Ruptured abdominal aortic aneurysm treated by endovascular aneurysm repair under local anaesthesia.

A 68 year old man with significant cardiorespiratory risks factors presented with a ruptured thoracic aortic aneurysm (TAA). This was treated by emergency thoracic endovascular aneurysm repair (TEVAR) under general anaesthesia (GA). An incidental abdominal aortic aneurysm (AAA) was not treated. Eight months later, he presented with ruptured AAA. Due to the patient's compromised respiratory system, he underwent endovascular aneurysm repair (EVAR) under local anaesthesia (LA). He had a smoother post-operation recovery compared to the first repair under GA.

Extreme value theory applied to postoperative breathing patterns.

BACKGROUND: There has been little published work on the statistical features of breath times in postoperative patients. We applied extreme value theory (a statistical method) to the variation in the timing of postoperative breathing. METHODS: We observed 49 patients 3-6 h after a variety of surgical procedures, once they had achieved a stable breathing pattern. The breathing patterns could be one of the three types predicted by the extreme value model. 'Finite' breathing patterns (n=30) have a finite upper limit of duration for any apnoea. Patients that displayed one of the other two patterns ('standard' and 'extended') have, potentially, no limit in duration of apnoea. RESULTS: The type of breathing pattern observed in each patient was not reliably identified by most of the commonly used risk factors (age, type of surgery, opioid type, dose, and route of administration). A finite pattern was observed in 13 of 26 patients receiving epidural (vs 17 of 23 parenteral analgesia: P=0.15), and 15 of 19 receiving morphine (vs 15 of 30 other opioids: P=0.05). The patients with 'finite' patterns were also significantly less drowsy (score 1.04 (0.92) vs 1.62 (0.62), P<0.05). CONCLUSIONS: The breathing pattern was not related to mean breath times, suggesting that the prevalence of apnoeas cannot be reliably predicted by measurement of the respiratory rate alone.

Results of 50 consecutive aneurysmectomies for abdominal aortic aneurysms at a private specialist centre.

The management of abdominal aortic aneurysms (AAA) at a private medical centre was reviewed. The criteria for surgery were AAA more than or equal to five centimeters in diameter, symptomatic AAA even if less than five centimeters and ruptured AAA. A total of 67 patients were seen between October 1991 to September 1994. The age range was 48 to 94 years, mean = 69.8. There were 58 males to nine females. Twelve patients presented with ruptured AAA. There were three suprarenal AAA and three mycotic AAA. Aneurysmectomies were performed on 50 patients. This include all patients with ruptured AAA. There was no mortality in the elective cases. One patient with ruptured AAA died, ie. an operative mortality of eight per cent. It was concluded that a very low operative mortality can be achieved in this group of high risk patients. Our results were comparable to those reported by other centres in the developed countries. Important factors contributing to these results include a team approach in a unit interested in this disease, careful pre-operative preparation and a rigid post-operative regime. For ruptured AAA, survival of the patient depended on a successful and timely operation. It was also concluded that no patient should be deemed unfit for surgery or denied an operation if they needed to have one and it was safe to transport patients with ruptured AAA to a centre where the operation can be performed.

Treatment of bleeding gastroesophageal varices: a report of forty-four cases.

Bleeding gastroesophageal varices is associated with a high morbidity and mortality. Forty-four cases of bleeding gastroesophageal varices were treated at the Department of Surgery, Universiti Kebangsaan Malaysia, General Hospital, Kuala Lumpur over four and a half years. Thirty-two of them had liver cirrhosis. Hepatitis B infection was noted in 13 and alcoholic abuse was present in 14 patients. Five patients had associated hepatoma. Thirty-four percent had gastric fundal varices and a third of these bled from them. A total of 179 endoscopic injection sclerotherapy sessions were performed averaging 4 per person. Rebleeding rate was 4% and mortality was high (50%) in these cases. It was concluded that injection sclerotherapy is a safe and effective means of controlling bleeding oesophageal varices. Operative surgery was employed in those who rebled after injection and would be considered in those in Child's A.

Duodenal leiomyosarcoma: a report of a rare and aggressive tumour.

A 45-year-old Malay lady who presented with intermittent abdominal pain and a left hypochondrial mass was found to have a 10 x 8 x 5 cm duodenal tumour without local invasion at laparotomy. En bloc resection of the tumour with adequate margin of clearance was done and histopathological diagnosis of low grade leiomyosarcoma was made. Fourteen months later, she returned with multiple metastases in the liver and needed palliative chemotherapy for pain relief. Duodenal leiomyosarcomata are very rare tumour. Their prognostic indicators include biological grading, tumour size and presence of metastases. Recognition of its high malignant potential calls for close surveillance calls even after apparent curative surgery.

Jugular venous aneurysm--a rare cause of neck swelling.

An 8-year old boy presented with a right neck swelling which appeared only intermittently. The swelling was well demonstrated by the Valsalva manoeuvre. The differential diagnosis include a laryngocele, a superior mediastinum tumour or cyst and a venous aneurysm. Plain radiography, computerized tomography, ultrasonography and venography were performed. A diagnosis of venous aneurysm was confirmed. Ultrasonography was the best modality for imaging of this rare condition. It is non-invasive and it will also delineate the extent of the lesion. The treatment is expectant. Surgery is reserved for cosmesis and symptomatic aneurysms.

In search of a recyclable sulphur dioxide sponge-a new look at an old system.

The sulphur dioxide content and thermal stability of the quinol-SO2 clathrate have been studied by thermogravimetric analysis (TG), its derivative (DTG) and differential scanning calorimetry (DSC). These analyses demonstrated the thermal recoverability of the quinol from the clathrate and hence its potential use as a sponge for SO2 present in the environment as a pollutant. Similarly, Bu4N(+)I(-) was found to occlude NO2 and SO2 at 50°C in solution.

Entrapping of organic wastes by coordination clathrates.

The feasibility of the Hofmann clathrates Ni(CN)2(NH3)·G(G=guest molecule) and the octahedral Werner-type complexes Ni(X)2(L)4 (X=NCS, NCO, CH3CO2, C6H5CO2; L=Py, 4-Mepy) as a scavenger for organic substrates in a polluted aqueous or organic medium is dependent on the complex lability, thermal stability and reversibility in solvent trapping which can be conveniently studied by thermogravimetric means. Besides the parent monomeric octahedral complexes, all the thermal decompositional intermediates, namely, monomeric tetrahedral, dimeric octahedral and polymeric octahedral, are also potential scavengers for selected organic substances though they operate via a cycle of bond-making and bond-breaking processes.

Internal iliac artery graft in the management of ruptured mycotic aneurysm of the femoral artery.

The use of an autologous ipsilateral internal iliac artery to restore circulation after excision of a ruptured femoral aneurysm in a patient addicted to drugs is described. Autogenous vein graft was not available. The advantages of using the internal iliac artery in this situation are discussed. The use of internal iliac artery graft in this situation has not been previously described in the literature.

Primary mesenteric venous thrombosis--a case report.

Mesenteric venous thrombosis has been described to occur in cases where there has been no apparent cause. The diagnosis is usually delayed because the signs and symptoms are non-specific. A case of primary mesenteric venous thrombosis is reported below. Its presentation and pathology are discussed. Treatment is surgery with resection of gangrenous bowel and primary anastomosis. Post-operative anticoagulation is advocated.

Resection for carcinoma of the oesophagus.

One hundred and seventy-one patients with oesophageal carcinoma were seen in the 7-year period October 1976 to September 1983. One hundred and thirty-three cases (77.8%) were explored with a view to curative resection. This was accomplished in 98 cases (73.6% of explored patients, 57.3% of the entire group). Overall operative mortality was 10.2%. Of patients undergoing curative resection, 9% developed benign strictures which responded to 1-4 dilatations, while 14.8% developed local recurrence which marked the terminal event. After excluding operative deaths, 61.3% of patients survived for 1 year, 27% for 3 years and 17.3% for 5 years. Five-year survival for patients with squamous carcinoma was 36% while that for adenocarcinoma patients was only 3%. It is concluded that curative resection can be accomplished in a selected group of patients dealt with in a specialized unit with low operative mortality. This approach offers the patient good palliation and the best chance of prolonged survival.

Intercostal blockade and pulmonary function after cholecystectomy.

Sixty-six patients undergoing cholecystectomy were randomly allocated to receive either intercostal blockade with bupivacaine supplemented with papaveretum or papaveretum alone for postoperative analgesia. Both groups were similar regarding distribution of sex, age, and weight. These two groups were compared. Patients who did not have intercostal blockade required postoperative analgesia sooner. There was no significant difference, however, in the total consumption of papaveretum. Both groups experienced similar degrees of pain, and there were no differences in postoperative pulmonary function. We conclude that although single intercostal blockade is an effective analgesic, it does not improve pain relief and does not improve pulmonary function after cholecystectomy when compared with a regimen of on-demand, intramuscularly administered papaveretum.

Omeprazole compared with ranitidine once daily in the treatment of duodenal ulcer.

A double-blind randomized study in 230 Malaysian patients with duodenal ulcer was conducted to compare the proton-pump inhibitor, omeprazole 20 mg, given once daily in the morning, with ranitidine 300 mg, administered once daily at night. After 2 and 4 weeks of treatment, 222 and 220 patients, respectively, were evaluable according to the study protocol. Omeprazole produced significantly higher healing rates than ranitidine at both 2 weeks (75% versus 46%, respectively, P less than 0.0001) and 4 weeks (97% versus 83%, respectively, P = 0.001). Ulcer symptoms were relieved more rapidly by omeprazole than ranitidine. After 2 weeks, daytime epigastric pain was reported by 30% of ranitidine-treated patients but only by 15% of omeprazole-treated patients, which is a statistically significant difference (P = 0.004). No major clinical or biochemical side effects were recorded for either omeprazole or ranitidine. In conclusion, omeprazole 20 mg was found to be superior to ranitidine 300 mg administered once daily for the treatment of duodenal ulcer as measured by ulcer healing and pain relief.

Gastric outlet obstruction due to gall stones (Bouveret syndrome).

Gastric outlet obstruction by gall stone is a rare complication of a common disorder. Two cases are reported here. The investigations are conducted along the same lines as for pyloric stenosis. The diagnosis can be made with a barium meal or gastroscopy. Treatment is by surgical intervention after adequate resuscitation.

Laboratory and field tests of temephos (AbateR) on mosquito larvae and non-target organisms in rice fields in Malaysia.

The toxic effects of Abate (temephos) on mosquito larvae and non-target organisms were studied in the rice-field and in the laboratory. In the laboratory tests, Culex tritaeniorhychus larvae and cladoceran zooplanktons (predominantly Diaphanosoma and Moinodaphnia species) were found to be highly susceptible to Abate with LC50 values of 0.27 and less than 0.10 parts per billion respectively. Other non-target species in decreasing degree of susceptibility to Abate were copepods (Tropodiaptomus spp.), Aplocheilus panchax and Tubifex worms. In field study, Abate at concentrations 60, 100 and 200 gm hectare-1 is effective in maintaining the rice-fields free of Anopheles and Culex mosquitoes for at least 2 days. No mortality was observed for Aplocheilus panchax and Tubifex worms at the above concentrations; nevertheless, populations of cladoceran zooplanktons and copepods were reduced up to seven days posttreatment.