CONGENITAL TRACHEO-OESOPHAGEAL FISTULA IN A YOUNG ADULT

Congenital tracheo-oesophageal fistula (TEF) is rare in adults. Patients who present with repeated attacks of chest infection since birth or cough, choking and cyanosis during feeding should be investigated for TEF. It should be possible to detect all cases of tracheo-oesophageal fistulae using bronchoscopy, oesophagoscopy and CT either singly or in combination. These investigations also help in deciding on the route of exploration and the type of surgery. Disconnection of the abnormal fistulous tract brings dramatic relief of symptom and prevents further pulmonary damage.     

THE ANAESTHETIC MANAGEMENT OF PATIENTS WITH BRONCHOPLEURAL FISTULA WITH THE ROBERTSHAW DOUBLE-LUMEN TUBE

A method of anaesthesia for the repair of bronchopleural fistulaeis described which involves the use of the Robertshaw double-lumentube. Our experience with its use on twenty occasions is described,and in eleven of them the method was completely successful.In none of the other nine cases were the difficulties encounteredsuch as to render the technique unsafe. Both from the pointof view of safety and for the patient's comfort, general anaesthesiafor intubation was found to be preferable. ^* Now at the Middlesex Hospital, London.     

CONGENITAL ANTERIOR URETHROCUTANEOUS FISTULA

PURPOSE: Congenital anterior urethrocutaneous fistula is a rare anomaly that may present in an isolated fashion or in association with other penile abnormalities, such as chordee or hypospadias. There have been 18 cases of congenital anterior urethrocutaneous fistula reported in the literature. We present 14 additional cases of congenital anterior urethrocutaneous fistula. MATERIALS AND METHODS: We treated 14 patients with congenital anterior urethrocutaneous fistula, of whom 9 were uncircumcised at presentation. Two patients had evidence of chordee and 4 had distal hypospadias. RESULTS: The type of repair was determined by the anatomical variations of this anomaly. All cases were corrected electively by various techniques based on the degree of the defect, including primary closure via a Thiersch-Duplay urethroplasty, pedicle flap urethroplasty, hinged flap urethroplasty and interpositioned island pedicle tube or onlay urethroplasty. CONCLUSIONS: To our knowledge the embryological events that cause anterior urethrocutaneous fistula are unclear but they likely result from a defective urethral plate or an abnormality of the infolding of the urethral groove. Surgical technique must be individualized to fit the defect. While there has been considerable skepticism regarding the existence of congenital urethrocutaneous fistula, the fact that 9 of our 14 patients were uncircumcised confirms the congenital nature of this lesion.     

SURGICAL MANAGEMENT OF BENIGN OESOPHAGO-PLEURAL FISTULA

Three cases of oesophago-pleural fistula are presented. Two resulted from foreign body perforation of the oesophagus and one followed left lower lobectomy for bronchiectasis. All three presented late; the time lapse ranged from 6 days to 2 months. An initial course of conservative treatment was given to all three patients. Alimentation via nasogastric tube feeding, gastrostomy or total parenteral nutrition was carried out. The pleural fluid grew the anaerobe, Baaeriodies melaninogenicus, in all three cases. Gram-negative aerobes, Escherichia coli and Proteus mirabilis, were also cultured. Closed intercostal drainage and a course of appropriate antibiotics were instituted. The patients were subjected to surgery after the infection had been brought under control. Simple repair was performed in two patients. Exclusion of the oesophageal leak with drainage and later reconstruction was carried out in the third patient. Although all three patients recovered, the morbidity was considerable. The duration of hospital stay ranged from 2 to 4 months.     

ANAESTHETIC MANAGEMENT OF MALIGNANT TRACHEO--OESOPHAGEAL FISTULA

The anaesthetic management is described, of a patient with malignanttracheo—oesophageal fistula undergoing palliative oesophagealbypass. The oesophagus was divided and closed at its upper endand replaced with a segment of colon. The fistula remained insitu and fundoplication was performed to allow drainage of theoesophageal remnant but prevent reflux of gastric contents.During a subsequent anaesthetic, gross intestinal distensionoccurred when gas that had passed through the fistula was unableto vent. The problems of dealing with patients with malignanttracheo—oesophageal fistula are discussed.     

THE SURGICAL TREATMENT OF CONGENITAL CORONARY TO PULMONARY ARTERY FISTULA

Six patients with coronary to pulmonary artery fistula underwent surgical treatment between January 1973 and August 1975. All fistulee terminated in the main pulmonary artery just distal to the pulmonary valve. Two patients had severe coronary artery disease associated with the fistula. In all patients, the fistula was over-sewn from ivithin the pulmonary artery in addition to ligation of the fistulous vessel on the surface of the pulmonary artery or heart, cardiopulmonary bypass being employed. Two patients underwent concomitant aortocoronary artery saphenous vein bypass for occlusive coronary artery disease. Follow-up data revealed that three patients were free of symptoms and two were improved, while one was lost to follow-up.     

EXTERNAL PANCREATIC FISTULA: A RECENT ADVANCE IN MANAGEMENT

The management of six consecutive recent cases of external pancreatic fistula Is reported in which the use of total parenteral nutrition resulted In rapid closure of the fistula. The flstulae closed from 11 to 28 days after the commencement of total parenteral nutrition, with an average of 19 days. Surgical intervention to close the fistula was not required In any of the cases.     

REVERSAL OF CURARIZATION WITH ATROPINE-NEOSTIGMINE MIXTURE IN PATIENTS WITH CONGENITAL CARDIAC DISEASE

Electrocardiographic changes during reversal of curarizationwith an atropine-neostigmine mixture were studied in 41 paediatricpatients with congenital cardiovascular disease. A slight statisticallysignificant rise in heart rate was observed 1 minute followingthe injection of the mixture. There was an inverse relationshipbetween the initial heart rate and maximum increase in rate.Normal sinus rhythm was maintained throughout the period ofreversal in 29 patients while 12 patients exhibited some e.c.g.changes. Electrocardiographic findings did not indicate theoccurrence of serious arrhythmias, but it is suggested thatthe incidence of arrhythmia may actually be higher in cyanoticthan acyanotic patients.     

BRONCHOPLEURAL FISTULA MANAGEMENT DURING ANAESTHESIA

The anaesthetic management of operations for bronchopleuralfistula in twenty-two patients is discussed. The fistulae followedpulmonary resection for tuberculosis or tuberculous empyema.A fistula may cause air leakage leading to spontaneous pneumothorax,collapse of the lung or mediastinal shift. Spillover of empyemafluid may lead to respiratory obstruction. Empyema fluid wasaspirated before operation and the intercostal catheter underwater seal was kept working during operation. In each case acuffed endotracheal tube was passed under general anaesthesia,thiopentone and suxamethonium being administered to the patientin the head-up position. Frequent aspiration through the endotrachealtube was required. These patients were not considered suitablefor intubation under local anaesthesia, nor was one-lung anaesthesia,or the use of bronchial blockers, considered necessary.     

先天性巨结肠病儿的肠电图改变

对16例先天性巨结肠病儿术前作直肠结肠肠电图检查，男14例，女2例，年龄3个月至2岁，11例同龄正常儿为对照组。巨结肠病儿直肠结肠肠电图上有异常波一无波、偶发波及微小波出现，它可作为诊断巨结肠的客观指标，同时根据异常波型出现部位可做为判断巨结肠类型的参考指标。     

RENAL ALLOGRAFT SURVIVAL IN PATIENTS WITH CONGENITAL OBSTRUCTION OF THE POSTERIOR URETHRA

In an attempt to clarify the influence of dysfunctional bladders on renal allograft outcome, graft survival was studied retrospectively in patients with congenital posterior urethral obstruction (posterior urethral valves). Using the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA), 25 index patients were compared to all other transplant recipients of the same age range. Three instances of abnormal bladder function leading to graft function deterioration were found, therefore we would recommend investigation of bladder function in all boys with congenital urethral obstruction prior to renal transplant, and as part of the work-up of graft failure, where the cause is otherwise not obvious.     

胆内瘘53例临床治疗分析

目的探讨胆内瘘的诊断及治疗方法。方法对1998年3月~2005年7月收治的53例胆内瘘患者进行回顾性分析。结果11.3%(6/53)的病人术前诊断为胆内瘘,88.7%(47/53)的病人为术中发现;在胆内瘘类型中,52.8%(28/53)为胆囊十二指肠内瘘,13.2%(7/53)为胆囊胃内瘘,15.1%(8/53)为胆囊横结肠内瘘,7.5%(4/53)为胆总管十二指肠内瘘,11.5%(6/53)为胆囊肝总管内瘘。胆石性肠梗阻占胆内瘘的7.5%。结论胆内瘘术前诊断困难,对长期胆囊结石病人,尤其是发现胆道积气征应高度怀疑,其治疗方法可采用胆总管瘘口、肝总管瘘口、十二指肠瘘口、横结肠瘘口修补等方法,对胃瘘口可采用瘘口修补或胃部分切除处理。     

EXPERIENCES WITH CRYOSURGERY IN THE MANAGEMENT OF BENIGN PROSTATIC OBSTRUCTION

Cryosurgery of the prostate gland has been used on mainly unfit patients for ten years as an alternative to open and endoscopic surgery in over 250 patients. With the use of a simple “rule of thumb” technique, blind cryosurgery can be recommended as causing few complications. Furthermore, the patient's early discharge from hospital can be achieved. Long-term functional results are satisfactory. More complicated techniques have been described and are mentioned, but as a result of experience simplicity of technique is recommended.     

METABOLIC EFFECTS OF CORRECTIVE SURGERY IN INFANTS AND CHILDRED WITH CONGENITAL HEART DEFECTS

We have measured oxygen consumption and carbon dioxide productionby indirect calorimetry in 25 infants and children immediatelybefore and after surgical correction of congenital cardiac malformations.Surgical correction of the cardiac defect caused a decreasein oxygen consumption towards normal. Greatly increased oxygenconsumption values were observed before surgery in the infantswith a large left-to-right intracardiac shunt and heart failureand the highest reduction in metabolic rate, up to 43% was observedin these infants. The results indicate that corrective surgeryfor congenital cardiac ma/formations reduces the load on thecardiopu/monary system immediately after operation. (Br. J.Anaesth. 1993; 70: 149–153)     

RECENT ADVANCES IN THE MANAGEMENT OF SPINAL INJURIES WITH PARALYSIS

In the last decade, by application of detailed methods of care, the previously accepted complications of urinary infection, pressure sores and motor skeletal problems of contractures and spasm, have largely been eliminated from the clinical picture of patients with spinal paralysis. Many professionals in medicine have contributed to these advances. Long-term or extended care in the area of tetraplegia and paraplegia need further stimulation, with continued application of all those methods used in acute rehabilitation in properly organized spinal units.