Antero-Medialisation of the Tibial Tubercle for Patellar Instability

We reviewed 19 patients (24 knees) with patellofemoral instability treated surgically with antero-medialisation of the tibial tubercle and lateral retinacular release. Twenty-two knees had recurrent patellar dislocation and two patellar subluxation. Lateral retinacular release was performed arthroscopically in 15 knees. Average follow-up was 52 (16-86) months. There was one postoperative haemarthrosis and one failed fixation, which needed surgical revision. The average Lysholm score improved from 63.3 to 98 and only one knee had persistent patello-femoral pain postoperatively. The patellar tilt angle improved from 9.4 degrees to 5.5 degrees . There were no redislocations. We find that the surgical technique produces a consistent correction of patellar instability, but long-term studies are needed to confirm whether it can prevent arthritic degeneration.

Acute postsurgical suppurative parotitis: current prevalence at Hospital das Clínicas, São Paulo University Medical School

Postsurgical acute suppurative parotitis is a bacterial gland infection that occurs from a few days up to some weeks after abdominal surgical procedures. In this study, the authors analyze the prevalence of this complication in Hospital das Clínicas/São Paulo University Medical School by prospectively reviewing the charts of patients who underwent surgeries performed by the gastroenterological and general surgery staff from 1980 to 2005. Diagnosis of parotitis or sialoadenitis was analyzed. Sialolithiasis and chronic parotitis previous to hospitalization were exclusion criteria. In a total of 100,679 surgeries, 256 patients were diagnosed with parotitis or sialoadenitis. Nevertheless, only three cases of acute postsurgical suppurative parotitis associated with the surgery were identified giving an incidence of 0.0028%. All patients presented with risk factors such as malnutrition, immunosuppression, prolonged immobilization and dehydration. In the past, acute postsurgical suppurative parotitis was a relatively common complication after major abdominal surgeries. Its incidence decreased as a consequence of the improvement of perioperative antibiotic therapy and postoperative support. In spite of the current low incidence, we believe it is important to identify risks and diagnose as quick as possible, in order to introduce prompt and appropriate therapeutic measures and avoid potentially fatal complications with the evolution of the disease.

Laparoscopic Assisted Vaginal Hysterectomy Versus Vaginal Hysterectomy

Introduction: Hysterectomy is the commonest gynecologic operation, performed for malignant and benign conditions. There are many approaches to hysterectomy for benign disease. Studies comparing the techniques have showed that vaginal hysterectomy has benefits in terms of reduced hospital stay, faster recovery and less operating time. Objective: The purpose of this study is to compare the surgical and immediate postoperative outcomes of Laparoscopic Assisted Vaginal Hysterectomy (LAVH) with those of Vaginal Hysterectomy (VH). Methods: Retrospective descriptive study, comparing two groups of women who underwent LAVH or VH in our department during a 24 months period, from January 2009 to December 2010. The two groups were compared regarding age, vaginal deliveries, previous abdominal surgery, uterine and adnexal pathology, intra-operative and post-operative complications, uterus weight, blood loss and number of days until discharge. Results: In our study 42 LAVH and 99 VH were included, with a patient mean age of 47 and 59, respectively. The most frequent indication for hysterectomy was fibroids (80%) for LAVH and POP(58.6%) for HV. In LAVH group 47.6% of patients had previous abdominal surgery, vs 28.2% in VH group. The medium operative time was 167 minutes for LAVH vs 99 minutes for HV. The intra-operative complications were one case (2%) of accidental incision of rectum in LAVH, and one bladder incision in the VH (1%). There were 3 conversions to laparotomy for difficult technique (7%) in LAVH group. There were no significant post-operative complications for LAVH. In VH group there were 2 cases of haemoperitoneum (2%) and 1 case requiring blood transfusion (1%). The mean time for discharge was 4.23 days for LAVH and 4.46 days for VH. Conclusions: In our study, the main advantage for VH was the reduced operative time. In terms of time to discharge there was no difference between the 2 groups. The main intra-operative complication of LAVH was the risk of conversion to laparotomy, but post-operatively this procedure had fewer complications than VH. In conclusion, LAVH is a safe option for women requiring hysterectomy in cases where VH is anticipated to be technically difficult.

Neurogenic Thoracic Outlet Syndrome Associated with Cervical Rib

A true neurogenic thoracic outlet syndrome (TOS) associated with a cervical rib is considered extremely rare. The authors present their experience with 5 cases of true neurogenic TOS associated with a cervical rib. All patients were female and had a cervical rib confirmed radiographically pre-operatively. Average age was 34,8 years. Although all patients had been treated with several combinations of diverse drugs and a rehabilitation program before referral to surgery, all described their pain as intense and debilitating before surgical treatment. All patients had pre-operative electromyographic abnormalities. Patients were operated on via a supraclavicular approach and the cervical rib was resected. No intra-operative or postoperative complications were noted. Two years postoperatively, all patients mentioned improvement. However, only 2 were symptomless, and on no medication. In one patient there was significant improvement, and in the remaining 2 patients some residual pain persisted that had to be dealt with pharmacologically. All patients were able to resume their daily life activities. Recovery was poorer in the 2 patients that had been referred to surgery after a longer period of time since the beginning of symptoms.

Um caso de variante folicular do carcinoma papilar da tiróide num teratoma quístico maduro numa mulher jovem

Malignant transformation of a teratoma occurs in 1-2% of cases, with carcinoma of the thyroid being extremely rare. It is usually diagnosed in the postoperative histopathological exam. We describe a case of thyroid carcinoma in a mature cystic teratoma.

Colesteatoma em idade pediátrica: análise retrospectiva de 12 anos de experiência do Hospital Fernando Fonseca

Objectivo: revisão de casos de colesteatoma em idade pediátrica do HFF durante um período de 12 anos. Desenho do estudo: retrospectivo. Material e métodos: análise de 30 casos de cirurgia para colesteatoma em doentes dos 0 - 18 anos de Janeiro de 2000 a Dezembro de 2011. Resultados: o colesteatoma inicial foi extenso na maioria dos casos. Realizou-se mastoidectomia com técnica aberta (66,7%), mastoidectomia com técnica fechada (26,7%), aticomia transmeática (3,3%) e remoção de colesteatoma da membrana timpânica (3,3%). O GAP pós-operatório médio foi de 22,5 dB, com GAP 0-10dB em 16,7%, GAP 11-20dB em 10%, GAP 21-30 dB em 30%, mais de 30dB em 16,7% e desconhecido em 26,7%. A taxa de recorrência de colesteatoma foi de 23,3% Conclusões: Na nossa amostra o colesteatoma foi extenso e agressivo. Realizámos mastoidectomia com técnica aberta na maioria dos casos. Para obter bons resultados a abordagem deverá ser individualizada, atendendo a factores clínicos, anatómicos e capacidade de adesão à terapêutica.

Iatrogenic Aortic Pseudoaneurysm: a Forgotten Complication

Pseudoaneurysms of the ascending aorta are a rare complication of cardiac surgery. However, the poor prognosis associated with this condition if untreated makes early diagnosis and treatment important. We present the case of a 66-year-old woman who had undergone mitral valvuloplasty 12 days previously, who was admitted with a diagnosis of new-onset atrial fibrillation. The transthoracic echocardiogram showed a clot in the right atrium and anticoagulation was initiated, followed by antibiotic therapy. After further investigation, the patient was diagnosed with a pseudoaneurysm of the ascending aorta and underwent surgical repair, followed by six weeks of antibiotic therapy. She was readmitted six months later for an abscess of the lower sternum and mediastinum. After a conservative approach with antibiotics and local drainage failed, recurrence of a large pseudoaneurysm compressing the superior vena cava was documented. A third operation was performed to debride the infected tissue and to place an aortic allograft. There were no postoperative complications.

Familial Abdominal Aortic Aneurysm Is Associated With More Complications After Endovascular Aneurysm Repair

OBJECTIVE: A familial predisposition to abdominal aortic aneurysms (AAAs) is present in approximately one-fifth of patients. Nevertheless, the clinical implications of a positive family history are not known. We investigated the risk of aneurysm-related complications after endovascular aneurysm repair (EVAR) for patients with and without a positive family history of AAA. METHODS: Patients treated with EVAR for intact AAAs in the Erasmus University Medical Center between 2000 and 2012 were included in the study. Family history was obtained by written questionnaire. Familial AAA (fAAA) was defined as patients having at least one first-degree relative affected with aortic aneurysm. The remaining patients were considered sporadic AAA. Cardiovascular risk factors, aneurysm morphology (aneurysm neck, aneurysm sac, and iliac measurements), and follow-up were obtained prospectively. The primary end point was complications after EVAR, a composite of endoleaks, need for secondary interventions, aneurysm sac growth, acute limb ischemia, and postimplantation rupture. Secondary end points were specific components of the primary end point (presence of endoleak, need for secondary intervention, and aneurysm sac growth), aneurysm neck growth, and overall survival. Kaplan-Meier estimates for the primary end point were calculated and compared using log-rank (Mantel-Cox) test of equality. A Cox-regression model was used to calculate the independent risk of complications associated with fAAA. RESULTS: A total of 255 patients were included in the study (88.6% men; age 72 ± 7 years, median follow-up 3.3 years; interquartile range, 2.2-6.1). A total of 51 patients (20.0%) were classified as fAAA. Patients with fAAA were younger (69 vs 72 years; P = .015) and were less likely to have ever smoked (58.8% vs 73.5%; P = .039). Preoperative aneurysm morphology was similar in both groups. Patients with fAAA had significantly more complications after EVAR (35.3% vs 19.1%; P = .013), with a twofold increased risk (adjusted hazard ratio, 2.1; 95% confidence interval, 1.2-3.7). Secondary interventions (39.2% vs 20.1%; P = .004) and aneurysm sac growth (20.8% vs 9.5%; P = .030) were the most important elements accounting for the difference. Furthermore, a trend toward more type I endoleaks during follow-up was observed (15.6% vs 7.4%; P = .063) and no difference in overall survival. CONCLUSIONS: The current study shows that patients with a familial form of AAA develop more aneurysm-related complications after EVAR, despite similar AAA morphology at baseline. These findings suggest that patients with fAAA form a specific subpopulation and create awareness for a possible increase in the risk of complications after EVAR.

Ophthalmic Complications of Bariatric Surgery

Obesity is increasing vastly in the world, and the number of bariatric surgeries being performed is also increasing. Patients being submitted to bariatric surgeries, especially malabsorptive procedures, have an increased risk of developing nutrient deficiencies, which can culminate in symptomatic hypovitaminosis, if supplementation is not done correctly. The eye and the optic system need an adequate level of several vitamins and minerals to perform properly, especially vitamin A, and this article wants to cover the main nutrients involved, the possible ophthalmic complications that can arise by their deficiency, and the management of those complications.

Hepatic Artery Thrombosis in Live Liver Donor Transplantation: How to Solve - a Case Report

The decrease in the number of cadaveric donors has proved a limiting factor in the number of liver transplants, leading to the death of many patients on the waiting list. The living donor liver transplantation is an option that allows, in selected cases, increase the number of donors. One of the most serious complications in liver transplantation is hepatic artery thrombosis, in the past considered potentially fatal without urgent re-transplantation. A white male patient, 48 years old, diagnosed with hepatocellular carcinoma in chronic liver failure caused by hepatitis B virus, underwent living donor liver transplantation (right lobe). Doppler echocardiography performed in the immediate postoperative period did not identify arterial flow in the right branch, having been confirmed thrombosis of the right hepatic artery in CT angiography. Urgent re-laparotomy was performed, which consisted of thrombectomy and re-anastomosis of the hepatic artery with segmental splenic artery allograft interposition. The patient started anticoagulation and antiplatelet therapy with acetylsalicylic acid. Serial evaluation with Doppler echocardiography showed hepatic artery patency. At present, the patient is asymptomatic. One of the most devastating complications in liver transplantation, and particularly in living liver donor, is thrombosis of the hepatic artery; thus, early diagnosis and treatment is vital. The rapid intervention for revascularization of the graft avoids irreversible ischemia of the bile ducts and hepatic parenchyma, thus avoiding the need for re-transplantation.

Intraocular Pressure in Eyes Receiving Intravitreal Antivascular Endothelial Growth Factor Injections

PURPOSE: The aim of the this study was to determine the effect of intravitreal antivascular endothelial growth factor injections on intraocular pressure (IOP) and identify possible risk factors for the development of increased IOP. MATERIALS AND METHODS: This prospective study included a total of 106 eyes receiving intravitreal injection of bevacizumab as treatment for macular edema or active choroidal neovascularization. IOP was measured by Goldmann applanation tonometry immediately before the intravitreal injection and 5 min, 1 h and 15 days after the procedure. The records of the study patients were reviewed for age, gender, history of glaucoma, diabetes mellitus, phakic status, systemic and topical medication and number of previous injections. Subconjunctival reflux was registered. IOP elevation was defined as IOP ≥21 mm Hg and/or a change from baseline of ≥5 mm Hg recorded at least on two or more measurements on the same visit. RESULTS: Mean preoperative IOP was 15.31 ± 3.90 mm Hg and postoperative IOP values were 27.27 ± 11.87 mm Hg (after 5 min), 17.59 ± 6.24 mm Hg (after 1 h) and 16.86 ± 3.62 mm Hg (after 15 days). The IOP variation was statistically significant between pre- and postoperative measurements (p < 0.05). Subconjunctival reflux was recorded in 11.3%, and in this subgroup the IOP at 5 min and at 1 h was lower than preoperative IOP (p < 0.05). CONCLUSIONS: More than one third of the eyes achieved IOPs >30 mm Hg 5 min after injection. Subconjunctival reflux contributed to a lower mean postoperative IOP (p < 0.05). Considerations for the management include prophylactic IOP lowering with medical therapy and/or preinjection ocular decompression for patients with a history of glaucoma or ocular hypertension and switching to an as-needed injection protocol in patients suffering a marked IOP rise in previous injections. © 2015 S. Karger AG, Basel.

Early Sac Shrinkage Predicts a Low Risk of Late Complications After Endovascular Aortic Aneurysm Repair

BACKGROUND: Aneurysm shrinkage has been proposed as a marker of successful endovascular aneurysm repair (EVAR). Patients with early postoperative shrinkage may experience fewer subsequent complications, and consequently require less intensive surveillance. METHODS: Patients undergoing EVAR from 2000 to 2011 at three vascular centres (in 2 countries), who had two imaging examinations (postoperative and after 6-18 months), were included. Maximum diameter, complications and secondary interventions during follow-up were registered. Patients were categorized according to early sac dynamics. The primary endpoint was freedom from late complications. Secondary endpoints were freedom from secondary intervention, postimplant rupture and direct (type I/III) endoleaks. RESULTS: Some 597 EVARs (71.1 per cent of all EVARs) were included. No shrinkage was observed in 284 patients (47.6 per cent), moderate shrinkage (5-9 mm) in 142 (23.8 per cent) and major shrinkage (at least 10 mm) in 171 patients (28.6 per cent). Four years after the index imaging, the rate of freedom from complications was 84.3 (95 per cent confidence interval 78.7 to 89.8), 88.1 (80.6 to 95.5) and 94.4 (90.1 to 98.7) per cent respectively. No shrinkage was an independent risk factor for late complications compared with major shrinkage (hazard ratio (HR) 3.11; P < 0.001). Moderate compared with major shrinkage (HR 2.10; P = 0.022), early postoperative complications (HR 3.34; P < 0.001) and increasing abdominal aortic aneurysm baseline diameter (HR 1.02; P = 0.001) were also risk factors for late complications. Freedom from secondary interventions and direct endoleaks was greater for patients with major sac shrinkage. CONCLUSION: Early change in aneurysm sac diameter is a strong predictor of late complications after EVAR. Patients with major sac shrinkage have a very low risk of complications for up to 5 years. This parameter may be used to tailor postoperative surveillance.

Adhesion Prevention in Laparoscopic Surgery

Adhesions have important consequences for patients, surgeons, and health services. Peritonealtissue injury can be prevented by using careful surgical techniques. A large number of antiadhesion products have been used experimentally and clinically to prevent postoperative adhesions. Methods: The current author reviewed the surgical literature published about epidemiology, pathogenesis, and various prevention strategies of adhesion formation. Results: Meticulous surgery is essential to reduce unnecessary morbidity and mortality rates from these untoward effects of surgery. Several preventive agents against postoperative peritoneal adhesions have been investigated. Bioresorbable membranes are site-specific antiadhesion products but may be more difficult to use laparoscopically. Liquids and gels have the advantage of more-widespread areas of action and increased ease of use, particularly during laparoscopic operations. Effective pharmacologic agents that can reduce release of proinflammatory cytokines or activate peritoneal fibrinolysis are under development. Their results are encouraging but most of them are contradictory. Conclusions: Many modalities are being studied to reduce this risk; despite initial promising results of different measures in postoperative adhesion prevention, none of them have become standard applications. With the current state of knowledge, preclinical or clinical studies are still necessary to evaluate the effectiveness of the several proposed prevention strategies for avoiding postoperative peritoneal adhesions.

Coronary Revascularization Induces a Shift From Cardiac Toward Noncardiac Mortality Without Improving Survival in Vascular Surgery Patient

OBJECTIVE: Although evidence has shown that ischemic heart disease (IHD) in vascular surgery patients has a negative impact on the prognosis after surgery, it is unclear whether directed treatment of IHD may influence cause-specific and overall mortality. The objective of this study was to determine the prognostic implication of coronary revascularization (CR) on overall and cause-specific mortality in vascular surgery patients. METHODS: Patients undergoing surgery for abdominal aortic aneurysm, carotid artery stenosis, or peripheral artery disease in a university hospital in The Netherlands between January 2003 and December 2011 were retrospectively included. Survival estimates were obtained by Kaplan-Meier and Cox regression analysis. RESULTS: A total of 1104 patients were included. Adjusted survival analyses showed that IHD significantly increased the risk of overall mortality (hazard ratio [HR], 1.50; 95% confidence interval, 1.21-1.87) and cardiovascular death (HR, 1.93; 95% confidence interval, 1.35-2.76). Compared with those without CR, patients previously undergoing CR had similar overall mortality (HR, 1.38 vs 1.62; P = .274) and cardiovascular mortality (HR, 1.83 vs 2.02; P = .656). Nonrevascularized IHD patients were more likely to die of IHD (6.9% vs 35.7%), whereas revascularized IHD patients more frequently died of cardiovascular causes unrelated to IHD (39.1% vs 64.3%; P = .018). CONCLUSIONS: This study confirms the significance of IHD for postoperative survival of vascular surgery patients. CR was associated with lower IHD-related death rates. However, it failed to provide an overall survival benefit because of an increased rate of cardiovascular mortality unrelated to IHD. Intensification of secondary prevention regimens may be required to prevent this shift toward non-IHD-related death and thereby improve life expectancy.

American Society of Anesthesiologists Score: Still Useful After 60 Years? Results of the EuSOS Study

OBJECTIVE: The European Surgical Outcomes Study described mortality following in-patient surgery. Several factors were identified that were able to predict poor outcomes in a multivariate analysis. These included age, procedure urgency, severity and type and the American Association of Anaesthesia score. This study describes in greater detail the relationship between the American Association of Anaesthesia score and postoperative mortality. METHODS: Patients in this 7-day cohort study were enrolled in April 2011. Consecutive patients aged 16 years and older undergoing inpatient non-cardiac surgery with a recorded American Association of Anaesthesia score in 498 hospitals across 28 European nations were included and followed up for a maximum of 60 days. The primary endpoint was in-hospital mortality. Decision tree analysis with the CHAID (SPSS) system was used to delineate nodes associated with mortality. RESULTS: The study enrolled 46,539 patients. Due to missing values, 873 patients were excluded, resulting in the analysis of 45,666 patients. Increasing American Association of Anaesthesia scores were associated with increased admission rates to intensive care and higher mortality rates. Despite a progressive relationship with mortality, discrimination was poor, with an area under the ROC curve of 0.658 (95% CI 0.642 - 0.6775). Using regression trees (CHAID), we identified four discrete American Association of Anaesthesia nodes associated with mortality, with American Association of Anaesthesia 1 and American Association of Anaesthesia 2 compressed into the same node. CONCLUSION: The American Association of Anaesthesia score can be used to determine higher risk groups of surgical patients, but clinicians cannot use the score to discriminate between grades 1 and 2. Overall, the discriminatory power of the model was less than acceptable for widespread use.