Endovascular approach to treat aortic pseudoaneurysms: could it be a safe alternative?

Aortic pseudoaneurysm is a rare complication after blunt chest trauma or cardiac surgical procedures and can occur at the site of cannulation or root vent insertion on the ascending aorta. These pseudoaneurysms have the potential to expand, erode, and rupture, and detecting this condition before complications occur is the key to successful management. We had replaced the mitral valve with a 31-mm bioprosthesis in an 82-year-old patient and repaired an ascending aorta aneurysm, but a computed tomography scan on postoperative day 18 revealed a pseudoaneurysm at the site of the previous aortic cannulation. Because of the patient's advanced age and multiple comorbidities, we sealed off the neck of the pseudoaneurysm with a 12-mm Amplatzer Vascular Plug in the interventional cardiology suite instead of subjecting her to a surgical repair involving redo sternotomy and a period of circulatory arrest. Deployment of the Amplatzer plug effectively shut off flow into the pseudoaneurysm, and the patient recovered well. Although the optimal management strategy for aortic pseudoaneurysms is a matter of controversy, endovascular interventions may be a safer alternative to surgery for patients with multiple comorbidities.     

Mucous cystadenoma of the appendix: is it safe to remove it by a laparoscopic approach?

Mucinous cystadenoma is an uncommon neoplasm of the appendix usually discovered intraoperatively. Its clinical significance lies in the possible rupture and consequent spillage of mucin into the peritoneal cavity, leading to pseudomyxoma peritonei. Even if laparoscopy has been successfully used to perform appendectomy, some concerns exist regarding its use in dealing with mucinous secreting lesions because of possible spillage of mucin during surgery. We report a case of mucous cystadenoma of the appendix, which was successfully removed using a laparoscopic approach. At a 12-month follow-up assessment, the patient was free of disease. We believe that the laparoscopic approach is safe if surgery can be performed without grasping the lesion, and if the specimen is removed through the abdominal wall using a bag. Conversion to laparotomy should be considered if the lesion must be traumatically grasped, or if the tumor clearly extends beyond the appendix.     

Open transumbilical pyloromyotomy: is it more painful than the laparoscopic approach?

Background

Open transumbilical pyloromyotomy (UMBP) and laparoscopic pyloromyotomy (LAP) have been compared on different outcomes, but postoperative pain as a primary end point had never been assessed. The aim of this study was to compare the use of analgesia in UMBP and LAP patients.

Methods

Infants with hypertrophic pyloric stenosis treated by UMBP in 2008-2009 were matched with LAP-treated infants. Demographics, type and use of analgesia, and length of stay were recorded. Statistical analysis was performed using the Fisher exact test.

Results

Each group contained 19 patients (N = 38) with comparable demographics and no comorbid condition. Bupivacaine was injected intraoperatively in all UMBP and 89% of LAP infants. There was a trend toward increased acetaminophen use in LAP infants (79% vs 58%, P = .61) in the recovery room. There was no difference in opiates use (3 UMBP vs 1 LAP, P = .60). In the ward, more UMBP patients received acetaminophen (78% vs 53%, P = .03). This difference was significant. Mean postoperative length of stay was similar in both groups.

Conclusion

Our study suggests that UMBP infants might experience more postoperative pain in the ward, without any impact on various outcomes. A prospective study with a larger sample size should be undertaken to verify these findings.     

Abdominal approach to chronic diaphragmatic hernias: is it safe?

Standard teaching has been to approach chronic diaphragmatic hernias (CDH) via a thoracotomy. It has been our experience that CDH can be safely approached via an abdominal incision. The objective of this study was to evaluate the outcome of patients undergoing the transabdominal approach for repair of CDH and comparing the outcome with that of patients undergoing a transthoracic (TT) approach. This is a retrospective chart review and was performed of patients with CDH secondary to trauma. Patient demographics, presenting symptoms, operative approach, and complications were collected. Patients were stratified by the surgical approach, TA versus TT. The endpoints of analysis were need for second incision, intraoperative and postoperative complications (enterotomies, pneumonia), need for a chest tube, mechanical ventilation postoperatively, and ICU and hospital days. Twenty-eight patients with CDH repairs performed between Jan 1993 and Dec 2002 were identified. Nineteen patients were in the TA group, and nine were in the TT group. Patients in the TA group had a higher incidence of emergent surgery (68% vs 11%, P = 0.005) and had a lower incidence of postoperative pneumonia (0% vs 33%, P = 0.009). No case of enteric injury from lysis of adhesions in the chest was identified. The need for a second incision (11%), the mortality (11%), ICU stay, and hospital stay were the same between the two groups. It appears that repair of CDH can be performed safely through an abdominal approach.     

Balloon-assisted endoscopic retroperitoneal gasless approach (BERG) for lumbar interbody fusion: is it a valid alternative to the laparoscopic approach?

OBJECTIVE: In the last years the use of interbody fusion devices with an anterior spinal lumbar approach has become a common procedure for the treatment of degenerative disc disease and spinal instability. We analysed our series of a simplified endoscopic approach to the anterior spine and made a review of the retroperitoneal endoscopically assisted approach to the anterior lumbar spine in the international literature. METHODS AND RESULTS: From 1999 through 2002, twenty consecutive "balloon-assisted endoscopic retroperitoneal gasless (BERG)" lumbar fusions were performed at San Filippo Neri Hospital in Rome, Italy. The surgical indications included patients with grade I or II spondylolisthesis and symptomatic degenerative disc disease with foraminal stenosis. Fourteen patients underwent a single level fusion (4 cases at L4-L5; 10 cases at L5-S1) and six patients underwent a double level fusion (L4-L5 and L5-S1). Mean operating time was 135 minutes (single level fusion), 175 minutes (double level fusion) and the mean intraoperative blood loss was 177 mL. No perioperative complications were observed and no procedure was converted to open surgical fusion. Patients were allowed to ambulate on the second postoperative day. Fusion was achieved in nineteen patients (fusion rate of 95%) 12 months after surgery. CONCLUSIONS: The BERG technique is a safe, effective, simplified, less technically demanding alternative approach when performing ALIF procedures, without the morbidity associated with laparoscopic or traditional approaches.     

Pectus excavatum repair according to Nuss: is it safe to place a retrosternal bar by a transpleural approach, under thoracoscopic vision?

We present a new case of cardiac perforation during retrosternal dissection beginning a Nuss procedure for pectus excavatum repair in an 18-year-old boy. The true incidence of life-threatening complications, such as heart injuries during Nuss bar placement for pectus excavatum repair, as well as cardiac lacerations during removal of the bar, remains unknown. Many papers suggest measures to prevent these complications: approaching the retrosternal space through an additional subxiphoid short incision, lifting the sternum during bar placement, or placing the bar extrapleuraly. Nuss procedure is gaining more and more popularity due to its apparent simplicity; however, its operational complications should be well known and discussed to be avoided later on.     

Outpatient thyroidectomy: is it a safe and reasonable option?

Background

Outpatient surgery is cost effective and convenient. The aim of this study was to determine the safety and feasibility of outpatient thyroidectomy.

Methods

Retrospective review was performed of all thyroidectomy patients from a tertiary care center between January 2004 and March 2010.

Results

One hundred forty-eight patients met the inclusion criteria. Subtotal and hemithyroidectomies (n = 79) were compared against completion and total thyroidectomies (n = 72). Nine total thyroidectomy patients (12.5%) required unplanned overnight admission, compared with 4 hemithyroidectomy patients (5.1%) (P = .15). The majority were admitted for pain and nausea control. Overnight admissions were highest among men (32% vs 5%, P = .002) and patients with Graves' disease (36% vs 6%, P = .003). Postoperative complications occurred in 6 total thyroidectomy patients (8.3%) and 3 hemithyroidectomy patients (3.8%) (P = .31). Only 4 patients (2.6%) required readmission for complications. There were no deaths.

Conclusions

Outpatient thyroidectomy performed by an experienced surgeon is safe and feasible. Men and patients with Graves' disease have a higher probability of requiring postoperative admission.     

Gomco circumcision: When is it safe?

BACKGROUND/PURPOSE: The Gomco clamp is used most commonly for neonatal circumcisions in the United States with reported rates of complication as low as 0.2%. Often, however, circumcision is delayed beyond the neonatal period because of illness, parental concerns, or physician bias with patients presenting for elective circumcision in the first few years of life. In neonates and infants, the "bloodless" Gomco circumcision is cost effective, can be performed with minimal anesthesia and gives good cosmetic results. However, the optimal age at which to perform this procedure remains controversial. We reviewed the experience of one pediatric urologist with Gomco circumcision in neonates and infants to determine the optimal age at which this procedure should be performed. METHODS: One hundred thirty patients underwent Gomco circumcision by 1 pediatric urologist between 1996 and 1998. Ninety-eight patients underwent Gomco circumcision as neonates or during early infancy at a mean age of 17 days (range, 4 to 30 days). Thirty-two patients underwent circumcision after early infancy at a mean age of 6.5 months (range, 90 days to 8.5 months). All patients younger than 1 month of age underwent circumcision while fully awake using a dorsal penile nerve block. Patients greater than 3 months of age were circumcised under general anesthesia. Gomco circumcision was performed using 1.1- to 2.1-cm bells. Patients were assessed with regard to outcome. RESULTS: None of the 98 patients in the early infancy group had postcircumcision complications. Of the 32 patients in the older group, 12 (30%) had postoperative bleeding requiring suture repair or fulguration. The skin edges separated in 2 patients, 1 less than 1 month of age and 1 in the older group. Neither patient required further intervention, and both healed spontaneously. There was no correlation between size of clamp and development of complications. CONCLUSION: Although safe and effective for circumcision in the neonatal period and in early infancy, use of the Gomco clamp for circumcision beyond early infancy (3 months of age) has substantial morbidity, and alternative methods of circumcision should be sought.     

Neuroleptic malignant syndrome and mivacurium: a safe alternative to succinylcholine?

Neuroleptic malignant syndrome (NMS) and malignant hyperthermia (MH) may have a common pathogenic mechanism; therefore, it has been suggested that known triggering agents for MH (such as succinylcholine) should be avoided in patients with NMS. Electroconvulsive therapy (ECT) continues to play a major therapeutic role in contemporary psychiatry, and succinylcholine has been the muscle relaxant of choice in attenuating violent muscle contractions induced by ECT. Mivacurium is a nondepolarizing muscle relaxant with a relatively rapid onset and a short duration of action, and to date it has been proved safe in MH- susceptible patients. In this case report, following succinylcholine use during ECT, a patient with NMS developed an increase in temperature and serum creatine kinase (CK) level, possibly due to an MH reaction. Since the patient’s mental status necessitated further ECT, mivacurium was administered during subsequent treatments and resulted in effective attenuation of muscle contractions without elevation of patient temperature or CK levels. In addition, there was no marked prolongation of the anaesthetic. Mivacurium is a suitable agent for patients with NMS undergoing ECT, as it has not been associated with precipitation of an MH response.     

Bisulfite-containing propofol: is it a cost-effective alternative to Diprivan for induction of anesthesia?

Propofol (Diprivan(TM); AstraZeneca, Wilmington, DE) is a commonly used drug for the induction of general anesthesia in the ambulatory setting. With the availability of a new bisulfite-containing generic formulation of propofol, questions have arisen regarding its cost effectiveness and safety compared with Diprivan(TM). Two hundred healthy outpatients were randomly assigned, according to a double-blinded protocol, to receive either Diprivan(TM) or bisulfite-containing propofol 1.5 mg/kg IV as part of a standardized induction sequence. Maintenance of anesthesia consisted of either desflurane (4%-8% end-tidal) or sevoflurane (1%-2% end-tidal) in combination with a remifentanil infusion (0.125 microg x kg(-1) x min(-1) IV). Patient assessments included pain on injection, induction time, hemodynamic and bispectral electroencephalographic changes during induction, emergence time, and incidence of postoperative nausea and vomiting. The two propofol groups were comparable demographically, and the induction times and bispectral index values during the induction were also similar. However, the bisulfite-containing formulation was associated with less severe pain on injection (5% vs 11%), with fewer patients recalling pain on injection after surgery (38% vs. 51%, P<0.05). None of the patients manifested allergic-type reactions after the induction of anesthesia. The acquisition cost (average wholesale price in US dollars) of a 20-mL ampoule of Diprivan(TM) was $15 compared with $13 for the bisulfite-containing propofol formulation. Therefore, we concluded that the bisulfite-containing formulation of propofol is a cost-effective alternative to Diprivan(TM) for the induction of outpatient anesthesia. Implications: Bisulfite-containing propofol and Diprivan(TM) (AstraZeneca, Wilmington, DE) were similar with respect to their induction characteristics; however, the generic formulation was associated with a smaller incidence of injection pain. Assuming that the drug costs are similar, these data suggest that the bisulfite-containing formulation of propofol is a cost-effective alternative to Diprivan(TM).     

The esophageal coin: is it a penny?

Because of their high zinc content modern U.S. pennies that become lodged in the esophagus may react with stomach acid thereby damaging the esophageal mucosa. Management of esophageal pennies may therefore differ from that of other esophageal coins making differentiation of pennies from other coins important. We reviewed the records of 111 children who underwent endoscopic esophageal coin removal over a 19-year period to determine the ability of history and size of esophageal coin images on posterior-anterior and lateral chest radiographs alone and in combination to differentiate esophageal pennies from other esophageal coins. History alone accurately identified 83 per cent of esophageal coins. Ranges of two standard deviations around mean image sizes were determined for each coin denominations. We determined the probability of an esophageal coin being a penny based on combinations of historical data and whether or not image sizes fell within the calculated range for a penny. When all data agree that a coin is or is not a penny they are nearly always correct. When there is disagreement among historical and image size data the probability that is a coin is a penny is strongly influenced by the size of the radiographic images.     

Radiofrequency energy delivery to the anal canal: is it a promising new approach to the treatment of fecal incontinence?

Background

The present study was conducted to assess the efficacy and safety of the delivery of radiofrequency energy to the anal canal (the SECCA procedure).

Methods

Eight patients with fecal incontinence underwent the SECCA procedure. The Fecal Incontinence Severity Index (FISI) score and the Fecal Incontinence-related Quality of Life (FIQL) scale were completed at baseline and after the procedure. Anorectal manometry and endoanal ultrasound also were conducted.

Results

Seven of the 8 patients were women, and the median age of the patients was 59 years (range, 28-73 y). The mean FISI score and all of the parameters in the FIQL scale with the exception of the embarrassment scale measured at 6 months after the procedure was not improved significantly. We observed no changes in the anal manometry and endoanal ultrasound parameters. Complications associated with the procedure developed in 7 of the 8 patients, including anal bleeding, anal pain, and anal mucosal discharge.

Conclusions

The FISI score and FIQL scale were not improved significantly after the SECCA procedure, and considerable complications were associated with the procedure.