Surgical management of patients with osteogenesis imperfecta: 10 years'' experience

INTRODUCTION: Chondromas are rare intracranial tumors. The authors present two cases of intracranial intradural chondroma, one originating from the falx cerebri and the other from the dura mater of the convexity. METHOD AND RESULTS: Diagnostic procedures, including magnetic resonance imaging, and surgical findings are described. In both cases, pre-operative diagnosis could have been at least suspected, and the tumor was completely removed, without recurrence after a follow-up of many years. The pathogenesis and pathological findings are discussed, and cases from the literature are reviewed. CONCLUSION: Benign intradural chondroma has a good prognosis, with no recurrence after surgical excision in most cases.     

Two-year experience with ureteral stones: extracorporeal shockwave lithotripsy v ureteroscopic manipulation

Extramedullary hematopoiesis associated with thalassemia causing spinal cord compression is an extremely rare event in the course of the disease. Documentation with an imaging technique, such as MRI, is mandatory. A patient with thalassemia intermedia, who developed paraparesis in spite of transfusion, underwent surgical decompression. Rapid neurological improvement was observed postoperatively and this neurological condition was protected with adequate hemoglobin level. Management of these patients remains controversial. Various modes of therapy such as surgical decompression, radiotherapy, and transfusion are discussed and the related literature is reviewed.     

Shoulder dystocia: fifteen years'' experience in Ramathibodi Hospital

Although shoulder dystocia does not occur frequently the adverse effect to the patient and especially to infants can be catastrophic. The purpose of this study was to evaluate the incidence, the factors which may be related to or predispose to this condition and the consequence to the patients and their infants. All cases of shoulder dystocia which occurred during the fifteen year period from January 1982 to December 1996 were scrutinized. There were 17 cases of shoulder dystocia from a total of 109,923 deliveries giving the incidence of 1.6 per 10,000 deliveries. Of these 17 patients, 11 (65%) were delivered by vacuum extraction. Two patients had postpartum hemorrhage requiring blood transfusion. Infants' birthweights ranged between 3350 to 5160 grams. Erb's palsy occurred in 6 infants and all made full recovery subsequently.     

Reported live births following induced abortion: two and one-half years'' experience in Upstate New York

A rat-liver microsomal system in vitro has been used to activate two indirectly acting carcinogens, DMN and DEN. On activation, both compounds were extremely potent in inducing chromosomal aberrations as well as sister chromatid exchanges in Chinese hamster cells. The implications of these findings and the potential utility of this technique to detect mutagens/carcinogens are discussed.     

Ureteroscopic management of intrarenal calculi

PURPOSE: To determine its potential role in stone therapy, we evaluated our experience with the ureteroscopic removal of intrarenal calculi in 100 patients. We review the indications, techniques, stone-free and overall success rates, and complications. MATERIALS AND METHODS: From July 1994 to December 1996 ureteroscopic stone removal was attempted in 100 patients a mean of 52 years old who had renal calculi. Indications for treatment included concurrent ureteral stones in 56 cases, and failed extracorporeal shock wave lithotripsy, medical or percutaneous management as well as obesity and anatomical anomalies. There were 2 or more calculi in the affected kidney in 68 patients and stones greater than 6 mm. in 67. Treatment of intrarenal calculi was performed with flexible ureteroscopes, a laser or electrohydraulic lithotriptor and endoscopic graspers. The number and size of calculi were noted in each patient. Stone-free and overall success rates defined as 1 residual fragment less than 3 mm. were noted at 1 and 3-month followup visits. RESULTS: The overall success rate was 89%. Ureteroscopic treatment of intrarenal calculi resulted in a 77% stone-free rate. Of the 23 patients with residual calculi 12 (52%) had a single residual fragment less than 3 mm. The targeted stone was removed or fragmented in 98 patients (98%) and no ureteral calculi remained postoperatively. As expected, the number and size of the original stones inversely correlated with the success rate. There were no intraoperative complications, and only 3 urinary tract infections and 3 fevers were noted postoperatively. CONCLUSIONS: The use of smaller diameter ureteroscopes, better working instruments and more effective lithotriptors allow calculi in all parts of the collecting system to be engaged and treated. Success rates throughout the whole collecting system are comparable to if not better than those of extracorporeal shock wave lithotripsy and percutaneous approaches.     

The ultrasonic diagnosis of ureteral stones in children

Ultrasonography (USG) was performed in 117 children aged 8 months-14 years with ureterolithiasis. X-ray and ultrasonic evidence was compared for the upper, middle and low parts of the ureter. USG proved preferable for imaging of the upper and low ureter, x-ray negative concrements, in loss of renal function, while x-ray was much more informative for visualizing middle part of the ureter. Thus, USG is thought highly effective in diagnosis of ureterolithiasis in children.     

Two years'' experience with photodynamic therapy of bladder carcinoma

Emergent cardiac catheterization was performed on a 70-year-old female patient who was admitted for further evaluation of acute myocardial infarction. Coronary angiography didn't reveal any significant stenotic lesion, but levogram showed extensively abnormal contractility around the center of the apex region. On the second hospital day, 99mTc-PYP/201TlCl dual SPECT gave findings similar to those found in acute myocardial infarction, but myocardium--released enzyme stayed within the normal range. Two weeks after, 201TlCl myocardial scintigraphy showed disappearance of the perfusion defect, and normal contractility was observed on the levogram of the chronic phase. Since this case was clinically denied to be myocardial infarction, it was considered a typical case of stunned myocardium which showed prolonged left ventricular abnormal contractility with transient myocardial ischemia. This is a case suggestive for estimations of myocardial reversibility in patients with myocardial perfusion and metabolic disorder in dual SPECT.     

Endoscopic papillary balloon dilation for the management of common bile duct stones: experience of 226 cases

PURPOSE: The purpose of this study was to assess the efficacy of the free fibula flap in patients who had failed prior attempts at bony reconstruction. PATIENTS AND METHODS: The records of all patients who had undergone free fibula reconstruction for segmental mandibular resections between 1993 and 1995 were retrospectively reviewed. Patients were divided into group I (14 patients who had failed previous bony reconstruction attempts) and group II (50 patients who had no previous reconstruction), and the two groups were compared. RESULTS: No statistical differences were found between group I and group II for mean age, mean hospital stay, mean intensive care unit stay, mean operating room time, mean intraoperative blood loss, mean colloid usage, or mean blood units transfused. Although group I had a statistically higher proportion of both patients with osteoradionecrosis and those receiving hyperbaric oxygen therapy (HBO), the number with a history of radiation therapy was not different in the two groups. Wound complication rates were not statistically different between groups I and II for all patients, or between those group I patients who did or did not receive HBO therapy. CONCLUSION: There was no increase in wound complications in the patients who had failed prior bony reconstructive attempts who underwent free fibula flaps. The free fibula flap is suggested as the reconstructive method of choice in this patient population.     

Endoscopic treatment of reflux by subureteric collagen injection: critical review of 5 years'' experience

This retrospective study analyses the benefit of surgery to patients with pelvic metastases. Forty-three patients were operated on between 1980 and 1992, 37 having intralesional and 6 extralesional resections. Thirty-nine had perioperative adjuvant therapy. Survival time was calculated by the Kaplan-Meier method. Clinical evaluation used the Karnofsky performance status which showed improvement from 55% before operation to 74% at 3 months (p = 0.0001) and 77% after 6 months (p = 0.0001). Those having an intralesional resection had a median survival time of 13 months, a complication rate of 24% and a local recurrence rate of 19%. The comparable figures for those with extralesional resection were 16 months survival, complications in 3 out of 6, and no local recurrences. The quality of life was improved by operation and intralesional resection is preferable in most of these patients.     

Primary biliary stones: diagnosis and management

To review the results of treatment of primary biliary stones, 96 consecutive patients managed from 1991 to 1996 were studied retrospectively. Acute cholangitis and abdominal pain were the presenting symptoms in 57 patients (59%) and 29 patients (30%), respectively. Fifty-four patients (56%) had a history of biliary surgery. Endoscopic retrograde cholangiopancreatography, ultrasonography, and computed tomography were frequently employed for diagnosis of primary biliary stones and were performed on 84 patients (88%), 90 patients (94%), and 89 patients (93%), respectively. Intrahepatic stones were identified in 91 patients (95%) and biliary strictures in 34 patients (35%). Concomitant cholangiocarcinoma occurred in 15 patients (16%). Hepatic resection was required in 55 patients (57%) for removal of an atrophic liver lobe or a segment related to repeated infection, biliary strictures, liver abscesses, or cholangiocarcinoma. Intraoperative choledochoscopy was routinely performed in all patients to detect, remove, or confirm clearance of biliary stones. A hepaticocutaneous jejunostomy (HCJ) was constructed in 70 patients (73%) to facilitate postoperative choledochoscopic examination or biliary stone extraction. Twenty-two patients (23%) had residual stones and required postoperative choledochoscopic extraction. Complete eradication of residual stones was achieved in all patients. Postoperative morbidity occurred in 28 patients (29%), and there was one hospital death (a patient with cholangiocarcinoma). With a median follow-up of 26 months (range 2-62 months), stones recurred in three patients. In conclusion, the early results of treatment of primary biliary stones were satisfactory owing to a systematic, aggressive approach that consisted of hepatic resection, frequent construction of an HCJ, and postoperative choledochoscopy.     

Treatment of ureteral stones: comparison of extracorporeal shock wave lithotripsy and endourologic alternatives

Demographic data, personal and familial characteristics, as well as DSM-III-R-based psychiatric diagnoses were collected in 369 adolescents and young adults aged between 15 and 29 years, referred to an Emergency Department for psychological problems. In total, 60% of them were suicide attempters. Separations before the age of 12 years and depression in the family emerged as the main features distinguishing the suicidal group from the psychiatric control group. Fifty per cent of suicide attempters were repeaters. Fostering during childhood, suicide attempts and depression in the family were found to be risk factors for repeated self-attempts. These results support the view that significant levels of dysfunction, together with increased psychiatric morbidity, especially suicidal behaviour, characterize the families of young self-attempters.     

Endoscopical management of ureteral trauma

Ureteric injuries are encountered with increasing frequency. Adequate definitions and etiologies are discussed. All treatment modalities are summarised with special attention for the use of JJ stents, the different endourological approaches and "urological pearls".     

Impact of early operation on the mortality from bleeding peptic ulcer --ten years'' experience

An experimental protocol was tested to measure elastic properties of connective tissue displaying viscoelastic as well as plastic properties. The protocol consisted of a slow rate, linear elongation (0.88 mms(-1), 8 mm) in combination with a superimposed sinusoidal vibration of small amplitude (50 Hz, 0.1 mm). Using digital filters and mathematical algorithms, the force responses to linear elongation and to vibration were obtained. The method was tested on excised fibromuscular tissue of the vaginal wall obtained from women who suffered a vaginal prolapse. The force-stiffness and force-elongation relationships based on the vibration response were unaffected by any long-term deformation of the specimens. The directly measured force-elongation curves were strongly affected by these deformations. It was therefore concluded that with the new method, it is possible to determine the elastic properties accurately. Furthermore, this method seems more sensitive to small changes in elastic properties than the classic tensile test.     

Medical management of common bile duct stones

Common bile duct stones are a common cause of morbidity and mortality in adults. An increasing number of surgical and medical therapies are available to manage them, with different success rates reported. The various medical treatment strategies were developed during the last decade, but these medical modalities should not be contemplated as a first-line alternative of treatment. A consensus from experts is that there is no primary indication to use solvents on common bile duct stones because they have a relatively high rate of adverse effects and their success is limited compared with lithotripsy. However, there is a subgroup of patients in whom invasive or surgical treatment is risky or may fail. In these patients stone dissolution by solvent may constitute a plausible therapeutic alternative or may help reduce the size of the stones sufficiently to facilitate subsequent endoscopic extraction. Solvents may also be indicated in settings where endoscopic techniques or lithotripsy are not available and the patient has a T-tube in the common bile duct. Even in this condition, however, it is probably quicker and more effective to refer the patient to a center with expertise and technologic support to practice stone removal.     

Retained stones in the common bile duct: results of management

Seventeen patients underwent treatment for retained common bile duct stones. In 7 patients the stones were removed via a T-tube tract using steerable catheters while 5 patients underwent ERCP and sphincterotomy and 5 underwent surgical re-exploration. Considering morbidity, mortality, success rate and patients' stay in the hospital, non-operative modalities should be the treatment of choice for retained common bile duct stones.     

Bacteriuria and colonization of double-pigtail ureteral stents: long-term experience with 237 patients

We prospectively studied 266 patients with indwelling double-pigtail ureteral stents to determine the incidence of stent colonization and associated bacteriuria. A urine culture was obtained just prior to stent insertion and was repeated at the time of its removal. The stent itself was also cultured. Of the 237 evaluable patients, 71 (29.9%) developed bacteriuria. Of the 237 stents, 161 (67.9%) became colonized with microorganisms. Pseudomonas aeruginosa was the most common pathogen isolated from the urine and the stents. Stents in female patients had a higher rate of colonization than those used in males (74.4% v 66.5%). The longer the duration of stenting, the higher was the rate of colonization (58.6% for stents left for < 1 month v 75.1% for those left for > 3 months). The rate of colonization according to catheter type was as follows: C-flex 55.5%, silicone 62.6%, urethane 100%, and Urosoft 56%. Long-term ureteric stenting is associated with a high rate of bacteriuria and stent colonization. The duration of stenting and the type of stent influence the results. We recommend that patients with double-J ureteral stents who could be at risk from bacteremia be covered by appropriate antibiotics, and the stents should be kept indwelling for the shortest possible time. If a patient with a stent develops symptomatic infection, an antibiotic should be started that covers the Pseudomonas species.     

Penetrating ureteral injuries: the impact of associated injuries on management

The ideal management for penetrating ureteral trauma is primary repair, but the effect of other abdominal injuries might preclude this. We attempted to determine what factors could be used to predict a poor outcome of a ureteral anastomosis, so that the initial management can be modified appropriately. The case notes of 41 patients treated for penetrating ureteral trauma were studied retrospectively. Any factors that could influence postoperative complications and outcome were statistically analyzed in order to determine which could be used pre- or intraoperatively to indicate a poor prognosis for the ureteral anastomosis. The presence of shock on admission (P = 0.013), intraoperative bleeding (P = 0.006), colonic injury and specifically injury requiring colectomy (P = 0.006) were associated with a high complication and mortality rate. Patients presenting with penetrating ureteral trauma who are severely shocked and have complicated intraoperative hemostasis and patients who require colectomy should not have a primary ureteral anastomosis, but rather initial ureteral exteriorization or even nephrectomy.     

Acute cholangitis and pancreatitis secondary to common duct stones: management update

Gallstones are found within the main bile duct (MBD) of 7% to 20% of patients undergoing cholecystectomy. MBD stones are the commonest cause of acute cholangitis and acute pancreatitis. Acute cholangitis is the result of infection superimposed on an obstructed biliary system and carries a high mortality rate if left untreated. The mainstay of treatment is a regimen of broad-spectrum intravenous antibiotics followed by prompt decompression of the obstructed biliary tree. Decompression is best accomplished by the endoscopic route, although transhepatic approaches may also be employed. Gallstone pancreatitis may be associated with cholangitis but is also common as a separate entity. Initial treatment is supportive, although new agents designed to suppress the systemic inflammatory response are under development and have proved beneficial in clinical trials. Severe cases should be treated with systemic antibiotics and early removal of the obstructing stones by endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy. Prophylactic cholecystectomy is recommended to prevent further episodes of gallstone pancreatitis.