Latissimus dorsi tendon transfer for massive, irreparable posterosuperior rotator cuff tears: surgical technique.

Massive rotator cuff tears remain a complex and challenging problem for both the patient and the surgeon. Although significant advancements in surgical techniques as well as technology for arthroscopic and mini-open rotator cuff repairs have been made, many massive tears result in failed repair with continued progressive tendon retraction and degeneration. In cases when primary tendon to bone healing is impractical, latissimus dorsi tendon transfer provides promising and reproducible clinical results. Herein, we present a latissimus tendon transfer surgical technique, a procedure we have used as a salvage operation for failed arthroscopic/mini-open primary rotator cuff repair.

Gastrogastric fistula following Roux-en-Y bypass is attributed to both surgical technique and experience.

BACKGROUND: The stomach can either be divided or undivided in performing Roux-en-Y gastric bypass (RGB) for morbid obesity. We evaluated whether surgical technique is the sole contributing factor to the formation of gastrogastric fistula (GGF). METHODS: A retrospective analysis of 1,036 consecutive patients was evaluated. RGB was performed as open undivided, open divided, and laparoscopic (divided). Incidence of GGF was identified for each technique and its relationship to surgical experience was assessed. RESULTS: Overall incidence of GGF was 1.3%. All fistulae occurred in patients who received undivided open RGB. There was a significant difference between the undivided open group and the divided open+laparoscopic groups (2.1% vs 0%, P<.01). Incidence of GGF decreased over time with increasing open undivided RGB volume. CONCLUSIONS: GGF was only identified in undivided RGB. The occurrence decreased with increasing surgical experience. Together, overall surgical technique in addition to gastric division must play a role in fistula formation.

Preoperative findings predict conversion from laparoscopic to open cholecystectomy.

BACKGROUND: Previous studies evaluating predictive factors for conversion from laparoscopic to open cholecystectomy have drawn conflicting conclusions. We evaluated objective preoperative variables to create an accurate, accessible risk score to predict conversion. METHODS: A retrospective review was performed of laparoscopic cholecystectomy patients at an urban tertiary care center. Seventy characteristics were subjected to bivariate and multivariate logistic regression analysis to identify parameters that independently predict conversion to open cholecystectomy. A model was created based on this analysis. RESULTS: Laparoscopic cholecystectomy was performed on 1377 patients for benign gallbladder disease over a 71-month period. There were 112 (8.1%) conversions to open cholecystectomy. The correlation between the preoperative clinical diagnosis and pathologic diagnosis for acute and chronic cholecystitis was 48.6% and 94.6%, respectively. Multivariate analysis identified male gender, elevated white blood cell count, low serum albumin, ultrasound finding of pericholecystic fluid, diabetes mellitus, and elevated total bilirubin as independent predictors of conversion. These 6 factors were also associated with the pathologic diagnosis of acute cholecystitis. A model to calculate the risk for conversion was created with an area under the receiver operator curve of 0.83. The risk for conversion also can be estimated based on the number of factors identified present and ranged from 2% when 1 factor was present to 89% with 6 factors. CONCLUSIONS: These results demonstrate that conversion to open cholecystectomy can be predicted based on parameters available preoperatively. Conversion is more likely in patients who have acute cholecystitis; however, the correlation between its clinical and pathologic diagnosis is poor. Improvements in the ability to determine the risk for conversion have important implications for surgical care.

Hemolytic anemia and severe rhabdomyolysis caused by compound heterozygous mutations of the gene for erythrocyte/muscle isozyme of aldolase, ALDOA(Arg303X/Cys338Tyr).

Aldolase (E.C. 4.1.2.13), a homotetrameric protein encoded by the ALDOA gene, converts fructose-1,6-bisphosphate to dihydroxyacetone phosphate and glyceraldehyde-3-phosphate. Three isozymes are encoded by distinct genes. The sole aldolase present in red blood cells and skeletal muscle is the A isozyme. We report here the case of a girl of Sicilian descent with aldolase A deficiency. Clinical manifestations included transfusion-dependent anemia until splenectomy at age 3 and increasing muscle weakness, with death at age 4 associated with rhabdomyolysis and hyperkalemia. Sequence analysis of the ALDOA coding regions revealed 2 novel heterozygous ALDOA mutations in conserved regions of the protein. The paternal allele encoded a nonsense mutation, Arg303X, in the enzyme-active site. The maternal allele encoded a missense mutation, Cys338Tyr, predicted to cause enzyme instability. This is the most severely affected patient reported to date and only the second with both rhabdomyolysis and hemolysis.