Transcranial cerebral oximetry and carotid cavernous fistula occlusion

Summary Different methods have been used in the evaluation and monitoring of the cerebral oxygen supply during neuro-interventional therapies. Attenuation of near-infrared light by the chromophores oxyhemoglobin and deoxyhemoglobin have shown to be useful in the study of the cellular oxygen metabolism and oxygen delivery to the brain. Transcranial cerebral oximetry (TCCO) has the advantage of providing real-time information regarding regional brain oxygen saturation (rSO₂) by using wavelengths in the near-infrared range.We present a patient with a carotid cavernous fistula who underwent balloon occulusion and concurrent continuous TCCO monitoring. TCCO was found to be a useful tool providing immediate rSO₂ values during the angiographic and interventional procedures. Initial balloon occlusion of a carotid cavernous fistula resulted in partial occlusion of the internal carotid artery lumen causing an immediate decrease in rSO₂ which correlated with angiographic findings. Subsequent reocclusion of the fistula produced a slower and smaller degree of decrease in rSO₂ with clinical improvement in the patient. Changes in rSO₂ were detected before any adverse clinical event was observed. TCCO was reliable, safe, sensitive, and provided a real-time assessment tool for the monitoring of brain oxygen supply in a patient undergoing a neuroendovascular procedure.     

硬脑膜动脉海绵窦瘘的眼眶CT表现,DSA检查及栓塞治疗

笔者分析了５例硬脑膜动脉海绵窦瘘伴突眼，结膜充血的病例，全部经ＣＴ及ＤＳＡ检查，同时进行了栓塞治疗，经随访７－９个月未见复发，主要ＣＴ表现为：（１）眼球突出，结膜充血；（２）眼上静脉扩张；（３）海绵窦增大；（４）眼外肌增厚：（５）眶尖软组织肿胀。并讨论了诊断鉴别诊断，ＤＳＡ检查及有关治疗问题。     

Oesophageal atresia: caudo-thoracic epidural anaesthesia reduces the need for post-operative ventilatory support

The mortality of neonates with oesophageal atresia in the Third World remains high because of delays in presentation and diagnosis. Lack of appropriate intensive care facilities is a further contributing factor. Caudothoracic epidural anaesthesia was used during surgical repair of oesophageal atresia in 35 patients in an attempt to minimise the need for post-operative ventionally support. This group was compared with 36 patients whose surgery was performed under general anaesthesia. The age at the time of referral, sex ratio, and weight were comparable in both groups. Using the Waterson classification, a greater number of poorer prognostic patients were seen in the epidural group (P <0.02). In all Waterson risk categories fewer patients required ventionally support post-operatively, which was statistically significant (P <0.01) when all categories were combined. We are encouraged by our results and believe this technique has a rôle in the management of neonates undergoing major surgery, both where neonatal intensive care exist or is deficient as in many parts of the Third World.     

Thoracotomy in the acute phase of staphylococcal lung disease

Two cases of staphylococcal lung disease in young infants are described. In each instance a life-threatening bronchopleural fistula in the acute phase was successfully managed by thoracotomy and suture repair. Offprint requests to: A. W. Auldist     

复发性甲状舌管囊肿和瘘的外科治疗

29例复发性甲状舌管囊肿和瘘中.男性20例,女性9例。复发次数1～4次,以2年或2年以内复发居多。作者对复发的有关因素进行了讨论,并且提出术中注射亚甲蓝显示瘘管,以利完全切除。     

Primary Adenocarcinoma in the Urethrorectal Fistula

A 60-year-old Japanese man was hospitalized because of urinary leakage from the anus on October 3, 1994. Retrograde urethrography detected a fistula between the bulbous urethra and the rectum. Urethrocystoscopy revealed a tumor on the urethrorectal fistula. Tumor biopsy showed a well differentiated adenocarcinoma. Cystourethrectomy with fistulectomy, and ileal conduit urinary diversion were performed. Pathological examination revealed primary adenocarcinoma in the fistula with invasion to the prostatic urethra and bladder wall. The patient showed no evidence of a recurrence as of August, 1996.     

Catheter embolization of pulmonary arteriovenous fistulas in an infant

Summary An infant with pulmonary arteriovenous fistulas is described. Surgical ligation of the fistulas and limited resection of paraenchyma from the right lung was followed at 11 months of age, by successful steel coil embolization of residual fistulas.     

Bile duct injury repair: when? what? who?

Laparoscopic cholecystectomy is associated with a two-to-four times higher risk of bile duct injury (BDI) than open cholecystectomy. BDI can lead to significant morbidity and even mortality. The first priority in BDI is to control peritoneal and biliary sepsis and to convert an acute BDI to a controlled external biliary fistula (EBF) — this can be achieved by endoscopic and/ or radiological intervention in most cases. This should be followed by assessment of the extent of injury — both biliary and vascular. Immediate management of BDI recognized during cholecystectomy depends on the type of injury, the condition of the patient, and the experience of the surgeon. For BDI recognized after cholecystectomy, early repair is not recommended, as the results are poor. The EBF may evolve into a benign biliary stricture (BBS), which should be electively repaired by a Roux-en-Y hepatico-jejunostomy. The use of an endoscopic stent as definitive management of BDI is not recommended. Long-term follow-up is essential after the repair of a BBS, as recurrence can occur several years after repair. Recurrent BBS is best treated with endoscopic balloon dilatation. Excellent early and long-term results can be obtained in specialized units at tertiary care referral centers.     

Congenital esophageal atresia successfully treated by early ligation of a tracheoesophageal fistula and delayed repair of the esophagus in a premature infant: Report of a case

We report herein the case of a premature infant with esophageal atresia (EA) and a tracheoesophageal fistula (TEF) associated with cardiac anomalies who was successfully treated by an early ligation of the TEF following gastrostomy, and delayed repair of the esophagus. A 1212-g male was born prematurely at 31 gestational weeks, at which time he was diagnosed as having EA with TEF and patent ductus arteriosus (PDA), ventricular septal defect (VSD), and atrial septal defect (ASD). A gastrostomy was initially performed but following extubation he gradually became tachypneic. A chest roentogenogram revealed atelectasis and ground-glass appearance, and reintubation was required. Ligation of the TEF was performed 53h after his birth. Following the improvement of his respiratory condition through ventilatory support and the intratracheal administration of pulmonary surfactant, he underwent repair of the esophagus on the 6th day of life. Postoperatively, he suffered from heart failure, but was treated with peritoneal dialysis and pharmacological closure of the PDA. Weaning the infant from the ventilator proved difficult, but it was finally achieved when he had reached a weight of 2268g at 3 months of age by enteral feeding. Our experience of this case demonstrates that early ligation of TEF should be performed for a premature infant with EA and TEF before respiratory distress syndrome (RDS) has developed. If a gastrostomy is required to prevent gastric distention, it should be followed by simultaneous or immediate ligation of the TEF.     

Postlaminectomy arteriovenous fistula masked by stenosis of the inferior vena cava

Discovery of a postlumbosacral discectomy fistula between the right iliac artery and vein was obscured by an associated severe stricture of the infrarenal inferior vena cava in a 49-year-old man. During venous stenting for treatment of peripheral edema, the fistula was suspected because of faint pulsatile right iliac vein flow and increased O₂ saturation of the venous blood. The suspicion was confirmed on subsequent iliac arteriography. Surgical closure of the fistula with arterial interposition grafting was then performed. The patient improved substantially.