Low Rate Of Serious Complications Research Articles

Clinical yield of diagnostic endoscopic retrograde cholangiopancreatography in orthotopic liver transplant recipients With suspected biliary complications

Diagnostic endoscopic retrograde cholangiopancreatography (D-ERCP) is commonly performed for the evaluation of biliary complications after orthotopic liver transplantation (OLT). This practice is contrary to the national trend of reserving endoscopic retrograde cholangiopancreatography (ERCP) for therapeutic purposes. Our aim was to evaluate the clinical yield and complications of D-ERCP in OLT recipients. In this retrospective study, 165 OLT recipients who underwent ERCP between January 2006 and December 2010 at the University of Michigan were divided into 2 groups: (1) a therapeutic endoscopic retrograde cholangiopancreatography (T-ERCP) group (if they met prespecified criteria that suggested a high likelihood of endoscopic intervention) and (2) a D-ERCP group (if there was clinical suspicion of biliary disease but they did not meet any criteria). The 2 groups were compared with respect to the proportion of subjects undergoing high-yield ERCP, which was defined as a procedure resulting in a clinically important intervention that modified the disease course. 66.3% of the D-ERCP procedures were classified as high-yield, whereas 90.1% of the T-ERCP procedures were (P < 0.001). Serious complications were infrequent in both groups. A survey of practitioners caring for OLT recipients suggested that the rate of high-yield D-ERCP seen in this study is congruent with what is considered acceptable in clinical practice. In conclusion, although T-ERCP is more likely to reveal a pathological process requiring an intervention, D-ERCP appears to be an acceptable clinical strategy for OLT recipients because of the high likelihood of a high-yield study and the low rate of serious complications.

Pancreatitis Can Be Caused Even By This!

Purpose: Learning objectives: To recognize that PEG tube balloon may migrate and get impacted in the second portion of duodenum leading to disturbance of pancreatic and biliary juice secretion at the papilla. PEG tube balloon impaction in the duodenum should be in the differential diagnoses list in patients who have PEG tube and pancreatitis with/without elevated LFTs. Case: A 62-year-old female was admitted to the hospital with complaints of fever, chills, difficulty breathing, and tachycardia. Her past medical history was significant for diabetes mellitus, seizure disorder, and Pick's disease with severe dementia. She also had PEG tube in place due to dysphagia. Her medications included insulin and valproic acid. On admission day, her physical examination was significant for tachycardia, tachypnea, and temperature of 102 F. Cardiopulmonary exam revealed bibasilar crackles. Her abdomen was benign with PEG in place. Her chest X-ray showed bibasilar consolidation. The diagnosis of pneumonia was made and broad spectrum antibiotics were commenced. On day 5 of hospitalization her condition began deteriorating. Work-up showed elevated WBC along with ESR, CRP, amylase, lipase, and LFTs which were suggestive for a pancreaticobiliary inflammatory process. CT abdomen showed diffuse pancreatitis without any evidence of phlegmon or abscess. The balloon of the G-tube appeared to be impacted in the duodenum near the ampulla of Vater. The PEG tube balloon was deflated and the tube was pulled up and guarded at 4 cm. After that her WBC, amylase, lipase, and LFTs started trending down significantly and returned to normal levels within a week. Discussion: Obstructive pancreatitis and cholangitis induced by migrated PEG-tube are the very rare complications of PEG tube. Although PEG-tube feeding is generally considered safe with a low rate of serious complications, dislocation of the PEG-tube into the duodenum can lead to symptoms of obstructive pancreatitis and cholangitis. Because a balloon with PEG-tube is hard to pass through the pyloric ring, a migrated balloon may obstruct the pyloric ring and cause vomiting.Figure: [784]

Complications of catheter ablation for atrial fibrillation in a high-volume centre with the use of intracardiac echocardiography

Catheter ablation (CA) for atrial fibrillation (AF) is a complex procedure that is associated with higher risk of complications. This study aimed at exploring the complication rate and corresponding risk factors in a high-volume centre with routine use of intracardiac echocardiography (ICE). In total 1192 consecutive AF ablation procedures (100% ICE-guided; 96.4% 3D-navigated; point-by-point radiofrequency ablation with open-irrigated tip catheter; 22.4% robotic navigation; 25.4% repeated ablation) were performed in 959 patients (aged 58 ± 9 years; 70.8% males; 35.9% persistent AF) between March 2006 and December 2010. Ablation endpoint in paroxysmal AF was complete electrical pulmonary vein isolation (PVI). Complex ablation was defined as PVI plus stepwise strategy for left atrial substrate ablation (43.5%) in persistent AF. Forty major complications (3.3%) during the procedure or within the 3 month follow-up were observed. No death or atrioesophageal fistula occurred. Three patients (0.25%) had cardiac tamponade/hemopericardium and five patients (0.42%) had cerebrovascular embolic event. Vascular injury was the most frequent (2.3%) complication. Low body weight was the only significant risk factor with 0.8% increase of complication rate per 10 kg of body weight decrease (P = 0.013). A trend for increase in complication rate was also observed for advanced age, female gender, and complex procedure. Atrial fibrillation ablation procedures guided by ICE in a high-volume centre are associated with low rate of serious complications. The composite risk score consisting of body weight, age, gender, and complexity of procedure predicted complications.

Uterine Artery Embolization Versus Laparoscopic Uterine Artery Occlusion: The Outcomes of a Prospective, Nonrandomized Clinical Trial

To compare outcomes of two different types of occlusive therapy of uterine fibroids. Women with fibroid(s) unsuitable for laparoscopic myomectomy (LM) were treated with uterine artery embolization (UAE) or laparoscopic uterine artery occlusion (LUAO). Before the procedure, patients treated with UAE (n = 100) had a dominant fibroid greater in size (68 vs. 48 mm) and a mean age lower (33.1 vs. 34.9 years) than surgically treated patients (n = 100). After 6 months, mean shrinkage of fibroid volume was 53 % after UAE and 39 % after LUAO (p = 0.063); 82 % of women after UAE, but only 23 % after LUAO, had complete myoma infarction (p = 0.001). Women treated with UAE had more complications (31 vs. 11 cases, p = 0.006) and greater incidence of hysteroscopically verified intrauterine necrosis (31 vs. 3 %, p = 0.001). Both groups were comparable in markers of ovarian functions and number of nonelective reinterventions. The groups did not differ in pregnancy (69 % after UAE vs. 67 % after LUAO), delivery (50 vs. 46 %), or abortion (34 vs. 33 %) rates. The mean birth weight of neonates was greater (3270 vs. 2768 g, p = 0.013) and the incidence of intrauterine growth restriction lower (13 vs. 38 %, p = 0.046) in post-UAE patients. Both methods are effective in the treatment of women with future reproductive plans and fibroids not suitable for LM. UAE is more effective in causing complete ischemia of fibroids, but it is associated with greater risk of intrauterine necrosis. Both methods have low rate of serious complications (except for a high abortion rate).

Genital prolapse in adult women with classical bladder exstrophy

The aim of this paper is to study the incidence and risk factors for genital prolapse in adult women with bladder exstrophy and to describe the long-term outcome of the Gore-Tex wrap procedure for genital prolapse. A retrospective observational study on adult women with classical bladder exstrophy in a tertiary referral centre for disorders of sex development, including complex urogenital anomalies. Medical notes were reviewed and a confidential postal questionnaire on urinary continence and symptoms of prolapse was carried out. Fifty-two women with bladder exstrophy and a mean age of 39 years (range 23 to 63) were identified, of whom 27 patients (52%) developed pelvic organ prolapse. Twenty-three out of 27 (85%) were treated surgically while only 4 patients were managed expectantly. Risk factors for prolapse included pregnancy in 10 (37%) patients and introitoplasty in 1 patient (4%). Of the 23 women treated surgically, 16 (70%) were treated using a Gore-Tex wrap, while 7 had other surgical procedures including colposuspension and hysterosacrocolpopexy. In the Gore-Tex wrap group, 12 out of 16 patients (75%) had had a successful result after the first repair compared with 2 out of the 7 patients (28%) in the group treated using other procedures. Mean follow-up was 8 years (range 1-15). One patient developed an infection after the procedure and another patient had Gore-Tex erosion. Prolapse is a common gynaecological complaint in adult women with bladder exstrophy and the majority will require treatment. At present the Gore-Tex wrap offers good results with a low rate of serious complications.

Percutaneous Endoscopic Gastrostomy Placement in a Human Immunodeficiency Virus–Positive Pediatric Population Leads to an Increase in Minor Complications

The development of effective multiple drug regimens for treating human immunodeficiency virus (HIV) are associated with nonadherence in children. HIV-positive children also have a higher incidence of malnutrition. Placement of a percutaneous endoscopic gastrostomy (PEG) is a potential solution. Primary outcome was to determine the complications of PEG placement in a pediatric HIV-positive population. A 10 year retrospective data analysis was carried out on all HIV-positive children undergoing insertion of a PEG at two institutions. Parameters examined included infections, leakage, displacement, reasons for removal, total time in situ, HIV stage, CD4 count, and serological investigation. Data were compared against published data for PEG insertion in pediatric oncology patients and other comparable pediatric series using Fisher's exact test. Eighteen children were identified, with a median age 35 months and follow-up of 62 months. The majority of patients had advanced disease (Stage C; 65%). Fifty percent of PEGs were inserted for feeding supplementation and all were used for the administration of medications. Sixty-one percent experienced a minor complication; 5/18 (27.7%) experienced peristomal infection; 2/18 (11.1%) experienced either bleeding, leakage, or excessive granulation; and 1/18 (5.6%) experienced dislodgement. Stage of HIV did not affect the incidence of bleeding or infection: 5/11(Stage C) versus 2/7(Stage B) (P = .3). There was no significant difference for major complications when compared with any series though comparison with a large pediatric series revealed a significant difference for minor complications 11/18 versus 27/120 (P = .0003). There is a low rate of serious complications with PEG insertion in our patients, and the rate is comparable to that seen in pediatric oncology patients. The minor complication rate is, however, higher than a nonimmune compromised population; and careful follow-up for these patients is recommended so that the appropriate therapy can be promptly initiated.

Malignant Gastric Outlet Obstructions: Treatment with Self-Expandable Metallic Stents

Unresectable malignant gastric outlet obstruction (GOO) severely affects the quality of life, with complications that include nausea, vomiting, aspiration, pain, and malnutrition. Although palliative surgical procedures have been traditionally performed, they are associated with high morbidity and mortality rates. Placing self-expandable metallic stents is associated with higher clinical success rates, lower morbidity, shorter time from the procedure to starting oral intake, lower incidence of delayed gastric emptying, and a shorter hospital stay than palliative surgery. Fluoroscopic or endoscopic placement of either bare or covered self-expandable metallic stents is a safe, nonsurgical, palliative treatment option for unresectable malignant GOOs, with a high clinical success rate and a low rate of serious complications. Stent obstruction and migration are the most common complications, but most can be managed by interventional treatments. Although there have been substantial developments in stent design over the past decade, large prospective, randomized studies are required to determine the ideal stent for malignant GOOs.

A prospective observational study of tracheal intubation in an emergency department in a 2300-bed hospital of a developing country in a one-year period

Objective:To assess the competency of physicians in the non-traumatic emergency department (ED) in intubating critically ill patients, to describe the methods, success rates and immediate complications after intubation in Siriraj...

Prophylactic Total Gastrectomy (PTG) for Hereditary Diffuse Gastric Cancer (HDGC): The Newfoundland Experience with 23 Patients

Hereditary diffuse gastric cancer (HDGC) results from truncating mutations of the CDH1 (E-cadherin) gene. It is an autosomal dominant cancer susceptibility syndrome with a lifetime risk of diffuse gastric cancer (DGC) of 60-80%, with a mean age of onset of 37 years. There exists no adequate screening test for DGC. Early intramucosal diffuse/signet-ring cell carcinomas have been found in prophylactic total gastrectomy (PTG) specimens following normal preoperative endoscopy. Total gastrectomy has been advocated on a prophylactic basis. The aim of this study was to report our experience with PTG in 23 patients from the Canadian province of Newfoundland and Labrador. This is the largest series worldwide. A retrospective study of consecutive patients undergoing PTG for HDGC was performed. All patients were confirmed to have a truncating mutation of the CDH1 gene. Twenty-three patients underwent PTG between February 2006 and November 2008. Major complications were found in 4/23 patients (17%), with no mortality. Two of 23 patients (9%) had positive mucosal biopsies on preoperative EGD. Twenty-two of 23 patients (96%) had evidence of diffuse/signet-ring carcinoma on final standardized pathological evaluation. Therefore, 21/23 (91%) were not picked up by preoperative EGD screening. PTG can be performed in patients with HDGC with a low rate of serious complications. Methods of reconstruction incorporating a pouch reservoir and preservation of the postgastric branches of the vagus nerves need to be explored. More refined penetrance estimates, effective screening protocols, and long-term psychological and functional outcomes following PTG require organized multicenter collaborative efforts.

Is cerebrospinal fluid drainage safe and of potential therapeutic benefit after acute traumatic spinal cord injury?

Following acute neurotrauma, including traumatic brain injury (TBI) and spinal cord injury (SCI), the primary mechanical trauma is followed by a series of pathological events including ischemia, oxidative cell injury, glutamatergic excitotoxicity, apoptosis, inflammation, and edema.2 In acute severe TBI, standard clinical management involves placing an intraventricular catheter that can be used to measure intracranial pressure and drain CSF.7 Of note, this approach has not been used in the setting of acute SCI, for a variety of reasons including concerns that release of CSF below a swollen, compressed cord could result in neurological deterioration.3 However, there are some theoretical advantages to placing a lumbar subarachnoid catheter following acute SCI: 1) there is evidence that drainage of CSF may enhance neurological recovery following ischemic cord injury in the setting of aortic surgery;1,5 2) measurement of spinal CSF pressures could allow targeted hypertensive therapy directed at maintaining spinal cord perfusion pressures (SCPPs) above a critical threshold; and 3) in the future, measurement of critical biomarkers in the CSF may provide prognostic and therapeutic information.4 To resolve issues related to the safety of lumbar spinal subarachnoid catheter placement and drainage of CSF following acute SCI, Kwon and colleagues6 undertook a prospective randomized clinical trial in 24 patients with ASIA Grade A–C cervical and thoracic SCI. Two patients were excluded from the analysis for technical reasons. Lumbar subarachnoid catheters were introduced 21 hours after injury and maintained for 72 hours. Patients were randomly assigned to undergo drainage or no drainage, and 11 patients were assessed in each group. The authors evaluated CSF laboratory studies, ITP, pressure waveforms, amount of drainage, motor outcome, and adverse events related to drainage and SCPP. There did not appear to be any serious permanent adverse events associated with placement of the catheters, monitoring of ITPs, or CSF drainage, although the numbers in this study were too small to exclude a low rate of serious complications. One patient (see Fig. 5) developed an epidural hematoma, although it is unclear whether this was related to placement of a lumbar subarachnoid catheter and release of CSF (which can occur around a catheter also). Interesting data were obtained with regard to ITP and CSF pressure waveforms. The ITP rose in all but one case after surgical decompression, which suggests that there was a subarachnoid block at the injury site that dampened transmission of CSF pressures. Unfortunately there was not a standardized protocol for mean arterial blood pressure (MABP) management. This was reflected in differences in the MABPs between the drainage and no-drainage groups, which rendered the small changes in apparent SCPP difficult to interpret. Peak ITP in the postoperative period was significantly higher than the peak intraoperative value in the no-drainage group but not in the drainage group. The CSF waveforms were dampened at initial placement of the lumbar subarachnoid catheters but assumed a more robust appearance after surgical decompression. In some clinical cases, spinal cord swelling or an epidural hematoma also contributed to a delayed attenuation of the waveform. Cerebrospinal fluid drainage was not associated with improved neurological recovery at 6 months, although the amount of CSF drained was fairly minimal (in 7 of 11 patients < 51 ml was drained). This reflected a conservatism by the authors against draining excessive amounts of CSF for fear of causing harm, technical issues related to the catheter, and the presence of relative subarachnoid block due to cord swelling. In summary, the study by Kwon and colleagues6 suggests that lumbar subarachnoid catheters can be placed safely in patients with acute SCI, particularly if spinal cord decompression is undertaken. This provides the opportunity to assess CSF for biomarkers that could provide prognostic and therapeutic insights. However, it is unclear whether measurement of lumbar ITP will provide meaningful acute physiological data given the high rate of subarachnoid fluid block that occurs after traumatic SCI (and which may persist in the initial acute period, even with extradural cord decompression—as shown in some of the MR imaging studies in the article). Although this study failed to show any therapeutic benefits to CSF drainage after acute SCI, the amounts of CSF drained were minimal. I look forward to further prospective studies of CSF drainage from this group to address some of the key outstanding issues raised by this small pilot study. In particular, elucidation of the potential role of CSF biomarkers will be of great interest to the field. i 179 18 , See the corresponding article in this issue, pp 181–193.

Efficacy of Cryotherapy versus Intralesional Meglumine Antimoniate (Glucantime) for Treatment of Cutaneous Leishmaniasis in Children

We compared intralesional glucantine and cryotherapy for treatment of children with cutaneous leishmaniasis in Iran. We observed that cryotherapy is an effective treatment for cutaneous leishmaniasis in children. No serious post-treatment side effects were observed in either group. At six months of follow-up, no recurrence of disease was observed in cured patients in either group. Because of its simplicity, lower cost, low rate of serious complications, and greater tolerability, cryotherapy should be recommended as an appropriate alternative treatment for leishmaniasis in children.

Otomicroscope in the emergency department management of pediatric ear foreign bodies

To determine the effect of a dedicated otomicroscope in the emergency department (ED) management of complex ear foreign bodies (FB). Prospective analysis of 85 patients with complex pediatric ear FB's. 65 (76%) of 85 FB's were successfully removed in the ED. 54 (63%) had previous attempted removal, 27 (31%) were less than age 4, 37 (44%) had ear FB's present longer than 24h, 3 (4%) had multiple ear FB's, and 9 (11%) had an external auditory canal (EAC) comorbidity prior to attempted removal. 31 (36%) were touching the tympanic membrane (TM). 20 (23%) had complications with removal with EAC laceration most common and no TM perforations or hematomas. Mean and median number of attempts for removal was 1.65 and 1.0. Successful removal was associated with the location of the FB, presence of an EAC comorbidity, and number of attempts (p<0.05). Complication rate was associated with an EAC comorbidity and number of attempts (p<0.05). EAC comorbidity was more common in FB's touching the TM (p<0.05). Increased number of attempts was associated with use of sedation (p<0.05). The implementation of an otomicroscope into the ED resulted in successful removal of complex pediatric ear FB's with few attempts and a low rate of serious complications.

New Technologies for Treating Glaucoma in Patients Undergoing Cataract Surgery

New surgical technologies, such as the ExPRESS™ shunt, iCath™ canaloplasty, Trabectome™ and endoscopic cyclophotocoagulation (ECP), have been developed to provide safe and effective control of intraocular pressure (IOP) while avoiding many of the complications associated with trabeculectomies or traditional glaucoma drainage implants. A benefit of some of the newer technologies, especially for patients for whom traditional glaucoma surgeries may not previously have been considered, is that they can be readily performed at the time of cataract extraction. Many surgeons are combining these new surgical techniques with cataract surgery because of the low rate of serious complications, limited manipulation of ocular tissue (especially the conjunctiva) and/or faster visual recovery than traditional glaucoma surgeries.

The results of cataract nigra cases operated with the mini-nuc technique

The purpose of this study was to evaluate the efficacy and safety of the mini-nuc technique for the removal of brunescent and black cataracts. A prospective study was carried out in 33 eyes of 33 patients with cataract nigra operated with the mini-nuc technique between April 2002 and June 2003. Slit-lamp examinations, intraocular pressure (IOP) measurements, and best-corrected visual acuity (BCVA) were assessed pre- and postoperatively. Accompanying systemic diseases were noted. Intraoperative and postoperative complications were evaluated. Unilateral eyes of 33 patients (18 male [54.5%], 15 female [45.5%]) aged between 65 and 90 years (mean 72 years) were operated with the mini-nuc technique. Preoperative BCVA values varied between light perception and 0.2 in the Snellen chart. Intraocular lenses (IOL) were implanted into all of the patients (27 in-the-bag [81.8%], four to sulcus [12.1%], and two with scleral fixation [6.1%]). During the surgery, five patients (15.15%) had zonular dialysis and two (6.1%) had posterior capsule rupture and vitreous loss. Postoperatively, three (9.1%) rises in IOP, two (6.1%) hyphema, and one (3%) IOL subluxation were observed. At the first day visit, the mean of the uncorrected visual acuities (UCVA) was 0.5 in the Snellen chart. At the third month visit, the mean BCVA was observed to be 0.8. The residual mean astigmatism was 0.75 D against the rule. The mini-nuc technique was effective in removing brunescent and black cataracts with a low rate of serious complications. The mini-nuc technique, which is also performed with a small incision and without sutures, might be an alternative to phacoemulsification in cases of cataract nigra.

Closed reduction and percutaneus Kirschner wire fixation for the treatment of dislocated calcaneal fractures: surgical technique, complications, clinical and radiological results after 2–10 years

IntroductionTo reduce complications, a minimally invasive technique for the treatment of dislocated intraarticular fractures of the calcaneus was used. Therefore previously described closed reduction and internal fixation techniques were combined and modified.Materials and methodsSixty-seven out of 92 calcaneal fractures could be retrospectively evaluated with an average follow-up time of 5.7 years (minimum 2–10 years follow-up). For radiographic evaluation, plain radiographs and CT scans were obtained. The Zwipp score was used for clinical evaluation. Sanders type II, III and IV fractures were diagnosed.ResultsLength of surgery averaged 61 min (range 20–175 min). The incidence of subtalar arthritis was correlated to the severity of fracture. Böhler’s angle was restored in 70.1% (47 of 67) of the cases. On the last follow-up evaluation the average Zwipp score was 130 points (range 48–186 points). The majority (77.7%) of patients were content with their treatment result. The rate of significant complications was 6.5%.DiscussionCompared to open techniques the presented minimally invasive technique showed comparable results with a low rate of serious complications and is a viable alternative for the treatment of intraarticular, dislocated calcaneal fractures.

Acute pancreatitis and cholangitis: A complication caused by a migrated gastrostomy tube

Percutaneous endoscopic gastrostomy (PEG) is generally considered safe with a low rate of serious complications. However, dislocation of the PEG-tube into the duodenum can lead to serious complications. An 86-year old Japanese woman with PEG-tube feeding sometimes vomited after her family doctor replaced the PEG-tube without radiologic confirmation. At her hospitalization, she complained of severe tenderness at the epigastric region and the PEG-tube was drawn into the stomach. Imaging studies showed that the tip of PEG-tube with the inflated balloon was migrated into the second portion of the duodenum, suggesting that it might have obstructed the bile and pancreatic ducts, inducing cholangitis and pancreatitis. After the PEG-tube was replaced at the appropriate position, vomiting and abdominal tenderness improved dramatically and laboratory studies became normal immediately. Our case suggests that it is important to secure PEG-tube at the level of skin, especially after replacement.

Renal manifestations of tuberous sclerosis complex: Incidence, prognosis, and predictive factors

Tuberous sclerosis complex is a genetic disorder characterized by hamartomatous lesions in multiple organs, frequently involving the kidney. We conducted a retrospective review of the clinical and radiographic records of 167 patients with tuberous sclerosis to determine the frequency of renal disease, the likelihood of significant renal morbidity, and the effects of genotype (TSC1 vs TSC2) and gender on renal phenotype. Renal lesions were seen in 57.5% of patients. Of these, angiomyolipoma (AML) occurred in 85.4%, cysts in 44.8%, and renal cell carcinoma in 4.2%. Both AML and cysts were significantly more common and more numerous in TSC2 than in TSC1. AML was significantly more common in female than in male patients, but cysts showed no correlation with gender. Eleven patients developed renal abnormalities during their care in this practice at an average age of onset of 11.3 years (range 3.8-23 years). The frequency and number of renal lesions were positively correlated with age. Interventions, including arterial embolization and nephrectomy, were performed in 11 (6.6%) patients. Among female patients with lymphangioleiomyomatosis, renal AML was universally present. Our findings confirm a high rate of renal involvement; a low rate of serious complications; significant associations between renal involvement, genotype, and gender; and a significant association between renal and pulmonary involvement in female patients.

Surgical Approaches to Obesity

Bariatric surgery has evolved considerably since the introduction of jejunoileal bypass in the 1950s. With modifications of early procedures, implementation of new techniques, and establishment of minimally invasive approaches, operative intervention has become the mainstay in the treatment of extreme (class III) obesity. The laparoscopic adjustable gastric band technique is the most common purely restrictive procedure. Advantages of the laparoscopic adjustable gastric band include reduced perioperative morbidity and mortality compared to other bariatric procedures, but this procedure has been associated with substantial intermediate and long-term complications. Although vertical banded gastroplasty was associated with decreased perioperative morbidity and acceptable early weight loss, results from long-term follow-up have been discouraging. Roux-en-Y gastric bypass (RYGB) is the most common bariatric procedure performed in the United States because of its effectiveness in long-term weight loss and low rates of serious complications. Modifications of RYGB to induce malabsorption have led to greater weight loss but increased risks of metabolic and nutritional sequelae. Duodenal switch is a malabsorptive procedure associated with excellent weight loss and resolution of weight-related comorbidities, but concerns regarding potential metabolic and nutritional sequelae have limited its widespread use. Laparoscopic approaches to bariatric procedures have reduced wound-related complications and improved patient recovery. However, the incidence of anastomotic leak and internal hernia is higher after laparoscopic RYGB compared to the open approach. Each of the currently available bariatric procedures has both advantages and disadvantages that must be considered in determining which operation should be selected for an individual patient.

Deep sclerectomy for the treatment of exfoliation and primary open‐angle glaucoma

To retrospectively compare the efficacy of deep sclerectomy in the treatment of primary open-angle glaucoma (POAG) and exfoliation glaucoma (ExG). Deep sclerectomy with either collagen or hyaluronate implants was performed in 31 eyes (45%) with POAG and 38 eyes (55%) with ExG. Pre- and postoperative intraocular pressure (IOP) was recorded, as was the number of glaucoma medications used pre- and postoperatively in each group. The follow-up data referred to a mean period of 18 months (range: 2 weeks to 36 months). At 18 months, complete success had been achieved in 56.3% of POAG eyes and 44.9% of ExG eyes. Qualified success had been achieved in 83.1% and 71.6% of POAG and ExG eyes, respectively. The mean IOP was 18.6 mmHg in POAG eyes and 16.3 mmHg in ExG eyes. YAG-descemetotomies were performed in nine eyes in each group. There were no statistically significant differences between the groups in IOP (except at 1 week postoperatively in favour of POAG; p = 0.05), success rates, need for postoperative glaucoma medication or number of complications. Reoperations were required in three (10%) POAG eyes and seven (18%) ExG eyes. Deep sclerectomy is equally effective in controlling IOP in both POAG and ExG and has low rates of serious complications, even when the surgeon is inexperienced in the technique. Both survival rates and IOP control were similar between the groups, and there were no serious intra- or postoperative complications.

Titanium Elastic Nailing of Pediatric Femur Fractures

In the last 3 decades, there has been a very strong trend for pediatric orthopedic traumatologists to use some form of fixation to mobilize the school-aged child with a femur fracture . Titanium elastic nailing of pediatric femur fractures is a widely adopted technique that has stood the test of time. Perhaps the most attractive features of this technique for pediatric femur fracture management are the low rate of serious complications and the relatively easy and safe learning curve for most surgeons. There are several pitfalls to the titanium elastic nail technique that should be emphasized. In multiple series, the most common problem is irritation caused by the nails at their entry site. To avoid this most common complication, the nail should not be bent away from the distal femur , and only 1 to 2 cm of nail should be left outside the cortex of the bone. It is essential to follow the principles that were outlined years ago by the French developers of elastic nailing. The nail entry site, nail size and nail length should be symmetric. The nails should be prebent so that they have good cortical contact at the fracture site, as this cortical contact is a key factor in stability. The nails should be used cautiously in length-unstable fractures and in patients older than 12 years of age or who are heavier than 50 kg.