Ingested foreign bodies of the gastrointestinal tract: retrospective analysis of 542 cases

Ingested foreign bodies (FBs) present a common clinical problem. As the incidence of FBs requiring operative removal varies from 1% to 14%, it was decided to perform this study and compare the data with those from the world literature, as well as to outline an algorithm for management, including indications for surgery. We reviewed all patients with FB ingestion from 1973 to 1993. There were 542 patients with 1203 ingestions, aged 15 to 82 years. Among them, 69. 9% (n = 379) were jail inmates at the time of ingestion, 22.9% (n = 124) had a history of psychosis, and 7.2% (n = 39) were alcoholics or denture-wearing elderly subjects. Most foreign bodies passed spontaneously (75.6%; n = 410). Endoscopic removal was possible in 19. 5% (n = 106) and was not associated with any morbidity. Only 4.8% (n = 26) required surgery. Of the latter, 30.8% (n = 8) had long gastric FBs with no tendency for distal passage and were removed via gastrotomy; 15.4% (n = 4) had thin, sharp FBs, causing perforation; and 53.8% (n = 14) had FBs impacted in the ileocecal region, which were removed via appendicostomy. Conservative approach to FB ingestion is justified, although early endoscopic removal from the stomach is recommended. In cases of failure, surgical removal for gastric FBs longer than 7.0 cm is wise. Thin, sharp FBs require a high index of suspicion because they carry a higher risk for perforation. The ileocecal region is the most common site of impaction. Removal of the FB via appendicostomy is the safest option and should not be delayed more than 48 hours.

Impact of graft type on outcome in pediatric liver transplantation: a report From Studies of Pediatric Liver Transplantation (SPLIT)

OBJECTIVE

To examine the outcome of technical variant liver transplant techniques relative to whole organ liver transplantation in pediatric liver transplant recipients.

BACKGROUND

Technical variant liver transplant techniques comprising split, reduced, and live-donor liver transplantation evolved to address the need for timely and size appropriate grafts for pediatric recipients.

METHODS

Analysis of data from the Studies of Pediatric Liver Transplantation (SPLIT) registry, a multicenter database of 44 North American pediatric liver transplant programs. The outcome (morbidity and mortality) of each of the technical variants were compared with that of whole organ recipients.

RESULTS

Data were available on 2192 transplant recipients (1183 whole, 261 split, 388 reduced, and 360 live donor). Recipients of all technical variant graft type were significantly younger than whole organ recipients, but on average spent 2.3 months less on the waiting list. Thirty-day post-transplant morbidity was increased for each type of technical variant relative to whole organ (45.1% whole, 66.7% split, 65.5% reduced, 51.9% live-donor). Biliary complications (30 day: 7.5% whole, 18.8% split, 16% reduced, 17.5% live-donor) and portal vein thrombosis (30 day: 3.6% whole, 8% split, 8% reduced, 7.5% live-donor) were more common in all technical variant types. Graft type was an independent predictor of graft loss (death or retransplantation) in a multivariate analysis. Split and reduced (relative risk = 1.74 and 1.77, respectively) grafts had a worse outcome when compared with whole organ recipients.

CONCLUSIONS

Technical variant techniques expand the pediatric donor pool and reduce time from listing to transplant, but they are associated with increased morbidity and mortality.

Disruption and infection of median sternotomy: a comprehensive review

Disruption and infection of median sternotomy wounds are grave complications often associated with prolonged hospitalization, high cost, and significant mortality. Effective prevention techniques are still debated. Successful management requires early recognition based on a high index of suspicion, detailed physical examination, appreciation of the clinical signs and symptoms, timely imaging studies, and prompt surgical therapy. Improvements in perioperative management and critical care of patients with multisystem organ failure can reduce morbidity and mortality rates. Sternal salvage and direct sternal reclosure are possible when the infection is diagnosed early. Techniques utilizing lateral sternal support should be first-line options in the condition. Muscle flap techniques should be the next consideration when direct closure has failed or cannot be attempted.

Entero-colocutaneous fistula: a late consequence of polypropylene mesh abdominal wall repair: case report and review of the literature

BACKGROUND

The underlying risk associated with visceral mesh erosion is the close opposition of adjacent intestines to the prosthetic graft. This highly morbid condition has been described with most types and techniques of abdominal wall mesh repair.

PATIENT

We report the case of a 52-year-old man who presented with an entero-colocutaneous fistula 10 years after prosthetic mesh repair of an incisional hernia. The fistula was excised and the abdominal wall defect repaired with a tissue-impervious composite.

CONCLUSIONS

The use of a tissue-impervious barrier avoids development of enteric fistula when a prosthesis is placed directly over the viscera.

Biomechanical comparison of median sternotomy closures

BACKGROUND

Poor healing of median sternotomy can significantly increase morbidity, mortality, and hospital costs. Effective union requires reliable sternal fixation. Although wire has proven the most reliable and widely used sternotomy closure material, no experimental studies have compared a large variety of wiring techniques in a human model. We developed an easily reproducible experimental model using cadaveric human sterna and compared several wiring methods to assess closure strength and stability.

METHODS

Fifty-three fresh adult human cadaveric sternal plates with adjacent ribs were fixed with specially designed spiked stainless steel clamps and attached to a texture analyzer. Single peristernal and transsternal, alternating single peristernal and transsternal, figure-eight peristernal, figure-eight pericostal, and Robicsek closures using no. 5 stainless steel wires were tested. We evaluated bone density, stiffness, and displacement using perpendicular, repetitive variable force loads of 800 Newtons cycling at a rate of 0.5 mm/s.

RESULTS

There were no significant differences in age, sex, or bone density in outcome measures of the sternal groups. No clamp failures or clamp damage to the specimens occurred. The single peristernal and alternating peristernal and transsternal closures proved superior in strength and stability (p < 0.001). The figure-eight peristernal, then the single transsternal, then the Robicsek were next stablest groups in decreasing order. The figure-eight pericostal closure had the highest failure rate (p < 0.001).

CONCLUSIONS

This novel model of sternotomy closure testing was reliable, inexpensive, and easily reproducible. The mechanical stability of peristernal and alternating peristernal and transsternal wires was significantly greater than that of the other tested methods. Pericostal figure-eight closures were not sufficiently stable to be considered a reliable method of primary sternotomy repair.

Preliminary experience with renal transplantation in HIV+ recipients: low acute rejection and infection rates

BACKGROUND

Only four centers have reported their results with renal transplantation in human immunodeficiency virus (HIV)+ recipients on highly active antiretroviral therapy, and acute rejection (AR) rates have consistently ranged from 43% to 67%.

METHODS

We examined the outcomes of eight adult HIV+ primary renal allograft recipients with median 15 (range 8-47) months follow-up with multiple other high-risk factors, including African American ethnicity, hepatitis C virus (HCV) positivity, long waiting times, prior sensitization, paucity of live donors, and delayed graft function. Our immunosuppressive protocol consisted of an anti-interleukin-2 receptor antibody for induction, and mycophenolate mofetil, cyclosporin A, and prednisone for maintenance. Initial and 3- to 6-month cyclosporin A trough level targets were 250 to 300 and 225 to 275 ng/mL, respectively, and mycophenolate mofetil dose was adjusted according to 2 to 4 week surveillance and subsequent as needed mycophenolic acid predose concentrations during the first 6 months.

RESULTS

Patient and graft survival were 100% and 88%, respectively, with an AR rate of 13% and excellent renal function. No patients developed new-onset diabetes, opportunistic or other serious infections, malignancy, or progression of hepatitis C virus-related liver disease. Excellent suppression of HIV replication with maintenance of CD4 counts was noted in all cases.

CONCLUSIONS

Our findings suggest that HIV+ patients on highly active antiretroviral therapy can undergo successful renal transplantation with a low incidence of both AR and AIDS-associated and non-AIDS associated infections, despite associated risk factors for poorer outcome. Our encouraging but preliminary results with this protocol will need to be verified in larger numbers of HIV+ renal allograft recipients with longer follow-up.

Preliminary experience with cinacalcet use in persistent secondary hyperparathyroidism after kidney transplantation

BACKGROUND

There is limited experience with the use of cinacalcet in the treatment of persistent secondary hyperparathyroidism after kidney transplantation.

METHODS

We retrospectively analyzed our experience in 18 renal allograft recipients who initiated cinacalcet therapy from 1 month to 23 years (median 3 years) posttransplantation and were maintained on the drug for 6 months. The daily dose was titrated from 30 mg up to a maximum of 180 mg to achieve a reduction in serum intact parathyroid hormone (PTH) levels.

RESULTS

Sustainable, significant decreases in mean calcium and alkaline phosphatase were noted at 1 month and intact PTH by 3 months, with 50% of patients achieving at least a 30% drop in PTH levels at 6 months. Serum phosphorous increased at 6 months, whereas urine N-telopeptides decreased. There were no significant changes in serum osteocalcin, albumin, and hemoglobin levels. We did not observe a tachyphylaxis phenomenon. Two patients reported occasional nausea, but did not require medication discontinuation. Estimated glomerular filtration rate did decrease progressively over the 6-month period.

CONCLUSION

Cinacalcet appears to be an effective drug for the treatment of posttransplant hypercalcemia due to persistent secondary hyperparathyroidism. Further studies with more patients and longer follow-up will be needed to better elucidate the efficacy/safety profile for this agent, particularly with regard to long-term bone histology and renal outcomes.

Handlebar hernia: ultrasonography-aided diagnosis

Traumatic hernia resulting from blunt impalement of the abdominal wall, known as "handlebar hernia," is seldom addressed in the surgical literature, with only 28 previously reported cases. We describe our experience with this rare traumatic hernia diagnosed by physical examination and confirmed by ultrasonography. Published reports suggest handlebar hernia's potential for serious underlying injury and the diagnostic importance of computed tomographic scanning. The case presented here demonstrates the value of bedside ultrasonography in diagnosis confirmation and surgical planning for this condition.

Technology insight: liver support systems

Emergency orthotopic liver transplantation (OLT) is currently the only standard treatment for fulminant hepatic failure (FHF). The waiting time for transplantation can exceed a week-using a liver assist device to bridge patients with FHF to OLT might therefore decrease the mortality rate. Several liver support systems have been described, but no system has gained FDA approval or widespread clinical acceptance. Although the results of many experimental and clinical trials are encouraging, the field is still in its initial stages. Using nonbiologic liver support is based on the assumption that several toxins that cause hepatic coma can be removed from the circulation by blood or plasma sorption methods. As these toxins could be involved in many FHF complications recovery without the need for transplantation is the ultimate aim. Biologic liver support uses xenogeneic livers or hepatocytes to support the failed human liver, exploiting biological cell functions, namely detoxification, metabolism, and biosynthesis. The classical nonbiologic dialysis methods could decrease mortality in patients with acute-on-chronic liver failure, but definitive conclusions are impossible to draw because of the small number of patients studied and inadequate follow-up. Larger studies performed in specialty centers should provide conclusive data about the role of the bioartificial liver support system as a possible universal bridge to OLT. This article presents an overview of published experience with liver support systems since the 1960s.

Congenital posterolateral diaphragmatic hernia in an adult

A Bochdalek hernia (BH) occurs when abdominal contents herniate through the posterolateral segment of the diaphragm. Most BHs present with life-threatening cardiorespiratory distress in the neonatal period. Rarely, hernias that remain clinically silent until adulthood present as life-threatening surgical emergencies. Our recent experience with a life-threatening emergency due to a BH in a 29-year-old male patient prompted us to reinforce that this entity does exist in adults and should be considered in the differential of acute abdominal pain.

Cyanoacrylate adhesive in management of severe presacral bleeding

Effective hemostasis is critical in severe presacral hemorrhage because the bleeding may be fatal. We report our successful use of combined hemostatic sponge and cyanoacrylate glue in three patients with life-threatening presacral hemorrhage after abdominoperineal resection of the rectum for carcinoma.

Mesenteric cystic lymphangioma: unusual cause of intra-abdominal catastrophe in an adult

Mesenteric cystic lymphangiomas (MCLs) are rare benign cystic tumours of unknown aetiology, most often seen in paediatric patients. The clinical presentation is diverse, ranging from an incidentally discovered abdominal cyst to symptoms of acute abdomen. A 20-year-old male presented with generalised abdominal pain, nausea and vomiting of several hours duration following heavy lifting. Emergency laparotomy revealed a 15 x 10 x 8-cm pedicled cystic mass of the mid-ileal mesentery, causing a volvulus. The cyst and a 20-cm gangrenous intestinal segment were resected with anastomosis. The postoperative course was uncomplicated. MCLs should be included in the differential diagnosis of cystic intra-abdominal lesions. Even when asymptomatic and discovered incidentally, they must be treated surgically because of the potential to grow, invade vital structures and develop life-threatening complications.

Recurrent intercostal herniation of the liver

Abdominal intercostal hernia occurs rarely, with only 26 previous cases reported in the professional literature. A 51-year-old man presented with a painful right chest protrusion. One year earlier he had experienced a severe coughing spell and spontaneous rib fracture and chest protrusion. He was treated with endogenous tissue reinforcement and had no clinical improvement. Magnetic resonance imaging revealed the liver protruding through the chest wall. The hernia was reduced and the chest wall was repaired with prosthetic mesh and cables. Attention to the chest wall anatomy and reliable tissue closure including pericostal or transcostal nonabsorbable sutures and a prosthetic bridge over the defect are the best way to eliminate the patient's risk for recurrence.

Single wire versus double wire loops for median sternotomy closure: experimental biomechanical study using a human cadaveric model

BACKGROUND

Healing of median sternotomy requires reliable sternal fixation. Although both single and double wire kits are commercially available, no experimental study has compared the two closures in a human cadaveric model. We used a recently described human experimental cadaveric model to compare the stability of the closures.

METHODS

Sixteen fresh adult human cadaveric sternal plates with adjacent ribs were fixed with custom designed spiked stainless steel clamps and attached to a biomechanical testing device. Single No. 5 peristernal and double peristernal closures were tested. The stability of the unions was tested using perpendicular, repetitive force loads increasing from 0 to 800 Newtons at a rate of 0.5 mm/second.

RESULTS

The two study groups did not differ in age or sex. No clamp failures or damage to the specimens occurred. The double peristernal closure exhibited a significantly lower permanent displacement than the single wire group, suggesting a superior strength and stability of that closure.

CONCLUSIONS

To the extent to which this human cadaveric model resembles in vivo median sternotomy, these data suggest that the biomechanical stability of the peristernal double wire closure may exceed that of single wires.

Ogilvie syndrome and herpes zoster: case report and review of the literature

BACKGROUND

The very unusual association between herpes zoster and Ogilvie syndrome has received scant attention in the published literature.

OBJECTIVES

This review discusses the published experience since 1950 and attempts to increase clinical awareness about the co-existence of both conditions.

CASE REPORT

An 84-year-old male patient affected by herpes zoster presented with advanced acute colonic pseudo-obstruction and was successfully treated with colonic diversion.

DISCUSSION

Twenty published studies (1950-2008) of 28 patients in whom the two conditions co-existed are reviewed. The review included 22 male and 7 female patients (24%) aged 32-87 years (mean, 61 years). Significant co-morbidities were present in 45% of the patients. The majority of patients were observed and treated conservatively (83%). Two patients died (7%), both suffering from respiratory complications and malignancy.

CONCLUSION

Recognition of the combined syndrome may help to avoid unnecessary surgery. Laparotomy should be reserved as a last resort for when the obstruction cannot be successfully managed by endoscopy. A diverting colostomy can be used to monitor the blood supply and thus provide early warning for an impending abdominal catastrophe.

Subxiphoid incisional hernias after median sternotomy

BACKGROUND

Subxiphoid incisional hernias are notoriously difficult to repair and are prone to recurrence. The few reports on subxiphoid hernia published over the last two decades have not fully addressed the etiology, pathology, treatment, and outcome of this problem. This review was performed to analyze the published experience and increase the understanding of these difficult hernias.

METHODS

We reviewed the extensive literature, including the Medline and Current Contents computerized database searches, and searched the available bibliographies.

RESULTS

Seven retrospective studies of a total of 113 patients who had clinical subxiphoid hernias after median sternotomy were found. An additional surgical technique describing a modified median sternotomy preventing the hernia, and a single review article on selected technical considerations of subxiphoid ventral repair were also found.

CONCLUSIONS

The incidence of subxiphoid hernia after median sternotomy can be possibly reduced by paraxiphoid extension of the sternotomy, reinforcement near the xiphoid end of the incision, or by optimizing closure of the distal sternotomy and the linea alba. Abdominal wall reinforcement by open-mesh closure or laparoscopic transperitoneal prosthetic repair can effectively deal with the defect. Long-term outcome analyses are not yet available.

Sciatic hernia: a comprehensive review of the world literature (1900-2008)

BACKGROUND

Sciatic hernias are considered the rarest pelvic floor hernias, with a very limited number of published reports worldwide. The condition has received limited attention in the surgical literature.

DATA SOURCES

The data reported herein are based on a literature review including MEDLINE and CURRENT CONTENTS computerized database searches. The existing bibliographies on sciatic hernia were explored for articles pertaining to the review. Finally, the Internet was searched for articles not listed in the available medical databases.

CONCLUSIONS

Sciatic hernia is unusual, and can present the physician with diagnostic and treatment dilemmas. The hernia may present with obscure pelvic pain, intestinal obstruction, life-threatening gluteal sepsis, or as an asymptomatic, reducible mass that distorts the gluteal fold. Small sciatic hernia can remain hidden behind the gluteus maximus muscle. The diagnosis requires imaging studies in such cases. Treatment of sciatic hernia is always surgical and requires prosthetic reinforcement for the best result.

Reconstructive renal surgery using a water jet

PURPOSE

We describe the successful application of a water jet to reconstructive renal surgery.

MATERIALS AND METHODS

Two consecutive patients underwent reconstructive renal surgery using a waterjet apparatus for a 4.0x6.5 cm. well encapsulated tumor of the lower pole of the left kidney and a 4.5x2.5 cm. staghorn calculus of the left kidney, respectively. The water jet apparatus (Parenchimotom 01) consists of a pressure generating pump and a flexible hose connected to the hand piece, and a nozzle with a pinhole opening of 0.3 mm.

RESULTS

Both patients underwent surgery through a left lumbar incision. Partial nephrectomy was performed in 1 patient and anatrophic nephrotomy for stone removal in the other. Dissection time was 25 and 12 minutes, with blood loss of 150 and 100 ml., respectively. No temporary vascular clamping or local hypothermia was necessary. Both patients were discharged home 10 days after surgery and at followup no negative sequelae were attributable to the procedure.

CONCLUSIONS

The operative procedures proved easy, fast and effective. No temporary vessel clamping or hypothermia was required. Using a water jet is a novel approach that is helpful in renal surgery.