Urgent laparoscopic splenectomy in a morbidly obese pregnant woman: case report and literature review

Laparoscopic splenectomy (LS) has undergone significant evolution since its introduction more than a decade ago. It clearly has been shown to be advantageous in comparison with open splenectomy and is considered by some to be the treatment of choice for routine uncomplicated elective splenectomy. When LS was first introduced, contraindications to the procedure included pregnancy, obesity, and splenomegaly. Both technologic advances and experience with the technique have enabled surgeons to perform LS for a growing number of indications with seemingly fewer contraindications. Here, we present a case of successful LS in a morbidly obese pregnant woman with splenomegaly and hemolysis secondary to hereditary spherocytosis.     

Knee dislocation of a morbidly obese patient: a case report

Knee dislocations of morbidly obese patients after a trivial fall are not uncommon. We report a case of closed reduction for a dislocated right knee of a 26-year-old obese woman. After closed reduction under general anaesthesia, her knee was supported by pillows in 30 degrees flexion. No external splint was used because of the enormous size of the leg. At day 4 after reduction, the patient had numbness over the dorsum of the right foot and was unable to dorsiflex. She was diagnosed as having peroneal nerve palsy and was fitted with a foot drop splint. One week after reduction, she started active, assisted knee mobilisation and tip-toe weight bearing. At 24 months after reduction, the patient was able to walk unaided and had 100 degrees of knee flexion. She had a good foot function and a grade II in the Lachman's test, with no varus or valgus instability. This case highlights the importance of early mobilisation, which can result in good outcome even without operative treatment.     

Respiratory function in the morbidly obese before and after weight loss.

The morbidly obese are known to have impaired respiratory function. A prospective study of the changes in lung volumes, carbon monoxide transfer, and arterial blood gas tensions was undertaken in 29 morbidly obese patients before and after surgery to induce weight loss. Before surgery the predominant abnormality in respiratory function was a reduction in lung volumes. These increased towards normal predicted values after weight loss, with significant increases in functional residual capacity, residual volume, total lung capacity, and expiratory reserve volume. The increases ranged from 14% for total lung capacity to 54% for expiratory reserve volume. After weight loss had been induced the smokers showed mild hyperinflation and air trapping. Resting arterial blood gas tensions improved, with a rise in arterial oxygen tension from 10.63 to 13.02 kPa and a fall in arterial carbon dioxide tension from 5.20 to 4.64 kPa. There was no correlation between weight loss and the changes in blood gas tensions or lung volumes. Loss of weight in the morbidly obese is thus associated with improved lung function. The effects of smoking on lung function could be detected after weight loss, but were masked before treatment by the opposing effects of obesity on residual volume and functional residual capacity.     

Retroperitoneoscopic adrenalectomy for phaeochromocytoma in a morbidly obese patient: A case report

A 38-year-old morbidly obese lady (BMI-46 kg/m²) was diagnosed with a right adrenal phaeochromocytoma. She successfully underwent retroperitoneoscopic adrenalectomy using a 3-port technique incurring a blood loss of 110 ml. Postoperatively her recovery was rapid and uneventful with stabilisation of blood pressure and relief of symptoms, thereby emphasising the safety and efficacy of retroperitoneoscopic adrenalectomy in morbidly obese patients.     

Total knee replacement in the morbidly obese: a literature review

Background: The ‘obesity epidemic’ is expected to result in an increased incidence of knee osteoarthritis and hence total knee replacements (TKRs). Reviews have demonstrated the conflicting results of TKR for all obese (body mass index (BMI) >30). The aim of this literature review was to specifically evaluate outcomes of TKR in patients with morbid obesity (MO; BMI >40). Methods: A systematic review of medical databases (PubMed, Medline, Cochrane Library, ScienceDirect) by use of keywords from January 1990 to September 2009 was undertaken. Results: Clinical and functional Knee Society Scores (KSS) improve after TKR for patients with MO. The post‐operative functional KSS was, in general, less than in controls. Radiographic analysis was inconclusive because of small study populations and short duration of follow‐up. All studies reporting complications noted a greater prevalence in MO patients (10–30%). Of concern was the significantly higher prevalence of deep prosthetic infection (3–9‐times that of controls). The morbidly obese also had a significantly higher incidence of wound complications. TKR did not result in weight loss for MO patients, and therefore has no benefit on weight‐related medical conditions. Bariatric surgery in MO under 65 years of age has been shown to be a cost‐effective and clinically effective method of weight reduction. This surgery also results in significant improvement in weight‐related medical conditions, the KSS and knee pain. Conclusions: Given the increase in complications for MO patients after TKR, these patients should be advised to lose weight before surgery and, if suitable, would probably benefit from bariatric surgery.     

颈椎术后视力丧失1例报告并文献复习

在脊柱外科手术中,术后视力丧失(PVL)是一种极为罕见但常导致灾难性后果的并发症.PVL最早由Slocum等[1]于1948年提出,主要表现为术后视力、视野的丧失.据国外文献[2]报道,在非眼科手术中,PVL的发生率仅为0.0008％ ～ 0.0030％,但在脊柱手术中达0.2％.然而,许多脊柱外科医师对这一并发症仍较...     

小肠移植术后慢性移植物失功1例报道及文献复习

目的探讨小肠移植术后慢性移植物失功(chronic graft dysfunction,CGD)的诊断及治疗。方法报道国内首例同种异体小肠移植患者术后CGD的临床资料,复习相关文献。结果患者因"门静脉血栓、脾静脉血栓致肠系膜血栓"切除了大部分小肠,后行同种异体小肠移植术。术后长期服用他克莫司(FK506),屡次发生排斥反应。术后3次因"小肠狭窄、不全性肠梗阻"行"小肠节段切除吻合术"。其中术后576d第3次出现肠梗阻,予经皮内镜下胃空肠造瘘术胃肠减压等治疗,确定移植肠不可逆性失功后行移植小肠切除术。结论 CGD治疗困难,预后不佳,预防胜于治疗。在确诊CGD不可逆后应尽快切除移植小肠,挽救患者生命,有条件应尽快安排再次移植。     

The state of the art in bariatric surgery for weight loss in the morbidly obese patient

Bariatric surgery is a safe and effective method for achieving durable weight loss for patients with morbid obesity. Gastric restrictive procedures include vertical banded gastroplasty and gastric banding. Malabsorptive procedures include long-limb gastric bypass, biliopancreatic diversion, and biliopancreatic diversion with duodenal switch. The gastric bypass has features of both restriction and malabsorption. The laparoscopic approach to bariatric surgery has substantially improved postoperative recovery. Careful patient selection and preoperative work-up are extremely important. A number of medical comorbidities are improved after surgically-induced weight loss.     

Prevention of gallstone formation in morbidly obese patients undergoing rapid weight loss: results of a randomized controlled pilot study.

INTRODUCTION: An increased risk of gallstone (GS) formation has been linked to obesity and to episodes of rapid and significant weight loss. Previous reports have suggested that bile salt therapy (ursodeoxycholic acid) or prostaglandin inhibition (ibuprofen) may prevent gallstone formation in this high-risk group. The purpose of this study was to investigate GS prevention following bariatric surgery. DESIGN: Randomized double blind controlled trial. METHODS: Sixty patients without gallstones preoperatively (gender, 9 male, 51 female; average preop wt, 349.6 lb; mean age, 38 years) were randomly assigned to receive urso (600 mg/day, n = 20), ibuprofen (600 mg/d, n = 20), or placebo (n = 20). At the time of standard open gastric bypass, intraoperative ultrasonography confirmed the absence of stones or microcalculi, and bile samples were collected via puncture of the gallbladder for bile lipid analysis. Following recovery and resumption of a bariatric diet, study medication was prescribed for the first 6 months postop. Gallbladder emptying and GS formation were assessed using ultrasonograms preop and at 3, 6, 9, and 12 months postop (gallbladder emptying following a high-fat liquid test meal was assessed preop, and at 3 and 6 months postop). RESULTS: Forty-one (68.3%, 8 male, 33 female) of the original 60 patients completed all phases of the study (15 urso, 15 ibuprofen, 11 placebo). The average weight loss was 98.5 +/- 7.2 lb over the 12-month period following bariatric surgery. Twenty-nine (71%) of 41 patients who completed the study developed GS. Of those who formed stones, 12 (41%) developed symptomatic GS and 8/12 (67%) underwent cholecystectomy (4 refused operation). Preoperative gallbladder emptying studies showed no differences in emptying between groups (urso 29%, ibuprofen 32%, and placebo 30%). There was no correlation found between the cholesterol saturation index (CSI mean 205.15, range 67-360) and the incidence of GS. There was a statistical difference (P < 0.01) between the ursodeoxycholic acid group and the ibuprofen group with respect to the incidence of stone formation. There was correlation between weight loss (mean 99 lb, range 21-278 lb) and GS formation, in that patients who lost more weight had a greater tendency to form gallstones. Complete medical compliance was achieved in only 17/60 (28%) of patients originally enrolled. CONCLUSIONS: This pilot study confirms the high incidence of gallstone formation (71% of assessed patients) associated with rapid weight loss in patients undergoing gastric bypass. Despite active enrollment in a supervised prevention trial, the two therapies investigated to reduce gallstone formation were not efficacious, likely because compliance with medical therapy was poor. These findings highlight the significant risk of gallstone formation in this patient cohort even when prevention strategies are utilized.     

Rhinoliths causing palatal perforation: case report and literature review.

Rhinoliths are calcified masses formed within the nasal cavity because of the solidification of mucus, debris, or foreign objects by gradual accretion of mineral salts. They are mostly asymptomatic and incidentally diagnosed, although some patients may complain of nasal discharge and obstruction. Ulceration of the nasal mucosa, facial swelling, and bone destruction are less frequently observed but bring about difficulties for differential diagnoses with several pathologic entities. This article presents a case of a 54-year-old woman with a rhinolith causing palatal perforation, focusing on the diagnostic process and histopathologic characteristics.     

Melorheostosis causing lumbar radiculopathy: a case report and a review of the literature

Background contextMelorheostosis is a rare sclerosing bone disorder with a predilection for the appendicular skeleton. Involvement of the spine is infrequent and largely asymptomatic. Surgical treatment for spinal involvement is therefore uncommon with only one reported case of lumbar fusion for painful lumbosacral melorheostosis.PurposeWe report a case of lumbar melorheostosis causing disabling radiculopathy treated with nerve root decompression.ConclusionsMelorheostosis of the lumbar spine causing radicular symptoms has not been reported before. Our message from the management of this particular patient is to consider surgical option in symptomatic individuals.     

Diabetes insipidus after endoscopic third ventriculostomy. A case report and review of the literature

Endoscopic third ventriculostomy has been found to be successful for treating occlusive hydrocephalus. The complication rate ranges from 6 to 12%. Intraoperative bleeding is the most common incident. Endocrinological failures are rare, mainly due to the proximity of the hypothalamic structures. We report the case of a 33-year-old man who was referred in emergency for subacute hydrocephalus related to a tentorium meningioma. The hydrocephalus was treated by endoscopic third ventriculostomy. During the procedure, the floor of the third ventricle was found to be thick but fenestration was performed without incident. After surgery, the clinical signs of hydrocephalus disappeared but diabetes insipidus was diagnosed the same day. There were no other endocrinology disorders. Medical treatment with vasopressin allowed resolution of the diabetes insipidus in fifteen days. Surgical debulking of the meningioma was then achieved via a subtemporal approach. There was no recurrence of the endocrinology disorder. Diabetes insipidus is an unpredictable complication of third ventriculostomy. The mechanism is not well known. It is however a transient disorder that can easily be treated with vasopresin and therefore should not modify the indications of third ventriculostomy, especially in tumor-related hydrocephalus.     

Sialadenoma papilliferum in a young patient: a case report and review of the literature.

Sialadenoma papilliferum is a rare exophytic tumor of salivary gland origin, accounting for less than 1% of minor salivary gland tumors. It usually occurs in males older than 50 years as a painless papillary intraoral lesion. An 18-year-old male patient presented with an exophytic intraoral lesion present for approximately 12 years. The tumor was excised with a clinical diagnosis of infected hemangioma. However, histopathological diagnosis was consistent with sialadenoma papilliferum. The patient was followed up at regular intervals and no evidence of recurrence was noted. Our patient, aged 18 years, with tumor lasting for 12 years becomes the youngest case of intraoral sialadenoma papilliferum yet reported. This case highlights the importance of keeping sialadenoma papilliferum as a differential diagnosis of an intraoral exophytic proliferative lesion even in a young patient.     

Mechanical prosthetic valve dysfunction causing pulsus alternans leading to intermittent electromechanical dissociation: a case report and literature review

We describe a case of electromechanical dissociation (EMD) in a 62-year-old female patient following insertion of a Medtronic Hall mitral valve prosthesis. She initially developed pulsus alternans which led, over a few hours, to intermittent electromechanical dissociation. Clinical and echocardiographic findings are described. Emergency surgical intervention revealed a piece of chorda wedged between the disc occluder and the valve ring. This case illustrates clinical and Doppler echocardiographic features associated with a rare presentation of an unusual perioperative complication of prosthetic mitral valve dysfunction. We have also included a brief review of related literature.     

Lipoblastomatosis of the neck causing hemiparesis: a case report and review of the literature

BACKGROUND: Lipoblastoma and lipoblastomatosis are rare pediatric adipose tumors that sometimes affect the neck or spinal cord. This case is the third report of lipoblastoma extending into the spinal canal, the first report of intradural tumor extension, and the first report of hemiparesis resulting from lipoblastoma compressing the spinal cord. METHODS: A 13-month-old boy was seen by a pediatrician for a firm, supraclavicular neck mass on the left side. After being evaluated by CT and MRI scanning, the tumor was partially resected. RESULTS: Postoperative microscopic examination of the tumor showed adipose cells with mature nuclei and well-formed fat vacuoles interspersed with fibrovascular septa, a finding consistent with maturing lipoblastoma. CONCLUSIONS: Although lipoblastomatous tumors are treated with complete surgical resection when possible, location of these tumors in the neck may dictate partial resection to avoid intraoperative injury to the spinal cord.     

Diaphragmatic rupture causing repeated vomiting in a combined abdominal and head injury patient: a case report and review of the literature

Background

Diaphragmatic rupture after blunt abdominal injury is a rare trauma condition. Delayed diagnosis is not uncommon especially in the emergency room setting. Associated injuries often shift diagnosis and treatment priorities towards other more life-threatening conditions.

Case presentation

We present a challenging case of a young male with combined abdominal and head trauma. Repeated episodes of vomiting dominated on clinical presentation that in the presence of a deep scalp laceration and facial bruising shifted differential diagnosis towards a traumatic brain injury. However, a computed tomography scan of the brain ruled out any intracranial pathology. Finally, a more meticulous investigation with additional imaging studies confirmed the presence of diaphragmatic rupture that justified the clinical symptoms.

Conclusions

The combination of diaphragmatic rupture with head injury creates a challenging trauma scenario. Increased level of suspicion is essential in order to diagnose timely diaphragmatic rupture in multiple trauma patients.     

Costal osteochondroma causing pneumothorax in an adolescent: a case report and review of the literature

Costal osteochondroma is a rare but important condition to recognize because of the possibility of serious consequences if not diagnosed and treated promptly. Patients can present with numerous complications, including hemothorax, pneumothorax, nervous or vascular impingement, and fracture. We report the case of a 17-year-old adolescent boy who presented to the pediatrician with intermittent shortness of breath and pleuritic chest pain. A chest x-ray demonstrated a left-sided pneumothorax and triangular opacity in the left chest. A computed tomographic scan of the chest revealed the cause to be a costal exostosis of the anterior fifth rib. The lesion was excised using video-assisted thoracoscopic surgery, which has become an increasingly popular method for treating these lesions, causing significantly less morbidity and allowing for a faster recovery than a major thoracotomy.     

Melanosis coli: a case report in a trauma patient and review of the literature

Melanosis Coli (MC) is a benign pigmentation disorder of the colon occasionally diagnosed at endoscopy. The authors report a case of M. coli in a patient with a gunshot to the abdomen, in whom the entity produced an interesting clinical picture, and a review of the literature on this condition.     

Loose body causing transient median nerve compression: a case report and literature review

Compression of median nerve at elbow secondary to loose body is very rare, only two cases have been reported in literature. Elbow swelling in this case led us to the cause of our patient’s median nerve dysfunction. A simple day case elbow arthroscopy procedure, and removal of loose body provided a cure for the elbow symptoms and the neuropathy. Compression neuropathy at the elbow, while rare, should be considered in the differential diagnosis of hand paraesthesia.