Correct Surgical Approach Research Articles

Surgical techniques of unilateral thalamic gliomas in adults

Objective The aims of this study were to determine how to choose the appropriate surgical approach based on the anatomical character of the thalamic gliomas and to investigate the corresponding surgical skill and assistive technology.Methods The records of 98 adult patients with thalamic tumor between 2004.1 and 2012.6 in our hospital were retrospectively reviewed.Of the 98 patients,53 had a low-grade tumor,and 45 had a high-grade tumor.Two groups of gliomas were analyzed separately:(1) unilateral thalamic gliomas (81 lesions); (2) thalamopeduncular gliomas (17 lesions).All the patients underwent tumor resection.Results Total resection of the tumor was achieved in 62 cases (63％),subtotal resection in 26 (27％) cases and most resection in 10 (10％) cases.Postoperative improvement was achieved in 61 cases (62％),unchange in 29 (30％) cases,aggravation in 6 (6％)cases,and death in 2 (2％) cases.Conclusions Total or subtotal remove and good results can be gained in the majority of the patients with unilateral thalamic gliomas based on the correct surgical approach,skill and assistive technology. Key words: Thalamic glioma; Surgical techniques ; Adult

Isolated Laryngeal Leishmaniasis in Immunocompetent Patients: An Underdiagnosed Disease

We describe a case of isolated primary laryngeal leishmaniasis in an immunocompetent Italian patient with a previous medical history negative for visceral or cutaneous leishmaniasis, presenting with hoarseness. We also summarize the epidemiological, clinical, and diagnostic features and the therapeutic management of other cases of laryngeal leishmaniasis in immunocompetent subjects, described in the literature. Considering the insidious and nonspecific clinical presentation, the increasing number of different forms of mild or underestimated immunosuppressive conditions, and the number of people travelling in endemic zones, along with the ability of Leishmania amastigotes to survive for a long period in the body, we believe it is important for pathologists and clinicians to be aware of this unusual form of leishmaniasis in order to avoid delayed recognition and treatment. The rarity of the presentation and the lack of guidelines on mucosal leishmaniasis may contribute to the potential undiagnosed cases or delayed diagnosis, the possible relapses, as well as the correct pharmacological and/or surgical therapeutic approach.

Surgical approaches to apical thoracic malignancies

Several surgical approaches have been described to access apical thoracic malignancies extending into the thoracic inlet. However, most publications have focused on a specific approach and considered the thoracic inlet as 1 entity. In the present analysis, we divided the thoracic inlet into 5 different zones requiring specific surgical considerations to identify the best approach for each zone. A review of 22 consecutive patients undergoing surgery for apical thoracic malignancies extending into the thoracic inlet from January 2005 to November 2011 was performed. Different surgical approaches were used for each zone. The first (anterolateral) zone required a subclavicular approach to open the costoclavicular space and expose the subclavian vein with or without elevating or removing the clavicle (n = 4). The second (anterocentral) zone required a transverse supraclavicular approach with or without extension to a partial (trapdoor) or full sternotomy (n = 10). The third (posterosuperior) zone located between the top of the subclavian artery and the T1 vertebra along the posterior superior border of the first rib was the most difficult area to access (n = 5). The transclavicular approach was ideally suited to expose this zone in our experience. The fourth (posteroinferior) zone and fifth (inferolateral) zone located posteriorly and laterally along the inferior border of the first rib were accessed using a posterolateral and posterotransaxillary approach, respectively (n = 3). The thoracic inlet could be divided into 5 zones requiring specific surgical considerations and different approaches. Division of the thoracic inlet into these zones could provide more clarity and guidance for thoracic surgeons to select the correct surgical approach.

Can a Novel MRI Staging System for Low Rectal Cancer Aid Surgical Planning?

Low rectal cancers are associated with worse outcomes in comparison with mid and upper rectal tumors. This study aimed to assess the predictive accuracy of MRI in identifying the correct surgical approach based on the mesorectal and extralevator planes. This study involved the retrospective analysis of MRI and histopathology data of 33 patients with low rectal cancer, with the use of an anatomically based staging system. Three radiologists reported on the available surgical planes of excision based on the predicted relationship of tumor to key anatomical features. MRI-predicted planes of excision were then compared with the histopathological planes actually required, with the use of the same staging criteria. The study was conducted at 4 English district general hospitals. Unselected patients with low rectal cancer, all of whom were participants in a multicenter study, were eligible for this study. : The main outcome measured was the accuracy of operative plane prediction on MRI. : On pathological analysis, the mesorectal plane would have been sufficient to achieve a clear margin in 28 of 33 (84.9%) of cases. The extralevator plane was required in 5 of 33 (15.1%). Planes were correctly predicted by MRI in 29 of 33 cases by radiologist 1 and 24 of 33 cases by radiologists 2 and 3 with an accuracy of 87.9% and 72.7%. Overstaging (extralevator plane predicted when a mesorectal plane would have sufficed) occurred in 3 of 33 and 7 of 33 cases. Understaging (mesorectal plane predicted when an extralevator plane was required) occurred in 1 of 33 and 2 of 33 cases. The positive and negative predictive values of MRI in determining the histopathological plane of excision required were 57% and 96% for radiologist 1 and 30% and 91% for radiologists 2 and 3. This study was limited by its retrospective nature and its relatively small patient numbers. No account was taken of postoperative function when recommending the surgical plane. This supports an anatomically based MRI staging system for low rectal cancer to predict the planes of surgical excision. This may help to reduce margin positivity and to improve outcome in patients with low rectal cancer.

Case report of xanthogranulomatous cholecystitis, review of its sonographic and magnetic resonance findings, and distinction from other gallbladder pathology

A case of xanthogranulomatous cholecystitis is presented with a brief review of its sonographic and magnetic resonance features. These imaging features are also compared to those seen in gallbladder adenomyomatosis and gallbladder carcinoma. While there are many overlapping imaging findings in these entities, it is important to recognize distinguishing characteristics so a correct surgical approach is chosen. Laparoscopic cholecystectomy attempted with existing xanthogranulomatous cholecystitis has an increased surgical complication rate compared to open cholecystectomy and often necessitates intraoperative conversion to open cholecystectomy.

Pediatric otorhinolaryngologic manifestations of endocrinological pathologies

Objective Aim of the present review is to offer a concise but complete discussion about pathologies with pediatric otorhinolaryngological interest recognizing: (i) growth disorders, (ii) chromosomal disorders, and (iii) tumors. Methods Pathologies characterized by a growth anomaly have been grouped, underlining the characteristics of otorhinolaryngological interest. Numerous syndromes typical of the pediatric age have been reported and classified according to the ailments of the orofacial district. Tumoral pathologies, for which the otorhinolaryngological operation is fundamental, have been descripted. We reviewed recent literature and older papers. We did not find recent literature regarding otorhinolaryngological features related to some of the pathologies described. Results/Conclusions Otorhinolaryngologists should be familiar with pediatric disorders, since many of them have head and neck manifestations. This knowledge allows to treat them with a correct surgical approach, in order to implore children's quality of life.

Value of Laparoscopic Appendectomy in the Elderly

The correct surgical approach in the treatment of acute appendicitis continues to be a source of debate and a ground for comparative studies, as physicians and surgeons seek to define the optimal management of this common and ‘‘simple’’ illness. Surely the place of laparoscopy in the treatment of appendicitis is still controversial, despite a major trend in this direction. Because this disease is so prevalent, it is possible to examine different subgroups separately, and this is what was done by Kirshtein et al. [1] in their report of elderly patients, 60 years old and older. Then, the question is twofold: Does the laparoscopic treatment of acute appendicitis differ between the young and the old? And how does the laparoscopic treatment in the elderly compare with the open approach? The authors address the first question, which has mainly academic interest because of the inherent differences between the young and the old. Discussion can only indirectly suggest whether laparoscopic appendectomy is justified in the older age group. The second question is more interesting clinically, and should be addressed separately, ideally in a prospective way, unlike this study. How does one decide whether the laparoscopic approach for a certain procedure is acceptable or even preferable? The potential for a laparoscopic procedure to be advantageous starts with the ratio between the access size and the magnitude of the task. If a large incision is required to remove a small and a simple organ (like the gallbladder), the advantages of minimizing abdominal wall trauma and the peritoneal exposure are obvious. If the incision is a relatively small part of a complicated task with many potential postoperative problems (like pancreaticoduodenectomy), then laparoscopy is much less appealing: Because it is time consuming and technically difficult, and it may lead to additional complications, the patient is less likely to benefit from the smaller access. At present, the role of laparoscopy remains to be established in smaller procedures (small incision/simple task), as the potential advantage of laparoscopy is less prominent, but may still exist. Appendectomy certainly belongs in this group of procedures. Evaluation may require larger series and optimal methodology to prove a small benefit—or perhaps disprove it or even demonstrate inferiority of the approach. Some early studies, for example, have claimed to find more pelvic abscesses in patients undergoing laparoscopic appendectomy, although many other studies have failed to support this claim. Furthermore, within the diverse group of patients with appendicitis, certain subgroups may differ in regard to the preferred surgical approach, because of different factors, such as stage of inflammation at presentation, or age. The present study, by Kirshtein et al., adds some information to our understanding of this question. Despite its admitted limitations, like incomparability of the groups (more complicated cases in the older age group, leading to more conversions), the two groups still had a similar rate of postoperative complications. Although this suggests that laparoscopic appendectomy in the elderly is acceptable, there is no way to infer from this kind of study whether an open approach would have been different in these patients—a direct comparison is mandatory. Should we offer laparoscopic appendectomy to our patients? Should a patient’s age have any influence on our decision? These questions cannot be answered from this study. It is probably okay; no major harm is done, but we D. Rosin (&) General Surgery & Transplantation, Sheba Medical Center, Tel Aviv University, Tel Hashomer 52621, Israel e-mail: drosin@mac.com

Rekonstrukcja części szyjnej przełyku techniką gastric pull-up w przebiegu wznowy raka gardła dolnego i krtani

Patient with hypopharyngeal cancer are difficult to treat because they usually present with advanced disease, poor general health status and severe nutritional problems. Because of the poor prognosis, careful consideration has to be given regarding the choice of the correct surgical approach for respirato-digestive tract reconstruction. The authors present a case of recurrent hypopharyngeal cancer with cervical esophagus infiltration successfully treated with total laryngectomy and esophagectomy and gastric pull up reconstruction. Indications for technique, method of reconstruction and complications are, discussed. As most authors we consider the gastric transposition method as the preferred approach to restore digestive continuity after total esophagectomy. As the method is the single stage procedure it provides the best palliation of dysphagia and allows early resumption of an oral diet.

Offene posteriore Dislokation des Ellbogens mit Frakturen des Caput radii, des Processus coronoideus und mehrfachen Diaphysenfrakturen der Ulna

A healthy, right-handed 34-year-old man was injured by repeated direct blows delivered to his left upper arm with a baseball bat. These blows led to a posterior dislocation of the elbow joint, associated with fractures of the radial head and the coronoid process. There was bone loss on the fractured joint surface of the olecranon, with simultaneous ipsilateral trauma to the ulna. The correct surgical approach in the case of such fractures is still the subject of some controversy. The treatment can have serious complications. The results of treatment are often poor, especially because of persisting instability and stiffness of the elbow following a long period of immobilisation. Few studies have been concentrated on this topic up to now. We report on the functional and radiological results 24 months after the treatment of this rare, open "shock triad in the elbow."

Temporal Bone Cholesteatoma: Surgical Results and Management of the Facial Nerve

Petrous bone cholesteatomas (PBC) are rare, slow-growing, expansible lesions which may be congenital or acquired in origin. Acquired PBC are secondary to middle ear cholesteatoma which has extended medially to the otic capsule and fallopian canal. All require extensive surgical removal in order to avoid recurrence but the different types of extension raise individual diagnostic and therapeutic challenges. Sensorineural hearing loss, vertigo, and facial paresis are common signs of petrous bone cholesteatoma. Facial nerve dysfunction may be present in 30 to 60% of cases and this symptom is often associated with apical extension of the lesion. Disequilibrium and dizziness are symptoms related to labyrinth invasion and erosion. The preoperative radiologic examination in extensive intratemporal cholesteatoma is based on high-definition CT and MRI with gadolinium. The preoperative radiologic assessment is mandatory to distinguish the different routes of intratemporal extension of the cholesteatoma and to select the correct surgical approach. We present our experience of 43 petrous bone cholesteatomas treated surgically in our third referral center between 1994 and 2006, focusing on the preoperatory radiologic assessment, the surgical strategy, and the management of the facial nerve.

Role of SPECT/CT in the preoperative assessment of hyperparathyroid patients

Our purpose was to assess the clinical value and additional benefit of fusion single-photon computed tomography (SPECT) and computed tomography (CT) images in locating the parathyroids in a selected group of patients affected by primary (PHP) and secondary hyperparathyroidism (SHP). Sixteen patients (11 women and five men; age range 35-80 years) with severe hyperparathyroidism (HP) (ten PHP, six SHP) were studied by ultrasound (US), and, after i.v. injection of 370 MBq of 99mTc-sestamibi, by planar parathyroid scintigraphy, SPECT and SPECT/CT using a dual-detector scintillation camera GE Infinia Hawkeye. All patients underwent parathyroidectomy. US findings were inconclusive in 12/16 patients affected by multinodular goitre, and two probable eutopic parathyroid glands were identified. "Double phase" parathyroid scintigraphy identified 14 probable parathyroid glands, SPECT 23 (14 ectopic and nine eutopic) and SPECT/CT confirmed all 23 probable parathyroid lesions, offering more precise localisation and an evident improvement in diagnostic accuracy. Sixteen of these foci of increased uptake were hyperplastic parathyroid glands, six were adenomas, one was a parathyroid carcinoma and one was a thyroid follicular carcinoma. Surgical detection of the 23 sestamibi-positive lesions was correctly matched with 100% of SPECT/CT images and 61% of SPECT data alone. Hybrid imaging thus provided additional data in 39% of lesions, and in three patients with retrotracheal glands, it modified the surgical approach. We believe 99mTc-sestamibi SPECT/CT to be a more reliable presurgical method to study a patient subgroup affected by PHP or SHP in whom conventional US and other scintigraphic methods have failed for intrinsic reasons due to the concomitant presence of multinodular goitre or ectopic parathyroid gland. The additional practical benefit derived from this methodology was evident. In fact, anatomical information provided by CT enables precise localisation of the functional abnormalities highlighted by SPECT, and both are essential to a correct surgical approach.

Acid normalization and improved esophageal motility after Nissen fundoplication: equivalent outcomes in patients with normal and ineffective esophageal motility

Background Severe gastroesophageal reflux disease may result in acquired esophageal dysmotility. The correct surgical approach to associated gastroesophageal reflux disease and dysmotility is controversial, in particular whether the “gold-standard” total fundoplication of Nissen is appropriate compared with partial fundoplication. Our unit has performed total fundoplication for all patients, irrespective of esophageal motility, and this article describes that experience. Methods Ninety-eight patients undergoing antireflux surgery were divided into 2 groups. Group 1 (n = 60) consisted of patients with normal esophageal motility, and group 2 (n = 38) had dysmotility. All patients underwent preoperative and postoperative manometry, 24-hour pH testing, symptom scoring, and quality-of-life assessment. Results The median postoperative acid score was not significantly different between groups 1 and 2. Eighty-eight percent of patients with normal motility and 89% of patients with dysmotility had no symptoms or minor symptoms, with a significant improvement in quality of life 6 months after surgery. There was a significant increase in esophageal wave amplitude in both groups, and 20 patients (53%) in the dysmotility group reverted to normal motility after surgery. Recurrent symptoms were associated with postoperative abnormal pH profiles in 5 patients from group 1 and 3 from group 2. Conclusions Preoperative dysmotility is not a contraindication for total fundoplication. Postoperative acid control is associated with improved esophageal clearance and symptoms.

Continuing medical education article — body contouring: Gynecomastia

The male patient's degree of breast sagging is the guideline that this author uses to determine the correct surgical approach to gynecomastia. When the patient has no sagging, a small infraareolar incision suffices. With significant sagging, alternative incisions are usually necessary for skin excision and areolar repositioning. Adjunctive lipoplasty is recommended to facilitate correction, improve results, and decrease morbidity and complications.

Value of magnetic resonance imaging in the evaluation of sex-reassignment surgery in male-to-female transsexuals.

We investigated the value of magnetic resonance imaging (MRI) in the evaluation of sex-reassignment surgery in male-to-female transsexual patients. Ten male-to-female transsexual patients who underwent sex-reassignment surgery with inversion of combined penile and scrotal skin flaps for vaginoplasty were examined after surgery with MRI. Turbo spin-echo T2-weighted and spin-echo T1-weighted images were obtained in sagittal, coronal, and axial planes with a 1.5-T superconductive magnet. Images were acquired with and without an inflatable silicon vaginal tutor. The following parameters were evaluated: neovaginal depth, neovaginal inclination in the sagittal plane, presence of remnants of the corpus spongiosum and corpora cavernosa, and thickness of the rectovaginal septum. The average neovaginal depth was 7.9 cm (range = 5-10 cm). The neovagina had a correct oblique inclination in the sagittal plane in four patients, no inclination in five, and an incorrect inclination in one. In seven patients, MRI showed remnants of the corpora cavernosa and/or of the corpus spongiosum; in three patients, no remnants were detected. The average thickness of the rectovaginal septum was 4 mm (range = 3-6 mm). MRI allows a detailed assessment of the pelvic anatomy after genital reconfiguration and provides information that can help the surgeon to adopt the most correct surgical approach.

Giant postdissection aneurysm of the ascending aorta after aortic valve replacement

A 72-year-old man was referred to our department with a diagnosis of ascending aorta aneurysm discovered in a control chest radiograph. The patient had been operated on for thoracic aorta replacement in 1990, for abdominal aorta replacement in 1994, and for aortic valve replacement with biological prosthesis in 1998. After the operation and for the following 3 years the patient was well without any relevant clinical problem. Considering the roentgenographic image (Fig 1), which showed the massive enlargement of the mediastinum with pulmonary compression, a computed tomographic scan of the chest was performed. That imaging study demonstrated a large aneurysm of 10 cm in diameter (true lumen of 7 cm) with a large thrombus surrounding the distal ascending aorta and an intimal flap originating above the right coronary ostium (Fig 2A). Moreover the anterior wall of the ascending aorta was completely adherent to the sternum (Fig 2B). The aortic arch was also dissected and had a diameter of 55 mm. Spiral tomographic scan reconstruction showed the enormous dimensions of the ascending aorta, which was completely attached to the sternum (Fig 3). Surgery consisted of aortic valve and ascending aorta replacement according to the modified Bentall procedure and aortic arch replacement with separate reimplantation of the innominate artery, left common carotid, and left subclavian arteries. The ascending aorta presented as a dissection with a completely thrombosed false lumen. Histologic findings confirmed the dissected wall: the false lumen wall was formed by adventitia and media, which had signs of elastic fiber fragmentation. Femorofemoral cardiopulmonary bypass was carried out and antegrade selective cerebral perfusion with moderate hypothermia (nasopharyngeal temperature of 26°C) was performed for brain protection. The patient recovered successfully without any complications from his surgery. This case illustrates the potential dimensions the ascending aorta and the arch may reach by a chronic dissection and how diagnostic imaging procedures are so important for taking a correct and safe surgical approach. Address reprint requests to Dr Martin-Suarez, Unita Ospedaliera di Cardiochirurgia, Universita degli Studi di Bologna, Policlinico S. Orsola, Via Massarenti 9, 40138 Bologna, Italy; e-mail: docsofi@yahoo.com. Fig 1.

Excellent outcome in patients with stage I germ cell tumors of the testes: A study of the Children's Cancer Group/Pediatric Oncology Group

Background/Purpose: The aim of this study was to correlate outcomes in patients with stage I testicular germ cell tumors with compliance to surgical guidelines and to confirm previous single-institution experiences that show excellent disease-free survival rates when treated with orchiectomy alone. Methods: Sixty-three patients were entered into this intergroup study (Children's Cancer Group 8881/Pediatric Oncology Group 9048) between 1990 and 1996. Surgical guidelines for orchiectomy included an inguinal approach, early vascular control of the cord structures, and a hemiscrotectomy if a transscrotal violation occurred. Failure of tumor marker normalization or subsequent elevation suggested advanced disease requiring further surgery and chemotherapy. Survival curves were compared using the log-rank test. Results: The median age was 16 months (range, 1 month to 5.6 years). Progression of disease occurred in 11 patients. The 6-year event-free survival (EFS) was 78.5% + 7%. The overall 6-year survival rate was 100%. Adherence to all guidelines was confirmed in only 43 patients (69%). Overall, there was no statistical significance in event-free survival rates between patients who had a correct surgical approach and all patients who had surgical violations; however, 4 patients with transscrotal violations showed a significantly higher rate of disease recurrence. Conclusions: Patients with stage I germ cell tumors of the testes have excellent survival rates when treated with surgery alone. Despite numerous surgical guideline violations, event-free survival in this multiinstitutional study was similar to previous single-institution reports. All patients with relapse or progression of their disease appear to be cured with further surgical excision and chemotherapy. J Pediatr Surg 38:319-324. Copyright 2003, Elsevier Science (USA). All rights reserved.

Laparoscopic evaluation of testicular mobility as a guide to management of intra-abdominal testes.

The optimal management of intra-abdominal testes is the subject of an ongoing debate as the result of widespread use of laparoscopy since early 1990's. A simple laparoscopic technique uses cord mobility to act as a guide to cord length and therefore predict the success of a conventional orchidopexy in cases of true intra-abdominal testes. In the technique described, the testis is displaced by stretching the testes to overly the opposite internal inguinal ring. Over a 3-year period, a total of 36 boys with 38 intra-abdominal testes, confirmed laparoscopically, were prospectively assessed. The reported "stretching maneuver" was carried out in all cases. Successful conventional orchidopexy as predicted by a positive stretch maneuver was carried out in 20 testes. When the stretch maneuver failed, conventional 2-stage open operation was done in 3 patients and Fowler-Stephens orchidopexies for the remaining 13 children. A simple test determining testicular mobility assessed during laparoscopic evaluation of intra-abdominal testes provides information of significant importance upon which the correct surgical approach can be based.

Telemedicine for cardiac surgery candidates.

Cardiac surgery is generally well or over-represented in many Western countries. Since the southern part of Switzerland relies on 300 km distance centers for cardiac surgery, we started a project of telemedicine for the distant evaluation of cardiac surgery candidates. We report our experience of the results of the diagnosis made by telemedicine and by direct scrutiny of coronary angiograms. Coronary angiography was performed at the distant hospital by an invasive cardiology team. Teletransmission of images was performed using three Integrated Service Digital Network (ISDN) lines by direct transmission of recent recording. A total of 98 cases were reviewed (87 aorto-coronary bypass candidates, seven valvular and four congenital heart disease). We further performed a prospective blinded comparison of 47 consecutive cases with severe coronary artery disease (CAD) with respect to localization and number of significant coronary lesions, obtained by direct scrutiny of the original angiograms and the evaluation obtained with the teletransmitted images. In 89 cases of the 98 analyzed (91%) correct diagnosis and surgical approach could be established by distant transmission. In nine cases (9%, all aortocoronary bypass candidates) definitive diagnosis and treatment was feasible only by direct scrutiny of the original angiograms. Five critically ill patients were urgently referred to the surgical care center based on the correct distant diagnosis. The blinded comparison of distant diagnosis and direct scrutiny of angiograms in defining 1-2-3 vessel CAD was good: r=0.87, P<0.01. Initial experience using non-sophisticated telemedical transmission of angiograms of cardiac surgery candidates seems to be a promising facility for distantly located centers.

Mediastinal Goitres : when the Transthoracic Approach?

The correct surgical approach to mediastinal goitre is not always well defined. We reviewed why and when our patients required a transthoracic approach.From 1979 to 1998, on 7.480 patients who underwent thyroid surgery in our hospital, 374 (5%) had a goitre whose greater bulk was inferior to the thoracic inlet; 43 patients of these last ones (11%) required a transthoracic approach. General anaesthesia was performed in all patients and orotracheal intubation was selective in 11 cases (double lumen tube of Carlens). In 34 cases, the first approach was a cervicotomy, followed by sternotomy in 23 cases or right posterolateral thoracotomy in 11 cases. Three patients underwent a sternotomy and 6 a thoracotomy only.We had neither perioperative mortality nor major complications. The mean hospital stay was 5 days. Mean goitre weight was 430 g and on average the greater diameter was 13 centimetres.The removal of a substernal goitre can be difficult and risky via the cervicotomy only. A transthoracic approach is often required in the case of greater secondary, primary and recurrent mediastinal goitres.

The gastric emptying scan as a tool for surgical management of severe bowel dysfunction in spinal cord injury: 2 Case reports

Mukand JA, Kaplan MS, Blackinton DD, Biener-Bergman S, Trojan DA. The gastric emptying scan as a tool for surgical management of severe bowel dysfunction in spinal cord injury: 2 Case Reports. Arch Phys Med Rehabil 2000;81:1531-4. We describe 2 patients with spinal cord injury (SCI) for whom the gastric emptying scan (GES) was crucial for determining the correct surgical approach in the therapeutic management of gastrointestinal complaints. Two men, ages 45 and 51 years, were admitted to a university hospital for delayed gastric complications from SCI. Both SCIs were traumatic, and the interval since injury was 18 months for the younger man and 6 months for the older man. Both men lacked voluntary motor and sensory function below the cord level of the lesion and had quadriplegia. Using GES, we measured motility (the cutoff for normal in this laboratory is 37%) and the time at which half the gastric contents were emptied (normal values are 45 ± 8min). Both patients had abnormal motility: residuals at 1 hour were above 50%. Half the gastric contents were emptied at 75 and 90 minutes, respectively. The therapeutic value of the GES was demonstrated for both patients, in combination with the history, physical examination, and abdominal radiographic studies. The first patient underwent ileostomy, and the second required a gastrostomy tube and a jejunostomy tube in addition to metoclopramide. The GES is a valuable diagnostic tool with an important role in the surgical management of patients with SCI. © 2000 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation