Management of thromboembolism-in-transit with pulmonary embolism.

We present a rare complication of deep venous thrombosis with pulmonary embolism that threatened the patient with systemic embolization. A 36-year-old female was referred to the hospital after five days of progressive shortness of breath and chest pain. Preceding onset of symptoms, she had undergone surgery leading to reduced physical activity and had just returned from vacation by a long flight. Investigations with transthoracic and transesophageal echocardiography revealed a thromboembolism-in-transit across a patent foramen ovale. Thoracic CT showed submassive bilateral pulmonary embolism. Hemodynamic parameters were stable. The patient was treated surgically with extraction of the thrombus, closure of the foramen ovale and removal of the bilateral pulmonary emboli. She was discharged after an uneventful hospital stay. LEARNING POINTS: Thromboembolism-in-transit across a patent foramen ovale usually occurs in the presence of deep venous thrombosis with pulmonary embolism. The abrupt rise in pulmonary arterial pressure may contribute to the migration of the thrombus across the atrial septum to the systemic circulation.If any abnormal structures are seen in the left atrium by TTE in a patient with pulmonary embolism, a TEE should be performed to rule out an embolus entrapped in a patent foramen ovale.When acute pulmonary hypertension cannot be assessed by conventional methods, additional parameters such as shortened right ventricular outflow tract acceleration time and a mid-systolic notching of the pulse wave Doppler profile in the right ventricular outflow tract may be useful.Mortality is highest during the initial 24 h after onset of chest symptoms; thus, optimal treatment must commence urgently.The choice of treatment in each individual patient must be made after a thorough discussion in a multidisciplinary heart team.

Logistics and outcome in urgent and emergency colorectal surgery.

AIM: Infrastructure-related factors are seldom described in detail in studies on outcome after surgical procedures. We studied patient, procedure, physician and infrastructure characteristics and their effect on outcome at a Norwegian University hospital. METHOD: All patients admitted between 1st January 2002 and 30th June 2003 who underwent urgent or emergency colorectal surgery were extracted from the hospital databases and retrospectively analysed. RESULTS: There were 196 patients. The overall complication rate was 39%. Forty-six (24%) patients died during admission after surgery. Those who died were less likely to be operated by a subspecialized colorectal surgeon (17%vs 30%, P = 0.001). The anaesthesiologist was a resident in most of the cases (> 75%) for both those who survived and those who died. Surgery performed out-of-office hours was common in both groups, although the patients who died were more likely to be operated upon at night (28%vs 18%, P = 0.001). The time interval standard from admission to surgery was met in only 84 (43%) patients. Forty-nine (49/196, 25%) procedures were delayed beyond the time requested by the surgeon by more than 120 min (mean 363 min). CONCLUSION: The outcome after emergency colorectal surgery was consistent with the literature but the infrastructure was not optimal. Improvements may be achieved by a focus on decreasing waiting times, abandoning of out-of-office emergency surgery and increasing the involvement of senior staff.

Benign rectal strictures managed with transanal resection--a novel application for transanal endoscopic microsurgery.

OBJECTIVE: Six cases of management of rectal strictures by transanal endoscopic microsurgery (TEM) are described. METHOD: Patients are placed in the lithotomy - Trendelenburg position and the stricture is resected from 4-8 o'clock through the entire thickness of the fibrosis. The upper resection edge is mobilized including all layers of the rectal wall and the defect is sutured along the circumference. RESULTS: Satisfactory anatomical and functional long-term results were obtained in 5 of 6 patients. CONCLUSION: TEM resection of benign strictures is feasible in some patients and should be tested in a randomized study against known procedures.

Development of a model for measurement of adhesion strength of fibrin sealant to human tissue.

It is crucial for the surgeon to know the physical properties of a surgical sealant. Current test methods of fibrin sealant involving animal testing or in vitro testing of sealant using artificial substrates have little clinical relevance. Most of these test methods also lack accuracy and reproducibility. A new model was developed for testing strength and in vitro adhesion of fibrin sealant to vital human tissue using fresh vein leftover from coronary artery bypass grafting. The vein leftover was cut into samples and fastened in a tensiometer linked to a computer. Patient-derived fibrin sealant (0.1 ml) was applied to the tissue, and the surfaces of the tissue samples were held together for 5 min, and then automatically pulled apart by the tensiometer. Data were generated in a load cell and recorded and analysed by the computer. The reproducibility for the adhesion strength was 6.6%, adhesion energy 9.8%, and elongation at break 8.4%. The method has been considered ethical and has good reproducibility. The method can be used for standardised measurements and comparison of different types of fibrin sealant without the sacrifice of animals.