Emergent Surgical Pulmonary Embolectomy in a Pregnant Woman: Case Report and Literature Review

Acute pulmonary embolism is a leading cause of death during pregnancy and delivery in the United States. We describe the case of a 25-year-old woman who presented in car-diogenic shock in week 38 of her first pregnancy. After the emergent cesarean delivery of a healthy male neonate, the mother underwent immediate surgical pulmonary embolec-tomy. We confirmed the diagnosis of pulmonary embolism intraoperatively by means of transesophageal echocardiography and removed large clots from the patient''s pulmonary arteries. Mother and child were doing well, 27 months later. In addition to presenting our patient''s case, we discuss the other relevant reports and the options for treating massive pulmonary embolism during pregnancy.     

Analysis of surgical success in preventing recurrent acute exacerbations in chronic pancreatitis

OBJECTIVE: To determine whether surgical intervention prevents recurrent acute exacerbations in chronic pancreatitis (CP). SUMMARY BACKGROUND DATA: The primary goal of surgical intervention in the treatment of CP has been relief of chronic unrelenting abdominal pain. A subset of patients with CP have intermittent acute exacerbations, often with increasing frequency and often unrelated to ongoing ethanol abuse. Little data exist regarding the effectiveness of surgery to prevent acute attacks. METHODS: From 1985 to 1999, all patients identified with a diagnosis of CP were recruited to participate in an ongoing program of serial clinic visits and functional and clinical evaluations. Patients were offered surgery using standard criteria. Data were gathered regarding ethanol abuse, pain, narcotic use, and recurrent acute exacerbations requiring hospital admission before and after surgery. Patients were broadly categorized as having severe unrelenting pain alone (group 1), severe pain with intermittent acute exacerbations (group 2), and intermittent acute exacerbations only (group 3). RESULTS: Two hundred fifty-nine patients were recruited. One hundred eighty-five patients underwent 199 surgical procedures (124 modified Puestow procedure [LPJ], 29 distal pancreatectomies [DP], and 46 pancreatic head resections [PHR; 14 performed after failure of LPJ]). There were no deaths. The complication rate was 4% for LPJ, 15% for DP, and 27% for PHR. Ethanol abuse was causative in 238 patients (92%). Mean follow-up was 81 months. There were 104 patients in group 1 (86 who underwent surgery), 71 patients in group 2 (64 who underwent surgery), and 84 in group 3 (49 who underwent surgery). No patient without surgery had spontaneous resolution of symptoms. Postoperative pain relief (freedom from narcotic analgesics) was achieved in 153 of 185 patients (83%) overall: 106 of 124 (86%) for LPJ, 19 of 29 (67%) for DP, and 42 of 46 (91%) for PHR. The mean rate of acute exacerbations was 6.3 +/- 2.1 events per year before surgery in group 2 and 7.8 +/- 1.8 events per year in group 3. After surgery, no acute exacerbations occurred in 42 of 64 (66%) group 2 patients and in 40 of 49 (82%) group 3 patients. The mean number of episodes of acute exacerbation after surgery was 1.6 +/- 2.3 events in group 2 and 1.1 +/- 1.9 events in group 3. Only four patients in group 2 and one patient in group 3 had an equal or increased frequency of attacks after surgery. Preventing attacks was most effective with LPJ (58/64, 91%) and least effective for DP (6/18, 33%). CONCLUSIONS: Surgical intervention prevents recurrent acute exacerbations. The overall frequency of events was reduced in nearly all patients. Therefore, surgical intervention is indicated in patients with CP whose disease is characterized by recurrent acute exacerbations.     

Inhibition of serum-induced proliferation of bovine tracheal smooth muscle cells in culture by heparin and related glycosaminoglycans.

1. The effect of heparin and related glycosaminoglycans on bovine airway smooth muscle proliferation has been investigated. 2. Foetal bovine serum stimulated division of bovine trachealis smooth muscle cells in a concentration-dependent fashion at concentrations between 1 and 30%. 3. Heparin (0.1-100 micrograms ml-1), heparan sulphate (0.1-100 micrograms ml-1) and fragmin (0.1-100 micrograms ml-1) inhibited smooth muscle division in a concentration-dependent fashion between 0.1-100 micrograms ml-1. A heparin disaccharide did not exhibit inhibition of division at 100 micrograms ml-1. 4. Dextran sulphate at molecular weights of 5 x 10(3) and 5 x 10(5) concentration-dependently inhibited division between 0.1-100 micrograms ml-1. Dextran without sulphation did not exhibit inhibition of division at 100 micrograms ml-1. 5. The magnitude of inhibition of proliferation did not reach 100% for any compounds examined at concentrations up to 100 micrograms ml-1 during incubations for 5 and 14 days. IC50 values for inhibition of proliferation ranged between 1-5 micrograms ml-1. 6. These findings suggest that heparin and related glycosaminoglycans inhibit bovine airway smooth muscle cell division.     

Percutaneous radiofrequency ablation of renal tumors: technique, complications, and outcomes

PURPOSE: To report the safety, technical success, and effectiveness of percutaneous radiofrequency (RF) ablation for renal tumors. MATERIALS AND METHODS: The authors retrospectively reviewed the medical records and imaging studies of 29 consecutive patients (18 men, 11 women; mean age, 65 +/- 2.62 years) with 30 renal tumors (mean diameter, 3.5 +/- 0.24 cm) who underwent percutaneous RF ablation at their institution from September 2001 to March 2004. All procedures were performed with computed tomography guidance with general anesthesia, and all patients were admitted to the hospital for overnight observation. Technical success, complications, and their management were recorded. Technique effectiveness was assessed by imaging and clinical follow up. RESULTS: Overall, 88 overlapping ablations were performed (mean, 2.6 +/- 0.16 ablations per tumor per session) in 34 sessions. There were four major complications (12%). Three patients had gross hematuria and urinary obstruction, all were successfully treated. One patient had persistent anterior abdominal wall weakness. There were also two minor complications (6%) without significant clinical sequelae. One patient had gross hematuria which resolved spontaneously, another patient had transient paresthesia of the anterior abdominal wall. There were no significant changes in renal function after RF ablation. The intent of RF ablation was eradication of the primary tumor in 27 patients and treatment of gross hematuria in the other two. Technical success was achieved in all cases. Follow-up images were available for 26 patients. The primary tumor was completely ablated in 23 of 24 patients (96%) in whom eradication of the primary tumor was attempted (follow up period: mean, 10 months, median 7 months). The two patients treated for hematuria remained asymptomatic for 6 and 27 months each. CONCLUSION: Percutaneous RF ablation for renal tumors is safe and well tolerated. High technical success rates are expected. Early reports of the technique's effectiveness are promising.     

Bilateral metastatic renal synovial sarcoma

Synovial sarcoma is a malignant soft-tissue neoplasm, usually arising in close association with the joints and generally carrying a poor prognosis. We describe the first report of bilateral renal metastases from synovial sarcoma in a long-term survivor. Treatment consisted of systemic therapy with bilateral partial nephrectomies. The patient was disease free at 1 year of follow-up.     

Initial evaluation of robotic technology for microsurgical vasovasostomy

PURPOSE: Conventional microscope assisted vasovasostomy (MAVV) is a technically difficult procedure that is most successful in the hands of well-trained microsurgeons. Robotics may help surgeons overcome the microsurgical challenges of tremor, limited dexterity, miniaturized instrumentation and use of fine suture. We determine the feasibility of a robotic assisted vasovasostomy (RAVV) and compare performance measures with those of conventional MAVV. MATERIALS AND METHODS: One surgeon performed 10 vasovasostomies with a modified 1-layer technique and 9-zero suture on fresh human vas specimens using the robot in 5 RAVV cases and standard microsurgical instrumentation in 5 MAVV cases. Pre-specified performance measures and adverse haptic events (broken sutures, bent needles or loose stitches) were recorded. Patency was evaluated by instilling saline through the anastomoses. RESULTS: Mean operating time and number of adverse haptic events were higher for RAVV than for MAVV (84 vs 38 minutes, p = 0.01; 2.4 vs 0.0 events, p = 0.03). The number of needle passes required for the 6 full-thickness stitches was similar in both groups (16.8 vs 15.2 passes, p = 0.55). Although no tremor occurred during RAVV, minimal to moderate amounts occurred during MAVV. Minimal fatigue was noted for both groups. Patency was confirmed in all 10 operations. CONCLUSIONS: Use of RAVV in this human ex vivo vas model was feasible. While RAVV took longer to perform and was associated with adverse haptic events, elimination of tremor and comparable patency rates suggest that it may be a viable surgical alternative for microsurgical vasovasostomy.