.METHODS: The case notes of all acute surgical patients admitted under the surgical team for a period of two weeks were reviewed for the data pertaining to the admission diagnoses, relevant investigations and final diagnoses confirmed by either surgery or various other diagnostic modalities. The diagnostic pathway was recorded from the source of referral [general practitioner(GP), A and E, in-patient] to the correct final diagnosis by the surgical team. RESULTS: Forty-one patients(23 males) with acute surgical admissions during two weeks of study period were evaluated. The mean age of study group was 61.05 ± 23.24 years. There were 111 patient-doctor encounters. Final correct diagnosis was achieved in 85.4% patients. The DA was 46%, 44%, 50%, 33%,61%, 61%, and 75% by GP, A and E, in-patient referral, surgical foundation year-1, surgical senior house officer(SHO), surgical registrar, and surgical consultant respectively. The percentage of clinical consensus diagnosis was 12%. Surgery was performed in 48.8% of patients. Sixty-seven percent of GP-referred patients, 31% of A and E-referred, and 25% of the in-patient referrals underwent surgery. Surgical SHO made the most contributions to the primary diagnostic pathway.CONCLUSION: Approximately 85% of acute surgical patients can be diagnosed accurately along the diagnostic pathway. Patients referred by a GP are more likely to require surgery as compared to other referral sources. Surgical consultant was more likely to make correct surgical diagnosis, however it is the surgical SHO that contributes the most correct diagnoses along the diagnostic pathway.     

Combined operation for congenital cardiovascular and other anomalies in children

Combination of congenital cardiovascular and other anomalies are often found. Combined operation is needed for some of these cases. We report 3 cases who underwent combined operations by combined team of cardiovascular and general surgical units. Case 1: A 10-month-old boy with VATER association was complicated with tetralogy of Fallot, double aortic arch and so on. He underwent division of left aortic arch for vascular ring by cardiovascular surgical unit and esophagogastrostomy for esophageal atresia by general surgical unit. Case 2: A 15-day-old girl with patent ductus arteriosus and eventration of the diaphragm underwent ligation of ductus arteriosus by cardiovascular surgical unit and plication of left diaphragm by general surgical unit. Case 3: An 8-month-old boy with tracheobronchomalacia and atrial septal defect underwent atrial septal defect (ASD) closure by cardiovascular, and extra tracheobronchial stenting on cardiopulmonary bypass by cardiovascular and general surgical unit. These 3 operations were successful, and we consider that combined operation is useful for certain surgical congenital multiple anomalies.     

Hans Christian Jacobaeus: Inventor of human laparoscopy and thoracoscopy

Hans Christian Jacobaeus performed the first clinical laparoscopic surgery in Stockholm. This pioneering procedure was based on the animal experiments of Georg Kelling (1866-1945), a German physician from Dresden, who performed the first laparoscopic intervention in 1901 using a Nitz cystoscope in a dog. In 1910, Jacobaeus published his initial experiences with laparoscopic surgery in the Münchner Medizinischen Wochenschrift under the title "The Possibilities for Performing Cystoscopy in Examinations of Serous Cavities." He used this technique for diagnostic purposes in undefined abdominal complaints and functional impairment. Jacobaeus was the first who pointed out the possibility of injuring organs, especially the intestines, by inserting the trocar. In 1910, Jacobaeus recognized the immense diagnostic and therapeutic possibilities of laparoscopic surgery, as well as its difficulties and limits. He also was the first to realize the need for initial endoscopic training in animals and corpses. He promoted the development of special laparoscopic instruments to optimize and simplify the procedure.     

Anaesthetic considerations during endoscopic retrograde cholangiopancreatography

Endoscopic retrograde cholangiopancreatography has evolved from being a simple diagnostic procedure, performed under proceduralist-administered sedation, to a therapeutic one involving increasingly complex techniques that require a high degree of patient cooperation. The anaesthetist has become a vital member of the team. Many of the patients are medically unfit for surgery. Sedation or general anaesthesia is generally indicated for the increasingly complex, long and painful procedures being performed. Although there is very little published evidence of specific anaesthetic techniques in this area, knowledge of these problems allows the anaesthetist to select an appropriate technique to provide safe and effective anaesthesia.     

Hans-Christian Jacobaeus (1879–1937)

Already 94 years ago in 1910, Dr. Hans Christian Jacobaeus performed the first clinical laparoscopic surgery in Stockholm. His pioneering procedure was based on the animal experiments of Georg Kelling (1866-1945), a German physician from Dresden, who performed the first laparoscopic intervention in 1901 using a Nitze cystoscope in a dog. In 1910 Jacobaeus published his first experiences with laparoscopic surgery in the Münchner Medizinische Wochenschrift under the title "The possibility to perform cystoscopy in examinations of serous cavities." He used this technique for diagnostic purposes in unclear abdominal complaints and functional impairment. Jacobaeus was the first who pointed out the possibility of causing injury to organs, especially the gut, by inserting the trocar. In 1910 Jacobaeus recognized the immense diagnostic and therapeutic possibilities of laparoscopic surgery, but also the difficulties and limits. He also was the first who recognized the need to complete training sessions on animals and corpses. He demanded the development of special laparoscopic instruments to optimize and simplify the operation.     

A historic perspective on the contributions of surgeons to the understanding of acute pancreatitis

BACKGROUND: Acute pancreatitis is a disease with a broad spectrum of presentation, severity, and treatment. Current management involves a multidisplinary team of surgeons, gastroenterologists, and interventional radiologists whose varied clinical skills contribute to the evolving diagnostic and therapeutic strategies for this disease. However, critical aspects of therapy have remained the responsibility of the general surgeon. The purpose of this review is to examine the many contributions of surgeons in acute pancreatitis. DATA SOURCES: A review of the literature taken from PubMed on seminal articles published by surgeons on the subject of acute pancreatitis. CONCLUSIONS: Surgeons have made significant contributions to the understanding of the pathophysiology and evolution of therapy of acute pancreatitis. The specialty should continue to take a leadership role to improve outcomes.     

Carcinosarcoma of the liver: a case report

Primary hepatic carcinosarcoma is a rare malignant hepatic tumor containing both carcinomatous and sarcomatous elements. A 40-year-old man referred to our liver transplant team because of hepatic cirrhosis was on the waiting list, having undergone all liver tests, ultrasonography, and with normal serum alpha fetoprotein markers every 6 months to search for a tumor. He underwent a liver transplantation without complication. The pathologic findings of the original liver indicated carcinosarcoma. We have reviewed the literature on this subject.     

Physical therapy for the patient with acquired immunodeficiency syndrome.

Treatment of HIV-infected patients has come a long way since the not-so-long-ago beginning of the AIDS epidemic. Implementation of new drug therapies has increased longevity of a patient's life after being diagnosed with the virus. Because HIV-related illnesses are consequently becoming more chronic in nature, patients commonly experience potentially debilitating CNS, PNS, or musculoskeletal problems during the course of the disease. As a result, these patients require delicate care from a number of different health care providers. A multidisciplinary team approach must be used within the podiatrist's treatment regimen. This team must include the physiatrist overseeing the physical therapist, to provide complete and optimal care to improve the patient's functional independence and quality of life. The conditions associated with HIV infection are insidious, slow, and crushing in nature. The medical community can help the patient with HIV infection and AIDS remain on his or her feet. By doing this, costs, both social and economic, can be lowered. The podiatrist must have a strong knowledge of the pathology of AIDS. He or she must use PT along with other disciplines: podiatric medicine, orthotic therapy, and general podiatric care. PT is effective in treating conditions of the lower extremities that affect the CNS, PNS, musculoskeletal system, and, lastly, rheumatologic effects of HIV infection.     

Improving team structure and communication: a key to hospital efficiency

HYPOTHESIS: Improving team structure and heightening communication will help provide cost-effective and high-quality patient care for general surgery patients. DESIGN: This study surveys teamwork initiatives and their effects on specific variables related to patient care. PATIENTS: The study population comprised all patients admitted to the hospital's general surgery teams during 5 years 3 months. SETTING: Tertiary care hospital. INTERVENTIONS: A complete restructuring of the patient care team for general surgery patients admitted to the hospital. The intervention occurred midway through the study period. MAIN OUTCOME MEASURES: Mean length of stay for general surgery patients as a marker of team efficiency and a standardized patient satisfaction survey. RESULTS: The mean length of stay after initiation of the restructured care team was significantly shorter than before initiation. The significance was present despite a consistent patient acuity measure and was associated with a high patient satisfaction level. CONCLUSIONS: Restructuring the patient care team yielded a decreased mean length of stay while maintaining a high level of patient satisfaction. This analysis helps validate a hospital-wide initiative to maintain a high level of patient care while increasing patient volume.     

Etienne-Louis Arthur Fallot and his tetralogy: a new translation of Fallot's summary and a modern reassessment of this anomaly

As this translation of Fallot's conclusions makes clear, he emphasized the clinical diagnostic usefulness of his findings because of the high frequency of this malformation in cyanotic congenital heart disease. Terming this anomaly "tetralogy," he clearly and simply delineated its four cardinal features. He stated that cyanosis was not due to a patent foramen ovale. He attributed the morphogenesis of the tetralogy to an intrauterine pathologic process at the level of the pulmonary valve leaflets and the subpulmonary infundibulum. The tetralogy and Fallot's contribution are reassessed in the light of present understanding.     

Awake GlideScope intubation in a critically ill pediatric patient

We report a challenging case of a 10‐year‐old boy with history of biventricular heart failure, pulmonary hypertension, severe asthma, and obesity with a BMI of 37. He presented to our hospital in acute decompensated heart failure. Our anesthesia team was consulted by the pediatric intensivist for urgent airway management in this rapidly deteriorating, premorbid patient. We describe here the use of the GlideScope^® in an awake pediatric patient of ASA 4E status with a potentially difficult airway who required to remain in the seated position and thus necessitating a face‐to‐face approach.     

Dr Robert McKechnie: Vancouver's pioneer surgeon and a patron of British Columbia sports & education

Robert E. McKechnie, M.D.C.M. (1861-1944), was a distinguished graduate of McGill Medical School and a pioneer in the early days of surgery in Vancouver, Canada. He was a long-standing Canadian leader in both clinical and academic surgery. In addition, he played an important role in the founding of the University of British Columbia. He also commissioned an important challenge cup for the British Columbia rugby championship team in the same time and place as the establishment of hockey's Stanley Cup.     

Structure and characteristics of community‐based multidisciplinary wound care teams in Ontario: An environmental scan

Multidisciplinary team approach is an essential component of evidence‐based wound management in the community. The objective of this study was to identify and describe community‐based multidisciplinary wound care teams in Ontario. For the study, a working definition of a multidisciplinary wound care team was developed, and a two‐phase field evaluation was conducted. In phase I, a systematic survey with three search strategies (environmental scan) was conducted to identify all multidisciplinary wound care teams in Ontario. In phase II, the team leads were surveyed about the service models of the teams. We identified 49 wound care teams in Ontario. The highest ratio of Ontario seniors to wound team within each Ontario health planning region was 82,358:1; the lowest ratio was 14,151:1. Forty‐four teams (90%) participated in the survey. The majority of teams existed for at least 5 years, were established as hospital outpatient clinics, and served patients with chronic wounds. Teams were heterogeneous in on‐site capacity of specialized diagnostic testing and wound treatment, team size, and patient volume. Seventy‐seven percent of teams had members from three or more disciplines. Several teams lacked essential disciplines. More research is needed to identify optimal service models leading to improved patient outcomes.     

Barotrauma as a possible cause of aneurysmal subarachnoid hemorrhage. Case report

The authors report the case of a 47-year-old man who suffered a diving accident. After regaining consciousness he experienced severe headache. He was initially treated for barotrauma, but the persistent headache led to diagnostic imaging that revealed an aneurysmal subarachnoid hemorrhage. To the authors' knowledge, this is the first report of a ruptured brain aneurysm associated with barotrauma.     

Traumatisches intrakranielles Aneurysma der Arteria carotis interna bei longitudinaler Fraktur des Orbitadaches

A case of traumatic supraclinoidal aneurysm of the internal carotid artery is presented. The patient with adventitious multiple lesions of the midface was successfully treated by a team consisting of a neurosurgeon, a traumatologist, and a dental surgeon. As an example, this case presents the diagnostic problems, and the operative treatment. Problems of post-traumatic intracranial vasospasm are discussed.