Iatrogenic recto-urethral fistula: perineal repair and buccal mucosa interposition

OBJECTIVE

To present a new and promising technique for repairing recto‐urethral fistulae (RUF) using a perineal approach and buccal mucosa graft interposition, as RUF are rare but severe complications of rectal or urinary tract surgery, radiation treatment, trauma or inflammation, and the repair of recurrent or persistent RUF is particularly difficult when previous surgical attempts have failed, resulting in high recurrence rates.

PATIENTS AND METHODS

Between 2004 and 2006, five men (aged 61–67 years) with iatrogenic RUF had the perineal fistula closed using a buccal mucosa graft interposition. The RUF had developed after laparoscopic or retropubic radical prostatectomy in four patients and after radical cystectomy and ileal neobladder in the fifth. Four of the patients had had at least one failed RUF repair before their referral to our institution.

RESULTS

Four of the five RUF were repaired successfully using the perineal approach and buccal mucosa graft interposition. Failure occurred in one patient who had developed a RUF after laparoscopic radical prostatectomy followed by two unsuccessful attempts at closure. The failure was most probably due to a previously undetected postoperative perineal haematoma with infection.

CONCLUSION

Our perineal approach for repairing RUF, combined with buccal mucosa graft interposition, is a simple technique fulfilling all the requirements for successful fistula closure, especially in repeat surgery.     

Reoperative lower extremity revascularization with cadaver vein for limb salvage

We evaluated our experience using cryopreserved cadaver vein allografts (CVGs) for infrageniculate revascularization in patients with a history of failed bypass or no suitable autogenous vein. Records of all patients who underwent lower extremity revascularization with CVG for critical limb ischemia were reviewed. Patient demographics, vessel treated, and postoperative course were analyzed. Patients who had a redo cadaver vein bypass were compared to those with a first-time cadaver vein bypass. Cumulative patency rates, limb salvage, mortality, and factors associated with outcomes were determined using the Kaplan-Meier method with Cox proportional hazards. Between January 2000 and December 2006, 66 CVGs were done in 56 patients out of 1,726 total bypasses. There were 36 men and 20 women, and the mean age was 71.67 +/- 10.50 years. Mean follow-up was 12.12 +/- 14.16 months. Seventy-eight percent of patients had previous bypasses, and 50% of all failed bypasses were failed expanded polytetrafluoroethylene bypasses. Operative indications were tissue loss (73%) and ischemic rest pain (27%). The mean preoperative ankle-brachial index was 0.43 +/- 0.16, and this increased to 0.89 +/- 0.18 at 30 days (p = 0.001). Procedure-related complications included graft infection (3, 4%), graft thrombosis (3, 4%), pseudoaneurysm (3, 4%), and bleeding (2, 3%). Cumulative 1-year primary, primary assisted, secondary patencies, limb salvage, and survival rates with confidence intervals were 0.19 (0.10-0.36), 0.29 (0.18-0.47), 0.42 (0.29-0.60), 0.73 (0.62-0.86), and 0.77 (0.65-0.90). Reoperative procedures fared the same as primary procedures. Multivariable analysis showed that predictors for increased risk of secondary patency loss were age >70 (hazard ratio [HR] = 3.13, p = 0.009) and patients with secondary revascularization (HR = 3.36, p = 0.015). Older patients (HR = 2.92, p = 0.042) and those with renal insufficiency (HR = 2.92, p = 0.019) were at increased risk of mortality. CVG remains an option for reoperative lower limb revascularization for limb salvage if there is no autogenous vein available. However, patency rates are poor, and patients older than 70 are more likely to have inferior outcomes.     

Caveat arthroplasty

Caveat arthroplasty is arthroplasty undertaken to treat a presumed nonneoplastic disorder, which is later determined to be secondary to an extraarticular tumor. We identified 6 patients who had caveat arthroplasty before referral to our orthopedic oncology center. Three patients had completed arthroplasties at an average of 29 weeks before discovery of a neoplasm. Three arthroplasties were aborted after a neoplasm was discovered intraoperatively. Prearthroplasty radiographs of 4 patients were reviewed, all demonstrating evidence of malignancy. Caveat arthroplasty may be avoided if malignancy is considered preoperatively, particularly in patients with atypical symptoms, histories of cancer, and rapid periarticular bone loss. If a neoplasm is discovered intraoperatively, the arthroplasty should be aborted. Patients in whom malignancy is suspected should be referred to a musculoskeletal oncologist.     

The Effects of botulinum toxin A on muscle histology during distraction osteogenesis

Distraction osteogenesis is a highly successful method of bone formation, yet muscle fibrosis and contractures can result in significant morbidity. In the current study, we investigate the efficacy of botulinum toxin A in preventing fibrosis and potentially increasing muscle development in distracted muscles. Fifteen New Zealand White rabbits underwent tibial distraction at 1.5 mm/day until a 20% gain was achieved. Treatment groups were divided by drug (saline or botulinum toxin) and target muscle (gastrocnemius or tibialis anterior). Two additional control animals received no treatment. Bromeodeoxyuridine was delivered continuously throughout the 8‐week experiment, and following muscle harvest. Tissues were stained for BrdU, Pax‐7, vimentin, and haematoxylin and eosin staining. Mitotic activity increased in all distracted animals; however, in the animals receiving botulinum toxin A injections into the gastrocnemius, the antagonist tibialis anterior suffered up to 9% less fibrosis than distraction alone (p = 0.024). Use of botulinum A toxin did not appear to promote or improve neogenesis of muscle fibers, nor did it decrease fibrosis in the injected muscles. It appears from this study, and a previously published study on the effects of this toxin on muscle function, that botulinum A toxin maybe of some benefit in decreasing morbidity in the antagonist muscle but not the muscle injected with the toxin. © 2008 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 27:310–317, 2009     

Profilaxis antibiótica en la biopsia transrectal de próstata

IntroductionTransrectal ultrasound-guided needle biopsy of the prostate is a safe technique, but it is not complication-free, and its most serious complications are genitourinary infections (GUI) and the conditions they cause. The purpose of antibiotic prophylaxis is to reduce this GUI incidence rate. However, no established guidelines exist and there are significant differences among centres where this procedure is performed. The objective of the present report is to review antibiotic prophylaxis protocols described in the literature.Material and methodsWe reviewed indexed articles published in English or Spanish and accessible through literature databases.ResultsFive articles comparing antibiotic prophylaxis with a placebo observe lower bacteriuria and infectious complications percentage rates in the group receiving prophylaxis. In most cases, E. coli is the microorganism responsible for infection. Oral quinolones are the most commonly prescribed prophylactic antibiotics. Three studies of oral vs. parenteral prophylaxis found no differences between the two groups. Three other articles comparing short term and single-dose prophylaxis found no differences between the two groups.ConclusionsAdministering prophylactic antibiotics is more advantageous than not doing so. The moment for beginning prophylaxis depends on the antibiotic's bioavailability and how it is administered. The chosen antibiotic will preferably be administered orally as a single dose or short term course, according to the sensitivities of prevalent microorganisms. More studies are needed to determine what role pre-biopsy enemas play in reducing infectious complications.     

Patterns of readmission and reoperation within 90 days after Roux-en-Y gastric bypass

BackgroundHealth insurance payors harbor concerns regarding the cost of bariatric procedures that are chiefly related to early readmissions and reoperations. We have attempted to identify the avoidable causes of readmission.MethodsWe retrospectively reviewed the indications for short-term (<90-d) emergency department (ED) visits, readmissions, and reoperations from August 2004 through May 2007 for patients undergoing primary Roux-en-Y gastric bypass (RYGB) for morbid obesity at a tertiary care teaching hospital. The electronic medical record of the primary hospital was reviewed, as well as the electronic medical records of 9 local hospitals serving the area, allowing the incorporation of data from 35 locoregional hospitals.ResultsA total of 1222 consecutive patients underwent RYGB, 1051 laparoscopically. Of these 1222 patients, 173 had 252 ED visits, readmissions, and/or reoperations; 147 (58%) visits were to the primary institution and 105 (42%) occurred at a local or regional hospital. No age difference was found between the patients who underwent ED visits, hospital readmissions, or reoperations and those who did not (mean age 43 yr for both groups, P > .05). Patients who were seen in the ED, readmitted to the hospital, or underwent reoperation had had a greater body mass index (50 kg/m² versus 48 kg/m², P = .001). On average, the readmissions occurred 27.3 days (range 2–88) postoperatively, and the mean hospital length of stay for readmitted patients was 3.3 days (range 1–16). Patients who presented for ED visits, readmission, or reoperations were more likely to have undergone open RYGB than laparoscopic RYGB (P = .002). The <90-day all-cause ED visit, readmission, and reoperation rate was 21% (n = 252). Considering all 1222 patients, the incidence of nausea, vomiting, and dehydration, abdominal pain, and wound issues was 5% (n = 65), 4% (n = 50), and 2% (n = 21), respectively. Considering only the 173 patients with ED visits, readmissions, or reoperations (n = 252), the admitting diagnosis was nausea, vomiting, and dehydration in 26%, abdominal pain in 20%, and wound issues in 8%. The unemployed, disabled, or retired were more likely to have been seen in the ED or readmitted compared with the employed, nondisabled, or not retired (P = .01).ConclusionA considerable number of patients are affected by nausea, vomiting, and dehydration, abdominal pain, and wound issues <90 days postoperatively. Socioeconomic and functional status might have an effect on the rate of ED visits and readmissions. By ensuring that the appropriate outpatient mechanisms for management of these problems are available, early ED visits and readmission rates should significantly decrease.     

How successful is the conservative management of pelvi‐ureteric junction obstruction in adults?

OBJECTIVE

To assess the conservative management of pelvi‐ureteric junction obstruction (PUJO), according to severity, accepted in paediatric urology but rarely reported in adults.

PATIENTS AND METHODS

A series of 23 patients (median age 58 years, 17 men and six women) with asymptomatic or minimally symptomatic PUJO were managed conservatively. The patients’ age, preference and comorbidities were considered. The diagnosis of PUJO was based on intravenous urography and isotopic renography. After stringently reviewing the renograms based on relative renal function (RRF) and output efficiency (OE), 15 patients had an OE consistent with definitive PUJO. One patient had no further imaging due to associated comorbidities. Ten patients had right PUJO, three left and one with bilateral PUJO, with unilateral conservative management. The follow‐up included annual renography and clinical consultation. Laparoscopic pyeloplasty was considered for patients with a >10% loss of RRF and/or <40% RRF during the follow‐up.

RESULTS

Overall, 14 of 15 patients had renograms during the follow‐up. The mean RRF of the affected kidney at diagnosis was 48.6% which marginally decreased to 46.7% after a median (range) follow‐up of 44 (23–75) months. The RRF of 11 patients remained stable and in three decreased significantly (median 11% RRF), requiring pyeloplasty. None of the patients became symptomatic throughout the follow‐up.

CONCLUSION

In asymptomatic adults the conservative management of PUJO appears to be safe during a short‐ to medium‐term follow‐up. We recommend that patients are regularly followed with renography and seen promptly should they become symptomatic. A longer follow‐up is needed in a larger group to confirm these findings.     

The operative treatment of pressure wounds: a 10‐year experience in flap selection

This study sought to both assist in the selection of flaps for ischial pressure wound reconstruction and evaluate the overall complication rates associated with reconstruction. A retrospective medical record review was conducted for 78 patients following the surgical reconstruction of an ischial pressure sore. Records were reviewed for demographics, location of sores, methods of reconstruction and flap selection, as well as any complications and recurrences. A total of 72 wounds were reconstructed with an average of 1·4 flaps used per wound. An ischial flap complication rate of 16% was observed in flap follow‐up, with a recurrence rate of 7% recorded. The vast majority of complications went on to heal with 15% of patients requiring a second reconstruction. Our relatively large sample of ischial flaps allowed for a close comparison with previously published work. Both flap selection and site of reconstruction significantly affected the success rates for pressure sore coverage. The overall complication rates by flap and reconstructive site in this review are lower than previously published reports. Our experience with ischial reconstruction was extensive enough to suggest a posterior medial thigh fasciocutaneous flap combined with a biceps femoris muscle flap as a first choice in ischial pressure wound reconstruction.     

Leukocyte Depletion in Allogeneic Blood Transfusion Does Not Change the Negative Influence on Survival Following Transthoracic Resection for Esophageal Cancer

Background  Perioperative transfusion of allogeneic blood has been hypothesized to have an immunomodulatory effect and influence survival in several cancer types. This study evaluates the association between receipt of leucocyte-depleted and non-depleted allogeneic blood and survival following esophagectomy for cancer. Methods  A retrospective analysis was performed including 291 patients with esophageal cancers who underwent transthoracic en bloc esophagectomy and extended mediastinal lymphadenectomy. Neoadjuvant chemoradiation was administered in 152 (52.2%) patients. Perioperative blood transfusions were quantified and the potential prognostic cutoff for transfused units was calculated according to LeBlanc. Results  The median number of perioperative blood transfusions was 2 (0–24), and 106 patients (36.4%) received no transfusions. Patients with one or less blood transfusion showed a significantly improved survival compared to patients receiving more than one unit (p < 0.009). In multivariate analysis, blood transfusion categories showed significance (p < 0.015) next to pT, pN, pM category, and residual tumor categories (R-categories). Separate analysis of 183 patients treated after the mandatory introduction of leukocyte-depleted blood transfusions detected a strong tendency, but no significant difference in survival for patients getting one or less or more than one transfusion (p = 0.056). Receipt of leukocyte-depleted versus non-depleted units, however, had no influence on survival (p = 0.766). Conclusions  The need for perioperative allogeneic blood transfusions is significantly associated with poorer survival following resection for esophageal cancer by univariate and multivariate analysis. Our data suggest that the reduction of leukocytes in allogeneic transfusions is not sufficient to overcome the negative influence on survival. This paper was presented at DDW 2008 in the San Diego Convention Center, San Diego, CA, May 17–22, 2008.