Postural orthostatic tachycardia syndrome and general anesthesia: a series of 13 cases

Study Objective

To investigate whether patients with postural orthostatic tachycardia syndrome (POTS) developed unexpected perioperative complications.

Design

Retrospective case series.

Setting

Academic medical center.

Measurements

The records of 13 patients with POTS, who underwent surgical procedures during general anesthesia, were studied. Details of disease management, anesthetic induction, hemodynamic response to induction and intubation, intraoperative course, and immediate postoperative management were analyzed.

Main Results

Three patients developed prolonged intraoperative hypotension, which was not associated with induction of anesthesia. All 13 patients were successfully treated and they recovered without complications. There were no unplanned hospital or intensive care admissions.

Conclusions

Intraoperative hypotension, but not tachycardia, was observed in three of 13 patients with POTS who received general anesthesia for a variety of surgical procedures using multiple medications and techniques.     

Transumbilical management for neonatal ovarian cysts

Background/Purpose

Since Tan and Bianchi (Br J Surg. 1986;73:399) reported umbilical incision as an access for pyloromyotomy in infantile hypertrophic pyloric stenosis, many pediatric surgeons have used this approach for a number of other procedures. Because of the long pedicle with good mobility and the frequent intraabdominal position of the neonatal ovarian cyst, we attempted to manage it via the transumbilical route.

Methods

All patients were treated under intubation general anesthesia. Semicircular infraumbilical incision was made, and the abdomen was entered through a transverse fascial incision. The partially collapsed cyst after aspiration was exteriorized through the incision for cystectomy, partial deroofing, or adnexectomy.

Results

From May 2000 to December 2006, 6 female newborns with ovarian cysts were treated via the transumbilical route. There were no complications from surgery. The operation time and duration of hospital stay were short. The cosmetic appearance after the procedure was good.

Conclusions

The initial result suggests that transumbilical management for neonatal ovarian cysts may be a good alternative procedure when laparoscopic equipment is unavailable or experienced technique is lacking.     

Inguinal hernia: relationship to respiratory disease in prematurity

Objective

The purpose of this study was to identify the risk of respiratory disease for developing inguinal hernia (IH).

Study design

A retrospective case-control study reviewed medical records of 100 outborn infant males, gestational age (GA) less than 35 weeks, admitted between July 1999 and November 2002 to our level III neonatal intensive care unit. Prospectively selected variables were reviewed from 50 cases of IH and 50 controls.

Results

Premature infants expressing IH were more likely to have had lower GA and birth weight, longer duration of mechanical ventilation, use of high-frequency oscillating ventilator (HFOV), higher peak mean airway pressures during mechanical ventilation, and postnatal dexamethasone exposure. Adjusted results showed dexamethasone, HFOV in infants less than 28 weeks GA, and length of mechanical ventilation remained significant. Multivariate analysis revealed dexamethasone as an independent risk for the expression of IH.

Conclusions

The association of IH expression with mechanical support and dexamethasone administration was substantial. These data provide further caution when using either HFOV or dexamethasone in preterm infants with respiratory insufficiency.     

Duhamel operation vs neonatal transanal endorectal pull-through procedure for Hirschsprung disease: which are the changes for pathologists?

Background

The aim of this study was to evaluate whether performing definitive surgery for Hirschsprung disease (HD) in neonatal period with a transanal endorectal pull-through (TEPT) procedure had modified our diagnostic relevance, particularly during intraoperative frozen sections (IOFS), compared to classic Duhamel (DH) surgery performed in older children.

Methods

We collected pathologic data for 47 children who underwent surgery for neonatal nontotal HD over a 5-year period.

Results

Twenty-nine patients underwent TEPT and 18 the DH operation. Mean age at operation was 19 days for TEPT and 4 months for DH operation. The mean number of IOFS was 2.6 for TEPT and 2.4 for DH operation. Gross examination could be fully completed in all TEPT cases, but was incomplete in 5 DH cases. The average total lengths of bowel, and aganglionic, transitional, and ganglionic segments were 12.3, 7.3, 3, and 2 cm for TEPT, and 17.6, 9.3, 3.5, and 4.8 cm for DH operation, respectively. Discordance between IOFS and paraffin-section analysis occurred in 5 cases (3 TEPT and 2 DH operation).

Conclusion

When TEPT was used, the gross examination and sampling was more accurate, leading to a clearer pathology report. The TEPT procedure facilitates the work of the pathologist without modifying the results of IOFS, if some precautions are taken.     

Recurrence rates in breast cancer patients with false-negative intraoperative evaluation of sentinel lymph nodes

Background

Intraoperative identification of sentinel lymph node (SLN) metastases in breast cancer patients results in synchronous axillary lymph node dissection. We examined the effect of false-negative SLN biopsy on breast cancer treatments and recurrence rate.

Methods

Patient and tumor characteristics, intraoperative and final SLN biopsy results, and treatments of patients with and without recurrence were compared.

Results

Recurrence rates for patients with true-positive SLN biopsy (9%) were significantly higher than rates for false-negative SLN biopsy patients (2%). Recurrence rates were significantly higher for patients with primary tumors greater than 2 cm, positive lymph nodes greater than 2 mm, and tumors with negative hormone receptors, and varied with treatment extent.

Conclusions

Patients with greater amounts of disease in the breast and axilla required more treatment and had a higher recurrence rate. False-negative SLN evaluation occurred more commonly in patients with less lymph node metastasis and was not associated with an increased recurrence rate.     

Biological Changes After Liver Transplantation According to the Presence or Not of Graft Steatosis

Aim

To assess the consequences of graft steatosis on postoperative liver function as compared with normal liver grafts.

Patients and methods

From January 2005 to December 2007, liver transplant patients were prospectively included, excluding those who experienced arterial or biliary complications or presented acute rejection. All patients had a surgical biopsy after reperfusion. Patients were compared according to the rate of macrovacuolar steatosis: namely above or below 20%.

Results

Fifty-three patients were included: 10 in the steatosis group and 43 in the control group. No significant difference was observed in terms of morbidity, mortality, and primary non- or poor function. Nevertheless, biological changes after the procedure were significantly different during the first postoperative week. Prothrombin time, serum bilirubin, and transaminases were significantly increased among the steatosis group compared with the control group (P < .05).

Conclusion

This case-controlled study including a small number of patients, described postoperative biological changes among liver transplantations with steatosis in the graft.     

Secretory Unit of Islet Transplant Objects (SUITO) Index Can Predict Outcome of Intravenous Glucose Tolerance Test

Background

Simple monitoring of engrafted islet function is important for follow-up of recipients after islet transplantation. We previously developed a simple assessment tool for islet graft function; the secretory unit of islet transplant objects (SUITO) index. The aim of this study was to clarify the relationship between the SUITO index and the outcomes of intravenous glucose tolerance tests (IVGTT).

Methods

Fifteen series of blood samples from 6 islet recipients were collected before 3, 5, 10, 20, and 30 minutes after injection of 0.5 g/kg 50% dextrose. The SUITO index was calculated using plasma C-peptide and glucose level at fasting baseline. Samples were divided into the following 3 groups; low-SUITO (SUITO index <10; n = 3); middle-SUITO (SUITO index ≥10 to <26; n = 4); and high-SUITO (SUITO index ≥26; n = 8).

Results

A threshold SUITO index of 26 showed good sensitivity (85.7%) and specificity (75.0%) to predict a blood glucose level of >10 mmol/L at 30 minutes. Blood glucose levels in the low-SUITO group were significantly higher than among the other 2 groups at baseline and 10, 20 and 30 minutes (P < .05). Glucose-level areas under the receiver-operating characteristic curve during IVGTT in the low-SUITO group were also significantly larger than among the other 2 groups (P < .05).

Conclusion

The SUITO index, using only a fasting blood sample, predicted IVGTT outcomes.     

A new fistulectomy method for the second pharyngeal arch remnants

Purpose

We present a new fistulectomy method for the second pharyngeal arch remnants.

Materials and Methods

Between 1991 and 2003, 4 patients have been treated with a new fistulectomy method.

Surgical Procedure

Under general anesthesia with nasotracheal intubation, the neck and mouth are prepared as one operative field. A nylon thread is inserted into the cervical opening. On the oral site of the nylon thread, a small gauze ball is tied and gently pulled from the neck site. At both opening sites of the fistula, a very small incision around the nylon thread is performed. Using the nylon thread as a guide, a fistulectomy is carried out.

Results

In all 4 patients, no complications have occurred during and after the fistulectomy. No recurrences were seen during 15 months to 9 years.

Conclusions

This is a simple and useful procedure for the treatment of second pharyngeal arch remnants. It produces an excellent cosmetic result compared with the standard method because only one small incision is necessary.     

The effect of clopidogrel and aspirin on blood loss in hip fracture surgery

Introduction

Anti-platelet drugs are commonly used for primary and secondary prevention of thrombo-embolic events and following invasive coronary interventions. Their effect on surgery-related blood loss and perioperative complications is unclear, and the management of trauma patients treated by anti-platelets is controversial. The anti-platelet effect is over in nearly 10 days. Notably, delay of surgical intervention for hip fracture repair for >48 h has been reported to increase perioperative complications and mortality.

Patients and methods

Intra-operative and perioperative blood loss, the amount of transfused blood and surgery-related complications of 44 patients on uninterrupted clopidogrel treatment were compared with 44 matched controls not on clopidogrel (either on aspirin alone or not on any anti-platelets).

Results

The mean perioperative blood loss was 899 ± 496 ml for patients not on clopidogrel, 1091 ± 654 ml for patients on clopidogrel (p = 0.005) and 1312 ± 686 ml for those on combined clopidogrel and aspirin (p = 0.0003 vs. all others). Increased blood loss was also associated with a shorter time to operation (p = 0.0012) and prolonged surgical time (p = 0.0002). There were no cases of mortality in the early postoperative period.

Conclusions

Patients receiving anti-platelet drugs can safely undergo hip fracture surgery without delay, regardless of greater perioperative blood loss and possible thrombo-embolic/postoperative bleeding events.     

Living Donor Renal Transplantation Using Grafts With Multiple Arteries Procured by Laparoscopic Nephrectomy

Objective

Kidney grafts with multiple renal arteries (MRAs) are not uncommon, but they do make transplantation more difficult. Laparoscopic graft nephrectomy has become the standard; however, the safety and reliability must be maintained for both a donor and a recipient even in case of MRAs. This study evaluated the short-term outcomes of living donor renal transplant using grafts with MRAs procured by laparoscopic nephrectomy.

Patients and Methods

This study reviewed all living donor kidney transplantations performed from January 2008 to June 2009, which were divided into 3 groups according to the number of renal graft arteries. The serum creatinine level, warm ischemic time (WIT), rewarming time, total ischemic time (TIT), operative time, acute rejection episodes, and complications in each group were evaluated.

Results

The serum creatinine level showed no difference among the groups. Longer TIT was observed in the MRAs group, but WIT and rewarming time did not differ. The acute rejection rate was not different. There were no vessel complications in any donors and recipients.

Conclusion

Harvesting kidney grafts with MRAs by laparoscopic nephrectomy requires a longer TIT; however, transplantation can be performed safely and reliably for both donors and recipients.     

Abdominal involvement in pediatric heart and lung transplant recipients with posttransplant lymphoproliferative disease increases the risk of mortality

Background

Posttransplant lymphoproliferative disease (PTLD) is a serious complication in transplant recipients. Abdominal PTLD has been reported, but the prognosis remains undefined. The purpose of this study was to identify the incidence, predisposing factors, and outcome of abdominal PTLD in pediatric cardiothoracic transplant patients.

Methods

Retrospective chart review of 134 transplant patients (50 heart, 77 lung, 7 heart/lung) at our institution (1995-2005).

Results

Posttransplant lymphoproliferative disease was diagnosed in 14 patients. Most were Epstein-Barr virus naive initially, but all had seroconverted when diagnosed with PTLD. Eight had abdominal involvement; 4 required surgical interventions—1 for intussusception and for bowel perforation, 2 for bowel perforation, and 1 for tumor debulking. All had lifelong follow-up, with an average follow-up of 3 years. Of 8 patients with abdominal PTLD, 4 died of complications related to PTLD, whereas 1 of 6 patients with extraabdominal PTLD died of PTLD.

Conclusions

Epstein-Barr virus infection after transplantation is a major risk factor for PTLD. Pediatric patients with PTLD who present with abdominal involvement are more likely to die of PTLD than those without abdominal disease. Delay in diagnosis may contribute to the high mortality. Therefore, prompt evaluation and surveillance for possible abdominal PTLD may decrease mortality associated with this devastating problem.     

Acute neonatal arterial occlusion: is thrombolysis safe and effective?

Purpose

We report our experience of the management of arterial occlusion in the newborn.

Methods

A case note review was carried out after ethical approval. Doppler ultrasonography confirmed the occlusion. Thrombolysis was the primary intervention. Surgery was used selectively. A good outcome was one without tissue loss or functional impairment or minimal tissue loss without functional impairment. Data are presented as medians with ranges.

Results

Ten patients (9 male; median gestational age, 35.5 weeks [range, 28-39 weeks]) presented on day 1 (range, 1-8 days). Initial management included systemic tissue plasminogen activator (8 patients) and surgery (2 infants in whom thrombolysis was contraindicated). Improvement was noted in 7 of 8 infants treated medically and in both who underwent surgery. Three infants had significant tissue loss. Outcome at 29 months (range, 1.3-95.4 months) was good in the remaining 7.

Conclusions

A multidisciplinary approach, thrombolysis and selective surgery achieved tissue preservation and function in the majority while minimizing complications. Early referral to centers with multidisciplinary teams is recommended.     

Prenatal diagnosis and multidisciplinary approach to the congenital gingival granular cell tumor

Objective

Congenital gingival granular cell tumor (CGCT) is a rare benign lesion appearing at birth on the alveolar median ridge of the maxilla. Etiology is still unclear because spontaneous regression of the lesion is rare.

Methods

The present report describes 2 cases of neonatal CGCT, highlighting benefits of ultrasonography to treatment of the prenatally diagnosed lesion.

Results

The patients immediately underwent surgical exeresis. Pathology revealed a tumor of large polyedric cells with vacuolar central nuclei and eosinophil granular cytoplasm.

Conclusions

Prenatal diagnosis is fundamental in the therapeutic approach to CGCT: ultrasonography methodologies allow diagnosis of the lesion in the uterus at the 36th gestational week, thus also allowing planning of delivery and, immediately later, the surgical treatment. That permits planning of delivery in a third-level center with considerable benefit for both the mother and the newborn.     

Acquired intestinal aganglionosis after a lytic infection with varicella-zoster virus

Background and Purpose

In this report, we present the first case of an immunologically impaired child surviving a lytic varicella-zoster virus infection affecting the enteric nervous system. In histological findings, myenteric and submucous enteric ganglia were nearly completely absent owing to virus infection.

Methods

A 3-year-old girl with acute lymphoblastic leukemia and generalized varicella-zoster infection developed an ileus. She underwent multiple laparotomies in which histological sections of the entire small intestine could be obtained.

Results

The histological evaluation of these samples showed a generalized aganglionosis with inflammatory residuals. A more detailed immunohistochemical analysis using neuronal (PGP, enolase), glial (S100), and lymphocytic (LCA) antibodies demonstrated a nearly complete neuronal loss.

Conclusion

To our knowledge, this is the first case of a secondary intestinal aganglionosis after varicella-zoster virus infection.     

Endoscopic tissue expansion placement in face and neck burn scar reconstruction

Introduction

Reconstruction of the face and neck after burn necessitates high-quality tissue for improving the appearance. Tissue expansion provides a greater opportunity, but, unfortunately, with relatively high complication rates. One potential alternative to reduce these complications is to place the expander with the assistance of the endoscope. In this study, we evaluated endoscopically assisted tissue-expander placement for the treatment of face and neck deformities after burn.

Materials and methods

Age, gender, site of burn to be reconstructed, shape and volume of expander inserted, expander volume reached after expansion, time reached to maximum volume expansion and complications for all patients having undergone endoscopically assisted tissue-expander placement were recorded during the period of the study. The details of the procedure used were described.

Results

A total of 14 expanders were placed assisted by an endoscope in 11 patients between April 2008 and October 2009. Anatomically, five expanders were placed in the neck, six expanders were placed in the cheek and three expanders were placed in the forehead. In all cases, tissue expansion was achieved without major complications; minor port complications occurred in two cases.

Conclusion

Endoscopically assisted tissue-expander placement allows for the use of smaller incisions, which can be placed in more cosmetically acceptable areas and away from the expansion site. This benefit would reduce the risk of wound dehiscence, and permits expansion to be initiated earlier. We believe that this technique is a safe and effective method that needs to be confirmed with a comparative study.     

Prospective randomized trial of paravertebral block for patients undergoing breast cancer surgery

Background

The goal of the current study was to evaluate the effect of regional anesthesia using paravertebral block (PVB) on postoperative pain after breast surgery.

Methods

Patients undergoing unilateral breast surgery without reconstruction were randomized to general anesthesia (GA) only or PVB with GA and pain scores assessed.

Results

Eighty patients were randomized (41 to GA and 39 to PVB with GA). Operative times were not significantly different between groups. Pain scores were lower after PVB compared to GA at 1 hour (1 vs 3, P = .006) and 3 hours (0 vs 2, P = .001) but not at later time points. The overall worst pain experienced was lower with PVB (3 vs 5, P = .02). More patients were pain-free in the PVB group at 1 hour (44% vs 17%, P = .014) and 3 hours (54% vs 17%, P = .005) postoperatively.

Conclusions

PVB significantly decreases postoperative pain up to 3 hours after breast cancer surgery.     

Percutaneous cholecysto-cholangiography in the diagnosis of obstructive jaundice in infants

Background

Once it is established that a jaundiced infant has an elevated direct bilirubin level, the principal diagnostic concern is the differentiation of hepatocellular from obstructive cholestasis, of disorders of physiology from disorders of anatomy, and of disease that is managed medically from disease that is managed surgically. Traditional tests such as ultrasonography, liver biopsy, and technotium 99m HIDA scan are often not sufficiently discriminating. General anesthesia is required for invasive imaging with endoscopic retrograde cholangio pancreatography (ERCP) or operative cholangiogram. The authors describe a facile alternative using percutaneous cholecystocholangiography (PCC) with intravenous sedation.

Methods

Nine cholestatic infants underwent PCC (age, 27 to 73 days; mean, 44 days) after ultrasoundscan, liver biopsy, and ^99mTcHIDA scan failed to provide a definitive diagnosis.

Results

In the 4 infants without complete biliary filling, we found biliary atresia (3) and biliary hypoplasia (1). The biliary tree was completely opacified in 5 infants with the following diagnosis: neonatal hepatitis (2), duplication of the gallbladder (1), choledochocele (1), total parenteral nutrition (TPN) cholestasis (1). There were no complications.

Conclusions

When the etiology of cholestasis remains elusive after traditional firstline tests, PCC has proven to be an accurate simple alternative in differentiating obstructive from hepatocellular causes of infantile cholestatic jaundice.     

Further reduction of hospital stay for laparoscopic colon resection by modifications of the fast-track care plan

Background

Fast-track surgery has been described as a plan to facilitate early recovery. We present one surgeon's modifications to fast-track surgery for laparoscopic colectomy patients.

Methods

We performed a retrospective review of 48 consecutive patients undergoing elective laparoscopic colectomy treated by a modified fast-track plan between 2004 and 2008. Elements included preoperative education, pre-anesthesia dexamethasone, immediate postoperative general diet, no urinary catheter, no epidural anesthesia, and no flatus or bowel movement as a discharge requirement. Data collected included the following: age, sex, body mass index, resection indications, surgical time, blood loss, pain score, time to ambulation, time to bowel function, length of stay, complications, and mortality.

Results

The mean length of stay was 37 hours (1.5 d), with 29 of 48 patients discharged without passage of flatus or stool. Only 1 patient required readmission.

Conclusions

Our modified fast-track plan achieved significant improvement in length of stay for laparoscopic colectomy compared with previous results.     

Do patients undergoing parathyroidectomy for primary hyperparathyroidism in San Francisco, CA, and Bursa, Turkey, differ?

Background

To compare the preoperative clinical symptoms and associated conditions and findings in operations in age- and sex-matched patients with primary hyperparathyroidism (PHPT) living in the two different regions of the world to determine whether PHPT differs in various countries.

Methods

Fifty-two patients from Bursa, Turkey were matched with 52 age and sex matched patients from San Francisco, USA. Patients' preoperative symptoms, biochemical and radiologic findings and surgical procedures were documented.

Results

More patients in the American Group (15%) had preoperatively persistant or recurrent hyperparathyroidism, P = 0.016. Serum parathyroid hormone levels were higher in Turkish group (546 ± 75.33 pg/mL) than in American group (146 ± 75.33 pg/mL). More Turkish patients had osteoporosis (P < 0.05). The size of parathyroid adenomas was significantly greater in Turkish patients (25.2 ± 1.18 mm) than in American patients (17.5 ± 1.18 mm), P < 0.001.

Conclusions

Patients with PHPT from Bursa, Turkey have higher plasma parathyroid hormone levels, larger parathyroid adenomas and more severe bone disease than in age and sex matched patients with PHPT in San Francisco.     

Pediatric trauma care: a profitable enterprise?

Purpose

We set out to examine whether pediatric trauma care resulted in a financial burden.

Methods

We reviewed financial data for children with an International Classification of Diseases, Ninth Edition, injury diagnosis code over 2 years at an urban level I pediatric trauma center. We divided inpatients into length of stay categories, and profit or loss was calculated for each payor/length of stay category. These figures were then used to estimate revenue for each hospital based upon their patients payor/length of stay distribution that was obtained from the KID database. Our payor-based outpatient revenue figures were also applied to the other hospital-calculated outpatient visits to obtain an estimate of their outpatient revenues.

Results

We treated 49,437 injured children with a revenue balance of more than $8 million. Commercial insurance resulted in a positive revenue stream. Losses increased as length of stay increased for patients with Medicaid or self-pay. Outpatient encounters resulted in 59% of the revenue. Extrapolating our data, 84% of pediatric trauma centers in 27 states generate an average of $800,000 revenue.

Conclusions

Pediatric trauma care is a profitable enterprise. Inadequate reimbursement remains for Medicaid and self-pay patients, which could result in financial losses should this proportion of the patient mix be more than 55%.