Vólvulo de ciego: presentación de 18 casos y revisión de la literatura

Introduction

Caecal volvulus is the second most frequent location of colonic volvulus after sigmoid colon. It usually shows up as bowel obstruction.

Material y method

We review our experience of 18 cases of cecal volvulus treated in our centre between 1987 and 2007.

Results

We studied 8 males (44.4%) and 10 females (55.6%), with a mean age of 63.3 years. As an associated factor it was noted that 10 patients (55.6%) were bedridden. The most common clinical signs were abdominal distensión and tenderness, constipation and vomiting. Simple abdominal X-rays have a low diagnostic accuracy, though they reveal a bowel obstruction. Only 1 patient underwent elective surgery. In 10 patients (55.6%) a right hemicolectomy was performed, in 3 (16.8%) cecostomy, in 3 cecopexy and in 2 (11.2%) devolvulation only. There were complications in 3 patients (16.8%), 2 prolonged ileus and 1 wound infection. There were no recurrences.

Conclusions

Caecal volvulus is an emergency pathology, requiring surgical treatment. Right hemicolectomy is the treatment of choice both in viable and gangrenous colon. Caecostomy is an alternative treatment in the high risk patient with a viable colon.     

Clinical value of office-based endoscopic incisional biopsy in diagnosis of nasal cavity masses

Objective

To evaluate clinical features and the diagnostic accuracy of office-based endoscopic incisional biopsy in patients with nasal cavity masses.

Study Design

Diagnostic test assessment with chart review.

Setting

Tertiary referral center.

Subjects and Methods

From January 1997 to August 2006, preoperative diagnosis was achieved using endoscopic incisional biopsy in 521 patients. Cytopathologic and histologic findings were categorized as malignancy, benign neoplasm, or non-neoplastic lesion. Preoperative imaging was done in 462 patients (computed tomography: 438 cases; magnetic resonance imaging: 24 cases). We investigated the accuracy of endoscopic incisional biopsy and preoperative imaging by comparing it with pathologic results from tumor resection as the “gold standard.”

Results

Most of the patients had unilateral nasal symptoms (e.g., nasal obstruction, unilateral epistaxis, unilateral facial pain), and the clinical symptoms were of little diagnostic value in the differentiation of tumor and inflammatory lesion. The sensitivity and specificity of endoscopic incisional biopsy were 43.7 and 98.9 percent, respectively, for the diagnosis of nasal cavity malignancies, and 78.2 and 96.2 percent, respectively, for the diagnosis of benign neoplasms. The sensitivity and specificity of preoperative imaging were 78.3 and 97.5 percent, respectively, for the diagnosis of nasal cavity malignancies and 66.4 and 86.3 percent, respectively, for the diagnosis of benign neoplasms. Combining the two modalities increased diagnostic accuracy in nasal cavity masses.

Conclusion

Endoscopic incisional biopsy alone did not ensure accurate diagnosis of nasal cavity tumors, but in combination with preoperative imaging it was helpful for the diagnosis of nasal cavity malignancies.     

Preliminary clinical experiences of a motorized manipulator for magnetic resonance image–guided microwave coagulation therapy of liver tumors

Background

In magnetic resonance (MR) image-guided microwave thermocoagulation of liver tumors, the choice of the optimal puncture route is an important and time-consuming process. To assist this process, we have developed a motorized MR-compatible manipulator.

Methods

The manipulator consists of a passive end effecter with 2 degrees-of-freedom (DOF) rotation and active base stages with 3 ultrasonic motors. It automatically chases the preset target point with synergetic remote-center-of-motion (RCM) control. A mechanical torque limiter and an electrical shutdown switch were added for patient safety.

Results

The manipulator was used for this procedure in 15 cases and successfully utilized to treat liver tumors in various locations. Thoracoscopic assistance was combined with the manipulator in 6 cases. No complications were experienced.

Conclusions

The manipulator was found to be very effective for assisting MR-guided microwave coagulation of liver tumors.     

Three phases of disaster relief in Haiti--pediatric surgical care on board the United States Naval Ship Comfort

Background

On January 12, 2010, Haiti experienced the western hemisphere's worst-ever natural disaster. Within 24 hours, the United States Naval Ship Comfort received orders to respond, and a group of more than 500 physicians, nurses, and staff undertook the largest and most rapid triage and treatment since the inception of hospital ships.

Methods

These data represent pediatric surgical patients treated aboard the United States Naval Ship Comfort between January 19 and February 27, 2010. Prospective databases managed by patient administration, radiology, blood bank, laboratory services, and surgical services were combined to create an overall patient care database that was retrospectively reviewed for this analysis.

Results

Two hundred thirty-seven pediatric surgical patients were treated, representing 27% of the total patient population. These patients underwent a total of 213 operations composed of 243 unique procedures. Orthopedic procedures represented 71% of the total caseload. Patients returned to the operating room up to 11 times and required up to 28 days for completion of surgical management.

Conclusions

This represents the largest cohort of pediatric surgical patients in an earthquake response. Our analysis provides a model for anticipating surgical caseload, injury patterns, and duration of surgical course in preparing for future disaster response missions. Moreover, we propose a 3-phased response to disaster medicine that has not been previously described.     

The effect of laparoscopic excision vs open excision in children with choledochal cyst: a midterm follow-up study

Purpose

Cyst excision with hepaticojejunostomy has been the classic procedure for treating choledochal cysts. Recently, laparoscopic treatment of the disease has gained popularity worldwide. The aim of this study is to evaluate whether laparoscopic management of choledochal cysts is as feasible and safe as conventional open surgery in children with this disease.

Methods

A retrospective study comparing the laparoscopic and the open procedures was performed in 77 consecutive patients with choledochal cyst in our hospital. Thirty-nine patients operated on between June 2001 and September 2003 were in the laparoscopic group, whereas 38 patients in the open group were operated on between February 1999 and May 2001.

Results

Patient demographics were similar between the 2 groups. The duration of operation was significantly longer in the laparoscopic group than in the open group (median, 230 vs 190 minutes; P < .001). In contrast, the durations of delayed oral feeding and hospital stay postoperatively were significantly shorter in the laparoscopic group (median, 4 vs 5 days [P < .01] and median, 5 vs 7 days [P < .01], respectively.) There were no differences in the early and late complication rates between the 2 groups.

Conclusions

Laparoscopic treatment of choledochal cyst in children is feasible and safe. For experienced centers, this procedure can be recommended.     

The use of vacuum assisted closure therapy in the management of Fournier's gangrene

Background

Vacuum Assisted Closure (VAC; Kinetic Concepts, Inc., San Antonio, TX) has been used to successfully treat a variety of complex wounds. This technique was investigated for use in managing Fournier's gangrene following initial debridement.

Methods

Ten patients with Fournier's gangrene were treated in this study. After initial surgical debridement, 5 were treated using conventional therapy and 5 were treated with VAC at each dressing change. The effectiveness and cost of VAC for this indication were assessed; patient and physician satisfaction were also determined.

Results

Conventional and VAC treatment were equally effective in healing the wounds. The total costs of each treatment were similar. With the use of VAC, patients had fewer dressing changes, less pain, fewer skipped meals, and greater mobility. Hands-on treatment time was decreased for physicians using VAC.

Conclusions

VAC therapy is an effective and economical way to manage Fournier's gangrene. Patients and physicians were more satisfied with VAC therapy than with conventional treatment.     

Resource utilization and its management in splenic trauma

Background

This study compared resource utilization and its management for splenic injury at 2 level-I trauma centers and a pediatric referral center with other facilities in a state currently developing a trauma system.

Methods

Management strategy, length of stay, and total charges for children were compared among the pediatric referral center, trauma centers, and other facilities. Adult management, length of stay, and total charges were compared between trauma centers and other facilities.

Results

Nonoperative management was more frequent in children at the pediatric referral center than trauma centers or other facilities and was more common in adults at trauma centers than at other facilities. Mean length of stay and total charges for children were significantly greater at the pediatric referral center and trauma centers than at other facilities and for adults at trauma centers than at other facilities. Facility type was associated with length of stay and total charges when injury type and severity were controlled.

Conclusions

Nonoperative management of splenic injury is more common at trauma centers, and splenic trauma management may be more costly at trauma centers.     

Nasal septum to columella attachment: A major tip support?

Objective

To determine whether surgical section of attachment of the medial crural footplates to the quadrangular cartilage produces loosening of the nasal tip.

Study Design

Prospective, observational, before-and-after study.

Setting

Tertiary care center.

Subjects and Methods

Hispanic patients undergoing septoplasty who required a transfixion incision were included. A six-month postoperative assessment of the nasal tip support was compared with preoperative values. As measures of the nasal tip support, we included tip recoil test, nasolabial angle, tip rotation angle, nasofacial angle, and the Goode method for determining tip projection.

Results

Twenty-seven patients completed the follow-up, and their results are reported. There were no statistically significant differences after septoplasty in any of the five measurements used to assess the nasal tip support (P > 0.05).

Conclusion

In this preliminary cohort of Hispanic patients, surgical section of the attachment of the medial crural footplates to the quadrangular cartilage does not produce significant changes in nasal tip support.     

A potent anti-angiogenic factor, vasohibin-1, ameliorates experimental bronchiolitis obliterans

Background

Bronchiolitis obliterans (BO) is a major cause of morbidity and mortality after lung transplantation. BO is pathologically characterized by neovascularized fibro-obliteration of the allograft airway. A recent study has shown that aberrant angiogenesis during fibro-obliteration contributes to the pathogenesis of BO. Vasohibin-1 (VASH1) has been isolated as a vascular endothelial growth factor-inducible gene in endothelial cells (ECs) that inhibits migration and proliferation of ECs and exhibits anti-angiogenic activity in vivo.

Purpose

This study examines whether VASH1 inhibits fibro-obliteration of the allograft in a murine intrapulmonary tracheal transplantation model.

Method

Tracheal allografts of BALB/c mouse were transplanted into the left lung of recipient C57BL/6J mouse. We performed gene transfer to the recipient lungs using an adenovirus vector encoding human VASH1 (Ad-VASH1) or beta- garactosidase (Ad-LacZ) as the control. Tracheal allografts were harvested and pathological on days 21 and 28.

Result

Ad-VASH1 treatment reduced the vascular area on day 21 (4.6% versus 13.0%, P = .037) and day 28 (5.4% versus 13.4%, P = .022) compared with the control group. This was accompanied by significantly inhibited luminal obliteration of the tracheal allografts in the animals transferred with Ad-VASH1 compared with the control (69% versus 93%, P = .028) on day 21. We were not able to observe this effect on day 28 (92% versus 97%, P = .48).

Conclusion

Transgene expression of VASH1 in the recipient lung significantly attenuated luminal obliteration of the tracheal allograft; this was associated with significantly reduced aberrant angiogenesis in the fibro-obliterative tissue in a murine model intrapulmonary tracheal transplantation.     

Outcome of right ventricle-to-pulmonary artery shunt in first-stage palliation of hypoplastic left heart syndrome: a multi-institutional study

Background

To evaluate the developing surgical technique of a modified Norwood procedure using a right ventricle-to-pulmonary artery shunt, we analyzed data obtained from 73 infants who underwent first-stage palliation for hypoplastic left heart syndrome between 1998 to 2002 at three centers in Japan.

Methods

Procedures performed included an aortopulmonary neoaortic reconstruction and a nonvalved polytetrafluoroethylene shunt between a small right ventriculotomy and a distal stump of the main pulmonary artery. The size of the shunt used was 4 mm in 6 patients, 5 mm in 41, and 6 mm in 26. Continuous cerebral perfusion was used in all patients and an additional descending aortic perfusion was used in 39. Postoperative management was basically the same as that for infants undergoing other types of operations.

Results

There were 61 hospital survivors (84%), including 5 of 6 patients weighing less than 2 kg, with 8 late deaths. Risk factors for hospital mortality include preoperative treatment without ventilatory support and surgeon's experience (first 10 cases). Three patients underwent a primary Fontan operation at 5, 9, and 10 months of age, with one late death. Forty-one patients underwent the bidirectional Glenn shunt after a mean interval of 6.9 months, and 19 of them completed the Fontan operation at median age of 2.1 years. Overall survivals were 65% at 1 year and 63% at 2 years.

Conclusions

Improved survival for patients after first-stage palliation of hypoplastic left heart syndrome is reproducible for many centers by an application of the modified Norwood procedure with the right ventricle-to-pulmonary artery shunt.     

Are mastectomy rates a reasonable quality measure of breast cancer surgery?

Background

Quality measures of breast cancer clinical management adopted by the National Quality Forum do not address the quality of surgical performance. We evaluated mastectomy rate as one potential quality indicator.

Methods

We reviewed the surgical management of small (stage T1; ≤2 cm) invasive breast tumors in patients treated from April 2003 through April 2007 at our institution. For patients undergoing mastectomy, factors leading to the selection of mastectomy were analyzed.

Results

We identified 496 patients with invasive breast cancer: 433 did not undergo neoadjuvant chemotherapy, and 319 of these had pathologic tumors ≤2 cm in size. Of these, 55 (17.2%) underwent initial mastectomy. Medical contraindications to breast conservation were identified in 42 of 319 (13.2%) patients, whereas the selection of mastectomy was attributed to patient choice in 13 of 319 (4.1%) patients.

Conclusions

Medical contraindications to breast-conserving therapy were much more common than patient choice as the indication for mastectomy. Institution- or surgeon-specific mastectomy rates are unlikely to reflect the complexity of decision making in the surgical management of patients with breast cancer.     

Gastric volvulus in children

Purpose

The aim of the study was to review the records of all children who presented with gastric volvulus in the past 10 years.

Methods

The study group consisted of 21 children with an age range from 0.2 months to 4.3 years who were operated for gastric volvulus from 1992 to 2003.

Results

Initial symptoms included acute abdominal pain after meals, vomiting, and in 8 cases, acute apnea associated with pallor, cyanosis, and hypotonia. After the first episode, barium studies revealed an organoaxial gastric volvulus in all cases. The surgical procedure was an anterior gastropexy with reinforcement of the esophagogastric angle performed by laparoscopy in 13 cases and by laparotomy in 8 (1 converted laparoscopy). An associated antireflux fundoplication was done in 3 patients. All children received postoperative antireflux medication for at least 1 month.The follow-up ranged from 4 months to 4.8 years. Two children in the laparotomy group required reoperation (Toupet fundoplication) for persistent gastroesophageal reflux disease. All children are currently symptom-free and without treatment.

Conclusions

Gastric volvulus is a clinical and radiological reality, which can be treated by a gastropexy. Initial fundoplication is not mandatory. The laparoscopic gastropexy is a good option and allows a repeat laparoscopic procedure if needed.     

American Pediatric Surgical Association New Technology Committee review on video-assisted thoracoscopic surgery for childhood cancer

Background/Purpose

Although the use of minimally invasive surgical (MIS) techniques for children with cancer is being practiced by some, its role remains unclearly defined. The purpose of this review was to describe the current literature on MIS for thoracic and mediastinal lesions in children.

Methods

We performed a literature search for English studies that evaluated MIS techniques for biopsy or resection in children with suspected or established cancer. Only studies with greater than 20 patients were included in the review.

Results

Ten studies were included for review. Each represented institutional retrospective reviews of experience. Seven were single-institution studies, and 3 were multi-institutional. There were no prospective nor randomized identified.

Conclusions

Based on primarily retrospective and observational data, the use of MIS for children with cancer who have pulmonary and mediastinal lesions seems to be effective and safe. Ideally, prospective studies are needed to evaluate this further.     

Is congenital lobar emphysema a surgical disease?

Background

The management of congenital lobar emphysema has traditionally been surgical. Because of increased use of imaging, this lesion is frequently found in asymptomatic and mildly symptomatic children, prompting us to adopt a more conservative approach to these children.

Methods

All children with congenital lobar emphysema presenting between 1995 and 2002 were included. Medical records, imaging files, and pathology reports were reviewed.

Results

Twenty children (0-17 years) were identified. Eight were diagnosed antenatally. Fourteen were managed without surgery. Of the 11 symptomatic children, 6 showed spontaneous improvement.

Conclusions

The favorable outcome of both asymptomatic and mildly symptomatic children suggests that a nonoperative approach should be considered in these patients.     

Sacrococcygeal teratoma--a 25-year experience in a UK regional center

Background

Sacrococcygeal teratoma (SCT) is uncommon (1:35,000-1:40,000 newborns). We report a 25-year single-center experience with a focus on late effects.

Methods

Surgical and tumor registries identified patients with SCT between 1977 and 2001. Perinatal data, associated anomalies, operative findings, histology, and survival were recorded. Continence was assessed clinically. Urodynamics and anorectal manometry were performed as indicated.

Results

Thirty-three patients (28 females) were treated for SCT. Before 1988, 2 of 18 were diagnosed antenatally compared with 8 of 15 between 1988 and 2001. Ten babies were delivered by cesarean birth. Seven children presented after the neonatal period. Surgery comprised tumor excision with coccygectomy. Histology was benign in 26 (79%), malignant in 6 (18%), and immature in a single patient. Presentation beyond the newborn period was associated with malignant disease and poorer outcome. Overall survival was 94%. Neuropathic bladder or bowel disturbance was identified in 7 of 20 patients on long-term follow-up.

Conclusions

Antenatal diagnosis of SCT appears to be increasing. Parental counseling should include the continence problems that may follow removal of even benign tumors. Resection by surgical oncologists and reconstruction by colorectal specialists may improve function. Follow-up by oncologists, surgeons, and urologists remains an important part of SCT management.     

Oncologic outcomes after resection of rectal cancer: Laparoscopic versus open approach

Background

This study examined outcomes of laparoscopic and open rectal cancer surgery in a community hospital setting.

Methods

A community health care system cancer registry was reviewed retrospectively (2004-2007) for rectal cancer patients undergoing surgical treatment. Primary end points were rates of recurrence and survival.

Results

Both open and laparoscopic resection groups had similar demographic, treatment, and tumor characteristics. Most patients in the open resection and laparoscopic resection populations experienced no recurrence (79% vs 83%, respectively; P = .5). Overall, the groups had similar mean (88% vs 96%, respectively; P = .4) and disease-free (21 and 23 months, respectively; P = .5) survival.

Conclusions

In a community hospital setting, laparoscopic resection of rectal cancer was found to be as safe and effective as open resection in selected patients.     

Outcomes after the Ladd procedure in patients with heterotaxy syndrome, congenital heart disease, and intestinal malrotation

Purpose

Heterotaxy syndrome (HS) patients often present with congenital heart disease and intestinal malrotation. Controversy exists regarding the management of these patients. Risk of midgut volvulus, morbidity from elective operations, and overall prognosis must be weighed when considering a Ladd procedure on asymptomatic HS/intestinal malrotation patients.

Methods

This is a retrospective review comparing HS and non-heterotaxy syndrome (NHS) patients undergoing a Ladd procedure at Children's Hospital Boston (Mass) from January 1997 to September 2007.

Results

Thirty-one HS and 51 NHS patients were identified. After a Ladd procedure, HS patients remained in the hospital 12.9 days, had a 9.7% risk of small bowel obstruction, and a 9.7% in-hospital mortality. If allowed to develop abdominal symptoms, 27% of HS patients with intestinal malrotation had a midgut volvulus at surgery. Intra-HS group comparison demonstrated longer hospital stays in symptomatic patients (P = .01). Mortality was greater in the HS than NHS patients, but deaths were related to cardiac disease and not to the Ladd procedure.

Conclusions

Elective Ladd procedures are well tolerated by HS patients. Given the risk of midgut volvulus and in light of improved survival beyond infanthood, once identified, HS patients with asymptomatic malrotation should be offered a prophylactic Ladd procedure.     

Laparoscopic excision of choledochal cyst and Roux-en-Y hepaticojejunostomy in symptomatic neonates

Purpose

Choledochal cysts require surgical excision, preferably before the onset of cholangitis. Recently, it has become feasible to accomplish the excision laparoscopically in adults and older children. Yet, whether laparoscopic excision of choledochal cyst can be performed safely in symptomatic neonates with choledochal cyst is unclear. We herewith reviewed our experience of laparoscopic excision of choledochal cysts in neonates.

Methods

We managed 9 neonates with choledochal cysts between April 2003 and February 2007. The choledochal cysts were excised laparoscopically. The Roux-en-Y hepaticojejunostomy was fashioned extracorporeally by exteriorizing the jejunum through the extended umbilical port site. End-to-side anastomosis between the common hepatic duct stump and Roux loop was carried out intracorporeally. The patients were followed up for an average of 26 months.

Results

The patients presented with jaundice, pale stool, and deranged liver function tests. The diagnosis was confirmed with ultrasonography postnatally. The median operation time was 3.6 hours. There was no operative complication and no conversion. The blood loss was minimal. The recovery was uneventful, and the median hospital stay was 6 days. The liver function tests normalized 3 to 16 weeks postoperatively. No complication was detected at the follow-up visits.

Conclusions

Our preliminary results show that laparoscopic excision of choledochal cyst and Roux-en-Y hepaticojejunostomy in neonates is both feasible and safe. It curtails further complication of the cysts and reverses the derangement of liver function. In addition, the laparoscopic approach minimizes surgical trauma.     

Inflammatory changes secondary to postoperative complications of Hirschsprung's disease as a cause of histopathologic changes typical of intestinal neuronal dysplasia

Purpose

The aim of this study was to clarify the pathogenesis of intestinal neuronal dysplasia (IND).

Methods

The bowel habits of 36 postoperative HD patients were assessed retrospectively. Twenty-five had no complaints. Seven had persistent enterocolitis and were the focus of our study. They were divided into group A (n = 2) if they were severe and had associated postoperative surgical complications, and group B (n = 5) if they were mild. The histological changes were assessed.

Results

The 7 patients who had persistent enterocolitis postoperatively had no AchE activity in the mucosa, and there was normal distribution of submucosal and myenteric ganglia in the proximal resection margin. Rectal biopsies performed postoperatively for investigation of persistent enterocolitis in group A showed inflammatory changes and typical histopathologic features of IND such as abundant acetylcholinesterase (AchE)-positive nerve fibers in the lamina propria associated with giant submucosal ganglia and hyperganglionosis, and in group B there was increased AchE activity without hyperganglionosis or giant ganglia.

Conclusions

This is the first report of histopathologic changes typical of IND occurring in response to persistent enterocolitis related to postoperative complications of surgery for HD.     

A prospective randomized controlled trial of simple Bascom's technique versus Bascom's cleft closure for the treatment of chronic pilonidal disease

Background

The aim of this study was to determine which of Bascom's simple techniques, Bascom's simple surgery or Bascom's cleft closure, is preferred in the management of moderate-severity pilonidal disease.

Methods

Fifty-five patients with chronic pilonidal disease were randomized to receive Bascom's simple surgery (n = 29) or cleft closure (n = 26) under local anesthetic. The primary end point was time to healing. Patients were followed up for a median of 3 years (range, .7-4 y).

Results

After Bascom's simple surgery, 5 of 29 patients did not heal and proceeded to cleft closure. The remaining patients healed at a median of 4 weeks (range, 3-35 wk). After cleft closure, 21 of 26 wounds healed primarily on removal of sutures at 10 to 13 days. The remaining 5 wounds healed at a median of 4.5 weeks (range, 2-5 wk). Fifty of 55 (91%) patients were contacted for follow-up evaluation, disease recurrence occurred in 2 of 24 after Bascom's simple surgery and in 0 of 26 after cleft closure.

Conclusions

Cleft closure offers more predictable healing than Bascom's simple surgery, with less need for re-operation. Disease recurrence is more prevalent after Bascom's simple surgery.