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Byline: Akash. Belenje, Brijesh. Takkar, Komal. Agarwal, Mudit. Tyagi, Vinod. Aggarwal, Tapas. Padhi, Raja. Narayanan Purpose: To evaluate the causes of jet stream injury (JSI)-related iatrogenic retinal breaks (IRBs) during [...]

PURPOSE: To summarize the most current information about the etiology, pathophysiology, clinical presentation, treatment, and outcome of esophagogastrostomy leaks following esophagectomy. METHOD: The English language literature was searched by manual methods and MEDLINE for original articles reporting results and complications of esophagectomy. RESULTS: Esophagogastrostomy anastomotic leaks cause considerable morbidity and mortality after esophagectomy. Their major etiologic factors are ischemia of the gastric fundus and errors in surgical technique. The clinical presentation of postoperative anastomotic leak ranges from an asymptomatic radiographic finding to a necrotizing thoracic infection. Severity of illness is largely dependent on four factors: gastric viability, the site (thorax or neck) and time of the leak, and its containment by surrounding tissues. Cervical anastomoses have a higher leak rate than thoracic anastomoses, but leaks from thoracic anastomoses are more morbid. CONCLUSION: Leaks from thoracic anastomoses require aggressive surgical treatment. Cervical anastomotic leaks that are truly confined to the neck can usually be managed at the bedside with wound drainage and packing. However, the seriousness of cervical anastomotic leaks should not be underestimated. Some leaks from anastomoses constructed in the neck are, in reality, mediastinal leaks. Selected patients with radiologically detected asymptomatic leaks can be managed conservatively.

Injury to the common duct during surgery has been reported to occur in 0.5 percent of patients who have cholecystectomy (removal of the gallbladder). A review was undertaken of 81 patients who had bile duct injury during either cholecystectomy or exploration of the common bile duct, the duct formed at the junction of the cystic duct and the hepatic duct. Recurrent stricture was reported by 33 of the patients. The average follow-up was nine years; 15 patients eventually died and 11 others had long-term consequences, including 8 patients who had intermittent cholangitis or liver cirrhosis. Circumstances that appeared to contribute to injury were: inadequate exposure or access to the duct, and inadequate assistance at surgery; lack of intraoperative cholangiogram (a radiographic study that outlines the major bile ducts); obesity of patient (more than 50 percent over normal body weight); and early dissection of the duct area, before the gallbladder had been freed. Neither the level of training of the surgeon, nor the type of hospital where the surgery was performed was a significant contributing factor. Factors related to morbidity and mortality were level of the stricture or narrowing (high strictures had a poorer prognosis); number of previous repair attempts; and quality of the reconstruction. Bile duct injuries that are recognized and repaired immediately have the best prognosis. Injuries identified after surgery should be referred to a special treatment center, to reduce the number of failed attempts at reconstruction. Four patients who developed liver failure following unsuccessful reconstruction were transferred to have a liver transplant, but none survived long enough to do so. (Consumer Summary produced by Reliance Medical Information, Inc.)

In a previous report from this institution, 21% of splenectomies performed between 1957 and 1967 were for iatrogenic injury to the spleen. In the present study, encompassing the years 1971 to 1987, the frequency of iatrogenic splenic injury was reduced to 9% (134 of 1,557 splenectomies). However, there has been no evidence of a progressive decrease in accidental splenic injury from 1971 to 1987. Although the number of injuries related to operations on the stomach or repair of hiatus hernia have declined somewhat in the past decade, the incidence of splenic injuries secondary to colectomy and nephrectomy has not changed appreciably, and injuries linked to complex operations on the aorta and its branches (19 cases) have increased. No evidence could be found that morbidity was increased if the splenic injury is promptly recognized and managed by splenectomy. However, 13 of these 134 patients required reoperation for control of continued bleeding from unrecognized iatrogenic splenic trauma. Constant awareness of the continued prevalence of this operative complication and the mechanisms by which it is produced should enable surgeons to lessen its frequency and potential sequelae., Iatrogenic injury is damage to the body caused by a physician or surgeon. During abdominal operations, such injuries can occur to the spleen, particularly when procedures are performed on the stomach, kidney, or aorta (the large artery carrying blood to the lower part of the body). Although surgeons are well aware of the possibility of this complication, the issue has not been recently assessed. To this end, a review was conducted of the records of 1,557 splenectomies (removal of the spleen) performed between 1971 and 1987. Of these, 9 percent (134) had been performed due to iatrogenic injury to the spleen; in the other 91 percent, the spleen was removed for other reasons. A partial breakdown of the operations during which the spleen was inadvertently damaged was: gastric procedures, 32 patients; nephrectomy (removal of a kidney), 28 patients; colectomy (removal of the colon), 24 patients; repair of hiatus hernia (protrusion of part of the stomach above the diaphragm), 14 patients; and resection of an aortic aneurysm (removal of a dilated part of the aortic wall), 11 patients. In many patients, extensive cancer in the region where the surgeon worked was associated with iatrogenic injury. Thirteen patients for whom splenic trauma was not noted during the original surgical procedure required re-operation to control bleeding. The consequences of damage to the spleen have been a subject of intense debate for decades; a review of relevant articles is provided. The complications are certainly more serious if damage to the spleen goes unrecognized and internal bleeding is allowed to continue. The importance of proper preventive and corrective measures is emphasized. (Consumer Summary produced by Reliance Medical Information, Inc.)

Byline: Photographed by Steven Klein Lumps, bumps, bruises, and worse: Cosmetic procedures don't always go exactly as planned. Jenny Bailly talks with the pros about temporary side effects, permanent problems--and [...]

By Melanie Newman melanie.newman@rbi.co.uk More damning evidence of poor quality patient care in independent sector treatment centres (ISTCs) has emerged in the face of Government denials that such evidence exists. [...]