Endoscopic dilation of gastroesophageal anastomosis stricture after gastric bypass.

BACKGROUND: The management of strictures after gastric bypass procedure using balloon dilation is described. METHODS: A retrospective review of all dilations performed is presented. Balloon dilators were used, and all strictures were dilated initially up to 12 to 15 mm for 1 min. RESULTS: The review included 24 patients with a mean age of 42.8 years and a mean body mass index of 49.6. All the patients except one were women. In terms of procedure, 67% required one dilation and 30% required two. In the first 3 months after surgery, 21 patients developed the stricture. Three patients (13%) had leaks. There was no endoscopic appearance suggesting the need for a repeated procedure. All the dilations were successful, and weight loss compared well with that in the rest of the patients. CONCLUSIONS: A successful technique for the treatment of anastomotic strictures after gastric bypass is presented. Most of the patients required one dilation. Most strictures appeared during the first 3 months after surgery. Female gender and leak may be high risk factors for the development of stricture.

A new cervical spine clearance protocol using computed tomography.

OBJECTIVE: The purpose of this study was to assess a cervical spine clearance protocol for blunt trauma patients using helical computed tomographic (CT) scan of the cervical spine (C-spine). METHODS: A protocol using CT scan of the C-spine was implemented and the first 6 months of use reviewed. Patients requiring a CT scan of the head had the C-spine evaluated by lateral C-spine radiography and a helical CT scan. Patients without indication for CT scan of the head had the C-spine evaluated by three-view radiography (anteroposterior, lateral, and odontoid) with selective CT scan of the C-spine for imaging areas not well visualized or those with abnormalities identified by radiography or by clinical examination alone. RESULTS: Three hundred twenty-four patients were admitted to the trauma center after blunt trauma during the first 6 months of protocol implementation. Head CT scans were obtained in 158 patients and lateral cervical spine radiography in conjunction with helical CT scanning evaluated the C-spine. The other 166 patients had the cervical spine cleared by three-view radiography series or by clinical examination alone. For patients in whom a head CT scan was not indicated, CT scanning was used only when plain radiographs failed to adequately visualize the entire C-spine. A total of 15 injuries (4.6% of the group) were detected. Seven injuries were suspected or detected by lateral plain radiographs and confirmed by CT scan. Six patients had an injury not detected by radiography but diagnosed by CT scan, and one patient had a false-positive radiograph. Of the remaining two injuries, one was diagnosed by magnetic resonance imaging and the other by CT scan outside of the protocol. Lateral plain radiographs alone failed to detect 46% (n = 6) of all injuries. CONCLUSION: In our series, the selective use of helical CT scanning with plain radiography increased the accuracy with which cervical spine injury was detected from 54% to 100%. The protocol allowed for more rapid evaluation in many patients as well. We recommend that practice guidelines include the use of helical CT scan of the entire C-spine as the diagnostic procedure for those blunt trauma patients undergoing CT scanning of the head.

The intensive care unit as an operating room.

This article is an overview of the different procedures currently performed on the ICU patient and emphasizes percutaneous tracheostomy and percutaneous gastrotomy. The steps necessary to prepare the patient, the ICU staff, and intensivist to achieve a safe and successful procedure are described, as are the indications, technique, complications, safety, and advantages to perform these techniques in the ICU.

Current practices in the prophylaxis of venous thromboembolism in bariatric surgery.

BACKGROUND: Morbidly obese patients undergoing bariatric surgery have commonly been concluded to be at high risk for the development of perioperative venous thromboembolism. Due to its clinically silent nature, primary prevention is the key to reduce morbidity and mortality. There is no clear consensus in the literature regarding the optimum approach to minimize this preventable phenomenon. METHODS: Members of the American Society for Bariatric Surgery were surveyed regarding their current practices in the prophylaxis of venous thromboembolism in their bariatric patients. RESULTS: 31% of the members completed the survey. 62% were in private practice, and 38% practiced in an academic hospital. The number of bariatric surgeries done per year ranged from 5 to 325, with a mean of 85 procedures per member. The gastric bypass was the most commonly performed procedure at 61.7%, followed by vertical banded gastroplasty at 23.3%, biliary pancreatic diversion at 9.3%, laparoscopic gastroplasty at 4.0%, laparoscopic gastric bypass at 1.6%, and horizontal banded gastroplasty at 0.1%. 86% felt that their bariatric patients were at high risk for developing deep vein thrombosis (DVT) and pulmonary embolism (PE) with a self-reported incidence of 2.63% and 0.95%, respectively. 48% had at least one death due to PE. Routine prophylaxis is used by over 95% of members. 62% ranked the various methods of prophylaxis from most preferred to least preferred, while 38% used a combination of 2 or more prophylactic methods simultaneously. Low-dose heparin was the most preferred prophylaxis by 50% of members, followed by intermittent pneumatic compression stockings at 33%, low molecular weight heparins at 13%, and other methods at 4%. Over 83% indicated that safety with few complications, ease of administration, and effectiveness were the most important criteria for selecting their most preferred prophylactic method. Only 2% routinely performed testing to rule out venous thromboembolism before discharge, and 11% routinely discharged patients with prophylaxis. CONCLUSIONS: The prevailing opinion of members of the American Society for Bariatric Surgery is that morbidly obese patients are at high risk for developing perioperative venous thromboembolism. A vast majority routinely use prophylaxis. Despite these measures, fatal PE is still widespread. A lack of consensus in the method of prophylaxis was seen. A multicentric randomized controlled study comparing the efficacy of the various methods of prophylaxis will be the only manner to determine the best prophylaxis and its usefulness. This study will be costly and probably not warranted due to the low incidence of this condition in the morbidly obese patient.

The metabolic response to acute traumatic brain injury and implications for nutritional support.

An overview of the metabolic response to acute traumatic brain injury is presented. The consequences of hypermetabolism, hypercatabolism, and an altered immune function are discussed. Once a person with acute traumatic brain injury develops this hyperdynamic state, the resultant excessive protein breakdown ensues. This can lead to malnutrition. The feeding methods used to prevent malnutrition are discussed, along with the proper alimentation to provide to diminish the hyperdynamic state and improve immune function.

[Non-specific bronchoprovocation with metacholine in children before and during sugar cane burning in Catanduva-SP] / Broncoprovocação inespecífica com metacolina em crianças antes e durante a queima dos canaviais em Catanduva-SP.

OBJECTIVE: Evaluate the influence of sugar cane burning on BHR of asthmatic and "normal" control children by metacholine bronchoprovocation tests; and verify if interferes in pulmonary function tests.METHODS: Twenty-two asthmatic children (A) aged from 7 to 14 years old, and twelve "normal" control children (C), aged from 8 to 13 years, were submitted to non-specific bronchoprovocation test with methacholine before and during the sugar cane burning. The metacholine concentrations used were 0.025; 0.25; 1.0; 2.5; 10.0; 25.0 mg/ml, and the results were expressed in PC(20) FEV1 (concentration of metacholine that induces a fall of 20% or more in the forced expiratory volume in the first second).RESULTS: The PC(20) average for asthmatic children was significantly lower than the control group, before (A= 3.68; C= 25.62 mg/ml) and during the burning (A= 4.11; C= 25.25 mg/ml) (p < 0.05). However, there were no significant differences, when compared in each group PC(20) values before and during burning. The same was observed regarding FEV1, forced vital capacity (FVC) and forced expiratory flux between 25 and 75% of FVC (FEF (25-75%)).CONCLUSIONS: It was not possible to demonstrate that cane plantation burning influences the BHR, and pulmonary functions tests of the studied children.

Bronchoscopic guidance makes percutaneous tracheostomy a safe, cost-effective, and easy-to-teach procedure.

BACKGROUND: We wanted to assess the efficiency of instituting a modified technique of percutaneous tracheostomy (PET) with bronchoscopic guidance. METHODS: During a 10-month period 48 consecutive trauma patients requiring tracheostomy were divided between a standard tracheostomy control group (ST) and a PET group. All patients were followed prospectively. The hospital charges were reviewed retrospectively. RESULTS: Age, gender, body habitus, and principal diagnosis were similar in the 21 ST patients and the 27 PET patients. All STs and 15 of the PETs were performed in the operating room (OR), and the 12 remaining PETs were done in the intensive care unit (ICU). Four patients in the ST group and six in the PET group died. One of these deaths occurred in a patient in the PET group with severe adult respiratory distress syndrome. Procedure time was shorter for PET (16 versus 45 minutes, p < 0.0001). Junior residents performed more PETs than STs (33% versus 10%), and PET was considered "easier" to perform than ST (81% versus 47%). Hospital charges for PET in the ICU were $3400 less per patient compared with ST or PET in the OR. CONCLUSIONS: PET was performed easily and safely in the OR and at the ICU bedside. PET required one-third the time of ST. Bronchoscopic supervision of PET may have contributed to the small number of complications and the educational experience of junior residents. PET in the ICU can reduce hospital charges significantly and avoids transport of patients to the OR. PET is as safe as ST and should be considered the procedure of choice for an ICU patient requiring an elective tracheostomy.

Hypopituitarism secondary to transfacial gunshot wound.

Hypopituitarism secondary to penetrating head trauma is extremely rare, and its diagnosis may be delayed for several years. We present a patient who developed hypopituitarism secondary to a transfacial gunshot wound and who experienced damage to the hypophysis secondary to transmission of energy and bullet fragments. The importance of a computerized tomographic scan of the head in facial gunshot wound is discussed.

Pelvic kidney laceration: an unusual complication of percutaneous diagnostic peritoneal lavage--case report.

Diagnostic peritoneal lavage (DPL) is considered the gold standard in the evaluation of patients with suspected blunt abdominal trauma when the results of the abdominal examination are equivocal or when the patient's mental status is altered. In recent years a percutaneous method using the Seldinger technique has been performed. We present a case report of an unusual complication of DPL using the percutaneous method.

Pseudoaneurysm of the cystic artery: a rare cause of hemobilia.

Aneurysms are a rare cause of hemobilia. The arteries most frequently involved are branches of the hepatic or gastroduodenal arteries. The authors report the case of a patient with hemobilia secondary to a pseudoaneurysm of the cystic artery. Only six other cases have been reported in the literature, and in all of them the condition was associated with inflammation of the gallbladder. Selective hepatic arteriography is the procedure of choice for diagnosis. Colour-Doppler ultrasonography aided in the diagnosis in the patient described in this report and may prove to be useful in equivocal cases. Cholecystectomy and ligation of the cystic artery with proximal control of the hepatic artery should be performed as soon as the diagnosis is made.