Efficacy of octreotide against chylothorax following lateral neck dissection for thyroid cancer: A case report

IntroductionPostsurgical chylothorax is a rare complication of cervical dissection for thyroid cancer. We report that octreotide, a synthetic analog of somatostatin, is effective in treating chylothorax after thyroid carcinoma surgery.Presentation of caseThe patient was a 48-year-old woman who presented to our institution complaining of a left anterior cervical mass. We diagnosed this as thyroid papillary carcinoma and performed a subtotal excision of the thyroid gland with left cervical lymph node dissection. The patient developed dyspnea, and a chest X-ray revealed bilateral chylothorax on Day 4 post-surgery. Octreotide was administered since bilateral chylothorax was noted. A marked decrease in chyle effusion was noted just 3 days after starting octreotide, and after a total of 9 days of treatment, there were no further signs of chylous effusion.DiscussionOctreotide is effective against postsurgical chylothorax; however, if there are no signs of improvement, we believe surgical treatment should be considered.ConclusionOctreotide should be administered first to treat postsurgical chylothorax before surgical treatment is considered.     

Intraoperative indocyanine green fluorescence lymphography,a novel imaging technique to detect a chyle fistula after an esophagectomy: Report of a case

Intraoperative indocyanine green (ICG) lymphography was performed on a 62-year-old man, who was diagnosed to have chylothorax after an esophagectomy for esophageal cancer. After exploration of the thorax, a slowly increasing effusion was identified in the mediastinal space above the diaphragm, but the exact site of the lymph fistula could not be identified. By injecting 1.5 ml of ICG subcutaneously at the bilateral inguinal region, fluorescence images of the lymph flow in the thoracic cavity were obtained using a near-infrared camera system. The detected leakage point was sutured and the chyle ooze stopped. The postoperative course was uneventful. The patient was discharged on the 16th postoperative day. This is the first report using ICG fluorescence lymphography for the successful intraoperative detection of the exact site of a fistula causing chylothorax.     

Use of Octreotide in association with talc poudrage for the management of a severe chylothorax: A case report

Introduction and importanceChylothorax is an uncommon form of pleural effusion characterized by the presence of chylomicrons, triglycerides and cholesterol in the physical and chemical examination of the pleural fluid. It may have poor prognosis if not properly treated. Currently, conservative measures are the first line of treatment for managing chylothorax. The aim of our study is to show and suggest the use of octreotide in association with talc poudrage as good option to manage post-operative a severe chylothorax.Case presentationA 59-year-old male patient who underwent a replacement of the ascending aorta, aortic hemiarch and surgery of the aortic valve for aortic dissection showed a severe pleural effusion three months after surgery. Because the physical and chemical examination of the pleural fluid revealed high levels of triglycerides and cholesterol, a conservative treatment with pleural drainage, TPN and nihil per os was attempted, with the introduction of 0.3 mg/die of octreotide on day thirty-four. With the application of talc poudrage, the chylothorax completely resolved.Clinical discussionOctreotide has been shown to significantly decrease chylous effusion in many studies, but the dose and duration of therapy have not yet been defined. Our patient responded partially to octreotide after two days of treatment, with the drainage leak reduced to less than 100 mL/day.ConclusionAfter octreotide treatment associated with talc poudrage, the drainage leak was drastically reduced, suggesting that this could be a useful approach in the management of severe chylous leaks.     

A modified vaginal wall patch sling technique as a first-line surgical approach for genuine stress incontinence with urethral hypermobility: long-term follow up

We describe our long-term outcome for patients with genuine stress incontinence (GSI) and urethral hypermobility using a modified vaginal wall patch sling technique. Fifty-three patients were studied. Preoperatively, all patients had a positive standing stress test and urethral hypermobility on Q-tip testing. On urodynamics, all patients had absence of detrusor contractions on subtracted cystometry. The mean age of the patients was 45+10.2 years. Forty-four patients demonstrated complete symptomatic and urodynamic improvement. Five patients had a noticeable failure observed within the first 12 months of follow up and four patients developed later recurrence despite initial success. The overall success rate after 5 years of follow up was 83% (n=44/53). The modified vaginal wall patch sling technique appears to have a good long-term success rate with low operative morbidity and minimal postoperative voiding dysfunction. The patch sling can be used as a first-line surgical approach for GSI with urethral hypermobility and be combined with other vaginal surgery. Editorial Comment: This report of results with the anterior wall suburethral patch sling over an extended period of time (5 years) is consistent with those in previous reports. The authors have given consideration to previous reports that the procedure is not successful in those patients with severe ISD by excluding them from the study. One might conclude from this that an in situ piece of vaginal tissue does not provide a good backboard effect to the outlet during Valsalva events. While synthetic materials and fascia have little elasticity, the vaginal wall is living vascularized tissue and may have more give in it, which may be important in preventing outlet obstruction in most stress incontinent patients, thus making it safer in those with adequate functioning urethras and explaining the failures others have discussed in those with severe ISD. In the properly selected patient it would appear to be a cost-effective option as no special commercial kit is necessary to get the job done     

甲状腺癌颈部淋巴结清扫术后双侧乳糜胸2例并文献复习

目的:探讨甲状腺癌颈部淋巴结清扫术后双侧乳糜胸的诊断及治疗。方法:回顾性分析2例甲状腺癌颈部淋巴结清扫术后出现的双侧乳糜胸患者的临床资料,并复习相关文献。结果:2例患者均因甲状腺乳头状癌行颈部淋巴结清扫术,术中均未发现淋巴液渗漏。均于术后第4天出现气促、呼吸困难,经胸部X线检查为双侧胸腔积液,行双侧胸腔闭式引流出乳白色乳糜液,证实为双侧乳糜胸。2例患者经禁食、奥曲肽等积极治疗后,引流量逐渐减少,复查胸部X线胸部无积液后拔除引流管。结论:双侧乳糜胸是甲状腺癌颈淋巴结清扫术后罕见的并发症,早期发现后给予积极的保守治疗是安全有效的。     

A novel surgical technique to prevent pancreatic fistula in distal pancreatectomy using a patch of the falciform ligament

Purpose

Pancreatic fistula (PF) is a serious complication of pancreatectomy and many techniques and devices have been designed to prevent PF and abdominal bleeding after pancreatectomy. We report a modified technique using a patch of the falciform ligament to prevent PF formation after distal pancreatectomy (DP).

Method

On completion of DP, the main pancreatic duct is sutured. The remnant pancreas is then closely patched and sutured vertically to the falciform ligament using 3-0 polypropylene suture. We compared the results of this method (group 1) with those of the simple method of covering the remnant pancreas with the falciform ligament (group 2).

Results

We performed this method in 14 patients undergoing DP. The rate of grade B or C PF in group 1 (7.1 %) was lower than that in group 2 (46 %).

Conclusion

This is a simple and effective method of preventing PF fistula in DP.

     

A novel surgical technique for management of vesicoureteral reflux following kidney transplantation: prospective study of 12 cases

The incidence of vesicoureteral reflux (VUR) varies between 10% and 80% of transplanted kidneys. In cases of failure of endoscopic treatment or recurrent urinary tract infections, surgical correction is proposed by ureteral reimplantation or pyeloureteral anastomosis using the native ureter. The aim of this study was to assess the results of a technique that increases the submucosal length of the ureter without a ureterovesical reimplantation. We treated 12 patients with VUR in the transplanted kidney by open surgery. Retrograde cystography showed resolution of reflux in all the patients. Our technique has the advantage of avoiding ureteral dissection thereby avoiding its devascularization and no invasion of the bladder mucosa.     

A retrospective review of an epidural blood patch database: the incidence of epidural blood patch associated with obstetric neuraxial anesthetic techniques and the effect of blood volume on efficacy

BackgroundThe optimal volume of blood required to treat post-dural puncture headache remains in question. In our institution a target volume of 30 mL is used for an epidural blood patch unless the patient experiences pain during injection.MethodsThe institutional database was retrospectively reviewed for epidural blood patch and delivery statistics over a 15-year period to determine if the volume of blood administered during the procedure directly correlated with the number of epidural blood patches administered. The primary endpoint was defined as the need for a repeat epidural blood patch.ResultsThere were 466 epidural blood patches performed on 394 patients, associated with 84 804 obstetric neuraxial procedures. Thirty-two percent (95% CI 28.3 to 34.9%) of patients who had an inadvertent dural puncture with an epidural needle received an epidural blood patch versus 0.19% (0.16% to 0.22%) of patients who received neuraxial anesthesia with no documented dural puncture with an epidural needle. All patients experienced relief of post-dural puncture headache, although 17% required two and 1.5% required three epidural blood patches. The mean ± SD volume of blood administered was 20.5 ± 5.4 mL and only 35 patients (8.9%) received 30 mL.ConclusionIncreasing blood volumes up to 30 mL did not reduce the need for repeat epidural blood patch. Although the optimal volume of blood to administer during epidural blood patch placement remains unknown, our institution will continue to administer up to 30 mL or until the patient experiences pain during epidural injection.     

Methicillin-resistantStaphylococcus aureus endocarditis following patch closure of a ventricular septal defect: Report of a case

We report herein the case of a 5-month-old infant who, after developing methicillin-resistantStaphylococcus aureus (MRSA) endocarditis following patch closure of a ventricular septal defect (VSD), was successfully treated by replacement of the Dacron patch with an autogenous pericardial patch. Initially, a large perimembranous VSD was repaired with a Dacron patch and after an uneventful recovery of 1 week, he began to spike intermittent fevers from 38°C to 39°C. Two blood cultures grew MRSA and a two-dimensional echocardiogram performed 16 days after surgery showed an irregular mass attached to the right ventricular aspect of the Dacron patch. At reoperation, a large vegetation attached to the Dacron patch was confirmed, but there was no patch dehiscence. Following removal of the patch, the VSD was repaired with an autogenous pericardial patch, soon after which the fever rapidly subsided. Imipenem, 125 mg every 6 h, and fosfomycin, 300 mg every 6 h, were administered for a total of 24 days after reoperation. The child remains well 12 months after his second operation.     

Xenogeneic patch closure of the small intestine: a novel approach to fistula management

Previous work from our laboratory demonstrated the feasibility of utilizing placental-derived collagen tissue matrix (CTM) as a bowel wall substitute. We reasoned that this technique would also be suitable in managing intestinal fistulae. To test this hypothesis, we created a chronic cecal fistula in rats and randomly managed some with primary repair and others with CTM replacement. Leak rates, mortality, bursting pressures and histologic scores were similar, suggesting that a chronic fistula can be successfully managed with either a CTM or primary repair.     

Roux-en-Y bleeding after living donor liver transplantation: a novel technique for surgical treatment

Upper gastrointestinal bleeding (GIB) is one of the most common gastroenterologic complications following liver transplantation. The aim of this study is to define the prevalence of GIB due to Roux- en Y (R-Y) enteral anastomoses after living donor liver transplantation (LDLT) and recommend an anastomotic technique for easy surgical intervention. Ninety-five patients underwent 96 LDLT from June 1999 through January 2003. R-Y biliary reconstruction was employed in 43 patients. Anastomoses were end-to-side (ES) in the first 25 patients and side-to-side (SS) type in the last 18 patients. GIB occurred in 13 patients (30%). The R-Y anastomotic line was shown to be the bleeding site in 10 patients. Anastomoses were in ES fashion in 7 of 10 patients (70%). In other words 28% of ES and 17% of SS anastomoses displayed a bleeding episode after LDLT. Four patients required surgical intervention (Three ES, one SS), namely an operative rate of 9%. The type of the jejunojejunostomy, the UNOS or Child-Pugh scores, the presence of preexisting portal hypertension, the duration of portal vein clamping, the GRWR of patients, revealed no statistical significant difference between bleeding and non- bleeding patients. Although statistical analyses did not reveal any significant difference (P =.47), GIB was higher among patients with an ES type of anastomoses. As a result we recommend a jejunojejunostomy in SS fashion on the antimesenteric borders of the jejunal segments with a 3-4 cm blind intestinal segment. The surgical procedure for R-Y bleeding may then be performed without disrupting the jejunojejunostomy.     

Laparoscopic repair of an abdominal hernia using an expanded polytetrafluoroethylene patch secured by a four-corner tacking technique

An improved technique for performing laparoscopic repair of an abdominal hernia is described herein. To ensure a successful repair, it is most important that adequate tension of the expanded-polytetrafluoroethylene (e-PTFE) patch be achieved, and that the defect be completely covered and securely stapled. Our technique involves tacking the four corners of the patch to the abdominal wall with a 2-0 nylon suture using a straight needle, then stapling it to the anterior abdominal wall over the defect with a laparoscopic stapler. We believe that this technique is a safe and reliable method which will prove useful for laparoscopic surgery.     

The inside-out trans-obturator sling: a novel surgical technique for the treatment of male urinary incontinence

Objectives

To describe a new sling procedure for treating stress urinary incontinence (SUI) after radical prostatectomy (RP) and prospectively evaluate its short-term safety and efficacy.

Methods

The sling technique uses specific instruments and a polypropylene mesh with two arms that are passed inside to outside through the obturator foramens, pulled for compressing the bulbar urethra upward, and tied to each other across the midline. Patients with detrusor overactivity were excluded. Baseline and follow-up evaluations included uroflowmetry and continence and quality of life (QoL) questionnaires. Cure was defined by no pad use and improvement by a number of pads/d ≤2 and reduced by at least 50%. Complications were recorded.

Results

From April 2006 through February 2007, 20 consecutive patients suffering from post-RP SUI underwent the sling procedure using the same operative protocol. Preoperatively, 3 (15%), 11 (55%), and 6 (25%) patients were using 2, 3–5, and >5 pads/d, respectively. The procedure was preceded by an endoscopic urethrotomy in four patients. No perioperative complication was noted; three patients required suprapubic catheterization. At 6 mo, nine (45%) patients were cured and eight others (40%) were improved (1 pad/d). QoL was significantly enhanced and 80% of patients were moderately to completely satisfied with the procedure. Preoperative and postoperative maximum flow rate and postvoid residual values were not statistically different. No sling infection, urethra erosion, persistent pain, or neurologic complications were observed.

Conclusions

The inside-out trans-obturator sling procedure appears to be safe and efficient at short term. Further studies are warranted to determine long-term outcome.     

Chylopericardium following thoracoscopic resection of a mediastinal cyst: A case report

IntroductionThoracic duct cysts are very rare, and diagnosis is often difficult. We report a rare case of chylopericardium following thoracic duct cyst resection. There are no established guidelines on the management of such cases. We reviewed the literature on postoperative complications after thoracic duct cyst resection, and conducted the first thorough review of the etiology and management of chylopericardium in surgical cases.Presentation of caseA 54-year-old male presented with cardiac tamponade due to chylopericardium. He had undergone resection of a thoracic duct cyst 2 years previously, which was complicated by postoperative chylothorax. Chyle accumulation resolved with conservative treatment.DiscussionChylothorax is a frequent complication following thoracic duct cyst resection, especially in cases where no intraoperative diagnosis is reached. Diagnosis may be difficult due to anomalous location of the cyst, as in our case. Chylopericardium is rarely reported, and may have occurred in our case because of prior pleurodesis. Chyle accumulation can reportedly be managed with diet restrictions in over half of reported cases, especially in cases of lung or mediastinal tumor resection.ConclusionThe most important points highlighted by this rare case of chylopericardium secondary to thoracic duct cyst resection are: 1) pedicles should be ligated in cyst resections, regardless of location; 2) careful assessment in the initial surgery may help identify the point of leakage; 3) low-fat diet is the first choice in the initial management of postoperative chylopericardium, but surgical repair may be considered in cases with no response after > 2 weeks of conservative treatment.