Tracheo-arterial fistula in tracheostomy patients with Duchenne muscular dystrophy

A tracheo-arterial fistula is a serious and life threatening potential complication of a tracheostomy. Since 1984, we experienced nine fatal cases of tracheo-arterial fistula among 60 Duchenne muscular dystrophy (DMD) patients who underwent a tracheostomy. Representative cases included a patient with lordosis (Case 8), in whom the fistula was located in the brachiocephalic artery close to the trachea, and another with severe scoliosis (Case 9), which caused the aorta to compress the trachea. Such anatomical changes can be the cause of a fistula between the trachea and brachiocephalic artery. The anatomical locations between the trachea and brachiocephalic artery are modified by thoracic deformities in DMD patients, and should be confirmed using computed tomography (CT) prior to a tracheostomy procedure. Further, during such a procedure, the tracheal stoma must be placed in a location clearly away from the arteries, and should be followed by regular post-operative examinations using CT and careful management to avoid a tracheo-arterial fistula.

ACC/AHA guidelines for preoperative cardiovascular evaluation for noncardiac surgery: a critical point of view

This review examines the issue of preoperative cardiac evaluation from a critical point of view, based on recent medical literature. We reviewed the history of that field and focused on the American College of Cardiology and American Heart Association guidelines, which are a cornerstone in the field of cardiac patients undergoing noncardiac surgery. These guidelines synthesized the data into a comprehensive format and established the concept of integrating the patient's risk with the surgical risk. Nevertheless, there are some weaknesses in the guidelines. We believe that a better understanding of the guideline limitations will allow an improved and more educated practice of its recommendations.

Preoperative Cardiac Evaluation: When Should the Surgeon Consult the Cardiologist?

PURPOSE

We compiled a manual aimed at reducing preoperative cardiac assessment costs and defining the roles of surgeons and cardiologists. We tested prospectively and retrospectively if this manual achieved these goals.

METHODS

Using the Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery of the American College of Cardiology (ACC) / American Heart Association (AHA), and other articles as a reference, we compiled the Jichi Medical School Hospital (JMSH) Manual in September 2002. This manual contains a novel checklist and flowcharts and includes all past and present cardiac disorders, complications, abnormalities in electrocardiograms (ECGs) and chest X-rays, and evaluation of daily activity. Using this manual, we prospectively studied 1087 surgical candidates from September 2002 to August 2003, and retrospectively analyzed 927 surgical candidates from September 2001 to August 2002.

RESULTS

In the prospective study, 39 (3.6%) patients were deemed to require further cardiac assessment and 4 (0.37%) suffered postoperative complications. In the retrospective study, 108 (11.7%) were deemed to require further cardiac assessment and 20 (2.2%) suffered postoperative complications. Using this manual reduced preoperative cardiac examination costs by 1323,600 Japanese yen, representing a 70.5% reduction.

CONCLUSIONS

The JMSH Manual defines the roles of surgeons and cardiologists and is useful for assessing preoperative cardiac function and surgical risks. This manual dramatically reduced the costs associated with preoperative cardiac examinations.

Compliance with surgical antibiotic prophylaxis--reporting from a statewide surveillance programme in Victoria, Australia

A statewide assessment of the compliance of surgical antibiotic prophylaxis (SAP) with guidelines was undertaken for large public hospitals in Victoria, Australia. This was carried out using data collected as part of a surveillance system for hospital-acquired infections. The study population comprised patients in Victorian public hospitals with >100 beds (N=27) undergoing cardiac surgical procedures, hip or knee arthroplasty, cholecystectomy, appendectomy, colon surgery or hysterectomy over a 21-month period. Australian guidelines recommend SAP for all 10 643 surgical procedures included in this study. Combining all procedures, 87% received SAP, the choice of antibiotic was concordant with guidelines for 53.3% of procedures, and the choice of antibiotic was considered to be 'adequate but not concordant' for 23.9% of procedures. SAP was considered to be inadequate for 18.9% of procedures. A large number of antibiotic regimens were utilized for cardiac and orthopaedic surgery. Documentation of timing of administration was not submitted for more than half of all procedures. Timing was concordant with guidelines for 76.4% of procedures when documented. Prophylactic antibiotic choice was generally more concordant with guidelines for cardiac and orthopaedic procedures than for other types of surgery. However, even for these procedures, where infections carry high morbidity, SAP was sometimes inadequate. Regular reporting on SAP compliance from data collected during surveillance for hospital-acquired infections is achievable. This should lead to improvements in both compliance and documentation.

Vascular injury and complication in neurosurgical spine surgery

Vascular injury is an uncommon, but not rare complication of spine surgery. The consequence of vascular injury may be quite devastating, but its incidence can be reduced by understanding the mechanisms of injury. Properly managing vascular injury can reduce mortality and morbidity of patients. A review of the literature was conducted to provide an update on the etiology and management of vascular injury and complication in neurosurgical spine surgery. The vascular injuries were categorized according to each surgical procedure responsible for the injury, i.e., anterior screw fixation of the odontoid fracture, anterior cervical spine surgery, posterior C1-2 arthrodesis, posterior cervical spine surgery, anterolateral approach for thoracolumbar spine fracture, posterior thoracic spine surgery, scoliosis surgery, anterior lumbar interbody fusion (ALIF), lumbar disc arthroplasty, lumbar discectomy, and posterior lumbar spine surgery. The incidence, mechanisms of injury, and reparative measures were discussed for each surgical procedure. Detailed coverage was especially given to vascular injury associated with ALIF, which may have been underestimated. The accumulation of anatomical knowledge and advanced imaging studies has made complex spine surgery safer and more reliable. It is not clear, however, whether the incidence of vascular injury has been reduced significantly in all procedures of spine surgery. Emerging new techniques, such as microendoscopic discectomy and lumbar disc arthroplasty, seem to be promising, but we need to keep in mind their safety issues, including vascular injury and complication.

Long-term surgical outcome in patients with intracranial hydatid cyst

BACKGROUND

Cerebral hydatid cysts account for up to 3.6% of all intracranial space-occupying lesions, in endemic countries. The vast majority of patients affected are children. Computed tomography (CT) and magnetic resonance imaging (MRI) have greatly contributed to a more accurate diagnosis of hydatids. However, correct pre-operative diagnosis still remains quite puzzling. Extirpation of the intact cyst is the treatment of choice, resulting in most cases to a complete recovery.

METHOD

In our retrospective study, we have reviewed 76 cases of intra-cranial hydatid disease operated on in our hospital over a 22 year period. Presenting clinical symptoms and signs and the radiological findings on CT and MRI were documented. Albendazole was given preoperatively to patients with giant (>5 cm) or multiple cysts and postoperatively to all patients. The follow-up period ranged from 12 months to 22 years and the outcome was assessed using the Glasgow Outcome Scale (GOS).

FINDINGS

Sixty seven (95.7%) of our patients were children. Increased intracranial pressure and papilledema were the predominant findings in this group, whereas focal neurological deficits were most prevalent in adults. CT and MRI revealed round cystic lesions, isodense and iso-intense respectively to cerebrospinal fluid (CSF), with no rim enhancement or perifocal edema. Multiple cysts were identified in 3 cases. Extirpation of the cyst without rupture was accomplished in 56 patients (73.7%). Recurrences occurred in 19 patients (25%). 4 patients (5.3%) died within 6 months after surgery; 3 of these patients had multiple cysts and one died shortly after the operation due to anaphylactic shock following intra-operative rupture of the cyst.

CONCLUSION

Long-term follow-up confirms that intracranial hydatid cysts should always be surgically removed without rupture; the outcome remains excellent in these cases. Correct preoperative diagnosis is vital for the successful outcome of surgery. A high index of suspicion is therefore required in endemic areas despite the availability of advanced neuro-imaging. Medical treatment with albendazole seems to be beneficial both pre- and post-operatively. Newer diagnostic methodologies, such as MR spectroscopy and MR diffusion weighted imaging, might lend themselves to the diagnosis of intracranial hydatid cysts.

High jugular bulb in the translabyrinthine approach to the cerebellopontine angle: anatomical considerations and surgical management

BACKGROUND

Evidence of a high jugular bulb position (HJBP) during the translabyrinthine approach may compromise the surgical removal of cerebellopontine angle (CPA) tumours. We report a simple surgical procedure to safely manage this frequent normal variation and comment on various alternative options.

METHODS

The translabyrinthine approach included a complete skeletonization of the sigmoid sinus and of the presigmoid dura. A thin eggshell bone was left at the jugular bulb surface. The dome of the jugular bulb was gently dissected from the jugular fossa and gradually retracted downward in a tailored way, allowing the surgeon to drill below the internal auditory meatus. A small piece of bone was wedged over the jugular dome in order to maintain its lowered position.

RESULTS

Among 178 consecutive translabyrinthine approaches performed for the removal of large CPA tumors, the use of this procedure was required in 44 cases of HJBP. Excepting minimal venous bleeding easily controlled in several cases, we never observed any complication from this procedure nor failure to expose the inferior compartment of the CPA.

CONCLUSIONS

The HJBP can be systematically diagnosed with the preoperative CT-scan using bone window imaging. Our results demonstrate that the described procedure is safe and effective to widen the operative corridor that is required for the exposure of the inferior compartment of the CPA in this anatomical situation.

Rerupture following endovascular treatment for dissecting aneurysm of distal anterior inferior cerebellar artery with parent artery preservation: retreatment by parent artery occlusion with Guglielmi detachable coils

Distal anterior inferior cerebellar artery (AICA) aneurysms are rare and most cases have been treated surgically by clipping, wrapping or trapping. We recently treated this 20-year-old male patient by an endovascular technique. At first, he was treated by intra-aneurysmal embolisation with parent artery preservation. But he presented with rerupture 1 month after embolisation. Follow-up angiography revealed the regrowth of the aneurysm, which was considered as a dissecting aneurysm. We performed occlusion of the AICA just proximal to the aneurysm to prevent fatal rebleeding. He gradually improved and his level of consciousness fully recovered. At 2 year follow up, he had no neurological deficits. We suggest that embolisation of distal AICA aneurysm with parent artery occlusion may be safe and a simple method in the treatment of distal AICA aneurysms.

Surgery in temporal lobe epilepsy patients without cranial MRI lateralization

High resolution MRI is very important in the evaluations of patients with intractable temporal lobe epilepsy in preoperative investigations. Morphologic abnormalities on cranial MRI usually indicate the epileptogenic focus. Intractable TLE patients who have normal cranial MRI or bilateral hippocampal atrophy may have a chance for surgery if a certain epileptogenic focus is determined. We evaluated the patients who were monitorized in Gazi University Medical Faculty Epilepsy Center from October 1997 to April 2004. Seventy three patients, who had a temporal epileptogenic focus, underwent anterior temporal lobectomy at Ankara University Medical Faculty Department of Neurosurgery. Twelve of them (16, 4%), did not have any localizing structural lesion on cranial MRI. Of the 12 patients examined 6 had normal findings and 6 had bilateral hippocampal atrophy. Of these 12 patients, 6 (50%) were women and 6 (50%) were men. The ages of patients ranged from 7 to 37 (mean: 24.5). Preoperatively long-term scalp video-EEG monitoring, cranial MRI, neuropsychological tests, and Wada test were applied in all patients. Five patients, whose investigations resulted in conflicting data, underwent invasive monitoring by the use of subdural strips. The seizure outcome of patients were classified according to Engel with postsurgical follow-up ranging from 11 to 52 (median: 35.7) months. Nine patients (75%) were classified into Engel's Class I and the other 3 patients (25%) were placed into Engel's Class II. One patient who was classified into Engel's Class II had additional psychiatric problems. The other patient had two different epileptogenic foci independent from each other in her ictal EEG. One of them localized in the right anterior temporal area, the other was in the right frontal lobe. She was classified in Engel's Class II and had no seizure originating from temporal epileptic focus, but few seizures originating from the frontal region continued after the surgery. In conclusion, surgery was successful in all 12 patients. We think that patients with no MRI lateralizing or localizing lesion should undergo epilepsy surgery after detailed presurgical evaluations, including invasive monitoring.

[Elective colon surgery according to a 'fast-track' programme]

In fast-track surgical programmes, a variety ofperioperative elements are combined in an intensive multidisciplinary approach for the purpose of preserving the preoperative body composition and organ functions and actively stimulating functional recovery. Such programmes have already been introduced in several surgical procedures. The essence of fast-track colon surgery consists of extensive preoperative counselling, adequate preoperative nutrition with the avoidance of prolonged fasting, a minimum of invasive procedures and anaesthesia, no routine use of drains and nasogastric tubes, adequate perioperative analgesia encompassing high thoracic epidural anaesthesia, rapid mobilisation, rapid resumption of postoperative feeding, and medicinal support with prokinetics and laxatives. A systematic review shows that this programme accelerates recovery and hence shortens the primary and total hospital stay.

Prediction of Soft-Tissue Injuries in Schatzker II Tibial Plateau Fractures based on Measurements of Plain Radiographs

BACKGROUND

Split-depression fractures of the lateral tibial plateau (Schatzker II) are associated with a significant risk of capsuloligamentous and meniscal injury. We hypothesized that the amount of fracture depression and widening on anteroposterior (AP) plain radiographs would correlate with the incidence of injury to these structures on magnetic resonance imaging (MRI).

METHODS

Sixty-two consecutive patients with Schatzker II tibial plateau fractures had a knee x-ray series and MRI preoperatively. AP plain radiographs were measured for lateral joint line depression and condylar widening, and MRIs were evaluated for injury to soft-tissue structures around the knee. For each structure, the threshold of depression and widening that led to the greatest disparity in soft-tissue injury was determined. Multiple logistic regressions were applied to calculate whether depression and/or widening above the thresholds were predictive for injury to individual soft-tissue structures.

RESULTS

When depression was greater than 6 mm and widening was greater than 5 mm, lateral meniscal injury occurred in 83% of fractures, compared with 50% of fractures with less displacement (p < 0.05). When either depression or widening was at least 8 mm, medial meniscal injury occurred more frequently (depression 53%, p < 0.05; widening 78%, p < 0.05; versus neither 15%). Lateral collateral ligament and posterior cruciate ligament tears were not seen with minimally displaced fractures (< 4 mm), but the incidence of injury approached 30% with increasing displacement.

CONCLUSIONS

Due to the limited availability of MRI in some centers, correlation of lateral condylar depression and widening, as measured on plain radiographs, to injury of various soft-tissue structures may be extremely helpful in planning open or arthroscopic treatment methods. Using these guidelines, Schatzker II fractures with depression or widening approaching 5 mm deserve heightened vigilance in diagnosing and treating these concomitant soft-tissue injuries.

Ultrasonographic detection of hepatocellular carcinoma: correlation of preoperative ultrasonography and resected liver pathology

AIM

The aim of this study was to determine the sensitivity of ultrasonography for detecting hepatocellular carcinoma in patients who underwent surgical liver resection.

MATERIALS AND METHODS

The preoperative ultrasonography reports of 103 patients who underwent hepatic resection surgery were retrospectively reviewed. The patients had chronic liver disease with good liver function and a relatively normal liver echo-texture. The presence of a mass or masses in the resected part of the liver segments on preoperative ultrasonography was regarded as possible hepatocellular carcinoma, and these results were compared with the surgically resected hepatic lobes or segments. Accuracy for detection was assessed on a lesion-by-lesion basis, on a segment-by-segment basis, and on a patient basis.

RESULTS

One hundred and fifty-seven hepatocellular carcinomas were found in 244 hepatic segments of 103 patients. One hundred and one of 157 hepatocellular carcinomas were detected using ultrasonography in 97 patients resulting in a sensitivity of 64%. In six patients, a solitary hepatocellular carcinoma was missed in each patient, a patient sensitivity being 94%. Using ultrasonography, 87 of 100 (87%) hepatocellular carcinomas larger than 2 cm in diameter, and 14 of 57 (25%) hepatocellular carcinomas 2 cm or smaller in diameter were revealed. On the basis of segment-by-segment analysis, the sensitivity was 78% (99 of 127 segments), specificity was 97% (114 of 117 segments), accuracy was 87% (213 of 244 segments), positive predictive value was 97% (99 of 102 segments), and negative predictive value was 80% (114 of 142 segments).

CONCLUSION

In patients with chronic liver disease and good hepatic function, ultrasonography has a sensitivity of 94% in the identification of affected patients, but for individual lesions, the sensitivity is only 64%.

A comparison between low-volume referring regional centers and a high-volume referral center in quality of preoperative metastasis detection in esophageal carcinoma

BACKGROUND AND AIM

An inverse correlation between hospital volume and esophageal resection mortality has been reported. In this study, we compared the quality of preoperative metastasis detection between a high-volume referral center with that of low-volume referring regional centers.

METHODS

In 573 patients diagnosed with esophageal cancer (1994-2003), the results of preoperative staging investigations (CT-scan, ultrasound of abdomen and neck, and chest x-ray) performed in 61 regional centers were re-evaluated and/or repeated in one referral center. The gold standards were a radiological result with > or =6 months follow-up, fine-needle aspiration, or the postoperative TNM-stage.

RESULTS

In the same group of patients, the preoperative investigations performed in regional centers detected true-positive malignant lymph nodes in 8% of patients and true-positive distant metastases in 7% of patients, whereas these percentages were 16% and 20%, respectively, in the referral center. In 72/573 (13%) patients, one or more metastases detected in the referral center had been missed in the regional centers. After allowing resectability in the presence of M1a lymph nodes, this would still have resulted in futile esophageal resections in 6% of patients. In contrast to the higher diagnostic sensitivity in the referral center, specificity was comparable between referral and regional centers.

CONCLUSIONS

This study found that, in assessing the operability of esophageal cancer, the diagnostic sensitivity of metastasis detection in a high-volume referral center was higher than that in referring regional centers. This resulted from both better CT-scanning equipment and more experienced radiologists in the referral center. Should the decision to perform esophagectomy have only been based on metastasis detection in these regional centers, over 1 in 20 patients would have undergone resection in the presence of metastases.

An audit of pre-operative skin preparative methods

INTRODUCTION

A study into how pre-operative skin preparation varies between surgical units and surgeons.

MATERIALS AND METHODS

A postal audit of general, vascular and thoracic surgeons in Northern Ireland was conducted together with a literature review to establish best practice.

RESULTS

Overall, 73 surgeons were contacted, and 63 (86.3%) responded. There was marked variation in shaving of the operative site. A wide range of solutions was used, and 14 different sequences were employed. All surgeons used a swab or sponge to apply the solutions. Several drying methods were employed.

CONCLUSIONS

There is variation in the method of skin preparation employed between surgical units and surgeons. There is limited evidence-based research on this topic. Recommendations are made as to best practice.

Incidence of Ischemic Lesions by Diffusion-Weighted Imaging After Carotid Endarterectomy With Routine Shunt Usage

Temporary intraluminal shunt was used during 72 consecutive carotid endarterectomies (CEAs) in 61 patients (bilateral CEA in 11 patients) during October 2001 and September 2005. The medical records of these patients were retrospectively reviewed. All procedures were performed with routine shunt insertion without monitoring such as electroencephalography. Pre- and postoperative diffusion-weighted magnetic resonance (MR) imaging was used to detect ischemic complications. Postoperative angiography was performed in 70 cases to detect abnormalities such as major stenosis or dissection of the distal end. Symptomatic ischemic complication occurred in one patient at 1 month. Postoperative diffusion-weighted MR imaging detected new hyperintense lesions in three patients including the symptomatic patient. Postoperative angiography confirmed that the distal end was satisfactory in all cases. The incidence of ischemic lesions of embolic origin after CEA with routine shunt usage is acceptably low if the procedure of shunt device insertion and removal is meticulously conducted.