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We report a case of a 53-year-old male who presented with acute onset right upper quadrant (RUQ) abdominal pain with investigations demonstrating malrotation causing midgut volvulus and subsequent intestinal obstruction. The patient was consented for an emergent operation and underwent an exploratory laparotomy. Operative findings included the presence of adhesive bands in the RUQ (Ladd's Band), volvulus of the mid-portion of the small bowel in a clockwise fashion and multiple intra-abdominal adhesions causing internal hernias. We subsequently performed a Ladd's procedure and the patient had an uneventful recovery with eventual discharge on postoperative day 8. This case report reviews the incidence of malrotation in adults. It also highlights the difficulty in diagnosing midgut volvulus in the adult population given the nonspecific, insidious symptoms therefore prompting awareness of its existence and a high degree of clinical suspicion.
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BACKGROUND: With the increased use of damage control surgery and open abdomens, there are growing challenges in achieving primary fascial closure. The purpose of this study was to retrospectively review our experience using the Abdominal Reapproximation Anchor (ABRA; Canica Design Inc, Almonte, Ontario, Canada), a dynamic fascial closure system, to gain fascial apposition in complex abdominal surgical patients. METHODS: A retrospective review of patients who underwent placement of the ABRA device to aid in abdominal closure was undertaken. Details including age, sex, the reason for an open abdomen, the number of operations, the time to primary closure, the success rate of primary closure, and complications related to the use of the ABRA were analyzed. RESULTS: Between January 2006 and July 2011, 36 patient charts were identified. The average Acute Physiology and Chronic Health Evaluation II score was 21.9 ± 6.9. There was a mean of 3.1 ± 1.8 laparotomies before ABRA placement for each patient, and the duration of ABRA placement until removal was 10.4 ± 6.1 days. Complete fascial apposition was achieved in 83% of the patients across the entire study and in 91% of the patients in the final 2 years. Component separation was used in 17% of cases. The incisional hernia rate was 13% at 6 months and 11% at 12 months. CONCLUSIONS: Our use of the ABRA system resulted in an 83% fascial apposition rate, which further improved when experience was taken into account. The incisional hernia rate was acceptable in this complicated patient group. This technique is an excellent addition to a surgeon's armamentarium for complicated abdominal cases that require an open abdomen. Further prospective studies are planned to identify ideal candidates for this technique.
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Traumatismos Abdominais/cirurgia , Técnicas de Fechamento de Ferimentos Abdominais/instrumentação , Fasciotomia , Tratamento de Ferimentos com Pressão Negativa/instrumentação , Adulto , Idoso , Feminino , Indicadores Básicos de Saúde , Hérnia Ventral/epidemiologia , Hérnia Ventral/etiologia , Humanos , Laparotomia/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Tratamento de Ferimentos com Pressão Negativa/métodos , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND/PURPOSE: Little is known about the quality of life (QOL) of children with Hirschsprung's disease (HD) as they grow older. The purpose of this study was to measure the QOL and bowel function of these children as they mature. METHODS: All children who were surgically treated for HD at British Columbia Children's Hospital, Vancouver, British Columbia, Canada between 1986 and 2003 were invited to participate. Each family was sent 3 previously validated questionnaires exploring current QOL and bowel function. RESULTS: Fifty-one families participated (49%), with children between the ages of 3 and 21 years. Fecal continence improved significantly with age (P = .04) and was the strongest predictor of QOL scores of all variables in our study. There was no statistically significant difference in QOL scores between children with HD and healthy children, although a clinically relevant impairment in QOL may be present, especially in psychosocial scores. CONCLUSIONS: Fecal continence is an important predictor of overall QOL in children surgically treated for HD. Although continence tends to improve with age, a number of older children still have ongoing continence problems, and they seem to be a group at risk for impaired QOL. Our study indicates that interventions for children with incontinence may offer gains in QOL as well as bowel function.
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Constipação Intestinal/fisiopatologia , Incontinência Fecal/fisiopatologia , Doença de Hirschsprung/fisiopatologia , Anormalidades Múltiplas/epidemiologia , Adolescente , Adulto , Análise de Variância , Criança , Pré-Escolar , Comorbidade , Constipação Intestinal/epidemiologia , Incontinência Fecal/classificação , Incontinência Fecal/epidemiologia , Feminino , Seguimentos , Doença de Hirschsprung/epidemiologia , Doença de Hirschsprung/cirurgia , Humanos , Masculino , Período Pós-Operatório , Qualidade de Vida , Índice de Gravidade de Doença , Distribuição por Sexo , Inquéritos e QuestionáriosRESUMO
OBJECTIVE: The abdominal compartment syndrome is a potentially life-threatening condition with frequent renal involvement. There are few if any means of inferring subclinical effects before organ dysfunction. Because intrarenal pressure correlates with renal sonographic indices in other renal diseases, the purpose of this study was to determine the relationship between increasing intraabdominal hypertension and renal vascular flow velocities in a porcine model using renal Doppler ultrasound. DESIGN: Animal study. SETTING: University research laboratory. SUBJECTS: Eight anesthetized, mechanically ventilated, well-hydrated, 30-kg female Yorkshire pigs. INTERVENTIONS: Intraabdominal hypertension was induced by instillation of warmed intraperitoneal saline through a midline laparoscopic port. Intraabdominal pressure (IAP) was continuously monitored directly from the peritoneum and indirectly from the bladder. IAP was varied from 0 to 50 mm Hg in increments of 5 mm Hg. At each IAP level, gray-scale, color, and spectral Doppler renal arcuate artery ultrasound was obtained and resistive index (RI) and peak airway pressure calculated. MEASUREMENTS AND MAIN RESULTS: Excellent agreement between direct and indirect IAP was found (bias, 0.032 mm Hg; 95% limits, -5.5 to 5.6 mm Hg). A linear relationship between RI and indirect IAP was observed and was defined by the regression equation: RI = 0.553 + 0.0104 x bladder pressure. There was a trend toward different RIs between left and right kidneys (p = .052) at the same IAP. RI varied in a linear fashion at low peak airway pressure and demonstrated an inflection point with steeper subsequent slope after peak airway pressure of 30 cm H2O. RI values rapidly returned to near baseline after abdominal decompression. CONCLUSIONS: In this model, the renal artery RI correlated strongly and linearly with the severity of intraabdominal hypertension, making renal Doppler ultrasound a potential noninvasive screening tool for the renal effects of intraabdominal hypertension. Further studies are warranted.
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Cavidade Abdominal , Modelos Animais de Doenças , Hipertensão , Artéria Renal/fisiopatologia , Índice de Gravidade de Doença , Resistência Vascular , Animais , Viés , Síndromes Compartimentais/complicações , Síndromes Compartimentais/diagnóstico , Síndromes Compartimentais/fisiopatologia , Feminino , Hipertensão/complicações , Hipertensão/diagnóstico , Hipertensão/fisiopatologia , Hipertensão Renal/diagnóstico por imagem , Hipertensão Renal/etiologia , Hipertensão Renal/fisiopatologia , Análise dos Mínimos Quadrados , Modelos Lineares , Programas de Rastreamento , Monitorização Fisiológica , Projetos Piloto , Valor Preditivo dos Testes , Artéria Renal/diagnóstico por imagem , Circulação Renal , Suínos , Ultrassonografia Doppler , Cateterismo UrinárioRESUMO
HYPOTHESIS: Management strategies affect the outcome of axillary recurrence in breast cancer. DESIGN: Population-based analysis. SETTING: Cancer agency breast cancer database. PATIENTS: Two hundred twenty women diagnosed with stage 0 through III breast cancer between 1989 and 2003 who subsequently developed an isolated axillary relapse. MAIN OUTCOME MEASURES: Overall survival rate and disease-free survival rate according to treatment strategy of the axillary recurrence. RESULTS: Among 19 789 women diagnosed with stage 0 through III breast cancer during the study era, 220 had an isolated axillary recurrence (Kaplan-Meier 5-year isolated axillary relapse rate, 1.0%). The median interval between primary breast cancer diagnosis and axillary recurrence was 2.2 years (range,1.8 months to 11.9 years). Median follow-up time after axillary recurrence was 5.4 years. Treatment for the axillary recurrence included lymph node biopsy (47.3%), complete axillary dissection (25.9%), axillary radiation (65.0%), chemotherapy (24.1%), and hormonal therapy (68.2%). The 5-year Kaplan-Meier overall survival rate estimate after axillary recurrence was 49.3% (95% confidence interval, 42.0-56.3). Median survival time from the isolated axillary recurrence was 4.9 years (range, 2.0 months to 15.1 years). Overall (P < .001) and disease-free (P = .006) survival times were highest in those treated with a combination of surgery and radiation. Other factors associated with improved overall survival rate were an interval from diagnosis to relapse greater than 2.5 years (P = .003), no initial axillary radiation (P < .001), asymptomatic presentation of the recurrence (P = .05), and subsequent systemic treatment (P = .02). CONCLUSIONS: The 5-year isolated axillary recurrence rate of women treated for breast cancer was 1.0%. Multimodality management at the time of recurrence, including axillary surgery, radiation, and systemic therapy, significantly improved overall and disease-free survival.
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Neoplasias da Mama/patologia , Linfonodos/patologia , Axila , Neoplasias da Mama/terapia , Terapia Combinada , Progressão da Doença , Feminino , Humanos , Excisão de Linfonodo , Metástase Linfática , Pessoa de Meia-Idade , Recidiva Local de Neoplasia , Estadiamento de Neoplasias , Prognóstico , Taxa de Sobrevida , Resultado do TratamentoRESUMO
BACKGROUND: Bicycling, skateboarding, and inline skating are popular recreational activities, with the potential of causing severe injury. METHODS: A retrospective, population-based, trauma registry analysis of severe injuries and deaths from nonmotorized wheeled vehicles (NMWV) over a 10-year period was performed. RESULTS: During the study period, 1475 cyclists, 141 skateboarders, and 112 inline skaters sustained injury meeting registry criteria (length of stay > or = 3 days or death). The majority were male. Lone crashes were the most common mechanism of injury, although collisions with motor vehicles accounted for 63.6% (n = 44) of observed deaths. Thoracic trauma and head injuries were more common in nonsurvivors. CONCLUSION: NMWV injuries pose a public health concern. We recommend enforcement of mandatory helmet laws and expansion of the existing law to include skateboarders and inline skaters. Education initiatives should also be expanded to include the adult population. NMWV should be separated from motorized vehicles as much as possible.
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Traumatismos em Atletas/epidemiologia , Ciclismo/lesões , Vigilância da População , Patinação/lesões , Adolescente , Adulto , Distribuição por Idade , Idoso , Traumatismos em Atletas/diagnóstico , Colúmbia Britânica/epidemiologia , Traumatismos Craniocerebrais/diagnóstico , Traumatismos Craniocerebrais/epidemiologia , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Traumatismo Múltiplo/diagnóstico , Traumatismo Múltiplo/epidemiologia , Estudos Retrospectivos , Distribuição por Sexo , Taxa de Sobrevida , Traumatismos Torácicos/diagnóstico , Traumatismos Torácicos/epidemiologia , Índices de Gravidade do TraumaRESUMO
BACKGROUND/PURPOSE: The purpose of this analysis was to investigate outcomes in newborns with esophageal atresia (EA) or tracheoesophageal fistula (TEF) with respect to prognostic classifications and complications. METHODS: Charts of all 144 infants with EA/TEF treated at British Columbia Children's Hospital (BCCH) from 1984 to 2000 were reviewed. Patient demographics, frequency of associated anomalies, and details of management and outcomes were examined. RESULTS: Applying the Waterston prognostic classification to our patient population, survival rate was 100% for class A, 100% for class B, and 80% for class C. The Montreal classification survival rate was 92% for class I and 71% for class II (P =.08). Using the Spitz classification, survival rate was 99% for type I, 84% for type II, and 43% for type III (P <.05). The Bremen classification survival rate was 95% "without complications" and 71% "with complications." Complications included stricture (52%), gastroesophageal reflux (31%), anastomotic leakage (8%), recurrent fistula (8%), and pneumonia (6%). Seventeen patients underwent fundoplication for gastroesophageal reflux, 16 pre-1992 and one post-1992. CONCLUSIONS: Comparing the major prognostic classifications, the Spitz classification scheme was found to be most applicable. In our institution, the trend in management of gastroesophageal reflux after repair of EA/TEF has moved away from fundoplication toward medical management.