Traumatic Injury of the Superior Mesenteric Vein: Ligate,Repair or Shunt?

Abstract We report a case of SMV injury in a critically ill patient. The patient was a 19-year-old woman involved in a motor vehicle collision. Her injuries included grade II splenic and renal lacerations, devascularized and lacerated right and transverse colon, a transected transverse mesocolon, a massive shear injury of her abdominal wall, and two partial SMV transections. At initial damage control laparotomy, the SMV was ligated, the devascularized bowel resected and a temporary abdominal closure applied. At re-operation, a mesocaval shunt using saphenous vein was employed. The shunt failed and the patient required a saphenous vein jump graft. Although visceral vascular injuries are rare, ligation of the SMV in a damage control situation is acceptable. This case study is the first to discuss appropriate treatment when interruption to a patient's collateral visceral venous drainage limits the surgeon’s ability to ligate. In these situations, bypass shunts may be successful.     

Sterile surgical technique for shunt placement reduces the shunt infection rate in children: preliminary analysis of a prospective protocol in 115 consecutive procedures

Objective The objective of this study was to evaluate whether the rigid application of a sterile protocol for shunt placement was applicable on a routine basis and allowed the reduction of shunt infections (SI) in children. Materials and methods Since 2001, a rigid sterile protocol for shunt placement in children using neither antibiotic-impregnated catheters nor laminar airflow was prospectively applied at Erasme Hospital, Brussels, Belgium. For assessing the protocol efficacy before continuation, we preliminarily analyzed the results of the first 100 operated children (43 females, 57 males, 49 aged <12 months; 115 consecutive shunt placement/revision procedures). All procedures were performed by the same senior surgeon, one assistant, one circulating nurse, one anesthesiologist. The sterile protocol was rigidly imposed to these four staff members: uniformed surgical technique; limited implant and skin edge manipulation; minimized human circulation in the room; scheduling surgery as first morning operation; avoiding postoperative cerebrospinal fluid (CSF) leak; double gloving; procedures of less than 30-min duration; systemic antibiotics prophylaxis. We analyzed separately: (1) children carrying an increased risk of SI (n = 38) due to preoperative external ventricular drainage, CSF leak, meningitis, glucocorticoids, chemotherapy; (2) children aged <12 months; (3) procedures for shunt revision. Results Errors in protocol application were recorded in 71/115 procedures. They were mainly done by non-surgical staff, decreased with time and were medically justified in some young children. Surprisingly, no SI occurred (follow-up, 4 to 70 months). One child developed an appendicitis with peritonitis (Streptococcus faecalis) after 6 months. No SI was found. After peritonitis was cured, shunt reinsertion was uneventful. Conclusion These preliminary results suggest that a uniform and drastic sterile surgical technique for shunt placement: (1) can be rigidly applied on a routine basis; (2) can lower the early SI rate below 1%; (3) might have a stronger impact to reduce SI than using antibiotic-impregnated catheters and optimizing the operative environment such as using laminar airflow and reducing the non-surgical staff. This last issue will be evaluated further in the present ongoing protocol.     

Transcranial doppler ultrasonography for the evaluation of shunt malfunction in pediatric patients

Previous studies have demonstrated a high correlation between hydrocephalus and the resistive index (RI), as determined by transcranial Doppler ultrasonography. Measurements of RI, calculated by dividing the difference between the peak systolic velocity and the enddiastolic velocity by the peak systolic velocity, were attempted in 55 pediatric patients during evaluations for ventriculoperitoneal shunt malfunctions; values were obtained in 52. Indications of shunt malfunction included both clinical and radiographic evidence of increased intracranial pressure. Eleven patients, determined to have functional shunts both by clincal criteria and subsequent outcome, had RIs of 47±5 (average±1 standard deviation). Shunt malfunctions were confirmed in 41 patients. Prior to shunt revisions, these 41 patients has RIs of 71±10%; following revision, the RIs fell to 53±12%. Nine patients had had pre-malfunction RIs of 48±11% obtained during routine follow-ups; when they subsequently had shunt malfunctions, their RIs had significantly increased. Four of the 41 patients with shunt malfunctions had essentially normal RIs (52±7%), but had fluid tracking along the shunt; in these, RIs were essentially unaffected by shunt revision. For comparison, 119 pediatric patients with clinically functional ventriculoperitoneal shunts had RIs of 50±9%. The data, statistically significant with a P value of <0.001, showed a correlation between elevated RIs and shunt malfunction; thus, transcranial Doppler ultrasonography is a practical, non-invasive technique useful in the diagnosis of ventriculoperitoneal shunt malfunction.Presented at the Annual Meeting of the Pediatric Section of the American Association of Neurological Surgeons, Washington D.C., November 1989     

The diagnosis of blocked cerebrospinal fluid shunts: a prospective study of referral to a paediatric neurosurgical unit

A prospective study was undertaken of all children referred to the Hospital for Sick Children with a provisional diagnosis of shunt blockage over a 5-month period. Fifty-two admissions were recorded, relating to 45 children, 5 of whom had multiple admissions. Only 19 of the 52 admissions led to a final diagnosis of shunt malfunction. No source of referral, whether by the child's general practitioner or from another hospital, was found to be more accurate than direct referral by the parents to the neurosurgical ward. Headache, vomiting and irritability were not significant indicators as to whether the child's shunt was actually blocked, and nor was the duration of the symptoms. Drowsiness was a significant, but not definite, indicator of shunt blockage, while pyrexia made it more likely that the patient had an alternative diagnosis. In 35 of the admissions a computed tomographic scan was performed: a normal scan, unchanged from previous scans, did not reliably exclude the diagnosis of shunt blockage. Percutaneous manometry via the reservoir of the shunt system was performed during 26 admissions: this investigation produced no false positives nor false negatives, but was equivocal in 5 cases, all of which were found at surgery to have a definite shunt blockage. The accuracy of the diagnosis of shunt blockage made prior to referral to a neurosurgical unit is discussed, together with the implications for resource use.     

The occurrence of obstructive vs absorptive hydrocephalus in newborns and infants: relevance to treatment choices

Background and objective The classification of hydrocephalus in newborns and in infants is different from the classification in adulthood. This difference exists due to disparity in the source pathologies that produce the hydrocephalus, and the practical distinctions in prognosis and treatment choices. The objective of this paper is to present the spectrum of obstructive-communicating hydrocephalus, which is more complex in the pediatric group, and to propose the relevance of this particular classification to treatment options. Materials and methods The authors categorized infants with active hydrocephalus at time of presentation into the following four groups along the spectrum of communicating vs obstructive HCP. Group 1: patients with a purely absorptive (communicating) HCP. In these patients, tetraventricular dilatation is usually observed with occasional extraaxial fluid accumulation. An extracranial CSF diversion (shunt) is the treatment of choice. Group 2: patients with an obstructive component together with a persistent absorptive component. In these patients, a technically successful endoscopic procedure will not prevent progression of clinical symptoms of HCP. An extracranial CSF diversion (shunt) should be the treatment of choice even though some of these patients are currently treated by endoscopy. Group 3: patients with an obstructive component together with a temporary absorptive component. In these patients, a technically successful ETV should be followed by temporary CSF drainage [via LP, continuous spinal drainage (CLD), or ventriculostomy] with or without supplemental medical treatment (i.e., Diamox) for several days. Such temporary drainage may decrease failure rate in this subgroup. Group 4: patients with a purely obstructive HCP. In these patients, an endoscopic procedure (ETV) is the treatment of choice. According to this spectrum classification, the authors classify different entities with representative cases and discuss relevancy to treatment options and prognosis. Results The data suggest that obstructive hydrocephalus in the very young population may be rather a combination of obstructive and absorptive problem. The outcome of the patient depends mainly not only on the basic pathology causing the hydrocephalus but also on the treatment that is chosen and its complications. While bleeding and infection represent the major causes for communicating hydrocephalus, patients with complex pathologies of congenital type and intra- or interventricular obstructions may reflect obstructive hydrocephalus. Treatment of these patients may be successful by shuntless procedures if the absorptive problem is not the major component. In transient absorptive hydrocephalus, temporary measures were effective in many cases leading to successful procedures of ETV and/or posterior-fossa decompression in selected cases. Conclusions Shuntless procedures are the dream of a pediatric neurosurgeon provided it solves the problem and does not imply unacceptable risk. However, the benefit has to be evaluated years after the procedure is performed, as only prospective multicenter studies will truly show which procedure may have the best overall results in the developing child. Until such studies are available, understanding the basic pathology or the combination of pathologies leading to hydrocephalus in a given child may open the window of opportunities for other than shunt surgery in many hydrocephalic children with major obstructive component.     

侧脑室－头静脉分流术治疗梗阻性脑积水

通过对２５例成人尸体的解剖学调查及应用＂侧脑室─头静脉分流术＂治疗２３例梗阻性脑积水的临床疗效观察，旨在确立一种脑积水症手术分流的新途径。２３例手术病人显效率９２％（２１／２３）。１８例（７８％）基本恢复正常。３例（１３％）明显好转。２例轻度改善。分析表明：头静脉具备位置浅表恒定、管径适宜、瓣膜可防止血液返流等解剖学特点。是一条可供选择的较为理想的脑积水症分流途径。     

A tidal ventilation model for oxygenation in respiratory failure

We develop tidal-ventilation pulmonary gas-exchange equations that allow pulmonary shunt to have different values during expiration and inspiration, in accordance with lung collapse and recruitment during lung dysfunction (Am. J. Respir. Crit. Care Med. 158 (1998) 1636). Their solutions are tested against published animal data from intravascular oxygen tension and saturation sensors. These equations provide one explanation for (i) observed physiological phenomena, such as within-breath fluctuations in arterial oxygen saturation and blood-gas tension; and (ii) conventional (time averaged) blood-gas sample oxygen tensions. We suggest that tidal-ventilation models are needed to describe within-breath fluctuations in arterial oxygen saturation and blood-gas tension in acute respiratory distress syndrome (ARDS) subjects. Both the amplitude of these oxygen saturation and tension fluctuations, and the mean oxygen blood-gas values, are affected by physiological variables such as inspired oxygen concentration, lung volume, and the inspiratory:expiratory (I:E) ratio, as well as by changes in pulmonary shunt during the respiratory cycle.     

Akute Schäden des proximalen Tubulusepithels der Rattenniere nach einer einmaligen hochdosierten Furosemid-Gabe

Zusammenfassung Eine einmalige intraperitoneale Furosemid-Gabe von 50–200 mg/kg KG führt in der Rattenniere zu Epithelschäden im Bereich der pars recta des proximalen Tubulus. Diese tubulären Veränderungen treten nicht auf, wenn der Furosemid-induzierte Wasser- und Elektrolytverlust durch einen experimentell angelegten vesico-venösen Shunt verhindert wird. Die Tubuluszellschäden werden als Folge einer intracellulären Furosemid-Anreicherung bei vermindertem intratubulären Harnstrom angesehen.Mit Unterstützung der Deutschen Forschungsgemeinschaft.     

A critical approach to gamma variate fit of radionuclide-angiography pulmonary histograms

Radionuclide-angiography (RNA_ left-to-right intracardiac-shunt quantification algorithms, based on the part-by-part fit technique and the use of a so-called gamma variate model function (GVF), were tested via simulation analysis using data obtained from normal subjects. A good bolus of radioindicator was obtained by administering it directly into the vena subclavia. Normal subjects were defined as those having pulmonary histograms (PH) with no visible distortion caused by a shunt. Pure, non-superimposed data on the downslope of the PH curves, which are lost in presence of a shunt, proved to be appropriate reference values for testing the accuracy of results of standard shunt quantification algorithms. A generalized four-parameter GVF was introduced in order to extend the flexibility of the model function. The use of the three-parametric GVF to reconstruct the downslope of the PH curve out of the upslope data proved to be inadequate. This reveals an evident source of error in algorithms that calculate the shunt contribution by fitting GVF parameters to so-called difference-curve data. It is concluded that the inherent restricted statistical weight of RNA data prevents accurate results being obtained from standard RNA-shunt-assessment algorithms.     

小肠短路术治疗病态肥胖症

过于肥胖是一种病态 ,它可以增加心、肺负担 ,引起心、肺疾病 ,高血压 ,下肢淋巴水肿 ,静脉淤滞 ,淤滞性皮炎等 ;还常伴有糖尿病、关节炎、痛风、月经紊乱和不育症。因而导致不同程度的劳力丧失和短寿。对病态肥胖症的治疗 ,一般先采取内科治疗法 ,包括用药 ,调节饮食和精神、心理方面的治疗。如果疗效不佳 ,才可考虑外科疗法。本文重点介绍了外科治疗中与小肠短路手术有关的一些问题。对于空肠 ,结肠端侧短路术、空肠 ,回肠端侧短路术、空肠 ,回肠端端短路术加回肠 ,结肠端侧吻合术 ,3种术式的优缺点作了详尽的比较。认为空肠 ,回肠端端短路术加回肠 ,结肠端侧吻合术是目前比较理想的术式。本文同时也对手术原理 ,手术适应证 ,禁忌证 ,围手术期准备 ,术后并发症以及疗效判定标准作出了详细的讨论。