Bicuspid pulmonary valve with atrial septal defect leading to pulmonary aneurysm

Pulmonary artery aneurysms are rare. We describe 2 adult patients with pulmonary artery aneurysm with normal pulmonary pressure associated with bicuspid pulmonary valve and atrial septal defect. One patient presented with moderate pulmonary valve stenosis and was treated with open surgery; the other patient had a small atrial septal defect and mild pulmonary valve insufficiency and is periodically still being evaluated. Hemodynamic alterations associated with a pulmonary artery aneurysm are described; the influence of additional volume overload and intrinsic wall abnormalities in pulmonary valvular lesions as potential triggers for the development of these aneurysms are analyzed and therapeutic strategies are discussed.     

A biomechanical evaluation of the tibiofibular and tibiotalar ligaments of the ankle

The purpose of this ex vivo biomechanical study was to determine the strength and stiffness of the anterior and posterior syndesmotic tibiofibular ligaments and the posterior tibiotalar component of the deltoid ligament. Injuries to these ligaments are a prevalent clinical problem, yet little is known about their mechanical behavior. Ten fresh-frozen cadaver lower extremities (average age at death, 72 +/- 8 years) were harvested. The anterior and posterior tibiofibular ligaments and the posterior tibiotalar component of the deltoid were isolated and prepared as bone-ligament-bone complexes for tensile testing to determine strength, stiffness, and mode of failure. The posterior tibiofibular ligament exhibited greater strength, but not significantly so (p < .05), than the anterior tibiofibular ligament and the posterior tibiotalar component of the deltoid ligament. There were no significant differences in stiffness between the three ligaments tested. The dominant mode of failure for the anterior tibiofibular ligament was ligament substance rupture, primarily near its fibular insertion, whereas the failure modes of the posterior tibiofibular ligament were evenly split between substance ruptures and fibular avulsions. The posterior tibiotalar component of the deltoid ligament ruptured most often near the talar insertion. The tibiofibular ligaments showed greater strength than the lateral collateral and deltoid ligaments, as mentioned in literature. The greater strength of the tibiofibular ligaments relative to the lateral collateral and deltoid ligaments suggests that these ligaments play an important role in ankle constraint.     

Laparoscopy as a treatment for intraperitoneal bladder injury

OBJECTIVE: To present our experience of laparoscopic repair of iatrogenic bladder perforation. MATERIAL AND METHODS: Four cases of intraperitoneal bladder perforation occurred as a complication of transurethral tumor resection. The mean age of the patients was 66 years. Details of the surgical technique are presented. RESULTS: The operation time ranged from 25 to 60 min. There were no intra- or postoperative complications. The average duration of hospitalization was 4 days and the recovery time was < or =12 days. CONCLUSION: Laparoscopic repair of iatrogenic bladder perforation is a valuable alternative to open surgery.     

Differential Effect of Diarrhea on FK506 Versus Cyclosporine A Trough Levels and Resultant Prevention of Allograft Rejection in Renal Transplant Recipients

Diarrhea is the most frequently reported adverse event in patients treated with mycophenolate mofetil. Twenty-six renal transplant patients on a mycophenolate mofetil-based immunosuppressive regime with persistent afebrile diarrhea were examined. Diarrhea caused a significant rise in FK-506 trough levels despite intake of stable doses, necessitating FK-506 dose reductions of 30% to obtain pre-diarrhea trough levels. In contrast, trough levels of cyclosporine A remained stable without dose adjustments. This suggests that absorption and/or metabolism is differentially altered for FK506 compared with cyclosporine A in patients with diarrhea. In nine patients mycophenolate mofetil was reduced or stopped because of persistent diarrhea without identifiable cause. This resulted in end-stage renal disease because of chronic rejection in two patients, and in acute rejection in two patients, all taking FK506 and steroids. Therefore, dose adjustments of FK506 in patients with diarrhea must be carefully monitored, especially when doses of mycophenolate mofetil are also reduced.     

Clinical diagnosis of syndesmotic ankle instability: evaluation of stress tests behind the curtains

We studied the feasibility of clinical tests in the diagnosis of syndesmotic injury of the ankle. 9 investigators examined 12 persons twice, including 2 patients with an arthroscopically-confirmed syndesmotic injury. They sat behind a curtain that exposed only the lower legs. We found a statistically significant relation between the final arthroscopic diagnosis and the squeeze, fibula translation, Cotton, and external rotation tests as well as for limited dorsal flexion. None of the syndesmotic tests was uniformly positive in chronic syndesmotic injury. The external rotation test had the fewest false-positive results, the fibula translation test the most. The external rotation test had the smallest inter-observer variance. The physical diagnosis was missed in one fifth of all examinations. When in accordance with medical history and physical examination, positive stress tests should raise a high index of suspicion of syndesmotic instability. The final diagnosis of such instability, however, should be made by additional diagnostic imaging and/or arthroscopy.     

Feasibility of diaphragm pacing in patients after bilateral lung transplantation

Recent animal studies and intraoperative studies in humans suggested that phrenic nerve stimulation could attenuate ventilator‐induced diaphragm dysfunction. The purpose of the present study is to examine the safety and feasibility of diaphragm pacing during the weaning process after bilateral lung transplantation. Four patients, suffering from chronic pulmonary disease, were included, and diaphragm pacing was evaluated after lung transplantation. Implantation of electrodes at the end of the lung transplant procedure was possible in three of the four patients. In all implanted patients, stimulation of the diaphragm could trigger the ventilator. Implanted electrodes were completely removed by percutaneous retraction after up to 7 days of pacing. Adverse events related to pacing included occurrence of pain. Diaphragm pacing with temporary electrodes, inserted during surgery, is feasible and is able to trigger the ventilator in patients after bilateral lung transplantation. The use of intradiaphragmatic electrodes creates the additional opportunity to monitor the evolution of diaphragm electromyography during the postoperative weaning process.     

Are routine preoperative liver function tests in patients with uncomplicated symptomatic gallstone disease necessary?

Background: The aim of this study was to evaluate the value of preoperative liver function tests (LFTs) in patients with uncomplicated gallstone disease and scheduled for laparoscopic cholecystectomy.

Methods: All 1112 patients who underwent a laparoscopic cholecystectomy for symptomatic gallstone disease during a 6-year cohort were retrospectively reviewed. Only patients who presented with uncomplicated disease were selected. Preoperative LFTs, pre-, and postoperative endoscopic retrograde cholangio pancreaticographies (ERCPs) and postoperative complications were collected.

Results: A total of 697 patients were included. There were 629 (90.2%) patients with (group I) and 68 (9.8%) patients without (group II) preoperative LFTs. The incidence of ERCPs, ERCPs positive for bile duct stones, and postoperative complications were not significantly different between groups. Second, Group I patients were divided into four groups: 360 patients with normal LFTs (I-A1), 269 patients with at least one LFT?>?normal value (I-A2), 531 patients with all LFTs <2× normal (I-B1), and 98 patients with at least one LFT >2× normal (I-B2). More ERCPs were performed in group I-A2 (10%) than in group I-A1 (2.2%) and more in group I-B2 (18.4%) than I-B1 (3.2%), as a consequence of significantly more ERCPs performed preoperatively. No differences were detected between groups regarding ERCPs positive for bile duct stones or postoperative complications.

Conclusions: Preoperative LFTs do not influence the occurrence of postoperative complications nor the total rate of ERCPs in patients undergoing cholecystectomy for uncomplicated gallstone disease. Preoperative determination of LFTs seems to cause a slight shift from post- to preoperative ERCPs without further clinical consequences.     

Early results for below-knee bypasses using Distaflo

In patients who require lower extremity revascularization, prosthetic graft is a reasonable alternative in the absence of a suitable autologous vein conduit. However, prosthetic bypass grafts have limited patency, especially for infrageniculate reconstruction. Polytetrafluoroethylene grafts were geometrically modified at the distal end to increase their patency. The authors reviewed their experience with the Distaflo graft in patients who required lower extremity below-knee popliteal and tibial bypasses when no suitable autologous vein conduit was available. Chart review was conducted of the 57 patients who underwent 60 lower extremity bypasses over a 3-year period between June 2003 and April 2006. Twenty-four revascularizations were constructed to the tibial outflow sites, whereas the remaining grafts were placed to the below-knee (28) and above-knee (8) popliteal artery, respectively. Study endpoints were primary, assisted primary, secondary patency, and limb salvage at the time of follow-up. Distaflo bypass was performed at the infrageniculate level in 86.7% of cases (28 below-knee popliteal, 24 tibial). Mean follow-up time was 12 months (range, 0.5-37.5 months). At 1 year, primary, assisted primary, and secondary patencies and limb salvage rates for below-knee popliteal bypasses were 83.5%, 89.5%, 94.7%, and 94.4%, respectively. Primary, assisted primary, and secondary patencies and limb salvage rates for tibial bypasses were 44.4%, 44.4%, 63.2%, and 74.9%, respectively. Distaflo precuffed graft is a good alternative conduit for below-knee popliteal and tibial lower extremity reconstructions in the absence of an autologous vein and appears to have promising early patency and limb salvage rates even when used for tibial bypasses.     

Causes of frequency and nocturia after renal transplantation

OBJECTIVE

To explore the role of bladder capacity, bladder pain, dysfunctional voiding, urgency, urinary tract infections (UTIs), and urinary output as potential causes of frequency and nocturia after renal transplantation.

PATIENTS AND METHODS

Data were gathered from 52 adult renal transplant patients (35 men and 17 women, mean age 49 years), using a written questionnaire, medical records, frequency/volume charts, and urinary cultures. The mean time between transplantation and data collection was 5 months. Structural equation modelling (SEM) was used for the simultaneous assessment of direct and indirect relationships between explanatory variables and voiding frequency.

RESULTS

Frequency and nocturia were found in 54% and 60% of the study population, respectively. Frequency was directly associated with a small bladder capacity, bladder pain, urgency, and a high daytime urine volume, and indirectly by UTIs (via urgency and bladder pain). Nocturia was associated with high nocturnal urine volume, small bladder capacity and dysfunctional voiding. A quarter of the patients had small bladders and another quarter had large bladders, the latter being associated with nocturnal polyuria.

CONCLUSIONS

The presence of frequency, especially when accompanied by bladder pain, might aid the physician to identify patients with small bladders. The presence of nocturia can be the result of a high nocturnal urine volume, which increases the risk of bladder enlargement. Because both abnormal bladder conditions can contribute to graft dysfunction, we recommend a urological follow‐up after renal transplantation, using frequency/volume charts.