A simple method to determine the resolution of operative cholangiograms

A cholangiographic technique which facilitates visualization of the catheter itself permits the surgeon to measure the resolution of the roentgenographic technique used. When the wall of the catheter is visible, the surgeon can be confident that the resolution of the technique is in the 0.3 mm range. It is unlikely that stones greater than 0.3 mm in diameter will be missed using this technique.     

A simple operative procedure for the treatment of Stahl's ear

Stahl's ear is a rather rare congenital deformity and operative procedures for its correction have seldom been reported. We recently devised a simple method of surgical treatment, which is briefly described as follows: incisions are made into the third crus cartilage to facilitate the formation of a helical fold, and the cartilage is sutured by means of a mattress suture. This method makes it possible to produce a natural helix, though it fails to eliminate the third crus.     

Comparison of the clinical presentations of ingested foreign bodies requiring operative and nonoperative management

Foreign body ingestion is commonly seen in emergency departments. Although most cases have a clear history, foreign bodies in the gastrointestinal tract can be an unexpected finding after operations for other conditions. This study compares the clinical presentations and outcomes for patients requiring or not requiring operations. Between January 1998 and December 2001, 80 patients with foreign body ingestion were included and divided into two groups. Specifically, group 1 patients were managed nonoperatively, and group 2 patients were managed operatively. The patient demographics, symptoms, foreign body ingestion mechanisms, type of diagnostic studies and management, and outcomes were compared between the two groups. Group 1 contained 44 patients, and group 2 contained 36 patients. Group 1 patients were significantly younger, but the incidence of underlying disease and the proportion of patients who ingested foreign bodies intentionally or incidentally was similar in groups 1 and 2. Most of the ingested foreign bodies in group 1 were in the esophagus and stomach, but for group 2 patients they were mostly in the small bowel. Moreover, most of group 1 patients were asymptomatic, which was not the case in group 2. Most group 2 patients had no known history of foreign body ingestion, and diagnoses generally were established during surgery. Neither group of patients displayed any mortality. Nonoperative management of foreign body ingestion usually can succeed in asymptomatic patients with a clear history; however, ingested foreign bodies can cause serious problems for those patients without a clear history of foreign body ingestion.     

Duplicated vena cava with tumor thrombus from renal cancer: use of venogram for safer operative planning

Renal and adrenal tumors can invade into the inferior vena cava (IVC) in 4%-10% of cases. Consequently, urologists must remain well versed in the anatomy of the IVC. The IVC develops embryologically from the coordinated growth and regression of a series of veins. Occasionally, these veins can persist, creating vena caval abnormalities. A completely duplicated caval system is 1 of these variations. We present a case of renal cell carcinoma with tumor thrombus extending into a duplicated IVC and show how understanding of venous drainage and pertinent imaging can aid with a successful outcome.     

Cost-effectiveness of teaching hospitals for the operative management of hip fractures

Hospitals with lower costs are not necessarily superior to those that are more expensive, because the more costly institutions might offer better outcomes. The purpose of this study was to consider prices and outcomes in an integrated model and thereby determine if teaching hospitals are cost-effective for the care of hip fractures. We analyzed the claims data of a sample of 18,908 Medicare patients who were admitted to one of 190 acute care hospitals for surgical treatment of a hip fracture. For each hospital, we assessed the relationship between the total per capita Medicare payments over a 6-month period following admission and the 30-day and 6-month mortality. The data were analyzed as a function of hospital type: teaching vs nonteaching. The mean adjusted costs were $5910 per patient higher at teaching hospitals compared to nonteaching hospitals (approximately $24,000 vs $18,000) However, the adjusted 6-month mortality was 1.4% lower at major teaching hospitals. The adjusted incremental cost-effectiveness for teaching hospitals was $422,143 per life saved. By that measure, each life saved would have to yield nearly 8.5 additional quality-adjusted life years (QALY) to attain the $50,000/QALY standard thought to represent cost-effective spending, an unlikely target given the age of the typical hip fracture patient. Nonetheless, because teaching hospitals are more expensive than non-teaching hospitals, a relatively small cut in the overall cost of care at teaching hospitals could dramatically decrease the marginal cost of each life saved. The elements of teaching hospital care that improve survival might be identified in further studies and instituted, perhaps, at non-teaching hospitals without greatly increasing their cost structure.     

The use of a cuffed endotracheal tube for repair of operative injuries to the atria

Injuries to the atria during closed heart and lung operations may cause fatal hemorrhage. A cuffed endotracheal tube placed through the atrial tear has been used successfully to control bleeding in 6 patients, permitting accurate repair of the injury.     

胃癌患者术前钡剂造影检查对诊断和制订手术方式的临床价值

目的探讨胄癌患者术前钡剂造影检查对诊断和制订手术方式的临床价值。方法回顾性分析229例胃癌患者的临床资料．将单纯胃镜检查及胃镜联合钡剂造影检查对肿瘤位置和大小的判断结果与手术所见进行比较。结果胃镜对贲门癌、胃体癌和胃窦癌的位置和范围判断的准确率分别为100％和78．4％、94．6％和86．5％以及98．1％和84．6％：胃镜联合钡剂造影检查判断的准确率则分别为100％和84．8％、100％和91．9％以及99．0％和90．4％：胃镜与胃镜联合钡剂造影检查对肿瘤位置和范围判断准确率的差异无统计学意义（P〉0．05）。胃镜判断贲门癌累及食管长度的准确率为60．6％．胃镜联合钡剂造影检查判断的准确率则为90．9％．两者差异具有统计学意义（P〈0．05）。胃镜联合钡餐检查较之胃镜能更准确地预测食管受累的贲门癌患者开胸手术的可能性（P〈0．05）。结论贲门癌患者术前有必要行钡剂造影检查以明确食管下端是否受累及受累长度．对选择手术入路有指导意义．而胃体癌和胃窦癌患者术前在胃镜能明确肿瘤位置和大小的情况下可不必行钡剂造影检查。     

A simple and inexpensive method of preoperative computer imaging for rhinoplasty

GOALS/PURPOSE: Despite concerns of legal liability, preoperative computer imaging has become a popular tool for the plastic surgeon. The ability to project possible surgical outcomes can facilitate communication between the patient and surgeon. It can be an effective tool in the education and training of residents. Unfortunately, these imaging programs are expensive and have a steep learning curve. The purpose of this paper is to present a relatively inexpensive method of preoperative computer imaging with a reasonable learning curve. MATERIALS AND METHODS: The price of currently available imaging programs was acquired through an online search, and inquiries were made to the software distributors. Their prices were compared to Adobe PhotoShop, which has special filters called "liquify" and "photocopy." It was used in the preoperative computer planning of 2 patients who presented for rhinoplasty at our institution. Projected images were created based on harmonious discussions between the patient and physician. Importantly, these images were presented to the patient as potential results, with no guarantees as to actual outcomes. RESULTS: Adobe PhotoShop can be purchased for 900-5800 dollars less than the leading computer imaging software for cosmetic rhinoplasty. Effective projected images were created using the "liquify" and "photocopy" filters in PhotoShop. Both patients had surgical planning and operations based on these images. They were satisfied with the results. CONCLUSIONS: Preoperative computer imaging can be a very effective tool for the plastic surgeon by providing improved physician-patient communication, increased patient confidence, and enhanced surgical planning. Adobe PhotoShop is a relatively inexpensive program that can provide these benefits using only 1 or 2 features.     

The use of operative ultrasonography for the localization of renal calculi

The ultrasonically guided nephrotomy technique using B-scanning to identify the localization of stones and Doppler sonography to identify avascular parenchymal areas for nephrotomies allows for transparenchymal stone removal without the need for renal artery clamping and renal cooling. In 175 procedures the average blood loss was 1,350 ml and the rate of residual stones requiring a secondary intervention was 2.8%. Despite the advent of new noninvasive treatment modalities, this technique is still applied in 23% of staghorn stones.

---

Resumen La técnica de nefrotomía guíada por ultrasonografía utilizando la escanografía de modo B para définir la localización de los cálculos y la sonografía de Doppler para identificar áreas avasculares del parenquima para la realización de las nefrotomías, permite la remoción tránsparenquimatosa de cálculos sin necesidad de oclusión de la arteria renal ni hipotermia del riñón. En 175 procedimientos realizados la pérdida promedio de sangre fue de 1,350 ml y la tasa de cálculos residuales que requirieron una intervención secundaria fue de 2.8%. A pesar del advenimiento de modalidades terapéuticas no invasivas, esta técnica todavía se aplica en 23% de los pacientes con cálculos coraliformes.

---

Résumé La technique de la néphrotomie guidée par l'échographie pour localiser les calculs rénaux et par la sonographie-Doppler pour identifier les zones avasculaires du parenchyme rénal permet l'ablation transparenchymateuse des calculs sans avoir recours au clampage de l'artère rénale et au refroidissement rénal. Au cours de 175 opérations de ce type la perte moyenne de sang a été de 1,350 ml et le taux des échecs nécessitant une intervention secondaire a été de 2.8%. Malgré l'avènement de nouvelles modalités thérapeutiques non-invasives, cette méthode de traitement est encore employée dans 23% des cas de calculs coralliformes.

     

In vitro and in vivo models for peritonitis demonstrate unchanged neutrophil migration after exposure to dialysis fluids.

BACKGROUND: Recurrent infections in peritoneal dialysis (PD) patients may alter the abdominal wall resulting in an impairment of its dialysis capacity. In this study we investigated both in vitro and in vivo the effects of mesothelial exposure to dialysis fluids on the migration of neutrophils and their capacity to clear a bacterial infection. METHODS: First, we evaluated neutrophil migration in an in vitro transwell model for the peritoneal membrane with monolayers of primary human mesothelial cells (MC) on the lower side and primary human endothelial cells (EC) on top of the same transwell membrane, upon exposure of MC to PD fluid (PDF)-derived components. In addition to this in vitro model, we combined chronic peritoneal exposure to PDF with a peritoneal infection model in the rat. We investigated the kinetics of the chemokine response, neutrophil recruitment and bacterial clearance. RESULTS: Known chemoattractants, such as fMLP and IL-8, strongly increased neutrophil migration across both cell layers in the in vitro model of the peritoneal membrane. Pre-incubation of the MC layer for 48 h with 55 mM glucose, a combination of two glucose degradation products, methylglyoxal and 3-deoxyglucosone, or conventional dialysis fluid (1:4 dilution), however, did not change the IL-8-induced migration of neutrophils. In concert with this finding we demonstrated an unchanged MC expression of ICAM-1 and VCAM-1 after these pre-treatments. Unexpectedly, chronic i.p. exposure to conventional PDF or a recently developed lactate/bicarbonate-buffered PDF in a rat peritoneal exposure model strongly hampered the chemokine response upon bacterial challenge. Nevertheless, neutrophil recruitment and bacterial clearance were effective and did not differ from rats not pre-exposed to PDF. CONCLUSIONS: We conclude that exposure of MC to PDF does not hamper the recruitment of functional neutrophils upon challenge.     

Effective use of the air ambulance for pediatric trauma

BACKGROUND: The purpose of this study was to compare outcomes of pediatric trauma patients transported by helicopter from the injury scene (IS group) to a trauma center and those transported by air after hospital stabilization (HS group). METHODS: A retrospective analysis of pediatric trauma patients (<19 years of age) transported by air ambulance and admitted to a pediatric trauma center was conducted. Outcomes compared were mortality and length of stay. Patients were subdivided into minor (Injury Severity Score [ISS] < 15) and major (ISS > 15) trauma. TRISS analysis was performed to verify the overall quality of the care. RESULTS: Eight hundred forty-two HS and 379 IS patients were included. The mean age, median ISS, and distribution of penetrating and blunt injuries did not differ significantly between the groups. The overall death rate was significantly lower for the interfacility transfer patients (HS group, 5.5%; IS group, 8.7%; p < 0.05). Mean intensive care unit (ICU) and hospital length of stay did not differ significantly. HS patients with major trauma had significantly less mortality (HS group, 15.5%; IS group, 26.7%; p < 0.05) and shorter mean ICU stays (HS group, 118.3 hours; IS group, 149.1 hours; p < 0.05) than IS major trauma patients. No differences were seen in patients with minor trauma. TRISS analysis showed improved survival for all patients compared with Major Trauma Outcome Study norms. CONCLUSION: Retrospective analysis was not able to demonstrate any benefit to direct transport from the scene to a trauma center. Hospital stabilization before transfer by air ambulance may improve survival and shorten ICU stays for patients with major trauma.