Prepare today for tomorrow

There has been a rapid advancement in cardiac surgery and anesthesia recently. The burden of cardiothoracic disease in south East Asia especially in Pakistan is on the rise. To meet the challenges of future, the present day cardiologist, cardiothoracic surgeons and cardiothoracic anesthesiologists should be equipped with knowledge and expertise to train work force for future capable to treat the burden of cardiothoracic diseases. The future of cardiothoracic surgery and anesthesia is dependent on the advancements made in recent years in this specialty. It is time that the cardiothoracic anesthesiologists of the country embrace technologies such as transesophageal echocardiography and extracorporeal membrane oxygenation so that they can help in providing safe anesthesia and post-operative care for complex cardiothoracic operations

Pre- and post-operative cardiac evaluation of dogs undergoing lobectomy and pneumonectomy

This study aimed to assess the influence of lobectomy and pneumonectomy on cardiac rhythm and on the dimensions and function of the right-side of the heart. Twelve dogs undergoing lobectomy and eight dogs undergoing pneumonectomy were evaluated preoperatively and one month postoperatively with electrocardiography and Doppler echocardiography at rest. Pulmonary artery systolic pressure (PASP) was estimated by the tricuspid regurgitation jet (TRJ) via the pulse wave Doppler velocity method. Systemic inflammatory response syndrome criteria (SIRS) were also evaluated based on the clinical and hematological findings in response to lobectomy and pneumonectomy. Following lobectomy and pneumonectomy, we predominantly detected atrial fibrillation and varying degrees of atrioventricular block (AVB). Dogs that died within seven days of the lobectomy (n = 2) or pneumonectomy (n = 1) had complete AVB. Preoperative right atrial, right ventricular, and pulmonary artery dimensions increased gradually during the 30 days (p<0.05) following pneumonectomy, but did not undergo significant changes during that same period after lobectomy. Mean PASP was 56.0 +/- 4.5 mmHg in dogs having significant TRJ after pneumonectomy. Pneumonectomy, but not lobectomy, could lead to increases (p<0.01) in the SIRS score within the first day post-surgery. In brief, it is important to conduct pre- and postoperative cardiac evaluation of dogs undergoing lung resections because cardiac problems are a common postoperative complication after such surgeries. In particular, complete AVB should be considered a life-threatening complication after pneumonectomy and lobectomy. In addition, pneumonectomy appears to increase the likelihood of pulmonary hypertension development in dogs.

Outcome and factors associated with hospital mortality in patients with impaired left ventricular function undergoing coronary artery bypass grafting: where do we stand?

Impaired ventricular function is a known risk factor for mortality after coronary artery bypass grafting however increasingly more patients with impaired ventricular function are referred for surgery. Currently no large data is available from Pakistan regarding this aspect of coronary surgery. Our objectives were to find out the hospital mortality and mid term functional improvement in patients with impaired ventricular function undergoing coronary artery by pass grafting and identify the risk factors for mortality. Retrospective analysis of preoperative, operative and postoperative variables of patients with impaired ventricular function who were operated for isolated first time coronary artery bypass between October 2006 to April 2009. Total 190 patients with impaired ventricular function underwent isolated first time coronary artery bypass grafting during this period with a male predominance [82.6%]. Mean ejection fraction of the group was 25.4 +/- 5.3%. Mean predicted mortality on logistic Euro score was 10.9 +/- 2.7%. Actual in hospital mortality of the group was 4.7% which is comparable to contemporary published results. Multivariate analysis identified use of intra aortic balloon pump, non use of internal mammary artery and preoperative NYHA functional class as factors associated with mortality. Coronary artery bypass grafting can be performed in patients with impaired ventricular function with acceptable hospital mortality and mid term functional improvement

Comparison of different bronchial closure techniques following pneumonectomy in dogs

The comparison of the histologic healing and bronchopleural fistula (BPF) complications encountered with three different BS closure techniques (manual suture, stapler and manual suture plus tissue flab) after pneumonectomy in dogs was investigated for a one-month period. The dogs were separated into two groups: group I (GI) (n = 9) and group II (GII) (n = 9). Right and left pneumonectomies were performed on the animals in GI and GII, respectively. Each group was further divided into three subgroups according to BS closure technique: subgroup I (SGI) (n = 3), manual suture; subgroup II (SGII) (n = 3), stapler; and subgroup III (SGIII) (n = 3), manual suture plus tissue flab. The dogs were sacrificed after one month of observation, and the bronchial stumps were removed for histological examination. The complications observed during a one-month period following pneumonectomy in nine dogs (n = 9) were: BPF (n = 5), peri-operative cardiac arrest (n = 1), post-operative respiratory arrest (n = 1), post-operative cardiac failure (n = 1) and cardio-pulmonary failure (n = 1). Histological healing was classified as complete or incomplete healing. Histological healing and BPF complications in the subgroups were analyzed statistically. There was no significant difference in histological healing between SGI and SGIII (p = 1.00; p > 0.05), nor between SGII and SGIII (p = 1.00; p > 0.05). Similarly, no significant difference was observed between the subgroups in terms of BPF (p = 0.945; p > 0.05). The results of the statistical analysis indicated that manual suture, stapler or manual suture plus tissue flab could be alternative methods for BS closure following pneumonectomy in dogs.

[Spontaneous spinal hematoma]

The spontaneous spinal hematoma is a rare and serious pathology. Through four observations colliged in the service of neurosurgery of the CHU of Casablanca, over one 10 years period, the authors point out the topographic, etiology aspects and the principles of treatment. Four types are distinguished according to the localization compared to the dura mater; the epidural hematoma, sub-dural hematoma, the sub-arachoidienne haemorrhage, and intra-medullarly hematoma. The etiologies are dominated by three principal causes with knowing; disorders of coagulation, arteriovenous malformations and the haemorrhage of tumoral origin. The assumption of responsibility starts with the correction of possible disorders of the coagulation generally followed by surgical evacuation

Non-traumatic spinal cord compression in children: 45 cases

Spinal cord compression occurs rarely in childhood and the diagnosis is usually made too late. We report 45 cases of non-traumatic spinal cord compression collected in our department between January 1982 and December 2002. Mean age was 11 years old with a male sex predominance [sex-ratio: 1.6]. Average delay of admission was 5 months. The most frequent complaints were gait disturbance [84.4%], pain [radicular or spinal] [66%] and sphincter dysfunction [24.4%]. Plain radiographs showed abnormalities in 46%. Magnetic resonance imaging has been more indicated since 1994. The distribution of lesions can be summerised as follows: predominance of dorsal involvement [37.7%], extramedullary lesions [75.6%] tumoural aetiologies [71.5%]. Forty-three cases were operated; 40 cases via posterior approach with laminectomy [33 cases] and laminotomy [7 cases], while anterior approach was performed in only 3 cases. Postoperative course showed neurologic improvement in 11 cases [24.4%], a stationary state in 28 cases [62.2%], and 3 cases of death. Unfortunately the long term outcome could not be followed in the majority of cases

Diagnosis and management of pituitary abscess

Pituitary abscess is a rare but serious intrasellar infection. To determine the signs and symptoms we present one case of a 40 year-old man without an infectious history nor of immunodepression, who had complained of severe headache, a right converge strablism, polyuria and polydipsia. The neurological examination was normal investigation of the old site was negative. Computerised tomography showed a pituitary adenoma. Magnetic resonance imaging [MRI] on the other hand, was in favour of a pituitary abscess: sellar hypointense T1-weighted, hyper-signal T2-weighted lesion with thin ring-enhancement following gadolinium injection. Transsphenoidal surgery was performed with a sterile culture. Anatomo-pathological study of the capsule showed nonspecific inflammatory tissue. Under antibiotherapy and after three months of clinical improvement, the symptomatology reappeared with a recurrence of the pituitary abscess on MRI. Drainage was carried out in the same manner as initially. Evolution under the same antibiotherapy was good with no recurrence of the pituitary abscess three years later. Pituitary abscess is a rare pathology, of difficult diagnosis even with MRI and often presents a surprise whilst operating. Outcome, except in recurrence, is excellent

[Intracranial aneurysm pronostics factors anout 22 ccases]

Ruptured intracranial aneurysms is uncommon but a serious disease with high morbidity and mortality. The follow-up is influenced by several factors. We presente 22 cases of intracranial anevrysms diagnosed after rup-tur in 21 cases. Age was varied between 14 years and 70 years. Eighteen patients were conscious or subcons-cious. Anevrysms were located in internal carotid artery in 44.3%. A good outcome [78.4%] was noted in patients who were WFNS I or II, with low or moderate subarachnoide hemorrage and supraclinoid iternal carotid artery aneurysms location

Tumor and Tumor-like conditions causing painful Ankle and foot: MRI findings

Accurate diagnosis of non-traumatic causes of painful ankle and foot is important so that proper medical and surgical management can be applied. The purpose of our study was to report the efficiency of MRI in the diagnosis of these cases and to correlate MRI diagnosis with the surgical and pathological results. This study included 10 patients suffering from painful ankle region and foot not related to trauma. They were 5 male and 5 female. Their age ranged from 11 to 42 years with an average of 26 years. All these patients were surgically managed, and we found good correlation between the MRI findings and the pathological diagnosis

[Cauda equina syndrome secondary to disc herniation. [Report of 24 cases]]

Cauda equina syndrome is secondary to lumbo sacral nerve roots compression, it is a rare complication of a lumbar disc herniation. Earlier surgical treatment has to be performed for a best improvement. We report 24 cases of cauda equina syndrome secondary to a disc herniation. 58% of our patients were males and the mean age was 47.7 years. Clinical examination found genito sphincteriens disturbances [80%], strenght deficits [62.5%], and sensitif troubles [84%]. CT scan and MRI confirmed the cauda equina compression by a disc herniation, wich were more frequent at L4L5 level [83%]. Surgical treatment was performed in all our cases: laminectomy and discectomy. Clinical out come was satisfactory in 83.5% of cases

[Cerebral hydatic cyst in children: a 40 cases report]

The cerebral hydatic cyst is uncommon, representing only 2 to 3% of all the localizations. Children are the most concerned by this disease. This retrospective study is about 40 cases of cerebral hydatic cyst [CHC] collected in the department of neurosurgery of Ibn Rochd Universitary Hospital of Casablanca between 1986 and 2002. These 40 cases were 70% of all the CHC. The mean age was 9 years [4 to 15 years. 64% were boys. All the children had progressive intracranial hypertension and 95% had neurological deficit. The cerebral CT scan of all the patients permitted to assess the diagnosis. The right hemispheric localization was predominant. 3 children had multivesicular cyst and 2 children had multiple cysts. All the patients were operated according to Arana-Iniguez's technique with a post-operative course characterized by 2 cases of meningitis. The medical treatment is still not useful for this disease. The outcome was good in 94% of the cases. 2 cases recurred after one and two years and had surgery once more. In conclusion, the CHC has a good prognosis in children if the diagnosis and the treatment are assessed early. Prevention campaign can avoid the disease and its neurological effects

Fractures of the odontoid process: 10 cases

The fractures of the odontoid process was exceptional, this complications was dramatic. In this retrospective study was about ten cases of fractures of odontoid process, collected at the department of neuro surgery between 1992-1998. The mean age of our patients was 27.4 years old, all patients are males. The highway accident was the most frequent etiology [90%]. The delay of consultation was were 3 days in 40% of the cases. The radiology study shows the existence of 9 cases of fractures type Ill and one case of fracture type according to ANDERSON and ALLONZO classification. The treatment was still orthopaedic in the majority of the cases, the surgery was indicated in the orthopaedic failures or in the primitively instable fracture. The evolution was characterised by the pseudarthrose complications in two patients and two cases was death

management of craniocerebral wounds about 73 cases

Our study was about 73 cases of craniocerebral wounds treated at the department of Neurosurgery in the UHC lbn Roshd in Casablanca. The mean age of our patients was 21 years old, with male predominance [87.7%]. 57.5% of these traumatisms were caused by aggression, 17,8% by road trafic accidents and 16.4% by falls. The neurological examination showed a normal consciousness in 80% of the cases, vigilance disorders in 20% of the cases, and signs of localizations in 23% of the cases. The radiography of the skull showed that the osseous damages [depressed fracture of the skull-pressed fracture of the skull were frequent in the parietal region [31%]. The computed tomography scan, achieved in all cases, was very useful in the detection of associated intracranial lesions. The management consists of a medical treatment and surgical intervention based on craniectomy and restoration of the dural plane. The craniocerebral wounds are rare but may have serious complications mainly infection and epilepsy

Avascular necrosis of the head of the femur, stage III, surgical management by drilling and bone grafting, clinical follow-up and magnetic resonance imaging results

This study was designed to elucidate the clinical, radiological and magnetic resonance imaging [MRI] results of management of atraumatic, aseptic, avascular necrosis of the head of the femur [AVN] in adults, stage III, by a new technique of drilling and autogenous bone grafting. 10 cases of AVN stage III were managed by drilling and bone grafting. There were 7 cases of corticosteroid therapy induced [AVN-CS] and 3 cases of idiopathic necrosis [AN-I]. The drilling was perofrmed by a 7mm reamer under image intensifier control. The cortical graft was obtained from the lateral cortex of the femur, and the cancellous bone grafts were obtained from the proximal femoral metaphysis, utilizing a single incision. Patients were evaluated prior to surgery and at 3, 6, 12, 18, and 24 month after surgery. Clinical evaluation, X-rays and MRI were all revised. Data were collected on all six appointments. Complaints and clinical examinations were summeriied by the Harris hip score. The aim of radiological examinations was to classify the stage of AVN before surgery and after 2 years follow-up and to assess the condition of AVN of the femoral head by detection of further collapse and osteoarthritic changes. MRI was performed for diagnosis and to demonstrate the extent of involvement of the head, to investigate the signal intensity and characteristics of the area of AVN during various stages of necrosis and healing, and to assess the viability of the graft and new bone formation. Clinically significant improvement of the hip score [pain, activity, gait, range of motion, and deformity] was noted in all cases. The hip score improved from an avarage of 27 points prior to surgery, to an average of 72 points after 24 month follow-up. 2 cases showed roentgenographic and MRI evidence of progression to stage IV. Plain radiography was useful in staging and follow-up of collapse and detection of the development of osteoarthritic changes. MRI proved to be a useful tool for diagnosis, staging, evaluation, and follow-up of reparative changes. MRI was useful in assessing marrow changes and graft incorporation and new bone formation after treatment of AVN of the femoral head by drilling and autogenous bone grafting. Drilling and bone grafting proved to be a useful method for treatment of AVN stage III as regarding pain and disability. This method is more suitable for the younger age group to defer early joint replacement. Radiography was usefeul for staging, detection of collapse, detecting progression of collapse, and detection of development of osteoarthritic changes. MRI proved to be an adequate tool for diagnosis, evaluation of the pathologic process, staging and classification of the disease, and for monitoring the incorporation of the graft, revasularization, healing and new bone formation in the necrotic femoral head