Ureteral Obstruction: Is the Full Metallic Double-Pigtail Stent the Way to Go?

Background

The Resonance metallic ureteral stent (Cook Medical, Bloomington, Indiana, USA) has been introduced for the management of extrinsic-etiology ureteral obstruction for time periods up to 12 mo.

Objective

The current study aims to determine short- and medium-term effectiveness of the Resonance stent in malignant and benign ureteral obstruction.

Design, setting, and participants

In total, 50 patients with extrinsic malignant obstruction (n = 25), benign ureteral obstruction (n = 18), and previously obstructed mesh metal stents (n = 7) were prospectively evaluated.

Intervention

All patients were treated by Resonance stent insertion. Twenty stents were inserted in antegrade fashion, and the remaining stents were inserted in a retrograde approach. No patient dropped out of the study. The follow-up evaluation included biochemical and imaging modalities.

Measurements

We evaluated the technical success rate, stricture patency rate, complications, and the presence and type of encrustation.

Results and limitations

The technical success rate of transversal and stenting of the strictures was 100%. In 19 patients, balloon dilatation was performed prior to stenting. The mean follow-up period was 8.5 mo. The stricture patency rate in patients with extrinsic malignant ureteral obstruction was 100% and in patients with benign ureteral obstruction 44%. Failure of Resonance stents in all cases of obstructed metal stents was observed shortly after the procedure (2–12 d). In nine cases, stent exchange was demanding. Encrustation was present in 12 out of 54 stents.

Conclusions

The Resonance stent provides safe and sufficient management of malignant extrinsic ureteral obstruction. Resonance stent use in benign disease needs further evaluation, considering the untoward results of the present study.     

Impact of Percutaneous Suprapubic Tube Drainage on Patient Discomfort after Radical Prostatectomy

Background

Patients undergoing radical prostatectomy (RP) traditionally require urethral catheterization for adequate bladder drainage in the postoperative period. However, many patients have significant discomfort from the urethral catheter.

Objective

To describe a technique of percutaneous suprapubic tube (PST) bladder drainage after robotic-assisted laparoscopic radical prostatectomy (RALP) and to evaluate patient discomfort, complications, continence, and stricture rate after this procedure.

Design, setting, and participants

Two hundred two patients undergoing RALP were drained with a 14F PST instead of a urethral catheter. The PST was placed robotically at the conclusion of the urethrovesical anastomosis and secured to the skin over a plastic button. Beginning on postoperative day 5, patients clamped the PST, urinated per urethra, and measured the postvoid residual (PVR) drained by PST. The PST was removed when residuals were <30 cm³ per void. The control group consisted of 50 consecutive patients undergoing RALP with urethral catheter drainage.

Measurements

The primary end point was catheter-associated discomfort as measured with the Faces Pain Score-Revised (FPS-R). Secondary end points included use of anticholinergics, complications related to the PST, urinary continence, and urethral stricture.

Results and limitations

When compared with urethral catheter patients, PST patients had significantly decreased catheter-related discomfort on postoperative days 2 and 6 (p < 0.001). Anticholinergic medication was required by one PST and four urethral catheter patients (p < 0.001). Ten patients required urethral catheterization for PST dislodgement (n = 5) or urinary retention (n = 5). No patient has developed a urethral stricture at a mean follow-up of 7 mo.

Conclusions

PST provides adequate urinary drainage following RALP with less patient discomfort and no increased risk of urethral stricture.     

Internal hemipelvectomy in the management of pelvic Ewing sarcoma – are outcomes better than with radiation therapy?

Background

Pelvic Ewing sarcoma (ES) is commonly associated with a worse prognosis. Large size and location limit local control options to radiation therapy, and local recurrences are common. We evaluated the impact of hemipelvectomy and radiation on outcomes, including function.

Materials and methods

Thirty-nine patients (median age 13.5 years) with ES of the pelvis and sacral bones were treated during the period 2000–2012. Fifteen were treated with definitive radiotherapy (RT), 9 patients underwent hemipelvectomy alone, and 15 were treated with combined hemipelvectomy and RT.

Results

Twenty patients (51.2%) are alive with a median follow-up 3.2 years from diagnosis. Median time from diagnosis to relapse was 1.3 years. Three-year estimates of EFS and OS were 47% and 61%, respectively. Patients treated with surgery or surgery with RT had better outcome than patients treated with RT only (3-year OS 78% or 81% vs. 36%, respectively, p = 0.00083). The outcome of patients with pelvic ES treated with hemipelvectomy was not significantly different from the outcome of all patients with Ewing sarcoma treated on the national Polish protocol.

Conclusions

Internal hemipelvectomy offers good chances of cure for patients with pelvic ES, with a reasonable rate of complications and good function.     

Measured gap length and outcomes in oesophageal atresia

Aims

Oesophageal atresia (OA) with or without tracheoesophageal fistula (TOF) is the most common congenital anomaly of the oesophagus. There is limited literature suggesting a linear relationship between increasing gap length and the incidence of all major complications. We sought to assess whether measured gap length at the time of surgery was related to outcomes in our patients.

Methods

All patients with a diagnosis of OA +/− TOF who underwent repair under a single surgeon between 1983 and 2012 were included. The length between the oesophageal pouches was measured at the time of surgery. Patients were then divided into three groups; short ≤ 1 cm, intermediate > 1–≤2 cm and long > 2–≤5 cm. Outcome measures were anastomotic leak, strictures requiring dilatation, gastrooesophageal reflux disease (GORD) and need for fundoplication.

Results

122 patients were included in the study. The outcomes for patients with short (n = 53), intermediate (n = 51) and long gaps (n = 18) were as follows: anastomotic leak — 1.9%, 2%, 5.5% (P = 0.66), strictures requiring dilatation — 32%, 33%, 50% (P = 0.67), GORD — 51%, 59%, 72% (P = 0.58) and need for fundoplication — 11%, 20%, 44% (*P = 0.02). There were no deaths related to the repair.

Conclusions

Measured gap length at the time of surgery did not have a linear relationship with leak or stricture rate. Our experience suggests that when primary repair is possible absolute gap length is irrelevant to the development of post-operative complications. There is however a significant increase in the need for fundoplication in those with a long gap.     

Laparoscopic pancreaticojejunostomy for pancreatic ductal dilatation in children

Purpose

The application of laparoscopic surgery in pancreatic surgery in children is limited. In this article, we describe laparoscopic pancreaticojejunostomy for children with congenital pancreatic ductal dilatation.

Methods

Four children with recurrent pancreatitis and pancreatic ductal dilatation underwent laparoscopic pancreaticojejunostomy between July 2009 and November 2011. Longitudinal incision of the dilated pancreatic ducts and side-to-side Roux-Y pancreaticojejunostomy were performed.

Results

Operative time ranged from 103 to 154 min, and blood loss was minimal. The average postoperative hospital stay was 4 to 6 days. There were no pancreatic leaks. None of the patients experienced recurrence of pancreatitis.

Conclusions

Laparoscopic pancreaticojejunostomy for children with congenital pancreatic ductal dilatation is safe and effective.     

The use of retrievable fully covered self-expanding metal stent in refractory postoperative restenosis of benign esophageal stricture in children

Purpose

This study analyzes the efficacy and safety of a retrievable, fully covered self-expanding metal stent (cSEMS) in the treatment of refractory benign esophageal restenosis in children.

Methods

This is a retrospective analysis of the application of a newly designed cSEMS in treating refractory benign postoperative restenosis in five children with ages ranging from 16 months to 8 years. Efficacy and safety were evaluated during the follow-up period.

Results

cSEMS with or without an antireflux valve at the distal end were successfully placed and removed in five children. These five patients were followed up for 4–12 months after stent removal. Among the five patients, ulcerative stricture was observed in two patients because of reflux esophagitis, while three patients showed no signs of stricture recurrence. Stent migration was observed in three patients, two of which required the stent to be reset. The narrow esophagus was successfully expended to a diameter of 12–13 mm. Besides the observation of mild granulation tissue growth in one case, no severe complications were observed during surgery and after stent placement.

Conclusion

Our study suggests that a retrievable, fully covered SEMS is safe and partially effective for treating refractory benign postoperative esophageal restenosis in children during short-term observation.     

Six-Year Follow-Up of Botulinum Toxin A Intradetrusorial Injections in Patients with Refractory Neurogenic Detrusor Overactivity: Clinical and Urodynamic Results

Background

Most reports in the literature on botulinum toxin A (BoNTA) therapy for neurogenic detrusor overactivity (NDO) are based on the results of a single injection. Because most patients may require retreatment, the efficacy and safety of multiple injections must be addressed clearly.

Objective

To investigate the effectiveness and safety of BoNTA intradetrusorial injections in a group of spinal cord–injured (SCI) patients with refractory detrusor overactivity (DO).

Design, setting, and participants

Seventeen SCI patients were prospectively included in the study and followed up to 6 yr.

Intervention

All patients received repeat intradetrusorial injections of BoNTA 300 units (Botox, Allergan, Irvine, CA) under cystoscopic control on an inpatient basis.

Measurements

The preliminary assessment included voiding diary, urodynamics, kidney and bladder ultrasound, and cystourethrography. Patients also completed a standardised quality-of-life (QoL) questionnaire. Clinical evaluation, urodynamics, urinary tract imaging, and QoL assessment were repeated every year throughout the follow-up.

Results and limitations

Before treatment, all patients complained of urinary incontinence and had DO. Bilateral and monolateral renal pelvis dilatation were detected in six and five patients, respectively, and a monolateral and third-grade vesicoureteral reflux was observed in three. At 6-yr follow-up, a significant decrease in the frequency of daily incontinence episodes (p < 0.01), a significant increase in first uninhibited detrusor contraction and in maximum bladder capacity (p < 0.001 for both), and a significant decrease in maximum pressure of these contractions (p < 0.01) were observed. Fifteen patients (88.2%) were completely continent. Renal pelvis dilatation and vesicoureteral reflux resolved in all cases, and the QoL index significantly increased. Limitations of the study are related to the small number of included patients.

Conclusions

In SCI patients with refractory NDO who do not want or are unfit for invasive reconstructive surgery, BoNTA intravesical treatment represents a valid alternative to control DO and urinary incontinence and to preserve upper urinary tract function over a long-term follow-up.     

Feasibility and potential effect of a low-cost virtual reality system on reducing pain and anxiety in adult burn injury patients during physiotherapy in a developing country

Objective

The purpose of this study was to ascertain the feasibility and potential effect of a low-cost VR system (eMagin Z800 3DVisor), used in conjunction with pharmacological analgesia, on reducing pain and anxiety in adult burn patients undergoing physiotherapy treatment, compared to pharmacologic analgesia alone at a South African hospital.

Study design

Single-blind, within-subject study design.

Methods

Pain and anxiety outcome measures were measured by a blinded assessor using the Numeric Pain Rating Scale and Burn Specific Pain and Anxiety Scale. Box-and-whisker plot method, Chi-square tests as well as the Student's paired t-test were used to analyze data.

Main findings

Eleven eligible adult burn patients consented to participate in this study (3 female, 8 male; median age 33 years: range 23–54 years). A marginal (p = 0.06) to insignificant (p = 0.13) difference between the two sessions (analgesia with VR and analgesia without VR) in reducing pain was found. No significant difference (p = 0.58) was found between the two sessions (analgesia with VR and analgesia without VR) for anxiety.

Conclusion

There seems to be a trend that the low-cost VR system, when added to routine pharmacological analgesics, is a safe technique and could be of considerable benefit if implemented into the pain management regime of burn units at a South African hospital.     

Treatment of anastomotic stenosis and leakage after colorectal resection for cancer with self-expandable metal stents

Background

Self-expandable metallic stents can be used to treat patients with symptomatic anastomotic complications after colorectal resection.

Methods

Twenty patients with symptomatic anastomotic stricture after colorectal resection were treated with endoscopic placement of a self-expandable metal stent. Ten patients had “simple” anastomotic stricture. In the remaining 10 patients, a leak was associated with the stricture.

Results

The anastomotic leakage healed without evidence of residual stricture or major fecal incontinence in 8 of 10 patients. Overall, the anastomotic stricture was resolved in 14 of the 20 patients.

Conclusions

Self-expandable metal stents represent a valid adjunctive to treat patients with symptomatic anastomotic complications after colorectal resection for cancer. They have a complementary role to balloon dilatation in case of simple anastomotic stricture, and they improve the rate of healing when the stricture is associated with a leak.     

Magnetic gastrointestinal anastomosis in pediatric patients

Background/Purpose

To describe 17 patients who underwent magnetic, non-surgical gastrointestinal (GI) anastomoses.

Methods

Patients with GI obstruction, stenosis, or atresia were treated with image-guided and/or endoscopically placed discoid magnet pairs or catheter-based bullet-shaped magnet pairs.

Results

Anastomosis was achieved in 7 days in an 11-year-old with gastric outlet obstruction due to metastatic colon cancer. Anastomosis was achieved in 8 and 10 days in 2 patients (age 2.0 years and 3.4 years) who had rectocolonic stenosis. Re-anastomosis was achieved in an average of 6 days (range 3 to 7 days) in 5 patients (age 6 months to 5.9 years) with severe recurrent postsurgical esophageal stenosis refractory to dilatation. Primary esophageal anastomosis was achieved in an average of 4.2 days (range 3 to 6 days) in 9 patients with esophageal atresia (Type A or Type C surgically converted to Type A) with a gap length of 4 cm or less. The average age of these esophageal atresia patients was 3 months (range 23 days to 5 months).

Conclusion

Minimally invasive magnet placement was feasible and achieved anastomosis in all patients.     

Endoscopic Vaporesection of the Prostate Using the Continuous-Wave 2-μm Thulium Laser: Outcome and Demonstration of the Surgical Technique

Background

The potential of a new continuous-wave (CW) 70-W, 2.013-μm thulium-doped yttrium aluminium garnet (Tm:YAG) laser for the endoscopic treatment of benign prostatic hyperplasia (BPH) is investigated.

Objective

The simultaneous combination of vaporisation and resection of prostatic tissue in a retrograde fashion is the main characteristic of this new laser technique. We provide a DVD that shows the main steps of this procedure.

Design, setting, and participants

We retrospectively evaluated 56 nonconsecutive patients who were treated by thulium laser vaporesection of the prostate in our institution between 2005 and 2007.

Surgical procedure

Vaporesection of the prostate is performed by moving the fibre semicircumferentially from the verumontanum towards the bladder neck, thereby undermining tissue and cutting chips.

Measurements

Blood loss, postvoiding residual urine (PVRU), maximum flow rate (Q_max), and the International Prostate Symptom Score (IPSS) were measured as well as prostate volume and prostate-specific antigen (PSA). The duration of the procedure, need for postoperative irrigation, duration of catheterisation, and hospital stay were recorded.

Results and limitations

The median procedure time was 60 min, postoperative irrigation was necessary in 19 out of 56 patients, and the median duration of catheterisation was 23 hr. At the day of discharge, the mean haemoglobin value decreased by 0.2 mg/dl (p = 0.13), the average Q_max improved from 8.1 to 19.3 ml/s (p < 0.001), and the PVRU decreased from 152 ml to 57 ml (p < 0.05). The blood transfusion rate was 3.6%, and two patients needed a recatheterisation postoperatively (3.6%). After a median follow-up of 9 mo, the IPSS improved from 19.8 at baseline to 8.6 (p < 0.001). Four patients had a repeat transurethral resection of the prostate (TURP) during the learning curve, but this was not necessary in any of the later patients. One patient developed a urethral stricture, and another developed a bladder neck contracture.

Conclusions

The thulium laser seems to be a suitable tool for the endoscopic treatment of BPH.     

Laparoscopic pneumovesical ureteral tapering and reimplantation for megaureter

Objective

To evaluate the efficacy of laparoscopic pneumovesical ureter reimplantation for congenital malformation involving the vesicoureteral junction in children.

Methods

From January 2005 to October 2010, 45 cases (comprising 61 ureters) were diagnosed as megaureter caused by vesicoureteral junction obstruction. A pneumovesical laparoscopic Cohen procedure was performed in all cases. Twelve of the ureters underwent excisional ureteral tapering. Ureteral diameters were obtained using ultrasonography and were divided into 4 groups according to the degree of dilatation.

Results

The procedure was completed in all but 2 patients, who were converted to open surgery. The mean operation time was 3.5 h (range, 2–8 h) for unilateral ureter cases, 3.7 h (range, 3.5–4.5 h) for duplicated ureter cases, and 5.4 h (range, 3.5–9 h) for bilateral cases. The mean duration of urethral catheter placement and hospital stay was 6.7 days (range, 3–14 days) and 8.3 days (range, 4–15 days), respectively. Thirty-five of the patients (48 ureters) were followed up by ultrasonography for 1–67 months (mean, 19.3 months). Ultrasound scans revealed improvement in the degree of dilatation of 32 ureters. In 1 patient, the ultrasound scan showed deterioration of ureteral dilatation. This patient developed stenosis at the neoureteral opening and underwent reoperation 6 months later. Fourteen patients were followed up by micturating cystourethrogram (MCU).Of these, 3 cases (4 ureters) exhibited reflux (2 unilateral cases of grade 1 reflux and grade 3 reflux, respectively, and 1 bilateral case of bilateral grade 1 reflux).

Conclusions

Pneumovesical ureteral reimplantation for vesicoureteral junction obstruction is feasible and effective. In this series, ultrasound scans showed improvement in most ureteral dilatation cases on follow-up.     

Step-Down Approach for Pharyngoesophageal Corrosive Stricture: Outcome and Analysis

Background

Pharyngoesophageal stricture (PES) is an Achilles’ heel in the management of corrosive injury. Advances in endoscopic techniques were utilized in its management. We classified the stricture as per its dilatability and then planned their treatment.

Methods

PES was sub-categorized based on endoscopic dilatation and availability of cervical oesophagus: group-1 stricture with available cervical oesophagus; group-2 stricture with some part of upper oesophagus made available after endoscopic dilatation and anastomosis in cervico-pharyngeal area; group-3 stricture not amenable for dilatation, anastomosis done at the pharynx. Endoscopic dilatation was performed using through-the-scope pyloric balloon. Number and duration of dilatation sessions before surgery, incidence of tracheostomy, time and incidence for re-stricture and present status of swallowing were evaluated.

Results

Of 226 patients managed, 46 underwent oesophageal replacement for PES. Group 1, 2 and 3 had 12, 14 and 20 patients, respectively. An average 3 (2–4) preoperative balloon dilatation sessions were performed over 6–8 weeks. Tracheostomy was required in 1, 0, 8 patients (p = 0.010), and median hospital stay was 10, 9 and 13 days (p = 0.09) in group 1, 2, 3, respectively. Re-stricture developed in 4/12, 4/14, 9/20 patients with average sessions of dilatation required in post-operative period was 4, 3.5 and 8 in group 1, 2, 3, respectively. >90% of patients are taking normal diet in each group.

Conclusion

We attempted to avoid the high anastomosis by dilating the PES and step down the level of anastomosis in two-third patients. We thereby avoided tracheostomy, aspiration and swallowing problems related to high strictures.

     

Surgical treatment of type IV-A choledochal cyst in a single institution: Children vs. adults

Background

The treatment of type IV-A choledochal cyst is particularly difficult and remains a challenge because of the rareness and the various presentations of the disease involving not only the extrahepatic but also the intrahepatic biliary tract. The purpose of this study is to analyze our clinical experience for surgical treatment of type IV-A choledochal cyst, and compare between children and adults.

Methods

During a 10-year period of time (2000–2010), clinical data of 81 consecutive patients with type IV-A choledochal cyst were retrospectively analyzed. We divided these patients into two groups, the child group (age ≤ 18 years) and the adult group (age > 18 years). According to whether the patient received additional liver resection, patients were divided into a extrahepatic cystectomy (EHC) group and an additional liver resection (LR) group. The long-term outcomes after surgery were evaluated in two groups.

Results

Of all 81 patients, there were 17 children and 64 adults; 16 children and 35 adults belonged to EHC group, one child and 29 adults belonged to LR group. The morbidity of biliary stricture and/or lithiasis in the adults was significantly higher than that in the children (p = 0.041 < 0.05). In the EHC group, the reoperation rate of adults was significantly higher than that of children (p = 0.019 < 0.05). For adult patients, the morbidity of biliary stricture and/or lithiasis and the reoperation rate in EHC group was significantly higher than that in LR group (p = 0.037 < 0.05 and p = 0.026 < 0.05 respectively). Five adults were found to have cholangiocarcinoma within a follow-up period, while no child was found to. However, for adult patients, no significant discrepancy was observed between EHC group and LR group (p = 0.366 > 0.05).

Conclusions

The present study suggests that the children have better outcomes than adults for patients with type IV-A choledochal cyst after EHC, while LR brings better outcomes than EHC for adult patients.     

Utilisation du facteur VIIa en cas d’hémorragie réfractaire sous ECMO centrale veino-artérielle

Objective

The purpose of our study is to describe the use of recombinant factor VIIa (rFVIIa) in patients on central veno-arterial ECMO with a particular attention on associated thrombotic complications.

Study design

Monocentric retrospective study.

Patients and methods

We examined 91 files of patients on ECMO between 2005 and 2010. During this period, eight patients presented refractory bleeding and benefited from rFVIIa treatment.

Results

In six of the eight patients, the bleeding stopped. A decrease of the bleeding was noticed after the treatment of rFVIIa (before rFVIIa: 40.1 ± 33.1 mL/kg per 3 hours after rFVIIa: 5.4 ± 3.2 mL/kg per 3 hours (P = 0.01). The transfusional needs were decreased after administration of rFVIIa. No thrombotic event was detected. Fibrinogen, d-dimers, platelet count and lactate were not modified by the treatment. Two patients were weaned from ECMO. One patient died 17 days after the weaning. The other patient survived without neurological damages.

Conclusion

The rFVIIa is a treatment of exception for patients on central veno-arterial ECMO and could be a last-resort treatment in the presence of a not curable massive bleeding.     

Treatment of postoperative tracheal granulation tissue with inhaled budesonide in congenital tracheal stenosis

Purpose

Tracheal obstruction by granulation tissue can compromise the postoperative course in congenital tracheal stenosis (CTS). Balloon dilatation and stenting may be required. Budesonide is a corticosteroid with topical anti-inflammatory effects. In 2008, we used inhaled budesonide for treatment of postoperative granulation tissue for the first time in CTS, resulting in significant improvement. The aim of this study was to evaluate the efficacy of inhaled budesonide for treatment of postoperative granulation tissue in CTS.

Methods

Retrospective chart review was conducted. From 2004 through 2011, we performed 39 tracheoplasties. Forced stenting ± balloon dilatation (S/B) was required when airway obstruction with tissue granulation was life-threatening. We compared the requirement for S/B between the early group without budesonide (2004–Nov. 2008, Early) and the late group with budesonide (Dec. 2008–2011, Late). Statistical analysis was performed using Fisher’s Exact test.

Results

Eleven of 22 in Early and 8 of 17 in Late were successfully extubated, never having had life-threatening tissue granulation. The remaining patients in each group (11 in Early and 9 in Late) required tracheostomies due to postoperative complication. Ten in Early and 5 in Late with tracheostomies developed granulation tissue. Of these patients, the 10 in Early required S/B, while none of the 5 in Late required S/B (P = .0003). Bronchoscopy demonstrated significant regression of granulation tissue in all cases treated with inhaled budesonide.

Conclusion

Inhaled budesonide is effective for treatment of tracheal granulation tissue in patients with tracheostomies after repair of CTS.     

Comparison of outcomes after triceps split versus sparing surgery for extra-articular distal humerus fractures

Objectives

To compare elbow range of motion (ROM), triceps extension strength, and functional outcome of AO/OTA type A distal humerus fractures treated with a triceps-split or -sparing approach.

Design

Retrospective review.

Setting

Two level one trauma centres.

Patients

Sixty adult distal humerus fractures (AO/OTA 13A2, 13A3) presenting between 2008 and 2012 were reviewed. Exclusion criteria removed 18 total patients from analysis and three patients died before final follow-up.

Intervention

Patients were divided into two surgical approach groups chosen by the treating surgeon: triceps split (16 patients) or triceps sparing (23 patients).

Main outcome measurements

Elbow ROM and triceps extension strength testing were completed in patients after fractures had healed. All patients were also given the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire.

Results

Compared to the triceps-split cohort, the triceps-sparing cohort had greater elbow flexion (sparing 143 ± 7° compared to split 130 ± 12°, p = 0.03) and less extension contracture (sparing 6 ± 8° compared to split 23 ± 4°, p < 0.0001). Triceps strength compared to the uninjured arm also favoured the triceps-sparing cohort (sparing 88.9 ± 28.3% compared to split 49.4 ± 17.0%, p = 0.007). DASH scores were not statistically significant between the two cohorts (sparing 14.5 ± 12.2 compared to split 23.6 ± 22.3, p = 0.333).

Conclusions

A triceps-sparing approach for surgical treatment of extra-articular distal humerus fractures can result in better elbow ROM and triceps strength than a triceps-splitting approach. Both approaches, however, result in reliable union and similar functional outcome.

Level of evidence

Level III.     

Évaluation des pratiques de prise en charge analgésique en postopératoire de césarienne avant et après mesures d’amélioration

Objective

To assess the improvement of practices in postoperative analgesia after a cesarean section post implementation of a corrective program.

Study design

Prospective impact study.

Patients and methods

After obtaining ethics approval, we included all patients undergoing a cesarean section at Montpellier University Hospital during February 2011 (PRE group) and March 2012 (POST group). The patients were interviewed on the fourth day postpartum about pain management and related data was collected from the chart. From March 2011 to February 2012, training sessions were held for the paramedical and medical teams.

Results

Sixty patients were included in each group. The two groups were not significantly different. The mean overall numeric rating scale worst pain score between Day 0 and Day 4 in POST group was lower (5.5 ± 2.5 vs. 6.5 ± 2.4 p < 0.01) and impairment during mobilization decreased significantly. Compliance with protocols improved in the POST group: the number of women receiving full analgesia regiment increased from 12% to 68% between PRE and POST period.

Conclusion

After an awareness campaign of the paramedical and medical staff, we succeeded in improving significantly the routine use of analgesics regardless of their level. Nevertheless healthcare professionals still seem reluctant to administer opioids.     

Preoperative imaging does not predict intrahepatic involvement in choledochal cysts

Introduction

Choledochal cyst (CDC) is a congenital malformation of the bile ducts, which can include the intrahepatic or extrahepatic bile ducts. We hypothesize that preoperative intrahepatic ductal dilation is not predictive of postoperative intrahepatic involvement.

Methods

We retrospectively reviewed all cases of CDC in children diagnosed at a single institution between 1991 and 2013.

Results

Sixty-two patients were diagnosed with CDC during the study period with a median follow-up time of 2.25 (range 0–19.5) years. Forty-two patients (68%) were diagnosed with type I disease preoperatively, and 15 patients (24%) were diagnosed with type IV-A disease. The most common presenting symptoms included pain (34%), jaundice (28%), and pancreatitis (25%). There were no deaths or malignancies and only one postoperative stricture. Forty-two patients (68%) had intrahepatic ductal dilation preoperatively. Only four patients (9%) had intrahepatic ductal dilation following resection (P < 0.0001). In one patient, this dilation resolved following stricture revision. Of the four patients with postoperative dilation, two were diagnosed with type I disease, and the other two were diagnosed with type IV-A disease preoperatively.

Conclusion

Preoperative intrahepatic ductal dilation is not predictive of postoperative intrahepatic ductal involvement in children with CDC. The preoperative distinction between type I and IV disease is not helpful in treating these patients.     

Four-Year Outcome of a Prospective Randomised Trial Comparing Bipolar Plasmakinetic and Monopolar Transurethral Resection of the Prostate

Background

No data have been published on the midterm efficacy of bipolar transurethral resection of the prostate (TURP).

Objective

To evaluate 4-yr results from a prospective randomised trial comparing bipolar TURP with standard monopolar TURP.

Design, setting, and participants

Seventy patients with symptomatic benign prostatic hyperplasia were enrolled in this prospective randomised controlled trial in a tertiary-care institution. Inclusion criteria were age >50 yr, good performance status, urinary retention, International Prostate Symptom Score (IPSS) ≥18, and maximal flow rate (Q_max) ≤15 ml/s. Exclusion criteria were prostate volume <30 cm³, documented or suspected prostate cancer, neurogenic bladder, bladder stone or diverticula, urethral stricture, and maximal bladder capacity >500 ml.

Intervention

Patients underwent standard or bipolar plasmakinetic TURP performed by the same surgeon using the same surgical technique.

Measurements

Treatment efficacy was evaluated at 1, 2, 3, and 4 yr by comparing urinary flow rates, IPSS, and estimated postvoid residual (PVR) urine volume. Midterm complications were also recorded.

Results and limitations

The number of dropouts was not statistically significantly different in the two groups (p = 0.2). The significant improvements in both groups were maintained at 4 yr for the IPSS, quality of life score, Q_max, and PVR versus baseline values. The main outcome variables at 4 yr for bipolar and monopolar TURP were mean IPSS 6.9 and 6.4 (p = 0.58); mean Q_max 19.8 ml/s and 21.2 ml/s (p = 0.44), and mean PVR volume 42 ml and 45 ml (p = 0.3). Overall, 2 of 32 (6.2%) and 3 of 31 (9.6%) patients required reoperation because of late complications (p = 0.15). The major study limitation was the small sample size.

Conclusions

This study represents the secondary, midterm analysis of a previously published trial. Our 4-yr data confirm our initial positive findings for the efficacy and safety of bipolar plasmakinetic TURP. Larger well-designed studies are needed to corroborate these findings.