Intraoperative endoscopic pneumatic testing for gastrojejunal anastomotic integrity during laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Gastrojejunal anastomotic leaks remain a major source of morbidity following laparoscopic gastric bypass. Intraoperative pneumatic testing has been offered as a method to reduce the incidence of this complication. This study's purpose was to assess the efficacy of intraoperative pneumatic testing during laparoscopic gastric bypass, to evaluate the types of air leaks detected, and to develop an algorithm for management that takes into account air leak categorization and drainage. METHODS: A retrospective analysis was performed on the initial 257 consecutive patients undergoing laparoscopic gastric bypass by a single surgeon over a 36-month period. The gastrojejunostomy was constructed using a linear stapler technique. All patients underwent intraoperative endoscopic pneumatic testing with a clamp applied to the Roux limb. All patients underwent water-soluble upper gastrointestinal radiography on the first postoperative day. RESULTS: Patients were divided based on the pneumatic testing results into groups for data analysis: persistent air leak (group 1), non-reproducible air leak (group 2), and no air leak (group 3). The overall age (41.7+/-9.3 years), body mass index (BMI) (47.3+/-6.4 kg/m2), conversion rate (2%), and length of stay (1.9+/-2.0 days) were not statistically different among groups (p>0.05). In group 1, the air leak site was repaired, and 11 (92%) were drained. In group 2, the air leak site could not be identified, and all 12 (4.7%) were treated by drainage alone. In group 3, drains were placed in 12 (5.2%) due to difficult construction of the gastrojejunostomy. Overall postoperative gastrointestinal leak rate was 0.78%. No postoperative clinical or radiological gastrointestinal leaks occurred within the region tested pneumatically. Intraoperative complications related to pneumatic testing occurred in 1 (0.39%) patient. CONCLUSIONS: Intraoperative pneumatic testing of the gastrojejunal anastomosis is a safe and rapid means of evaluating anastomotic integrity. Application of this technique permitted timely repair of flawed anastomoses, thereby averting potential postoperative leaks.

Hemodynamic and respiratory responses to carotid sinus pressure alteration in experimental hypertension.

The purpose of this study was to determine whether baroreflex control of respiratory responses is diminished in hypertension. Ten dogs were made chronically hypertensive with use of a bilateral renal wrap technique. Eight sham-operated dogs served as normotensive controls. After the development of experimental hypertension, carotid baroreflex control of arterial pressure, heart rate, respiratory frequency, tidal volume, and ventilation was acutely assessed. Under pentobarbital anesthesia and with bilateral vagotomy, the carotid sinuses were isolated and perfused at controlled pressures. Before the carotid sinus region was manipulated, the mean arterial pressure was significantly higher (P < 0.005) in the hypertensive group (146.4 +/- 2.3 mmHg) than in the normotensive group (124.7 +/- 2.6 mmHg). The mean arterial pressures and heart rates measured at every level of carotid sinus pressure were significantly higher in the hypertensive group. Reflex gain of heart rate, but not mean arterial pressure, was significantly reduced in the hypertensive group. Respiratory frequency, tidal volume, and ventilatory responses to changes in carotid sinus pressure were significant and resulted in an approximately 40% reflex change in ventilation. These responses were not diminished in the hypertensive group. We conclude that respiratory baroreflex responses are preserved in experimental hypertension.

Laparoscopic transcystic sphincter of Oddi manometry is not affected by carbon dioxide pneumoperitoneum.

Sphincter of Oddi (SO) dysfunction as a potential cause of chronic acalculous cholecystitis (CAC) has not been studied in cases for which intraoperative SO manometry was used during laparoscopic cholecystectomy. In this study, we evaluated the effects of carbon dioxide pneumoperitoneum on laparoscopic transcystic SO manometry. In 27 patients with CAC, transcystic SO manometry had been attempted during laparoscopic cholecystectomy. The mean age of the patients was 46 years (range, 22-71). Complete manometric data sets were obtained in 18 patients. The mean SO pressure, phasic SO pressure, and phasic frequency were 35.4 +/- 29.1 mm/Hg versus 30.8 +/- 23.8 mm/Hg, 104.8 +/- 63.0 mm/Hg versus 73.6 +/- 34.6 mm/Hg, and 2.1 +/- 1.8 contractions/min versus 2.8 +/- 3.4 contractions/min with and without pneumoperitoneum, respectively. All differences were nonsignificant (P > 0.05). Two complications (7.4%) were observed: pancreatitis and jaundice. SO manometry is not affected by CO2 pneumoperitoneum. It may be used to study SO motility in patients with CAC.

Bilateral intraosseous ganglia of the scaphoid and lunate bones.

A rare case of simultaneous bilateral intraosseous ganglia of the scaphoid and lunate bones is presented. The cysts were removed and the carpal bones were grafted with cancellous bone, resulting in a satisfactory outcome.

Cementless coated and noncoated Mathys acetabular cups: radiographic and histologic evaluation.

This study evaluated 185 cementless Mathys coated and uncoated acetabular cups inserted for total hip replacement since September 1984. All of the cups were high-density polyethylene. Sixty were uncoated (group A), 96 were coated with hydroxyapatite (group B), and 29 were coated with titanium (group C). Cup survival was assessed clinically, histologically, and radiographically, and a computer-assisted EBRA method was used to evaluate cup migration. After a mean follow-up of 8 years, five cups in group A that had previously shown migration were revised as a result of aseptic loosening, while no loosening of hip sockets occurred in groups B and C. These results suggest that Mathys cups should be used only if coated with hydroxyapatite or titanium. Furthermore, the histologic evaluation in four cups from groups B and C revealed normal bone formation without inflammation or fibrotic tissue around the cups, promising long-term survival.

Humeral fracture following shoulder arthroplasty.

Fracture of the humeral shaft after total or hemiarthroplasty of the shoulder occurs infrequently but has serious consequences. This article reports on five patients with ipsilateral humeral fractures following shoulder hemiarthroplasty who were treated either conservatively or surgically. Fractures in the three patients treated conservatively healed on average by 7 months. The results were satisfactory in one patient and unsatisfactory in two patients. Both of these patients complained of pain and limitation of shoulder motion. Fractures in the two patients treated by open reduction and Mennen plate fixation healed on average by 2 months, resulting in a better outcome for these patients treated surgically.

The effect of intramedullary bone plug on femoral stem migration of hydroxyapatite-coated hip arthroplasty.

This study investigated the effect of intramedullary corticocancellous bone plug on the fixation and stability of hydroxyapatite-coated femoral stems in total hip arthroplasty (THA). Intramedullary corticocancellous bone plug was used in 30 patients with hydroxyapatite-coated femoral stems (group A) and a consecutive series of 30 patients with hypdroxyapatite-coated stems without bone plug served as the control group (group B). Patients underwent clinical and radiographic follow-up for at least 2 years. The addition of corticocancellous bone plug to the hydroxyapatite-coated stem significantly improved clinical and radiographic results. The mean Harris Hip Score at 3 and 6 months postoperatively was 92 and 94 in group A, and 84 and 87 points in group B (P<.004 and P<.001, respectively). There was no significant difference between groups at 1 year postoperatively and thereafter. The predominant cause for the difference was the thigh pain score, which was reduced at both 3 and 6 months in group A compared to group B (P<.01 and P<.05, respectively). There also were statistical differences between the two groups regarding radiographic signs. The evidence of endosteal bone formation in group A patients was superior at 3 and 6 months (P<.001 and P<.01, respectively). The appearance of a radiolucent line was significant in group B patients at 3 and 6 months (P<.001). Femoral stem migration of 3 mm was noted in three group B patients versus no group A patients (P<.05). These short-term clinical and radiographic results suggest corticocancellous bone plug can provide early pain relief and durable implant fixation, but long-term follow-up should be considered.

The effect of abduction differences between cup and contralateral acetabular angle on polyethylene component wear.

One hundred forty-two patients who underwent cemented or uncemented hip replacement were studied radiographically to determine acetabular component wear. Mean duration of follow-up was 58 months (range: 35-92 months). Average linear wear was 0.78 mm (range: 0-1.9 mm), and average wear rate was 0.16 mm/year (range: 0-0.45 mm/year). An increased wear rate per year correlated with a discrepancy >18.3 degrees between contralateral acetabular angle and acetabular cup inclination (P<.005). Statistical analysis revealed no significant correlation between cup inclination and polyethylene wear, which was studied without considering the contralateral hip (P>.3). There was no relationship between polyethylene wear and cup design, weight, and initial polyethylene thickness.

Revision arthroplasty of femoral cortex defect using a noncemented stem, Mennen plate, and bone graft.

Twelve patients who underwent total hip replacement complicated by aseptic loosening with severe bone loss were included in this study. Two patients had aseptic loosening of the second revision, six of the third revision, and the remaining four patients of the fourth revision total hip replacement. In all patients, the radiographs revealed an extremely thin cortex around the stem of the prosthesis and almost complete disappearance of one cortex. All patients were treated by revision total hip replacement in conjunction with Mennen plate fixation and allograft bone support. The allograft bone support included three cortical struts and nine massive bone grafts that used cement as a strew. The results were satisfactory in 10 patients in respect to functional activity, pain and radiographic evaluation. In two patients who underwent their fifth revision, the results were unsatisfactory but better than before the operation. Mennen plate fixation provides a sufficient and easy technique for aseptic loosening of total hip replacement with severe bone loss. By preserving the periosteal blood supply, the time required for bone graft incorporation is shortened, resulting in an early final outcome.

[Femoral fracture following total hip replacement].

Between January 1990 and May 1996 we performed 500 total hip replacements, 6 of which were complicated by ipsilateral femoral fracture. Treatment was either by skeletal traction or by internal fixation, with or without revision-total hip replacement. Results of surgical treatment were superior to those of conservative treatment. This study supports use of Mennen plate-fixation. Further studies are necessary for final evaluation of the efficacy of this method.

[Glenoid fossa fracture].

4 patients with displaced intra-articular glenoid fossa were treated either surgically or conservatively. After an average follow-up of 7 years, the clinical and radiographic results were satisfactory in all. The 2 treated surgically required shorter follow-up than those treated conservatively. Conservative treatment should be considered a good option for displaced intra-articular glenoid fossa fracture.

[Magnetic resonance imaging for suspected femoral neck fractures].

Painful hip as a result of injury, with or without a history of trauma, is a common reason for referring elderly patients to the emergency room. The diagnosis of femoral neck fracture requires the combination of a physical examination, X-rays, and in problematic cases, a bone scan. However, even this combination does not always provide a diagnosis. We present 50 patients with painful hip who complained of limp and reduced hip joint motion, but had no evidence of fracture, either on X-ray or bone scan. After conservative treatment, 5 patients with no history of trauma underwent hemiarthroplasty of the hip for displaced subcapital fracture. In addition, we present a case of subcapital fracture which was diagnosed only by MRI, in whom both X-rays and bone scan were considered normal.

[Intra-osseous ganglion of scaphoid and lunate bones].

We present a patient with intra-osseous ganglion of the left scaphoid and lunate bones. These were excised and a bone graft inserted. 1 year after operation the patient was free of pain, without limitation of wrist motion. Intra-osseous ganglion of the carpal bone is not common and lunate and scaphoid intra-osseous ganglion has rarely been reported. Awareness of this condition may lead to earlier diagnosis and treatment, with satisfactory outcome.

[Conversion total hip replacement after failed internal fixation of intertrochantric fracture].

Between 1933-1995, 16 patients underwent conversion-total hip replacement after internal fixation of an intertrochanteric fracture failed. Clinical results were unsatisfactory compared to primary total hip replacement. There was a high incidence of intra- and postoperative complications, including femoral fracture, wound infection, and aseptic loosening. This study should increase the surgeon's awareness of the difficulties encountered in conversion of failed intertrochanteric fractures to total hip replacement.

[Total knee replacement].

The medical records of 319 patients who underwent 350 primary total knee replacements were analyzed retrospectively. The age range was 44-89 years (average 66). In all we used a Biomet ACG prosthesis and preserved the posterior cruciate ligament. Results, measured objectively with Knee Society scores, were satisfactory for all ages, especially the younger. However, even in older age groups subjective results were promising. We emphasize the importance of preserving the posterior cruciate ligament and its advantages for all age groups.

[Recurrent chronic multifocal bone infection].

We present a 9-year-old girl who had chronic recurrent multifocal osteomyelitis. The bones involved were: right clavicle, distal fibula (bilateral), left sacroiliac and right wrist. After 10 years of follow-up; she is asymptomatic but presents radiological evidence of lesions in the right clavicle and left sacroiliac joint. The diagnosis was made by exclusion criteria. The biopsy and results of cultures from various bones were negative 4 times. Although chronic recurrent multifocal osteomyelitis is rare, it should be considered in the differential diagnosis of acute or chronic osteomyelitis and neoplasma. Its recognition avoids unnecessary laboratory tests and antibiotic therapy.

[Fracture of the humerus after hemiarthroplasty of the shoulder].

Fracture of the humeral shaft as a complication of total shoulder replacement or shoulder hemiarthroplasty is infrequent, but has serious consequences. Traumatic injury is the most common reason for humeral fracture. The prosthesis causes corticolysis as a result of aseptic and septic loosening. Concomitant with increasing use of total and hemiarthroplasty of the shoulder, is an increase in aseptic loosening of the prosthesis. This increases the frequency of humeral fracture after the procedures. We reviewed the results of 3 patients, women aged 54 and 68 years, respectively, and a man of 65, who were treated for humeral fracture as a complication of hemiarthroplasty of the shoulder. We recommend surgical treatment for fracture around the tip of the prosthesis. Humeral fracture below the tip of the prosthesis should be treated individually, depending on the surgeon's experience.

Hydroxyapatite-coated total hip arthroplasty in osteoporotic patients.

A prospective review was performed on 22 osteoporotic patients (rated from 1 to 3 on the Singh Index) with hydroxyapatite-coated total hip replacements. These results were compared with a control group (Singh Index 4 to 6) of 45 patients (48 hips) with respect to clinical and radiographic data. Surgery was performed over a six-year period (1991 to 1996) and the time to follow-up evaluation averaged 5 years (range: 2 to 7 years). All patients, in both groups, were over 65 years old with an average age of 71 and 73 years, respectively. The pre-operative diagnoses and Harris hip scores were also similar for both groups. Clinical evaluation was based on the Harris Hip score and radiographic evaluations using Engh's criteria. There was no significant difference between the final average Harris hip score in the osteoporotic bone group, which was 87 points, and that for the control group, which was 91 points (p > 0.05). Radiographic evaluation demonstrated confirmed bone ingrowth in most patients in each group; one patient in each group had suspected bone ingrowth. No stems were revised for aseptic loosening and no endosteal lysis was found. Progressive bone formation was seen around the femoral stem proximally. The acetabular components demonstrated no sign of mechanical loosening or osteolysis. Bone formation was found in most patients in zone I, and in a few patients also in zone III. On the basis of the results of this study, it is believed that osteoporotic bone as a factor by itself should not compromise the early results of hydroxyapatite total hip arthroplasty and should provide good results in the long term.

Urografin injection demonstrated soft tissue ganglion communication with an intraosseous ganglion cyst.

Intraosseous ganglion cysts rarely occur in the hand or wrist. We present a case of a soft tissue ganglion cyst that communicated with the intraosseous ganglion of the scaphoid. Typical diagnostic studies include radiography, computed tomography, and magnetic resonance imaging. The diagnosis was made in this case by injection of Urografin into the soft tissue ganglion. The patient underwent excision of both ganglion cysts, resulting in a satisfactory outcome.

Mennen plate in hip and shoulder joint replacement.

Sixteen patients complicated by femoral fracture and aseptic loosening with severe bone loss and two patients complicated by humeral fracture after hip and shoulder joint replacement, respectively, were collected from the Carmel and Ichilov teaching hospitals. All patients underwent internal fixation with the Mennen plate or in conjunction with revision joint replacement, either for internal fixation or for bone graft support. The results were satisfactory in fifteen patients with respect to functional activity, pain, and the radiographic evaluation. In three patients who underwent their fourth revision, the results were unsatisfactory but were better than their preoperative status. Our conclusion is that Mennen plate fixation provides a sufficient and easy internal fixation technique for a fracture around or below the un-dislodged stem of hip and shoulder in joint replacement. In an unstable femoral fracture or in a case of aseptic loosenings with marked bone loss, we recommend Mennen plate fixation in conjunction with long stem revision total hip replacement and bone graft.