Profound bradycardia with lidocaine during anesthesia induction in a silent sick sinus syndrome patient

Sick sinus syndrome is caused by sinus node dysfunction that renders it unable to function as a pacemaker. Patients with sick sinus syndrome are often asymptomatic or have symptoms that are mild and nonspecific. Lidocaine (0.5 mg/kg) injection is used for reduction of pain associated with intravenous injection of propofol. Episodes of marked bradycardia with sinus arrest after prophylactic lidocaine injection are reported in a 69-y-old man with no apparent preoperative cardiac disease or electrocardiographic abnormality. Surgery was postponed, and he was later diagnosed with sick sinus syndrome.     

Ruptured sinus of a Valsalva aneurysm associated with autosomal-dominant polycystic kidney disease in an elderly patient: Report of a case

We report herein the case of a 71-year-old woman with autosomal-dominant polycystic kidney disease (ADPKD), who was referred to our hospital for investigation of facial edema. Echocardiography demonstrated a large aneurysm arising from the noncoronary sinus of Valsalva, with a left to right shunt and jets of blood passing from the aneurysm toward the septal leaflet of the tricuspid valve. Surgical treatment was successfully carried out by resecting the aneurysmal wall and performing a patch closure of the orifice. It is well known that ADPKD predisposes patients to cardiovascular disease, and this case report serves to demonstrate that when a patient with ADPKD presents with progressive heart failure, the possibility of a ruptured sinus of a Valsalva aneurysm must be considered. Received: March 1, 1999 / Accepted: March 24, 2000     

Sinus formation after insertion of a silicone-coated suburethral sling

We report the case of a 65-year-old woman who developed a sinus tract after a suburethral synthetic silicone mesh sling placement. After removal of the sling material with debridement and reconstruction of the suburethral tissue, fascia lata harvest with a sling to abdominal rectus fascia was performed. Silicone mesh may erode to form a sinus tract if used as suburethral sling material.     

Multiple perineal abscesses and sinus tracts as a complication of vaginal mesh

Understanding the occurrence and management of mesh kit complications has become increasingly important. A 54-year-old woman presented to our tertiary care center with complaints of constant perineal pain, and copious, foul-smelling vaginal discharge after anterior and posterior placement of a synthetic mesh and mid-urethral sling 3 months earlier. She was found to have two vaginocutaneous sinus tracts (to the left ischiorectal fossa and to the left labia majora), as well as bilateral abscess cavities within the ischiorectal fossae. The posterior mesh was completely excised, the tracts were opened, and the wound was packed and allowed to heal by secondary intention.     

Effect of fentanyl nasal packing treatment on patients with acute postoperative pain after closed reduction of nasal bone fracture: a randomized double-blind controlled trial

Purpose: Nasal bone fracture reduction surgery is normally followed by nasal packing to control bleeding. Yet, patients suffer from pain and require further analgesic treatments following nasal packing and removal. This study aimed to evaluate the effect of fentanyl-soaked packing as a method of controlling pain after nasal surgeries in a prospective, randomized, double-blind controlled trial.

Methods: Sixty-five patients that have undergone closed nasal bone fracture reduction surgery were included in this study. Thirty-two patients were treated postoperatively with 50?mcg fentanyl-soaked Merocel^®, a biodegradable synthetic polyurethane foams packing, and the other 33 patients were treated with saline-soaked packings. To analyze the relative nasal pain control effect of fentanyl, Numeric Rating Scale, patient satisfaction and Ramsay Sedation Scale were used. Patients were closely monitored to record relevant cardiopulmonary indicators and degree of adverse symptoms such as headache or sore throat.

Results: Fentanyl group had a significantly lower Numeric Rating Scale and higher patient satisfaction for most of the time periods after operation (p?p?p?>?.05).

Conclusion: Fentanyl-soaked packing significantly decreased postoperative pain with no observable adverse effects. Our results demonstrate that topical fentanyl application to nasal packing is an effective method of postoperative pain control after closed nasal bone fracture reduction surgery.     

Endoscopic surgery of the rhinobasis with a computer-assisted localizer

The endoscope is useful for the diagnosis and surgical therapy of diseases of the nose, the paranasal sinuses and its neighboring regions, and allows for microinvasive, functional approaches. The reduced invasiveness of therapeutic procedures is sometimes accompanied by insufficient clearness of the surgical field, however. This significant problem is solved by the computer-assisted-surgery (CAS) system, an intraoperative localizer. It allows continuous orientation based on three-dimensional reconstructed preoperative CT scans with superimposed positioning of the endoscope. We have now adapted CAS for endoscopic sinus surgery, which meant that a variety of visualization methods were tested. A conventional straightforward endoscope was used in combination with, or as, the localizing probe. A dual-display technique was adjusted to video-endoscopic procedures: the information of the localizer is displayed on one monitor while the video-endoscopic picture is viewed on a second screen. In addition, a single-display technique with both images on one monitor was developed. It proved to be the most promising way of combining endoscopy and intraoperative CT-image-guided localization.     

Intraoperative packing of a pancreatic pseudocyst complicated with bleeding pseudoaneurysm

Hemosuccus pancreaticus (HP) is a rare cause of gastrointestinal bleeding, usually due to rupture of a visceral artery aneurysm in chronic pancreatitis. Other causes of HP are rare. We present a case of HP which occurred in a patient with chronic calcifying pancreatitis and a pancreatic pseudocyst documented by ultrasonography and computed tomography. With detectable fresh blood in the descending duodenum, an aneurysm in the pancreatic head was revealed by superior mesenteric angiography as the suspected origin of intermittent bleeding from the pancreatic duct. Because an artery feeding the pseudocyst could not be identified, angiographic embolization was not possible. Surgical resection or ligation was difficult by laparotomy; therefore, intraoperative packing of the pseudocyst with absorbable gelatin sponges was achieved via a cannula through a directly punctured site in the pseudocyst wall. The patient has been followed for 4.25 years with no further episodes of HP. It is possible that the packing of a pancreatic pseudocyst with gelatin sponges is a method that can be used in similar cases, where control of hemostasis is the primary concern. The packing of a pancreatic pseudocyst with gelatin sponges is a technique that can be performed not only via laparotomy but also via laparoscopy or concomitant angiography and ultrasonography.     

Gluteal V-Y advancement fasciocutaneous flap for treatment of chronic pilonidal sinus disease

Although pilonidal disease is quite common, controversy still exists about the treatment. The procedure should cure the patient, and allow speedy resumption of normal activities by reducing pain and disability. This retrospective study was conducted to evaluate our experience with the V-Y fasciocutaneous advancement flap and to review current publications about flap surgery for the treatment of sacrococcygeal pilonidal sinus. We describe the application of the fasciocutaneous V-Y advancement flap for reconstruction of defects after radical excision of recurrent pilonidal sinus in 11 cases. Primary and uneventful wound healing was achieved in all patients but two who developed minor wound breakdown. Large defects after excision can easily be closed using the V-Y advancement flap. This type of flap closure in selected cases offers tension-free, recurrence-free, and reliable skin coverage while flattening the natal cleft that predisposes to recurrences. Reliable flap closure reduces hospital stay, costs, as well as disability and time spent off work.     

Recurrent deep neck abscess and piriform sinus tract: A 15-year review on the diagnosis and management

Background

Piriform sinus tract (PST) is a rare congenital condition. A delay in diagnosis is common leading to recurrent inflammation.

Method

A retrospective review was performed on all cases of PST treated at a tertiary referral centre between May 1997 and May 2012.

Results

Eighteen patients were reviewed with a mean age of 5.4 years at presentation (ranged from 0 day to 14 years). Most patients presented as acute inflammation (88.9%) and 16 had a left sided lesion. 72.2% of the PST are identified by contrast swallow study. The diagnostic yield was significantly higher if the study was done after the initial acute inflammation settled. Ultrasonography and computer tomography are less sensitive. The median duration from presentation to diagnosis was 17.6 months (ranged 0–120 months). Ten patients (55.6%) experienced recurrent inflammation before confirming the diagnosis. Fistulectomy alone was performed in 15 patients while an additional en-bloc hemithyroidectomy was done in 2 patients.

Conclusion

PST should be suspected in children presenting with a left deep neck abscess. Contrast swallow study is very effective in making diagnosis but has to be postponed after the acute inflammation settles. The condition can be effectively treated by fistulectomy without hemithyroidectomy in majority of our cases.     

右美托咪定对家兔窦房结和房室结功能的影响

目的研究不同剂量右美托咪定对家兔窦房结和房室结功能的影响。方法健康雄性新西兰大白兔24只,体重1.5~2.8kg,按随机数字表分为三组(n=8):对照组(C组),以12ml/kg速度持续泵注生理盐水;造成心动过缓最低剂量组(D1组),负荷量10μg/kg,持续泵注量5μg·kg-1·h-1;6倍剂量组(D2组),负荷量60μg/kg,持续泵注量30μg·kg-1·h-1。麻醉家兔,分离右侧股动脉并置管,实时监测MAP和HR。右侧颈外静脉置入起搏电极,深度位于上腔静脉下段和右心房交界处,通过程控刺激的方法获取窦房结、房室结的功能指标。于右美托咪定泵注前(T0)、右美托咪定持续泵注后20~30min(T1)、50~60min(T2)测量窦房结恢复时间(SNRT)、校正窦房结恢复时间(CSNRT)、窦房结总恢复时间(TRT),和房室结前传功能2∶1点。结果 C组各时点SNRT、CSNRT、TRT和2∶1点差异均无统计学意义。与T0时比较,T1、T2时D1组和D2组SNRT、CSNRT和TRT明显延长,T1时D1组和D2组2∶1点明显缩短,T2时D2组2∶1点明显缩短(P0.05)。与T1时比较,T2时D1组SNRT、CSNRT和TRT明显缩短,2∶1点明显延长(P0.05)。与C组比较,T1、T2时D1组和D2组SNRT、CSNRT和TRT明显延长,T1时D1组和D2组2∶1点明显缩短,T2时D2组2∶1点明显缩短(P0.05)。与D1组比较,T1、T2时D2组SNRT、CSNRT和TRT明显延长,2∶1点明显缩短(P0.05)。结论 10μg/kg负荷剂量右美托咪定泵注结束后对家兔窦房结和房室结功能抑制较显著,并在短时间内有所恢复(≤1h),而60μg/kg负荷量抑制效应更明显,并持续抑制窦房结和房室结功能。     

Left Atrial Appendage Outflow Velocity Index is Superior to Conventional Criteria for Prediction of Maintenance of Sinus Rhythm after Cardioversion. An Echocardiographic Study in Patients with Atrial Fibrillation of a Few Months' Duration

Objective - To investigate whether left atrial appendage outflow velocity alone or in relation to left atrial diameter is a superior predictor of sinus rhythm maintenance after cardioversion compared with traditional clinical or echocardiography parameters. Design - Sixty-two patients with their first episode of atrial fibrillation were examined using echocardiography before DC-cardioversion. At one month's follow-up, 42 patients had maintained sinus rhythm (group A), and 20 had relapsed into atrial fibrillation (group B). There were no differences in arrhythmia duration or antiarrhythmic therapy between the groups. Results - Left atrial diameter measured by echocardiography was smaller in group A (42 mm, 95% CI 40.9-44.1 mm) compared with group B (46 mm, 95% CI 43.4-48.2, p < 0.05). Patients in group A had a higher left atrial appendage outflow velocity at 0.44 m/s (95% CI 0.39-0.49) compared with 0.34 m/s (95% CI 0.30-0.37) in group B (p < 0.01). The ratio of left atrial appendage flow to left atrial diameter was 0.011 (95% CI 0.009-0.012) in group A compared with 0.008 (95% CI 0.007-0.009) in group B, and 63% (95% CI 33-78) of the patients in group A had velocity ratio >0.009 compared with 20% (95% CI 2-38) in group B, (p < 0.01). Stepwise multiple logistic regression analysis showed that a velocity ratio >0.009 was the only predictor for maintenance of sinus rhythm one month after cardioversion with an odds ratio of 6.4 (95% CI 1.9-23.8), (p = 0.004). Conclusion - The ratio of left atrial appendage outflow velocity to left atrial diameter is superior to the traditionally used criteria for prediction of maintenance of sinus rhythm following DC-conversion of first-episode atrial fibrillation.     

Gluteo-vaginal fistula after posterior intravaginal slingplasty: a case report

In patients with posthysterectomy prolapse of the vaginal vault, the posterior intravaginal slingplasty (posterior IVS, Tyco Healthcare, USA) has been suggested as an alternative to traditional vaginal vault suspensions. The goal of this technique is to recreate the uterosacral ligaments and to reinforce the rectovaginal fascia with the use of prosthetic material. We report the case of a 53-year-old woman with a history of 27 months of perineal suppurative discharge after she underwent a vaginal vault prolapse and rectocele repair using a posterior IVS (Tyco Healthcare®, USA). The IVS tape was reinforced by interposing a rectovaginal monofilament polypropylene mesh (Parietex®, Sofradim®, France). Imaging studies and surgical exploration confirmed infection of the IVS mesh with the formation of a gluteo-vaginal fistula while the rectovaginal mesh was intact.     

Impact of Anatomical Difference of the Cerebral Venous System on Microcirculation in a Gerbil Superior Sagittal Sinus Occlusion Model

Sinus-vein thrombosis (SVT) is known to have a wide spectrum of clinical manifestations, and the formation of venous collateral pathways is considered to be one of the most important factors influencing the individual outcome. Here, we examined the relationship between the anatomical differences in bridging veins and cerebral microcirculation in a gerbil superior sagittal sinus (SSS) occlusion model. In male Mongolian gerbils (n=26), the SSS was ligated close to the confluence sinuum. Four additional animals served as the sham-operated control. Regional cerebral blood flow (rCBF) and haemoglobin oxygen saturation (HbSO2) were assessed by Laser-Doppler flowmetry and a microspectrophotometric method at 36 identical locations in the both hemispheres every 20 minutes for 120 minutes after ligation using a "scanning" technique. Furthermore, we examined change in the diameter of the bridging vein by fluorescence angiography and brain damage by histological investigation after 48 hours. Based on the anatomical findings, the hemispheres were classified into two groups: group A with one bridging vein, n=24/52 sides (46.2%) and group B with more than two bridging veins, n=28/52 sides (53.8%). Significant decreases in rCBF (P<0.05) and rHbSO2 (P<0.05) were seen from 20 minutes after the ligation to the end of the experiment in group A, but not in group B. A detailed analysis of individual cases in changes of local (l) CBF and lHbSO2 revealed three patterns: 1) pattern-1, no change; 2) pattern-2, decrease with following recovery; 3) and pattern-3, decrease without recovery. There were no significant differences in the diameter of the bridging vein and no venous infarction in either groups. The group A frequency, which consisted of pattern-3 (58.3%)>pattern-2 (29. 2%)>pattern-1 (12.5%), was opposite to that of group B, which consisted of pattern-1 (71.4%)>pattern-2 (25.0%)>pattern-3 (3.6%) (P<0.001). Based on the results of this study, the anatomical structure and an opening of the collateral pathways of the venous drainage system are closely related to microcirculatory alterations after venous occlusion. The experimental model is suitable for the study of the pathophysiological mechanism responsible for the high variability of SVT.     

An unusual and life-threatening cause of epigastric pain presenting to the general surgical team: a case report

As general surgeons, we are regularly referred patients with epigastric pain. There are a huge number of common pathologies which cause this complaint, most of which are gastrointestinal in origin. Although the old adage goes ’common things are common’, we must always keep our minds open to the possibility of the uncommon and not miss warning signs which are present in the history or examination. We present the case of a 59-year-old woman with a ruptured sinus of Valsalva aneurysm presenting to the accident and emergency department as epigastric pain.     

两种封堵器治疗主动脉窦瘤破裂的疗效及安全性

目的探讨应用动脉导管未闭(PDA)封堵器和室间隔缺损(VSD)封堵器治疗主动脉窦瘤破裂的疗效和安全性。方法对19例主动脉窦瘤破裂患者,按所用封堵器分为PDA封堵器组和VSD封堵器组,根据升主动脉造影结果,选择比破口直径大2~5mm的PDA封堵器或VSD封堵器进行经导管介入封堵。术后随访观察临床症状、心电图、残余分流、封堵器形态、有无瓣膜反流等情况。结果两组患者年龄、发病时间和术前TTE所示破口直径、主动脉造影示破口直径差异均无统计学意义(P均0.05)。19例均经升主动脉造影确诊为主动脉窦瘤破裂,其中15例右冠状动脉窦瘤破裂入右心室,3例为右冠状动脉窦瘤破裂入右心房,1例无冠状动脉窦瘤破裂入右心室;共使用PDA封堵器10枚,VSD封堵器11枚,成功率分别为60.00%(6/10)和90.91%(10/11)。术后随访6个月~6年,未发生血栓事件,无瓣膜反流,无心律失常、感染性心内膜炎、心力哀竭及死亡。结论经导管介入治疗主动脉窦瘤破裂安全有效;应用VSD封堵器较PDA封堵器有一定优势。     

Rosai-Dorfman disease mimicking meningiomatosis: a case report

Rosai-Dorfman disease (RDD), also known as sinus histocytosis with massive lymphadenopathy, is a rare idiopathic histioproliferative disease affecting the lymph nodes. Although extranodal involvement has been reported in diverse sites, central nervous system manifestations, particularly in the absence of nodal disease with clinical and radiological findings suggestive of meningioma, are extremely rare. Histopathology and immunohistochemistry are essential for a positive diagnosis. We report a case of RDD in a patient presenting multiple meningeal nodules with a review of the literature and discussion of differential diagnosis.     

Successful treatment of increased intracranial pressure by barbiturate therapy in a patient with severe sinus thrombosis after failure of osmotic therapy. A case report

Summary A patient with sinus thrombosis and characteristic magnetic resonance imaging (MRI) findings, who was managed successfully by barbiturate therapy, is reported. MRI showed massive highintensity lesions on T2-weighted image which indicated venous cerebral infarction and brain oedema. Intravenous infusion of thiopental decreased increased intracranial pressure (ICP). The effectiveness of barbiturate therapy is discussed in terms of the similarity between this case and experimental sinus thrombosis. Barbiturate therapy should be considered in cases of severe sinus thrombosis with elevated ICP.     

Current trends in the management of frontal sinus fractures

The majority of frontal sinus fractures are sustained by young male adults involved in vehicle accidents. Treatment of these fractures is of paramount importance because of the anatomical relationship of the sinus with the brain and the delicate periorbital region. The optimal treatment of frontal sinus fractures remains controversial. However, most authors would accept an open exploration and obliteration of the sinus in the presence of a depressed or displaced anterior wall fracture or injury to the nasofrontal duct. A successful obliteration requires meticulous extirpation of the frontal sinus mucosa, removal of the inner cortex of bone and permanent occlusion of the nasofrontal duct. If the posterior wall is involved, a concomitant dural tear is a common phenomenon. The main goal in this case is the restoration of the dural integrity and the isolation of the intracranial contents from the outer environment. Devastating complications such as meningitis, encephalitis or brain abscess are quite uncommon nowadays. Nevertheless, late development of invasive mucoceles is not a rarity and therefore long-term follow-up is mandatory.     

经导管封堵主动脉窦瘤破裂

目的探讨经导管介入封堵主动脉窦瘤破裂的临床疗效。方法7例主动脉窦瘤破裂患者,5例为主动脉无冠状动脉窦（无冠窦）破裂至右心房,2例为主动脉右冠状动脉窦（右冠窦）破裂至右心室。对5例患者经同侧的右股动、静脉建立轨道,应用PDA单盘蘑菇伞封堵器进行封堵;对2例患者经同侧右桡动脉及右股静脉建立轨道,置入“细腰大边”的室间隔封堵器。结果7例患者均封堵成功,技术成功率100％;仅2例患者出现微量残余分流,术后2天心脏超声证实完全封闭,无相关并发症。术后1、3、6个月超声心动图显示舒张末期左心室内径均较术前明显改善,封堵器形态、位置良好,无残余分流及主动脉瓣反流。结论介入封堵主动脉窦瘤破裂微创、有效,近期疗效尚满意,中远期的疗效有待进一步随访观察。对于合并心力衰竭或心功能控制不满意的患者,经桡动脉建立轨道是有益的尝试。