Dysphagic Patients with Tracheotomies: A Multidisciplinary Approach to Treatment and Decannulation Management

In 2000 a multidisciplinary protocol for weaning dysphagic patients from the tracheotomy tube and a decannulation decision chart created according to principles of the F.O.T.T.((R)) Concept (Face and Oral Tract Therapy) were introduced in the Swiss Neurological Rehabilitation Centre REHAB in Basel. In the present study we introduce these guidelines and present an evaluation of the treatment and decannulation procedure. We retrospectively compared data from patients before and after introduction of the multidisciplinary procedure with regard to mean cannulation times and success of decannulation. Furthermore, we analyzed the rehabilitation progress of the group who underwent multidisciplinary treatment as well as the participation of the speech language therapist. The results show that the treatment introduced to improve swallowing functions and wean patients from the tracheotomy tube led to a fast and safe decannulation of our patients. The mean length of cannulation time was reduced significantly. After decannulation the patients showed clear functional improvements. Interdisciplinary treatment using the approach discussed in this study can be considered efficient and an important basis for further functional progress in the rehabilitation process.     

Bilateral brachial pull-through technique for stenting in a patient with stenosis of the vertebral artery origin: technical case report

Stenting for stenosis of the proximal vertebral artery (VA) is commonly performed via a femoral approach. However, iliofemoral occlusive disease such as arteriosclerosis obliterans sometimes prevents safe transfemoral access. In certain situations where both femoral access and ipsilateral brachial access are difficult because of a concomitant vascular diseases or particular anatomic setting, a contralateral brachial approach using the brachiobrachial pull-through technique may allow efficient and accurate stenting. A case of VA origin symptomatic stenosis successfully treated with stenting using the new pull-through technique from the contralateral brachial artery to the brachial artery on the affected side is described.     

Transvenous embolization of a dural arteriovenous fistula of the laterocavernous sinus through the pterygoid plexus

We present a novel access for transvenous embolization of a dural arteriovenous fistula of the laterocavernous sinus through the external jugular vein and the pterygoid plexus. The anatomy of the laterocavernous sinus is reviewed, and its clinical implications discussed in light of the case of a patient whose management was modified after identifying this anatomical variation.     

Percutaneous Transhepatic Portography for the Treatment of Early Portal Vein Thrombosis After Surgery

We treated three cases of early portal vein thrombosis (PVT) by minimally invasive percutaneous transhepatic portography. All patients developed PVT within 30 days of major hepatic surgery (one case each of orthotopic liver transplantation, splenectomy in a previous liver transplant recipient, and right extended hepatectomy with resection and reconstruction of the left branch of the portal vein for tumor infiltration). In all cases minimally invasive percutaneous transhepatic portography was adopted to treat this complication by mechanical fragmentation and pharmacological lysis of the thrombus. A vascular stent was also positioned in the two cases in which the thrombosis was related to a surgical technical problem. Mechanical fragmentation of the thrombus with contemporaneous local urokinase administration resulted in complete removal of the clot and allowed restoration of normal blood flow to the liver after a median follow-up of 37 months. PVT is an uncommon but severe complication after major surgery or liver transplantation. Surgical thrombectomy, with or without reconstruction of the portal vein, and retransplantation are characterized by important surgical morbidity and mortality. Based on our experience, minimally invasive percutaneous transhepatic portography should be considered an option toward successful recanalization of early PVT after major liver surgery including transplantation. Balloon dilatation and placement of a vascular stent could help to decrease the risk of recurrent thrombosis when a defective surgical technique is the reason for the thrombosis.     

Multivariate random-effects approach: for meta-analysis of cancer staging studies

RATIONALE AND OBJECTIVES: Meta-analyses of diagnostic accuracy studies produce summary estimates of sensitivity and specificity. Cancer staging relies on staging systems and meta-analysis is often performed after dichotomization of the staging results. For each dichotomization, summary estimates of sensitivity and specificity can be calculated by repeated bivariate random-effects analyses. In this process, staging information is lost and under- and overstaging can not be adequately expressed. MATERIALS AND METHODS: We propose a new multivariate random-effects approach, which is an extension of the bivariate random-effects approach. To illustrate the principles and outcomes of both approaches, we used data from a meta-analysisevaluating endoluminal ultrasonography in staging of rectal cancer. In the multivariate approach, results on correct staging and under- and overstaging were calculated. In addition, the results from this analysis were used to calculate sensitivity and specificity estimates for each dichotomization and these estimates were compared with the results of the repeated bivariate analyses. RESULTS: By the multivariate analysis, results on correct staging and under- and overstaging were obtained. The sensitivity and specificity estimates for the dichotomizations, calculated from the results of this multivariate approach, were also comparable with the sensitivity and specificity estimates obtained by the repeated bivariate analyses. CONCLUSIONS: The multivariate random-effects approach can be a useful meta-analytic method for summarizing cancer staging data presented in diagnostic accuracy studies.     

Lateral popliteal sciatic nerve block: a single injection targeting the tibial branch of the sciatic nerve is as effective as a double-injection technique

BACKGROUND: Evidence indicating that single- and double-injection techniques for inducing a sciatic nerve block via a posterior subgluteal approach yield a similar success rate prompted us to investigate whether the two anesthetic techniques yield a similar success rate via a lateral approach. We also hypothesized that, owing to the peculiar anatomic features of the sciatic nerve at the popliteal level, a single injection via the lateral approach might induce effective anesthesia by targeting the tibial nerve only. METHODS: Ninety-six patients undergoing popliteal sciatic nerve block via a lateral popliteal approach for foot surgery were randomized to receive a single 30-ml injection of ropivacaine 7.5 mg/ml to block the tibial nerve (TN group, n= 32) or the common peroneal nerve (CPN group, n= 32), or two separate 15-ml injections (TN + CPN group, n= 32), after stimulation to evoke motor responses from the target nerves. RESULTS: The mean time to obtain a complete sensory blockade (surgical anesthesia) was shorter in the TN group than in the CPN and TN + CPN groups (14 +/- 7 min vs. 23 +/- 17 and 21 +/- 14 min, respectively; P < 0.05). The success rate was similar in the TN and TN + CPN groups (94%) and, 25 min after the initial injection, was already better in these groups than in the CPN group (94% vs. 75%; P < 0.05). CONCLUSIONS: A lateral popliteal sciatic nerve block obtained with a single 30-ml injection of ropivacaine 7.5 mg/ml after electrostimulation to locate the tibial nerve is as effective as multiple TN + CPN stimulation and injection, and local anesthesia has a significantly shorter onset time.     

Classification-related approach in the surgical treatment of thoracolumbar fractures

Background:

Advanced diagnostic tools, classification systems and accordingly selected surgical approaches are essential requirements for the prevention of failure of surgical treatment of thoracolumbar fractures. The present study is designed to evaluate the contribution of classification to the choice of a surgical approach using the current fracture classification systems.

Materials and Methods:

We studied prospectively a group of 64 patients (22 females, 42 males) of an average age of 43 years, all operated on for thoracolumbar fractures during the year 2001. The AO-ASIF classification was used preoperatively with all imaging studies (X-ray, computed tomography (CT) and magnetic resonance imaging (MRI)). When the damage was detected only in the anterior column (A type), an isolated anterior stabilization (n = 22) was preferred. If the MRI study disclosed an injury in the posterior column, a posterior approach (n = 20) using the internal fixator was chosen. Injuries involving the posterior column (B or C type) were classified additionally according to the load-sharing classification (LSC). If LSC gave six or more points, treatment was completed with an anterior fusion. The combined postero-anterior procedure was carried out 22 times. The minimum followup period was 22 months.

Results:

Neither implant failure and nor significant loss of correction were observed in patients treated with anterior or combined procedures. The average loss of correction (increase of kyphosis) in simple posterior stabilization was 3.1 degree.

Conclusion:

Complex fracture classification helps in the selection of the surgical approach and helps to decrease the chances of treatment failure.     

Sliding trochanteric osteotomy in acetabular fractures: a review of 30 cases

OBJECTIVE: To assess the results of using sliding trochanteric osteotomy as an adjunct procedure for acetabular fractures. DESIGN: Retrospective review. SETTING: Level 1 trauma centre. METHODS: Thirty patients (19 men, 11 women, mean age 40 years, range 23-80 years) having fracture of acetabulum underwent sliding trochanteric osteotomy for a better exposure of the fracture involving the dome of acetabulum during the period January 1999-January 2004. MAIN OUTCOME MEASUREMENTS: Clinical evaluation was based on modified Merle d' Aubigne and Postel scoring. Motor strength of the abductors was evaluated according to the Medical Research Council (MRC) grading system. Radiographic evaluation of the joint was also documented. RESULTS: All the osteotomies healed within 12 weeks without any proximal migration except for one patient with infection in whom nonunion occurred. Two patients underwent removal of implants from greater trochanter because of irritation. The strength of the abductors was of Grade 2/5 in one patient, Grade 3/5 in one patient, Grade 4/5 in six patients and Grade 5/5 in the rest. Clinical scoring was excellent to good in 77%. Heterotopic ossification occurred in six patients and was of modified Brooker's classes 1 and 2. CONCLUSIONS: This technique can be relied upon to provide an adequate exposure of the dome of acetabulum without the associated complications like malunion, non-union, etc., known to occur with standard oblique osteotomy.     

经穹隆间第三脑室底锁孔入路的显微解剖

目的 探索经穹隆间第三脑室底锁孔入路的可行性和手术方法。 方法 设计经穹隆间第三脑室底锁孔入路(第三脑室底切口起自灰结节向后,经乳头体间,止于后穿质)。运用解剖学方法在导航辅助下在16例尸头标本上模拟经穹隆间第三脑室底锁孔入路手术,在手术显微镜下对手术显露进行观察,利用导航作解剖学测量。 结果 导航辅助下能顺利完成16例尸头标本的经穹隆间第三脑室底锁孔入路手术。冠状缝与矢状缝交点到室间孔上缘、丘脑间黏合、乳头体和中脑导水管上缘的距离分别为（68.4±4.6）mm、(66.3±6.0)mm、(86.3±5.3)mm、(82.0±7.6)mm,冠状缝与矢状缝交点到基底动脉末端分叉的操作距离为(91.8±5.0)mm。灰结节向后经乳头体间止于后穿质切开第三脑室底可获得长（9.5±2.6）mm的手术通道。术中经第三脑室底切口能清晰显露脚间池内的基底动脉末段、大脑后动脉P1段、P2段、小脑上动脉、后交通动脉以及它们的穿通支血管。向前解剖Liliequist膜可显露斜坡和鞍背,侧方可显露出动眼神经,向后显露出脚间窝。基底动脉末端分叉多偏于左侧（68.8%）,两侧大脑后动脉多向前外侧斜行（68.8%）。大部分大脑后动脉夹角上有1～4支小穿支血管自基底动脉末端分出。 结论 经穹隆间第三脑室底锁孔入路在技术上可行,深入研究可望应用于基底动脉末端动脉瘤的直接手术。     

肘前、外侧两种手术入路治疗桡骨头骨折的比较

目的探讨显露桡骨头骨折的有效手术入路。方法采用肘前侧手术入路显露桡骨头并结合微型空心螺钉固定治疗桡骨头骨折12例,其中2例MasonⅢ型骨折的骨折块于前臂完全旋后时位于桡骨头的前侧。采用传统的肘外侧手术入路10例,显露桡骨头骨折并用微型空心螺钉埋头固定。结果前侧手术入路显露骨折时间平均为20．7分,外侧入路显露骨折时间平均为11．6分。按照Broberg和Morrey肘关节评分标准评定手术疗效：前侧入路组优良率为92％,外侧入路组优良率为90％,两组间无明显差异。结论肘前侧入路可有效显露并固定桡骨头骨折,降低桡神经深支损伤的可能性,尤其适用于治疗前臂完全旋后时桡骨头前侧骨折这一特殊类型骨折。两种入路可视具体情况加以选用。