Paragastric Autonomic Neural Blockade to Prevent Early Visceral Pain and Associated Symptoms After Laparoscopic Sleeve Gastrectomy: a Randomized Clinical Trial.

BACKGROUND: Visceral pain (VP) following laparoscopic sleeve gastrectomy remains a substantial problem. VP is associated with autonomic symptoms, especially nausea and vomiting, and is unresponsive to traditional pain management algorithms aimed at alleviating somatic (incisional) pain. The present study was performed to evaluate the safety and effectiveness of laparoscopic paragastric autonomic neural blockade (PG-ANB) in managing the symptoms associated with VP following sleeve gastrectomy. STUDY DESIGN: This prospective, double-blinded, randomized clinical trial involved patients undergoing laparoscopic sleeve gastrectomy at two high-volume institutions. The patients were randomized to laparoscopic transversus abdominis plane block with or without PG-ANB. The primary outcome was patient-reported pain scores assessed at 1, 8, and 24 h postoperatively. The secondary outcome measures were analgesic requirements, nausea, vomiting, hiccups, and hemodynamic changes immediately after PG-ANB and postoperatively. RESULTS: In total, 145 patients (block group, n = 72; control group, n = 73) were included in the study. The heart rate and mean arterial pressure significantly decreased 10 min after PG-ANB. The visual analog scale score for pain was significantly lower in the PG-ANB than in the control group at 1 h postoperatively (p < 0.001) and 8 h postoperatively (p < 0.001). Vomiting, nausea, sialorrhea, and hiccups were significantly less prevalent in the PG-ANB group. Patients in the PG-ANB group received fewer cumulative doses of analgesics at 1 h postoperatively (p = 0.003) and 8 h postoperatively (p < 0.001). No differences between the groups were detected at 24 h (p = 0.298). No complications related to PG-ANB occurred. CONCLUSION: PG-ANB safely and effectively reduces early VP, associated autonomic symptoms, and analgesic requirements after laparoscopic sleeve gastrectomy.

Intractable Hiccups as the Primary Symptom of a Perimedullary Arteriovenous Fistula at the Craniocervical Junction.

BACKGROUND: Hiccups are a well-known short-term phenomenon in daily life. If they persist or become intractable, they may be a primary symptom of a disease. Recent studies identified the medulla oblongata as the neuroanatomic center of the hiccup reflex arc. In previous cases, an isolated lesion at the dorsal side of the medulla oblongata induced intractable hiccups. CASE DESCRIPTION: We herein describe a patient with a perimedullary arteriovenous fistula (PMAVF) at the craniocervical junction who had intractable hiccups. A 70-year-old male presented with a 3-year history of intractable hiccups that continued for a few days every week. An initial examination failed to identify the underlying cause, and neither medicine nor self-treatment attenuated his symptoms. Intracranial T2-weighted magnetic resonance imaging showed a hyperintensity area within the dorsolateral medulla and flow voids along the dorsal side of the cervical spine. Angiography revealed PMAVF fed by the left C1 radiculomedullary artery. Obliteration of the fistula was performed, after which intractable hiccups had completely disappeared within 1 week. CONCLUSIONS: This is the first case report of PMAVF at the craniocervical junction presenting with intractable hiccups that suggested a lesion in the dorsal side of the medulla. The mechanisms underlying hiccups are also discussed.

Hiccups triggered by bladder filling after bilateral pontine hemorrhage: A case report.

INTRODUCTION: A hiccup is myoclonus of a sudden involuntary contraction of the diaphragm. Hiccups have various causes, and brain stem stroke is one of the causes of central hiccups. Certain types of hiccups are caused by diseases that can be fatal. Therefore, it is beneficial for physicians to be familiar with the various cases of unusual hiccups. We report a case of hiccups triggered by urinary bladder filling in a brain stem stroke patient. To the best of our knowledge, previous reports have not described a similar case. PATIENT CONCERNS: We describe the case of a 54-year-old patient who had acute bilateral pontine hemorrhage. The patient had intermittent hiccups in the early stages of the stroke onset. The hiccups ceased by the administration of medication or stimulation of the pharyngeal or tracheal wall. Two months after the onset, the Foley catheter was removed to check if the patient could void the bladder voluntarily. Hiccups occurred whenever the bladder was filled with some amount of urine. DIAGNOSIS: Pontine hemorrhage, neurogenic bladder, and quadriplegia. INTERVENTIONS: When the hiccups occurred, the amount of urine in the bladder was checked using a transabdominal bladder ultrasonography scanner. After clean intermittent catheterization for bladder emptying, the hiccups subsided. OUTCOMES: The hiccups occurred 5 or 6 times a day, as often as the bladder was filling. He was unable to void the urine voluntarily for 5 days after the removal of the Foley catheter. Percutaneous suprapubic cystostomy was performed finally to remove the stimulation of bladder filling and the hiccups disappeared. CONCLUSION: Bladder filling is suspected to increase the sympathetic tone and cause a hiccup reflex. Bladder filling could be a factor triggering hiccups in pontine hemorrhage.

Intractable Hiccups Associated with Chiari Type I Malformation: Case Report and Literature Review.

BACKGROUND: The authors report the case of a 34-year-old man who presented with intractable hiccups. The imaging examination showed that the patient was suffering from syringomyelia associated with Chiari type I malformation. CASE DESCRIPTIONS: The patient underwent posterior fossa decompression combined with bilateral tonsillectomy and duroplasty. The intractable hiccups completely resolved 1 week after operation and had not recurred at 2 months after surgery. Postoperative magnetic resonance imaging showed the atrophy of the tonsils of the cerebellum and disappearance of the cavities of the spinal cord. CONCLUSIONS: Intractable hiccups as the main symptoms of Chiari type I malformation are extremely rare in the clinic. Decompression surgery should be an appropriate method to relieve the symptoms.

Brain Abscess of Basal Ganglia Presenting with Persistent Hiccups.

BACKGROUND: Brain abscesses are well-known to neurologic surgeons with well-recognized presentations, which include seizures, neurologic deficit, and headache. Rare symptoms may lead to a delay in diagnosis, which can be life threatening in the setting of a brain abscess. CASE DESCRIPTION: We present the case of a 46-year-old male with intractable hiccups found to have an abscess of the right basal ganglia. The brain abscess was treated by frameless stereotactic-guided aspiration. The patient's hiccups improved after surgical aspiration and medical management. CONCLUSIONS: A comprehensive literature review confirmed brain abscess as a rare cause of intractable hiccups. In addition, there are few reports of lesions of the basal ganglia causing intractable hiccups. Aspiration and medical therapy resulted in resolution of the hiccups. Knowledge of the hiccup reflex arc and unusual presentation of basal ganglia lesions may shorten time to diagnosis.

Microvascular decompression for intractable singultus.

Intractable singultus due to cerebrovascular disease is very rare. We report a case of intractable singultus that improved after microvascular decompression and present a literature review. The patient was a 58-year-old man with a 30-year history of persistent singultus. Its frequency and duration gradually increased and it was resistant to multiple medical treatments. Microvascular decompression to relieve pressure on the anterolateral surface of the lower medulla oblongata from the vertebral artery resulted in the resolution of singultus. Patients with intractable idiopathic singultus who fail to respond to medical therapy need to be considered for the evaluation of cerebrovascular diseases and microvascular decompression.

Recurrent intractable hiccups treated by cervical phrenic nerve block under electromyography: report of a case.

Intractable or persistent hiccups require intensive or invasive treatments. The use of a phrenic nerve block or destructive treatment for intractable hiccups has been reported to be a useful and discrete method that might be valuable to patients with this distressing problem and for whom diverse management efforts have failed. We herein report a successful treatment using a removable and adjustable ligature for the phrenic nerve in a patient with recurrent and intractable hiccups, which was employed under the guidance of electromyography.

Intractable hiccup accompanying pleural effusion: reversible clipping of an intrathoracic phrenic nerve.

Hiccup is usually a self-limiting condition, and can be treated with medications and physical maneuvers. However, hiccup episodes continuing for days or weeks can be incapacitating, and disturb work, sleep, and eating. Therefore, timely therapeutic intervention is needed to achieve early resolution of this treatable condition. We report on a successful phrenic nerve block for intractable hiccups, which consisted of thoracoscopic nerve clipping under general anesthesia and reversal under local anesthesia. This method has the advantage of assured diaphragmatic functional recovery while controlling intractable hiccups.

Microvascular decompression for intractable singultus: technical case report.

OBJECTIVE: Intractable singultus is a rare but significantly disruptive clinical phenomenon that often accompanies other diseases but can present in isolation due entirely to intracranial pathology. We report a case of intractable singultus that improved after microvascular decompression and present a comprehensive review of singultus by discussing its similarity to other cases of microvascular decompression, its history and etiology, and its evolutionary basis. CLINICAL PRESENTATION: The patient exhibited intractable singultus for 15 years, resistant to multiple medical regimens. INTERVENTION: Microvascular decompression to relieve pressure on the tenth cranial nerve and medulla oblongata resulted in near total resolution of the singultus. CONCLUSION: Neurovascular compression should be considered a potentially reversible cause of intractable singultus, a significantly disabling clinical phenomenon.

"C3, C4, C5 keep you alive," or do they?

Contrary to traditional teaching in anatomy courses, historical data suggest that bilateral loss of phrenic nerve function does not necessarily result in death.

An unusual cause of hiccup: costal exostosis. Treatment by video-assisted thoracic surgery.

The described case is of a 15-year-old boy who presented with a persistent hiccup and repeated episodes of left-sided chest pain. At computed tomography scan an exostosis originating from the costo-chondral junction of the left 4th rib was seen. The tip of the exostosis reached the external surface of the pericardium. Removal of a 2 cm rib segment including the implantation basis of the exostosis was achieved by video-assisted thoracic surgery. Symptoms disappeared after surgery. This report shows an exceptional symptom of costal exostosis.

Intractable hiccup: an odd complication after laparoscopic fundoplication for gastroesophageal reflux disease.

Intractable hiccup can be an unbearable circumstance and its treatment is often frustrating. More than 100 causes for hiccup have been described in the literature; the most common cause is gastroesophageal reflux disease (GERD). We report a case of a 31-year-old patient who suffered from intractable hiccup starting 3 weeks after laparoscopic Nissen fundoplication for GERD, a potential surgical complication that has not been described. After frustrating medical treatment, the patient underwent computed tomography and nerve stimulator-guided blockade of vagal and phrenic nerves on each side separately. Hiccup ceased only after blockade of the right phrenic nerve with 4 ml/h l% ropivacaine and relapsed soon after discontinuation. He underwent thoracoscopic right phrenicectomy, which rendered him symptom free for well over 2 months, at the time of this writing.

Intractable hiccups: treatment by microvascular decompression of the vagus nerve. Case Report.

Idiopathic hiccups are usually managed with pharyngeal stimulation or a plethora of pharmacological agents. Hiccups that persist and prove intractable to these medical measures are treated by crush or ablation of the phrenic nerve, which denervates the major respiratory muscle. This is the first reported case of nondestructive microvascular decompression of the vagus nerve for the treatment of intractable idiopathic hiccups. The success of microvascular decompression has been documented with other conditions, such as trigeminal neuralgia and hemifacial spasm, that are characterized by hyperactive dysfunctional neurovascular contact. The vagus nerve was separated from the posterior inferior cerebellar artery by inserting a Teflon pledget between the nerve and vessel which eliminated the neurovascular contact. One year after the initial surgery, the hiccups recurred. The Teflon pledget had fallen out of place and the nerve was once again in contact with the artery. Once the contact was eliminated by wrapping the artery with a tuft of Teflon, the hiccups stopped. The patient has remained free of hiccups for 3 years. It is concluded that patients with intractable idiopathic hiccups who fail medical therapy should be considered for microvascular decompression of the vagus nerve.

Hiccups: esophageal manometric features and relationship to gastroesophageal reflux.

Gastroesophageal reflux (GER) has been reported to be a cause of hiccups. Conversely, some reports state that hiccups cause or adversely affect GER disease. There have been few descriptions in the literature of what hiccups do to esophageal motility. We present a patient with long-standing symptomatic GER and intractable hiccups. Esophageal manometry during hiccups showed absence of LES pressure and absence of peristaltic activity in the esophageal body in response to swallowing, factors which could aggravate GER. Esophageal motility in the absence of hiccups was normal. Antireflux surgery in our patient relieved heartburn but not hiccups. Based on our case and a review of the literature, we believe that clinicians should be cautious in recommending antireflux surgery to treat hiccups in patients with both hiccups and heartburn.