Traumatic diaphragmatic hernias: a report of 26 cases

Traumatic diaphragmatic hernias, when diagnosed many years after the traumatic event, are observed in about 10% of diaphragmatic injuries. Due to coexisting injuries and the silent nature of diaphragmatic injuries, the diagnosis is easily missed or difficult. The medical records of 26 patients, who were treated for diaphragmatic hernias during the last 20 years, were analysed retrospectively. The patients were divided into acute phase and late-presenting groups, in whom emergency surgery and elective intervention were performed respectively. Chest radiography was diagnostic in 34.6% (n=9) of patients. 92.3% of the hernias were on the left side, while the most common herniated organs were the stomach (31.8%) and the colon (27.2%). Coexisting injuries were recorded in 38.4% (n=10) of the patients. Primary repair was predominantly used (92.3%). The hospitalisation period was longer in the late-presenting group (24.1±18.8 vs. 14.3±7.7 days). Two deaths occurred in the late-presenting group. Diaphragmatic hernia should be suspected in all blunt abdominal trauma patients. Prompt surgical repair is the treatment of choice in all traumatic diaphragmatic hernias.     

Reversal of secondary protein‐losing enteropathy after surgical revision of a jejunal Roux‐en‐Y loop in a patient after liver transplantation

Secondary protein‐losing enteropathy (PLE) is a rare complication following pediatric liver transplantation (LT), mostly related to venous outflow obstruction of the liver. Here, we discuss a thus far unknown cause of secondary PLE following pediatric LT. A 7‐month‐old boy underwent LT with biliary anastomosis using a Roux‐en‐Y jejunal loop. Eleven months later he developed PLE. Routine diagnostic workup was negative. No hepatic outflow obstruction was detected during catheterization. Although the hepatic venous pressure gradient was slightly increased (10 mm Hg), there were no clinical signs of portal hypertension. Albumin scintigraphy with specific early recordings suggested focal albumin intestinal entry in the jejunal Roux‐en‐Y loop. Local bacterial overgrowth or local lymphangiectasia, possibly due to (venous) congestion, was considered. Treatment with metronidazole did not improve albumin loss. Next, surgical revision of the jejunal Roux‐en‐Y loop was performed. The explanted loop contained a small abnormal area with a thin hyperemic mucosa, near the former anastomosis. Histopathological analysis showed changes both in the blood vessels and the lymphatic vessels with focal deeper chronic active inflammation resulting in congestion of vessels, hampering lymphatic outflow leading to lymphangiectasia and patchy distortion of lymphatic vessels. Following surgical revision, secondary PLE disappeared, up to now, 1.5 year post revision.     

Bare dorsal thoracic fascial flap for esophageal defects: an experimental study with dogs

Background

Reconstruction of esophageal defects has challenged reconstructive surgeons for a long time. Problems that affect the continuity of the orogastic tract influence the patient’s quality of life and general health. Bare free fascial flaps are used to restore soft tissue defects of the oral cavity because they provide thin, pliable tissues with a high capacity for epithelialization to preserve the local anatomy. An experimental study was planned to investigate reconstruction of anterior cervical esophageal defects using a pedicled dorsal thoracic fascial flap.

Methods

Eight hybrid dogs were used in the study. All operations were planned in three steps and performed with the animals under general anesthesia. For the two-layered reconstruction, the bare dorsal thoracic fascial flap was harvested and adapted like a patch to the defect.

Results

No partial or total flap loss was observed. On postoperative day 20 surgery, a complete epithelial lining on the same plane as the esophageal mucosa was observed over the flap tissue. A 4- to 5-mm longitudinal scar that did not form even a minimal stricture in any dog also was observed. No significant changes from postoperative day 20 to postoperative days 40 and 60 were observed.

Conclusion

Bare fascial flaps in the oral cavity heal with spontaneous epithelialization and with no need for skin and mucosal grafts. Fascial flaps are easy to harvest and do not cause any functional loss because they are nonfunctional units. Their thin constitution helps the surgeon to shape the tissue and even form tubed flaps.     

Comparison of percutaneous nephrolithotomy and retrograde flexible nephrolithotripsy for the management of 2-4 cm stones: a matched-pair analysis

Study Type – Therapy (case control) Level of Evidence 3b What's known on the subject? and What does the study add? Recently European Association of Urology 2011 guidelines on urolithiasis recommended retrograde intrarenal surgery as the second‐line therapy for the treatment of kidney stones <10 mm in diameter. This study shows that retrograde intrarenal surgery may be an alternative therapy to percutaneous nephrolithotomy, with acceptable efficacy and low morbidity for 2–4 cm stones.

OBJECTIVE

• ? Currently, the indications for retrograde intrarenal surgery (RIRS) have been extended due to recent improvements in endoscopic technology. In this study, we compare the outcomes of percutaneous nephrolithotomy (PCNL) and RIRS in the treatment of 2–4 cm kidney stones.

MATERIALS AND METHODS

• ? Between September 2008 and January 2011, 34 patients who had renal stones ranging from 2 to 4 cm in diameter were treated with RIRS. The outcomes of these patients were compared with patients who underwent PCNL using matched‐pair analysis (1:1 scenario).
• ? The matching parameters were the size, number and location of the stones as well as age, gender, body mass index, solitary kidney, degree of hydronephrosis, presence of previous shock wave lithotripsy and open surgery.
• ? Data were analysed using Fisher's exact test, Student's t test and the Mann–Whitney U test.

RESULTS

• ? Stone‐free rates after one session were 73.5% and 91.2% for RIRS and PCNL respectively (P= 0.05). Stone‐free rate in the RIRS group improved to 88.2% after the second procedure.
• ? Mean operation duration was 58.2 (±) 13.4 min in the RIRS group but 38.7 (±) 11.6 min in the PCNL group (P < 0.0001). Blood transfusions were required in two patients in the PCNL group.
• ? Overall complication rates in the PCNL group were higher, but the differences were not statistically significant. Hospitalization time was significantly shorter in the RIRS group (30.0 + 37.4 vs 61.4 + 34.0 h, respectively; P < 0.001).

CONCLUSION

• ? Satisfactory outcomes can be achieved with multi‐session RIRS in the treatment of 2–4 cm renal stones. RIRS can be used as an alternative treatment to PCNL in selected cases with larger renal stones.

     

A Placebo-Controlled, Multicenter, Randomized, Double-Blind, Flexible-Dose, Two-Way Crossover Study to Evaluate the Efficacy and Safety of Sildenafil in Men With Traumatic Spinal Cord Injury and Erectile Dysfunction

Background/Objective:     

Adenocarcinomas of the jejunum and ileum: A 25-year experience

Adenocarcinomas of the jejunum and ileum are rare gastrointestinal malignancies. Because few large published experiences exist, we reviewed patients with jejunal and ileal adenocarcinoma treated at our institution over the last 25 years. Between January 1976 and December 2001, 77 patients had an operation for a jejunal or ileal adenocarcinoma. Records were retrospectively reviewed for patient, tumor, and treatment variables. Factors affecting disease recurrence and patient survival were investigated. Fifty-two of the adenocarcinomas (67%) occurred in the jejunum and 25 occured in the ileum (33%). Mean patient age was 63 ±14 years. Segmental bowel resection was performed in 50 patients (65%) with curative intent. Palliative operative procedures including resection or bypass were performed in 27 patients (35%). One (1%) patient had stage I, 18 (23%) stage II, 19 (25%) stage III, and 39 (51%) stage IV adenocarcinoma at diagnosis. Postoperatively, 12 patients had palliative and 18 adjuvant chemotherapy (n 5 30), radiation therapy (n = 1), or combination treatment (n = 7). Median patient survival was 19 months. Sixty-six percent of patients who had a curative operation had a tumor relapse. Tumor stage had a highly significant effect (P < 0.0001) on median survival (72 months for stage I and II, 30 months for stage III, and 9 months for stage IV disease). In multivariate analysis of patients having curative treatment, tumor recurrence (P < 0.0001), stage (P < 0.0002), and weight loss (P < 0.001) were significant negative prognostic indicators. Most patients with adenocarcinoma of the jejunum or ileum present with advanced disease. Tumor stage, disease recurrence, and weight loss predicted patient outcome following a curative operation. Early recognition of these tumors requires a high index of suspicion. Presented at the Forty-Fifth Annual Meeting of The Society for Surgery of the Alimentary Tract, New Orleans, Louisana, May 15–19, 2004 (poster presentation).     

Long-term oral ciprofloxacin in the treatment of prosthetic valve endocarditis due to Pseudomonas aeruginosa.

Prosthetic valve endocarditis caused by Pseudomonas aeruginosa is refractory to medical treatment alone and early valve replacement is necessary. We describe a 40-year-old patient in whom endocarditis developed in the early postoperative period, and reoperation was not considered feasible. Ciprofloxacin was administered orally in order to suppress bacteremia for 36 months. Long-term oral ciprofloxacin may provide an opportunity in the treatment of prosthetic valve endocarditis caused by Ps. aeruginosa in patients who are unfavorable candidates for reoperation.     

Emotional intelligence and leadership traits among family physicians

Objectives: High emotional intelligence and leadership traits are essential for physicians in managing their responsibilities and thus building successful interactions with patients. This study explored the relationship between emotional intelligence and leadership traits among family physicians.

Methods: Participants (2975 men, 972 women, mean = 42.0 ages, SD = 7.47) were family physicians working at family health-care centers across the seven geographical regions of Turkey who were contacted by e-mail. The Trait Emotional Intelligence Questionnaire (TEIQue) and Leadership Traits Tool were used to collect data. Data were analyzed concerning physicians’ sex, age, health-care experience, and geographical region. The correlation between Trait Emotional Intelligence (TEI) and leadership was also being examined.

Results: Our findings suggest that family physicians’ TEI differs based on sex, age, health-care experience, and the geographical region where they work. Women had higher mean values than did men for well-being, emotionality, and global TEI. Physicians aged younger than 29 years had the lowest mean values for emotional intelligence. As physicians’ health-care experience increased, they received higher scores for emotional intelligence. Physicians working in the Mediterranean had the highest mean TEI scores. There was a positive correlation between family physicians’ emotional intelligence and leadership traits. Higher emotional intelligence was correlated with increased leadership traits.

Conclusion: Emotional intelligence and leadership traits play crucial roles in increasing physicians’ personal and professional development. This may also increase physicians’ caregiving competencies and thus the quality of health services, as well as potentially decreasing physicians’ burnout and health-related costs.     

Two-suture fish-mouth end-to-side microvascular anastomosis with fibrin glue

The most decisive step during free tissue transfers and replantation surgery may be respected as microvascular anastomosis. The conventional end-to-side anastomosis technique with simple interrupted sutures is well established and proven to be successful. On the other hand, conventional technique can be time consuming and can cause vascular thrombosis, vessel narrowing, and foreign-body reactions. Search for a more rapid and secure alternative to conventional technique is carried on. In this study, we defined a new technique for end-to-side anastomosis with fish-mouth incisions and application of fibrin glue and compared our results with those we obtained with conventional end-to-side anastomosis. We evaluated end-to-side anastomosis of carotid arteries of a total number of 64 Wistar-Albino rats. In control group (n = 32), conventional anastomoses with 8 to 10 sutures were performed. In experimental group (n = 32), fish-mouth incisions were applied first on the recipient artery, followed by performing anastomosis with only 2 corner sutures and applying commercially available fibrin glue. Time taken to perform the anastomosis was significantly shorter with the experimental group (P = 0.001), whereas early and late patency and aneurysm rates were comparable to those achieved with control group. Histological evaluation did not point out any significant differences between the groups. We have defined a rapid and safe alternative technique of end-to-side anastomosis with the use of fibrin glue. This method may be an alternative especially where multiple anastomoses are required or where it is difficult to approach anastomotic line, as it is easily performed, rapid, safe, and not involving any complex equipments.     

Health literacy in chronic kidney disease patients: association with self-reported presence of acquaintance with kidney disease,disease burden and frequent contact with health care provider

International Urology and Nephrology - Limited data suggest that health literacy (HL) is associated with kidney functions and clinical outcomes in patients with non-dialysis chronic kidney disease...