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Abstract
Vascular type Ehlers-Danlos syndrome is an inherited connective tissue disease, which is typified by tissue fragility, joint hypermobility, a tendency to bleed excessively and rupture of the uterus, the bowel and arteries. Two case reports are presented which describe the anaesthetic management of patients with spontaneous bowel perforations due to vascular type Ehlers-Danlos syndrome. Both cases were associated with relatively minor problems. The implications of this condition for anaesthesia include difficulty (and risk of complications) with vascular access, a risk of spontaneous arterial rupture in the perioperative period, possible cervical spine instability and airway trauma on intubation. There is also a risk of excessive bleeding, potentially difficult neuraxial anaesthesia and an increased risk of epidural haematoma. There also may be associated cardiac or pulmonary disease. However, these two cases and the limited previously published literature suggest that such potential complications are actually rare and that anaesthesia may be conducted in a relatively standard manner in most circumstances.
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Affiliation(s)
- D Lane
- Department of Anaesthesia, Calvary Hospital, Australian Capital Territory, Australia
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El Masri H, Loong TH, Meurette G, Podevin J, Zinzindohoue F, Lehur PA. Bowel perforation in type IV vascular Ehlers-Danlos syndrome. A systematic review. Tech Coloproctol 2018; 22:333-341. [PMID: 29700641 DOI: 10.1007/s10151-018-1783-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Accepted: 03/05/2018] [Indexed: 12/31/2022]
Abstract
Spontaneous gastrointestinal (GI) perforation is a well-known complication occurring in patients suffering from Type IV vascular Ehlers-Danlos syndrome (EDS IV). The aim of the present study was to review the current literature on spontaneous GI perforation in EDS IV and illustrate the surgical management and outcome when possible. A systematic review of all the published data on EDS IV patients with spontaneous GI perforation between January 2000 and December 2015 was conducted using three major databases PUBMED, EMBASE, and Cochrane Central Register of Controlled Trails. References of the selected articles were screened to avoid missing main articles. Twenty-seven published case reports and four retrospective studies, including 31 and 527 cases, respectively, matched the search criteria. A case from our institution was added. Mean age was 26 years (range 6-64 years). The most frequent site of perforation was the colon, particularly the sigmoid, followed by small bowel, upper rectum, and finally stomach. The majority of cases were initially managed with Hartmann's procedure. In recurrent perforations, total colectomy was performed. The reperforation rate was considerably higher in the "partial colectomy with anastomosis" group than in the Hartmann group. Colonic perforation is the most common spontaneous GI perforation in EDS IV patients. An unexpected fragility of the tissues should raise the possibility of a connective tissue disorder and prompt further investigation with eventual management of these high-risk patients with a multidisciplinary team approach in dedicated centres. In the emergency setting, a Hartmann procedure should be performed.
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Affiliation(s)
- H El Masri
- Digestive and Endocrine Surgery Clinic, Institute of Digestive Diseases, University Hospital of Nantes, CHU Hôtel Dieu, 1, Place Alexis Ricordeau, 44035, Nantes, France
| | - T-H Loong
- Digestive and Endocrine Surgery Clinic, Institute of Digestive Diseases, University Hospital of Nantes, CHU Hôtel Dieu, 1, Place Alexis Ricordeau, 44035, Nantes, France
| | - G Meurette
- Digestive and Endocrine Surgery Clinic, Institute of Digestive Diseases, University Hospital of Nantes, CHU Hôtel Dieu, 1, Place Alexis Ricordeau, 44035, Nantes, France
| | - J Podevin
- Digestive and Endocrine Surgery Clinic, Institute of Digestive Diseases, University Hospital of Nantes, CHU Hôtel Dieu, 1, Place Alexis Ricordeau, 44035, Nantes, France
| | - F Zinzindohoue
- HEGP Paris, National Referral Centre for Rare Diseases "Ehlers-Danlos Syndrome", Paris, France
| | - P-A Lehur
- Digestive and Endocrine Surgery Clinic, Institute of Digestive Diseases, University Hospital of Nantes, CHU Hôtel Dieu, 1, Place Alexis Ricordeau, 44035, Nantes, France.
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Wiesmann T, Castori M, Malfait F, Wulf H. Recommendations for anesthesia and perioperative management in patients with Ehlers-Danlos syndrome(s). Orphanet J Rare Dis 2014; 9:109. [PMID: 25053156 PMCID: PMC4223622 DOI: 10.1186/s13023-014-0109-5] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 07/02/2014] [Indexed: 01/29/2023] Open
Abstract
Ehlers-Danlos syndrome (EDS, ORPHA98249) comprises a group of clinically and genetically heterogeneous heritable connective tissue disorders, chiefly characterized by joint hypermobility and instability, skin texture anomalies, and vascular and soft tissue fragility. As many tissues can be involved, the underlying molecular defect can manifest itself in many organs and with varying degrees of severity, with widespread implications for anesthesia and perioperative management. This review focuses on issues relevant for anesthesia for elective and emergency surgery in EDS. We searched the literature for papers related to all EDS variants; at the moment most of the published data deals with the vascular subtype and, to a lesser extent, classic and hypermobility EDS. Knowledge is fragmented and consists mostly of case reports, small case series and expert opinion. Because EDS patients commonly require surgery, we have summarized some recommendations for general, obstetrical and regional anesthesia, as well as for hemostatic therapy.
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Shirley ED, Demaio M, Bodurtha J. Ehlers-danlos syndrome in orthopaedics: etiology, diagnosis, and treatment implications. Sports Health 2012; 4:394-403. [PMID: 23016112 PMCID: PMC3435946 DOI: 10.1177/1941738112452385] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Ehlers-Danlos syndrome is a heterogeneous connective tissue condition characterized by varying degrees of skin hyperextensibility, joint hypermobility, and vascular fragility. Joint dislocations, musculoskeletal pain, atrophic scars, easy bleeding, vessel/viscera rupture, severe scoliosis, and obstetric complications may occur. These manifestations are secondary to abnormal collagen, with specific molecular defects in types I, III, and V collagen; they may also be related to tenascin-X, which has been identified in some patients. Ehlers-Danlos syndrome has been classified into 6 types, with variable degrees of joint instability, skin hyperextensibility, wound healing difficulty, and vascular fragility. Diagnosis begins with recognition of the signs and symptoms of global hypermobility and referring appropriate patients for genetic consultation. It is important to accurately identify patients with Ehlers-Danlos syndrome to initiate appropriate musculoskeletal treatment, optimize anesthetic and postoperative management, perform appropriate vascular screening, and help families address their concerns with other families and advocacy groups.
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Stalla-Bourdillon A, Dureau P, Adamou K, Tassin M, Franck M, Fischer C, Mercier FJ. [Scheduled caesarean delivery in a patient with vascular type Ehlers-Danlos syndrome]. ACTA ACUST UNITED AC 2012; 31:265-6. [PMID: 22305393 DOI: 10.1016/j.annfar.2011.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Wegener JT, Frässdorf J, Stevens MF. Effective plexus anaesthesia in a patient with Ehlers-Danlos syndrome type III. Eur J Anaesthesiol 2009; 26:619-21. [PMID: 19522056 DOI: 10.1097/eja.0b013e328324044e] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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21st ESICM Annual Congress. Intensive Care Med 2008. [PMCID: PMC2799007 DOI: 10.1007/s00134-008-1240-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Fernández-Alcantud J, López RC, Osado IR, Castro MR. [Management of anesthesia in vascular-type Ehlers-Danlos syndrome (type IV)]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2008; 55:312-313. [PMID: 18661692 DOI: 10.1016/s0034-9356(08)70576-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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Fèvre MC, Falcon D, Jouk PS, Seinturier C, Jacquot C. [Vascular Ehlers-Danlos syndrome: a clinical syndrome to be known by every anaesthesiologist and intensive care physician]. ACTA ACUST UNITED AC 2007; 27:90-3. [PMID: 18068944 DOI: 10.1016/j.annfar.2007.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2007] [Accepted: 10/22/2007] [Indexed: 10/22/2022]
Abstract
We report the case of a 29-year-old female who presented with a series of major vascular complications in rapid succession: haemothorax following rupture of a mammary artery aneurysm, pulmonary embolism, anterior myocardial infarction secondary to spontaneous dissection of the left anterior descending artery and rupture of a false aneurysm of the splenic artery. A diagnosis of Ehlers-Danlos syndrome (vascular variant) was considered the most likely in this context. Characterized by an extreme vascular fragility, this rare disease poses important clinical management issues for the anaesthetist and intensive care physician.
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Affiliation(s)
- M-C Fèvre
- Service de réanimation chirurgicale et polyvalente, CHU Albert-Michallon, B.P. 217, 380432 La Tronche cedex 09, France
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Seo BS, Kim EJ, Lee JH, Lee SG, Ban JS, Min BW. Anesthesia for a Cesarean Section in a Patient with Ehlers-Danlos Syndrome - A case report -. Korean J Anesthesiol 2007. [DOI: 10.4097/kjae.2007.53.1.140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Bo Seong Seo
- Department of Anesthesiology and Pain Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Eun Ju Kim
- Department of Anesthesiology and Pain Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Ji Hyang Lee
- Department of Anesthesiology and Pain Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Sang Gon Lee
- Department of Anesthesiology and Pain Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Jong Suk Ban
- Department of Anesthesiology and Pain Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Byung Woo Min
- Department of Anesthesiology and Pain Medicine, Daegu Fatima Hospital, Daegu, Korea
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