Plastic surgery after gastric bypass improves long-term quality of life.

BACKGROUND: Excess skin after massive weight loss impairs patient's health-related quality of life (HRQoL). Therefore, body-contouring surgeries can be proposed. However, few data exist concerning the effect of body contouring after bariatric surgery on HRQoL, including control group with a long-term follow-up. METHODS: In a prospective study, 98 consecutive patients who had body contouring after gastric bypass for obesity (BMI > 40) were included (group A). A matched control-group containing 102 patients who had only gastric bypass was selected (group B). HRQoL was measured by Moorehead-Ardelt questionnaire before (group A1) and after (A2) body contouring, and at different time points for group B until 8 years post-gastric bypass. To evaluate the effect of body contouring by two parallel methods, HRQoL was compared between groups A1 and A2, and between A2 and B. RESULTS: We found that body contouring procedures improved significantly patients' HRQoL, in comparison to those who had only gastric bypass. Of the patients who had body contouring (group A2), 57 % evaluated their HRQoL "much better" in comparison to only 22 % of patients before body contouring (group A1) or those who never had body contouring (group B) (p < 0.001). The improvement was significant in all sub-domains of HRQoL: self-esteem, social life, work ability, sexual activity and physical activity (p < 0.001), and remained stable over time. CONCLUSIONS: Our study confirms the important role of plastic surgery in treatment of patients after massive weight loss. We demonstrated that body contouring, despite important scars, significantly improves satisfaction and HRQoL of patients after gastric bypass. Therefore, the treatment of morbid obesity should not be deemed achieved unless plastic surgery has been considered.

Altemeier's procedure for rectal prolapse: analysis of long-term outcome in 60 patients.

AIM: Altemeier's procedure (perineal rectosigmoidectomy) is the operation of choice for rectal prolapse in the elderly. The aims of this prospective observational study were to evaluate its long-term actuarial recurrence risk and the influence of the length of rectosigmoid resection and associated levatorplasty on recurrence rate and continence. METHOD: The perioperative and long-term data for all patients undergoing Altemeier's procedure since 1992 were analysed with regard to mortality, morbidity, continence, anorectal function and recurrence rate. RESULTS: Sixty patients [median age 77 years (35-98)] underwent rectosigmoid resection [median length of bowel 14 (6-60) cm] with associated levatorplasty in 21 (35%). Overall mortality and morbidity were 1.6 and 11.6%, respectively. Manometry showed increased anal sphincter basal pressure and maximal squeeze pressure. We observed a decrease in postoperative rectal compliance (P=0.002). Age, gender, prolapse duration before surgery, levatorplasty and length of resection had no statistically significant relationship with recurrence. Continence improved in 62% and was stable over a median follow-up of 48 (1-186) months. Continence was positively related to a short length of bowel resection, but not to decreased rectal compliance. Actuarial recurrence was 14% at 4 years. CONCLUSION: The long-term recurrence rate after the Altemeier procedure was low and not linked to resection length or to levatorplasty. Improvement in continence was stable over time.

[Exotic snake bites in Switzerland]. / Morsures de serpents exotiques en Suisse.

Exotic snake bites are not rare in Switzerland. Treatment can be challenging for medical staff particularly as rapid and focused management are critical to improve patient outcome. The case of a young herpetologist bitten by an exotic venomous snake is used to review measures to be taken before arrival at the emergency department and to highlight key points of management. Resources for the obtention of expert advice and antivenoms are also reported.

Vascular invasion in pancreatic cancer: evaluation of endoscopic ultrasonography, computed tomography, ultrasonography, and angiography.

PRINCIPLES: Current methods for detecting vascular invasion in pancreatic cancer can be inaccurate, invasive, and expensive. The aim of this study is to assess the value of current imaging modalities in determining vascular invasion by pancreatic cancer. METHODS: The results of Endoscopic Ultrasonography (EUS), Computed Tomography (CT), Ultrasonography (US), and Angiography performed in 170 patients, suffering from pancreatic cancer, were retrospectively studied and correlated with intra-operative findings and surgical anatomopathological diagnosis after resection. We assessed sensitivity, specificity, positive and negative predictive values, and accuracy for detecting vascular invasion. RESULTS: EUS turned out to be the most reliable imaging technique for detecting vascular invasion in pancreatic cancer, with a sensitivity of 55%, specificity of 90%, positive predictive value of 61.1%, negative predictive value of 87.5%, and accuracy of 82.2%. CT results were 39.4%, 90%, 52%, 84.4%, and 79.1% for the respective categories, with however, better results with multislice CT. The US results were 3.7% for the sensitivity, 96.3% for the specificity, 25% for the positive predictive value, 75.2% for the negative predictive value, and 73.4% for the accuracy. For angiography, the sensitivity, the specificity, the positive predictive value, the negative predictive value, and the accuracy were 52.6%, 72.3%, 43.5%, 79.1%, and 66.7% respectively. CONCLUSION: In this study, EUS was the most valuable imaging modality in assessing vascular invasion (especially for venous invasion) for pancreatic cancer, with an accuracy of more than 80%. A further prospective study should be carried out to evaluate the combination of imaging modalities for the detection of vascular involvement, especially with multi-slice CT which almost reached the performances obtained by EUS.

Paraganglioma of the ampulla of Vater: a potentially malignant neoplasm.

Paragangliomas are rare tumours originating from neuroectodermic remnants and are usually considered as benign. We present two cases of paraganglioma of the ampulla of Vater that were treated surgically by pancreaticoduodenectomy. In one case, histopathology revealed malignant characteristics of the tumour with invasion of the pancreas and simultaneous duodenal lymph-node metastases. Both patients had a favourable outcome without disease recurrence at 40 and 44 months postoperatively. Only 21 cases of ampullary paraganglioma have been reported in the literature, 7 of them with malignant characteristics. In conclusion, paragangliomas of the ampulla of Vater have malignant potential. Surgical therapy of these tumours should not be limited to local resection, as disease recurrence and lymph node involvement have been reported. We propose that paragangliomas of the ampulla of Vater should be operated by cephalic pancreaticoduodenectomy, which allows long-term and disease-free survival.

Medical problems occurring during the long-term follow-up after liver transplantation.

Liver transplantation is a standardized therapy for end-stage liver disease. With current immunosuppressive protocols and patient care, ten-year patient survival rate has reached 60%. Several medical complications may develop during this period, including renal dysfunction, hypertension, diabetes mellitus, hyperlipidemia, and metabolic bone disease. The aim of this article is to analyze long-term results of several clinical trials reporting common medical dysfunctions after liver transplantation and to discuss their management.

Surgical treatment of sacrococcygeal pilonidal sinus disease by excision and skin flaps: the Toulouse experience.

OBJECTIVE: To compare various techniques for the treatment of pilonidal sinus. DESIGN: Retrospective study SETTING: University Hospital of Toulouse, France. SUBJECTS: 246 consecutive patients who presented between 1979 and 1996. The male:female ratio was 2:1, and the mean age 26 years (range 18-69). INTERVENTIONS: 218 one or two stage excision and rotation skin flaps, and 28 simple incisions. RESULTS: 16 sinuses recurred, and no flaps necrosed. CONCLUSION: Excision and rotation skin flaps offers an effective and elegant alternative to the more classic operations for pilonidal sinus as it causes less postoperative pain and shortens convalescence.

Optimization of the kinetics of cooling of kidneys: a pig model.

We determined the kinetics of cooling in multiple organ procurement for the kidney in a pig model. A biometric analysis by regression enables us to define the factors which influence the rate of temperature decrease: weight of the donor, average rate of perfusion and difference of temperature between the rectal temperature and the temperature of the perfusion solution at initiation of cooling. The description of the temperature as a function of time follows an exponential model of the type T(t) = T0. e(dt) where d is the rate of decrease. The rate of decrease varies according to the above factors. The cellular viability ratio (CVR), was correlated to the rate of cooling. The mean CVR was 91% (SD 4.95) when the rate of cooling was more than 1 degrees C/min. This was compared to 75% (SD 11.17) when the rate was less than 1 degrees C/min (p = 0.023). Our experience leads us to believe that the average cooling rate is frequently too low (<1 degrees C/min). This model can be used to predict and control the kinetics of cooling and may help to define the best way of cooling for future xenotransplantation.

Preoperative counts of CD4 T-lymphocytes and early postoperative infective complications in HIV-positive patients.

OBJECTIVE: To assess the relationship between postoperative infective complications and the CD4 count. DESIGN: Retrospective and biometric study. SETTING: Two university hospitals, Switzerland. SUBJECT: 40 HIV-positive patients who had had CD4 counts done during the three months before operation. INTERVENTIONS: Clean and contaminated gastrointestinal and orthopaedic procedures. MAIN OUTCOME MEASURE: Postoperative infective complications. RESULTS: 15 patients developed postoperative infective complications (38%), 6 of which (40%) were HIV-related. CD4 cell count, as well as the type of operation (contaminated or clean), influenced the infective complication rate. The risk of infective complications after a contaminated procedure when the CD4 count was below 200 mm3 was more than 50%. In clean operations, even when the CD4 cell count was close to 0, the rate of infective complications was never as high as 50%. Patients with a CD4 cell count of 500 or more have a similar rate of infective complications as HIV seronegative patients. CONCLUSION: Indications for operation in HIV-positive patients must take into account the CD4 cell count and the type of operation.

Blunt injury to the supra-aortic arteries.

BACKGROUND: Blunt trauma causing injury to the vessels of the aortic arch is uncommon but may be attended by serious consequences. Most surgeons will experience only an occasional case and will need to rely on published literature for guidance. METHODS: A Medline search over 1986-1995 was carried out using the following keywords: brachiocephalic trunk, common carotid artery and subclavian artery; injury was used as a subheading. RESULTS AND CONCLUSION: After the aortic isthmus, the innominate is the most commonly injured artery in the chest. Whatever the site of an arterial lesion, however, angiography is the diagnostic test of choice. Some vascular lesions are relatively benign and may be managed without operation; this form of management may also be appropriate if there is severe associated neurological injury. Otherwise, operation using an approach and technique suited to the site of the injury is advocated.

Day-case surgery in children under 2 years of age: experience in a district general hospital and survey of parental satisfaction.

One surgeon's experience of day-case paediatric surgery in a population aged less than 2 years at a district general hospital is reported. During a 6-year period from 1989 to 1994, 82 day-case operations were performed in 79 infants and young children. All children were managed by a multidisciplinary team including surgeon, paediatric anaesthetist and paediatric nurses. There was no mortality and minimal morbidity. A telephone survey of parents enquiring into satisfaction with all aspects of pre-, peri-, and post-operative care revealed that the procedures are well-accepted. The survey also showed that there was no increased utilization of primary health care professionals when day-case surgery is performed in this young age group. We conclude that paediatric day-case surgery is safe and well-tolerated by both infants and parents and is suitable for performance in non-specialist centres provided a team approach is adopted.

Lower limb trauma with injury to the popliteal vessels.

A retrospective analysis of blunt trauma to the lower extremity with injury to the popliteal vessels was undertaken in an attempt to determine the major predictors of outcome and to expose the shortcomings of our management. Thirty-one patients with lower extremity trauma including a popliteal artery injury were admitted to our clinic between 1979 and 1993. Two patients died of hemorrhagic shock or from associated lesions. Amputation of the leg was performed primarily in one patient because of massive tissue damage and secondarily in five patients because of uncontrolled local infection (two patients), excessive tissue damage (two patients), and persistent ischemia (one patient who later died). A peripheral neurologic deficit resulted in 12 of 24 non-amputated extremities. Three additional patients suffered sequelae from bone and joint damage. In all, nine patients recovered completely from their limb injury. Severe ischemia of the leg was found to be an indicator of major limb damage and was a strong determinant of poor outcome. Of 18 patients with severe ischemia, two died (one after amputation), five were amputated, and eight were left with a peripheral neuropathy. Only two patients recovered completely. Of 13 patients with relative ischemia, five recovered completely and four sustained a peripheral neuropathy. The deleterious effects of delayed revascularization were evident in four patients who developed a peripheral neuropathy secondarily. Morbidity from the ischemic insult could have been reduced in seven patients: the diagnosis was missed in two, its seriousness not realized in one, and a non-optimal management led to an excessive ischemic time in four. The magnitude of skeletal and soft tissue injury, alone or in combination, was also strongly associated with an increased morbidity. Most patients with blunt lower limb trauma and popliteal vascular injury are left with serious sequelae from associated neuro-musculo-skeletal damage and from ischemia. Although the magnitude of the first variable is determined by initial trauma and cannot be altered, a constant awareness of possible arterial injury in lower limb trauma, and adherence to a plan of management according to the ischemic state of the leg, should help avoid the additional deleterious effects of prolonged ischemia.

Effects of water restriction on nitrogen metabolism and urea recycling in the macropodid marsupials Macropus eugenii (tammar wallaby) and Thylogale thetis (red-necked pademelon).

The effects of water restriction on nitrogen metabolism were compared in the semi-arid adapted tammar wallaby (Macropus eugenii) and a wallaby from a moist forest environment, the red-necked pademelon (Thylogale thetis). On a medium (9 to 13%) protein diet water restriction depressed dry matter and nitrogen intakes in both species. Nitrogen balance remained positive, but fell further in the pademelons. Urea excretion decreased in the tammars, but increased in the pademelons. Urea recycling as a proportion of urea entry rate tended to increase in the tammars but not in the pademelons. These findings suggest that T. thetis is not as well adapted as M. eugenii to coping with water shortages. In a second experiment water restriction depressed nitrogen balance in tammars on both high (15%) and low (5%) protein diets, but only on the latter diet did nitrogen balance become negative. Urea recycling was greater on the low than on the high protein diet, but was unaffected by water restriction. Although better able to withstand water stress, M. eugenii was unable to cope with both water stress and a low protein diet together. The reported ability of M. eugenii to maintain water intake by drinking sea water during the dry season when fresh water is unavailable and vegetation is of low protein content is thus of great ecological significance.