Management of post-traumatic arterial priapism in children: Presentation of a case and review of the literature

In this article, a 9-year-old boy with arterial priapism is presented. The patient was managed with the conservative measures including imipramine hydrochloride and a favorable outcome was achieved after 2 months of follow-up. The pathophysiology, diagnostic tools and treatment alternatives are discussed.     

Transosseous capsuloplasty improves the outcomes of Lindgren–Turan distal metatarsal osteotomy in moderate to severe hallux valgus deformity

Introduction

Lindgren–Turan osteotomy used in hallux valgus deformity is a subcapital, transverse displacement osteotomy of the first metatarsal without any additional capsular repair. The aims of this study are to describe a transosseous capsuloplasty technique in this procedure and evaluate whether capsuloplasty would improve the clinical and radiological outcomes in patients with moderate to severe hallux valgus deformity.

Methods

Twenty-three feet operated by Lindgren–Turan osteotomy (Group B) and 25 feet operated by the same osteotomy combined with transosseous capsuloplasty (Group A) were evaluated retrospectively for the correction of the hallux valgus, intermetatarsal and distal metatarsal articular angles, sesamoid reduction, American Orthopaedic Foot and Ankle Society (AOFAS) Clinical Rating Scale as well as patient satisfaction. The mean postoperative follow-up was 14 (range 12–28) months.

Results

All radiological parameters improved considerably as a result of both groups. However, postoperative improvements in intermetatarsal and distal metatarsal articular angles were greater in Group A. Complete reduction of medial sesamoid was achieved in 52% of patients in Group A, whereas 17.4% of patients in Group B had complete reduction. AOFAS scores and number of patients with complete satisfaction in Group A were significantly greater than that in Group B.

Conclusion

Better clinical and radiological outcomes can be achieved in patients with moderate to severe hallux valgus deformity operated by Lindgren–Turan distal metatarsal osteotomy, when it combines with transosseous capsuloplasty.     

Reduction of the sinotubular junction in patients undergoing ascending aortic replacement with coexisting aortic insufficiency

Abstract Background and Aim of the Study: Dilatation of the STJ may cause consequent aortic insufficiency (AI) in patients with normal aortic valve, in patients with ascending aortic aneurysm. In this study, we analyzed the results of ascending aorta replacement with STJ diameter reduction to correct consequent AI in patients with ascending aortic aneurysm. Methods: Forty‐five consecutive patients who had ascending aortic aneurysm underwent replacement of ascending aorta with reduction of the STJ diameter to correct AI. Mean age of the patients was 61.3 ± 5.2. Twenty‐six (57.8%) were female. Six patients had arch aneurysm. Postoperative echocardiographic studies were performed at discharge and annually thereafter. The mean duration of follow‐up was 4.6 ± 2.9 years. Results: Hospital mortality rate was 4.9% (n = 2). Three patients died during follow‐up. Three patients had late recurrence of AI that was caused by aortic root dilatation. One of these patients required aortic valve replacement because of severe aortic insufficiency. The five‐year survival and survival free from aortic insufficiency were 91.4%± 5.0% and 91.2%± 5.1%, respectively. Conclusions: Reduction of the diameter of STJ can be used to treat AI in patients with ascending aortic aneurysm with nearly normal aortic cusps. Midterm results of this procedure are encouraging. (J Card Surg 2011;26:88‐91)     

Lumbar intraradicular disc herniation: report of a rare and preoperatively unpredictable case and review of the literature.

BACKGROUND CONTEXT: Intraradicular lumbar disc herniation is rare, having been reported to date in only three postoperative patients. The diagnosis is typically made intraoperatively. PURPOSE: To report a fourth case of intraradicular disc herniation, to emphasize its radiological characteristics and operative findings. STUDY DESIGN: Case report. PATIENT SAMPLE: A 41-year-old female. METHODS: Retrospective case review. RESULTS: The patient underwent a second operation and intraradicular disc fragment was removed. She was completely well at her 9-month check up. CONCLUSIONS: The diagnosis, mechanism, and surgical treatment of intraradicular lumbar disc herniation are reviewed. The round shape of the sequestrated fragment, as seen on magnetic resonance imaging, may help to establish the correct diagnosis.     

Effects of resterilization on mechanical properties of polypropylene meshes

BACKGROUND: The re-use of sterile packaged polypropylene meshes in hernia surgery is not recommended by the manufacturers. However, especially in developing and underdeveloped countries, many surgeons are obliged to re-use the mesh pieces after resterilization because of economic problems. The purpose of this study was to determine the effects of ethylene oxide and autoclave resterilization on the mechanical properties of polypropylene meshes. METHODS: Repetitive ethylene oxide gas and autoclave sterilizations were applied to polypropylene meshes (Herniamesh S.r.l., San Mauro, Italy) up to 3 times and the effects on the mechanical properties were examined. Gas resterilizations were applied for 4.5 hours at 55 degrees C, whereas for autoclave resterilizations the specimens were kept at 134 degrees C and 3 atm pressure for 64 minutes. Ethylene oxide gas-sterilized samples were labeled as G(n) and autoclave-sterilized samples were labeled as A(n). Effects of the resterilizations on maximum load (Fmax), elongation at maximum load (deltaL), and energy required for complete failure of the specimen (E) were measured. RESULTS: Fmax in the groups showed no significant differences. DeltaL values of groups A2, A3, and G3 were found to be significantly lower in comparison with the control group, whereas differences between the control group and other groups were not statistically significant. E values of A2 and A3 groups were significantly lower than that in the control group (P < .05), whereas the differences between the control group and other groups were not found to be statistically significant. No significant variations were determined between samples sterilized 1, 2, or 3 times in scanning electron microscopy micrographs, however, small irregularities were observed on autoclaved samples. CONCLUSIONS: Single use of polypropylene meshes is always recommended because of biocompatibility and infection risks. However, if re-use of the open packages is needed, ethylene oxide sterilization is preferred over autoclave sterilization. If ethylene oxide sterilization is not available then 1 cycle of resterilization with an autoclave can be used.     

Anterolateral approach to the cervical spine: major anatomical structures and landmarks. Technical note

OBJECT: The authors undertook a study to explore the topographic anatomical features seen during the anterolateral approach to cervical spine, anatomical variations, and certain landmarks related to the surgical procedure. METHODS: The study was conducted in 30 fresh cadavers. RESULTS: The common carotid artery bifurcation was mostly found at the level of C-4 (78%). The inferior belly of the omohyoid muscle was seen to cross the sternocleidomastoid muscle at the C5-6 disc level along the entire C-6 vertebral body. To reach the lower cervical region, the sacrifice of this muscle makes the procedure easier. The facial vein drained into the internal jugular vein mostly at the level of C3-4 (54%). The superior ganglion of the cervical sympathetic chain was located at the C-4 vertebra, but the location of the intermediate ganglion exhibited some variation. The vertebral artery entered the transverse foramen of C-6 in 27 cadavers (90%), the transverse foramen of C-7 in two cadavers (7%), and the transverse foramen of C-4 in one cadaver (3%). Because the inferior thyroid artery crossed the C6-7 interspace obliquely, the course of the inferior thyroid artery may complicate the procedure. The C-5 uncinate process was shortest and narrowest and had the greatest distance from the medial edge of the process to the anterior tubercle (p < 0.001). CONCLUSIONS: Understanding the qualitative anatomy of this region not only improves the safety of anterior and anterolateral cervical spine surgery but also allows adequate decompression of neural elements and resolution of the other pathological processes of this region. In this fresh cadaveric study, our goal was to improve the approach and decrease the incidence of complications.     

Use of Stapling Devices for Safe Cholecystectomy in Acute Cholecystitis

Many techniques are described for the ligation of a difficult cystic duct (CD). The aim of this study is to assess the effectiveness and safety of stapling of a difficult CD in acute cholecystitis using Endo-GIA. From January 2008 to June 2012, 1441 patients with cholelithiasis underwent laparoscopic cholecystectomy (LC) at the Department of General Surgery, Haydarpasa Numune Education and Research Hospital. Of these, 19 (0.62%) were identified as having a difficult CD and were ligated using an Endo-GIA stapler. All patients were successfully treated with a laparoscopic approach. The length of hospital stay was 3.4 days. There were umbilical wound infections in 4 patients (21%). The length of follow-up ranged from 1.0 to 50.4 months. In conclusion, Endo-GIA is a safe and easy treatment method for patients with a dilated and difficult CD. The cystic artery should be isolated and ligated if possible before firing the Endo-GIA stapler. If isolation and stapling are not possible, fibrin sealant can be applied to avoid bleeding. The vascular Endo-GIA can be applied in a large CD, but for acute cholecystitis with an edematous CD, the Endo-GIA roticulator 4.8 or 3.5 stapler is preferred.Key words: Cholecystectomy, Endo-GIA, Acute cholecystitis, StaplerAfter the introduction of laparoscopic cholecystectomy (LC) in 1987,¹ LC replaced open cholecystectomy as the gold standard for the treatment of cholelithiasis in international guidelines.² LC was initially considered to be contraindicated for acute gallbladder inflammation, but it is currently a common procedure for acute cholecystitis.Some of the difficult situations a surgeon is likely to face during the performance of a laparoscopic cholecystectomy include anatomic anomalies such as a sessile gallbladder or short cystic duct and pathologic entities such as an empyema, Mirizzi syndrome, or a frozen Calot''s triangle secondary to infection and fibrosis.³It is suggested that laparoscopic surgery should be carried out within 72 hours from the onset of the symptoms because after that time there are higher rates of conversion to open procedures, increased risks of complications, and longer operative times.^4–6 The generally accepted procedure in patients whose symptoms started 72 hours before admission is to “cool down” the patient with appropriate medical therapy and to perform LC after a period of 6 to 12 weeks.^7,8 This approach aims to avoid a potentially more difficult cholecystectomy during an emergency admission and to avoid the difficulties of access to an emergency room.^9,10 However, more than 20% of patients may fail to respond to conservative treatment and require an urgent and rather more difficult cholecystectomy, and a further 25% of patients will require readmission with a severe acute complication of cholelithiasis while awaiting a cholecystectomy.^11,12 The scar formation, distortion, and organized adhesions around the gallbladder occurring secondary to the chronic inflammation in Calot''s triangle make the dissection difficult. The cystic duct (CD) is sometimes edematous, fibrous, or enlarged owing to inflammation and adhesions in acute cholecystitis and may be difficult to manage. Several methods were proposed for ligating the CD, including titanium or absorbable endoclip, endoloop, tie, ultrasonic or bipolar sealer, and the Endo-GIA stapler (Covidien, Mansfield, Massachusetts).^13–19This study proposes an effective, safe, and easy procedure for the stapling of dilated or difficult CD using the Endo-GIA.     

Eculizumab therapy in a patient with dense-deposit disease associated with partial lipodystropy

Background

Dense deposit disease (DDD) (also known as membranoproliferative glomerulonephritis type II) in childhood is a rare glomerulonephritis with frequent progression to end-stage renal disease (ESRD) and a high recurrence after kidney transplantation. The pathophysiologic basis of DDD is associated with the uncontrolled systemic activation of the alternative pathway (AP) of the complement cascade.

Case-diagnosis/treatment

A 14-year-old girl presented with edema and nephrotic range proteinuria. Blood tests showed hypoalbuminemia, nephrotic range proteinuria, normal renal function, and a low C3 level. Renal biopsy confirmed the diagnosis of crescentic DDD. Complement analysis revealed strong AP activation (low C3), positive C3 nephritic factor (C3NeF), and a decreased complement factor H (CFH) levels with CFH polymorphisms. Therapy with eculizumab was considered after the failure of corticosteroid and plasmapheresis to modulate the ongoing massive proteinuria and persistence of low serum C3 levels. There was a marked clinical and biochemical response following the administration of eculizumab.

Conclusions

Our case emphasizes the efficacy of eculizumab in the management of crescentic DDD in a patient with a normal renal function, in a short follow-up period. Considering previously reported cases, it appears that eculizumab represents a promising new approach which may prevent progression to ESRD in a subset of patients with DDD.