Causes and Costs of a Decade of Litigation Following Emergency Appendectomy in England

Background

There has been recent interest in the delayed and nonoperative management of appendicitis. The present study assessed the causes and costs of litigation against surgeons following emergency appendectomy, with an emphasis on claims relating to preoperative management.

Materials and methods

Data were obtained from the English NHS Litigation Authority for claims relevant to appendectomy between 2002 and 2011. Two authors independently extracted data and classified it against predetermined criteria.

Results

Successful litigation occurred in 66 % of closed cases (147/223) with a total payout of £8.1 million. There were 24 claims against organizational operating room delays (9 % of total) and 27 against delayed diagnosis (10 %), with respective success rates of 70 and 68 %. From 21 claims relating to damage to fertility, nine were due to either delayed diagnosis or organizational operating room delays. Misdiagnosis was the second most common cause for litigation (16 %), but it had the lowest likelihood of success (49 %). Faulty surgical technique was the most common reason for litigation (39 %), with a 70 % likelihood of success. Of eight claims related to fatality, one was due to unacceptable preoperative delay leading to preventable perforated appendicitis. The overall highest median payouts were for claims of damage to fertility (£52,384), operating list delays (£44,716), and delayed diagnosis (£42,292).

Conclusions

There were significant medicolegal risks surrounding delays related to access to operating lists and diagnosis. Whereas future evidence regarding the safety of delayed appendectomy may provide scientific defense against these claims, the present study provides evidence of the current medicolegal risk to surgeons following delayed treatment of appendicitis.     

Trends in joint arthroplasty litigation over five years: the British experience

INTRODUCTION

Increasing numbers of joint arthroplasty are performed in Britain. While associated complications are well documented, it is not known which of those initiate malpractice claims.

METHOD

A five-year period was assessed for trends to highlight areas for further improvement in patient information and surgical management.

RESULTS

The National Health Service paid out almost £14 million for 598 claims. Forty per cent of this was for legal costs. The number of claims increased over time while the rate of successful claims decreased.

CONCLUSIONS

A failure to consent adequately and to adhere to policies and standard practice can result in a successful malpractice claim. Protecting patients intrao-peratively and maintaining high technical expertise while implementing policies and obtaining informed consent decreases the litigation burden.     

Lawsuits against plastic surgeons: Does locale affect incidence of claims?

BACKGROUND:

Physicians continue to practice in a very litigious environment. Some physicians try to mitigate their exposure to lawsuits by avoiding geographical locations known for their high incidence of medical malpractice claims. Not only are certain areas of the United States known to have a higher incidence of litigation, but it is also assumed that certain areas of the hospital incur a greater liability. There seems to be a medicolegal dogma suggesting a higher percentage of malpractice claims coming from patients seen in the emergency room (ER), as well as higher settlements for ER claims.

OBJECTIVE:

To determine if there is any validity to the dogma that a higher percentage of malpractice claims arise from the ER.

METHODS:

An analysis of common plastic surgery consults that result in malpractice claims was performed. The location where the basis for the lawsuit arose – the ER, office (clinic) or the operating room (OR) – was evaluated. The value of the indemnity paid and whether its value increased or decreased based on the location of the misadventure was evaluated.

RESULTS:

According to the data, which represented 60% of American physicians, there was a larger absolute number of malpractice claims arising from the OR, not the ER. However, the highest average indemnity was paid for cases involving amputations when the misadventure originated in the ER.

CONCLUSIONS:

The dogma that a greater percentage of lawsuits come from incidents arising in the ER is not supported. However, depending on the patient’s injury and diagnosis, a lawsuit from the ER can be more costly than one from the OR.     

Written consent - a prospective audit of practices for ENT patients

INTRODUCTION

It is very important that patients are given sufficient time to consider the implications of surgical treatment.

PATIENTS AND METHODS

The authors audited the consenting practices for patients undergoing surgery in a busy ENT unit.

RESULTS

The first cycle demonstrated that 15% of patients were providing written consent for surgery on the same day as their operation. Subsequent to a simple change in departmental policy, this was reduced to 2%. The medicolegal implications of this audit are discussed with reference to current recommendations.

CONCLUSIONS

This simple policy change not only protects the hospital trust from potential litigation but also provides a smooth journey for the patients from diagnosis to making the decision to operate and finally to undergoing surgery.     

Cranial nerve injuries and the retrojugular approach in carotid endarterectomy

INTRODUCTION

This is a retrospective case series analysis to compare the incidence of cranial nerve injuries in carotid endarterectomy by the retrojugular and anteromedial approaches.

PATIENTS AND METHODS

Data were extracted from a prospectively collected database. Ninety-one retrojugular carotid endarterectomies were compared with 145 anteromedial carotid endarterectomies. All were performed under local anaesthesia and used the eversion technique. Data were analysed using the chi-squared test.

RESULTS

Nine (3.8%) cases were complicated by cranial nerve injuries. In four cases, multiple nerves were involved. In total, 13 (5.5%) cranial nerves were injured. The affected nerves were: two (0.8%) marginal mandibular, two (0.8%) laryngeal, three (1.2%) accessory and six (2.5%) hypoglossal. There was no statistically significant difference in total or specific cranial nerve injuries between the two surgical approaches.

CONCLUSIONS

The risk of cranial nerve injuries was similar following either the retrojugular or anteromedial approach. Accessory nerve injuries were only seen in the retrojugular approach but this did not reach statistical significance.     

What is the Utility Of a Limb Lengthening and Reconstruction Service in an Academic Department of Orthopaedic Surgery?

Background

Limb lengthening and reconstruction surgery is a relatively new subspecialty of orthopaedic surgery in the United States. Despite increased awareness and practice of the specialty, it is rarely vested as a separate clinical service in an academic department of orthopaedic surgery. We have had experience growing such a dedicated service within an academic department of orthopaedic surgery over the past 9 years.

Questions/purposes

We explored (1) the use of a limb deformity service (LDS) in an academic department of orthopaedic surgery by examining data on referral patterns, our clinical volume, and academic productivity; and (2) the surgical breadth of cases comprising the patients of the LDS in an academic department of orthopaedic surgery by examining data on caseload by anatomic sites, category, and surgical techniques/tools.

Methods

We (SRR, ATF, EWB) retrospectively examined data on numbers of surgical cases and outpatient visits from the limb lengthening and complex reconstruction service at the Hospital for Special Surgery from 2005 to 2013 to evaluate growth. We studied 672 consecutive surgical cases performed by our service for a sample period of 1 year, assessing referral patterns within and outside our medical center, anatomic region, surgical category, and surgical technique/tool. Academic productivity was measured by review of our service’s publications.

Results

During the time period studied (2005–2013), outpatient and surgical volume significantly increased by 120% (1530 to 3372) and 105% (346 to 708), respectively, on our LDS. Surgical volume growth was similar to the overall growth of the department of orthopaedic surgery. Referrals were primarily from orthopaedic surgeons (56%) and self/Internet research (25%). Physician referrals were predominantly from our own medical center (83%). Referrals from within our institution came from a variety of clinical services. Forty-nine peer-reviewed articles and 23 book chapters were published by staff members of our service. Anatomic surgical sites, surgical categories, and technique/tools used on our LDS were diverse, yet procedures were specialized to the discipline of limb deformity.

Conclusions

There is a substantial role for an LDS within an academic department of orthopaedic surgery. With establishment of a dedicated service comes focus and resources that establish an environment for growth in volume, intramural and extramural referral, and purposeful research and education. The majority of referrals were from orthopaedic surgeons from our own medical center, suggesting needfulness. The LDS provides patients access to specialized surgery. The number of intramural referrals suggests that the specialty service helps retain patients within our academic orthopaedic department. Future research will try to determine if such a dedicated service leads to improved outcomes, efficiency, and value.

Level of Evidence

Level IV, retrospective study.     

Litigation costs of wrong-site surgery and other non-technical errors in orthopaedic operating theatres

Introduction

This study reviews the litigation costs of avoidable errors in orthopaedic operating theatres (OOTs) in England and Wales from 1995 to 2010 using the National Health Service Litigation Authority Database.

Materials and methods

Litigation specifically against non-technical errors (NTEs) in OOTs and issues regarding obtaining adequate consent was identified and analysed for the year of incident, compensation fee, cost of legal defence, and likelihood of compensation.

Results

There were 550 claims relating to consent and NTEs in OOTs. Negligence was related to consent (n=126), wrong-site surgery (104), injuries in the OOT (54), foreign body left in situ (54), diathermy and skin-preparation burns (54), operator error (40), incorrect equipment (25), medication errors (15) and tourniquet injuries (10). Mean cost per claim was £40,322. Cumulative cost for all cases was £20 million. Wrong-site surgery was error that elicited the most successful litigation (89% of cases). Litigation relating to implantation of an incorrect prosthesis (eg right-sided prosthesis in a left knee) cost £2.9 million. Prevalence of litigation against NTEs has declined since 2007.

Conclusions

Improved patient-safety strategies such as the World Health Organization Surgical Checklist may be responsible for the recent reduction in prevalence of litigation for NTEs. However, addition of a specific feature in orthopaedic surgery, an ‘implant time-out’ could translate into a cost benefit for National Health Service hospital trusts and improve patient safety.     

Medicolegal claims following laparoscopic cholecystectomy in the UK and Ireland

INTRODUCTION

The causes and outcomes of medicolegal claims following laparoscopic cholecystectomy were evaluated.

SUBJECTS AND METHODS

A retrospective analysis of the experience of a consultant surgeon acting as an expert witness within the UK and Ireland (1990–2007).

RESULTS

A total of 151 claims were referred for an opinion. Sixty-three related to bile duct injuries and four followed major vascular injury. Bowel injury resulted in 17 claims. A postoperative biliary leak not associated with a bile duct injury was responsible for 25 claims. Other reasons for claims included spilled gallstones, port-site herniae, haemorrhage and other recognised complications associated with laparoscopic cholecystectomy. Twelve of the claims are on-going, two went to trial, 79 (52%) were settled out of court and 58 (38%) were discontinued after the claimants were advised that they were unlikely to win their case. Disclosed settlement amounts are reported.

CONCLUSIONS

Bile duct and major vascular injuries are almost indefensible. The delay in diagnosis and (mis)management of other recognised complications following laparoscopic cholecystectomy have also led to a significant number of successful medicolegal claims.     

A pioneer of urologic surgery from a small town in Ontario,Canada: A tribute to Abraham Groves (1847–1935)

Background:

Abraham Groves worked as a general practitioner and surgeon in the small town of Fergus, Ontario, Canada. Several priority claims have been attributed to Groves’ life in surgery, including aseptic surgery (1874), appendectomy (1883) and the use of surgical gloves (1885). He was also an early practitioner of urological surgery.

Objective:

The purpose of this paper is to describe and objectively assess his contributions as a pioneer in urological surgery.

Methods:

A systematic search of contemporary journals was made for articles by or about Groves. These articles and his 1934 autobiography were reviewed. The information was assessed not only for priority, but also for the development of organized surgical principles and thought.

Results:

Groves published frequently throughout his career; up to this point, 36 papers have been identified. Groves’ claims are verifiable for aseptic surgery, which were the result of logical surgical thought and was practiced throughout his career. Contemporary publications support his early use of suprapubic lithotomy (1875), prostatotomy (1887), bladder repair (1892), urethral repair (1903), renal decapsulation (1905) and prostatectomy (1911).

Conclusions:

Despite his isolation, Abraham Groves independently developed a full range of surgical techniques and principles relevant to modern-day urology. His impact was reduced by the nature of the environment in which he worked and by the limited circulation of the journals in which he chose to publish.     

A surgical review of the priority claims attributed to Abraham Groves (1847–1935)

Background

The practice of surgery had changed little over millennia when Abraham Groves and William Osler attended medical school together in Toronto, Ontario. The invention of anesthesia sparked such rapid development that by the time of Groves’ and Osler’s deaths, surgical practice resembled the current model. Several priority claims have been attributed to Groves’ life in surgery, including aseptic surgery (1874), suprapubic lithotomy (1878), appendectomy (1883), surgical gloves (1885) and cancer radiotherapy (1903). These claims arise from an autobiography written by Groves at the age of 87 years in 1934.

Methods

The purpose of this paper is to assess these priority claims from a modern surgical perspective. We did a systematic search of contemporary (1873–1934) and modern journals for articles by or about Groves. We searched relevant archives and museums. We reviewed the 1934 autobiography, notes held by descendants, reminiscences by contemporaries and collateral information. We assessed the information not only for priority but also for the development of organized surgical thought.

Results

Groves published frequently throughout his career; thus far we have located 36 papers, almost all of which were published in Canadian journals. He spoke regularly at regional meetings in Ontario. Many medical students apprenticed with him (including his brother, son and grandson), he established a hospital and he founded a school of nursing. His contemporaries published complimentary reminiscences, but no correspondence with his classmate, William Osler, is known. Groves’ priority claims for aseptic surgery, suprapubic lithotomy and radiotherapy are supported by contemporary publications. Groves independently developed an organized surgical system that remains valid today. Priority claims for appendectomy and the use of surgical gloves are entirely consistent with that system.

Conclusion

Although Groves’ impact was reduced by his location and the limited circulation of the journals in which he wrote, he demonstrated a systematic understanding of modern surgery well ahead of his contemporaries.     

A cross-specialty survey to assess the application of risk stratified surgery for differentiated thyroid cancer in the UK

Introduction

This study describes variability of treatment for differentiated thyroid cancer among thyroid surgeons, in the context of changing patterns of thyroid surgery in the UK.

Methods

Hospital Episodes Statistics on thyroid operations between 1997 and 2012 were obtained for England. A survey comprising six scenarios of varying ‘risk’ was developed. Patient/tumour information was provided, with five risk stratified or non-risk stratified treatment options. The survey was distributed to UK surgical associations. Respondent demographics were categorised and responses analysed by assigned risk stratified preference.

Results

From 1997 to 2012, the Hospital Episode Statistics data indicated there was a 55% increase in the annual number of thyroidectomies with a fivefold increase in otolaryngology procedures and a tripling of cancer operations. Of the surgical association members surveyed, 264 respondents reported a thyroid surgery practice. Management varied across and within the six scenarios, and was not related consistently to the level of risk. Associations were demonstrated between overall risk stratified preference and higher volume practice (>25 thyroidectomies per year) (p=0.011), fewer years of consultant practice (p=0.017) and multidisciplinary team participation (p=0.037). Logistic regression revealed fewer years of consultant practice (odds ratio [OR]: 0.96/year in practice, 95% confidence interval [CI]: 0.922–0.997, p=0.036) and caseload of >25/year (OR 1.92, 95% CI: 1.044–3.522, p=0.036) as independent predictors of risk stratified preference.

Conclusions

There is a substantial contribution to thyroid surgery in the UK by otolaryngology surgeons. Adjusting management according to established case-based risk stratification is not widely applied. Higher caseload was associated with a preference for management tailored to individual risk.     

Granulomatous Peritonitis After Laparoscopic Cholecystectomy

Background:

Granulomatous peritonitis may indicate a number of infectious, malignant, and idiopathic inflammatory conditions. It is a very rare postoperative complication, which is thought to reflect a delayed cell-mediated response to cornstarch from surgical glove powder in susceptible individuals. This mechanism, however, is much more likely to occur with open abdominal surgery when compared with the laparoscopic technique.

Methods:

We report a case of sterile granulomatous peritonitis in an 80-y-old female after a laparoscopic cholecystectomy. Management was conservative, and no relapse was observed after over 1-y of follow-up.

Discussion:

We propose that peritoneal exposure to bile acids during the laparoscopic removal of the gallbladder was the trigger of granulomatous peritonitis in this patient. Severe complications, such as peritoneal adhesions, intestinal obstruction, and fistula formation, were observed, but no fatalities were reported.

Conclusion:

We should be aware of this rare cause of peritonitis in the surgical setting.     

The incidence of spinal surgery in canada

Objective

To estimate the incidence of spinal surgery in 5 Canadian provinces over a 12-month period.

Design

Cumulative incidence study.

Setting

Five provinces (63% of Canada’s population).

Participants

All patients who underwent spinal surgery between July 1, 1992, and June 30, 1993, in British Columbia, Alberta, Ontario, New Brunswick and Newfoundland.

Main outcome measure

Overall spinal surgery rates per province and by age and sex.

Results

In the 5 provinces over the allotted 12-month period, 12 329 spinal surgical procedures were performed. The overall rate of spinal surgery for the 5 provinces was 80 per 100 000 population. Ontario had the lowest rate of 61 per 100 000; British Columbia had the highest at 89 per 100 000. Men aged 40 to 49 years in Newfoundland had the highest overall rate at 210 per 100 000. Calculation of relative risks determined that Newfoundland’s under-20 age groups for both sexes were almost 3 times as likely to undergo spinal surgery as the same age groups in Ontario (male relative risk = 2.73, female relative risk = 2.84). Males in British Columbia and Alberta had a statistically significant increased risk of surgery across all age groups except for those under 20 years old, and females in British Columbia showed a statistically significant increased risk of surgery across all age groups compared with those in Ontario. Males underwent 57.7% of all spine operations.

Conclusions

The incidence of spinal surgery is not uniform across Canada. Overall, the per capita rate is lower than in the United States. The explanation for this divergence remains unclear.     

Management of giant inferior triangle lumbar hernia (Petit's triangle hernia): A rare complication following delayed breast reconstruction with extended latissimus dorsi myocutaneous flap

INTRODUCTION

Lumbar triangle hernia after breast reconstruction with latissimus dorsi flap (LDMF) is a very rare complication and few cases were previously described. Muscle mobilization and iatrogenic fascia defect are related etiologic factors.

PRESENTATION OF CASE

The authors describe a rare case of lumbar hernia in a 58-year-old woman who underwent delayed left breast reconstruction with LDMF. Two months after surgery, a progressive symptomatic lower left lumbar bulge was observed. The CT scan confirmed the diagnosis and delineated an 18 cm lumbar defect filled with lower and large bowel. At operation, the defect was exposed and the hernia sac reduced. In order to obtain stability, the remained local muscle and fascia flaps were mobilized into the defect. Additional strength was achieved with a two-layer closure of prosthetic mesh (intra/extra peritoneal). The patient is currently in the 10th postoperative year of hernia repair and satisfactory lumbar wall contour was achieved. Neither the recurrence of lumbar hernia nor symptoms compliance was noted.

DISCUSSION

Lumbar hernia is an uncommon complication of LDMF harvest. Although it is a rare disease, general and plastic surgeons must be on alert to avoid complications and misdiagnosis. Seroma differential diagnosis is important in order to avoid bowel perforation due to aspiration. Defect reconstruction is necessary with a muscular and fascia flaps mobilization and synthetic mesh in order to obtain a stable repair.

CONCLUSION

The knowledge of this rare post-operative complication following delayed breast reconstruction is crucial to its surgical management. Early surgical intervention is warranted in order to avoid severe complications.     

QUALITY OF LIFE OF IN PATIENTS SUBMITTED TO ANTERIOR ABDOMINAL WALL LAPAROSCOPIC HERNIOPLASTY

Background

The laparoscopic ventral hernia repair technique made possible surgeries with smaller skin incisions and smaller dissection of the soft tissue around the hernia, therefore with a better wound, a quicker postoperative recovery and a lower complication rate.

Aim

To evaluate the applicability of a quality of life survey based on the molds of the American Hernia Society, European Hernia Society and Carolinas Equation for Quality of Life, through telephone in patients submitted to laparoscopic hernioplasty by IPOM technique.

Methods

A retrospective cohort study was made to evaluate the quality of life of 21 patients that underwent anterior abdominal wall laparoscopic hernioplasty by intraperitoneal onlay mesh technique. Questionnaire was applied through telephone.

Results

Of the 21 patients, 19% felt that the hernia recurred. Also 19% passed through another abdominal wall surgery, and among these, 75% was related to the previously hernia correction. Finally, 81% of patients did not undergo any other abdominal wall surgery.

Conclusion

It was possible to apply the quality of life questionnary by telephone on patients who underwent an anterior abdominal wall. The results, in its turn, were satisfactory and showed that patients, in general, were satisfied with the surgical procedure.     

Outcomes and complications of ulnar shortening osteotomy: an institutional review

Background

Ulnar impaction syndrome (UIS) is a common cause of ulnar wrist pain. Patients may be candidates for surgical intervention if nonoperative options are ineffective. At our institution, ulnar shortening osteotomy is the preferred procedure to manage this disorder. The purpose of this study was to present patient reported outcomes and complication rates of ulnar shortening osteotomy (USO) at mid-term follow-up.

Methods

A retrospective chart review of 72 patients (75 wrists) obtained from our institutional database was performed. At a mean 32 months postoperatively, telephone interviews (n = 53) were performed for all patients who were available for follow-up. The patient-rated wrist evaluation (PRWE), a validated outcome tool, was completed and complications were reviewed.

Results

Patient-rated outcomes were favorable; however, complications were frequent and included: delayed union (10/75, 13.3 %), nonunion (6/75, 8 %), and complex regional pain syndrome (5/75, 6.7 %). Ten patients (13.3 %) required revision surgery. Thirty-four patients (45.3 %) required hardware removal with 4/30 (11.4 %) of these patients experiencing refracture. Smokers (mean PRWE 67.1) and patients with workers’ compensation claims (mean PRWE 64.9) reported higher residual pain and disability than their counterparts (mean PRWE 28.0; 25.2).

Conclusions

General outcome measures were favorable. Smokers and patients with workers’ compensation claims experienced significantly poorer outcomes. However, the incidence of nonunion and delayed union was higher than most reports in the literature. Furthermore, we demonstrated a high refracture rate (11.4 %) following removal of hardware.     

Incidence of Port-Site Incisional Hernia After Single-Incision Laparoscopic Surgery

Background and Objectives:

Single-incision laparoscopic surgery is gaining popularity among minimally invasive surgeons and is now being applied to a broad number of surgical procedures. Although this technique uses only 1 port, the diameter of the incision is larger than in standard laparoscopic surgery. The long-term incidence of port-site hernias after single-incision laparoscopic surgery has yet to be determined.

Methods:

All patients who underwent a single-incision laparoscopic surgical procedure from May 2008 through May 2009 were included in the study. Single-incision laparoscopic surgical operations were performed either by a multiport technique or with a 3-trocar single-incision laparoscopic surgery port. The patients were seen at 30 to 36 months'' follow-up, at which time they were examined for any evidence of port-site incisional hernia. Patients found to have hernias on clinical examination underwent repairs with mesh.

Results:

A total of 211 patients met the criteria for inclusion in the study. The types of operations included were cholecystectomy, appendectomy, sleeve gastrectomy, gastric banding, Nissen fundoplication, colectomy, and gastrojejunostomy. We found a port-site hernia rate of 2.9% at 30 to 36 months'' follow-up.

Conclusion:

Port-site incisional hernia after single-incision laparoscopic surgical procedures remains a major setback for patients. The true incidence remains largely unknown because most patients are asymptomatic and therefore do not seek surgical aid.     

Fractures of the knee in children—what can go wrong? A case file study of closed claims in The Patient Compensation Association covering 16?years

Introduction

Intra-articular knee fractures in children are rare. The Patient Compensation Association (PCA) receives claims for financial compensation from patients who believe they have sustained damage from their treatment in the health care system. We used relevant cases of closed claims to identify causality and co-factors contributing to these apparent malpractices.

Materials and methods

A partial root core analysis was performed on closed claims from the PCA database concerning proximal tibial fractures in children aged ≤15 years.

Results

We identified 13 cases. The main complaint was missed diagnosis (6 cases)—fractures of the tibial eminence were the main culprit, with damage to the popliteal artery caused by a medial condyle fracture being the most serious. All cases were missed by junior doctors. Secondary complaints were problems with casting, dissatisfaction with correct treatment, and insufficient surgery or complications relating to surgery. Eight of the complaints were acknowledged, with six receiving financial compensation ranging from EUR 9,600 to EUR 70,000. Five out of the six cases of missed diagnosis were acknowledged.

Conclusions

This study indicates that recognizing the degree of injury to the knee in children, which should include an X-ray examination, is key to preventing missed diagnosis and delayed and potentially more difficult surgery with long-lasting sequelae for the child. The PCA database seems to be a useful way to highlight systematic problems in the Danish health care system and could potentially be an important means to improving patient safety and preventing treatment-related injuries.     

Management of open abdominal wounds with a dynamic fascial closure system

Background

In damage-control surgery, definitive abdominal closure may not be possible for several days or weeks after laparotomy until the patient has stabilized.

Methods

We present 23 patients treated with the Canica ABRA^® dynamic wound closure system that re-approximated open abdomens with silicone elastomers placed transfascially across the wound. This study aimed to assess the results of using this system and to identify risk factors for unsuccessful closure. The system maintains a medially directed force across the wound. A traditional regimen of wound dressing changes was performed.

Results

The dynamic closure system remained in place an average of 48 days and was applied an average of 18 days after the beginning of treatment for the open abdominal wound. Delayed primary fascial closure was achieved in 14 of 23 patients (61%) without further surgery. Six patients (26%) healed with ventral hernias but with a smaller abdominal defect. Two patients (9%) developed enterocutaneous fistulae through the wound that required further surgery. An overall reduction in wound area of 95% was achieved.

Conclusion

This dynamic wound closure technique permitted the delayed primary closure of open abdomens in 61% of cases when treatment was instituted an average of 18 days after initial laparotomy.     

Thoracic outlet syndrome: Fact or fancy? A review of 409 consecutive patients who underwent operation

Objectives

From an analysis of patients operated on by a single surgeon between 1973 and 1994 for thoracic outlet syndrome (TOS), to determine what findings are helpful in substantiating this diagnosis and what are the results of decompressive thoracic outlet surgery in the management of TOS.

Design

A chart review with emphasis on signs, symptoms and results. A preoperative questionnaire was presented to all patients operated on since 1989. Postoperative follow-up was by interview or telephone.

Setting

A 560-bed university-affiliated tertiary-care teaching hospital.

Patients

There were 409 adults; 83% were women and the average age was 36 years. In 95% of patients physiotherapy had been unsuccessful. Patients presented with neurologic type (368 [(90%]), arterial impingement (29 [7%]) and venous obstructive symptoms (12 [3%]). The series included 44 patients with bilateral symptoms and 26 patients with cervical ribs. Some form of litigation or compensation was associated with 177 patients.

Interventions

Transaxillary first rib resection in 380 (93%) patients and supraclavicular thoracic outlet decompression in 29 (7%). In 244 patients there was a follow-up of at least 2 years. These patients constituted the follow-up group.

Results

Preoperatively, in the 368 patients who had neurologic TOS, 99% displayed supraclavicular brachial plexus tenderness and 98% exacerbation of symptoms with arms in the abduction external rotated position. There were eight complications of surgical intervention (1.9%). In the follow-up group, there were no deaths, no subclavian/axillary artery or vein damage and no brachial plexus injury. Seventy-eight percent of the patients with neurologic TOS in this group improved postoperatively; 21% had complete relief, 32% had good relief and 25% had fair relief. Twenty-two percent showed no improvement.

Conclusions

Signs and symptoms helpful in making the diagnosis of neurologic TOS are supraclavicular tenderness on palpation and exacerbation of symptoms with the arms in the abducted external rotated position. The surgical procedures are safe. Patients with TOS refractory to medical management can benefit from thoracic outlet decompression.