Hide and seek: pre-operative ultrasonic localization of non radio-opaque foreign bodies

Ultrasound has long been used as a diagnostic and therapeutic tool in surgery. We have extended its use to hand surgery, where is has several applications. Non radio-opaque foreign body extraction is invariably a frustrating exercise of 'hide and seek'. Accurate pre-operative localization with ultrasound illustrating size, shape, depth, soft tissue and bony relationships can ensure rapid and complete removal. Several cases are presented to demonstrate the use of ultrasound for the detection of non radio-opaque foreign bodies. The technique used will be described. We feel pre-operative localization by ultrasound is a useful technique to assist with the removal of non radio-opaque foreign bodies.     

Mediastinoscopy and video-assisted thoracoscopic surgery: anesthetic pitfalls and complications

Endoscopic evaluation of the thoracic cavity was first described in 1910 when Jacobaeus used a cystoscope for pleural examination. Significant advances in thoracoscopic surgery, including the use of high-definition videoscopy and refinements in surgical technique, have created a vast array of increasingly complex procedures that can be performed. The minimally invasive nature of video-assisted thoracoscopic surgery (VATS) makes it ideal for diagnostic and therapeutic procedures in ambulatory and critically ill patients. Mediastinoscopy is often performed immediately preceding VATS to permit sampling of mediastinal lymph nodes. As the indications for thoracoscopic surgery expand, the anesthesiologist must be familiar with common anesthetic and surgical complications, which occur in up to 9% of patients.     

Laparoscopy in malignant disease.

The use of laparoscopy in patients with malignant disease is particularly helpful diagnostically and will often impact on future therapy. The indications and complications of this technique in combination with other diagnostic and therapeutic modalities in patients with malignant disease are evaluated and the accuracy of results are compared to laparotomy procedures. Future trends in laparoscopic surgery also are discussed.     

Intraoperative ultrasonography imaging in spinal surgery (technique and indications).

Intraoperative ultrasonography was conducted in 20 patients; the technique of intraoperative ultrasonography for use in spinal surgery is described. The authors emphasize that this non-invasive method obtains real time images of considerable diagnostic importance, allowing for a significantly minor use of image intensifier, with a consequent reduction in doses for both the patient and the staff.     

One-port (uniportal) video-assisted thoracic surgical resections-A clear advance

One-port (uniportal) video-assisted thoracic surgery (VATS) consists of approaching an intrathoracic target lesion through a sagittal, craniocaudal plane through 1 single-port incision. The use of articulating instruments inserted parallel to the videothoracoscope enables the surgeon to mimic inside the chest the maneuvers that are usually performed during open surgery. Through this VATS approach, several thoracic conditions can be addressed, including lung cancer in selected patients. Unlike conventional, 3-port VATS, the uniportal VATS technique enables the surgeon to bring the operative fulcrum inside the chest when the target lunge lesion is approached through a sagittal plan, thanks to articulating instruments. Uniportal wedge VATS resections of peripheral nodules can help in solving diagnostic dilemmas, be of therapeutic benefit, and provide tissue for biomolecular studies.     

Renal hemorrhage in polyarteritis nodosa: Diagnosis and management

We report a patient with biopsy-proven polyarteritis nodosa with massive hemorrhage from presumed interlobar artery rupture. The use of interventional radiology techniques such as embolization are discussed in the acute management of such patients. Embolization by interventional radiology should be considered a useful alternative to surgery in these patients. The utility of angiography as a diagnostic and therapeutic tool is demonstrated in this case.     

New cell-based technologies in bone and cartilage tissue engineering. II. Cartilage regeneration

A tissue engineering, cell-based therapeutic approach could be essential for extensive bone or cartilage reconstruction. This article is divided in two chapters and describes new cell-based surgical techniques for cartilage and bone reconstruction. The second part of the article, regarding cartilage repair, describes a new arthroscopic surgical technique for tissue engineered cartilage grafting. A 3-dimensional hyaluronic acid support is used for autologous chondrocyte culturing. The technique reduces morbidity of classic autologous implant avoiding open surgery and periosteal flap use. With this technique is possible to reduce the patient morbidity, time and cost of surgery.     

Intestinal perforation and vascular rupture in Ehlers-Danlos syndrome

Ehlers-Danlos syndrome is a rare genetically determined disorder of connective tissue. Such patients often present challenges in clinical diagnosis and management. Dramatic life-threatening presentations include gastrointestinal perforation and vascular rupture, both occurring in the patient described. This case illustrates diagnostic features and therapeutic maneuvers important in the management of such complications of this disorder.     

Epiduroscopy

Epiduroscopy is a minimally invasive diagnostic and therapeutic technique used in patients with chronic low back pain with or without radiculopathy. Epiduroscopic procedures are particularly indicated in cases of failed spinal surgery. This review discusses the indications, contraindications, and complications of the technique, describing in detail the sacral (caudal) and interlaminar approaches and noting their advantages and disadvantages. Practical recommendations are made, along with an attempt to assess future prospects for epiduroscopy.     

LAPAROSCOPIC REMOVAL OF INFLAMED OR BULKY TISSUE: PRESERVATION OF THE PNEUMOPERITONEUM

A technique is described for extraction of bulky tissue during laparoscopic surgery using a dedicated non-disposable instrument specifically designed for the purpose. The technique was used on seven patients with acute cholecystitis, three patients with big gallstones in elective cholecystectomy and two patients with acute appendicitis. The procedure took about 1 min in all patients. No patient suffered from complications related to the procedure.     

Antibodies to neutrophil cytoplasmic antigens in Wegener''s granulomatosis and other conditions.

The use of serum antibodies to neutrophil cytoplasmic antigens (ANCA) as a diagnostic marker for Wegener's granulomatosis and other forms of vasculitis has been assessed. Although ANCA have been described by several groups the precise antigenic targets are unknown, and detection of ANCA still relies on an indirect immunofluorescence assay technique. Several different patterns of fluorescence have been produced by using sera from different groups of patients, and insufficient information is available on the frequency of positive results and of the patterns of immunofluorescence obtained when serum from patients with vasculitis as a part of a generalised connective tissue disease is used. A study was carried out on serum from 240 patients, including 23 patients with Wegener's granulomatosis, 12 with microscopic polyarteritis, and 30 with various connective tissue diseases. Three patterns of fluorescence were observed: bright coarsely granular cytoplasmic, bright non-granular cytoplasmic, and weak diffuse cytoplasmic. The bright, coarsely granular pattern was 86% specific for Wegener's granulomatosis in this series and was observed in 18 of 23 cases. Other patterns of fluorescence were found in various conditions and were not of diagnostic value. The technique is simple, inexpensive, rapid, and reproducible.     

A retrospective study to assess the results of CT-directed peri-neural root infiltration in a cohort of 56 patients with low back pain and sciatica

Fifty-six patients with low back pain and sciatica following radiological investigation were found to have abnormalities at multiple levels, more than one of which could be responsible for the clinical picture or at a single level, which correlated poorly with the clinical findings. Thirty-four patients had a diagnostic peri-neural root infiltration to clarify whether surgery would be appropriate. Evaluation of the technique was by reduction in analgesia. Eighteen patients have had surgery, 14 with a successful, two a moderate and two a poor outcome. Four patients have been denied and two are awaiting an operation. Ten patients referred for a diagnostic procedure deferred surgery in favour of a therapeutic course. Of 22 patients referred directly for a therapeutic course, 15 had a successful, three a moderate and four a poor result. CT-directed peri-radicular root infiltration is a useful adjunct in the management of low back pain and sciatica.     

Latissimus dorsi free flap for restoration of facial contour defects

The treatment of facial asymmetries presents an aesthetic component of great importance. To correct facial contour defects, there are many therapeutic possibilities available, such as autologous tissue grafts and inorganic implants. The arrival of microsurgical techniques has improved the outlook for facial contour restoration. Among the tissues used are groin, escapular, and omentum flaps. This article introduces our experience with the latissimus dorsi free flap for the restoration of facial contour defects. Our experience is based on 7 patients affected with hemifacial microsomia and Romberg's disease. Operative planning, surgical procedure, and results are described. The use of the latissimus dorsi free flap is our procedure of choice for its greater adaptability in conforming to the shape of the defect, its long vascular pedicle, the abundance of available tissue, and minimal tendency to ptotic changes. At present we recommend this technique for replacement of soft tissue in severe defects of the face.     

Natural Orifice Translumenal Endoscopic Surgery (NOTES) Transvaginal Cholecystectomy in a Morbidly Obese Patient

Transvaginal natural orifice translumenal endoscopic surgery (NOTES) is a new diagnostic and potentially therapeutic method of surgical endoscopy. The first case of NOTES transvaginal cholecystectomy in a morbid obese patient in the literature is described. IRB approval was obtained at the institution for transvaginal NOTES clinical trials. A 58-year-old female patient with cholelithiasis, hypertension, and type II diabetes, and BMI of 35.8 kg/m(2) was submitted to the technique. After transvaginal access, a two-channel gastroscope was introduced into the abdominal cavity along with a laparoscopic trocar. There were 2 umbilical punctures for use of 3 mm laparoscopic equipment. Operative time was 85 min. There was no use of postoperative analgesia, and the patient was discharged on the third postoperative day. Transvaginal NOTES is a feasible alternative method for cholecystectomy in the morbidly obese, although available technology is limited for natural orifice surgery.     

Frequency of use of diagnostic and manual therapeutic procedures of the spine taught at the Canadian Memorial Chiropractic College: A preliminary survey of Ontario chiropractors. Part 1 – practice characteristics and demographic profiles

Background:

Students learn a plethora of physical examination and manual therapy procedures over the course of their chiropractic education. However, it is uncertain to what extent they continue to use these procedures in practice after graduation.

Objective:

The purpose of this study was to determine which diagnostic and therapeutic procedures of the spine are most commonly utilized by chiropractors practicing in Ontario. In Part 1 of this study (presented here), the demographics and practice patterns of the respondents are presented. Part 2 of this study will present the results of the utilization rates of diagnostic and therapeutic procedures used by respondents.

Methods:

The study consisted of a paper-based survey that was sent to 500 pseudo-randomly selected Ontario chiropractors who responded confidentially. Survey questions inquired into demographic and practice style characteristics.

Results:

There were 108 respondents to the survey, giving a response rate of 22.4%. Many chiropractors self-identified themselves with more than one practice style characteristic such as 72.4% of the self-described pain-based chiropractors who also described themselves as evidence-based, compared with 51.9% of subluxation-based chiropractors who also described themselves as evidence-based. Diversified technique was the most commonly employed technique used by 90.7% of respondents, followed by trigger point therapy indicated by 57.4% of respondents.

Conclusions:

Despite a low response rate, respondents reported practice characteristics in this study that were similar to practice characteristics previously published, particularly in terms of professional demographics and techniques employed. While Diversified was the most commonly used technique, respondents reported higher levels of use of proprietary soft tissue techniques systems and upper cervical techniques than have been previously reported.     

The value of ultrasonic B-mode scanning in the diagnosis of persistent jaundice

The use of ultrasonic B-mode scanning of the liver and biliary tract in patients with persistent jaundice is described. Sixty-seven consecutive jaundiced patients have been scanned. A correct diagnosis was obtained in 66 per cent, useful information in 26 per cent and in only 8 per cent was the information misleading or of no diagnostic value. In our opinion this simple and non-invasive technique is of great value in the definite diagnosis of persistent jaundice and should allow earlier surgery in the obstructive cases.     

Transcerebellar biopsy in the posterior fossa: 12 years experience

Utilizing the Leksell stereotactic system, the transcerebellar approach was used for posterior fossa biopsies. During a period of 12 years, a total of 29 patients were operated on by this technique, among them 12 children. In the adult, the procedure was carried out with the patient awake and sitting upright; the pediatric patients required general anesthesia and the head was supported either manually or by a clamp. Representative specimens were obtained in all cases but one, showing a wide diagnostic spectrum. As a rule, the procedures were performed smoothly, with no serious side effects. Stereotactic biopsies in the posterior fossa, hitherto seldom performed, open new diagnostic perspectives, one of which is for use in obscure brain stem lesions. The transcerebellar approach has been proven to be easy, direct, and safe provided an appropriate technique is used, such as that described in the present paper.     

Ureteroscopic approach to upper-tract urothelial tumors

Transitional-cell carcinoma (TCC) of the upper urinary tract has traditionally been managed by nephroureterectomy, whereas nephron-sparing surgery has been reserved for those few patients with solitary kidneys or bilateral lesions. However, with the introduction of improved diagnostic and therapeutic technology, including smaller ureteroscopes and working instruments, and the concomitant ease of surveillance, ureteroscopic treatment of upper-tract urothelial tumors has become a reasonable alternative to open operative intervention in patients requiring conservative management. Furthermore, as preoperative grading and staging have improved, ureteroscopic treatment of upper-tract urothelial tumors is assuming an increasingly important role in the management of some patients who might have otherwise been treated with a nephroureterectomy. The technique of ureteroscopic resection is described in detail.     

Parathyroid gland radionuclide scanning--methods and indications

The usefulness of preoperative radionuclide scanning of the parathyroid glands in patients with primary or secondary hyperparathyroidism was long controversial because available techniques were of limited diagnostic efficacy. Technetium-99m-labeled sestamibi (99Tc-sestamibi) is a new radiopharmaceutical agent easily detected by gamma cameras. The first parathyroid imaging studies done with 99Tc-sestamibi about 10 years ago used a double-phase technique to separate thyroid and parathyroid tissue. Although promising, this method was less than ideal, particularly in multiple gland primary hyperparathyroidism and in secondary hyperparathyroidism. For several years, we have been using subtraction between two images acquired simultaneously, one with 99Tc-sestamibi, which binds to thyroid and parathyroid tissue, and the other with 123-iodine, which binds only to thyroid tissue. The remarkable efficacy of this technique in both primary and secondary hyperparathyroidism invites a reappraisal of the place of radionuclide imaging as a preoperative localization procedure done to reduce the need for repeat surgery. The usefulness of this technique in selecting candidates for unilateral surgery among patients with primary hyperparathyroidism is discussed.     

Breast Reduction with Inferior Pedicle Fascial Suspension

The ultimate aim of breast reduction surgery is to reduce breast tissue with long-term maintenance of good breast shape. A technique using interwoven fascial flap suspension of the inferior pedicle through the pectoralis muscle and fascia is described. For this study, 25 patients were followed for 1 year after surgery. The vertical length of the breast between the lower midline of the areola and the new inframammary fold was measured 10 days after surgery and compared with a follow-up measurement 1 year later. These measurements were expressed as a ratio and compared with visual impressions. A ratio of more than 1.3 or a 2-cm difference in length or more was considered representative of breast “bottoming out.” This was the case with two patients, both of whom had put on substantial weight after the procedure. The author contends that a consistently reliable technique that maintains good breast shape with more extensive scarring is preferable to a technique that occasionally “gets it right” with less scarring. Good scar management and variations in technique such as the fascial flap suspension described in this report have been of considerable benefit to the author’s patients undergoing breast reduction surgery.