Paediatric angiodysplasia of the jejunum: a case report and review of the literature.

Gastrointestinal angiodysplasia (GIAD) of the jejunum is a rare cause of acute upper and lower gastrointestinal bleeding in the paediatric population. This is the case of a previously well 10-year-old girl who presented with acute rectal haemorrhage, haematemesis and syncope. Despite an exploratory laparotomy, the cause of bleeding remained unknown. A computerized tomography angiogram was performed once she was haemodynamically stable. It indicated bleeding in the jejunum. Repeat laparotomy was performed including enterotomy, copious small bowel washout and visualization of the whole small bowel. The lesion was identified at approximately 100 cm from the duodenojejunal flexure and confirmed by isolating the lesion and testing for bleeding. A 30 cm length of jejunum was resected and primary anastomosis performed. She recovered well and was discharged three days postoperatively. She remained well at six-month follow-up. This case highlights the importance of considering upper GIAD in an acute paediatric gastrointestinal bleed and the way in which surgical management can prevent a potentially fatal outcome.

Wall or machine suction rectal biopsy for Hirschsprung's disease: a simple modified technique can improve the adequacy of biopsy.

Suction rectal biopsy (SRB) may not include sufficient submucosa for histological diagnosis of Hirschsprung's disease (HD) and a repeat biopsy is required. Substitution of the conventional syringe for sustained suction from a machine or wall suction unit could provide a more consistently adequate tissue biopsy. This study was conducted to compare the adequacy of SRB specimens using a conventional method of syringe suction (SSRB) with those taken by wall or machine suction (WSRB). Hospital records of patients who had a SRB between 2002 and 2004 were studied retrospectively. The biopsy was considered inadequate if there was insufficient submucosa and a repeat specimen was requested. SSRB were taken using the conventional SSRB technique. WSRB were taken with the same Noblett forceps but with suction from wall suction or from a portable suction machine. Ninety-five infants had 103 SRB, 24 had WSRB and all (100%) were adequate for histopathological diagnosis or exclusion of HD. Seventy nine conventional SSRB were undertaken in 71 infants of which 64 (81.02%) were adequate. The difference in adequacy between WSRB and SSRB was statistically significant (P = 0.02). There were no instances of haemorrhage or bowel perforation in either subgroup. WSRB with the Noblett biopsy forceps is more likely to produce an adequate specimen and to reduce the incidence of repeat biopsies.

Does Down syndrome affect the outcome of congenital duodenal obstruction?

Congenital duodenal obstruction (DO) has a well-known association with Down syndrome (DS) and other congenital malformations. Previously reported series on DO have not examined the influence of DS on associated congenital malformations and postoperative morbidity and mortality. We report on a retrospective study of all children born with DO over an 11-year period to investigate this. A total of 79 patients with DO were studied: group 1 consisted of 51 (64.6%) children without DS, and group 2 consisted of 28 (35.4%) children with DS. There was no significant difference in mean gestational age and birth weight between groups 1 and 2. A coexisting congenital malformation was found in 68% of patients. Gastrointestinal malformations were the most common in group 1 (71.1%), and cardiac malformations were the most common in group 2 (81.5%). The mean time to reach full intragastric feeds was 12 days, with no significant difference between the two groups ( p=0.383). Seven (8.9%) patients developed a postoperative complication, with no significant difference between both groups ( p=0.853). A total of 11 patients died: six (12%) in group 1 and five (28%) in group 2, with no significant difference between the groups ( p=0.454). DS does not influence the morbidity and mortality of DO but does carry a higher incidence of congenital cardiac abnormalities. Delayed mortality was a result of coexisting congenital cardiac and respiratory disease.

Case report: the transvesical approach to a traumatic rectovesical fistula.

A case of traumatic rectovesical fistula in a 14-year-old boy is presented. A transvesical approach was employed to access the defect. This approach provided excellent exposure, ease of surgery, and an uncomplicated post-operative course. The operative procedure is described, and aspects of the case are discussed.

Outpatient laparoscopic cholecystectomy. Outcomes of 847 planned procedures.

BACKGROUND: Cholecystectomy is now being performed on an outpatient basis at many centers. The purpose of this study was to review the results of our large experience with this procedure. METHODS: Between 1990 and 1997, 2288 patients underwent laparoscopic cholecystectomy at our clinic. A total of 847 (37%) were scheduled as outpatients. The selection criteria for planned outpatient laparoscopic cholecystectomy called for nonfrail patients with an ASA < 4 who were living < 2 h from the hospital. All patients received detailed preoperative instruction about outpatient laparoscopic cholecystectomy. A questionnaire was sent to 309 patients to sample their opinions. RESULTS: Since 1993, we have increased the number of planned outpatient cholecystectomies performed at our clinic, but the percentage of cholecystectomies completed on an outpatient basis has remained approximately 60%. A total of 547 of 847 operations scheduled as outpatient procedures (74.5%) were completed as planned, and 204 patients (24%) were kept in the hospital overnight. Twenty-seven (3%) were converted to open procedures. Eighteen laparoscopic patients (2%) stayed > 1 day (range, 2-20). None of the patients died. Of the 142 patients (46%) who completed our opinion survey, 66% were happy with their experience, 32% would like to have stayed in the hospital, and 2% were undecided. CONCLUSION: Successful same-day surgery requires proper patient instruction, appropriate patient selection, and a low threshold to convert patients to inpatient status when the situation warrants. No major complications occurred as a result of same-day discharge, and two-thirds of the patients said that they preferred outpatient surgery.

Contributions of strength and body composition to the gender difference in anaerobic power.

BACKGROUND: The purpose of this study was to determine the significant factors contributing to the difference between men and women in anaerobic power (AP) generation. METHODS. PARTICIPANTS: College men (n = 113) and women (n = 175) were randomly selected for evaluation from a fitness class prior to training. MEASURES: AP was determined from the Margaria-Kalamen stair run. Dynamic strength was evaluated from the 1-RM single-leg extension. Body composition was estimated from gender-specific skinfold prediction equations. RESULTS: Discriminant analysis identified %fat, fat-free mass (FFM), and leg extension strength as significant components differentiating between men and women and allowed proper gender classification in 99% of the cases. When both strength and body composition variables were held constant by covariance, there was no significant difference between men and women in AP (F = 1.25). A multiple regression equation using %fat, FFM, and leg extension strength predicted AP (R = 0.91) with an error of 150 W. When the multiple regression equations was applied to a cross-validation sample, AP could be accurately predicted (r = 0.91, t = 0.17) with an average error of 3% +/- 21%. CONCLUSIONS: Body size and dynamic strength are the major factors explaining the explosive leg power difference between men and women without a specific or unique gender quality.

Identification of trauma patients at risk of thoracic aortic tear by mechanism of injury.

OBJECTIVE: We sought to identify potential measurable on-scene information that would assist clinicians in the identification of patients at risk for thoracic aortic tear (AT) after vehicular trauma. METHODS: Data were prospectively collected at the scene of 295 motor vehicle crashes from 1995 to 1999. There were 34 cases (12%) with AT. Scene data consisted of vehicle maximal crush, maximal intrusion into the occupant compartment, change in velocity (Delta V) and principal direction of force. Thoracic aortic injuries were confirmed radiographically or at autopsy. Crash factors were analyzed for correlation with AT by logistic regression. RESULTS: Delta V > or = 20 mph and near-side impact were the factors having the strongest correlation with thoracic aortic injury. Delta V > or = 20 mph (n = 32 with AT) had an odds ratio = 6.4, (p < 0.01). Near impact (n = 20 with AT) had an odds ratio = 2.3, (p < 0.05) and intrusion > or = 15 inches had an odds ratio = 3.2, p < 0.05. The sensitivity, specificity, and accuracy of the presence of near impact, Delta V > or = 20 mph, or both, were 100%, 34%, and 64%. The positive and negative predictive values were 16% and 100%, respectively. There was no relationship of AT to use of seat belts or airbags. CONCLUSION: Thoracic aortic injury after vehicular collision can be reliably excluded if near-impact, Delta V > or = 20 mph, or intrusion > or = 15 inches are not present. Mechanism of injury in the form of crash scene information may aid clinicians in identifying individuals at risk for thoracic aortic tear after vehicular trauma.

Treatment of experimentally induced caval thrombosis with oral low molecular weight heparin and delivery agent in a porcine model of deep venous thrombosis.

OBJECTIVE: This experiment evaluated enterally administered low molecular weight heparin (LMWH) combined with sodium N-[10-(2-hydroxybenzoyl)amino] decanoate (SNAD) for the treatment of induced venous thrombosis. SUMMARY BACKGROUND DATA: SNAD is a delivery agent that potentiates the gastrointestinal absorption of LMWH. METHODS: Forty female pigs were equally assigned to four groups: control (saline); enteral LMWH, 2,000 IU/kg; enteral SNAD, 50 mg/kg; and enteral LMWH, 2,000 IU/kg and SNAD, 50 mg/kg. Under fluoroscopic guidance, the infrarenal vena cava was occluded with a balloon catheter. Two milliliters of ethanol was injected into the distal vena cava. The inflated balloon catheter remained in situ for 5 days, at which time animals angiographically exhibiting thrombus were randomly assigned to the four groups. Study medications were dosed at 12-hour intervals by means of a gastrostomy tube placed previously. After 7 days of treatment, thrombus was extracted. A separate group of 10 animals was used to measure plasma antifactor Xa levels for 6 hours after enteral dosing of LMWH/SNAD. RESULTS: The amount of residual thrombus after treatment with enteral LMWH/SNAD was significantly decreased. Antifactor Xa levels were significantly elevated in the LMWH/SNAD group versus baseline. CONCLUSION: The combination of enterally administered LMWH and SNAD given for 7 days appeared to decrease caval thrombosis in this model of deep vein thrombosis. Enteral LMWH/SNAD effected an increase in plasma levels of antifactor Xa.

Steep learning curve of laparoscopic splenectomy.

BACKGROUND AND PURPOSE: In 1992, Ochsner Foundation Hospital was among the first institutions in which laparoscopic splenectomy was performed. The aim of this study is to review our experience and discuss the lessons learned. METHODS: A retrospective review of 33 cases of laparoscopic splenectomy for idiopathic thrombocytopenic purpura (ITP) (N = 22), autoimmune hemolytic anemia (AIHA) (5), thrombocytopenic purpura (TTP) (2), and other disorders (4) at Ochsner Foundation Hospital between 1992 and 1999 was conducted. Several measures, including rates of conversion to open splenectomy, were recorded and analyzed. RESULTS: Of the 33 cases, 26 (79%) were completed laparoscopically. Four were converted to an open procedure secondary to bleeding and three secondary to difficulty in dissection. Six conversions to open surgery were necessary during the first eight laparoscopic splenectomies and only one during our last 25 cases. Two patients required reoperations for bleeding. The average hospital stay after laparoscopic splenectomy was 2.3 days; eight patients stayed only 1 day. All of the TTP patients, 86% of the patients with ITP, and 40% of those with AIHA responded well to splenectomy. CONCLUSION: Laparoscopic splenectomy is a safe although complex procedure. Bleeding is the major complication but has been less common with experience. Even with today's technology, very large spleens are still extremely difficult to remove. With the short recovery and ready acceptance of patients and physicians, this technique is being used with increasing frequency. A significant learning curve exists for the safe completion of this challenging procedure.

Minimally invasive abdominal surgery.

In the last decade, laparoscopy has been the most innovative surgical movement in general surgery. Minimally invasive surgery performed through a few small incisions, laparoscopy is the standard of care for the treatment of gallbladder disease and the gold standard for the treatment of reflux disease. The indications for a laparoscopic approach to abdominal disease continue to increase, and many diseases may be treated with laparoscopic techniques. At Ochsner, laparoscopic techniques have demonstrated better cosmetic results, shorter recovery times, and an earlier return to normal activity compared with open surgery.

Carotid endarterectomy in patients with significant renal dysfunction.

PURPOSE: Recent reports suggest that carotid endarterectomy (CEA) should not be performed in patients with end-stage renal disease (ESRD) because of an unacceptable rate of perioperative stroke and other morbidity. Because these conclusions were based on a small number of patients, we reviewed the perioperative and long-term outcome of patients with ESRD and chronic renal insufficiency (CRI) who underwent CEA at our institution. METHODS: The 1081 patients who had a CEA between 1990 and 1997 were cross-referenced with those patients in whom renal insufficiency had been diagnosed. These charts were reviewed for patient demographics and perioperative and long-term outcome. Patients undergoing CEA during a 1-year period (1993) served as controls. RESULTS: Fifty-one CEAs were performed in 44 patients with CRI (32 in 27 patients) and ESRD (19 in 17 patients). In the CRI+ESRD group, 66.7% were symptomatic, and 70.7% of the control group were symptomatic. Six operations (11.8%) in the CRI+ESRD group were redo endarterectomies. There were no perioperative strokes in the CRI+ESRD group, but one patient died 29 days postoperatively because of a myocardial infarction, for a combined stroke-mortality rate of 2.0%. The control group had a 2.6% combined stroke-mortality rate. Long-term survival analysis revealed a 4-year survival rate of 12% for patients with ESRD and 54% for patients with CRI, compared with 72% for controls (P <.05). CONCLUSION: CEA can be performed safely in patients with ESRD or CRI, with perioperative stroke and death rates equivalent to that of patients without renal dysfunction. However, the benefit of long-term stroke prevention in the asymptomatic patient with ESRD is in question because of the high 4-year mortality rate of this patient population.

The etiology of intestinal obstruction in patients without prior laparotomy or hernia.

Patients with clinical features of intestinal obstruction without a history of prior laparotomy or physical evidence of a hernia can be a diagnostic challenge. We attempted to evaluate our preoperative diagnostic accuracy, to assess the effectiveness of our diagnostic tools, and to determine the incidence of various causes of intestinal obstruction in this select group. Medical records of all patients admitted to our institution and taken to surgery with a diagnosis of intestinal obstruction from 1975 through 1995 were reviewed. Patients with a history of prior laparotomy, evidence of hernia, or emergent indications for surgery on admission were excluded. The most common cause of intestinal obstruction in this select group of patients was malignancy. The ability to detect malignancy preoperatively is significantly better than the ability to detect benign causes of obstruction (Pearson Chi square = 4.09 with a P value of 0.04). Preoperative detection of malignancy in these patients is critical for optimal treatment planning and counseling for patients and their families.

Minimally invasive esophageal surgery.

Laparoscopic procedures have achieved results equivalent to their open counterparts, with shorter hospital stays and less incisional morbidity. These procedures should be performed by surgeons trained in minimally invasive techniques. Overall, patient satisfaction with regard to symptom response is excellent.

Cost savings associated with the nonroutine use of carotid angiography.

BACKGROUND: To evaluate the economic impact of performing carotid endarterectomy based only on a diagnosis of duplex scanning, we evaluated a cohort of patients treated at our institution during 1 calendar year. METHODS: Ninety-seven patients were evaluated and divided into two groups: those with and without arteriogram prior to their operation. Duplex scan and arteriogram results were reviewed to determine their effect on the operative plan. Hospital charges and physician fees were assessed for each patient admission. Operative results, complications, and total charges were compared between the two groups. RESULTS: There was one operative stroke in each group for a stroke rate of 2%. Angiographic complications included one stroke and one femoral artery thrombosis. Two arteriograms led to a change in the operative plan. The hospital charges for patients without an arteriogram was $10,292 verses $13,906 for patients with an arteriogram (P < 0.01). Physician charges for patients without an arteriogram were $3,882, with angiograms and $6,297. The total charges related to the endarterectomy were $14,174 and $20,203, respectively. Arteriograms accounted for an increase of 43% in total charges. CONCLUSION: Nonroutine use of angiography does not increase operative risk or postoperative length of stay, and preoperative angiography increases total charges by 43% ($6,029) per patient.

Implications for the vascular surgeon with prolonged (3 to 89 days) intraaortic balloon pump counterpulsation.

PURPOSE: The intraaortic balloon pump (IABP) is useful in the treatment of failing hearts. Although most experience with IABPs has been with acute short-term use, the safe duration of therapy and possible complications of long-term IABP use are uncertain. We evaluated the feasibility, management, and complications associated with long-term IABP therapy. METHODS: Fifty consecutive patients with 87 IABPs were evaluated retrospectively. All patients had IABP support for greater than 72 hours. Results and complications were evaluated. RESULTS: The mean duration of IABP support was 23.2 days. There were 21 IABP-related complications in 16 patients: (16 ischemic, three infections, two hemorrhage). The rate of complications was 0.13 per patient-week of support. Significant predictors of complications were total days of IABP support (p < 0.0001), use of multiple IABPs (p < 0.0001), and attempted but unsuccessful percutaneous insertions (p < 0.001). Complications led to 14 vascular procedures (five patch angioplasties, four bypass procedures, two major amputations, one fasciotomy, one groin exploration for hemorrhage, and one removal of an infected Dacron patch). Percutaneous removals had a 14% complication rate compared with none after operative removal (p = 0.02). Thirty-two patients survived (64%). Of the survivors, 27 underwent transplant. CONCLUSIONS: Prolonged IABP therapy is feasible and is associated with an acceptable rate of complications. Operative removal is superior to percutaneous removal. Percutaneous removal should be limited to short-term therapy. There is no need for mandatory removal or site rotation based solely on indwelling time.

Endovascular treatment of abdominal aortic aneurysms: case report and review of literature.

A case of endovascular treatment of abdominal aortic aneurysm is discussed along with a review of the literature. This recently introduced Food and Drug Administration Phase II treatment modality may have a significant impact on the approach to the treatment of aneurysmal disease. This discussion details the treatment of one typical patient and reviews the current status of endovascular therapy as it applies to infrarenal abdominal aortic aneurysms.

Anomalous branch of the internal carotid artery maintains patency distal to a complete occlusion diagnosed by duplex scan.

A 67-year-old man had symptoms of peripheral vascular disease and was noted to have a carotid bruit. Duplex ultrasound examination of the neck demonstrated a short segmental occlusion of the proximal internal carotid artery (ICA) with antegrade flow distal to the occlusion maintained by an anomalous branch of the ICA. Angiography confirmed the findings and suggested that the branch was from the distribution of the occipital artery. The ICA findings were surgically proved, and endarterectomy was successfully performed without complication. This case reinforces the usefulness of duplex ultrasonography of the carotid arteries and is a rare situation in which a completely occluded ICA can be repaired with a good clinical outcome.

The incidence, morbidity, and mortality of surgical procedures after orthotopic heart transplantation.

OBJECTIVE: The authors present their experience with patients having undergone orthotopic heart transplantation (OHT) in whom surgical conditions subsequently developed that required operative intervention. The incidence, morbidity, and mortality of these procedures are reported. SUMMARY BACKGROUND DATA: Several studies have evaluated the management options of biliary tract disease after OHT. Multiple reports of patients having undergone OHT who subsequently underwent peripheral vascular reconstructions, plastic reconstructive, and thoracic procedures also have been published. METHODS: A chart review of 349 patients who underwent OHT between 1985 and 1996 was conducted to identify surgical procedures that were required in the post-transplant period. Their outcomes are reported. RESULTS: Of 349 patients who underwent OHT, conditions requiring 94 surgical procedures developed in 54 patients (15%). Biliary tract disease developed in 17 patients (5%) who required cholecystectomy, 2 of the 5 patients with acute cholecystitis died. Eight patients (2%) underwent orthopedic procedures with no operative mortality. Flap advancements for sternal wound infections were performed in five patients and four deaths occurred. Seventeen thoracic procedures were performed in 11 patients with an overall mortality of 45%. Twenty-one vascular procedures were performed on 17 patients with 1 delayed death due to a malignancy. Seven patients underwent procedures of the colon and rectum with no mortality. Seven patients underwent repair of inguinal or incisional hernias with no mortality. Various infections occurred with one resultant death after operative intervention. Six procedures were performed for diseases of the small intestine with no resultant mortalities. CONCLUSIONS: Patients having undergone OHT and chronic immunosuppression are at increased risk of having complications develop from infection. Acute cholecystitis and sternal wound infection caused an inordinate risk of complications and death. Malignancies developed in four patients who required surgical intervention. A heightened awareness of coexisting peripheral vascular disease in patients transplanted for ischemic cardiomyopathy should exist. Close screening before surgery and surveillance after surgery to identify risk factors for infection and vascular disease and to screen for malignancies are essential.

Sites of recurrence and long-term results of redo surgery.

OBJECTIVE: The authors determined whether carotid endarterectomy in patients with recurrent stenosis could provide durable stroke prevention with acceptable perioperative risk. SUMMARY BACKGROUND DATA: Balloon angioplasty and stenting are being advocated for recurrent stenosis because of the presumption that reoperation is unsafe with poor results. METHODS: The authors retrospectively reviewed their experience with 67 patients undergoing 74 operations for recurrent stenosis in a recent 11-year period. This represented 8.4% of 883 endarterectomies performed during the same period. RESULTS: At original operation, 55% had primary closure and 45% were patched. Reoperation was performed for amaurosis fugax and transient ischemic attack (45%), post-stroke (7%), global ischemia (10%), and asymptomatic severe occlusive disease (35%). Four patients (6%) undergoing simultaneous cardiac procedures were excluded from further analysis. Mean duration between primary and first redo operation was 78 months (range, 1-240 months). The 30-day combined mortality and stroke morbidity was 2.8%, evenly divided with 1.4% stroke and 1.4% mortality rates. Recurrent disease occurred predominantly (69%) in the previous endarterectomy site. Follow-up ranged from 1 to 162 months (mean, 48.2). Seventeen deaths occurred, of which 10 (59%) were cardiac. Two late ipsilateral neurologic events and four late contralateral events occurred. Two patients required third ipsilateral reoperation. Life-table analysis shows the ipsilateral stroke-free rate at 5 years to be 93.6% CONCLUSIONS: Recurrent stenosis occurs either proximal to or in the previous endarterectomy site in the majority of patients. Recurrent stenosis can be treated surgically with low morbidity and mortality and durable long-term stroke prevention. The presumption that results of redo carotid surgery are poor is disproved.

Endoscopic abdominoplasty with repair of diastasis recti and abdominal wall hernia.

Endoscopic abdominoplasty is feasible, safe, and effective in the proper surgical candidate. Excellent results can be expected when proper patient selection criteria are followed. With future refinements in technique and equipment, this procedure may be extended safely to those patients with more severe deformities.