Guided Treatment Improves Outcome of Patients with Enterocutaneous Fistulas

Background

The present study was designed to evaluate the effects of guided treatment of patients with an enterocutaneous fistula and to evaluate the effect of prolonged period of convalescence on outcome.

Methods

All consecutive patients with an enterocutaneous fistula treated between 2006 and 2010 were included in this study. Patient information was gathered prospectively. Treatment of patients focused on sepsis control, optimization of nutritional status, wound care, establishing the anatomy of the fistula, timing of surgery, and surgical principles. Outcome included spontaneous and surgical closure, mortality, and postoperative recurrence. The relationship between period of convalescence and recurrence rate was determined by combining the present prospective cohort with a historical cohort from our group.

Results

Between 2006 and 2010, 79 patients underwent focused treatment for enterocutaneous fistula. Cox regression analysis showed that period of convalescence related significantly with recurrence of the fistula (hazard ratio 0.99; 95?% confidence interval 0.98–0.999; p?=?0.04). Spontaneous closure occurred in 23 (29?%) patients after a median period of convalescence of 39 (range 7–163) days. Forty-nine patients underwent operative repair after median period of 101 (range 7–374) days and achieved closure in 47 (96?%). Overall, eight patients (10?%) died.

Conclusions

Prolonging period of convalescence for patients with enterocutaneous fistulas improves spontaneous closure and reduces recurrence rate.     

Factors related to the spontaneous regression of cancer

The goal of the present editorial is to remind us of a very rare phenomenon in medicine, which is the spontaneous regression of cancer. Factors related to this type of regression are mentioned. Among them are the following:

• Infections
• Fever and therapeutic hyperthermia
• Hormonal factors
• Various other factors
• Exclusion of inaccurate diagnosis of malignancy of a tumour is essential to the validity of reported cases.

     

Abdominoperineal excision of the rectum: A prospective study based on a standardized method

A prospective and consecutive series of 72 patients with rectal carcinoma was subjected to excision of the rectum. The operations were performed according to a standardized program based on previous studies and established surgical principles:

1. Two days on a liquid diet, laxative, and enemas.
2. Irrigation of the pelvic cavity with 5 liters of saline solution after removal of the specimen.
3. Leaving the pelvic peritoneum unsutured.
4. Obliteration of the presacral cavity with living omentum, uterus, or small intestine.
5. Suprapubic, closed suction drainage.
6. Primary closure of abdominal and perineal wounds without drainage.
7. Antibiotic prophylaxis against aerobic as well as anaerobic bacteria.
8. Parenteral nutrition from the first postoperative day and until the bowel acts properly.

Two patients died postoperatively (3%), and 93% achieved primary healing of the perineal wound.     

Crohn's disease simulating tuberculous ureteritis

A case of ureteral obstruction due to perforation of an ileal segment, affected by Crohn's disease, into the extraperitoneal space is described. After a right hemicolectomy combined with uretero-cutaneous fistula and subsequent replacement of the ureter by ileum, the patient is in very good condition. Urinary stasis has completely ceased. The following points are of special interest:

1. false diagnosis of tuberculosis,
2. rarity of ureteral involvement in Crohn's disease,
3. possibility of recurrence of the disease within the ileal segment taken for ureteral replacement.

     

A pull-through operation for the treatment of lesions of the posterior and bulbar urethra

Authors describe a pull-through operation for treatment of lesion of the posterior and bulbar urethra. Membranous and bulbomembranous stricture, recent rupture of posterior urethra and rectourethral fistula were approched by this surgical procedure. Modifications are introduced on this technique and for the first time it was used for the treatment of early lesions of the posterior urethra. Some conclusions may be drawn.

1. The pull-through operation provided good functional results in 76.6% of the cases, irrespective of the etiology.
2. Urethral caliber became normal in 86.66% of the cases; a comparison of the 3 groups showed that the etiology did not influence the results.
3. An evaluation of the results showed that the urinary infection was independent of the etiology.
4. An excretory urography of the upper urinary tract was normal in 77.27% of the cases irrespective of the etiology.
5. The middle and lower urinary tract were normal in 42.85% of the cases.
6. The greater the number of surgical interventions, previous to the pullthrough operation, the higher the incidence of poor results, as judged by urethrccystography.

     

Progress in the treatment of thoracic aortic aneurysms

Progress in the management of thoracic aortic aneurysm includes the following aspects:

1. the concepts of the disease itself, which is frequently generalized so that the second most common cause of late death is rupture of another aneurysm;
2. the diagnostic techniques used: computed tomographic scanning as well as aortography;
3. the medical treatment: with beta blockade and antihypertensive drugs in stable aortic injury in the patient with multiple critical injuries;
4. that hypothermic circulatory arrest with cardiopulmonary bypass and brain temperatures down to 16–20°C has increased successful aortic arch replacement from 50–75% to over 90%;
5. that rapid autologous transfusion by means of a modified Hemonetics machine can collect and process a unit of shed blood in 2–3 minutes and has reduced transfusion requirements by more than half;
6. the vigorous treatment of both consumptive and dilutional coagulopathies;
7. the new reconstructive techniques: involving composite valve graft replacement of the aortic valve, root, and arch as well as coronary artery reattachment;
8. that the use of viable tissue flaps in the treatment of infected aortic grafts as well as intravenous and local irrigation with antibiotics was successful in 8 of 9 of our cases;
9. that graft replacement with intensive antibiotic therapy was effective in 19 of 22 of our patients with mycotic thoracic aortic aneurysm.

     

Choice of preoperative treatment in hyperthyroidism

From our knowledge of thyroid pathophysiology and from morphological studies, preoperative treatment of hyperthyroidism should consist of:

1. A period of treatment to control hyperthyroidism by giving the patient antithyroid drugs (carbimazole) and, if necessary, propranolol.
2. An attempt to keep the patient euthyroid. It seems reasonable to add thyroxine to a relatively high dosage of carbimazole in order to be sure of both euthyroidism and a hormone-free gland.
3. Inhibition of all stimulation of the gland by TSH in order to minimize the risk of bleeding. A bloodless operation guarantees the best anatomical dissection, which gives the best results with an absolute minimum of damage to the parathyroid glands or recurrent nerves.

This treatment fulfills the objectives of an ideal preoperative treatment of hyperthyroidism.     

A comprehensive treatment approach is necessary for the closure of open window thoracostomy: an institutional review of 35 cases

Purpose

Although life-threatening situations can be avoided using an open window thoracostomy (OWT), the closure is often difficult. We investigated the predictors of a successful closure of an OWT at the time of OWT creation.

Methods

Thirty-five consecutive patients who underwent an OWT at our institute between January 1991 and December 2010 were reviewed. We directly compared the patients with and without a successful OWT closure. A logistic regression analysis was employed to determine the predictive factors of a successful closure.

Results

OWT closure was only achieved in 12 patients. The closure of the OWT and absence of diabetes mellitus significantly influenced the survival of the OWT patients. The OWT in patients with preceding lung resection was difficult to close, especially if the underlying disease was lung cancer. The existence of a bronchopleural fistula (BPF) was not related to successful closure. Among the post-lung resection patients, the nutritional status tended to affect the success of the closure.

Conclusion

Successful closure is difficult to predict at the time of the creation of an OWT. A comprehensive approach, including nutritional support and the precise timing of intervention is critical to promote a successful closure.     

Einsatz der Bisphosphonate in der Orthopädie und Unfallchirurgie

Over the past three decades, the members of the substance group called bisphosphonates (BP) have been employed with growing success to manage osteopathies caused by increased osteoclastic activity. The following developments in BP are responsible:

Modern BP are now already 20,000 times more potent than the first preparation approved for use.

Their biochemical and cellular mechanisms of action have meanwhile been elucidated.

They have no effect on hormones so that they are open for all patients.

They are well tolerated and can be administered orally or intravenously.

They have admirably been thoroughly studied in multinational trials.

They are the “gold standard” in the treatment of osteoporosis, a widespread disease.

Rare but serious side effects such as osteonecrosis of the jaw or acute renal insufficiency can be avoided to a large extent.

BP also have tumoricidal properties and are used to suppress tumor growth in bones.

Their anti-inflammatory activity is also successfully used in the treatment of bone marrow edema and bone pain.

     

Further histochemical studies on the testes of infertile men

Enzyme-histochemical investigations performed on testicular biopsies of 20 patients with various testicular disorders gave the following results:

1. Severe hypospermatogenesis and spermatogenetic arrest were accompanied
2. In the cases of germinal aplasia no alkaline phosphatase activity was present in the Sertoli cells.
3. The other enzymes investigated were not noticeably changed in comparison with the control group.
4. The number of Leydig cells seemed to be increased in some cases and they appeared as clusters between the atrophic tubules. There was no reduction of enzyme activity within these cells.

Possible pathogenetic mechanisms are discussed.     

Chronic encapsulated intracerebral hematoma —a well-defined disease. Report on two cases and review of the literature

Chronic encapsulated intracerebral hematoma (CEIH) is a rare disease which is believed to be caused by angiographically negative vascular malformations. CEIH has the following characteristic findings:

1. It affects all age groups
2. Clinical symptoms progress slowly after sudden onset. Often there is a latency of months or years
3. There is no correlation with arterial hypertension
4. Imaging reveals a typical fibrous capsule with enclosed blood contents and signs of recurrent bleedings
5. Cavernoma was identified histologically as the cause of bleeding in 30% of cases
6. All patients had a primary diagnosis of intracerebral tumor

To the best of our knowledge, 27 cases have been reported in the literature. We now add two cases, one of which is the first in the available literature which was not operated and could be followed by imaging.     

Reliability of the measurement of intrarenal haemodynamics in the dog,as determined by the radioactive microsphere technique

In the anaesthetized dog total renal blood flow (RBF) and its intrarenal distribution were investigated by the radioactive microsphere technique under control conditions and after various experimental interventions.

1. In five control series performed within the last four years, there was a small but significant scatter in total RBF, due entirely to changes in inner cortical (IC) perfusion, while outer cortical (OC) perfusion proved to be constant.
2. Repeated measurements in the same dog, performed after 1 h interval, revealed constancy of total RBF with some inward shifting in cortical perfusion.
3. Surgical intervention or manipulation of the kidney did not alter total RBF but led to an increase in IC, compensated by a decrease in OC perfusion.
4. The possible role of local intrarenal hormones (angiotensin and prostaglandin) in the above changes is discussed.

     

Prämature Atherosklerose—vererbt oder erworben?

The Viennese Initiative for Prostaglandin (VIP) Screening investigates patients suffering from clinically manifest vascular disease below the age of 40 years. Data obtained over a 15-year period during the VIP Screening project on the prevalence of vascular events, risk factors, and genetic defects in juvenile atherosclerosis are documented.

The extremely high prevalence of cigarette smoking (>90% !) confirms its key role in the pathogenesis, particularly at a young age

There is an accumulation of risk factors

Juvenile atherosclerosis is associated with (acquired and/or inborn) defects

Homocysteine is (mainly in cigarette smokers) elevated to above 15 μmol/l

Coronary arteries are most frequently involved

A screening investigation for abnormalities in coagulation, prostaglandin system, and lipid metabolism is highly recommended particularly in juvenile premature atherosclerosis

The economic value of screening is supported by the finding that >95% of premature events are found in less than 5% of the families

Other “unusual causes” should be prevented by information and risk awareness

     

Relationship of inorganic pyrophosphatase and alkaline phosphatase activities in hamster molars

1. Some properties of inorganic pyrophosphatase (PP_i-ase) and alkaline phosphatase (p-NPP-ase) in the molars of 3-day-old hamsters are described.
2. The pH optimum for inorganic pyrophosphatase is 8.7, for alkaline phosphatase 10.3.
3. The ratio of Mg²⁺: PP_i for optimal inorganic pyrophosphatase activity is 1∶1. There is no clear optimal ratio in the case of p-NPP-ase.
4. The ratio of the enzymic activity of the membrane bound fraction to the soluble fraction is 3.4∶1 (S.E. 0.37) for PP_i-ase and 3.2∶1 (S.E. 0.42) for p-NPP-ase activity.
5. A mutual substrate competition for the pyrophosphatase and alkaline phosphatase activities is demonstrated.
6. Both enzymatic activities have similar temperature-activity curves with the same maximum at 38°.
7. Microdissection of ameloblasts and stratum intermedium cells from lyophilized sections showed the same activity ratio for both enzyme activities: Stratum intermedium: ameloblasts for PP_i-ase 4.7 (S. E. 0.93) and for p-NPP-ase 4.2 (S.E. 0.79).
8. High-voltage, free-flowing electrophoresis of the homogenate gave equal distribution patterns for p-NPP-ase and PP_i-ase greatly different from the protein distribution pattern.
9. It is concluded that the two activities are due to the same enzyme.

     

Assessing the gap between the acute trauma workload and the capacity of a single rural health district in South Africa. What are the implications for systems planning?

Introduction

This study focuses on a single rural health district in South Africa, and attempts to establish the burden of disease and to review the capacity of the district hospitals to deal with this load.

Methods

Ethical approval to undertake this study was obtained from both the University of Kwa-Zulu Natal and the Department of Health. The audit was performed over a 6-month period in the four district hospitals of rural Sisonke District. There were four components to this audit.

1. Information on the hospital incidence of acute trauma in Sisonke was also sourced from the epidemiology unit of the Department of Health in Pietermaritzburg
2. Each of the district hospitals was visited and the medical manager was interviewed. The medical manager was asked to complete the World Health Organization’s Tool for Situational Analysis to Assess Emergency and Essential Surgical Care. (SAT).
3. The operative registers were reviewed to determine the number of index cases for trauma. This information was used to determine the unmet need of acute trauma in the district.
4. Each hospital was classified according to the Trauma Society of South Africa (TSSA) guidelines for levels of trauma care.

Results

The annual incidence of trauma in the Sisonke District is estimated to be 1,590 per 100,000 population. Although there appeared to be adequate infrastructure in the district hospitals, the SAT revealed significant deficits in terms of capacity of staff to adequately treat and triage acute trauma patients. There is a significant unmet need for trauma care in Sisonke. The four district hospitals can best be classified as Level IV centers of trauma care.

Conclusion

There is a significant burden of trauma in the Sisonke District, yet the capacity to deal with this burden is inadequate. Although the physical infrastructure is adequate, the deficits relate to human resources. The strategic choices are between enhancing the district hospitals’ capacity to deal with acute trauma, or deciding to bypass them completely and deliver all acute trauma patients to large regional trauma centers. If the first option is chosen, urgent intervention is required to build up the human resource capacity of district hospitals.     

A survey of obstetrical anaesthesia practice,teaching and research in canadian university departments of anaesthesia

A report is presented of a questionnaire survey of obstetrical anaesthesia practice patterns, academic structure, resident teaching and research programmes in Canadian University Departments of Anaesthesia. Replies were received from 13 of the 16 departments, representing 24 university-affiliated hospitals. It is apparent that the majority of these hospitals do not have adequate obstetrical anaesthesia coverage. In most instances the delivery suite is covered by the anaesthetists on duty in the operating rooms. While epidural analgesia is widely used during labour, there are some hospitals where it still has a limited use, or is not used at all. Caesarean sections are still largely done under general anaesthesia in most reporting hospitals, with a few institutions reporting an increasing use of regional (mainly epidural) anaesthesia. Resident training in this branch of anaesthesia is felt to be deficient, based on the reports from many hospitals that resident staff are frequently not in attendance at deliveries; and on the evident failure in the majority of institutions to utilize their clinical material for teaching purposes. Research programmes in obstetrical anaesthesia are rare. The most common reason cited was the difficulty experienced in obtaining research funds. It is suggested that the major problems in obstetrical anaesthesia service, teaching and research are:

1. Economic,
2. Lack of interest, and
3. Lack of manpower.

It is recommended that consideration be given to:

1. Consolidation of obstetrical services into larger units wherever practical.
2. Creation of more geographic full time appointments in obstetrical anaesthesia.
3. More efficient use of clinical material for teaching.
4. Development in individual hospitals of prenatal and public education programmes.

     

Angiotensin and renal function

The effects of angiotensin infused via the renal artery, and subsequently by the venous route, have been studied on the renal function in anaesthetized dogs.

1. Infusion of angiotensin into the renal artery in large doses (0.5 or 1.0 μg per min) produces a fall in the parameters of renal function to a certain level which even more massive doses fail to lower any further.
2. Infusion of angiotensin reduces PAH- and creatinine clearances as well as the excretion of water and sodium.
3. The angiotensin-induced impairment of renal function is attributed to glomerular changes. The results of the present study rule out tubular involvement.
4. The blood pressure changes resulting from administration of angiotensin by the intravenous route are connected with a prompt tachyphylactic effect.
5. In the present study no angiotensin-tachyphylaxis was demonstrable in the renal vessels.
6. The angiotensin-induced retention of sodium and water may reduce the therapeutic value of this substance.

     

Le basi biomeccaniche del trattamento delle fratture toraco-lombari

The key objectives for the ideal surgical treatment of thoracolumbar fractures are:

• immediate stability for full weight bearing
• restoration and maintenance of the sagittal alignment
• decompression of the spinal canal, where required
• limitation of the fixation construct to the injured segments

These goals can be successfully achieved by a thorough understanding of the biomechanical concepts of the spine and spinal injuries. Posterior only short segment instrumentation and/or fusion do not achieve these goals. Understanding of spine biomechanics has evolved to the present system of fracture classification based on the pathomechanism of the injury pattern. This classification system based on biomechanics allows the spine surgeon to understand the forces involved and provides the surgeon with the concept to restore the spine to near normal alignment and function. Today’s surgical techniques and modern spinal fixation constructs allow the spine surgeon to accomplish these goals. Surgical procedures which do not fulfil these requirements should not be performed!     

What is new in Sweden? Changing pattern of general surgery

The results of recent studies on the development of general and vascular surgery in Sweden have been analyzed. Among the findings were the following:

1. There was a marked decrease in the number of cholecystectomies performed. Related findings seem to indicate a decline in the incidence of gallstone disease.
2. A slight but continuous decrease in the number of appendectomies performed has occurred over the last decade.
3. There was a decrease in the number of gastric resections performed for gastroduodenal ulcer since 1970 and a considerable total decrease in the number of surgical interventions for this disease since 1977.
4. Arterial reconstructive surgery has increased considerably during the last decade.

The decline in the number of surgical procedures being performed concomitant with an increase in the number of surgeons may have significant impact on departments of surgery throughout Sweden in the near future.