Impact of stapled haemorrhoidopexy on stool continence and anorectal function—long-term follow-up of 242 patients

Background and aims Several studies have proved the feasibility and safety of stapled anopexy for treating haemorrhoidal prolapse. However, stool urgency and faecal incontinence as possible side effects are still debated. Therefore, the present study was designed to assess the impact of Longo’s procedure on stool continence and anorectal function. Materials and methods From 1999 to 2005, 300 patients underwent stapled haemorrhoidopexy for symptomatic haemorrhoidal prolapse. Two hundred forty-two patients (100 women, 142 men) were available for follow-up and were retrospectively reviewed. All operations were performed by one single surgeon. To evaluate anorectal function, the results of a validated incontinence score (total incontinence score [IS]: 0 = best, 20 = worst) and evacuation score (total evacuation score [ES]: 0 = worst, 28 = best) were compared pre- and postoperatively. Results The total IS showed no difference in means before and after operation (p = 0.875, CI 95%) retrospectively. Concerning the ES, paired sample t-test showed a weak positive correlation, indicating a significant difference in score means (p = 0.041, CI 95%). The group means changed from 26.24 before operation to 26.60 after the follow-up period. Conclusion The present data revealed no significant negative impact of Longo’s technique on anorectal function. In contrast, according to the evacuation score, the results showed a significant improvement of evacuation.     

Insall Proximal Realignment of the Patella for Recurrent Dislocation or Subluxation

Objective

Proximal realignment of the patella for the treatment of patellar subluxation or dislocation consisting of a lateral release and advancement of the vastus medialis.

Indications

Recurrent lateral subluxation or dislocation of the patella despite a supervised exercise program. Recurrent subluxation or dislocation of the patella.

Contraindications

Congenital dislocation of the patella. Generalized degenerative arthritis of the patellofemoral joint. Excessive valgus deformity of the knee. Moderate to severe muscular atrophy of the vastus medialis muscle (i.e., in neurologic disorders).

Surgical Technique

Lateral parapatellar incision of skin. Detachment of the fibers of the iliotibial tract and the lateral retinaculum from the lateral patella. Medial capsular incision extending from the quadriceps tendon over the patella into the patellar ligament. The quadriceps expansion is shaved from the medial third of the patella preserving the longitudinal continuity. The vastus medialis is advanced and sutured onto the middle and distal aspects of the patella.

Results

Out of 21 patients (16 women, five men) who received a proximal realignment procedure during 1989 and 1993, all could be evaluated after 6.3 years (minimum follow-up of 4 years 5 months, maximum of 8 years 3 months). In 13 patients the diagnosis was recurrent dislocationof the patella, in eight patients a true primary traumatic dislocation was noted. A generalized ligamentous laxity was seen in three patients. One patient had a superficial wound infection postoperatively. Two patients had an excellent, 13 patients a good, six patients a fair and no patient a poor result according to the subjective score of Turba et al. Three patients experienced a recurrence of instability (one to three events) after the operation. One of these patients had to be revised for postoperative recurrent dislocation of the patella. The other two patients experienced no more symptoms of instability after muscle strengthening exercises of the vastus medialis muscle.     

Post-transplant survival after lowering fixed pulmonary hypertension using left ventricular assist devices.

OBJECTIVE: We have previously shown that fixed pulmonary hypertension in cardiac transplant candidates can be lowered using left ventricular assist devices (LVADs). The post-transplant survival of these patients is uncertain as pulmonary hypertension may reappear, possibly affecting post-transplant survival. MATERIALS AND METHODS: Between 01/2000 and 01/2005 a total of 26 cardiac transplant candidates (92% male; mean age 56.2 years) in whom fixed pulmonary hypertension was lowered by LVAD implantation (pulmonary vascular resistance (PVR) before implantation: 5.1+/-2.8wood units (WU); PVR before cardiac transplantation: 2.0+/-.9WU) underwent cardiac transplantation at our institution. These patients were age and sex matched with 52 cardiac transplant candidates without pulmonary hypertension undergoing cardiac transplantation during the same time period. Study endpoints were peri-transplant complications and long-term survival. Mean follow-up was 36+/-14 months. RESULTS: Peri-transplant mortality was 5% in patients after LVAD therapy and 7% in patients without prior LVAD therapy (p=.089). We observed 2 cases (4%) of acute right heart failure requiring mechanical support in patients without prior LVAD therapy. None of the patients with LVAD therapy developed peri-transplant right heart failure requiring mechanical support. Incidence of other peri-transplant complications was comparable between the two groups. Log-rank (p=.124) revealed comparable long-term survival between patients with (1 year: 85%, 2 year: 85%, 3 year: 85%) and without (1 year: 90%, 2 year 82%, 3 year prior 79%) prior LVAD therapy. CONCLUSION: LVAD therapy lowers fixed pulmonary hypertension in cardiac transplant candidates with fixed pulmonary hypertension. Thereafter, long-term post-transplant survival is comparable to cardiac transplant recipients without pulmonary hypertension.     

Technical aspects and feasibility of laparoscopic ultrasound navigation in radiofrequency ablation of unresectable hepatic malignancies

PURPOSE: Laparoscopic radiofrequency ablation is safe, practicable, and combines minimally invasive surgery with the advantages of laparotomy. However, application of the laparoscopic freehand puncture is restricted because of capnoperitoneum and the consequent fixation of the needle on two different points. The use of a laparoscopic ultrasound probe with a canal for puncture can solve this problem and improve precision. However, a stiff needle limits the necessary angulation that is needed to reach right-lateral and cranial liver metastases. Therefore we present a new navigation tool for laparoscopic interventions. MATERIALS AND METHODS: The US Guide 2000 (Ultra Guide, Tirat Hacarmel, Israel) is an independent navigation system compatible with all ultrasound machines and has six degrees of freedom. After proper evaluation of this system under operating room conditions during transcutaneous radiofrequency ablation, we used this technique in laparoscopic radiofrequency ablation. A special adapter was developed to attach the ultrasound-based navigation system to a laparoscopic ultrasound probe. After calibrating the system with an ultrasound phantom, laparoscopic navigation in a liver organ model was studied. RESULTS: Even in cases of angulation of the ultrasound probe no disturbances of the navigation system could be detected. Anatomic landmarks in the liver could be safely reached. No interaction between the navigation system and the laparoscopic ultrasound probe or operating instruments was observed. CONCLUSION: Our preliminary results show the feasibility of this technique in laparoscopic radiofrequency ablation. The use of an ultrasound-based laparoscopic inline navigation system offers the possibility of out-of-plane needle placement and could combine the flexibility of freehand puncture with the accuracy of a canal for puncture. This could increase the safety and accuracy of punctures.     

Hybrid procedures as a combined endovascular and open approach for pararenal and thoracoabdominal aortic pathologies

OBJECTIVES: to report our experience with hybrid vascular procedures in patients with pararenal and thoracoabdominal aortic pathologies. METHODS: 68 patients were treated for thoracoabdominal aortic pathologies between October 1999 and February 2004; 19 patients (16 men; mean age 68, range 40-79) with high risk for open thoracoabdominal repair were considered to be candidates for combined endovascular and open repair. Aortic pathologies included five thoracoabdominal Crawford I aneurysms, one postdissection expanding aneurysm, three symptomatic plaque ruptures (Crawford IV), five combined thoracic descending and infrarenal aneurysms with a healthy visceral segment, three juxtarenal or para-anastomotic aneurysms, and two patients with simultaneous open aortic arch replacement and a rendezvous maneuver for thoracic endografting. Commercially available endografts were implanted with standardized endovascular techniques after revascularization of visceral and renal arteries. RESULTS: Technical success was 95%. One patient developed a proximal type I endoleak after chronic expanding type B dissection and currently is waiting conversion. Nine patients underwent elective, five emergency and five urgent (within 24 h) repair. 17 operations were performed simultaneously, and 2 as a staged procedure. Postoperative complications include two retroperitoneal hemorrhages, and one patient required long-term ventilation with preexisting subglottic tracheal stenosis. Thirty-day mortality was 17% (one multiple organ failure, one secondary rupture after open aortic arch repair, one myocardial infarction). Paraplegia or acute renal failure were not observed. Total survival rate was to 83% with a mean follow-up of 30 months. CONCLUSIONS: Midterm results of combined endovascular and open procedures in the thoracoabdominal aorta are encouraging in selected high risk patients. Staged interventions may reduce morbidity.     

Cervical soft tissue imaging using a mobile CBCT scanner with a flat panel detector in comparison with corresponding CT and MRI data sets.

OBJECTIVE: The aim of this study was to evaluate soft tissue image quality of a mobile cone-beam computed tomography (CBCT) scanner with an integrated flat-panel detector. STUDY DESIGN: Eight fresh human cadavers were used in this study. For evaluation of soft tissue visualization, CBCT data sets and corresponding computed tomography (CT) and magnetic resonance imaging (MRI) data sets were acquired. Evaluation was performed with the help of 10 defined cervical anatomical structures. RESULTS: The statistical analysis of the scoring results of 3 examiners revealed the CBCT images to be of inferior quality regarding the visualization of most of the predefined structures. Visualization without a significant difference was found regarding the demarcation of the vertebral bodies and the pyramidal cartilages, the arteriosclerosis of the carotids (compared with CT), and the laryngeal skeleton (compared with MRI). Regarding arteriosclerosis of the carotids compared with MRI, CBCT proved to be superior. CONCLUSIONS: The integration of a flat-panel detector improves soft tissue visualization using a mobile CBCT scanner.     

Outcome treatment of pseudoarthrosis of long bones with decortication method depends on osteosynthesis]

Purpose of work was estimation of the results of treatment of pseudoarthrosis of the long bone with the method of decortication, with use of autogenic bone depends on kind of pseudoarthrosis and kind of osteosynthesis. In the years 1995-2005 56 patients were treated because of pseudoarthrosis of long bone in our Clinic. Pseudoarthrosis is classified according to Weber-Cech classification. In the methodology of clinical estimation and subjective estimation of the patient Stewart and Hundley and Anderson classification were used. Union was achieved in 51 cases. Time of bone union achievement was 5 months. The results of treatment are depends on morfology of pseudoartrosis and are independs of kind of osteosynthesis.     

Surgical management of pancreaticoduodenal artery aneurysms in association with celiac trunk occlusion or stenosis

Aneurysms of the visceral arteries, especially of the pancreaticoduodenal artery, are rare. They show a wide clinical spectrum, ranging from asymptomatic incidental findings to rupture-inducing catastrophic bleedings. Since growth progression and the risk of rupture cannot be foreseen and there is no relation between the size of the aneurysm and propensity to rupture, rupture unfortunately carries a high mortality, >50%. Thus, all aneurysms of the pancreaticoduodenal artery should be treated. The therapy of choice, either operative intervention or catheter embolization, is determined by many factors. Among these are localization, size, relation to other vessels and neighboring organs, the urgency of intervention, and the experience of the therapist. Surgical therapy should be favored in patients with pancreaticoduodenal artery aneurysm due to celiac trunk occlusion. We report here our experience in the surgical treatment of pancreaticoduodenal artery aneurysms in association with celiac trunk occlusion or stenosis over the last 5 years.     

Eine minimalinvasive Technik zur Entfernung eines fest verklemmten Küntscher-Nagels in der primären Hüftendoprothetik

Die Unfallchirurgie - Es wird über einen 80-jährigen Patienten berichtet, der sich mit einer symptomatischen Coxarthrose der linken Seite in unserer Klinik vorstellte. Das Besondere an...