Management Of Disruption Research Articles

Immediate Management of Posterior Urethral Disruptions Due to Pelvic Fracture

Immediate Management of Posterior Urethral Disruptions Due to Pelvic Fracture

Immediate Management of Posterior Urethral Disruptions Due to Pelvic Fracture: Therapeutic Alternatives

We retrospectively reviewed the results of 3 types of initial management of pelvic fracture urethral disruption in children. From 1980 to 1994, 35 boys 2 to 15 years old (mean age 8.1) with prostatomembranous urethral disruption were treated, including 17 who also had associated injuries. Immediate treatment included suprapubic cystostomy and delayed urethroplasty in 19 patients (group 1), urethral catheter alignment without traction and concomitant suprapubic cystostomy in 10 (group 2), and primary retropubic anastomotic urethroplasty in 6 (group 3). In all patients in groups 1 and 2 severe urethral obliteration developed. Four group 3 patients (66%) had a stricture at the site of anastomotic repair. After delayed urethroplasty 16 group 1 (84%) and all 10 group 2 patients were continent. However, only 3 group 3 patients (50%) achieved continence. Retrospectively associated bladder neck injury occurred in 5 of the 6 incontinent boys. Erections were observed before and after treatment in all but 3 children. Unstable pelvic ring fractures (type IV) comprised 28% of all pelvic fractures with a high rate of associated injuries. As described, urethral alignment was not beneficial for avoiding urethral obliteration. Therefore we recommend suprapublic cystostomy as the only form of initial treatment in these cases. Urinary incontinence seems more likely related to associated bladder neck rupture and the severity of pelvic fracture rather than to initial treatment or delayed urethral repair. Consequently, when associated bladder neck injury is present, we advocate immediate surgical repair.

Endoscopic Repair in 154 Cases of Urethral Occlusion: The Promise of Guided Optical Urethral Reconstruction

We determined whether optical urethral reconstruction, with the use of a Béniqué bougie in the proximal urethra and transrectal digital guidance, is effective for the treatment of long and severe urethral occlusions. However, with some skill the procedure can be done without the bougie for the treatment of short occlusions. During a 9-year period 154 men with complete urethral occlusion underwent core through optical urethrotomy via transrectal digital guidance, using the Béniqué bougie in 89 (58%). A total of 400 urethrotomies was performed. All lesions were in the posterior urethra except 8 in the pendulous portion. There were 64 war related injuries (41.6%). Combined voiding and retrograde urethrography was not useful to measure the length of the occlusion due to failure of proximal urethral filling. Guided optical urethral reconstruction consisted of optical urethrotomy performed with a Béniqué bougie introduced proximally through the suprapubic catheter site and into the proximal urethra with the index finger of the operator in the rectum. The same procedure was performed blindly without use of the bougie in 65 patients (42%), and in 43 with lesions shorter than 1 cm. and 4 with multiple annular lesions. We also used the blind technique successfully to reestablish 18 occlusions longer than 1 cm. For optimal epithelialization of the urethral tract we suggest leaving a silicone catheter indwelling for 3 months. No prophylactic antibiotics were given. Of the patients 54 (35%) were cured after 1 procedure, whereas the remaining 100 (65%) required 1 to 9 additional urethrotomies (mean 3). Patients with an uninstrumented urethra who were treated initially with suprapubic catheterization required 1 to 6 urethrotomies (mean 2), compared to 1 to 10 (mean 3) for those who had undergone a prior procedure. Hematuria occurred in 9% of the patients, symptomatic urinary tract infection in 7% and slight extravasation in 3.2%. One patient had stress incontinence. Our procedure is effective, simple, safe, repeatable, inexpensive and minimally invasive, and it does not require special or sophisticated guiding instruments, which are necessary for previously described techniques. It can be performed with or without use of a Béniqué bougie depending on the extent of the lesion and skill of the surgeon. The outcome can be judged from the symptomatic response of the patient, and flow studies and urethrography are not mandatory during routine followup.

When more is less: A minimalist architecture for manufacturing

To have recorded somewhere, instant by instant, every detail of the operation of a manufacturing system - what more could management want? ‘What less?’ asks Ramchandran Jaikumar, who contends that the data collection capabilities of modern, advanced technology-based manufacturing systems, especially when highly and tightly integrated, transcend the analytical capabilities of manufacturing management. Arguing that management has, in documented specifications and procedures, all of the information it needs about ‘things that go right’, Jaikumar proposes a comprehensive new architecture for manufacturing premised on the collection only of data related to exceptions, that is, ‘things gone wrong’. Dubbed by him Minimalism, this architecture by design elicits and exploits synergies among inventory management, quality and production control, and learning from the management of disruptions. Its adoption has invariably enabled plants to ‘do more, better, with less’.

Role of transesophageal echocardiography in the diagnosis and management of traumatic aortic disruption: Vignon PV, Gueret P, Vedrinne J-M. Circulation. 1995; 92:2959–2968

Role of transesophageal echocardiography in the diagnosis and management of traumatic aortic disruption: Vignon PV, Gueret P, Vedrinne J-M. Circulation. 1995; 92:2959–2968

Surgical Wound Infection and Management of Extrafascial Wound Disruption

Surgical Wound Infection and Management of Extrafascial Wound Disruption

Save the child's esophagus: Management of major disruption after repair of esophageal atresia

Purpose: Given the bias that the native esophagus is the best conduit between the oropharynx and the stomach, the authors report a “conservative” approach to massive esophageal leak, which may be considered “radical” by others. Major disruption of the anastomosis after primary repair of esophageal atresia is a recognized and feared complication. Historically, management has been the performance of cervical esophagostomy and gastrostomy. The aim of this report is to describe the authors' approach to this difficult and serious complication. Methods: A 15-year retrospective analysis was performed of all patients having esophageal atresia. Data collection focused on the management of all patients with clinically significant esophageal disruption. Radiographically detected (clinically asymptomatic) leaks were managed by continuation of drainage by thoracostomy tubes already in place and are not included. Reoperative thoracotomies were performed, which included primary repair (2), placement of pleural patch alone (2), pleural patch with intercostal muscle flap buttress (2), and operative debridement and drainage alone (1). Results: It was noted that seven patients had clinically significant esophageal disruption requiring reoperation, with circumferential disruptions ranging from 15% to 85%. Presentation included persistent pleural collection (4) and pneumothorax (3). Both patients who underwent primary repair had no evidence of leakage on follow-up esophagograms, neither did one with a pleural patch alone and one with an intercostal muscle flap. Five of the seven patients were tolerating oral feedings at the time of follow-up (range, 6 months to 8 years). One of the two others (both currently inpatients), has a recurrent leak associated with mediastinitis, and the other (who had primary repair) has a presumed neurological impairment of eating. Conclusion: Clinically significant disruption of primary esophageal repair should not warrant a cervical esophagostomy and placement of a gastrostomy tube, thus precluding eventual use of the native esophagus. The authors have shown that management by reoperation with primary repair, intercostal muscle flap with or without pleural patch, and/or drainage allows the patient to maintain the native esophagus and yields a generally good outcome after a prolonged healing time.

Delayed Rupture of the Abdominal Aorta in a Child after a Suspected Handlebar Injury

Blunt abdominal trauma resulting in a laceration of the abdominal aorta is extremely rare. Only one previous example of this injury has been reported in a child. We present the clinical course and surgical management of blunt disruption of the infrarenal aorta in a 13-year-old boy with a subsequent delayed rupture of a third aortic laceration. This is the youngest patient to die from this type of injury after blunt abdominal trauma.

Delayed management of posterior urethral disruption in children: A.H. Kardar, T. Sundin, and S. Ahmed. Br J Urol 75:543–547, (April), 1995

Delayed management of posterior urethral disruption in children: A.H. Kardar, T. Sundin, and S. Ahmed. Br J Urol 75:543–547, (April), 1995

Surgical management of abdominal wall disruption after blunt trauma.

Abdominal wall disruption following blunt trauma is a rare but challenging injury, both in the acute and convalescent phases. The present report describes the recent experience with this injury at a single adult trauma center. In a 22-month period, nine patients with traumatic abdominal wall disruption were managed. Flank and anteroinferior abdominal wall defects were most common. Associated injuries included 6 patients with a pelvic fracture and 4 patients with rectosigmoid injuries. Immediate primary repair of the defect was attempted in seven cases at the time of trauma laparotomy, but was difficult and often unsuccessful because of the related tissue destruction. Delayed abdominal wall repair was performed in patients with symptomatic disability (n = 5) and, if required, restoration of intestinal continuity was performed at a separate operation before abdominal wall repair. Delayed repair with autogenous tissue included the use of tensor fascia lata, rectus femoris muscle, rectus abdominis fascia, and latissimus dorsi muscle. Reconstruction with prosthetic mesh was required in two patients. One early and one late recurrence occurred, resulting in reoperation. In conclusion, traumatic abdominal wall disruption represents a complex challenge for both general and plastic surgeons. The key to successful surgical management seems to be a delayed staged repair with autogenous tissue when feasible.

Delayed management of posterior urethral disruption in children

To review the results of delayed operative treatment of total disruption of the posterior urethra in children. Twelve boys (3-12 years, mean 7.5) with a suprapubic catheter were referred after primary management in other hospitals. All but one had been involved in road traffic accidents. In addition to their urethral injury, they all had pelvic fractures and the majority also had other major associated injuries. Six to 14 months after injury, abdominoperineal transpubic urethroplasty was performed in 11 patients according to Turner-Warwick. In one case a perineal anastomotic urethroplasty was performed. After the operation, voiding cysto-urethrography showed a wide anastomosis in all cases. After 3 to 45 months follow-up, there were no strictures. Eight boys were continent, two were totally incontinent, two had stress incontinence and one nocturnal enuresis. All patients with confirmed erections after injury also had erections after their operation. Primary suprapubic cystostomy and delayed repair can be used successfully for the treatment of posterior urethral disruption in children.

An alternate approach to the management of tracheal perforation in a child

Tracheal perforation can be difficult to manage when standard approaches are not feasible. We present a case report of a 2-year-old child who sustained a traumatic laceration of the intrathoracic trachea in the face of tracheitis and bronchitis. Accepted management techniques could not be employed because the child developed mediastinitis and respiratory distress syndrome. The use of extracorporeal membrane oxygenation (ECMO) facilitated ventilation and oxygenation when standard modes of ventilation failed. ECMO also provided a compliant low-pressure environment that allowed primary tracheal repair by wrapping the tracheal tear with a pedicle of intercostal muscle. A brief overview of the management of intrathoracic tracheal disruption is presented.

The central slip tenodesis test for early diagnosis of potential boutonnière deformities

Disruption of the central slip is the primary defect leading to boutonnière deformity. In the closed injury early diagnosis of this lesion is rarely achieved due to the limitations of current methods and difficulties encountered in assessing a painful finger. We describe a simple, non-invasive method of diagnosis which can be carried out on all patients and with minimal discomfort. This test is also beneficial in monitoring the progress of conservative management of central slip disruption.

Accidents of elderly drivers and intersection traffic control devices: N. Stamatiadis, W. C. Taylor, and F. X. McKelvey. Journal of Advanced Transportation, 24(2), 99–112

Most investigations of incident-related delay duration in the transportation context are restricted to highway traffic, with little attention given to delays due to transit service disruptions. Studies of transit-based delay duration are also considerably less comprehensive than their highway counterparts with respect to examining the effects of non-causal variables on the delay duration. However, delays due to incidents in public transit service can have serious consequences on the overall urban transportation system due to the pivotal and vital role of public transit. The ability to predict the durations of various types of transit system incidents is indispensable for better management and mitigation of service disruptions. This paper presents a detailed investigation on incident delay durations in Toronto’s subway system over the year 2013, focusing on the effects of the incidents’ location and time, the train-type involved, and the non-adherence to proper recovery procedures. Accelerated Failure Time (AFT) hazard models are estimated to investigate the relationship between these factors and the resulting delay duration. The empirical investigation reveals that incident types that impact both safety and operations simultaneously generally have longer expected delays than incident types that impact either safety or operations alone. Incidents at interchange stations are cleared faster than incidents at non-interchange stations. Incidents during peak periods have nearly the same delay durations as off-peak incidents. The estimated models are believed to be useful tools in predicting the relative magnitude of incident delay duration for better management of subway operations.

Mediastinoscopic injury to the bronchus: Use of in-continuity bronchial flap repair

There is little written in the literature regarding the management of major bronchial disruptions occurring during mediastinoscopy. This report illustrates the use of an in-continuity flap bronchoplasty of middle lobe bronchial tissue to repair such an iatrogenic intermediate bronchus injury.

Immediate Management of Prostatomembranous Urethral Disruptions

We present 33 patients with complete prostatomembranous urethral disruptions: 20 were managed by immediate realignment, while 13 were managed by initial cystotomy and delayed urethroplasty. Techniques for immediate realignment are described. Immediate realignment of complete prostatomembranous disruptions resulted in an overall potency rate of 80% compared to only 50% in patients who underwent delayed repair. In addition, there was an increased need for a secondary operation when the repair was delayed. Continence rates were excellent and similar in both groups. Immediate urethral realignment as described results in impotence and incontinence rates that are comparable to or better than delayed repair techniques without the need for multiple surgical procedures.

Primary endourologic re-establishment of urethal continuity after disruption of prostatomembranous urethra

A new technique for the early management of traumatic disruption of the prostatomembranous urethra has been used in 4 consecutive young patients. Urethral realignment by stenting the injured urethra with a catheter was achieved by combined urethroscopy and suprapubic instrumentation one to three days after the injury. We describe herein our experience with this technique and we suggest that it could be a valuable alternative in posterior urethral repair.

Technical report: Management of tract disruption due to radiologic T-tube extraction of a retained common bile duct stone

When a T-tube is in situ after cholecystectomy and common bile duct exploration, the treatment of choice for retained common duct stones is removal through the T-tube tract. Tract disruption during stone removal is uncommon. It may be a significant complication resulting in biliary peritonitis. We report a case of tract disruption during removal of a stone through a T-tube tract and discuss its management.

A Closer Look at “Local Control”: Communities, Commodities, and the Collapse of the Coast1

Abstract Particularly when discussing the effects of large‐scale industrial projects, the existing community literature exhibits a curious duality about relationships between local communities and outside forces. While explicitly noting the external origins of large‐scale industrial projects, the literature shifts to a focus on local planning when discussing the management of any resultant disruptions. Little attention is devoted to the possibility that the magnitude of external boom‐bust forces may be so great as to overwhelm even the best‐prepared communities. This exploratory study examines the extent of external influences on two resource‐dependent parishes (counties) in coastal Louisiana with long histories of offshore oil and gas development—one a predominantly blue‐collar area and the other an administrative center. The drop in oil prices since 1981 created differently structured but equally devastating impacts on the two. Simple indices suggest that the parishes experienced four‐to‐ten times as much instability over the past two decades as the nation as a whole. In both parishes, simple regression equations using commodity‐related variables that are completely outside the control of local communities are found to explain over 90 percent of the variation in total employment and over 70 percent of the change in employment that cannot be explained by preexisting conditions.

Effects of high-dose methylprednisolone on NA +-K +- atpase and lipid peroxidation after experimental subarachnoid hemorrhage

Delirium is frequently observed in the postoperative and intensive care unit (ICU) population. Due to the multifactorial origin of delirium and according to international guidelines (e.g., American Geriatrics Society; Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption (PADIS) guideline), there are several but no incontestable options for prevention and symptomatic treatment.The purpose of the Baden PRIDe (Prevention and Reduction of Incidence of postoperative Delirium) trial was to determine whether postoperative cognitive dysfunction and delirium could be prevented by the combination of possible preventive agents such as haloperidol and ketamine. In addition, pre- and postoperative levels of the biomarkers cortisol, neuron specific enolase (NSE) and S100β were measured to investigate their dynamics in delirious and non-delirious patients after surgery.The Baden PRIDe Trial was an investigator-initiated, phase IV, two-centre, randomised, placebo-controlled, double-blind clinical trial.Perioperative care.182 adult patients that underwent elective or emergency surgery under general or combined (i.e., general and regional) anaesthesia.Pre-anaesthetic, pharmacologic prevention of postoperative brain dysfunction with haloperidol, ketamine, and the combination of both vs. placebo.Assessment of cognitive performance pre- and postoperatively with the MMSE, the DOS, the Nursing Delirium Screening Scale (Nu-DESC) or the Intensive Care Delirium Screening Checklist (ICDSC) during ICU stay.None of the three study arms – haloperidol, ketamine, or both drugs combined - was significantly superior to placebo for prevention of postoperative brain dysfunction and delirium (P = 0.39). Measured levels of postoperative cortisol were significantly higher in delirious patients. S-100β levels were significantly higher in all postoperative outcome groups (cognitive impairment, delirium, no cognitive decline), whereas postoperative NSE levels declined in all groups.The study results offer no possibility for a novel recommendation for prevention of postoperative cognitive decline including delirium. Perioperative S-100β trajectories in patients with cognitive deterioration suggest affection of glial cells in particular.ClinicalTrials.gov NCT02433041; registered on April 7, 2015.