Postanesthesia death and suspected peracute endotoxic shock due to Pseudomonas putida in a cynomolgous macaque (Macaca fascicularis)

An adult male cynomolgous macaque (Macaca fascicularis) died suddenly after anesthesia for a positron emission tomography scan. Bacteriologic culture of the mucopurulent secretions recovered from the endotracheal tube yielded heavy growth of Pseudomonas putida, a known endotoxin producer. Histologically, the lungs had severe, diffuse perivascular edema and neutrophils marginating to the endothelium. The sudden death and the pathologic findings were consistent with peracute endotoxic shock. Numerous environmental swab specimens of the surgical suite and equipment were submitted for bacteriologic culture, as were swab specimens of endotracheal secretions from a control animal; however, Pseudomonas putida was not isolated from any specimen. The animal in this report may have carried Pseudomonas putida as a commensal in the oropharynx, and the stress of anesthesia may have resulted in increased sensitivity to the endotoxin.

Randomized controlled study of laparoscopic total extraperitoneal versus open Lichtenstein inguinal hernia repair

BACKGROUND

Whereas open anterior inguinal herniorrhaphy is a time-tested, safe, and well-understood operation with a high success rate, laparoscopic techniques of inguinal hernia repair are fairly recent. Consequently, short- and long-term outcomes are still being evaluated. Few studies have compared laparoscopic extraperitoneal inguinal hernia repair with tension-free open hernia repair. The current study was conducted to compare complications, operative time, postoperative pain, length of hospital stay, and return to work between open tension-free mesh Lichtenstein (open) repair and laparoscopic total extraperitoneal (TEP) repair.

METHODS

In a prospective randomized study, open hernia repair was performed in one group (n = 25), and TEP repair using a large mesh was performed in another (n = 25). Then intraoperative and postoperative complications and results were compared.

RESULTS

The mean operative time in the TEP group was 75.72 +/- 31.6 min, which was significantly longer than the mean operative time in the open group (54 +/- 15) min (p <0.001). The mean pain scores in the TEP group were 2.64 +/- 1.4 at 12 h and 1.76 +/- 1.4 at 24 h. These scores were significantly lower than the corresponding scores of 3.52 +/- 1.7 (p <0.04) and 2.74 +/- 1.5 (p <0.01) in the open repair group. The mean postoperative analgesic dose was 2.6 +/- 2.3 in the TEP group, which was significantly lower than in the open group 5.76 +/- 3.5 (p <0.001). There was no major complication in either group. The time until return to work was significantly lower in the TEP group (12.8 +/- 7.1) days versus 19.3 +/- 4.3 days; than in the open group (p <0.001). In terms of cosmetics, all 25 patients (100%) in TEP group rated themselves as "highly satisfied," as compared with 7 patients (28%) in the open group (p <0.001). After a mean follow-up period of 13 months (range, 9-18 months), no recurrence was seen in either of the two groups.

CONCLUSION

In terms of complications and short-term recurrence, TEP repair is comparable with open repair. Moreover, TEP is significantly less painful in the early postoperative period, leading to earlier ambulation than open repair. Additionally, TEP results in significantly earlier return to work and better cosmetic results. Currently, TEP seems to be a better alternative than the existing open repair, provided the long-term recurrence rates are comparable. Despite the fact that TEP was a new procedure for the surgeon and the study was conducted during the learning phase, the results are comparable with those in the world literature.

Intraoperative surgical complication during cesarean section: an observational study of the incidence and risk factors

BACKGROUND

The study was intended to estimate the incidence of intraoperative surgical complications with the impact of the educational level of the surgeon and a history of previous cesarean section on intraoperative complications at cesarean childbirth.

METHODS

In the period between August 1st 1995 and July 30th 1996, 7782 women gave birth at the three Obstetric Departments in Copenhagen County, Denmark, of which 929 (11.9%) were delivered by cesarean section. These women served as the study population, and their medical records were reviewed and data obtained immediately after delivery.

RESULTS

The overall intraoperative complication rate was 12.1%. The rate of complications in emergency cesarean sections was 14.5% compared with 6.8% in the elective group. The educational level of the surgeon and a history of previous cesarean section were not found to be significantly associated to intraoperative complications. Low station of the presenting part of the fetus, high fetal birth weight, fetal distress and dystocia as indications and increasing maternal age were significant risk factors of lacerations. Placenta previa and placental abruption as indications, increasing prepregnancy body mass index, as well as low and high birth weight were significant risk factors for intraoperative blood loss more than 1 l. Duration of regular painful contractions had a preventive effect.

CONCLUSION

Utero-cervical lacerations and blood loss of more than 1 l were the most frequent intraoperative complications in cesarean section in the present study. The educational level of the surgeon or history of a previous cesarean section were not significantly related to these complications.

Penetrating corneal transplant with inadvertent corneal button inversion

PURPOSE

To report a penetrating corneal transplant in which there was inadvertent inversion of the corneal button.

DESIGN

Interventional case report.

METHODS

A 48-year-old man with lattice corneal dystrophy had a third penetrating keratoplasty in the right eye 3 years after the second procedure and 2 years following renal transplantation.

RESULTS

Histologic examination of the corneal button from the second penetrating keratoplasty disclosed inadvertent corneal graft inversion. Survival epithelium from the donor in the anterior chamber may be explained by the ocular anterior chamber-associated immune deviation or by the patient's systemic cyclosporine A (CsA) treatment after renal transplantation.

CONCLUSIONS

Histologically proven corneal button inversion is a rare cause of corneal graft failure.

Anastomotic vessels in the retropubic region: corona mortis

Anastomosis between the pubic rami of the inferior epigastric and the obturator arteries has been referred to as the corona mortis. Because anomalous vessels in the retropubic region are at risk in groin or pelvic surgeries, they have an importance not only for general surgery but also for orthopaedics. Because it is hard to distinguish these vessels, they can be injured during ilioinguinal incision, which can lead to massive uncontrolled bleeding. For this purpose, 54 cadaver halves were dissected to determine the occurrence and location of the corona mortis anastomosis. We found venous corona mortis in 11 halves (20.37%). Additionally, in 8 halves (14.81%), the obturator artery originated from the inferior epigastric artery.

[Reduction of severe cardiac complications during implantation of cemented total hip endoprostheses in femoral neck fractures]

Intraoperative circulatory and pulmonary problems occuring during the repair of femoral neck fractures with cemented hip arthroplasty are a common problem, that cannot be ultimately explained. As a possible reason for this problem is air embolism during the polymerisation of the methylmethacrylat discussed. We started a prospective randomised clinical examination with 72 patients to prove the efficiency of palacos mixed in vacuum, with respect to the reduction of severe cardiovascular complication during endoprosthetic repair of femoral neck fractures. In the control group with 36 patients, surgical repair was performed with palacos mixed conventionally. In the second group (vacuum group), also consisting of 36 patients, surgical repair was performed with palacos mixed in vacuum. Invasive hemodynamic monitoring and transesophageal echocardiography was performed in all cases. In the control group pulmonary embolism occurred echocardiographically in 86% of the cases vs. 14% in the vacuum group. 53% of the control patients--vs. 11% of the vacuum patients--showed clinical complications in form of significant decrease of arterial oxygenation and circulatory insufficiency with the need of catecholamines. Clinical complications occurred in the control group in 80% of the patients--vs. 13.7% in the vacuum group--whose pulmonal arterial pressure was higher than 30 mmHg preoperatively and only in 18.8% of the cases--vs. 7.1% in the vacuum group--with a normal pulmonal arterial pressure. Mortality in the control group amounted to 13.8% in the vacuum group to 2.8%. Through the use of methylmethacrylate mixed in vacuum for surgical repair of femoral neck fractures with cemented hip arthroplasty, the incidence of severe cardiac complications could be reduced significantly. Patients with increased pulmonal arterial pressure have the highest risk for cardiac complications.

Nasotracheal intubation: a simple and effective technique to reduce nasopharyngeal trauma and tube contamination

Our hypothesis was that nasopharyngeal passage of an endotracheal tube can be facilitated by a nasopharyngeal airway (Wendl tube) acting as a "pathfinder." Accordingly, we performed a randomized, controlled trial with blinded assessment of nasopharyngeal bleeding and contamination of the tip of the endotracheal tube. After the induction of anesthesia, a Wendl tube (28 Ch) was inserted into the more patent nostril. In the control group (n = 30), the Wendl tube was retrieved before nasopharyngeal passage was attempted with an endotracheal tube (inner diameter, 7.0 mm). In the intervention group (n = 30), the Wendl tube was kept in position and only its adjustable flange was removed. Then, we inserted the tip of the endotracheal tube into the trailing end of the Wendl tube. Subsequently, the endotracheal tube was advanced under visual control to the oropharynx guided by the Wendl tube. After the endotracheal tube was positioned in the oropharynx, the Wendl tube was removed and intubation completed. Six hours after surgery, we determined the patients' nasal pain. The "pathfinder" technique reduced the incidence (P < 0.001) and severity (P = 0.001) of bleeding, decreased tube contamination with blood and mucus (P < 0.001), and diminished postoperative nasal pain (P = 0.036).

IMPLICATIONS

Nasopharyngeal passage of an endotracheal tube can be facilitated by a flexible Wendl tube (nasopharyngeal airway) covering and guiding the rigid tube tip. This technique is helpful in reducing the incidence and severity of nosebleeds and in minimizing contamination of the tip of the endotracheal tube with blood and mucus.

Five-year results of 206 laparoscopic left colectomies for cancer

BACKGROUND

The purpose of this study was to evaluate the 5-year survival of 206 consecutive patients with left colon carcinoma operated with a laparoscopic procedure between March 1992 and December 2000.

METHODS

Patients with obstructing or bulky cancers were excluded from this study. Tumor stage was defined according to the Dukes modified classification. The laparoscopic-assisted technique included primary high vascular ligation, centrifugal dissection of the mesentery, and "no touch" technique. The survival rates were calculated with the Kaplan-Meier test.

RESULTS

There were 109 males and 97 females, median age 67 (range 34-91). There were 30 left hemicolectomies (15%) and 177 sigmoid colectomies (85%). 22 patients required open conversion (11%). Overall operative mortality (1 month) was 1% and morbidity 12% (surgical and medical). There were 56 Dukes A carcinomas (27%), 69 Dukes B (34%), 54 Dukes C (26%), and 27 Dukes D (13%). 125 patients (61%) are alive and disease free, 22 (11%) are alive with disease recurrence, and 59 patients (28%) are deceased. None have been lost to follow-up. Only 1 case of trocar site implantation occurred after curative resections. Three-year observed survival rate were 93% for Dukes A + B (node negative tumors confined to the bowel wall), 78% for Dukes C, and 15% for Dukes D. The 5-year survival rates were 85% for Dukes A + B, 61% for Dukes C, and 8% for Dukes D.

CONCLUSION

Laparoscopic colectomy for cancer seems to be a safe procedure. The long-term results are comparable to those of open surgery. Further randomized trials will be necessary to confirm the value of this technique.

[Long-term results of endoscopic treatment of biliary stenosis from laparoscopic cholecystectomy]

BACKGROUND

The outcome of endoscopic biliary stent insertion for postoperative bile duct stenosis was retrospectively evaluated.

METHODS

Fifty-seven patients with biliary stenosis from laparoscopic cholecystectomy were included from February 1992 to January 2000. One to three stents were inserted for an average of 12.4 months, with stent exchange every three months to avoid cholangitis caused by obstruction.

RESULTS

Successful stent insertion was achieved in 43/57 (75.4%) patients. Stent insertion failed in 10 patients with complete and four patients with incomplete biliary obstruction. Early complications occurred in four patients. Late complications occurred in 5/43 patients. Five patients experienced recurrence of stenosis.

CONCLUSIONS

Endoscopic treatment should be the initial management of choice for postoperative bile duct stetiosis.

Surgical management of Spetzler-Martin grade V AVM

The surgical management of giant arteriovenous malformations (AVMs) has been complicated and fraught with considerable risk. We retrospectively analysed seven patients with giant AVMs classified into Spetzler-Martin Grade V between 1993 and 1999. Six of seven surgical cases presented with haemorrhagic episodes and the other single case developed progressive neurological deficits. Four out of seven surgical cases developed haemorrhagic complications during surgery or postoperatively. This resulted in poor outcomes in two of four cases. The other five cases recovered well from surgery. Although no morbidity was found after preoperative embolisation in this series, incomplete embolisation did not decrease the rate of haemorrhagic complication. Nonhaemorrhagic complications of a new focal neurological deficit occurred in three cases, one case in hemiparesis and two cases in quadrant hemianopsia. This resulted in surgical injury of white matter pathway where deep feeders such as the lenticulostriate arteries or wedge shape nidus were evident. Successful removal of giant AVM depends on not only stepwise obliteration of AVM but also successful management of the deep feeders that may reside in white matter pathways. Preoperative embolisation should target inaccessible deep feeders.

Do complications related to laparoscopic cholecystectomy influence the prognosis of gallbladder cancer?

BACKGROUND

Laparoscopy is thought to worsen the prognosis of gallbladder cancer (GBC) discovered unexpectedly at laparoscopic cholecystectomy (LC). However, laproscopy has never been shown to have an influence on patient survival in clinical series.

METHODS

We Performed a two-center retrospective analysis of 28 patients with GBC (11 previously known, 17 unexpectedly discovered by LC) to determine whether laparoscopy and complications related to LC had any influence on the prognosis of GBC. Resectability for cure after LC, survival, and recurrence related to both the procedure itself and complications associated with LC were analyzed.

RESULTS

Of the 17 patients with unexpected GBC, 16 were considered resectable for cure at the time of LC. Advanced disease was detected in eight patients by re staging (n = 5) or exploration (n = 3). Seven patients (43.8%) underwent reoperation for cure. Mean survival of patients with unexpected GBC was 26.5 months. Mean survival was shorter when complications (bile spillage, injury of common bile duct, or tumor violation) occurred during LC (10.2 vs 33 months, p = 0.016). If bile spillage was the only complication at LC, there was also a trend to shorter survival (12 vs 33 months, p = 0.061).

CONCLUSION

Complications during LC significantly worsen the prognosis of GBC. Therefore, bile spillage and excessive manipulation of the gallbladder should be avoided.

[Massive pulmonary capillary occlusion by microthrombi. Unexpected cause of fatal right heart failure during liver transplantation]

We report the case of a 46-year old man who developed an unexpected fatal cardiac failure during liver transplantation. Attempts at resuscitation were unsuccessful. At necropsy the lungs showed numerous microthrombi occluding small lung vessels and pulmonary capillaries. Thrombi were not found in other organs. The source of this extensive thrombus formation is not known. The thrombi could have been developed within the liver, the venous blood stream between liver and lungs or the pulmonary capillaries. In our experience, this complication is very rare, and a risk profile is not known.

Delayed cholangitis resulting from a retained T-tube fragment encased within a stone: a rare complication

Inserting a T-tube after choledochotomy for the removal of bile duct stones remains a time-honored practice. Biliary drainage after bile duct exploration has some advantages. It minimizes bile leakage, provides access for cholangiography, and removes occasional retained stones. The use of T-tubes also has been associated with significant complications. Biliary sepsis, bile duct trauma during removal, bile leakage leading to peritonitis, retention of a fragment, stricture formation after removal have been reported. We report an unusual case of cholangitis caused by a T-tube fragment within a large stone, occurring 11 years after bile duct exploration. A 39-year-old woman underwent common bile duct exploration with insertion of a T-tube. Cholangiography was normal, but as the T-tube was removed, its horizontal limb was missing. The patient failed to present for endoscopic removal a few weeks after surgery Five years later, she presented with recurrent biliary pains and a mild episode of cholangitis. This last episode was associated with severe pain and jaundice. After initial conservative treatment, endoscopic retrograde cholangiopancreatography was performed, and endoscopic removal of the fragment and stone material was successful. Despite the declining numbers of bile duct explorations in the laparoscopic era and the tendency to use transcystic drainage or primary closure of a choledochotomy, the T-tube will continue to be a useful tool in biliary surgery, subject to consideration of the indications and the available alternatives. The reported case highlights the importance of careful tube preparation to prevent partial separation at removal, and early removal of a missing fragment to avoid potential serious complications.

Acute distortion of the anatomy of the third ventricle during third ventriculostomy. Report of four cases

The authors report on four third ventriculostomy procedures in which upward ballooning of the third ventricular floor occurred immediately after perforation of the floor and withdrawal of a Fogarty catheter. The floor herniated into the third ventricle, hindering the endoscopic view. Preoperative magnetic resonance imaging demonstrated a similar anatomy in all four cases, consisting of hydrocephalus, extreme dilation of the third ventricle, and disappearance of the interpeduncular cistern due to a very thin, membranous floor of the third ventricle, which herniated downward, draping over the basilar artery. The authors suggest that excessive rinsing in combination with this anatomical configuration provoked the phenomenon of upward ballooning of the third ventricular floor, which is described in this report.

[Pathology of the gynecologic ureter: our experience]

Endometriosis, surgery and radiotherapy are the main causes of ureteral injuries in gynaecologic pathology.

MATERIALS AND METHODS

In this paper we present our experience about ureteral injuries. We treated 31 patients; 6 cases of endometriosis, 13 cases of pelvic radiotherapy for gynecologic tumors, 12 cases of ureteral injuries after gynecologic surgery. The treatments were different depending on the cause of the lesion and on the site of the lesion. In 3 cases we performed an ureteral-bladder implant with bladder psoas hitch, in 2 cases an end to end anastomosis was made. In 2 cases we made an ureteric substitution with Boari bladder flap. In 8 cases the ureteral stenting with DJ or a percutaneous nephrostomy was the solution.

RESULTS AND CONCLUSIONS

In our experience good results can be obtained with ureteral implant and bladder psoas hitch. The end to end ureteral anastomosis had disappointing results in our hands. In case of ureteral fistula it would be better repair it as soon as possible. If the ureteral lesion is recognised during surgery and the loss of substance is not complete, the suture on stent can be performed.

[Pathology of the gynecologic ureter]

OBJECTIVE

Ureteral lesions due to pelvic endometriosis, gynecological surgery and post-actinic are common findings in urology. Pelvic endometriosis can also be caused by a direct or indirect ureteral lesion after laparoscopic procedures. Stenosing ureteral lesions can be found after major gynecological surgery and after laparoscopic procedures. Many surgical techniques have been described to reduce the risks and to correct the complications.

MATERIALS AND METHODS

In our experience (1985-2000) we registered 2 ureteral lesions due to pelvic endometriosis. The patients were treated with resection and end-to-end anastomosis. We also protected the site of suture with omentoplasty. 49 patients developed a post-actinic ureteral lesion (43 unilaterally and 6 bilaterally). In 20 cases we performed an end-to-end anastomosis, in 25 cases we re-implanted the ureter and in 10 cases we performed a psoas hitch. In 36 patients we performed an omentoplastic procedure. Ureteral lesions after gynecological surgery were registered in 44 patients (33 after trans-vaginal hysterectomy, 6 after colposuspension, 5 after Wertheim). 40 ureters underwent open air surgery (26 patients, resection + end-to-end anastomosis, 6 patients simple re-implantation, 4 psoas hitch). In 32 patients we performed an omentoplastic procedure. 4 patients were corrected with an endoscopic procedure. These patients had a fulgurating lesion of the ureter with a consequent urinary fistula. A long-term drainage with endoureteral stent avoided the operation. All patients with an acute ureteral lesion were treated with a nephrostomic drainage and a short term repair.

RESULTS

In 2 patients with ureteral lesions due to pelvic endometriosis the results after corrective operation (3-4 years follow-up) were excellent with a good conservation of kidney function. In patients that underwent operation due to post-actinic ureteral stenosis, long-term results were: 78% complete preservation of kidney function without the need for permanent stents, 20% preservation of kidney function with need to conserve endoureteral stents, 2% loss of kidney function and consequent nephrectomy. Long-term results in patients that underwent an operation for ureteral lesions following surgical gynecological procedures were: 87% complete preservation of kidney function without the need of permanent stents, 13% conservation of kidney function but no need to preserve the endoureteral stent.

DISCUSSION

Lower urinary tract lesions after gynecological surgery are present in every surgical study. Most authors describe that intraoperative cystoscopy can immediately enhance the problem avoiding a re-operation. The laparoscopic risk seems to be for the cardinal ligaments when they divide beneath the uterine veins. Most authors seem to agree with the immediate need for a nephrostomic drainage followed by a postponed intervention. These procedures seem to reduce morbidity and the risk for a re-operation. In extended ureteral lesions there is agreement that psoas hitch is the best procedure. In our experience a nephrostomic drainage and a postponed intervention (2 weeks) has given comparable results with the best in literature as far as kidney function is concerned. The worst results were registered in patients with chronic lesions and with a deteriorated kidney function at the moment of the corrective procedure.