Clinical experience with automated percutaneous discectomy

Three cases of X-linked auto-immune enteropathy with haemolytic anaemia and polyendocrinopathy are described from one related Japanese kindred. Two boys had died due to severe diarrhoea accompanied by total or subtotal intestinal villous atrophy. In contrast, although one patient showed the same symptoms and had circulating IgG antibodies against enterocytes, his condition improved dramatically and he developed well following the use of cyclosporin A (CSA). CSA may be beneficial in patients with this rare disorder. Auto-immune enteropathy should be considered as a cause of protracted diarrhoea with unknown aetiology.     

Direct endoscopic percutaneous jejunostomy (EPJ). Clinical results

Direct puncture of the small bowel under endoscopic guidance (direct EPJ) is possible in patients whose stomach has been removed or whose small bowel cannot be punctured by other methods. From January 1990 to June 1992 a total of 39 patients underwent successful direct EPJ at our institution. The indications were malnutrition after partial or total gastrectomy (n = 19), insufficient anastomosis or a stenosis after esophageal resection and esophagojejunostomy (n = 13), esophageal perforation (n = 3), fistulas (n = 2), or severe trauma (n = 2). The tubes were inserted at the bedside under local anesthesia using the string pull-through technique. The procedure was attempted in five other patients but it was technically impossible to insert the tubes in these patients. Postoperative enteral feeding was possible in all 39 patients whose direct EPJ was successful. Complications included tube dysfunction due to plugging and fracture in five patients, pressure-induced enteric ulcers in two, and local infections in three patients. The ulcers and infections were managed conservatively. We conclude that direct EPJ is a safe, effective alternative to surgical catheter-jejunostomy.     

Percutaneous bipolar discectomy. Technical principles and initial results with an in vitro model]

In the present study, the effect of bipolar radio-frequency thermocoagulation of intervertebral discs was evaluated in an in vitro model. In fresh human cadaveric thoracic and lumbar motion segments, we applied radio-frequency energy to the intervertebral disc via a variety of different bipolar HF electrodes, while simultaneously recording the temperature of the dorsal longitudinal ligament. All the segments were weighed in a standardised manner prior to and after the procedure. It was found that a combination of coagulation and vaporisation was most suitable for working on the disc. Applying energy for 300 secs resulted in an average weight loss ranging, electrode-dependently, from 0.3 to 0.7 grams, the mean temperature increase in the longitudinal ligament was 0.1 degree C per min. Clinical relevance: Our experimental data suggest that PBD may be used for the same indications as the laser in the treatment of disc disease.     

Functional results following the antegrade continence enema procedure

BACKGROUND: Forty children who underwent the antegrade continence enema (ACE) procedure for faecal soiling were studied to determine factors predictive of outcome. METHODS: There were four patient groups: (1) ambulant with spinal dysraphism (n = 13), (2) wheelchair bound with spinal dysraphism (n = 14), (3) ambulant with miscellaneous disorders (n = 11) and (4) wheelchair bound with miscellaneous disorders (n = 2). Effectiveness of the procedure was assessed using technical evaluation and quality-of-life improvement (QOLI) scores (0-5). Objective assessment included colonic transit time (CTT) and anorectal manometry. Median follow-up was 21 (range 5-37) months. RESULTS: Some 28 of 40 children achieved continence. The procedure was reversed in four of 40 children. Of the other 36 children with a functioning ACE stoma, all reported improvement in quality of life (mean QOLI score 3.5). There were no significant differences in technical evaluation score, QOLI score, CTT, manometry findings or continence between ambulant groups and the wheelchair-bound group with miscellaneous disorders. QOLI score, anorectal squeeze pressure and continence were significantly poorer in those who were wheelchair bound with spinal dysraphism. Absent squeeze pressure was associated with poor outcome. CONCLUSION: Wheelchair-bound children with spinal neuropathy have a poorer outcome following the ACE procedure. Although ACE is an effective method of promoting faecal continence, it is essential to determine the aetiology of incontinence and sphincter function before operation.     

Functional results of different reconstructive procedures after total gastrectomy

In 181 patients six reconstructive procedures were performed after total gastrectomy: Roux-en-Y (95), Henley (42), omega (21), Tomoda (16, Rosanov (4) and neogastrium (3). The functional results 2-4 months after operation were studied and compared by medical observers independently of the surgeons who had selected and performed the reconstructive procedures. Analysis of the functional results, and consideration of the degree to which the functional disorders associated with the various reconstructive procedures lend themselves to treatment, suggest that the Henley reconstructive procedure is the best, with the Roux-en-Y as a good second-best.     

The dissected aorta: percutaneous treatment of ischemic complications--principles and results

PURPOSE: Describe the principles and results of percutaneous treatment of ischemic complications of aortic dissection. MATERIALS AND METHODS: Twenty-four patients with aortic dissection complicated by ischemic compromise of the liver or bowel (n = 15), kidney (n = 18), or lower extremity (n = 13) were evaluated by means of aortography, intravascular ultrasound, and manometry, and were treated percutaneously. Visceral arteries were classified as obstructed or nonobstructed. Obstruction was classified as static, in which the dissecting hematoma extended into and narrowed the lumen of a branch artery, or dynamic, in which the dissection flap prolapsed into the vessel origin or narrowed the true lumen (TL) above it. Treatment consisted of vascular stents alone (n = 4), or balloon fenestration (n = 20) without (n = 8) or with (n = 12) vascular stents. RESULTS: Obstruction was present in 77 arteries and was static in 12 arteries, dynamic in 45 arteries, static and dynamic in 17 arteries, and indeterminate in three arteries. Percutaneous treatment did not alter false lumen (FL) pressure, but reduced the peak systolic interluminal pressure gradient from 28 mm Hg to 2 mm Hg and restored flow in 71 of 77 arteries (92%). Six patients died within 30 days (25% operative mortality), none as a result of the procedure. Two additional patients died in follow-up from complications of an expanding FL. Technical complications in two patients due to altered hemodynamics after initial intervention were recognized and corrected percutaneously during the same procedure. CONCLUSIONS: Percutaneous fenestration and endovascular stent deployment are indicated to restore blood flow to arteries compromised by aortic dissection. The prognosis of patients is related to the ischemic injury sustained prior to the percutaneous interventional procedure and, in patients with acute type I dissection who have not undergone surgery, to the preoperative stability of the FL.     

Report of a controlled clinical trial comparing automated percutaneous lumbar discectomy and microdiscectomy in the treatment of contained lumbar disc herniation

STUDY DESIGN: The results of a randomized controlled trial comparing automated percutaneous lumbar discectomy (APLD) with lumbar microdiscectomy for the treatment of small contained lumbar discal herniations are reported. All patients gave full informed consent and were assessed by an independent observer. Seventy-one patients with radiologically confirmed small contained lumbar disc herniations were randomly assigned to undergo either APLD or lumbar microdiscectomy. All patients were formally assessed by the independent assessor using the Macnab outcome classification at 3 weeks, 2 months, and 6 months after the procedure with follow-up being continued for the duration of the study. OBJECTIVE: The objective was to complete the first randomized and blinded study with sufficient numbers to provide a valid statistical evaluation of these procedures. SUMMARY OF BACKGROUND DATA: No previous randomized controlled study comparing these methods has been previously reported. METHODS: Each procedure was performed by the same surgeon using standard techniques. Statistical analysis was by the chi-square method. RESULTS: In the APLD group only 9 of 31 (29%) had satisfactory outcomes as compared to 32 of 40 (80%) for the microdiscectomy group. Of those patients in the APLD group who had an unsatisfactory outcome and who then opted to undergo surgery (20 of 22 patients), the final success rate was only 65%. Thus, the cumulative success rate of the group initially randomized to APLD including those undergoing either APLD alone or APLD and microdiscectomy after unsuccessful APLD was 22 of 31 (71%). CONCLUSION: In this group of patients, APLD is seen to be ineffective in the treatment of contained lumbar disc herniation.     

Functional results of single-lung transplantation for chronic obstructive lung disease

The feasibility and immediate tolerance of single-lung transplantation were recently demonstrated in patients with severe obstructive lung disease. Since initial reports, hundreds of procedures have been performed worldwide in such patients, but views regarding the results are still controversial. Since few data concerning medium-term functional results are available, we report here our series of 20 patients with chronic obstructive pulmonary disease who received a single-lung transplant. A group of 16 patients who survived for 6 mo or more form the basis of this report. Current 1- and 2-yr actuarial survival are 75 and 70%, respectively, with 4 perioperative deaths and 2 deaths at 9 and 15 mo after transplantation. Before transplantation the patients were severely obstructive, with a FEV1 of 17 +/- 6% of predicted, a PaO2 of 51 +/- 10 mm Hg, a PaCO2 of 49 +/- 11 mm Hg, and a 6 min walk test of 99 +/- 84 m. A significant functional improvement was observed postoperatively, the patients' FEV1 at 3 mo reached 53 +/- 13%, PaO2 81 +/- 3 mm Hg, and PaCO2 39 +/- 3 mm Hg. The distance covered during 6 min was 587 +/- 147 m at 6 mo. Throughout postoperative follow-up, lung function remained stable in some patients but decreased in others after several mo, this decline related to the occurrence of bronchiolitis obliterans, except in two patients who had airway complications. Impairment in lung function led to retransplantation in four patients, with good clinical results in three patients, one patient dying postoperatively.(ABSTRACT TRUNCATED AT 250 WORDS)     

Cockett syndrome. Initial results with percutaneous treatment in 6 patients

Intimal hypertrophy with venous spur formation caused by compression of the left common iliac vein by the right common iliac artery is advanced as the etiology of the higher incidence of deep venous thrombosis involving the left leg. In most cases of left iliofemoral thrombosis no underlying compression syndrome is detected or treated because the left common iliac vein has to be cleared from thrombi before compression can be identified. A series of 6 consecutive retrospectively analyzed patients with acute left iliofemoral thrombosis is presented. In these patients a left iliac vein compression syndrome was detected after percutaneous intraluminal thrombolysis with Actilyse (rt-PA). This compression was successfully relieved by insertion of a wall stent. Percutaneous treatment of Cockett's syndrome seems an attractive alternative for conservative and/or surgical management.     

Functional results of cataract surgery with implantation in Fuchs'' heterochromic cyclitis

Cataract removal with implantation of an intraocular lens (IOL) was performed in 66 cases of Fuchs' heterochromic cyclitis. After an average postoperative follow-up of 40 months (6 months to 10 years, 81.6% of cases obtained visual acuity superior or equal to 5/10 (16.6% with a final visual acuity of 10/10). Thirty cases were analysed, 27 had satisfactory binocular vision. Two complications explained this limited visual performance: vitreal disorders observed in 45.5% of cases were responsible for visual acuity inferior or equal to 5/10 in 23% of cases, glaucoma observed in 12.1% of cases (3 cases were secondary to cataract surgery), 25% of these patients with glaucoma lost all visual acuity and 62.5% had a high intraocular pression uncontrolled by surgery (5 cases). Other risk factors were less important: loss of transparency of intraocular lens caused by precipitates observed in one case, Irvine-Gass syndrome and retinal detachment observed in one case. The restoration of satisfactory binocular vision justifies the risks of intraocular lens implantation in cases of Fuchs' heterochromic cyclitis.     

Functional results after resective procedures involving the supplementary motor area

In this article, the authors report their experience with surgically induced supplementary motor area (SMA) deficiency syndrome in a prospective clinical trial of 28 patients who underwent surgery for tumorous (19 patients) or nontumorous (nine patients) lesions. The dominant side was affected in 17 patients and the nondominant side in 11 patients. The primary presenting symptoms included seizure activity (23 patients), hemiparesis (four patients), and aphasia (one patient). Functional topographic mapping, achieved by phase reversal of somatosensory evoked potentials, allowed precise localization of the central sulcus in 25 of the 28 patients. Motor evoked potential (MEP) monitoring, which was performed successfully in 13 of 15 cases during the resective procedure, showed no significant changes in the potentials in any patient. Immediately after surgery, 25 (89%) of the 28 patients displayed additional neurological deficits (aphasia and/or hemiparesis) that depended on the extent of the SMA resection. In 12 patients the SMA was resected completely: nine of these patients demonstrated a complete and three an incomplete deficit. In 16 patients the SMA resection was incomplete: 13 of these patients displayed an incomplete deficit, whereas three had no deficit. Neurological disorders resolved completely within 3 to 42 days (mean 11 days), except for a minimal disturbance of fine motor and/or speech function in complex tasks or at high speed. Electromagnetically elicited MEPs, examined postoperatively in five patients, were initially absent but recovered with improvement of motor function. In conclusion, although the SMA is known to control important functions such as initiation of motor activity or speech, our findings show that unilateral SMA removal can be accomplished without resulting in significant permanent deficits. Functional topographic mapping and monitoring facilitate the exact delineation of the adequate resection plane along the precentral sulcus, and postoperative magnetic resonance imaging allows precise correlation of clinical and anatomical data.     

Functional endoscopic sinus surgery: results in the young child

Recent studies have addressed the usefulness of functional endoscopic sinus surgery (FESS) in both adult and pediatric patients, but little information is available concerning the long-term followup of young children. During a 31 month period, 57 children, age six years or less had FESS performed by a single surgeon. In each case the child had failed aggressive medical management including long-term oral antibiotics. A coronal sinus CT scan was obtained prior to surgery and showed opacification of the maxillary and/or ethmoid sinuses with obstruction of the ostiomeatal complexes. A similar surgical approach was used in each case. There were no major surgical or anesthetic complications noted during the initial procedure or the followup debridement. To evaluate the results of FESS, a questionnaire was mailed to the parents of each patient. The questionnaires were completed 5 to 36 months after surgery (mean 17.3 months). Ninety-three percent of the children showed improvement based on the observations of their parents. Improvement was judged primarily by reduced symptoms, reduced need for antibiotics, and the need for fewer doctor visits during the followup period. In summary, FESS appears to offer a safe and effective technique to control sinus disease in children who do not respond to aggressive medical management. In skilled hands, this technique is associated with few complications and appears to offer relief even in young patients.     

Prostaglandin production after experimental discectomy

STUDY DESIGN: This study ascertained the effects of discectomy on prostaglandin synthesis. OBJECTIVES: The purpose of these novel experiments was to measure the levels of two prostaglandins in lumbar epidural fluid obtained from an area subjected to discectomy. For comparison, lumbar epidural fluid from a site not disturbed by discectomy and fluid from a subcutaneous site were analyzed for the prostaglandins. SUMMARY OF BACKGROUND DATA: Previous studies have shown that nuclear material obtained from degenerative discs manifests an extraordinarily high level of phospholipase A2 activity. Others have hypothesized that the known inflammatory effects of phospholipase A2 are due to the release of arachidonic acid, which is converted to various eicosanoids, including several algesic prostaglandins (PGI2 and PGE2). No previous study has continuously measured prostaglandin levels in epidural fluid or assessed the effect of discectomy on prostaglandin production. METHODS: An ultrafiltrate of lumbar epidural fluid of dogs was obtained from indwelling catheters located adjacent to spinal areas that were and were not subjected to discectomy as well as from subcutaneous tissue. The fluid was collected daily for 14 days and analyzed for PGE2 and 6-keto PGF1(alpha) (the stable metabolite of PGI2) by radioimmunoassay. RESULTS: The concentration of 6-keto PGF1(alpha) and PGE2 in fluid collected during the first 24 hours was significantly higher in the area of discectomy than in the epidural region that was not subjected to discectomy and significantly higher than in fluid obtained from the subcutaneous site. The high level of these prostaglandins at the discectomy site fell rapidly, so that by the end of 48 hours the differences in values between spinal fluid from the discectomy and nondiscectomy regions were not statistically significant. The concentration of the prostaglandins in epidural fluid decreased with time and became minimal within the second week. CONCLUSION: The removal of normal discs is accompanied for 24 hours by a marked rise in the synthesis of two prostaglandins known to produce pain. Because the concentration of prostaglandins in epidural fluid decreased rapidly thereafter, the initial surge obtained appears to be associated more with chemical factors such as phospholipase A2 than with wound healing.     

Video-assisted thoracoscopic discectomy and fusion

Anterior discectomies and fusions are performed on patients who have anteriorly herniated discs. Fusions are accomplished using bone grafts harvested from the patient or by using cadaveric bone grafts that are inserted into the disc space for stability. This procedure traditionally has been performed through an open incision, but now can be accomplished using a video-assisted thoracoscope. The benefits of this minimally invasive technique for patients include decreased blood loss, less postoperative pain, and a shorter hospital stay.     

Long-term results of percutaneous endopyelotomy in the treatment of children with failed open pyeloplasty

PURPOSE: We reviewed our experience with the safety and long-term efficacy of percutaneous endopyelotomy in children with secondary ureteropelvic junction obstruction who previously underwent open pyeloplasty. MATERIALS AND METHODS: Nine patients a median of 7 years old underwent endopyelotomy between June 1985 and July 1995. Anderson-Hynes pyeloplasty had previously been performed in all children. Antegrade endopyelotomy was done with a cold knife in conjunction with balloon dilation in some cases. Postoperative stenting lasted 6 weeks. RESULTS: The median interval between pyeloplasty and endopyelotomy was 7.5 months. Mean operative time was 240 minutes. Percutaneous endopyelotomy was successful in 8 of the 9 patients. One patient who required repeat endopyelotomy after 4 years is presently well at 5 years of followup. Average followup was 5.6 years (range 2 to 10). There was a low morbidity rate, including 1 case of urinary tract infection, 1 of pneumonia and 1 that required blood transfusion. CONCLUSIONS: Percutaneous antegrade endopyelotomy is a safe, effective and durable alternative for children who previously underwent unsuccessful pyeloplasty.