Paraspinous Sagittal Shift (PSSS): a novel approach for transmuscular quadratus lumborum block for hip surgery analgesia - four cases report / Paraespinhoso Sagital (PES): nova técnica no bloqueio transmuscular do quadrado lombar para analgesia em cirurgia de quadril - relato de quatro casos

Abstract Background: Effective pain management is essential for successful rehabilitation and enhanced recovery after joint arthroplasty. The Quadratus Lumborum Block (QLB) has mostly been described for abdominal surgery, but has also recently been applied to hip surgery patients. Methods: In the following cases series, we suggest a modification of the TQL block described as Paraspinous Sagittal Shift QL block. We hypothesize that this approach may allow better LA spread to the lumbar nerve roots. Such technique involves a craniocaudal approach of LA injection between the QL and PM muscles behind the Anterior Thoracolumbar Fascia (ATLF) at the level of L4. Cases were provided with combined GA and PSSS modification of QL block via a single shot or catheter technique. Results: Sensory distribution of the block in the four patients studied was found to cover the area between the T11-12 and L4-5 dermatomes. Spread of the injectate was confirmed via an A-P fluoroscopy imaging of the lumbosacral spine after injection of a mixture of LA and a contrast in the plane between the QL and PM muscles in two cases. Conclusions: The PSSS technique for TQL block may be beneficial as a part of multimodal analgesia for hip surgeries. This technique may be a safe alternative to psoas compartment block; however, future comparative studies are recommended. The PSSS technique for TQL block also may provide an easy access for catheter insertion.

Resumo Justificativa: O controle efetivo da dor é essencial para a reabilitação bem-sucedida e melhor recuperação após artroplastia. O bloqueio do quadrado lombar tem sido descrito principalmente para cirurgia abdominal, mas recentemente também tem sido usado para pacientes submetidos a cirurgia de quadril. Método: Na série de casos a seguir, sugerimos modificação na técnica do bloqueio transmuscular do quadrado lombar descrita como bloqueio do Quadrado Lombar Paraespinhoso Sagital (PES). Nossa hipótese é de que a técnica permitiria melhor dispersão do anestésico local para as raízes dos nervos lombares. Tal técnica envolve acesso craniocaudal para injeção do anestésico local entre os músculos quadrado lombar e psoas maior atrás da Fáscia Toracolombar Anterior (FTLA) no nível de L4. Os casos foram submetidos a anestesia geral combinada a técnica modificada PES para bloqueio do quadrado lombar via injeção única ou cateter. Resultados: Verificou-se que a distribuição sensorial do bloqueio nos quatro pacientes estudados cobriu a área entre os dermátomos T11-12 e L4-5. A dispersão do anestésico injetado foi confirmada via fluoroscopia A-P da coluna lombo-sacral após injeção, em dois casos, de solução de anestésico local e contraste no plano entre os músculos quadrado lombar e psoas maior. Conclusões: A técnica PES para bloqueio transmuscular do quadrado lombar pode ser benéfica como componente da analgesia multimodal para cirurgias de quadril. A técnica pode ser alternativa segura para bloqueio do compartimento psoas; entretanto, estudos comparativos futuros são recomendados. A técnica PES para bloqueio transmuscular do quadrado lombar pode também fornecer acesso fácil para inserção do cateter.

Vascular endothelial growth factor [VEGF] in serum and peritoneal fluid of patients with endometriosis

Abstract: Endometriosis can be defined as a non-neoplastic disease in which an endometrium- like tissue implants itself outside the uterine cavity conserving its histological and functional structure. VEGF concentration elevates in peritoneal fluid of patients with endometriosis which indicate that VEGF is also modulated in the serum of these patients. The aim of this study is to determine the behavior of VEGF in plasma and peritoneal fluids of patients with endometriosis, also correlation between VEGF level and stage of endometriosis. This study was carried out on 60 infertile patients. They were divided after laparoscopy into two groups study group including 40 endometriotic patients and control group including 20 patients without endometriosis. The study group was subdivided into two subgroups according to stage of endometriosis first subgroup [a] including 20 patients with minimal to mild endometriosis and subgroup [b] including 20 patients with moderate to severe endometriosis VEGF levels were measured by enzyme Linked immunosorbent assay [ELISA] in serum and Peritoneal fluid of all patients. The mean VEGF levels were significantly increased in serum and peritoneal fluid samples of cases with endometriosis compared with control cases, this increase was statistically significant in patients with moderate to severe stage. Also VEGF levels in peritoneal fluids was greater than that of the serum levels which was also significant in patients with moderate to severe stage

Conclusions: VEGF is present in increased amount in the serum and peritoneal fluid of women with endometriosis. This increase correlates with the stage of the disease

CT guided transthoracic catheter drainage of intrapulmonary abscess

Objective: to determine, the efficacy of CT guided transthoracic catheter drainage of intrapulmonary abscess considering success rate versus complications

Material and methods: nineteen patients were selected for CT guided percutaneous drainage using Seldinger technique. All patients were followed up clinically and radiologically by chest X-ray and CT scan

Results: nineteen patients with lung abscess were selected in this study for percutaneous CT guided drainage. In nine patients [47.36%] no complication occurred and lung abscess was completely resolved with no residual cavity. Five patients [26.31%] developed pneumothorax, which is the most common complication occurred diving this study. These patient= were kept under observation and followed-up by chest X-rays. Three of them [15.78%] had mild pneumothorax which. Resolved and needed no further management while two patients [10.52%] developed moderate pneumothorax and chest tube was inserted. Two out of nineteen patients [10.52%] had residual cavity left, but no other complications occurred, surgery was done for both patients. Two patients [l0.52%] developed mild hemoptysis and it was resolved within two hours, hence, no further management was required. One patient [5.26%] developed bronchopleural fistula and was operated. No mortality occurred during or after procedure

Conclusion: from this study it is inferred that CT-guided percutaneous transthoracic catheter drainage is safe and effective therapeutic modality for patients with lung abscess in whom medical therapy has failed and those who are unsuitable for surgery

Emergent thoracotomy in congenital malformations of the lung experience in 32 cases

Background: congenital anomalies of the lung are rare disorders that can present by life threatening emergency which may need emergent thoracotomy

Aim: to evaluate our methods of investigations and emergent management of these life threatening problems

Patients and Methods: this study represents the experience of Cardio Thoracic Surgery Department in collaboration with General Surgery Department, Mansoura University Hospital, Mansoura, Egypt on 32 cases who needed emergent thoracotomy for different congenital lung anomalies. Thirty two Consecutive patients had emergent operations from January 1996 until December 2001

Results: eighteen patients had tension lung cysts, 11 patients had congenital lobar over inflation, 2 patients had sequestrated segment, and one patient had congenital arteriovenous malformation. There were 14 males and 18 females, the age ranged from 3 days up to 16 years [mean age4+/-4.2y]. Patients less than 2 years presented with dyspnea, tachypnea, cyanosis, and respiratory distress, while the older patients presented with chest pain, hemoptysis. Plain X-ray chest was sufficient for the diagnosis in 26 patients [81.25%], while CT chest was done in 23 patients [71.8%], bronchoscopy was also done in 6 patients [18.75 %] for exclusion of foreign body inhalation. Curative surgery was achieved by 28 lobectomies, 3 bilobectomies, and in one case by cyst enucleation. The complications were in the form of postoperative pneumonia, atelectasis, air leak and empyema in 14.5% of cases which managed easily. Infants and children tolerate lobectomy extremely well, with compensatory lung growth, so that total lung volume and gas exchange capacity returns to normal during somatic maturation

Conclusion : it is concluded from this study that these congenital lung malformations may cause respiratory distress and hemoptysis and need emergent thoracotomy which is curative. X-ray chest and CT scan are sufficient for accurate diagnosis. Emergent surgery is safe and curative in those patients as infants and children tolerate lung resection very well with compensatory lung growth during somatic maturation

Prosthetic valve endocarditis

Background: prosthetic valve endocarditis [PVE] remains a serious complication of cardiac valve replacement. Patients with valve replacement are at constant risk of 0.6-1% per patient-year for PVE. The mortality is high despite major advances in the treatment of infective endocarditis, which includes more effective antimicrobial therapy and more aggressive surgical procedures

Aim of the work: this study is directed to evaluate patients with prosthetic valve endocarditis managed at the Cardiothoracic Surgery Department, Mansoura University. Evaluation included the mode of presentation, methods of diagnosis and results of different management modalities

Patients and Methods: this is a retrospective study. Between 1994 and 2000, 19 patients were admitted at the Department of Cardiothoracic Surgery, Faculty of Medicine, and Mansoura University for suspected prosthetic valve endocarditis [PVE]. All of the patients have been operated on before in the same department. Retrospective analysis of the patient's charts was performed

Results: the mean age of the patients was 26+/-5.1 years [range 17-41 years] and the male to female ratio was 2:1. Eighteen patients [94.74%] had mechanical valve replacement using bileaflet valves and only one patient [5%] had mitral valve repair using prosthetic ring. Of the 18 patients who had received single valve prosthesis, 8 [42.11%] underwent mitral valve replacement, 6. [31.38%] aortic valve replacement, 4 patients [20.05%] had both aortic and mitral valves replaced. In this study, four patients [21.05%] treated medically using9 antibiotics and supportive medical treatment for heart failure. Fifteen patients [78.9%] required valve medical treatment including antibiotic and supportive treatment of average 15 days. The most common indication for surgery was congestive heart failure caused by paravalvular leakage due to the endocarditis. Paravalvular leak involved more than 50% of the valve circumference with prosthesis dehiscence in 2 patients. In 2 patients, there was persistent fever with refractory sepsis and one patient had septic embolism. The mean aortic cross clamp time was 70+/-14.1 minutes [Interval 55-150 minutes]. The mean cardiopulmonary bypass time was 165+/-26.1 minutes [Interval 100-230 minutes]. The mortality in the medically managed patients was 75% [3 patients] compared to 33.3% [3 patients] in the surgically treated group

Conclusion: 1. PVE remains a surgical challenge, but in order to optimize surgical results, early diagnosis and aggressive medical theraou should go hand-in-hand with Carly surgical intervention especially in those patients known to have a poor prognosis for medical cure and who are at risk for surgical morbidity and mortality. 2. Early reoperation, extensive tis sue debridement with annular reconstruction, could improve the results of the treatment of PVE, but strict prevention measures of intraoperative contamination during valve replacement remains the optimal goal to de crease the incidence and dismal outcome of PVE

Serious chest trauma in children requiring emergency thoracotomy

Background: pediatric trauma remains a major health and social problem. Thoracic injuries are the second leading cause of death in children

Aim of the work: to evaluate our experience in diagnosis and management of serious chest trauma in children either blunt or penetrating which required emergency thoracotomy

Patients and methods: this is a retrospective study of all emergency thoracotomies performed for pediatric patients at Mansoura University Emergency Hospital [MUEH] from January 1997 to December 2002. We reviewed the hospital charts of all patients admitted with the diagnosis of chest injuries either blunt or penetrating injury and selected cases needed emergency thoracotomy. Of the pediatric group, only 50 patients [5%] had serious chest injury, either blunt or penetrating and required emergency thoracotomy were included in this study. Hospital charts of this group of patients were reviewed and classified according to the mechanism of trauma into two groups: Group A: Patients with blunt thoracic trauma; 26 patients [52 %]. Group B Patients with penetrating thoracic trauma; 24 patients [48%]

Results: in the blunt group, 20 patients [76.9%] were males and 6 patients [23.1%] were females, with age ranged from 1 to 16 years [mean 10.0+/-6.4]. In penetrating group, 20 patients [83.3%] were males and 4 patients [16.7 %] were females, with age ranged from 6 to 17 years [mean 12.6+/- 3.4]. In the blunt group, the mechanism of injury was: road traffic accidents in 18 patients [69.26] and falling from height in 8 patients [30.8%]. In the penetrating group, the mechanism of injury was: stab injury in 17 patients [70.8%], gunshot injury in 2 patients [8.4%], 4 patients [16.7%] were victims of iatrogenic trauma and one patient [4.2%] was involved in explosion injury. In both groups the most common side of injury was the left side 29 patients [58 %]. Fifteen patients [57.3%] were in the blunt group and 14 patients [58.3] were in the penetrating group. The pediatric trauma score [PTS] of all children was calculated, it was found that 7 patients [26.9%] of the blunt group and 8 patients [33.3%] of the penetrating group had PTS

Conclusion: from this study concludes that: *A high survival rate can be achieved if emergency thoracotomy, when indicated, is done as long as the patients shows vital signs on admission. *Excellent results are predicted when the surgical interference is performed within the first 2 hours of injury. The emergency thoracotomy could be done in the operating room or in the emergency room provided that the good monitoring and ventilation is available, then patients can be transferred after resuscitation to the operating room for definitive repair of the injuries