Showing papers in "Canadian Journal of Surgery in 1995"

Fixation of intertrochanteric hip fractures: gamma nail versus dynamic hip screw. A randomized, prospective study

Abstract: Objective To compare the efficacy of the gamma nail (GN) to the dynamic hip screw (DHS) in the management of intertrochanteric hip fractures. Design Randomized, prospective clinical trial with a mean follow-up of 52 weeks (range from 11 to 82 weeks). Setting A university teaching hospital. Patients One hundred and one patients with 102 fractures: 49 fractures were treated with the DHS and 53 fractures were treated with the GN. Interventions Fracture fixation with the DHS or the GN. Main outcome measures Comparison of duration of operation, blood loss, early and late complications, functional outcome and duration of hospital stay. Results There was no significant difference between the two groups with respect to intraoperative blood loss, days in hospital, time to union and eventual functional outcome. The length of the procedure and fluoroscopy time were longer for the GN group. Conclusions Both the GN and the DHS can be used effectively for the treatment of intertrochanteric fractures. In this study the DHS was associated with a lower risk of local complications and should still be considered to be the implant of choice for patients with intertrochanteric fractures.

Routine outpatient laparoscopic cholecystectomy.

Abstract: OBJECTIVE To determine what proportion of patients booked for elective cholecystectomy can be treated on an outpatient basis and what criteria will predict the need for hospital admission. DESIGN A prospective analysis. SETTING A 306-bed, nonteaching, acute-care community hospital on the outskirts of a major urban centre. PATIENTS One hundred consecutive patients in private referral practice scheduled for outpatient laparoscopic surgery between November 1992 and January 1994. INTERVENTION Laparoscopic cholecystectomy. MAIN OUTCOME MEASURES The proportion of patients who successfully avoided hospital admission, the degree of discomfort, complications and the objective criteria that assist in predicting the need for initial or eventual hospital admission. RESULTS Outpatient cholecystectomy was successful in 87% of the patients, and patient acceptance of the procedure was good. Advanced age, major associated health problems, acute cholecystitis and longer operations were the criteria most likely to lead to hospital admission, although none of these factors, alone or in combination, was a contraindication to outpatient cholecystectomy. CONCLUSIONS Outpatient laparoscopic cholecystectomy can be performed successfully in most patients. There are four criteria that increase the likelihood of hospital admission after this procedure.

Learning surgical technical skills

Abstract: Training issues raised by the recent introduction of laparoscopic surgical techniques led to this analysis of motor-skill learning principles as they apply specifically to the learning of technical surgical skills. The most accepted theories of motor-skill learning are presented, not as opposing views, but as complementary constructs. The behaviourist school of thought's main contribution is the executive routine or knowledge of the steps of a procedure. Schmidt's schema theory and MacKay's node theory suggest that perceptual information may play an important role in the quality of the performance. The conclusions reached from neuropsychologic testing experiments on surgeons are that visuospatial perceptual skills (the ability to represent mentally the physical environment and the movement to be performed) are the major determinants of surgical technical performance. Learners should make use of learning strategies that improve mental representation of a skill and the corresponding anatomy. Specific strategies discussed include imagery, mental practice and a systematic review of performance that focuses on the perceptual feedback received by the learner.

Stoma closure and wound infection: an evaluation of risk factors.

Abstract: Objective To assess the infection rate in the nonstoma wound in patients who undergo stoma closure. Design Chart review. Setting A tertiary-care hospital. Patients Ninety-five patients who underwent elective closure of an abdominal wall stoma requiring a separate abdominal incision. Interventions Elective general surgery procedures. Main outcome measure Wound infection rate. Results The overall wound infection rate was 29%. Primary wound closure was associated with a markedly increased wound infection rate (41%) compared with delayed primary or secondary wound closure (15%). No other preoperative factor specifically predicted a high rate of postoperative nonstoma wound infection. Conclusions The nonstoma wound during elective closure of an abdominal stoma is at high risk for infection postoperatively. Delayed primary or secondary closure may lessen this risk.

Benefit of palliative surgery for bowel obstruction in advanced ovarian cancer.

Abstract: Objectives To determine the benefit of palliative surgery for patients with advanced ovarian cancer and bowel obstruction and to identify criteria for selecting patients who are most likely to benefit from palliation. Design A retrospective study of patients treated between 1982 and 1992. Setting A university-affiliated hospital. Patients Fifty-three patients with complete and unresolved bowel obstruction caused by ovarian cancer. Intervention Surgery for relief of bowel obstruction. Main outcome measures Postoperative survival longer than 60 days, return home and relief of bowel obstruction for longer than 60 days, factors associated with failure of palliative surgery. Results Successful palliation was achieved in 27 (51%) patients and was associated with the absence of four prognostic factors: palpable abdominal and pelvic masses, ascites exceeding 3 L, multiple obstructive sites and preoperative weight loss greater than 9 kg. Age, time interval between diagnosis of ovarian cancer and bowel obstruction, stage of disease at initial diagnosis, tumour type and grade, site and degree of obstruction, presence of gross residual tumour after initial operation and preoperative use of chemotherapy or radiotherapy did not indicate the success or failure of palliative surgery. Conclusions Palliative surgery for bowel obstruction in advanced ovarian cancer can be worthwhile, and there are four prognostic factors that indicate the likely failure of palliation.

The role of hip arthroscopy in the diagnosis and treatment of hip disease.

Abstract: OBJECTIVE To report the results of arthroscopy performed on adults with hip disease who did not respond to extended conservative treatment and to evaluate the relationship between clinical findings, radiologic tests and surgical abnormalities. DESIGN A case study. SETTING New England Baptist Hospital, Boston, Mass. PATIENTS Fifty-nine patients (32 women, 27 men) with refractory hip pain, between the ages of 17 and 69 years, who were seen between January 1989 and January 1992. INTERVENTION Hip arthroscopy. MAIN OUTCOME MEASURES Cause of hip pain, results of physical examination and operative findings. RESULTS In 26 patients the cause of hip pain was traumatic; in 21 the cause was idiopathic. On physical had pain on straight leg examination, 56% of patients reported painful clicking of the hip joint, 37% had pain on straight leg raising, 9% had decreased extension and 34% had had episodes of locking of the joint. Five percent had pain predominantly in the thigh, 41% reported at least one episode of "giving way" of the hip and 7% had snapping of the iliotibial band. At arthroscopy, 69% of patients had synovitis in the hip joint, 59% had a tear of the acetabular labrum, 39% had loose bodies, 32% had degenerative arthritis and 27% had a chondral defect. On statistical analysis, significant (p < 0.05) relationships were found between acetabular labral tears and preoperative complaints of clicking or giving way, between loose bodies and preoperative locking and between degeneration of the hip joint and thigh pain. CONCLUSION Arthroscopy of the hip is a valuable diagnostic and therapeutic procedure for patients with hip pain refractory to conservative therapy.

Problem-based learning: its role in undergraduate surgical education.

Abstract: Objective To familiarize the surgeon with problem-based learning (PBL) and to discuss the current and future role of PBL in undergraduate surgical education. Data sources Two meta-analyses comparing the outcome of a PBL curriculum with a traditional curriculum and other studies in the English-language literature. Study selection Data on the effectiveness of PBL can best be assessed by a meta-analysis in which the conclusions of many studies are reviewed and combined to provide a more comprehensive picture. The studies chosen represent those from the only two recent meta-analyses of the problem that have appeared in reputable journals. Data extraction Results reported are those obtained using appropriate techniques and published in reputable journals. Information relevant to the major issues in undergraduate surgical training was selected for inclusion. Data synthesis PBL depends on self-directed learning, triggered by a clinical problem. The students meet in small groups led by a facilitator and discuss carefully designed clinical cases. At the conclusion, the students will have encountered all the information necessary to solve the case and, in so doing, will have gained knowledge that in a conventional curriculum would usually have been disseminated by lecture. There were only small differences between graduates from the two types of curricula. Those from a PBL curriculum had comparable examination results to those from a traditional curriculum on both basic science and clinically based examinations but were happier with their educational experiences. Conclusions Centres that have adopted a PBL approach have found improved student motivation and enjoyment, but there has been no convincing evidence of improved learning. An intelligent combination of both traditional and PBL approaches will likely provide the most effective training for undergraduate surgical clerks.

Ten-year experience with a basic technical skills and perioperative management workshop for first-year residents.

Abstract: Teaching technical skills is one of the most crucial tasks of the academic surgeon. The 10-year experience with a psychomotor skills laboratory at the Department of Surgery of the Universite de Montreal is reported. Since 1983, first-year trainees were freed of hospital duties for "a week of surgical techniques" to develop their basic surgical technique and perioperative skills. Cognitive and practical sessions were designed for two groups of 10 residents. Teaching videos, suture boards, biologic substitutes, animal laboratory, round table discussions and formal lectures were the techniques used. Cognitive sessions were designed to provide information on instrumentation, adequate preoperative preparation, general organization of the operating room, intensive care and endoscopy units. The surgical procedures were approved by the local animal ethics committee. The program helped residents achieve surgical dexterity in a less stressful and more controlled manner than in the operating room. Close relationships of the trainees with their peers and teachers were established early helped to improve the operating environment. This program helps junior residents understand the complex world of the operating room and reduces the operative risks related to technique.

Laparoscopic splenectomy for massive splenomegaly: operative technique and case report.

Abstract: Although laparoscopic splenectomy is the preferred technique for the elective removal of normal-sized and moderately enlarged spleens, its value in the management of massive splenomegaly has not been defined. A 33-year-old woman with massive splenomegaly was managed by laparoscopic splenectomy. The splenic vessels were embolized preoperatively to reduce operative blood loss. Laparoscopic surgery involved dissection of the suspensory ligaments at the lower pole of the spleen followed by dissection and ligation of all splenic branches near the splenic parenchyma. The operative field was explored manually through a 10-cm long Pfannenstiel incision at the public hairline, and under videoscopic control the remaining structures were safely secured. The spleen was delivered into the pelvis, fragmented and removed in large pieces. The incisions were closed after proper irrigation and laparoscopic inspection of the operative field. Further clinical evaluation is required to determine if the procedure is more efficacious than the open technique for massive splenomegaly.

The inflammatory response to particulate wear debris in total hip arthroplasty.

Abstract: Objective To identify the cell types and patterns of cell distribution associated with particulate wear debris in the membranes of patients who undergo revision of hip arthroplasty. Design Case series. Setting Three university-affiliated hospitals. Patients Twenty-nine patients who underwent revision of a hip arthroplasty for reasons other than infection. Eight patients were excluded because loosening of the prosthesis was found to be associated with infection, leaving 21 patients, 18 with aseptic loosening and 3 with recurrent dislocation. Intervention Retrieval of inflammatory membranes from loosened total hip prostheses. Main outcome measures Results of aerobic and anaerobic tissue cultures, number of macrophages, T cells and B cells, and presence and histologic pattern of particulate debris in the membranes. Results None of the tissue cultures grew any organisms. All membranes contained T cells and macrophages, but B cells were present in only three patients at a low level. Particulate debris, surrounded by macrophages and foreign-body giant cells, was present in all membranes. Three histologic patterns were noted: type I--mostly fibrous tissue with cells and macrophages widely scattered through membrane (3 membranes); type II--fibrous membrane with a significant number of T cells, macrophages and foreign-body giant cells and well-defined foreign-body granulomas (7 membranes); type III--diffusely scattered T cells, ill-defined granulomas, "foamy" macrophages and fewer foreign-body giant cells than in type II (11 membranes). Conclusions These findings document the key cellular elements involved in cell-mediated immunity in association with particulate wear debris in aseptically loosened total hip arthroplasty membranes. T-cell amplification of the innate macrophage inflammatory reaction to particulate debris may play a role in the mechanism of particle clearance.

Core decompression of the femoral head for avascular necrosis: indications and results.

Abstract: Objective To evaluate the effectiveness and safety of core decompression in the treatment of avascular necrosis (AVN) of the femoral head. Design A case study. Setting The department of orthopedic surgery in a major university hospital. Patients All patients with AVN of the femoral head, stages I to IVA, were included regardless of the cause of the necrosis. Three hundred hips were available for analysis. The follow-up ranged from 2 to 12 years. Intervention Core decompression of the femoral head was performed with an 8-mm Michele trephine inserted from just below the greater trochanter into the centre of the necrotic lesion to within 5 mm of the articular surface. Two more trephine tracts were made with a 5-mm or 6-mm trephine. The normal portion of cancellous bone recovered from the intertrochanteric region was thinned with a rongeur and was placed loosely into the central decompression channel at the end of the procedure to serve as a graft. Main outcome measures Anteroposterior and lateral radiographs, taken immediately before surgery and at the final follow-up, clinical hip evaluation according to the Harris scoring system, and the need for total hip replacement. Results One patient sustained a subcapital fracture 1 month after surgery due to a fall. There was one case of nonfatal pulmonary embolism, one case of pneumonia and one case of thrombophlebitis of the thigh. Forty-six percent of operatively managed hips showed no radiographic progression of disease compared with only 19% of nonoperatively managed hips. Thirty-five percent of the operatively managed hips required total hip replacement compared with 77% of nonoperatively managed hips. The results in hips with early (stages I and II) AVN were only slightly better than those of hips with advanced (stages III and IVA) disease. However, the results in hips with small areas of necrosis in both stages I and II were much better than those with larger lesions; only 7% of the former group required total hip replacement after decompression and cancellous bone grafting. Conclusions Core decompression with cancellous bone grafting is a safe and effective procedure for the treatment of early AVN of the femoral head. Results with this form of treatment are considerably better than those obtained in patients treated nonoperatively. Decompression with or without bone grafting is the author's treatment of choice for patients with early AVN of the femoral head.

Natural history of strictureplasty in Crohn's disease: 9-year experience.

Abstract: Objective To study the short- and long-term outcomes in patients with Crohn's disease who have undergone strictureplasty. Design A retrospective review with a prospective follow-up (mean 54.4 months [range from 4 to 108 months]). Setting The Inflammatory Bowel Disease Centre at Mount Sinai Hospital in Toronto. Patients Forty-three patients (29 men, 14 women) who underwent 154 strictureplasties for Crohn's disease. The mean age of the patients was 32.5 years (range from 17 to 55 years). Intervention Strictureplasty by either the Heineke-Mikulicz (145 strictureplasties) or the Finney (9 strictureplasties) technique in the duodenum, small intestine and at the site of the previous anastomosis. Main outcome measures Factors studied for symptomatic recurrence included the type of procedure previously performed, the type of strictureplasty, the number of previous operations and the site of the disease. Results There were no deaths. There was one documented leak. Twenty-six patients remained symptom free during the follow-up period. Fourteen patients required reoperation for progressive obstructive disease. None of the differences in the variables studied was statistically significant when related to the symptomatic recurrence rate. However, only 2 of 11 patients who had strictureplasty as the only procedure have required reoperation. Conclusions Strictureplasty is a safe and useful procedure in the management of extensive obstructive Crohn's disease. Strictureplasty does not seem to alter the natural history of the disease.

Biaxial total wrist arthroplasty in rheumatoid arthritis.

Abstract: OBJECTIVE To judge the outcome of total wrist arthroplasty. DESIGN A retrospective study of 13 patients. SETTING A university hospital. PATIENTS Seventeen patients with stage III or IV rheumatoid arthritis of the wrist. Only 13 patients were studied because 3 died and 1 was lost to follow-up. INTERVENTION Biaxial total wrist arthroplasty (15 procedures). MAIN OUTCOME MEASURES Clinical assessment and the Hospital for Special Surgery scoring system and radiologic review. RESULTS Good or excellent results were achieved in all patients after an average follow-up of 54 months. CONCLUSION Biaxial total wrist arthroplasty is a reasonable treatment in rheumatoid patients when preservation of wrist motion is critical.

Diagnostic peritoneal lavage versus abdominal computed tomography in blunt abdominal trauma: a review of prospective studies.

Abstract: Objective To determine whether abdominal computed tomography (CT) or diagnostic peritoneal lavage (DPL) should be used in the evaluation of hemodynamically stable patients with blunt abdominal trauma and equivocal findings on physical examination. Data source MEDLINE. Study selection Prospective studies of hemodynamically stable trauma patients with blunt abdominal trauma and equivocal findings on physical examination that compared abdominal CT and DPL. Data extraction Data were extracted by a single observer. Data synthesis Most studies had excellent DPL results. The mean sensitivity was 98% (range from 90% to 100%), the mean specificity was 92% (range from 73% to 100%), the mean positive predictive value (PPV) was 82% (range from 57% to 92%), the mean negative predictive value (NPV) was 100% (range from 99% to 100%) and the mean accuracy was 93% (range from 80% to 98%). One study reported a low specificity (73%), PPV (57%) and accuracy (80%) for DPL, which may have been due to the loose criteria for red blood cells used in that study. The mean CT values were as follows: sensitivity 60% (range from 20% to 97%), specificity 98% (range from 91% to 100%), PPV 88% (range from 50% to 100%), NPV 84% (range from 76% to 93%) and accuracy 87% (range from 73% to 97%). In studies done in the mid-1980s the CT results were inferior, but they were improved in studies reported in the 1990s (sensitivity 88%, NPV 97%, accuracy 92%). These latest studies also suggest that CT and DPL are complementary rather than equivalent studies. Conclusion DPL should be performed if there are no contraindications and no associated injuries that would be better delineated by CT, in which case abdominal CT is indicated.

Preliminary experience with percutaneous laser disc decompression in the treatment of sciatica.

Abstract: OBJECTIVE: To examine the usefulness of percutaneous laser decompression of a herniated lumbar intervertebral disc. DESIGN: A case series. SETTING: A university-affiliated hospital. PATIENTS: Sixteen patients with clinical and radiologic evidence of herniated lumbar intervertebral discs. INTERVENTIONS: Percutaneous introduction of a fine optical fibre into a herniated lumbar disc and delivery of short pulses of laser energy. MAIN OUTCOME MEASURE: The relief of intractable leg pain. RESULTS: Nine of 14 patients with intractable leg pain experienced total relief after percutaneous laser disc decompression. Four patients required subsequent microsurgical discectomy, and one required a decompressive laminectomy. Of the two patients who had back pain as their major complaint, one required microsurgical discectomy after laser disc decompression. CONCLUSIONS: Percutaneous laser disc decompression can relieve sciatica caused by a herniated intervertebral disc. The technique requires limited use of health resources. Preliminary results suggest that an early return to work can be expected in patients successfully relieved of their leg pain.

Giant synovial cyst of the hip: an unusual presentation with compression of the femoral vessels.

Abstract: A case of synovial cyst of the hip with symptomatic compression of the femoral vessels is described. A 75-year-old woman with severe unilateral osteoarthritis of the right hip was referred because of an intermittent, unpleasant sensation of coolness in the right foot and hip pain. A large mass was palpable in the femoral triangle. Computed tomography and arthrography revealed a large cyst communicating with the hip joint and compressing the femoral vessels ventrally. Total hip arthroplasty was carried out, and the stalk communicating with the cyst was ligated and divided. The unpleasant sensation of coolness in the right foot disappeared postoperatively. The authors concluded that iliopsoas bursitis should be considered in the evaluation of a patient with nonspecific pelvic or groin pain. As demonstrated in this rare case, the main symptom may be misleading and the typical syndrome of a tender groin mass with an underlying history of rheumatoid arthritis may be absent. Treatment should be directed to the underlying joint disease.

Reoperation for cysts of the thyroglossal duct.

Abstract: Objective To determine the causes of recurrence of thyroglossal duct cysts (TDCs). Design A case series. Setting A university-affiliated children's hospital. Patients Between 1974 and 1990, 121 children were treated for TDCs. They ranged in age from 1 month to 18 years. Of these 121 children, 23 had recurrent TDC. Interventions Simple aspiration of the cyst, incision and drainage, cystectomy without hyoidectomy and the Sistrunk operation. Main outcome measures Initial procedures that led to recurrence and procedures that resulted in cure. Results Six children had recurrence of TDCs after simple cystectomy without hyoidectomy; all were cured by the Sistrunk operation. Fourteen children with infected cysts initially underwent a variety of procedures with recurrence and were eventually managed by the Sistrunk operation. TDCs recurred in eight of these. Three children without infected cysts had recurrence after the Sistrunk operation. Of 34 TDCs infected initially, 40% recurred, whereas of 87 TDCs that were not infected initially, only 8% recurred. Conclusion Simple cystectomy without hyoidectomy and pre-existing infection are the main causes of recurrence of TDCs.

The effect of surgical wound infection on postoperative hospital stay.

Abstract: Objective To determine the effect of surgical wound infection on postoperative duration of hospital stay. Design A case-control study nested within a cohort. Setting A tertiary-care hospital. Patients Selected from a cohort of 4702 inpatients who underwent surgical procedures over a 12-month period. There were 3602 patients, 1100 having been excluded because of lack of infection associated with a particular surgical procedure, because of "lumping" of procedures under a nonhomogeneous heading or because a procedure was unlikely to be the reason for the patient's hospitalization. Main outcome measure Postoperative duration of hospital stay. Results In the cohort 89 wound infections were identified, 73 of these occurring with procedures selected for study. Five patients were excluded from the study because of data deficiencies, leaving 68 patients who underwent 15 different procedures. These were compared with 136 control patients selected by stratified random sample from a list of patients who underwent the same risk-indexed procedure in the same surgical division. Wound infection patients and controls did not differ in anesthetic risk score or procedure duration. Patients with infection remained in hospital 19.5 days longer than controls (95% confidence interval, range from 11.0 to 27.9 days). Deep-seated infections prolonged the hospital stay more than superficial incisional infections (24.3 versus 13.2 days). Conclusions Surgical wound infection markedly prolonged the duration of hospitalization in the University of Alberta Hospitals, longer than that documented in previous studies in other countries. Maximizing opportunities to prevent wound infection would be beneficial to both patients and hospitals.

Ectopic thyroid gland simulating a thyroglossal duct cyst: a case report.

Abstract: There have been many reports of the inadvertent removal of an ectopic thyroid gland that was mistaken for a thyroglossal duct cyst. The differentiation of these two conditions is extremely important, because inadvertent removal of an ectopic thyroid gland may result in profound hypothyroidism. The authors report the case of a 5-year-old girl with an ectopic thyroid gland in whom the preliminary diagnosis was a thyroglossal duct cyst. They review the embryologic features in the development of an ectopic thyroid gland and discuss an approach to the management of this congenital anomaly.

Compression of the deep branch of the peroneal nerve by the extensor hallucis brevis muscle: a variation of the anterior tarsal tunnel syndrome.

Abstract: Anterior tarsal tunnel syndrome is a rare condition in which the deep peroneal nerve is trapped below the extensor retinaculum at the ankle. The authors report a variation of this condition: a 67-year-old woman who had anterior tarsal tunnel syndrome caused by entrapment of the deep peroneal nerve by the extensor hallucis brevis muscle. Conservative treatment was unsuccessful, but surgical decompression of the nerve provided immediate improvement, and by 2 weeks postoperatively she had no residual pain or paresthesia, although there was some numbness in the first web space.

The effect of intramedullary cement on intercalary allograft reconstruction of bone defects after tumour resection: a pilot study.

Abstract: OBJECTIVE A pilot study to evaluate the surgical and functional results of resection and reconstruction of diaphyseal bone tumours with cemented and uncemented intercalary allografts. DESIGN A retrospective case series. SETTING A quaternary care unit within a teaching hospital. PATIENTS Twenty-two patients with diaphyseal bone tumours treated between 1988 and 1992, with mean follow-up of 38 months (range from 20 to 70 months). INTERVENTIONS Diagnostic biopsy in all patients. Preoperative and postoperative chemotherapy in patients with high-grade sarcoma. En-bloc excision of all tumours. Reconstruction of the defect with cemented (15 patients) or uncemented (7 patients) intercalary allografts. MAIN OUTCOME MEASURES Nonunion at one or both osteosynthesis sites, death from systemic disease, amputation. RESULTS Six of the 22 patients died of systemic disease with the graft intact, and 3 subsequently had amputation for either local recurrence (2 patients) or failure of free tissue transfer (1 patient), leaving 13 patients alive with the allograft in situ at an average of 36 months (range from 24 to 64 months). There were no revision procedures to remove or replace the original allograft. Five patients had nonunion at one or more osteosynthesis sites on plain radiographs 9 months after resection. Four patients with nonunion were in the cemented group of 13 patients available for assessment at 9 months, and 1 was in the uncemented group of 5 patients available for assessment at 9 months. There were two graft fractures, both in the uncemented group. CONCLUSION The results of this pilot study offer guarded support for the use of pressurized cement in allografts prior to reconstruction of intercalary defects.

Recognition of renal actinomycosis: nephrectomy can be avoided. Report of a case.

Abstract: Nephrectomy is performed for the diagnosis and treatment of renal actinomycosis. A cachectic 62-year-old man with a left renal mass underwent exploration and needle biopsy of the mass. No malignant disease was found. When his condition further deteriorated, the kidney was re-explored. Numerous biopsies intraoperatively finally revealed actinomycosis, so the operation was terminated with preservation of the kidney. Long-term treatment with antibiotics was begun with immediate, marked improvement in the patient's condition. At 1 year the renal mass had almost resolved. This is the first reported case of the diagnosis and treatment of renal actinomycosis without nephrectomy.

Benefit of open lung biopsy in patients with respiratory failure.

Abstract: OBJECTIVE: To determine the benefit of open lung biopsy (OLB) in patients with respiratory failure in whom medical therapy is unsuccessful. DESIGN: A retrospective case series. SETTING: A tertiary care centre. PATIENTS: Thirty-one patients (20 men, 11 women, mean age 55 years) without the human immunodeficiency virus or AIDS who were suffering from respiratory failure. INTERVENTION: OLB through a limited anterior thoracotomy. MAIN OUTCOME MEASURES: Diagnosis, change in therapy, timing of OLB, immune status, survival. RESULTS: A specific diagnosis was made in 68% of patients, and nonspecific pulmonary fibrosis was found in 32%. Eighteen patients (59%) had a change in therapy: 11 had new therapy and 7 had medical therapy withdrawn because of irreversible disease. There was a significant (p = 0.012) improvement in survival in those who had OLB early compared with those who had OLB later in the course of the disease (70% versus 14%). There was a significant (p = 0.026) difference in the proportion of specific diagnoses made among those who had OLB early compared with those who had it later (100% versus 52%). A significant (p = 0.18) improvement in survival was noted in those who had new therapy instituted as a result of early OLB compared with late OLB (86% versus 25%). Patients not immunocompromised before OLB had a significantly (p = 0.02) better survival rate than those who were immunocompromised. CONCLUSIONS: The duration of respiratory failure before OLB and the immune status were associated with improved survival in patients with respiratory failure and unsuccessful medical therapy. This was not directly attributable to changes in therapy after OLB. However, five survived as a direct result of therapy instituted after OLB and seven were spared needless therapy when irreversible disease was found. Overall survival may not be altered by OLB, but individual clinical benefit may be seen in nearly 40% of patients.

Laparoscopic cardiomyotomy with a Dor patch for achalasia.

Abstract: Objective To evaluate early experience with laparoscopic Heller's cardiomyotomy with placement of a Dor patch for achalasia. Design A prospective case series. Setting A university teaching hospital. Patients Fourteen patients (5 men, 9 women, median age 47 years) with esophageal achalasia, treated between July 1992 and July 1994. Interventions Laparoscopic Heller's cardiomyotomy with a Dor patch. Main outcome measures Clinical relief of symptoms, confirmed by esophageal manometry, 24-hour ambulatory pH monitoring and barium-contrast radiography. Results Three of the 14 patients required conversion to an open procedure, and 1 underwent early laparotomy for postoperative bleeding. The median operating time was 120 minutes (range from 75 to 210 minutes), and the median duration of hospitalization was 4 days (range from 3 to 18 days). Normal physical activity was resumed after a median of 2 weeks (range from 0.5 to 6 weeks). Symptomatic dysphagia was completely relieved in 12 patients and improved in 2. Only one patient experienced symptoms of reflux postoperatively. Postoperative esophageal manometry (seven patients), 24-hour pH monitoring (five patients) and barium-meal radiography (seven patients) confirmed the clinical results. Conclusion Laparoscopic Heller's cardiomyotomy with a Dor patch provides a viable alternative to open cardiomyotomy and forceful endoscopic dilatation.

Skeletal muscle injury induced by ischemia-reperfusion.

Abstract: OBJECTIVE: To study the temporal progression of injury in skeletal muscle after ischemia-reperfusion insult by means of intravital videomicroscopy and nuclear fluorescent dyes DESIGN: A controlled study in an animal model SETTING: A vascular research laboratory at a university-affiliated hospital SUBJECTS: Eight male Wistar rats, for each of which the extensor digitorum longus muscle of the hind limb was exposed and prepared INTERVENTIONS: Two hours of complete no-flow ischemia followed by 90 minutes of reperfusion in five of the rats; the other three rats acted as controls and underwent the same surgical procedure but not ischemia During the reperfusion period the fluorescent vital dyes bisbenzimide, which permeates all cells, and ethidium bromide, which permeates cells with damaged membranes, were applied Recordings to videotape were made with the intravital microscope very 15 minutes during the reperfusion period MAIN OUTCOME MEASURES: The number of perfused capillaries crossing three straight lines on the video monitor were counted as a measure of microvascular dysfunction An index of tissue injury was calculated as the ratio of the number of nuclei stained by ethidium bromide to the number stained by bisbenzimide (E/B) The number of stuck and rolling leukocytes and the velocity of the rolling leukocytes were determined in postcapillary venules RESULTS: The mean number of perfused capillaries (and standard error of the mean) fell from 2071 (164)/mm before ischemia to 1169 (118)/mm during reperfusion in the experimental group but remained constant in the control group In the experimental group E/B progressed from 043 (005) at the onset of reperfusion to 087 (003) at the end of reperfusion, the number of rolling leukocytes increased from a preischemia mean of 400 (190) to 1480 (130)/1000 microns2, and the number of stuck leukocytes increased from 142 (020) to 920 (070)/1000 microns2 The velocity of the rolling leukocytes did not differ between the control and the experimental groups CONCLUSIONS: Although microvascular perfusion decreased quickly to a constant level after 2 hours of noflow ischemia plus reperfusion, a progressive increase in tissue injury occurred, which may correlate with the number of stuck leukocytes

Is there a difference between the epidemiologic characteristics of hip dislocation diagnosed early and late

Abstract: OBJECTIVE To determine if there are epidemiologic differences between patients with early and late developmental dislocation of the hip (DDH). DESIGN A chart review. SETTING A university-affiliated children's hospital. PATIENTS Two hundred and forty-three children, 191 with early DDH and 52 with late DDH. MAIN OUTCOME MEASURES Sex, side involved and prevalence of bilaterality. RESULTS There were significant differences between the two groups with respect to side involved (p < 0.0002) and bilaterality (p = 0.006) but not in relation to sex. Left-sided dislocations were predominant in the early group and right-sided dislocations in the late group. Bilaterality was more common in the late group. CONCLUSION There is circumstantial epidemiologic evidence that late DDH may be a different entity from early DDH.

Reuse of disposable laparoscopic instruments: a study of related surgical complications.

Abstract: OBJECTIVE To determine the rate of surgical complications related to reuse of disposable laparoscopic instruments. DESIGN A review of all laparoscopic and thoracoscopic procedures done between August 1990 and January 1994 in which disposable laparoscopic instruments were reused. SETTING Department of general surgery in a 461-bed teaching hospital. PATIENTS Patients who underwent 874 laparoscopic and thoracoscopic procedures in which disposable laparoscopic instruments were reused according to validated reprocessing protocols. MAIN OUTCOME MEASURES The incidence of superficial and deep wound infections and complications related to instrument malfunction. RESULTS The combined rate for deep and superficial infections was 1.8%. No complications related to a disposable instrument malfunction were found. CONCLUSION Disposable laparoscopic instruments may be safely reused under carefully monitored conditions and with strict guidelines.

Streptomycin-loaded bone cement in the treatment of tuberculous osteomyelitis: an adjunct to conventional therapy.

Abstract: Streptomycin-loaded bone-cement (7 g of streptomycin in 40 g of bone cement) beads were used in the treatment of tuberculous bursitis and osteomyelitis of the greater trochanter in a 76-year-old woman. Wound drainage, serum and urine concentrations of streptomycin were measured. For the first 96 hours, the streptomycin levels in the wound drainage ranged from 2932 mg/L to 414.4 mg/L, and in the serum, streptomycin levels ranged from 1.7 mg/L to 13.7 mg/L. The patient recovered without complication and at follow-up 2 years later was free of infection and walking without pain. The authors conclude that the use of streptomycin-loaded bone cement can safely and effectively eradicate mycobacterial tuberculosis osteomyelitis.

Tarsal tunnel syndrome: an unusual case resulting from an intraneural degenerative cyst

Abstract: Multiple local and systemic entities have been implicated as causes of tarsal tunnel syndrome. In this report, a 31-year-old man presented with medial plantar nerve compression caused by an intraneural degenerative cyst of the posterior tibial nerve. Removal of the cyst and decompression of the nerve relieved his symptoms. This is the first time that such an entity has been reported as a cause of tarsal tunnel syndrome.

Spontaneous rupture of a pancreatic pseudocyst into the portal vein.

Abstract: An unusual complication of pancreatic pseudocyst is reported. A 47-year-old woman with chronic liver disease and a history of recurrent pancreatitis died of fulminant, gram-negative septic shock. Acute, bilateral thigh cellulitis with tissue culture positive for Escherichia coli was the only potential infectious source identified. Autopsy revealed a pseudocyst in the head of the pancreas that had eroded into the portal vein, with embolization of mucoid cyst material into intrahepatic portal vein branches. Fibrous organization and recanalization of some of the occluded portal vein branches indicated that this process had been present for weeks to months and was therefore not the direct cause of death. The literature on this unusual complication of pancreatic pseudocyst is also reviewed.