Primary thoracoscopic evaluation of pleural effusion with local anesthesia: an alternative approach.

OBJECTIVE: The development of a thoracoscopically assisted technique to be performed with the patient under local anesthesia for both diagnostic and therapeutic purposes when treating pleural effusions and empyemas in high-risk surgical patients. METHODS: Twenty patients with pleural effusion or empyema who were also determined to be at high risk for complications following a thoracotomy, pleural biopsy, general anesthesia, or all of these, underwent placement of a thoracoscope while under local anesthesia followed by thoracic fluid drainage, pleural biopsy, and pleurodesis as required. Patients were retrospectively evaluated for a variety of factors including personal history, pre-existing medical conditions, and pre- and postoperative course. RESULTS: The average age of the patients was 59 years (18 to 89) with a 55% male/45% female sex distribution. Patients had this procedure as a consequence of malignancy (50%), empyema (30%), spontaneous pneumothorax (10%), bronchiectasis (50%), or heart failure (5%). The average duration of the procedure was 62 minutes (20 to 190), with an average of 861 mL of fluid drainage, and 114 mL of estimated blood loss. The tube thoracostomy was usually removed on the sixth (0 to 13) postprocedure day. This procedure was well tolerated by the patients with the majority of pain management being achieved with patient controlled analgesia (58%). The direct complication rate was 10%, with 2 patients requiring endotracheal intubation. CONCLUSION: This novel thoracoscopic procedure represents an acceptable alternative to the traditional treatment of pleural effusions and empyema with comparable outcome parameters and morbidity. This technique may eventually become the standard of care for the treatment of pleural effusions.     

Intussusception After Laparoscopic Roux-en-Y Gastric Bypass

Intussusception after open Roux-en-Y gastric bypass procedure (RYGBP) is a rare complication. We present a retrospective review of three cases of antegrade intussusception occurring after laparoscopic RYGBP. To our knowledge, these are the first documented cases of intussusception after laparoscopic RYGBP. We describe the clinical presentation and our management of these three cases. Furthermore, we believe that the initial clinical presentation, radiographic findings, and management of these patients may be different than those patients who have undergone an open RYGBP. With increasing popularity of laparoscopic RYGBP, we are likely to see more of this entity.     

Bariatric surgery improves cardiac function in morbidly obese patients with severe cardiomyopathy.

BACKGROUND: Longstanding morbid obesity can be associated with severe cardiomyopathy. However, the safety and efficacy of bariatric surgery in patients with severe cardiomyopathy has not been studied, and the effect of surgical weight loss on postoperative cardiac function is also unknown. In addition, morbidly obese patients have significantly increased mortality associated with cardiac transplantation, often precluding them from becoming recipients. METHODS: A retrospective study of patients with a left ventricular ejection fraction < or =35% who underwent bariatric surgery (1998-2005) was performed. Short-term morbidity/mortality, length of stay, excess weight loss, pre- and postoperative left ventricular ejection fraction, and New York Heart Association (NYHA) functional class were assessed. RESULTS: A total of 14 patients (10 men and 4 women) with a mean preoperative body mass index of 50.8 +/- 2.04 kg/m(2) underwent bariatric surgery (10 underwent laparoscopic Roux-en-Y gastric bypass, 1 open Roux-en-Y gastric bypass, 2 sleeve gastrectomy, and 1 laparoscopic gastric banding). The complications were pulmonary edema in 1, hypotension in 1, and transient renal insufficiency in 2. The median length of stay was 3.0 days (range 2-9). The mean excess weight loss at 6 months was 50.4%, with a decrease in the mean body mass index from 50.8 +/- 2.04 kg/m(2) to 36.8 +/- 1.72 kg/m(2). The mean left ventricular ejection fraction at 6 months had significantly improved from 23% +/- 2% to 32% +/- 4% (P = .04), correlating with improved functional capacity, as measured by the NYHA classification. Preoperatively, 2 patients (14%) had an NYHA classification of IV, 6 (43%) a classification of III, and 6 (43%) a classification of II. At 6 months postoperatively, no patient had an NYHA classification of IV, 2 (14%) had a classification of III, and 12 (86%) an NYHA classification of II. Two patients had undergone cardiac transplant evaluations preoperatively and underwent successful transplantation after weight loss. CONCLUSION: The results of our study have shown that bariatric surgery for patients with cardiomyopathy is feasible and effective. Surgically induced weight loss results in both subjective and objective improvement in cardiac function. In addition, surgical weight loss can provide a bridge to transplantation in patients who were prohibited secondary to their morbid obesity.     

Extended trans-septal approach for mitral valve surgery: Our early experience

Background Extended trans septal (ETS) approach for mitral valve surgery often divides the artery to the Sino-Atrial node. The clinical implication of this is contentious. We analyzed our early results with ETS approach. Methods Between June 1998 and September 2003 eleven patients underwent mitral valve surgery by ETS approach. Six were females. Age ranged from 19 years to 67 years (median 40 years). Six underwent mitral valve replacement (MVR). Four underwent aortic and mitral (double) valve replacement (DVR). One had mitral valve repair. Three had additional procedures (tricuspid valve repair=1, Coronary artery bypass=1, Aorto bifemoral graft=1). Cardiopulmonary bypass ranged from 64 minutes to 77 minutes (median 72 minutes) for MVR and 112 minutes to 178 minutes (median 140 minutes) for DVR. Aortic cross clamp times ranged from 39 minutes to 52 minutes (median 47 minutes) for MVR and 74 minutes to 120 minutes (median 95 minutes) for DVR. Results There was no mortality or morbidity attributed to the ETS approach. One early death in emergency DVR was due to heart failure. Three patients needed seqeuntial pacing in the immediate post-operative period. Nine out of ten survivors were back to their preoperative rhythms on hospital discharge (6 sinus rhythm; 3 atrial fibrillation). One patient with preoperative trifascicular block who underwent reoperation to fix a paravalvular mitral leak needed a permanent pacemaker (VVI). The follow-up ranged from 1 month to 64 months (median 6 months) and is 100% complete. There was no late death or new arrhythmia. Conclusions Extended trans septal approach is safe. It gives excellent exposure of the mitral valve. division of the sinus node artery is not deleterious in the short to intermediate term. Presented at the 50th Annual Meeting of IACTS. New Delhi, Feb. 2004.     

Propofol-ketamine versus propofol-fentanyl for outpatient laparoscopy: comparison of postoperative nausea,emesis, analgesia,and recovery

STUDY OBJECTIVE: To compare postoperative nausea, emesis, analgesia, and recovery between propofol-ketamine and propofol-fentanyl in outpatient laparoscopic tubal ligations with general anesthesia. STUDY DESIGN: Prospective, randomized, blinded study. SETTING: Tertiary-care women's hospital. PATIENTS: 120 ASA physical status I and II ambulatory patients scheduled for elective laparoscopic tubal ligation. INTERVENTIONS: Patients were randomized to two groups to receive either ketamine (1-1.5 mg/kg) or fentanyl (3-5 microg/kg). MEASUREMENTS: Measured variables included total dose of ketamine, fentanyl, propofol, and operating time. Vital signs, pain visual analog scale scores (VAS), nausea VAS, presence of emesis, treatment for nausea and vomiting, pruritus, sedation, and presence of dreaming were recorded on postanesthesia care unit (PACU) admission, PACU discharge, stepdown unit admission, and hospital discharge. Results are expressed as means +/- SD or medians and analyzed using t-test, Chi-square, or Mann-Whitney (p < 0.05). MAIN RESULTS: No differences were noted with respect to propofol dose, operating times, pain or nausea VAS scores, emesis, treatment for nausea and vomiting, pruritus, and sedation on PACU admission, PACU discharge, stepdown unit admission, and hospital discharge. The ketamine group had a higher heart rate, required more pain medication, and had a higher frequency of dreaming on PACU admission than the fentanyl group. These differences became insignificant on PACU discharge. CONCLUSIONS: For outpatient laparoscopic tubal ligations with general anesthesia, propofol-ketamine does not improve postoperative nausea, emesis, analgesia or recovery compared with the propofol-fentanyl combination.     

Nitrous oxide anxiolysis for elective cesarean section

STUDY OBJECTIVE: To determine if inhaled 40% nitrous oxide (N(2)O) via facemask is an effective anxiolytic in women undergoing elective cesarean section under spinal anesthesia. STUDY DESIGN: Prospective, randomized, double-blinded study. SETTING: Tertiary-care women's hospital. PATIENTS: Sixty American Society of Anesthesiologists physical status I and II patients scheduled for elective cesarean section under spinal anesthesia. INTERVENTIONS: Patients were randomized to 2 groups to receive either 100% O2 via facemask or 40% N2O in O2 via facemask. MEASUREMENTS: Vital signs (blood pressure, heart rate, and oxygen saturation) and measured variables (visual analog scale [VAS] anxiety, VAS pain, and sedation scores) were obtained at specific periods during the procedure (preoperatively, entering the operating room, spinal injection, skin incision, uterine incision, delivery, and at the conclusion of the surgical procedure). In addition, surgical time and delivery time, mean dose and percentage of patients requiring ephedrine or phenylephrine boluses, the emesis rate, and Apgar scores were measured. MAIN RESULTS: No differences were noted with respect to maternal mean blood pressure, heart rate, pulse-oximeter oxygen saturation, and sedation or VAS pain scores during the measured periods. No differences were noted in surgical and delivery times, mean dose, or percentage of patients who required ephedrine or phenylephrine to maintain maternal blood pressure, the emesis rate, or 1- and 5-minute Apgar scores. Mean anxiety scores for the N2O group were significantly lower at the time of spinal injection, skin incision, and uterine incision. Multivariate analysis of variance for high-anxiety patients (> or =50 VAS) revealed significantly lower VAS scores in the N2O group, compared with the O2 group again at spinal injection, skin incision, and uterine incision. CONCLUSIONS: Inhaled 40% N2O via facemask provides effective anxiolysis in women undergoing elective cesarean section under spinal anesthesia in patients with high anxiety (> or =50 VAS) at the time of spinal injection, skin incision, and uterine incision.     

Incidence of Extensor Digitorum Brevis Manus Muscle

The extensor digitorum brevis manus, a supernumerary muscle in the fourth extensor compartment of the dorsum of the wrist, is a relatively rare anomalous muscle. Extensor digitorum brevis should be included in the differential diagnosis of soft tissue masses on the dorsal aspect of the hand as it may mimic cystic, neoplastic, inflammatory, and infectious masses arising in the dorsum of the wrist. Seventy-two upper limbs of male and female cadavers were dissected and examined to study the pattern of extensor tendons of the index finger. In the present study, we observed three cases (4.2%) of the extensor digitorum brevis manus on the left side. In one cadaver (0.72%), there was an additional tendon arising from the extensor indices which was inserted to the radial side of the dorsal digital expansion of the index finger. The extensor digitorum brevis manus muscle (EDBM), an anatomic variant of the extensor muscle of the dorsum of the hand, is found in approximately 2% to 3% of the population. This variation is, therefore, clinically and surgically relevant because the EDBM may be the only muscle responsible for the independent extension of the second digit. The aim of the present study is to report the incidences of this muscle thereby creating awareness of its existence and of its characteristic appearance to surgeons.     

Predictability model of the need for extracorporeal membrane oxygenation in neonates with meconium aspiration syndrome treated with inhaled nitric oxide

Background

As the use of inhaled nitric oxide (iNO) resulted in a decline in the need for extracorporeal membrane oxygenation (ECMO) in neonates with hypoxic respiratory failure, iNO has become an accepted treatment modality even in non-ECMO centers. However, because not all neonates respond to iNO, the timely identification and transfer of nonresponders to an ECMO center are important.

Objectives

The objective of this study was to identify the risk factors predictive of the need of ECMO in neonates with hypoxic respiratory failure after the first 6 hours of iNO treatment in an ECMO center.

Methods and Patient Population

Forty-nine patients with hypoxic respiratory failure transferred for iNO therapy and potential ECMO during a 2-year period were identified in this retrospective study. None of the patients had received iNO before admission. Strict clinical guidelines were used to standardize lung inflation, cardiovascular support, and iNO administration and weaning and to define treatment failure. The relationship between treatment failure (ie, the need for ECMO) and a set of suspected risk factors after 6 hours of iNO administration was examined by logistic regression analysis.

Results

Twenty-two neonates responded to iNO (non-ECMO group) whereas 27 neonates failed and met ECMO criteria (ECMO group). There was no difference between the 2 groups in demographic data, ventilatory support, air leak syndrome at 6 hours of iNO treatment, and survival to discharge. However, the dose and duration of iNO therapy were predictive of the need for ECMO with an adjusted odds ratio of 1.12 (95% CI, 1.01-1.25; P = .04) and 0.45 (95% CI, 0.27-0.65; P = .0002), respectively.

Conclusions

By the end of the first 6 hours of iNO treatment and under the specific conditions established by the use of the clinical guidelines, the dose and the duration of iNO administration were predictive of the probability for the need of ECMO in this patient population. Thus, one can establish a center-specific predictability model for the need of ECMO in neonates with hypoxic respiratory failure treated with iNO if strict clinical guidelines for iNO administration and weaning and respiratory and cardiovascular support are used in the given center.     

Chemotherapeutic trials with different regimens containing rifampicin in paucibacillary type of leprosy cases--a preliminary report

Different regimens containing Rifampicin have been tried in treating paucibacillary leprosy patients. In our study we have studied three regimens. Regimen I consists of treating patients with Rifampicin 600 mg once a month for six months combined with Dapsone 100mg daily and treatment is stopped at six months. Regimen II is same as regimen I except that instead of stopping treatment at the end of six months the treatment was continued with dapsone 100 mg daily for another six months and treatment was stopped at one year. Regimen III is the same as recommended by I.A.L. in which treatment is started with Rifampicin 600 mg daily for seven days in the first month to be followed by Rifampicin 600 mg once a month for five more months. This is combined with dapsone 100mg daily for one year. Treatment in this group is also stopped at one year. Eighty one patients in Regimen I, thirty five patients in Regimen II and sixty three patients in Regimen III completed the six month treatment. It was found that the inactivation index in all the three regimens was nearly the same.