Surgery for Hirschsprung's disease: comparison between the Duhamel method and the transanal endorectal pull-through based on 59 patients and a review of the literature

Background:¦Hirschsprung's disease (HSCR) is a congenital malformation of the enteric nervous system due to the¦arrest of migration of neural crest cells to form the myenteric and submucosal plexuses. It leads to an anganglionic intestinal segment, which is permanently contracted causing intestinal obstruction. Its incidence is approximately 1/5000 birth, and males are more frequently affected with a male/female ratio of 4/1. The diagnosis is in most cases made within the first year of life. The rectal biopsy of the mucosa and sub-mucosa is the diagnostic gold standard.¦Purpose:¦The aim of this study was to compare two surgical approaches for HSCR, the Duhamel technique and the transanal endorectal pull-through (TEPT) in term of indications, duration of surgery, duration of hospital stay, postoperative treatment, complications, frequency of enterocolitis and functional outcomes.¦Methods:¦Fifty-nine patients were treated for HSCR by one of the two methods in our department of pediatric¦surgery between 1994 and 2010. These patients were separated into two groups (I: Duhamel, II: TEPT), which were compared on the basis of medical records. Statistics were made to compare the two groups (ANOVA test). The first group includes 43 patients and the second 16 patients. It is noteworthy that twenty-four patients (about 41% of all¦patients) were referred from abroad (Western Africa). Continence was evaluated with the Krickenbeck's score.¦Results:¦Statistically, this study showed that operation duration, hospital stay, postoperative fasting and duration of postoperative antibiotics were significantly shorter (p value < 0.05) in group II (TEPT). But age at operation and length of aganglionic segment showed no significant difference between the two groups. The continence follow-up showed generally good results (Krickenbeck's scores 1; 2.1; 3.1) in both groups with a slight tendency to constipation in group I and soiling in group II.¦Conclusion:¦We found two indications for the Duhamel method that are being referred from a country without¦careful postoperative surveillance and/or having a previous colostomy. Even if the Duhamel technique tends to be replaced by the TEPT, it remains the best operative approach for some selected patients. TEPT has also proved some advantages but must be followed carefully because, among other points, of the postoperative dilatations. Our postoperative standards, like digital rectal examination and anal dilatations seem to reduce the occurrence of complications like rectal spur and anal/anastomosis stenosis, respectively in the Duhamel method and the TEPT technique.

Métastases pulmonaires: quelle place pour la chirurgie [Management pulmonary metastases: when operate?].

Thirty percent of patients suffering from malignant disease will develop pulmonary metastases. Effective chemotherapy is lacking for many of these tumors. Many studies suggest survival benefit in selected patients when pulmonary metastasectomy allows complete resection. Several operative approach may be offered in order to achieve complete resection and maximal lung sparring. Pre-operative workup must assess the control of the primary tumor and the possibility of performing complete resection. Minimally invasive approaches may offer better quality life and equivalent oncologic outcomes than open approach.

HPV & head and neck cancer: a descriptive update

The incidence of head and neck squamous cell carcinoma (HNSCC) has been gradually increasing over the last three decades. Recent data have now attributed a viral aetiology to a subset of head and neck cancers. Several studies indicate that oral human papillomavirus (HPV) infection is likely to be sexually acquired. The dominance of HPV 16 in HPV+ HNSCC is even greater than that seen in cervical carcinoma of total worldwide cases. Strong evidence suggests that HPV+ status is an important prognostic factor associated with a favourable outcome in head and neck cancers. Approximately 30 to 40% of HNSCC patients with present with early stage I/II disease. These patients are treated with curative intent using single modality treatments either radiation or surgery alone. A non-operative approach is favored for patients in which surgery followed by either radiation alone or radiochemotherapy may lead to severe functional impairment. Cetuximab, a humanized mouse anti-EGFR IgG1 monoclonal antibody, improved locoregional control and overall survival in combination with radiotherapy in locally advanced tumours but at the cost of some increased cardiac morbidity and mortality. Finally, the improved prognosis and treatment responses to chemotherapy and radiotherapy by HPV+ tumours may suggest that HPV status detection is required to better plan and individualize patient treatment regimes.

[Medium-term results after m. vastus medialis obliquus-plasty for lateral patellar dislocation]

Progressive retropatellar arthrosis is often seen in dated rigid distal realignment (i.e. osteotomy of tuberositas) at long-term follow-ups. Therefore, operations for lateral dislocation of the patella are still discussed controversially. Dynamic, proximal realignments seem to have lower rates of arthrosis but higher rates of redislocation. Recently, in anatomic and biomechanic studies, the m. vastus medialis obliquus (vmo) was found to be one of the most important proximal restraints to lateral dislocation of the patella.A total of 28 patients (mean age 21.5 years) were treated between 1994 and 2003 with a plasty of the vmo for lateral patellar dislocation. The technique was performed for most etiologies of femoropatellar instability.For this proximal soft tissue technique, the muscle tendon is detached from its patellar insertion. Subsequently, the tendon is reinserted at the patella 10-15 mm more distally and fixed with Mitek anchors. Full weight bearing in extension is possible immediately after surgery. An active vastus medialis training is started after 6 weeks.Of the patients, 27 were evaluated clinically and radiologically in 2004 (a mean of 5 years postoperatively). A total of 83% of the patients estimated the result to be good or excellent, 10% were satisfied and 7% were discontent. The mean Lysholm-Knee-Score was 83.1 points. Two patients suffered a patella redislocation (7%). A statistically significant improvement of the congruence angle was noted in the radiographs, even in medium-term controls. In 89% of the cases no or only little retropatellar arthrosis was observed. These 5 year results are comparable to those of other techniques for distal or proximal realignments. The rate of redislocation was below average. Compared to the rate of retropatellar arthrosis in long-term results of rigid distal realignment, our patients demonstrated a relative low rate after 5 years. We attribute this to the minimal interference in physiological joint mechanics and to the restored anatomy. In terms of future long-term results, our findings are promising. The idea of a proximal dynamic stabilization and the causal operative approach at the origin of pathology using vmo-plasty was confirmed in recent anatomic and biomechanic studies. Over or under correction of soft tissues could be adapted. More rigid techniques of distal realignment do not allow an adaptation to this extent and can lead to prearthrotic hyperpression in the medial femoropatellar and femorotibial joints.

Mini-arthrotomy for lateral discoid menisci in children

BACKGROUND: Long-term results after partial, extended, or complete resection of lateral discoid meniscus in children revealed knee arthritis. The purpose of this study was to evaluate whether the operative approach, arthrotomy or arthroscopy, has an impact on the outcome and the development of arthritis. METHODS: A retrospective comparison of 2 well matching groups totaling 40 children with symptomatic lateral discoid meniscus (48 knees, mean age 8.9 years, 13 male and 27 female patients). Meniscus resection was performed via mini-arthrotomy in group 1 (n=17 patients, 20 knees) and arthroscopically in group 2 (n=23 patients, 28 knees). RESULTS: In the follow-up (mean 57 months in group 1, 62 months in group 2), functional results indicated a trend to better results in the International Knee Documentation Committee score (P=0.12) and in the Lysholm score for group 1 (P=0.13) but not in the Ikeuchi score (P=0.48). The comparison of the radiographic arthritis grading in the follow-up showed no significant arthritis in either group (P=0.22). The overall complication rate was similar in both groups (2/20, 10% in group 1; 3/28, 12% in group 2). CONCLUSIONS: Most likely because of the appropriate visualization of the children's joint and the easier instrumentation, the mini-arthrotomy led to slightly superior results compared with those after arthroscopic resection regarding functional outcome and 5 years after surgery. We can recommend the mini-arthrotomy for the resection of lateral discoid meniscus particularly in young children with narrow joint spaces and for surgeons that are not familiar with arthroscopies of small joints. LEVEL OF EVIDENCE: III (therapeutic study, case series with control group).

Free abdominal fluid without obvious solid organ injury upon CT imaging: an actual problem or simply over-diagnosing?

Whereas a non-operative approach for hemodynamically stable patients with free intraabdominal fluid in the presence of solid organ injury is generally accepted, the presence of free fluid in the abdomen without evidence of solid organ injury not only presents a challenge for the treating emergency physician but also for the surgeon in charge. Despite recent advances in imaging modalities, with multi-detector computed tomography (CT) (with or without contrast agent) usually the imaging method of choice, diagnosis and interpretation of the results remains difficult. While some studies conclude that CT is highly accurate and relatively specific at diagnosing mesenteric and hollow viscus injury, others studies deem CT to be unreliable. These differences may in part be due to the experience and the interpretation of the radiologist and/or the treating physician or surgeon.A search of the literature has made it apparent that there is no straightforward answer to the question what to do with patients with free intraabdominal fluid on CT scanning but without signs of solid organ injury. In hemodynamically unstable patients, free intraabdominal fluid in the absence of solid organ injury usually mandates immediate surgical intervention. For patients with blunt abdominal trauma and more than just a trace of free intraabdominal fluid or for patients with signs of peritonitis, the threshold for a surgical exploration - preferably by a laparoscopic approach - should be low. Based on the available information, we aim to provide the reader with an overview of the current literature with specific emphasis on diagnostic and therapeutic approaches to this problem and suggest a possible algorithm, which might help with the adequate treatment of such patients.

Long-term survival after multidisciplinary management of resected pancreatic adenocarcinoma.

INTRODUCTION: Actual 5-year survival rates of 10-18% have been reported for patients with resected pancreatic adenocarcinoma (PC), but the use of multimodality therapy was uncommon in these series. We evaluated long-term survival and patterns of recurrence in patients treated for PC with contemporary staging and multimodality therapy. METHODS: We analyzed 329 consecutive patients with PC evaluated between 1990 and 2002 who underwent resection. Each received a multidisciplinary evaluation and a standard operative approach. Pre- or postoperative chemotherapy and/or chemoradiation were routine. Surgical specimens of 5-year survivors were re-reviewed. A multivariate model of factors associated with long-term survival was constructed. RESULTS: Patients underwent pancreaticoduodenectomy (n = 302; 92%), distal (n = 20; 6%), or total pancreatectomy (n = 7; 2%). A total of 108 patients (33%) underwent vascular reconstruction, 301 patients (91%) received neoadjuvant or adjuvant therapy, 157 specimens (48%) were node positive, and margins were microscopically positive in 52 patients (16%). Median overall survival and disease-specific survival was 23.9 and 26.5 months. Eighty-eight patients (27%) survived a minimum of 5 years and had a median overall survival of 11 years. Of these, 21 (24%) experienced recurrence, 7 (8%) after 5 years. Late recurrences occurred most frequently in the lungs, the latest at 6.7 years. Multivariate analysis identified disease-negative lymph nodes (P = .02) and no prior attempt at resection (P = 0.01) as associated with 5-year survival. CONCLUSIONS: Our 27% actual 5-year survival rate for patients with resected PC is superior to that previously reported, and it is influenced by our emphasis on detailed staging and patient selection, a standardized operative approach, and routine use of multimodality therapy.

EACTS expert consensus statement for surgical management of pleural empyema

Pleural infection is a frequent clinical condition. Prompt treatment has been shown to reduce hospital costs, morbidity and mortality. Recent advances in treatment have been variably implemented in clinical practice. This statement reviews the latest developments and concepts to improve clinical management and stimulate further research. The European Association for Cardio-Thoracic Surgery (EACTS) Thoracic Domain and the EACTS Pleural Diseases Working Group established a team of thoracic surgeons to produce a comprehensive review of available scientific evidence with the aim to cover all aspects of surgical practice related to its treatment, in particular focusing on: surgical treatment of empyema in adults; surgical treatment of empyema in children; and surgical treatment of post-pneumonectomy empyema (PPE). In the management of Stage 1 empyema, prompt pleural space chest tube drainage is required. In patients with Stage 2 or 3 empyema who are fit enough to undergo an operative procedure, there is a demonstrated benefit of surgical debridement or decortication [possibly by video-assisted thoracoscopic surgery (VATS)] over tube thoracostomy alone in terms of treatment success and reduction in hospital stay. In children, a primary operative approach is an effective management strategy, associated with a lower mortality rate and a reduction of tube thoracostomy duration, length of antibiotic therapy, reintervention rate and hospital stay. Intrapleural fibrinolytic therapy is a reasonable alternative to primary operative management. Uncomplicated PPE [without bronchopleural fistula (BPF)] can be effectively managed with minimally invasive techniques, including fenestration, pleural space irrigation and VATS debridement. PPE associated with BPF can be effectively managed with individualized open surgical techniques, including direct repair, myoplastic and thoracoplastic techniques. Intrathoracic vacuum-assisted closure may be considered as an adjunct to the standard treatment. The current literature cements the role of VATS in the management of pleural empyema, even if the choice of surgical approach relies on the individual surgeon's preference.

Usos de la escritura en la enseñanza de la historia

Se presenta una caracterización de usos de la escritura en la enseñanza de la historia, producida en el marco de una investigación en Didácticas Específicas que estudia las relaciones entre la lectura y la escritura en la enseñanza y el aprendizaje escolar de historia. Se analizan usos de la escritura relacionados con distintas finalidades, además de los que impone el funcionamiento didáctico habitual de la historia como disciplina escolar. Se señalan posibles complementariedades y tensiones entre distintas racionalidades que intervienen en la generación de propuestas de escritura, en particular la tensión entre la lógica del estudio y la lógica del ejercicio. Por último, se caracteriza un problema del uso de las producciones escritas para la evaluación, relativo al modo en que pueden operar las consignas en la posibilidad de que los alumnos desplieguen -o no- los contenidos aprendidos sobre el tema evaluado

Entre lo informativo y lo estratégico : La cuestión de los abordajes del conocimiento histórico en la enseñanza de la historia

Este trabajo se centra en las distintas maneras en las cuales un lector-profesor de historia aborda el conocimiento histórico. Esos diferentes modos de abordarlo (informativa, operativa y estratégica) están presentes tanto en el momento de la lectura de los textos historiográficos como en el de la enseñanza del conocimiento que es su fruto. Así, la noción de abordaje se presenta como el eje tanto de la producción de sentido para la lectura de un libro de historia como de la configuración de los modos en que los contenidos de enseñanza son presentados a los estudiantes. Finalmente, es su condición de herramienta de análisis para la práctica de la enseñanza la que le permite dirigir una mirada renovada y más profunda a distintas situaciones relacionadas con la práctica de la enseñanza de la historia, que van desde la planificación de una clase o un curso hasta la comprensión de encuentros y desencuentros con los estudiantes en el plano de la ejercitación y la evaluación

Usos de la escritura en la enseñanza de la historia

Se presenta una caracterización de usos de la escritura en la enseñanza de la historia, producida en el marco de una investigación en Didácticas Específicas que estudia las relaciones entre la lectura y la escritura en la enseñanza y el aprendizaje escolar de historia. Se analizan usos de la escritura relacionados con distintas finalidades, además de los que impone el funcionamiento didáctico habitual de la historia como disciplina escolar. Se señalan posibles complementariedades y tensiones entre distintas racionalidades que intervienen en la generación de propuestas de escritura, en particular la tensión entre la lógica del estudio y la lógica del ejercicio. Por último, se caracteriza un problema del uso de las producciones escritas para la evaluación, relativo al modo en que pueden operar las consignas en la posibilidad de que los alumnos desplieguen -o no- los contenidos aprendidos sobre el tema evaluado

Entre lo informativo y lo estratégico : La cuestión de los abordajes del conocimiento histórico en la enseñanza de la historia

Este trabajo se centra en las distintas maneras en las cuales un lector-profesor de historia aborda el conocimiento histórico. Esos diferentes modos de abordarlo (informativa, operativa y estratégica) están presentes tanto en el momento de la lectura de los textos historiográficos como en el de la enseñanza del conocimiento que es su fruto. Así, la noción de abordaje se presenta como el eje tanto de la producción de sentido para la lectura de un libro de historia como de la configuración de los modos en que los contenidos de enseñanza son presentados a los estudiantes. Finalmente, es su condición de herramienta de análisis para la práctica de la enseñanza la que le permite dirigir una mirada renovada y más profunda a distintas situaciones relacionadas con la práctica de la enseñanza de la historia, que van desde la planificación de una clase o un curso hasta la comprensión de encuentros y desencuentros con los estudiantes en el plano de la ejercitación y la evaluación

Entre lo informativo y lo estratégico : La cuestión de los abordajes del conocimiento histórico en la enseñanza de la historia

Este trabajo se centra en las distintas maneras en las cuales un lector-profesor de historia aborda el conocimiento histórico. Esos diferentes modos de abordarlo (informativa, operativa y estratégica) están presentes tanto en el momento de la lectura de los textos historiográficos como en el de la enseñanza del conocimiento que es su fruto. Así, la noción de abordaje se presenta como el eje tanto de la producción de sentido para la lectura de un libro de historia como de la configuración de los modos en que los contenidos de enseñanza son presentados a los estudiantes. Finalmente, es su condición de herramienta de análisis para la práctica de la enseñanza la que le permite dirigir una mirada renovada y más profunda a distintas situaciones relacionadas con la práctica de la enseñanza de la historia, que van desde la planificación de una clase o un curso hasta la comprensión de encuentros y desencuentros con los estudiantes en el plano de la ejercitación y la evaluación

Usos de la escritura en la enseñanza de la historia

Se presenta una caracterización de usos de la escritura en la enseñanza de la historia, producida en el marco de una investigación en Didácticas Específicas que estudia las relaciones entre la lectura y la escritura en la enseñanza y el aprendizaje escolar de historia. Se analizan usos de la escritura relacionados con distintas finalidades, además de los que impone el funcionamiento didáctico habitual de la historia como disciplina escolar. Se señalan posibles complementariedades y tensiones entre distintas racionalidades que intervienen en la generación de propuestas de escritura, en particular la tensión entre la lógica del estudio y la lógica del ejercicio. Por último, se caracteriza un problema del uso de las producciones escritas para la evaluación, relativo al modo en que pueden operar las consignas en la posibilidad de que los alumnos desplieguen -o no- los contenidos aprendidos sobre el tema evaluado

Nutrition for the pediatric surgical patient: approach in the peri-operative period

Nutrition is essential for maintenance of physiologic homeostasis and growth. Hypermetabolic states lead to a depletion of body stores, with decreased immunocompetence and increased morbidity and mortality. The purpose of this paper is to provide an update regarding the provision of appropriate nutrition for the pediatric surgical patient, emphasizing the preoperative and postoperative periods. Modern nutritional support for the surgical patient comprises numerous stages, including assessment of nutritional status, nutritional requirements, and nutritional therapy. Nutritional assessment is performed utilizing the clinical history, clinical examination, anthropometry, and biochemical evaluation. Anthropometric parameters include body weight, height, arm and head circumference, and skinfold thickness measurements. The biochemical evaluation is conducted using determinations of plasma levels of proteins, including album, pre-albumin, transferrin, and retinol-binding protein. These parameters are subject to error and are influenced by the rapid changes in body composition in the peri-operative period. Nutritional therapy includes enteral and/or parenteral nutrition. Enteral feeding is the first choice for nutritional therapy. If enteral feeding is not indicated, parenteral nutrition must be utilized. In all cases, an individualized, adequate diet (enteral formula or parenteral solution) is obligatory to decrease the occurrence of overfeeding and its undesirable consequences.