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PubMed2005

[Severe airway obstruction relieved by sedation using sevoflurane in a pediatric patient with tracheobronchomalacia].

A 3-month-old baby with trisomy 18 syndrome was scheduled for tracheostomy under general anesthesia because of the prolonged tracheal intubation. Immediately after transferring the patient to the operating table, the patient suddenly began crying and coughing, resulting in severe hypoxia. The patient's lungs could not be ventilated by manual and positive pressure ventilation, and airway obstruction could not be relieved until the respiratory effort spontaneously decreased. We started to administer sevoflurane on the recommendation of pediatricians who had successfully treated the patient with sedation using either midazolam or trichlorethylphosphate in similar situations. After sevoflurane administration, the sedated patient never developed the respiratory effort, and the lungs could be ventilated by manual and positive pressure ventilation without difficulty. The patient was diagnosed as tracheobronchomalacia as a result of intraoperative flexible bronchoscopy performed through tracheostomy tube, revealing significant narrowing of both the trachea and mainstem bronchus lumens. Sedation using sevoflurane may be helpful in maintaining airway patency in the pediatric patient with tracheobronchomalacia.

Airway Obstruction↗

PubMedDate not supplied

Treatment of gunshot wounds to the colon: experience in a rural hospital during the civil war in Somalia.

BACKGROUND: In the last few decades there has been a clear tendency in civilian practice towards primary repair of gunshot wounds to the colon, resulting in a substantial decrease in the number of colostomies performed for this type of injury. METHODS: The series described here comprises 24 patients with gunshot wounds to the colon treated at the hospital of Jowar in the Middle Shebelle region of Somalia between 1999 and 2001. All injuries were caused by war arms firing high-velocity projectiles. RESULTS: In 18 patients surgery consisted of resection and immediate anastomosis, while in the remaining six patients colostomies were performed including five loop colostomies and one terminal colostomy. The sepsis-related mortality was 25% (6/24). CONCLUSION: Our experience had a peculiar setting, namely that of a civil war in a developing country. In this kind of "difficult" situation there probably exists no ideal procedure and the decisions taken at the operating table are influenced by various factors that are often related to subjective assessment.

Adolescent↗

PubMed2005

Intraoperative evaluation of implants in anterior cervical spine surgery by three-dimensional fluoroscopy.

OBJECTIVE: Accurate radiographic documentation of the proper placement of cages, plates, and screws following cervical spine surgery significantly impacts clinical outcome. Postoperative computed tomography scans clearly show that the position of implants is sometimes far from ideal. The morbidity of anterior cervical disc surgery is well documented, but the incidence and influence of the misplacement of interbody spacers, plates, and screws are underestimated. We used isocentered fluoroscopy with three-dimensional image reconstruction intraoperatively to evaluate the extent of bony decompression and position of implants before wound closure. METHODS: From October 2003 through April 2004, 27 patients had anterior cervical procedures: 22 one-level and 5 two-level operations. Herniated cervical discs were diagnosed in 21 individuals, whereas 6 exhibited spondylosis. A radiolucent operating table made of carbon fibers was used in all patients. Before wound closure, intraoperative three-dimensional fluoroscopy was performed to evaluate the location of cervical implants and anterior bone resection. RESULTS: The entire scanning procedure required 5 minutes; the actual scanning time was only 120 seconds. In all patients, we were able to adequately evaluate the placement of cage, plates, and screws. Utilization of intraoperative three-dimensional fluoroscopy revealed that two cages were malpositioned and required revision before wound closure. CONCLUSIONS: Intraoperative three-dimensional fluoroscopy is a valuable tool for the intraoperative imaging of bony decompression and implants in anterior cervical spine surgery. The technique is safe and reliable and should help us to avoid incomplete decompression or misplacement of implants and therefore improve long-term functional outcomes in the future.

Adult↗

PubMedDate not supplied

[Laparoscopic and left thoracoscopic Collis-Nissen procedure: technique and short term results].

The aim of this paper is to illustrate a laparoscopic-thoracoscopic technique for the surgical management of foreshortened esophagus in patients affected by severe gastro-esophageal reflux disease. The patient is placed on the operating table with the left chest and arm lifted to perform a thoracostomy in theV-VI space, posterior to the axillary line. The hiatus is opened and the distal esophagus is mobilized. With intraoperative endoscopy the position of the gastroesophageal junction in relationship to the hiatus is determined in order to decide whether to perform a standard procedure for reflux or to lengthen the esophagus. In the second case, short gastric vessels are divided and the gastric fundus is mobilized. An endostapler is introduced into the left chest. The Collis gastroplasty is performed over a 42 Maloney bougie. A floppy Nissen and the hiatoplasty complete the procedure. Twenty-two procedures of laparoscopic-thoracoscopic Collis gastroplasty were performed. The postoperative course was regular in 17 patients and complicated in 5 cases. Two procedures were converted for split of the endosuture caused by an oversized Maloney bougie (52 Ch). Other complications included intrathoracic migration of the fundoplication with need for repeating laparoscopic surgery, an empyema without fistula and atrial fibrillation. In conclusion, this technique corresponds to all principles of anti-reflux surgery and makes it possible to properly treat any anatomical condition.

Adult↗

PubMed1976

Observations on abdominal injuries in the Nigerian Civil War.

A retrospective study of 331 patients who sustained abdominal injuries during the Nigerian Civil War 1967-70 and were treated at Base Surgical Centres in the 3 Field Ambulance Nigerian Army is made. The most commonly injured organs are small intestine 148, caecum and colon 80, liver 69, spleen 26, stomach 28 and kidney 24. Case fatality rate is 33.8%. Factors influencing case mortality rate include type of organ injured, number of organs hit by penetrating missile, peri-operative complication. Other factors, not measurable in this study are mentioned. The few patients with injuries severally to the pancreas or the gall bladder who reached the operating table alive, all showed injuries to some other organs; these are among those with the highest mortality rates. Comparisons are made with similar studies from the Second World War 1942-45 and the Korean War 1952-53.

Abdominal Injuries↗

PubMed1992

[Complications in surgical management of pelvic fractures].

In the care of pelvic injuries complications arise because of organizational and technical factors, some of which are described here. The following measures are important: autotransfusion, emptying the bladder and catheterization, checking and protection of the colon, correct management of the operation table, and prophylactic measures to avoid thrombosis. From an operational/technical point of view, it is most important that a larger with good exposure route be chosen that takes the anatomical structures into account. Of 123 cases, 20% were not ideally reduced. Twice massive bleeding occurred from the A. glutea superior, once the sacral dura was opened without any adverse effects, infection occurred 8 times and 10 times peroneal paralysis was observed.

Acetabulum↗

PubMedDate not supplied

Coexistence of Crohn's disease and inflammatory fibroid polyp of the small bowel. Report of a case and review of the literature.

BACKGROUND/AIM: The Authors report a case of a woman aged 35, with concurrent appearance of Crohns disease and Inflammatory Fibroid Polyp of the terminal ileum. CASE REPORT: The combination of the two disorders was clinically manifested as an obstructive ileus. On the operative table, a 4-cm polypoid mass causing intussusception of the bowel was obvious. The resected specimen of the ileum showed profound distention, several ulcerations and fissures. The histological examination confirmed the diagnosis of Crohn's disease coexisting with an Inflammatory Fibroid Polyp. Immunostaining of the lesion for actin showed focal positivity. However, staining for desmin, CD31, S100-protein, PGM-1 CD34, CD117, and bc1-2, was negative. CONCLUSION: Coexistence of Inflammatory Fibroid Polyp with Crohn's disease causing obstructive ileus could be the first manifestation of the disease. The combination of the two disorders corroborates the reparative character of the lesion. Nevertheless, the exact etiopathogenetic relationship between the two entities remains obscure.

Abdomen, Acute↗

PubMed2006

Hernia through an iliac crest bone graft site: report of a case and review of the literature.

The iliac crest is a common donor site for autogenous bone graft as it offers the advantage of easy access and a relatively large and safe supply of bone. One of the less frequently reported complications of harvesting bone grafts from the iliac crest is a graft-site hernia. In the last decade less than 15 cases have been reported, however the true incidence of this complication is unknown. We report a case of iliac crest bone graft hernia in an obese diabetic female. The significant feature of this case was a large swelling six weeks postoperatively that was thought to be a hematoma. The actual diagnosis of hernia was made on the operating table during an attempt to evacuate the hematoma. Hence a high degree of suspicion is needed to diagnose a hernia following an iliac crest bone graft, particularly in obese patients and the suspicion should lead to confirmation by a CT scan.

Aged↗

PubMedDate not supplied

[Experience with epidural anesthesia during myocardial revascularization operations].

The paper presents the results of 213 myocardial revascularization using epidural anesthesia. The used anesthesiological protocol combining intravenous proforol sedation and epidural naropine block proved to be effective and safe and ensured adequate anesthesia that made possible myocardial revascularization both without using extracorporeal circulation (transmyocardial laser revascularization, mini-invasive myocardial revascularization) and with complex repairs of the geometry of the left ventricle and cardiac valvular apparatus and provides a means for the activation of patients and extubation on the operating table in the absence of surgical complications, hemorrhages, and extracorporeal circulation procedures even after reconstructive surgery.

Anesthesia, Epidural↗

PubMedDate not supplied

Optimizing the medical management of diabetic patients undergoing surgery.

Patients with diabetes are prone to metabolic derangements because of their lack of effective insulin. Comorbid conditions, such as coronary artery disease, nephropathy, and autonomic neuropathy warrant preoperative assessment to ensure safety in the perioperative period. Preoperative evaluation must include assessment of chronic complications of diabetes. A thorough history and physical should guide preoperative testing which should be aimed at detecting correctable abnormalities and assessing the extent of end-organ disease. Surgery poses special challenges to patients with diabetes because the stress response, interruption of food intake, altered consciousness, and circulatory alterations all lead to unpredictable glucose and electrolyte levels. The management of insulin perioperatively depends on the preparation normally taken by the patient, and the glucose level on the morning of surgery. The goal is to avoid hypoglycemia and extreme hyperglycemia. Oral hypoglycemic agents should be held on the morning of surgery. Metformin should be discontinued 48 hours prior to and subsequent to surgery in order to reduce the risk of lactic acidosis. The avoidance of hypoglycemia and excessive hyperglycemia intraoperatively is best achieved with frequent monitoring of blood glucose and treating abnormalities according to patients' preoperative regimen and current condition. Maintaining blood glucose levels below 110 mg/dL reduces morbidity and mortality in critically ill patients. Measure blood glucose immediately following surgery because progression of the stress response postoperatively, in addition to possible nausea and vomiting, can complicate the patient's management. Precautions should be taken to prevent damage to peripheral nerves while diabetics are on the operating table because their nerves and limbs are already vulnerable to pressure and stretch injuries secondary to neurologic and vascular disease. With thorough and careful management, metabolic control in the perioperative period is a goal that is attainable for most patients.

Diabetes Complications↗

PubMed1991

[Fentanyl vs alfentanil anesthesia for in vitro fertilization].

In a prospective double-blind study, 36 women undergoing ultrasonically guided oocyte retrieval for in vitro fertilization (IVF) were examined. Anesthesia in 19 was based on alfentanil, up to 0.025 mg/kg and in 17, fentanyl, 0.0025 mg/kg. There were no significant differences between groups with regard to age, weight, duration of procedure and pregnancy rate. There were no complications aside from nausea and vomiting. Amnesia for the puncture and analgesia were always perfect. Induction was significantly shorter for alfentanil, 1.3 +/- 0.7 min, than for fentanyl, 3.4 +/- 2.2 (p less than 0.01). All who received fentanyl were drowsy at the end of the procedure, while those in the alfentanil group were fully awake and able to move from operating table to stretcher with minimal help. We therefore recommend alfentanil as the base for anesthesia for IVF.

Alfentanil↗

PubMed1991

The results of completion angiography after acute lower limb thromboembolectomy.

The results of completion angiography after acute thromboembolectomy with a Fogarty balloon catheter were evaluated. There were 62 patients (median age 72 years, range 44-92 years) and completion angiograms were made in 44 of them (71%). Incomplete runoff was demonstrated in 26 patients (59%) and rethromboembolectomy or vascular reconstruction was made in 18 cases (41%) under the same anaesthesia, while additional vascular surgery was technically impossible in 8 patients (18%). Supplementary surgery resulted in radiological improvement in 56% of operated cases. Reocclusion rate after 6 months was 50% in patients without patent tibials compared to 15% in patients with two or three patent tibial arteries (P less than 0.05). Eighteen patients had no completion angiograms after thromboembolectomy and 5 (28%) required early reoperation due to ischaemia. Completion angiograms are advocated in all cases of acute thromboembolectomy before the patient leaves the operating table.

Acute Disease↗

PubMedDate not supplied

[Use of low-frequency ultrasound in preoperative care of the conjunctival cavity].

Experimental and clinical studies of the efficacy of preoperative treatment of the conjunctival cavity with low-frequency ultrasound were carried out. Ultrasound parameters employed were as follows: 20-70 kHz frequency, 25-35 microns oscillation amplitude, length of exposure 60-120 sec. Such treatment was found to reduce bacterial contamination of the conjunctival cavity. Clinical studies were carried out on 20 eyes of 14 patients operated on for cataracts and glaucomas at the department for ocular diseases of the Moscow municipal clinical hospital No. 15. Low-frequency ultrasound treatment of the conjunctival cavity was carried out before surgery in all these patients. In the reference patients (n = 15, 15 eyes) the conjunctival cavity was washed with 1:5000 furacilin solution and 30% sodium sulfacil solution or kanamycin solution (10,000 U in 1 ml) on the operation table. The bacterial contamination of the conjunctival cavity prior to surgery in 24 eyes has made up 84.1 bacterial colonies per Petri dish on an average. Preoperative treatment of the conjunctival cavity with low-frequency ultrasound has reduced the bacterial contamination to 6.3 colonies per Petri dish, i.e. by 13.3 times.

Animals↗

PubMed1991

Heparin as the cause of coagulopathy which may complicate grafting of the liver.

Disposal of heparin is accomplished rapidly by the normal liver, but the effects of ischemia, flushing and hypothermia during hepatic transplantation have not been investigated before. The results of the present study showed that neither laparotomy, hypothermia nor insertion of the portosystemic bypass seemed markedly to affect the coagulation profile, but autograft associated with 30 to 45 minutes of warm ischemia resulted in a twofold prolongation of the t1/2 heparin as calculated from sequential measurements of the activated clotting time. Unexpectedly, the storage of livers for four hours in EuroCollins solutions seemed to result in more rapid disappearance of heparin than in animals after laparotomy. After hepatectomy, the clearance of heparin was delayed for two hours but, thereafter, the slope of the disappearance resembled that in sham operated animals. Autograft and allograft of livers in normal pigs that did not receive transfusion were also associated with changes in fibrinolysis and declining levels of fibrinogen together with severe intraoperative bleeding problems and rapid death on the operating table in 30 per cent of the pigs. While administration of heparin alone did not appear to precipitate these changes, use of the drug after dissection, mobilization and storage of the liver may release other tissue factors that activate fibrinolysis.

Animals↗

PubMed1991

[Pathogenesis of congenital clubfoot].

Experiments, carried out by the author, have shown that the pathogenesis of congenital talipes is based on congenital muscular disbalance between flexors-supinators and extensors-pronators at the expense of strengthening of the former and insufficiency of the latter. An object of treatment of the considered developmental defect is restoration of myogenic balance. The existing methods of conservative treatment result in preservation of insufficiency of the anterolateral group of the crus muscles. Only the method of Vilensky V. Ya. allows to completely solve the posed problem. Operations on the posteromedial section of foot result in reduction of the myogenic disbalance as there is preserved insufficiency of extensors-pronators. Only operations, accompanied by shortening of anterolateral groups of the crus muscles allow to restore the myogenic balance straight on the operating table. The cause of recurrencies in case of congenital talipes is preservation of myogenic disbalance between flexors-spinators and their antagonist more frequent at the expense of insufficiency of the latter.

Clubfoot↗

PubMed1991

A case of extragenital choriocarcinoma in the jejunum.

A case of extragenital choriocarcinoma which produces human chorionic gonadotropin (HCG) in the small intestine of a 48-yr-old Japanese women is reported. Only seven such cases have been reported. The patient complained of postprandial upper abdominal pain and vomiting of 5 months' duration. Nine years before, right upper lobectomy was performed because of lung undifferentiated carcinoma. Double-contrast examination of the small intestine showed irregular ulceration in the lower jejunum. Celiac angiography demonstrated a hypervascular tumor stain in the branch of the jejunal artery. The serum HCG level was elevated. Gynecological examination revealed nothing abnormal. A small intestinal neoplasm was diagnosed, and a partial resection of the jejunum was performed. Endoscopy on the operating table showed a large, irregularly shaped sessile ulcer. Histologically the tumor was diagnosed as choriocarcinoma, composed of syncytiotrophoblastic cells and cytotrophoblastic cells. Immunohistochemical staining for HCG was positive. No metastasis was present. Although extragenital choriocarcinoma in the small intestine is rare, it should be included in the differential diagnosis of small intestinal neoplasm.

Choriocarcinoma↗

PubMed1991

[Penetrating neck injuries].

The frequency of penetrating neck injuries has increased in recent years. In 16 patients with such injuries treated during the past 2 years, neck exploration was performed immediately. In 4 there was destruction of the throat or trachea, in 3 a tear in the esophagus, in 1 a tear in the hypopharynx and in 1 a tear in the submandibular region penetrating the floor of the mouth. In 8 there was no damage to the neck organs. Of the 16, 1 died on the operating table from hemorrhage from multiple tears of the hypopharynx, the esophagus and the thyroid gland. 2 different approaches are used in dealing with penetrating neck injuries: immediate exploration, or the use of imaging methods to diagnose the degree of damage, followed by close supervision. In the light of our experience we advocate immediate neck exploration.

Humans↗

PubMed1991

[Rational use of bed capacity in surgical clinic].

Surgical activity can be intensified in the presence of 3 factors: optimal full-time work of surgeons, the existence of one operating table per 20 surgical beds, and financial stimulation of the entire personnel for hospital-bed turnover. Calculation of optimal full-time work of surgeons is given in illustration.

Cost-Benefit Analysis↗