This study summarizes the diagnosis and management of 26 cases of recurrent tracheoesophageal fistulas over 27 years. The average gestational age and birth weight of patients who developed recurrent fistulas was lower than typical. Most recurrent fistulas were discovered due to respiratory or feeding symptoms and were diagnosed via contrast study, which revealed the fistula in over 90% of cases. Repairs involved sharply separating the trachea and esophagus and placing tissue like pericardium between the suture lines. Post-operative complications occurred in about 30% of patients, but long-term follow-up showed that over 80% took full nutrition by mouth.
Redo Pull-Through in Hirschsprung Disease ArticleAlexander Coe
This document discusses patients who experience recurrent obstructive symptoms after undergoing surgery (pull-through) to treat Hirschsprung's disease. Sixteen patients required reoperation due to residual aganglionosis or transition zone bowel found on histopathology. These patients presented months after their initial surgery with constipation, enterocolitis, or failure to thrive. Reoperation involved transanal resection and resolved the obstructive symptoms in all cases. The findings suggest that a full-thickness biopsy at the initial surgery may help identify residual disease and prevent the need for reoperation.
This review article summarizes the history and outcomes of treating Hirschsprung's disease. It describes how the cause was discovered in 1948 and the original Swenson procedure was developed. Over time, modifications like the Duhamel and Soave procedures were introduced. The article reviews diagnostic techniques, operative mortality rates, complications, and long-term outcomes for different surgical approaches. It finds that while modifications aimed to improve on the original Swenson procedure, they were associated with higher complication and reoperation rates compared to the original approach.
Crimson Publishers-A Newborn Presenting With Bilious Vomiting: A Case Report...CrimsonPublishersAICS
Jejunal atresia is a rare cause of small bowel obstruction in newborns, occurring in approximately 1-3 per 10,000 live births. It is caused by in utero vascular insult and presents with abdominal distention and bilious vomiting. Imaging shows dilation of the stomach and proximal small bowel loops ("triple bubble" sign). An upper gastrointestinal study can determine the level of obstruction and rule out malrotation/midgut volvulus, which is a surgical emergency. Surgical resection of the atretic bowel segment and primary anastomosis is the definitive treatment.
Standard approach for focal disease
(<25% bowel involved)
Bowel resection with
primary anastomosis
For:
Case series showing feasibility and
safety in selected patients31–34
Instrumental esophageal perforation a case seriesAbdulsalam Taha
1) The document describes three cases of instrumental esophageal perforation that were treated surgically.
2) The first case involved a 4-year-old girl who developed an empyema after multiple esophageal dilatation sessions for a corrosive stricture, and ultimately underwent gastric pull-up surgery.
3) The second case was a 54-year-old man who experienced an intraoperative perforation during rigid esophagoscopy that was immediately repaired via thoracotomy.
4) The third case was a 24-year-old man who perforated during balloon dilatation for achalasia and required an emergency esophagectomy.
This document reviews appendicitis in children. It discusses the demographics, natural history, diagnosis, medical and surgical management of both acute and perforated appendicitis. Key points include that appendicitis is most common in adolescents, is caused by luminal obstruction, and diagnosis involves clinical exam and imaging studies like ultrasound or CT scan. Treatment involves antibiotics for uncomplicated cases or appendectomy for acute or perforated cases, which can be performed laparoscopically or openly. Outcomes of laparoscopic appendectomy are generally better with less complications compared to open surgery.
In a study comparing the midline and flank surgical approaches to spaying cats, veterinary students at a teaching hospital performed 32 spay procedures via midline incision and 34 via flank incision under faculty supervision. The time taken for various stages of each procedure was recorded. There was no significant difference in total surgery time or students' assessment of difficulty between the two approaches. However, making the initial skin incision to entering the abdomen took longer with the flank approach, while finding the uterus took longer with the midline approach. Owners reported a higher incidence of wound discharge with the flank approach. The study concluded that both approaches can be taught effectively to students, with some stages taking less time depending on the approach.
Redo Pull-Through in Hirschsprung Disease ArticleAlexander Coe
This document discusses patients who experience recurrent obstructive symptoms after undergoing surgery (pull-through) to treat Hirschsprung's disease. Sixteen patients required reoperation due to residual aganglionosis or transition zone bowel found on histopathology. These patients presented months after their initial surgery with constipation, enterocolitis, or failure to thrive. Reoperation involved transanal resection and resolved the obstructive symptoms in all cases. The findings suggest that a full-thickness biopsy at the initial surgery may help identify residual disease and prevent the need for reoperation.
This review article summarizes the history and outcomes of treating Hirschsprung's disease. It describes how the cause was discovered in 1948 and the original Swenson procedure was developed. Over time, modifications like the Duhamel and Soave procedures were introduced. The article reviews diagnostic techniques, operative mortality rates, complications, and long-term outcomes for different surgical approaches. It finds that while modifications aimed to improve on the original Swenson procedure, they were associated with higher complication and reoperation rates compared to the original approach.
Crimson Publishers-A Newborn Presenting With Bilious Vomiting: A Case Report...CrimsonPublishersAICS
Jejunal atresia is a rare cause of small bowel obstruction in newborns, occurring in approximately 1-3 per 10,000 live births. It is caused by in utero vascular insult and presents with abdominal distention and bilious vomiting. Imaging shows dilation of the stomach and proximal small bowel loops ("triple bubble" sign). An upper gastrointestinal study can determine the level of obstruction and rule out malrotation/midgut volvulus, which is a surgical emergency. Surgical resection of the atretic bowel segment and primary anastomosis is the definitive treatment.
Standard approach for focal disease
(<25% bowel involved)
Bowel resection with
primary anastomosis
For:
Case series showing feasibility and
safety in selected patients31–34
Instrumental esophageal perforation a case seriesAbdulsalam Taha
1) The document describes three cases of instrumental esophageal perforation that were treated surgically.
2) The first case involved a 4-year-old girl who developed an empyema after multiple esophageal dilatation sessions for a corrosive stricture, and ultimately underwent gastric pull-up surgery.
3) The second case was a 54-year-old man who experienced an intraoperative perforation during rigid esophagoscopy that was immediately repaired via thoracotomy.
4) The third case was a 24-year-old man who perforated during balloon dilatation for achalasia and required an emergency esophagectomy.
This document reviews appendicitis in children. It discusses the demographics, natural history, diagnosis, medical and surgical management of both acute and perforated appendicitis. Key points include that appendicitis is most common in adolescents, is caused by luminal obstruction, and diagnosis involves clinical exam and imaging studies like ultrasound or CT scan. Treatment involves antibiotics for uncomplicated cases or appendectomy for acute or perforated cases, which can be performed laparoscopically or openly. Outcomes of laparoscopic appendectomy are generally better with less complications compared to open surgery.
In a study comparing the midline and flank surgical approaches to spaying cats, veterinary students at a teaching hospital performed 32 spay procedures via midline incision and 34 via flank incision under faculty supervision. The time taken for various stages of each procedure was recorded. There was no significant difference in total surgery time or students' assessment of difficulty between the two approaches. However, making the initial skin incision to entering the abdomen took longer with the flank approach, while finding the uterus took longer with the midline approach. Owners reported a higher incidence of wound discharge with the flank approach. The study concluded that both approaches can be taught effectively to students, with some stages taking less time depending on the approach.
1) The document reports on two cases where the StomaphyX device was used to repair gastric leaks that developed after bariatric revision surgeries.
2) In both cases, the StomaphyX procedure lasted approximately 30 minutes and was performed without complications, resulting in resolution of the gastric leaks.
3) The StomaphyX device allowed for repair of the leaks in a minimally invasive manner through the mouth, avoiding the risks of open or laparoscopic surgery in these high-risk patients.
This document summarizes a study on using an endoluminal device called the StomaphyX to reduce gastric pouches after Roux-en-Y gastric bypass surgery in patients experiencing weight regain. Thirty-nine patients underwent the procedure, with an average excess weight loss of 7.4% at 2 weeks, 10.6% at 1 month, and 19.5% at 1 year. Minor complications included sore throat and epigastric pain. The procedure may offer an alternative to open or laparoscopic revisional surgery for weight regain with no major complications observed.
Appendicitis is a common cause of abdominal pain in children. A careful history and physical can diagnose most cases. Ultrasound or CT scan may help if diagnosis is unclear. Treatment involves intravenous fluids, antibiotics, and an appendectomy, which is often performed laparoscopically. Post-operative care depends on whether the appendix was perforated.
Perforated Appendicitis Preoperatively complicated by Multiple Intra-Abdomina...Crimsonpublisherssmoaj
Perforated Appendicitis Preoperatively complicated by Multiple Intra-Abdominal Abscesses by Juan Velasquez Lopez, Tarik Zahouani* and Franscene Oulds in Crimson Publishers: Annals of Medicine and Surgery
Acute appendicitis is the most common surgical emergency in the pediatric population [1]. Complications are seen in 30 to 40% of cases, and include perforated, gangrenous, intra-abdominal abscess and peritonitis [1]. The rate of perforated appendicitis is higher in children compared to adults and varies from 30% to 74% [2]. We report a case of perforated appendicitis preoperatively complicated by multiple intra-abdominal abscesses
https://crimsonpublishers.com/smoaj/fulltext/SMOAJ.000528.php
For more Open access journals in Crimson Publishers
Please click on: https://crimsonpublishers.com/
For more Articles on Annals of Medicine and Surgery
Please click on link: https://crimsonpublishers.com/smoaj/index.php
improving the out come of diaphragmatic herniaMEDHAT EL-SAYED
This document discusses recurrent diaphragmatic hernias after initial repair in infants born with congenital diaphragmatic hernias. It notes that recurrence rates can be as high as 42% and the need for reoperation is often predictable. The most common indications for reoperation are recurrence of the hernia and feeding problems like gastroesophageal reflux. Recurrence usually presents within the first 2 years of life. Symptoms may include pulmonary or gastrointestinal issues. Diagnosis involves imaging studies like chest x-rays, UGI, or CT scan. Repair can be done via open or minimally invasive approaches depending on factors like hernia size and location. The goal is to ascertain the mode of initial repair failure and
This product discuss Hirschsprung’s disease in pediatrics included [pathology, presentation, diagnostic tools, surgical procedures complications and management. Also discuss the recent concepts of management of post operative complications.
The document discusses a prospective study that compares the incidence of incisional hernia in 134 patients undergoing gastric bypass surgery who received either primary fascial closure or closure with a prophylactic biological mesh. The results showed a significantly lower incidence of incisional hernia in patients who received the biological mesh (2.3% vs 17.7%), though these patients experienced a higher rate of seroma formation. After adjusting for risk factors, prophylactic mesh placement was found to be protective against hernia development while smoking increased hernia risk. The study provides evidence that prophylactic biological mesh may reduce incisional hernia rates in high-risk patients.
Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) were performed on 31 patients with peritoneal recurrence of ovarian cancer. Complete cytoreduction was achieved in 90% of patients. Morbidity rates were acceptable and comparable to literature. Organ-preserving cytoreductive surgery, when possible, reduced complications and hospital stay compared to those requiring colon resection. 25% of patients experienced tumor recurrence within a median follow-up period of 798 days, most commonly in the parietal abdominal wall. This multimodal approach shows promise for recurrent ovarian cancer but randomized trials are still needed.
Alimentacion nasogastrica vs nasoyeyunal en pancreatitis agudaFerstman Duran
A randomized study compared early nasogastric (NG) versus nasojejunal (NJ) feeding in 50 patients with severe acute pancreatitis. Patients were randomized to receive feeding via NG tube or NJ tube. There were no significant differences between the groups in markers of the acute inflammatory response, pain scores, or complications. Both NG and NJ feeding were well tolerated. The simpler NG feeding approach was found to be as effective as NJ feeding in patients with severe acute pancreatitis.
1. The authors present their 10-year experience with 43 jejunal free flaps for reconstruction following pharyngolaryngectomy.
2. They report a 100% acute flap survival rate and an overall benign fistula rate of 4.7%. No fistulas occurred in patients who received a prophylactic pectoralis major muscle flap after radiotherapy.
3. Using a gastrointestinal stapler for the proximal and distal anastomoses was associated with a lower fistula rate compared to hand-sewn anastomoses.
This case report describes a 4-day old male neonate admitted with severe birth asphyxia, anemia, and sepsis who developed massive pneumoperitoneum. Abdominal x-rays showed a large amount of free gas under the diaphragm compressing the abdominal viscera. Emergency laparotomy revealed a 9cm longitudinal tear in the descending colon and perforation in the sigmoid colon with fecal soilage. The affected colon segments were resected and anastomosis performed. Post-operatively, the patient recovered well and was discharged at 6 weeks old. The report discusses pneumoperitoneum causes in neonates, signs on imaging, and importance of immediate surgical intervention for perforated viscus with per
Chirurgia ricostruttiva pelvica fasciale: Il compartimento centraleGLUP2010
This document discusses surgical techniques for reconstructive pelvic surgery involving the central compartment. It compares surgery for primary pelvic organ prolapse (POP) grade 2 or higher to surgery for apical prolapse. Different techniques are described for vaginal vault repair involving the uterus versus repair after hysterectomy. Variations of sacrospinous hysteropexy and iliococcygeus fixation are outlined. Studies comparing outcomes of abdominal sacral colpopexy to vaginal repairs are summarized. The document advocates following principles of regenerative surgery using native tissues to repair defects and avoid excessive tension.
1) Recurrent anterior vaginal wall prolapse can be repaired using traditional native tissue repair involving re-suturing of fascial attachments or using mesh-augmented repairs.
2) Studies show anatomical success rates are higher with mesh but mesh repairs also carry higher risks of complications like erosion.
3) Ensuring apical support with procedures like sacrocolpopexy may reduce recurrence rates compared to anterior repair alone.
4) Tissue quality, surgical technique including suture type and tension, and risk factors like wide genital hiatus can also affect recurrence rates.
This document summarizes a study investigating whether cardiac mucosa can develop in the remnant cervical esophagus after esophagectomy. The study found that:
- Cardiac mucosa, which is normally found in the stomach, developed in the cervical esophagus of 10 out of 20 patients who underwent post-operative biopsies.
- The cardiac mucosa displayed immunohistochemical staining patterns similar to Barrett's esophagus, indicating it has Barrett's-like features. Further, one patient developed dysplasia and adenocarcinoma in the cardiac mucosa.
- The findings suggest cardiac mucosa is an acquired epithelium that can develop in response to reflux of acid into the remnant
Prolasso e chirurgia fasciale: steps ed evidenze - COMPARTIMENTO ANTERIOREGLUP2010
This document discusses the anatomy of pelvic floor support structures and techniques for fascial colporrhaphy surgery to repair anterior vaginal prolapse. It notes that traditional vaginal surgery often had high recurrence rates of 20-40%. The key anatomical structures of pelvic floor support are identified as the pubocervical and rectovaginal fascia. Successful colporrhaphy requires identifying and repairing individual fascial defects at specific sites. The objective of anterior colporrhaphy is to reattach the pubocervical fascia over the bladder to reduce protrusion. Modifications to the standard technique include more lateral dissection and fixation of the pubocervical fascia to other pelvic ligaments
A Case of Abdominal Pregnancy, Primary vs Secondary – Radiological Workupiosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Tuberculosis (TB) remains a public health problem, especially among young people. The diagnosis of TB in children is difficult to confirm as the bacterium is only cultured in a small percentage of cases. Chest radiography and presence of lymphadenopathy are important diagnostic features. This study assessed the value of ultrasound (US) for detecting mediastinal lymphadenopathy in 32 children with positive tuberculin skin tests. US identified lymphadenopathy in 90.5% of children with radiographic abnormalities suggestive of TB and in 66.7% of children with normal chest radiographs. US findings agreed with computed tomography findings in most cases, showing US is useful for detecting enlarged lymph nodes when chest radiographs are normal.
The IOSR Journal of Pharmacy (IOSRPHR) is an open access online & offline peer reviewed international journal, which publishes innovative research papers, reviews, mini-reviews, short communications and notes dealing with Pharmaceutical Sciences( Pharmaceutical Technology, Pharmaceutics, Biopharmaceutics, Pharmacokinetics, Pharmaceutical/Medicinal Chemistry, Computational Chemistry and Molecular Drug Design, Pharmacognosy & Phytochemistry, Pharmacology, Pharmaceutical Analysis, Pharmacy Practice, Clinical and Hospital Pharmacy, Cell Biology, Genomics and Proteomics, Pharmacogenomics, Bioinformatics and Biotechnology of Pharmaceutical Interest........more details on Aim & Scope).
All manuscripts are subject to rapid peer review. Those of high quality (not previously published and not under consideration for publication in another journal) will be published without delay.
This document discusses several studies on urological injuries and conditions:
1. A study of 25 female patients with urethral and bladder neck injuries from pelvic fractures, finding many required surgical repair and long-term urinary and sexual dysfunction for some.
2. A study of 8 girls with pelvic fracture urethral strictures, finding 1-stage repair and substitution urethroplasty had 100% success rates and advocating early cystostomy drainage and deferred reconstruction when needed.
3. An editorial comment on female urethral injuries from pelvic fractures, noting they require high suspicion to diagnose and advocating early repair of urethral and vaginal injuries to
Lipoma is one of the most common soft tissue tumor arising from the mesenchyme. It is slow growing, encapsulated, and usually benign in nature. Tumors over the back, shoulder, and neck region have a high propensity to assume large size thereby getting redefined as a giant lipoma when they exceed 10 cm in width or weigh more than 1000 grams. MRI is the investigation of choice for evaluating giant lipomas. Fine needle aspiration cytology (FNAC) or frozen section may be pertinent in suspected cases of liposarcoma. Complete surgical incision is the treatment of choice. A case of a giant lipoma on the back of a 64-year-old lady is presented with a view to revisit conceptual understanding of the clinical evaluation, investigation, and management of giant lipomas.
The document discusses biorhythms and how they fluctuate in cycles for intellectual, emotional, and physical rhythms over periods of 23, 28, and 33 days respectively. It notes that each cycle has high, critical, and low phases and provides more details on cycle durations and phase times. The summary also explains that the document contends biorhythms differ between men and women, with women's cycles described as "vertical waves" and men's as "horizontal elastic." It recommends ways to support each during low periods.
Prediction of Atrial Fibrillation AMA-IEEE 2011m_o
This document presents a study that uses neuro-fuzzy modeling to predict the onset of atrial fibrillation (AF) in postoperative patients using electrocardiogram (ECG) parameters. The researchers developed a neuro-fuzzy network using 15 ECG parameters from 45 subjects. Testing showed the model could distinguish between AF prone patients and controls in the last 9 hours prior to AF onset. The study concludes the neuro-fuzzy model indicates trends for AF and control patients and proposes refining the model and testing it on more data, as well as a clinical trial to predict AF onset.
1) The document reports on two cases where the StomaphyX device was used to repair gastric leaks that developed after bariatric revision surgeries.
2) In both cases, the StomaphyX procedure lasted approximately 30 minutes and was performed without complications, resulting in resolution of the gastric leaks.
3) The StomaphyX device allowed for repair of the leaks in a minimally invasive manner through the mouth, avoiding the risks of open or laparoscopic surgery in these high-risk patients.
This document summarizes a study on using an endoluminal device called the StomaphyX to reduce gastric pouches after Roux-en-Y gastric bypass surgery in patients experiencing weight regain. Thirty-nine patients underwent the procedure, with an average excess weight loss of 7.4% at 2 weeks, 10.6% at 1 month, and 19.5% at 1 year. Minor complications included sore throat and epigastric pain. The procedure may offer an alternative to open or laparoscopic revisional surgery for weight regain with no major complications observed.
Appendicitis is a common cause of abdominal pain in children. A careful history and physical can diagnose most cases. Ultrasound or CT scan may help if diagnosis is unclear. Treatment involves intravenous fluids, antibiotics, and an appendectomy, which is often performed laparoscopically. Post-operative care depends on whether the appendix was perforated.
Perforated Appendicitis Preoperatively complicated by Multiple Intra-Abdomina...Crimsonpublisherssmoaj
Perforated Appendicitis Preoperatively complicated by Multiple Intra-Abdominal Abscesses by Juan Velasquez Lopez, Tarik Zahouani* and Franscene Oulds in Crimson Publishers: Annals of Medicine and Surgery
Acute appendicitis is the most common surgical emergency in the pediatric population [1]. Complications are seen in 30 to 40% of cases, and include perforated, gangrenous, intra-abdominal abscess and peritonitis [1]. The rate of perforated appendicitis is higher in children compared to adults and varies from 30% to 74% [2]. We report a case of perforated appendicitis preoperatively complicated by multiple intra-abdominal abscesses
https://crimsonpublishers.com/smoaj/fulltext/SMOAJ.000528.php
For more Open access journals in Crimson Publishers
Please click on: https://crimsonpublishers.com/
For more Articles on Annals of Medicine and Surgery
Please click on link: https://crimsonpublishers.com/smoaj/index.php
improving the out come of diaphragmatic herniaMEDHAT EL-SAYED
This document discusses recurrent diaphragmatic hernias after initial repair in infants born with congenital diaphragmatic hernias. It notes that recurrence rates can be as high as 42% and the need for reoperation is often predictable. The most common indications for reoperation are recurrence of the hernia and feeding problems like gastroesophageal reflux. Recurrence usually presents within the first 2 years of life. Symptoms may include pulmonary or gastrointestinal issues. Diagnosis involves imaging studies like chest x-rays, UGI, or CT scan. Repair can be done via open or minimally invasive approaches depending on factors like hernia size and location. The goal is to ascertain the mode of initial repair failure and
This product discuss Hirschsprung’s disease in pediatrics included [pathology, presentation, diagnostic tools, surgical procedures complications and management. Also discuss the recent concepts of management of post operative complications.
The document discusses a prospective study that compares the incidence of incisional hernia in 134 patients undergoing gastric bypass surgery who received either primary fascial closure or closure with a prophylactic biological mesh. The results showed a significantly lower incidence of incisional hernia in patients who received the biological mesh (2.3% vs 17.7%), though these patients experienced a higher rate of seroma formation. After adjusting for risk factors, prophylactic mesh placement was found to be protective against hernia development while smoking increased hernia risk. The study provides evidence that prophylactic biological mesh may reduce incisional hernia rates in high-risk patients.
Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) were performed on 31 patients with peritoneal recurrence of ovarian cancer. Complete cytoreduction was achieved in 90% of patients. Morbidity rates were acceptable and comparable to literature. Organ-preserving cytoreductive surgery, when possible, reduced complications and hospital stay compared to those requiring colon resection. 25% of patients experienced tumor recurrence within a median follow-up period of 798 days, most commonly in the parietal abdominal wall. This multimodal approach shows promise for recurrent ovarian cancer but randomized trials are still needed.
Alimentacion nasogastrica vs nasoyeyunal en pancreatitis agudaFerstman Duran
A randomized study compared early nasogastric (NG) versus nasojejunal (NJ) feeding in 50 patients with severe acute pancreatitis. Patients were randomized to receive feeding via NG tube or NJ tube. There were no significant differences between the groups in markers of the acute inflammatory response, pain scores, or complications. Both NG and NJ feeding were well tolerated. The simpler NG feeding approach was found to be as effective as NJ feeding in patients with severe acute pancreatitis.
1. The authors present their 10-year experience with 43 jejunal free flaps for reconstruction following pharyngolaryngectomy.
2. They report a 100% acute flap survival rate and an overall benign fistula rate of 4.7%. No fistulas occurred in patients who received a prophylactic pectoralis major muscle flap after radiotherapy.
3. Using a gastrointestinal stapler for the proximal and distal anastomoses was associated with a lower fistula rate compared to hand-sewn anastomoses.
This case report describes a 4-day old male neonate admitted with severe birth asphyxia, anemia, and sepsis who developed massive pneumoperitoneum. Abdominal x-rays showed a large amount of free gas under the diaphragm compressing the abdominal viscera. Emergency laparotomy revealed a 9cm longitudinal tear in the descending colon and perforation in the sigmoid colon with fecal soilage. The affected colon segments were resected and anastomosis performed. Post-operatively, the patient recovered well and was discharged at 6 weeks old. The report discusses pneumoperitoneum causes in neonates, signs on imaging, and importance of immediate surgical intervention for perforated viscus with per
Chirurgia ricostruttiva pelvica fasciale: Il compartimento centraleGLUP2010
This document discusses surgical techniques for reconstructive pelvic surgery involving the central compartment. It compares surgery for primary pelvic organ prolapse (POP) grade 2 or higher to surgery for apical prolapse. Different techniques are described for vaginal vault repair involving the uterus versus repair after hysterectomy. Variations of sacrospinous hysteropexy and iliococcygeus fixation are outlined. Studies comparing outcomes of abdominal sacral colpopexy to vaginal repairs are summarized. The document advocates following principles of regenerative surgery using native tissues to repair defects and avoid excessive tension.
1) Recurrent anterior vaginal wall prolapse can be repaired using traditional native tissue repair involving re-suturing of fascial attachments or using mesh-augmented repairs.
2) Studies show anatomical success rates are higher with mesh but mesh repairs also carry higher risks of complications like erosion.
3) Ensuring apical support with procedures like sacrocolpopexy may reduce recurrence rates compared to anterior repair alone.
4) Tissue quality, surgical technique including suture type and tension, and risk factors like wide genital hiatus can also affect recurrence rates.
This document summarizes a study investigating whether cardiac mucosa can develop in the remnant cervical esophagus after esophagectomy. The study found that:
- Cardiac mucosa, which is normally found in the stomach, developed in the cervical esophagus of 10 out of 20 patients who underwent post-operative biopsies.
- The cardiac mucosa displayed immunohistochemical staining patterns similar to Barrett's esophagus, indicating it has Barrett's-like features. Further, one patient developed dysplasia and adenocarcinoma in the cardiac mucosa.
- The findings suggest cardiac mucosa is an acquired epithelium that can develop in response to reflux of acid into the remnant
Prolasso e chirurgia fasciale: steps ed evidenze - COMPARTIMENTO ANTERIOREGLUP2010
This document discusses the anatomy of pelvic floor support structures and techniques for fascial colporrhaphy surgery to repair anterior vaginal prolapse. It notes that traditional vaginal surgery often had high recurrence rates of 20-40%. The key anatomical structures of pelvic floor support are identified as the pubocervical and rectovaginal fascia. Successful colporrhaphy requires identifying and repairing individual fascial defects at specific sites. The objective of anterior colporrhaphy is to reattach the pubocervical fascia over the bladder to reduce protrusion. Modifications to the standard technique include more lateral dissection and fixation of the pubocervical fascia to other pelvic ligaments
A Case of Abdominal Pregnancy, Primary vs Secondary – Radiological Workupiosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Tuberculosis (TB) remains a public health problem, especially among young people. The diagnosis of TB in children is difficult to confirm as the bacterium is only cultured in a small percentage of cases. Chest radiography and presence of lymphadenopathy are important diagnostic features. This study assessed the value of ultrasound (US) for detecting mediastinal lymphadenopathy in 32 children with positive tuberculin skin tests. US identified lymphadenopathy in 90.5% of children with radiographic abnormalities suggestive of TB and in 66.7% of children with normal chest radiographs. US findings agreed with computed tomography findings in most cases, showing US is useful for detecting enlarged lymph nodes when chest radiographs are normal.
The IOSR Journal of Pharmacy (IOSRPHR) is an open access online & offline peer reviewed international journal, which publishes innovative research papers, reviews, mini-reviews, short communications and notes dealing with Pharmaceutical Sciences( Pharmaceutical Technology, Pharmaceutics, Biopharmaceutics, Pharmacokinetics, Pharmaceutical/Medicinal Chemistry, Computational Chemistry and Molecular Drug Design, Pharmacognosy & Phytochemistry, Pharmacology, Pharmaceutical Analysis, Pharmacy Practice, Clinical and Hospital Pharmacy, Cell Biology, Genomics and Proteomics, Pharmacogenomics, Bioinformatics and Biotechnology of Pharmaceutical Interest........more details on Aim & Scope).
All manuscripts are subject to rapid peer review. Those of high quality (not previously published and not under consideration for publication in another journal) will be published without delay.
This document discusses several studies on urological injuries and conditions:
1. A study of 25 female patients with urethral and bladder neck injuries from pelvic fractures, finding many required surgical repair and long-term urinary and sexual dysfunction for some.
2. A study of 8 girls with pelvic fracture urethral strictures, finding 1-stage repair and substitution urethroplasty had 100% success rates and advocating early cystostomy drainage and deferred reconstruction when needed.
3. An editorial comment on female urethral injuries from pelvic fractures, noting they require high suspicion to diagnose and advocating early repair of urethral and vaginal injuries to
Lipoma is one of the most common soft tissue tumor arising from the mesenchyme. It is slow growing, encapsulated, and usually benign in nature. Tumors over the back, shoulder, and neck region have a high propensity to assume large size thereby getting redefined as a giant lipoma when they exceed 10 cm in width or weigh more than 1000 grams. MRI is the investigation of choice for evaluating giant lipomas. Fine needle aspiration cytology (FNAC) or frozen section may be pertinent in suspected cases of liposarcoma. Complete surgical incision is the treatment of choice. A case of a giant lipoma on the back of a 64-year-old lady is presented with a view to revisit conceptual understanding of the clinical evaluation, investigation, and management of giant lipomas.
The document discusses biorhythms and how they fluctuate in cycles for intellectual, emotional, and physical rhythms over periods of 23, 28, and 33 days respectively. It notes that each cycle has high, critical, and low phases and provides more details on cycle durations and phase times. The summary also explains that the document contends biorhythms differ between men and women, with women's cycles described as "vertical waves" and men's as "horizontal elastic." It recommends ways to support each during low periods.
Prediction of Atrial Fibrillation AMA-IEEE 2011m_o
This document presents a study that uses neuro-fuzzy modeling to predict the onset of atrial fibrillation (AF) in postoperative patients using electrocardiogram (ECG) parameters. The researchers developed a neuro-fuzzy network using 15 ECG parameters from 45 subjects. Testing showed the model could distinguish between AF prone patients and controls in the last 9 hours prior to AF onset. The study concludes the neuro-fuzzy model indicates trends for AF and control patients and proposes refining the model and testing it on more data, as well as a clinical trial to predict AF onset.
The document provides information about jQuery:
1) jQuery is an open-source JavaScript library developed by John Resig in 2006 that simplifies HTML document traversal and manipulation, events, animations and Ajax interactions for rapid web development.
2) It is used by many large companies and websites and has two versions: compressed and uncompressed, under both MIT and GPL licenses.
3) The document outlines jQuery's main features including being lightweight, having a large plugin library, easy to learn and use, CSS3 support, documentation and examples. It then provides examples of how to implement jQuery.
El documento presenta una descripción general de las Normas APA, que son un conjunto de directrices propuestas por la Asociación Americana de Psicología para asegurar una presentación clara y consistente del material escrito. También describe el software libre como programas de computadora que se pueden descargar gratuitamente de Internet y compartir libremente, y explica los diferentes tipos de derechos de autor y licencias que rigen el uso y distribución de obras creativas.
El documento presenta varios problemas relacionados con funciones matemáticas. En la primera sección, se pide identificar valores de entrada y salida de una función dada. Luego, se calculan valores de funciones lineales y cuadráticas. Finalmente, se plantean problemas sobre funciones de demanda y oferta lineales, solicitando hallar las funciones y calcular precios para cantidades dadas.
Prediction of Atrial Fibrillation AMA-IEEE 2011m_o
This document presents a study that uses neuro-fuzzy modeling to predict the onset of atrial fibrillation (AF) in postoperative patients using electrocardiogram (ECG) parameters. The researchers developed a neuro-fuzzy network using 15 ECG parameters from 45 subjects. The network consisted of 7 rules and was able to distinguish AF prone patients from controls with good performance. Testing over the last 9 hours before AF onset showed potential for predicting AF onset by monitoring trends in the developed AF prediction index value. The researchers propose refining the model and conducting further testing and a clinical trial to evaluate prediction of AF onset.
Digital storytelling and place-attachment: a 'lens' through which to analyse ...Antonia Liguori
Digital storytelling is a form of engagement that enables people to share personal stories and to produce new knowledge(s). Digital stories reveal unexpected connections across different communities of interest, places and time periods. They reflect shared and conflicting values, feelings and concerns surrounding a particular place. Place is the background to stories and memories and also the context through which stories emerge (Pile 2002). Therefore we propose ‘sense of place’ (Shamai & Ilatov, 2005 Jones et al 2003) is an important factor in the way that people respond to extreme weather and disruptive events in their communities and ‘local distinctiveness’ might be a reason for different responses and ways of coping/adapting. We ask how might digital storytelling triangulate between personal experience, place attachment and crisis (drought) response.
The RCUK funded Drought Risk and You (DRY) Project is adopting digital storytelling as one of the multiple narrative approaches to investigate people’s perceptions and behaviours in relation to their river, water use and water scarcity within and across seven rivers catchments in UK. We are exploring this across a complex patchwork of different communities including business and tourism sectors, agriculture, environmental management and health, to reveal nuances of “sense of place”. Specifically we will explore people’s values in relation to how they frame their stories and what is important to them (Schwartz, S.H. 2006 and Public Interest Research Centre (PIRC) 2011).
Comparing digital stories is a way of uncovering conflicts and discovering unexpected common ground in the dialogue between lay and expert narratives due to the authenticity of personal stories and the natural “mess” of storytelling (Wilson, 2014). Through this project we contribute to the field of digital humanities by building an open, online digital storytelling archive, creating a legacy of rich data informing future work on water, water scarcity, personal and social relationships in river catchments in the anthropocene.
The document discusses several studies on the use of laparoscopic (TEP) and open preperitoneal (OPM) approaches for repairing recurrent inguinal hernias. The studies found that both approaches had low recurrence rates of around 2%, with the TEP approach having shorter operating times and hospital stays compared to OPM. Overall, the studies concluded that the preperitoneal approaches, whether open or laparoscopic, are good options for repairing recurrent inguinal hernias when performed by experienced surgeons.
This study compares two surgical procedures for esophageal replacement in children with esophageal atresia - coloplasty (using the colon) and gastroplasty (using the stomach). The study found that gastroplasty, especially when performed through the posterior mediastinum, has more advantages over coloplasty. Gastroplasty requires only one anastomosis, is less complex, and results in fewer early complications. Children who underwent gastroplasty also showed better long-term adaptation and quality of life compared to those who received coloplasty. The study concludes that gastroplasty through the posterior mediastinum is the preferred technique for esophageal replacement in children.
1) The study reviewed 5 cases of fetal abdominal cysts detected by ultrasound in the first trimester between 10-13 weeks of gestation.
2) In 3 cases, the cyst resolved spontaneously by the detailed second trimester scan, though 1 infant later required surgery for intestinal malrotation.
3) In the remaining 2 cases, 1 cyst was aspirated at 19 weeks for enlargement and the other remained stable but the infant later required surgery for a choledochal cyst.
Drs. Penzler, Ricker, and Ahmad’s CMC Abdominal Imaging Mastery Project: Dece...Sean M. Fox
Dr. Morgan Penzler is an Emergency Medicine Resident and Drs. Raza Ahmad and Ansley Ricker are Surgery Residents at Carolinas Medical Center in Charlotte, NC. They are interested in medical education. With the guidance of Drs. Kyle Cunningham and Michael Gibbs, they aim to help augment our understanding of emergent abdominal imaging. Follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides. This month’s cases include:
- Gastric Perforation
- Pneumoperitoneum
- Lower GI Bleed
- Parastomal Hernia
Pyloric stenosis usually presents with well defined symptoms and signs. However, these may be absent in neonates in intensive care for other conditions. This paper reports 2 cases of congenital diaphragmatic hernia that developed pyloric stenosis during the critical care period and illustrates the atypical presentation of pyloric stenosis and the diagnostic difficulties encountered in this setting
This study evaluated the efficacy of laparoscopically assisted high ligation of patent processus vaginalis in 40 children aged 6 months to 7 years. The laparoscopic procedure detected unsuspected contralateral hernias in 28.1% of cases, without increasing operative time. All procedures were completed without complications. The mean operative time was 25 minutes for unilateral hernias and 35 minutes for bilateral cases. The mean post-operative hospital stay was 4 hours. One recurrence occurred among 57 hernias repaired over an average 18-month follow-up. Laparoscopic repair was found to be a safe and effective procedure for detecting and repairing hernias in children.
This case report describes a rare case of triple intestinal atresia involving the jejunum, ileum, and colon in a newborn female with Down syndrome and imperforate anus. The baby underwent emergency laparotomy which revealed atresias in the jejunum, ileum, and colon. Histopathology of the resected intestinal segments showed no specific cellular abnormalities. Unfortunately, the baby did not survive due to post-operative cardiopulmonary complications. Triple intestinal atresia is an extremely uncommon condition. The presence of Down syndrome and imperforate anus with triple atresia makes this an especially rare case.
This document discusses the principles of surgical treatment for Zenker diverticulum. It begins with an introduction that discusses the etiology and pathogenesis of Zenker diverticulum. It then describes a study of 11 patients who underwent surgical treatment for Zenker diverticulum between 2001-2011. The surgical approach involved resection of the diverticular pouch and esophageal myotomy. Complications included postoperative hematoma in two patients and esophageal leak in two patients. Early postoperative results showed relief of dysphagia symptoms. Long term follow up was limited due to the short monitoring period for many patients.
Laparoscopic Natural Orifice Specimen Extraction (NOSE) Total Colectomy with ...semualkaira
The benefit of laparoscopic surgery in terms of
reduced pain and fewer cosmetic problems is not always obvious,
and surgeons continue to seek the best ways to limit incision trauma and improve outcomes in laparoscopic colorectal surgery
1) The authors reviewed outcomes of 104 consecutive minimally invasive esophagectomies (MIEs) performed between 1998-2007.
2) Surgical approaches included thoracoscopic/laparoscopic esophagectomy with cervical anastomosis (n=47), minimally invasive Ivor Lewis esophagectomy (n=51), and others.
3) Complications included anastomotic leak in 9.6% of patients and stricture in 26%. Mortality was 1.9% at 30 days and 2.9% in-hospital. Mean lymph nodes retrieved was 13.8.
This case report describes a rare combination of anomalies in a female newborn with Down syndrome that included jejunal atresia, colonic atresia, and imperforate anus. The newborn underwent surgery including jejunal, duodenal, and colon resection and anastomosis with appendectomy and colostomy. However, the newborn did not survive due to postoperative cardio-respiratory arrest from pulmonary hemorrhage. This combination of multiple intestinal atresias with imperforate anus in a female newborn with Down syndrome represents an extremely rare presentation.
1) A 6-month-old female infant presented with recurrent episodes of bloody vomiting and was initially diagnosed with gastritis. She later developed respiratory symptoms. 2) Imaging studies including chest X-ray and CT scan revealed a mass in the right thoracic cavity, and barium study confirmed gastric herniation through the diaphragm (hiatal hernia). 3) Surgical correction of the hiatal hernia and gastric volvulus resolved the patient's symptoms. The case illustrates how hiatal hernia can be overlooked in patients with gastrointestinal or respiratory complaints.
Adult Intussusception A Retrospective ReviewDeja Lewis
This document summarizes a retrospective review of 22 cases of adult intussusception encountered at two hospitals between 1989 and 2000. The average age was 57 years and abdominal pain was the most common symptom. 86% of cases had an identifiable lesion. Small bowel lesions were more often benign (64%) while large bowel lesions were frequently malignant (50%). Surgical intervention was required in all cases except one, with reduction attempted for small bowel intussusceptions when possible but resection typically used for large bowel intussusceptions due to higher risk of malignancy. The review supports reduction of small bowel intussusceptions before resection if benign but resection of large bowel intussusceptions due to higher cancer rates.
This document summarizes a study on esophageal perforation in children conducted in Kurdistan, Iraq between 2006-2013. The study found 10 cases of esophageal perforation in children, most commonly caused by complications from esophageal dilation procedures (7 cases). Symptoms included respiratory distress and subcutaneous emphysema. Conservative management including nothing by mouth, antibiotics, and chest tube drainage was successful in 7 patients, while 2 patients required surgery. The study concludes that iatrogenic causes are the most common, and conservative management can have favorable outcomes in children with esophageal perforation.
Drs. Potter and Richardson's CMC Pediatric X-Ray Mastery January CasesSean M. Fox
This document provides an overview of pediatric chest x-ray cases from the month. It discusses several cases including a child who swallowed magnets, a case of complex left lower lobe pneumonia evaluated with chest x-ray, CT, and ultrasound, a case of right middle lobe pneumonia in a child found to have a low hemoglobin, and finally a series of cases demonstrating the chest wall deformity pectus excavatum.
This case report describes a successful case of managing placenta percreta with invasion into the bladder. A 33-year-old woman at 35 weeks of gestation was found to have placenta previa and suspected placenta percreta. During a cesarean section and hysterectomy, it was discovered that newly formed vessels from the placenta had invaded the bladder wall. Prophylactic balloon occlusion of the lower abdominal aorta was performed to control hemorrhaging. The placenta, uterus, and part of the invaded bladder wall were removed. The massive intraoperative hemorrhage was successfully controlled and the patient recovered well. The management of newly formed vessels is crucial for effective treatment of placent
A clinical study of intussusception in childreniosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
This study analyzed 52 pediatric patients who underwent intestinal resection over a 10-year period at a hospital in Nigeria. The most common indication for resection was gangrenous or irreducible intussusception (28 cases, 53.8%). Other common reasons included strangulated hernia (7 cases) and typhoid intestinal perforation (6 cases). Most patients were infants under 1 year old. Complications occurred in 38.4% of patients, most commonly surgical site infection. The mortality rate was 15.4%. The study concluded that late presentation and lack of awareness contributed significantly to the high number of intestinal resections required in this patient population.
Drs. Olson’s and Jackson’s CMC Pediatric X-Ray Mastery: September CasesSean M. Fox
Drs. Olson and Jackson are interested in education and Pediatric Emergency Medicine. Follow along with the EMGuideWire.com team and Drs. Nikki Richardson, Mary Grady, and Michael Gibbs as they post these educational, self-guided radiology slides on Pediatric Emergency Medicine Radiology. This month’s topics include:
• Non-accidental Trauma (NAT)
• Hyperinflated Lungs
• Esophageal Foreign Body
• Neonatal Pulmonary Abscess
• Neonatal Pneumatocele
• Tuberculosis
• Interstitial Lung Disease of Prematurity
• Disseminated Neonatal HSV
• Aspirated Foreign Body
This document summarizes the case of a newborn baby born via elective C-section with anorectal malformations. Key details include:
- Baby was born at term with normal APGAR scores and weight of 2.83kg.
- During birth it was noted the baby had no patent anal opening and a single umbilical artery, so the baby was referred for further management.
- Investigations found the baby had an anorectal malformation, ASD, and L5 hemivertebrae, consistent with VACTERL association.
- A colostomy was performed on the baby. No growth was found on cultures and antibiotics were stopped. The baby was being managed for the
Similar to 2010 the diagnosis and management of recurrent (20)
ABDOMINAL TRAUMA in pediatrics part one.drhasanrajab
Abdominal trauma in pediatrics refers to injuries or damage to the abdominal organs in children. It can occur due to various causes such as falls, motor vehicle accidents, sports-related injuries, and physical abuse. Children are more vulnerable to abdominal trauma due to their unique anatomical and physiological characteristics. Signs and symptoms include abdominal pain, tenderness, distension, vomiting, and signs of shock. Diagnosis involves physical examination, imaging studies, and laboratory tests. Management depends on the severity and may involve conservative treatment or surgical intervention. Prevention is crucial in reducing the incidence of abdominal trauma in children.
Does Over-Masturbation Contribute to Chronic Prostatitis.pptxwalterHu5
In some case, your chronic prostatitis may be related to over-masturbation. Generally, natural medicine Diuretic and Anti-inflammatory Pill can help mee get a cure.
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by...Donc Test
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Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
2. Children's Hospital/University of Michigan Medical Center
found 13 children who were treated for a recurrent TEF. Four
of these were initially repaired at outside institutions. The
other 13 children included in the study were operated on in 4
hospitals throughout the United States and across the world.
The senior author (ACG) was involved in all the cases.
Gestational age and birth weight were recorded. Details of
the original repair as well as complications were identified.
The symptoms leading to diagnosis and the method of
diagnosis were documented. Data are reported as mean
(range). Descriptive statistical analysis was performed using
the SPSS program (SPSS, Inc, Chicago, IL). Missing data
were excluded from the statistical analysis.
2. Results
Twenty-six children with a recurrent TEF had a mean
gestational age of 35.3 (24-40) weeks and a mean birth weight
of 2100 (795-3500) g. Of those developing a recurrence; 21
initially had an EA and distal TEF, 1 had an EA with both a
proximal and distal TEF, and 4 had an H-type TEF. Their first
operation was a primary repair (n = 21), gastrostomy tube
placement and delayed repair (n = 3), and ligation of the
fistula followed by delayed repair (n = 2). A leak was noted in
18 (68%) of 26 infants on their postoperative esophagram
after original repair.
Most children who develop a recurrent fistula have
respiratory and/or feeding problems leading to the diagnosis.
These symptoms are often difficult to distinguish from those
of tracheomalacia and gastroesophageal reflux (GER) that
occur frequently in infants born with EA. Our group
included 11 with tracheomalacia, 1 requiring an aortopexy,
and 19 with GER, of which 14 required a fundoplication.
Symptoms leading to the diagnosis of recurrence were
respiratory symptoms only (n = 7), a combination of
respiratory symptoms and feeding issues (n = 15), and
feeding issues only (n = 1). Three recurrences were
asymptomatic and discovered on routine contrast studies.
These symptoms usually occurred relatively soon after the
original repair. There were 2 patients who were diagnosed a
long time after their original diagnosis, one 5 years after the
original repair and one 18 years after her first repair.
Excluding these 2 outliers, the mean time to recurrence was
2.1 months. Diagnosis was made in 24 children with a
contrast study and then confirmed with bronchoscopy. When
bronchoscopy was used, a fistula was seen directly in one
half of the recurrences, whereas in the others, a dye study
was required to confirm the presence of the TEF. In both
recurrent fistulas diagnosed only with bronchoscopy, a dye
study was required.
Three children in this series underwent at least 2 unsuc-
cessful attempts at endoscopic closure before definitive repair.
At the time of exploration, the recurrent fistulas were
located almost exclusively at the site of the original TEF. On
2 occasions, the fistula was found at the site of an injury to
the trachea that occurred during the original operation. The
repairs entailed locating the fistula, separating the trachea
from the esophagus sharply, and then placing some type of
tissue between the suture lines to prevent future recurrences.
Multiple types of tissue were used for this purpose
including pleura (n = 11), pericardium (n = 8), a muscle flap
(n = 3), and lymph nodes (n = 2). One recurrent fistula was
repaired with no tissue between the suture lines, and one
eventually resulted in a gastric pull-up. Postoperatively, the
majority of the children did well; however, there were some
complications. Contrast studies performed postoperatively in
25 children revealed 7 leaks, 5 being minor and resolving by
the next contrast study. Strictures developed in 4, and 3
repairs resulted in a second recurrent fistula.
In the first of these re-recurrences, the original repair had
been attempted in a 920-g, 24-week-premature infant that
resulted in a tracheal injury—the site of recurrence. At the
subsequent operation, no tissue was placed between the
suture lines; and a second recurrence resulted. This was
repaired through the neck, and a portion of the sternoclei-
domastoid muscle was secured between the suture lines. The
second patient had a pleural flap interposed at the time of first
repair and a pericardial flap used for the second successful
repair. The third patient was a 1.43-kg, 32-week-premature
infant who underwent repair at day 2 and then had a “revision
of the TEF with tracheal repair,” both at an outside hospital.
This infant had an esophageal stricture and a fistula
extending from the stricture to the carina. At the repair of
the first recurrence, a catheter was not placed across the
fistula; and there was difficulty identifying the esophageal
side of the fistula. Routine postoperative esophogram
showed a recurrence, and he went on to have a cervical
esophagostomy and eventually a gastric pull-up.
Long-term outcome was reviewed with a median follow-
up of 84 (6-287) months looking at method of feeds and
growth. Almost all children were eating exclusively by
mouth, 3 took all nutrition by tube, and 2 required a
combination of oral and tube feeding. Growth chart data
were available in 23 of the children and showed the
following distribution: 0 to 25th percentile (n = 16), 26th
to 50th percentile (n = 4), and 51st to 75th percentile (n = 3).
3. Discussion
Recurrent TEF continues to occur at a rate of up to 10%,
making this a complication that most pediatric surgeons will
have to deal with at some time [1-3]. In our series, the infants
who developed a recurrent fistula tended to be born more
prematurely and at a lower birth weight than expected, had a
tracheal suture line, and tended to have a leak on contrast
study after their initial repair. Purisch et al [4] in a review of
congenital malformations in preterm infants found a mean
gestational age of 37.6 weeks and a mean birth weight of
338 S.W. Bruch et al.
3. 2742 g in 93 infants born with a tracheoesophageal anomaly.
Our study group was born at a mean of 35.4 weeks, with a
mean birth weight of 2100 g. This birth weight falls between
the fifth and 10th percentile of the expected birth weight of
infants born at 35.4 weeks' gestation [5]. All of the
recurrences had a tracheal suture line after their initial repair.
The recurrences entered the trachea at the original fistula site
or at the site of a tracheal injury repaired at the initial
procedure. No fistulae occurred in infants after a pure EA
repair. An anastomotic leak was noted in 68% of the initial
repairs that eventually developed a recurrence. This leak rate
is more than triple the expected 15% to 20% leak rate after
TEF repair as quoted in a review by Spitz in 2007 [1].
Most infants who develop a recurrent TEF usually have
symptoms. These symptoms are often difficult to distinguish
from symptoms of tracheomalacia or GER commonly found
in infants with repaired EA. These symptoms were evaluated
with a contrast study looking for reflux and ended up
showing the recurrence (Fig. 1). Most of our recurrences
were detected in this way. This probably has more to do with
the frequency with which the study is ordered and not
necessarily with its sensitivity. Recurrent fistulas can be
missed quite easily on routine contrast studies, especially if a
prone pull-back method is not used. The best way to
demonstrate a fistula is to place a tube down the esophagus to
the gastroesophageal junction, place the infant prone, and
inject contrast into the esophagus as the tube is pulled back
into the proximal esophagus [6]. Bronchoscopy is then used
to help make or confirm the diagnosis of a recurrence. At the
time of bronchoscopy, the pit from the original fistula that
was repaired is easily seen usually near the carina or in the
upper trachea in the case of an H-type fistula. A small
Fogarty catheter may be passed into the pit and then retrieved
in the esophagus with esophagoscopy. This is ideally placed
just before definitive repair, as the catheter can be left in
place to assist in finding the exact location of the fistula
intraoperatively (Fig. 2). However, as most have a small
diameter fistula, it may be difficult to place a tube through it
to make the diagnosis. In those cases, a methylene blue test
can be used to make the diagnosis of a recurrence. The
bronchoscope is placed in the trachea, and the pit is
identified. The bronchoscope is then removed, and an
Fig. 1 Esophagram showing a recurrent TEF with contrast
running off into the distal bronchus.
Fig. 2 Depiction of a Fogarty catheter placed through the TEF
via bronchoscopy. Having this catheter in place makes locating the
fistula at the time of repair much easier.
Fig. 3 Schematic depicting the pericardial flap that is raised after
dissecting away the phrenic nerve with its accompanying blood
supply. The pericardial flap is rolled into the grove between the
trachea and the esophagus and sutured in place to provide 2 layers
of viable pericardium between the 2 suture lines.
339Management of recurrent tracheoesophageal fistulas
4. endotracheal tube one-half size smaller than would fit snug is
introduced and placed above the area of the pit. An
endoscope is then placed in the esophagus. Methylene blue
(about 5 mL) is then placed in the endotracheal tube, and the
baby is ventilated to spread the methylene blue around the
trachea. Inspection of the esophagus will reveal blue dye in
the esophagus at the location of the fistula.
There are several options for repair. There have been a
number of reports describing endoscopic techniques placing
adhesives in the recurrent fistula tract. The quoted rates of
success vary from 60% to 90% overall, with about 2 attempts
on average being required for closure [7-10]. This method
works best when the fistula tract is first de-epithelialized by
mechanical means and then fibrin glue or a similar agent is
placed into the fistula tract. There was more than the usual
amount of inflammation at the site of recurrence in those
children who had failed endoscopic closures.
We believe there are 3 key points that should be adhered
to at the time of repair to minimize the chances of a second
recurrence: the placement of a catheter through the fistula
before opening the chest, complete separation of the trachea
from the esophagus before dividing the fistula, and
placement of viable tissue between the suture lines. If the
fistula cannot be cannulated, the dye study described earlier
can be done to localize the fistula opening in the esophagus.
A small flexible endoscope can then be placed in the
esophagus; and during the thoracotomy, its light will help
identify the site of the fistula. With the fistula identified, the
esophagus and trachea are completely separated before
dividing the fistula. The 2 ends can then be sutured closed,
and viable tissue is placed between the suture lines. Our
tissue preference is pericardium, if available [11]. This flap
should be fashioned avoiding the phrenic nerve and inter-
posed between the suture lines (Fig. 3) to provide a well-
vascularized piece of tissue that has enough substance to
prevent recurrence.
A recurrent TEF presents a difficult problem, both with
diagnosis and treatment. Hopefully, this series, the largest so
far reported in the literature, will provide a framework to
assist in its management.
References
[1] Spitz L. Oesophageal atresia. Orphanet J Rare Dis 2007;2:24.
[2] Ghandour KE. Recurrent tracheo-oesophageal fistula: experience with
24 patients. J Paediatr Child Health 1990;26:89-91.
[3] Kovesi T, Rubin S. Long-term complications of congenital esophageal
atresia and /or tracheoesophageal fistula. Chest 2004;126:915-25.
[4] Purisch SE, DeFranco EA, Mugllia LJ, et al. Preterm birth in
pregnancies complicated by major congenital malformations: a
population-based study. Am J Obstet Gynecol 2008;199:287.e1-8.
[5] Kramer MS, Platt RW, Wen SW, et al. A new and improved
population-based Canadian reference for birth weight for gestational
age. Pediatrics 2001;e35:108.
[6] Ein SH, Stringer DA, Stephens CA, et al. Recurrent tracheoesophageal
fistulas seventeen-year review. J Pediatr Surg 1983;18:436-41.
[7] Richter GT, Ryckman F, Brown RL, et al. Endoscopic management of
recurrent tracheoesophageal fistula. J Pediatr Surg 2008;43:238-45.
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