Effects of epidural anesthesia and analgesia on coagulation and outcome after major vascular surgery

To examine the interaction of epidural anesthesia, coagulation status, and outcome after lower extremity revascularization, 80 patients with atherosclerotic vascular disease were prospectively randomized to receive general anesthesia combined with postoperative epidural analgesia (GEN-EPI) or general anesthesia with on-demand narcotic analgesia (GEN). Demographics did not differ between groups except that the GEN-EPI group had a higher incidence of diabetes mellitus and of previous myocardial infarction. Coagulation status was monitored using thromboelastography. An additional 40 randomly selected patients without atherosclerotic vascular disease undergoing noncardiovascular procedures served as controls for coagulation status. Vascular surgical patients were hypercoagulable compared with control patients before operation and on the first postoperative day. Postoperatively, this hypercoagulability was attenuated in the GEN-EPI group and was associated with a lower incidence of thrombotic events (peripheral arterial graft coronary artery or deep vein thromboses). The rates of cardiovascular, infectious, and overall postoperative complications, as well as duration of intensive care unit stay, were significantly reduced in the GEN-EPI group. Stepwise logistic regression demonstrated that the only significant predictors of postoperative cardiovascular complications were preoperative congestive heart failure and general anesthesia without epidural analgesia. We conclude that in patients with atherosclerotic vascular disease undergoing arterial reconstructive surgery (a) thromboelastographic evidence of increased platelet-fibrinogen interaction is associated with early postoperative thrombotic events, and (b) epidural anesthesia and analgesia is associated with beneficial effects on coagulation status and postoperative outcome compared with intermittent on-demand opioid analgesia.

Melanotic neuroectodermal tumour of infancy (progonoma)

A case of Melanotic neuroectodermal tumour of infancy (melanotic progonoma, melanoameloblastoma, retinal anlarge tumour) presenting as tumour of maxilla in a female infant is reported. Clinically a teratoma was suspected but ultrasound shoved it a solid mass. At exploration, characteristic melanotic pigmentation clinched the diagnosis which was later confirmed by histopathological examination.

Transanal and intraperitoneal prolapse in intussusception

An infant with intussusception who developed an unusual complication of transanal and intraperitoneal prolapse is reported. Complete venous occlusion of the intussusceptum for a prolonged period in a patient with congenital anomalous vascular supply of the colon is suggested as a mechanism responsible for rupture of the intussuscepiens.

Infantile myofibromatosis of omentum

A unique case of solitary infantile myofibromatosis arising in the omentum is presented. The essentiality of wide surgical resection to avoid recurrence is emphasised.

Successful management of late presentation neonatal oesophageal atresia with distal tracheo-oesophageal fistula and significant pulmonary complications

The successful management of a neonate presenting with oesophageal atresia and a distal tracheo-oesophageal fistula on the twelfth day of life is described. This case is the most delayed diagnosis associated with survival known to have been reported. There were significant pulmonary complications at presentation and initial treatment was by gastrostomy under local anaesthesia, followed by a delayed primary repair.