Emergency treatment of haemorrhaging coeliac or mesenteric artery aneurysms and pseudoaneurysms in the era of endovascular management.

OBJECTIVES: Patients requiring emergency treatment of visceral artery aneurysms (VAAs) can be treated by endovascular or surgical techniques. Outcomes after failed attempts at endovascular control are unclear as is the present role of surgery. This study reviewed treatment and outcomes of a contemporary cohort of patients with symptomatic VAAs at a tertiary referral centre. METHODS: Patients undergoing emergency treatment of a VAA of the coeliac, mesenteric arteries, or their branches were identified over a 5-year period. Patient variables, treatments, and outcomes were assessed. RESULTS: Forty-eight patients underwent 65 radiological and two surgical procedures. Pseuodaneuryms were present in 45 (94%) of patients. Interventional radiology procedures were the initial treatment in every patient. The initial success was 40 out of 48 (83%). Patients requiring more than one procedure were all successfully treated. Regarding initial failures, if the VAA sac could not be accessed at angiography an alternative procedure to control the VAA was required in every case. If initial endovascular treatment failed, repeating the same procedure was successful in half of the patients. Ultrasound-guided percutaneous VAA embolisation was used in four patients. The 30-day mortality was eight out of 48 (17%). There were four recorded complications including one death directly attributable to VAA treatment. CONCLUSIONS: Patients needing emergency treatment of a VAA could be well served by non-surgical management. When the initial attempt at control of bleeding is unsuccessful it is important to consider non-conventional means of accessing these arteries. The need for surgery, in selected centres, may exist for a small group of patients after initial failed radiological treatment only.

Good clinical outcomes following transjugular intrahepatic portosystemic stent-shunts in Budd-Chiari syndrome.

BACKGROUND: There have been encouraging reports on transjugular intrahepatic portosystemic stent-shunt (TIPSS) for Budd-Chiari syndrome (BCS). Long-term data are lacking. AIM: To assess long-term outcomes and validate prognostic scores following TIPSS for BCS. METHODS: A single centre retrospective study. Patients underwent TIPSS using bare or polytertrafluoroethane (PTFE)-covered stents. RESULTS: Sixty-seven patients received successful TIPSS between 1996 and 2012 using covered (n = 40) or bare (n = 27) stents. Patients included had a Male: Female ratio of 21:46, and were characterised (mean ± s.d.) by age 39.9 ± 14.3 years, Model of end stage liver disease (MELD) 16.1 ± 7.0 and Child's score 8.8 ± 2.0. Seventy-eight percent had haematological risk factors. Presenting symptoms were ascites (n = 61) and variceal bleeding (n = 6). Nine patients underwent hepatic vein dilatation or stenting prior to TIPSS. Mean follow-up was 82 months (range 0.5-184 months). Fifteen percent had post-TIPSS encephalopathy. Two have been transplanted. Primary patency rates (76% vs. 27%, P < 0.001) and shunt re-interventions (22% vs. 100%, P < 0.001) significantly favoured covered stents. Secondary patency was 99%. Six-, 12-, 24-, 60- and 120-month survival was 97%, 92%, 87%, 80% and 72% respectively. Six patients had liver related deaths. Two patients developed hepatocellular carcinoma. The BCS TIPS PI independently predicted mortality in the whole cohort, but no prognostic score was a significant predictor of mortality after subgroup validation. CONCLUSIONS: Long-term outcomes following TIPSS for Budd-Chiari syndrome are very good. PTFE-covered stents have significantly better primary patency. The value of prognostic scores is controversial. TIPSS should be considered as first line therapy in symptomatic patients in whom hepatic vein patency cannot be restored.

Pinworm infection masquerading as colorectal liver metastasis.

Enterobius vermicularis is responsible for a variety of diseases but rarely affects the liver. Accurate characterisation of suspected liver metastases is essential to avoid unnecessary surgery. In the presented case, following a diagnosis of rectal cancer, a solitary liver nodule was diagnosed as a liver metastasis due to typical radiological features and subsequently resected. At pathological assessment, however, a necrotic nodule containing E. vermicularis was identified. Solitary necrotic nodules of the liver are usually benign but misdiagnosed frequently as malignant due to radiological features. It is standard practice to diagnose colorectal liver metastases solely on radiological evidence. Without obtaining tissue prior to liver resection, misdiagnosis of solitary necrotic nodules of the liver will continue to occur.

The 'pulseless pink' hand after supracondylar fracture of the humerus in children: the predictive value of nerve palsy.

We compared two management strategies for the perfused but pulseless hand after stabilisation of a Gartland type III supracondylar fracture. We identified 19 patients, of whom 11 were treated conservatively after closed reduction (group 1). Four required secondary exploration, of whom three had median and/or anterior interosseus nerve palsy at presentation. All four were found to have tethering or entrapment of both nerve and vessel at the fracture site. Only two regained patency of the brachial artery, and one patient has a persistent neurological deficit. In six of the eight patients who were explored early (group 2) the vessel was tethered at the fracture site. In group 2 four patients also had a nerve palsy at presentation and were similarly found to have tethering or entrapment of both the nerve and the vessel. The patency of the brachial artery was restored in all six cases and their neurological deficits recovered completely. We would recommend early exploration of a Gartland type III supracondylar fracture in patients who present with a coexisting anterior interosseous or median nerve palsy, as these appear to be strongly predictive of nerve and vessel entrapment.

Tetraplegia following cervical spine cord contusion from indirect gunshot injury effects.

We present the case of a 31 year old British soldier who sustained a high energy gunshot injury to the neck with delayed onset tetraplegia. The bullet's transcervical track was subsequently shown to have had no direct contact with the spinal cord, but four to five minutes after injury the patient developed tetraplegia. Subsequent Magnetic Resonance Imaging confirmed this to be due to contusion of the cervical spinal cord. This case illustrates the high levels of energy potentially transferred to surrounding tissues by the passage of a high available energy projectile, causing significant injury to nearby structures not actually impacted by the missile.

Postoperative radiographs following hip fracture surgery. Do they influence patient management?

There is still much debate on the appropriateness of taking postoperative radiographs following hip fracture surgery. In our unit, it is routine practice to request postoperative radiographs after hip hemiarthroplasty but not after internal fixation. An audit conducted in our unit highlighted the low acute implant-related complications. This prompted us to conduct a national audit on current UK practice regarding the use of check radiographs following hip fracture surgery. Retrospective case note review of all patients undergoing hip fracture surgery at our hospital, from 2002 to 2004, was performed. Patients undergoing revision surgery in the same admission were identified to determine whether check radiograph influenced the decision. Subsequently a postal performa was sent to 450 randomly chosen UK Orthopaedic Consultants. The performa was designed to determine practice relating to postoperative radiographs. It also attempted to determine whether postoperative radiographs (when requested) influenced the subsequent clinical management of the patient. A total of 1265 hip fractures treated surgically were reviewed locally. Average length of stay was 29.5 days. There were five acute implant-related complications. One revision was performed for a long hip screw which was obvious on the intra-operative image intensifier films. Only one decision to revise (because of incongruous reduction of a hip hemiarthroplasty) was based on a problem identified on a routine check radiograph. All patients undergoing revision were clinically symptomatic. We received 300 responses. Ninety-six per cent routinely took postoperative radiographs following hip hemiarthroplasty of which 83% allowed the patient to mobilise before checking the radiograph. Following dynamic hip screw (DHS)/dynamic condylar screw (DCS) fixation, 61% took check radiographs of which 75% allowed the patient to mobilise prior to reviewing the radiograph. Following cannulated screw (CS) fixation, 58% routinely performed check radiographs of which 67% allowed the patient to mobilise before reviewing the radiograph. The study highlights the lack of national consensus on the use of postoperative radiographs. We recommend that following DHS/DCS fixation and CS fixation, the use of postoperative radiographs should only be undertaken when clinically indicated. Postoperative radiographs following hip hemiarthroplasty should only be undertaken if there are operative concerns or postoperative complications.

Cerebellar peduncle myelinolysis: case report.

We present a case of bilateral middle cerebellar peduncle myelinolysis, in which the diagnosis modality was MRI.

Results of middle ear ventilation with 'Mangat' T-tubes.

Tympanostomy tube placement has been shown to be an effective treatment for recurrent acute otitis media and chronic otitis media with effusion. The Senior author, (K.S. Mangat), considered stiffness and the longer inner limbs of the Goode (Xomed) or Treace (Treace Medical) T-tubes as important factors in the high incidence of complications, and used smaller soft silicone. Mangat-tube (Xomed) with shorter inner limbs. A prospective study was undertaken over a five year period (July 1987-July 1992) which was a continuation of a previous retrospective study of Goode and Treace T-tubes (Mangat, K.S., Morrison, G.A.J., and Ganiwalla, T.M. (1993) Int. J. Pediatr. Otorhinolaryngol. 25, 119-125). 322 Mangat tubes (M-tubes) were inserted in 191 patients with persistent otitis media with effusion. The peak ages for insertion were between 4 and 6 years. Spontaneous extrusion occurred in 240 ears (66.5%; 154 patients) at a mean time of 29.3 months. Of these, there were 60 perforations at three months follow-up (18.6%) which fell to 31 perforations after six months (9.6%). Surgical extraction of the M-tube was necessary in 82 ears (22.7%; 50 patients) following persistent otorrhoea or resolution of the condition. Otorrhoea, requiring treatment, was noted in 36 ears (11%). No association was found between the occurrence of infection and the incidence of perforation persisting after a year. There was a higher incidence of persistent perforation in those requiring surgical extraction. The overall persistent perforation rate of only 9.6% would appear to be less than that experienced with Goode or Treace T-tubes.

Transtympanic myringoplasty in children.

Our experience with myringoplasty by the transtympanic "push through' technique in paediatric patients is described. We have used this method in 40 children utilizing autologous temporalis fascia as the graft material. The procedures were all performed as day cases under general anaesthesia. The overall success rate for perforation closure was 77.5% at 6 months which is comparable to conventional methods. We conclude that the "push-through' technique is a safe, simple, reliable and cost-effective procedure that can be performed as a day case in paediatric patients. It avoids the necessity for pressure bandaging or formal ear packing. To our knowledge this is the first paper evaluating this technique in children.

T-tubes: a retrospective review of 1274 insertions over a 4-year period.

1274 T-tubes were inserted for persistent otitis media with effusion in 661 patients over a 4-year period. The peak ages for insertion were between 4 and 7 years, and by 11 years the condition is uncommon. If a tube has not extruded spontaneously after 30 months it becomes increasingly less likely to do so. Complications were persistent perforations (32.6%), tympanosclerosis (23.6%), repeated otorrhoea or tympanic membrane granulations (21%), and impacted wax (10.9%). Forty-eight percent of patients experienced one or more complication in the study period, and the complication rate increased dramatically in patients whose tubes had remained in situ for longer than 36 months. After this time surgical removal is recommended.

Closure of tympanic membrane perforation after the removal of Goode-type tympanostomy tubes: the use of silastic sheeting.

The reported incidence of persistent tympanic membrane perforation after the extrusion or removal of Goode-type tympanostomy tubes varies from 3 per cent to 47.5 per cent. A prospective randomized study of 152 Goode-type T-tube removals is presented. In one group of 79 ears, the edge of the defect was just freshened, but in the other 73 ears, the edge was freshened and a small piece of 0.13 mm silastic sheeting placed over the defect. Follow-up was performed at six weeks and three, six and nine months and shows that the use of silastic sheeting increases the rate of closure of the perforation and also significantly decreases the number of persistent perforations at nine months.

A comparison of audiometric performance and complications of T tubes and Shepard grommets.

Since T tubes were introduced in 1972 their use in cases of chronic Eustachian-tubal insufficiency has been reported on several occasions, (Goode, 1973, 1983; Rothera and Grant, 1985). T tubes remain in-situ for longer than grommets, and they are frequently used in cases where multiple grommet insertions have failed to provide adequate middle ear ventilation. They have also been used when prolonged Eustachian-tubal insufficiency is anticipated, for instance in children with cleft palate. Shepard grommets continue to be the most commonly used type of ventilating tube for short-term use and a significant proportion of children with glue ear require repeated insertions. In an attempt to reduce the need for repeated myringotomy, and also to reduce the need for adenoidectomy in children with glue ear, it has been the recent practice of one Consultant (K.S.M.) to use T tubes routinely in all cases of glue ear. This study analyses the audiometric performance and complications of 32 children (60 ears) who underwent myringotomy and insertion of T tubes for glue ear. In all cases no previous treatment for glue ear had been undertaken. The results are compared with those of a control group who underwent myringotomy with insertion of Shepard grommets and adenoidectomy as a first-line treatment.