Results of treatment of injuries to the spleen in children at the remote postoperative period

Long-term results of treatment were studied in 56 children. Splenectomy was fulfilled in 17 of them, splenectomy with autolientransplantation--in 39 children. The results have shown that the greatest number of complications was noted in the group of patients after splenectomy (48), after autolientransplantation there were 13 cases. The complications were mostly associated with the lowered immune resistance of organism.     

Antithrombotic therapy in operations on extracranial arteries

Application of Clopidogrel in the postoperative period in patients after surgery on extracranial arteries was analyzed. The preparation was used in 56 patients. Uninterrupted intake of the drug took place during 5 to 12 months, 7+/-1.6 months on average. Stomach and duodenal ulcer was diagnosed in 11 patients (20%), 3 patients (5%) had chronic pancreatitis with periodical exacerbations and 2 patients (4%) had erythrocytemia. One bleeding requiring revision of the wound took place in the nearest postoperative period. During the whole period of observation there were no thrombotic or thromboembolic complication against the background of using plavix. In none of the patients granulocytopenia was revealed with continuous intake of plavix. An ultrasonic investigation of the operated arteries in the remote postoperative period failed to reveal hemodynamically significant restenoses of carotid arteries.     

The hemostasis system indices after operations of spleen trauma

The authors have studied changes of the hemostasis system in 85 patients operated on the traumatized spleen, followed up from 1 through 15 years after operation. It was established that organ-saving operations and autolientransplantation fail to result in substantial changes in indices of the hemostasis system, while after spleenectomy there were pronounced shifts.     

Immune status late after surgery for spleen injuries

Immune status was studied in patients who had undergone surgery for spleen injuries (splenectomy, autolientransplantation and organ-saving surgeries). It is demonstrated that splenectomy leads to immunosuppression in long-term postoperative period. For prevention of these complications the organ-saving surgeries or autolientransplantation in addition to splenectomy are recommended.     

The course of the nearest postoperative period in patients with injuries of the spleen

The authors have analyzed the course of the postoperative period in 410 patients operated on for isolated, combined and multiple traumas with injuries of the spleen. The character of the operation (splenectomy, splenectomy with autolientransplantation, organ preserving operations) had no significant influence on frequency of complications or lethality.     

Resection of the left atrium in lung cancer

An analysis of results of surgical treatment of 28 patients with lung cancer who underwent resection of the left atrium has shown that squamous cell cancer was diagnosed in 18 patients (64%), adenocarcinoma--in 5 (18%), dimorphous cancer--in 2 (7%), mucoepidermoid cancer in 2 (7%), atypical carcinoid--in 1 patient (4%). The degree of regional lymphogenic spread of the tumor NO took place in 11 patients (39%), N1--in 6 patients (22%), N2--in 11(39%). True invasion of the tumor to the left atrium myocardium took place in 20 patients (71%), involvement of the pulmonary vein orifices in the tumor process--in 8 (29%). Resection of the atrium was made using mechanical suturing apparatuses. The right side resections were fulfilled in 16 patients (57%), left side resections in 12 patients (43%). Pneumonectomy was fulfilled in 26 patients (93%), lobectomy--in 2 patients (7%). The operative interventions in five cases (18%) were estimated as microscopically non-radical (R1). The average time in the intensive care unit after operation was 3 days (from 1 till 12), in the surgical thoracal department--18 days (from 13 till 37). In the early postoperative period one patient died (4%), complications were noted in 5 patients (18%). The total one year survival was 69%, three year survival--39%, 5 year survival--17%. The survival median was 23 months. Resection of the left atrium in the selected lung cancer patients was not followed by growing operative lethality and the acceptable long term results were obtained.     

The physiological aspects of the efficacy of reconstructive operations in arteriosclerosis obliterans of the lower extremities]

Reconstructive operations in the aorto-iliac and femoro-popliteal segments were performed on 281 patients with obliterating atherosclerosis. An attentive examination of the patients in the nearest postoperative period and within the first 5 years has shown different efficiency of the operation in different patients. Favorable changes took place in regional hemodynamics, while disturbances retained in microcirculation and function of the extremity. Another cause of insufficient efficiency of the interventions was an initial stable suppression of tissue respiration and oxygen utilization in the extremity tissues. The dynamics was positive during a year followed after that by new symptoms of progressing disease.     

Traumatic aneurysms of the thoracic aorta

Under observation were 12 patients with traumatic aneurysms of the descending thoracic aorta, 11 of them were operated on. Diagnostic thoracotomy had been performed in the past in 4 patients. In 50% of the patients the course of the disease was asymptomatic. Resection of the aneurysm with alloplastic prosthesis under conditions of superficial hypothermia was performed in all of the patients. The average time of compression of the aorta for the period of reconstruction of the aneurysm was 40.1 min. One lethal outcome took place. There were no paraplegia, no complications of the operative and postoperative period.     

Esophageal replacement with colon interposition in children.

During a 21-year period, 39 colon interposition operations were performed on 37 children at the UCLA Medical Center and the Childrens Hospital of Los Angeles. The average age at the time of operation was 5.8 years. The indications for operation were esophageal atresia in 23 patients and other benign strictures in 14 patients. The duration of patient follow-up ranged from 6 months to 21 years (mean: 9.7 years). The most common complications were esophagocolonic anastomotic leak (12), esophagocolonic anastomotic stricture (14), pneumonia, and pneumothorax. Fourteen of the 25 patients with retrosternal colon interposition had complications (56%), whereas 10 of 14 patients with left thoracic colon interposition had complications (71%). One patient died (mortality: 3%) after left thoracic interposition because of severe respiratory distress associated with other malformations. Each of the 18 patients with isoperistaltic colon interposition showed rapid transit and emptying, provided that obstruction or extensive dilatation did not occur; reverse colon segments were more dilated and emptied more slowly. The 25 patients with retrosternal colon segments had less colonic distension with better emptying than did the 14 patients with left thoracic interposition. Thirty-two of the 36 children increased their weight percentile after colon interposition. Within 2 years after cervical anastomotic stricture or leak, 78% of these children were asymptomatic and gaining weight. Thirty-one of the 37 patients (84%) had excellent results with colon interposition, with a mean follow-up of 9.7 years. Most of the major postoperative complications occurred within the first few weeks and were corrected during the first few months after operation. Preservation of the esophagus should be the surgeon's first priority; however, prolonged attempts to elongate the esophagus for anastomosis in certain patients with long-gap esophageal atresia have been more hazardous in our experience than has colon interposition.     

Prevention of hypergranulation tissue after gastrostomy tube placement: A randomised controlled trial of hydrocolloid dressings

Hypergranulation tissue formation is a common complication after gastrostomy tube (G‐tube) placement, occurring in 44%–68% of children. Hydrocolloid dressings are often used in the treatment of hypergranulation tissue but have not been studied for the prevention of postoperative hypergranulation tissue. An institutional review board (IRB)‐approved, prospective, randomised study was performed in paediatric patients who underwent G‐tube placement at a single, large children's hospital from January 2011 to November 2016. After placement, patients were randomly assigned to (1) standard postoperative G‐tube care, (2) standard hydrocolloid G‐tube dressing, or (3) silver‐impregnated hydrocolloid G‐tube dressing, and the incidences of postoperative hypergranulation tissue formation, tube dislodgement, infection, and emergency department use were compared. A total of 171 patients were enrolled; 128 patients (75%) had at least 4 months of follow up and were included in the analyses. Eighty‐nine patients (69.5%) developed hypergranulation tissue during the postoperative period, with no significant differences in incidence among the three treatment arms. Of those who developed hypergranulation tissue, 46 (56%) visited the emergency department, compared with 6 of the 39 patients (19%) who did not develop hypergranulation tissue. Hydrocolloid dressings (standard or silver‐impregnated) do not prevent the development of hypergranulation tissue or other complications after G‐tube placement in paediatric patients.     

Repeated operations after reconstructive interventions on the aortofemoral segment]

At the department of vascular surgery of the Novgorod regional hospital 455 reconstructive operations for atherosclerotic occlusions in the aorto-femoral segment were performed at the period from 1984 to 1991. Specific complications requiring reconstructive reoperations took place in 92 patients (20.2%), 21 patients (4.6%) having earlier specific complications and 71 patients (15.6%)--late ones. Causes of the appearance of the specific complications are analyzed, the methods of treatment of such patients are recommended. Lethality after reoperations for late complications made up 9.8%, amputation of the extremity was performed in 14.1% of the patients. The positive result of the reoperations with a regress of ischemia and the preserved function of the extremity was noted in 76.1% of the patients.     

Gangrenous appendicitis in children: a prospective evaluation of definition, bacteriology, histopathology, and outcomes

IntroductionThe definition and treatment of gangrenous appendicitis are not agreed upon. We performed a prospective study in children to evaluate an objective definition of gangrenous appendicitis, as well as associated bacteriology, histopathology, and outcomes.MethodsFive staff pediatric surgeons prospectively enrolled patients in the study at the time of appendectomy if the following five criteria were met: gray or black discoloration of the appendiceal wall; absence of fecalith outside the appendix; absence of visible hole in the appendix; absence of gross purulence or fibrinous exudate remote from the appendix; and absence of intraoperative appendiceal leak. Peritoneal fluid was cultured, and a standard histopathologic review was undertaken. Persistence of fever (>37.5°C) and ileus was documented daily. Patients were continued postoperatively on ampicillin, gentamicin, and metronidazole until they tolerated diet, manifested a 24-h afebrile period, and had a normal leukocyte count. Hospital stay, readmissions, and infectious complications were recorded. The study took place over a 12-mo period.ResultsThirty-eight patients were enrolled, representing 17% of all patients with appendicitis treated during the year. Average age was 10.8 ± 3.5 y. Peritoneal cultures were positive in 53% of cases. Gangrene was documented histologically in 61% of specimens. Hospital stay was 3.2 ± 1.1 d. There were no postoperative infectious complications or readmissions related to the disease. Neither culture results nor histologic gangrene had a statistically significant effect on hospital stay.ConclusionsAn objective definition of gangrenous appendicitis is reproducible and has good histopathologic association. Recovery from gangrenous appendicitis is not influenced by culture or pathology results, and postoperative complications are rare. Limiting postoperative antibiotics to 24 h in gangrenous appendicitis may significantly decrease the cost of treatment without increasing morbidity.     

Urologic complications in 1523 renal transplantations: The Baskent University experience

Urologic complications, observed since the beginning of renal transplantation, cause significant morbidity and mortality. In the first few years the procedure was performed, incidence of urologic complications was reported to be 10% to 25%. Recently, the incidence of urologic complications after renal transplantation has decreased to 2.5% to 12.5%; unfortunately, a higher incidence exists in pediatric recipients, reaching approximately 20% with an associated 58% and 74% graft survival rates for cadaveric and living-related transplantation, respectively. We retrospectively analyzed the postoperative urologic complications reported in the medical charts of 1523 consecutive kidney transplantations (1130 men, 74.2%; 393 women, 25.8%; mean age, 31.9 +/- 10.9 years; range, 7 to 64 years; 354 cadaveric, 23.2%; 1169 living, 76.8%) performed by our team since 1975. The first 321 procedures took place at Hacettepe University Hospital in Ankara, Turkey, and the remaining 1202 were performed at Baskent University Hospital in Ankara. Urologic complications occurred in 46 (3%) recipients. Twenty-three (1.5%) of these patients had urine leakage, 15 (1%) had urinary obstruction due to ureteral stricture, 6 (0.4%) had distal ureter necrosis, and 2 (0.1%) developed renal calculi in the late postoperative period. Twenty-four out of 46 required reoperation for urologic complications. The remaining 22 patients were treated conservatively in our interventional radiology department with excellent results. In conclusion, urologic complications will always occur in the posttransplant period. Early diagnosis by experienced personnel and use of interventional radiology can greatly reduce the need for surgical treatment.     

Hyperglycemic syndrome at the early postoperative period

An analysis of treatment of 141 patients with hyperglycemic syndrome at the early postoperative period was made, which was 1.3% of all the patients operated on during this period. Inflammatory postoperative complications took place in 30 (21.3%) patients in the group of patients with hyperglycemic syndrome. It suggests that hyperglycemia at the early postoperative period should be considered not simply as criterion of a severe state, but also as a factor having a direct influence on the course of the pathological process. So, these patients should be given sugar-decreasing therapy with monitoring of the glucose level.     

Analysis of risk factors following pediatric liver transplantation

Abstract Several recipient, donor and operation factors as well as postoperative complications related to patient survival after liver transplantation (LT) in children were studied by univariate and multivariate analyses. In a 13‐year period, 103 patients under 15 years of age underwent 120 LT; the mean age was 63 months and 36% were under 2 years of age. Indications for LT were cholestatic disease in 68 (56%), metabolic diseases in 18 (14%), fulminant hepatic failure in 8 (7.5%), cirrhosis in 7 (5.8%), and retransplants in 17 (14%). Whole liver was transplanted in 79% of cases and partial liver in 21 %. Actuarial survival at 1, 5, and 10 years was 70 %, 61 %, and 57 %, respectively. United Network of Organ Sharing (UNOS) I recipients (RR = 2.7), primary non‐function (PNF) (RR = 13.9), and hepatic artery thombosis (HAT) (RR = 3.8) were independent factors for lower patient survival in multivariate analysis. Thus, in our experience, postoperative mortality as a consequence of the patient's condition before transplantation, or complications such as PNF or HAT, are the major causes of decreased survival in pediatric LT.     

In situ split liver transplantation for adult and pediatric recipients: an answer to organ shortage

BACKGROUND: We report our initial experience with in situ split liver transplantation (SLT) for adult and pediatric patients. PATIENTS AND METHODS: From June 2003 to August 2005, 177 liver transplantations in 165 patients, 133 adults (81%) and 32 children (19%), were performed at our institution. Over this period, 45 liver transplantations (25%) were performed with an in situ split liver technique in 44 patients: 17 (39%) were adults and 27 (61%) children. All of the adult split liver recipients were transplanted with an extended right graft (ERG; segments I + IV-VIII), while pediatric recipients received in 23 cases a left lateral segment (LLS; segments II-III) and in 4 cases an ERG from a pediatric donor. The 45 split liver grafts (21 ERGs and 24 LLSs) were generated from 35 donors. In 10 cases we used both grafts generated with an in situ split procedure to transplant our patients, while in 25 cases the procurement procedure was performed in collaboration with other transplant centers. RESULTS: After a median follow-up of 9 months (range, 1-27 months), the overall patient survival rate was 88% for adult patients and 82% for pediatric patients. Graft survivals were 88% and 79%, respectively. Two adult patients (12%) died from sepsis in the early postoperative period. Five children (18%) died after their transplantations. Only one pediatric recipient (2%) of primary SLT underwent retransplantation. Vascular complications were absent in adult recipients, whereas 4 arterial (14%) and 4 venous (14%) complications developed in the pediatric population. The incidence of biliary complications was 23% in adult and 18% in pediatric recipients. CONCLUSIONS: The use of in situ SLT for adult and pediatric populations allowed us to expand the cadaveric donor pool, significantly eliminating pediatric waiting list mortality without penalizing the adult population.     

Nissen fundoplication in children with profound neurologic disability. High risks and unmet goals.

Anti-reflux procedures have been advocated in children with profound neurologic disability referred for feeding gastrostomy when gastroesophageal reflux is present. Facilitation of care, reduction in pneumonia and vomiting, and improvement in the general health and survival of these children have been major goals of fundoplication and gastrostomy. In large pediatric series, these procedures have been reported to have low risk and negligible mortality rates. Recent reports, however, document an increased incidence of sequelae of fundoplication in children with profound neurologic disability. This paper retrospectively reviews a series of 35 nonverbal, nonambulatory pediatric patients undergoing a total of 39 fundoplications (37 Nissen, 1 Thal, and 1 Belsey) over an 11-year period. Neurologic impairment of 17 (49%) patients was acquired, 13 (37%) congenital, and 5 (14%) due to a syndrome. Perioperative complications occurred in six (17%). Three additional complications led to early postoperative death. A fourth early death was unexplained. Fourteen (40%) had recurrent pneumonia, 11 (31%) recurrent vomiting, 8 (23%) choking-gagging-retching complex, and 3 (9%) bowel obstruction requiring laparotomy. Recurrent gastroesophageal reflux was documented in seven (20%) patients. A second ARP was performed in six (17%). There were 14 (40%) late deaths. Although the major goals of anti-reflux procedure are clearly achieved in many severely impaired children with gastroesophageal reflux, the use of Nissen fundoplication to resolve the complications of swallowing disorders and improve outcome with an acceptably low risk in this complex set of patients does not appear to be established.     

Safety of ketorolac in the pediatric population after ureteroneocystostomy

PURPOSE: Ketorolac has been used to provide effective postoperative analgesia in children and decreases hospitalization for pediatric patients undergoing ureteroneocystostomy. However, it can cause severe side effects, including increased bleeding and renal insufficiency, which can be devastating in a child. Little has been reported on the safety of ketorolac by evaluating creatinine, hematocrit and complications. MATERIALS AND METHODS: An institutional retrospective review was performed during an 18-month period in which 118 patients underwent ureteroneocystostomy. One group containing 50 patients received caudal anesthetic preoperatively and narcotic analgesics postoperatively, while another 68 received caudal anesthetic preoperatively and ketorolac postoperatively. Patient ages, type of procedure, preoperative and postoperative creatinine and hematocrit, and complications were noted in each cohort. RESULTS: Average patient age of the control analgesic and ketorolac groups was 5.3 years (range 1 to 17) and 5.5 (1 to 12), respectively. There was no statistical difference between postoperative creatinine (0.68 and 0.65 mg./dl.) and hematocrit (33% and 34%) between the groups. One patient in each group had increased creatinine postoperatively. Minor complications, for example ileus and bladder spasms, were equivalent in both groups. No patient receiving ketorolac had any allergic or hypersensitivity reaction to the medication, and no major complications were reported. CONCLUSIONS: Ketorolac given after ureteroneocystostomy did not cause a significant decrease in hematocrit, increase in creatinine or overall complications. Because of the safety of ketorolac in our series, and ability to decrease hospital stay and narcotic requirements in children as reported previously, it is used as standard postoperative protocol after ureteroneocystostomy at our institution.     

Comparative assessment of the results of open carotid endarterectomy and carotid aftery stenting

A comparative study of 48 carotid stent grafting and 23 open carotid endarterectomies was carried out. Patients of both groups were comparable by cerebrovascular insufficiency degree and concomitant diseases. General rate of complications after carotid stent grafting (CSG) was 5.1%. There was a small ischemic stroke with right-sided hemiparesis and aphasia in one patient during CSG. Complete regress of the neurological symptoms was seen on the 5th day. In the nearest postoperative period after CSG there was a big ischemic stroke in the territory of MCA in one patient. Rate of complications after open carotid endarterectomy (OCEAE) was 8.7% Transient ischemic attacks were seen in 2 patients in early postoperative period. Paresis of the IX cranial nerves was in one patient. In long-term postoperative period after CSG 2 patients died due to cardiac causes. One patient died 18 months after OCEAE due to ischemic stroke. In long-term period after OCEAE restenosis of the internal carotid artery was seen in 4.5% cases, while there were no restenosis after CSG. It is concluded that CSG is an effective method of treatment of carotid stenosis with lower lethality and postoperative complications rate compared with OCEAE. Indications for CSG are symptomatic stenosis of ICA (>60%), asymptomatic stenosis of ICA(>70%), two-sided lesions of the carotid arteries, carotid stenosis with lesions of other brachiocephalic arteries, insufficiency of Willis circle.     

Dermal autograft immersion plasty by a flap method for large postoperative hernias of the abdomen

The authors present results of treatment of 128 patients aged 32-75 with great ventral hernias using the method of autodermal immersion graft hernioplasty. Hernias most often appeared after low median laparotomies. Planned operations were performed in 94.6% of cases, in 5.4% plasty was carried out in patients with incarcerated hernias without pyo-inflammatory alterations in the hernia sac. The implant was treated by the V.N. Yanov method. The postoperative period was mainly favorable, without lethal outcomes. Suppuration of the wounds took place in 2.3% of cases. Long-term results were followed-up in 80.5% of the patients (during the periods 6 months--11 years). Recurrent hernias were found in 3.1%. The other patients had good results of operations.