Surgical emergencies in pregnancy in the era of modern diagnostics and treatment

Pregnancy can be complicated with different surgical emergencies which may potentially endanger the mother as well as foetus. In the modern era of advanced diagnostics and treatments, neither of them in response to a surgical emergency in a pregnant woman should be delayed. Appropriate early intervention is essential to decrease the morbidity and mortality. Following article encompasses common surgical emergencies that can arise in a pregnant woman and tries to suggest the approach that may be taken to reduce the burden of morbidity and mortality.     

Cleft closure for the treatment of unhealed perineal sinus

OBJECTIVE: Despite improvements in surgical practice, persistent perineal wound sinus is still a common complication after proctectomy. This study presents the success of a modified cleft closure technique in dealing with this problem. METHODS: From May 1997 patients with a persistent perineal sinus after surgery underwent a cleft closure - similar to that performed for patients with pilonidal sinus disease. RESULTS: Eight patients (6 male, 2 female) with an average age of 52 years underwent a cleft closure for a persistent perineal sinus after surgery. Four patients had undergone a proctocolectomy (ulcerative colitis), 2 an abdominoperineal excision of the rectum (adenocarcinoma) and 2 a proctectomy (1 Crohn's disease, 1 complication of diverticular disease). Symptoms had been present for an average of 41 months (range 5-152 months) and 3 patients had undergone other procedures attempted previously to deal with the problem. The first three patients had the procedure as an inpatient with an average stay of 4.7 days. The next 5 patients had the procedure as a day case (2 local anaesthetic, 3 general anaesthetic). Two patients developed a postoperative wound infection and all but one wound had healed completely by 8 weeks. In this patient the procedure was repeated to achieve healing. There was no other associated morbidity and no postoperative deaths. There have been no recurrences to date. CONCLUSION: Modified cleft closure for persistent perineal sinus is a simple procedure with low morbidity that can be performed under local anaesthetic in the day surgery unit.     

TANDEM URETEROCYSTOPLASTY

Background : Bladder augmentation may be undertaken by using various gastrointestinal segments but their use is associated with a multitude of well-recognized complications. The mega-ureter has proven to be a satisfactory alternative; in patients with bilateral mega-ureters, both ureters may be used for this purpose. Methods : Seventeen patients had augmentation ureterocystoplasty, including three in whom both distal ureters were used in tandem. The latter included two patients with neurogenic bladder and one with bladder exstrophy. Results : Satisfactory augmentation was achieved in all patients undergoing tandem ureterocystoplasty. The neurogenic bladder patients are managed by urethral clean intermittent catheterization (CIC) and the exstrophy patient is managed by CIC of an appendico-vesicostomy (Mitrofanoff). All are continent. Conclusions : The mega-ureter provides an excellent source of augmentation material in patients with small non-compliant bladders. In those with bilateral mega-ureters, consideration should be given to using both ureters in tandem to achieve the maximum possible bladder capacity.     

Depletion of neuropeptides during wound healing in rat skin

The peptides substance P, calcitonin gene-related peptide and somatostatin are present in nerve fibres in mammalian, including human, skin. There is evidence that in addition to having a putative neurotransmitter role, they may be trophic agents: a study was therefore undertaken of peptide changes during wound healing in rat skin. A significant depletion of the neuropeptides was found in the region of the wound within two days, and this persisted for two weeks. A smaller and delayed depletion also occurred in intact skin of the same dermatome, but not in an adjacent dermatome.     

Zinc depletion and complications of surgery

Zinc is essential for protein synthesis and reduced levels may impair recovery from surgery. To study this prospectively, clinical, anthropometric, haematological and biochemical indices of malnutrition were measured in 46 patients undergoing elective surgery and were related to the frequency and type of post-operative complications. In addition, leucocyte zinc levels, which are an estimate of tissue zinc levels, were measured. The diagnoses of the patients did not correlate with any of these parameters. Many patients were malnourished. 39% of the patients had a post-operative complication, of whom 8 had a wound complication. The frequency of complications as a whole was inversely related to serum albumin and transferrin levels, while wound complications were in addition associated with low leucocyte zinc levels. Malnutrition may therefore increase post-operative complications in general, but tissue zinc deficiency may contribute to wound problems.     

Successful in vitro fertilization in women with Fontan physiology

PurposePatients with single ventricle anatomy palliated with Fontan operation are at risk for thromboembolism, arrhythmia, and heart failure rendering pregnancy high risk or even contraindicated. Infertility and high rates of first trimester miscarriage are not uncommon. In vitro fertilization (IVF) with or without gestational surrogacy can be an option, but poses risks during ovarian stimulation, oocyte retrieval, and the post-procedural period. We present six cases of women with complex congenital heart disease status post Fontan operation who underwent successful IVF.MethodsCase series from a single-center tertiary care setting.ResultsIndications for referral were cardiac or fertility concerns for pregnancy of the congenital cardiologist. One woman had mild volume overload after oocyte retrieval requiring furosemide and one experienced post-operative colitis. There were no thrombotic complications.ConclusionsA multidisciplinary team-based approach can result in successful oocyte retrieval and IVF in women with complex congenital heart disease and Fontan physiology.