Necrotizing Fasciitis Originating in the Hand: A Systematic Review and Meta-Analysis

Necrotizing Fasciitis (NF) is a rapidly progressive and potentially lethal infection. This systematic review focused on the treatment and prognosis of the NF of the hand. The literature search was performed in PubMed database, and cohort studies and case reports were deemed eligible. Proportions were pooled to estimate overall mortality and amputation rates, and a logistic regression analysis was performed to evaluate predictors of amputation and mortality. The search algorithm resulted in 51 eligible articles including 48 case reports (54 patients) and 3 larger retrospective cohort studies (107 patients). Most patients had a monomicrobial infection, a surgical debridement on the day of admission, and hospital stay of more than 10 days. The estimated overall amputation rate was 28%, whereas overall mortality was equal to 8%. In the pooled set of case reports, mortality was significantly associated with age older than 54 years and marginally with diabetes mellitus. Necrosis expanding more proximally to the forearm correlated with both amputation and mortality. It is reiterated that early diagnosis of NF is of paramount importance and that early and decisive surgical intervention should have low threshold, especially when potential risk factors are identified.

National audit of non-melanoma skin cancer excisions performed by plastic surgery in the UK

A national, multi-centre audit of non-melanoma skin cancer excisions by plastic surgery.

371 Use of Trello as a Project Management Tool for Collaborative Surgical Research and Audit

Introduction

Managing surgical research projects alongside clinical commitments requires organisation, prioritisation, and communication. Our unit is a tertiary plastic surgery centre with a large workforce, high volume case load and abundant research opportunity. In a busy department, co-ordination and communication is imperative for timely high-quality research and audit output and maximum productivity. Tools can be used to support this output; we trialled use of Trello project management software to increase productivity in this context.

Method

We set up a Trello account for our unit’s plastic surgery department. All consultants and trainees have access, and each project has a timeline and standardised progress checklist to support completion of projects to a uniform high standard.

Results

Our Trello for Surgical Research pilot has promoted organised collaborative working and reduced duplication and partial completion of audit and research projects within our department. It has encouraged engagement between smaller subgroups within the unit, and a platform to monitor progression through key stages of project development with oversight of an appointed Research Lead, resulting in an increase in completion of closed loop audits and research projects.

Conclusions

Similar experiences have been described in mathematics and engineering research groups, and delivery of educational material for English Literature study, but we have not identified description of Trello as a tool for medical research. Use of such platforms increases productivity and likelihood of completion of projects, as well as providing a clear outline of a departments’ research priorities and accessible opportunities for rotating juniors.

1465 Anaesthetic Preferences in a Tertiary Hand Surgery Unit & Aetiology of Hand Trauma Presentations During the First UK lockdown: Lessons for the Future

Introduction

Our tertiary plastics unit serves a 4.3 million population in the South East, providing a seven-day hand trauma service. Our aim was to assess differences in quantity and aetiology of hand trauma during the April 2020 lockdown compared with the equivalent period in 2019, and our ability to reduce risk by carrying out more procedures under local anaesthetic.

Method

Retrospective notes review for hand trauma surgery patients in April 2020 (3 weeks in first UK lockdown), with a comparative period in April 2019. Fisher’s Exact Test was applied to assess for difference in method of anaesthetia, injury location (workplace vs home) and DIY versus non-DIY aetiology.

Results

2020 group: n = 165. 2019: n = 239. (31% reduction). Mean age 45 during lockdown vs 49 in 2019. There was significant reduction in the proportion of workplace injuries in 2020 (22% vs 29%), but the proportion of power tool injuries was similar (31.6% 2020 vs 26.6%). DIY injuries increased significantly (33.5% versus 9.2%). Use of local anaeshesia including increased significantly in our unit (84.2% vs 66.1% 2019) with reduction in use of regional and general anaesthesia.

Conclusions

Caseload somewhat reduced during lockdown. Fewer injuries occurred in the workplace. Our unit made good use of local anaesthetic techniques to avoid regional anaesthesia (and risk of need for GA conversion) wherever possible. Public safety warnings existed (BAPRAS and BSSH), but perhaps were less publicly available than desirable. Improving awareness further could reduce trauma surgery burden as we enter a third wave of the pandemic.

The perils of dressings: a cautionary tale of ischaemia

A cohort of patients presented to Queen Victoria Hospital, UK, with iatrogenic toe ischaemia following application of a different, newly available post-procedure dressing with different properties to those usually used. This resulted in ischaemia with extensive skin and soft tissue damage, requiring debridement surgery and, in some cases, skin grafting. We aim to highlight the risk of morbidity from dressing application to the digits. This is a key learning skill for anyone who may either perform dressings or evaluate dressings on digits in the community and across multiple specialties in hospital. This article follows a thorough root cause analysis and addresses other possible causes of an acutely painful erythematous toe post-Zadek's procedure.

Dilemmas in the management of rhinophyma in pigmented individuals

Rhinophyma affects predominantly the Caucasian population and is rare in those with Fitzpatrick skin type IV-VI. Diagnosis is based on clinical evaluation. Prominent features include abnormal coloration and texture of skin, impaired vascularity, irregular nodular exophytic growth and telangiectasia. Management can be surgical or dermatological. Surgery remains the mainstay of treatment but achieving an acceptable aesthetic result can be challenging, particularly in those with pigmented skin. Postsurgical hyper- and hypopigmentation make for unpredictable outcomes requiring appropriate preoperative counselling. We present a case that exemplifies this issue and discuss our recommended approach to counselling, consenting and managing such dilemmas in these patients, and a proposal for further investigation into the role of autologous melanocyte transplantation in reducing the effect particularly of hypopigmentation on aesthetic outcomes in this group.

Optimal postoperative management of perineal flaps in oncologic patients undergoing extralevator abdominoperineal excision: An introduction of a postoperative monitoring and flap management protocol

There is extensive discussion regarding method of perineal defect closure extralevator abdominoperineal excision, but little consideration of optimal postoperative management of the flaps, or use of Enhanced Recovery After Surgery in flap reconstruction. Literature review revealed little discussion of optimum postoperative care of perineal flaps following extralevator abdominoperineal excision. We have developed a protocol for postoperative care of perineal flaps for use in conjunction with colorectal Enhanced Recovery After Surgery pathways, easily followed in units not specialising in plastic surgery. The protocol was developed using translatable evidence from guidelines for flap care from other subspecialties, as well as the experience of management of post-extralevator abdominoperineal excision perineal flaps in our trust, with the aim of enabling early detection of deterioration in this complex cohort, with a multidisciplinary enhanced recovery approach.

Prevalence of eosinophilic esophagitis: A multicenter study on a pediatric population evaluated at thirty-six Latin American gastroenterology centers

INTRODUCTION AND OBJECTIVE

Eosinophilic esophagitis is a chronic, immune-mediated disease described in case series and publications worldwide. Over the past twenty years, the authors of different studies have attempted to evaluate its incidence and prevalence. The objetive of the present study was to estimate the prevalence of eosinophilic esophagitis in a group of children seen at 36 pediatric gastroenterology centers in ten Latin American countries.

MATERIALS AND METHODS

A multicenter, observational, and cross-sectional study was conducted that estimated the period prevalence of eosinophilic esophagitis in children seen at outpatient consultation and that underwent diagnostic upper gastrointestinal endoscopy for any indication at 36 centers in 10 Latin American countries, within a 3-month time frame.

RESULTS

Between April and June 2016, 108 cases of eosinophilic esophagitis were evaluated. Likewise, an average of 29,253 outpatient consultations and 4,152 diagnostic upper gastrointestinal endoscopies were carried out at the 36 participating centers. The period prevalence of eosinophilic esophagitis in the population studied (n=29,253) was 3.69 cases×1,000 (95% CI: 3.04 to 4.44), and among the children that underwent routine upper gastrointestinal endoscopy (n=4,152), it was 26x1,000 (95% CI: 22.6 to 29.4).

CONCLUSIONS

The general period prevalence of eosinophilic esophagitis in a group of children evaluated at 36 Latin American pediatric gastroenterology centers was 3.69×1,000, and in the children that underwent endoscopy, it was 26×1,000. There was important prevalence variability between the participating countries and centers. The present analysis is the first study conducted on the prevalence of pediatric eosinophilic esophagitis in Latin America.

Improving weekend review for trauma and elective orthopaedic patients in the post-operative period

Purpose

Weekend surgery carries higher mortality than weekday surgery, with complications most commonly arising within the first 48 hours. There is a reduced ability to identify complications at the weekend, with early signs going undetected in the absence of thorough early patient review, particularly in the elderly with multiple co-morbidities. Weekend working practices vary amongst UK hospitals and specialties. The weekend effect has been a prominent feature in the literature over the past decade. The purpose of this paper is to identify the number of patients undergoing weekend surgery who receive a Day 1 post-operative review and improve this outcome by implementing an effective change.

Design/methodology/approach

It was observed that not all patients undergoing surgery on a Friday or Saturday at the authors’ District General Hospital were receiving Day 1 post-operative review by a clinician. A retrospective audit was carried out to identify percentage of patients reviewed on post-operative Day 1 at the weekend. A change in handover practice was implemented before re-audit.

Findings

In Phase 1, 54 per cent of patients received Day 1 post-operative reviews at the weekend against a set standard of 100 per cent. A simple change to handover practice was implemented to improve patient safety in the immediate post-operative period resulting in 96 per cent of patients reviewed on Day 1 post-operatively at re-audit.

Originality/value

This study confirms that simple changes in handover practices can produce effective and translatable improvements to weekend working. This further contributes to the body of literature that acknowledges the existence of a weekend effect, but aims to evolve weekend working practices to accommodate improvement within current staffing and resource availability by maximising efficiency and communication.

Time to resolution: A prospective evaluation from the Society for Fetal Urology hydronephrosis registry

INTRODUCTION

The resolution rate of prenatal urinary tract dilation (UTD) has been documented in several retrospective studies. The present study analyzed prospective observational registry data, with the aim of determining time to resolution among patients prenatally identified with mild postnatal UTD.

MATERIALS AND METHODS

A total of 248 subjects, from four centers, were prospectively enrolled from 2008 to 2015. Exclusion criteria included other anomalies (n = 69), fewer than two ultrasounds, and/or <3 months follow-up (n = 26). Resolution was defined as Outcome A (SFU 0) and Outcome B (SFU 0/1). Fisher's exact test, Mann-Whitney U or Kruskal-Wallis test and Kaplan-Meier were used for analysis.

RESULTS/DISCUSSION

The median follow-up for 179 (n = 137 males) subjects was 15 months (IQR 7-24), range 0-56 months. VCUG was performed in 100 (57%) and VUR identified in 15 (15%). There was no association with reflux and resolution (P = 0.72). For resolution assessment (n = 153), lower grades were likely to resolve and demonstrated a higher rate in the Outcome B classification. Time to resolution also favored lower grades, with the majority resolving within 2 years (Figure). Surgical intervention was performed in 14 (8%). It is interesting to note that regardless of grade of UTD, there was no difference in frequency of US or the time that RUS was first performed. Practitioners performed the first RUS of life within a narrow window ranging from 0.27 RUS/month for Grade 1 UTD to 0.30 RUS/month for Grade 4 UTD. It was speculated that this practice pattern occurrence likely reflected the deficiency in knowledge by primary care providers, and identified a potential opportunity for education. The SFU registry substantiates that the vast majority of patients will demonstrate transient UTD and most cases that do not resolve will improve within 2 years of life. This data could be used to further an evidenced-based approach towards the evaluation and management of prenatal UTD, as outlined in the multidisciplinary consensus statement for prenatal urinary tract dilation.

CONCLUSIONS

This prospective registry confirms that the majority of prenatal UTD is transient, resolution occurs within the first 3 years of life, and most patients will not need intervention. Redefining SFU 1 as normal increased the resolution rate. A large proportion of patients were not evaluated with a VCUG, therefore impact of VUR could not be determined.

Diverse outcome following early prenatal diagnosis of pulmonary stenosis

OBJECTIVE

To assess the natural history and outcome of fetal pulmonary stenosis (PS), particularly that detected at 14-17 weeks' gestation.

METHODS

In this retrospective study we searched an electronic database of women from the general Israeli population attending a private ultrasound institute (Al-Kol ultrasound institute in Haifa) for routine complete early fetal ultrasound, including all fetal systems and a fetal echocardiogram, between 2004 and 2015. Ninety-seven percent of the women were at low risk of fetal malformations, and 3% had risk factors such as maternal Type-1 diabetes mellitus, exposure during pregnancy to teratogenic drugs, or anomalies in previous pregnancies or in other family members. At presentation at 14-17 weeks of gestation, color and pulsed Doppler imaging were performed across the four cardiac valves. We identified cases in which abnormal flow was detected, leading to suspicion of PS; in these cases, a follow-up examination was carried out at 17-19 weeks and then monthly until delivery or resolution of the finding, and postnatal echocardiography was performed at birth, 4-6 weeks thereafter, and yearly afterwards. Outcome data for suspicious cases, including postnatal diagnosis and general or specific symptoms, were collected by contacting the parents via email or telephone.

RESULTS

Among 24 185 early prenatal transvaginal ultrasound screening examinations, 23 cases of suspected PS were identified. They were classified into three groups, according to their ultrasound findings. In Group A (n = 8), the ultrasound screen was normal except for high flow velocity across the pulmonary valve. In six cases, this finding had resolved by 20-21 weeks of gestation and all were found to be normal at postnatal follow-up, one case underwent termination of pregnancy at 19 weeks and PS was confirmed at autopsy and one case was lost to follow-up. In Group B (n = 12), there was aliasing across the pulmonary valve. Two of these cases were normal postnatally and eight had mild-to-moderate PS; the remaining two cases developed hypoplastic right ventricle and pulmonary atresia at 19-20 weeks and the pregnancies were terminated. In Group C (n = 3) PS was associated with other anomalies; all three pregnancies were terminated. There were an additional six cases (Group D) not identified in early gestation, in which PS was late-onset. One had tricuspid regurgitation at the early screen, but was subsequently diagnosed with Ebstein's anomaly and pulmonary atresia, at 22 weeks, and was terminated. The other cases had completely normal early ultrasound screening examinations: one case had Ebstein's anomaly and PS was diagnosed at birth; four had isolated mild PS, of which one was diagnosed at 22 weeks' gestation and the other three were diagnosed postnatally, before 3 months of age. The sensitivity for detection of the ascertained cases of PS was 64% (11/17) and the specificity was > 99%.

CONCLUSION

There is a diverse spectrum of presentation of fetal PS in the early mid-trimester. A possible explanation for this could be different pathophysiological pathways. Further study is needed to explain the different prenatal sonographic presentations in an unselected population. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Femoral neck pseudoarthrosis in a polio patient treated with closed reduction and cell therapy

Poliomyelitis disease affects the anterior horns cells of the spinal cord and certain motor nuclei of the brain stem. Paralysis type is flaccid and asymmetrical and result in muscular imbalance.

Due to this, in case of having a hip muscles involvement, degenerative or posttraumatic, total hip arthroplasty is normally contraindicated because of the excessive risk of hip dislocation. In cases of subcapital femoral neck fractures the femoral head vascularization is a main concern, and in cases of neglected fracture with pseudoarthrosis the vascular status to the head must be investigated prior to further decisions.

We report the case of a femoral neck fracture non-union after a missed femoral neck fracture in a polio affected leg treated with cannulated screws and percutaneous autologous injection of processed total nuclear cells (TNC) mixed with putty demineralized bone matrix.

Outcome of femoral fractures care as a measure of trauma care between level I and level II trauma systems in Israel

Background

Our hypothesis in this study was that the outcome of patients with femur fractures would be favorable in a level I trauma center (LITC).

Methods

A prospective multicenter cohort study. 5 LITC and 6 regional (level II) trauma centers (RTCs) were enrolled to participate in the study. A total of 238 patients suffering from a femoral fracture were recruited to the study. 125 patients were treated in LITCs and 113 in RTCs. Data were extracted from the emergency medical services ambulances, emergency department records, patient hospitalization and discharge records, operating room records, and the national trauma registry (for LITCs). A study questionnaire was administered to all participating patients at discharge, 6 weeks and 6 months postoperatively. The following parameters were studied: mechanism of injury, time from injury to the hospital, Injury Severity Score, classification of femoral fracture, additional injuries, medical history, time to surgery, implant type, skill level of the surgical team, type of anesthesia, length of stay and intensive care unit (ICU) stay, postoperative and intraoperative complications and mortality.

Results

There was a significant difference in the modality of patient transfer between the 2 study groups-with the LITC receiving more patients transported by helicopters or medical intensive care. Time to surgery from admission was shorter in the LITC. Length of stay, ICU stay, and mortality were similar. In the LITCs, 47% of the procedures were performed by residents without the supervision of an attending surgeon, and in the RTCs 79% of the procedures were performed with an senior orthopaedic surgeon. Intraoperative and immediate complication rates were similar among the 2 groups.

Conclusions

A femoral shaft fracture can be successfully treated in an LITC and RTC in the state of Israel. Both research and policy implementation works are required. Also, a more detailed outcome analysis and triage criteria for emergency are desired.

Level of evidence

II.

Performance of manual ventilation: how to define its efficiency in bench studies? A review of the literature

Bench studies have become the preferred way to evaluate the performance of airway equipment, since clinical trials are not specifically required before marketing these devices. However, it is difficult to assess the efficiency of ventilation without recording physiological data. This review analyses how efficiency of manual ventilation has been defined in recent studies, and how their results may be affected. We searched electronic databases from 2000 to April 2014. The main inclusion criterion was the analysis of performance of ventilation. Nine relevant articles were selected from 53 eligible publications. Most studies used the same parameters; tidal volume and ventilation rate. However, there were significant differences between the definitions of performance of ventilation, both in terms of criteria of judgement and methods of analysis. None of these approaches is able to provide a clear understanding of variability of ventilation during a given period. A new definition may increase the relevance of bench studies to clinical medicine, by more appropriately assessing the performance of ventilation.

Reliability of manikin-based studies: an evaluation of manikin characteristics and their impact on measurements of ventilatory variables

Findings from manikin-based studies on ventilation are commonly directly extrapolated to clinical practice. The aim of this study was to determine how the use of manikins affects measurements of ventilatory variables. We connected a lung simulator to a manikin, which was then ventilated at different inspiratory flows. We defined three experimental models to compare measurements of ventilatory variables between the mechanical ventilator and the lung simulator. Even when no leakage occurred, significant tidal volume deviations were observed; from a mean (SD) of 21 (2) ml to 49 (9) ml, and from 40 (4) ml to 88 (5) ml for invasive and non-invasive ventilation, respectively (p < 0.001). Significant peak pressure deviations from 0.7 (0.1) cmH2 O to 10.6 (0.3) cmH2 O were also recorded during non-invasive ventilation (p < 0.001). Evaluation of manikin resistance and airway dead space may be essential to limit study bias. We suggest a recalibration of the recorded data if comparisons are made between different tests performed at different inspiratory flows.

Generalized lock-in detection for interferometry: application to phase sensitive spectroscopy and near-field nanoscopy

A generalized lock-in detection method is proposed to extract amplitude and phase from optical interferometers when an arbitrary periodic phase or frequency modulation is used. The actual modulation function is used to create the reference signals providing an optimal extraction of the useful information, notably for sinusoidal phase modulation. This simple and efficient approach has been tested and applied to phase sensitive spectroscopy and near-field optical measurements. We analyze the case where the signal amplitude is modulated and we show how to suppress the contribution of unmodulated background field.

The morphological applicability of a novel endovascular aneurysm sealing (EVAS) system (Nellix) in patients with abdominal aortic aneurysms

OBJECTIVE

Endovascular aneurysm sealing (EVAS) using the Nellix system is a promising alternative to endovascular repair (EVR) and open surgery for abdominal aortic aneurysms (AAA). The aim of this study was to investigate the proportion of patients with AAA who are morphologically suitable for treatment with Nellix.

METHODS

Patients presenting with AAA were investigated at two regionalised vascular units. Separate cohorts were identified, who had undergone infrarenal EVR, open aneurysm repair, fenestrated endovascular repair (FEVR) or non-operative management. Pre-operative morphology was quantified using three-dimensional computed tomography according to a validated protocol. Each aneurysm was assessed for compliance with the instructions for use (IFU) of Nellix

RESULTS

776 patients were identified with mean age 75 ± 9 years. 730/776 (94.1%) had undergone infrarenal EVR, 6/776 (0.8%) open repair, 27/776 (3.5%) FEVR and 13/776 (1.7%) had been managed non-operatively. 544/776 (70.1%) of all AAA were morphologically suitable for Nellix. 533/730 (73.0%) of patients who had undergone infrarenal EVR were compliant with Nellix IFU, compared with 497/730 (68.1%), 379/730 (51.9%) and 214/730 (29.3%) with the IFU for Medtronic Endurant (p = .04) or Cook Zenith (p < .01) and Gore C3 Excluder (p < .01) endografts respectively.

CONCLUSIONS

Nellix technology appears widely applicable to contemporary infrarenal AAA practice, and may provide an option for patients that are outside current EVR device instructions for use. However, formal outcomes study is still required, and will ultimately dictate the clinical relevance of this feasibility study. The major limitation to anatomic suitability for Nellix is currently the maximum patent lumen diameter of large AAA.

Tracheostomy in the critically ill: the myth of dead space

Benefits and advantages of tracheostomy have been vigorously debated. There is a lack of consensus as to whether perceived clinical improvement is attributable to fundamental changes in respiratory dynamics. We compare the effect of tracheostomy versus endotracheal tube on dead space, airway resistance and other lung parameters in critically ill ventilated patients. Data collected included patients who were admitted to surgical, burn and neurosurgical intensive care units at the University of North Carolina. Twenty-four intubated patients were included in our analysis with various aetiologies of respiratory failure. Tracheostomy was deemed necessary either for severe neurological devastation or failure to wean from the ventilator. The diameter of the endotracheal tubes ranged from 6-8 mm and the tracheostomy tube diameters were from 6.4-8.9 mm. Internal diameters between endotracheal tube and tracheostomy tubes, ventilator settings and sedation were kept consistent throughout the study. Respiratory parameters were measured using the Respironics' non-invasive cardiac output 2 device (Phillips, Andover, MA) immediately prior to tracheostomy and repeated within 24 hours of tracheostomy. Only two (8%) of the patients had slight improvement (>6% decrease in dead space). The average dead space of endotracheal versus tracheostomy tubes was 41±12.6% and 40±14.6%, respectively (P=0.75). The remaining 22 patients (92%) had no significant change in dead space, compliance or other respiratory parameters. This study shows that there is no significant difference in respiratory mechanics and dead space with a tracheostomy versus endotracheal tube.

Orthogonal double plate fixation for long bone fracture nonunion

PURPOSE OF THE STUDY

The treatment of long bone diaphyseal fracture-nonunion is challenging. While taking into account biological needs, a stable mechanical environment is pertinent for fracture healing. This work aims at evaluating the surgical management of stubborn ununited fractures using orthogonal double plating of diaphyseal fractures with limited periosteal stripping and soft tissue dissection.

PATIENTS AND METHODS

Retrospective analysis in a level I trauma center. Between the years 2007-2009, 22 patients were treated with double plating due to nonunion of long bone fractures. Long bones included three clavicles, six humeri, three femora, seven ulnae, two tibiae and one radius. The mean period between index procedures (if existed) and revision procedures was 53.35 weeks (range 6 months-3 years). The same surgical technique, independent on the anatomical location was utilized. Perioperative intravenous antibiotics were withheld until intraoperative cultures were obtained in all patients. An approach to the fracture site was performed with removal of all previous existing hardware, including aggressive debridement of the nonunion site while keeping stripping to the necessary minimum. After primary plate fixation of the fracture with adequate compression, a second plate, with at least two well spaced screws on each side, was placed at a ninety degree angle to the primary plate. Autologous bone graft or bone graft substitute was placed in most, but not all cases. All procedures and assessment of union were done by fellowship trained trauma surgeons. In the infected cases, culture specific intravenous antibiotics were administered for six weeks. Quality of life measures included DASH score of the upper extremity, lower extremity functional score (LEFS) for the lower extremity and Short From 12 (SF-12) for all patients.

RESULTS

Union was achieved in all patients, with an average time to union of 5.8 months (range 2-24 months). One patient healed after a repeat double plating, since the first procedure was unsuccessful. Tissue culture were positive in 11 out of 22 patients. One clavicular plate was removed, due to irritation. No hardware failure was noted in these cases. Mean LEFS was 59%, quick DASH score -18.5 20 and SF-12 MCS and PCS were 50.37 15.22 and 49.96 8.5 receptively.

CONCLUSION

Double plating is a biomechanically sound option for treating long bone fracture nonunion with reasonable results, provided adequate biological conditions are met including eradication of infection.

Household characteristics and allergen and endotoxin levels in Aleppo, Syrian Arab Republic

Few data are available from Eastern Mediterranean countries about levels of domestic allergens and endotoxins. Dust samples were collected from mattresses and floors of 457 homes in the Syrian city of Aleppo and analysed for antigens and endotoxins. The most important predictors for detectable levels of house-dust mite allergen Der p 1 were Arabic-style houses (OR 3.21) and newer houses (OR 1.56). In homes without cats, rubber mattresses were associated with detectable cat allergen Fel d 1 in mattress dust (OR 1.6). Cockroach allergen Bla g 2 was significantly more likely to be detected in houses over 20 years old than newer houses. Endotoxin levels were significantly higher in wool/cotton mattresses and older houses.

Out-of-hospital ventricular fibrillation in three adolescents

We describe three adolescents who experienced sudden cardiac arrest due to ventricular fibrillation in an out-of-hospital setting and survived with good neurological outcome despite delayed time to defibrillation. All three were treated with prolonged cardiopulmonary resuscitation (CPR) by certified basic life support providers prior to first defibrillation. This report stresses the importance of early, minimally interrupted, chest compression CPR in children who suffer sudden cardiac arrest in the out-of-hospital setting where defibrillation could be delayed.

Intraoperative cone-beam CT for image-guided tibial plateau fracture reduction

OBJECTIVES

A mobile isocentric C-arm was modified in our laboratory in collaboration with Siemens Medical Solutions to include a large-area flat-panel detector providing multi-mode fluoroscopy and cone-beam CT (CBCT) imaging. This technology is an important advance over existing intraoperative imaging (e.g., Iso-C(3D)), offering superior image quality, increased field of view, higher spatial resolution, and soft-tissue visibility. The aim of this study was to assess the system's performance and image quality in tibial plateau (TP) fracture reconstruction.

METHODS

Three TP fractures were simulated in fresh-frozen cadaveric knees through combined axial loading and lateral impact. The fractures were reduced through a lateral approach and assessed by fluoroscopy. The reconstruction was then assessed using CBCT. If necessary, further reduction and localization of remaining displaced bone fragments was performed using CBCT images for guidance. CBCT image quality was assessed with respect to projection speed, dose and filtering technique.

RESULTS

CBCT imaging provided exquisite visualization of articular details, subtle fragment detection and localization, and confirmation of reduction and implant placement. After fluoroscopic images indicated successful initial reduction, CBCT imaging revealed areas of malalignment and displaced fragments. CBCT facilitated fragment localization and improved anatomic reduction. CBCT image noise increased gradually with reduced dose, but little difference in images resulted from increased projections. High-resolution reconstruction provided better delineation of plateau depressions.

CONCLUSION

This study demonstrated a clear advantage of intraoperative CBCT over 2D fluoroscopy and Iso-C(3D) in TP fracture fixation. CBCT imaging provided benefits in fracture type diagnosis, localization of fracture fragments, and intraoperative 3D confirmation of anatomic reduction.

Neonatal atrial fibrillation after surgical repair of tracheoesophageal fistula with esophageal atresia

Atrial fibrillation is rare in childhood that had not been reported in neonates with normal cardiac morphology and function. The authors present a newborn who underwent surgical repair of a tracheoesophageal fistula with esophageal atresia at the age of 2 days and experienced atrial fibrillation 16 days after the procedure. A report of 35 pediatric patients in a single center over a period of 22 years identified atrial fibrillation in children with a variety of ailments including congenital cardiac anomalies before and after corrective surgery, rheumatic valve disease, Marfan's syndrome with mitral regurgitation, infective endocarditis, cardiomyopathy, endocardial fibroelastosis, paroxysmal atrial tachycardia of infants, and cardiac tumors [2]. All these patients had underlying cardiac disease.

The use of intraoperative three-dimensional imaging (ISO-C-3D) in fixation of intraarticular fractures

INTRODUCTION

The purpose of this study was to analyse the applicability and advantages of the intraoperative use of a mobile isocentric C-arm with three-dimensional imaging (Siremobil ISO-C-3D) in fixation of intraarticular fractures.

METHODS

After the fixation was judged to be satisfactory relying on the images provided by routine fluoroscopy, intraoperative CT visualisation with ISO-C-3D was performed to evaluate the fracture reduction and implant position. Intraoperative revision was performed based on the additional information ISO-C-3D provided beyond routine fluoroscopy. ISO-C-3D was used on a series of 72 closed-intraarticular fractures in 70 patients. Fracture distribution was: calcaneus (25), tibial plateau (17), tibial plafond (12), acetabulum (11), distal radius (3), ankle Weber-C (3) and femoral head (l). The primary outcome measure was revision rate after final ISO-C-3D data acquisition and prior to wound closure. Secondary objectives were to measure the additional time required for ISO-C-3D use and to determine the rate of further re-do surgeries.

RESULTS

Eight out of 72 (11%) fracture fixations were judged by the surgeon to require intraoperative revision following ISO-C-3D imaging. Prior to leaving the operating room, the surgeon was satisfied with fracture alignment in all the procedures. The mean additional operative time using ISO-C-3D was 7.5 min (8.2% of the mean total operative time). No patient required re-do surgery.

CONCLUSION

: Intraoperative three-dimensional visualisation of intraarticular fractures enables the surgeon to identify inadvertent malreductions or implant malpositions which may be overlooked by routine C-arm fluoroscopy and hence may eliminate the need for re-do procedures. ISO-C-3D adds little operative time and may preclude the need for pre-operative and post-operative CT-scans in selected cases.

Osteoid osteoma: CT-guided radiofrequency ablation using a water-cooled probe

BACKGROUND

The purpose of this study was to assess the safety and efficacy of computed tomography (CT) guided percutaneous radiofrequency (RF) ablation of osteoid osteoma by using the water-cooled probe.

METHODS

During the period from July 2002 to February 2006, fifty-one patients with osteoid osteomas localized in femur (29), tibia (10), calcaneus (2), talus (2), metatarsus (2), humerus (1), sacrum (1), scapula (1), olecranon (1), patella (1) and thoracic vertebra (1) were treated with CT-guided RF ablation using the Cooltiptrade mark Tyco Healthcare probe. Mean age was 20 (range, 3.5-57 years) and male to female ratio was 36/15. Mean follow-up period was reported 2 years (range, 9-51 months). The procedures were carried out under general anesthesia and the patients were discharged from the hospital within 24 h.

RESULTS

Technical failure was reported in only one procedure. Pain disappeared postoperatively in all the patients within 2-3 days and no patients needed analgesic treatment after a week. All patients were allowed fully weight bear and function without limitation after the procedure. Recurrence of the pain was observed in one patient who was treated successfully with a second ablation. Our primary and secondary clinical success rates were 98 and 100% respectively. In one case, wound infection was observed after the procedure as the only post-operative complication in our series.

CONCLUSION

CT-guided percutaneous RF ablation of osteoid osteomas using the water-cooled probe is a safe, effective and minimally invasive procedure with high success rate and lack of relapses.

Size and geometry of hepatic radiofrequency lesions

AIM

To report and compare the size and geometry of hepatic radiofrequency (RF) lesions using the currently available commercial devices.

METHODS

A literature search was carried out for the period from January 1st 1990 to June 15th 2003. The commercial suppliers were asked to provide all available data. For each electrode and protocol, size and geometry of single-cycle thermal lesions were registered.

RESULTS

No information at all on size and geometry of the inducible lesions was available for 17 of the 28 current commercial electrodes. Many descriptions of RF lesions are limited to the mean transverse diameter. With normal blood flow, diameter of lesions is often smaller than suggested by the length of the electrode tip or the diameter of the deployed prongs. Lesions are rarely perfect spheres but either ellipses or flattened spheres. Distortion of the RF lesion by nearby blood vessels is very common. Fusion of thermal zones between prongs of expandable electrodes can be incomplete. Blood flow interruption using a Pringle maneuver yields larger lesions that are less distorted and more complete.

CONCLUSIONS

There is insufficient experimental data for many electrodes that are currently used in patients. RF companies should provide these data before releasing electrodes for use. For those electrodes for which data exist, coagulation lesions are often smaller, less spherical, less complete and less regular than generally presumed. Accurate knowledge of size and geometry of RF lesions is crucial to prevent local recurrence.

Management of oesophageal perforation after delayed diagnosis: the merit of tissue flap reinforcement

Oesophageal perforation remains a life-threatening situation and its management represents a challenge for the surgeon, especially if diagnosis has been delayed. In most cases, a surgical approach is indicated. Simple primary repair often result in leakage. In order to avoid leakage, the primary repair should be buttressed with some kind of tissue flap. We here report our experience with 15 esophageal perforations and 10 tissue flap reinforcements performed during the last decade. The different types of tissue flap are illustrated and their results are compared with more aggressive alternatives such as oesophagectomy, T-tube drainage and oesophageal exclusion.

Mentored retroperitoneal laparoscopic renal surgery in children: a safe approach to learning

OBJECTIVE

To review the feasibility of introducing advanced retroperitoneal renal laparoscopic surgery (RRLS) to a paediatric urology division, using the mentorship-training model. Although the scope of practice in paediatric urology is currently adapting endoscopic surgery into daily practice, most paediatric urologists in North America have had no formal training in laparoscopic surgery.

METHODS

The study included four paediatric urologists with 3-25 years of practice; none had had any formal laparoscopic training or ever undertaken advanced RRLS. An experienced laparoscopic surgeon (the mentor) assisted the learning surgeons over a year. The initial phases of learning incorporated detailed lectures, visualization through videotapes and 'hands-on' demonstration by the expert in the technique of the standardized steps for each type of surgery. Over 10 months, ablative and reconstructive RRLS was undertaken jointly by the surgeons and the mentor. After this training the surgeons operated independently. To prevent lengthy operations, conversion to open surgery was planned if there was no significant progression after 2 h of laparoscopic surgery.

RESULTS

Over the 10 months of mentorship, 36 RRLS procedures were undertaken in 31 patients (28 ablative and eight reconstructive). In all cases the mentored surgeons accomplished both retroperitoneal access and the creation of a working space within the cavity. The group was able to initiate ablative RRLS but the mentor undertook all the reconstructive procedures. After the mentorship period, over 10 months, 12 ablative procedures were undertaken independently, and five other attempts at RRLS failed.

CONCLUSION

Although the mentored approach can successfully and safely initiate advanced RRLS in a paediatric urology division, assessing the laparoscopic practice pattern after mentorship in the same group of trainees is warranted. Ablative RRLS is easier to learn for the experienced surgeon, but reconstructive procedures, e.g. pyeloplasty, require a high degree of skill in laparoscopic technique, which may only be acquired through formal training focusing primarily on suturing techniques.

Percutaneous transaortic occlusion of patent ductus arteriosus using a new versatile angiographic and delivery catheter

We evaluated the usefulness of patent ductus arteriosus (PDA) occlusion using a new catheter that combines good angiographic properties, easy manipulation across the duct, documentation of aortic and pulmonary artery pressure, and coil delivery for percutaneous transaortic ductal occlusion. Thirty patients (13 females and 17 males) who met the clinical and echocardiographic criteria for the percutaneous closure of PDA were catheterized. The patients selected for this study had a small to moderate PDA with a conal or tubular shape, adequate aortic ampula, and normal or mildly elevated pulmonary artery pressure. The median age was 4.8 years (range, 10 months-20 years). Patients were catheterized by the transaortic approach using the new angiographic and coil delivery catheter specially designed for this procedure. A PDA was closed in every case. A single DuctOcclud pfm coil was delivered in 28 patients, and 2 patients had NitOcclud pfm coils for ductal occlusion. The screening time was measured and found to be 50% less than the measured screening time using other catheters in our laboratory. Only one catheter and one guidewire were used per procedure, with no need for exchange wires or the establishment of an arteriovenous loop. The procedure time was also reduced by 50%. A minimal residual shunt, demonstrated by color-flow Doppler mapping, was present in 2 patients. The new combined angiographic and coil delivery catheter is most suitable for transaortic PDA coil occlusion, significantly decreasing the procedure and screening time.

Cardiac manifestations in thiamine-responsive megaloblastic anemia syndrome

Thiamine-responsive megaloblastic anemia (TRMA) syndrome is a rare autosomal recessive disorder defined by the occurrence of megaloblastic anemia, diabetes mellitus, and sensorineural deafness, responding in varying degrees to thiamine treatment. Other features of this syndrome gradually develop. We describe three TRMA patients with heart rhythm abnormalities and structural cardiac anomalies. Eight other reported TRMA patients also had cardiac anomalies. Recently, the TRMA gene, SLC19A2, was identified, encoding a functional thiamine transporter. Characterization of the metabolic defect of TRMA may shed light on the role of thiamine in common cardiac abnormalities.

Laparoscopic dismembered pyeloplasty by a retroperitoneal approach in children

OBJECTIVES

To report our experience with dismembered laparoscopic pyeloplasty by a retroperitoneal approach in children with pelvi-ureteric junction (PUJ) obstruction.

PATIENTS AND METHODS

Between 1999 and 2002, retroperitoneal laparoscopic dismembered pyeloplasty was attempted in 21 children (one bilateral; mean age 8 years, range 1.7-17). In a flank position with four ports (one of 5 or 10 mm and three of 3 mm), the PUJ was resected and the anastomosis made using 6/0 absorbable sutures. Any redundant renal pelvis was reduced when needed. A JJ stent was inserted in all patients.

RESULTS

The procedure could not be completed by laparoscopy in four patients, the main reason being difficulty in completing the anastomosis; in the other 18 patients the procedure was successful. An aberrant crossing vessel was found in nine patients and dismembered pyeloplasty enabled ureteric transposition in all, with no conversion. The mean (range) operative duration was 228 (170-300) min and the mean hospital stay 2.5 (2-4) days. In three patients the JJ stents were not in the bladder at the time of removal by cystoscopy, and ureteroscopy was used to retrieve them. All children returned to full activities within 7 days of surgery. The mean (range) follow-up was 12.7 (2-36) months, with six children followed for> 2 years; all were asymptomatic, with imaging confirming improved hydronephrosis.

CONCLUSIONS

These mid-term results confirm that retroperitoneal laparoscopic dismembered pyeloplasty is a safe and feasible approach in children. Although the technique is very demanding it has the advantage of duplicating the principles of the open approach. The long operative duration and high conversion rate might be reduced with experience. Before expanding this approach to younger children, refinements in the anastomotic technique are needed.

Retroperitoneal laparoscopic vs open partial nephroureterectomy in children

OBJECTIVES

To compare the results of retroperitoneal laparoscopic with open partial nephroureterectomy.

PATIENTS AND METHODS

Laparoscopic retroperitoneal partial nephroureterectomy was undertaken in 15 children (13 upper and two lower poles; median age at the time of surgery 61 months, range 5-212). A three-trocar retroperitoneal approach was used. The polar vessels were identified and either coagulated or clipped before transecting the parenchyma using a harmonic scalpel. An additional 13 consecutive children underwent similar procedures (11 upper and two lower poles) by conventional open surgery (median age at surgery 16 months, range 1.5-72).

RESULTS

One patient in the laparoscopy group required conversion to open surgery because of a peritoneal tear and was excluded from the analysis. The mean (range) operative duration was 146 (50-180) and 152 (75-240) min for the open surgery and laparoscopy groups, respectively. The blood loss was minimal (< 20 mL) in both groups. The mean (range) hospital stay was 1.4 (1-3) and 3.9 (3-5) days for the laparoscopy and open groups, respectively (P < 0.001). Eight patients were discharged on the day after the laparoscopic procedure. In addition, of those patients in the laparoscopy group who had a lower-pole partial nephrectomy, one had a urinoma after surgery.

CONCLUSION

Laparoscopic retroperitoneal partial nephrectomy is a safe and feasible procedure in children. It requires a similar operative duration to that of an open procedure. The main advantage to the laparoscopic approach is that it significantly decreases the hospital stay compared with that after an open procedure.