The retained surgical specimen, an unappreciated retained foreign object

A retained foreign object is a preventable surgical error and has typically been considered a surgical instrument, needle, or sponge. A new retained surgical object is a retained surgical specimen (RSS). This case study outlines the nature of the RSS, the paradigm shift that has led to this becoming a new healthcare error, and steps to prevent this new type of retained object from occurring.     

Cowper's syringocele: symptoms, classification and treatment of an unappreciated problem

PURPOSE: Cowper's syringocele is a rare deformity in the male urethra that is a distention of the duct of the bulbourethral (Cowper's) gland. We report on 7 cases, review the symptoms and pathophysiology, and propose a simplified classification of this uncommon lesion. MATERIALS AND METHODS: We reviewed 7 cases of Cowper's syringocele diagnosed from 1997 to 1998 at our hospital. RESULTS: Cowper's syringocele was diagnosed in 7 patients 25 to 51 years old with persistent post-void dribbling, frequency, urethral pain, hematuria or sudden urethral discharge. Diagnosis was made with urethrocystoscopy or retrograde urethrogram. Cowper's syringocele may be closed (a distended cyst-like swelling in the wall of the urethra) or open (an opening enabling urine reflux into the syringocele). In 2 patients asymptomatic open syringocele was diagnosed. In 1 patient symptomatic syringocele resolved spontaneously following an infection. In 4 patients open syringocele was treated with transurethral marsupialization because of persistent post-void dribbling. Postoperatively patients were completely symptom-free with a mean followup of 12 months (range 6 to 23). CONCLUSIONS: Cowper's syringocele may be more common than currently realized. Urologists should rule out this possibility in young male patients with lower urinary tract symptoms and persistent post-void dribbling as it can be treated easily.     

Idiopathic duodenal obstruction: an unappreciated complication of pancreatitis.

Intestinal obstruction as a complication of pancreatitis is infrequently recognized. Only four cases of idiopathic duodenal obstruction associated with pancreatitis have been previously reported. In a three-year study of 878 patients with pancreatitis, nine cases of idiopathic duodenal obstruction associated with pancreatitis have been found. Each of the nine cases was characterized by frank obstruction in the second or third portions of the duodenum and an intact mucosa in the area of stricture. Four patients gave an abrupt history of moderately severe pancreatitis. Resolution of the duodenal obstruction occurred by three weeks in each of these four cases. Surgical exploration in one of these patients revealed marked duodenal edema with intramural hematoma. The remaining five patients reported a chronic history of obstruction. Inadequate resolution of the obstruction after four weeks of hyperalimentation led to surgical bypass. Duodenal biopsy specimens revealed inflammation, muscle destruction, and extensive fibrosis. Duodenal involvement in the inflammatory process of moderately severe pancreatitis was discovered in 25% of the upper gastrointestinal studies, but was usually self-limiting and of a mild degree. Since contiguous duodenal edema is common and fibrosing pancreatoduodenitis only occurs in an occasional patient, surgical intervention for duodenal obstruction associated with pancreatitis should only be considered after demonstrated failure of conservative management.     

Diverticulitis in women: an unappreciated clinical presentation.

A final diagnosis of diverticulosis or diverticulitis was made in 1,031 women over a 10 year period. The 69 patients who underwent abdominal operation for what proved to be diverticulitis are discussed in detail. Thirty-eight per cent of these women were believed to have gynecologic disease because of the presence of a pelvic mass. Diverticulitis is an important differential diagnosis of a pelvic mass with or without clinical and laboratory indications of infection and with or without history of diverticulosis or diverticulitis. The increasing awareness of ovarian carcinoma and its ominous prognosis make this differential diagnosis especially important. Diverticular disease should always be considered among such patients and preparations made to allow optimal treatment at that operation, whatever the ultimate cause of the mass.     

The oxygram: an unappreciated technique for assessing hypoventilation in paediatric anaesthesia

This study assessed the use of the oxygram, specifically the difference between inspired and end tidal oxygen concentrations, F₁-eto₂, to detect hypoventilation in a paediatric population. Ten healthy unpremedicated children, aged 1-5 years, scheduled for elective minor urologic surgery were studied. A Modulus® II Plus Anesthesia System was used, with Rascal® II Anesthesia Gas Monitor for analysis of anaesthetic and respiratory gases with a Wright spirometer to monitor minute ventilation. Following inhalational induction, intubation, and caudal anaesthetic administration, the children breathed end-tidal halothane concentrations of 0.5%, 2%, 1.5%, 1.0%, and again 0.5% with measurements of inspired and end-tidal oxygen and halothane concentrations, end tidal CO₂ (Petco₂), minute ventilation (VE), respiratory rate (f), pulse oximetry saturations (Spo₂), heart rate (HR), and mean blood pressure (BP). FI-ETO₂ increased proportionately with hypoventilation at 2%, 1.5%, and 1% halothane concentrations compared to the 0.5% halothane group (P < 0.0001, 0.0008, and 0.0013 respectively), associated with corresponding increases of Petco₂ and decreases of minute ventilation (VE). We conclude the oxygram was effective in monitoring hypoventilation in paediatric patients within the format of the protocol studied     

Parathyroid hormone assay drift: an unappreciated problem in dialysis patient management

The Kidney Disease Outcomes Quality Initiative (K/DOQI) bone metabolism guidelines assume that clinicians use the Nichols intact parathyroid hormone immunoradiometric assay (iPTH IRMA) upon which K/DOQI was based. But for more than a decade, virtually all PTH assay results used for routine end-stage renal disease (ESRD) clinical management have not been generated with this test. Results from the most widely used PTH assays for ESRD patient testing in the United States have varied from 1999 to 2005. The Nichols chemiluminescent Advantage iPTH assay results shifted upwards significantly in 1999 and remained elevated until 2005. From 2003 to 2005, results from the Nichols Advantage Bio-Intact PTH assay shifted upward on average by 29% to 52%. These changes in the most widely used PTH assays have made use of the K/DOQI guidelines with these assays both inappropriate and potentially harmful to patients.     

术后疲劳综合征评估的研究进展

【摘要】〓术后疲劳综合征(POFS)是手术后常见的并发症,因其评估方法的缺乏,严重阻碍了研究进展。本文就目前国内外术后疲劳综合征研究,旨在探讨一种公认能动态评估术后疲劳综和征的方法,综述其研究进展,生化指标主要用比较术后疲劳综合征的不同水平,不作为诊断指标;心理学的调查量表或问卷主要用来辅助诊断。总之,POFS是一种复杂的疾病,尚没有很好的评估不方法,多种评估手段互补使用是值得推荐的。     

Chronic exertional compartment syndrome

Chronic exertional compartment syndrome is an often overlooked and uncommon cause of pain in the extremities of individuals who engage in repetitive physical activity. A thorough history, a careful physical examination, and compartment pressure testing are essential to establish the diagnosis. Catheter measurements can provide useful information on baseline resting compartment pressures as well as compartment pressures after exercise or trauma. Patients with chronic exertional compartment syndrome usually do not respond to nonsurgical therapy other than completely ceasing the activities that cause the symptoms. Surgical intervention entails fasciotomies of the involved compartments. Although obtaining accurate compartment pressure measurements can be difficult and fascial releases must be done carefully, patients typically have satisfactory functional results and are able to return to their usual physical activities after fasciotomy.     

Chronic exertional compartment syndrome

Chronic exertional compartment syndrome is an overuse condition affecting primarily active, athletic people. Its etiology is unclear, but several theories have been proposed. The syndrome is characterized by recurrent, often severe muscle compartment pain that occurs with vigorous exercise and subsides with rest. Physical examination usually provides little helpful information. Compartment pressure measurement before and after exercise is the mainstay of objective diagnosis. Conservative management has been highly unsuccessful. Overall, considerable success can be expected from fasciotomy of the involved compartments followed by a rigorous rehabilitation program, though recurrence of symptoms is a reported complication. Recent research efforts have focused on the development of less invasive and more accurate diagnostic modalities and safer and more effective surgical procedures.     

Chronic pain syndrome in uorology

Chronic pain of the genital region remains a therapeutic challenge. Among men, symptoms are mainly related to the prostate, bladder and scrotal organs, and among women to the bladder and vagina. Only some of the cases demonstrate pathologic changes of the symptomatic organs requiring specific treatment. Among pain medications, peripheral analgesics are the most suitable. In the case of chronic pain, which can be classified according to Gerbershagen, a psychosomatic origin also has to be considered and needs to be evaluated. Analgesics are of minor importance in the treatment of psychosomatic syndromes but tricyclic antidepressants or anticonvulsants may be helpful. Relaxation techniques also need to be considered.     

Chronic venous compartment syndrome]

Various forms of compartment syndrome can now be distinguished. Acute compartment syndrome is the result of a discrepancy between the volume of the compartment and its contents. This leads to increased pressure at rest and during load, which cuts off the micro-circulation and hence destroys the intracompartmental structures. Chronic compartment syndrome had only been seen in athletes and soldiers up to now. The disease mainly affects the anterior compartment and the fibular muscle group, and only rarely the lateral muscle compartment. In the course of severe venous diseases, a chronic venous compartment syndrome develops which is fundamentally different from the clinical pictures previously known. The cicatricial destruction of the crural fascia exerts an effect on the intracompartmental pressure with every step the patient takes. In severe cases, this results in considerable changes in the muscles involving chronic ischaemia associated with necrosis and glycogen deficiency. Further investigations are necessary in order to define the clinical picture, particularly by measuring the intracompartmental pressure under dynamic and standardised conditions. We suggest also making a verbal distinction between the two forms: a chronic exertional compartmental syndrome and a chronic venous compartmental syndrome.     

Vena cava filter migration: an unappreciated complication. About four cases and review of the literature

Inferior vena cava filter placement is performed to prevent pulmonary risk secondary to deep venous thrombosis. Indications for this treatment are limited to patients experiencing recurrences under well-managed anticoagulant treatment or presenting with contraindication to anticoagulant treatment. Nowadays, as these clinical situations are rare, this device is less and less used, all the more since, for several years now, thrombosis, fracture, or infectious complications as well as filter migration have been reported. Filter migrations are responsible for atypical and varied clinical presentations likely to defer diagnosis. To treat them, the filter is extracted, which is very risky in patients with a thromboembolic history. In our center, during a period of 14 years, we retrospectively collected and studied partial or complete vena cava filter migration cases that had been treated by extraction. We are reporting four very different clinical cases and, more specifically, the second published case of migration to a renal vein, which mimicked a systemic disease. Because of its very atypical clinical presentations, cava filter migration is an unappreciated and certainly underdiagnosed complication. However, this complication must not question cava filter placement when it is justified. In contrast, it prompts early filter extraction or long-term radiological surveillance.