Tratamiento quiúúrgico del megaesófago sigmoideo, grado iv por acalaiia / Surgicaltreatmennt of sigmoid megaesophagus, achalasia by grade iv

La Acalasia presenta ausencia del peristaltismo esofágico, falta de relajación del esfínter esofágico Inferior y una zona de alta presión en el esófago distal, con compromiso del plexo mioentérico y degeneración ganglionar, determinan alteraciones severas en la deglución. Para el tratamiento quirúrgico se han propuesto múltiples técnicas operatorias con la finalidad de restablecer la alimentación oral en pacientes que presentan dificultad del pasaje de los mismos. En el Instituto Gastroenterológico Boliviano Japonés - de La Paz se ha incluido 4 pacientes con diagnóstico de Acalasia en el grado IV avanzado, con diversos grados de afectación nutricional. (3 pacientes por enfermedad chagásica y 1 paciente afectado por estenosis cáustica del esófago distal), edad comprendida entre los 45 y 60 años. Se realizo esofagoectomía distal y anastomosis esófago - gástrica T-T . resección del esófago distal con acalasia, y a nivel del área dilatada del esófago una anastomosis con el fondo gástrico T-T, con piloroplastia añadida. Dos casos con yeyunostomía de alimentación preoperatoria. Los resultados postoperatorios son altamente satisfactorios, seguimiento de 7 meses y 12 meses, con controles clínicos, radiológicos contrastados y endoscopia, se comprobó tubolización del estómago ascendido, con buena tolerancia a la dieta y ausencia de reflujo gastroesofágico. El procedimiento quirúrgico utilizado con morbimortalidad ausentes, es un aporte de la medicina boliviana, ya que no se han descrito técnicas similares en la revisión de la literatura mundial y con una ventaja clara frente a las técnicas quirúrgicas clásicas, en los que la esofagoectomía total tiene un alto riesgo para el tratamiento de la acalasia de grado avanzado.

Achalasia presents The absence of esophageal peristalsis, lack of Lower Esophageal sphincter relaxation and an area of high pressure in the distal esophagus, with involvement of the myentericplexus and ganglionic degeneration, determines severe alterations in swallowing. For surgical treatment multiple operative techniques have been proposed with the aim of restoring oral feeding in patients who have difficulty passage thereof. In the Japanese-Bolivian Gastroenterological Institute of city La Paz- Bolivia, inclusion of 4 patients diagnosed with achalasia in grade IV advanced, with varying degrees of nutritional impairment. (3 patients for Chagas disease and 1 patient affected by distal esophageal caustic stenosis), aged between 45 and 60 años. The esofagoectomy distal anastomosis performed esophageal - gastric TT. with resection distal esophagus with achalasia, dilated area level and esophageal anastomosis with the gastric fundus TT, with pyloroplasty. Twos cases with preoperative feeding jejunostomy. Postoperative results are highly satisfactory, follow up of 7 months and 12 months, with clinical, radiological and endoscopic contrasted, the stomach was found tube promoted, with good tolerance to the diet. The surgical procedure used morbidity absent, is contributed Bolivian medicine since no similar techniques are described in the review of the world literature a clear advantage over conventional surgical techniques, in which the aggregate has esofagoectomy a high risk for the treatment of achalasia of advanced degree.

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.

The Outcome of Urgent Surgery for Hunt-Hess Grade IV Patients with Ruptured Intracranial Aneurysm

OBJECTIVE: About 40% of patients who admit to the hospital after subarachnoid hemorrhage are poor clinical grade(Hunt-Hess grade IV, V). The majority of these patients have been excluded from early, aggressive treatment. The current study was undertaken to evaluate the outcome of urgent surgery for Hunt-Hess grade IV aneurysmal subarachnoid hemorrhage. MATERIALS AND METHODS: We reviewed hospital records and radiographic studies of 36 patients who were Hunt-Hess grade IV among 201 cases with ruptured intracranial aneurysm admitted between Sep. 1995 and Dec. 2000. Operated patients were treated with urgent angiography and surgery within 24 hours of presentation, except six patients, and medical records of these patients were reviewed for the clinical course and Glasgow outcome scale(GOS). RESULTS: Overall management results of the 36 patients were good recovery in 13(36.1%), moderate disability in 12 (33.3%), severe disability in 1(2.8%), vegetative state in 1(2.8%) and 9(25.0%) of surgically treated patients had died. CONCLUSION: Although with limited number of patients, we conclude that urgent surgery for Hunt-Hess grade IV patients results in a better neurologic outcome and urgent surgery combined with aggressive postoperative management can minimize mortality.

Pollicization of Patients with more than Buck-Gramcko Grade IV Congenital Hypoplasia of the Thumb / 대한정형외과학회잡지

PURPOSE: Thumb hypoplasia gives rise to various derangement of hand functions, leading to various degrees of malformation. The treatment of choice for grade IV or V congenital hypoplasia of the thumb, classified by Buck-Gramcko's criteria, is the pollicization of the index finger. The purpose of this article is to review the clinical usefulness of pollicization for more than grade IV hypoplasia. MATERIALS AND METHODS: Three grade IV and 3 grade V hypoplastic thumbs in 6 patients, one with radial club hand, were reviewed retrospectively. They underwent pollicization between 1987 and 1997. The index metacarpi were osteotomized for shortening and readjusted by pronation. To evaluate postoperative function, authors used the criteria of Sundararaj and Mani. RESULTS: Except for the exclusion of one patient, four had excellent and one had good functional statuses. CONCLUSION: Pollicization was considered to be worthwhile for functional improvement of the hands in more than grade IV congenital hypoplasia of the thumb.

Contributing Factors for Favorable Outcome in Spite of Initially Poor Graded Aneurysmal Subarachnoid Hemorrhage Patients(Hunt-Hess grade IV, V)

Aneurysmal subarachnoid hemorrhage carries a high rate of morbidity and mortality despite recent advance in the care of such patients. This is especially true in patients in poorer neurological condition(Hunt-Hess grade IV, V) after initial hemorrhage. Many factors are known to contribute to this poor outcome, but other factors might be contribute to the favorable outcome. This study underwent to examine in a prospective fashion to evaluate the influence of different clinical, radiological, and intra-operative factors upon eventual outcome to aid in determining the rationale for an aggressive management on individual cases. Total of 494 cases of SAH were surgically treated from Jan. 1984 to Sep. 1996. Among them, 92 cases(18.6%) were classified as Hunt-Hess grade IV, V. Favorable outcome was noted in 59 cases(64.1%), and poor outcome in 33 cases(35.9%). Statistically significant contributing factors for favorable outcome aare systolicBP24hr), and short operation time(<6hr).

Treatment Policy for Patients with Hunt-Hess Grade IV and V SAH

To settle the controversy over the optimum management strategy for patients with poor-grade(Hunt-Hess grade IV and V) aneurysmal subarachnoid hemorrhage, the medical records of 50 patients admitted in poor Hunt-Hess grade have been examined retrospectively with literature review. Twelve patients underwent early surgery for aneurysmal neck clipping, and for the other patients, initial conservative management was done followed by delayed operation for 19 patients who showed stabilization or improvement of neurologic status. All patients were managed by active treatment(hypertensive, hypervolemic and hemodilutional therapy) after aneurysmal neck clipping. Initial findings such as better neurological condition(Hunt-Hess grade IV) and presence of intracerebral hemorrhage were indicators of good prognosis. Patients with intraventricular hemorrhage and uncontrollably increased intracranial pressure(>40 cm H20 after extraventricular drainage) resulted in severe morbidity or mortality. Regarding the timing of surgery, early intervention led to a better outcome with less morbidity(8% vs. 26%) compared with delaying operation, because of the lower incidence of rebleeding, reduced vasospasm and more effective management of delayed ischemia after surgery. The incidence of intraoperative premature rupture and mortality were not significantly influenced by the timing of surgery. It is concluded that, for poor-grade aneurysm patients without a definite evidence of irreversibility such as brainstem failure signs or uncontrollably increased intracranial pressure, early surgery followed by aggressive treatment to prevent cerebral vasospasm is the treatment of choice.