Pseudoaneurisma da artéria poplítea em um paciente com Síndrome de Ehlers-Danlos Tipo VI / Pseudoaneurysm of the popliteal artery in a patient with Type VI Ehlers-Danlos Syndrome

A Síndrome de Ehlers-Danlos (EDS) é uma rara doença hereditária do tecido conjuntivo proveniente de uma alteração da síntese do colágeno. A principal característica da EDS é a extrema fragilidade do tecido conjuntivo, que pode resultar em rotura uterina, perfuração intestinal espontânea e várias doenças vasculares como aneurismas, pseudoaneurismas, dissecções arteriais e roturas espontâneas. Os autores relatam o caso de um paciente de 11 anos de idade que apresentava tumor pulsátil na fossa poplítea esquerda após trauma leve com bola de futebol. Diagnosticado pseudoaneurisma de artéria poplítea pelo doppler arterial, confirmado através da angiografia, optou-se pela exploração arterial e devido à fragilidade da parede não foi possível a sua reconstrução. Realizada a ligadura simples da artéria proximal. Evoluiu com isquemia grave do membro e após autorização da família foi realizada a sua amputação. No segundo dia do pós-operatório o paciente apresentou uma dissecção aguda da aorta torácica, evoluindo a óbito.

Ehlers-Danlos Syndrome (EDS) is a rare inherited connective tissue disease arising from an abnormality of collagen synthesis. The main feature of EDS is the extreme fragility of connective tissues, which can result in uterine rupture, spontaneous intestinal drilling and vascular diseases such as aneurysms, pseudoaneurysms, arterial dissections and spontaneous ruptures. This paper describes the case of an 11-year-old patient who presented a pulsatile mass in the left popliteal fossa after a minor trauma caused by a soccer ball. A pseudoaneurysm of the popliteal artery was diagnosed with arterial Doppler ultrasound and confirmed using angiography. An exploratory investigation revealed that the artery wall was too weak to allow reconstruction and the proximal artery was ligated. The patient developed severe limb ischemia and after authorization by the family the limb was amputated. Two days after surgery, the patient died as a result of acute thoracic aortic dissection.

Thyroid surgery performed on an overnight basis: a 17 years of experience

Objective This study aimed to evaluate the results of thyroid surgeries with hospitalization periods shorter than 18 hours performed in a surgical endocrinology service, correlating these results with type of procedure, the definitive diagnosis and complications associated with the procedure.Subjects and methods The procedures performed, complications associated, hospitalization period, and relationships among these variables were assessed in consecutive patients subjected to different types of thyroid surgeries from January 1997 to March 2014 by the same group of surgeons. Data were analyzed by frequency, and the associations between the hospitalization period and other variables were analyzed using the Pearson chi-square test and Fisher’s exact test, using a multiple comparisons test with Bonferroni correction.Results Among the 3,411 surgeries performed, 799 of them were malignant neoplasia, 2,505 were benign tumors and 107 were Graves’ disease. The following procedures were performed: total thyroidectomy (1597 patients); total thyroidectomy with neck exploration (369 patients); lobectomy plus isthmectomy (1084 patients); total thyroidectomy complementation (145 patients); total thyroidectomy with neck dissection (84 patients); modified radical total thyroidectomy (13 patients); nodulectomy (11 patients); unresectable (9 patients); central neck dissection (48 patients); lateral neck dissection (38 patients); and others (13 patients). The following surgical complications, characteristic of the procedure: hemorrhage in 41 (1.2%) patients, hypoparathyroidism in 10 (0.3%) patients and recurrent laryngeal nerve (RLN) injury in 23 (0.7%) patients. Hospitalization shorter than 18 hours was observed in 97% of patients.Conclusion Thyroid surgery can be safely performed in virtually all patients on an overnight basis in specialized services.

Fatal hemmorhage following extraction of first molar.

A case involving extraction of right upper 1st molar leading to massive hemorrhage and death in an undiagnosed case of Arteriovenous Venous Malformation of maxilla is presented along with the relevant investigations, standard treatment to be given and the related medicolegal issues. A 16 year old male presented to a dentist with history of Grade III mobility of right upper 1st molar without any known etiology. The dentist extracted the tooth without properly assessing the patient clinically and advising any relevant investigations thereby leading to massive hemorrhage and death of the patient. Proper clinical assessment, relevant investigations adequate treatment is to be given or the surgeon faces the risk of legal action for medical negligence under the provisions of Sec.304A of IPC. History taking, proper clinical examination, relevant investigations and adequate treatment are imperative in treating any case and in case of complications, the patient must be shifted to the ED of the nearest hospital without any delay.

Recombinant activated factor VII in cardiac surgery: Is it effective in reducing postoperative bleeding?

The FDA approved recombinant factor Vila [rFVIIa][Novo Nordisk, Bagsvaerd, Denmark] in 1999 for treatment of spontaneous or surgical bleeding episodes in patients with hemophilia A or B. rFVIIa was rapidly used in the treatment or prophylaxis of bleeding in other conditions including cardiac surgery. The question addressed was whether use of rFVIIa could help Hemostasis, and decrease blood or blood product requirements in cardiac surgery patients and its safety as regards thrombosis risk. This is a retrospective comparative study conducted in King Fahad Cardiac Center [KFCC], King Saud University [KSU] Riyadh, KSA. Discharge data of 250 patients who had cardiac surgery through August 2010 to July 2011 were reviewed, 14 patients without hemophilia received Recombinant Activated Factor VII were included in the study as rFVIIa group. Another 15 patient were randomly assigned to the control group. Data analyzed are: patient's age, sex, procedure done, CPB time, blood loss, blood or blood products transfusion, intensive care unit [ICU] stay, dose of rFVIIa, and any reported thrombotic adverse effect. A single dose of 1.2 rFVIIa was given to rFVIIa group patients, Demographic data were comparable in both groups without significance. Cardiopulmonary bypass time was 114.91 +/- 654 minutes in rFVIIa group and 119.44 +/- 139 in control group [p=0.6229]. Post operative drain was 598.33 +/- 153.68 and 945.75 +/- 946.8 in rFVIIa and control group respectively [p=0.395]. Blood and product transfusion showed no statistical difference between the groups as well as ICU stay and hospital stay. One patient in the control group was re-explored due to a surgical cause. No reported thrombo embolic complications among study patients. Small dose rFVIIa cannot be considered effective for bleeding after cardiac surgery. Further larger randomized trials will better provide evidence of the effective value of rFVIIa in this setting. Further investigation is warranted in order to design guidelines on the use of rVIIa in cardiac surgery and to determine its safety and efficacy profile

Sternotomy complications after Coronary Artery Bypass Grafting [CABG] risk factors?

The development of a sternotomy complication is multifactorial and numerous studies point to a multitude of patient- and procedure-related variables as underlying factors in this complication. Retrospective study analysis of 132 patients operated upon coronary artery bypass grafting. Sternal wound complications occurred to 19 patients [14.4], statistical analysis of the results demonstrated that prolonged mechanical ventilation, post operative blood loss and transfusion, prolonged bypass time, and diabetes mellitus was significant predictor risk factors for sternal wound complications risk factors. Identification of both patients' related risk factors and procedures related risk factors for sternal wound infection is very beneficial. Patients related factors should be lessened as much as possible while procedures related factors should be eliminated to abort any chance for sternal wound complication

Tumores hepáticos benignos complicados / Complicated bening liver tumors

Antecedentes: Los tumores benignos sólidos del hígado (TBSH) constituyen una patología poco común. La mayoría de ellos son asintomáticos y de diagnóstico accidental. Un pequeño número de pacientes sufre complicaciones entre las que se encuentran la hemorragia y la transformación maligna. Objetivo: Describir las complicaciones observadas en los pacientes operados por TBSH y analizar la conducta terapéutica y la evolución postoperatoria de este grupo de enfermos. Diseño: Estudio clínico restrospectivo. Población: De los 99 pacientes portadores de TBSH que fueron operados, 18 (18,1 por ciento) estaban complicados. En este grupo se incluyen: 6/49 (12,2 por ciento) hemangiomas, 8/21 (38,1 por ciento) adenomas, 2/16 (12,5 por ciento) hiperplasias nodulares focales, 1 hamartoma y 1 pseudotumor inflamatorio. La complicación más frecuente fue la hemorrágica (66,6 por ciento) en 3 casos por biopsias preoperatorias. Todos los pacientes con adenomas asociados a hemorragia presentaban antecedentes de ingesta de anticonceptivos orales. Además se describen 3 transformaciones malignas, 1 necrosis infectada, 1 síndrome de Kasabach Merrit y 1 síndrome de Budd Chiari. Método: Con excepción de un caso, todos los pacientes fueron resecados requiriendo de trasplante hepático en 2 oportunidades. El paciente no resecado fue sometido a laparotomía exploradora y biopsia por un hemangioma con comportamiento agresivo. El seguimiento se realizó mediante evaluación clínica y estudios por imágenes. Resultados: La morbilidad postoperatoria en los TBSH complicados fue de 4/18 (22,2 por ciento). No hubo mortalidad postoperatoria en este grupo, siendo la global de la serie de 1 por ciento (1 hemorragia cerebral por ruptura de una malformación vascular). El seguimiento alcanzó un promedio de 3,2 años (rango 1 mes-12 años). Todos los pacientes resecados se hallan libres del tumor. El paciente con el hemangioma invasivo falleció a los 26 meses del postoperatorio. Conclusiones: 1. La ingesta de anticonceptivos orales podría ser un factor importante en la parición de complicaciones hemorrágicas en pacientes con adenomas hepáticos. 2. La malignización es una complicación a tener en cuenta en los adenomas y las hiperplasias nodulares focales. 3. Deben sospecharse patologías cerebrales asociadas en pacientes con tumores hepáticos benignos. 4. Debe evitarse la biopsia hepática que no modifica la conducta terapéutica, ya que puede precipitar una complicación...

Iatrogenic bile duct injuries

Twenty-two patients with postcholecystectomy bile duct injuries were managed in the Surgical Unit in period from June 1989 to June 1992. They were 18 females and 4 males. Their ages ranged between 25-60 years with a mean of 43 years. The timing and mode of presenting manifestation varied. In only two patients injuries were recognized intraoperatively. Thirteen patients [59.1%] presented within one month POP. Recurrent cholangitis was the most frequent presenting manifestation [54.5%]. Preoperative diagnostic work up included US, PTC, ERCP and CT, and when added to operative findings, stricture level and type of injury could be demonstrated. Bismuth types 2 and 3 strictures were found in 16/22 [77.7%], while ligated bile duct was the most frequent type of injury 14/22 [63.6%]. End to side Roux en Y hepaticojejunostomy was performed in 14.22 [63.3%], while end-to-end anastomosis on a T-tube stent wasdone for 2 patients with intraoperative recognition of injury [9.1%]. Choledochoduodenostomy was performed in 2 patients [9%], Roux en Y choledochojejunostomy in 2 patients [9.1%] while, portojejunostomy was done for another 2 patients [9.1%]. The period of postoperative follow up ranged between 12-36 months with a mean of 20.5 months. Only one mortality [4.65%] was met with, while early specific morbidity were encountered in 6 patients. Five patients showed late specific morbidity [one restenosis and 4 mild recurrent cholangitis]