Descending necrotizing mediastinitis which may occur as a complication of neglected oropharynx infection is an uncommon disease, although it is lethal in most cases. Trismus and dyspnea are usual with palpable crepitation located in the cervico-thoracic area. Early diagnosis can be confirmed with accuracy by CT scan. Treatment is based on early mediastinal drainage by cervical approach, intravenous antibiotics and reanimation. The reported case had a favorable outcome.
An analysis of the results achieved with intracordal autologous fat injection for unilateral laryngeal nerve paralysis after surgery.
A study group of 46 patients with unilateral laryngeal nerve paralysis was treated by intracordal injection of autologous fat with a minimum follow-up of eight months. All patients had severe dysphonia and 39 had breathlessness. Twenty-nine patients had aspiration problems with difficulties in swallowing.
The only adverse side-effect was a subcutaneous abdominal hematoma in two patients and the development of an intracordal cyst in two patients. Aspiration disappeared immediately after the intracordal injection. Immediate improvement of speech, cough, and breathlessness was achieved in all patients. Over time, speech and voice, and swallowing remained stable in 67% and 80% of patients, respectively.
Such data suggest that the intracordal injection of autologous fat is a valuable method in patients with unilateral laryngeal nerve paralysis after surgery.
The aim of this retrospective study was to compare two concurrent series of patients operated on for inguinal hernia with the same laparoscopic procedure, the first one in a teaching hospital with a number of trained surgeons and the second one in a private center with only one trained surgeon.
Five hundred and forty-one patients with 757 hernias were operated on over a period of six years by a totally pre-peritoneal laparoscopic approach. Two hundred and sixteen patients were operated on in a teaching hospital by 48 surgeons (six senior and 42 trainee surgeons; group I), 325 were operated on in a private center by one surgeon who had been trained in the same teaching hospital (group II). The two groups of patients and their hernias were comparable. The comparison was established on the following criteria: duration of operation, rate of conversion, length of hospitalization, morbidity and mortality rate, recurrence rate and costs.
Operations performed by surgical trainees were associated with: (1) a mean operative time significantly (P = 0.01) longer for both unilateral (68 vs. 41 min) and bilateral (108 vs. 68 min) hernias. The operative time did not change in the teaching hospital and decreased with experience in private practice (from 62 to 25 min for unilateral hernias); (2) more frequent per-operative complications, particularly opening of the peritoneum (28% vs. 3%, P = 0.001); (3) a mean duration of hospitalization significantly (P = 0.05) longer, on average by 1.6 d; (4) a morbidity rate after 30 days significantly higher (16.2% vs. 4.9%, P = 0.01); and, (5) higher costs. There was no significant difference concerning mortality rate (nil), conversion rate (1.5%) and recurrence rate (1.3% vs. 0.6%, non significant).
Surgical training for laparoscopic treatment of inguinal hernias was associated with a longer operation time and hospital stay, and with higher morbidity and costs. After a good initial training in a teaching hospital, surgeons were capable of performing laparoscopic repair of inguinal hernias with good results.
The aim of this retrospective study was to report the modalities and results of the surgical treatment of renal artery lesions in children.
The series included 78 patients (43 girls, 35 boys), 16 months to 18 years of age, operated on from between 1975 to 1998. Lesions were bilateral in 24 cases. Due to bilateral procedures and to secondary or late re-operations, the number of surgical procedures was 106 (91 repairs and 15 nephrectomies). The repairs were performed by extracorporeal surgery in 22 cases and by in situ surgery in 69 cases. Whenever an arterial substitute was necessary, an arterial autograft was preferred
Fibrodysplasia of the renal artery was the prevailing pathologic finding (63%). Associated lesions were observed in 64% of the patients: coarctation of the abdominal aorta (n=20), stenoses, obstructions, or aneurysms of splanchnic arteries (n=15), and pheochromocytoma (n=2). There was no postoperative death in this series. Seven postoperative thromboses occurred (7.7%). In the long-term follow-up, three recurrent stenoses, two stenoses of the opposite artery, and one aneurysm of a venous autograft were repaired surgically. In two patients, a stenosis of the abdominal aorta worsened and required an aortic by-pass at 3 and 12 years. A complete cure of arterial hypertension was observed in 87% of the patients. In young children, growth of the repairs appeared normal when age increased.
Surgery still has a prominent role in the treatment of these lesions. The prognosis is favorable since atheroma, visceral or renal lesions are usually lacking.
To determine the feasibility, operative risk and patients'benefit of laparoscopy in emergency cholecystectomy for acute calculous cholecystitis.
From January 1991 to December 1998, 234 patients with acute calculous cholecystitis were operated on by emergency laparoscopic cholecystectomy. There were 131 women and 103 men (mean age: 57 years), (Asa 2: 48%, Asa 3: 10%). In seven patients, choledocolithiasis was detected by endoscopic ultrasonography and preoperatively treated by endoscopic sphincterotomy. The mean delay between in-hospital admission and cholecystectomy was 20 hours (2–160). Cholecystectomy was performed with primary approach of Calot's triangle. Intraoperative cholangiography, selectively performed (n = 70), detected choledocolithiasis in three patients.
The mean duration of surgery was 149 minutes (62–313). The conversion rate was 13 % and decreased through the years. The postoperative complication rate was 18%. Eight patients (3.4%) had an abdominal complication. One patient (0.4%) died of bile peritonitis after intraoperative undetected main bile duct injury. The mean postoperative hospital stay was 6.04 days. It was 3.5 days only, very old patients and those with severe associated disease being excluded.
Laparoscopy appears to be a good approach for emergency cholecystectomy in patients with acute calculous cholecystitis.
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