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The use of two Hulka-Clemens spring clips on each Fallopian tube has been recommended to reduce the risk of sterilisation failure due to clip faults. We report a case in which the use of two clips caused failure.
One-hundred patients undergoing Falope ring or clip laparoscopic tubal ligation were given either a placebo or a 100 mg indomethacin rectal suppository one hour pre-operatively. Treatment was randomised and double-blind. Post-operative analgesic requirements and side effects were monitored. Forty-seven patients receiving indomethacin and 48 patients receiving placebo were available for analysis. Thirty-five patients in the indomethacin group required Meperidine (pethidine) analgesia (mean dose 58 mg) compared to 41 patients (mean dose 65 mg) in the placebo group. These differences were not significant. There were no significant differences in the non-narcotic analgesia given to each group, the side effects or the number requiring to stay overnight in the hospital. Analysis of the analgesic requirements of the 53 patients having clip sterilization and the 42 patients sterilized with Falope rings showed no statistical differences. This trial suggests that the immediate post-operative discomfort rates between ring and clip tubal occlusion are not different and that there is no significant benefit from the use of an indomethacin suppository pre-operatively.
Spectral analysis was recently chosen to characterize the fast oscillations, depending on the autonomic nervous system, in heart rate and blood pressure variabilities. Humoral stimuli could impinge on the low-frequency domain of blood pressure variability since the time lag to humoral system activation is greater. This study was designed to analyse low-frequency components of short-term variability of blood pressure of conscious rats in conditions where humoral systems were activated. We studied rats with two-kidney, one-clip Goldblatt hypertension in which the blood pressure level was dependent upon the renin-angiotensin and kallikrein-kinin systems. Spectral powers of the systolic and diastolic blood pressure and heart rate were computed in the high (respiratory)-, mid (0.2-0.6 Hz)- and low (0.02-0.2 Hz)-frequency bands, as detected by the fast Fourier transform technique in consecutive 102-s stationary periods. Hypertensive rats exhibited a marked low-frequency component of systolic (+261%) and diastolic (+169%) blood pressure variabilities when compared to sham-operated animals. First, losartan, a selective non-peptide angiotensin AT1 receptor antagonist, reduced this low-frequency component (-44% and -25% for systolic and diastolic blood pressure). In a second series of hypertensive rats, HOE 140, D-Arg-[Hyp3,Thi5,D-Tic7,Oic8]bradykinin, a bradykinin B2 receptor antagonist, decreased the low-frequency component of systolic (-28%) and diastolic (-40%) blood pressure. Losartan, added after HOE 140, induced a supplementary decrease of the low-frequency component (-60% and -42% for systolic and diastolic blood pressure). After the combined blockade, the low-frequency components of systolic and diastolic blood pressure variabilities of the hypertensive rats were equivalent to those of the control rats. Two-kidney, one-clip hypertension was also associated with an elevation of the mid-frequency component of the systolic blood pressure (+55%). The administration of HOE 140 did not change this component while losartan, alone or added after HOE 140, led to an increase (around +100%) in mid-frequency oscillations of systolic blood pressure. The high-frequency oscillations of systolic blood pressure were increased by losartan in the two series of hypertensive rats. Losartan increased the mid-frequency component of heart rate variability in sham-operated rats while the heart rate variability was not modified during any of the treatment periods in two-kidney, one-clip rats. In conclusion, an increase in the low-frequency component of blood pressure variability was observed in a model of hypertension where the blood pressure is dependent upon humoral activities. The reduction of the slow fluctuations following the combined blockade of the kallikrein-kinin and the renin-angiotensin systems suggested the contribution of these humoral systems to this low-frequency component of blood pressure variability.
Regional variations in the size and shape of isolated myocytes were studied using the two-kidney, one clip (2K1C) renal model of hypertension. Weanling male Sprague-Dawley rats (50 to 75 g) were anesthetized by ketamine (100 mg/kg) during renal artery clipping (0.2 mm internal diameter silver clip) and were then allowed to grow for 6 to 8 weeks, when the blood pressure had stabilized at 180 mmHg. Hearts were removed, weighed and then were perfused with a calcium-free Joklik medium containing collagenase. Isolated myocytes were collected from five regions and fixed in isoosmolar glutaraldehyde: right ventricular free wall (RVFW), right and left halves of the interventricular septum (RIVS, LIVS), and epicardial and endocardial halves of the left ventricular free wall (LEPI, LENDO). Myocyte volume was measured by Coulter Counter. Myocyte length was measured by sonic digitizer. Cross-sectional area was calculated from myocyte volume and length. Tailcuff systolic pressure and heart weight were significantly increased in 2K1C rats as compared to control. Body weights were not different. Cell volume was significantly increased in RIVS, LIVS, LEPI, and LENDO, but not in RVFW. Cell length was not significantly increased in any region. Thus, the 2K1C model showed a predominant left ventricular hypertrophy in which the right half of the septum acted in concert with the left ventricle. The shape of the hypertrophied myocytes, having an increase in volume due to an increase in cross-sectional area but not length, was most consistent with a pressure-induced form of cardiac hypertrophy.
Refitting clip-retained complete dentures for patients with osseointegrated implants as abutments presents problems in maintaining occlusion and protecting the clip during processing. This article describes a technique for functionally relining osseointegrated prostheses containing anterior clip-bar attachments.
The role of 1-alkyl-2-acetyl-sn-glycero-3-phosphorylcholine in regulating blood pressure was studied in one-kidney, one clip hypertensive rats using 3-(N-n-octadecylcarbamoyloxy)-2-methoxypropyl-2-thiazolio ethylphosphate, which specifically inhibited the hypotensive activity of exogenously injected 1-alkyl-2-acetyl-sn-glycero-3-phosphorylcholine. The blood pressure of rats with established hypertension produced by clipping one renal artery and contralateral nephrectomy normally decreases rapidly after unclipping the artery, but this rapid decrease was significantly inhibited by intravenous infusion of 3-(N-n-octadecylcarbamoyloxy)-2-methoxypropyl-2-thiazolio ethylphosphate. This shows that endogenous 1-alkyl-2-acetyl-sn-glycero-3-phosphorylcholine participates in the rapid decrease of blood pressure after unclipping the kidney in one-kidney, one clip hypertensive rats.
Proximal clipping has been performed recently as the main surgical treatment for a dissecting aneurysm of the vertebral artery. When there is a contralateral vertebral artery of a smaller size with arteriosclerotic changes, some form of bypass to prevent cerebellar and brain stem infarction is needed in addition to proximal clipping. We treated a 50-year-old man with a ruptured dissecting aneurysm of the left vertebral artery and stenosis at the V3 segment of the right vertebral artery. The caliber of the right vertebral artery was smaller than the left. After an anastomosis between bilateral vertebral arteries using a radial arterial graft, dissecting aneurysm was clipped at the proximal portion of the aneurysm.
Blade-deviated fenestrated clips developed by one of the authors were applied very successfully in 15 cases of A Com A aneurysms which corresponded to 32% of the aneurysms upon which were operated. Of the 15, 13 cases were projected superiorly, which is the most difficult and hazardous type if ruptured at the neck. The characteristic feature of the clip is the lateral deviation of occluding blades. The superiorly projecting type A Com A aneurysm is located posterolateral to the A Com A in the operative field, and the clips were extremely useful in the aneurysms in providing safer and more exact occlusion via parallel closure of the A Com A or the aneurysm neck.
OBJECTIVE: The purpose of this study was to evaluate postoperative pain after the administration of topical bupivacaine during laparoscopic sterilization with Filshie clips. STUDY DESIGN: Sixty-three women who underwent laparoscopic tubal sterilization with Filshie clips were assigned randomly to receive topical bupivacaine or placebo. Presence of pain, pain intensity, nausea, vomiting, timing of request for pain medication, and pain medication requirements were assessed postoperatively. RESULTS: Patient demographics were similar between the 2 groups. Topical bupivacaine decreased the incidence (P=.005) and intensity (P=.028) of postoperative pain at 30 minutes. No differences in incidence or severity of pain were seen at hospital discharge or on postoperative day 1. CONCLUSION: Topical bupivacaine that is applied to the fallopian tubes at the time of laparoscopic tubal sterilization with the Filshie clip decreases immediate postoperative pain.
OBJECTIVE: To overcome drawbacks of thoracotomy and percutaneous techniques, we have performed video-assisted thoracoscopic surgery (VATS) since 1991 to treat patent ductus arteriosus (PDA). This retrospective study aims to analyse morbidity and outcome in order to add data in the evaluation of minimally invasive operations. METHODS: From September 1991 to March 2003, 703 patients underwent PDA clipping by VATS. The indications for operation were clinically significant patency or failure to close in older children. Diameter >8 mm, previous thoracotomy, calcifications, infection, or aneurysm were contraindications to VATS. In right decubitus, only two thoracostomy incisions (for 5-mm trocars) and a smaller one (for direct hook insertion) were required. In the post-operative stay two echocardiographic controls were scheduled, the first before extubation and the second before discharge. Referring cardiologists assured follow-up. RESULTS: Mean age was 3.0+/-3.8 years (5 days-33 years), mean weight 10.7+/-8.0 kg (1.2-65 kg), and 3.1% of our activity were low birth-weight infants (LBWIs) weighting < or =2.5 kg. Operative and 30-day mortality was nil. Median operative time was 20 min and median stay 2 days. Unfavourable events globally occurred in 6.8% of cases (13.6% of the LBWIs, RR 4.0, CL 95% 1.5-10.4). Recurrent laryngeal nerve injury was noted in 3% (13.6% of the LBWI, RR 5.1, CL 95% 1.6-15), but only 0.4% had long lasting dysfunction. Incidence of chylothorax was 0.6%, thoracotomy 1%, transfusion for bleeding 0.1%, pneumothorax 1.3%. LBWIs were at increased risk for the latter two events. Residual patency was detected immediately in 1.4% (all non-LBWI) and underwent additional surgery. Incidence of residual patency at follow-up was 0.6% (0% LBWI, 0.6% in 2.5-25 kg group, 5.0% in >25 kg group, P=0.001). CONCLUSIONS: This study records a long experience of PDA treatment in a wide range of body size and age. VATS clipping is safe, but LBWIs are at augmented risk of complication. It may be carried out with a high degree of efficacy in all the ductus diameters <9 mm. VATS clipping requires minimal operating time and avoids morbidity related to chest wall trauma, percutaneous vascular access, and intravascular foreign bodies.
OBJECTIVE: Control of the renal pedicle is the most challenging step during laparoscopic nephrectomy. The standard method is to clip the artery and control the vein with an endovascular gastrointestinal anastomosis stapler. However, this device is expensive and has been reported to malfunction, leading to major complications even death. We describe an easy, quick, and cost-effective alternative technique. METHODS: From June 2002 to July 2005, two surgeons used this simplified technique to control the renal vein during laparoscopic nephrectomy. After pedicle dissection and control of the artery with a clip, the vein was grasped and gently pulled with a laparoscopic Babcock to reduce its diameter. Two Hem-o-lok clips (Weck Closure Systems, Research Triangle Park, NC) were easily placed on the renal vein, which was then transacted safely. RESULTS: We used this technique successfully for 130 consecutive laparoscopic nephrectomies (10 simple, 47 radical, 7 nephroureterectomies, and 66 live donor nephrectomies). No perioperative complications occurred with this technique in this series. There was no increase in the warm ischemia time when used during laparoscopic live donor nephrectomy. CONCLUSIONS: The Hem-o-lok technique is easy, safe, and rapid and offers cost savings when compared to the endovascular gastrointestinal anastomosis stapler. We recommend its use during laparoscopic nephrectomy and live donor nephrectomy.
BACKGROUND: Chronic gastrocutaneous fistula with intermittent drainage is a common outcome after removing long-standing gastrostomy tubes. The standard treatment is surgery with laparotomy and excision of the fistula tract. This study describes the results of an endoscopic closure technique by using a combination of electrocautery and metal clips. METHODS: Three patients with gastrocutaneous fistulas (duration 3 months to 3 years) after gastrostomy tube removal were treated endoscopically by electrocautery of the tract and application of metal clips. OBSERVATIONS: Treatment resulted in complete fistula closure in two patients and partial closure in a third patient. CONCLUSIONS: Combined endoscopic therapy with electrocautery and clipping may be an alternative to surgical closure of chronic gastrocutaneous fistulas.
This study examined whether a participant's level of interest in visual materials could be assessed by event-related potentials to auditory probe stimuli. Twelve young adults performed an auditory target detection task while viewing either interesting or less interesting (neutral) silent video clips. The auditory probe stimuli consisted of target (2000 Hz, p=0.15), standard (1800 Hz, p=0.70), and nontarget deviant (500 Hz, p=0.15) tones. Button press responses to target tones were required. Both target and deviant tones elicited a large P3 wave, the amplitude of which was smaller while participants were viewing interesting video clips than neutral video clips or simple still images (control condition). The amplitude reduction of the P3 to deviant tones was more prominent than that of the P3 to target tones. The difference between the neutral and control conditions was significant only for the deviant P3. The three-tone probe task using perceptually deviant, nontarget stimuli may be a useful objective method to assess how strongly a visual material attracts the viewer's attention.
BACKGROUND/PURPOSE: Alternatives are still being sought in vascular surgery to address the problem of arrested growth after anastomosis in growing vessels, and opinions differ widely regarding the most suitable technique. This study compared vascular growth and permeability after anastomosis using the latest-generation vascular closure staple (VCS) system and the conventional suture technique to ascertain which approach yielded better results. METHODS: Thirty 55-day-old lambs underwent end-to-end anastomosis of the carotid artery and jugular vein. Serial ultrasonography and angiography were carried out over the ensuing 6-month growth period, after which lambs were euthanized. RESULTS: Both VCS clips and polypropylene suture allowed longitudinal and transverse vessel growth; however, longitudinal growth was significantly greater in clip-closed vessels than in either sutured or untreated vessels. CONCLUSIONS: The results obtained for vascular growth and permeability suggest that VCS clips may provide a suitable alternative to conventional suture in pediatric vascular surgery.
PURPOSE: Metallic implants cause enlarged artifacts in magnetic resonance (MR) images at higher magnetic fields, B0, due to their magnetic susceptibility. Interactions of conductive material with radio frequency (RF) pulses also change for higher field strengths, B0, due to the frequency dependence of resonance conditions. Systematic measurements on commercial aneurysm clips and simplified copper models were performed in order to investigate both phenomena at 1.5 and 3 T. MATERIALS AND METHODS: Six different commercial aneurysm clips made of titanium, straight copper wires and bent copper models were examined in Gd-DTPA-doped water. RF-related effects were measured by adapted 2D and 3D spin-echo sequences. For reliable differentiation from susceptibility-related effects, variable transmitter voltages were applied. In addition, RF-induced heating was controlled by an infrared (IR) camera. RESULTS: At 3 T, a significant RF-induced electric response could be demonstrated for the copper samples and more moderate for one of the commercial clips, dependent on the geometrical structure determining possible resonant RF coupling. Related RF effects could be distinguished from susceptibility artifacts: a signal enhancement at reduced transmitter voltages indicated locally amplified B1-field amplitudes. No significant heating effect could be measured by IR measurements. CONCLUSION: MR imaging was used to analyze possible RF-induced effects. At 3 T, resonant RF coupling even of small metallic implants has to be considered carefully. Despite a local enhancement of the RF amplitude, no significant RF-induced heating inside the surrounding fluid was found. A direct thermal endangering of patients seems to be unlikely, but extremely high B1-field amplitudes might occur adjacent to the metallic surface with potential nonthermal affection of tissue.
BACKGROUND: The combination ascites, pleural effusion, and elevated CA 125 are usually associated with a malignancy. CASE: A 38-year-old SLE patient consulted her physician for shortness of breath. On clinical examination, she had a tender abdomen and reduced breathing sounds. X-ray and computed tomography of the chest showed pleural effusion. An adjustment of her SLE maintenance therapy was performed. Vaginal ultrasound and computed tomography of the abdomen revealed massive ascites and an intracavitair myoma of 2 cm, but no obvious mass in the pelvis. CA 125 was 887 U/ml. A laparoscopy was performed showing ascites and 2 Filshie clips embedded in the peritoneum of the vesicouterine pouch, but no sign of malignancy. Both clips were removed. The cytology of the aspirated ascites showed sings of acute inflammation. Within 10 weeks, the pleural effusion was resolved and the CA 125 normalized. CONCLUSION: The combination of ascites, pleural effusion, CA 125 elevation, and no tumor in an SLE patient is either a Tjalma syndrome or due to the migrated Filshie clips a pseudo-Meigs syndrome.
BACKGROUND: Expensive devices are increasingly used to close a patent fenestration after a modified Fontan operation. We report our 5-year institutional experience of clipped tube fenestration after extracardiac Fontan operation, which allows for simple transcatheter coil occlusion. METHODS: We retrospectively reviewed 30 children, median age of 4.0 years (range, 2.4 to 8.8 years) who underwent extracardiac Fontan operation between May 1996 and May 2001, and were fenestrated using a 4- to 8-mm diameter clipped tube graft. RESULTS: Ten children had a patent fenestration occluded by transcatheter placement of 15 detachable coils (5- to 8-mm diameter). Aortic oxygen saturations increased on average by 5.5% (2% to 14%) and mean pressures in the Fontan circuit by 2.5 mm Hg (0 to 3 mm Hg). Four had immediate complete occlusion angiographically and 6 had trivial residual shunt, but complete occlusion by echocardiography at follow-up. There have been no immediate complications, late coil embolizations, thromboembolic events, or documented hemolysis within a follow-up after coil implantation of 1.7 years (0.4 to 4.5 years). Spontaneous fenestration closure was documented in 8 patients at cardiac catheterization and 9 patients by echocardiography with consistent improvement in resting transcutaneous oxygen saturation. Two children with a patent fenestration have been considered inappropriate for closure, and there was one early surgical death. There have been no complications related to the tube fenestration modification within a follow-up postoperation of 2.6 years (0.1 to 5.5 years). CONCLUSIONS: Clipped tube fenestration after extracardiac Fontan operation is a useful surgical modification that allows for simple transcatheter coil occlusion.
Between September 1972 and March 1974, laparoscopic tubal sterilization was performed on 394 patients with the use of a spring-loaded plastic clip under local analgesia and on an outpatient basis. Intravenous fentanyl and infra-umbilical infiltration and tubal spray with 1% lidocaine were found to be very acceptable and effective forms of analgesia. The average time spent by a patient in the hospital was 4 hours, 26 minutes. There was no major immediate complications apart from vasovagal reactions in 34 patients. Up to June 30, 1974, six patients in the series had become pregnant, not as a failure of the clip per se, but as a result of improper application of the clips. This seems to be a safe, simple, and effective method of female sterilization with great potentials of reversibility.