technique to improve results in colon replacement of the oesophagus

This study aimed to present a simple method to improve the results of colon replacement of the oesophagus in children with post-corrosive oesophageal stricture or long gap oesophageal atresia. At the operation to establish a gastrostomy, the abdomen and colon are explored and the segment of colon to be used for replacement is chosen. The trunk of the middle colic artery supplying the transverse colon is ligated and divided proximal to the marginal artery or if another segment of the colon is chosen, the corresponding vessel is ligated. Between November 1999 and October 2002, 11 children [6 boys and 5 girls] had the middle colic vessels ligated during the gastrostomy operation. Five neonates had long gap oesophageal atresia with or without fistula. The other 6 had long segment oesophageal stricturedue to swallowing caustic potash. Their ages ranged from one day to 40 months. The hospital stay ranged from 10 to 14 days. The interval between vascular ligation and the replacement was one to 3 months depending on the general condition of the patient. The follow up period is 9 to 44 months. The results revealed that after the definitive operation of colon replacement of the oesophagus, the children resumed feeding through the gastrostomy on day 5. They were fed by mouth from day 8 and all were home by day 15. There was no wound infection, no fistula, or chest complications. One patient developed stricture at the colo-oesophageal anastomosis two months after surgery. The oesophageal anastomosis was excised six months after the colon interposition surgery and reanastomosis performed through the same neck incision and the patient was sent home 7 days later. The study concluded that ligation of the middle colic vessels during the gastrostomy operation increases the blood supply to the transverse colon through the left upper colic and marginal vessels. This adds extra ten minutes to the operation of gastrostomy. This technique has increased the success rate in colonic replacement and minimized morbidity in the unit. The principle is commonly used in plastic surgery in pedicled flap reconstruction and in pediatric surgery in high abdominal testis

double mesh intraperitoneal repair [ADMIR] for the management of large recurrent ventral hernia

This prospective study was performed on 31 patients who underwent surgery between January 2000 and August 2003 for recurrent large ventral hernias. The patients were randomized into two groups: Group A included 16 patients who were subjected to suture repair with or without onlay polypropylene MeSH and group B included 15 patients who were subjected to a tailored double MeSH [vicryl + polypropylene] intraperitoneal repair. Superficial wound infection occurred in two patients, one in each group. Following a median follow up of 23 months, no seroma formation or hernia recurrence were encountered in group B in comparison with five and four cases, respectively, in group A. There was no intra-abdominal complications in the form of intestinal obstruction and enterocutaneous fistula observed in this study. In cases subjected to double intraperitoneal MeSH repair, this may be due to the protective effect of the inner vicryl layer which is characterized by its low reactivity

Hyperacute soft tissue infection in diabetics

Hyperacute soft tissue infection is an uncommon infection entity, which mostly affects immunocompromized individuals, mainly diabetics and poses difficult diagnostic and therapeutic management decision. This study addresses the presentation, evaluation and management of 27 diabetic patients with acute necrotizing fasciitis treated throughout the period between August 1993 and July 2003 by the main author. Extremities, trunk and perineum were the most commonly involved sites with an incidence of 37%, 29.6% and 26% respectively. All patients presented with cellulitis, which was associated with edema in 74% of cases, skin gangrene in 48% of cases and brown echymotic patches in 29.6% of cases. skin vesicles, tenderness and creiitations were present in 15%, 11% and 11% of cases respectively. Streptococci, Staphylococci and E-Coli were the most commonly encountered organisms, which affected 70% of cases, either alone or in combination. Anaemia and hypoalbuminaemia were the most commonly encountered laboratory findings in 74% and 85% of cases respectively. The mortality rate in the27 patients included in this study was 44% [12 cases]; in 8 of them infection was located in the truk. Once necrotizing fasciitis is suspected, exploration of the fasica is mandatory with pathological assessment of tissue specimens. Radical debriement of the affected area, maintenance of adequate nutritional support and systemic antibiotic therapy should be implemented at once to reduce mortality and insure safe recovery of patients

Cervical lympho-venous shunt versus denver shunt in management of intractable ascites [analysis of 170 cases]

The present study was conducted on 170 patients with intractable ascites secondary to liver cirrhosis. The present study showed that both peritoneo-venous and lympho-venous shunts are technically simple procedures that could be done under local anesthesia in nearly similar time duration. However, Denver shunt is expensive, it costs between LE 4000-6000. Lympho-venous shunt is a biological cheap procedure. It can be concluded from this study that patients with intractable ascites could be offered surgical therapy with either shunts with a high success rate. Cervical lympho-venous shunt appears to be a simple, safe, cheap and effective method for achieving a long-term control of refractory ascites. The use of a biological shunt is an added advantage over prosthetic shunts for drainage of ascetic fluid with almost negligible complications. Failure does not interfere with the future use of the expensive peritoneo-venous Denver shunt. Denver peritoneo-venous shunt is a good device to relieve ascites, thereby reducing the risk of complications and the number of hospital admissions due to repeated paracentesis and consequently improving the quality of life. However, its high cost limits its wide scale application. A careful patient selection is mandatory for optimal results

Retroperitoneal pus collection: image guided percutaneous versus primary surgical drainage

Retroperitoneal infection is an uncommon entity, mostly presents as psoas abscess. This may be primary with no definite aetiology mostly caused by staphylococcus aureus, or secondary to tuberculosis of the spine or infection of adjacent retroperitoneal organs. Clinical diagnosis is difficult because of non-specific symptoms, resulting in delayed discovery and high morbidity and mortality. Modern imaging diagnostic techniques such as ultrasound and computerized tomography have allowed for a refinement in both the aetiologic diagnosis and the treatment by means of CT-guided or ultrasound-guided percutaneous drainage of the abscess, thus avoiding surgical drainage in many cases. This study included 29 cases [20 males and 9 females, ratio 2.2: 1], studied Between August 1995 and August 2001. Their age ranged from 10 to 77 years [mean 43 years]. Pus collection was located on the right side in 17 cases, on the left side in 7 cases and bilateral collection was reported in 5 cases. Out of the 29 patients included in the study 15 cases [52%] had primary psoas abscess while the remaining 14 cases [48%] had retroperitoneal infection secondary to T.B. spine [5 cases], appendicitis [3 cases], pancreatitis [one case], and kidney disease [5 cases]. The main presenting symptoms were abdominal pain [86%], fever [83%] and swelling [62%]. Patients were classified into two groups: group [A] included 13 cases and were subjected to primary surgical drainage under general anaesthesia, and group [B] included 16 patients who were treated by image [U/S and or CT scan] guided percutaneous drainage under local anaesthesia. Patients were followed for a period of 6 to 72 months with a mean follow up period of 36 months. Surgical drainage was successful in all cases with one postoperative mortality and no relapses on long term follow up [92% overall success]. While the localization of pus using image guidance was successful in all cases in-group B but follow up revealed recollection in 3 cases [19%] that required surgical intervention [81% overall success]. Immediately on diagnosis of retroperitoneal pus collection prompt treatment is necessary. Percutaneous drainage should be performed whenever possible and in case of failure, surgical drainage should be done. Surgical drainage has the advantage of dealing with the offending organ and can properly drain a multi-locular and rigid walled abscess. Image guided drainage can be used in critically ill patients not fit for anaesthesia and for primary unilocular thin walled abscess. It is a safe procedure with lower morbidity and mortality, shorter drainage time, better patient acceptance, easier nursing care, less hospital stay and more cost effective than open surgical drainage

Non penetrating abdominal trauma: Key points to explore or to conserve

Seventy-eight patients with blunt abdominal trauma [either isolated or as a part of polytrauma] were stratified into four management groups based on a clinical scoring system. Immediate laparotomy was done in 36 cases, diagnostic peritoneal lavage followed by further management in 18 cases, auxiliary radiological investigation in the form of ultrasonography and/or CT scan in 14 cases and the conservative treatment based on mere clinical judgment in 10 cases. The study devised a Clinical Abdominal Scoring System [CASS] which helped in proper patient selection for definitive management. This is reflected on the high accuracy and specificity of the auxiliary radiological investigation [100%] and minimizes cost as well as subsequent mortality that would result from delayed or improper diagnosis