Late Postoperative Course Research Articles

Neurological Outcome and Respiratory Insufficiency in Intramedullary Tumors of the Upper Cervical Spine.

Background and Objectives: Intramedullary spinal cord tumors (IMSCT) are rare entities. A location in the upper cervical spine as a highly eloquent region carries the risk of postoperative neurological deficits, such as tetraparesis or respiratory dysfunction. Evidence for respiratory dysfunction is scarce. This study aimed to describe these highly eloquent tumors' early and late postoperative clinical course. Materials and Methods: This is a single-center retrospective cohort study. We included 35 patients with IMSCT at levels of the craniocervical junction to C4 who underwent surgical treatment between 2008 and 2022. The authors analyzed the patients' preoperative status, tumor- and surgery-specific characteristics, and follow-up functional status. Results: The study cohort included twenty-two patients with grade II ependymoma (62.9%), two low-grade astrocytomas (5.7%), two glioblastomas (5.7%), six hemangioblastomas (17.1%), two metastases (5.7%), and one patient with partially intramedullary schwannoma (2.9%). Gross total resection was achieved in 76% of patients. Early dorsal column-related symptoms (gait ataxia and sensory loss) and motor deterioration occurred in 64% and 44% of patients. At a follow-up of 3.27 ± 3.83 years, 43% and 33% of patients still exhibited postoperative sensory and motor deterioration, respectively. The median McCormick Scale grade was 2 in the preoperative and late postoperative periods, respectively. Only three patients (8.6%) developed respiratory dysfunction, of whom, two patients, both with malignant IMSCT, required prolonged invasive ventilation. Conclusions: More than 60% of the patients with IMSCT in the upper cervical cord developed new neurological deficits in the immediate postoperative period, and more than 40% are permanent. However, these deficits are not disabling in most cases since most patients maintain functional independence as observed by unchanged low McCormick scores. The rate of respiratory insufficiency is relatively low and seems to be influenced by the rapid neurological deterioration in high-grade tumors.

Choledochal Cyst Excision in Infants-A Retrospective Study.

A choledochal cyst is a rare malformation primarily diagnosed in children. The only effective therapy remains surgical cyst resection followed by Roux-en-Y hepaticojejunostomy. Treating asymptomatic neonates remains a point of discussion. Between 1984 and 2021, we performed choledochal cyst (CC) excision in 256 children at our center. Out of this group, we retrospectively reviewed the medical records of 59 patients who were operated on under one year of age. Follow-up ranged from 0.3 to 18 years (median 3.9 years). The preoperative course was asymptomatic in 22 (38%), while 37 patients (62%) had symptoms before surgery. The late postoperative course was uneventful in 45 patients (76%). In symptomatic patients, 16% had late complications, while in asymptomatic patients, only 4%. Late complications were observed in the laparotomy group in seven patients (17%). We did not observe late complications in the laparoscopy group. Early surgical intervention is not followed by a high risk of complications and may prevent the onset of preoperative complications, giving excellent early and long-term results, especially after minimally invasive laparoscopic surgery.

Prehabilitation of overweight and obese patients with dysglycemia awaiting bariatric surgery: Predicting the success of obesity treatment.

Bariatric surgery offers the best health results in overweight and obese patients but is not a risk and/or complication-free treatment. In cases with additional hyperglycemia, the burden of surgery can be even higher and alter both short-term and long-term outcomes. Although bariatric surgery offers glycemic improvements and in the case of early onset diabetes disease remission, weight loss results are lower than for obese patients without diabetes. Different multimodal programs, usually including interventions related to patients' performance, nutritional and psychological status as well as currently available pharmacotherapy before the surgery itself might considerably improve the immediate and late postoperative course. However, there are still no clear guidelines addressing the prehabilitation of obese patients with dysglycemia undergoing bariatric surgery and therefore no unique protocols to improve patients' health. In this minireview, we summarize the current knowledge on prehabilitation before bariatric surgery procedures in patients with obesity and dysglycemia.

Identification and treatment of potentially destabilizing Vancouver B-lesser trochanter periprosthetic fracture (“New B2”): A 33-case series

IntroductionA new type of periprosthetic fracture, between Vancouver-SoFCOT types A and B, was recently described and labeled “new B2”. It occurs intraoperatively or in the early postoperative period, on cementless implants, and features a posteromedial cortical fragment around the lesser trochanter. The main aim of the present study was to report clinical and radiological results in a series of 33 cases of what is better called Vancouver B-lesser trochanter (VB-LT) fracture. The secondary objective was to identify risk factors. The study hypothesis was that VB-LT fracture might occur in the late postoperative course. Material and methodA2 single-center retrospective study included all patients with postoperative periprosthetic VB-LT fracture diagnosed on standard X-ray. Treatment was operative or non-operative depending on femoral implant subsidence and the patient's general health status. ResultsThere were 33 VB-LT fractures out of 445 periprosthetic femoral fractures (7.5%), in 27 women and 6 men; all were postoperative, at a mean 47 months (range, 1 day to 20 years). Mean subsidence of the femoral stem was 8.8mm, in 73% of cases (24 out of 33 implants). The 9 VB-LT1 fractures (without subsidence) were treated non-operatively, without secondary displacement. Thirteen of the 24 VB-LT2 fractures (with subsidence) were managed by stem exchange and cerclage; 3 other patients had isolated stem exchange, 2 had isolated internal fixation by cerclage, and 6 in poor health were managed non-operatively. At a mean 28 months’ follow-up (range, 6–48 months), mean PMA score was 15.5 (range, 10–18), Harris Hip score 72.4 (range, 43–100) and Parker score 7.2 (range, 4–9). All cases showed osseointegration and implant stability; there was 1 case of non-union, without impact on stability. ConclusionPostoperative Vancouver B-lesser trochanter fracture seemed specific to cementless implants and did not occur exclusively in the early postoperative period. Non-operative treatment gave good results when there was no implant subsidence (type VB-LT1). Level of evidenceIV, retrospective.

Self-Mechanical Anal Dilatation: A Simple Trick to Minimize Postoperative Pain and Stenosis Following Hemorrhoidectomy With Radiofrequency.

Aim: Hemorrhoidectomy is still the most effective surgical treatment for hemorrhoidal disease, but it is, however, associated with complications such as pain and stenosis. We proposed to break the “vicious circle” of “pain–sphincteric spasm–stenosis–pain” with the postoperative use of self-mechanical anal dilation.Methods: We retrospectively analyzed patients with hemorrhoidal disease presenting with a minimum of piles of three quadrants, treated with radiofrequency hemorrhoidectomy between January 2018 and December 2019. All the patients that at 3 weeks presented sphincteric spasms with painful defecation, were considered. Thirty-nine patients performed the cycle of self-mechanical anal dilation (Group A). This group was 1:1 matched with homogeneous patients from our historical cohort of patients (Group B). The primary endpoint was the pain evaluation, secondary endpoints: WCS, overall satisfaction of the patient, anal sphincter spasm, scarring, and the incidence of postoperative stenosis.Results: In Group A mean VAS was 3.25 after 14 days of application and 1.15 at the end of the application. In Group B mean VAS was persistently higher, with a mean VAS of 5 (p = 0.000002) and 3.38 (p = 0.0000000000009). In Group A we observed an improvement of symptoms at the end, with a good overall satisfaction (Group A 7.4 vs. Group B 5.9; p = 0.0000007) and a better mean WCS (Group A WCS 2.8 vs. Group B WCS 4.18; p = 0.0001). Stenosis was observed in 3/39 patients of Group B (7.7%).Conclusions: Self-mechanical anal dilation improves the pain in the late postoperative course, minimizing the risk of anal stenosis.

Identifying Risk Factors for Complicated Post-operative Course in Tetralogy of Fallot Using a Machine Learning Approach.

Introduction: Tetralogy of Fallot (TOF) repair is associated with excellent operative survival. However, a subset of patients experiences post-operative complications, which can significantly alter the early and late post-operative course. We utilized a machine learning approach to identify risk factors for post-operative complications after TOF repair.Methods: We conducted a single-center prospective cohort study of children <2 years of age with TOF undergoing surgical repair. The outcome was occurrence of post-operative cardiac complications, measured between TOF repair and hospital discharge or death. Predictors included patient, operative, and echocardiographic variables, including pre-operative right ventricular strain and fractional area change as measures of right ventricular function. Gradient-boosted quantile regression models (GBM) determined predictors of post-operative complications. Cross-validated GBMs were implemented with and without a filtering stage non-parametric regression model to select a subset of clinically meaningful predictors. Sensitivity analysis with gradient-boosted Poisson regression models was used to examine if the same predictors were identified in the subset of patients with at least one complication.Results: Of the 162 subjects enrolled between March 2012 and May 2018, 43 (26.5%) had at least one post-operative cardiac complication. The most frequent complications were arrhythmia requiring treatment (N = 22, 13.6%), cardiac catheterization (N = 17, 10.5%), and extracorporeal membrane oxygenation (ECMO) (N = 11, 6.8%). Fifty-six variables were used in the machine learning analysis, of which there were 21 predictors that were already identified from the first-stage regression. Duration of cardiopulmonary bypass (CPB) was the highest ranked predictor in all models. Other predictors included gestational age, pre-operative right ventricular (RV) global longitudinal strain, pulmonary valve Z-score, and immediate post-operative arterial oxygen level. Sensitivity analysis identified similar predictors, confirming the robustness of these findings across models.Conclusions: Cardiac complications after TOF repair are prevalent in a quarter of patients. A prolonged surgery remains an important predictor of post-operative complications; however, other perioperative factors are likewise important, including pre-operative right ventricular remodeling. This study identifies potential opportunities to optimize the surgical repair for TOF to diminish post-operative complications and secure improved clinical outcomes. Efforts toward optimizing pre-operative ventricular remodeling might mitigate post-operative complications and help reduce future morbidity.

Post-CABG Deep Sternal Wound Infection: A Retrospective Comparative Analysis of Early versus Late Referral to a Plastic Surgery Unit in a Tertiary Care Center.

Background Deep sternal wound infections (DSWI) following median sternotomy are initially treated by the cardiothoracic surgeons and are referred to a plastic surgical unit late in the course of time. Methods This is a retrospective review done in a tertiary care teaching institute from January 2005 to June 2018 and the data of 72 patients who had DSWI out of 4,214 patients who underwent median sternotomy for coronary artery bypass grafting (CABG) was collected with respect to the duration between CABG and presentation of DSWI as well as time of referral to a plastic surgery unit. We defined early referral as < or equal to 15 days from presentation and late referral as > 15 days. Both groups were compared with respect to multiple parameters as well as early and late postoperative course, postoperative complications, and mortality. Results The early group had 33 patients, while the late group had 39 patients. The number of procedures done by the cardiothoracic team before referral to the plastic surgery unit is significant ( p = 0.002). The average duration from the presentation of DSWI to definitive surgery was found to be 16.58 days in the early group and 89.36 days in the late group. The rest of the variables that were compared in both the groups did not have significant differences. Conclusion There is no statistical difference between early and late referral to plastic surgery in terms of mortality and morbidity. Yet, early referrals could lead to highly significant reduction in total duration of hospital stay, wound healing, and costs. Early referral of post-CABG DSWIs to Plastic surgeons by the cardiothoracic surgeons is highly recommended.

Mechanical colon obstruction due to the alimentary limb after Roux-en-Y gastric bypass: a case report

BackgroundSmall bowel obstruction is a known and potentially lethal complication after gastric bypass surgery, in both the early and the late postoperative course. Colon or large bowel obstruction, on the other hand, seems to be rare after gastric bypass surgery and thus is not routinely considered.Case presentationWe present the case of a 21-year old morbidly obese caucasian patient who underwent laparoscopic Roux-en-Y gastric bypass surgery and developed an early severe transverse colon obstruction due to compression of the transverse colon by the antecolic alimentary limb. Emergency revisional surgery showed a short and tense alimentary limb mesentery and possibly tight closure of Petersen’s space contributing to the compression. Through opening of Petersen’s space and mobilization of alimentary limb mesentery, decompression was achieved, and the patient fully recovered.ConclusionsThis is a rare case of colon obstruction caused by direct compression of the transverse colon by the antecolic alimentary limb. We propose that a combination of short tense alimentary limb mesentery and perhaps tight closure of Petersen’s space was responsible for the obstruction in this case. Surgeons and treating physicians need to be aware of such rare causes of early postoperative bowel obstruction and take these into consideration when evaluating patients.

Fundamental and essential techniques for supermicrosurgical lymphaticovenular anastomosis: the art of Isao Koshima’s supermicrosurgery

Lymphaticovenular anastomosis (LVA) is a highly effective, minimally invasive surgical treatment for lymphedema. The effect of LVA appears immediately after the creation of lymph-to-venous pathway. However, the long-term outcome of LVA is not always promising when the lymph-to-venous anastomosis has any potential risk of occlusion. The reasons of postoperative LVA occlusions are considered both a technical matter in performing LVA and a strategic matter in preoperative planning. This report focuses on intraoperative techniques of LVA to avoid postoperative occlusions. Depending on the types of undesirable surgical procedures, lymphaticovenular anastomoses are at risk of future occlusions in early, mid-, or late-postoperative course. The authors describe fundamental and essential techniques to perform supermicrosurgical LVA, and the true concept of Isao Koshima’s supermicrosurgery, in which the pith and marrow of the doctrine is not only the way of handling the small vessels or needles, but also the surgeons’ skills to feel intima of the vessels and lymphatic flow itself.

Transdiaphragmatic herniation after transthoracic esophagectomy: an underestimated problem.

Diaphragmatic transposition of intestinal organs is a major complication after esophagectomy and can be associated with significant morbidity and mortality. This study aims of to analyze a large series of patients with this condition in a single high-volume center for esophageal surgery and to suggest a novel treatment algorithm. Patients who received surgery for postesophagectomy diaphragmatic herniation between October 2003 and December 2017 were included. Retrospective analysis of demographic, clinical and surgical data was performed. Outcomes of measure were initial clinical presentation, postoperative complications, in-hospital mortality and herniation recurrence. A total of 39 patients who had surgery for postesophagectomy diaphragmatic herniation were identified. Diaphragmatic herniation occurred after a median time of 259days following esophagectomy with the highest prevalence between 1 and 12months. A total of 84.6% of the patients had neoadjuvant radiochemotherapy prior to esophagectomy. The predominantly effected organ was the transverse colon (87.2%) prolapsing into the left hemithorax (81.6%). A total of 20 patients required emergency surgery. Surgery always consisted of reposition of the intestinal organs and closure of the hiatal orifice; a laparoscopic approach was used in 25.6%. Major complications (Dindo-Clavien ≥ IIIb) were observed in 35.9%, hospital mortality rate was 7.7%. Three patients developed recurrent diaphragmatic herniation during follow-up. Postesophagectomy diaphragmatic herniation is a functional complication of the late postoperative course and predominantly occurs in patients with locally advanced adenocarcinoma having chemoradiation before Ivor-Lewis esophagectomy. Due to a high rate of emergency surgery with life-threatening complications not a 'wait-and-see' strategy but early surgical repair may be indicated.

Robotic pancreaticoduodenectomy with right hepatic artery resection

Background: Pancreaticoduodenectomy(PD) with en bloc hepatic arterial resection and reconstruction remains a controversial topic. Although use of robotic surgery has been increasing worldwide in patients requiring PD, hepatic arterial resection and reconstruction has not been previously described. This video depicts a first in utilizing the Davinci Si robotic system to perform a hepatic arterial vascular resection and anastomosis during PD. Methods: A 69 year-old female, presenting with obstructive jaundice, was diagnosed with a distal common bile duct cancer by ERCP and brushing cytology. CT scan imaging revealed the suspected tumor mass involving the proximal right hepatic artery. We performed a total robotic PD. Right hepatic artery (RHA) was involved by the tumor and segmental resection was performed to achieve en bloc resection. End-to-end anastomosis of RHA stump to distal part was carried out by using 5-0 proline suture robotically. The reconstruction, including the modified Blumgart fashion pancreatojejunostomy, choledochojejunostomy and gastrojejunostomy, were all accomplished intracorporeally using the robotic platform. Results: The total operative time was 499 minutes and estimated blood loss was 500ml. The patient was discharged on post-OP day 4 without complications. The final pathology was moderately differentiated pancreatic adenocarcinoma with extensive perineural invasion. Metastatic carcinoma was found in one of the ten lymph nodes. Conclusion: PD with hepatic artery resection and reconstruction can be performed safely using robotic surgery. Restoration of the resected hepatic artery may ensure the bilio-enteric anastomosis in the immediate and late post-operative course.

L’évolution à long terme du reflux vésico-rénal chez l’enfant

Le reflux vésico-rénal (RVR) est une pathologie assez fréquente chez l'enfant nécessitant un suivi long pour réduire l'évolution vers l'insuffisance rénale chronique. L'objectif de notre étude est d'analyser les aspects épidémiologiques, le diagnostic, la prise en charge du reflux vésico-rénal et l'évolution à long de terme de cette pathologie. Pour cela on a mené une étude rétrospective portant sur une série de 42 patients hospitalisés au Service de Chirurgie Pédiatrique Viscérale du CHU Hassan II de Fès suspectés porteurs d'un reflux vésico-rénal (RVR) sur une période de 6 ans allant de janvier 2010 à décembre 2015. On a trouvé que l'âge médian au moment du diagnostic était de 3 ans et 2 mois. Le sex ratio était de 1,8 garçon pour fille. Le RVR était retrouvé isolé chez 81%, et secondaire ou associé chez 19%. Le principal mode de révélation était l'infection urinaire (90,4%). La fonction rénale était altérée chez 54,8% des enfants. Le traitement a consisté en une antibiothérapie des IU documentées (90,4%) et une antibio-prophylaxie si récidive, une réimplantation de type COHEN dans 97,62%. L'indication chirurgicale a concerné d'emblée tous les grades IV et V (73,9%), ainsi que les reins altérés, et 26,1% après traitement médical. L'évolution postopératoire précoce et tardive était en général satisfaisante: on a noté 92,68% de disparition du RVR. L'UHN a régressé sauf chez 9,52% patients, 95,23% malades ont normalisé leur fonction rénale. La récurrence des IU a diminué (19,04 % après la chirurgie). La majorité des parents ont jugé positivement l'évolution de l'état général de leurs enfants (54,76 %) après la chirurgie.

Post-cholecystectomy bile duct injuries: when to repair?

Background: Post cholecystectomy bile duct injury (BDI) though rarely happens; it has its own impact on postoperative outcomes. There is controversy on the optimal time for repair of such injuries. The aim of this study was to analyze the different time modalities used for repair of these injuries and its outcomes.Methods: This was a prospective randomized study conducted at General Surgery Department, Sohag university hospital, from August 2013 to March 2017. It included forty patients diagnosed to have BDI after cholecystectomy divided into 3 groups according to the time of intervention; early, intermediate, and late. We compared them regarding the pre-operative, operative variables and analyzed the post-operative outcomes among groups with one year follow-up after repair. Results: Bile leakage was the main presenting symptom in 100% of patients of early intervention group while there was combination of jaundice (71.43%) and bile leakage (28.57%) in the other two groups, 28.57% of patients of intermediate intervention required ICU admission. In the early intervention group there were tendency towards less severe injuries requiring simpler maneuvers for repair with primary repairs or end to end anastomoses while in late intervention group there were tendency towards more severe injuries requiring more complex maneuvers for reconstruction. In the post-operative course there was a tendency for intermediate intervention group to have higher incidence of complications in the early and late post-operative course (57%, p=0.007). Add to this the intermediate intervention group had the longest hospital stay (p=0.008) and was plagued by mortality rate of 21% (p=0.049).Conclusions: Late repair is superior to other time modalities of intervention in post-cholecystectomy BDI in terms of postoperative outcomes.

Predictive factors of late cholangitis in patients undergoing pancreaticoduodenectomy

BackgroundBecause the survival rate for patients experiencing late complications after pancreaticoduodenectomy (PD) is increasing, late complications should receive as much attention as early complications do.MethodsBetween April 2007 and August 2016, 133 patients underwent PD at our institution. We analyzed their cases to determine the predictors of late cholangitis after PD.ResultsOf the 133 patients, 28 (21.1%) were diagnosed with postoperative cholangitis. A multivariate analysis showed that abnormal postoperative values of alkaline phosphatase were independently associated with postoperative cholangitis (odds ratio, 3.81; 95% confidence interval, 1.519–9.553; P = 0.004). The optimal cut-off value for postoperative alkaline phosphatase calculated from the receiver operating characteristic curve was 410 IU/L (sensitivity, 76.2%; specificity, 67.9%; area under the curve, 0.73). A univariate analysis to identify risk factors showed that pneumobilia was significantly related to a postoperative alkaline phosphatase value ≥ 410 IU/L (P = 0.041).ConclusionThis study suggests that an alkaline phosphatase level ≥ 410 IU/L is a predictor of late postoperative cholangitis. In addition, pneumobilia is also related to the postoperative alkaline phosphatase level. Therefore, alkaline phosphatase levels should be carefully monitored in patients with postoperative pneumobilia in the late postoperative course.

Hemobilia following laparoscopic cholecystectomy: computed tomography findings and clinical outcome of transcatheter arterial embolization.

Hemobilia following laparoscopic cholecystectomy (LC) can occur in the early or late postoperative course and poses a diagnostic and therapeutic challenge. To assess computed tomography (CT) findings and clinical outcomes after transcatheter arterial embolization (TAE) in patients presenting with hemobilia following LC. Fourteen patients treated for hemobilia following LC were included in the study. Three patients were diagnosed by endoscopy and 11 by abdominal contrast-enhanced CT. Coils or microcoils were superselectively deployed to occlude the bleeding vessel during TAE. Abdominal CT findings of hemobilia, and the success rate and complication of TAE were observed. Abdominal CT provided the following signs of hemobilia: hematoma within the abdominal cavity and gallbladder fossa, blood clots containing high attenuation within the bile duct, biliary dilatation, pseudoaneurysm of the right hepatic artery, contrast extravasation, enhancement of the bile duct wall, and hypoperfusion of the right lobe. The success rate of TAE was 100% and rebleeding did not occur in any patient. Post-embolization syndrome and hepatic ischemia occurred in nine patients, which was associated with age and the time interval between the LC and TAE. Abdominal CT provided direct signs that can aid in the diagnosis of hemobilia after LC. TAE allowed for successful treatment of hemobilia with minor complications.

One-stage reconstruction of isolated and combined tendon defects with the vascularized adductor magnus tendon graft: Surgical technique and preliminary results

Secondary reconstructions of isolated and combined tendon defects are still a challenge for plastic surgeons. Due to its reliable anatomy, reconstructive potential and low donor-site morbidity, the medial femoral condyle is an ideal area for harvesting isolated and combined tendon flaps. This study evaluates our preliminary results with the vascularized adductor magnus tendon flap. The study included six patients who received a vascularized tendon flap (upper extremity: three patients; lower extremity: three patients) from 2011 to 2015. For three patients, the adductor magnus tendon was used as a single flap; for the other three patients, the tendon was included in a composite flap. A retrospective chart review provided the patients' demographic data, surgical details and the post-operative course. The further objective and patient-reported outcome was evaluated with a long-term follow-up. All of the free vascularized flaps healed without complications and with good vascularization upon duplex ultrasonography. One patient did, however, require revision surgery in the late post-operative course. At the end point, all patients showed good functional results without any donor-site morbidity. For carefully selected isolated and combined tendon defects on the upper and lower extremities, the vascularized adductor magnus tendon flap provides a reliable and versatile method for microsurgical reconstruction.

Cosmetic Outcomes of Sutureless Closure in Gastroschisis.

Purpose A sutureless gastroschisis repair allows for spontaneous closure of abdominal wall defect. We report our experience focusing on final esthetic outcome. Methods Retrospective data were collected from medical reports of all neonates with gastroschisis operated from January 2009 to December 2013. Variables recorded included patients descriptors, management modality, and cosmetic outcome. Results From the overall group of 38 patients with gastroschisis, 20 infants treated with sutureless closure were included in this study. In the analyzed cohort, 17 (85%) children were operated under general anesthesia and 3 (15%) without intubation. Primary reduction was possible in 15 (75%) cases, and in 5 (25%) we used silo. There were two (10%) deaths in late postoperative course due to septic complications. Three (15%) infants needed laparotomy because of adhesions and bowel obstruction. There were no infectious complications of the wound. Only 55% (10/18) of children presented umbilical hernia prior to discharge. Only two (11%) children with umbilical hernia were operated until now. Almost all patients (16/18; 89%) present excellent final cosmetic result without scar formation. Conclusion Sutureless closure of uncomplicated gastroschisis is a safe technique that reduces need of intubation and provides excellent cosmetic results.

Laparoscopic management of post-cholecystectomy sectoral artery pseudoaneurysm

Vascular injuries during laparoscopic cholecystectomy can occur similar to biliary injuries and mostly represented by intraoperative bleeding. Hepatic artery system pseudoaneurysm are rare. It occurs in the early or late postoperative course. Patients present with pallor, signs of haemobillia and altered liver function. We report a case of right posterior sectoral artery pseudoaneurysm detected 2 weeks after laparoscopic cholecystectomy and successfully repaired laparoscopically. We also describe how laparoscopic pringle clamping saved the conversion. The actively bleeding right posterior sectoral artery pseudoaneurysm was diagnosed by CT angiogram. Embolisation, usually the treatment of choice, would have risked liver insufficiency as hepatic artery proper was at risk because the origin the bleeding artery was just after its bifurcation. Isolated right hepatic artery embolisation can also cause hepatic insufficiency. To our knowledge this is the first reported case of laparoscopic repair of post-laparoscopic cholecystectomy bleeding sectoral artery pseudoaneurysm.

Elderly patients are at increased risk for mortality undergoing surgical repair of dens fractures

ObjectiveDens fractures are common cervical injuries in advanced aged patients. The presented study was undertaken to analyze the clinical results and risks of surgically treated patients with dens fractures over 70 years. MethodsData of 28 patients (17 female, 11 male) over 70 years treated from September 2004 to October 2009 were recorded. Clinical and radiological parameters were obtained including type of fracture, associated cervical and/or other injuries, comorbidities, symptoms, neurological condition, surgical strategy, postoperative course and complications. Results89% were in a good neurological condition before surgery (ASIA E or D). In most cases, surgery was performed at an early stage after trauma (21 patients within 5 days). Ventral screw fixation was the preferred surgical strategy (64%). A slight worsening of neurological functions immediately after operation was only seen in one patient. Five patients died in the early and 2 in the late postoperative course which means a treatment mortality of 25%. Among the surviving patients two had general medical complications. ConclusionType II dens fractures are a common fracture of elderly patients. Our results are good concerning the neurological functions. Surgical and general medical complications were acceptable. However, the study also underlines that mortality rate is high and therefore treatment options should be well-considered in this high risk group.

Electrocardiographic impacts of lung resection

IntroductionElectrocardiographic (ECG) changes accompanying lung resection have not been well investigated previously in a large controlled series of human adults. Thus, our current investigation was undertaken for a better understanding of the ECG changes associated with lung resection. Materials and MethodsMedical records of 117 patients who underwent lung resection (segmentectomy, lobectomy, or pneumonectomy) were reviewed. Their clinical course and ECGs were compared during early, intermediate and late postoperative course (<1month, 1month to 1year and >1year post-op respectively). ResultsPatients in the acute postoperative phase had higher heart rate, increased maximum P-duration and P-dispersion, increased incidence of atrial arrhythmias and frequent ST-T changes. P-vector and QRS-vector were significantly affected after the lung resections; the correlation being most consistent between the anatomical displacements and the QRS-vector in the majority of patients. The axial shifts also demonstrated a characteristic temporal relationship after left pneumonectomy (a leftward deviation in the acute, normal or slight rightward deviation in the intermediate and a rightward deviation in the late postoperative course). The precordial R/S transition is often affected due to the mediastinal shifts and the ECGs in patients after left lung resection may simulate acute anteroseptal myocardial infarction due to a delayed R/S transition. ConclusionThe understanding and recognition of the expected ECG findings after lung resection are imperative to avoid confusing these changes with other acute cardiopulmonary events which would prevent unnecessary further investigational work-up. These ECG changes are often dynamic and may bear a temporal relationship to the dynamic post-surgical changes in the thoracic anatomy.