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PubMed2006

Pelvic MRI in children with Crohn disease and suspected perianal involvement.

MRI is an important imaging tool in evaluation of adult and pediatric patients with Crohn disease. Pelvic MRI, in particular, has become the method of choice to evaluate for perianal fistulas and associated complications of Crohn disease. MRI can define the extent and location of perianal fistulas and abscesses, as well as provide critical information for operative management. In this pictorial essay, we describe useful MRI techniques for evaluation of perianal complications in pediatric patients with Crohn disease. We review pertinent anatomy and illustrate typical examples of perianal fistulas with and without abscess. We show one case of clinically suspected perianal fistula that was actually a pilonidal sinus.

Child↗
PubMed2004

[Type II split cord malformation of late clinical onset].

A 68-year-old patient suffered for 8 years from radicular S1 pain on the left side, which was aggravated by walking. After an increased effort, he experienced a violent dorsal pain and sensitive troubles in the left T1 and T2 territories. Low back pain and painful paresthesiae of right leg came on next. Physical examination revealed proprioceptive symptoms on the left, a left pyramidal syndrome and a sacral pilonidal sinus. MRI showed on level of L2 vertebra, a spinal cord duplication in a unique dural tube, corresponding to diplomyelia or split cord malformation (SCM) type II. The patient had low conus medullaris anchored on L3-L4 level. A syringomyelia surmounted this medullar dysraphia. Split cord malformations, SCM type I (diplomyelia) or SCM type II (diastematomyelia), are usually revealed in infancy or early childhood. They are very rarely discovered late in the life. With progress in noninvasive spinal cord imaging, such diagnoses will undoubtedly be made more often in adults.

Age of Onset↗
PubMed2000

Contribution of the outpatient surgery unit ITO the general surgery department of a district hospital.

Introduction: The creation of Outpatient Surgery (OPS) units to combine the quality of medical attention and rationalize costs allows for greater efficiency in the use of resources. Aim: To report our series of patients undergoing surgery at the OPS units integrated into our Hospital (Type II): Patients and method: Between May 1994 and March 1998, 832 outpatients, of a total of 5230, underwent surgery at our General Surgery Unit. The criteria for exclusion from the programme depended on the patient and the enviroment or resulted from the operation itself. Results: Mean patient age was 47.5 years; there were 420 males and 412 females. Surgery was performed for 229 inguinofemoral hernias, 47 umbilical-epigastric hernias, nine incisional hernias, 193 pilonidal sinuses, 156 mammary nodules, 65 varicose veins, 64 arteriovenous fistulae and 69 proctology operations. The most common anesthesia techniques performed were rachianesthesia and local anesthesia. Eight point seven percent of the patients required admission (OPS failure), the most frequent causes being excessive pain, orthostatic-syncopal hypotension, nausea and vomiting and urine retention. There was no morbidity or mortality. Conclusion: OPS is a highly efficient procedure for resolving the most common pathologies in General Surgery. The anesthesia technique was an important factor in the rate of failure.

Journal Article↗
PubMed2001

Differences in length of stay for Hospital in the Home patients: comparing simple clinical coding with medical record review.

AIM: To determine whether the apparently longer length of stay (LOS) reported for patients with cellulitis managed in Hospital in the Home (HITH) compared with those managed as inpatients was correct. METHODS: Data, including LOS, from the Victorian In-patient Minimum Database (VIMD) of all patients with cellulitis managed between July 1998 and June 1999 at a large metropolitan teaching hospital were analysed and compared with a retrospective medical record review of the same patients. RESULTS: In the VIMD data, there were 266 episodes of cellulitis during the study period. However, the medical record review found that six episodes were not separate, but rather a continuation of treatment for the same episode of cellulitis, and that 18 were not episodes of cellulitis, but were pilonidal sinus infections. In the VIMD data set, the mean LOS for patients treated in HITH was generally longer than that for inpatients (7.2 days vs 5.1 days, respectively, P = 0.002). However, in the retrospective medical record review, the LOS for patients treated in HITH was similar to inpatients (7.3 days versus 7.0 days, respectively, P = 0.68). CONCLUSIONS: In contrast to the VIMD data, the medical record review demonstrated that, overall, patients with cellulitis had a similar LOS irrespective of whether they were managed at home or in hospital. This study confirms that caution is required in interpreting the VIMD data, highlights the importance of carefully monitoring the introduction of new treatment modalities and indicates areas for further research.

Analysis of Variance↗
PubMed1988

Subcutaneous sacrococcygeal ("myxopapillary") ependymal rests.

Ependymal cell rests of the sacrococcygeal area are relatively common; they may occur in association with postcoccygeal (pilonidal) dimples or in the absence of observable abnormalities. Some of the lesions are poorly organized, whereas others closely resemble minute myxopapillary ependymomas. Most authorities believe that the majority of subcutaneous sacrococcygeal myxopapillary ependymomas arise in ependymal cell rests. Myxopapillary ependymomas may be locally aggressive and may metastasize, whereas ependymal rests are biologically indolent. We studied cutaneous ependymal rests of the sacrococcygeal region in four children to compare them with myxopapillary ependymomas of this anatomic site. All lesions were small (less than 0.5 cm) and were discovered incidentally in tissue from surgically corrected pilonidal sinuses. In no case was a mass lesion observed either clinically or upon gross examination of the excised specimen. Microscopically, the lesions consisted of clusters of ependymal cells near the junction of dermis and subcutis. Central vascular channels were surrounded by myxomatous material and rows of cuboidal cells, mimicking patterns seen in myxopapillary ependymomas. They differed from ependymomas in that they lacked characteristics associated with neoplasia--expansile, infiltrative, and destructive properties. Careful attention to histologic detail allows distinction of these lesions, which, though related, differ significantly in terms of prognosis.

Child, Preschool↗
PubMed2005

Clinical experience with the hatchet-shaped gluteus maximus musculocutaneous flap.

One of the most frequently used flaps for the coverage of sacral skin and soft-tissue defects (primarily decubiti) is the gluteus maximus musculocutaneous flap. The authors have developed a new, hatchet-shaped incision direction for the flap and have been using it for 6 years in the surgical treatment of various pelvic-area defects with good results. At the beginning, the gluteus maximus hatchet-shaped flap was used for treatment of pressure sores in the pelvic area: sacral decubitus on 31 patients, ischial pressure ulcer on 12 patients, and trochanteric ulcer on 1 patient. However, later the method was applied to nondecubitus defects, such as myelomeningocele on 4 patients, Crohn disease on 3 patients, pilonidal sinus on 2 patients, and traumatic defect on 1 patient, totaling 71 flaps on 54 patients. The seroma (4), hematoma (2), postoperative bleeding (1), and partial flap necrosis (1) healed following emptying and repeated surgery; recurrent ulcer was seen in 2 cases. Advantages of the method are the fewer incisions needed, the shorter operating time, and the smaller blood loss as compared with the methods known so far. The new incision direction improves the safety of circulation in the flap, the closure of the donor site is simpler, and no contour difference remains in the surgical area.

Adolescent↗
PubMed2005

[Improving communication between levels of health care: direct referral of patients to a one-stop service for major outpatient surgery].

OBJECTIVE: To analyze the results obtained with a "one-stop" specialty service designed as part of a collaborative program involving primary and specialized care in order to improve communication between levels of care and reduce the delay in referral and surgical treatment for patients eligible for outpatient surgery. DESIGN: Prospective, descriptive, longitudinal study. SETTING: Major Outpatient Surgery Unit of the Hospital Clinico San Carlos and health centers serving Health Area 7 in Madrid, central Spain. PARTICIPANTS: Patients more than 14 years of age with a surgical condition involving the abdominal wall, pilonidal sinus, soft-tissue tumor, or proctological disease. INTERVENTION: Direct referral, with completed preoperative work-up, of patients from health centers to the Major Outpatient Surgery Unit of the Hospital Clinico San Carlos according to a protocol developed by consensus. The patient is seen on the same day for surgical work-up and anesthesia work-up, and is given preoperative information. Patients then make only one further visit to the hospital to undergo surgery. MAIN MEASURES: Number of patients with each diagnosis referred, diagnostic concordance between the health center and hospital, delay from referral to surgical treatment, number of trips made for different appointments, and referral rate. RESULTS: A total of 188 patients were referred. More than two thirds (68.7%) had an abdominal wall condition eligible for direct referral. Diagnostic concordance was 96%. The delay from referral until surgery was reduced by 60%, and the number of trips for appointments was reduced by 66.6%. The overall referral rate was 12.6%. CONCLUSIONS: Because of its feasibility, acceptability, and cost-efficiency, the direct referral system has the potential to improve relations between primary and specialized care and enhance the quality of care by shortening the delay to treatment.

Adolescent↗
PubMed2000

Acute and chronic wounds: differences in self-reported health-related quality of life.

Seventeen patients (10 female) with acute wounds (pilonidal sinus) and 32 patients (19 female) with chronic wounds (venous leg ulcers) attending a specialist wound clinic completed a condition-specific health-related quality of life (HRQoL) tool on two occasions five to seven days apart. The ratings from the two groups were statistically different for two sub-scales, with those with acute wounds rating themselves more positively. There were no differences between the groups for overall HRQoL or satisfaction with HRQoL--although there was a trend for those with chronic wounds to rate their overall HRQoL as higher than those with acute wounds, possibly indicating adaptation to their health status. While possible demographic and aetiological differences must be borne in mind, the tool used in this study appears to be sensitive to different types of wound.

Acute Disease↗
PubMed2002

A 25-year study of emergency surgical admissions.

BACKGROUND: Numbers of emergencies are increasing, but no comprehensive data are available for emergency surgical admissions. This study documents the changes over 25 years in a district general hospital. METHODS: Details of all general surgical (including urological) emergency admissions were analysed for every fourth calendar year from 1974 to 1998. RESULTS: A total of 19,931 patients were admitted during the 7 years studied, rising from 2137 in 1974 to 3578 in 1994 (3377 in 1998). Mean age increased from 47.9 years to 52.6 years while mean length of stay fell from 9.5 days to 5.3 days. Hospital mortality decreased from 6.6% to 3.7%. When calculated per 100,000 population, the increase in admission rate was significant (P < 0.001) but bed requirements did not increase despite the increase in workload. Several diagnoses became significantly more frequent (ruptured aortic aneurysm, gallstones, constipation, cutaneous abscess, diverticular disease, gastroenteritis, non-specific abdominal pain, pilonidal sinus and urinary diagnoses). Appendicitis and non-malignant intestinal obstruction became significantly less common. CONCLUSIONS: This study has documented a progressive increase in surgical admissions. Despite increasing age of patients, lengths of stay and hospital mortality have decreased.

Age Distribution↗