Jejunal Gallstone Ileus: An Unusual Site of Gallstone Impaction

Introduction  Gallstone ileus is a life-threatening surgical emergency where characteristic imaging can be diagnostic. Jejunum is the one of the rare sites of gallstone impaction. Materials and Methods  We hereby emphasize the role of multidetector computed tomography (MDCT) by describing a case of jejunal gallstone ileus with cholecystoduodenal fistula in a 59-year-old lady who presented with symptoms and signs of proximal small bowel obstruction. Conclusion  MDCT of the abdomen established the diagnosis, and the patient managed surgically.     

Autosomal dominant progressive nephropathy with deafness: linkage to a new locus on chromosome 11q24

Focal segmental glomerulosclerosis (FSGS) and Alport syndrome (AS) are two major causes of end-stage renal disease (ESRD). A few families with autosomal dominant FSGS have been reported with linkage to chromosome 19q13 or 11q22, while AS is usually linked to mutations in type IV collagen (COL4) subunit genes. A phenotype resembling AS may also be seen with myosin heavy chain-9 (MYH9) gene mutations. This study ascertained a multigeneration family (CHP-177) with clinical aspects of both FSGS and AS where we identified a new locus for the trait. A genome-wide scan was performed with 400 markers, and fine mapping was performed for chromosome 11 markers. Data were analyzed by GENEHUNTER and VITESSE under various models. CHP-177 is a 39-member kindred residing near New Delhi, India, with seven affecteds and showed male-to-male transmission. Two members had ESRD. Renal biopsies showed both FSGS lesions and thin glomerular basement membranes. Five of the affecteds also had sensorineural deafness, which involved both low and high frequency in some members. The AS loci, i.e., COL4A3/COL4A4 and MYH9 (LOD scores: -6.1 and -4.3, respectively) and FSGS loci, on 19q13 and 11q22, were excluded from linkage. A significant evidence of linkage was observed for 11q24 region, with a multipoint LOD (z-score) of 3.2 for marker D11S4464 at theta = 0. The z-1 confidence interval for the linked region spans a genetic distance of 7 cM. This study thus reports an autosomal dominant nephropathy with features of both FSGS and AS in which linkage to currently known loci for such phenotypes was excluded and a new locus on 11q24 was identified. The findings suggest further locus heterogeneity for the autosomal dominant nephropathy phenotype.     

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.     

Prone thoracoscopic thoracic duct ligation for postsurgical chylothorax

Background  Chylothorax after complex abdominal and thoracic procedures remains a challenging complication with a mortality rate reaching 50% if untreated [1]. Iatrogenic trauma accounts for almost 20% of all chyle leaks, and esophagectomy is the most common iatrogenic cause [2]. Consequences of ongoing chyle leak include dehydration, malnutrition, and immunocompromise. Methods  When nonoperative management techniques fail, prompt ligation of the thoracic duct at the diaphragmatic hiatus should be attempted. The authors present prone thoracoscopic thoracic duct ligation performed for two patients after laparoscopic transthoracic esophagectomy and revision paraesophageal hernia repair. Results  The prone position for thoracoscopic thoracic duct ligation offers several benefits to the surgeon. Gravity retracts the lung anteriorly, exposing the diaphragmatic hiatus. Single-lumen endotracheal intubation combined with low-pressure carbon dioxide insufflation efficiently collapses the lung to create ample working space. For the two reported patients, only three trocars were necessary to complete suture ligation of the thoracic duct via the right chest. Both patients had complete resolution of their chylothorax and recovered uneventfully. Based on this experience, the authors currently advocate early thoracoscopic treatment for cost and morbidity savings. Conclusions  The authors believe prone thoracoscopic thoracic duct ligation offers significant advantages to the patient in preventing the dangerous consequences of chyle leak in a timely, minimally invasive fashion. Importantly, the prone technique with carbon dioxide insufflation makes the technical challenges of thoracic duct ligation more facile for the surgeon. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Endonasal Ethmoidectomy and Bifrontal Craniotomy with Craniofacial Approach for Resection of Frontoethmoidal Osteoma Causing Tension Pneumocephalus

Tension pneumocephalus is an unusual, potentially life-threatening complication of frontal fossa tumors. We present an uncommon case of a frontoethmoidal osteoma causing a tension pneumocephalus and neurological deterioration prompting a combined endonasal ethmoidectomy and bifrontal craniotomy with craniofacial approach for resection. A 68-year-old man presented with a 1-week history of worsening headache, slowness of speech, and increasing confusion. Standard computed tomography scan revealed a marked tension pneumocephalus with ventricular air and 1-cm midline shift to the right. Further studies showed a calcified left ethmoid mass and a left anterior cranial-base defect. A team composed of neurosurgery and otolaryngology performed a combined endonasal ethmoidectomy and bifrontal craniotomy with craniofacial approach to resect a large frontoethmoid bony tumor. No abscess or mucocele was identified. The skull base defect was repaired with the aid of a transnasal endoscopy, a titanium mesh, and a pedunculated pericranial flap. Postoperatively, the pneumocephalus and the patient's symptoms completely resolved. Pathology was consistent with a benign osteoma. This is an uncommon case of a frontoethmoidal osteoma associated with tension pneumocephalus. Recognition of this entity and timely diagnosis and treatment, consisting of an endonasal ethmoidectomy and a bifrontal craniotomy with craniofacial approach, may prevent potential life-threatening complications.     

Recent advances in the pharmacotherapy of chronic anal fissure: an update

Surgical sphincterotomy reduces anal tone and sphincter spasm and promotes ulcer healing. Because the surgery is associated with the side effect of faecal incontinence, pharmacological agents to treat chronic anal fissure have been explored recently. Glyceryl trinitrate (GTN) ointment (0.2%) has an efficacy of up to 68% in healing chronic anal fissure, but it is associated with headache as the major and most common side effect. Though botulinum toxin injected into the anal sphincter healed over 80% of chronic anal fissures, it is more invasive and expensive than GTN therapy. Diltiazem ointment achieved healing of chronic anal fissure comparable to 0.2% GTN ointment but was associated with fewer side effects. Other drugs that have been tried are lidocaine, the alpha-adrenergic antagonist indoramin, and the potassium channel opener minoxidil.     

Comparison of caudal epidural bupivacaine with bupivacaine plus tramadol and bupivacaine plus ketamine for postoperative analgesia in children

This study compared the effect of single-dose caudal epidural bupivacaine, bupivacaine plus ketamine and bupivacaine plus tramadol for postoperative pain management in children having surgery for inguinal hernia. Following ethics committee approval and informed parental consent, 75 children ASA PS I and II, between three and nine years of age and scheduled for elective unilateral inguinal hernia repair with general anaesthesia were recruited. The patients were randomly divided into three groups to receive 0.5 ml/kg caudal bupivacaine 0.25% (group B), bupivacaine 0.25% plus tramadol 1 mg/kg (group BT) or bupivacaine 0.25% plus ketamine 0.5 mg/kg (group BK). The injections were performed under general anaesthesia. Mean arterial pressure, heart rate, pulse oximetry, respiratory rate and sedation and pain scores were recorded at defined intervals following recovery from anaesthesia. The groups were similar in age, weight and duration of operation (P >0.05). No patient experienced hypotension, bradycardia or respiratory depression. Duration of analgesia was (mean+/-SD) 6.5+/-4.1 h in group B, 9.2+/-3.9 h in group BK, and 8.5+/-3.1 h in group BT (P <0.05). More patients in group B required supplementary analgesics in the first 24 h (P <0.05). Sedation scores were comparable in all groups. Incidence of emesis and pruritus was similar in all the groups. Caudally administered 0.5 ml/kg bupivacaine 0.25% plus ketamine or bupivacaine 0.25% plus tramadol 1 mg/kg provided significantly longer duration of analgesia without an increase in the adverse effects when compared to bupivacaine alone.     

Cyclophosphamide-induced agenesis of cerebral aqueduct resulting in hydrocephalus in mice

The present work was undertaken to reveal the mechanism of cerebral aqueduct agenesis found to result in hydrocephalus following intrauterine exposure to model teratogen, cyclophosphamide, in murine fetuses. A single dose of 10-mg/kg body weight cyclophosphamide was injected intaperitoneally to pregnant mice on day 10, 11 or 12 of gestation. Fetuses were collected through abdominal incision on day 18 and studied for various malformations of brain and cranium including hydrocephalus. Incomplete development and failure of canalization of the cerebral aqueduct were detected when serial sections of brain in coronal and transverse planes were studied under the microscope. Biotechnological investigations such as % DNA fragmentation, % viable cell count and cell proliferation assay were carried out on brain cells for further studies. Agenesis and non-canalization of the cerebral aqueduct resulted in increased pressure of CSF, which led to rupture of the aqueduct complicated by leakage and accumulation of CSF in brain substance forming a cavity containing CSF parallel and lateral to the unopened part of the cerebral aqueduct. Incomplete development along with non-canalization of the cerebral aqueduct resulted in blockage of CSF flow through the ventricles that manifest as internal hydrocephalus. External hydrocephalus on the other hand was detected where the CSF accumulated in the cavity formed inside the brain substance and established communication with the CSF in the subarachnoid space. Cyclophosphamide induced inhibition of mitosis and cell differentiation of ependymal cells reflecting a decreased % viable cell count and cell proliferation assay along with augmentation of apoptosis of brain cells quantified as increased % DNA fragmentation count, which were identified as the contributing factors underlying the agenesis and incomplete development of the cerebral aqueduct. The study also suggests that cell survival, proliferation, migration or differentiation of ependymal cells might have been affected, and we speculate that CSF may have an inducing role in the development and canalization of the cerebral aqueduct.     

Mechanisms underlying greater sensitivity of neonatal cardiac muscle to volatile anesthetics

BACKGROUND: In neonatal heart, plasma membrane Na+-Ca2+ exchange (NCX) and Ca2+ influx channels play greater roles in intracellular Ca2+ concentration [Ca2+]i regulation compared with the sarcoplasmic reticulum (SR). In neonatal (aged 0-3 days) and adult (aged 84 days) rat cardiac myocytes, we determined the mechanisms underlying greater sensitivity of the neonatal myocardium to inhibition by volatile anesthetics. METHODS: The effects of 1 and 2 minimum alveolar concentration halothane and sevoflurane on Ca2+ influx during electrical stimulation in the presence or blockade of NCX and the Ca2+ channel agonist BayK8644 were examined. [Ca2+]i responses to caffeine were used to examine anesthetic effects on SR Ca2+ release (via ryanodine receptor channels) and reuptake (via SR Ca2+ adenosine triphosphatase). Ca2+ influx via NCX was examined during rapid activation in the presence of the reversible SR Ca2+ adenosine triphosphatase inhibitor cyclopiazonic acid and ryanodine to inhibit the SR. Efflux mode NCX was examined during activation by extracellular Na+ in the absence of SR reuptake. RESULTS: Intracellular Ca2+ concentration transients during electrical stimulation were inhibited to a greater extent in neonates by halothane (80%) and sevoflurane (50%). Potentiation of [Ca2+]i responses by BayK8644 (160 and 120% control in neonates and adults, respectively) was also blunted by anesthetics to a greater extent in neonates. [Ca2+]i responses to caffeine in neonates ( approximately 30% adult responses) were inhibited to a lesser extent compared with adults (35 vs. 60% by halothane). Both anesthetics inhibited Ca2+ reuptake at 2 minimum alveolar concentration, again to a greater extent in adults. Reduction in NCX-mediated influx was more pronounced in neonates (90%) compared with adults (65%) but was comparable between anesthetics. Both anesthetics also reduced NCX-mediated efflux to a greater extent in neonates. Potentiation of NCX-mediated Ca2+ efflux by extracellular Na+ and NCX-mediated Ca2+ influx by intracellular Na+ were both prevented by halothane, especially in neonates. CONCLUSIONS: These data indicate that greater myocardial depression in neonates induced by volatile anesthetics may be mediated by inhibition of NCX and Ca2+ influx channels rather than inhibition of SR Ca2+ release.