Evaluation of the findings of computed tomography of the lungs in patients with nonspecific pneumothorax in late periods after surgical treatment

By using the results of examination of 54 patients operated on for nonspecific spontaneous pneumothorax (NSP), the authors conclude that X-ray computed tomography (CT) is of high value. In addition to external respiratory function that identifies pulmonary functional changes, it is recommended that a comprehensive examination should include X-ray CT with parenchymal densitometry of the upper, middle and lower lung to reveal lung tissue structural changes. The examination of patients should be performed as soon as possible when the disease is detected and in the late postoperative period for early surgical correction of an emphysematous process in the lung.     

Antibacterial therapy in disseminated purulent peritonitis

Analysis of 156 records relating to patients at the age of 15 to 85 years with extended purulent peritonitis of the surgical and gynecological genesis (the toxic phase, VI category ASA) showed that combination of programmed sanitation laparotomy and intensive antibacterial therapy performed as short-term courses before, during and after the operation with an account of the information on the nature of the microbial associations and antibioticograms was an efficient procedure in treatment of severe peritonitis. It was indicated in treatment of patients with polyorgan deficiency. When the surgical treatment was adequate early antibiotic therapy allowed to decrease the number and intensity of postoperative complications: the frequency of abscessing in the abdominal cavity and formation of intestinal fistulas lowered 2 and 1.5 times respectively. Such a decrease was also observed in asthenic patients with lowered protective reactions to development of new infectious foci in the abdominal cavity complicating the peritonitis process. It was also possible to prevent with that procedure the infection generalization and development of peritoneal sepsis. With application of the procedure to such patients (20 per cent) lethality lowered 2-fold.     

Optimal Surgical Options for Descending Necrotizing Mediastinitis of the Anterior Mediastinum

The mortality rates from descending necrotizing mediastinitis (DNM) are between 25 and 40 % mainly because of delayed diagnosis and inappropriate surgical treatment. This study was undertaken to examine two surgical options for DNM and determine the optimal surgical option for DNM of the anterior mediastinum. Fifteen cases of DNM of the anterior mediastinum, January 2001 and October 2010, were retrospectively reviewed. Eleven were anterosuperior mediastinitis, with infection located above the tracheal bifurcation and four had infections involving the entire anterior mediastinum. Depending on the location of mediastinitis, open drainage of the submandibular and neck abscesses, in addition to other surgical treatments, was performed. If the infection was anterosuperior, transcervical mediastinal drainage or thoracotomy was performed. If the entire anterior mediastinum was involved, necrotic tissue was removed with thoracoscopic via subxiphoid incision, the bilateral pleurae were opened for drainage, and a tunnel connecting the neck incision and the subxiphoid incision through the whole anterior mediastinum was made for drainage. The anterosuperior mediastinitis cases were treated with either transcervical mediastinal drainage (n = 8) or thoracotomy (n = 3). Patients healed after an average of 24.5 and 20.0 days in the hospital, respectively. For the four other cases, one patient died of septic shock, while the other three patients were healed after and an average of 43.3 days in the hospital. Mortality rate was 6.7 %. The surgical procedure used to treat DNM should be selected according to the location of the infection. DNM involving the anterosuperior mediastinum can be treated by transcervical mediastinal drainage. If anterosuperior mediastinitis spreads to the side of the trachea, open thoracotomy is a suitable therapy. If the entire anterior mediastinum is involved, debridement and drainage of the anterior mediastinum should be performed with a thoracoscope via the subxiphoid incision.     

X-ray and radiological aspects of primary and reconstructive jejunal interposition

The late outcomes of primary and reconstructive jejunogastroplasty for motor and evacuatory dysfunctions of the graft and the gastrointestinal tract as whole were studied. Based of X-ray and radioisotopic findings, the paper shows the procedure used to form an artificial stomach from the large intestinal loop to obtain an invaginational valve at the site of jejunoduodenal atastomosis to be beneficial. This procedure makes it possible to recover the evacuatory function of the stomach removed, to prevent a number of postgastrectomic and postresectional disorders in the late postoperative period. Dynamic hepatobiliary scintigraphy was shown to be effective in examining the functional outcomes of gastric surgery and in diagnosing suspected reflux.     

The application of ultrasound in neuroendoscopic procedures: first results with the new tool "NECUP-2"

In this paper, our experience with originally constructed Neurosurgical Endoscopic Contact Ultrasound Probe "NECUP-2" in neuroendoscopy is reported. Between June 1997 and June 2007, 132 neuroendoscopic procedures have been performed: 102 endoscopic thrid ventriculostomies (ETV), 15 arachnoid cysts and 5 intraventricular tumours operations. The "NECUP-2" was applied effectively in all cases in which blunt perforation was not possible: 38/102 ETY, 10/10 septostomies, 15/15 arachnoid cysts. In five cases of intraventricular tumours, neuroendoscopic procedure was combined with open microsurgery for tumour removal with preservation of vascular structures. There were no "NECUP-2" related complications. Of postoperative complications, we had liquorrhea (9 patients), and symptoms of meningitis (6 patients). In the follow-up period (6 months to 6 years), we had a patency rate of 80% (50/63 patients). All patients improved in clinical status. According to the first results, it seems that ultrasonic contact probe NECUP-2 presents a new device in neurosurgical armamentarium that can be used in various fields of neurosurgery. With minimal and controlled lesion that is produced at the tip of the probe, it can be used in highly demanding operations such as third ventriculostomy and tumour resection.     

Comparison of Hemodynamic and Inflammatory Changes between Transoral and Transthoracic Thoracoscopic Surgery

Background

Natural orifice transluminal endoscopy has been developed for abdominal surgical procedures. The aim of this study was to compare the surgical outcome between a novel transoral approach and a standard transthoracic approach for the thoracic cavity in a canine model.

Methods

Twenty-eight dogs were assigned to transoral (n = 14) or standard thoracoscopy (n = 14). Each group underwent thoracic exploration, pre-determined surgical lung biopsy, and pericardial window creation. Blood draws were obtained before surgery and at postoperative days 1, 3, 7, and 14. Operative time, complications, laboratory parameters, hemodynamic parameters, and inflammatory parameters were compared between the two procedures. The animals were monitored for two weeks and necropsy were performed for surgical outcome evaluation.

Results

The thoracic procedures were successfully performed in all of the dogs, with the exception of one animal in the transoral group. There were no serious acute or delayed complications related to surgery. There was no difference between the two surgical groups for each of the hemodynamic parameters that were evaluated. Regarding the immunological impact of the surgeries, transoral thoracoscopy was associated with significant elevations in interleukin 6 and c-reactive protein levels on postoperative days 1 and 3, respectively, when compared with the standard thoracoscopy. All dogs recovered well, without signs of mediastinitis or thoracic infection. Necropsy revealed absence of infection, no injury to vital organs, and confirmed the success of the novel procedure.

Conclusions

This study suggests that both techniques were comparable with respect to procedure success rate, hemodynamic impact, and inflammatory changes. Furthermore, there was no difference in the incidence of postoperative discomfort between groups.     

Re-operations for bleeding in cardiac surgery: treatment strategy

Aims: Cardiac surgery patients are prone to bleeding postoperatively owing to the extensive sternotomy wound, multiple vessel and heart sutures, and disorders of hemostasis. In this study we retrospectively analyzed the outcomes for all patients in our department who were re-operated for bleeding, over a 5 year period. Methods: A total of 4297 patients underwent heart surgery between February 2002 and January 2007, of which 98 (2.3 %) were emergency reoperations for bleeding. We analyzed the process of indication for repeat surgery, possible source of bleeding, and postoperative complications. Results: Most (85.7 %) of the reoperated patients had undergone their first operation as an elective cardiac procedure. The mean blood loss before the reoperation was 1557 ml. The studied group was characterized by increased mortality (11.2 %), longer ventilation period (35.1 hours) and ICU (4.5 days) and hospital (13.3 days) stays. The postoperative outcomes did not differ significantly between patients with TEG-detected coagulation disorder and the rest of the patients, or between patients treated with antilysin and those who did not receive antifibrinolytics. Conclusions: It is vital for the indication process leading to reoperation of the bleeding patient to be as short as possible so as to minimize the delay to repeat surgery. Echocardiography including ultrasound of both pleural spaces, and TEG could shorten that time delay, and should always be included when evaluating patients. Platelets should be administered more often, with the use of antifibrinolytics reserved for cases with confirmed fibrinolysis.     

Transblepharoplasty lower eyelid and midface rejuvenation: part I. Avoiding complications by utilizing lessons learned from the treatment of complications

Transblepharoplasty midface elevation has become a common aesthetic procedure in recent years. As new techniques have been utilized, complications have arisen. Management of these referred complications has resulted in the development of a technique that elevates the midface and restores the normal position and shape to the lower eyelid with minimal postoperative problems. Four principles must be followed to achieve satisfactory results. The orbicularis oculi/orbital septum bond must not be altered in midface surgery. The lateral canthus must be reattached to its normal anatomic location at the lateral orbital rim if there is lateral canthal tendon laxity. The orbital fat should be addressed via a transconjunctival approach, when necessary, to prevent middle lamella inflammation and orbital septum retraction. A suture at the inferior lateral orbital rim simulating the orbitomalar ligament, as well as orbicularis oculi muscle sutures, elevates the midface. Utilizing these steps, the midface and lower eyelid can be satisfactorily repositioned with minimal complications. This surgical approach can be utilized in all appropriate candidates but is especially useful in reoperative cosmetic surgery patients and the older patient population.     

Physician's use of laparoscopy.

The role of laparoscopy in medical practice was assessed by studying 238 consecutive laparoscopies performed under local anaesthesia by physicians in a single teaching hospital. Indications for laparoscopy were assessment of possible and known hepatic disease, possible disseminated abdominal malignancy, abdominal mass, and conditions such as ascites and splenomegaly. A definitive diagnosis was reached in 223 cases (76.5%). No organic disease was detected in 41 patients, though findings were false-negative in two of them (0.8%). The procedure failed in 15 (6.3%), mostly because adhesions from previous surgery hindered adequate visualisation. Six patients (2.5%) had complications, one of whom subsequently died. If patients are appropriately selected laparoscopy is relatively free of postoperative complications, and is an effective diagnostic procedure in abdominal malignancy and decompensated liver disease. Cost-effectiveness is an additional advantage.     

A model of using magnetic resonance imaging in osteoarticular tumor lesion in case of giant cell tumors

Fifty-eight patients with giant cell tumors (GCT) underwent a comprehensive radiation diagnosis involving X-ray study and magnetic resonance imaging (MRI). The obtained MR images indicated the high efficiency of this combination of radiation diagnostic techniques in solving the problems in the visualization of osteoarticular tumor lesions. GCT is characterized by well-known primary X-ray semiotics; MR images are also rather pathognomonic of these tumors and they illustrate the process of morphogenesis of these masses. MRI made it possible to solve the specific problems facing a physician (a radiation diagnostician), to determine the site, shape, sizes, volume, and local extent of a tumor, which permitted the planning of surgical treatment policy; to assess its results, to reveal possible inflammatory complications; and to visualize a local recurrence and on-going growth of a tumor, including the signs of GCT malignancy.     

Local treatment in unresectable hepatic metastases of carcinoid tumors: Experiences with hepatic artery embolization and radiofrequency ablation

Background

The study was aimed to identify pre- and intraoperative risk factors that potentially influence morbidity and mortality after esophagectomy for esophageal carcinoma with particular emphasis on the predominant tumor types.

Patients and methods

Between September 1985 and March 2004, 424 patients underwent esophagectomy for esophageal carcinoma. Of these, 186 (43.9%) patients had a transhiatal, and 231 (54.5%) patients underwent a transthoracic procedure with two-field lymphadenectomy. Pre-, intraoperative risk factors and tumor characteristics were included in the risk analysis to assess their influence on postoperative morbidity and mortality.

Results

Multivariate analysis (logistic regression model) identified the surgical procedure as the most important risk factor for postoperative morbidity and mortality with the transthoracic technique associated with a significant higher risk. The comparison of the risk profile between the different histological tumor types, a significantly higher nutritional risk, poorer preoperative lung function and a higher prevalence of hepatopathy was observed in patients with squamous cell carcinoma (n = 229) compared to adenocarcinoma (n = 150) (p < 0.05). Although there was no significant difference in surgical complications between the two groups, the rate of general complications, length of postoperative intensive care unit-stay and mortality rate was significantly higher in patients with squamous cell carcinoma (p < 0.05).

Conclusion

The present risk analysis shows that the selection and the type of the surgical procedure are crucial factors for both the incidence of postoperative complications and the mortality rate. The higher risk of the transthoracic procedure is justified with a view to a better long term prognosis.     

Estimation of Growth Norms from Incomplete Longitudinal Data

Longitudinal studies are rarely complete due to attrition, mistimed visits and observations missing at random. When the data are missing at random it is possible to estimate the primary location parameters of interest by constructing a modification of Zellner's (1962) seemingly unrelated regression estimator. Such a procedure is developed in this paper and is applied to a longitudinal study of coronary risk factors in children. The method consists of two stages in which the covariance matrix is estimated at the first stage. Using the estimated covariance matrix a generalized least squares estimator of the regression parameter vector is then determined at the second stage. Limitations of the procedure are also discussed.     

Belt lipectomy for circumferential truncal excess: the University of Iowa experience

When some patients with circumferential truncal excess undergo traditional abdominoplasty, the trunk is not addressed as a unit. Belt lipectomy, a procedure that combines abdominoplasty with circumferential excision of skin and fat, is often more ideal for these patients. In this article, the authors review the literature on belt lipectomy and evaluate their series of 32 patients who underwent belt lipectomy at the University of Iowa. The evolution and current preoperative markings, intraoperative surgical technique, and postoperative care are described. The patients' charts and their preoperative and postoperative photographs were examined retrospectively. It was found that belt lipectomy improved abdominal contour, abdominal wall laxity, mons pubis ptosis, back rolls, waist contour, and buttocks contour. Initially, the procedure was performed on post-weight-reduction patients only, but its indications were extended to three other groups: patients who were 30 to 50 pounds overweight, patients of normal weight who desired a significant overall truncal improvement, and an obese patient with persistent intraabdominal excess. The improvements were significant in all groups of patients except for the latter patient. Complications included a 37.5 percent seroma rate, a 9.3 percent pulmonary embolus rate, and one dehiscence that required reoperation. The authors concluded that belt lipectomy should be seriously considered for patients who present with circumferential truncal excess and for a select group of normal-weight patients. It is not recommended for the obese patient with excessive intraabdominal content. Furthermore, belt lipectomy should be undertaken only in patients who are well informed about the possible risks and complications.     

Are geriatric units needed for elderly patients with hip fractures?

To assess the need for a multidisciplinary geriatric unit in the treatment of elderly patients with hip fractures, we reviewed the charts of all patients aged 60 years or older who were treated for hip fractures in five hospitals in Hamilton, Ont., between August 1982 and September 1983. We hypothesized that discharge to a different location from that before admission would indicate reduced functional status and classified the reasons for a change in residence as poor patient motivation, need for rehabilitation, compromised ambulation, postoperative complications and inevitable deterioration. We believed that geriatric care would be most beneficial to those in the first three groups. Of the 327 patients with hip fractures 40 (12%) died before discharge. Of the 287 surviving patients 149 (52%) had been discharged by 4 weeks, and only 29 (10%) remained in hospital by 12 weeks. Of the 287, 44 (15%) were discharged to a different location from that before admission: in 75% the cause appeared to be inevitable deterioration (57%) or postoperative complications (18%). The remaining 25% needed rehabilitation and were all sent to appropriate facilities. None of the patients with ambulation problems or poor motivation required an increased level of care. We could not show a need for geriatric care in our population; possible explanations are discussed.     

柱状经腹会阴直肠癌切除术后并发症分析及对策

目的:探讨分析柱状经腹会阴直肠癌切除术术后并发症发生的可能原因,并提出解决对策。方法:回顾分析我院自2010年1月至2014年5月采用柱状经腹会阴直肠癌切除术的68例直肠癌患者的临床资料。记录并分析患者发生术后并发症的情况,探讨发生的可能原因及可行对策。结果:68例患者术后出现并发症共9例,占13.2%。切口并发症4例,术后排尿困难2例,术后骶尾部疼痛3例。结论:柱状经腹会阴直肠癌切除术因为手术切除范围大,术后并发症亦随之凸显。但通过精细的术中解剖、重叠缝合腹膜关闭盆底、骶前通畅引流、合理掌握尿管拔管时机等手段,可有效降低术后并发症的发生。     

X-ray morphometric evaluation of the location of an intercalated fragment in double fractures of the shoulder

The Academician G.A. Ilizarov Russian Research Center "Reconstructive Traumatology and Orthopedics" treated 40 patients with double humeral fractures. On examining their X-ray films, the patients were divided into groups according to the location of an intercalated fragment. The Eletto procedure was used to estimate the levels of fractures. Comparison of the X-ray morphometric studies, the diagram of the humeral architectonics, and clinical observations revealed a relationship between the time of consolidation and the location of an intercalated fragment, which is explained by the degree of preservation of the latter's intramedullary blood flow. While treating patients with double fragments of the shoulder, it is expedient to use the Eletto index to determine the levels of the fragments.     

Spiral computed tomography in the diagnosis of inflammatory diseases of the vertebral column

A Somatom Plus 4 spiral computed tomograph was used to examine 40 patients with purulent spondylitis and 8 patients with tuberculous spondylitis. Analysis of the primary examination, postoperative status, and follow-up of patients on medical therapy identified the main signs of an inflammatory process from a great variety of the computed tomographic (CT) signs of a lesion. They made it possible not only to reveal the inflammatory nature of a lesion, but also to differentiate purulent and tuberculous spondylitis. The main CT signs that allow a purulent spondylitis to be differentiated from tuberculous one are as follows: the location of involved veterbrae, the number of and the pattern of destruction of trabecular and cortical layers, the extent of and the form of paravertebral tissue lesion.     

Cardiac evaluation and risk reduction in patients undergoing major vascular operations.

Occult coronary artery disease often accompanies symptomatic peripheral vascular disease and has an important effect on survival. Most perioperative and late fatalities after peripheral vascular operations are due to cardiac causes. Noninvasive cardiac testing can identify patients at increased risk for postoperative cardiac complications, although controversy exists regarding the optimal preoperative evaluation. Risk reduction strategies for patients known to be at high risk are also controversial. Some authors advocate coronary revascularization with coronary artery bypass grafting or percutaneous transluminal coronary angioplasty before the vascular procedure. Others believe that the combined morbidity and mortality of 2 operations exceed those of a peripheral vascular operation performed with aggressive monitoring and medical therapy. Continuous electrocardiographic monitoring after an operation has identified silent myocardial ischemia as a powerful predictor of cardiac complications. Ongoing research is likely to provide insights into the pathogenesis of postoperative cardiac complications and may lead to specific therapeutic interventions. Few prospective studies have been done in this area, and the threshold for preoperative and postoperative intervention is unknown. I review the literature and present an algorithm to guide cardiac testing and risk reduction in patients undergoing elective vascular surgical procedures.     

Breast reconstruction following lumpectomy and irradiation

The traditional approach to breast cancer has been the surgical mastectomy. The cosmetic deformity resulting from this procedure has led to the development of our current methods of breast reconstruction. The inherent attraction of lumpectomy and radiotherapy has been its equation with improved cosmesis. This procedure may be an effective alternative to surgery from the cancer perspective and does produce, in the majority of patients, an acceptable cosmetic result. However, this paper demonstrates that it may produce a result that is less optimal than mastectomy with postoperative breast reconstruction. The etiology of the increased deformity can either be the localized lumpectomy with marked internal derangement of breast volume or the radiation therapy itself. In addition, those who develop a combination require a solution to both. We describe three patients who illustrate these problems and believe that a greater awareness of these potential complications should be available to aid patients in choosing their cancer treatment.     

Ultrastructure and development of Pleistophora ronneafiei n. sp., a microsporidium (Protista) in the skeletal muscle of an immune-compromised individual

This report provides a detailed ultrastructural study of the life cycle, including proliferative and sporogonic developmental stages, of the first Pleistophora species (microsporidium) obtained from an immune-incompetent patient. In 1985, the organism obtained from a muscle biopsy was initially identified as belonging to the genus Pleistophora, based on spore morphology and its location in a sporophorous vesicle. Since that initial report, at least two new microsporidial genera, Trachipleistophora and Brachiola, have been reported to infect the muscle tissue of immunologically compromised patients. Because Trachipleistophora development is similar to Pleistophora, and as Pleistophora was only known to occur in cold-blooded hosts, the question of the proper classification of this microsporidium arose. The information acquired in this study makes it possible to compare Pleistophora sp. (Ledford et al. 1985) to the known human infections and properly determine its correct taxonomic position. Our ultrastructural data have revealed the formation of multinucleate sporogonial plasmodia, a developmental characteristic of the genus Pleistophora and not Trachipleistophora. A comparison with other species of the genus supports the establishment of a new species. This parasite is given the name Pleistophora ronneafiei n. sp.