Mediastinal reinforcement after induction therapy and pneumonectomy: comparison of intercostal muscle versus diaphragm flaps.

OBJECTIVE: Prospective non-randomised comparison of full-thickness pedicled diaphragm flap with intercostal muscle flap in terms of morbidity and efficiency for bronchial stump coverage after induction therapy followed by pneumonectomy for non-small cell lung cancer (NSCLC). METHODS: Between 1996 and 1998, a consecutive series of 26 patients underwent pneumonectomy following induction therapy. Half of the patients underwent mediastinal reinforcement by use of a pedicled intercostal muscle flap (IF) and half of the patients by use of a pedicled full-thickness diaphragm muscle flap (DF). Patients in both groups were matched according to age, gender, side of pneumonectomy and stage of NSCLC. Postoperative morbidity and mortality were recorded. Six months follow-up including physical examination and pulmonary function testing was performed to examine the incidence of bronchial stump fistulae, gastro-esophageal disorders or chest wall complaints. RESULTS: There was no 30-day mortality in both groups. Complications were observed in one of 13 patients after IF and five of 13 after DF including pneumonia in two (one IF and one DF), visceral herniations in three (DF) and bronchopleural fistula in one patient (DF). There were no symptoms of gastro-esophageal reflux disease (GERD). Postoperative pulmonary function testing revealed no significant differences between the two groups. CONCLUSIONS: Pedicled intercostal and diaphragmatic muscle flaps are both valuable and effective tools for prophylactic mediastinal reinforcement following induction therapy and pneumonectomy. In our series of patients, IF seemed to be associated with a smaller operation-related morbidity than DF, although the difference was not significant. Pedicled full-thickness diaphragmatic flaps may be indicated after induction therapy and extended pneumonectomy with pericardial resection in order to cover the stump and close the pericardial defect since they do not adversely influence pulmonary function.

Caspofungin for prevention of intra-abdominal candidiasis in high-risk surgical patients.

PURPOSE: Thirty to forty percent of patients with recurrent gastrointestinal perforation/anastomotic leakage or acute necrotizing pancreatitis develop intra-abdominal invasive candidiasis (IC). A corrected Candida colonization index (CCI) > or =0.4 is a powerful predictor of IC. Fluconazole prevents intra-abdominal IC in this setting, but azole-resistant Candida species are emerging. The aim of this study was to explore the efficacy and safety of caspofungin for prevention of intra-abdominal IC in high-risk surgical patients. METHODS: Prospective non-comparative single-center study in consecutive adult surgical patients with recurrent gastrointestinal perforation/anastomotic leakage or acute necrotizing pancreatitis. Preventive caspofungin therapy (70 mg, then 50 mg/day) was given until resolution of the surgical condition. Candida colonization index and CCI, occurrence of intra-abdominal IC and adverse events were monitored. RESULTS: Nineteen patients were studied: 16 (84%) had recurrent gastrointestinal perforation/anastomotic leakage and 3 (16%) acute necrotizing pancreatitis. The median duration of preventive caspofungin therapy was 16 days (range 4-46). The colonization index decreased significantly during study therapy, and the CCI remained <0.4 in all patients. Caspofungin was successful for prevention of intra-abdominal IC in 18/19 patients (95%, 1 breakthrough IC 5 days after inclusion). No drug-related adverse event requiring caspofungin discontinuation occurred. CONCLUSION: Caspofungin may be efficacious and safe for prevention of intra-abdominal candidiasis in high-risk surgical patients. This needs to be further investigated in randomized trials.

Expérience de dix ans de réanimation chirurgicale d'un centre hospitalier universitaire. Détermination d'un critère d'identification des patients à risque de décéder de coagulopathie irréversible [10 years experience in surgical resuscitation at a university hospital center. Determination of a criterion for identifying patients at risk for fatal irreversible coagulopathy]

The authors evaluated ten years of surgical reanimation in the University Centre of Lausanne (CHUV). Irreversible coagulopathy (IC) is the predominant cause of death for the polytraumatized patient. Acidosis, hypothermy, and coagulation troubles are crucial elements of this coagulopathy. The authors looked for a criterion allowing the identification of dying of IC. In a retrospective study, laboratory results of pH, TP, PTT, thrombocyte count and the need for blood transfusion units were checked for each major step of the primary evaluation and treatment of the polytraumatized patients. These results were considered as critical according to criteria of the literature (30). The authors conclude that the apparation of a third critical value may be useful to identify the polytraumatized patient at risk of dying of IC status. This criterion may also guide the trauma team in selecting a damage control surgical approach (DCS). This criterion was then introduced into an algorithm involving the Emergency Department, the operating room and the Intensive Care Unit. This criterion is a new tool to address the patient at the crucial moment to the appropriate hospital structure.

The future of patient safety: Surgical trainees accept virtual reality as a new training tool.

BACKGROUND: The use of virtual reality (VR) has gained increasing interest to acquire laparoscopic skills outside the operating theatre and thus increasing patients' safety. The aim of this study was to evaluate trainees' acceptance of VR for assessment and training during a skills course and at their institution. METHODS: All 735 surgical trainees of the International Gastrointestinal Surgery Workshop 2006-2008, held in Davos, Switzerland, were given a minimum of 45 minutes for VR training during the course. Participants' opinion on VR was analyzed with a standardized questionnaire. RESULTS: Fivehundred-twenty-seven participants (72%) from 28 countries attended the VR sessions and answered the questionnaires. The possibility of using VR at the course was estimated as excellent or good in 68%, useful in 21%, reasonable in 9% and unsuitable or useless in 2%. If such VR simulators were available at their institution, most course participants would train at least one hour per week (46%), two or more hours (42%) and only 12% wouldn't use VR. Similarly, 63% of the participants would accept to operate on patients only after VR training and 55% to have VR as part of their assessment. CONCLUSION: Residents accept and appreciate VR simulation for surgical assessment and training. The majority of the trainees are motivated to regularly spend time for VR training if accessible.

Surgical treatment of lamellar macular hole associated with epimacular membrane.

BACKGROUND:: Although the surgical treatment of full-thickness macular hole is well established, the utility of pars plana vitrectomy in the treatment of lamellar macular hole (LMH) remains less clear. The purpose of the study is to report functional results of surgical treatment of LMH associated with epiretinal membrane. METHODS:: Retrospective chart review of patients undergoing pars plana vitrectomy and peeling of epiretinal membrane and internal limiting membrane, with or without air or gas tamponade, for symptomatic LMH associated with epimacular membrane. RESULTS:: Forty-five eyes of 44 patients were operated for LMH associated with epimacular membrane between May 2000 and July 2009. Pars plana vitrectomy and membrane peeling were combined with air or gas tamponade in 43 of 45 cases. Mean logarithm of the minimum angle of resolution best-corrected visual acuity improved from 0.4 preoperatively to 0.13 postoperatively (P < 0.0001). Improvement in visual acuity ranged from 0 Early Treatment Diabetic Retinopathy Study (ETDRS) lines to 8.9 ETDRS lines (mean, 2.65 ETDRS lines). Visual acuity improved by ≥1 ETDRS line(s) in 40 of 45 eyes (89%) and by ≥2 ETDRS lines in 26 of 45 eyes (58%) after the surgical procedure. No patient lost vision. CONCLUSION:: This small retrospective study suggests that surgical treatment of LMH associated with epimacular membrane may improve visual acuity in symptomatic patients.

What influence do anticoagulants have on oral implant therapy? A systematic review.

OBJECTIVES: This systematic review aims to assess the risks (both thromboembolic and bleeding) of an oral anticoagulation therapy (OAT) patient undergoing implant therapy and to provide a management protocol to patients under OAT undergoing implant therapy. MATERIAL AND METHODS: Medline, Cochrane Data Base of Systematic Reviews, the Cochrane Central Register of Controlled Trials and EMBASE (from 1980 to December 2008) were searched for English-language articles published between 1966 and 2008. This search was completed by a hand research accessing the references cited in all identified publications. RESULTS: Nineteen studies were identified reporting outcomes after oral surgery procedures (mostly dental extractions in patients on OAT following different management protocols and haemostatic therapies). Five studies were randomized-controlled trials (RCTs), 11 were controlled clinical trials (CCTs) and three were prospective case series. The OAT management strategies as well as the protocols during and after surgery were different. This heterogeneity prevented any possible data aggregation and synthesis. The results from these studies are very homogeneous, reporting minor bleeding in very few patients, without a significant difference between the OAT patients who continue with the vitamin K antagonists vs. the patients who stopped this medication before surgery. These post-operative bleeding events were controlled only with local haemostatic measures: tranexamic acid mouthwashes, gelatine sponges and cellulose gauzes's application were effective. Post-operative bleeding did not correlate with the international normalised ratio (INR) status. In none of the studies was a thromboembolic event reported. CONCLUSIONS: OAT patients (INR 2-4) who do not discontinue the AC medication do not have a significantly higher risk of post-operative bleeding than non-OAT patients and they also do not have a higher risk of post-operative bleeding than OAT patients who discontinue the medication. In patients with OAT (INR 2-4) without discontinuation, topical haemostatic agents were effective in preventing post-operative bleeding. OAT discontinuation is not recommended for minor oral surgery, such as single tooth extraction or implant placement, provided that this does not involve autogenous bone grafts, extensive flaps or osteotomy preparations extending outside the bony envelope. Evidence does not support that dental implant placement in patients on OAT is contraindicated.

Long-term in vivo regeneration of peripheral nerves through bioengineered nerve grafts.

Although autologous nerve graft is still the first choice strategy in nerve reconstruction, it has the severe disadvantage of the sacrifice of a functional nerve. Cell transplantation in a bioartificial conduit is an alternative strategy to improve nerve regeneration. Nerve fibrin conduits were seeded with various cell types: primary Schwann cells (SC), SC-like differentiated bone marrow-derived mesenchymal stem cells (dMSC), SC-like differentiated adipose-derived stem cells (dASC). Two further control groups were fibrin conduits without cells and autografts. Conduits were used to bridge a 1 cm rat sciatic nerve gap in a long term experiment (16 weeks). Functional and morphological properties of regenerated nerves were investigated. A reduction in muscle atrophy was observed in the autograft and in all cell-seeded groups, when compared with the empty fibrin conduits. SC showed significant improvement in axon myelination and average fiber diameter of the regenerated nerves. dASC were the most effective cell population in terms of improvement of axonal and fiber diameter, evoked potentials at the level of the gastrocnemius muscle and regeneration of motoneurons, similar to the autografts. Given these results and other advantages of adipose derived stem cells such as ease of harvest and relative abundance, dASC could be a clinically translatable route towards new methods to enhance peripheral nerve repair.

Retrograde ascending aortic dissection during or after thoracic aortic stent graft placement: insight from the European registry on endovascular aortic repair complications.

BACKGROUND: Single-center reports have identified retrograde ascending aortic dissection (rAAD) as a potentially lethal complication of thoracic endovascular aortic repair (TEVAR). METHODS AND RESULTS: Between 1995 and 2008, 28 centers participating in the European Registry on Endovascular Aortic Repair Complications reported a total of 63 rAAD cases (incidence, 1.33%; 95% CI, 0.75 to 2.40). Eighty-one percent of patients underwent TEVAR for acute (n=26, 54%) or chronic type B dissection (n=13, 27%). Stent grafts with proximal bare springs were used in majority of patients (83%). Only 7 (15%) patients had intraoperative rAAD, with the remaining occurring during the index hospitalization (n=10, 21%) and during follow-up (n=31, 64%). Presenting symptoms included acute chest pain (n=16, 33%), syncope (n=12, 25%), and sudden death (n=9, 19%) whereas one fourth of patients were asymptomatic (n=12, 25%). Most patients underwent emergency (n=25) or elective (n=5) surgical repair. Outcome was fatal in 20 of 48 patients (42%). Causes of rAAD included the stent graft itself (60%), manipulation of guide wires/sheaths (15%), and progression of underlying aortic disease (15%). CONCLUSIONS: The incidence of rAAD was low (1.33%) in the present analysis with high mortality (42%). Patients undergoing TEVAR for type B dissection appeared to be most prone for the occurrence of rAAD. This complication occurred not only during the index hospitalization but after discharge up to 1050 days after TEVAR. Importantly, the majority of rAAD cases were associated with the use of proximal bare spring stent grafts with direct evidence of stent graft-induced injury at surgery or necropsy in half of the patients.

Comparisons of Preoperative Three-Dimensional Planning and Surgical Reconstruction in Primary Cementless Total Hip Arthroplasty

La planification scanographique (3D) a démontré son utilité pour une reconstruction anatomique plus précise de la hanche (longueur du fémur, centre de rotation, offset, antéversion et rétroversion). Des études ont montré que lors de la planification 2D 50% seulement correspondaient à l'implant définitif du fémur alors que dans une autre étude ce taux s'élevait à 94% pour une planification 3D. Les erreurs étaient liées à l'agrandissement des radiographies. L'erreur sur la taille de la tige est liée à l'estimation inadéquate de la morphologie osseuse ainsi qu'à la densité osseuse. L'erreur de l'antéversion, augmentée par l'inclinaison du bassin, a pu être éliminée par la planification 3D et l'offset restauré dans 98%. Cette étude est basée sur une nouvelle technique de planification scanographique en trois dimensions pour une meilleure précision de la reconstruction de la hanche. Le but de cette étude est de comparer l'anatomie post-opératoire à celle préopératoire en comparant les tailles d'implant prévu lors de la planification 3D à celle réellement utilisée lors de l'opération afin de déterminer l'exactitude de la restauration anatomique avec étude des différents paramètres (centre de rotation, densité osseuse, L'offset fémoral, rotations des implants, longueur du membre) à l'aide du Logiciel HIP-PLAN (Symbios) avec évaluation de la reproductibilité de notre planification 3D dans une série prospective de 50 patients subissant une prothèse totale de hanche non cimentée primaire par voie antérieure. La planification pré-opératoire a été comparée à un CTscan postopératoire par fusion d'images. CONCLUSION ET PRESPECTIVE Les résultats obtenus sont les suivants : La taille de l'implant a été prédit correctement dans 100% des tiges, 94% des cupules et 88% des têtes (longueur). La différence entre le prévu et la longueur de la jambe postopératoire était de 0,3+2,3 mm. Les valeurs de décalage global, antéversion fémorale, inclinaison et antéversion de la cupule étaient 1,4 mm ± 3,1, 0,6 ± 3,3 0 -0,4 0 ± 5 et 6,9 ° ± 11,4, respectivement. Cette planification permet de prévoir la taille de l'implant précis. Position de la tige et de l'inclinaison de la cupule sont exactement reproductible. La planification scanographique préopératoire 3D permet une évaluation précise de l'anatomie individuelle des patients subissant une prothèse totale de hanche. La prédiction de la taille de l'implant est fiable et la précision du positionnement de la tige est excellente. Toutefois, aucun avantage n'est observée en termes d'orientation de la cupule par rapport aux études impliquant une planification 2D ou la navigation. De plus amples recherches comparant les différentes techniques de planification pré-opératoire à la navigation sont nécessaire.

Nasopalatine duct cyst: report of 22 cases and review of the literature

Objectives: Nasopalatine duct cysts (NPDCs) are the most common developmental, epithelial and non-odontogenic cysts of the maxillae. The present study describes the clinicopathological characteristics of 22 NPDCs and discusses their etiology, incidence, treatment and prognosis, with a review of the literature on the subject. Study design: A retrospective observational study was made comprising a period of 36 years (1970-2006), and yielding a series of 22 patients with histopathological confirmation of NPDC. Surgical treatment was carried out under local anesthesia and comprised the dissection and removal of the cyst adopting a usually palatine approach, with the preparation of an enveloping flap from 1.4 to 2.4. Results: No statistically significant correlation was observed between the size of the lesion and patient age, although the size of the cyst differed according to patient gender, with a mean NPDC diameter of 16 mm in males and 12 mm in females. In no case did we observe root reabsorption or loss of vitality of the upper incisors following surgery. The X-ray image was rounded in 15 cases and heart-shaped in the remaining 7 cases. In the majority of cases panoramic X-rays and periapical and occlusal X-rays sufficed to identify the lesion, though computed tomography was used in cases of doubt. Conclusions: The etiology of NPDC is unclear. Simple surgical resection is recommended, followed by clinical and radiological control to ensure correct resolution of the case.

Precordial abscess inducing chest pain 20 years after surgical repair of a pentalogy of fallot.

A 25-year-old male asylum-seeker presented with chest pain, exertional dyspnea, and orthopnea 20 years after the surgical repair of a pentalogy of Fallot. An extracardiac mass compressing the right ventricle was subsequently detected and surgical decompression was performed to relieve the resulting right intraventricular hypertension. At operation, the mass proved to be a coagulase-negative, staphylococcal abscess. In addition, the removal of the mass unmasked a previously nonrecognized pulmonary outflow stenosis that required balloon dilatation and beta-blocker therapy. While infections are known to occur after sternotomy, the formation of an abscess in the anterior mediastinum several years after the intervention appears to be exceptional; this diagnosis came to mind only after the more common complications had been considered, e.g., pseudoaneurysm or pericardial hematoma. To our knowledge, this is the first report of an abscess in the anterior mediastinum that had probably formed over many years following a sternotomy, compressed the right ventricle and masked a pulmonary stenosis.

Lésions traumatiques rachidiennes et indications au traitement chirurgical [Surgical indications in spinal trauma]

Surgical indications in spinal trauma remain a controversial topic. In general, unstable cervical injuries such as displaced odontoid fractures, burst fractures or tear drop fractures require surgical intervention. Thoracolumbar compression injuries without posterior wall involvement or significant kyphosis can be treated conservatively. Surgery is indicated in fractures-dislocations and burst fractures with significant canal narrowing and/or major kyphosis. The role of emergency decompression as well as that of steroids remain uncertain since no study to date has convincingly proven their efficacy.