1/254. Profound hypothermia and circulatory arrest with skull base approaches for treatment of complex posterior circulation aneurysms.OBJECTIVE: cardiopulmonary bypass with profound hypothermia and circulatory arrest has seen a resurgence as an adjunct technique in neurological surgery. We report our experience with this technique in treating seven complex vertebro-basilar aneurysms. methods: skull base approaches were used in all cases, providing excellent exposure and minimizing brain retraction. There were six basilar artery aneurysms and one giant fusiform vertebro-basilar artery aneurysm. All aneurysms but one had an apparent neck, which could be clipped. The fusiform vertebro-basilar artery aneurysm was trapped, partially resected, and the circulation was reestablished with a saphenous vein graft from the cervical internal carotid artery to the mid-basilar artery. RESULTS: Five patients had an excellent outcome and two had a good outcome at one year or at latest follow up. Two of the patients showed improvement of neurological deficits which were present before the surgical intervention. CONCLUSION: Applying very strict selection criteria in this small series of patients with posterior circulation aneurysms, excellent or good results were achieved using the profound hypothermic circulatory arrest technique.- - - - - - - - - - ranking = 1keywords = tract (Clic here for more details about this article) |
2/254. Undiagnosed Mirizzi's syndrome: a word of caution for laparoscopic surgeons--a report of three cases and review of the literature.The mirizzi syndrome is often undiagnosed before surgery and can carry a high risk of iatrogenic damage to the common bile duct when encountered during open or, especially, laparoscopic surgery. Endoscopic management has recently been reported, but this treatment can be performed only when there is a high index of suspicion based on clinical criteria that the condition is present and therefore suggests the indication for endoscopic retrograde cholangiopancreatography (ERCP). This is not always the case. Consequently, in a considerable percentage of patients, the syndrome is discovered only after the bile ducts have been damaged during surgery. Three cases of Mirizzi's syndrome were observed in our experience of 896 laparoscopic cholecystectomies (0.3%). All patients were without typical symptoms, and the syndrome was unsuspected in spite of preoperative intravenous cholangiography. All patients required conversion to an open procedure, with two injuries of the common bile duct (a complete transection and a tear) being promptly repaired. We conclude that when this syndrome is suspected or found during surgery, the surgeon should follow these guidelines: (1) perform intraoperative cholangiography when possible, even through the gallbladder wall; and (2) dissect the gallbladder from above and, if necessary, open it to extract the stone. dissection of Calot's triangle should never be attempted. Great expertise is required to complete the operation laparoscopically. The reported cases in the literature refer to a high percentage of conversion, underlining the technical difficulties and making this syndrome, when undiagnosed and unsuspected, a real challenge for laparoscopic surgeons.- - - - - - - - - - ranking = 1keywords = tract (Clic here for more details about this article) |
3/254. Critical obstruction of the right ventricular outflow tract by a primary hemangioendothelioma in a seven month old.A 7-month-old presented with failure to thrive and a murmur. echocardiography demonstrated a large mass in the right ventricular outflow tract, extending through the pulmonary valve. During anaesthetic induction this caused critical obstruction of the outflow tract and cardiac arrest. Pathological diagnosis showed the lesion to be a primary hemangioendothelioma. Despite surgical excision and steroid therapy, the mass continued to grow for a period of 8 weeks, but then began to regress spontaneously.- - - - - - - - - - ranking = 6keywords = tract (Clic here for more details about this article) |
4/254. arteriovenous fistula after injury of the left internal mammary artery during extraction of pacemaker leads with a laser sheath.The left internal mammary artery was severed and an arteriovenous fistula created during extraction of pacemaker leads with a laser sheath.- - - - - - - - - - ranking = 5keywords = tract (Clic here for more details about this article) |
5/254. Severe aortic regurgitation immediately after mitral valve annuloplasty.We report a case of severe aortic regurgitation occurring immediately after the insertion of a mitral annuloplasty ring. On transesophageal echocardiography, regurgitation was found to originate from the retracted left coronary cusp. On direct examination, part of the aortic wall was folded, but no suture could be identified. It was reasoned that tension created by the ring caused the retraction. The problem was corrected by releasing three sutures on the ring. Postoperative course was uneventful.- - - - - - - - - - ranking = 2keywords = tract (Clic here for more details about this article) |
6/254. Aortic obstruction caused by device occlusion of patent arterial duct.A 2 year old girl is reported in whom deployment of the Amplatzer ductal occluder caused significant aortic obstruction, requiring surgical removal of the device. This case emphasises the need for careful echocardiographic and angiographic assessment of the position of the Amplatzer ductal occluder before and after detaching the device from its delivery system, with particular emphasis on the position of the aortic retention ring. Careful assessment of ductal anatomy must guide case selection.- - - - - - - - - - ranking = 10.060337308074keywords = anatomy (Clic here for more details about this article) |
7/254. Rapunzel syndrome--a case report.The gastric trichobezoars usually occur in young girls, often those with psychiatric disorders. Rarely these are known to extend from the stomach to the small intestine as a tail, when they are termed the Rapunzel syndrome. Until 1997, only 10 such cases have been reported in the literature. We report another case in which we could extract the trichobezoar by gastrotomy and enterotomy.- - - - - - - - - - ranking = 1keywords = tract (Clic here for more details about this article) |
8/254. Pocket infection complicating inadvertent transarterial permanent pacing. Successful percutaneous explantation.This report describes a patient admitted for the treatment of a pocket infection occurring 5 months after a dual chamber pacemaker implantation. The ventricular lead had been inadvertently placed into the left ventricle through the arterial system. After careful examination using transesophageal echocardiography and left heart angiogram, successful percutaneous extraction was performed without complication.- - - - - - - - - - ranking = 1keywords = tract (Clic here for more details about this article) |
9/254. Internal iliac artery embolisation for intractable bladder haemorrhage in the peri-operative phase.Intractable haemorrhage from the bladder wall during transurethral resection of bladder tumour is uncommon but potentially catastrophic. Internal iliac artery embolisation is a minimally invasive technique, which is now widely practised to stop bleeding from branches of these arteries is situations including pelvic malignancy, obstetric and gynaecological emergencies and trauma. We report its successful use peri-operatively, in an unfit, elderly patient with uncontrolled bleeding.- - - - - - - - - - ranking = 5keywords = tract (Clic here for more details about this article) |
10/254. life-threatening haemorrhage following obturator artery injury during transurethral bladder surgery: a sequel of an unsuccessful obturator nerve block.In spite of prior blockade of the obturator nerve with 1% mepivacaine (8 ml) utilizing a nerve stimulator, violent leg jerking was evoked during transurethral electroresection of a bladder tumour approximately 1 h after the blockade in a 68-year-old man. The patient became severely hypotensive immediately following the jerking, and a large lower abdominal swelling concurrently developed. The urgent laparotomy indicated that the left obturator artery was severely injured by the resectoscope associated with the bladder perforation, causing acute massive haemorrhage. The patient recovered uneventfully after adequate surgery. Investigation of the literature suggested that both our nerve stimulation technique and anatomical approach were appropriate. It was therefore unlikely that our block resulted in failure because of an inappropriate site for deposition of the anaesthetic. However, consensus does not appear to have been obtained as to the concentration and volume of the anaesthetic necessary for prevention of the obturator nerve stimulation during the transurethral procedures. The concentration and volume of mepivacaine we used might have been too low and/or small, respectively, to profoundly block all the motor neuron fibres of the nerve. Alternatively, stimulation of the obturator nerve might occur because of the presence of some anatomical variant, such as the accessory obturator nerve or its abnormal branching. In conclusion, some uncertainty appears to exist in the effectiveness of the local anaesthetic blockade of the obturator nerve. In order to attain profound blockade of the motor neuron fibres of the obturator nerve and thereby prevent the thigh-adductor muscle contraction which can lead to life-threatening situations, we recommend, even with a nerve stimulator, to use a larger volume of a higher concentration of local anaesthetic with a longer duration in the obturator nerve block for the transurethral procedures.- - - - - - - - - - ranking = 1keywords = tract (Clic here for more details about this article) |
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