Thirty-day and 90-day hospital readmission after outpatient upper extremity hemodialysis access creation

Objective

Patients with end-stage renal disease have multiple comorbidities and are at increased risk for postoperative complications and resource utilization. Our goal was to determine the rate and causes of 30-day and 90-day hospital readmissions after the creation of outpatient hemodialysis access.

The effect of glossopexy on weight velocity in infants with Pierre Robin syndrome

Aim

In infants with Pierre Robin syndrome (PRS), mandibular distraction may be more advantageous than glossopexy as it not only relieves oropharyngeal airway obstruction but also reverses body growth retardation. Because no data are available on body weight velocity after glossopexy, we assessed longitudinally the body weight velocity in a cohort of children undergoing glossopexy.

Methods

The records of 48 infants with PRS undergoing glossopexy after unsuccessful nonoperative treatment between 1981 and 2005 were reviewed. Weight measurements were analyzed at 4 time-points: at birth, on admission for glossopexy, on admission for lysis of lip-tongue adhesion (TLA), and at follow-up. Weight velocity was assessed using Tanner's tables.

Main Results

Adhesion dehiscence occurred in 9 patients (18.7%). Lip-tongue adhesion resolved airway compromise in 36 infants (75%). Release of TLA was accomplished in 34 patients. Data on weight velocity from birth to follow-up (mean, 5.57 ± 0.59 years) were available for 31 patients. After glossopexy, mean body weight increased from the 9.7 ± 2.6th to the 17.5 ± 4.6th percentile (P > .05), whereas mean weight velocity increased from the 19.1 ± 4.9th to the 74.2 ± 4.7th percentile (P < .001). No temporal correlation was found between glossopexy and oropharyngeal dysphagia.

Conclusion

In infants with PRS, glossopexy is a valid alternative to mandibular distraction because it does not cause decline in body growth.     

Circumumbilical pyloromyotomy in the era of minimally invasive surgery

Background/purpose

No studies have investigated the cosmetic outcome of current approaches to pyloromyotomy in infants with hypertrophic pyloric stenosis. The purpose of this study was to evaluate the final appearance of the scar in patients undergoing circumumbilical pyloromyotomy.

Methods

During a 16-year period, 86 infants underwent circumumbilical pyloromyotomy at our institution. A detailed questionnaire was created to document the family members' perceptions of the esthetic appearance of the scar. Data were collected by telephone interview and at clinic visit. In addition, cosmesis was assessed by 5 staff members who scored blindly the esthetic outcome of the scars with comparative photographs, using a categorical scale.

Results

Fifty-seven families were tracked by telephone contact. In the family questionnaire, 100% of families reported an excellent or good scar. Of these, forty-one (72%) were available for cosmetic assessment. Follow-up ranged between 5 months and 15 years (mean, 6 years). The panel members ranked the scar, on average, as excellent or good for 90% of the patients. No assessor stated that a scar was unacceptable. Intra- and interobserver agreement was 0.72 and 0.78, respectively.

Conclusions

Overall satisfaction with the cosmetic outcome of circumumbilical pyloromyotomy is very high.     

Endovascular management of visceral artery aneurysms: When to watch,when to intervene?

Visceral artery aneurysms (VAA) include splanchnic and renal artery aneurysms. They represent a rare clinical entity, although their detection is rising due to an increased use of cross-sectional imaging. Rupture is the most devastating complication, and is associated with a high morbidity and mortality. In addition, increased percutaneous endovascular interventions have raised the incidence of iatrogenic visceral artery pseudoaneurysms (VAPAs). For this reason, elective repair is preferable in the appropriately chosen patient. Controversy still exists regarding their treatment. Over the past decade, there has been steady increase in the utilization of minimally invasive, non-operative interventions, for vascular aneurysmal disease. All VAAs and VAPAs can technically be fixed by endovascular techniques but that does not mean they should. These catheter-based techniques constitute an excellent approach in the elective setting. However, in the emergent setting it may carry a higher morbidity and mortality. The decision for intervention has to take into account the size and the natural history of the lesion, the risk of rupture, which is high during pregnancy, and the relative risk of surgical or radiological intervention. For splanchnic artery aneurysms, we should recognize that we are not, in reality, well informed about their natural history. For most asymptomatic aneurysms, expectant treatment is acceptable. For large, symptomatic or aneurysms with a high risk of rupture, endovascular treatment has become the first-line therapy. Treatment of VAPAs is always mandatory because of the high risk of rupture. We present our point of view on interventional radiology in the splanchnic arteries, focusing on what has been achieved and the remaining challenges.     

Could post-liver transplantation course be helpful for the diagnosis of so called cryptogenic cirrhosis?

Cryptogenic cirrhosis (CC) is diagnosed in 5-30% of cirrhotic patients overall and 7% of patients who undergo liver transplantation for cirrhosis. In our series of patients transplanted for CC, pre-transplant clinical and histological data and the post-transplant course were reexamined in an attempt to identify the aetiology. Among the 881 patients transplanted in our centre between 1987 and 2000, 28 patients with a median age of 46 yr (range: 18-69) at transplantation were initially classified as having CC. Two patients were excluded because of intense ischaemic lesions caused by chemoembolization prevented histological analysis of the native liver (n = 1) and because of cryptic HBV infection (n = 1). Among the remaining 26 patients, four groups were individualized: (i) patients with chronic inflammatory liver disease with autoimmune features (n = 14, 54%); (ii) patients with features suggestive of non-alcoholic fatty liver disease (n = 3, 11.5%); (iii); patients with incomplete septal cirrhosis (ISC) and vascular liver disease (n = 3), and (iv) patients with unresolved CC (n = 6, 23%). In the autoimmune liver disease group, the median International Autoimmune Hepatitis score was 12.5 (range: 11-19) after reevaluation and review of the post-transplantation course was helpful to confirm the diagnosis with the occurrence of active graft hepatitis in nine patients, with autoantibodies in five patients. The vascular group was characterized by lesions of obliterative portal venopathy and ISC in all native livers. Diagnosis of NAFLD was based on the clinical background of obesity and/or type 2 diabetes and the presence of steatosis or steatohepatitis in native livers and graft biopsies. A definite aetiological diagnosis can be achieved in the majority of patients initially diagnosed with CC. Autoimmune liver disease emerged as the main aetiology (14 of 26 patients, 54%) and frequently recurred on the grafted liver (nine cases). In all cases a precise diagnosis is obviously of practical interest for better management of post-transplant survey and treatment.     

Clinical and radiological outcome of anterior–posterior fusion versus transforaminal lumbar interbody fusion for symptomatic disc degeneration: a retrospective comparative study of 133 patients

Abundant data are available for direct anterior/posterior spine fusion (APF) and some for transforaminal lumbar interbody fusion (TLIF), but only few studies from one institution compares the two techniques. One-hundred and thirty-three patients were retrospectively analyzed, 68 having APF and 65 having TLIF. All patients had symptomatic disc degeneration of the lumbar spine. Only those with one or two-level surgeries were included. Clinical chart and radiologic reviews were done, fusion solidity assessed, and functional outcomes determined by pre- and postoperative SF-36 and postoperative Oswestry Disability Index (ODI), and a satisfaction questionnaire. The minimum follow-up was 24 months. The mean operating room time and hospital length of stay were less in the TLIF group. The blood loss was slightly less in the TLIF group (409 vs. 480 cc.). Intra-operative complications were higher in the APF group, mostly due to vein lacerations in the anterior retroperitoneal approach. Postoperative complications were higher in the TLIF group due to graft material extruding against the nerve root or wound drainage. The pseudarthrosis rate was statistically equal (APF 17.6% and TLIF 23.1%) and was higher than most published reports. Significant improvements were noted in both groups for the SF-36 questionnaires. The mean ODI scores at follow-up were 33.5 for the APF and 39.5 for the TLIF group. The patient satisfaction rate was equal for the two groups. This work is dedicated to the memory of Grace and Julia Hanson.     

Cervical degenerative index: a new quantitative radiographic scoring system for cervical spondylosis with interobserver and intraobserver reliability testing

Background  The lack of a widely available scoring system for cervical degenerative spondylosis encouraged the authors to establish and validate a systematic quantitative radiographic index. Materials and methods  This study included intraobserver and interobserver reliability testing among three reviewers with different years of experience. Each observer independently scored four cervical radiographs of 48 patients at separate intervals, and statistical analysis of the grading was performed. Results  There was high intraobserver and interobserver reliability between the two experienced observers. There was fair reliability between the less experienced observer and the more experienced observers. Conclusions  The cervical degenerative index appears to be a reliable and reproducible radiographic assessment of cervical spondylosis. The index will have direct applicability for longitudinal study of cervical spondylosis and may be clinically relevant as well.     

Efficacy of left thoracoscopy and blunt mediastinal dissection during the Nuss procedure for pectus excavatum

Background/Purpose

The minimally invasive Nuss procedure is emerging as the preferred technique for repair of pectus excavatum. Original methods of pectus bar placement have been modified to improve safety and efficacy and avoid cardiothoracic complications. The currently reported modifications to facilitate retrosternal pectus bar placement include routine use of right thoracoscopy or a subxiphoid incision. The purpose of this article is to describe additional modifications of the Nuss procedure to improve safety and efficacy.

Methods

A retrospective analysis was performed on 51 patients who have had a thoracoscopic-assisted Nuss procedure at The Children's Hospital, Denver, Colo, between 1999 and 2002. Technical modifications included patient positioning, routine use of left thoracoscopy, and an Endo-kittner.

Results

Fifty-one patients have successfully undergone the Nuss procedure using the new modifications. Surgical time ranged from 45 to 120 minutes. There have been no intraoperative or postoperative bleeding complications. There have been 2 large pneumothoraces requiring needle thoracenteses in the operating room before extubation. No chest tubes were required postoperatively. Subjectively, all patients have been satisfied with their surgical correction. Average length of hospital stay was 4 to 6 days.

Conclusions

By using left chest thoracoscopy and Endo-kittner dissectors, the risk of cardiothoracic injury can be eliminated. Moreover, other methods to ensure safe substernal dissection are unnecessary.