Surgical management of giant intracranial aneurysms

OBJECTIVES: The natural history of giant intracranial aneurysms is generally morbid. Mortality and morbidity associated with giant aneurysms is also higher than for smaller aneurysms. This study was carried out to assess the demographic profile, presenting features, complications, and outcome after surgical treatment of giant intracranial aneurysms. PATIENTS AND METHODS: A retrospective review of the medical records of all patients with giant intracranial aneurysms treated in the Department of Neurosurgery, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, from January 1995 through June 2007 was performed. The demographic profiles, presenting features, radiological findings, surgical treatments, and outcomes were assessed. RESULTS: A total of 1412 patients harboring 1675 aneurysms were treated. Out of these, 222 patients had 229 (13.7%) giant aneurysms, and of those, 181 aneurysms in 177 patients were managed surgically while 48 were treated with endovascular therapy. In the patients treated with surgery, common clinical presentations included subarachnoid hemorrhage (SAH) in 110 (62%) cases followed by mass effect in 57 (32%) cases. In patients who presented with SAH, the Hunt and Hess SAH grading was: grade I in 43 (39%), grade II in 40 (36%), grade III in 23 (21%), grade IV in two (2%), and grade V in 2 (2%) patients. One hundred and seven aneurysms (in 103 patients) were treated using direct surgical clipping. Forty-six patients with good collateral circulation were treated by gradual occlusion and ligation of the internal carotid artery (ICA) in the neck with a Silverstone clamp. Another nine patients with good collateral circulation, but persisting symptoms after ICA ligation, required trapping for obliteration of the aneurysm. Eleven patients with poor collateral circulation required extracranial-intracranial (EC-IC) bypass before proximal ICA ligation. A post-operative digital subtraction angiography (DSA) was performed in 118 patients and revealed well-obliterated aneurysm in 106 patients. The total treatment mortality rate was 9%. In the last 5 years, 117 patients were operated on with four operative deaths. Overall, the outcome was excellent in 131 (74.0%), good in 22 (12.4%), and poor in eight (4.5%) cases. CONCLUSIONS: It is concluded that 14% of all intracranial aneurysms are giant. The most common clinical presentation is SAH followed by features of an intracranial mass lesion. The cavernous ICA is the most common portion of the ICA affected. Direct surgical clipping is a safe and effective method of treatment and should be considered the first line of treatment whenever possible. With proper case selection, optimal radiological evaluation, and appropriate surgical strategy, it is possible to achieve a favorable outcome in almost 90% of the cases.     

Elastic stable intramedullary nailing of tibial shaft fractures in children

Most pediatric tibia shaft fractures are amenable to nonoperative treatment with satisfying results, yet surgical stabilization is necessary in certain cases. The purpose of our study was to determine the effectiveness and the complications associated with elastic stable intramedullary nailing in severe pediatric tibial fractures. We retrospectively reviewed 24 tibia shaft fractures in 24 patients that were treated operatively by elastic stable intramedullary nailing between 1997 and 2005 at our institution. Extensive review of all charts and radiographic data was completed at Cincinnati Children's Hospital Medical Center. There were 8 closed and 16 open fractures. The average union time for all tibia fractures was 20.4 weeks. The average union time for closed and open fractures was 21.5 and 20.2 weeks, respectively. Complications include 2 (8%) neurovascular, 2 (8%) infections, 2 (8%) malunions, and 1 (4%) leg-length discrepancy. Although complications do exist, elastic stable intramedullary nailing of pediatric tibia shaft fractures using Nancy nails is an effective treatment option.     

Pseudoaneurysm after Ponseti percutaneous Achilles tenotomy: a case report

The Ponseti method has become a popular technique to treat idiopathic clubfoot. In most cases, a percutaneous Achilles tenotomy is required to correct residual equinus contracture. Bleeding has been reported as a complication of percutaneous tenotomy. We present a case of a baby who developed a pseudoaneurysm after undergoing an appropriate Ponseti percutaneous Achilles tenotomy at the age of 8 weeks. The diagnosis of pseudoaneurysm was confirmed by color ultrasonography, which showed active flow in the base of the mass. This complication has not been previously described after Ponseti percutaneous Achilles tenotomy. The large pseudoaneurysm mass together with an incomplete correction made bracing with straight last shoes and Denis Browne bar impossible, and the patient developed an immediate relapse of the clubfoot deformity. The relapsed deformity was successfully treated with 4 weeks of additional Ponseti casting, with an emphasis on applying pressure over the pseudoaneurysm by molding the cast. Repeat ultrasonogram at that time showed that the pseudoaneurysm completely resolved, making invasive treatment of the pseudoaneurysm unnecessary. Physicians should be aware that vascular injury could lead to pseudoaneurysm after performing this otherwise simple office procedure.     

Gender and age differences in blood utilization and length of stay in radical cystectomy: a population-based study

Objective  Radical cystectomy is a major surgical procedure associated with significant blood loss and lengthy hospital stays. This surgical procedure is more challenging in women than men due to anatomical-based differences. We evaluated resource utilization and complication rates of patients undergoing radical cystectomy or exenteration using the Texas Hospital In-Patient Discharge Data Collection. Methods  This was a retrospective study of 1,493 patients, 35 years of age or older, who underwent radical cystectomy for bladder cancer from January 2000 to December 2003. We evaluated blood product charges, length of stay, and complication rates during hospitalization. Results  In this sample, 24% of the patients (n = 356) were women. Overall, women had significantly increased blood product charges and length of stay compared to men, $1,392.87 vs. $718.21 (P < 0.001) and 12.72 vs. 11.64 (P = 0.03), respectively. During hospitalization, 26 of the patients died. No differences in mortality or complication rates were observed between men and women. Multivariate analysis showed that female sex (P < 0.001) and age (P = 0.003) were independent predictors of increased blood product charges. Multivariate analysis showed that female sex (P = 0.015), age (P = 0.003), and Charlson’s comorbidity index >1 (P = 0.05) were predictors of longer length of stay. Conclusion  Women and older patients with bladder cancer are at risk of increased blood products utilization and length of hospital stay after a radical cystectomy. Appropriate postoperative care and referrals should improve postoperative outcomes for these vulnerable patients.     

A Pilot Study on the Role of T-Tube in Typhoid Ileal Perforation in Children

BACKGROUND: Ileostomy is usually performed for patients of typhoid intestinal perforation with poor general condition, but it is associated with significant morbidity. We have used the T-tube in such patients as an alternative to ileostomy. METHODS: This is a prospective evaluation of a cohort of children with proven typhoid intestinal perforation. Patients with multiple perforations and poor general condition were managed with a T-tube inserted into the bowel lumen after closing all distal perforations (group 3). They were compared with patients who had primary closure of perforation (group 1) or bowel resection (group 2) to determine the efficacy of the use of T-tube. RESULTS: The total number of patients for groups 1, 2, and 3 was 51, 4, and 12 (n = 67). The mean number of perforations for the three groups was 1, 3.5 +/- 0.58, and 4.25 +/- 0.97. The operation time for the three groups was 37.29 +/- 3.24, 59.25 +/- 3.09, and 59.17 +/- 4.17 minutes, respectively. The T-tube was removed after 13.17 days. The mean duration of fistula at T-tube site to heal was 8.58 +/- 2.11 days. The overall follow-up period was 10.94 +/- 1.15 months and none of the patients with T-tube placement had features of intestinal obstruction. CONCLUSIONS: In children with multiple typhoid intestinal perforations and poor general condition, the use of T-tube may be an effective management option.     

Ligamentotaxis for complex calcaneal fractures using Joshi's external stabilization system

Background:

Controversies exist in the literature regarding the management of complex fractures of the calcaneum. We evaluated a series of complex fractures of the calcaneum managed by ligamentotaxis using Joshi''s external stabilization system (JESS) for its efficacy.

Materials and Methods:

Forty-five patients having complex (comminuted, intra-articular fracture with compromised soft tissue condition) fractures of the calcaneum, who were treated by external fixator (JESS) based on the principle of ligamentotaxis. The gradual distraction was done to bring the articular margins together to maintain both alpha and beta angles to near normal range. Thirteen (28.9%) patients underwent additional corticocancellous bone grafting with elevation of posterior facet. All patients were evaluated for their functional outcomes by American Orthopedic Foot and Ankle society (AOFAS) Score for the ankle and hind foot. Mean duration of follow-up was 20.5 months.

Results:

Forty-two (93.4%) of our patients did well with the ligamentotaxis. On evaluating final outcomes by AOFAS, approximately 71% of cases showed good results. Eleven patients (24.4%) complained of persistent heel pain in the long-term follow-up. Out of these, eight (17.8%) patients were those who had severe comminution with almost total loss of calcaneal height. The origin of heel pain was not the subtalar joint in all of these patients.On long-term follow-up none of these patients suffered from such severe pain so as to compel them to change the nature of their activity.

Conclusion:

We conclude that ligamentotaxis by JESS provides a viable and user-friendly alternative method of management of these complex calcaneal fractures.     

Single-stage repair for rectovestibular fistula without opening the fourchette

Background

Anorectal malformations are one of the most common congenital defects. This study is conducted to demonstrate new technique for treatment of rectovaginal fistula without disturbing the fourchette through posterior sagittal approach.

Method

All the patients of rectovestibular fistula admitted after the neonatal age were treated with posterior sagittal anorectoplasty without opening the fourchette. The results were evaluated for cosmetic appearance and anal continence.

Result

A total of 40 patients were included in our study. All patients were more than 1 month old. Operative time ranges from 70 to 150 minutes. The cosmetic appearance was good. Anal continence was good in 72% cases and fair in 20% cases. Fifteen percent of patients had minimal constipation and 7.5% patients had mucosal prolapse.

Conclusion

Single-stage repair for vestibular anus through posterior sagittal anorectoplasty without opening fourchette has a good cosmetic appearance and good anal continence.     

Use of fibrin glue in preventing urethrocutaneous fistula after hypospadias repair

Urethrocutaneous fistula is one of the most common complications after hypospadias surgery.The incidence of fistula development has varied from 4% to 20% in larger series. We sought to investigate the role of fibrin glue (Tisseel manufactured by Baxter India Pvt Ltd, Chennai, India) to reduce the chances of fistula formation in cases in proximal penile hypospadias.

Method

A total of 120 patients with proximal penile hypospadias (patients having urethral meatus at posterior third of penile shaft and at penoscrotal junction) were included in the present study. Patients were randomly allocated into 2 groups of 60 each by using Strata 9 software random number table. In group A, fibrin glue was used as a sealant after hypospadias surgery, whereas in group B, no sealant was used. All the operations were performed by single surgeon using transverse preputial tubularized island flap urethroplasty.

Result

Fistula formation occurred in 6 cases in group A (10%) and 19 cases in group B (32%) (P = .027). The fistulae observed in fibrin glue group A were single and small in size (<1 mm). Multiple (≥2 fistulae) and larger fistulae (>2 mm) were observed in group B. Overall complication was significantly higher in group B (P = .006).

Conclusion

Fibrin glue in hypospadias repair does not eliminate fistula formation. However, it seems that it minimizes the incidence of fistula formation.