Subacute airway obstruction from a tracheal mucosal flap.

We report the case of a 15-year-old girl with a near fatal obstructive tracheal lesion following tracheal intubation. The patient developed stridor and acute respiratory distress 29 h following tracheal extubation, after 35 h intubation in the intensive care unit. The failure of conventional management of stridor, including re-intubation, to provide a satisfactory airway prompted an urgent bronchoscopy, which revealed a tracheal mucosal flap causing 80% obstruction of the subglottic trachea. The fibreoptic bronchoscope allowed careful placement of a tracheal tube distal to the obstruction. The patient eventually made a full recovery. The low incidence of similar lesions and the lack of distinguishing clinical features from other causes of post-extubation stridor make diagnosis and appropriate management of this life-threatening condition difficult. We discuss how early consideration of the diagnosis and optimal initial management reduce the risk of an adverse outcome.

Randomized prospective comparison of laparoscopic and open peritoneal dialysis catheter insertion.

OBJECTIVE: To compare laparoscopic and conventional peritoneal dialysis catheter insertion with respect to post operative discomfort, complication rates, and catheter survival. DESIGN: Randomized prospective study. SETTING: Tertiary referral renal unit. PATIENTS: Fifty patients commencing peritoneal dialysis. INTERVENTION: Catheters were implanted laparoscopically or by a conventional surgical technique. MAIN OUTCOME MEASURES: The duration of surgery, hospital stay, pain scores, and analgesic requirements were recorded. Complications (early/late) and catheter survival were compared. RESULTS: The conventional procedure was faster than the laparoscopic (14.3 vs 21.9 minutes, p < 0.0001). There was no difference in any other parameter assessed. CONCLUSIONS: The data suggest that the insertion techniques are equivalent, and that laparoscopic insertion does not reduce early complication rates.

Atherosclerotic renovascular disease in the elderly: angioplasty with stenting versus reconstructive surgery.

We reviewed our experience of surgical and radiological intervention in 43 patients between 1987 and 1994 with angiographic renovascular disease. We retrospectively compared the effect of angioplasty with stenting versus reconstructive surgery on renal function and blood pressure in those patients with significant atherosclerotic renovascular stenosis. Twenty patients with moderate/non ostial stenosis (less than 60% stenosis) and two with fibromuscular displasia underwent renal angioplasty only. Indications for intervention were refractory hypertension (n = 20), flash pulmonary oedema (n = 8) and/or renal salvage (n = 31). All patients were hypertensive. Angioplasty with stenting was performed in ten patients, (2 female, 8 male), mean age 69 years, 9 with bilateral disease. Plasma creatinine was greater than 240 mumol/L in seven patients. A unilateral procedure was performed in 9 patients. Unilateral reconstructive surgery was performed in eleven patients (4 female, 7 male), mean age 63 years. Plasma creatinine was greater than 240 mumol/L in eight patients. Ten had bilateral disease. In the angioplasty/stenting group there were three technical failure. The mortality rates in the angioplasty/stenting group and surgical group were 10% and 27% respectively. Fifty-one and 165 patient months had elapsed in the stenting and surgical groups respectively. Blood pressure fell in each group, mean decrease in mean arterial pressure (MAP) 16 mmHg (p = 0.025) and 30 mmHg (p < 0.01) respectively. Improvement or stabilisation of renal function was achieved in 67% and 91% of cases respectively. Two surgical patients were able to discontinue haemodialysis. The two methods of treatment appear to be equally effective in lowering blood pressure. Reconstructive surgery offers greater improvement in renal function with the possibility of withdrawal of dialysis, at the expense of a higher mortality rate.

Case report: Klippel-Feil syndrome with coexistent hypoparathyroidism.

A 72-year old man presented with clinical signs of cervical myelopathy , a short neck, low posterior hairline, and limited neck movements. He also had a solitary kidney and anomaly of the third rib. Biochemical hypoparathyroidism with low parathyroid hormone level was discovered and secondary causes excluded. Treatment with alfacalcidol, calcium, and spinal decompression by complex laminectomy allowed complete recovery of symptoms. Klippel-Feil syndrome encompasses an increasing constellation of clinical features that affect most organs. The association with hypoparathyroidism, however, has not been described previously. This may be yet another syndrome with single pathology responsible for all the findings.

Peripheral vein and fistula blood samples after single-needle dialysis.

It is traditional in renal units to check patients' biochemical parameters pre- and postdialysis. When a single-needle system is used, the blood is obtained through the arterial limb of the Y cannula, thus avoiding an extra venipuncture. The pre-sample is taken immediately after the cannula is inserted and the post-sample is taken after the blood lines have been disconnected and the venous limb clamped. It was the purpose of this investigation to determine whether the post-samples gave an accurate indication of the patient's electrolyte status. Samples taken from the arteriovenous fistula and those taken simultaneously from a peripheral vein in the opposite arm were compared. It is concluded that postdialysis concentrations should be determined from peripheral vein samples only.

Successful pregnancy following haemodialysis and pyeloplasty.

A successful pregnancy in a patient who presented with renal failure secondary to pelvi-ureteric obstruction is described. Haemodialysis was instituted during the pregnancy. An Anderson-Hynes pyeloplasty was performed, probably preventing deterioration of remaining renal function. Metabolic acidosis was managed using additional bicarbonate in the dialysate. An active, multidisciplinary approach is recommended in the management of such patients.

Renal autotransplantation in the treatment of hypertension and uraemia due to renal artery stenosis.

Four cases of renovascular hypertension cured or improved by renal autotransplantation are described. In one case correction of renal ischaemia resulted in an improvement of renal function. Previous reports of this technique are reviewed and the limitations of the more standard operation of saphenous vein bypass graft are discussed.