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Can J Surg

Ventriculoperitoneal shunt knot: a rare cause of bowel obstruction and ischemia.

Year 1998
Starreveld Y. Poenaru D. Ellis P.
Department of Surgery, Queen's University, Kingston, Ont.
Small-bowel obstruction caused by knotting of a peritoneal shunt catheter is an extremely rare and severe complication of a ventriculoperitoneal (VP) shunt. In the 1-week-old female infant reported here who had a VP shunt, inability to remove the peritoneal catheter was followed by small-bowel obstruction and necrosis due to intestinal strangulation in a tight loop of the catheter. An uncomplicated primary resection of the necrotic segment was followed by placement of a temporary ventriculoatrial shunt. The authors suggest that when withdrawal of the peritoneal part of a VP shunt meets with resistance, an intraoperative radiograph should be obtained to assess the position of the remaining catheter. If knotting is observed, an attempt to straighten the catheter with a guide wire is worthwhile. Should this fail, immediate laparoscopy or laparotomy is indicated.

Surgical management of acquired rectourethral fistula, emphasizing the posterior approach.

Year 1998
Boushey RP. McLeod RS. Cohen Z.
Division of General Surgery, Mount Sinai Hospital, Toronto, Ont.
Rectourethral fistula is an uncommon surgical entity having a variety of congenital and acquired causes. Although several surgical approaches have been proposed in the literature, successful repair is often difficult. The 2 patients described had rectourethral fistulas after radical prostatectomy. One patient failed previous transabdominal and perineal repairs. The authors propose a 3-step approach to management of acquired rectourethral fistulas. A diverting transverse colostomy with insertion of a suprapubic or indwelling silicone rubber Foley catheter for 3 to 6 months will allow for a decrease in the inflammatory response surrounding the involved area and possible spontaneous closure. If spontaneous closure does not occur within this time, the fistula should be closed operatively through a posterior approach (modified York-Mason procedure). This approach provides excellent exposure and allows the suture lines to be offset, which in turn allows for better healing, present a minimal risk of impotence or incontinence and allows for complete separation of urinary and fecal streams. The third step involves closure of the colostomy followed by removal of the Foley or suprapubic catheter if there is no recurrence. Timing of this step is crucial and should be individualized according to the postoperative course.

Duplication cyst of the antrum: a case report.

Year 1998
Gupta S. Sleeman D. Alsumait B. Abrams L.
Department of Surgery, University of Miami School of Medicine, Fla., USA.
Gastrointestinal duplication is a rare congenital anomaly. Although it usually presents within the first few years of life, it may appear much later as described in this report of a 19-year-old man who had symptoms of gastric outlet obstruction. He was found to have a noncommunicating antral duplication cyst. The cyst was managed by antrectomy with excision of the cyst and several centimetres of duodenum. Microscopically the duplication cyst contained a mucosa, submucosa and muscularis. There was no evidence of ulceration or malignant cells. His recovery was smooth. The etiology, presentation and management of antral duplication cysts causing gastric outlet obstruction are discussed.

Balloon pyloroplasty in children with delayed gastric emptying.

Year 1998
Skarsgard PL. Blair GK. Culham G.
Department of Surgery, British Columbia's Children's Hospital, Vancouver.
OBJECTIVE: To evaluate initial experience with balloon pyloroplasty for delayed gastric emptying in children. DESIGN: A retrospective review. SETTING: A tertiary care pediatric hospital. PATIENTS: Seven children with scintiscan-proven delayed gastric emptying that was refractory to maximal medical therapy. INTERVENTIONS: Balloon pyloroplasty under fluoroscopic guidance, mostly on an outpatient basis. For 1 child, the procedure was endoscopically monitored also. OUTCOME MEASURES: Postoperative symptoms and physical findings, gastric emptying and complications. RESULTS: Of the 7 children who underwent balloon pyloroplasty, 3 were rendered asymptomatic and 2 more were symptomatically improved. Four of the original 7 patients underwent postdilation scintigraphy, and all 4 showed normalization of the gastric emptying time. There were no complications. CONCLUSIONS: Initial experience with fluoroscopically-guided balloon pyloroplasty indicates that it is a safe and easily tolerated procedure, worthy of further study.

Necrotizing fasciitis of the retroperitoneum: an unusual presentation of group A Streptococcus infection.

Year 1998
Devin B. McCarthy A. Mehran R. Auger C.
National Defence Medical Centre, Ottawa, Ont.
A 14-year-old girl presented with symptoms resembling acute appendicitis. Five days after appendectomy and continued fever and severe abdominal pain, blood cultures were found positive for Streptococcus pyogenes. Two days later a diagnosis of group A streptococcal peritonitis with necrotizing retroperitoneal fasciitis was confirmed by retroperitoneal cultures obtained at laparotomy. Although multiple organ systems showed impaired functioning, including hepatic, renal and respiratory changes, she did not meet the criteria for streptococcal toxic shock syndrome. She was treated with a combination of high-dose parenteral penicillin and clindamycin, followed by prolonged treatment with clindamycin orally. Recovery was complicated by persistent hydronephrosis, which was slow to resolve.

Laparoscopic resection of an intra-abdominal cystic mass: a cystic mesothelioma.

Year 1998
Birch DW. Park A. Chen V.
Department of Surgery, McMaster University, St. Joseph's Hospital, Hamilton, Ont.
The clinical features of a patient with an intra-abdominal cystic mass do not lead to a specific diagnosis. Aspiration is usually ineffective because the mass recurs and cytologic investigation is often non-diagnostic. Conservative management is unsuccessful because symptoms often persist. Surgical management of cystic masses is required for definitive management and pathologic diagnosis. A laparoscopic approach to the diagnosis and treatment can provide essential anatomic information and a complete resection with minimal morbidity. A laparoscopic technique using 3 trocars and maintaining the integrity of the mass allows complete excision and removal of large intra-abdominal cystic masses as reported in a 43-year-old patient with a large intra-abdominal cystic mass identified as a benign cystic mesothelioma.

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