Early Surgical Repair Research Articles

Precision in cardiology: should all cases of myocardial infarction with ventricular septal rupture require early repair?

Though the incidence of ventricular septal rupture (VSR) after myocardial infarction (MI) has reduced from 3%1 to 0.2%2 due to improvements in cardiac pharmacotherapy and intervention, the mortality rate still...

Prenatal Diagnosis and Successful Outcome in Neonate of Aorto-Left Ventricle Tunnel

Aorto-left ventricular tunnel (ALVT) is an abnormal congenital communication between the ascending aorta and the left ventricle. Prenatal diagnosis is rare and can be misinterpreted as aortic insufficiency on fetal echocardiogram. We present a case of ALVT diagnosed in a fetus who underwent successful early neonatal surgical repair.

Management and outcomes of penile fracture: 10 years’ experience from a tertiary care center

To evaluate our experience on diagnosis and management of penile fractures. This retrospective study included 31 patients who were treated for penile fracture between 2002 and 2012. We analyzed the etiology of penile fracture, concomitant pathologies such as urethral injury, deep or superficial dorsal vein ruptures, treatment modalities (surgery or conservative treatment) and complications of treatment modalities. The mean age of the patients was 32 years (range, 23-47 years). In 27 patients (87%), the cause of penile fracture was sexual intercourse. Patients presented with swelling, pain and popping or cracking sound in penis. The diagnosis of penile fracture was established clinically in all of the patients. There were no urethral injuries or dorsal vein ruptures. Ten patients who refused surgical treatment were treated conservatively and remaining 21 patients with early surgical intervention. Among conservatively treated patients, two suffered from erectile dysfunction, two from painful erection and another two from penile curvature. No serious complications such as erectile dysfunction, penile curvature or painful erection were observed in surgically treated patients. Penile fracture can be diagnosed easily with history and physical examination, and favorable functional results can be achieved with early surgical repair.

Primary versus delayed repair for bile duct injuries sustained during cholecystectomy: results of a survey of the Association Francaise de Chirurgie

BackgroundBile duct injuries (BDIs) sustained during a cholecystectomy still remain a major surgical problem, and it is still not clear whether the injury should be repaired immediately or a delayed repair is preferred. MethodsA retrospective national French survey was conducted to compare the results of immediate (at time of cholecystectomy), early (within 45 days after a cholecystectomy) and late (beyond 45 days after a cholecystectomy) surgical repair for BDI sustained during a cholecystectomy. ResultsForty‐seven surgical centres provided 640 cases of bile duct injury sustained during a cholecystectomy of which 543 were analysed for the purpose of the present study. The timing of repair was immediate in 194 cases (35.7%), early in 216 cases (39.8%) and late in 133 cases (24.5%). The type of repair was a suture repair in 157 cases (81%), and a bilio‐digestive reconstruction in 37 cases (19%) for immediate repair; a suture repair in 119 cases (55.1%) and a bilio‐digestive anastomosis in 96 cases (44.9%) for the early repair; and a bilio‐digestive reconstruction in 129 cases (97%) and a suture repair in 4 cases (3%) for late repair. A second procedure was required in 110 cases (56.7%) for immediate repair, 80 cases (40.7%) for early repair (P < 0.05) and in 9 cases (6.8%) for late repair (P < 0.001). ConclusionThe timing of surgical repair for a bile duct injury sustained during a cholecystectomy influences significantly the rate of a second procedure and a late repair should be preferred option.

Early surgical repair of iatrogenic ureterovaginal fistula secondary to gynecologic surgery

ObjectiveTo describe the early surgical repair of iatrogenic ureterovaginal fistula (UVF) secondary to gynecologic surgery, and evaluate the efficacy and feasibility of early surgical intervention. MethodsData were retrospectively reviewed for 52 patients with iatrogenic UVF who underwent early surgical repair between January 1996 and January 2011 at the Sir Run Run Shaw Hospital, Hangzhou, China. Preoperative patient characteristics and postoperative endpoints, including type of index procedure, repair technique, operative time, perioperative complications, and postoperative follow-up data were assessed. ResultsAll early surgical repairs were uneventful. The mean time from diagnosis to surgery was 15.7days (range, 14–21days). The mean operative time was 73.4min (range, 51–110min) for ureteroneocystostomy, and 104min (range, 91.5–153min) for Boari flap procedure. The mean estimated blood loss was 57.8mL (range, 35–80mL). No major intraoperative complications occurred, although 5 patients had postoperative surgical site infections. Forty-three patients were followed for a mean of 18.4months (range, 10.5–24.0months). Ureteral stricture with asymptomatic hydronephrosis occurred in 2 (4.7%) patients. Ipsilateral renal function was preserved in all patients. ConclusionEarly surgical repair of UVF secondary to gynecologic surgery was safe and effective, and preserved ipsilateral renal function.

Spontaneous osteo-dural fistulae of petrous bone posterior wall

To raise awareness of the possibility of spontaneous temporal bone cerebrospinal fistula in case of clear retrotympanic effusion. A 63-year-old man with no particular history presented with unilateral spontaneous right retrotympanic clear effusion. CT found defects in the posterior part of the right temporal bone, in contact with arachnoid granulations, with no other visible abnormalities. Unilateral clear retrotympanic effusion in an adult subject should, apart from serous otitis media, suggest possible cerebrospinal fistula. In the absence of otologic or traumatic history, arachnoid granulation is one possible etiology, inducing spontaneous cerebrospinal fluid leakage when facing the temporal bone. Diagnosis is suggested by bone defects in the tegmen tympani or posterior wall of the temporal bone on CT, with the adjacent mastoid cavities filled with fluid. Pneumococcal vaccination and early surgical repair of the fistula should be performed to avoid neuromeningeal infection.

EComment. Fistulous complications of acute dissection of the ascending aorta

We read the article by Pagni et al. [1] with great interest. The authors have documented a case of aorto-right atrial fistulization after type A aortic dissection well. We think that the discussion should be primarily focused on fistulous complications of acute ascending aortic dissection, occurring after previous cardiac or aortic surgery. Acute dissection of the ascending aorta is a life-threatening pathology and may lead to serious complications. They include rupture to neighbouring structures, aortic insufficiency, haemothorax, haemopericardium, and occlusion of the major vessels originating from the aorta [2-5]. These complications may occur as the false lumen enlarges. Free rupture of aortic dissection into the pleural and pericardial spaces often results in sudden cardiovascular collapse and death. Fistulization to the cardiac chambers (right atrium, left atrium, and right ventricle) and the pulmonary artery is a rare and often fatal occurrence [2-5]. Fistulous complications can be explained by considering the anatomy of the aortic root. Aortopulmonary, aorta-right atrial, and aorta-right ventricular fistulas produce a left-to-right shunt and congestive heart failure. Pagni et al. [1] have reported a right-to-left shunt depending on the patent foramen ovale. Fistulous complications of aortic dissection may occur in any patient, especially in those with a history of previous cardiac or aortic surgery [2-5]. The incidence of fistulous formation tends to increase with redo surgery. Postoperative adhesions may play an important role in the pathogenetic mechanism of the fistula. In such patients, the dense adhesions probably restrain the free rupture and contribute to the fistulous occurrence. Undoubtedly, prompt diagnosis and early surgical repair of the dissection and fistula would provide for an excellent outcome. In such complicated situations, we think that one should use all the information and imaging techniques available to provide a timely diagnosis and treatment. Conflict of interest: none declared.

Emergency surgical management of double penile fracture at a peripheral hospital

Penile fractures are an uncommon surgical emergency. They result from trauma to the erect penis leading to rupture of the tunica albuginea of the penile corpora. Prompt diagnosis and early surgical repair are essential to ensure a successful outcome.1 We report a case of a young male with penile fracture who presented late to the hospital. Urgent imaging and emergency surgery were undertaken. He was found to have two separate fractures of the tunica which were repaired successfully without any complications. The aim of the report is to highlight the importance of imaging, and complete degloving of the penile shaft and meticulous search to avoid missed injuries. This would avoid devastating physical and psychological disabilities.

Long-term respiratory complications of congenital esophageal atresia with or without tracheoesophageal fistula: an update

Despite early surgical repair, congenital esophageal atresia with or without tracheoesophageal fistula (EA ± TEF) has long-term effects on respiratory and gastrointestinal function. This review updates summarizes research published since 2003 on long-term respiratory complications in patients with a history of EA ± TEF. Pulmonary hypoplasia appears to not be rare in patients with EA ± TEF. Tracheomalacia is common and is associated with respiratory symptoms in childhood. Aspiration, associated with esophageal dysmotility and/or gastroesophageal reflux, may lead to reduced pulmonary function and bronchiectasis. Pulmonary function is generally normal, although lower than in control patients, and restrictive defects tend to be commoner than obstructive defects. Abnormal airway reactivity is common and, along with respiratory symptoms, is associated with atopy. However, the inflammatory profile in EA ± TEF patients based on bronchial biopsies and exhaled nitric oxide differs from typical allergic asthma. Recent studies suggest that in older patients, respiratory symptoms tend to be associated with atopy, but abnormal lung function tends to be associated with gastroesophageal reflux and with chest wall abnormalities. Early detection and management of aspiration may be important to help prevent decrements in pulmonary function and serious long-term complications in EA ± TEF patients.

Early versus delayed repair of vesicouterine fistula

Vesicouterine fistulas (VUF) are a pathological and uncommonconnection between the uterus and the bladder. Although rare,they are usually related to cesarean section. Nowadays, theirincidence increases because of the increase in Cesarean sections.Patients with VUF may have various clinical presentations. Themain symptoms are urinary incontinence, which may be associatedwith hematuria. Vesicouterine fistulas are usually associated withpsychological distress and have a negative effect on quality of life.The accurate and early diagnosis of VUF can be difficult. There aremultiple ways to investigate VUF and several examinations may berequired to confirm the diagnosis; these examinations may includea cystoscopy, a retrograde cystography, methylene blue test and acomputed tomography scan. We present 3 cases of vesicouterinefistula with successful surgical repair in which 2 patients had anearly repair. One patient had an early surgical repair because ofintractable pain and the other patient because of the large sizeof the fistula. The fistula repair surgeries were uneventful andthe patients had an unremarkable recovery. We report that earlysurgical management is technically feasible without significantlyincreasing the difficulty of the surgery, with an excellent outcomein selected patients.

Penile fracture with bilateral corporeal rupture and complete urethral disruption: case report and literature review

Penile fracture is a rare injury most commonly sustained duringsexual intercourse. We report the case of a 35-year-old man whopresented with bilateral rupture of the corpora cavernosa andcomplete disruption of the urethra. A review of the literature onpenile fracture is also presented. Urgent surgical exploration wasperformed and the injuries repaired primarily. In follow-up, thepatient reported satisfactory erectile function. This case highlightsthe importance of early surgical repair and evaluation for concomitanturethral injuries in cases of penile fracture.

Results for Surgical Closure of Isolated Ventricular Septal Defects in Patients Under One Year of Age

This study evaluated the outcomes of patients undergoing surgical repair of isolated ventricular septal defect (VSD) in the first year of life with particular attention to age and severity of pulmonary hypertension (PH). Between July 1, 2002 and May 31, 2012, 282 patients aged less than one year underwent isolated VSD closure at a median age of five months (range, 21 days to 1 year) and a median weight of 5.3 kg (range, 2.9 to 12.5 kg). Patients were divided into three groups according to the age at surgery (0-3, 3-6, and 6-12 months), and groups were compared in regard to severity of PH associated with morbidity and mortality. Four (1.4%) early and four (1.4%) late deaths occurred postoperatively. All mortalities were patients with severe PH, aged between 3 and 12 months. Although hemodynamic studies revealed a higher incidence of persistent postoperative PH in patients above three months of age, there was no statistically significant difference in morbidity associated with prolonged mechanical ventilation, and long intensive care unit and hospital stays between age-related groups. In this study, the incidence of mortality was higher in patients over three months of age undergoing repair of isolated VSD; the data suggest that the mortality may be decreased in patients with severe PH who were operated on earlier in life. We conclude that in infants with severe PH, early surgical repair (less than three months) of isolated VSDs is strongly advised to achieve more favorable results.

Avulsion fracture and complete rupture of the thumb radial collateral ligament

Acute grade III tears of the radial collateral ligament (RCL) of the thumb as well as certain bony avulsion fractures receive early surgical repair at our institution. The aim of this study was to evaluate if patients would benefit from this treatment algorithm at long-term. 47 patients with RCL bony avulsion fracture or grade III RCL tear were evaluated at a median follow-up of 4.5years (range 1-17.3years). Grade III RCL tears were treated operatively when presenting >30° angulation in stress X-ray together with palmar subluxation of ≥3mm. Further, avulsed bony fragments with diastasis >2mm or fragment rotation >30°-45° in conventional X-ray underwent surgery. 6 patients with grade III RCL tear as well as 9 patients with bony avulsion underwent surgical repair. At follow-up, metacarpophalangeal joint stability and pain free ROM did not differ significantly between the groups. Subjective satisfaction based on the Catalano grading system revealed excellent results in operatively and conservatively treated patients. This retrospective analysis indicates that early surgical repair in severe RCL injuries is associated with unrestricted ROM, persistent joint stability, and subjective patient satisfaction. This data suggest that surgical treatment in certain RCL injuries might be a feasible therapeutic option in order to avoid chronic instability.

Triceps Brachii Distal Tendon Reattachment With a Double-row Technique

Case reports and small series have reported variable results regarding the treatment of choice for patients with triceps brachii tendon ruptures. Early surgical repair has been recommended for acute complete ruptures of the triceps brachii distal tendon to prevent late functional disability. However, controversy exists regarding the optimum surgical technique of reattachment. In addition, various attachment techniques have been described, with none shown clinically to be superior. Therefore, the authors present a technique for triceps brachii distal tendon reattachment following acute complete ruptures and evaluate their results in a series of patients.

An Evidenced-Based Examination of the Epidemiology and Outcomes of Traumatic Rotator Cuff Tears

The purpose of this study was to systematically review the literature to better define the epidemiology, mechanism of injury, tear characteristics, outcomes, and healing of traumatic rotator cuff tears. A secondary goal was to determine if sufficient evidence exists to recommend early surgical repair in traumatic rotator cuff tears. An independent systematic review was conducted of evidence Levels I to IV. A literature search of PubMed, Medline, Embase, and Cochrane Collaboration of Systematic Reviews was conducted, with 3 reviewers assessing studies for inclusion, methodology of individual study, and extracted data. Nine studies met the inclusion and exclusion criteria. Average patient age was 54.7 (34 to 61) years, and reported mean time to surgical intervention, 66 days (3 to 48 weeks) from the time of injury. The most common mechanism of injury was fall onto an outstretched arm. Supraspinatus was involved in 84% of tears, and infraspinatus was torn in 39% of shoulders. Subscapularis tears were present in 78% of injuries. Tear size was <3 cm in 22%, 3 to 5 cm in 36%, and >5 cm in 42%. Average active forward elevation improved from 81° to 150° postoperatively. The weighted mean postoperative UCLA score was 30, and the Constant score was 77. Traumatic rotator cuff tears are more likely to occur in relatively young (age 54.7), largely male patients who suffer a fall or trauma to an abducted, externally rotated arm. These tears are typically large and involve the subscapularis, and repair results in acceptable results. However, insufficient data prevent a firm recommendation for early surgical repair. Level IV, systematic review Levels III and IV studies.

Triceps Rupture: A Case Series, Anatomical Study of the Triceps Footprint and Description of Surgical Technique

BackgroundDistal triceps tendon ruptures are rare accounting for less than 1% of all tendinous injuries in the upper extremity. Such injuries should be suspected in patients who have pain about the elbow following an eccentric contraction to the upper extremity. Complete ruptures should be treated with early surgical repair with reattachment of the tendon to the olecranon. Most reports to date have used suture fixation through olecranon drill holes. This study was performed to asses the anatomy of the triceps insertion and it's implications on the adequate fixation of the triceps tendon using a novel technique.MethodsTen cadaveric adult upper extremities with no signs of prior trauma or surgery were used in this study. The specimens were stripped of all skin and subcutaneous tissue through a direct posterior approach, to identify the triceps insertion. The insertion of the triceps tendon was then mapped and the area of the medial, long and lateral heads measured. Three cases of distal triceps rupture using this new open repair technique are also described using two distal drill holes and sutures augmented with a proximal anchor. Two of the three patients also needed LARS ligament augmentation at the time of surgery due to tissue loss.ResultsIn all cadaveric sections separate insertions were found consisting of the medial head and the conjoint tendons of the long and lateral heads. The mean surface areas for the medial and long/lateral insertions were 100.4 mm2and 307.9 mm2respectively. The mean total area for the triceps insertion was found to be 408.3 mm2. At follow up all cases were assessed using the Oxford Elbow Score, Mayo Elbow Performance Scores and Disabilities of the Arm, Shoulder and Hand Scores.ConclusionsWe have shown that the insertion of the triceps tendon is a “footprint” made from the tendon of the medial head and a conjoint tendon of the long and lateral heads. For cases of distal triceps rupture we have described an open procedure using a “double row footprint reconstruction” technique which we believe anatomically reconstructs the triceps insertion.

Endoscopic Treatments of Endoscopic Retrograde Cholangiopancreatography-Related Duodenal Perforations

Iatrogenic duodenal perforation associated with endoscopic retrograde cholangiopancreatography (ERCP) is a very uncommon complication that is often lethal. Perforations during ERCP are caused by endoscopic sphincterotomy, placement of biliary or duodenal stents, guidewire-related causes, and endoscopy itself. In particular, perforation of the medial or lateral duodenal wall usually requires prompt diagnosis and surgical management. Perforation can follow various clinical courses, and management depends on the cause of the perforation. Cases resulting from sphincterotomy or guidewire-induced perforation can be managed by conservative treatment and biliary diversion. The current standard treatment for perforation of the duodenal free wall is early surgical repair. However, several reports of primary endoscopic closure techniques using endoclip, endoloop, or newly developed endoscopic devices have recently been described, even for use in direct perforation of the duodenal wall.

Early diagnosis and treatment of growing skull fracture

Growing skull fracture (GSF) is a rare complication of pediatric skull fractures and causes delayed-onset neurological deficits and cranial asymmetry. Early treatment is pivotal to prevent those complications. The aim of this study is to highlight the early diagnosis and treatment of GSFs. Between January 2000 and June 2013; 6,916 children with linear fracture were treated in three separate hospitals. Inclusion criteria were: Patients who were diagnosed and treated within 30 days and had one or more following features: (a) 3 years or less age with cephalohematoma; (b) seizures immediate to the injury; (c) underlying brain damage; and (d) bone diastasis 4 mm or more. A review was retrospectively carried out to identify those patients who had early diagnosis and surgical intervention. Eighty-six patients met the inclusion criteria and all had magnetic resonance imaging (MRI) brain scans. Twenty-two patients had GSF, fall was the most frequent cause of injury and cephalohematomas the most common symptom. The most common injury site was the parietal region. Early surgical repair of dura and skull was associated with good outcomes. The patients aged 3 years or less with cephalohematoma, underlying brain damage, bone diastasis ≥4 mm on computed tomography (CT), and seizures immediate to the injury were high risk group for developing GSFs. Early diagnosis and surgical treatment of GSF can yield a good outcome.

Urgent-setting magnetic resonance imaging allows triage of extensive penoscrotal hematoma following blunt trauma

Although uncommon, blunt trauma to the perineum may cause serious injury to the penis. Differentiation between penile fracture with torn tunica albuginea versus extratunical or cavernosal hematomas is crucial because the former condition needs early surgical repair to avoid future deformity and erectile dysfunction, whereas approach is conservative with even large penoscrotal hematomas with albugineal integrity. Urgent-setting magnetic resonance imaging including multiplanar images of the injured penoscrotal region allows precise identification or exclusion of presence, site, and extent of tears of the tunica albuginea, providing a consistent basis for therapeutic choice.

50 Years Ago in The Journal of Pediatrics: Female Adrenogenital Syndrome: Early Surgical Repair

50 Years Ago in The Journal of Pediatrics: Female Adrenogenital Syndrome: Early Surgical Repair