Intraoperative anoxic spells in patients with tetralogy of Fallot

We experienced 5 cases of intraoperative anoxic spell in 48 patients with tetralogy of Fallot (TOF). One of 5 cases had tetralogy with pulmonary atresia (Type A), and the others had tetralogy alone (Type D). The patient of type A who had anoxic spells during preoperative period had been on chronic propranolol therapy. However, the patients of type D had no anoxic spells during preoperative period and one in this type had not been on beta-adrenergic blocking drugs preoperatively. One patient was anesthetized with fentanyl-diazepam-O2, and the others were anesthetized with morphine-diazepam-O2. We used mainly alpha-adrenergic drugs and sodium bicarbonate for the therapy of intraoperative anoxic spells. Concerning the intraoperative anoxic spell, we have to be aware in the management of the patients with TOF, whether the patient had anoxic spells during preoperative period or not.     

Four-part proximal humerus fractures: evaluation and treatment

Four-part proximal humerus fractures represent a difficult entity in the management of upper extremity trauma. Most of these fractures are not amenable to operative fixation; thus, surgical address is necessarily one of fracture arthroplasty. Timely reestablishment of the Gothic arch using a fracture-specific prosthesis leads reliably to anatomic tuberosity osteosynthesis. Hence, shoulder arthroplasty for fracture should be considered an augmented osteosynthesis, with precise prosthetic implantation supplementing anatomic tuberosity reconstruction. Further investigations are ongoing regarding the use of specific fracture implants and biologic substrates in an attempt to improve further the rate of tuberosity healing in the older patient population after this operation.     

Challenges of laparoscopic colectomy in the obese patient: a review

BACKGROUND: Perioperative care of clinically severely obese patients presents numerous unique challenges. These patients have distinctive issues with regard to cardiovascular, pulmonary, and thromboembolic complications. In addition, hospital equipment must be able to accommodate the body habitus of this population. METHODS: A Medline search using the terms "morbid obesity," "colon resection," "obesity comorbidities," "laparoscopic colectomy," "perioperative challenges," and "risk factors" was performed for English-language articles. Further references were obtained through cross-referencing the bibliography cited in each publication. RESULTS: The authors discussed the most relevant challenges surgeons encounter in the perioperative setting when treating obese patients. COMMENTS: The management of the morbidly obese patient requires meticulous preoperative, intraoperative, and postoperative care. Colorectal surgeons should be familiar with obesity-related problems when treating colorectal disease processes in this patient population. The associated comorbid illnesses in this population, as well as the technical difficulties regularly posed by them, make laparoscopic colectomy a more challenging procedure than normally encountered in the nonobese patient population.     

The Pregnant Patient – Why Do My Feet Hurt?

Although hormonal and anatomical changes that occur during pregnancy have been well documented, how these changes affect foot and ankle function are less understood. Changes during pregnancy in body mass, body-mass distribution, joint laxity, and muscle strength can all contribute to alterations in gait pattern that can lead to pain or injury to the foot and ankle. This review provides an overview of the various foot and ankle anatomic, biomechanic, and kinematic changes that occur during pregnancy. In addition, this article presents the most common causes of foot and ankle symptoms expressed by the pregnant patient population and discuss the management and treatment of each condition.     

Pediatric nasal injuries and management

Although serious trauma injuries are uncommon in the pediatric population, nasal injuries are a more common problem. In this population, many physicians are uncomfortable managing these injuries. The evaluation and treatment of nasal trauma differ considerably in children compared with adult nasal fractures. Poor patient cooperation during the physical exam coupled with significant anatomic differences can present the nasal surgeon with a difficult diagnostic dilemma. The surgical management of pediatric nasoseptal injuries is not without controversy, as disturbing the nasal growth centers can have significant effect on future nasal and midfacial development. This article reviews the diagnostic and therapeutic challenges presented by these injuries for children and provides recommendations to successfully manage nasal injuries in this population.     

Percutaneous fixation of forefoot, midfoot, hindfoot, and ankle fracture dislocations

Open reduction with rigid internal fixation is the basic principle for surgical management in foot and ankle trauma. High-risk patients present a surgical dilemma for the foot and ankle surgeon because the possible complications are magnified in this patient population. Percutaneous fixation is a unique alternative for achieving anatomic stabilization without increased physical strain to the patient. The significant advantages of percutaneous fixation include minimizing damage to the vascular supply, maintaining and preserving a stable soft tissue envelope, and decreasing the potential risk for infection. This article provides an overview of percutaneous surgical fixation methods and their role in foot and ankle trauma for the high-risk patient.     

Prune belly syndrome: treatment of terminal renal failure by hemodialysis and renal transplantation.

The second case of successful renal transplantation in a patient with "prune belly" syndrome is reported. In spite of early aggressive surgical approach in the management of this disease terminal renal failure frequently ensues. Hemodialysis and renal transplantation have offered new possibilities of prolonging life in these patients. The success of renal transplantation depends on the anatomic and functional state of the lower urinary tract. Pretransplant urologic examination is extremely important for the evaluation of urinary tract abnormalities.     

The pediatric patient and thoracic trauma

Trauma remains the leading cause of death for children aged 1 to 14 years. Thoracic trauma is seen in 4% to 6% of pediatric patients presenting to pediatric trauma centers and rarely occurs in isolation. The medical and surgical evaluation of children is a challenging task to even the most experienced physician. Effective treatment of the pediatric trauma patient can only be provided if the physician understands the major pitfalls which are common in the pediatric population. The assessment of the pediatric patient is simplified by an understanding of specific anatomic and physiologic differences between children and adults. While noting children are not small adults, the systematic approach taken towards the evaluation of an adult is similar. Sequential evaluation and management of the ABCs by a caregiver familiar with age specific norms is the most important initial consideration. The care of specific injuries is similar to those found in adults but the patient's size limits the physician's options in many cases.     

Prognostic factors predicting treatment response

Summary This study demonstrated that the anatomic distribution of disease in the patient with renal adenocarcinoma is the single most important factor in predicting the impact of surgical intervention. Ninety-six patients underwent radical nephrectomy for control of renal adenocarcinoma. The survival in this patient population was dependent upon whether the disease was confined to the primary organ of origin or whether it had extended outside the primary organ site. Survivals greater than 90 percent in ten years were experienced for patients with organ confined disease irrespective of the cell type.     

Carpal tunnel syndrome

Carpal tunnel syndrome is the most common compressive neuropathy of the upper extremity. As a result of median nerve compression, the patient reports pain, weakness, and paresthesias in the hand and digits. The etiology of this condition is multifactorial; anatomic, systemic, and occupational factors have all been implicated. The diagnosis is based on the patient history and physical examination and is confirmed by electrodiagnostic testing. Treatment methods range from observation and splinting, to cortisone injection and splinting, to surgical intervention. Both nonsurgical and surgical management provide symptom relief in most patients. The results of open and endoscopic surgery essentially are equivalent at 3 months; the superiority of one technique over the other has yet to be established.     

Apnoeic spells following general anaesthesia in a patient with familial hemiplegic migraine

Hemiplegic migraine is an unusual variant of migraine, characterised by a temporary hemiparesis or hemiplegia associated with headache. We report a patient with hemiplegic migraine who developed atypical migraine with apnoeic spells, aphasia and hemiparesis following general anaesthesia. We review the clinical features of hemiplegic migraine and the considerations for its anaesthetic management.     

Long-term Management of Ureterocele in Duplex Collecting Systems: Reconstruction Implications

Purpose of Review

Significant variance exists in the management of duplex collecting system ureteroceles (DSU). There is a great spectrum in classification, management, and surgical interventions. The practice of performing bladder level operations for vesicoureteral reflux (VUR) and trigonal anatomic distortion, either after ureterocele puncture or in a single setting, has come into question as to whether all DSU patients require it. In this review, we sought to discuss DSU management trends and the need for bladder reconstruction in these patients, as well as to describe our institution’s practices.

Recent Findings

Recent advances regarding DSU management revolve around differing surgical approaches, although adequately powered randomized control trials are lacking. These approaches include nonoperative management, various forms of endoscopic puncture, ureteroureterostomy, and most recently upper pole ureteral ligation. A common theme appears to reflect the acceptance that “less is more” when it comes to managing DSU.

Summary

There is no consensus for the decision to treat or the surgical approach of DSU. Ureteral reimplantation and bladder neck reconstruction appears to be unnecessary in a significant portion of the DSU population, but ureterocele treatment needs to be individualized. There is an ongoing need for large, multi-institutional randomized control trials to evaluate this further.

     

Submentoplasty

Aging changes to the anterior neck can produce skin laxity, accumulation of submental fat, platysmal banding, and ptosis of the underlying neck structures. To rejuvenate the cervicomental region, the surgeon must accurately diagnose the anatomic irregularities and make appropriate recommendations for surgical correction. Because there are wide variations of anterior neck anatomy among individuals, it is necessary to "customize" the surgery in this area for each patient by employing single isolated procedures or multiple techniques. A stepwise approach in the management of the submentum can facilitate this goal and guide the surgeon in selecting the appropriate procedures for each individual.     

Diagnosis and management of metastatic cervical spine tumors

The bony spine is overall the third most common site for distant cancer metastasis, with the cervical spine involved in approximately 8 to 20% of metastatic spine disease cases. Diagnosis and management of metastatic spine disease requires disease categorization into the compartment involved, pathology of the lesion, and anatomic region involved. The diagnostic approach should commence with careful physical examination, and the workup should include plain radiographs, magnetic resonance imaging, computed tomography, and bone scintigraphy. Management ranges from palliative nonoperative to aggressive surgical treatment. Optimal management requires proper patient selection to individualize the most appropriate treatment modality.     

Cervical spine trauma in children and adults: perioperative considerations

A wide spectrum of cervical spine injuries, including stable and unstable injuries with and without neurologic compromise, account for a large percentage of emergency department visits. Effective treatment of the polytrauma patient with cervical spine injury requires knowledge of cervical spine anatomy and the pathophysiology of spinal cord injury, as well as techniques for cervical spine stabilization, intraoperative positioning, and airway management. The orthopaedic surgeon must oversee patient care and coordinate treatment with emergency department physicians and anesthesia services in both the acute and subacute settings. Children are particularly susceptible to substantial destabilizing cervical injuries and must be treated with a high degree of caution. The surgeon must understand the unique anatomic and biomechanical properties associated with the pediatric cervical spine as well as injury patterns and stabilization techniques specific to this patient population.     

Anesthetic management of the pediatric patient undergoing solid organ transplantation

Solid organ transplantation is now routinely performed at many institutions. Pediatric organ recipients present difficult challenges to pediatric anesthesiologists. Physiologic, anatomic, and pharmacologic derangements in this population may make both the surgical procedure and the anesthetic management complicated. This article presents an overview of the unique problems and the strategies to solve them in this population.     

Sacrocolpopexy: Surgical Technique,Outcomes, and Complications

Purpose of Review

Pelvic organ prolapse is a non-life-threatening condition that has a wide variety of symptoms. Sacrocolpopexy has been the “gold standard” for management of apical pelvic organ prolapse with reported high success rates for anatomic correction. Herein, we review the surgical procedure, anatomic, and functional outcomes, as well as the intraoperative and postoperative complications.

Recent Findings

Findings suggest that the ASC has an acceptably low overall complication rate comparable between open and minimally invasive approach. Mesh extrusion and anatomic failure have been shown to increase over time.

Summary

Patient education and counseling are important preoperatively. It is important to discuss with the patient risks of the surgical procedure, specifically mesh-related extrusion, longer term anatomic recurrence rates, rates of functional improvement, or worsening of bladder and bowel symptoms, as well as rates of dyspareunia.

     

Role of sublobar resection (segmentectomy and wedge resection) in the surgical management of non-small cell lung cancer

Segmentectomy demands a thorough knowledge of the three-dimensional bronchovascular anatomy of the lung. This anatomic detail makes segmentectomy significantly more challenging than lobectomy. Several principles must be applied when performing segmental lung resection: (1) the surgeon should avoid dissection in a poorly developed fissure, (2) use the transected bronchus as the base of the segmental resection during the division of the lung parenchymal in the intersegmental plane, (3) consider the use of endostapler division of the pulmonary parenchyma to reduce the air leak complications related to "finger fracture" dissection of the intersegmental plane, and (4) consider the use of adjuvant iodine 125 brachytherapy as a means of reducing local recurrence following sublobar resection. Increasing evidence supports the use of anatomic segmentectomy in the treatment of primary lung cancer for appropriately selected patients. This resection approach seems most appropriate in the management of the small (<2 cm in diameter) peripheral stage I NSCLC in which a generous margin of resection can be obtained. Accurate intraoperative nodal staging is important to estimate the relative use of these approaches compared with more aggressive resection and to determine the need for adjuvant systemic therapy if metastatic lymphadenopathy is identified. Future investigations comparing the results of sublobar resection with lobectomy will more clearly define the role of segmentectomy among good-risk patients with clinical stage I NSCLC. At the present time, it seems that sublobar resection is an appropriate therapy for the management of stage I NSCLC identified in the elderly patient, those individuals with significant cardiopulmonary dysfunction, and for the management of peripheral solitary metastatic disease to the lung. Because the primary disadvantage of sublobar resection is that of local recurrence, intraoperative adjuvant iodine 125 brachytherapy may be considered to minimize this local recurrence risk.     

Bradycardia and sinus arrest following saline irrigation of the brain during epilepsy surgery

Adverse cardiac events during the intraoperative period are life-threatening. The authors report three episodes of severe bradycardia and sinus arrest that occurred in a patient undergoing anterior temporal lobectomy and amygdalo-hippocampectomy for the treatment of epilepsy. The first episode occurred during resection of the amygdala; the other two episodes were observed during subsequent irrigation of the exposed brain structures, most likely the brain stem structures, because of a rent that the surgeon had deliberately made into the basilar cistern for better anatomic appreciation of the structures to be excised. The patient responded well to treatment with no adverse outcomes. The probable mechanisms leading to this event are discussed; the authors excluded insular cortex stimulation, the effects of the anesthetic drugs used, and venous air embolism as a cause of bradycardia and sinus arrest. The amygdala resection was the most likely cause of the first episode of bradycardia; the second episode of bradycardia and sinus arrest occurred because of inadvertent stimulation of brain structures by the high temperature (42 degree C) of the saline used for irrigation. To counter its effects, saline irrigation at room temperature (20 degree C) was started, and this caused the third episode of bradycardia, most likely because of "temperature shock" of the exposed brain. Prompt communication with the surgical team and vigilance are crucial for the appropriate management of such an incident, which may pose a threat to life. Avoiding irrigation of the exposed brain with high-temperature saline may prevent such an incident.     

Orthotopic ileal neobladder. Postoperative management and results

Urinary diversion after cystectomy have evolved from simple diversion and protection of the upper tracts to functional and anatomic restoration as close as possible to the natural preoperative state. Over the past 15 years, orthotopic reconstruction has evolved from "experimental surgery" to the "preferred method of urinary diversion" in both sexes. Urologist that perform this technique should have an appropriate experience with pelvic surgery and be able to perform a nerve sparing radical cystectomy. Nevertheless, the postoperative management of these patients is more important than the surgical construction if good longterm results are to be achieved. For this reason, a great knowledge about the neobladder's physiology, postoperative complications and their treatment are needed. We review the most important aspects in the postoperative management of patients with ileal neobladder. We also resume the long term outcomes concerning to continence, sexual function, renal impairment, oncologic safety and quality of life.