Modified Thiersch operation for rectal prolapse. Technique and results

Rectal prolapse is best treated by intra-abdominal or perineal procedures that either resect the redundant rectosigmoid colon or fix the rectum within the pelvis. We have found the Thiersch procedure to be adequate treatment in patients who are high risk or who have only mild to moderate prolapse of the rectum. Over the past 20 years, we have treated 15 patients with a modified Thiersch procedure, using a knitted Dacron vascular graft to encircle the anus. One patient required a second Thiersch procedure after failure of a Ripstein procedure that followed failure of a Thiersch procedure done with wire. A second Thiersch procedure was required in two patients after suture breakage, and in one patient after removal of an infected graft. Two other patients had graft infections necessitating removal of the Dacron graft; one patient had a perianal infection that was treated without removing the graft. Continence was achieved in six of nine patients previously incontinent, and maintained in the six patients who had been continent before operation. Prolapse was corrected in 13 of the 15 patients. Although the Thiersch procedure is not applicable to all patients with rectal prolapse, it can be used successfully when performed properly.     

Extracorporeal Membrane Oxygenation Outcomes After the Comprehensive Stage II Procedure in Patients With Single Ventricles

Outcomes for extracorporeal membrane oxygenation (ECMO) have been described for patients with single ventricle physiology (SVP) undergoing cavopulmonary connection (Glenn procedure). An alternative surgical pathway for patients with SVP consists of an initial hybrid procedure followed by a comprehensive Stage II procedure. No data exist describing the outcomes of patients requiring ECMO after the comprehensive Stage II procedure. The goal of this study is to describe the outcomes for patients who required ECMO after the comprehensive Stage II procedure. Data from the Extracorporeal Life Support Organization (ELSO) registry from 2001 to 2015 for children undergoing the comprehensive Stage II procedure older than 3 months of age were retrospectively analyzed. Demographics and ECMO characteristics were recorded. A total of six children required ECMO support after the comprehensive Stage II procedure (2 males, 4 females). Four patients had the diagnosis of hypoplastic left heart syndrome and two patients had the diagnosis of an unbalanced atrioventricular septal defect. Bypass time was 242.8 ± 110.9 min and cross‐clamp time was 91.2 ± 46.2 min for the surgical procedure. Weight was 5.8 ± 1.3 kg and age was 150.2 + 37.9 days at time of ECMO. ECMO duration was 276.0 ± 218.1 h. Complications during the ECMO run included hemorrhage in four patients (67%), renal dysfunction in two patients (33%), and neurologic injury in two patients (33%). Four patients (67%) were discharged alive after ECMO decannulation. Despite being a much more extensive surgical procedure, the morbidity and mortality after ECMO in patients undergoing the comprehensive Stage II procedure are similar to those in patients undergoing the Glenn procedure. If needed, ECMO support is reasonable for patients after the comprehensive Stage II procedure.     

Surgical treatment of atrial fibrillation: predictors of late recurrence

OBJECTIVE: The Cox maze procedure was introduced in 1987 for the treatment of atrial fibrillation. This study evaluated the predictors of late atrial fibrillation recurrence in 276 consecutive patients who underwent this procedure at our institution. METHODS: From 1987 through June 2003, 276 patients (79 female and 197 male patients; mean age, 55 +/- 11 years) underwent the Cox maze procedure. Thirty-three patients had Cox maze procedure I, 16 patients had Cox maze procedure II, and 197 patients had Cox maze procedure III. The last 30 patients underwent a modified procedure (Cox maze procedure IV) with bipolar radiofrequency ablation. There were 113 (41%) patients who had a concomitant operation, most commonly either a mitral valve procedure (19%) or coronary artery bypass grafting (20%). Data were analyzed by means of univariate analysis, with preoperative and perioperative variables used as covariates. Patient follow-up was conducted by means of questionnaire, physician examination, and electrocardiographic documentation. All patients had a minimum of 6 months of follow-up. RESULTS: Patient follow-up was achieved in 92.8% of cases, with a mean follow-up time of 5.8 +/- 3.6 years. Risk factors for late atrial fibrillation recurrence were duration of preoperative atrial fibrillation (P = .01) and Cox maze procedure version (P = .001). There was no difference in actuarial 10-year survival between the Cox maze procedure versions. CONCLUSION: The Cox maze procedure remains the gold standard for the treatment of atrial fibrillation and has excellent long-term efficacy. The most significant predictor of late recurrence was duration of preoperative atrial fibrillation, suggesting that earlier surgical intervention would further increase efficacy.     

Vulvar pain after spondylosyndesis procedure: a presentation of 2 cases

Vulvar pain can be a difficult and frustrating problem for patients and practitioners. Often, no specific etiology can be determined for these symptoms. Treatment can be long and difficult as well.Spondylosyndesis is a common surgical procedure where the vertebrae are fused to decrease motion. There are several indications for this procedure. We report 2 patients who developed vulvar pain postoperatively after a spondylosyndesis procedure. Neither patient had a history of vulvar pain before their procedure. Of note, both patients had had a previous spondylosyndesis procedure in the past.Damage to lumbar nerves during spondylosyndesis procedures may precipitate vulvar pain in some patients.     

Reversal of Hartmann's procedure after surgery for complications of diverticular disease of the sigmoid colon is safe and possible in most patients

BACKGROUND: Although evidence is growing that most patients who need an operation for diverticular disease of the sigmoid colon can be treated by a single-stage procedure, a two-stage procedure will still be necessary in some patients because of significant sepsis or technical difficulties. The outcomes of 65 patients who underwent secondary restoration after a Hartmann procedure for complicated diverticulitis were studied and the factors leading to complications and mortality were identified. PATIENTS AND METHODS: Of 91 patients, in a consecutive 12-year period, whose primary operation was a Hartmann procedure, 72 survived longer than 3 months after discharge. Sixty-five underwent an attempted reversal of the Hartmann procedure. The POSSUM scores were calculated in all patients as well as the morbidity and mortality rates. RESULTS: In 63 (96.9%) patients the bowel continuity could be restored with a morbidity of 38.5% and a mortality of 3.1%. The POSSUM and p-POSSUM scores adequately predicted the mortality in this series. CONCLUSION: This series shows that when surgical treatment for complicated diverticular disease of the sigmoid colon is necessary, the Hartmann procedure is still a valid indication. In a high percentage of patients the Hartmann procedure could be restored with a low mortality.     

HARTMANN PROCEDURE: IS IT STILL RELEVANT TODAY?

BACKGROUND: With more and more centres worldwide resorting to primary anastomosis for most left sided colonic pathology, the place for a Hartmann procedure seems to be relegated to surgical history books. However, in our centre it is still being performed on a regular basis. As such, we decided to retrospectively look at our results for the procedure. METHODS: All hospital records of patients undergoing the Hartmann procedure between January 1998 and December 2001 were retrospectively analysed looking at demographics, comorbidities and indications of the procedure. RESULTS: There were 52 men and 33 women with a median age of 69 years (range 31-96 years). Sixty-six per cent of the patients had medical comorbidities at the time of the operation. The indications for performing the procedure were: 45 patients for cancer (31 patients for obstruction, 11 patients for perforation, two patients for fistulation to other organs and one for uncontrollable bleeding). 19 patients had the procedure for complicated diverticulitis while four patients had anastomotic leaks, which required conversion to the procedure. Other indications include trauma (four patients), ischemic bowel (six patients) and iatrogenic (one patient). Our median operating time was 160 min (range 50-415 min). Our reversal rate was 32%. Our mortality rate for the first stage was 16% and our morbidity, 51%. The morbidity for the reversal was 29%, with no mortalities. CONCLUSION: Though the idea of primary anastomosis with on table lavage for left sided anastomosis seems attractive, we think the Hartmann procedure is still useful for selected patients.     

The Cox-Maze procedure: the Cleveland Clinic experience

The Cox-Maze procedure was designed to address the consequences of atrial fibrillation, tachycardia, hemodynamic impairment, and thromboembolism. From 1991 until June 1999, 100 patients underwent the Maze operation at the Cleveland Clinic Foundation. The group included 72 men with a mean age of 58 +/- 11 years (range, 23 to 78 years). Initially, the Maze-I procedure was performed primarily for patients with lone atrial fibrillation. However, since 1995, the Maze-III procedure has been performed exclusively, and it is typically combined with mitral valve repair. Twenty-three patients had only a Maze procedure, 60 patients had the Maze procedure/mitral valve repair, 10 patients had Maze procedure/coronary artery bypass, 6 had Maze procedure/mitral valve replacement, and 1 had Maze procedure/atrial septal defect repair. Chronic atrial fibrillation was present in 78% of patients for a mean of 8 +/- 9 years. There was a 1% perioperative mortality and 5% late mortality rate. Median hospital stay was 9 +/- 5 days. Six patients required new early permanent pacemaker insertion. With a mean follow-up of 3 years, 90.4% of patients are in sinus rhythm (or atrial pacing). Preoperative symptoms were reduced: 24% had preoperative syncope; none had syncope in follow-up; 14% of patients preoperatively had cerebral or systemic emboli; and there were no perioperative or late embolic events. The Maze procedure effectively addressed the major complications of atrial fibrillation and was associated with low perioperative and late morbidity rates.     

Sugiura procedure outside Japan. The Mexican experience

In the last 10 years, we operated on 231 patients with hemorrhagic portal hypertension. Most of these patients had some form of liver disease. We performed various surgical procedures: 47 conventional shunts with H grafts and terminolateral portacaval shunts with arterialization of the portal stump, 139 selective Warren shunts, and in those patients in whom a selective portasystemic shunt could not be performed for technical reasons, esophagogastric devascularization in the form of the Sugiura procedure. Forty-five patients were treated with the Sugiura procedure as a one stage or two stage procedure. A total of 68 emergency and elective operations were performed. The operative mortality rate for the emergency thoracic operation was 41 percent and for the abdominal operation, 42 percent. The overall operative mortality rate in the emergency group was 41 percent. The incidence of recurrent variceal bleeding and encephalopathy was 0 in the surviving patients. The survival rate at 3 year follow-up was 40 percent. The elective group was made up of 24 patients. Eighteen patients had a two stage procedure and 6 patients had a one stage procedure. The operative mortality rate for the abdominal operation was 11 percent, whereas that for the thoracic operation was 7 percent. The operative mortality rate for the one stage procedure was 16 percent. The overall operative mortality rate in the elective group was 10.8 percent. None of these patients had recurrent variceal bleeding and encephalopathy developed in only one (5 percent). The encephalopathy was easily controlled with medical treatment. The 3 year survival rate was 83 percent. We conclude that the Sugiura procedure is an effective procedure to treat hemorrhagic portal hypertension when a selective shunt cannot be performed.     

The indications and surgical treatment in the complications of colonic diverticular disease

In this work the authors describe the different stages of diverticulosis and analyze the pathogenetic principal factors. During the period from 1979 to 1998 they observed 420 patients affected by diverticular disease (224 M; 196 F), 42 (10%) of them were operated on for complications. Fifteen patients operated on in elective time underwent a one stage procedure of resection and anastomosis with derivative colostomy; 27 patients were operated on in emergency: 6 patients had one stage procedure of resection and anastomosis with derivative colostomy, 16 patients Hartmann's procedure, 3 patients Mikulicz's procedure and 2 patients colostomy and peritoneal drainage. Two patients died from septic shock. There was absence of postoperative complications for the patients operated on in elective time, while 8 cases (29.6%) showed peritoneal sepsis and 4 cases (14.8%) infection of wound in the patients operated on in emergency. The Authors describe the different surgical options in the treatment of colonic complicated diverticular disease and conclude that the surgical treatment is not definite. A tendency is to make a one-stage procedure of resection and anastomosis and to reduce the Hartmann's procedure or the simple colostomy with drainage of abdominal cavity.     

Norwood术后心导管造影检查的应用及介入治疗

目的 探讨Norwood术后心导管造影检查结果以及介入治疗方法和疗效.方法 13例病婴均为Norwood术后而尚未行Glenn手术者,其中12例接受了介入治疗.结果 13例中6例出现新主动脉弓再狭窄,行主动脉成形术.1例左肺动脉狭窄,行左肺动脉球囊扩张术,3个月后左肺动脉置入支架.2例Sano-Shunt狭窄和1例BT-Shunt狭窄,均置入支架治疗,改善肺血流.4例合并体肺动脉侧支,其中3例采用Coil行侧支血管堵塞术,另1例于次日Glenn手术术中结扎.结论 Norwood术后血流动力学异常的发生率很高,术后造影和血流动力学的评估以及对新主动脉弓或肺动脉狭窄的介入治疗是必要的.

Abstract：

Objective To evaluate the outcome of the cardiac catheter angiograplasty for patients after Norwood procedure. Methods 13 patients, who had undergone Norwood procedure (prior to Glenn procedure)received cardiac catheterization and angiography. lnterventional therapy was performed in 12 patients as indicated. Results Angioplasty was carried out for re-coarctation in 6 of the13 patients. 1 patient with left pulmonary artery stenosis received balloon dilation and 3 months later a stent implantation. A stent was implanted to improve the pulmonary blood flow in 2 patients with Sano-Shunt stenosis and 1 patient with BT-Shunt stenosis. Transcatheter coil embolization was performed in 3 of the 4 patients with systemic to pulmonary collateral vessels. The other one was scheduled for Glenn procedure the next day. Conclusion The incidence of hemodynamic restrictions after Norwood procedure is high (12 of 13 patients). Postoperative angiography and hemodynamic assessment for diagnosis and interventional treatment for new pulmonary artery or aortic arch stenosis is necessary after Norwood procedure.     

Repeat radiosurgery for refractory trigeminal neuralgia

OBJECTIVE: Stereotactic radiosurgery has become an important and minimally invasive alternative for patients with refractory trigeminal neuralgia. When a second procedure is necessary, the outcomes are unknown. The degree of pain relief and morbidity after repeat radiosurgery were studied. METHODS: Thirty-one patients underwent a second gamma knife radiosurgery procedure because of unsatisfactory or unsustained relief of pain after the first procedure. Twenty-seven patients were assessable at median follow-up periods of 42.7 and 20.4 months after the first and second procedures, respectively. Most patients had undergone multiple previous operations of other types (microvascular decompression, radiofrequency rhizotomy, glycerol rhizotomy, balloon compression). The median target doses of the first and second radiosurgeries were 75 and 64 Gy, respectively. All patients were evaluated by a physician who did not participate in patient treatment. RESULTS: After the first radiosurgical procedure, 13 patients had an excellent response initially (complete relief without any medication), 3 had a good response (complete relief with some medication), 7 had a fair response (>50% relief), and 4 had a poor response (<50% pain relief or treatment failure). Repeat radiosurgery was performed in patients with recurrent or residual pain. After the second radiosurgical procedure, 5 patients had an excellent response, 8 had a good response, 10 had a fair response, and 4 had a poor response. Thirteen patients (48%) achieved complete pain relief (with or without medication). Two patients (7.4%) experienced new sensory symptoms after the first radiosurgical procedure, and three (12.7%, actuarial) experienced new sensory symptoms after the second procedure. CONCLUSION: Repeat radiosurgery provided a similar rate of pain relief as the first procedure, despite a modest dose reduction. The risk of new sensory symptoms was increased, but no other morbidity was identified. For patients who experience recurrent pain and choose to undergo a second procedure, our current procedure is to deliver a maximum dose of 50 to 60 Gy to a trigeminal target anterior to the root entry zone near the entrance of the nerve beneath the petrous dura.     

Adult Hirschsprung's disease: results of the Duhamel procedure

Hirschsprung's disease is a rare condition in the adult. The case reports of 39 patients managed by the Duhamel procedure were reviewed. One-third of the patients underwent at least one abdominal surgical procedure before the correct diagnosis was made. The operative mortality of the Duhamel procedure was zero. In 29 patients no defunctioning procedure was used to protect the anastomosis. The incidence of anastomotic dehiscence was 13 per cent. Thirty-six of the thirty-nine patients have excellent functional results.     

Laparoscopic Ladd procedure: a minimally invasive approach to malrotation without midgut volvulus

The management of intestinal malrotation without midgut volvulus is controversial. Some advocate the Ladd procedure in all patients with malrotation, whereas others propose a more selective approach. We attempted the laparoscopic Ladd procedure on nine patients who were diagnosed with intestinal malrotation without volvulus. Patient records were retrospectively reviewed. Data were collected on patient presentation, operative procedure, hospital course, and outcome. The laparoscopic Ladd procedure was successfully completed in eight patients (aged 10 weeks to 25 years). One patient required conversion to an open procedure. Operative time averaged 111 minutes (range, 77-176 minutes). Hospital stay ranged from 3 to 5 days (average, 3.6 days). All patients were discharged home on a regular diet. There was one complication and no deaths. Eight patients had complete resolution of their symptoms. The laparoscopic Ladd procedure is a safe and effective procedure for infants, children, and adults who have intestinal malrotation without midgut volvulus. The operative times, hospital stay, and clinical outcomes were acceptable. We recommend that laparoscopic intervention be considered in patients with intestinal malrotation without volvulus. Intestinal malrotation occurs along a wide spectrum of anatomic variants and clinical presentations. The management of malrotation without midgut volvulus remains controversial. Most advocate performing the Ladd procedure on all patients found to have malrotation because there is no way to know which of these patients will develop catastrophic midgut volvulus. Some propose a more selective approach because of the morbidity associated with operative intervention. There have been a number of small series and case reports describing the use of laparoscopy to diagnose and correct malrotation. Proponents of this method point out its minimally invasiveness, patients' quick recoveries, and successful outcomes. We describe our experience with the laparoscopic Ladd procedure and its long-term results.     

Femoral head autograft in simultaneous primary and revision total hip arthroplasty

Bilateral total hip arthroplasty during one anesthetic procedure can be beneficial in properly selected patients. For patients who have a failed hip arthroplasty requiring revision and a contralateral arthritic hip requiring primary arthroplasty, bilateral surgery permits the resected femoral head from the primary procedure to be used as a fresh autogenous bone—graft during the revision procedure. Four patients underwent combined primary hip arthroplasty and contralateral revision hip arthroplasty during one anesthetic procedure. The femoral head obtained during the primary procedure was used as a structural acetabular bone—graft in three patients, and bone slurry was used to fill cavitary acetabular defects in one patient. A femoral neck autograft was used to reconstruct a calcar defect in one of the patients. After an average follow-up period of 27 months, all hips were functioning well with healed bone—grafts and stable prosthetic components.     

Stamey-Martius procedure for severe genuine stress incontinence.

There are few options now available to treat patients with severe genuine stress incontinence caused by urethral failure. These patients usually have a low maximum urethral closure pressure (less than 20 cm of water) and anterior vaginal wall scarring caused by previous surgery. In 32 such patients we used the Martius fat pad insertion procedure, in addition to the Stamey procedure, and achieved a 91% symptomatic success rate over a mean 13-month follow-up period. Because of its simplicity, reliability and low morbidity, we recommend this procedure in this difficult group of patients before performing a sling procedure or insertion of an artificial urinary sphincter.     

Operation of female stress incontinence--comparison between Raz procedure and Gittes procedure]

We performed Raz procedure and Gittes procedure for female stress incontinence since October 1986. Raz procedure was performed on 19 patients between October 1986 and February 1990, and Gittes procedure was performed on 18 patients between June 1990 and May 1991. We followed up 17 patients who underwent Raz procedure and all the patients who underwent Gittes procedure at the time August 1991. Disappearance or marked improvement of incontinence was confirmed in 12 patients by Raz procedure, and 16 patients by Gittes Procedure. No serious complications were recognized. The reason why the result of Raz procedure was not sufficient was due to our immature operative technique and incorrect patient selection in our early experience. From this experience, we believe that both procedures can be very useful and minimal invasive operation for female stress incontinence.     

Management of the bladder outlet in patients requiring enterocystoplasty.

We reviewed 30 patients who required augmentation enterocystoplasty and a procedure to modify the bladder outlet for the treatment of intractable incontinence. Of the 30 patients 16 were treated with simultaneous cystoplasty and an outlet procedure, 6 initially underwent an outlet procedure followed by cystoplasty and in 8 cystoplasty was performed first with a subsequent operation to modify the bladder outlet. Continence was achieved in 29 patients. The current methods for evaluation of the bladder and its outlet are reviewed, focusing on the predictive value of preoperative testing to determine which patients require cystoplasty and an outlet modifying procedure.     

Renal malignancies: Outcome of patients in stage 4 with or without embolization procedure

During four and one-half years a total of 44 patients with renal cell carcinoma in Stage 4 were admitted to our hospital. Of these, 18 patients were treated with an embolization procedure, 8 patients had nephrectomy without embolization, and another 18 patients received no active treatment. Except for the treatment there were no differences between these groups. The survival time was equal whether or not the patients underwent an angioinfarction procedure. We conclude that the embolization procedure has no beneficial effect in itself in these patients.     

Gasless video-assisted reversal of Hartmann's procedure

More than 60% of patients who are submitted to Hartmann's procedure refuse to undergo reversal. This procedure is in fact a major undertaking associated with significantly mortality and morbidity rates. The authors suggest a minimally invasive approach without pneumoperitoneum.A consecutive series of four male patients, average age 64 years, underwent laparoscopic assisted reversal of Hartmann's procedure in our department. The procedure was performed for intestinal malignant occlusion in two cases and for perforated diverticulitis in the other two. Mobilization was nearly immediate and incisional pain almost absent; peristalsis restarted after 36–48 h. Finally, the patients were discharged on day 6. Neither mortality nor morbidity occurred in the 8-month follow-up period. The authors conclude that this new laparoscopic procedure may lead to shorter hospital stays and increased acceptance by patients, while maintaining the same safety of the traditional open procedure.     

A new era in the surgical treatment of atrial fibrillation: the impact of ablation technology and lesion set on procedural efficacy

BACKGROUND/OBJECTIVE: While the Cox-Maze procedure remains the gold standard for the surgical treatment of atrial fibrillation (AF), the use of ablation technology has revolutionized the field. To simplify the procedure, our group has replaced most of the incisions with bipolar radiofrequency ablation lines. The purpose of this study was to examine results using bipolar radiofrequency in 130 patients undergoing a full Cox-Maze procedure, a limited Cox-Maze procedure, or pulmonary vein isolation alone. METHODS: A retrospective review was performed of patients who underwent a Cox-Maze procedure (n = 100), utilizing bipolar radiofrequency ablation, a limited Cox-Maze procedure (n = 7), or pulmonary vein isolation alone (n = 23). Follow-up was available on 129 of 130 patients (99%). RESULTS: Pulmonary vein isolation was confirmed by intraoperative pacing in all patients. Cross-clamp time in the lone Cox-Maze procedure patients was 44 +/- 21 minutes, and 104 +/- 42 minutes for the Cox-Maze procedure with a concomitant procedure, which was shortened considerably from our traditional cut-and-sew Cox-Maze procedure times (P < 0.05). There were 4 postoperative deaths in the Cox-Maze procedure group and 1 in the pulmonary vein isolation group. The mean follow-up was 13 +/- 10, 23 +/- 15, and 9 +/- 10 months for the Cox-Maze IV, the pulmonary vein isolation, and the limited Cox-Maze procedure groups, respectively. At last follow-up, freedom from AF was 90% (85 of 94), 86% (6 of 7), and 59% (10 of 17) in the in the Cox-Maze procedure group, limited Cox-Maze procedure group, and pulmonary vein isolation alone group, respectively. CONCLUSIONS: The use of bipolar radiofrequency ablation to replace Cox-Maze incisions was safe and effective at controlling AF. Pulmonary vein isolation alone was much less effective, and should be used cautiously in this population.