Anaesthetic management of a pregnant patient with Takayasu's disease undergoing abdominal aortic aneurysm repair.

We report the successful anaesthetic management of repair of an abdominal aortic aneurysm in a patient with Takayasu's disease at 14 weeks' gestation. Anaesthesia was managed with combined epidural and general anaesthesia. During the intraoperative period haemodynamic parameters were well maintained. There were no episodes of haemodynamic fluctuations, oxygen desaturation or metabolic acidosis. Aortic cross-clamp time was 105 min, blood loss around 1200 mL, and central venous pressure maintained between 8 and 10 cm H2O. There were no sudden changes in cardiac parameters, base deficit or urine output before or after cross clamping. The patient later delivered a full term, normal fetus.

Ultrasonography in detection of single and multiple abnormal parathyroid glands in primary hyperparathyroidism: comparison with radionuclide scintigraphy and surgery.

BACKGROUND: Among the parathyroid imaging techniques, ultrasonography (USG) has the advantage of convenience, easy availability and low cost. OBJECTIVE: To study the role of USG in localization (side and/or site) of abnormal parathyroid glands in primary hyperparathyroidism (PHPT) and to compare with radionuclide scintigraphy and the 'gold standard', surgery. METHODS: Forty-six consecutive patients undergoing USG of the anterior neck for a diagnosis of PHPT in whom a nuclear scan (technetium-99m sestamibi and/or thallium-201/technetium-99m pertechnetate scintigraphy) was also performed, were studied. The results of imaging were independently interpreted and correlated with reference to surgical findings. RESULTS: Forty-six patients had 52 abnormal parathyroid glands on surgical exploration and surgery was successful in all but one. Forty-one patients had a single adenoma, four had multigland disease and one had a paraganglioma. USG correctly localized the abnormal gland in 30 (73%) and scintigraphy was positive in 40 (98%) out of 41 patients with a single adenoma as confirmed on surgical exploration. Scintigraphy showed a positive concordant test in all 30 patients with a single abnormal gland detected on USG and picked up 10 out of 11 abnormal glands where USG was negative. The sensitivity and positive predictive value of USG for detecting a single abnormal gland was 73% and 100%, respectively, whereas the sensitivity and positive predictive value for scintigraphy was 98%. In patients with multigland disease, USG missed 3 (30%) out of 10 and scintigraphy missed 6 (60%) out of 10 abnormal parathyroid glands as confirmed on surgical exploration (P < 0.05). However, in two patients who had ectopic parathyroid gland, both the modalities localized the lesion in one (paraganglioma), whereas in the other neither test was helpful (left retro-esophageal). CONCLUSION: USG is a convenient, affordable and useful modality to localize abnormal enlarged parathyroid glands in the majority of patients with PHPT. However, when USG is negative, scintigraphy is complementary to it.

Childhood sporadic pheochromocytoma: clinical profile and outcome in 19 patients.

Sporadic pheochromocytoma is a rare tumor of childhood and accounts for less than 1% of cases of hypertension. We describe the presentation and outcome of 19 adolescents with sporadic pheochromocytoma seen over past 10 years at a tertiary care center in north India. The mean age (+/- SD) at presentation was 15.1 +/- 2.4 years with range from 9-18 years. The male to female ratio was 12:7. The lag time between onset of symptoms to diagnosis ranged from 1 month to 5 years with mean (+/- SD) of 1.09 +/- 1.02 years. The majority of children presented with hypertension and paroxysms. Paroxysms, characterized by the triad of headache, palpitations and sweating, was present in 13 (68%) of these patients. Twelve (63%) patients had postural fall in blood pressure, ten (53%) had abdominal pain, four (21%) had visual blurring, and three (16%) each had palpable abdominal mass and significant weight loss at presentation. Nausea and vomiting are common symptoms in children with pheochromocytoma and were present in six (32%) and three (16%) patients, respectively. Café-au-lait macule was present in only two (11%) patients. Urinary vanilyl mandelic acid (VMA) was found to be significantly high in ten (53%) patients, and urinary epinephrine and norepinephrine in eight (42%). Six (32%) patients had both VMA and urinary epinephrine and norepinephrine within normal limits and five (26%) had significant elevation of both. The tumor was localized by ultrasonography in 17 (89%) patients and by computed tomography in 18 (95%), and in one patient it was localized by 131I-MIBG scan. Sixteen (84%) patients had adrenal pheochromocytoma (including four with bilateral masses), while the remaining three (16%) had abdominal extra-adrenal pheochromocytoma originating from sympathetic ganglions. The mean (+/- SD) diameter of the tumor was 4.4 +/- 1.7 cm, ranging from 2.2-7.5 cm. Pre-operatively, hypertension was managed by phenoxybenzamine in six (32%), sustained release prazosin in 12 (63%), beta-blockers in 14 (74%), calcium channel blockers in 12 (63%), and angiotensin converting enzyme inhibitors and diuretics in only two (11%) patients. Eighteen (85%) patients underwent exploratory laparotomy for removal of the tumor. On follow-up, 13 (72%) patients became normotensive, while six (32%) patients continued to have hypertension. In conclusion, childhood pheochromocytoma is characterized by atypical symptomatology; ultrasonography is a useful modality in localizing the lesions in the majority of patients; surgery is rewarding in most patients.

[Revision surgery for knee prostheses using the DRG system]. / Wechseloperationen in der Kniegelenkendoprothetik im DRG-System.

Due to an increasing life expectancy and earlier primary implantation of total knee replacements, the number of patients requiring revision surgery in Germany is increasing by 7% every year. These revision cases belong to the most treatment and cost intensive operations in joint replacement surgery. Presently, the description of these procedures in the German DRG system, which defines the financial reimbursement for the hospitals, is changing yearly with the development of new catalogues. The changes made from 2003 to 2005 are outlined in the following article. A correct depiction of the treatment and procedures required in such cases is a prerequisite for an adequate reimbursement. In the long-term, hospitals will only be able to offer such complex treatment forms if the financial compensation correctly reflects the costs incurred.

Retained surgical sponge: an unusual cause of malabsorption.

Retained surgical sponge is an unpleasant surprise in clinical practice. Intraluminal migration of the retained sponge, though rare, can lead to intestinal obstruction and other complications. We describe two cases of retained surgical sponge, both following gynaecological surgery, presenting several years after surgery with features of subacute intestinal obstruction, malabsorption and several years after surgery with features of subacute intestinal obstruction, malabsorption and sever hypoproteinemia which reverted after surgical removal.

Watermelon stomach: a rare cause of upper gastrointestinal bleeding.

Watermelon stomach is a rare cause of upper gastrointestinal bleeding. We report a middle-aged woman who had been having recurrent bleeding from watermelon stomach. She was treated surgically by gastrectomy and Billroth II anastomosis.

T-tube access for endoscopic sphincterotomy: a variant of combined percutaneous and endoscopic approach.

Selective deep cannulation of the common bile duct (CBD), which is essential for successful endoscopic sphincterotomy, may not be possible in all patients. Three patients with retained CBD stones with T-tube in situ in whom selective deep cannulation failed, underwent successful sphincterotomy using a combined percutaneous and endoscopic procedure through the T-tube. CBD stones were then extracted with a Dormia basket. In situ T-tube can provide percutaneous access for combined approach in patients with retained CBD stones in whom endoscopic cannulation is not successful.

Lovastatin maintains nitric oxide--but not EDHF-mediated endothelium-dependent relaxation in the hypercholesterolemic rabbit carotid artery.

The endothelium contributes to the regulation of vascular tone by producing nitric oxide (NO) and the endothelium-derived hyperpolarising factor (EDHF). In hypercholesterolemia, endothelium-dependent relaxation is impaired but can be restored by treatment with lovastatin (LOVAS). We investigated the effects of LOVAS on NO and EDHF-mediated relaxation. Rabbits were fed 1% cholesterol diet for 4 weeks and 0.5%) cholesterol for the following 12 weeks (CHOL-group). The LOVAS group additionally received 10 mg of lovastatin over the last 12-week period. Experiments were performed in carotid artery rings. Relaxant responses to acetylcholine (ACh) were recorded in the presence of indomethacin. Nitro-L-arginine (NOARG, 100 microM) and potassium chloride (KCl, 35 mM) were used to differentiate between NO- and EDHF-mediated relaxations. Cholesterol impaired ACh-induced relaxations and this effect was prevented by LOVAS (control 100+/-1%, CHOL 81+/-6%, LOVAS 98+/-1%). In the presence of NOARG, relaxations to ACh were not different between the LOVAS and CHOL groups (control 78+/-4%, CHOL 64+/-6%, LOVAS 64+/-5%). When KCl was used, ACh-induced relaxations were similar in the LOVAS and control group (control 75+/-5%, CHOL 49+/-6%, LOVAS 76+/-2%). In arteries treated with NOARG and KCl together, no relaxations were observed. Relaxations of arteries from the control group were not affected by 18 h preincubation with lovastatin (10 microM). Lovastatin selectively maintains nitric oxide-mediated endothelium-dependent relaxation in hypercholesterolemic rabbit carotid arteries.

Helicobacter pylori infection in patients with perforated duodenal ulcer.

AIM: Perforation is the commonest complication of duodenal ulcer. Helicobacter pylori is found in 95% patients with duodenal ulcer. However, there is paucity of reports on prevalence of H. pylori infection in patients with duodenal ulcer perforation. We, therefore compared the incidence of H. pylori infection in patients with duodenal ulcer perforation with the incidence in patients having complicated duodenal ulcers and non-ulcer dyspepsia. PATIENTS AND METHODS: The study was conducted on 45 patients (complicated duodenal ulcer 15, duodenal ulcer perforation 15, non-ulcer dyspepsia 15). Per-operative punch antral biopsies were taken in patients with duodenal ulcer perforation whereas endoscopic punch biopsies of antrum were taken in patients with non-ulcer dyspepsia. The criteria for H. pylori positivity was i) growth of H. pylori on culture, ii) combination of rapid urease test (RUT) and Giemsa staining, combination of RUT and Gram stain being positive for H. pylori. RESULTS: While 9 of 15 cases with complicated duodenal ulcer, 7 of 15 cases with non-ulcer dyspepsia were positive for H. pylori, none of the patients with duodenal ulcer perforation tested positive for H. pylori (p < 0.000). All patients with perforated duodenal ulcer had histological gastritis (H. pylori -ve). Fourteen of 15 patients (9 H. pylori +ve, 5 H. pylori -ve) with complicated duodenal ulcer and 9 of 15 patients (7 H. pylori +ve) with non-ulcer dyspepsia had histological gastritis. CONCLUSION: Patients with duodenal ulcer perforation do not have H. pylori infection. H. pylori negative patients of duodenal ulcer may have more predilection for perforation.

N(G)-nitro-L-arginine- and indomethacin-resistant endothelium-dependent relaxation in the rabbit renal artery: effect of hypercholesterolemia.

Studies were designed to compare the N(G)-nitro-L-arginine- and indomethacin-resistant, endothelium-dependent relaxation to acetylcholine in isolated renal artery rings from normal and cholesterol-fed rabbits. It was assumed that the resistant part in response to acetylcholine is mediated by the endothelial-derived hyperpolarizing factor (EDHF). Rabbits were fed normal (n = 15) or cholesterol enriched chow (n = 13, 1% cholesterol for 4 weeks, 0.5% for 12 weeks). In organ chamber experiments, renal artery rings were precontracted with 0.1-1 microM phenylephrine or 35 mM KCl, and relaxed with acetylcholine (0.001-10 microM) in the presence of 10 microM indomethacin. Studies were performed in the presence or absence of: 100 microM N(G)-nitro-L-arginine (L-NOARG) to inhibit the nitric oxide pathway, 100 nM charybdotoxin (CTX) or 1 mM tetrabutylammonium (TBA) to inhibit Ca2+-activated K+ channels, and 100 microM SKF 525a to inhibit cytochrome P450 monoxygenase pathway. In normal arteries, L-NOARG partially inhibited acetylcholine-induced relaxation. The resistant part was almost abolished when the arteries were depolarized with KCl, or when L-NOARG was combined with either CTX, TBA or SKF 525a. In arteries from hypercholesterolemic animals, the relaxation to acetylcholine was only slightly impaired as compared to normal animals. However, in comparison to arteries from normal animals, the L-NOARG-resistant part of acetylcholine-induced endothelium-dependent relaxation was enhanced. It is speculated that differences in the balance between nitric oxide (NO)- and EDHF-mediated control of vascular tone may maintain acetylcholine-induced vasodilatation of the renal artery in hypercholesterolemia.

Endoscopic management of pancreatic diseases.

Endoscopic management has recently been used for a variety of chronic pancreatic diseases. We used this approach in five patients with pancreatic diseases (calcific pancreatitis 2, pancreatic pseudocyst 3). Nasocystic drain was placed in a patient with pancreatic pseudocyst at the tail end of the pancreas; a 5 Fr stent was placed over 0.021"/0.035" guide wire in the main pancreatic duct in the others. All patients had relief of pain. Nasocystic drain led to resolution of pseudocyst, perisplenic collection and pleural effusion. Endoscopic treatment is safe and effective in various pancreatic disorders.