Cholestasis as a side effect of bupivacaine?

Background and Objectives. Cholestasis has been proposed as a side effect of interpleural bupivacaine. Therefore, the effects of various application techniques on liver enzymes were studied following ethics committee approval and informed patient consent. Methods. Patients following scheduled thoracotomy and laparoscopic cholecystectomy were prospectively studied and randomized to the following application techniques of bupivacaine: Thoracic surgery. T0: Control (systemic analgesia only: patient-controlled analgesia with opioids; n = 26); T1: Repetitive intercostal blocks (10–20 mL 0.5% bupivacaine, 2–4 times per day for 3–6 days; n = 17); T2: Interpleural injections via a catheter placed intraoperatively (20 mL 0.25%, 4–6 times per day for 3–6 days, right: n = 25 or left: n = 12). Laparoscopic cholecystectomy. Intraperitoneal application (single injection). L0: 50 mL saline (Control) (n = 21). L1: 50 mL 0.125% bupivacaine (n = 18); L2: 50 mL 0.25% (n = 20). The serum concentrations of bilirubin, γ-GT, alkaline phosphatase, leucine amino peptidase, glutamate oxalacetate transaminase, and glutamate pyruvate transaminase were measured preoperatively and on day 1, 3, and 7 postoperatively. Results. Neither application of plain bupivacaine was associated with significant changes in the postoperative concentration of hepatic enzymes. In particular, there was no difference between left- and right-sided interpleural application. Although increases in hepatic enzyme concentrations were observed in some patients postoperatively, this was similar in the bupivacaine and control groups. Conclusion. Perioperative interpleural, intercostal, and intraperitoneal administration of bupivacaine was not associated with findings indicative of cholestasis in the early postoperative course.     

Cholestasis associated with small bowel atresia: do we always need to investigate?

Background/Purpose

Cholestasis occurs frequently in patients with small bowel atresia (SBA) and is often attributed to prolonged parental nutrition. When severe or prolonged, patients may undergo unnecessary intensive or invasive investigation. We characterized cholestasis and analyzed the pertinence of investigating this patient population.

Methods

With Research Ethics Board approval, patients with SBA between 1996 and 2005 were retrospectively reviewed. Demographics, location of atresia, operative findings, complications, investigations, resumption of feeding, duration of prolonged parental nutrition, and follow-up information were examined. Cholestasis was evaluated for incidence, severity, and evolution.

Results

Fifty-five patients (29 male, 26 female), with a median gestational age and birth weight of 36 weeks and 2025 g, respectively, were reviewed. Care was withdrawn for 2 patients before repair. For the remaining 53 patients, SBA were duodenal atresia in 18, jejunoileal atresia in 32, and multiple atresia in 3. Of 53, 24 (45%) patients developed cholestasis postoperatively (direct/total bilirubin >20%). All patients with short bowel (4) and 60% (6/10) of patients with a delay of enteral feeding more than 14 days postoperatively had cholestasis. Ten patients (36%) proceeded with in-depth evaluations for cholestasis, with 8 (28%) undergoing liver biopsy. No patient had biliary atresia. No deaths were related to isolated cholestasis/cirrhosis. Cholestasis resolved spontaneously in all the survivors.

Conclusions

Small bowel atresia is frequently associated with postoperative cholestasis that will resolve with time. We recommend a more selective and expectant approach to SBA-associated cholestasis to minimize unnecessary investigations.     

“Like a rabbit from a hat!”—a case of a sacrocolpopexy mesh being taken out by a patient

Sacrocolpopexy, be it laparoscopic or abdominal, is associated with a risk of mesh extrusion. We report an interesting case of mesh extrusion with subsequent removal of the mesh from the vagina by the patient. We take this opportunity to review the literature regarding incidence, predisposing factors and complications of sacrocolpopexy mesh extrusion with specific reference to this case.     

When is a pneumothorax not a pneumothorax?

The authors report on a 13-year-old boy who, after exercise, had respiratory distress and left upper quadrant abdominal pain. Initially, a mistaken diagnosis of pneumothorax was made, and a chest tube was inserted. A nasogastric tube was then visualized on chest x-ray in the left hemithorax. He underwent a laparotomy and had herniation of spleen, stomach, and large and small bowel in the left pleural space passing through a traumatic defect in the hemidiaphragm. The laparoscopic Nissen fundoplication 3 years prior was felt to have contributed. A timely and correct diagnosis is essential to avoid the sequelae associated with these injuries and with inappropriate tube thoracostomy.     

Desmoid tumour following a distal radius fracture – a complication or a coincidence?

We describe a case of a desmoid tumour occurring 15 months following an uncomplicated fracture of the left distal radius. The occurrence of a desmoid tumour after fracture is extremely rare and a Medline search revealed only two previous reports. The correlation between the site of trauma and the tumour and the time interval between trauma and presentation strongly supports a causal role of the fracture in the occurrence of this tumour.     

Can a Picture Really Paint a Thousand Words?

Plastic surgeons require a three-dimensional appreciation of form and function in order to meet reconstructive challenges. The popular perception that plastic surgeons must be artistic was tested in an observational study of sketch illustrations in plastic surgery case notes. Only in the trunk and breast category of illustrations could career plastic surgeons demonstrate superior artistic skill to non-career plastic surgeons and there was little correlation between the artistic merit of a diagram and the likelihood of its meaning being understood by an independent observer. Simple but accurate outline sketches are as capable of leading an observer to the correct diagnosis as complex works of art, while illustrations with low diagnostic scores are not only misleading but may also have medico-legal implications.     

Development of a solitary bone cyst – a report of a case suggesting its pathogenesis

The origin and natural course of solitary bone cysts (SBC) still remain controversial. Knowledge of the process of cyst formation and enlargement would be helpful for investigating its pathogenesis. Only two papers have described a radiodense nidus of the diaphysis as a precursor. Their cases were unique in that the initial lesions were in the diaphysis and that the cysts did not abut onto the epiphyseal line. This study reports a case in a patient with a tiny erosive lesion in the endosteal surface of the humeral metaphysis, which developed expansively into a typical large cyst over 6 years. Serial roentgenograms taken every year demonstrated the process of cyst enlargement. This is the first longitudinal study of a case with SBC documented from its onset. Received: 2 June 1998     

When should a cardiologist refer a patient with aortic valve disease to a surgeon?

In general, aortic stenosis and regurgitation are the 2 main aortic valve diseases which require surgical treatment. Surgical indication for each has been described in detail in the guidelines established by the Japanese Circulation Society and American Heart Association/American College of Cardiology (AHA/ACC). Most of the cases we daily encounter in clinical practice can be managed within the guideline, although the patient's many other factors are needed to be taken into consideration. On the contrary, in those cases with the conditions which are not mentioned in the guidelines, diagnosis and decisions are always difficult to make. In this article, we are to discuss how to manage cases within and without the guidelines.     

Necrosis and glioblastoma: a friend or a foe? A review and a hypothesis

OBJECTIVE: Two main forms of cell death are encountered in biology: apoptosis (i.e., programmed cell death) and necrosis (i.e., accidental cell death). Because necrosis and apoptosis can lead to cell removal, one might intuit that they are both desirable in cancer treatment. However, in the setting of glioblastoma multiforme, a malignant brain tumor for which the presence of necrosis is an important diagnostic feature, clinical studies indicate that as the degree of necrosis advances, the patient's prognosis worsens. Despite the apparent importance of this form of cell death, the mechanism of development of necrosis in glioblastomas remains unelucidated. The purpose of this article is to try to resolve this dilemma by hypothesizing the mechanism of necrosis formation in these tumors. METHODS: On the basis of an extensive review of the literature, we present a hypothesis for the mechanism of necrosis formation in glioblastoma multiforme. RESULTS: One of the many possible pathways leading to necrosis formation may involve increased tumor cell secretion of tumor necrosis factor. Procoagulation and antiapoptotic mechanisms resulting from certain pathways could prevent the completion of tumor necrosis factor-induced apoptosis and could promote necrosis as the final mode of cell death. Such a hypothesis would explain the inverse correlation that exists between tumor necrosis and the survival of patients with glioblastomas, because the hypoxia that results from procoagulation selects for tumor cells that are more aggressive and more resistant to apoptosis-inducing therapies. CONCLUSION: A complete understanding of the series of events surrounding necrosis development in glioblastomas that is evidence-based is likely to provide targets for future therapies. On the basis of the potential mechanisms of development of necrosis described in this article, we postulate that effective therapies may have to be directed against the pathways that result in the formation of necrosis.     

Is a fat stitch required when closing a hip hemiarthroplasty wound without a drain?

Studies have shown no benefit of a subcutaneous fat stitch when closing hip wounds, but all have been in the presence of a drain. Our aim was to determine whether, in the absence of a drain, suturing or not of the subcutaneous fat layer in hip hemiarthroplasty wounds had any significant effect on wound complication rate. We performed a prospective cohort study of 45 hip hemiarthroplasty patients who had a fat stitch and 40 who did not. No drains were used in either group. There were 44 patients in the fat stitch group and 35 in the no fat stitch group after six patients were excluded. The infection rate was 2% for the fat stitch group, and 20% for the no fat stitch group (p=0.02). There were no cases of deep dehiscence in the fat stitch group, but four cases (11%) in the no fat stitch group (p=0.035). The overall complication rate in the fat stitch group was 6.8% compared to 33% in the no fat stitch group (p=0.007). In the absence of a drain, we have found a significant increase in hip hemiarthroplasty wound complications when the subcutaneous fat is not sutured.     

Renal transplantation from a living related donor with a retrocaval ureter – a note of caution

In our study we describe a renal transplant from a living related donor who was found to have a retrocaval ureter. The retrocaval ureter is a rare congenital anomaly resulting from a defect in the embryological development of the ureter and the inferior vena cava (IVC). The compression of the ureter between the IVC and the vertebrae can result in progressive hydronephrosis. The non-dilated segment of the ureter was used for the uretero-neocystostomy. The patient presented with ureteric obstruction in the immediate post-transplant period, and at surgical exploration the uretero-neocystostomy was revised using the dilated portion of the ureter. We recommend that when transplanting a kidney with a retrocaval ureter, caution should be exercised in using the non-dilated portion of the ureter, since either the blood supply may be compromised or the peristalsis may be interrupted. Received: 30 June 1998 Received after revision: 26 January 1999 Accepted: 26 February 1999