Assessing the reliability of the modified Gartland classification system for extension-type supracondylar humerus fractures

PURPOSE

The Gartland extension-type supracondylar humerus (SCH) fracture is the most common paediatric elbow fracture. Treatment options range from nonoperative treatment (taping or casting) to operative treatments (closed reduction and percutaneous pinning or open reduction). Classification variability between surgeons is a potential contributing factor to existing controversy over treatment options for type II SCH fractures. This study investigated levels of agreement in extension-type SCH fracture classification using the modified Gartland classification system.

METHODS

A retrospective review was conducted on 60 patients aged between two and 12 years who had sustained an extension-type SCH fracture and received operative or nonoperative treatment at a tertiary children's hospital. Baseline radiographs were provided, and surgeons were asked to classify the fractures as type I, IIA, IIB or III according to the modified Gartland classification. Respondents were then asked to complete a second round of classifications using reshuffled radiographs. Weighted kappa values were calculated to assess interobserver and intraobserver levels of agreement.

RESULTS

In all, 21 paediatric orthopaedic surgeons responded to the survey and 15 completed a second round of ratings. Interobserver agreement for classification based on the Gartland criteria between surgeons was substantial with a kappa of 0.679 (95% confidence interval (CI) 0.501 to 0.873). Intraobserver agreement was substantial with a kappa of 0.796, (95% CI 0.628 to 0.864).

CONCLUSION

Radiographic classification of extension-type SCH fractures demonstrated substantial agreement both between and within surgeon raters. Therefore, classification variability may not be a major contributing factor to the treatment controversy for type II SCH fractures and treatment variability may be due to differences in surgeon preferences.

LEVEL OF EVIDENCE

III.

[Cost of laparoscopic and open incisional hernia repair]

The economic impact of new technologies must be analyzed and known by surgeons. In laparoscopic incisional hernia repair, the cost of surgery is higher than open repair because of the longer duration of surgery and the cost or materials. The cost of the hospital stay is lower because the stay is shorter and the postoperative complication rate is lower. Overall hospital costs in laparoscopic repair are lower than or equivalent to the cost of open repair. Many variables come into play in these costs. The modification of any of these cost variables will influence overall costs of either procedure. To determine the economic consequences of choices made in surgery, all surgeons must evaluate the costs generated by their practice and compare the results to published data.

[What are the traps of incisional hernia open repair?]

Open repair of incisional hernia is a simple surgery. Nevertheless, uncountable traps wait for the operator during surgery. They mark out all the stages of the procedure, from incision to skin closure. They are source of intraoperative incidents and postoperative complications. Some of these complications could be very serious and require removing the prosthesis. To avoid these incidents and these complications, the surgeon has to remain watchful throughout the procedure and has to anticipate all the traps that could arise.

[Epidemiology and delays in the management of 355 patients with lung cancer]

BACKGROUND

The epidemiology of patients with lung cancer in a Seine-Saint-Denis hospital are reported, as well as causes of diagnostic and therapeutic delays in their management.

MATERIAL AND METHODS

Retrospective analysis of cases diagnosed from January 1, 1997 to December 31, 2003.

RESULTS

Of 355 cases, 15.8% were women; the average age was 62 +/- 11. Mean smoking history was 50 +/- 24 pack years. Women were more likely to be non-smokers than men (16% and 1% respectively, p < 0.01) and were more likely to present at a young age (under the age of 50: 26.8% and 13.7% respectively, p < 0.05). Among women, adenocarcinoma was more frequent (41% vs. 25%, p < 0.05), and often presented with stage IV disease (74%). Squamous cell carcinoma occurred more frequently with increasing age (18.7% vs. 32.2% before and after the age of 60, p < 0.01). The median pre hospital, diagnostic and treatment delays were respectively 30, 10 and 9 days, the global delay from first symptom to treatment was 62 days. Surgery increased therapeutic delay by 20 days.

CONCLUSION

Our results are complementary to those found in KBP-2000-CPHG study. Young women are diagnosed at a late stage. Influence of delays on prognosis is not proved and require others studies.

Ruptured spleen: an unusual complication of laparoscopy

INTRODUCTION

Splenic rupture is a well-known complication of open surgery but is much less common at laparoscopic surgery.

CASE OUTLINE

A 45-year-old man underwent laparoscopy for perforated duodenal ulcer. The abdominal cavity was washed out and the ulcer was sutured. He was discharged on the fifth postoperative day but was readmitted because of a sharp pain in the left upper quadrant radiating to the left shoulder. He then developed haemorrhagic shock. Urgent laparotomy revealed a diffuse haemoperitoneum consequent upon a posterior subcapsular haematoma of the spleen.

DISCUSSION

There are four previous case reports of splenic rupture at laparoscopy. In the present case, a posterior subcapsular haematoma arose during lavage of the left subdiaphragmatic area. Such a haematoma is undetectable during laparoscopy.

Retroperitoneoscopic tension-free repair of lumbar hernia

Lumbar hernia is an infrequent pathology that is difficult to treat through open surgery. A 65-year-old man presented with a right-sided lumbar mass responsible for pain. This was a fatty mass of 10 x 15 cm, located in the lumbar fossa. A CT scan showed the hernia and the defect. Through a small incision in the flank, dissection was initiated with one finger; a 10-mm trocar was inserted into this incision and the retroperitoneal space inflated. Under direct vision, dissection of retroperitoneal fat was undertaken with the scope. A 5-mm trocar was inserted beyond the 11th rib. Fat in the lumbar hernia was reintegrated into the retroperitoneal space, allowing the lumbar wall defect to be seen. A polypropylene mesh was applied and stapled onto the lumbar wall to widely cover the defect. Under trans-abdominoretroperitoneal laparoscopy, lateral peritoneum, colon, and ureter are detached to explore the lumbar wall and are reinserted at the end of the procedure. Under retroperitoneoscopy, even if the space is small, retroperitoneal fat is easily detached at a distance from the colon and ureter. The defect is covered with a polypropylene mesh. It is covered with an ePTFE mesh if the retroperitoneal space cannot be closed. Surgery and follow-up were uneventful with no recurrence in this case or in the published cases. Retroperitoneoscopy and trans-abdominoretroperitoneal laparoscopy are two easy approaches for a tension-free repair of lumbar hernia.

Spigelian hernia long considered as diverticulitis: CT scan diagnosis and laparoscopic treatment. Computed tomography

Spigelian hernia (SH) develops in the spigelian aponeurosis. In some cases, its clinical symptoms may mimic those infrequently the diagnosis of sigmoid diverticulitis. Herein we report the case of a patient who for 12 years experienced a pain and a mass in the left lower quadrant that appeared after straining and then disappeared again after rest. A diagnosis of sigmoid diverticulitis was made. She was admitted to hospital for the acute onset of an intense abdominal pain in the left lower quadrant associated with fever. Physical exam showed a 10 x 15 cm mass in the left lower quadrant. Computed tomography (CT) scan showed a left-sided SH containing a small bowel loop and a sigmoid loop. The SH was reduced easily with bed rest and external pressure. Under laparoscopy, a Gore-Tex mesh was stapled on the posterior side of the anterolateral abdominal wall so that it widely covered the abdominal wall defect. The reducible SH, the incarcerated SH, and the strangulated SH represent the majority of the clinical aspects of SH. Although many differential diagnoses are proposed, but the diagnosis of sigmoid diverticulitis is an infrequent one. Ultrasound (US) scan or a CT scan that shows the defect in the abdominal wall, the hernial sac, and its contents is an easy means of confirming the diagnosis of SH. SH can be treated through a direct approach or through a midline laparotomy. Laparoscopy is advisable for a tension-free treatment with an intraperitoneal mesh. It is important to make the diagnosis of SH before its strangulation. For that reason, CT scan and US scan are highly recommended. Laparoscopic treatment, which is effective and safe, is advisable in such cases.

Digestive complications of gallstones lost during laparoscopic cholecystectomy

INTRODUCTION

Serious complications can ensue if a gallstone is dropped into the peritoneal cavity during laparoscopic cholecystectomy and not retrieved.

CASE OUTLINE

A 75-year-old-man was admitted with intestinal obstruction 8 years after laparoscopic cholecystectomy. Ultrasound scan and a contrast x-ray of the small bowel showed a gallstone within the small bowel lumen that CT scan had failed to identify. Laparotomy showed a Meckel's diverticulum plus a 4 x 6-cm gallstone in the terminal ileum. The gallstone had penetrated into the Meckel's diverticulum before migrating into the ileum and obstructing it.

DISCUSSION

Gallstones lost during laparoscopic cholecystectomy can cause an intraperitoneal abscess. In addition, they can migrate through the anterior or posterior abdominal wall or the diaphragm and into the urinary tract or bronchus. The resulting abscess can obstruct the digestive tract or drain into the digestive tract to cause a communicating abscess. It can also drain through the abdominal wall and the digestive tract to cause an enterocutaneous fistula. Lastly, the stone can migrate into the intestine and cause gallstone ileus. Following laparoscopic cholecystectomy, patients with a lost gallstone may suffer from abdominal pain and fever within days or months. Thus, all dropped gallstones should be removed during laparoscopy.

[Actinomycosis of the appendix. Report of two cases]

INTRODUCTION

We report two patients with actinomycosis of the appendix extending to the caecum and the ileum, and diagnosed postoperatively on histological analysis, the authors reviewed the literature.

EXEGESIS

Actinomycosis of the appendix can be acute or chronic. Diagnosis may be obtained preoperatively on the analysis of aspiration or biopsy material under CT scan control. It is frequently done postoperatively on the analysis of surgical specimen. Actinomycosis can be treated with antibiotics only during six months if the diagnosis is made preoperative, by surgery followed by antibiotics during 6-12 months, according to the extension of the actinomycosis, if the diagnosis is made after surgery, and by a combination of a surgery and antibiotics in complex forms.

CONCLUSION

Actinomycosis of the appendix is an infrequent pathology that merits to be known. With antibiotic therapy, we can avoid surgery or wide resections.

[Complications of misdiagnosed Bochdalek hernia in adults. Literature review]

AIM OF THE STUDY

To report 3 new cases of complicated Bochdalek hernia (BH) in adulthood and to review the literature about this rare condition.

CASE REPORT

Three adult patients were operated on for a BH undiagnosed until occurrence of acute complication. The first patient, 27 years-old, had small bowel obstruction and the diagnosis of BH, unrecognized on chest X-ray, was established on barium meal and CT scan. The second patient, 38 years-old, had epigastric pain and gastric obstruction: diagnosis of BH, unrecognized at a previous laparotomy, was established on CT scan and barium enema. The third patient, 88 years-old, had respiratory failure and gastric obstruction: diagnosis of BH, unrecognized on chest X-ray, was established on CT scan. The 3 patients were operated on through laparotomy (n = 2) ou thoracotomy (n = 1) with one post-operative death.

DISCUSSION

In adulthood, BH can remain asymptomatic for a long time before occurrence of a acute digestive or respiratory complication. Chest X-ray can be normal or misinterpreted. CT scan seems to be the most reliable examination to diagnose BH.

CONCLUSION

In adulthood, diagnosis of BH should be evocated in case of respiratory or upper digestive symptoms.

[Retroperitoneoscopy in tension-free repair of lumbar hernia in adults]

A 65 year-old-patient who had a right-side 10 x 15 cm wide lumbar hernia, with a 3 x 4 cm wide parietal defect was operated in a left lateral position, under retroperitoneoscopy. The procedure consisted in dissection of the retroperitoneal fat, reduction of the hernia and insertion of a polypropylene mesh stapled on the lumbar wall. This approach provided a good postoperative comfort, a short hospital stay and an early recovery of autonomy and activities.

[Indications for laparoscopic treatment of incisional hernias]

OBJECTIVE

The aim of this article is to describe the technique used in the treatment of ventral hernia using the laparoscopic method and at the same time to evaluate the possible advantages of this surgical approach.

METHODS

The clinical case we present regards a case of a patient who had undergone a double eventration treated with an application of a new type of prosthesis Parietex Composite of the Sofradim, using the laparoscopic method, we can be applied in intraperitoneal in contact with the intestinal loops.

RESULTS

The method we used in the laparoscopic treatment of ventral hernias has highlighted, in a short time, the solidity of the abdominal wall, a noticeable reduction of infections and a reduction of hospitalization. There developed no long term recurrence in our patients treated with this technique.

CONCLUSIONS

Laparoscopic ventral hernia treatment is currently used in a limited amount even though this pathology could be approached using the laparoscopic method. Our laparoscopic method, using the Composite prosthesis could represent a very valid method for primary and recurrent ventral hernia. This technique gives the opportunity to repair the eventration applying a prosthesis without any muscular tension, consenting, furthermore a reduction of any complications (infections, seroma, pain) that could arise and of any recurrence after the operation. Furthermore the surgical access is minimum and as we know this is of noticeable importance in aesthetics today.

[Hematemesis revealing chronic volvulus of a wandering spleen]

A 23 years old woman was admitted on emergency for an upper digestive tract bleeding and endoscopy found gastric varices. CT scan revealed a splenomegaly, a twisted aspect of the splenic pedicle and varices in the gastrosplenic ligament. Arteriography showed a narrow splenic artery and varices in the gastrosplenic ligament. After a recurrent bleeding, splenectomy was performed. There was a chronic volvulus of a wandering spleen; the splenic venous flow was passing through the left gastroepiploic vein and a gastrosplenic vein. Chronic volvulus of a wandering spleen with gastric varices is an unfrequent pathology, diagnosed by imaging and requiring splenectomy.

[Traumatic rupture of an accessory spleen]

A cyclist knocked over by a car was admitted with pain in the left upper quadrant that progressively worsened with haemorrhagic shock. Ultrasound showed a heterogenous spleen and perisplenic haematoma. Emergency laparotomy was performed and revealed rupture of an accessory spleen located on the splenocolic ligament.

[Diagnosis and treatment of spleen rupture during pancreatitis]

A 31-year old man was admitted for acute pancreatitis. His condition deteriorated progressively and he developed an acute anemia followed five days after admission by an hemorrhagic shock consecutive to splenic rupture. A 45-year old woman was admitted because of an acute episode of chronic pancreatitis. She improved progressively but developed eleven days after admission an hemorrhagic shock consecutive to the rupture of a subcapsular haematoma of the spleen. Splenic rupture, an infrequent complication of acute or chronic pancreatitis, is responsible for anemia and hemorrhagic shock. Abdominal ultrasonography and CT scan are necessary to make the diagnosis of splenic rupture and to look for risk factors of splenic rupture, i.e. necrosis in the spleen hilium, left pancreatic pseudocyst, splenic vein thrombosis, segmental portal hypertension, splenomegaly and intrasplenic collection. When possible, embolization of the splenic artery can stop bleeding. Splenectomy with distal pancreatectomy seems to be the appropriate treatment of splenic rupture.

[Value of celioscopy in treatment of isolated torsion of the Fallopian tube. Review of the literature. Apropos of 3 cases]

Isolated fallopian tube torsion (ITT) is infrequent and associated with morphologic and dynamic disturbances. Mr L, 31 years old, suffered from right lower quadrant pain which became worse during the following 48 hours. Laparoscopy revealed a right necrotic ITT which was resected by laparotomy. Mr L, 49 years old, suffered from by left lower quadrant pain with progressive onset. Laparoscopy revealed a left necrotic ITT which was resected. Mr P, 76 years old, suffered from left lower quadrant pain for 14 days. Ultrasonography revealed an adnexal mass. Laparotomy revealed a left necrotic ITT which was resected. On literature review, ITT (81 cases) was revealed by lower quadrant pain, acute onset, which quickly became worse. Pelvis examination revealed a lateral cul-de-sac pain. Ultrasonography identified tubal cystic mass with high-impedance arterial waveform on colour Doppler sonography. Diagnosis was easily established by laparoscopy. In case of clinical symptoms suggestive of ITT, pelvic and endovaginal ultrasonography and laparoscopy are indicated. Tubal preservation must be the rule.

[Cost of appendectomy: laparoscopy versus laparotomy. A retrospective study of two series of 114 cases]

This retrospective study was designed to compare the cost of laparoscopic appendicectomy (LA) in patients operated in 1991-92 and open appendicectomy (OA) in patients operated in 1989-90. Patients were matched for sex, ASA score and age into 2 homogeneous series: 114 LA and 114 OA. Costs of accommodation, operation and time off work were calculated by the observed costs method: daily cost of the inpatient unit, hourly cost of the operating room-recovery ward, and the patient's consumption. A mean specific cost was added in the case of LA. A significant difference was observed for operating time, time off work and for the cost of postoperative stay, the operation and time off work and the total cost of the disease. The excess cost of the operation in the case of LA was not compensated by the reduction of the accommodation costs A clinical benefit in terms of reduction of pain and local complications has been reported in the literature. The cost of hospitalisation is higher with LA, but the cost of time off work is decreased. LA provides a clinical comfort in all patients and an economic benefit in patients with a professional activity.

[Pre-peritoneal bisaccular umbilical and subcutaneous abscess after laparoscopic appendectomy]

Laparoscopic surgery has gained much interest since its advent the late eighties. A 36-year-old patient underwent laparoscopic appendicectomy via the transumbilical route. She was rehospitalized three times thereafter for subumblical pain. At day +48, an abscess was evacuated at the point of the umbilical trocar insertion. This hour-glass shaped abscess had a preperitoneal and subcutaneous localization, blocked by the epiploic reaction. The infection this patient developed is an unusual clinical finding as pain was localized at a distance. The umbilical site and the preperitoneal subcutaneous nature of the abscess are also unusual. This case emphasizes the gravity of post-operative abscess of the abdominal wall and the necessity for adequate prophylaxy.

[Triple jejuno-jejunal intussusception discovered and treated with laparoscopy]

Jejunojejunal intussusception is infrequent in the adult. A 17 years old women presented a right lower quadrant pain since 24 hours. Under coelioscopy, jejunum was thickened, and hyperrontractible. Three jejunojejunal intussusceptions were discovered and ensily treated under coelioscopy. During post-operative days, fibroptic gastroscopy was normal, and the first jejunal segment was normal. Intestinal barium transit showed a dilated jejunal segment with thichened mucosa. Stools parasitology was negative. Three months later, patient was admitted with right lower quadrant pain recurrence. Coelioscopy did not show any intussusception. Appendectomy was undertaken. Histological analysis showed appendiceal oxyuris. The case described is characterised by three concomitant intussusceptions, the proximal jejunal site of the intussusceptions, the site of the pain distant from the intussusceptions, the occurrence in a young adult, the coelioscopic diagnosis, and the coelioscopic treatment. Diagnostic coelioscopy with complete exploration of the small intestine permit diagnosis and treatment under coelioscopy of jejunojejunal intussusception.

Shouldice inguinal hernia repair in the male adult: the gold standard? A multicenter controlled trial in 1578 patients

BACKGROUND

Hernia repair is the second most frequently performed operation in France and in the United States, the prevalence being 36 for every 1000 males. Lowering the recurrence rate by 1% would mean 1000 fewer operations for hernia repair per year in France.

METHODS

Between 1983 and 1989, 1578 adult males with a total of 1706 nonrecurrent inguinal hernias were prospectively and randomly allotted to undergo either a Bassini's repair, Cooper's ligament, or Shouldice repair with polypropylene or a Shouldice repair with stainless steel for determination of which technique was associated with the lowest recurrence rate. Fifty-nine hernia repairs were withdrawn after inclusion. Of the 1647 remaining hernias, 52.2% were indirect, 25.6% were direct, and 23.2% were combined. Patients were seen every 6 months for 3 years and then every year. Median follow-up was 5 years 8 months (range, 3 months-8.5 years).

RESULTS

At 8.5 years, 5.6% of hernias were lost to follow-up. Ninety-seven hernia repairs failed, 50% during the first 2 years. The actuarial recurrence rate was 7.94% at 8.5 years. The Shouldice repair (stainless steel or polypropylene) was associated with fewer recurrences (6.1%) than either the Bassini's (8.6%) or Cooper's ligament repair (11.2%) technique (p < 0.001). This difference remained significant even when the maximal bias test was used. Fewer recurrences (5.9%) were observed with the stainless steel wire Shouldice repair than with polypropylene version (6.5%), but the difference was not significant.

CONCLUSIONS

Shouldice hernia repair provides the patient with the best chances of nonrecurrence regardless of the anatomical type of hernia. The Shouldice hernia repair should be the gold standard for inguinal hernia repair in men and serves as the basis for comparison with all other techniques, be they prosthetic or laparoscopic.