Endovascular treatment of post-traumatic carotid-cavernous fistulae using latex detachable balloons

Objective. To determine the efficiency of latex detachable balloons in the treatment of post-traumatic carotid-cavernous fistulae (CCF). Methods. Management and outcome were reviewed for 34 consecutive patients with post-traumatic CCF personally treated by one of the authors (PS) using latex detachable balloons during the 4-year period 1996 - 2000. Results. Endovascular embolisation of 34 CCFs was attempted in 33 patients. In 1 patient where the fistula was a result of rupture of an intracavernous aneurysm, the fistula thrombosed spontaneously before embolisation was attempted. In the 33 treated patients, the fistula was occluded in 30 cases (91%). Patency of the internal carotid artery was preserved in 16 cases (53%). Conclusion. A high percentage (91%) of direct CCFs were successfully occluded with latex detachable balloons. There were no permanent neurological complications in any of the patients treated

A cost analysis of operative repair of major laparoscopic bile duct injuries

Background. Major bile duct injuries occur infrequently after laparoscopic cholecystectomy, but may result in life-threatening complications. Few data exist on the financial implications of duct repair. This study calculated the costs of operative repair in a cohort of patients who underwent reconstruction of the bile duct after major ductal injury.Objective. To calculate the total in-hospital cost of surgical repair of patients referred with major bile duct injuries.Methods. A prospective database was reviewed to identify all patients referred to the University of Cape Town Private Academic Hospital, South Africa, between 2002 and 2013 for assessment and repair of major laparoscopic bile duct injuries. The detailed clinical records and billing information were evaluated to determine all costs from admission to discharge. Total costs for each patient were adjusted for inflation between the year of repair and 2013.Results. Forty-four patients (33 women, 11 men; median age 48 years, range 30 - 78) underwent reconstruction of a major bile duct injury. First-time repairs were performed at a median of 24.5 days (range 1 - 3 662) after initial surgery. Median hospital stay was 15 days (range 6 - 86). Mean cost of repair was ZAR215 711 (range ZAR68 764 - 980 830). Major contributors to cost were theatre expenses (22%), admission to intensive care (21%), radiology (17%) and specialist fees (12%). Admission to a general ward (10%), consumables (7%), pharmacy (5%), endoscopy (3%) and laboratory costs (3%) made up the balance.Conclusions. The cost of repair of a major laparoscopic bile duct injury is substantial owing to prolonged hospitalisation, complex surgical intervention and intensive imaging requirements

The new DEAL - a novel technique using a double-entry access loop to facilitate bilateral intrahepatic biliary access for complex intrahepatic stones

The management of patients with primary intrahepatic stones may be complex as the natural history is frequently complicated by further episodes of cholangitis after initial treatment because of residual or recurrent intrahepatic stones or strictures.1 Curative segmental or lobar hepatic resection of atrophic segments and diseased ducts is possible in only the 20% of patients with localised stones or strictures.2 Complete stone removal by resection is therefore not feasible in the majority of patients with bilateral lobar stones and strictures. Patients who subsequently develop cholangitis pose a major operative risk if secondary biliary cirrhosis, portal hypertension or the atrophy-hypertrophy complex has occurred.3 Treatment of recurrent stones and strictures via the percutaneous transhepatic biliary route is successful in only 70% of patients.3 In order to avoid these hazards, to reduce the incidence of incomplete operative stone removal and to facilitate extraction of recurrent intrahepatic stones, we have used a multidisciplinary approach in complex hepatolithiasis, combining resection of atrophic liver segments with a modified hepaticojejunostomy incorporating permanent access for interventional radiological procedures via a jejunal access loop

Other manifestations of HIV vasculopathy

Descriptions of the numerous manifestations of human immunodeficiency virus (HIV) infection affecting almost every organ system have abounded in recent publications. Multiple radiological, clinical and postmortem reports have recorded the cerebral, pulmonary, cardiac, renal, rheumatological and gastrointestinal pathologies in HIV-infected individuals, ranging from the bizarre to the mundane. Large-vessel HIV-related vascular manifestations have previously been reported in the surgical literature. We describe and review the manifestations of HIV-associated vasculopathy as it pertains to the cerebral, cardiovascular, mesenteric and renal circulations

The management of complex pancreatic injuries

Major injuries of the pancreas are uncommon, but may result in considerable morbidity and mortality because of the magnitude of associated vascular and duodenal injuries or underestimation of the extent of the pancreatic injury. Prognosis is influenced by the cause and complexity of the pancreatic injury, the amount of blood lost, duration of shock, speed of resuscitation and quality and nature of surgical intervention. Early mortality usually results from uncontrolled or massive bleeding due to associated vascular and adjacent organ injuries. Late mortality is a consequence of infection or multiple organ failure. Neglect of major pancreatic duct injury may lead to life-threatening complications including pseudocysts, fistulas, pancreatitis, sepsis and secondary haemorrhage. Careful operative assessment to determine the extent of gland damage and the likelihood of duct injury is usually sufficient to allow planning of further management. This strategy provides a simple approach to the management of pancreatic injuries regardless of the cause. Four situations are defined by the extent and site of injury: (i) minor lacerations, stabs or gunshot wounds of the superior or inferior border of the body or tail of the pancreas (i.e. remote from the main pancreatic duct), without visible duct involvement, are best managed by external drainage; (ii) major lacerations or gunshot or stab wounds in the body or tail with visible duct involvement or transection of more than half the width of the pancreas are treated by distal pancreatectomy; (iii) stab wounds, gunshot wounds and contusions of the head of the pancreas without devitalisation of pancreatic tissue are managed by external drainage, provided that any associated duodenal injury is amenable to simple repair; and (iv) non-reconstructable injuries with disruption of the ampullary-biliary-pancreatic union or major devitalising injuries of the pancreatic head and duodenum in stable patients are best treated by pancreatoduodenectomy. Internal drainage or complex defunctioning procedures are not useful in the emergency management of pancreatic injuries, and can be avoided without increasing morbidity. Unstable patients may require initial damage control before later definitive surgery. Successful treatment of complex injuries of the head of the pancreas depends largely on initial correct assessment and appropriate treatment. The management of these severe proximal pancreatic injuries remains one of the most difficult challenges in abdominal trauma surgery, and optimal results are most likely to be obtained by an experienced multidisciplinary team

Emergency room arteriography: An updated digital technology

Background: Emergency room arteriography (ERA) is a safe, accurate, simple and costeffective method of defining arterial injuries. Limitations include the difficulty of evaluating limb vasculature distal to the suspected site of injury. Statscan is a novel, low-dose digital X-ray machine that can rapidly obtain a whole body image inasingle scan. Our goal was to evaluate the role of Statscan technology in ERA. Methods: A 24 month retrospective review of all patients who underwent a Statscan assisted ERA at the Groote Schuur Hospital Trauma Unit was completed. Indications for ERA included a hemodynamically stable patient with hard signs of a vascular injury in conjunction with the clinical assessment of a threatened limb. Contraindications encompassed instability, massive bleeding or a rapidly expanding hematoma. Results: Ten patients underwent Statscan assisted ERA of their lower limbs. Eight had cold, pulseless limbs with impaired neurological examinations. Common femoral, superficial femoral and popliteal artery lacerations were displayed. Three patients had no identifiable injury and were observed. Seven patients underwent operative management for threatened limbs. Two had Statscan evidence of arterial emboli distal to the site of injury leading to further exploration and distal embolectomy. Conclusions: Statscan ERA is safe, rapid, simple and accurate. It has the advantage of providing arteriography distal to the site of injury. This directly altered patient care in 20% of cases, primarily by detecting distal arterial emboli. Thirty percent of patients with normal ERA also avoided an unnecessary operation. This study demonstrates a new role for Statscan technology

Primary hydatid cysts of the pancreas

Pancreatic involvement by hydatid disease is uncommon. Establishing a precise diagnosis may be difficult because the presenting symptoms and findings of investigations may be similar to other more commonly encountered cystic lesions of the pancreas. We report 4 patients with primary hydatid cysts in the head of the pancreas. The records of all patients treated for hydatid disease from 1980 to 2000 were reviewed. During the study period a total of 280 patients were treated, 4 of whom had hydatid disease involving only the pancreas. The 4 patients (3 women, 1 man) ranged in age from 17 to 60 years. Three patients presented with jaundice, abdominal pain and weight loss, 2 with hepatomegaly and 1 with an epigastric mass. All 4 lesions involved the head of the pancreas and ranged in size from 3 to 10 cm in diameter. In 2 patients the investigations incorrectly suggested a cystic tumour and both underwent pancreaticoduodenectomy. In 2 patients the correct diagnosis allowed local excision to be performed. Hydatid cyst is a rare cause of a cystic mass in the head of the pancreas, but should be included in the differential diagnosis of cystic lesions of the pancreas, especially in endemic areas

Evaluation of a new type of direct digital radiography machine

Objective. To evaluate a recently developed low-dose, largefield, direct digital X-ray scanning system for medical use.Method. Radiation dose, image quality, diagnostic capability and clinical utility of the unit were compared with those of conventional radiography.Results. Radiation doses ranged from 3% to 5% of conventional radiographic values, and a mean of 1 line-pair per millimetre could be detected. Ease of use, anatomical coverage and tolerance to patient motion were advantages. However, image quality was inferior to that of conventional radiographs, with limited fine detail visibility and penetration. Only 67 of 156 (42.9%) pathological features seen on conventional radiographs were detected, including 13 of 41 fractures (31.7%) and 11 of 18 pneumothoraces (61.1%).Conclusion. Although image quality and diagnostic performance were not ideal, potential roles in triage, foreign body detection and possibly screening were promising. Radiographic factors may have affected sensitivity. This machine demonstrated useful attributes that may, with improvement, be beneficial in the imaging of trauma and other patients

Photographic measurement of upper-body sitting posture of high school students: A reliability and validity study

<p>Abstract</p> <p>Background</p> <p>All the reported measures of sitting posture, as well as photographs, have one flaw, as these measures are external to the body. These measures use calculations from external bony landmarks to estimate spinal posture, on the understanding that what is being measured externally reflects the shape, health and performance of structures of the underlying spine. Without a comparative measure of the relative position of the structures of the spine, the validity of any external spinal posture measure cannot be established. This paper reports on a study which tests the validity of photographs to measure adolescent sitting posture.</p> <p>Methods</p> <p>The study was conducted in a laboratory at the Department of Human Biology, University of Cape Town. A random sample of 40 adolescents were recruited from the Cape metropolitan schools, to detect differences of three degrees or more between the repeated measures of upright, normal or slouched posture (photographs) and between the posture photographs and LODOX measures. Eligible participants were healthy male and female subjects aged 15 or 16 years old, in Grade 10, and who were undertaking Computer or Computype studies at their schools. Two posture measurement tools were used in the study, namely: Photographs were taken using the Photographic Posture Analysis Method (PPAM) and Radiograph<it>s </it>were taken using the LODOX (LODOX (Pty) Ltd) system. Subjects' posture was assessed in simulated computer workstations. The following angles were measured: the sagittal head angle, cervical angle, protraction/retraction angle, arm angle and the thoracic angle.</p> <p>Results</p> <p>Data from 39 subjects (19 males, 20 females) was used for analysis (17 15-year-olds (7 boys and 10 girls), 22 16-year-olds (12 boys and 10 girls)). All but one photographic angle showed moderate to good correlation with the LODOX angles (Pearson r values 0.67–0.95) with the exception being the shoulder protraction/retraction angle Pearson r values. Bland Altman limits of agreement illustrated a slight bias for all angles. The reliability study findings from repeated photographs demonstrated moderate to good correlation of all angles (ICC values 0.78–0.99).</p> <p>Conclusion</p> <p>The findings of this study suggest that photographs provide valid and reliable indicators of the position of the underlying spine in sitting. Clinically it is important to know whether a patient is showing true progression in relation to a postural intervention. Based on the results of this study, the PPAM can be used in practice as a valid measure of sitting posture.</p