Non-operated Ones Research Articles

Treatment of portal hypertension complicated by variceal bleeding

Background. Mortality in variceal bleeding (VB) on the background of portal hypertension (PH) is highest among patients with gastrointestinal bleeding. The treatment of PH complicated by VB is a complex problem that is far from being solved, especially in case of Child-Pugh class B and C decompensation. The aim of the study was to determine the causes of PH complicated by VB, features of conservative and interventional therapy, indications and nature of surgical procedures, treatment efficacy, as well as causes of complications and mortality. Materials and methods. We analyzed treatment outcomes of 923 inpatients with PH complicated by VB who were treated in the clinic of the Department of Surgery of the Faculty of Dentistry of Bogomolets National Medical University on the basis of the Kyiv City Clinical Emergency Hospital from 2012 to 2023. It was possible to talk about the cause of PH based on anamnestic data in 61 % of cases. In 711 (77 %) patients, the source of bleeding was detected endoscopically within 30–60 minutes from the moment of admission to the clinic. Conservative therapy included the administration of hemostatic and agents lowering pressure in the portal system, as well as vasoconstrictors that reduce portal blood flow. For the failure of conservative therapy, unstable hemostasis, and repeated previous bleedings, 59 (6.4 %) patients were operated. The methodology of the research analysis consisted in the fact that the arithmetic mean and standard error (M ± m) were determined as the characteristics of the groups for features with a distribution corresponding to the Gaussian law. This reference method of descriptive statistics was applied to evaluate surgical treatment in comparison with conservative therapy and interventional measures. Results. Endoscopic hemostasis by the ligature method was achieved in 97 (10.5 %) patients. Repeated endoscopy due to VB recurrence was done in 276 (29.9 %) participants. In cases of unsatisfactory endoscopic hemostasis, as well as recurrent VB, a Sengstaken-Blakemore probe was installed. In case of right-sided PH, the formation of varices in the esophagus is caused by the discharge of blood mainly through the coronary vein, which required its transection during еsophagogastric devascularization. In compliance with this rule, the patients underwent esophagogastric devascularization, circular transection of the esophagus, which provided portoazygous disconnection. The total mortality rate was 43.1 %, among operated people — 8.5 %, and among non-operated ones — 42.1 %. Conclusions. PH complicated by VB is evidence of decompensated processes in the liver parenchyma or obstruction in the portal system. Conservative therapy and interventional measures make it possible to stop bleeding and prepare the patient for elective surgery, if necessary. An operation that stops blood flow through dilated veins of the esophagus or stomach is an effective method of treating bleeding in portal hypertension.

Reducing post-operative length of stay, is it worth the effort?

Studies show that reducing the length of hospital stay (LOS) for surgical patients leads to cost savings. We hypothesize that LOS has a nonlinear relationship to cost of care and reduction may not have a meaningful impact on it. We have attempted to define the relationship of LOS to cost of care. We utilized the itemized bill, generated in real time, for hospital services. Adult patients admitted under General, Neuro, and Orthopedic surgery over a 3-month period, with an LOS between 4 and 14days, were the study population. Itemized bill details were analyzed. Charges in Pakistani rupees were converted to US dollar. Ethical exemption for study was obtained. Of the 853 patients, 38% were admitted to General Surgery, 27% to Neurosurgery, and 35% to Orthopedics. A total of 64% of the patients had an LOS between 4 and 6days; 36% had an LOS between 7 and 14days. Operated and conservatively managed constituted 82% and 18%, respectively. Mean total charge for operated patients was higher $3387 versus $1347 for non-operated ones. LOS was seen to have a nonlinear relationship to in-hospital cost of care. The bulk of cost was centered on the day of surgery. This was consistent across all services. The last day of stay contributed 2.4%-3.2% of total charge. For surgical patients, the cost implications rapidly taper in the postoperative period. The contribution of the last day of stay cost to total cost is small. For meaningful cost containment, focus needs to be on the immediate perioperative period.

End-to-Side vs. Free Graft Nerve Reconstruction-Experimental Study on Rats.

The long history of regeneration nerve research indicates many clinical problems with surgical reconstruction to be resolved. One of the promising surgical techniques in specific clinical conditions is end-to-side neurorrhaphy (ETS), described and then repeated with different efficiency in the 1990s of the twentieth century. There are no reliable data on the quality of recipient nerve regeneration, possible donor nerve damage, and epineural window technique necessary to be performed. This research attempts to evaluate the possible regeneration after end-to-side neurorrhaphy, its quality, potential donor nerve damage, and the influence of epineural windows on regeneration efficiency. Forty-five female Wistar rats were divided into three equal groups, and various surgical technics were applied: A-ETS without epineural window, B-ETS with epineural window, and C-free graft reconstruction. The right peroneal nerve was operated on, and the tibial nerve was selected as a donor. After 24 weeks, the regeneration was evaluated by (1) footprint analysis every two weeks with PFI (peroneal nerve function index), TFI (tibial nerve function index), and SFI (sciatic nerve function index) calculations; (2) the amplitude and latency measurements of motor evoked potentials parameters recorded on both sides of the peroneal and tibial nerves when electroneurography with direct sciatic nerve electrical stimulation and indirect magnetic stimulation were applied; (3) histomorphometry with digital conversion of a transverse semithin nerve section, with axon count, fibers diameter, and calculation of axon area with a semiautomated method were performed. There was no statistically significant difference between the groups investigated in all the parameters. The functional indexes stabilized after eight weeks (PFI) and six weeks (TFI and SFI) and were positively time related. The lower amplitude of tibial nerve potential in groups A and B was proven compared to the non-operated side. Neurophysiological parameters of the peroneal nerve did not differ significantly. Histomorphometry revealed significantly lower diameter and area of axons in operated peroneal nerves compared to non-operated nerves. The axon count was at a normal level in every group. Tibial nerve parameters did not differ from non-operated values. Regeneration of the peroneal nerve after ETS was ascertained to be at the same level as in the case of free graft reconstruction. Peroneal nerves after ETS and free graft reconstruction were ascertained to have a lower diameter and area than non-operated ones. The technique of an epineural window does not influence the regeneration result of the peroneal nerve. The tibial nerve motor evoked potentials were characterized by lower amplitudes in ETS groups, which could indicate axonal impairment.

A Comprehensive Evaluation of Minimally Invasive Achilles Tendon Reconstruction with Hamstring Graft Indicates Satisfactory Long-Term Outcomes.

Background and objectives: The Achilles tendon, the largest tendon in the body, is vulnerable to injury because of its limited blood supply and the combination of forces to which it is subjected. Given the relevance of the Achilles tendon in the proper function of the foot and ankle, the primary goal of the present study was to use a holistic approach for a comprehensive evaluation of Achilles tendon reconstruction results on multiple levels. Materials and Methods: The study was designed in the following way: 30 patients with partial or total Achilles tendon tears were subjected to the minimally invasive Achilles tendon reconstruction. Patients were then subjected to the clinical, functional and isokinetic tests 12 and 24 months after the treatment. The clinical evaluation included calf circumference measurements and subjective patient-reported tests: ATRS, EQ-5D-5L and VAS scales. The functional evaluation was based on three tests: the weight-bearing lunge test, the heel rise test and single leg hop. Isometric and isokinetic evaluation was performed using a Biodex 3 dynamometer. Results: The calf circumference of the operated limbs was significantly lower than the non-operated limb 12 months after the surgical procedure, however this improved at the second evaluation. All subjective outcomes improved significantly 24 months after the surgery. Significantly better results in the function of the operated limbs were also obtained 24 months after the surgery. However, most of the muscle strength parameters of the operated limbs were already comparable to non-operated ones 12 months after the surgery and were comparable between two evaluation times. Conclusions: The overall results of this extensive evaluation are highly satisfactory and patients returned to their normal physical activity. From a medical point of view, it is assumed that the healing process is completed 12 months after the surgery, however, importantly, our results indicate that we should consider the healing process and the rehabilitation process separately.

Long-term results of surgical treatment of patients with tuberculosis

ntroduction. There are 2 challenges when assessing the effectiveness of TB surgical treatment: а) significant dif-ferences between groups of patients after surgery and without surgery; and b) difficulty to assess effectiveness of surgical treatment separate from other comprehensive methods of treating TB, since it is based, first and fore-most, on evaluation of post-op complications and lethal-ity in the course of hospital stay. Маterials and meth-ods. Based on monitoring the data of 18,033 TB patients treated in Moscow throughout 2010–2015, effectiveness of surgical treatment was assessed by calculating the risk of adverse outcomes (AO) during 4 years: TB relapse, transfer of patient into the group of dispansery observa-tion of chronic TB forms (II GDN), death from TB or other causes. Chances of AO in groups of operated and non-op-erated patients were assessed by way of multivariate lo-gistic regression, which allowed to compensate the dif-ferences between the groups. Results and discussion. It was shown that in the group of operated patients vs non-operated ones: the chance of TB relapse 4 years af-ter the start of treatment was 2.1 times lower, the chance of patients’ transfer to II GDN group was 2.9 times lower, the chance of death from TB 2.4 times lower, while the chance of death from concomitant diseases and infec-tions, including HIV, was 3 times lower among patients after surgery. Conclusion. The results demonstrated that surgical methods as part of the comprehensive treatment of TB patients in Moscow allowed to significantly raise the effectiveness of treatment in the long-term perspective

The Effect of Place of Residence on Treatment Outcomes and Survival in Octogenarian and Nonagenarian Breast Cancer Patients.

IntroductionThe number of octogenarian invasive breast cancer cases is projected to increase, as there is a significant increase in life expectancy. However, no specific treatment guideline has been established so far for this vulnerable group of patients. The aim of the present study was to evaluate the treatment outcomes of octogenarians diagnosed with early and locally advanced invasive breast cancer, to compare those who underwent surgery with conventional treatment and those who did not, and to reveal the potential social factors that may affect their therapy outcomes.Material and methodsA total of 78 patients aged 80 and over were included in the study. There was a significant relationship between a patient’s social milieu and treatment status (p < 0.001). The relationship between receiving endocrine therapy or surgical treatment was also significant (p = 0.029).ResultsThe surgical treatment rate was 90.9% in survivors, which was significantly lower in those who passed away (37.8%, p < 0.001). According to the log-rank test results, life expectancy was significantly longer in operated patients than in non-operated ones (p < 0.001). The median survival length was 62 months (range: 33.8-90.2) in operated patients 80 years of age and above and 19 months (range: 16.3-21.7) in non-operated ones. The surgical treatment frequency was 15.30 times (range: 4.86-48.21) higher in patients living with family than in patients living alone or in a nursing home.ConclusionThus, the social milieu of the patients, especially the place of residence, had a major impact on the treatment of the elderly (octogenarians) patients with breast cancer. Surgery and endocrine therapy as an adjuvant treatment were tolerable and had positive impacts on survival.

The Ischial Spine in Developmental Hip Dysplasia: Unraveling the Role of Acetabular Retroversion in Periacetabular Osteotomy.

Purpose Radiological diagnosis of acetabular retroversion (AR) is based on the presence of the crossover sign (COS), the posterior wall sign (PWS), and the prominence of the ischial spine sign (PRISS). The primary purpose of the study is to analyze the clinical significance of the PRISS in a sample of dysplastic hips requiring periacetabular osteotomy (PAO) and evaluate retroversion in symptomatic hip dysplasia. Methods In a previous paper, we reported the classic coxometric measurements of 178 patients with symptomatic hip dysplasia undergoing PAO where retroversion was noted in 42% of the cases and was not found to be a major factor in the appearance of symptoms. In the current study, we have added the retroversion signs PRISS and PWS to our analysis. Among the retroverted dysplastic hips, we studied the association of the PRISS with the hips requiring PAO. We also defined the ischial spine index (ISI) and studied its relationship to the coxometric measurements and AR. Results In hips with AR, the operated hips were significantly associated with the PRISS compared to the nonoperated ones (χ2 = 4.847). Additionally, the ISI was able to classify acetabular version (anteverted, neutral, and retroverted acetabula). A direct correlation between the ISI and the retroversion index (RI) was found, and the highest degree of retroversion was found when the 3 signs of acetabular retroversion were concomitantly present (RI = 33.6%). Conclusion The PRISS, a radiographic sign reflecting AR, was found to be significantly associated with dysplastic hips requiring PAO where AR was previously not considered a factor in the manifestation of symptoms and subsequent requirement for surgery. Moreover, the PRISS can also serve as an adequate radiographic sign for estimating acetabular version on pelvic radiographs.

Radiologically defined lipid-poor adrenal adenomas: histopathological characteristics

Adrenal lipid-poor adenomas (LPA) are defined by high unenhanced density (≥ 10 HU), and absolute and relative contrast medium washout > 60% and > 40%, respectively, at computerized tomography (CT). To date, no thorough histopathological characterization has been performed in those frequent lesions (one-third of adrenal adenomas). Our aim was to analyze the histopathological characteristics of adrenal LPA. Patients with LPA (n = 57) were selected among consecutive subjects referred for an adrenal incidentaloma or ACTH-independent Cushing syndrome. FluoroDeoxyGlucose-Positron Emission Tomography (FDG-PET) was performed in 37 patients. In patients treated by adrenalectomy (n = 17), Weiss score and Lin-Weiss-Bisceglia score (in tumors composed entirely or predominantly of oncocytes) were calculated. Radiological parameters did not differ among patients with ACTH-independent Cushing syndrome (n = 6) and those with adrenal incidentalomas associated with primary aldosteronism (n = 2), autonomous cortisol secretion (n = 14), or non-functioning (n = 35). Patients treated by adrenalectomy had larger tumors (28.9 ± 11.2 vs 17.3 ± 8.4mm, P < 0.001), higher CT unenhanced density (29.1 ± 11.0 vs 23.1 ± 9.0 HU, P = 0.043), and FDG-PET adrenal uptake (9.0 ± 6.4 vs 4.4 ± 2.3 SUV, P = 0.003) than non-operated ones. Oncocytic features > 75% of the tumor were detected in 12/17 cases (70.6%). Five of those showed borderline-malignant histopathological characteristics by Lin-Weiss-Bisceglia score. Among remaining non-oncocytic tumors, 1/5 had a Weiss score ≥ 3. Overall, 6/17 tumors (35.3%) had borderline-malignant potential. Radiological parameters were similar between patients with benign and borderline-malignant tumors. Adrenal LPA are a heterogeneous group of tumors, mostly composed of oncocytomas. Up to 1/3 of those tumors may have a borderline-malignant potential at histopathology.

Eight-plate epiphysiodesis: are we creating an intra-articular deformity?

Guided growth using eight-plates is commonly used for correction of angular limb deformities in growing children. The principle is of tethering at the physeal periphery while enabling growth in the rest of the physis. The method is also applied for epiphysiodesis to correct limb-length discrepancy (LLD). Concerns have been raised regarding the potential of this method to create an epiphyseal deformity. However, this has not been investigated. The purpose of this study was to detect and quantify the occurrence of deformities in the proximal tibial epiphysis following treatment with eight-plates. A retrospective study was performed including 42 children at a mean age of 10.8 years (3.7 to 15.7) undergoing eight-plate insertion in the proximal tibia for correction of coronal plane deformities or LLD between 2007 and 2015. A total of 64 plates were inserted; 48 plates (34 patients) were inserted to correct angular deformities and 16 plates (8 patients) for LLD. Medical records, Picture Archive and Communication System images, and conventional radiographs were reviewed. Measurements included interscrew angle, lateral and medial plateau slope angles measured between the plateau surface and the line between the ends of the physis, and tibial plateau roof angle defined as 180° minus the sum of both plateau angles. Measurements were compared between radiographs performed adjacent to surgery and those at latest follow-up, and between operated and non-operated plateaus. Statistical analysis was performed using BMDP Statistical Software. Slope angle increased in 31 (49.2%) of operated epiphyses by a mean of 5° (1° to 23°) compared with 29 (31.9%) in non-operated epiphyses (p = 0.043). Roof angle decreased in 29 (46.0%) of operated tibias and in 25 (27.5%) of non-operated ones by a mean of 5° (1° to 18°) (p = 0.028). Slope angle change frequency was similar in patients with LLD, varus and valgus correction (p = 0.37) but roof angle changes were slightly more frequent in LLD (p = 0.059) and correlated with the change in inter screw angles (r = 0.74, p = 0.001). The use of eight-plates in the proximal tibia for deformity correction and limb-length equalization causes a change in the bony morphology of the tibial plateau in a significant number of patients and the effect is more pronounced in the correction of LLD. Cite this article: Bone Joint J 2018;100-B:1112-16.

Assessment of splanchnic hemodynamics in patients with cirrhosis after separating operations in comparison with non-operated patients with compensated and decompensated clinical course

Separating operations are recommended for treatment and prophylaxis of bleeding from varicose veins of gullet as a result of portocaval (azygoportal) shunting at cirrhosis and directed to its elimination using azygoportal separation. At the same time the frequency of relapse of bleeding after operations remains rather high. And the formation of new varicose nodi as a result of disorder of hepatic and splanchnic hemodynamics that inevitably appears at different dates after operation is considered as the main cause of it. At the same time an assessment of hemodynamic changes after azygoportal separation is interpreted in different ways by different authors.Aim of research. To assess an influence of separating surgical interventions on the character of changes of splanchnic hemodynamics in patients with cirrhosis in comparison with non-operated patients with compensated and decompensated clinical course.Material and methods. There were examined 190 patients with cirrhosis: in 133 took place gastrointestinal bleeding from varicose veins of gullet, in 57 – diuretic resistant ascites. 16 patients underwent separating operations. 20 patients underwent endoscopic sclerotherapy of gullet veins. 84 patients died during observation (7 after surgical treatment). Duration of observation was from 2-3 weeks to 2,5-3 years. All patients underwent the repeated ultrasound of abdominal cavity. There were assessed diameter of hepatic and splenic vessels; quantitative and qualitative characteristics of blood flow in hepatic and splenic arteries, portal and splenic veins.Results of research. At assessment of splanchnic hemodynamics the changes of portal blood flow in first months after operation characterized with moderate dilation of portal vein and decrease of linear speed in it. At the same time the volumetric blood flow did not essentially change. It was noticed the decrease of volumetric blood flow in splenic vein at the expense of constriction of its lumen and decrease of linear speed in it. Arterial blood flow characterized with decrease of inflow to liver through hepatic artery and increase of blood flow through splenic artery. At later dates the character of changes of splanchnic hemodynamics after azygoportal separation was analogous on all indicators to non-operated patients at transfer from compensated to decompensated course of cirrhosis – decrease of blood flow through the portal vein and hepatic artery at relative increase of splenic blood flow. An increase of index of stagnation in the portal vein and splenic-hepatic portal index that took place in all operated patients and non-operated ones at the stage of decompensation was an unfavorable prognostic indication.Conclusion. The character of changes of splanchnic hemodynamics after gastroesophageal separation is analogous to non-operated patients at transfer from compensated course of cirrhosis to decompensated one. Decrease of the portal blood inflow through the splenic vein is a compensatory mechanism that must decrease the portal pressure. The quality of life in postsurgical period is determined by duration of compensation of hemodynamic disorders

Improving the outcome of acute cholecystitis: the non-standardized treatment must no longer be employed.

Therapeutic recommendations of acute cholecystitis are not consistently implemented, which generates greater patient morbidity and higher health care costs. The aim of this article is to evaluate the burden of acute cholecystitis, to detect potentially modifiable variables, and to propose a therapeutic strategy that will allow us to improve the quality of care. We carried out a retrospective study of patients who were admitted to the hospital from January 2010 to December 2012 using a univariate analysis of parameters including the admitting department, age, treatment administered, and length of stay. A total of 967 patients were admitted to the hospital with a diagnosis of acute cholecystitis, 692 (72%) to the Surgery Department, 257 (26%) to Internal Medicine-Digestive, and 18 (2%) to other departments. Four hundred ninety-eight (51.5%) were operated on: 107 (21%) on an urgent basis, 111 (22%) at an early stage (<96 h at diagnosis), 152 (30%) at a late stage (>96 h at diagnosis), and 128 (26%) at a delayed date (other admission). Patients who were admitted into the surgery department were five times more likely to be operated on than patients admitted into other departments (p<0.01). Patients operated on at a late stage had a longer length of stay than early stage surgery patients (p<0.05) and than non-operated ones (p<0.05). Patients<74 years old were more frequently operated than older ones (p<0.05). The non-standardized treatment of acute cholecystitis causes high clinical and surgical variability, long average stay, more readmissions, and high hospital costs. Therefore, patients with a diagnosis of acute cholecystitis should be admitted to the Surgery Department, thereby increasing the probability of receiving definite treatment.

Behaviour problems in adolescents with cardiac disease: an exploratory study in a paediatric cardiology outpatient clinic

To assess behavioural problems in adolescents with congenital and acquired heart disease in comparison with healthy controls. The perception of behavioural problems by the patients' parents was also assessed and compared. A cross-sectional study was carried out in 130 adolescents with congenital and acquired heart disease and 246 healthy controls. The second part of the Youth Self-Report was applied to the patients and controls, and the Child Behavior Checklist to the patients' parents. Male patients showed significantly fewer behavioural problems compared with male controls. No significant difference was found in the female gender. Healthy male adolescents scored significantly higher in the Internalising, Externalising, and in the Total Problems scales. Patients scored significantly higher only on the Social Problems subscale. Female patients in middle and late adolescence and male patients in early adolescence displayed more problems. No significant difference was found between the diagnostic groups. Operated patients did not differ from the non-operated ones. Patients scored significantly lower than did their parents. Male adolescents with cardiac disease reported fewer behavioural problems when compared with healthy controls, but no difference was observed in the female gender. Patients also reported fewer behavioural problems than did their parents. Adolescents with cardiac disease scored higher than did controls only on the Social Problems subscale. Analysing the patients' behavioural profile, female patients in middle and late adolescence and male patients in early adolescence were the most problematic ones. No difference was observed between the diagnostic groups, nor between operated and non-operated patients.

Surgery versus Watchful Waiting in Patients with Craniofacial Fibrous Dysplasia – a Meta-Analysis

BackgroundFibrous dysplasia (FD) is a benign bone tumor which most commonly involves the craniofacial skeleton. The most devastating consequence of craniofacial FD (CFD) is loss of vision due to optic nerve compression (ONC). Radiological evidence of ONC is common, however the management of this condition is not well established. Our objective was to compare the long-term outcome of patients with optic nerve compression (ONC) due to craniofacial fibrous dysplasia (CFD) who either underwent surgery or were managed expectantly.Methodology/Principal FindingsWe performed a meta-analysis of 27 studies along with analysis of the records of a cohort of patients enrolled in National Institutes of Health (NIH) protocol 98-D-0145, entitled Screening and Natural History of Fibrous Dysplasia, with a diagnosis of CFD. The study group consisted of 241 patients; 122 were enrolled in the NIH study and 119 were extracted from cases published in the literature. The median follow-up period was 54 months (range, 6–228 months). A total of 368 optic nerves were investigated. All clinically impaired optic nerves (n = 86, 23.3%) underwent therapeutic decompression. Of the 282 clinically intact nerves, 41 (15%) were surgically decompressed and 241 (85%) were followed expectantly. Improvement in visual function was reported in fifty-eight (67.4%) of the clinically impaired nerves after surgery. In the intact nerves group, long-term stable vision was achieved in 31/45 (75.6%) of the operated nerves, compared to 229/241 (95.1%) of the non-operated ones (p = 0.0003). Surgery in asymptomatic patients was associated with visual deterioration (RR 4.89; 95% CI 2.26–10.59).ConclusionsMost patients with CFD will remain asymptomatic during long-term follow-up. Expectant management is recommended in asymptomatic patients even in the presence of radiological evidence of ONC.

Is Mastoid Pressure Dressing Necessary?

Objective: Assess whether mastoid pressure dressing is necessary after ear surgery to prevent complications such as hematoma or protruding ear. Method: Thirty-seven patients were included in the study. Of the 37 patients, 17 were in the mastoid dressing group and 20 were in the no-mastoid dressing group. We measured the distance from mastoid scalp to helix rim at the most posterior level of upper auricular rim in the operated and non-operated ears. Results: For mastoid to helix distance of the operated ears of the patients, there was no statistically significant difference between the mastoid dressing group and the no-mastoid dressing group. We found a significant difference for the measured distance between operated and nonoperated ears of the mastoid dressing group, the mean value of distance in the operated ears being lower than that in the nonoperated ones ( P &gt; .05). Conclusion: This study showed that mastoid to helix distance did not change significantly when the mastoid dressing was not applied, while mastoid dressing seemed to decrease the mastoid-to-helix distance. For his reason, the application of a mastoid pressure dressing following ear surgery seems to be unnecessary and may contribute to increased wound morbidity.

La mortalité des perforations instrumentales de l’œsophage est élevée : expérience de 54 cas traités

Objective: To underline the severity of instrumental esophageal perforations and to discuss their management. Patients and methods: Data from patients treated for instrumental esophageal perforation were collected retrospectively from 1980 to 1995 then prospectively since 1995 to 2000. Results: Fifty-four patients were treated for instrumental perforations. Perforation occurred after exploratory endoscopy ( n=24), endoscopic dilation ( n=13), attempted tracheal intubation ( n=5), foreign body extraction ( n=5), treatment of esophageal varices ( n=4), trans-esophageal echocardiography ( n=2), and duodenal prosthesis implantation ( n=1). Clinical manifestations were immediate in 18 cases and delayed in all others, with an interval before treatment ranging from 2 hours to 45 days (mean= 70 hours). All patients were operated after large spectrum antibiotherapy and intensive care, except 3 who were treated medically due to their poor general condition. Fourteen (26%) patients died, including the 3 non-operated ones. Conclusion: Instrumental esophageal perforations are associated with a high mortality, probably due to the poor general condition of the patients. Diagnosis of these perforations is often delayed. A good experience of endoscopic maneuveurs and adequate post-endoscopic monitoring could allow earlier surgical treatment with lower mortality.

Magnetic resonance imaging after operative repair of Achilles tendon rupture

We performed a magnetic resonance imaging (MRI) study in 16 consecutive patients who had undergone open repair of a unilateral Achilles tendon rupture (ATR) at an average of 32.5 (SD 3.2) (range 29-36) months from the operation. We measured the widest antero-posterior diameter of the tendon, the longest distance between the insertion of the Achilles tendon on the calcaneum and the musculo-tendinous junction of the soleus muscle on the Achilles tendon, the distance between the insertion of the Achilles tendon on the calcaneum and the point of maximal width of the tendon. We also ascertained whether areas of altered signal were present in and around the tendon. The operated tendons were always significantly thicker than the non-operated ones. There was a non-significant trend for the other measurements to be greater in the operated tendons. In five patients, areas of dishomogeneous signal were present in the operated tendon. These areas were less than 25% of the antero-posterior diameter of the tendon, and were clinically silent. These findings probably represent normal features of long-term tendon healing following open repair of an ATR.

Évaluation de l’état nutritionnel de 57 malades âgés hospitalisés : influence de la pathologie causale

Purpose. – To study the nutritional status in elderly patients hospitalized for rehabilitation and to compare it among patients with hip fracture and those with medical care. Methods. – Patients were nutritionally assessed upon admission (d0) to our unit by measurement of anthropometric, biological parameters and dietary intake. Thrirty-seven patients were operated for hip fracture (group I) and 21 were hospitalised for medical disease (group II). Nutritional status was compared in the two groups on d0 and was evaluated after one month (d30) in the operated group. Results. – No significant difference could be observed for any anthropometric or biologic (albumin, transthyretin and transferrin) in the two groups. Daily food intake related to body weight was much the same in both groups (31 kcal/kg). C-reactive protein and orosomucoid levels were above the reference range in both groups. Hip fracture operated patients had higher orosomucoid than non-operated ones (1.50 ± 0.4 versus 1.14 ± 0.4 g/L; P = 0.002). One-month follow-up of nutritional status performed in 31 operated patients showed a significant decrease in TST and MAC (respectively p = 0.02 and p = 0.007) and in orosomucoid (p = 0.003) although daily food intake increased. Conclusion. – Twenty-eight percent of patients were undernourished upon admission in the unit. A moderate inflammatory state still remained in all our patients, particularly in those who had undergone surgery. This inflammatory state persisted two months after surgery.

Prevention of restrictive adhesions in primary tendon repair by HA-membrane: experimental research in chickens

Hyaluronic acid (HA) is a glycosaminoglycan polymer that has been found to have some beneficial effects on the prevention of adhesions in primary tendon repairs. The need for slow elimination preparations of HA has been identified. We have combined HA and carboxymethylcellulose (CMC) in order to get a slow elimination preparation of HA and studied its possible effect on primary tendon healing.A gel form of NaHe (19 mg/ml; mw: 6.5 × 106) was mixed with Na CMC (degree of substitution: 0.8) under sterile conditions. A jelly like mixture was thinned and HA membrane was achieved after drying in the refrigerator. The right legs of Leghorn chickens (n= 30) were prepared under IM ketamine anaesthesia by making partial cuts (75%) of flexor profundus tendons at zone II in the second, third and fourth toes, and repaired using a modified Kessler type suture (5/0 nylon). HA-membranes were applied around the repair sites in the third toes while 0.5 ml of hyaluronic acid and saline were poured on to the repair sites in the second and fourth toes, respectively. Skin incisions were closed and the legs were splinted for 15 days. Biomechanical and histological controls were made at the first, second and third postoperative months.No wound dehiscence or exposure of repaired tendons was observed on the operated toes. After collection of samples by amputation at MP levels, two-phalanx free biomechanical assessment was done. The calculated peaks of differential joint motion were very similar to the corresponding non-operated contralateral toes in the HA-membrane treated group. The toe tip displacement curves also resembled the non-operated ones in this group. HA membrane was detected as blue particles on specimens taken at the 30th day following surgery. There were few adhesions in this group microscopically at the third month. Adhesions were similar in the HA treated group while dense adhesions were seen in the saline treated group.These findings suggest that HA membrane acting as a physicochemical barrier can prevent restrictive adhesions in primary tendon repairs.

Suppression of epthelial cell proliferation in mice by splenocytes from unilaterally sialadenectomized syngeneic donors

Partially hepatectomized CBA mice immediately after the operation were intra-orbitally injected with splenocytes of intact (I), Sham-operated (SH-0) or unilaterally sialadenectomized (USAE) syngenic donors. It was shown that splenocytes from USAE donors in contrast to their types of splenocytes acutely suppress the mitotic activity of hepatocytes in the regenerating liver 48 and 72 h after their transfer. Splenocytes isolated 17, 144 and 168 h after removal of submandibular (together with sublingual) gland had the biggest inhibiting ability. Similar effect was obtained in respect of corneal epithelium due to administration of USAE mice splenocytes 17, 48 and 72 h after surgery. Operated recipients are more susceptible to the action of splenocytes from USAE donors, than the non-operated ones.

Indications for surgical treatment in post-infarction angina.

In order to evaluate whether or not criteria for surgical revascularization in patients with early post-infarction angina (EPIA) should be different from those commonly used for patients with angina, the incidence and prognostic implications of EPIA were analysed in 188 AMI patients in Killip's class I or II on admission. Sixty-two patients (33%) complained of EPIA (Group I) and 126 patients were symptom-free (Group II). There were no differences between the two groups in in-hospital and late mortality and reinfarction. On the contrary, severity of angina was significantly associated with the occurrence of in-hospital and late cardiac death, reinfarction and revascularization procedures. EPIA patients underwent revascularization procedures significantly more frequently than group II patients, both during hospitalization (29% versus 1%; P less than 0.001) and follow up (10% versus 1%; P less than 0.01). Coronary artery involvement was significantly more severe in group I than in group II and in the operated patients compared with the non-operated ones. Our data suggest that the severity of angina should be the leading criterion for surgery, as it is able to identify most of the patients with severe coronary artery disease and poor prognosis.