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Refusion of anterior cerebral artery after aneurysm clipping--a case report.
Herein, we are describing an unusual case suffering from a left anterior cerebral artery aneurysm (A1). Both the anterior cerebral arteries were supplied by the left internal carotid artery as was found in digital substraction angiography (DSA) preoperatively. The postoperative angiograms revealed that left anterior cerebral artery was supplied from the left internal carotid artery and the right anterior cerebral artery by the right internal carotid artery respectively. This finding of cerebral angiograms is interesting and rarely mentioned in the literature. Its hemodynamic change and pathogenesis were unclear and different to that of the coronary circulation, ischemic change of gut and skeletal muscle. The causes may include: 1) vasospasm at the anterior communicating artery after manipulation at surgery; 2) desiccation or shrivelling the adjacent artery by intraoperative electrocoagulation; 3) occlusion the anterior communicating artery by the wing of clip. 4) the deprivation of the blood flow from the left internal carotid artery after totally or partially narrowing left A1 by an aneurysm clip. The redistribution of blood volume in the previously hypoplastic right anterior cerebral artery and decreased caliber of the left anterior cerebral artery (A1) are likely playing a role in this case.
An operative complication in a patient with a true posterior communicating artery aneurysm: case report and review of the literature.
Intraoperative oculomotor nerve injury in a patient with a true posterior communicating artery aneurysm is reported in detail. A comparison of internal carotid artery aneurysms at the posterior communicating artery junction with true posterior communicating artery aneurysms deserves special attention, because the vascular relationships of the aneurysm are more complex. A clip along the internal carotid artery does not occlude blood flow to the aneurysm, and the aneurysmal neck and the distal posterior communicating artery are closer to the oculomotor nerve. This is the 27th reported case of a true posterior communicating artery aneurysm. The incidence of true posterior communicating artery aneurysms ranges from 0.1 to 2.8% of all aneurysm patients. Such aneurysms constitute 4.6 and 11% of so-called posterior communicating aneurysms in two series. Difficulty associated with a preoperative diagnosis has been documented in at least 4 cases. An awareness of this rare aneurysm is stressed in order to avoid operative complications.
Laparoscopic transabdominal lumboperitoneal shunt.
Communicating hydrocephalus can be handled either by the ventriculoperitoneal or, occasionally, the ventriculoatrial shunt. The lumboperitoneal shunt is another option. It does not require a transcranial approach; therefore, it is safer for the patient. We describe a technique that can be performed easily by a skilled laparoscopic surgeon through an anterior approach transabdominally. The lumboperitoneal (LP) shunt is placed laparoscopically under direct videoscopic vision, with the catheter inserted transabdominally through the L3 disc space into the thecal sac. In our patient, the lumboperitoneal shunt was placed at the L3 disc space for communicating hydrocephalus. There were no intraoperative or postoperative complications. The LP shunt can be easily placed by a skilled laparoscopic surgeon. The incidence of infection and complications is lower, and the patency rate is higher. This should be the initial choice for communicating hydrocephalus.
Intraoperative electrically elicited stapedius reflex threshold is related to the dosage of hypnotic drugs in general anesthesia.
Today cochlear implantation is a widely used means of treatment in deafness and severe hearing disorders in adults, children, and infants. Postoperative fitting of the externally worn speech processor is very important for successful use of the cochlear implant. However, especially in infants and young children, this fitting process can be difficult because of limited communication capabilities. The use of intraoperatively obtained stapedius reflex thresholds has been proposed for postoperative speech processor fitting, but the influence of anesthetics on threshold values needs to be taken into account. In a retrospective study with 20 patients between 3 and 43 years of age, a highly significant correlation between the dosage of methohexital and the mean stapedius reflex threshold value could be shown (r = 0.65, p = .002). We conclude that more reliable threshold values can be obtained by reducing the dosage of hypnotics to achieve a lighter level of hypnosis during stapedius reflex measurement. To achieve a light, but still sufficient level of hypnosis, electroencephalographic monitoring including automatic interpretation of the complex raw signal should be used.
Anatomy of the venous drainage of the human testis: testicular vein cast, microdissection and radiographic demonstration. A new anatomical concept.
The venous drainage of the testis was identified and described in an autopsy, radiographic and operative series of 30, 28 and 7 adult males, respectively. Testicular vein cast--right and left--was prepared in autopsy specimens to identify the course, tributaries and communications of the testicular vein. Intraoperative spermatic venography was done in 17 men with and in 11 men without varicocele. The retrograde spermatic venography showed the precise anatomy of the pampiniform plexus. Antegrade spermatic venography was done to identify the valves. During cystectomy in 7 adult men, the whole tree of the spermatic vein was taken and microdissected. Our findings show that the venous drainage of the testis cannot be looked upon as it is in the standard anatomy; on the contrary, it deviates from the description in the text. We demonstrated that the venous drainage of the testis is via the pampiniform plexus, which is primarily drained by the testicular and external pudendal veins. The testicular vein--midway between the internal inguinal ring and the lower pole of the kidney--divides into the medial and lateral branch to form a delta. The medial branch communicates with the ureteral and contralateral veins; there, it terminates in the left renal vein or inferior vena cava on the right side. The lateral branch communicates with colonic and renal capsular veins and terminates in the perinephric space. There is no cross-communication between the left and right testicular venous systems in the scrotal, retropubic or pelvic areas. The only cross-communication is in the abdomen, and is seen in only 50% of men. The testicular vein has no valves.
Anesthetic considerations for gynecologic cancer surgery.
Preoperative, intraoperative, and postoperative anesthetic considerations in gynecologic cancer surgery are discussed. Preoperatively, the anesthetist must document the patient's disease state, physical condition, responses to prior chemotherapeutic regimens and toxic side effects, particularly from Adriamycin and bleomycin. Laboratory studies should include electrolytes, hepatic, renal, and hematologic indices. The anesthetist should also recognize that patients may be under great emotional stress, which may require prescribing anti-anxiety medications for several days prior to surgery. Planning the anesthetic includes consultation with the surgeon relative to procedure planned, positioning requirements, anticipated blood loss, monitoring and postoperative care requirements. Intraoperative considerations again involve close communication with the surgeon. The use and benefits of a combined regional/general anesthetic technique are discussed. Postoperative considerations are directed toward hemodynamic stability and control of postoperative pain. Techniques of epidural narcotic and local anesthetic administration, as well as patient-controlled analgesia (PCA) are discussed.
[Development of telepathology systems between different types of terminals based on the standard for image collaboration command protocol].
In Japan telepathology systems have been developed in medical or pathological environment such as a shortage and an uneven distribution of pathologists. More than 100 telepathology terminals are working mainly for intraoperative quick diagnosis. They cannot communicate with different types each other. In March 2000 the Medical Information System Development Center(MEDIS-DC) successfully demonstrated the interconnection between different types of telepathology terminals based on the Standard for Image Collaboration Command Protocol (SICCP). Nikon, NTTdata and Olympus had joined the development. In February 2002 MEDIS-DC examined these systems for pathological consultations in the fields of Okinawa-Kyoto, Kyoto-Mie and Mie-Okinawa. These successful examinations let us know that telepathology systems need new observation methodologies for telecytology and teleconsultation in addition to the flow for intraoperative quick diagnosis, new GUI guidelines for telepathology terminal design and, education and support for users of their smooth operation. Outcomes of MEDIS-DC activities encourageed us to challenge the next generation telepathology. We found some new trends in telepathology or pathology informatics such as virtual slide technologies and the internet applications in US and Europe. In order to keep Japanese priority, MEDIS-DC telepathology comittee has started investigations to construct a strategy for development of Japanese next generation telepathology.
Standardized visual overlays enhance laparoscopic instruction: A mixed-methods evaluation.
Effective communication during laparoscopic procedures is frequently undermined by spatial disorientation and inconsistent terminology between instructors and trainees. This study examined whether standardized visual overlays on endoscopic monitors could enhance communication and learning. We conducted a three-phase mixed-methods study: qualitative observation of 20 laparoscopic teaching cases; a randomized trial of 63 second-year medical students assigned to control, clock, or alphanumeric grid (AG) overlays during three trials of a standardized transfer task; and intraoperative implementation in 44 cases (30 AG, 14 clock) with post-case surveys and qualitative feedback. In simulation, the clock overlay produced the fastest completion times, whereas the AG yielded the lowest error scores, and both overlays outperformed the control. Intraoperatively, the AG was rated higher than the clock for communication clarity, spatial orientation, perceived operative efficiency, and trainee confidence. Standardized visual overlays, particularly the AG, appear to support intraoperative teaching by providing a shared spatial frame of reference.
Recurrence of varicocele after high retroperitoneal repair: implications of intraoperative venography.
PURPOSE: We determined whether intraoperative venography results in a decreased recurrence rate after varicocele repair in adolescence. MATERIALS AND METHODS: We evaluated 177 male adolescents 14 to 19 years old who underwent varicocele repair via the high retroperitoneal approach with artery sparing and intraoperative venography. RESULTS: Overall the recurrence rate was 2.8% (5 of 177 cases) in the venography group and 11% in historical controls without venography. We identified left-to-right cross communicating vessels in 3 patients with recurrence. Intraoperatively venography revealed nonligated vessels in 21 patients (12%), resulting in revision and repair during the same procedure. CONCLUSIONS: Intraoperative venography seems to decrease the rate of recurrence. Left-to-right cross communicating vessels may be present in some adolescents with recurrence after varicocelectomy.
Health-related quality of life after aneurysmal subarachnoid hemorrhage: impacts of bleeding severity, computerized tomography findings, surgery, vasospasm, and neurological grade.
OBJECT: Based on the results of earlier studies it is agreed that the significance of aneurysm location and surgery for neuropsychological impairments after subarachnoid hemorrhage (SAH) is secondary to the effects of the bleeding itself. Therefore, the present study was performed to evaluate whether bleeding, acute clinical course, and surgery have persistent effects on health-related quality of life (QOL) after SAH. METHODS: A series of 116 patients was examined for 4 to 5 years (mean 52.2 months) after aneurysmal SAH by means of a QOL questionnaire. Eighty-six patients (74.1%) had undergone surgery early (< or = 72 hours post-SAH). There were 77 women (66.4%) and 39 men (33.6%) in the study group, and the mean age of the patients was 50.3+/-13.3 years (range 30-69 years). Patients who had undergone surgery for a left-sided middle cerebral artery (MCA) aneurysm complained of significantly more impairments in social contact, communication, and cognition than those treated for a right-sided MCA aneurysm. No other effects of aneurysm location (including the anterior communicating artery) emerged. Multiple aneurysms, intraoperative aneurysm rupture, and partial resection of the gyrus rectus had no adverse effects on later daily life. Only temporary clipping was associated with increased complaints in some QOL areas. Disturbances of the circulation of cerebrospinal fluid and the presence of intraventricular hemorrhage led to more impairments in daily life. Specific effects of the anatomical pattern of the bleeding could be identified, but no adverse effects of vasospasm were found. Multivariate analyses revealed, in particular, that patient age and admission neurological status (Hunt and Hess grade) are substantial predictors of the psychosocial sequelae of SAH. CONCLUSIONS: In contrast to the mild effects of aneurysm surgery, patient's age, initial neurological state on admission, and the bleeding pattern substantially influence late QOL after SAH.
Cholecysto-hydatid cyst fistula.
A 27-year-old woman developed recurrent hydatid of liver. CT scan showed unilocular cysts in segments IV and VII. Intraoperatively, there was a fistulous communication between the gall bladder and the cyst in segment IV. Partial pericystectomy along with cholecystectomy was done for the segment IV cyst; percutaneous aspiration, instillation and re-aspiration using hypertonic saline was done for the cyst in segment VII. This was followed by albendazole treatment.
[Treatment of low cardiac output syndrome in newborn infants and children].
A refractory low-cardiac-output syndrome is, in pediatric patients, most often due to impaired myocardial function after corrective surgery in congenital heart disease. Therapy has to focus on postoperative adaptation, which usually takes place within a few days. We report on three therapeutic strategies to "bridge" this phase of postoperative adaptation. Improving the contractile state of the myocardium using enoximone was attempted in 16 neonates with low-cardiac-output syndrome refractory to catecholamines (Dosage: loading-dose 1 mg/kg in 10 min intravenously, followed by an infusion of 10 mcg/kg/min). In 12/16 neonates cardiac index increased by more than 20% ("responder"), while in 4/16 neonates cardiac index remained unchanged ("non-responder"). All non-responders succumbed due to refractory low-cardiac-output syndrome, while only one responder died in low-cardiac-output syndrome. Hemodynamically, enoximone resulted in an increase of cardiac index and stroke volume (p < 0.003), a reduced systemic vascular resistance (p < 0.0022), and reduced right and left atrial pressures (p < 0.003). Heart rate and mean arterial pressure remained unchanged. No rhythm disturbances were observed. Another therapeutic approach to postoperative low-cardiac-output syndrome is atrial decompression by creating an atrial septal defect. Due to the possibility of later transcatheter closure of these defects, the acceptance for the intraoperative creation of an atrial communication to decompress the right or left atrium is increased. The defect size is critical and should be below 9 mm, so that the Rashkind-PDA-Occluder can be used for later transcatheter closure. We performed such a "surgical-interventional" decompression in 18 patients (age: 2 weeks to 7 years). In six patients the atrial defect was created because of an underdeveloped left ventricle (body weight 2.9-9.2 kg), in 12 patients for right atrial decompression during a total cavopulmonary shunt (body weight 15.2-54.2 kg). A spontaneous closure of the defect did not occurred in any of the patients, thus, transvenous closure of the defect was performed 2 to 10 weeks postoperatively. In the follow-up period of 4 to 22 months no complications such as thrombus formation, thromboembolic events or infections occurred. In low-cardiac-output syndrome refractory to all therapeutic measures mechanical circulatory support is the final method to keep the patient alive. In 11 children with refractory low-cardiac-output syndrome mechanical circulatory support was performed. In three of these, extracorporal membrane oxygenation (ECMO) was used, in eight children a ventricular assist device (Berlin Heart) was used.(ABSTRACT TRUNCATED AT 400 WORDS)
Intraoperative angiography in cerebral aneurysm surgery: a prospective study of 100 craniotomies.
OBJECTIVE: To determine the frequency of unexpected major arterial occlusion and incomplete aneurysm clipping on intraoperative angiography after cerebral aneurysm clipping and to determine factors that predict these unexpected findings. METHODS: Data was collected prospectively on 100 consecutive craniotomies for the clipping of 107 aneurysms in 92 patients. Patient age and sex, aneurysm location and size, how the aneurysm presented, day of surgery after hemorrhage, intraoperative rupture, and postoperative course were recorded. After clipping, the surgeon recorded whether he thought the aneurysm was obliterated and whether he thought the clip occluded a major artery. Intraoperative angiography was then performed. The incidence of unexpectedly finding a major arterial occlusion or residual aneurysm was determined. Factors predicting these unexpected findings revealed by intraoperative angiography were identified by logistic regression. RESULTS: There were 11 giant (10%), 13 posterior circulation (12%), and 68 (64%) ruptured aneurysms. Unexpected angiographic findings necessitating at least one clip adjustment occurred in 12 cases (11%). Clip readjustments restored flow through six major arterial occlusions (6%) and completely obliterated 10 persistently filling aneurysms (10%). Logistic regression showed that factors predicting an unexpected arterial occlusion were giant aneurysm and basilar apex location (P < 0.05). Unexpected residual aneurysm was predicted by giant aneurysm and posterior communicating artery location (P < 0.05). CONCLUSION: Intraoperative angiography detects unexpected arterial occlusions and residual aneurysms in 12% of cases and can decrease complications of aneurysm surgery, although the yield in unselected patients is low. The subgroup of patients with giant, basilar apex, and posterior communicating artery aneurysms has a significantly higher incidence of untoward findings and may benefit from increased usage of intraoperative angiography.
Iliopsoas bursal distension caused by acetabular loosening after total hip arthroplasty. A rare complication of total hip arthroplasty.
In a 58-year-old woman, a cystic mass at the ileocecal region communicated with the loosened hip prosthesis 20 years after total hip arthroplasty (THA). The preoperative arthrogram of the hip and the intraoperative cystogram suggested a one-way communication from the hip to the cystic mass. The mass was diagnosed as an iliopsoas bursitis distended by the influx of the synovial fluid from the loosened THA.
[Intraoperative management of unexpected arterial hypotension during lumbar diskectomy].
An anesthesiological management is difficult in surgical procedures in which the operative situs is not to be seen by the anesthesist. Therefore specific knowledge of the operative procedure and related hazards are mandatory for optimal anesthesiological care. By describing the anesthesiologic proceduces in two lumbar discectomys, the specific problems in recognition and treatment of severe injuries of retroperitoneal vascular structures are explained. In addition, the differential diagnosis of intraoperative arterial hypotension is described. The communication between all disciplines involved is mandatory, especially in cases of severe complications. The management of such complications can only be solved through in-time interdisciplinary cooperation of all involved disciplines.
Automatic detection of intraoperative neurological injury.
Neurological injuries occurring during high-risk surgical procedures can be detected by monitoring intraoperative evoked potential signals. In this communication, an automatic injury detection algorithm is proposed in which the EP signal is modeled as a pole-zero filter and then the model parameters are applied as inputs to a classifier type neural network. A recognition rate of 96% is achieved using an experimental model of brain injury.
Awareness under anesthesia and the development of posttraumatic stress disorder.
Failure of general anesthesia to render a patient insensate, termed "awareness," is estimated to affect between 40,000 and 140,000 patients in the US each year. This study investigated the occurrence of post-traumatic stress disorder (PTSD) in subjects who reported a past episode of intraoperative awareness. We inquired about intraoperative and postoperative experiences and studied the relationship between various surgical experiences and currently meeting the diagnosis of PTSD. Sixteen postawareness subjects and 10 postgeneral anesthesia controls completed the Clinician Administered PTSD Scale (CAPS), a standardized clinical rating scale for PTSD, and a questionnaire about peri-operative experiences. Nine of 16 subjects (56.3%), a mean of 17.9 postoperative years, and no controls met diagnostic criteria for current PTSD (X(2)= 8.6, df = 1, P<.01). Common intraoperative experiences included an inability to communicate, helplessness, terror, and pain. Postawareness patients had significant postoperative distress related to feeling unable to communicate, unsafe, terrified, abandoned and betrayed. Perioperative dissociative experiences predicted having current PTSD. Being conscious during surgery is a traumatic event that may result in developing chronic PTSD. Further studies should include prospective designs of prevalence and long-term psychological, social, and overall health effects, and ways of preventing and treating awareness-induced PTSD.