Lacrimal sac volume measurement during eyelid closure and opening

BACKGROUND: Jones' theory of tear drainage suggests that the lacrimal sac fills when the eyelids are closed and empties when the eyelids are opened. This study was undertaken to see if there is any change in the volume of the lacrimal sac during eyelid closure and opening using images obtained from magnetic resonance dacryocystography using a topical magnetic resonance contrast agent. METHODS: This is a prospective non-randomized comparative study in a tertiary hospital setting. Magnetic resonance dacryocystography scans were performed on five volunteers using 0.5% topical gadolinium-DTPA (MagneVist, Schering AG, Berlin, Germany) as a contrast agent. A T1-weighted magnetic resonance imaging scan with 2-mm contiguous coronal cuts was performed after localizing the lacrimal sac and instilling the contrast agent. The scans were performed with eyelids closed and opened. Volumes of 10 lacrimal sacs of five volunteers were calculated using pixel calibration and computer graphics. RESULTS: No statistical difference in size of the lacrimal sacs was demonstrable between when the eyes were opened and when they were shut. CONCLUSION: The present study could not demonstrate any volume change in the sac between eyelid closure and opening. Magnetic resonance imaging dacryocystography measures sac volume at two static end-points, so it cannot show any transient volume change that might occur during blinking. Various factors that may be affecting tear flow through the nasolacrimal system are discussed.     

Transcatheter closure of patent foramen ovale during a radiofrequency ablation procedure

A 43-year-old woman was undergoing radiofrequency catheter ablation of a symptomatic supraventricular tachycardia when a patent foramen ovale (PFO) was detected with passage of the diagnostic electrocatheter into the left atrium. Prior echocardiographic studies had been unrevealing. Upon questioning during the procedure, the patient now admitted to frequent and disabling daily migraine attacks, while her family described two recent brief episodes of disorientation and dysarthria, consistent with transient ischemic attacks. The patient was informed of the option of future closure of the PFO, but she insisted on having this done concurrently with her ablation procedure. After successful ablation of the slow pathway considered responsible for the supraventricular tachycardia, an Amplatzer closure device was utilized and the PFO was successfully closed during the same procedure. A postprocedural transesophageal echocardiogram showed complete sealing of the PFO, while over the ensuing 10 months the patient reported virtual elimination of her daily attacks of migrainous headaches, limited to a single episode the day after the procedure and none thereafter.     

The effects of anesthesia and muscle paralysis on the respiratory system

Background Oxygenation is impaired in almost all subjects during anesthesia, and hypoxemia for shorter or longer periods is a common finding. Moreover, postoperative lung complications occur in 3–10% after elective abdominal surgery and more in emergency operations.Discussion Rapid collapse of alveoli on induction of anesthesia and more widespread closure of airways seem to explain the oxygenation impairment and may also contribute to postoperative pulmonary infection. Causative mechanisms to atelectasis and airway closure seem to be loss of respiratory muscle tone and gas resorption.Conclusion Avoiding high inspired oxygen fractions during both induction and maintenance of anesthesia prevents or reduces atelectasis, while intermittent vital capacity maneuvers recruit atelectatic lung regions.     

Dysphagia after laparoscopic antireflux surgery: a problem of hiatal closure more than a problem of the wrap

Background Postoperative dysphagia after laparoscopic antireflux surgery usually is transient and resolves within weeks after surgery. Persistent dysphagia develops in a small percentage of patients after surgery. There still is debate about whether postoperative dysphagia is caused by the type or placement of the fundic wrap or by mechanical obstruction of the hiatal crura. This study aimed to investigate patients who experienced recurrent or persistent dysphagia after laparoscopic antireflux surgery, and to identify the morphologic reason for this complication. Methods A sample of 50 patients consecutively referred to the authors’ unit with recurrent, persistent, or new-onset of dysphagia after laparoscopic antireflux surgery were prospectively reviewed to identify the morphologic cause of postoperative dysphagia. According to their radiologic findings, these patients were divided into three groups: patients with signs of obstruction at or above the gastroesophageal junction suspicious of crural stenosis (group A; n = 18), patients with signs of total or partial migration of the wrap intrathoracically (group B; n = 27), and patients in whom the hiatal closure was radiologically assessed to be correct with a supposed stenosis of the wrap (group C; n = 5). The exact diagnosis of a too tight (group A) or too loose (group B) hiatus in contrast to a too tight wrap (group C) was established during laparoscopic redo surgery (groups B and C) or by x-ray during pneumatic dilation (group A). Results For all 18 group A patients, intraoperative x-ray during pneumatic dilation showed the typical signs of hiatal tightness. Of these, 15 were free of symptoms after dilation, and 3 had to undergo laparoscopic redo surgery because of persistent dysphagia. In all these patients, the hiatal closure was narrowing the esophagus. All the group B patients underwent laparoscopic redo surgery because of intrathoracic wrap migration. Intraoperatively, all the patients had an intact fundoplication, which slipped above the diaphragm. Definitely, only in 10% of all 50 patients (group C) presenting with the symptom of dysphagia, was the morphologic reason for the obstruction a problem of the fundic wrap. Conclusions In most patients, postoperative dysphagia is more a problem of hiatal closure than a problem of the fundic wrap. Poster presentation at the 45th annual meeting of the Society for Surgery of the Alimentary Tract (SSAT), Digestive Disease Week (DDW), New Orleans, Louisiana, 15–19 May, 2004     

A new proposal of skin-closure system for median sternotomy: usefulness and cosmetic results analysis of MEDIZIP Surgical Zipper in neoplastic immuno-compromised patients

BACKGROUND AND OBJECTIVES: The authors evaluate the effectiveness and the cosmetic results obtained using the new skin closing system MEDIZIP Surgical Zipper in oncological immuno-compromised patients submitted to median sternotomy. METHODS: In our Institute, from 1999 to 2002, MEDIZIP was used to close the sternal wounds in 45 patients undergoing median sternotomy for bilateral metastasectomy, It took about half a minute (mean time: 32.00 +/- 11.48 sec) to perform the application. To evaluate the cosmetic results, a three-level scale was conceived: level 1: very good, level 2: satisfactory, level 3: inadequate. RESULTS: Overall forty-two 20 cm-long zippers were used, two 25 cm-long and one 30 cm-long. MEDIZIP remained in situ for an average of 9.98 +/- 2.23 days (median: 9 days; range: 8-13 days). The average time taken for inspection was 70.00 +/- 2.48 sec (median: 70, range: 45-130) and the zipper was removed in a few seconds. No wound infections were observed. We classified 39 patients at level 1 (very good, 87%), and 6 at level 2 (satisfactory, 13%). CONCLUSIONS: MEDIZIP can be considered an effective skin-closure system which is easily and quickly handled and assures good cosmetic results with non-invasive removal; it proves particularly useful in pediatric patients and in adults affected by neoplastic diseases and undergoing multiple combined anti-cancer treatments.     

Observations on the function of the female urethra: I: relation between maximum urethral closure pressure at rest and urethral hypermobility

AIMS: To study the relation between maximum urethral closure pressure at rest and urethral hypermobility in female patients. PATIENTS AND METHODS: We selected 255 patients aged 20 years and older, with a stable bladder on multichannel urodynamics, without known neurological pathology, and without a history of pelvic or anti-incontinence surgery. A resting urethral pressure profile and the degree of urethral hypermobility were registered. Two-tailed analyses of variance (ANOVA) with Fisher's post-hoc tests were used to detect any statistically significant difference (P < 0.05) in urethral closure pressure between groups with varying degrees of urethral hypermobility. RESULTS: Mean age was 45.6 +/- 12.7 (range 20-77) years. Mean maximum urethral closure pressure for the entire group was 62.7 +/- 29 (range 10-150) cm of water. A statistically significant inverse relationship was found between age and maximum urethral closure pressure (r = 0.489, P < 0.0001) when both analyzed as continuous variables, and with age categorized in 10-year increments (P < 0.0001). When comparing mean urethral closure pressure in each group examined for urethral hypermobility, a statistically significant difference was noted when grades I, II, and III were compared to grade 0 hypermobility. No significant difference was observed when grades I, II, and III were compared to each other. Even if statistically non-significant, there exists an inverse relationship between the degree of urethral hypermobility and the maximum urethral closure pressure: a higher hypermobility is associated with a lesser urethral closure pressure. CONCLUSIONS: Urethral closure pressure falls significantly when urethral hypermobility is present. This decrease is not related to patient's age or parity. Our observations demonstrate an inverse relation between urethral closure pressure and the degree of cysto-urethrocele. As hypermobility increases, closure pressure decreases, even if this decrease does not reach the level of statistical significance.     

The use of cyanoacrylates for wound closure in head and neck surgery

The purpose of this study was to compare the mean duration and complication rates of cyanoacrylate application in head and neck incision closures to those performed with conventional sutures. Eighty patients who underwent head and neck surgical operations (20 thyroidectomies, 13 submandibular gland resections, 9 parotidectomies, 6 neck dissections in conjunction with other surgical procedures, 1 lateral rhinotomy, 1 thyroglossal cyst resection and 30 open neck biopsies) were included in the study. The incisions were closed either with interrupted suture technique (32 patients) or cyanoacrylate (48 patients). The duration of skin closure time was compared between the two groups with nonparametric Mann–Whitney U test and a P value <0.05 was considered as statistically significant. The patients were followed up for complications at 2 weeks, 1 and 3 months after surgery. The two treatment groups were similar with respect to age, gender, and wound lengths (P = 0.27, 0.22 and 0.99, respectively). The mean wound length was 7.21 + 3.15 cm in the cyanoacrylate group and 7.22 + 2.99 cm in the suture group within a range of 5–15 cm. The mean closure time was 33.69 + 9.77 s in the cyanoacrylate group and 504.38 + 169.27 s in the suture group (P < 0.001). The patients in the cyanoacrylate group were satisfied with their scar appearances. No complication was observed in both the groups. Cyanoacrylates provide an easy and convenient application resulting in a faster wound closure as compared to the interrupted suture technique.     

Use of the vacuum-assisted closure device in enhancing closure of a massive skull defect

OBJECTIVES/HYPOTHESIS: The objective was to describe a novel technique for reconstructing the cranial vertex without the use of free tissue transfer. STUDY DESIGN: Case report, literature review, and discussion. METHODS: A 50-year-old woman presented from a remote Pacific Island community with a 12 x 14-cm, necrotic, grossly contaminated eccrine gland carcinoma of the cranial vertex that extended through the calvarium but did not invade the dura. Following tumor extirpation, the resulting bony defect was 10 x 12 cm in size, with a concomitant scalp defect of 14 x 16 cm. Free tissue transfer was impossible because of severe intimal peripheral vascular disease, posing a challenging reconstructive dilemma. After tumor resection, the bony edges were covered with local scalp flaps and the vacuum-assisted closure device was placed over the wound at a constant setting of -50 mm Hg. The vacuum-assisted closure device was changed three times per week for 3 weeks. RESULTS: A thick, 1-cm bed of granulation tissue developed over the dura, allowing temporary coverage by a split-thickness skin graft, and the scalp defect decreased in size by approximately 25%. The patient did not develop meningitis, headache, or localized infection as a result of placement of the vacuum-assisted closure device and tolerated the vacuum-assisted closure well. After a requisite period of healing, tissue expanders and calvarial reconstruction will be performed. CONCLUSION: Use of the vacuum-assisted closure device is a safe, reliable adjunct in the closure of large cranial defects with exposed dura and offers a novel reconstructive option for complex defects of the head and neck.     

Can women without visible pubococcygeal muscle in MR images still increase urethral closure pressures?

OBJECTIVE: The purpose of this study was to determine if the ability to increase maximum urethral closure pressure (MUCP) with a pelvic muscle contraction is impaired in women without pubococcygeal muscle (PCM). STUDY DESIGN: This was a cross-sectional study of continent women comparing those with (n=28) and those without (n=17) PCM as identified by MR scans. A pelvic muscle contraction was performed simultaneously with recordings of urethral and bladder pressures. RESULTS: Eighty-six percent of the women with PCM compared with 41% of the women without could volitionally increase (>5 cm H(2)O) their MUCP. Those with PCM generated a mean intraurethral pressure rise of 14.0 (10.8) cm H(2)O, compared with 6.2 (8.7) cm H(2)O in those without (P=.015). Among women who could produce a visible pressure rise, there was not a statistically significant difference between groups (with PCM=17.2 [7.8] cm H(2)O; without PCM=14.7 [7.5] cm H(2)O; P=.457). CONCLUSION: Selective women without visible PCM can increase MUCP.     

Alternative for primary pericardial closure: sentry for re-entry

BACKGROUND: Redo cardiac surgery is considered high-risk surgery as accidental injury to the aorta, the innominate vein, the ventricles and the atria is a possibility. Such accidental injury occurs when the cardiac chamber is adherent to the undersurface of the sternum. Closure of pericardium at the time of primary surgery can prevent adherence of cardiac chambers to the sternum, but may increase the risk of tamponade. This study aimed to show that covering heart with a pedicled pericardial fat pad not only serves the purpose of cover but also avoids the adverse haemodynamic effects of primary pericardial closure. METHODS: Forty patients undergoing elective cardiac surgery were randomised into two groups depending on the way pericardium was managed. Both techniques were already in routine use in our unit and in other units around the country. One method is to leave the pericardium widely open, the other is to loosely oppose the pericardial fat pad over the surface of the aorta and right ventricle. Twenty-three patients had a pedicled pericardial fat pad covering the heart: Closure Group. Seventeen patients had no pericardial fat pad cover over the heart: Open Group. A haemostasis clip was used as a radio-opaque marker over the epicardium in both groups. Post-operation heart rate, central venous pressure, pulmonary artery diastolic pressure, mean arterial pressure and cardiac index were measured and recorded 1, 3 and 8h after surgery. The distance between the haemoclip and the posterior table of the sternum was measured at 6 days and 6 months post-operation. Haemodynamic parameters and the retrosternal space depth were compared between the two groups. RESULTS: There were no important differences in haemodynamic parameters between the two groups. Post-operative lateral chest Roentgenograms showed that the distance between epicardial surface and the posterior table of sternum was larger in the Closure Group compared to Open Group on post-operative day 6, 17.5+/-1.0mm versus 13.4+/-1.3mm (P=0.0013) and 6 months later, 12.3+/-0.8mm versus 6.0+/-1.2mm (P<0.001). There was no mortality in either group. CONCLUSION: Pedicled pericardial fat pad cover is a good alternative to primary pericardial closure as there are no adverse haemodynamic effects in early post-operative period and the long-term benefit of protection of heart at the time of re-sternotomy can be expected.