Giant cavernous hemangioma of the adrenal gland

INTRODUCTIONCavernous hemangioma of the adrenal gland is a rare non-functioning benign neoplasm.PRESENTATION OF CASEA 62-year-old woman with chronic obstructive pulmonary disease was diagnosed as having an incidental non-functioning adrenal tumor. Because of the impossibility of ruling out the presence of malignancy, conventional surgical resection was carried out. The histopathology revealed a 12.5 cm × 11.5 cm × 8 cm adrenal mass with large and lacunae vascular spaces lined with mature endothelial cells. These findings were compatible with cavernous hemangioma.DISCUSSIONThe majority of patients in the literature underwent surgical resection due to the impossibility of excluding malignancy, because of related symptoms in patients with large masses, or because of the risk of spontaneous tumoral rupture.CONCLUSIONThese tumors are quite infrequent. Due to the low frequency and the lack of specific symptoms, most adrenal hemangiomas are diagnosed postoperatively.     

Magnitude of surgical burden associated with pediatric intestinal failure: A multicenter cohort analysis

BackgroundPediatric intestinal failure (IF) patients require many surgical procedures over the course of their illness. The number and variety of surgical procedures, as well as patient characteristics associated with this burden of surgical procedures, remain largely unknown.MethodsData from a large, multicenter retrospective study of pediatric intestinal failure (PIFCON) were reviewed. Infants from 14 multidisciplinary IF programs were enrolled, with study entry defined as PN dependence for > 60 days.ResultsA total of 272 infants were followed for a median (IQR) of 33.5 (16.2, 51.5) months, during which time they underwent 4.0 (3.0, 6.0) abdominal surgical procedures. Intestinal resections were performed in 88/97 (92%) necrotizing enterocolitis patients versus 138/175 (80%) in non-NEC patients (P < 0.05). Patients who underwent ≥ 5 operations had more septic events, compared to those who underwent ≤ 2 operations (3 (1, 6) versus 1 (0, 3), respectively, P < 0.01). Patients treated at centers with transplantation capability had lower odds of undergoing > 2 abdominal operations [OR 0.37 (95% CI: 0.21, 0.65)] after multivariable adjustment.ConclusionsIndividual and center-specific characteristics may help determine surgical practices experienced by infants with IF. Further study may delineate additional details about the nature of these characteristics, with the goal of optimizing patient care and minimizing individual and overall healthcare burden.     

Nossa experiência clínica e resultados no acompanhamento de casos de cisto hidático

Background and objectivesHydatid cyst is a zoonotic disease caused by Echinococcus granulosus. The aim of our study is to present the clinical features of the patients who were treated for hydatid cyst, determine the interventional techniques and anesthesia methods used and review the occurred complications in detail.MethodsThis study included 393 patients who were followed up and/or treated with the diagnosis of hydatid cyst between January 2013 and November 2018. The patients’ data was evaluated retrospectively.ResultsThe mean age of the patients was 31.0 ± 17.2 years. Of the patients, 111 (28.4%) had more than one cyst and 36 (9.2%) patients had multi‐organ involvement. Six of the patients refused the intervention or was transferred to another hospital. Among the remaining 387 patients, 335 (85.2%) received general anesthesia and intubation, 9 patients (2.3%) received general anesthesia and laryngeal mask airway, 39 patients (9.9%) received sedoanalgesia and 4 patients (1%) received regional anesthesia. Perioperative mortality was developed in one patient. The most common periopertaive complication was allergic reaction (1.5%), whereas the most common post‐operative complications were atelectasis (3.3%) and biliary fistula (3%). The mean Intensive Care Unit stay (ICU) was 1.9 ± 1.1 days in patients requiring ICU. Recurrence during the 40 ± 17 months follow‐up occurred in 8.4% patients.ConclusionsAnesthesiologists have an important role in the management of hydatid cyst patients. Patients should be evaluated exhaustively in terms of multi‐organ involvement and the presence of more than one cyst in the same organ. The type of treatment procedure and the localization of the cysts determine the anesthetic management.     

Characteristics of gastroesophageal reflux in adults with cystic fibrosis

BackgroundGastroesophageal reflux (GER) in adults with cystic fibrosis (CF) is poorly characterized. This study examines the frequency and predictors of GER symptoms and their relationship to lung function in adults with CF.MethodsCross-sectional study of adults at the University of Minnesota CF Clinic using two validated self report surveys: The Mayo GER questionnaire and the GERD Symptom Assessment Scale (GSAS).ResultsOf 274 invited patients, 201 (73%) completed the surveys and 173 performed spirometry at the same visit. Frequent symptoms (at least weekly) were reported by 24% of the patients and an additional 39% experienced occasional symptoms. Heartburn, acid regurgitation and dysphagia were the most common symptoms and 18% reported that GER symptoms worsened their respiratory condition. Females and patients reporting weight loss had more symptoms (mean GSAS symptom score 4.9 vs. 4.0, p = 0.025 and 5.3 vs. 4.2, p = 0.04) and more severe symptoms (mean GSAS distress score 5.6 vs. 3.8, p = 0.005 and 6.8 vs. 4.0, p = 0.01) compared to males and those who did not report weight loss. Patients on acid suppression (n = 122, 61%) continued to report heartburn (n = 80, 66%) and acid regurgitation (n = 47, 23%). GER symptoms and severity of symptoms were not predictive of FEV₁ or FVC.ConclusionsGER symptoms were present in a majority of patients. Females and patients with weight loss require special attention to their GER symptoms. Many patients on acid suppression continued to be report symptoms.     

Cyst decreased in size post maxillary sinus floor augmentation surgery in diabetic patient: A case report

IntroductionWhether mucosal cyst of maxillary sinus is contraindication for sinus floor augmentation surgery has been a controversial hot spot for years.Presentation of caseThis case aims to present the surgical procedure of sinus floor augmentation surgery with cyst (18.72 mm × 24.61 mm) in diabetic patient. And 6 months later, the cyst decreased in size. The authors elevated the sinus floor and cyst simultaneously. The surgery was carried out successfully without sinus membrane perforation and the alveolar ridge gained about 8 mm height. Six months later, the cyst decreased in size and osseointegration was observed.DiscussionInterdisciplinary cooperation is encouraged to diagnose benign mucosal cyst. The isolation between sinus lumen and the grafted sub-sinus space is important. Graft contamination or dispersion into the sinus lumen should be avoided. The integrity of the sinus membrane and use of antibiotics are very important to prevent the occurrence of postoperative sinus infectionConclusionThe authors conclude that sinus augmentation surgery could be done with mucosal cyst in diabetic patient.     

Intratendinous ganglion cyst of the extensor digitorum longus tendon: A case report

IntroductionGanglion cysts are benign lesions, common in the hand and wrist. Intratendinous ganglion, however, are rare. We present the first reported case of an intratendinous ganglion cyst in an extensor digitorum longus (EDL) tendon of the foot.Case reportA 35-year old presented with a left-sided painful dorsolateral foot swelling. Ultrasound suggested a ganglion cyst in proximity to the EDL tendon of the 5th toe. Two distinct swellings were identified on surgical exploration, including a 6 × 1 cm ganglion lying within the EDL tendon substance that had resulted in tendon splitting. The lesions were excised and EDL tendon repaired. Histological analysis confirmed that both lesions were ganglion cysts. Post-operative recovery was uneventful.DiscussionIntratendinous ganglion cysts are rare lesions that pose a unique set of diagnostic and treatment challenges. Unlike conventional ganglion, their diagnosis may not be possible until surgical exploration. They have been reported to increase the risk of spontaneous tendon rupture. As such, a lower operative threshold should be applied to prevent their progression. A high index of suspicion should be applied to any ganglion reported radiologically to be in close contact with tendons. If diagnosed upon surgical exploration, it is essential that the operating surgeon is prepared to appropriately modify the procedure to involve primary tendon repair, tendon transfer or tenodesis.     

Hiperparatiroidismo primario y crisis hipercalcémica aguda tóxica

ObjectivesTo describe the clinical characteristics and surgical treatment of patients with acute hypercalcaemia due to primary hyperparathyroidism (PHPT) and compare them with other patients with PHPT without associated acute hypercalcaemia.Material and methodsA prospective, observational study (1998-2010) was conducted on 158 patients with PHPT treated by parathyroidectomy. Those with acute hypercalcaemia (>14 mg/dl -3.5 mmol/L- or >3 mmol/L with symptoms of calcium toxicity) were evaluated by recording their clinical and treatment characteristics, and comparing them, using the Mann-Whitney U test and the Fisher test, with the 146 PHPT patients without hypercalcaemic crisis.ResultsTwelve patients (7.6%) had acute hypercalcaemia with symptoms of calcium toxicity and other symptoms of chronicity. The preoperative calcium and PTH values were 14.5 ± 1.3 mg/dL and 648.2 ± 542 pg/dL, respectively. There were 10 adenomas, 1 hyperplasia and 1 carcinoma. The mean weight of the surgical pieces was 4.075 ± 2.918 mg, with a diameter greater than 27 ± 14 mm. The gradients of PTH at 10 and 25 minutes were 79 ± 18% and 92 ± 6%, respectively. Post-operative calcium values on discharge and at 6 months were 8.2 ± 0.7 mg/dL and 9.1 ± 0.9 mg/dL, respectively. The plasma concentrations of calcium, PTH, and the size of the surgical pieces were higher in patients with hypercalcaemic crisis (P<0.001). There were no differences in the other parameters studied or in the cure rate.ConclusionsHypercalcaemic crises were caused by larger and heavier tumours that led to higher plasma Ca and PTH plasma concentrations. All patients had long-standing symptoms and parathyroidectomy led to cure of the disease.     

Linking systemic angiogenic factors (VEGF,angiogenin, TIMP-2) and Doppler ultrasound to anti-inflammatory treatment in rheumatoid arthritis

ObjectiveTo evaluate an association between synovial Doppler flow and serum levels of vascular endothelial growth factor (VEGF), angiogenin and TIMP-2 in patients with rheumatoid arthritis during anti-inflammatory treatment with glucocorticoids and TNF-α inhibitors.MethodsInflamed wrists of 15 patients with rheumatoid arthritis (RA) were examined by two independent ultrasound investigators prior to and at days 3, 7, 14 and 42 after the initiation of treatment with glucocorticoids in therapy-naïve patients or after the beginning of a therapy with a TNF-α inhibitor in patients with DMARD failure. Quantitative three-dimensional power Doppler ultrasonographic assessment of synovial vascularization was compared at each visit with serum levels of VEGF, angiogenin and TIMP-2.ResultsIn the glucocorticoid group, synovial Doppler signals decreased significantly at day 3 (?44%; P = 0.003) in comparison to a delayed decrease in the TNF-α inhibitor group after 6 weeks (?46%; P = 0.001). A significant reduction of serum VEGF levels could be determined with a delay of 1 week after the decrease of Doppler activity but no correlation was found between both parameters (rho: P = 0.7; r = ?0.03). Angiogenin concentrations decreased in the TNF group and increased in the GC group. Levels of TIMP-2 did not change significantly in both groups.ConclusionThe decrease of serum VEGF levels under treatment with glucocorticoids or TNF-α inhibitors followed the reduction of the intra-articular synovial Doppler flow. This result supports the idea that the reduction of synovial perfusion due to anti-inflammatory treatment is not regulated by systemic VEGF, but that the inflamed joints are the source for circulating VEGF.     

Polyarticular sonographic assessment of gout: A hospital-based cross-sectional study

ObjectiveTo assess the sonographic frequency of synovial effusion, synovial hypertrophy, synovitis, and double contour sign at joints commonly affected by gout and whether these features differ according to serum urate levels, disease duration, and use of urate-lowering therapy.MethodsParticipants with gout were recruited from rheumatology clinics. A detailed clinical assessment was undertaken of gout history, co-morbidities, medication, alcohol consumption, height, weight, clinical synovitis, tophi, and serum urate. Sonographic examination of the metatarsophalangeal joints, ankles, knees, metacarpophalangeal joints, wrists and elbows for synovial effusion, synovial hypertrophy, synovitis and double contour sign was undertaken. The mean number of joints affected were compared according to serum urate (< 360 μmol/L versus ≥ 360 μmol/L), urate-lowering therapy (yes/no), and disease duration (≤ 5 years versus > 5 years).ResultsForty patients participated in the study. Synovial effusion, synovial hypertrophy, synovitis, and double contour sign were identified in 36 (90%), 38 (95%), 24 (62%) and 37 (93%) participants respectively. Synovial effusion was seen most frequently at the knee (right 70%, left 68%) followed by the first metatarsophalangeal (right 48%, left 40%) and lesser metatarsophalangeal joints (right 45%, left 35%). Synovial hypertrophy, synovitis, and double contour sign were seen most frequently at the first metatarsophalangeal joint (hypertrophy: right 65%, left 60%; synovitis: right 18%, left 18%; double contour: right 60%, left 68%). These findings did not differ according to serum urate, disease duration, or use of urate-lowering therapy.ConclusionPolyarticular sonography frequently identifies synovial effusion, synovial hypertrophy, synovitis and double contour sign in patients with gout, particularly at the metatarsophalangeal joints and knees.     

Simple radiographic assessment of bone quality is associated with loss of surgical fixation in patients with proximal humeral fractures

AimThis study aimed to determine if the ratio of cortical thickness to shaft diameter of the humerus, as measured on a simple anterior-posterior shoulder radiograph, is associated with surgical fixation failure.Patients and Methods64 consecutive fractures in 63 patients (mean age 66.1years, range 35–90) operated with surgical fixation between March 2011 and July 2014 using PERI-LOC locking plate and screws (Smith and Nephew, UK) were identified. Predictors of bone quality were measured from preoperative radiographs, including ratio of the medial cortex to shaft diameter (medial cortical ratio, MCR). Loss of fixation (displacement, screw cut out, or change in neck-shaft angle >4 degrees) was determined on follow-up radiographs.ResultsLoss of fixation occurred in 14 patients (21.9%) during the follow up. Patients were older in the failure group 72.8 vs. 64.2 years (p = 0.007). The MCR was significantly lower in patients with failed fixation 0.170 vs 0.202, p = 0.019. Loss of fixation is three times more likely in patients with a MCR <0.16 (41% vs. 14%, p = 0.015). Increased fracture parts led to increased failure rate (p = 0.0005).ConclusionMedial cortex ratio is significantly associated with loss of surgical fixation and may prove to be a useful adjunct for clinical decision making in patients with proximal humeral fractures.     

Outcome of percutaneous rupture of lumbar synovial cysts: a case series of 101 patients

Background contextLumbar facet joint synovial cysts are benign degenerative abnormalities of the lumbar spine. Previous reports have supported operative and nonoperative management. Facet joint steroid injection with cyst rupture is occasionally performed, but there has been no systematic evaluation of this treatment option.PurposeTo profile the role of facet joint steroid injections with cyst rupture in the treatment of lumbar facet joint synovial cysts.Study design/settingRetrospective chart review and long-term follow-up of patients treated for lumbar facet joint synovial cysts.Patient sampleOne hundred one patients treated for lumbar facet joint synovial cysts with fluoroscopically guided corticosteroid facet joint injection and attempted cyst rupture.Outcome measuresOswestry Disability Index and numeric rating scale score for back and leg pain.MethodsA retrospective review and a subsequent interview were conducted to collect pretreatment and posttreatment pain and disability scores along with details of subsequent treatment interventions. Group differences in pain and disability scores were assessed using paired t test. Multiple clinical factors were analyzed in terms of risk for surgical intervention using logistic regression modeling and Cox proportional hazards modeling.ResultsSuccessful cyst rupture was confirmed fluoroscopically in 81% of cases. Fifty-five patients (54%) required subsequent surgery over a period averaging 8.4 months because of inadequate symptom relief. All patients reported significant improvement in back pain, leg pain, and disability at 3.2 years postinjection, regardless of their subsequent treatment course (p<.0001 in all groups). There was no significant difference in current pain between patients who received injections only and those who underwent subsequent surgery.ConclusionsThis study presents the largest clinical series of nonsurgical treatment for lumbar facet joint synovial cysts. Lumbar facet joint steroid injection with attempted cyst rupture is correlated with avoiding subsequent surgery in half of treated patients. Successful cyst rupture does not appear to have added benefit, and it was associated with worse disability 3 years postinjection. Long-term outcomes are similar, regardless of subsequent surgery.     

Sintomas psiquiátricos em pacientes com lúpus eritematoso sistêmico: frequência e associação com atividade da doença com o uso do Questionário de Morbidade Psiquiátrica em Adultos

IntroductionWhile the neurolupus criteria are well-established, global psychiatric manifestations are of variable frequency in patients with systemic lupus erythematosus (SLE); their relation with disease activity is unknown.ObjectiveTo evaluate the frequency of psychiatric symptoms in SLE using the Adult Psychiatric Morbidity Questionnaire (APMQ); to correlate APMQ changes with disease activity and socio-economic variables.Materials and methodsThis cross-sectional study evaluated patients with active or inactive SLE as to the prevalence of psychiatric symptoms utilizing, for the first time, the APMQ. Eight or more affirmative replies out of 45 questions defined the APMQ as abnormal. Patients were classified according to the American Collge of Rheumatology 1997 criteria, and disease activity was measured by the SLEDAI.ResultsSeventy-two SLE patients entered the study, being 68 females (94.4%). Mean age was 46.1 years ( ± 12 SD). The frequency of abnormal APMQ was of 89%. Out of the 64 SLE patients with altered APMQ, 60 (93.7%) had common mental disorders, mostly anxiety and somatization. There was no correlation of psychiatric symptoms with active disease (rs = 0.09; P = 0.46), or with history of psychosis and/or seizures attributable to SLE (P = 1.00). Psychiatric symptoms also did not correlate with age at disease onset (rs = 0.16) or disease duration (rs = 0.11). There was an association of abnormal APMQ with low education level (P = 0.02), but not with family income allotted to the patient (P = 0.24).ConclusionThe frequency of psychiatric symptoms measured by the APMQ was high in our SLE population. An abnormal APMQ was disconnected from SLE activity, but it did associate with low education level.     

Diagnostic performance of isolated orbital CT scan for assessment of globe rupture in acute blunt facial trauma

ObjectivesWe determine the diagnostic performance of emergent orbital computed tomography (CT) scans for assessing globe rupture in patients with blunt facial trauma.MethodsWe performed a retrospective cohort study based on prospectively collected trauma registry and acute care surveillance data in a tertiary-care hospital. Patients aged at least 18 years who underwent isolated orbital CT scanning for assessing potential ocular trauma were examined. Analyses were performed to evaluate the magnitude of agreement between diagnosis by CT scanning and ophthalmic assessment, including globe rupture.ResultsOur study cohort comprised 136 patients, 30% of whom (41 patients) sustained orbital wall fractures. Concordance for orbital CT diagnosis and the ophthalmic assessment of globe rupture was substantial (k = 0.708). The relative risk of globe rupture was 0.692 (95% confidence interval (CI): 0.054–8.849) for superior wall fractures, 0.459 (95% CI: 0.152–1.389) for inferior wall fractures, 2.286 (95% CI: 1.062–4.919) for lateral wall fractures, and 0.637 (95% CI: 0.215–1.886) for medial wall fractures. According to multivariate analysis, lateral wall fractures were an independent risk factor for globe ruptures (adjusted odds ratio (OR) = 12.01, P = 0.011), and medial or inferior wall fracture was a protective factor (adjusted OR = 0.14, P = 0.012). In the stratified analysis of diagnostic performance of CT scan, specificity was highest among patients with orbital wall fractures (97.2%), followed by negative predictive volume (NPV, 97%), and accuracy (95.1%).ConclusionAmong patients with blunt facial trauma who underwent isolated orbital CT scanning as part of ocular trauma assessment, the diagnostic performance of CT in detecting globe rupture is more accurate in patients with orbital wall fractures. Nevertheless, isolated orbital CT alone does not have a sufficiently high diagnostic performance to be reliable to rule out all globe ruptures. Lateral orbital wall fractures in blunt facial trauma patients, in particular, should prompt thorough evaluation by an ophthalmologist.     

Impacto de la presentación tardía al servicio de Urgencias por cólico renal agudo en los resultados bioquímicos y clínicos

Introduction and objectiveTo verify the impact of delay on biochemical and clinical outcomes for patients presenting to the emergency department (ED) with acute renal colic.Materials and methodsData were retrospectively collected from 3 institutions of 2 European countries between 01 January and 30 April 2020. Patients who presented to the ED with unilateral or bilateral renal colic caused by urolithiasis confirmed by imaging tests during the study period were included. A presentation after 24 hours since the onset of symptoms was considered a delay. Patients presenting before 24 hours from the symptom onset were included in Group A, while the patients presenting after 24 hours in Group B. Clinical and biochemical parameters and management were compared.Results397 patients who presented to ED with confirmed urolithiasis were analyzed (Group A, n = 199; Group B, n = 198. The median (IQR) delay in presentation was 2 days (1,5-4). At presentation, no statistically significant differences were found amongst the 2 groups of patients regarding presenting symptoms such as fever and flank pain, and the median serum levels of creatinine, C reactive protein and white blood cells. No differences were found in terms of conservative or operative management.ConclusionsDelay in consultation >24 hours is not associated with worsening biochemical parameters and clinical outcomes. Most patients with acute loin pain do not necessarily need urgent attendance to the ED and may be managed in the outpatients.     

Evaluation of the efficacy of endovascular treatment of pelvic congestion syndrome

AimTo assess the efficacy of venous embolization treatment for the pelvic congestion syndrome (PCS).Patients and methodsRetrospective study of 33 female patients undergoing pelvic venous embolization between January 2008 and May 2012 in Bordeaux. The inclusion criteria were clinical symptoms of PCS documented by transabdominal Doppler ultrasound and/or pelvic magnetic resonance imaging. Patients with pelvic varicose veins feeding saphenous varicose veins were excluded. The efficacy of treatment was assessed on a Visual Analog Scale (VAS).ResultsThirty-three patients were included and the mean follow up period was 26 months (3–59 months). The VAS was 7.37 (standard deviation: 0.99) before embolization and 1.36 (standard deviation: 1.73) after embolization (P < 0.0001). Twenty patients reported that their symptoms had completely disappeared, 11 had partially disappeared and two had gained no improvement. A significant fall was found in the number of patients with dyspareunia (P < 0.0001). A single technical embolization failure was reported.ConclusionOur series demonstrates the efficacy of embolization treatment with a significant fall in the VAS in patients with PCS.     

Primary hydatid cyst of pancreas: Case report and review of literature

IntroductionHydatid disease is caused by the larval stage of Echinococcus granulosus. It most commonly affects the liver and lung. Pancreatic hydatid cyst (PHC) is very rare with incidence of 0.14%–2%.Presentation of caseA 40 year old lady presented with epigastric pain for last 3 months. A 5 × 5 cm abdominal lump occupying the epigastric and left hypochondrial region was noted on physical examination. Ultrasonography (USG) and Contrast enhanced Computed Tomogrpahy (CT) revealed a 55 × 57 mm cystic structure in the pancreatic body. Endoscopic ultrasound guided fluid aspiration cytology revealed normal Carcinoembryonic antigen and Amylase levels. Cytological examination was noncontributory. During open surgical exploration, it was found to be a hydatid cyst. After irrigation with scolicidal agent and evacuation of cystic contents, Partial cystectomy with external drainage was done. Histopathological biopsy revealed Hydatid cyst. Post-operative ELISA (Enzyme linked immunosorbent assay) for Echinococcal antigen was positive.DiscussionPHC is a rare entity. Most common mode of spread is hematogenous. Cysts in pancreatic head can present as obstructive jaundice. Cysts in body and tail are usually asymptomatic. USG, CT and Hydaitd serology can help in diagnosis and monitoring recurrence. Surgical exploration is treatment of choice. Options include pericystectomy, partial cystectomy +/− external drainage/omentopexy, marsupialization or cysto-enterostomy. Preoperative and Post-operative anti helminthic (Albendazole) is recommended.ConclusionPHC can masquerade as pseudocyst or cystic neoplasm of pancreas. It should always be considered in the differential diagnosis of cystic pancreatic lesion in patients from endemic regions.     

Influence of depth of neuromuscular blockade on surgical conditions during low-pressure pneumoperitoneum laparoscopic cholecystectomy: A randomized blinded study

Study objectiveTo evaluate the influence of neuromuscular blockade (NMB) on surgical conditions during low-pressure pneumoperitoneum (8 mm Hg) laparoscopic cholecystectomy (LC), while comparing moderate and deep NMB. Secondary objective was to evaluate if surgical conditions during low-pressure pneumoperitoneum LC performed with deep NMB could be comparable to those provided during standard-pressure pneumoperitoneum (12 mm Hg) LC.DesignProspective, randomized, blinded clinical trial.SettingOperating room.PatientsNinety ASA 1–2 patients scheduled for elective LC.InterventionsPatients were allocated into 3 groups: Group 1: low-pressure pneumoperitoneum with moderate-NMB (1–3 TOF), Group 2: low-pressure pneumoperitoneum with deep-NMB (1–5 PTC) and Group 3: standard pneumoperitoneum (12 mm Hg). Rocuronium was used to induce NMB and acceleromiography was used for NMB monitoring (TOF-Watch-SX).MeasurementsThree experienced surgeons evaluated surgical conditions using a four-step scale at three time-points: surgical field exposure, dissection of the gallbladder and extraction/closure.Main resultsLow-pressure pneumoperitoneum (Group 1 vs. 2): good conditions: 96.7 vs. 96.7%, 90 vs. 80% and 89.6 vs. 92.3%, respectively for the time-points, p > 0.05. No differences in optimal surgical conditions were observed between the groups. Surgery completion at 8 mm Hg pneumoperitoneum: 96.7 vs. 86.7%, p = 0.353.Standard-pressure pneumoperitoneum vs. low-pressure pneumoperitoneum with deep NMB (Group 3 vs. 2): good conditions: 100% in Group 3 for the three time-points (p = 0.024 vs. Group 2 at dissection of the gallbladder). Significantly greater percentage of optimal conditions during standard-pressure pneumoperitoneum LC at the three time points of evaluation.ConclusionsThe depth of NMB was found not to be decisive neither in the improvement of surgical conditions nor in the completion of low-pressure pneumoperitoneum LC performed by experienced surgeons. Surgical conditions were considered better with a standard-pressure pneumoperitoneum, regardless of the depth of NMB, than during low-pressure pneumoperitoneum with deep NMB.     

Outcome of the TURP-TUVP sandwich procedure for minimally invasive surgical treatment of benign prostatic hyperplasia with volume larger than 40cc over a 4-year period in Nigeria

IntroductionTransurethral resection of the prostate (TURP) remains the reference standard for the surgical treatment of infravesical obstruction due to benign prostatic hyperplasia (BPH). While TURP has proven long-term efficacy, it has some associated morbidities. This has fuelled the drive to develop alternative cost-effective options with comparable functional outcomes and a superior safety profile.ObjectivesThe aim of this study was to evaluate transurethral electro-vaporization of the prostate (TUVP) combined with TURP as a “sandwich” procedure in relieving the obstruction caused by BPH with volume of 40-80cc.Patients and MethodsThe medical notes of 57 consecutive patients with moderate to severe bladder outflow symptoms due to BPH who underwent TURP-TUVP as a sandwich procedure from April 2007 to March 2011 were reviewed for prostatic volume, duration of surgery, volume of irrigation fluid used intra-operatively and post-operative hospital stay. Similarly, the patients IPSS, Qmax and PVR were evaluated pre- and postoperatively.ResultsThe mean patient age was 64.1 years (SD = 9.1), mean prostatic volume was 56.8 cc (SD = 8.9), mean resection time was 69.5 minutes (SD = 23.9) and mean volume of irrigation fluid (1.5% Glycine) used was 21.5 L (SD = 4.9).The mean post-operative hospital stay was 3.5 days (range 3- 4 days). Overall, 11 (19%) patients had blood transfusion, there was no incidence of TUR syndrome and one mortality was recorded from primary plasminolysis. Compared with baseline values, on follow-up at 3 months the IPSS, Qmax and PVR had improved significantly. Bladder neck stenosis occurred in 3 patients and was successfully treated with bladder neck incision.ConclusionsThe sandwich combination of TURP and TUVP for the surgical treatment of BPH with volume larger than 40cc had satisfactory patient safety profile and resulted in significant improvement in IPSS, Qmax and PVR on follow-up at 3 months.