Preoperative diagnosis of bronchial atresia presenting with recurrent respiratory symptoms in an infant

Bronchial atresia (BA) is a rare respiratory malformation that may be diagnosed from infancy to adulthood. A typical feature of the disease is involvement of the left upper lobe and a mass-like lesion surrounded by a hyperlucent and nondeflating zone. We present a six-month-old male infant who was diagnosed by contrast-enhanced spiral computed tomography (CT) with three-dimensional (3D) technology, and by Tc-99m-macroalbumin aggregate (Tc99m-MAA) radionuclide scintigraphy. We stress that early diagnosis of BA can be made noninvasively using contrast-enhanced spiral CT and radionuclide scintigraphy. 3D computed tomographic reformation allows a more accurate diagnosis as well as a more specific approach to management and follow-up.     

Thrombolytic therapy with tissue plasminogen activator for superior vena cava thrombosis in an infant with sepsis

Superior vena cava syndrome is rare in infants, and rarely responds to conservative treatment. We report a 22-mo-old girl with superior vena cava syndrome due to the use of a central venous line and/or sepsis. Doppler study and computed tomography angiography of the neck showed thrombosis within the superior vena cava and jugular veins. She was admitted to a monitored setting and received recombinant tissue plasminogen activator for 2 d. The clinical features of superior vena cava syndrome disappeared completely 3 d after treatment. No complications were observed and radiological investigations showed blood flow through the thrombus after treatment. Systemic recombinant tissue plasminogen activator may be useful in the treatment of superior vena cava syndrome in children.     

Endothelial functions improve with decrease in asymmetric dimethylarginine (ADMA) levels after renal transplantation

BACKGROUND: Chronic kidney disease (CKD) is associated with increased cardiovascular events. The relationships between the markers of inflammation and endothelial dysfunction were investigated both before and after living donor kidney transplantation. METHODS: Twenty-seven renal transplant patients were studied. Eleven patients (six male, five female) were on cyclosporine A, whereas 16 patients (nine male, seven female) were treated with tacrolimus based regimes. Twenty-seven subjects (12 males, 15 females) were studied as controls. Plasma adiponectin, high sensitive C reactive protein (hsCRP), Asymetric dimethyl arginine (ADMA) levels were studied before transplantation and on days 1, 3, 7, 14, and 28. The brachial artery flow mediated dilatation (FMD) was studied before transplantation and on the 28th day. RESULTS: Serum hsCRP and ADMA levels decreased significantly from the first posttransplantation day on each measurement (P<0.001 for all) while the decrement of plasma adiponectin started in the third day (P<0.001 for all). The FMD was lower in the patients than the control group (P<0.001) and improved significantly in the 28th day of transplantation (P<0.001). CONCLUSIONS: The results indicate that ADMA is associated with FMD in CKD both before and after kidney transplantation. Endothelial functions improve at the very beginning of the posttransplantation period with accompanying reduction in ADMA and hsCRP levels.     

Minimally invasive anterior contralateral approach for the treatment of cervical disc herniation

BACKGROUND: During the practice of ipsilateral approach to the offending lesion in anterior simple discectomy, the authors realized that it achieves better surgical exposure of the opposite foraminal area. In addition, it was also realized that routine procedures for better visualization of the foraminal area, such as stripping longus colli muscles, further excising of the anterior longitudinal ligament, or using a spreader, which cause more invasive surgery during the standard anterior approach, are not necessary because the contralateral approach already achieves sufficient exposure of the target foraminal area. OBJECTIVE: Evaluation of the results and effectiveness of this minimal invasive technique in patients with either soft or hard disc herniations. METHODS: Between January 1994 and April 2002, 216 patients underwent anterior contralateral microdiscectomy without fusion for cervical disc herniation at 1 or 2 adjacent levels. Anterior contralateral microdiscectomy is a less invasive technique than standard anterior simple discectomy in which longus colli muscles are not stripped, and the lateral part of annulus fibrosis at the side of intervention and ventrolateral part of it at the opposite side are not removed. In addition, a mini Zenker handheld retractor is used for retraction of paravertebral soft tissues and a spreader is not used during the discectomy procedure. There were 182 patients diagnosed with radiculopathy and 34 patients with myelopathy. Assessments of the neurological status of patients with radiculopathy were done by physical examinations, and of those with myelopathy according to the modified Japanese Orthopaedic Association cervical spine functional assessment scale. These neurological assessments were repeated in the 18th month after surgery. In the follow-up period, the outcomes of surgery were also assessed for all patients in 4 categories, from failure to excellent. RESULTS: Surgery outcomes generally have been good to excellent and none of the patients were made worse by the procedure. The outcomes were significantly better in the radiculopathy and soft disc herniation groups. Other positive outcome factors were short duration and sudden onset of symptoms, normal cervical curvature, and single-level disease. Follow-up radiological studies revealed fibrous healing with normal or slight loss of disc height in 199 (92.1%) patients and total obliteration of the involved disc space representing radiological fusion signs in 13 (6%) patients. The overall complications observed in this study were 2 spontaneous and 2 postinfection collapses of disc level, 1 excessive fibrosis of disc level, and 2 adjacent-level diseases. CONCLUSION: Anterior contralateral microdiscectomy without fusion achieves better exposure for resection of the offending foraminal or far lateral lesions, ventral osteophytes, or a disc fragment under direct microscopic visualization. Collapse and instability of the involved disc level can also be avoided via this less invasive technique.     

Medical haemostasis in acute hepatocyte injury and experimental liver trauma

BACKGROUND: The aim of the present study was to test the effectiveness of aprotinin to reduce bleeding in liver resection of guinea pigs with acutely injured hepatocyte using intraperitoneal d(+)Galactosamine. METHODS: Thirty-two guinea pigs were divided equally into four groups. Group 1 was the control group. Group 2 received intraperitoneal D(+)galactosamine. Group 3 received intraperitoneal d(+)galactosamine prior to a standard liver resection. Group 4 received 10.000 KIU/kg aprotinin infusion via jugular catheter in 10 min prior to standard liver resection in pretreated animals with d(+)galactosamine. All of the measurements and surgical interventions were made 24 h after the administration of d(+)galactosamine. Bleeding amounts were recorded in groups 3 and 4 for 1 h by weighing the sponges placed into the abdomen. Liver function tests, histologic, haematologic and fibrinolytic parameters were measured. RESULTS: Hepatocyte injury and hyperfibrinolysis were seen at the end of 24 h after application of d(+)galactosamine in groups 2, 3, and 4. Statistically significant amounts of bleeding from the resected livers were observed in group 3 and 4. In group 4, the bleeding was reduced (P < 0.05) and fibrinolytic parameters were normalized (P < 0.05) with aprotinin infusion. CONCLUSIONS: Significant bleeding diathesis and hyperfibrinolysis occurred in groups 2, 3, and 4, which had hepatocyte injury proved with histopathologic and haematologic tests. Prothrombin time (PT) and partial thromboplastin time (aPTT) in groups 3 and 4 were fivefold higher than that in the control group (P = 0.0001). The bleeding tendency according to high PT and aPTT levels were continued with application of aprotinin while reduction of bleeding was seen. Parenchymatous organ haemorrhage in acute liver failure or hyperfibrinolytic conditions could be reduced significantly with aprotinin without procoagulant effect.     

Importance of identifying the course of the recurrent laryngeal nerve in total and near-total thyroid lobectomies

In our clinic, near-total thyroidectomy is the principal surgical procedure performed for benign thyroid diseases. We conducted a single-institution study on 176 consecutive patients who underwent near-total thyroidectomy due to various thyroid diseases. We compared the incidence of recurrent laryngeal nerve injury between total and near-total thyroid lobectomy sides in each patient. Our hypothesis was that the incidence of recurrent laryngeal nerve injury after total thyroid lobectomy would be similar to that of near-total thyroid lobectomy when the course of the recurrent laryngeal nerve was identified during surgery. The temporary recurrent laryngeal nerve palsy rates on the total and near-total thyroid lobectomy sides were 3.9 per cent (7 of 176 nerves) and 2.2 per cent (4 of 176 nerves), respectively. The difference was not statistically significant. Permanent recurrent laryngeal nerve palsy did not occur in any of our patients. In conclusion, the incidence of recurrent laryngeal nerve injury in total versus near-total thyroid lobectomy is not different when the course of the recurrent laryngeal nerve is identified during surgery.