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PubMed2006

Visceral sliding technique is useful for detecting abdominal adhesion and preventing laparoscopic surgical complications.

STUDY OBJECTIVE: Introduce a non-invasive method preoperatively to prevent bowel injury by the Veres needle and trocar during laparoscopy. DESIGN: Case-controlled study. SETTING: A hospital-based study. PATIENTS: Five hundred and twelve patients who underwent laparoscopic surgery were prospectively enrolled. INTERVENTION: A simple and non-invasive method to detect bowel adhesions preoperatively. RESULTS: A total of 512 patients who underwent operative laparoscopy were prospectively enrolled for ultrasonographic visceral sliding evaluation. They were subdivided into two groups as follows: group I, 332 patients without previous abdominal surgery; group II, 180 patients with previous abdominal surgery. No bowel adhesion to the umbilicus was present in group I. In group II, only two cases with bowel adhered to the periumbilical area were found by visceral sliding technique. No patients suffered any bowel injury. CONCLUSION: The proposed technique is useful and highly effective in guiding the insertion of the Veres needle and trocar to prevent bowel injury in laparoscopy.

Abdomen↗
PubMed2006

Predicting anastomotic disruption after emergent small bowel surgery.

BACKGROUND/AIMS: Small bowel anastomoses performed in the emergent setting have a high risk of leakage. Attention to technical detail is imperative but does not guarantee success in these situations. We sought out factors that could play a role in the process of anastomotic dehiscence under these conditions. METHODS: 70 patients underwent 74 emergency small bowel anastomoses over a 21-month period in our institution during this prospective study. Patients with anastomotic disruption formed the case group and those without, the control group. Several preoperative, intraoperative and postoperative variables identified at the outset of the study were analyzed for possible associations with anastomotic dehiscence. RESULTS: Suture line disruption occurred in 26 of 74 anastomoses (35%). The duration of symptoms before presentation did not differ significantly between groups. Hypoalbuminemia (p = 0.004), hyponatremia at presentation (p = 0.012), and intraoperative hypotension (p = 0.042) were found to be significantly associated with disruption. Neither the nature of the primary pathology in the bowel nor the anastomotic level had a significant bearing on anastomotic leakage. CONCLUSION: Risk factors for leakage of emergent small bowel anastomoses include hypoalbuminemia, hyponatremia at presentation, and intraoperative hypotension. Under these circumstances, the creation of a temporary stoma or exteriorization may be a wiser option than primary anastomosis.

Adolescent↗
PubMed1987

Childhood dermatomyositis. Clinical course and long-term follow-up.

The presentation, clinical course, and long-term follow-up (3-22 years) of 39 children with dermatomyositis followed from 1962-1982 is presented. The medical course of these patients was complicated by respiratory diseases (20%), gastrointestinal diseases (24%), and calcinosis (30%). Patients presenting prior to 1972 received a wide variety of treatments. Since 1972, treatment has consisted of long-term prednisone, supplemented in some patients with azathioprine. Ten patients died (eight of whom were first seen before 1972) of complications after intestinal perforation (5) or aspiration pneumonia (5). Of 29 survivors, three have persistent calcinosis and/or contractures. Improved outcome since 1972 probably relates to better clinical assessment, management of complications, and regulation of drug therapy.

Adolescent↗
PubMed2005

Adding dietary green beans resolves the diarrhea associated with bowel surgery in neonates: a case study.

Feeding intolerance is a common problem in infants who have had multiple or extensive resections of their small bowel. Chronic malabsorption and diarrhea are common side effects that inhibit the advancement of enteral feedings and prolong dependence on parenteral nutrition (PN). Poor growth, recurrent central line infections, cholestasis, and osteopenia are well-known complications associated with long-term PN dependency. It has been shown that, in adults with short bowel syndrome, providing dietary fiber can improve tolerance to enteral feeding. There are no published studies that have addressed the influence of dietary fiber on feeding intolerance in infants after bowel resections. The ensuing case studies illustrate the positive outcomes of fiber use in infants with diarrhea secondary to small bowel resections.

Diarrhea↗
PubMedDate not supplied

Implementing feeding guidelines for NICU patients<2000 g results in less variability in nutrition outcomes.

BACKGROUND: We devised a consistent approach to instituting and advancing enteral nutrition among neonatal intensive care unit (NICU) patients<2000 g birth weight. We then assessed variability in feeding-related outcomes during a period before (period 1) vs after (period 2) implementing these guidelines. METHODS: Using data from period 1 vs period 2, we statistically compared the equivalence of variance, focusing on certain feeding-related outcomes. Specific outcomes we chose to examine were (1) day of life when the first enteral feedings were given, (2) number of days during the entire hospitalization when no feedings were given, (3) number of days parenteral nutrition (PN) was administered, and (4) day of life when feedings of 80 mL/k/d and 100 kcal/k/d enteral were achieved. RESULTS: Fifty-eight patients<2000 g were admitted to the NICU in period 1, of which 56 survived to discharge home. In period 2, 68 patients<2000 g were admitted and 66 survived to discharge. Demographic features of the patients in periods 1 and 2 did not differ. In both periods, feedings were begun on a median of day 1. However, in period 1 the range was from day 0 to day 24, and in period 2, the range was from day 0 to day 6 (equivalence of variance p<.001). After feedings were initiated, they were withheld for a median of 2 days (range, 0-23) during the remainder of the hospitalization in period 1 vs a median of 1 day (range, 0-12) in period 2 (p<.001). During period 1, PN was used for a median of 10 days (range, 0-72) vs 7 (range, 0-47) in period 2 (p=.001). During period 1, more variability occurred in the day of life when 80 mL/k/d and 100 kcal/k/d were achieved (both p<.001). No differences were seen in necrotizing enterocolitis, intestinal perforation, mortality, or length of hospital stay. CONCLUSIONS: Implementing feeding guidelines was associated with significantly less variability in feeding-related outcomes. We speculate that this is a reflection of better feeding tolerance, which resulted from a more consistent approach to initiating and advancing enteral feedings.

Enteral Nutrition↗
PubMed2006

Double kidney transplantation: initial experience of the Bologna Transplant Center.

AIM: Double-kidney transplantation is performed using organs from marginal donors with a histological score not suitable for single kidney transplantation. The aim of the study is to verify the results obtained with double-kidney transplantation in terms of graft and patient survival and complications. METHODS: Between September 2001 and September 2004, 16 double-kidney transplantations were performed in our center. The kidneys were all perfused with Celsior solution and the mean cold ischemia time was 17.6+/-2.7 hours. In all cases a pre-transplant kidney biopsy was performed to evaluate the damage. Immunosuppression was tacrolimus based for all patients. RESULTS: Eight patients had good renal postoperative function while the other eight had acute tubular necrosis. Two of the patients who had severe acute tubular necrosis never recovered renal function. There was only one episode of acute rejection, while the incidence of urinary complications was 31.2%; there were two surgical revisions for intestinal perforation. The graft and recipient survival was 78.1% and 100% and 78.1% and 93.7% at 3 and 36 months. CONCLUSIONS: Double-kidney transplantation is a safe way to face the organ shortage. Moreover the score used in this study is useful to determine whether a kidney should be refused or suitable for single or dual-kidney transplantation. The results of our initial experience are encouraging, but this series is too small in number to consent a conclusive statement.

Aged↗
PubMed2006

Autopsy findings in patients on postcardiotomy extracorporeal membrane oxygenation (ECMO).

OBJECTIVES: To assess the clinical sensitivity of causes of death, concomitant diseases and postoperative complications including thromboembolic events in ECMO patients. METHODS: Between January 2000 and December 2004 154/202 patients (76.2%) died after postcardiotomy ECMO circulatory support. Autopsy was performed in 78 (50.6%) consecutive patients. Clinical and post-mortem data were prospectively recorded and compared concerning causes of death and postoperative complications including venous and arterial thromboembolisms and significant comorbidities. RESULTS: Mean age was 62.1+/-11.3 years, ejection fraction was 43.4+/-17.3%. 39.7% were emergency operations including acute coronary syndrome in 25.6% and preoperative cardiogenic shock in 28.2%. Successful ECMO weaning rate was 43.6%. Mean postoperative survival was 11.3 days. Premortem unknown concomitant diseases were found in 63 patients (80.8%) with clinical relevance in 9 patients (11.5%). Clinically unrecognized postoperative complications were found in 59 patients (75.6%) including acute cerebral infarction (n=7), acute bowel ischemia (1), intestinal perforation (3), pneumonia (4), venous thrombus formation (25) and systemic thromboembolic events (24). Clinically based causes of death were cardiac in 62.8%, multi-organ failure in 10.3%, cerebral in 5.1%, respiratory in 10.3%, fatal pulmonary embolism in 2.6%, technical in 5.1%, and others in 3.8%. Unexpected causes of death were found by autopsy in 22 patients (28.2%) including myocardial infarction (n=5), acute heart failure (4), fatal pulmonary embolism (2), pneumonia (2), ARDS (1), lung bleeding (1), fatal cerebrovascular event (4) and multiorgan failure (3). CONCLUSIONS: In ECMO patients major discrepancies between clinical and post-mortem examination were found. The true incidence of thromboembolic events is highly underestimated by clinical evaluation.

Aged↗
PubMed2003

[Postoperative management and complications in living-related liver transplantation].

Living-related liver transplantation is widely accepted as a treatment for patients with end-stage liver disease, with survival rates of up to 80%. Liver transplant recipients are at risk for the same postoperative complications as any patient undergoing a major intraabdominal operation, in addition to several complications specific to this procedure. Maintenance immunosuppression relies principally on administration of tacrolimus and methylprednisolone. Nevertheless, approximately 36% of liver transplant recipients suffer acute rejection in the early posttransplant period and require bolus steroid therapy as a rescue agent. Vascular complications, including hepatic arterial thrombosis and portal vein thrombosis, are additional major problems. When they occur in the immediate postoperative period, they can produce fulminant hepatic necrosis requiring retransplantation, so intensive anticoagulation therapy is needed as prophylaxis against these vascular complications. If thrombosis of the hepatic artery or portal vein is diagnosed early in the postoperative course, emergency thrombectomy with reanastomosis should be attempted. Outflow obstruction by hepatic vein stenosis sometimes causes liver dysfunction, pleural effusion, and hepatosplenomegaly. Percutaneous transhepatic or transjugular approached hepatic vein dilatation is very useful in case of hepatic vein stenosis. Recipients are generally immunocompromised secondary to immunosuppressive therapy and their poor clinical condition and are at high risk for postoperative infection. Infection is a major cause of morbidity and the most common cause of death in liver transplant recipients. Antibiotic, antifungal, and antiviral agents are used empirically, and serologic examinations and bacterial investigations of blood, sputum, stool, urine, and discharge from drains should be performed as well as antibiotic sensitivity tests when necessary. Other complications related to the operation are intraabdominal bleeding, bile leakage, biliary anastomotic stenosis, and intestinal perforation. The postoperative course of liver transplant recipients with these complications depends on making an accurate diagnosis promptly and initiating appropriate management. Postoperative complications of living-related liver transplantation are protean, so it is very important to communicate with professionals in each specialized field to ensure optimal treatment.

Humans↗
PubMed1984

Moxalactam disodium-induced pulmonary hemorrhage.

Fatal pulmonary hemorrhage occurred on the eighth day of moxalactam therapy. No other pharmacologic agent or obvious cause could be attributed to the hemoptysis. Moxalactam-induced pulmonary hemorrhage should be included in the differential diagnosis of an infiltrate when moxalactam is being administered.

Aged↗
PubMed1997

Pediatric nonpowder firearm injuries: outcomes in an urban pediatric setting.

BACKGROUND: Approximately 32 000 nonpowder firearm injuries are reported annually with more than 60% occurring in the pediatric population. Case reports of serious and fatal injuries have been described; however, no large inclusive series have been published. We reviewed an 11-year experience of an urban pediatric emergency department to evaluate the circumstances, spectrum of injuries, and outcomes attributable to nonpowder firearms. METHODS: A retrospective, descriptive case series of all children 18 years of age or younger evaluated at an urban children's hospital from January 1983 through December 1994 were eligible for study. Patients were identified using a computerized database, the National Electronic Injury Surveillance System, and the trauma registry in the department of surgery. Medical records were reviewed to collect demographic information, circumstances of injury, anatomic site and type of injury, treatment, and outcomes for nonpowder firearm injuries. RESULTS: One hundred eighty patients were identified, and a complete data set was available for 166 (92%). The mean age was 12 +/- 3.7 years, 24% of children were <10 years old, and 71% of the children were male. Three patients returned with a second nonpowder firearm injury during the study period. Forty-nine percent of injuries were intentional and 44% of all injuries occurred during the summer and early fall months. The most common sites of injury were the extremity/buttocks (39%), head and neck (33%), thorax (13%), and eye (8%). Serious injuries included intracranial hemorrhage, cardiac right ventricle laceration, hyphema, and abdominal visceral injury (liver laceration, pancreatic laceration, intestinal perforation). The majority of wounds required local wound care, and the children (74%) were discharged from the emergency department. Of the patients admitted to the hospital (27%), 45% required operative intervention. There were no deaths. Seven percent (12/166) of patients sustained some functional deficit with 42% (5/12) the result of an ocular injury. CONCLUSION: The majority of nonpowder firearm injuries are minor; however, the potential for serious injury should not be underestimated. Minor injuries can be treated with local wound care and tetanus prophylaxis, and patients can be discharged from the emergency department. Education of parents and children to the potential risks associated with these weapons is essential. Stricter regulations regarding ownership of nonpowder firearms and mandatory safety instruction should be considered.

Adolescent↗
PubMed2006

Low-dose dexamethasone facilitates extubation among chronically ventilator-dependent infants: a multicenter, international, randomized, controlled trial.

OBJECTIVE: Postnatal corticosteroid therapy is controversial. The aim of this study was to determine the short-term effects of low-dose dexamethasone treatment among chronically ventilator-dependent neonates. METHODS: Very preterm (gestational age: <28 weeks) or extremely low birth weight (birth weight: <1000 g) infants who were ventilator dependent after the first 1 week of life were eligible and were assigned randomly to receive masked dexamethasone (0.89 mg/kg over 10 days) or saline placebo. Data on ventilator and oxygen requirements and deaths were recorded. RESULTS: Seventy infants were recruited from 11 centers, at a median age of 23 days. More infants were extubated successfully by 10 days of treatment in the dexamethasone group (60%, 21 of 35 patients) than in the control group (12%, 4 of 34 patients) (odds ratio [OR]: 11.2; 95% confidence interval [CI]: 3.2-39.0). Ventilator and oxygen requirements improved substantially, and the duration of intubation was shorter. There was little evidence for a reduction in either the mortality rate (dexamethasone group: 11%; control group: 20%; OR: 0.52; 95% CI: 0.14-1.95) or the rate of oxygen dependence at 36 weeks (dexamethasone group: 85%; control group: 91%; OR: 0.58; 95% CI: 0.13-2.66). There were no obvious effects of low-dose dexamethasone on blood glucose concentrations, blood pressure, or other complications. No infant experienced intestinal perforation. CONCLUSIONS: Low-dose dexamethasone treatment after the first 1 week of life clearly facilitates extubation and shortens the duration of intubation among ventilator-dependent, very preterm/extremely low birth weight infants, without any obvious short-term complications. Combined with recent evidence that infants at very high risk of bronchopulmonary dysplasia may benefit in the long term, our study reopens debate regarding the role of low-dose, late postnatal, corticosteroid therapy.

Bronchopulmonary Dysplasia↗
PubMed2000

Survey of necropsy results in captive red wolves (Canis rufus), 1992-1996.

Through the Red Wolf Species Survival Plan, the captive red wolf (Canis rufus) population was developed with the intent of reestablishing wild populations. One part of the plan was a survey for diseases that might occur as a result of population homogeneity or that might impede breeding success and reintroduction. For this survey, complete necropsies and histopathologic analyses were performed on 62 red wolves from 1992 to 1996. Major causes of 22 neonatal deaths were parental trauma, parasitic pneumonia, and septicemia. Common neonatal lesions included pododermatitis and systemic ascariasis. Cardiovascular anomalies and systemic parasitism were found in two juveniles. Causes of death in the 38 adults included conspecific trauma, neoplasia, or gastrointestinal diseases such as necrotizing enteritis, intestinal perforation, and gastric volvulus. Lymphosarcoma represented 50% of the fatal neoplasms. Three adults died from cardiovascular failure or hyperthermia during handling, and several adults were euthanized for suspected genetic diseases. Overall, the captive population had few significant health problems, but population fitness might be improved by continued removal of potentially deleterious genes from the breeding population and by modifying the husbandry of neonates and adults.

Age Factors↗
PubMed1984

Evaluation of the gasless abdomen in the newborn and young infant with metrizamide.

The finding of a gasless abdomen on the abdominal radiograph of an infant over 12 hr old is usually abnormal and may reflect a serious pathologic disorder. Accurate diagnosis is important to plan appropriate therapy. A careful review of the clinical history and the plain chest and abdominal radiographs will often permit an accurate diagnosis to be made. In cases where the diagnosis remains in doubt, contrast studies of the bowel with metrizamide have proved helpful. This report presents six infants with gasless abdomens of unknown cause. In each case, a metrizamide contrast study of the bowel was helpful in providing an accurate diagnosis.

Child, Preschool↗