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PubMed1993

[Two cases of mediastinitis as a complication of odontogenic infection and tonsillitis].

We experienced two cases of descending necrotizing mediastinitis with different etiology. Case 1: A 59-year-old woman presented with chief complaints of dyspnea and swallowing disturbance. She had been diagnosed as having tonsillitis one week before. She was very pyrexic, and laboratory examination indicated acute inflammation. Chest X-ray and CT-scan showed enlargement of the mediastinum and pleural effusion. We diagnosed the mediastinitis to be a complication of tonsillitis. Case 2: A 54-year-old man had a tooth extracted 3 weeks prior to admission. His chief complaints were craniomandibular disturbance and neck swelling. Laboratory examination disclosed multiple organ failure and DIC. Chest X-ray and CT-scan showed enlargement of the mediastinum and pleural effusion. We diagnosed the mediastinitis in this case to be a consequence of an odontogenic infection following tooth extraction. Both patients received continuous drainage and irrigation of the abscesses and recovered in about 2 months. Case 1 showed an impaired glucose tolerance after recovery from mediastinitis. Although the main causes of mediastinitis are cardiac surgery and esophageal perforation, our cases demonstrate that mediastinitis may occur as a complication of deep neck infection.

Female↗
PubMed1993

Blunt chest trauma.

The spectrum of injuries after blunt chest trauma presents a challenging problem to the emergency physician. The clinician must select among a number of diagnostic tests and therapeutic options after the initial history and physical examination has been performed. Nine clinical entities are discussed: sternal fracture, flail chest, pulmonary contusion, tracheobronchial injuries, myocardial contusion, myocardial rupture, aortic disruption, esophageal perforation, and diaphragm rupture. Emphasis is placed on newer diagnostic modalities available for these conditions.

Aorta, Thoracic↗
PubMed1996

Microbiology of mediastinitis.

OBJECTIVE: To study the microbiologic and clinical characteristics of patients with mediastinitis. METHODS: Retrospective review of clinical and laboratory data of 17 patients treated between 1980 and 1987. RESULTS: Aerobic or facultative bacteria only were present in three patients (18%), anaerobic bacteria only in seven (41%), and mixed aerobic-anaerobic flora in seven (41%). In total, there were 42 isolates, 13 aerobic or facultative and 29 anaerobic bacteria, an average of 2.5 per specimen. Anaerobic bacteria predominated in infections that originated from esophageal perforation and orofacial, odontogenic, and gunshot sources. The predominant aerobes were alpha-hemolytic Streptococcus (three isolates), Staphylococcus aureus (two isolates), and Klebsiella pneumoniae (two isolates). The predominant anaerobes were Prevotella and Porphyromonas species (eight isolates), Peptostreptococcus species (seven isolates), and Bacteroides fragilis group (three isolates). CONCLUSION: These data highlight the polymicrobial aerobic-anaerobic nature of mediastinitis.

Adult↗
PubMed1996

Laparoscopic fundoplication: a three-year review.

Laparoscopic treatment of gastroesophageal reflux disease provides decreased postoperative pain and shortens hospitalization. Experience with this procedure continues to grow. The charts of patients who had laparoscopic fundoplication for the treatment of symptomatic refractory gastroesophageal reflux over a three year period were reviewed. Age, sex, preoperative evaluation, surgical technique, length of procedure, length of hospitalization, time to regular diet, conversion to laparotomy, complications, and long-term outcome were analyzed. Eighty-eight patients, 39 females and 49 males, underwent laparoscopic gastric fundoplication. All patients has symptomatic gastroesophageal reflux. Preoperative evaluation including upper endoscopy demonstrated esophagitis in 71 patients (81%) with changes of Barrett's esophagitis in 12 patients (14%). Decreased lower esophageal sphincter pressures were found in 33 of 73 patients (45%) and none had abnormal motility identified. A 2-3 cm fundoplication with nonabsorbable suture was performed over a large dilator. Mean operative time was 109 minutes. The mean length of hospitalization was 1.9 days in patients completed laparoscopically and six days in the 3 patients that required conversion to celiotomy for completion of their fundoplication. A clear liquid diet was offered the evening of surgery and advanced to regular as tolerated. Mild dysphagia was found in most patients for the first week and full liquid or soft diet was prescribed. All but seven patients advanced to regular diet by two weeks. Operative complications occurred in four patients and included two pneumothoraces and two esophageal perforations. Follow-up to 40 months has identified one partial wrap disruption and one crural breakdown both repaired laparoscopically. Seventy-seven patients (88%) have remained asymptomatic and off all medication. Laparoscopic fundoplication is safe and effective, allowing the benefits of minimal access surgery, including decreased postoperative pain and disability.

Adolescent↗
PubMed1996

Median corpectomy in cervical spondylotic multisegmental stenosis.

Cervical median corpectomy as an alternative to laminoplasty and laminectomy has been suggested as an effective treatment for cervical spondylotic myelopathy (CSM) in cases of multisegmental spondylotic stenosis. We report on our experience with this procedure with particular reference to neurological outcome and complications. Median corpectomy was performed in 17 cases (3 female, 14 male; mean age 59 yrs, (41-80 yrs.) with cervical myelopathy (CM) and radiologically diagnosed multisegmental spondylotic stenosis and spinal cord compression seen on MRI. The degree of stenosis was determined by means of the modified Pavlov's index (ratio between spinal canal width at the level of the intervertebral disc and the diameter of the vertebral body itself). 3/17 patients suffered from acute, 4/17 from subacute and 10/17 from chronic CM. Single level corpectomy was performed in 9 cases, one and a half vertebrae were removed in 2 cases and dual level corpectomy was performed in the remaining 6 cases. All patients received an autologous bone graft and AO - anterior plate stabilization or were stabilized as described by Morscher. Postoperative follow - up was possible in 16/17 cases over a mean time of 13.5 months. Myelopathy was graded according to Nurick's scale. Postoperatively, 12% with chronic CM improved by two grades, 38% (2 pts, with acute, 3 with subacute and 1 with chronic CM) improved by one grade. The other patients remained stable, none showed worsening of their myelopathy. Paresis improved in 92%, sensory deficits in 69%, spasticity in 73%, pain in 60%, and vegetative disturbances in 100% of all patients presenting these preoperative symptoms respectively. One patient died due to esophageal perforation and subsequent lethal mediastinitis caused by screw loosening 4 months following surgery and after initial neurological improvement. 4 other patients experienced screw loosening, three with acataposis, one remained clinically asymptomatic with concomitant graft displacement in two of these. One patient had to be re-operated due to a hematoma at the iliac crest and 2 suffered from a pelvic fracture of the spina iliaca at the site of graft removal. With respect to the neurological improvement, especially to the motor function and spasticity, median corpectomy can be regarded as an effective procedure in selected cases with cervical myelopathy, even when treatment related complications are taken into consideration.

Adult↗
PubMed1996

Microbiology of acute purulent pericarditis. A 12-year experience in a military hospital.

OBJECTIVE: To study the aerobic and anaerobic micro-biological and clinical characteristics in 15 cases of acute pericarditis treated over a 12-year period. DESIGN: Retrospective review of microbiological and clinical data. SETTING: Military hospital in Bethesda, Md. RESULTS: Aerobic or facultative bacteria alone were present in 7 specimens (47%), anaerobic bacteria alone in 6 specimens (40%), and mixed aerobic-anaerobic flora in 2 specimens (13%). In total, there were 21 isolates: 10 aerobic or facultative bacteria and 11 anaerobic bacteria, an average of 1.4 per specimen. Anaerobic bacteria predominated in patients with pericarditis who also had mediastinitis that followed esophageal perforation and in patients whose pericarditis was associated with orofacial and dental infections. The predominant aerobic bacteria were Staphylococcus aureus (3 isolates) and Klebsiella pneumoniae (2 isolates), and the predominant anaerobic bacteria were Prevotella species (4 isolates), Peptostreptococcus species (3 isolates), and Propionibacterium acnes (2 isolates). CONCLUSION: The findings in our study highlight the potential importance of anaerobic bacteria in acute pericarditis.

Acute Disease↗
PubMed1996

Barrett's ulcer: the clinical significance today.

OBJECTIVES: The present day clinical significance and natural history of Barrett's esophageal ulcer are compared with those reported originally by Barrett. METHODS: Records of patients with Barrett's ulcers followed by the Gastroenterology Service at the Medical College of Wisconsin were reviewed to assess the natural history of the ulcers in patients with Barrett's esophagus. RESULTS: The histories of 14 patients with ulcers in Barrett's esophagus were reviewed. Average follow-up was 5 yr. Ulcers occurred in both short and long segment Barrett's and responded poorly to therapy. Dysplasia occurred in eight patients, and carcinoma developed in two. CONCLUSIONS: Barrett's ulcers occur today and are difficult to manage, as they were 45 yr ago. Complications today, especially dysplasia and carcinoma, are different than those reported by Barrett (life-threatening hemorrhage, esophageal perforation, and stenosis.)

Anti-Ulcer Agents↗
PubMed1996

[The reason for the removal of springing foreign bodies in the esophagus].

The author described a group of 28 prisoners with the springing foreign bodies. In this group were follow foreign bodies diagnosed: so called anchors, crabs and crossbreeds. Three prisoners no consent to esophagoscopy and two, with symptoms of thoracic esophageal perforation, were treated in Thorax Surgery Department. 21 foreign bodies were removal esophagoscopical and 2 remaining were extracted by the lateral pharyngotomy. Own observations have confirmed the effectiveness of esophagoscopy in removal of the springing foreign bodies in the esophagus.

Endoscopy↗
PubMed1997

[Nissen fundoplication by laparoscopy].

Short term results following laparoscopic Nissen fundoplication were evaluated in 31 patients with symptomatic gastroesophageal reflux. 6 were females and 26 males, and they ranged in age from 5 months to 64 years (mean: 4.9 years in 19 younger than 18 years, and 39.3 years in 12 adults). Most of the adults who complained of pain and heartburn underwent pH monitoring, endoscopy, and manometry as needed. Milk scan was the most useful diagnostic tool for the evaluation of the children, who suffered mainly from gastroesophageal-related pulmonary disease. Indications for laparoscopic operation were identical with those for conventional open Nissen fundoplication. 1 case of dysautonomia died postoperatively; the rate of complications, mostly minor, was 22.5%. 3 patients required conversion to open Nissen fundoplication due to cardiorespiratory instability secondary to pneumothorax in 2, and to esophageal perforation in the third. 5 adults developed temporary dysphagia. 3 children had only partial improvement in their pulmonary disease following the operation, while the other 15 had complete relief. The total time for the laparoscopic operation averaged 245 minutes in adults, and 228 in children. Discharge was usually on the fourth postoperative day in adults (mean: 6.0 days). Regurgitation and heartburn were cured in 10 out of 11 adults (91%). All parents of children were satisfied. Symptomatic outcomes following laparoscopic Nissen fundoplication compare favorably with those of open surgery with respect to mortality, complications, and outcome.

Adolescent↗
PubMed1998

Management of descending necrotizing mediastinitis.

BACKGROUND: Descending necrotizing mediastinitis (DNM) is uncommon, and may be lethal if not treated adequately and promptly. Delayed diagnosis of the disease is sometimes encountered in clinical practice. METHODS: Eight consecutive patients with acute DNM were identified between 1991 and 1995, including five men and three women. The mean age was 45.8 years (range, 22-71 years). The infectious sources consisted of six esophageal perforations, one cervical cutting injury and one tonsillitis. The clinical presentations were evaluated. Diagnostic procedures including chest radiograph, sonogram and computerized tomography scans of the chest and neck were examined. Diagnosis and treatment, including culture results from drained fluids and debrided tissues, and antibiotic and supportive therapies were reviewed. RESULTS: Six patients who underwent aggressive surgical treatment recovered well. Two patients who received supportive treatment died of sepsis alone. The cultured bacteria included: Klebsiella oxytoca, Staphylococcus aureus, Trichosporum and other mixed oral cavity flora. CONCLUSIONS: Early diagnosis and adequate antibiotic and support therapies are essential to achieve good patient outcomes in acute descending mediastinitis. Adequate drainage and debridement, appropriate antibiotic therapy, and sufficient nutritional and respiratory support are the main treatment elements.

Adult↗
PubMedDate not supplied

Results of laparoscopic Nissen fundoplication.

BACKGROUND/AIMS: Laparoscopic surgery for treatment of gastroesophageal reflux disease was first described 5 years ago. The more widespread technique is the Nissen fundoplication with its different modifications. The early results suggest that this operation is equivalent in efficacy to the open antireflux operations. METHODOLOGY: Over a 5 year period, 622 patients underwent laparoscopic fundoplication for gastroesophageal reflux disease. Five hundred and fifty patients underwent Nissen fundoplication. Preoperative, operative and postoperative data were prospectively reviewed. One hundred twenty seven patients were evaluated 1 to 4 years after the operation. RESULTS: Laparoscopic Nissen fundoplication with standard gastric mobilisation and without division of the SGV was performed during the first three years of the laparoscopic approach. Since early 1994, we applied division of the SGV with complete mobilisation of the upper part of the gastric fundus in all the patients. The mean operative time was 86 minutes (range 30-180 minutes). Conversion to open surgery was necessary in 5 patients (0.9%). There was neither incidence of splenic trauma nor esophageal perforation. There was no mortality. Morbidity was 2.3%. Mean hospital stay was 3.1 days (range 1-13 days). Postoperative dysphagia was observed in all the patients and resolved after 2 to 6 weeks in all but 12 patients (2.1%) who were submitted to endoscopic dilatation with success in 9 patients. At a median follow-up period of 2 years (16-44 months), 127 consecutive patients from the initial experience (series 1991-1992) volunteerd for mid term follow-up evaluation. We obtained Visick I and II grading in 92% of the patients. Reoperation for failure has been necessary in 6 patients (1.0%). CONCLUSIONS: The long term results of laparoscopic Nissen fundoplication are not yet available. The incidence of poor long term outcome or recurrence of symptoms cannot be assessed. At present, we feel that, in experienced hands, the laparoscopic operation is as good as the open procedure if all the surgical principles of antireflux surgery are respected. One of our complications is related to the choice of the operative technique and that highlights the absolute necessity of strict preoperative assessment and selection of the patient but also selection of the type of operation, tailored to the patient.

Adolescent↗
PubMed1998

[Enteral feeding of problem patients: replacement of surgical catheter jejunostomy by an endoscopic concept].

Percutaneous endoscopic gastrostomy (PEG), is widely used as a safe, effective method of providing enteral nutrition to patients in whom oral feeding is not possible. However, in patients with malnutrition after partial or total gastrectomy, anastomotic insufficiency after gastric resection or esophageal resection with gastric pull-up, esophageal perforation and fistulas, the stomach cannot be punctured. In these cases endoscopic percutaneous jejunostomy (EPJ) by direct punction of the small intestine is a reasonable alternative; the technique is described, and the results of a series of 103 EPJs are reported.

Adolescent↗