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PubMed2003

Primary and revision total hip arthroplasty for patients 90 years of age and older.

OBJECTIVE: To assess the reliability, durability, and safety of primary and revision total hip arthroplasty (THA) in patients 90 years of age and older. PATIENTS AND METHODS: Between 1970 and 1997, 66 THAs, 48 primary and 18 revision, were done for 65 patients aged 90 to 104 years (mean, 92 years). The Harris hip score was used to assess hip pain and function. RESULTS: Patients were evaluated for pain, function, and satisfaction at a mean of 3.2 years after the THA. The Harris hip scores improved significantly (P = .004) for both primary and revision groups: from preoperative mean scores of 39 and 45 points to follow-up scores of 80 and 75 points, respectively. Two patients died in the early postoperative period of causes related to the operation. Thirty-seven other patients were dead at last follow-up and had lived a mean +/- SD of 6 +/- 2.2 years after the primary THA and 4.2 +/- 2.8 years after the revision THA. No hips required subsequent revision. CONCLUSION: Total hip replacement was reliable, durable, and safe in this study group. Primary care physicians and surgeons should be aware that both primary and revision total hip replacement can be done safely and effectively in patients aged 90 years and older and can result in years of relief of pain and functional improvement.

Activities of Daily Living↗

PubMed2004

Monofocal acute large demyelinating lesion mimicking brain glioma.

We report the case of a 34-year-old woman with clinical, neuroradiological and intraoperative histological findings, suggesting a low-grade astrocytic tumour. The demyelinating nature of the lesion was established through biopsy only after neurosurgery. The lesion size, in fact, greatly exceeded that of the perivenous demyelination seen in typical multiple sclerosis (MS) and tended to present as a space-occupying mass. This case underlines the importance of considering demyelinating isolated lesions in the differential diagnosis of a brain mass. Since misdiagnosis can result in unwarranted and aggressive therapy, it is critical for the neurologist to be aware of this serious diagnostic pitfall.

Adult↗

PubMed1996

Pitfalls in the surgical management of cervical spine injuries.

Records of 69 cervical spine injury patients referred to the authors' institution over a 3-year period were reviewed. The senior author documented "definite" and "probable" pitfalls occurring in the pre-, intra-, and postoperative management. Diagnosis, traction, bracing, surgical timing, intraoperative technical errors, and incorrect surgical decisions were noted. Of the 69 patients, 39 (56%) suffered a pitfall of management. Twenty-seven patients (39%) accumulated 49 "definite" pitfalls between them and 12 patients (17%) suffered a total of 20 "probable" pitfalls. Of the 49 definite pitfalls, 7 (14%) were preoperative, 17 (34%) were those of surgical decision making, 21 (43%) were operative, and 4 (9%) postoperative. Diagnostic errors and incorrect bracing and traction led to neurological worsening. Intraoperatively, technical errors (30%), wrong timing of surgery (24%), and incorrect choice of operation (16%) were the common pitfalls. Postoperative pitfalls consisted of inappropriate bracing (17%). A Cervical Spine Research Society review (1989) rated complications of cervical spine surgery at 6.3% (63/992). In this study, a sizeable portion (56%) of cervical spine injury patients requiring surgery were at a risk of complications. Short of complications, there are areas of management where errors may have less well-documented undesirable effects or increase the potential for morbidity. An awareness of these pitfalls and increased use of non-operative treatment may eliminate up to 73% of the pitfalls and thereby decrease the morbidity associated with the management of cervical spine injuries.

Adolescent↗

PubMed2003

A prospective endoscopic study of retropubic vascular anatomy in 121 patients undergoing endoscopic extraperitoneal inguinal hernioplasty.

BACKGROUND: A sound knowledge of retropubic pelvic vascular anatomy is pivotal to the successful performance of endoscopic total extraperitoneal (TEP) inguinal hernioplasty. The objective of the current study was to evaluate the incidence and anatomy of iliopubic and aberrant obturator vessels. METHODS: Between July 2001 and March 2002, a prospective endoscopic evaluation of retropubic vascular anatomy was performed on patients who underwent TEP. Endoscopic photographs of the vasculature overlying the superior pubic ramus in the recruited patients were captured on a computer. RESULTS: The retropubic vascular anatomy of 121 patients, who underwent either unilateral (n = 100) or bilateral (n = 21) TEP was examined. The iliopubic artery and vein were invariably present in every patient, and traversed along the iliopubic tract toward the pubic symphysis. The aberrant obturator artery was present in 31 pelvic halves, giving an overall incidence of 22%. The aberrant obturator vein existed between the external iliac and obturator venous system in 27% (n = 38) of the 141 pelvic halves examined. The overall incidence of corona mortis, in the form of either an aberrant obturator vein or artery, was 40% (n = 56). CONCLUSIONS: Iliopubic vein and artery are universal findings in every patient. Both aberrant obturator artery and vein cross the superior pubic rami, and are therefore susceptible to injuries during dissection of the Bogros space and stapling of the mesh onto Cooper's ligament. Awareness of these aberrant vessels will help to reduce bleeding and subsequent morbidity. Tracing along the aberrant vessel can easily identify the obturator foramen, which is an anatomic landmark that indicates an adequate inferior dissection of the preperitoneal space.

Aged↗

PubMed1989

Kaposi's sarcoma in patients with AIDS.

All health care providers must become increasingly aware of the early signs and symptoms of AIDS as KS frequently appears in the head, neck, and oral regions. Dentists are responsible for recognizing these lesions, especially the early lesions, providing dental treatment as appropriate, and for referring patients with AIDS for counseling and treatment that cannot be provided in their office. Early detection of KS is particularly important for patients receiving dental treatment. The dentist must be careful not to further compromise the patient's health by extensive or stressful dental treatment and to prevent intraoperative or postoperative complications. Early supportive and palliative care will improve the patient's prognosis. Dental care will help HIV-infected patients and those with AIDS to avoid caries and periodontal disease. In addition, regular dental care will enable the dentist in the early diagnosis of the disease's oral manifestations, such as candidiasis, hairy leukoplakia, KS, or other oral opportunistic infection. Treatment of these conditions can significantly improve the patients' quality of life and their chances for survival. When universal precautions are used for infection control in the dental office there is no reason that comprehensive dental care cannot be provided for HIV infected patients--both for those that we know are infected and for those that are infected and we don't know about.

Acquired Immunodeficiency Syndrome↗

PubMed2002

[The management of HIV patients during surgery and in the delivery ward: anesthetic considerations].

To date a total of more than 50 million individuals worldwide have been infected with HIV and more than 20 million have died from the disease. Two thirds of the known carriers of HIV 36 million worldwide, live in Africa. In Israel, as of December 31, 2000, there are a total of 2,843 reported carriers and 165 persons alive with AIDS. On the basis of future projections of increasing incidence of HIV/AIDS in obstetric patients undergoing anesthesia and surgery, obstetricians and anesthesiologists should be aware of the disease and its impact on anesthetic techniques and possible interactions between anesthetic drugs and HIV therapeutic agents. Surgical staff members should be knowledgeable and updated concerning safety precautions during surgical and anesthetic procedures.

Anesthesia↗

PubMed1989

Aorta-vena cava fistula.

In 1831 James Syme described the unusual occurrence of an aortocaval fistula in a 22-year-old man with luetic aortitis. This initial report was followed by illustration of this phenomenon in Rokitanski's Book of Pathologic Anatomy in 1841 and by Ryle's delineation of an aortocaval fistula on a pathologic specimen placed in Guy's Hospital Museum in 1892. The first series of aortocaval fistulas, cited by Rudolf Matas in 1909, consisted of a collection of 20 cases gathered by Boinet 10 years earlier. Several later reports, including those by Reid in 1925 and by Lehman in 1938, failed to add any additional cases. It was not until 1955 that Boffi presented an additional six patients who had this disorder, none of whom survived. Since that time, more than 100 cases of spontaneous aortocaval fistulas have been documented. This increasing experience has resulted in improved understanding and surgical treatment of these large-vessel arteriovenous communications. Nevertheless, lack of awareness and failure of recognition of this problem continue to impede its successful management. In this review we present two additional illustrative cases, summarize the clinical and pathophysiologic features of aortocaval fistulas, and outline present approaches to treatment.

Adult↗

PubMedDate not supplied

[Identification of gallbladder pedicle anatomy during laparoscopic cholecystectomy].

Laparoscopic cholecystectomy is widely accepted nowadays as the gold standard in the treatment of cholelithiasis. This new technique was initially associated with a significant increase in morbidity, and in particular in iatrogenic biliary injuries and arterial haemorrhages, perhaps due to a lack of knowledge of the "laparoscopic anatomy" of the gallbladder pedicle. In this technique the anatomical structures are viewed on a two-dimensional video monitor, and the dissection is performed with long instruments without manual sensitivity. Therefore, the laparoscopic surgeon has to deal with new anatomical views and must be aware of the possible arterial and biliary variants. In this review we describe our technique of laparoscopic cholecystectomy, with particular reference to manoeuvres useful for identifying the various anatomical structures at the gallbladder hilum. In our opinion, it is mandatory to avoid cutting any duct if its identity has yet to be established. For this reason, we pay great attention to the anatomical dissection of Calot's triangle, in order to accurately identify the cystic duct and the cystic artery and any other vascular or biliary structures. Routine intraoperative cholangiography may be useful for identifying the biliary anatomy. When in doubt, the surgeon should not hesitate to convert the procedure to open surgery.

Biliary Tract↗

PubMed1996

Perioperative complications in combined aortic valve replacement and extraanatomic ascending-descending bypass.

BACKGROUND: In adult patients, the combination of severe aortic valve stenosis and coarctation is rare. Surgical options comprise either a two-stage approach with valve replacement and subsequent repair of the coarctation or a one-stage repair involving valve replacement and insertion of an extraanatomic bypass graft from the ascending to the descending aorta. METHODS: We report the cases of 2 adult patients with this combined lesion who underwent simultaneous aortic valve replacement and transpericardial bypass of the coarctation. RESULTS: Weaning from extracorporeal circulation and restoration of spontaneous circulation required resuscitative measures. By increasing mean arterial perfusion pressure using norepinephrine, the observed hemodynamic instability could be controlled effectively. CONCLUSIONS: Changes in the hemodynamics of the thoracic vascular bed resulting in coronary malperfusion are discussed to be the major cause of heart failure and life-threatening ventricular arrhythmias seen in our patients after aortic valve replacement and insertion of an ascending-descending aorta bypass graft. Awareness of the complications described is considered important for successful management of these high-risk patients.

Amiodarone↗

PubMed2002

Hepatic abscess in patients with chronic granulomatous disease.

OBJECTIVE: To evaluate the clinical presentation, diagnostic procedures, and surgical management of hepatic abscesses in patients with chronic granulomatous disease (CGD). SUMMARY BACKGROUND DATA: Chronic granulomatous disease is a rare inherited primary immunodeficiency in which phagocytes cannot destroy catalase-positive bacteria and fungi. Defects in the phagocytic cells' respiratory burst lead to life-threatening infections, including hepatic abscess. These abscesses are recurrent and often multiple and are treated differently from bacterial abscesses in patients without CGD. METHODS: Between 1980 and 2000, 61 cases of hepatic abscess in 22 patients with CGD were treated at the National Institutes of Health. Clinicopathologic features were investigated by retrospective review of the medical records, radiographs, and histopathology. RESULTS: Twelve of the 61 cases were primary hepatic abscesses. Twenty-nine of the cases were recurrent hepatic abscesses, and 20 cases were persistent hepatic abscesses. The median age at the time of initial hepatic abscess presentation was 14 years. Subjective fever was the most frequent presenting symptom, and the erythrocyte sedimentation rate was elevated in 98% of cases. Fifty-two cases were managed surgically and eight cases were managed with percutaneous drainage. One patient refused surgery. The surgical complication rate was 56%; however, there were no deaths directly related to the hepatic abscesses. Staphylococcus aureus was the most frequent organism identified in culture (88% of positive cultures). Aggressive surgery and antibiotics ultimately resulted in successful treatment of all patients. CONCLUSIONS: Hepatic abscesses occurring in patients with CGD represent a difficult diagnostic and treatment challenge. Early excision and treatment with antibiotics directed against S. aureus is necessary. General surgeons should be aware of this rare immunodeficiency and should aggressively manage hepatic abscesses in these patients.

Adolescent↗

PubMed2004

Adverse events associated with the intraoperative injection of isosulfan blue.

STUDY OBJECTIVE: To describe the adverse events associated with the intraoperative injection of isosulfan blue in a large group of patients having a wide range of surgical procedures, and to identify risk factors for these events. DESIGN: Retrospective chart review. SETTING: University-affiliated institution specializing in malignancies PATIENTS: 1835 patients representing a total of 1852 surgical procedures. MEASUREMENTS: Incidence, type, severity, onset time, duration, management, and the presence of potential risk factors for adverse events. Events were considered "major" if potentially life-threatening hypotension occurred. MAIN RESULTS: Adverse events occurred in 28 procedures (1.5%) and 14 of these adverse events (0.75%) were classified as major. The types of events were: skin reactions in 21 patients, hypotension in 14 patients, edema in 1 patients, and unspecified in 1 patient. The time of onset for adverse events was 42.2 +/- 53.9 minutes (median, 17.5; range, 1 to 180 min) after isosulfan blue injection, and was significantly longer for minor reactions compared with major events (p = 0.015). The longest adverse event lasted at least 21 hours. Treatment was successful with usual antiallergy/antianaphylaxis medications. Ten patients received diphenhydramine alone, and four patients received intravenous epinephrine infusions. Factors associated with a significantly increased incidence of adverse events were isosulfan blue injection in the vulvar area (p = 0.000038), and the chronic preoperative use of angiotensin-converting enzyme inhibitors or angiotensin receptor-blocking agents (p = 0.043). Trends toward an increased risk of an adverse event were noted with isosulfan blue injection in the breast area (p = 0.19), and having more than one surgical procedure with isosulfan blue (p = 0.14). CONCLUSIONS: Although the most frequent adverse event associated with injection of isosulfan blue was a skin reaction, potentially life-threatening hypotension occurred in 0.75% of all procedures. Anesthesiologists must be aware of the variable onset time and potentially prolonged duration of the adverse events. They should recognize the need for extra vigilance in patients with potential risk factors, and have the usual antiallergy/antianaphylaxis medications available for administration if necessary.

Adolescent↗

PubMed1996

Current surgical management of Wilms' tumor.

Wilms' tumor is an ideal model to demonstrate how multimodality treatment strategies have reduced disease mortality over the past three decades. More than 80% of all patients are currently long-term survivors. Greater understanding of biology and awareness of clinical syndromes have led to more risk-based therapies. Although routine imaging provides adequate information for staging, advanced radiographic techniques, including spiral CT scanning and enhanced magnetic resonance imaging, can delineate improved anatomic detail. Recently, parenchymal sparing operations have been undertaken as long-term renal insufficiency after nephrectomy for Wilms' tumor has been more frequently recognized. Primary chemotherapy with delayed tumor resection is increasingly advocated for patients with bilateral disease, tumors with intravascular extension, or for those whose tumors are considered "inoperable." Technical advances, including intraoperative ultrasonography, regional hypothermia, laser technology, and minimally invasive surgery, will influence future tumor resections. Nevertheless, primary nephrectomy with appropriate operative guidelines and systemic therapy remain important standards for management of sporadic unilateral Wilms' tumor.

Antineoplastic Agents↗

PubMed1998

[Pulmonary fat embolism during bipolar hip endoprosthesis].

Two patients had fatal fat pulmonary embolism during bipolar hip endoprosthesis. Two women, 71-year-old and 76-year-old, with femoral neck fracture underwent bipolar hip endoprosthesis under combined lumbar epidural/general anesthesia. Soon after the placement of bone cement and a femoral stem with a bipolar endoprosthesis in the femoral shaft, the patients developed circulatory collapse. Immediate cardiopulmonary resuscitation did not restore adequate circulation and the patients died 3.5 hours and 1 hour thereafter, respectively. Pathological examination revealed the presence of fat particles within the entire pulmonary arteries, arterioles and capillaries. Main cause of the present pulmonary fat embolism may be an increase in the intramedullary pressure during cement pressurization and femoral stem placement. Anesthetists have to be aware of occurrence of this serious syndrome during bipolar hip endoprosthesis. For earlier detection of this serious complication we recommend to monitor central venous pressure and pulmonary artery pressure in patients undergoing bipolar hip endoprosthesis.

Aged↗

PubMed2002

[Telecommunication and telepathology. New diagnostic routes for orthopaedics and orthopaedic pathology].

In a pilot project of the Department of Bone Pathology of the University of Hamburg and the Orthopaedic Department of the University of Heidelberg, the cases of 121 patients with suspicion of a primary bone tumour have been discussed at weekly interdisciplinary conferences during the period from July 2001 to May 2002., The consequent differential diagnoses were made prior to the biopsy, the optimal location of the biopsy and the further strategy was determined according to the guidelines of the international bone tumour centres. The latter includes the decision if a conventional biopsy or a intraoperative pathology examination on frozen sections should be performed. In 27 cases an intraoperative pathology examination was performed and then assessed in Hamburg. In 24 cases this diagnosis was identical with the final diagnosis. In three cases no definitive diagnosis could be made from the frozen sections. Additionally the pathohistological diagnoses of the cases of the previous week have been discussed in the video-conferences. Through this a unusually close interdisciplinary cooperation over a large distance has evolved, that is highly appreciated especially by the young and less experienced colleagues at the department of bone pathology and the orthopaedic department in Heidelberg. The awareness of the potential and limitations of a medical subject leads to an improved safety in the diagnostic process for bone tumours. The interdisciplinary discussion of all aspects of the diseases may also optimise the therapy of bone tumours.

Bone Neoplasms↗

PubMed1977

Calcium microemboli and microfilters in valve operations.

Fatal microemboli occurred in 3 of 100 consecutive patients having aortic valve replacement; 2 occurred during perfusion before the microfilter era, and 1 occurred intraoperatively despite the use of in-line filters. In all 3 patients cerebral symptoms were present immediately postoperatively, and each died of severe brain damage. On postmortem examination cerebral calcium microemboli were verified in only 2 patients, although the brain of each patient contained minute infarctions. However, calcium particles were found in the kidneys of all 3 patients. Thus the kidneys proved to be the best place for detection of calcium emboli on postmortem examination. Although the microfilters currently available effectively prevent microemboli during extracorporeal circulation, the surgeon should be aware that embolization can also occur immediately after discontinuation of perfusion. The means of protecting the patient from this are discussed.

Aortic Valve↗

PubMed2006

Ocular morbidity associated with intravitreal triamcinolone acetonide.

AIM: To report on the complications associated with the use of intravitreal triamcinolone acetonide (IVTA) in a tertiary referral hospital setting. MATERIALS AND METHODS: A retrospective case series review of all IVTA injections carried out over a period of 30 months. RESULTS: One hundred and thirty IVTA injections were performed; nine with limited local follow-up were excluded. Thus, 121 injections (108 patients, 114 eyes) were included in the study. Triamcinolone (4 mg) was used in all cases. Indications were diabetic macular oedema (n=41 eyes), retinal vein occlusions (n=27), postoperative cystoid macular oedema (n=24), exudative age-related macular degeneration (n=16), and others (n=6). No intraoperative complications were recorded. Postoperative intraocular pressure (IOP) readings of 22, 28, 35, and 40 mmHg or higher were recorded in 46.5, 29.8, 12.3, and 7.9% of eyes, respectively. IOP elevation was treated with antiglaucoma medication in all but one eye (0.9%) that required trabeculectomy and one (0.9%) that required vitrectomy with cataract extraction for suspected phacoanaphylactic glaucoma. Two eyes (1.8%) developed retinal detachment; both had previously been treated for retinal breaks. One eye (0.9%) developed culture-positive endophthalmitis. CONCLUSIONS: Significant morbidity is associated with IVTA injection; clinicians should be aware when considering treatment options.

Adult↗

PubMed1991

Insulin-dependent diabetes. Its effect on the surgical patient.

Physicians and nurses need to be aware of the metabolic needs of the diabetic patient and incorporate those requirements into the plan of care during the perioperative period. With appropriate management, morbidity and mortality rates for diabetic patients who undergo surgery may approach those for the nondiabetic population.

Adult↗

PubMed1992

[Ureteral and bladder lesions after gynecologic surgery. Value of early diagnosis].

Ureteric and bladder injuries are recognized complications of gynaecologic surgery. Efficiency of conservative treatments is directly related to early diagnosis. Urinary vaginal fistulas are easily diagnosed in view of post-operative continuous leakage. Ureteral or bladder obstructions can be quite asymptomatic and result in renal destruction or bladder impairment. Reviewing 17 cases, we emphasize abnormal post-operative pain and biological changes which must aware of urologic complications and lead to radiographic studies. Double-J stenting or bladder drainage associated with filling of fistula with fibrin sealant gives a chance of complete recovery to urogenital fistulas. Percutaneous nephrostomy or clean intermittent catheterisation preserves renal or bladder function until adequate treatment of obstruction has been defined.

Adult↗