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Biomedical subjects

S Sabanathan

Publications and source records attributed to S Sabanathan.

At least 37 records · Page 2Linked to original sources
PubMed1995

Traumatic rupture of diaphragm.

Traumatic diaphragmatic rupture remains a diagnostic challenge, and associated injuries determine the outcome in those diagnosed early, whereas that of latent cases is dependent on the consequence of the diaphragmatic rupture: namely, the diaphragmatic hernia. To analyze the clinical and radiologic features and the therapeutic implications, we reviewed 980 patients reported in the English-language literature. This injury affects predominantly males (male:female = 4:1) in the third decade of life, and is often caused by blunt trauma (75%). There were 1,000 injuries, of which 685 (68.5%) were left-sided, 242 (24.2%) right-sided, 15 (1.5%) bilateral, and 9 (0.9%) pericardial ruptures; 49 cases were unclassified. Chest (43.9%) and splenic (37.6%) trauma were the most common associated injuries. The diagnosis was made preoperatively in 43.5% of cases, whereas in 41.3% it was made at exploration or at autopsy and on the remaining 14.6% of the cases the diagnosis was delayed. The mortality was 17% in those in whom acute diagnosis was made, and the majority of the morbidity in the group that underwent operation was due to pulmonary complications. Uniform diagnosis depends on a high index of suspicion, careful scrutiny of the chest roentgenogram in patients with thoracoabdominal or polytrauma, and meticulous inspection of the diaphragm when operating for concurrent injuries. Repeated evaluation for days after injury is necessary to discern injury in patients not requiring laparotomy. Acute diaphragmatic injuries are best approached through the abdomen, as more than 89% of patients with this injury have an associated intraabdominal injury. Patients with diaphragmatic rupture presenting in the latent phase have adhesion between the herniated abdominal and intrathoracic organs, and thus the rupture is best approached via a thoracotomy.

Adult↗
PubMed1995

A prospective, randomized comparison of interpleural and paravertebral analgesia in thoracic surgery.

We have undertaken a prospective, randomized comparison of the superficially similar techniques of interpleural and paravertebral (extrapleural) analgesia in 53 patients undergoing posterolateral thoracotomy. Local anaesthetic placed anterior to the superior costotransverse ligament and posterior to the parietal pleura produces a paravertebral block and instilled between the parietal and visceral pleurae produces an interpleural block. Patients received preoperative and postoperative continuous bupivacaine paravertebral blocks in group 1 and interpleural blocks in group 2. Premedication comprised diclofenac and morphine, and after operation all patients had regular diclofenac and patient-controlled morphine (PCM). Analgesia was assessed by visual analogue pain scores (VAS), PCM requirements, ratio of preoperative to postoperative spirometric values (PFT), rates of postoperative respiratory morbidity (PORM) and hospital stay, all recorded by blinded observers. Eight patients were withdrawn and data from 45 patients were analysed. Patient characteristics, surgery, VAS scores and PCM use were similar in both groups. PFT were significantly better (P = 0.03-0.0001) in group 1, and PORM was lower and hospital stay approximately 1 day less in this group. Five patients in group 2 became temporarily confused, probably because of bupivacaine toxicity (P = 0.02). We conclude that bupivacaine deposited paravertebrally produced greater preservation of lung function and fewer side effects than bupivacaine administered interpleurally.

Adolescent↗
PubMed1995

Bilateral paravertebral analgesia for major abdominal vascular surgery: a preliminary report.

Paravertebral analgesia is highly effective in blocking unilateral afferent input from the trunk, but its bilateral use does not appear to have been described. Eight patients undergoing major abdominal vascular surgery had pre-operative bilateral paravertebral catheters inserted. A dose of 25 ml of bupivacaine 0.5% divided between the two catheters provided the basis of an effective intra-operative analgesic regimen which was continued postoperatively by infusion of bupivacaine for 4 days. Diclofenac and morphine completed a balanced analgesic regimen which was started pre-operatively and continued for 5 and 3 days respectively. Cardiovascular stability was notable throughout surgery, even with aortic clamping and all patients were extubated at the end of surgery. Good quality analgesia was obtained as assessed by low postoperative pain scores at rest and on movement. Three patients were not admitted to the intensive care unit, where mean stays for the group was 10 h (range 0-24 h) and mean hospital stay was 10 days (range 7-14). There were no additional demands made on the nursing staff and no postoperative pain-related complications occurred. We conclude that bilateral paravertebral analgesia, as part of a balanced analgesic technique, is an alternative method of providing effective afferent blockage for major abdominal surgery.

Abdomen↗
PubMed1995

A thermographic study of paravertebral analgesia.

Six patients undergoing paravertebral blocks for chronically painful conditions of the chest wall were thermographically imaged so that the extent of cutaneous vasodilatation and hence sympathetic block could be correlated with the distribution of the somatic block. All blocks were performed by a single experienced operator, with a single percutaneous entry, using 15 ml of 0.5% bupivacaine at a mean level of T9-10 (range T7-8--T10-11), with radiological confirmation of correct needle placement. There was a mean distribution of the somatic block of five dermatomes (range 1-8), as evidenced by loss of pinprick sensation, with upper and lower limits of T6 and L3. The mean distribution of the sympathetic block was eight dermatomes (range 6-10), as evidenced by ipsilateral skin warming (p = 0.0005-0.001), with upper and lower limits of T5 and L3. No bilateral spread was observed. No significant postural changes in blood pressures were seen, although there was a small but significant decrease in supine heart rate (p = 0.05). This study demonstrates that a large unilateral somatic and sympathetic block is obtainable with a single thoracic percutaneous paravertebral injection. It challenges the suggestions that this method of analgesia is ineffective and hazardous, that a sympathetic component is a rare accompaniment and that the lumbar nerve roots are spared.

Adult↗
PubMed1995

Thoracic paravertebral analgesia.

Thoracic paravertebral nerve blockade, although once widely practised, has now only a few centres which contribute to the literature. Data production has, however, continued and this review correlates this new information with existing knowledge. Its history, taxonomy, anatomy, indications, techniques, mechanisms of analgesia, efficacy, contraindications, toxicity, side effects and complications are reviewed. Thoracic paravertebral analgesia is advocated for surgical procedures of the thorax and abdomen, especially wherever the afferent input is predominantly unilateral eg. thoracotomy, cholecystectomy and nephrectomy. It is also of benefit in the prevention and management of chronic pain. It is a simple undertaking with impressive efficacy. Plasma local anaesthetic levels are acceptable and its side effect and complication rates are low. No mortality has been reported. For unilateral surgery of the chest or truck, thoracic paravertebral analgesia should be considered as the afferent block of choice. For bilateral surgery, its efficacy may be limited by the doses of local anaesthetic which could safely be used and further study in this area in particular is required. This form of afferent blockade deserves greater consideration and investigation.

Analgesia↗
PubMed1995

Self-expanding tracheobronchial stents in the management of major airway problems.

The management of patients with critical major airways obstruction has been made possible by the recent introduction of expandable metal stents as the sole treatment or as an adjunct to other treatment modalities, to alleviate the distressing symptoms from tracheobronchial obstructions Gianturco self-expanding stents were used successfully in the management of 27 patients. The indications were: stenosis from postoperative strictures and recurrent tumours (n = 6), extrinsic compression from metastatic disease (n = 9), inoperable primary tumours of central airways (n = 9), airway collapse from relapsing polychondritis (n = 1), excessive mediastinal shift following right pneumonectomy (n = 1) and endobronchial non-Hodgkin's lymphoma (n = 1). Twenty three patients had immediate relief of stridor and the remaining two patients were successfully weaned from ventilatory support. There were two postoperative deaths. The stents were inserted under general anaesthesia through a rigid bronchoscope under direct vision. The ease of insertion under radiological control, self-expanding nature of the stents and the lack of major complications on follow-up of up to 47 months are particular advantages. The self-expanding tracheobronchial stents are a useful addition to our armamentarium in maintenance of the airways in patients with major airway stenosis and collapse.

Adult↗
PubMed1995

Has postoperative pain been eradicated?

Recent evidence suggests that surgical trauma induces a process of central nervous system sensitisation that contributes to and enhances postoperative pain. These changes are also thought to be the underlying cause of much chronic pain. Central sensitisation is generated not only during surgery, but also postoperatively as a result of the inflammatory response to the damaged tissue. This knowledge provides a rational basis for pro-active, pre-emptive and postoperative analgesic strategies to reduce the neuronal barrage associated with tissue damage. Reduction or elimination of postoperative pain is therefore possible. We advocate the use of continuous extrapleural intercostal nerve block for postoperative analgesia in patients undergoing thoracotomy. When this is begun pre-emptively (by precutaneous, pre-incisional paravertebral block) it is combined with an opiate and a non-steroidal anti-inflammatory drug premedication. In a randomised study of 56 patients, pain scores of less than 0.5 cm on a 10 cm scale were produced, postoperative lung function was preserved and glucose and cortisol responses were significantly unchanged from preoperative values. Evidence that effective perioperative analgesia reduces the incidence of chronic post-thoracotomy chest wall pain was found in a retrospective study of 1000 consecutive thoracotomies. The endpoints of a zero pain score, complete preservation of preoperative lung function and prevention of the stress response to trauma are currently achievable and should be provided for virtually all patients undergoing chest surgery. Pre-empting pain must be the goal for all those involved in the postoperative care of patients.

Acute Disease↗
PubMed1995

Rhabdomyosarcoma of the oesophagus. A case report.

A rare case of rhabdomyosarcoma of the oesophagus is presented. The clinical, radiologic, and histopathologic features are reviewed. A review of the literature revealed only thirteen cases of this type.

Aged↗
PubMed1995

Pain management in video assisted thoracic surgery: evaluation of localised partial rib resection. A new technique.

We undertook a re-evaluation of acute and chronic pain generation following Video Assisted Thoracic Surgery (VATS) with regard to chest wall trauma produced by the instruments and their ports. From intercostal space (ICS) measurements made on 40 patients, it was confirmed that both the camera and the staple gun port diameters are too large for insertion without trauma. An instrument was produced (the "Sari" Punch, Bolton Surgical Services, Sheffield, England) which cleanly excises an elipse of the superior aspect of a rib, prior to the introduction of the ports. At the same time, the recommended orbit of the instruments about the surgical focus was abandoned in favour of an alignment along one ICS so that only one nerve was potentially traumatised. These modifications were then combined with balanced, pre-emptive and continuous paravertebral analgesia and the efficacy of this approach was evaluated in nine patients undergoing VATS. Operation of the rib punch was easy in all patients and was carried out without clinical or radiological trauma to the rib. Insertion of the ports was easy and access was good to all intrathoracic structures. Postoperative analgesia was good and the mean hospital stay was 2.7 days (range 2-4). Follow-up two months later confirmed a satisfactory surgical procedure and no patients complained of chest wall pain or numbness. We conclude that pain generation with VATS must be seriously considered if the technique is to become truly successful. Balanced, pre-emptive, paravertebral analgesia will protect the central nervous system while the removal of an elipse of rib and alignment of the instruments along one ICS will reduce the likelihood of peripheral nerve trauma.

Adult↗
PubMed1994

Surgical management of intrathoracic oesophageal rupture.

Intrathoracic oesophageal rupture is a life-threatening condition that requires early diagnosis and effective treatment if death or serious prolonged illness is to be avoided. Six consecutive patients with intrathoracic oesophageal rupture were treated by debridement and irrigation of the mediastinum and primary suture closure with reinforcement of the suture line by pedicled omentum. The cause of the rupture was Boerhaave's syndrome in five patients and compressed air injury to the oesophagus in one. All but one patient presented more than 24 h after onset of symptoms, with a mean of 38 (range 12-72) h. All the patients recovered well with no postoperative oesophageal leakage. The mean hospital stay was 11.5 (range 9-15) days. Irrespective of the duration of the oesophageal rupture, aggressive resuscitation and prompt primary suture closure with reinforcement of the suture line with a well vascularized pedicled tissue flap is required for optimal results.

Adult↗
PubMed1994

Late esophageal fistula after pneumonectomy.

Esophageal fistula formation after pulmonary resection is rare. We present a case of esophagocutaneous fistula 9 years after left pneumonectomy for squamous cell carcinoma of the bronchus. This was confirmed on barium swallow and endoscopy. The fistula was sealed successfully with monomeric n-butyl-2-cyanoacrylate tissue adhesive. The simplicity and effectiveness of this method of management is discussed and the multitude of surgical options considered.

Bronchial Neoplasms↗
PubMed1994

Results of surgical treatment of stage III lung cancer.

The role of surgery in the management of Stage III lung cancer is controversial. A retrospective analysis of our experience with 220 Stage III patients treated surgically (Stage IIIa n = 174, Stage IIIb n = 46) form the basis of this report. Of the 140 patients who underwent resection only 88 were considered to be potentially curative, all but two being operated in Stage IIIa. The overall 5-year survival rate for Stage III lung cancer was 12.1% whilst curative resection had a 5-year survival rate of 31.8%. The 5-year survival rate increased to 42% with curative resection for T3N0M0 patients. There were no 5-year survivors with incomplete resection. There were no 5-year survivors in Stage IIIb disease. Five-year survival rates for N0 (n = 62), N1 (n = 78), and N2 (n = 80) irrespective of T status were 37.2%, 3.4% and 5.6%, respectively. The operative mortality rate was only 3.4% for curative resection while palliative or non-resection patients had a mortality rate of 10.6%. Eighty-eight patients, 55 of Stage IIIa and 23 of Stage IIIb had postoperative radiotherapy with a median survival of 12 and 9 months, respectively. Fifteen small cell carcinoma patients had postoperative adjuvant chemotherapy with a median survival of 6.5 months. The only 5-year survivor in this group also had a curative resection. We conclude that metastasis to lymph nodes usually implies systemic disease and a poor prognosis. Surgical therapy continues to be the treatment of choice in a small subset of patients with Stage III resectable lung cancer discovered at thoracotomy.(ABSTRACT TRUNCATED AT 250 WORDS)

Female↗