Local and systemic consequences of large retroperitoneal clot burdens.

BACKGROUND: There is a paucity of data regarding the impact of retroperitoneal hematoma (RPH) volumes, as detected by computed tomography (CT) scanning, on patient morbidity and mortality. Therefore, we wanted to determine the natural history of RPHs and the effect of size on local and systemic outcomes. METHODS: We performed a volumetric analysis of CT-documented RPHs managed at our institution between 1985 and 2006 along with a retrospective chart review. RESULTS: We included 81 cases of RPH in this study. The mean Acute Physiology, Age, and Chronic Health Evaluation II (APACHE II) score was 12.8 +/- 0.72 (score +/- SE). By univariate analysis, the size of the hematoma showed a significant correlation with the development of local mass effects, delayed mass effects, 6-month mortality, major morbidity, pulmonary complications, fluid overload, and the requirement for operative evacuation (p < 0.05). Receiver operating characteristic analysis revealed that a size > or = 1600 cm(3) was > 80% sensitive and specific for predicting a delayed mass effect or an increase in 6-month mortality. Multivariate analysis controlling for factors such as APACHE II and packed red blood cells transfused showed that the volume of the RPH was an independent predictor for the development of local mass effects, pulmonary insufficiency, and fluid overload. CONCLUSIONS: Large RPHs are clearly associated with worse patient outcomes. Surgical intervention may be warranted for the treatment of RPHs > or = 1600 cm(3).

Axillary vein rupture after angioplasty.

Venous rupture is an uncommon complication resulting from dialysis graft interventions. The authors describe a case of axillary vein rupture following angioplasty necessitating placement of a covered stent for the control of hemorrhage.

Computed tomography appearance of the Lapra-Ty and Weck hem-o-lok clips in patients who recently underwent laparoscopic urologic surgery.

The nonmetal suture securing Lapra-Ty clip (LTC) and vessel ligating Weck hem-o-lock clip (WKHL) are useful tools for the laparoscopic surgeon. We report the postoperative computed tomography (CT) scan appearance of these clips. The CT imaging of patients who underwent urologic surgery demonstrate the WKHL and LTC to be radiopaque. Urologists and radiologists should be aware of the radiographic appearance of the LTC and WKHL given the ease with which they could be confused with urinary lithiasis when applied near the urinary system.

Sexual function following sphincteroplasty for women with third- and fourth-degree perineal tears.

OBJECTIVE: Our goal was to evaluate sexual function following anal sphincteroplasty in women with third and fourth degree perineal tears secondary to birth trauma METHODS: Our study was performed using a retrospective cohort design in a group of women (n = 32) who had experienced either third-degree or fourth-degree perineal tears during labor and then elected to undergo sphincteroplasty for fecal incontinence. We surveyed our patients with a questionnaire that was developed by the Obstetrics and Gynecology Epidemiology Center at Harvard Medica School and was previously used to survey women with obstetric injuries. Self-reported presphincteroplasty and post sphincteroplasty degree of physical sensation, sexual satisfaction, and likelihood of achieving orgasm were measured Also measured were libido, partner satisfaction, and presence of emotional or physical inability to engage in sexual behavior. RESULTS: Our results reaffirmed the findings of the Obstetrics and Gynecology Epidemiology Center's study that sexual function is compromised in women with third and fourth-degree perineal tears. For our patients with this degree of perineal tearing who underwent sphincteroplasty after primary repair, our survey showed consistent improvement in several parameters of sexual function. After sphincteroplasty, physical sensation was higher/much higher in 40 percent, sexual satisfaction was better/much better in 33.3 percent, and 28.6 percent of the patients were more/much more likely to reach orgasm. Libido was improved in 37.5 percent of the study population, and 20 percent reported increased partner satisfaction. Before surgery, 23.5 percent of patients were physically and 31.2 percent emotionally unable to participate in sexual activity because of fear of incontinence or intimacy; after surgery only 6.3 percent were physically unable and 0 percent were emotionally unable to engage in sexual activity. The response rate for our study was 18/32 (56 percent). CONCLUSIONS: Anal sphincteroplasty for the treatment of incontinence in women with third- and fourth-degree perineal tears improves physical and emotional sexual well-being and function.

Intraoperative total serum calcium levels, unlike intraoperative intact PTH levels, do not correlate with cure of hyperparathyroidism.

BACKGROUND: Intraoperative intact parathyroid hormone (iPTH) monitoring is useful in the operative management of hyperparathyroidism. Recent studies suggest that measurement of intraoperative total serum calcium (TSC) levels may be a more cost effective and readily available method of intraoperative guidance during neck dissection than iPTH levels, the gold standard. We compared the accuracy of intraoperative TSC to iPTH in predicting surgical cure during parathyroidectomy. PATIENTS AND METHODS: From September 1, 2001 to October 31, 2002, 88 parathyroidectomies were performed. iPTH and TSC were measured at the start of the operation, and at 5 and 10 min after gland removal. Data were compared, and trends were analyzed with respect to removal of abnormal parathyroid tissue as confirmed by pathology. One-way analysis of variance was used to determine if decreases in TSC were significant. RESULTS: The mean baseline iPTH level (418 +/- 610 pg/ml) dropped by 70% 5 min after removal of the abnormal glands (86 +/- 102 pg/ml) and by 85% at 10 min (39 +/- 39 pg/ml). The mean baseline TSC level (10.0 +/- 0.8 mg/dl) dropped by 4% at 5 min after removal of the abnormal glands (9.6 +/- 0.9 mg/dl) and remained at 4% at 10 min (9.6 +/- 0.8 mg/dl). iPTH dropped by > or =50% in 73 patients (83%) at 5 min and in 87 patients (99%) at 10 min after gland resection. TSC decreased below baseline at 5 min and remained below baseline at 10 min in only 47 patients (54%). In the remaining patients, intraoperative TSC changes were less predictable and did not respond consistently to resection of abnormal glands. CONCLUSIONS: The decreases in TSC during parathyroidectomy, if present, are minimal. Unlike iPTH levels, TSC levels do not consistently decrease at 5 and 10 min after gland resection. While attractive in terms of cost and availability, intraoperative TSC levels are not clinically reliable in confirming removal of abnormal parathyroid tissue.