Complications of long-term jejunostomy in children

The authors reviewed 64 jejunostomies performed in 57 patients. Data were collected regarding complications and performance of the catheters. Patient diagnoses were grouped as follows: cystic fibrosis (25), neurological impairment (14), and miscellaneous other (25). Indications were malnutrition (43), inability to feed (17), and gastroesophageal reflux (4). Complications were compared between these groups. The age range was 7 days to 23 years. There were 251 tube changes over 142 years of cumulative site patency, for an average of 1.8 tube changes per year and an average life of 2.2 +/- 2.4 years per site. The longest duration was 11.7 years. Four tube changes resulted in intraperitoneal insertion (6.2% of changes). The overall complication rate was 37.5%. The major and minor complication rates were 21.9% each. Some patients had more than one complication. Stratification of complications by diagnosis showed that the highest incidence was among the neurologically impaired children (64%), followed by those with cystic fibrosis (32%) and then others (28%). Sixty-four percent of major and 54% of minor complications occurred within the first 6 months. The mortality rate was 4.7%. Infections requiring intravenous antibiotics occurred in 9.4% of the sites, at an average site age of 8.7 +/- 7.7 months. Tube dislodgment requiring surgical replacement occurred in 9.4% of the patients. Our mortality and complication rates compare favorably to those of previously reported series. Surgical jejunostomy is a reliable long-term solution to feeding but is associated with a significant risk of complications, especially in neurologically impaired children. The risk is greatest in the first 6 months after insertion, then decreases as the site "matures."     

Complications following vaginal hysterectomy

Model experiments with two structurally different proteins (alcohol dehydrogenase and salmine) show that glycine, alanine, and tyrosine are by far more frequently involved in photochemically induced cross-link formations with DNA than is cysteine. The yields for cross-link formation of thymidine with salmine (cysteine-free) are about as high as those with alcohol dehydrogenase (athiol protein).     

Evaluation of long-term results and donor site defects following transposition of connective tissue flaps

Tracheoesophageal fistula, with or without esophageal atresia (TEF/EA) appears to be a defect of blastogenesis, as is the oculoauriculovertebral (Goldenhar) spectrum (OAVS), with which it has occasionally been associated. We reviewed the records of all OAVS patients evaluated through the University of South Florida Regional Genetics Program between 1985 and 1993. Of 60 OAVS patients, three had TEF/EA. These results suggest that TEF/EA in association with OAVS is underreported. The occurrence of TEF/EA should prompt a thorough search for other known anomalies of OAVS.     

Procedural results and long-term clinical outcomes following coronary stenting in perimyocardial infarction syndromes

STUDY DESIGN: A 15-year clinical follow-up of tuberculous lesions of the lumbosacral region. OBJECTIVES: To verify the hypothesis that the lumbar lordosis and the specific biomechanics of the lumbosacral region influence and alter the healing pattern and progress of the disease when compared with their effects in other regions of the spine. SUMMARY OF BACKGROUND DATA: An estimated 2 million or more patients have active spinal tuberculosis, and the global incidence of the disease is increasing. The involvement of the lower lumbar region and the lumbosacral junction is relatively rare, with few reports in English literature. METHODS: Of a total of 304 patients forming a part of a controlled clinical trial comparing two forms of therapy in spinal tuberculosis, 53 patients had involvement of L3 and below. The following data were studied in these patients: age at start of treatment, number of vertebra involved, vertebral body loss, progress of the angle of kyphosis, and anterior and posterior growth of the involved segment during a period of 15 years. Student's t test for independent samples was used for statistical analysis. RESULTS: The fourth lumbar vertebra was the most common vertebral segment involved, and the lumbosacral junction was affected in 12 patients. The average pretreatment kyphosis was 6.4 degrees and increased to 10.2 degrees at the end of 15 years. The average kyphotio angle per vertebral body loss was 4.9 degrees, far less than in the dorsolumbar region in which kyphotic angles of 27-30 degrees have been reported. Children younger than 10 years old differed in clinical appearance and progress compared with those older than 17 years. They not only showed more extensive involvement but also had more deformity with the same vertebral loss. Twelve patients less than 10 years old had an average involvement of 3.1 vertebral bodies and an average vertebral loss of 2.2 bodies. In comparison, the average number of vertebrae involved was 1.9 (P < 0.01) and the vertebral body loss was only 0.87 (P < 0.01) in patients older than 17 years. Also, the average kyphosis was 6.4 degrees compared with only 4.2 degrees (P < 0.01) in adults. In patients older than 17 years, there was no change after 2 years, by which time the collapse was complete. Four of 12 patients less than 10 years old, showed progressive kyphosis caused by continued growth of posterior parts of the body (i.e., sequestrated hemivertebrae). CONCLUSIONS: In tuberculosis of the lumbosacral region, the development of kyphosis is minimal in patients older than 17 years, when growth has already stopped, and deformity is expressed more as foreshortening of the trunk. Children younger than 10 years old have more severe involvement with increased tendency toward greater kyphosis. They are also prone to progressive deformity through the years when the anterior growth plates are destroyed. Surgery is indicated in this group to prevent greater deformity.     

Treatment approaches following foot and ankle injury

A complete and effective rehabilitation program begins with a thorough subjective and objective evaluation of the problem and injury presented. Biomechanical changes, whether they are anatomically induced or as a result of a form of compensation, must be identified and properly addressed. During the initial phase of rehabilitation, the issues of pain and swelling often must be resolved before full range of motion and return to normal strength can be achieved successfully during the more advanced stages. It is important to incorporate the entire lower quadrant in exercises that are designed to improve proprioception and function, using both in open and closed kinetic chain exercises. Finally, the demands to which the patient is returning to must be recognized to successfully complete the recovery phase.     

Value of arthrography after supination trauma of the ankle

OBJECTIVE: To investigate the merits of arthrography after supination trauma of the ankle. DESIGN AND PATIENTS: In a group of 160 consecutive patients operative exploration was performed in cases where arthrography and/or a delayed physical examination showed positive findings. In all patients arthrography was performed within 48 h after trauma. To determine interobserver agreement, all arthrograms were independently evaluated by two radiologists, both ignorant of the first assessment. RESULTS: The prevalence of an ankle ligament lesion was found to be 76%. Of the 122 patients with a rupture of one or more ankle ligaments, 52% had an isolated anterior talofibular ligament lesion, 3% had an isolated calcaneofibular ligament lesion, and 45% had combined lesions. The site of the lesion was predominantly intraligamentous. In the determination of the presence or absence of an ankle ligament lesion, the specificity and sensitivity of the ankle arthrogram were 71% and 96% respectively. Interobserver agreement on the arthrogram was very good (kappa 0.9). In 1% of patients a clear diagnosis was not possible by means of arthrography. CONCLUSION: Arthrography provides information of high diagnostic quality with excellent interobserver agreement and therefore remains the gold standard for early diagnosis (within 48 h) of a lateral ankle ligament rupture.     

Complications and failures of total ankle prosthesis. Apropos of 21 cases

PURPOSE OF THE STUDY: The authors relate a heterogeneous series of twenty one total ankle prosthesis performed by the same surgeon with an average follow up of 37 months. MATERIAL AND METHODS: Four types of prosthesis were implanted: 4 Ramses, 8 New Jersey, 5 Star, 4 Freeman. The etiology was seven times a rheumatoid polyarthritis, ten times post-traumatic, two idiopathic arthrosis, an hemochromatosis and a late clubfoot sequelae. RESULTS: Results were appreciated according to Bousquet's criteria: 4 excellent results, 5 good, 3 fair, 9 bad. The ankle mobility was not improved by arthroplasty. We noticed 7 loosening whose 2 septic occurring between 18 and 38 months after implantation of prosthesis. DISCUSSION: This series indicates that prosthesis should be only suggested for patients over sixty years old. No difference was found between post-traumatic and rhumato?d. The pre-operative subtalar arthrosis promoted in significant way an unexpected failure occurrence. CONCLUSION: Indications for total ankle arthroplasty must remain selected. Arthrodesis remains in the immediate future, the best solution for young patients with post-traumatic arthrosis.     

Complications following total knee replacement

Forty-two months follow-up examinations on 30 total knee arthroplasties revealed the following significant complications: phlebothrombosis, 13 knees (46%); pulmonary embolism 3 patients (11%); asymptomatic loosening, 8 knees (11.4%); symptomatic loosening, 3 knees (4.8%); superficial infections, 4 knees (5.4%); deep infections, 4 knees (5.4%); peroneal palsy, 3 patients (4.3%). Early detection of thrombophlebitis by 125I fibrinogen scan and possible aspirin prophylaxis were evaluated. In view of the limited number of encouraging results, e.g. excellent 58.6 per cent; good 28.5 per cent; fair 5.4 per cent and poor 7.1 per cent, caution is advocated until extensive time elapses for more clinical experience with total knee arthroplasty.     

Complications and results of peri-aortocoval lymphadenectomy in gynecology

Periaortocaval lymphadenectomy has a low morbidity and mortality rate. The extent of affiliated procedures like radical hysterectomy and the general risk pattern of the individual patient determines the morbidity and mortality of the whole procedure. The necessary extent of periaortocaval lymphadenectomy can be derived from anatomic autoptic and histologic studies. The resection of 20 +/- 5 lymphatic notes can be achieved safely. This number can be regarded as a quality standard. The diagnostic impact on prognosis and therapy is well established while the therapeutic value of periaortocaval lymphadenectomy remains to be evaluated.     

Evaluation of treatment results for lateral ankle fractures

An analysis was performed of 18 lateral ankle fractures with fracture fissure running from above-back forward and down-ward. In this group, 15 cases were treated conservatively and three cases surgically. In eight patients an evident limitation of pronation movements was found, the remaining movement being limited to a lesser degree. In six patients traces after previous separation of tibiofibular syndesmosis were found. The conservative treatment failed to maintain normal conditions in the talocrural joint.     

Clinical results of the Mayo total ankle arthroplasty

Two hundred and four primary Mayo total ankle arthroplasties were performed in 179 patients at the Mayo Clinic from 1974 through 1988. We evaluated the clinical result after 160 arthroplasties in 143 patients who had been followed for two years or more (mean, nine years; range, two to seventeen years). The result was good for thirty-one ankles (19 per cent), fair for fifty-five (34 per cent), and poor for seventeen (11 per cent); fifty-seven arthroplasties (36 per cent) were considered to be a failure (defined as removal of the implant). Adequate preoperative and follow-up radiographs were available for 101 ankles (eighty-nine patients). There was radiographic evidence of loosening of eight tibial components (8 per cent) and fifty-eight talar components (57 per cent), but we found no association between the clinical and radiographic results. Complications occurred after nineteen (12 per cent) of the 160 arthroplasties, and ninety-four additional reoperations were necessary after sixty-six (41 per cent). On the basis of these findings, we do not recommend ankle arthroplasty with a constrained Mayo implant for rheumatoid arthritis or osteoarthrosis of the ankle.     

Complications following day case paediatric surgery

Several children have day surgery under general anaesthesia and depend on adult relatives for support and postoperative care at home. This prospective review examines the post operative problems encountered by 62 such children from the time of discharge from hospital to the first outpatient visit. The children were in the age range 3 months to 12 years. The commonest complications reported were:- Pain (18.9%), Cough/Sore throat (18.9%), Fever (16.2%), Restlessness (13.5%), Vomiting (12.2%), and Sleeplessness (6.7%). Eight patients reported more than three complications each. Day case surgery should not be regarded as "Minor Surgery" under Minor Anaesthesia", rather, the concerns for safety and comfort of the patients should extend beyond the recovery room to the ward and home.     

Acute appendicitis following abdominal trauma

Acute appendicitis (AA) is generally considered to be a consequence of lumenal obstruction and inflammation of the appendix. At the beginning of the 20th century, trauma was considered to be one of the possible causes of AA but this relationship has not been examined much since then. Our experience with three cases of AA following blunt abdominal trauma led to an extensive review of the world literature on the subject. We believe that abdominal trauma might be causative of AA. The potential for this hazardous and easily missed diagnostic entity should be appreciated in cases of blunt abdominal trauma both for sound clinical decision making and for its potential medical and legal implications.     

Difficult intubation following thoracic trauma

A previously fit 20-year-old man presented with a large haemothorax following a stab wound to the left chest. Pre-operative airway assessment indicated that tracheal intubation would be routine. On induction of anaesthesia, visualisation of the larynx proved impossible because of soft tissue swelling. Successful intubation was eventually achieved with the aid of a gum elastic bougie. At operation, the patient's common carotid artery was found to have been perforated close to its origin on the aorta. The patient made an uneventful recovery.     

Acute and long-term outcomes of extremely injured blunt trauma victims

Long-term outcomes after blunt trauma remain poorly defined. The purpose of this study was to document such outcomes in extremely injured adults (Injury Severity Score > or = 50). From April 1990 to June 1993, 76 patients (5% of all trauma victims) had an ISS > or = 50 at a single trauma center. Thirty-five (46%) survived to hospital discharge. The mean duration of hospital stay was longer for survivors than for nonsurvivors (92 days versus 16 days, p < 0.001). Of the 35 survivors, 26% were discharged directly home, 60% to a rehabilitation hospital, 8% to a chronic care facility, and 6% to an acute care hospital. After a mean follow-up of 27 months, 6% had died, 9% refused participation, and the remaining 30 patients (91% of long-term survivors) demonstrated significant residual disabilities in physical, emotional, and mental health status. We suggest that extremely injured patients comprise a small proportion of blunt trauma victims, consume substantial acute care hospital resources, often survive, and yet frequently have residual disability. A reduction in this long-term disability may represent the greatest challenge in modern trauma care.     

Complications, hospital mortality and survival following partial pancreaticoduodenectomy

OBJECTIVE: To analyse hospital mortality, complications and survival of patients after subtotal pancreaticoduodenectomy in the Academic Medical Centre, Amsterdam, the Netherlands, 1983-1996. DESIGN: Partly retrospective (1983-August 1987), partly prospective (September 1987-1996). METHOD: Patient characteristics, indication for surgery, postoperative complications, mortality and survival of patients who underwent subtotal pancreaticoduodenectomy were recorded in a computer database. Patients were subdivided into three groups (1983-September 1992; October 1992-1994; 1995-September 1996) to analyse the influence of change in surgical technique and the increase of experience. RESULTS: From 1983-to September 1996, 312 consecutive patients underwent a subtotal pancreaticoduodenectomy. Hospital mortality decreased from 4.9% to 1.4% in the last period (1995-1996). The complication rate decreased from 60% to 41%. The hospital stay decreased from median 24 days to 16 days. The actualized 5-year survival analysed for patients operated from 1983-to September 1992 was 31%. Patients with ampullary tumours had a 5-year survival of 50%. The 5-year survival of patients with bile duct and pancreatic carcinoma was 24% and 15% respectively. CONCLUSIONS: Subtotal pancreaticoduodenectomy can be performed safely with a low mortality (< 2%) in specialised centres. The morbidity is still substantial (40%). The survival is mainly dependent on type of tumour and patient selection and is approximately 50% for patients with ampullary tumours. The pylorus preserving procedure has become the standard operation.