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PubMed2002

[Acute non-traumatic mediastinitis].

UNLABELLED: Acute mediastinitis is uncommon. When it occurs, it usually follows an esophageal perforation or thoracic surgery. CASE REPORT: We report on a case of a ten-year-old girl with non traumatic mediastinitis secondary to a pleuro-pulmonary infection due to Klebsiella pneumoniae.

Acute Disease↗
PubMed2002

Quality of life after antireflux surgery compared with nonoperative management for severe gastroesophageal reflux disease.

BACKGROUND: Gastroesophageal reflux disease significantly affects a patient's quality of life (QOL). Laparoscopic fundoplication offers an alternative to medical therapy, but few studies have compared outcomes. Our objective was to examine QOL scores in gastroesophageal reflux disease patients treated medically and surgically. STUDY DESIGN: We undertook a retrospective analysis of patients undergoing surgical or medical treatment for gastroesophageal reflux disease over a 1-year period (August 1997 to August 1998). Followup QOL was measured using the Short-Form 36, and heartburn severity was measured using the Health Related Quality of Life scale (a disease-specific instrument with a best score of 0 and a worst score of 45). RESULTS: Laparoscopic fundoplication was undertaken in 120 patients with a median age of 47 years (range 17 to 80 years). The medical cohort included 51 patients selected from the gastroenterology clinic with a median age of 48 years (range 17 to 82 years). Duration of heartburn was not significantly different, with 40 (78.4%) of the 51 medical and 98 (81.7%) of the 120 surgical patients having had symptoms for longer than 12 months. There were no operative deaths. There were 12 complications (esophageal perforation 1, pneumothorax 2, pneumonia 1, pulmonary embolus 3, other/miscellaneous 5). Mean length of stay was 1.6 days, time to oral intake 1.2 days, and return to normal activity 4.2 weeks. Routine followup was available in 118 surgical and 47 medical patients. The medical cohort had increased (p < 0.05) symptoms of heartburn (43% versus 19%), waterbrash (26% versus 8%), and regurgitation (30% versus 8%) and greater requirement for proton pump inhibitors (74% versus 19%) and propulsid (19% versus 3%) over the surgical group. Detailed outcomes were available in 101 surgical and 37 medical patients. Mean (+/-SE) Health Related Quality of Life scores were better (p < 0.05) in the surgical group (4+/-0.6 versus 21+/-1.4). More of the medical patients were dissatisfied (21.6% versus 5.9%). Short-Form 36 scores at followup were better (p < 0.05) in six of eight domains for surgical patients. CONCLUSION: Heartburn scores and global QOL scores were superior after laparoscopic fundoplication compared with medical management in this patient population. Laparoscopic fundoplication should be considered for patients who are dissatisfied with medical treatment.

Adolescent↗
PubMed1999

Conversions and complications of laparoscopic treatment of gastroesophageal reflux disease.

BACKGROUND: Although several authors have documented the safety and efficacy of laparoscopic fundoplication, it is important to determine the rate of conversions and complications of this procedure. STUDY DESIGN: We retrospectively reviewed the protocol sheets of 503 consecutive patients with gastroesophageal reflux disease who underwent laparoscopic fundoplication over a period of 5 years. A Nissen-Rosetti procedure was performed in 492 patients (97.8%) and a Toupet procedure in 11 (2.2%). Sixty-four patients were also subjected to a concurrent cholecystectomy, and one patient had a concurrent cervical pharyngoesophageal diverticulectomy with cricopharyngeal myotomy. Thirty-one patients had previous upper abdominal operations. RESULTS: The period of hospitalization varied from 12 hours to 16 days, with an average of 1.2 days. The operation was converted to an open procedure in 10 patients (2%). The main cause of conversion was the presence of adhesions. The most frequent intraoperative complication was pneumothorax. All pneumothoraces occurred in the first 100 patients. Five patients had significant operative bleeding; two of them required laparotomy for bleeding control. Gastric ulcer was diagnosed in six patients. One alcoholic patient died of acute pancreatitis. Other major complications were two intraabdominal abscesses, one esophageal perforation, one sepsis from gastric perforation, one hemorrhagic shock, and one gastric obstruction from fundoplication herniation. CONCLUSIONS: Conversions and complications of laparoscopic fundoplication are low and decrease significantly with the surgeon experience, but severe and lethal complications may occur.

Adolescent↗
PubMed2004

Removal of a foreign body from the upper gastrointestinal tract with a flexible endoscope: a prospective study.

BACKGROUND AND STUDY AIMS: There have so far been no prospective studies on the value of flexible endoscopy for removing foreign bodies in the upper gastrointestinal tract. This study presents a clinical analysis of accidents with foreign bodies and prospectively evaluates the effectiveness of flexible endoscopy for removing them. PATIENTS AND METHODS: A total of 105 cases of foreign-body ingestion in the upper gastrointestinal tract were evaluated, 29 (27.6 %) in children and 76 (72.4 %) in adults. Thirty patients (28.5 %) had esophageal strictures. RESULTS: Thirty-nine of the foreign bodies (37.1 %) consisted of food and 66 (62.9 %) were not food-related. The success rate of foreign-body extraction using only a conventional flexible endoscope and accessories for treatment was 98.0 %, and with only a polypectomy snare and rat-toothed forceps it was 91.2 %. Complications at the moment of foreign-body removal occurred in nine patients (8.6 %); there was only one (1 %) esophageal perforation. The incidence of complications related to the duration of foreign-body impaction was six (10.5 %) with foreign bodies impacted for up to 24 h, 13 (52.0 %) for those impacted for 24-48 h, and three (60.0 %) for those impacted for 48-72 h ( P < 0.05). CONCLUSIONS: The flexible endoscope is an effective and safe device for removing foreign bodies from the upper gastrointestinal tract, with a high success rate using only the polypectomy snare and the rat-toothed forceps as accessories. If foreign-body impaction lasts for more than 24 h, there is a significant increase in the incidence of complications.

Adult↗
PubMed1998

Video-assisted thoracoscopic surgery in the management of acute purulent mediastinitis and pleural empyema.

Management of acute purulent mediastinitis requires broad-spectrum antibiotics and proper surgical drainage-routine use of thoracotomy is recommended by several authors. We describe two cases where video-assisted thoracoscopic surgery (VATS) was used instead of thoracotomy. Etiology of mediastinitis in one patient was a stab wound and in the other an iatrogenic esophageal perforation. In addition, the first patient had purulent pericarditis and suppurated haemothorax and the second a pleural empyema. In both cases VATS allowed debridement of the entire thoracic cavity and subsequent drainage of the mediastinum. Continuous irrigation was used postoperatively until pleural fluid became clear. Both patients recovered without a need for further surgical treatment. They are doing well 8 and 9 months later. Adequate debridement and drainage of pleural empyema and mediastinitis can be achieved using VATS instead of a thoracotomy approach.

Acute Disease↗
PubMedDate not supplied

Choice of airway devices for 12,020 cases of nontraumatic cardiac arrest in Japan.

OBJECTIVE: This retrospective study was designed to determine the choice of airway devices used for nontraumatic, out-of-hospital cardiac arrest patients and to evaluate the success and failure of insertion and airway control/ventilation by three airway adjuncts, the Combitube, the esophageal gastric tube airway (EGTA), and the laryngeal mask (LM), which were used in conjunction with the bag-valve-mask (BVM) by emergency life-saving technicians (ELSTs) in Japan. METHODS: A survey of 1,085 ELSTs was performed to identify the type of airway devices, the success rates of airway insertion, the effectiveness of airway control/ventilation in comparison with the BVM prior to each airway insertion, and associated complications. The type of education for airway skills was also surveyed. RESULTS: 1,079 surveys were returned and 12,020 cases of cardiac arrest were studied. Choice of airway devices: BVM, 7,180 cases; EGTA, 545 cases; Combitube, 1,594 cases; and LM, 2,701 cases. Successful insertion rates on the first attempt: EGTA, 82.7%; Combitube, 82.4%; and LM, 72.5% (p < 0.0001). Failed insertions: EGTA, 8.2%; Combitube, 6.9%; and LM, 10.5% (p < 0.0001). Successful ventilation: EGTA, 71.0%; Combitube, 78.9%; and LM, 71.5% (p < 0.0004). Six cases of aspiration were reported in the LM group, whereas nine cases of soft-tissue injuries, including esophageal perforation, were reported in the Combitube group. 17.8% had vomited either prior or during airway placement. CONCLUSION: The Combitube appears to be the most appropriate choice among the airway devices examined. However, serious injuries to the tissues, though they rarely occurred in the study, remain a major concern.

Aged↗
PubMed1995

Laparoscopic treatment of duodenal ulcer by bilateral truncal vagotomy and endoscopic balloon dilatation.

The low morbidity and early recovery associated with laparoscopic procedures have shown a new direction for many types of surgery. We performed a laparoscopic bilateral truncal vagotomy (BTV) with pyloric dilatation (PD) in 20 patients (11 men, 9 women, ranging in age from 32 to 56 years, with a mean age of 42 years). All patients had chronic duodenal ulcer diagnosed endoscopically, with a mean duration of symptoms of 2.6 years (range 2-8 years). The mean length of surgery was 55 min (range 45-90 min). The mean follow-up period was 16 months (range 3-25 months). In 1 patient, esophageal perforation occurred during the dissection of the left vagus nerve and was sutured laparoscopically. Acid secretion tests under basal conditions and pentagastrin stimulation preoperatively and 1 month postoperatively showed a decrease in basal acid output (BAO) of 76% and maximal acid output (MAO) of 84.2%. Endoscopy at the second and sixth postoperative month showed healing of the ulcer in 19 of 20 patients (95%). One patient had partial pyloric stenosis due to chronic duodenal ulcer before BTV and PD and developed complete pyloric stenosis after the surgery. Despite repeated pyloric balloon dilatation, he required an open drainage procedure (gastroduodenostomy, Jaboulay). Three patients (15%) had postoperative diarrhea and responded very well to medical treatment. The preliminary results showed that laparoscopic BTV with PD is a simple and effective procedure for the treatment of chronic duodenal ulcer.

Adult↗
PubMed2001

The safety of intraoperative transesophageal echocardiography: a case series of 7200 cardiac surgical patients.

UNLABELLED: Transesophageal echocardiography (TEE) is an invaluable intraoperative diagnostic monitor that is considered to be relatively safe and noninvasive. Insertion and manipulation of the TEE probe, however, may cause oropharyngeal, esophageal, or gastric trauma. We report the incidence of intraoperative TEE-associated complications in a single-center series of 7200 adult cardiac surgical patients. Information related to intraoperative TEE-associated complications was obtained retrospectively from the intraoperative TEE data form, routine postoperative visits, and cardiac surgical morbidity and mortality data. The overall incidences of TEE-associated morbidity and mortality in the study population were 0.2% and 0%, respectively. The most common TEE-associated complication was severe odynophagia, which occurred in 0.1% of the study population. Other complications included dental injury (0.03%), endotracheal tube malpositioning (0.03%), upper gastrointestinal hemorrhage (0.03%), and esophageal perforation (0.01%). TEE probe insertion was unsuccessful or contraindicated in 0.18% and 0.5% of the study population, respectively. These data suggest that intraoperative TEE is a relatively safe diagnostic monitor for the management of cardiac surgical patients. IMPLICATIONS: The overall morbidity (0.2%) and mortality (0%) rates of intraoperative transesophageal echocardiography (TEE) were determined in a retrospective case series of 7200 adult, anesthetized cardiac surgical patients. The most common source of TEE-associated morbidity was odynophagia (0.1%), which resolved with conservative management. These results suggest that TEE is a safe diagnostic tool for the management of cardiac surgical patients.

Adult↗
PubMed2000

Pneumomediastinum after injection injury to the hand.

Pneumomediastinum as a consequence of injection injury to the hand has not been previously reported. We present a 22-year-old male who developed pneumomediastinum when a high pressure hose injected air into his hand. The anatomic continuity between peripheral ulnar neurovascular bundle and the hilar vessels provided the route for air entering the hypothenar eminence to penetrate the mediastinum. After ruling out life-threatening causes of pneumomediastinum such as esophageal perforation, his management included observation and serial radiographs. By one week there was complete resolution of the mediastinal air. This report demonstrates that pneumomediastinum may be associated with air injection injury of the hand, and that expectant management is appropriate.

Adult↗
PubMed2000

Laparoscopic repair of giant paraesophageal hernia: 100 consecutive cases.

OBJECTIVE: To summarize the authors' laparoscopic experience for paraesophageal hernia (PEH). SUMMARY BACKGROUND DATA: Laparoscopic antireflux surgery and repair of small hiatal hernias are now routinely performed. Repair of a giant PEH is more complex and requires conventional surgery in most centers. Giant PEH accounts for approximately 5% of all hiatal hernias. Medical management may be associated with a 50% progression of symptoms and a significant death rate. Conventional open surgery has a low death rate, but complications are significant and return to routine activities is delayed in this frequently elderly population. Recently, short-term outcome studies have reported that minimally invasive approaches to PEH may be associated with a lower complication rate, a shorter hospital stay, and faster recovery. METHODS: From July 1995 to February 2000, 100 patients (median age 68) underwent laparoscopic repair of a giant PEH. Follow-up included heartburn scores and quality of life measurements using the SF-12 physical component and mental component summary scores. RESULTS: There were 8 type II hernias, 85 type III, and 7 type IV. Sac removal, crural repair, and antireflux procedures were performed (72 Nissen, 27 Collis-Nissen). The 30-day death rate was zero; there was one surgery-related death at 5 months from a perioperative stroke. Intraoperative complications included pneumothorax, esophageal perforation, and gastric perforation. There were three conversions to open surgery. Major postoperative complications included stroke, myocardial infarction, pulmonary emboli, adult respiratory distress syndrome, and repeat operations (two for abscess and one each for hematoma, repair leak, and recurrent hernia). Median length of stay was 2 days. Median follow-up at 12 months revealed resumption of proton pump inhibitors in 10 patients and one repeat operation for recurrence. The mean heartburn score was 2.3 (0, best; 45, worst); the satisfaction score was 91%; physical and mental component summary scores were 49 and 54, respectively (normal, 50). CONCLUSION: This report represents the largest series to date of laparoscopic repair of giant PEH. In the authors' center with extensive experience in minimally invasive surgery, laparoscopic repair of giant PEH was successfully performed in 97% of patients, with a minimal complication rate, a 2-day length of stay, and good intermediate results.

Aged↗
PubMedDate not supplied

Esophageal dilators.

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Dilatation↗