Clinical study, management and outcome of gall bladder perforation in a tertiary care hospital

Background: The objective of the study was to present our clinical experience with gall bladder perforation cases. This may help in the management and decision making of such cases.Methods: Records of 480 patients who received medical and/or surgical treatment with the diagnosis of acute cholecystitis in our hospital between 2007 and 2014 were reviewed retrospectively. Twenty nine (6%) of those patients had gall bladder perforation. Original Niemeier’s classification of gall bladder perforation used to describe the type of perforation. The parameters including age, gender, duration of symptoms, diagnostic procedures, medical or surgical or radiological interventional treatment used, morbidity and mortality were evaluated.Results: Out of the 29 patients, 25 patients had subacute type of gall bladder perforation (Niemeier type II) and 4 patients had chronic (Niemeier type III) perforation. None of the patients encountered had generalized peritonitis (Niemeier type I). The diagnosis in all these patients was established on admission to the hospital by means of abdominal ultrasound and computed tomography. Twelve (43%) patients underwent early surgery. The rest (58.6%) either underwent conservative medical line of management or pigtail catheter insertion in the collection followed by interval cholecystectomy. Three (10.7%) patients died of sepsis and associated comorbid condition.Conclusions: Early diagnosis of gall bladder perforation is of critical importance. Abdominal ultrasound coupled with computerized tomography is useful in diagnosis of gall bladder perforation. Management strategies include early surgery in patients with generalized peritonitis or suspicion of gall bladder necrosis, and initial conservative line of management and/or pigtail insertion in surgically high risk patients which can be followed up by interval cholecystectomy.

Ultra-Early Versus Early Aneurysm Surgery After Subarachnoid Hemorrhage: A Retrospective Outcome Analysis

Object The timing of definitive management of ruptured intracranial aneurysms has been the subject of considerable debate, although the benefits of early surgery (until 72 hours postictus) are widely accepted. The aim of the present study is to evaluate the potential benefit of ultra-early surgery (until 24 hours) when compared with early surgery, in those patients who were treated by surgical clipping at the Neurosurgery Department of the Coimbra Hospital and University Centre. Methods A 17-year database of consecutive ruptured and surgically treated intracranial aneurysms was analyzed. Outcome was measured by the Glasgow Outcome Scale (GOS). Baseline characteristics were analyzed by the Fisher exact test, the chi-squared and Mann-Whitney tests. Logistic regression was used to assess the impact of good grade according to the World Federation of Neurological Surgeons (WFNS) scale and ultra-early surgery in a good GOS outcome. Results 343 patients who were submitted to surgical clipping in the first 72 hours postictus were included, 165 of whom have undergone ultra-early surgery. Demographics and preoperative characteristics of ultra-early and early surgery patients were similar. Goodgrade patients according to the WFNS scale submitted to ultra-early surgery demonstrated an improvedGOS at discharge and at 6months. Poor-grade patients according to theWFNS scale submitted to ultra-early surgery demonstrated an improved GOS at discharge. Conclusions Ultra-early surgery for aneurysmal subarachnoid hemorrhage patients improves outcome mainly on good-grade patients. Efforts should be made on the logistics of emergency departments to consider achieving treatment on this timeframe as a standard of care.

Value of Early Surgery in Small Intestinal Crohn's Disease / 胃肠病学

Crohn's disease (CD) is a gastrointestinal tract chronic inflammatory disease with an increasing incidence worldwide. Treatment of CD is focused on symptom control and healing the intestinal mucosa in order to improve the quality of life and prevent complications. The early use of anti-TNF agents such as infliximab in CD patients with high risk factors has become the main treatment of CD clinically. However, infliximab has its limitations, early surgery might benefit the patient more. This article reviewed the therapeutic value of early surgery in small intestinal CD.

Application value of early and delayed laparoscopic cholecystectomy after percutaneous transhepatic gall-bladder drainage in 65 years of age or older patients with severe acute cholecystitis: a prospective analysis / 中华消化外科杂志

Objective To investigate the application value of early and delayed laparoscopic cholecystectomy (LC) after percutaneous transhepatic gallbladder drainage (PTGD) in 65 years of age or older patients with severe acute cholecystitis.Methods The prospective study was conducted.The clinical data of 80 patients with severe acute cholecystitis who were admitted to Shanxi Dayi Hospital of Shanxi Academy of Medical Sciences from May 2016 to January 2018 were collected.All patients were divided into two groups by random number table,including patients undergoing LC 72 h later after extubation of PTGD in the PTGD + early LC group,and patients undergoing LC 5-14 days later after extubation of PTGD in the PTGD + delayed LC group.Observation indicators:(1) surgical situations;(2) analysis of liver function before and after LC in the two groups;(3) analysis of serum-related inflammatory factors before and after LC in the two groups;(4) follow-up situations.Patients were followed up by outpatient examination or telephone interview to detect the postoperative complications in the postoperative three months up to April 2018.Measurement data with normal distribution were represented as Mean ± SD,and comparison between groups was done using the paired t test.Count data were represented as absolute number,and comparison between groups was analyzed using the chi-square test or Fisher exact probability.Results Eighty patients were screened for eligibility,including 41 males and 39 females,aged from 65 to 70 years,with an average age of 67 years.There were 40 patients in the PTGD + early LC group and 40 in the PTGD + delayed LC group,respectively.(1) Surgical situations:the operation time,volume of intraoperative blood loss,and duration of postoperative hospital stay were (52± 15) minutes,(29± 11) mL,(18.9± 1.6) days in the PTGD + early LC group,and (88± 13)minutes,(69± 11)mL,(27.7±4.8)days in the PTGD + delayed LC group,respectively,showing significant differences in the above indicators between the two groups (t =11.668,16.219,11.000,P＜0.05).(2) Analysis of liver function before and after LC in the two groups:the levels of aspartate transaminase (AST),alanine aminotransferase (ALT),gamma glutamyl transferase (GGT),and total bilirubin (TBil) of PTGD + early LC group were (53 ± 11) U/L,(203 ±40) U/L,(128± 22) U/L,(19± 6)U/L,(86±21)μmol/L before LC,and (26±5)U/L,(83±23)U/L,(29±3)U/L,(11±5)U/L,(27± 7) μmol/L at 24 hours after LC,showing significant differences in the above indicators before and after LC (t =12.562,16.448,28.199,6.478,16.857,P＜0.05).The levels of AST,ALT,GGT,and TBil of PTGD + delayed LC group were (54± 12) U/L,(203±48) U/L,(130±24) U/L,(19±6) U/L,(85±20) μmol/L before LC,and (29±5) U/L,(151±36) U/L,(53±7)U/L,(17±3)U/L,(31±8)μmol/L at 24 hours after LC,showing significant differences in the above indicators before and after LC (t =13.622,5.481,2.169,1.988,15.855,P＜0.05).There was no significant difference in the levels of AST,ALT,ALP,GGT,TBil before LC between the two groups (t=0.389,0.000,0.389,0.000,0.218,P＞0.05),meanwhile,there were significant differences in the levels of AST,ALT,ALP,GGT,TBil after LC between the two groups (t =2.683,10.067,19.931,6.508,2.380,P＜0.05).(3) Analysis of serum-related inflammatory factors before and after LC in the two groups:the levels of interleukin-1 (IL-1),interleukin-6 (IL-6),high-sensitivity C-reactive protein (CRP),interleukin-10 (IL-10),and tumor necrosis factor-α (TNF-α) of PTGD + early LC group were (71 ±9) ng/L,(82±9)ng/L,(137±16)ng/L,(75±6)ng/L,(67±9)μg,/L before LC,and (87±13)ng/L,(97±9)ng/L,(81± 19)ng/L,(145±6)ng/L,(85±6)μg/L at 24 hours after LC,showing significant differences in the above indicators before and after LC (t ==6.400,7.454,14.259,52.175,10.525,P＜0.05).The levels of IL-1,IL-6,high-sensitivity CRP,IL-10,and TNF-α of PTGD + delayed LC group were (71±9) ng/L,(82± 10) ng/L,(145±28)ng/L,(75±6)ng/L,(67±10) μg/L before LC,and (145±7)ng/L,(135±16) ng/L,(101±1S)ng/L,(146±9) ng/L,(113±10)μg/L at 24 hours after LC,showing significant differences in the above indicators before and after LC (t =41.079,17.766,8.360,41.525,27.578,P ＜ 0.05).There was no significant difference in the levels of IL-1,IL-6,high-sensitivity CRP,IL-10,and TNF-α before LC between the two groups (t =0.000,0.000,1.569,0.000,0.000,P＞0.05),meanwhile,there were significant differences in the levels of IL-1,IL-6,high-sensitivity CRP,and TNF-α after LC between the two groups (t=24.844,13.092,4.833,15.185,P＜0.05).(4) Follow-up situations:80 patients were followed up for 3 months.Two patients in the PTGD + early LC group had postoperative complications,including 1 of bile duct injury and 1 of incisional infection;9 patients of PTGD + delayed LC group had postoperative complications,including 3 of bile duct injury,3 of multiple organ failure,2 of incisional infection,1 of death.There was a significant difference in the postoperative complication between the two groups (x2 =5.165,P＜0.05).Conclusion Early LC after PTGD can effectively shorten operation time,reduce volume of intraoperative blood loss,shorten duration of postoperative hospital stay,protect liver function,reduce the expression of serum inflammatory factors at 24 hours after surgery,and reduce postoperative complications.

Orbital Wall Fracture Repair: The Results of Early and Delayed Surgery

PURPOSE: To investigate the surgical results of early and delayed repair of orbital wall fracture after multiple subgrouping of patients by time between the operation and injury. METHODS: Eighty-eight eyes of 88 patients who underwent orbital wall fracture repair from January 2002 to December 2014 and who were followed up for more than 3 months postoperatively were included in this study. We divided the 88 patients into three groups: Early surgery group (surgery within 2 weeks after the injury), slightly delayed surgery group (surgery between 3 weeks and 2 months after the injury), delayed surgery group (surgery after 2 months of the injury). Preoperative and postoperative ocular motility, diplopia, and the degree of enophthalmos were analyzed retrospectively. RESULTS: The early surgery group consisted of 30 eyes; slightly delayed surgery group, 42 eyes; and delayed surgery group, 16 eyes. The mean duration between injury and surgery was 8.6 +/- 22.5 weeks in all patients, 1.5 +/- 0.5 weeks in the early surgery group, 3.5 +/- 1.3 weeks in the slightly delayed surgery group, and 35.3 +/- 44.7 weeks in the delayed surgery group. All patients were followed up for a mean of 12.9 +/- 10.8 weeks. Gaze limitation in all directions showed improvement in all groups, with the most shown in up gaze limitation. There were no significant differences in the degree of improvement between preoperative and postoperative gaze limitation among the three groups. Enophthalmos improved as well, without any significant differences among the three groups. CONCLUSIONS: Improvement in ocular motility limitation and enophthalmos after orbital wall fracture repair did not vary significantly according to the duration between the surgery and injury. Therefore, surgical repairment even for old orbital fractures may successfully treat enophthalmos or diplopia and relieve symptoms.

Early and midterm follow-up of vascular endothelial function in children with surgical repair for coarctation of aorta / 实用医学杂志

Objective To evaluate the endothelium-dependent vasodilation in children after repair for coarctation of aota (CoA). Methods A group of 20 children having undergone CoA repair between January 2010 and October 2010 in Guangzhou Women and Children′s Medical Center were include in the study , including 12 infants aged less than 6 months and 8 ones aged more than 6 months. Another 20 healthy children were enrolled during the same period as controls. All the subjects underwent monitoring of resting blood pressure and flow-mediated dilation (FMD) of the brachial artery in 4-year follow-up. Results There were no resting hypertension in all subjects , but FMD in the CoA group was higher than in the control group and so it was with the early surgery group and non early surgery group. Conclusion The surgical repair for coarctation of aorta could not cure the vascular function impairment satisfactorily , neither is the early surgery effective in alleviating the injuries in vascular endothelia.

Is Taking an Antiplatelet Agent a Contraindication for Early Surgery in Displaced Femur Neck Fracture? / 대한고관절학회지

PURPOSE: The purpose of this study was to evaluate whether we have to stop the antiplatelet agents prior to hemiarthroplasty surgery in patients with displaced femur neck fractures to reduce postoperative complications. MATERIALS AND METHODS: We enrolled forty-three patients with displaced femur neck fractures who were treated by bipolar hemiarthroplasty and were taking antiplatelet agents. Group I included 21 patients who discontinued antiplatelet agents and had delayed operations at an average 5.7 days and group II included 22 patients who had had early operations within 24 hours without stopping the antiplatelet agents. We compared the pre- and postoperative levels of hemoglobin, the volume of postoperative transfusion requirement and complications. Student's t-test and chi-square test were used for statistical analysis. RESULTS: The average differences between preoperative and postoperative hemoglobin was 1.4+/-0.4 g/dL decrease in group I and 2.1+/-0.5 g/dL decrease in group II (P<0.001). Patients who received a blood transfusion were 11 in group I and 13 in group II (P=0.66). Total number of blood transfusion was 13 pints in group I and 18 pints in group II (P=0.23). Pneumonia occurred in one patient in each group. Four pressure sores and three diaper rashes were developed in group I. But there were no patients requiring massive transfusion, reoperation due to hematoma and infection in each group. CONCLUSION: Although continuous taking of antiplatelet agents in displaced femur neck fracture is associated with an increased risk of postoperative bleeding, taking an antiplatelet agent itself is not a contraindication of early surgery.

Outcomes of Ultra-Early Decompressive Craniectomy after Severe Traumatic Brain Injury-Treatment Outcomes after Severe TBI / 대한신경손상학회지

OBJECTIVE: The beneficial effect of decompressive craniectomy in the treatment of severe traumatic brain injury (TBI) is controversial, but there is no debate that decompression should be performed before irreversible neurological deficit occurs. The aim of our study was to assess the value of ultra-early decompressive craniectomy in patients with severe TBI. METHODS: Total of 127 patients who underwent decompressive craniectomy from January 2007 to December 2013 was included in this study. Among them, 60 patients had underwent ultra-early (within 4 hours from injury) emergent operation for relief of increased intracranial pressure. Initial Glasgow coma scale, brain computed tomography (CT) scan features by Marshall CT classification, and time interval between injury and craniectomy were evaluated retrospectively. Clinical outcome was evaluated, using the modified Rankin score. RESULTS: The outcomes of ultra-early decompressive craniectomy group were not better than those in the comparison group (p=0.809). The overall mortality rate was 68.5% (87 patients). Six of all patients (4.7%) showed good outcomes, and 34 patients (26.8%) remained in a severely disabled or vegetative state. Forty of sixty patients (66.7%) had died, and two patients (3.3%) showed good outcomes at last follow-up. CONCLUSION: Ultra-early decompressive craniectomy for intracranial hypertension did not improve patient outcome when compared with "early or late" decompressive craniectomy for managing severe TBI.

Rates of Early Surgery and Associated Risk Factors in Crohn's Disease / 대한소화기학회지

BACKGROUND/AIMS: The individual course of Crohn's disease is diverse, and some patients may require bowel resection. The aims of this study were to determine the early surgery rate of Crohn's disease and to identify risk factors associated with early surgery in Korea. METHODS: Ninety six patients with Crohn's disease (68 men; median age at the time of diagnosis: 25 years), who had been followed up more than a year, were retrospectively analyzed. Early surgery was defined as a bowel operation for Crohn's disease or its complications occurring within 3 years from diagnosis. Early surgery rate and risk factors for early surgery were identified. RESULTS: Fifteen patients (15.6%) underwent early surgery. The cumulative surgery rate was 8.6% after 6 months, 11.9% after 12 months, 14.1% after 18 months, and 16.7% after 24 to 36 months. Multivariate analysis revealed penetrating or stricturing behavior to be an independent risk factor for early surgery (p<0.001, Exp (B)=2.97 CI 1.39-6.37). CONCLUSIONS: The cumulative early surgery rate in Korean patients seems to be lower than Western patients. Penetrating or stricturing behavior is significantly associated with early surgery, requiring early aggressive medical treatments.

Early and non- early surgery for ruptured intracranial aneurysms: analysis of 184 cases / 中华急诊医学杂志

Objective To compare the therapeutic efficacy between emergency and non-emergency operation for ruptured intracranial aneurysms. Method A retrospective analysis of 184 patients with ruptured intracranial aneurysms the Second Affiliated Hospital Zhejiang University College of Medicine, admitted from Dec 2008 to Sep 2009, was carried out to evaluate the efficacy of operation to be done earlier. The patients were divided into 2groups according to the time of surgery. In the early operation group ( n = 102), the patients were operated on within 3 days of rupture of aneurysms, and in the delayed operation group ( n = 82), the patients were operated on after 3 days. The comparison in the rate of rebleeding before surgery, rate of complete occlusion of the ruptured aneurysm and rate of major complications such as cerebral infarction and hydrocephalus between two groups was made. The Glasgow outcome scale (GOS) scores of these patients were also evaluated by 6- 12 months follow-up after operation. Results Preoperative re-bleeding happened in 2 patients of the early operation group and in 7 patients of the delayed operation group. The rates were significantly different ( P ＜ 0.05). The complete occlusion rate in the early operation group was 91.2 % ( 93/102 ), while was 80.5 % ( 66/82 ) in the delayed operation group (P＜0.05). There were no statistically significant differences in post-operative cerebral infarction rate, post-operative hydrocephalus rate or GOS scores on follow-up between two groups. Conchusions Early operation can significantly reduce the re-bleeding before surgery, reducing the risk of death and disability. In early operation, the continuous lumbar drainage by cannulation and other methods can be used to reduce intracranial pressure, significantly increasing the rate of complete occlusion, and promoting rehabilitation.

Surgical Experience of Distal Middle Cerebral Artery Aneurysm Rupture / 대한뇌혈관외과학회지

OBJECTIVE: Distal middle cerebral artery (MCA) aneurysms are the least frequent aneurysms of the MCA, and they represent about 1.1 to 5% of all MCA aneurysms. Patients with ruptured distal MCA aneurysms generally have a poor clinical outcome. The purpose of this article is to review the characteristics of distal MCA aneurysms to avoid the complications of microsurgical dissection and clipping of distal MCA aneurysms. METHODS: A total of 1187 patients with ruptured aneurysms were treated at our hospital between January 1997 and May 2008. All patients underwent surgical procedures. Computed tomography (CT) revealed rupture of distal MCA aneurysms in 15 (1.26%) patients. The location of the aneurysm were the M2 (insular) segment in seven patients, the M2-3 junction in three and the M3 (opercular) segment in five. Brain CT images revealed the presence of both subarachnoid hemorrhage (SAH) and intracranial hemorrhage (ICH) in 11 of 15 (77.3%) patients, with a mean ICH volume of 14.5 cc (range : 5 to 32 cc). Rebleeding occurred in 7 out of the 15 (46.7%) patients. RESULTS: All the patients underwent early surgical procedures, including clipping in seven, trapping in two, bypass surgery in four, Guglielmi detachable coil embolization in one and exploratory craniotomy in one patient. The aneurysm had a fusiform appearance in 9 out of 15 cases (60%), and the mean size of the aneurysm was 10.4 mm (range : 2 to 35 mm). Three patients died due to severe brain swelling (20%). CONCLUSION: In this study, distal MCA aneurysms had a relatively fusiform shape as well as high rates of rebleeding and ICH. A good clinical outcome was associated with early surgery for adequately controlling brain swelling and preventing rebleeding.

Early surgery for ruptured cerebral aneurysms: technical note

We describe a collection of techniques to be considered in the early clipping of ruptured cerebral aneurysms located in the anterior circulation when dealing with the swollen red and scaring brain many times found after craniotomy.

Descrevemos uma coleção de técnicas a serem consideradas na clipagem precoce dos aneurismas cerebrais rotos localizados na circulação anterior quando lidando com o cérebro vermelho inchado e assustador encontrado muitas vezes após a craniotomia.

Early Surgery for Intermittent Exotropia in Children less than 4 Years of Age

PURPOSE: To determine the result of early surgery for intermittent exotropia for children under 4 year old and the factors which affect it. METHODS: The study subjects consisted of 25 children younger than 4 years who had received surgery for intermittent Exotropia. They were followed up for more than 1 year after surgery by the Department of Ophthalmology of the Gachon Medical School, between July 1998 and December 2003. The interval from onset to initial surgery, preoperative deviation angle, dissociated vertical deviation, stereopsis, preoperative patching, type of surgery, and initial postoperative deviation angle were compared and analyzed in a retrospective manner. RESULTS: The average age of the subjects and the preoperative deviation angle were 3.2 years and 28.67+/-8.08PD respectively. The average deviation angle at postoperative year 1 was 5.60+/-8.69PD. Out of the 25 patients, 19 (76%) showed a deviation angle less than 10PD were and 4 (16%) had recurrence of exotropia. Consecutive esotropia occurred in 2 (8%). The clinical factor statistically related to results was the initial postoperative deviation angle. The group who had esophoria of more than 10 PD (18.27+/-6.18 PD) showed 93% orthophoria at postoperative year 1, which was statistically significant. CONCLUSIONS: Though a patient be under 4 years old, if their deviation angle is in progress or if non-surgical treatment is ineffective in the case when surgery is delayed, it is presumed that performing surgery at postoperative day 1 with an overcorrection of about 10 PD is preferred.

Clinical Analysis of Poor grade Subarachnoid Hemorrhage Patients / 대한뇌혈관외과학회지

PURPOSE: Subarachnoid hemorrhage (SAH) resulting from aneurysmal rupture carries a high rate of morbidity and mortality despite of intensive care. Owing to the advance in surgical techniques, the management results of good grade patients have shown better outcomes than the past, but those of poor grade patients have been still unsatisfactory. The aim of this study is to determine the treatment and the prognostic factors in the poor grade SAH patients. METHOD: We have analyzed 43 patients of Hunt & Hess (H&H) grade IV and V among 438 SAH patients treated between 1998 and 2004. The patients were divided into two groups (Good outcome group and Poor outcome group) according to the management outcomes. Each group was analyzed about the various prognosis factors; age, sex, H&H grade, Fisher grade, location and size of aneurysm, timing of operation, and complications. RESULTS: Among the various factors evaluated, the preoperative H&H grade only showed statistical significance (P value=0.0173). The better H&H grade seemed to show the more favorable outcome, especially surgically treated cases. CONCLUSIONS: An aggressive treatment including early surgery seems to contribute to a better outcome of poor grade SAH patients, especially H&H grade IV. But further clinical study should be researched to improve clinical outcomes in H&H grade V patients.

Early Aneurysm Surgery using Eyebrow Incision for Poor Grade Patients

OBJECTIVE: This study is aimed to assess the clinical outcome in early and minimally invasive surgery using an eyebrow incision for the patients with poor grade aneurysm. METHODS: The authors retrospectively reviewed all 46 poor grade patients of Hunt and Hess(H-H) grade IV and V who suffered aneurysmal subarachnoid hemorrhage(SAH) between 1999 and 2004. All 35 patients harboring 43 aneurysms who underwent early surgery within 72 hours were included in this study. Clinical outcome was assessed by Glasgow outcome scale(GOS) and compared with that of conventional pterional approach. RESULTS: Twenty four patients were operated with conventional pterional approach and 11 with eyebrow approach within 72 hours after SAH. Seven multiple aneurysm patients harbor 15 aneurysms. Forty one aneurysms were treated with clippings. All 11 patients of eyebrow surgery group(ESG) were in H-H grade IV, 3 in Fisher grade III and 8 in Fisher grade IV. Among 24 patients of pterional approach group(PAG), 20 were in H-H grade IV and 4 in H-H grade V, 3 were in Fisher grade III and 21 in Fisher grade IV. Overall favorable outcome was achieved in 41.7% and 54.5% in PAG and ESG, respectively. Favorable outcome of H-H grade IV in PAG showed 45.0%. Overall mortality rate was 14.3%. CONCLUSION: It is concluded that the clinical outcome of early and minimally invasive aneurysmal surgery using eyebrow incision in the selected poor grade aneurysm patients can be compatible with that of conventional pterional surgery.

Early surgery for acute injuries of cervical spinal cord / 中华创伤骨科杂志

Objective To study the clinical results of early surgery for acute cervical spinal cord injury. Methods 24 cases of acute cervical spinal cord injury were treated with early surgery in our hospital from 1999 to 2002. The average interval from injury to surgery was 67 hours. The injured cervical segments were reduced, decompressed and fixed through anterior approach, posterior approach or anterior posterior approach. Results 22 cases got follow ups of 12 to 38 months (mean 18 months), but 2 cases were lost. 2 cases of the 11 patients of ASIA Grade A did not experience any restoration, but all the other patients got significant restoration and an average improvement of 1.8 ASIA grades. Conclusion Operation should be performed as soon as possible for acute cervical spinal cord injury, for good results can be achieved by early surgery.

Early Surgery before 4 years of Age in Intermittent Exotropia

PURPOSE: We performed this study to evaluate the occurrence of consecutive esotropia after early surgery in the patients with intermittent exotropia less than 4 years of age. METHODS: We analyzed the surgical results of 37 patients who underwent surgery before 4 years of age retrospectively. They were followed up at least more than 1 year after surgery. The orthophoria was defined as an exophoria of 0 to 12PD or an esophoria of 0 to 5PD after surgery. The consecutive esotropia was defined as an esodeviation lasting more than 3 months that needed surgical correction due to sensorial deterioration. RESULTS: Preoperative angle of exodeviation at distance ranged from 20PD to 60PD (mean 35.1 +/- 9.2PD). Twenty-seven of 37 patients (75.7%) showed orthophoria after surgery in 1 year follow-up and 20 of 31 patients (64.5%) in 2 years follow-up. Five patients (13.5%) showed recurrence and 4 patients (10.8%) consecutive esotropia. Immediate postoperative overcorrection was 14.1 +/- 8.7PD(0-30) in patients who were orthophoric after postoperative follow-up more than 2 years. The rate of consecutive esotropia was high in patients with an exo-angle of 30PD or more and a large amount of recession of lateral recti more than 7mm. CONCLUSIONS: This study revealed that consecutive esotropia after early surgery for intermittent exotropia less than 4 years of age was noted to the 10.8%.

Long Term Surgical Results after Early Surgery for Infantile Esotropia Before and After 1 year of Age

PURPOSE: To analyze the long term surgical results after early surgery for infantile esotropia before and after 1 year of age and to investigate postoperative eye alignments. METHODS: This retrospective study included 46 patients with infantile esotropia who underwent surgery before 2 years of age and were followed up for a minimum of 5 years. Subjects were divided into 2 groups: those who underwent surgery before 1 year of age (n=22, group 1), and the ones who underwent surgery between 1 year of age and 2 years of age (n=24, group 2). RESULTS: Long term postoperative alignment between two groups was not statistically significant. In postoperative stereopsis test, 11 patients (78.6%) of group 1 and 7 patients (41.2%) of group 2 had stereopsis and the patients of group 1 had more favorable stereoacuity than the patients of group 2. These differences were statistically significant, respectively (p=0.039). In postoperative eye alignment, patients of group 1 showed tendency to become exodeviated to esodeviated and patients of group 2 showed tendency to become esodeviated to exodeviated. These differences were statistically significant, respectively (p=0.023, p=0.042). CONCLUSIONS: To achieve better binocular function, early surgical alignment before 1 year of age is more recommended. Because early surgery before and after 1 year of age displays contradictory postoperative eye alignment, close follow up and careful consideration at reoperation is recommended.

Management Outcome of Poor Grade Patients with Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE: The aim of this study is to determine the treatment strategies for the poor grade patients with aneurysmal subarachnoid hemorrhage(SAH) with respect to the timing of surgery. METHODS: We have analyzed 51 patients of Hunt and Hess grade IV and V at admission among 140 SAH patients who were managed during recent three years. They were devided into two groups according to the interval between SAH and surgery: 30 early treatment group(operated within 3 days) and 21 delayed treatment group(6 delayed operation cases and 15 unoperated cases). RESULTS: Clinical outcome of early surgery group was favorable(Good or Fair) in 23 cases(76.7%) and unfavorable in 7 cases(23.3%, 2 Poor, 5 Dead). On the contrary, those of delayed surgery group or without surgery group was favorable in 4 cases(19.1%) and unfavorable in 17 cases(80.9%, 1 Poor, 16 Dead). Overall management outcome of poor grade SAH patients was favorable in 27 cases(52.9%), unfavorable in 24 cases(47.1%) and mortality rate was 41.2%. Unfavorable outcome in poor grade SAH patients was largely affected by the initial hemorrhage and subsequent development of intractable intracranial hypertension(Hunt and Hess grade IV: 5 cases, grade V: 8 cases), cerebral infarction(grade IV: 3 cases, grade V: 1), rebleeding(grade IV: 3 cases), and surgical complication(4 cases). CONCLUSION: An active treatment policy including early surgery might achieve a better outcome of poor grade SAH patients.

Management Outcome of Poor Grade Patients with Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE: The aim of this study is to determine the treatment strategies for the poor grade patients with aneurysmal subarachnoid hemorrhage(SAH) with respect to the timing of surgery. METHODS: We have analyzed 51 patients of Hunt and Hess grade IV and V at admission among 140 SAH patients who were managed during recent three years. They were devided into two groups according to the interval between SAH and surgery: 30 early treatment group(operated within 3 days) and 21 delayed treatment group(6 delayed operation cases and 15 unoperated cases). RESULTS: Clinical outcome of early surgery group was favorable(Good or Fair) in 23 cases(76.7%) and unfavorable in 7 cases(23.3%, 2 Poor, 5 Dead). On the contrary, those of delayed surgery group or without surgery group was favorable in 4 cases(19.1%) and unfavorable in 17 cases(80.9%, 1 Poor, 16 Dead). Overall management outcome of poor grade SAH patients was favorable in 27 cases(52.9%), unfavorable in 24 cases(47.1%) and mortality rate was 41.2%. Unfavorable outcome in poor grade SAH patients was largely affected by the initial hemorrhage and subsequent development of intractable intracranial hypertension(Hunt and Hess grade IV: 5 cases, grade V: 8 cases), cerebral infarction(grade IV: 3 cases, grade V: 1), rebleeding(grade IV: 3 cases), and surgical complication(4 cases). CONCLUSION: An active treatment policy including early surgery might achieve a better outcome of poor grade SAH patients.