Well‐leg compartment syndrome after laparoscopic low anterior resection for lower rectal cancer in the lithotomy position: A case report

A 64‐year‐old man underwent laparoscopic low anterior resection for lower rectal cancer. Because he was overweight (BMI, 28.1 kg/m²) with rich visceral fat and a narrow pelvic cavity, the operation was technically difficult and the operation time was 686 min. Postoperatively, the patient immediately complained of pain and swelling of the left lower limb. Laboratory examination showed that serum creatinine kinase was markedly increased and urine myoglobin was positive on postoperative day 1. He was diagnosed with well‐leg compartment syndrome and was transported to the trauma and critical care center for emergency fasciotomy. After initial treatment, he was transferred to our hospital on postoperative day 7. He completely recovered after 2 months. Although well‐leg compartment syndrome is rare, it is necessary to consider it as a potential complication when performing a long colorectal cancer surgery with the patient in the lithotomy position, particularly when laparoscopic surgery is planned.     

Ligamentoplastie synthétique de la luxation acromio-claviculaire : à propos de 25 cas

The aim of this retrospective study was to evaluate the results of coraco-clavicular ligamentoplasty by TightRope^® system. In fact, this retrospective study had been practiced in the period between 2006 and 2008 in only one department by one surgeon. It had been used over 25 patients who had suffered from recent or ancient acromio-clavicular dislocation. Those patients were reviewed with a mean follow-up of 16 weeks. As a result, this revision gives us 80% of subjective and satisfactory appreciations and 96% of good functional outcome as assessed by the Taft score. The results obtained were not statistically modified, neither by age nor by the grade of the injury. None of our patients had declared his intolerance to the ligament, with a decline of 16 weeks. We did not register any case of calcification or arthritis. The synthetic coraco-clavicular ligamentoplasty enables the achievement of good functional results, and also a well-sustained stable reduction of both recent and ancient dislocations. This technique has the advantage of being simple, safe and with no need of any immobilization.     

Elective re‐intubation to treat complete left lung collapse following Tetralogy of Fallot repair in a very young child

An 18‐month‐old boy weighing 6 kilograms developed complete collapse of left lung following total correction of Tetralogy of Fallot on the next day of extubation. He received extensive chest physiotherapy, along with lung recruitment maneuver by using bubble CPAP, which failed to show any improvement in lung expansion in 2 days. He was then electively intubated on 3rd postoperative day (POD3) for the purpose of suctioning tracheobronchial secretions and maintaining positive airway pressure to open up the left lung. Good results were obtained immediately after intubation, and he was extubated 9 h later. His lung showed complete aeration afterward. He was transferred out of ICU on POD5 and discharged home on POD10.     

Reversible clopidogrel resistance due to right ventricular myocardial infarction: risk factor of recurrent stent thrombosis?

A 63-year-old male Patient was admitted to the intensive care unit due to acute inferior myocardial infarction with right ventricular dysfunction. He received a loading dose of clopidogrel (600 mg) and aspirin (500 mg) and was immediately revascularized by reopening of the proximal right coronary artery (RCA) and implantation of a bare metal stent. After primary successful intervention the patient suffered from thoracic pain on day 5 of admission. The ECG indicated reinfarction. The proximal RCA was again re-opended by PTCA alone. The following day the patient suffered again from thoracic pain with ST-elevation in the inferior leads, this time complicated by additional total AV-blockade. The angiography showed another time a thrombotic occlusion of the initially implanted stent. He received another intervention with implantation of additional two baremetal stents, an aortic counter-pulsation and a temporary two-chamber pace maker. Tirofiban was administered for 24 h and the IABP was withdrawn after 60 h. The patient was discharged on Aspirin 300 mg/d, Clopidogrel 150 mg/d and Enoxaparin 40 mg/d. Six weeks later the patient demonstrated an improved right ventricular function (TAPSE 18 mm), liver enzymes were normal, and inhibition of platelet aggregation by clopidogrel (150 mg/d) was sufficient. In conclusion this implies that the reversible “clopidogrel-resistance” might have been due to congestion and reduced metabolism due to right ventricular infarction.     

Factor XIII activity in patients requiring surgical re-exploration for bleeding after elective cardiac surgery – A prospective case control study

PurposeSurgical re-exploration due to postoperative bleeding is associated with increased morbidity and mortality. The aim of our study was to assess a potential association between the level of postoperative FXIII activity and need for re-exploration due to bleeding in patients undergoing cardiothoracic surgery.Materials and methodsIn our prospective single center observational cohort study, we enrolled patients who underwent elective cardiothoracic surgery. Patients who required re-exploration (RE group) were matched to patients from the study population (non-RE group).ResultsThe study included 64 patients, out of a cohort of 678 patients, of whom 32 required surgical re-exploration due to bleeding within the first 24 h. Between patients of the RE and non-RE group, a significantly reduced FXIII activity was observed postoperatively (59.0 vs 71.1; p = .014). Multivariable analysis revealed reduced FXIII activity (p = .048) as a parameter independently associated with surgical re-exploration. Further, reduced FXIII activity (p = .037) and surgical re-exploration (p = .01) were significantly associated with increased 30 day mortality. In multivariable analysis re-exploration was independently associated with increased risk of 30 day mortality (p = .004, HR 9.68).ConclusionsReduced postoperative FXIII activity may be associated with the need for surgical re-exploration. Postoperative assessment of FXIII activity should therefore be considered in patients undergoing elective cardiothoracic surgery.     

Transarterial Embolization for Traumatic Intractable Oronasal Hemorrhage

Background

Severe craniofacial injury may cause intractable oronasal bleeding, a rare but life-threatening surgical emergency that may occur in the Emergency Department (ED). Uncontrolled massive bleeding is the major cause of mortality. This kind of trauma is usually associated with the transfer of high kinetic energy such as a motor vehicle collision.

Objective

We report an unusual case of intractable oronasal bleeding diagnosed by angiography.

Case Report

A 43-year-old man was brought to the ED after being in a high-energy motor vehicle collision. He had suffered severe craniofacial trauma, including intracranial hemorrhage and intractable oronasal bleeding; he later developed a large pseudoaneurysm arising from the right internal maxillary artery. In the ED, the patient successfully underwent endovascular treatment (EVT) using angiography with transarterial embolization (TAE) therapy to control the bleeding.

Conclusion

EVT by TAE for intractable oronasal bleeding was an effective treatment in this life-threatening situation.     

Correction of amino-acid imbalance in postoperative portosystemic shunts

We report on 22 cirrhotic patients suffering from portal hypertension and bleeding esophageal varices. Sixteen of them underwent H mesocaval shunt with internal jugular vein graft and 6 spleno-renal shunts. Mortality was 13.2%. All the patients were treated postoperatively with parenteral and oral nutritional support with solutions containing no aromatic amino-acids, following Fischer's formula. We determined Fischer's index (formula; see text); normal value 2.67 +/- 0.22) on the day of operation (1.6 +/- 0.22), on the 8th postoperative day (2.32 +/- 0.49), and on the 15th postoperative day (1.85 +/- 0.37). Only 1 patient suffered from hepatic encephalopathy in the immediate postoperative period. Three months after operation Fischer's index was 1.20 +/- 0.11 and only 2 patients with an index below 1 suffered from chronic encephalopathy. We conclude that there is a correlation between Fischer's index and the presence of post-shunt hepatic encephalopathy. The proposed policy of parenteral nutrition improves the values of Fischer's index in the immediate postoperative period and we believe that nutritional support should be included routinely as an adjuvant therapy in portosystemic shunts in cirrhotic patients.     

Diagnostic accuracy of lactate levels after initial fluid resuscitation as a predictor for 28 day mortality in septic shock

PurposeThe aim of the study was to investigate the diagnostic accuracy of initial and post-fluid resuscitation lactate levels in predicting 28 day mortality.Materials and methodsWe retrospectively analyzed a multi-center registry of suspected septic shock cases that was prospectively collected between October 2015 and December 2018 from 11 Emergency Departments. The primary outcome was 28 day mortality. The diagnostic performance of the initial and post-fluid resuscitation lactate levels as a predictor for 28 day mortality was assessed.ResultsA total of 2568 patients were included in the final analysis. The overall 28 day mortality rate was 23%. The area under the receiver operating characteristic curve (AUROC) of initial lactate for predicting 28 day mortality was 0.66 (95% CI, 0.64–0.69) and that of after fluid administration lactate was 0.70 (95% CI, 0.67–0.72), and there was a significant difference (p < 0.001). The optimal cutoff point of lactate after fluid administration was 4.4 mmol/L. Compared with this, the Sepsis-3 definition with a lactate level of 2 mmol/L or more was relatively more sensitive and less specific for predicting 28 day mortality.ConclusionThe post-fluid resuscitation lactate level was more accurate than the initial lactate level in predicting 28 day mortality in patients with suspected septic shock.     

Semuloparin for prevention of venous thromboembolism after major orthopedic surgery: results from three randomized clinical trials,SAVE‐HIP1, SAVE‐HIP2 and SAVE‐KNEE

Background:  Semuloparin is a novel ultra‐low‐molecular‐weight heparin under development for venous thromboembolism (VTE) prevention in patients at increased risk, such as surgical and cancer patients. Objectives:  Three Phase III studies compared semuloparin and enoxaparin after major orthopedic surgery: elective knee replacement (SAVE‐KNEE), elective hip replacement (SAVE‐HIP1) and hip fracture surgery (SAVE‐HIP2). Patients/Methods:  All studies were multinational, randomized and double‐blind. Semuloparin and enoxaparin were administered for 7–10 days after surgery. Mandatory bilateral venography was to be performed between days 7 and 11. The primary efficacy endpoint was a composite of any deep vein thrombosis, non‐fatal pulmonary embolism or all‐cause death. Safety outcomes included major bleeding, clinically relevant non‐major (CRNM) bleeding, and any clinically relevant bleeding (major bleeding plus CRNM). Results:  In total, 1150, 2326 and 1003 patients were randomized in SAVE‐KNEE, SAVE‐HIP1 and SAVE‐HIP2, respectively. In all studies, the incidences of the primary efficacy endpoint were numerically lower in the semuloparin group vs. the enoxaparin group, but the difference was statistically significant only in SAVE‐HIP1. In SAVE‐HIP1, clinically relevant bleeding and major bleeding were significantly lower in the semuloparin vs. the enoxaparin group. In SAVE‐KNEE and SAVE‐HIP2, clinically relevant bleeding tended to be higher in the semuloparin group, but rates of major bleeding were similar in the two groups. Other safety parameters were generally similar between treatment groups. Conclusions:  Semuloparin was superior to enoxaparin for VTE prevention after hip replacement surgery, but failed to demonstrate superiority after knee replacement surgery and hip fracture surgery. Semuloparin and enoxaparin exhibited generally similar safety profiles.     

Effectiveness of prothrombin complex concentrate for the treatment of bleeding: A systematic review and meta‐analysis

Prothrombin complex concentrate (PCC) is increasingly being used as a treatment for major bleeding in patients who are not taking anticoagulants. The aim of this systematic review and meta‐analysis is to evaluate the effectiveness of PCC administration for the treatment of bleeding in patients not taking anticoagulants. Studies investigating the effectivity of PCC to treat bleeding in adult patients and providing data on either mortality or blood loss were eligible. Data were pooled using Mantel‐Haenszel random effects meta‐analysis or inverse variance random effects meta‐analysis. From 4668 identified studies, 17 observational studies were included. In all patient groups combined, PCC administration was not associated with mortality (odds ratio = 0.83; 95% confidence interval [CI], 0.66‐1.06; P = .13; I² = 0%). However, in trauma patients, PCC administration, in addition to fresh frozen plasma, was associated with reduced mortality (odds ratio = 0.64; CI, 0.46‐0.88; P = .007; I² = 0%). PCC administration was associated with a reduction in blood loss in cardiac surgery patients (mean difference: ?384; CI, ?640 to ?128, P = .003, I² = 81%) and a decreased need for red blood cell transfusions when compared with standard care across a wide range of bleeding patients not taking anticoagulants (mean difference: ?1.80; CI, ?3.22 to ?0.38; P = .01; I² = 92%). In conclusion, PCC administration was not associated with reduced mortality in the whole cohort but did reduce mortality in trauma patients. In bleeding patients, PCC reduced the need for red blood cell transfusions when compared with treatment strategies not involving PCC. In bleeding cardiac surgery patients, PCC administration reduced blood loss.     

Potential of a new cw 2 μm laser scalpel for laparoscopic surgery

The potential of a new continuous-wave (cw) thulium–YAG laser for laparoscopic small intestine resection was investigated in pigs in comparison to standard bipolar scissors.

Method

A diode-pumped solid-state thulium–YAG laser system emitting at a wavelength of 2.01 μm was used. Laser power up to 25 W in cw mode was transmitted via a quartz fibre (400 μm core diameter). In order to resect 1 m of the small intestine, the accompanied mesentery was dissected with both devices in 12 pigs (six each group). Arteries and veins of 0.25–3.2 mm inner diameter were dissected in vivo and the resistance of the occluded vessels to pressures up to 375 mmHg was measured by an in vitro set-up. Samples were prepared for histological evaluation.

Results

With respect to intestine resection with bipolar scissors, bleeding occurred significantly less (25%) and dissection time was reduced by 19% using the 2 μm laser scalpel. With the 2 μm laser scalpel, small vessels (<0.5 mm) were successfully occluded up to 100% (arteries) and 89% (veins), larger vessels (1–2.3 mm) to 74% (arteries) and 65% (veins) in vivo. In the in vitro pressure measurement with 375 mmHg, 30% of veins and 35% of arteries stayed closed. In conclusion, the first experiments show that the 2 μm laser scalpel is a promising dissection device for minimally invasive surgery.     

Therapy limitation in octogenarians in German intensive care units is associated with a longer length of stay and increased 30 days mortality: A prospective multicenter study

PurposeThe approach to limit therapy in very old intensive care unit patients (VIPs) significantly differs between regions. The focus of this multicenter analysis is to illuminate, whether the Clinical Frailty Scale (CFS) is a suitable tool for risk stratification in VIPs admitted to intensive care units (ICUs) in Germany. Furthermore, this investigation elucidates the impact of therapeutic limitation on the length of stay and mortality in this setting.MethodsGerman cohorts' data from two multinational studies (VIP-1, VIP-2) were combined. Univariate and multivariate logistic regression were used to evaluate associations with mortality.Results415 acute VIPs were included. Frail VIPs (CFS > 4) were older (85 [IQR 82–88] vs. 83 [IQR 81–86] years p < .001) and suffered from an increased 30-day-mortality (43.4% versus 23.9%, p < .0001). CFS was an independent predictor of 30-day-mortality in a multivariate logistic regression model (aOR 1.23 95%CI 1.04–1.46 p = .02). Patients with any limitation of life-sustaining therapy had a significantly increased 30-day mortality (86% versus 16%, p < .001) and length of stay (144 [IQR 72–293] versus 96 [IQR 47.25–231.5] hours, p = .026).ConclusionIn German ICUs, any limitation of life-sustaining therapy in VIPs is associated with a significantly increased ICU length of stay and mortality. CFS reliably predicts the outcome.     

Two Cases of Thenar Compartment Syndrome from Blunt Trauma

Background

Compartment syndrome is a limb-threatening complication associated with extremity trauma. The existence of compartment syndrome involving the thenar space is considered controversial and has not been reported in association with blunt traumatic injury of the hand.

Objective

We report two cases involving compartment syndrome of the thenar space in association with blunt trauma to the hand.

Case Report

Patient A was a young man who suffered a fracture/dislocation of the right thumb after a fall. Compartment pressures were measured at 70 mm Hg in the thenar space. The patient underwent successful fasciotomy and K-wire stabilization of the thumb and was ultimately discharged with good function on day 4. Patient B suffered a crush injury of the right hand and presented with diffuse swelling associated with median nerve paresthesia. Radiographs revealed a fracture of the triquetrum and of the base of the third metacarpal bone. The patient underwent multiple fasciotomies of the hand, including a release of the thenar space. He was discharged on day 2 with improving function of his thumb.

Conclusion

Compartment syndrome of the thenar space may be more common than previously reported. Given the limited time frame after which permanent damage occurs, clinicians should consider measurement of thenar compartment pressures in high-risk injuries.     

血流导向装置Pipeline治疗椎动脉V4段动脉瘤患者一例的围术期护理

目的探讨血流导向装置Pipeline治疗椎动脉V4段动脉瘤患者围术期的护理要点。方法对在我院神经外科行血流导向装置Pipeline治疗椎动脉V4段动脉瘤的1例患者,给予充分的术前准备、全面的术中配合、精心的术后护理,以保证手术安全、顺利地进行。结果成功植入1枚血流导向装置Pipeline,术中未发生并发症,术后第1天计算机断层扫描(computed tomography,CT)示右侧小脑半球少量渗血,但无临床症状,功能恢复良好,无后遗症。结论对血流导向装置Pipeline治疗椎动脉V4段动脉瘤的患者,全方位的围术期护理,是手术成功的重要保障。     

Treatment of recurrent hypoglycemia with plasmapheresis and steroid in nondiabetic patient

We recently encountered a 35-year old man who suffered from frequent hypoglycemia. His blood test revealed the presence of high and suppressed level of insulin with supressed C-peptide levels, hypothalamic-pituitary axis was normal response in hypoglycemia and negative for anti-insulin antibody. Endocrinological and imaging data eliminated the possibility of insulinoma. His symptoms responded well to the therapy of prednisolone (60 mg/day) and plasmapheresis. We followed up the patient over the subsequent 6 months without remarkable lesions. He has had no further recurrences of hypoglycemia. We believe that the antiinsulin receptor antibody might have induced hypoglycemia in this patient.     

直肠癌低位前切除术后早期吻合口出血的处理

目的通过总结直肠癌低位前切除术后早期吻合口出血发生的危险因素和临床处理,探讨适当的治疗和预防手段,为临床上此类问题的解决提供参考方案。 方法选取2010年1月至2016年12月北京大学首钢医院收治并行直肠癌低位前切除术的直肠癌患者418例,分别按照患者的性别、年龄、肿瘤分期、肿瘤位置、肿瘤大小、是否接受新辅助治疗、采用的手术方式（开腹或腹腔镜）、预防性造口与否等项目,统计术后早期吻合口出血的发生例数,并采用χ²检验和Fisher确切概率法进行统计学分析,总结发生早期吻合口出血后的各种处理措施,探讨治疗和预防早期吻合口出血的有效方法。 结果418例直肠癌低位前切除病例中,21例（5.02%）发生早期吻合口出血。男性患者相对于女性患者更容易出现术后早期吻合口出血,差异具有统计学意义（P=0.01）;肿瘤距离肛缘<6 cm患者明显多于≥6 cm者,差异具有统计学意义（χ²=4.76,P=0.03）;≥65岁和<65岁患者,肿瘤Ⅰ~Ⅱ期和Ⅲ期患者,肿瘤最大直径≥3 cm和<3 cm患者,是否接受新辅助治疗的患者,手术方式为开腹和腹腔镜的患者,是否接受预防性造口的患者,其发生术后早期吻合口出血的例数差异均无统计学意义（χ²=0.00,P=1.00;χ²=1.13,P=0.29;χ²=1.08,P=0.30;P=0.47;χ²=0.00,P=1.00;P=0.29）。11例吻合口出血发生在术后1 d内,均接受了急诊内镜下处理,其中10例经过内镜下处理和综合治疗后出血停止,另外1例患者内镜处理过程中发生医源性吻合口漏,给予急诊外科手术治疗;另外10例患者吻合口出血发生在术后3~10 d以内,其中有4例给予内镜下止血治疗后出血停止,2例经过内科保守治疗后出血停止,4例合并吻合口漏（其中2例出现吻合口近端肠管坏死或部分坏死）。4例出现吻合口漏的患者中有2例经积极盆腔引流后好转,另2例给予手术治疗。所有21例患者未发生死亡。1例患者因吻合口漏、腹腔严重感染继发多脏器功能衰竭,经过35 d重症监护治疗后好转,住院时间明显延长。 结论直肠癌低位前切除术后早期吻合口出血重在预防,若在此基础上仍发生吻合口早期出血,则治疗关键是早期作出诊断,并尽早处理。     

低分子肝素在中老年人腹部肿瘤围手术期的应用研究

目的 探讨小剂量低分子肝素(法安明)对腹部肿瘤围手术期患者凝血试验的变化及出血的影响.方法 90例行腹部肿瘤择期手术的患者随机分为两组,即法安明组45例,空白对照组45例.法安明组于术前2 h、术后1 h、术后第6天各给予法安明2500 U一次.对照组未予以任何抗凝药物处理.所选参与者的年龄均在50岁以上.两组的年龄、性别、术前凝血酶原时间(PT)、肿瘤类型均具可比性.分别测定患者术前及术后血浆中的抗Ⅹa活性,并记录患者术中及术后的出血情况.结果 法安明组术前2 h、术后1 h、术后第6天的抗Ⅹa活性分别为0.023 IU/ml、0.225 IU/ml、0.271 IU/ml,术后抗Ⅹa活性明显高于术前抗Ⅹa活性(均P<0.05).而对照组术前相应时间点的抗Ⅹa活性分别为0.017 IU/ml、0.003 IU/ml、0.014 IU/ml,手术前后抗Ⅹa活性均无明显差异(P>0.05).两组之间术前抗Ⅹa活性无明显差异(P>0.05).法安明组术中弥漫性出血量明显高于对照组(P<0.05),术中和术后的外科出血量与对照组均无明显差异(P>0.05),但术后伤口出血量明显高于对照组(P<0.05).结论 小剂量的法安明(2500 U)能明显增加抗Ⅹa活性,从而达到预防腹部肿瘤术后深静脉血栓形成的目的,但术前给药能明显增加术中弥漫性出血以及术后伤口出血,不推荐术前预防性应用法安明.     

Incidence and Factors Contributing to Low Back Pain in the Nonobstetrical Patients Operated Under Spinal Anesthesia: A Prospective 1-Year Follow-Up Study

PurposeTo determine the incidence and factors contributing to postspinal anesthesia (SPA) low back pain (LBP) in patients undergoing nonobstetrical surgeries.DesignA prospective 1-year follow-up study.MethodsPatients having nonobstetrical surgery using SPA were included. The patients were followed up through phone calls and interviews every postoperative day for the first week, weekly for a month, and then monthly for a year after SPA. Patients' duration of LBP, duration of surgery, and need for LBP treatment were recorded.FindingsOf 410 patients, 5.8% (24 patients) experienced LBP. The incidence of LBP did not have a significant correlation with the recorded variables (P > .05). There was a negative significant correlation between duration of LBP and duration of surgery (r = −0.5096; P = .001). Of the 24 patients experiencing LBP, 16.7% (four patients) experienced it for less than 1 day, 66.7% (16 patients) 1 to 7 days, 16.7% (four patients) more than 7 days, and only one patient (4.2%) for up to 17 days. Special LBP treatment was not needed in any of the patients.ConclusionsThe incidence of LBP was very low, and those patients undergoing nonobstetrical surgery and receiving SPA did not experience persistent LBP.     

Open-label study of the safety,pharmacokinetics, and effectiveness of a 2 mg/kg dose of baloxavir marboxil 2% granules in children <20 kg with influenza

IntroductionBaloxavir marboxil is an oral anti-influenza drug with demonstrated safety and efficacy in pediatric patients when a 2% granules formulation is administered at 1 mg/kg. This study assessed safety, effectiveness, and pharmacokinetics of a higher dose (2 mg/kg) of baloxavir marboxil 2% granules in pediatric patients weighing <20 kg.MethodsThis multicenter, open-label, noncontrolled study was conducted at 15 sites in Japan (January 2019–March 2020; JapicCTI-194577). Patients aged <12 years with confirmed influenza received a single oral dose of baloxavir marboxil at 2 mg/kg if body weight was <10 kg or 20 mg if ≥ 10 to <20 kg. Safety, pharmacokinetics, effectiveness (time to illness alleviation [TTIA] of influenza; time to resolution of fever; virus titer), and polymerase acidic protein (PA) substituted viruses were assessed over 22 days.Results45 patients, all aged ≤6 years, were enrolled. Adverse events were reported in 24 (53.3%) patients, most commonly nasopharyngitis, diarrhea, and upper respiratory tract infection. Median (95% confidence interval [CI]) TTIA was 37.8 (27.5–46.7) hours; median (95% CI) time to resolution of fever was 22.0 (20.2–28.6) hours. A >4 log decrease in mean viral titer occurred at day 2 and a subsequent temporary 1–2 log increase in patients with influenza A(H3N2) and B. Treatment-emergent PA/I38X-substituted virus was detected in 16/39 (41.0%) patients, but no prolonged TTIA or time to resolution of fever was associated with its presence.ConclusionsBaloxavir granules administered at 2 mg/kg in children <20 kg were well tolerated, with symptom alleviation similar to 1 mg/kg.