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Paul of Aegina: landmark in surgical progress.

During the Byzantine period the most prominent medical personalities were Oribasius, Aetius of Amida, Alexander of Tralles, and Paul of Aegina (Paulus Aegineta). The last of the eclectic Greek compilers, Paul of Aegina (625-690 AD) was born on the island of Aegina and practiced medicine in Alexandria. He was the author of the Epitome of Medicine (seven books), which was first printed in Greek by the Aldine Press in Venice in 1528. The Syndenham Society of London published an English translation by Francis Adams of Banchory between 1844 and 1847. The most noteworthy of his Epitome is the sixth book on surgery. Paul was not only a scribe but also a highly capable surgeon. He was the quintessential student of the best medical authorities: Hippocrates and Galen in Greek and Roman medicine, respectively. He also displayed a peculiar genius in the field of surgery. He gave us novel descriptions of tracheotomy, tonsillectomy, catheterization of the bladder, lithotomy, inguinal hernia repair, abdominal paracentesis for ascites, and many other surgical procedures including reduction of breast size. He not only influenced those in his own era but had great influence on physicians such as Rhazes, Haly Abbas, Albucasis, Avicenna, and Fabricius ab Aquapendente, who lived in subsequent eras. This historical article emphasizes the role of Paul of Aegina in the history of surgery and provides a comprehensive review of his surgical treatise with original case examples that represent his contributions to surgical progress.

General Surgery↗

Management of ascites after radical surgery in gastric cancer patients with liver cirrhosis and minimal hepatic dysfunction.

A radical lymph node dissection is important for the cure of gastric cancer. However, such a procedure in patients with liver cirrhosis (LC) could develop serious complications such as massive ascites. To determine the management of postoperative ascites, 26 gastric cancer patients with LC were reviewed retrospectively. Child-Pugh status was grade A in all 26 patients. Thirteen (50%) patients had advanced gastric cancer, and a D2 lymph nodes dissection was performed in 25 (96.2%) patients. The mean number of dissected lymph nodes was 33 +/- 11 (range: 11-54). An abdominal closed suction drain was placed in 12 (46.2%) patients, and the average amount of fluid drainage was 463 ml/day. The drainage tube was removed on about the eleventh postoperative day (range: day 6 to day 13), and diuretics were used in 8 (30.8%) patients. A paracentesis was needed in one patient but no postoperative surgical morbidity or mortality was observed. Therefore, an extended lymph node dissection is safe in gastric cancer patients with mild hepatic dysfunction. Liver cirrhosis and postoperative ascites can be managed conservatively without any complications.

Aged↗

Peritoneovenous shunt insertion for intractable ascites: a district general hospital experience.

Ascites often contributes to patient morbidity and discomfort. When refractory to medical management, it has been managed with repeated paracentesis, implantable ports for drainage, or diversion to the urinary bladder. Peritoneovenous shunt insertion has been a technique that was traditionally performed only by surgeons but is now within the realm of interventional radiologists. Its advantage is that protein-rich ascitic fluid is returned to the intravascular compartment. This retrospective study elaborates on the successes and problems encountered during shunt insertion in our first 13 patients. Two patients are well with a functioning shunt at 14 and 32 weeks. In 6 the shunt functioned until the patients' death from the underlying malignancy. Two required revision with variable success and in 2, shunt function could not be salvaged. There was one procedure-related mortality. Radiological insertion of these shunts is feasible and should be considered for selected patients. Options are available for assessment and salvaging of dysfunctional shunts.

Adult↗

Percutaneous placement of peritoneal port-catheter in patients with malignant ascites.

We report our experience with a radiologically placed peritoneal port-catheter in palliation of malignant ascites. Port-catheters were successfully placed under ultrasonographic and fluoroscopic guidance in seven patients (five women, two men) who had symptomatic malignant ascites. The long-term primary patency rate was 100%. The mean duration of catheter function was 148 days. Seven patients had a total of 1040 port-days. Two patients received intraperitoneal chemotherapy via the port-catheter. There were no procedure-related mortality and major complications. Minor complications such as ascitic fluid leakage from the peritoneal entry site, migration of the catheter tip to the right upper quadrant, and reversal of the port reservoir occurred in four patients. None of these complications affected the drainage and required port explantation. In patients with symptomatic malignant ascites, a peritoneal port-catheter can provide palliation and eliminate multiple hospital visits for repeated paracentesis with high patency and low complication rates.

Adult↗

Leukemic hypopyon in acute myelogenous leukemia.

We encountered a patient with acute myelogenous leukemia (AML) who developed leukemic hypopyon. Leukemia initially spread into the pharynx, gingiva, lymphnode, and bone marrow. He achieved complete remission after chemotherapy but developed blurred vision and hypopyon. Anterior chamber paracentesis disclosed leukemic infiltration of the anterior chamber. Infiltration of the central nervous system also occurred. He received systemic chemotherapy, intrathecal chemotherapy, and local chemotherapy. However, he did not achieve prolonged remission. These findings suggest that these chemotherapy treatments have an inadequate effect for AML with anterior chamber infiltration. This rare complication is associated with extramedullary infiltration of leukemia.

Anterior Chamber↗

Diffuse neonatal abdominal lymphangiomatosis: management by limited surgical excision and sclerotherapy.

Complete excision of diffuse abdominal lymphangiomatosis in the newborn is next to impossible. A 3-day-old female infant was found to have diffuse abdominal lymphangiomatosis predominantly in the left mesocolon and retroperitoneum. Initial management was by marsupialization, which was complicated by chylous ascites requiring periodic paracentesis and nutritional support. At the age of 45 days, left hemicolectomy and partial excision of the retroperitoneal cysts were performed together with intracystic injection of OK-432 into the residual cysts. The patient's progress after the second operation was satisfactory. Initial marsupialization followed by delayed partial resection together with injection of OK-432 into the residual cysts is an effective method of managing diffuse abdominal lymphangiomatosis in the newborn.

Abdominal Neoplasms↗

Blunt abdominal trauma in children: epidemiology, management, and management problems in a developing country.

Trauma is the leading cause of death in children in developed countries. In tropical Africa, it is only beginning to assume importance as infections and malnutrition are controlled. In developed countries, the availability of advanced imaging modalities has now reduced the necessity for laparotomy to less than 10% following blunt abdominal trauma (BAT) in children. This report reviews the epidemiology, management, and unnecessary laparotomies for pediatric BAT in a developing country in a retrospective review of 57 children aged 15 years or less at the Ahmadu Bello University Teaching Hospital, Zaria, Nigeria over 12 years. The average age was 9 years and the male-female ratio 3.8:1. Seventy-four percent (74%) of abdominal injuries in children were due to blunt trauma. The commonest causes of injury were road traffic accidents (RTA) (57%), 88% in pedestrians and 59% in children aged 5-9 years. Falls were the cause of trauma in 36%, 60% of them aged 10-15 years. Other causes of injury were sports in 5% and animals in 2%. Diagnosis was clinical, supported by diagnostic peritoneal lavage or paracentesis. Two patients had ultrasonography, and none had computed tomography. Fifty-three patients had a laparotomy, 2 died before surgery, 1 was managed nonoperatively, and in 1 surgery was declined. There were 34 splenic injuries, 20 treated by splenic preservation, splenectomy in 13, and non-operative in 1. Fourteen gastrointestinal injuries were treated in 12 patients. Of 9 hepatic injuries, 4 were minor and were left untreated, 3 were repaired, 1 was packed to arrest hemorrhage, and a lacerated accessory liver was excised. Four injuries to the urinary tract (bladder contusion 2, bladder rupture 1, ruptured hydronephrotic kidney 1) were treated accordingly. There were 4 retroperitoneal hematomas associated with other intra-abdominal injuries and 2 pancreatic contusions. One lacerated gallbladder was treated by cholecystectomy and a ruptured left hemidiaphragm was repaired transperitoneally. In retrospect, 27 (51%) patients could have been managed by observation (splenic injury 20, liver injury 5, bladder contusion 2) using advanced imaging modalities. One patient developed an intra-abdominal abscess following splenorrhaphy. The average hospital stay was 17 days. Mortality was 8 (14.5%) from gastric perforation (3), liver injury (2), splenic injury (1), and 2 patients died before surgery. BAT in this population results predominantly from RTA in pedestrians. Laparotomy may be avoided in 51% of cases if advanced imaging modalities are readily available.

Abdominal Injuries↗

Does pancreatico-biliary maljunction play a role in spontaneous perforation of the bile duct in children?

Spontaneous perforation of the bile duct (SPBD) is a rare disease in children. Pancreatico-biliary maljunction (PBM) has been postulated to contribute to its etiology. We have treated three children with SPBD over 30 years, two of whom had PBM. There was one boy and two girls aged 10 months to 2 years with symptoms of abdominal distension, vomiting, abdominal pain, jaundice, and acholic stools. The diagnosis of SPBD was made by paracentesis showing biliary ascites, and primary biliary and intra-abdominal drainage was performed in all cases. The site of perforation was at the connection of the common bile duct (CBD) with the cystic duct in all cases. In two cases reflux of contrast into the pancreatic duct was noted, the common channel was long (17 and 12 mm, respectively), and the bile amylase level in the CBD was abnormally high (50,000 and 67,000 IU/l, respectively). In the third patient there was no reflux of contrast into the pancreatic duct and the bile amylase and trypsin levels in the CBD and gallbladder were not measurable. Thus, SPBD in children may not be due solely to PBM, but may involve multiple mechanisms.

Abnormalities, Multiple↗

Spontaneous perforation of the extrahepatic bile duct in an infant.

A 1.2-year-old male presented with gradual-onset biliary ascites, mild icterus, and failure to thrive due to spontaneous bile-duct perforation (SPBD) confirmed by technetium 99Tc HIDA scan and abdominal paracentesis. Peritoneal tube drainage for 2 weeks helped the perforation to seal spontaneously, as there was no distal obstruction. No surgery was needed. Only less than 100 cases of SPBD have been reported in the English literature. The pathogenesis and treatment options are reviewed and discussed.

Ascites↗

Perforation during gas reduction of intussusception.

Perforation during attempted gas-enema reduction of intussusception is more common than during a barium enema. In a review of 650 consecutive attempted gas enemas, perforation occurred in 7 infants (1.1%). Gross abdominal distension from the pneumoperitoneum may be rapid and cause splinting of the diaphragm, which leads to acute respiratory distress. This complication is readily recognised at the time of the gas enema, and may require immediate intervention by paracentesis using a 14-gauge needle. A review of 7 children with intussusception in whom perforation occurred revealed that all had radiologic evidence of bowel obstruction (air-fluid levels) prior to the enema, and the patients had had a relatively long history since the onset of symptoms. No perforation occurred during a delayed repeat enema reduction. Perforation during gas enema produces minimal peritoneal contamination. No pathological lesion at the lead point of the intussusception was identified in any of the children in whom perforation occurred.

Enema↗

Gastric perforation in infants with oesophageal atresia and distal tracheo-oesophageal fistula.

Gastric perforation (GP) is a well-recognised complication of oesophageal atresia (OA) with distal tracheo-oesophageal fistula (TOF), and is usually associated with extreme prematurity, hyaline membrane disease, and the requirement for assisted ventilation. The presentation is sudden, and leads to further deterioration in respiratory function because of increasing abdominal distension from pneumoperitoneum and splinting of the diaphragm. Unrelieved, the infant becomes increasingly hypoxic and may die. A review of six infants with OA and distal TOF in whom GP occurred has enabled us to develop the following guidelines for the appropriate initial surgical management of this complication: (1) Needle paracentesis of the abdomen en route to surgery if the infant continues to deteriorate; (2) Urgent laparotomy to decompress the abdomen and to occlude the lower oesophagus with a catheter introduced through the GP; (3) Thoracotomy and division of the fistula; (4) Oesophageal anastomosis if the infant's condition improves sufficiently and the anatomy is favourable; and (5) Repair of the GP and formation of a gastrostomy.

Abnormalities, Multiple↗

Primary abdominal pregnancy associated with severe ovarian hyperstimulation syndrome.

An uncommon case of primary abdominal pregnancy that was detected after rapid resolution of OHSS is reported. A 27-years-old nulligravida woman underwent ovarian hyperstimulation with human menoposal gonadotrophin (hMG) at another clinic and was admitted to our hospital with severe OHSS. Intravenous fluid therapy, albumin supplementation, and abodminal paracentesis was performed. The patient's massive ascites rapidly resolved, and she was discharged from our hospital. However, 4 weeks later, at about the 8th gestational week, she was readmitted to our hospital because of strong suspicion of abdominal pregnancy. Ultrasonography revealed a gestational sac (GS) and fetus with heartbeat in Douglas' pouch and an emergency laparotomy was performed. Both fallopian tubes, both ovaries and the uterus were completely intact and the GS was found on the anterior surface of the rectum. After removing GS, the muscle layer and serosal layer of the rectum were repaired. No bowel complications developed, and the post operative course was uneventful. To our knowledge, this is the first report of this very rare variant of ectopic pregnancy complicated by OHSS.

Adult↗

Vitreous prolapse and IOL dislocation during intravitreal injection of triamcinolone acetonide.

BACKGROUND: To report on procedure-related anterior segment complications during intravitreal injections. METHODS: In a prospective interventional case series, 614 eyes received a total of 723 intravitreal injections of about 20 mg triamcinolone acetonide (in 0.2 ml) after paracentesis and aqueous humor drainage for various indications. RESULTS: In three eyes (0.49% of all eyes) a vitreous prolapse occurred during the injection. In one eye, the vitreous prolapse was combined with dislocation of the intraocular lens (IOL). All three eyes were pseudophakic, showing an posterior capsule defect, and the IOL located in the ciliary sulcus. They were treated by translimbal vitrectomy, and one eye with reposition of the IOL. No other procedure-related postoperative complications were observed during injection or follow-up (7.8+/-7.1 months). CONCLUSIONS: Intravitreal injections may cause a vitreous prolapse into the anterior chamber with or without IOL decentration or dislocation in predisposed eyes. Ophthalmologists should be aware of this possible complication and inform patients at risk.

Anterior Chamber↗

Effect of application duration of 2% lidocaine jelly on aqueous lidocaine concentration for topical anesthesia in cataract surgery.

BACKGROUND: To evaluate the intraocular penetration of lidocaine 2% gel after different duration of application and to assess their effects on intraoperative pain. METHODS: Samples of aqueous humor were obtained in 41 eyes that had phacoemulsification under topical anesthesia with 2% lidocaine gel. The duration between lidocaine gel application and paracentesis was recorded. The aqueous concentration of lidocaine was measured using high performance liquid chromatography (HPLC). Patients were also asked to report the severity of intraoperative pain using a verbal analogue scale. Correlation analysis was performed to analyze the relationship between duration of lidocaine gel application, aqueous lidocaine concentration and intraoperative pain score. RESULTS: The mean duration of lidocaine gel application was 20.3+/-6.1 min and the mean aqueous lidocaine level was 14.2+/-8.5 micro g/ml. Longer duration of lidocaine gel application was significantly associated with higher aqueous concentration of lidocaine (Spearman's rho=0.58, P<0.001). Eyes in which lidocaine gel was applied for 20 minutes or more had significantly higher aqueous lidocaine level (two-tailed t-test, P=0.001) However, the duration of lidocaine gel application and the aqueous concentration of lidocaine showed no correlation with the patent's perceived pain score (P=0.20 and P=0.79, respectively). CONCLUSIONS: Increase in duration of lidocaine gel application resulted in higher aqueous concentration of lidocaine. Patients' level of perceived pain during phacoemulsification under lidocaine gel anesthesia was not related to the intraocular lidocaine absorption level after 10 min of gel application.

Adult↗

Substance P in proliferative vitreoretinopathy: the significance of aqueous humor levels for evolution of the disease.

PURPOSE: We detected aqueous humor levels of substance P in patients with various grades of proliferative vitreoretinopathy and with uncomplicated rhegmatogenous retinal detachment. To evaluate the significance of the concentration of substance P at the time of surgery for retinal detachment for subsequent development of proliferative vitreoretinopathy, the latter patients also underwent fundoscopic control examination. METHODS: Using a highly specific and sensitive radioimmunoassay, the content of substance P in fresh samples of aqueous humor obtained by paracentesis was determined both in cataract controls and in patients with uncomplicated rhegmatogenous retinal detachment and with various grades of proliferative vitreoretinopathy. Retinal detachment patients underwent fundoscopic control examination 6 months after surgical reattachment. RESULTS: The mean concentration of substance P in cataract controls was 40.3 (+22.4) fmol/mg protein, in the retinal detachment group 61.9 (+/-13.9) fmol/mg protein and in proliferative vitreoretinopathy 335.2 (+/-24.8) fmol/mg protein, but no correlation between levels of the peptide and various grades of the disease was observed. Already at surgery for retinal detachment three in four patients who developed proliferative vitreoretinopathy presented with levels of substance P in the range of the disease. CONCLUSION: The concentration of substance P in aqueous humor is significantly high in patients with proliferative vitreoretinopathy in whom surgery is indicated. Furthermore, elevation of the peptide in retinal detachment that originates most obviously from a neurogenic mechanism may indicate initiation of processes associated with proliferative vitreoretinopathy, thus representing an indicator of significant risk for evolution of the disease at a very early time.

Adult↗

Elevated levels of calcitonin gene-related peptide in aqueous humor of patients with proliferative vitreoretinopathy.

PURPOSE: To detect the levels of the sensory peptide calcitonin gene-related peptide in aqueous humor of patients with proliferative vitreoretinopathy and to compare them with those of uninflamed eyes (cataract and uncomplicated rhegmatogenous retinal detachment). MATERIALS AND METHODS: Using a highly specific and sensitive radioimmunoassay the concentration of calcitonin gene-related peptide was detected in fresh samples of aqueous humor obtained via paracentesis. Furthermore, calcitonin gene-related peptide-like immunoreactivities were characterized by high-pressure liquid chromatography. RESULTS: The mean level of calcitonin gene-related peptide was 6.11 fmol/ml in cataract controls and 14.77 fmol/ml in uncomplicated rhegmatogenous retinal detachment. In the cataract group, 9 of 18 cases were below the detection limit and in the retinal detachment group, 5 of 16. In proliferative vitreoretinopathy, the peptide averaged 76.92 fmol/ml and none of the samples was below the detection limit. High-pressure liquid chromatography revealed one major peak corresponding to synthetic calcitonin gene-related peptide. CONCLUSION: In recent studies, we found elevated levels of the sensory peptide substance P in aqueous humor of patients with proliferative vitreoretinopathy. This fact and the present result, the elevation of calcitonin gene-related peptide in aqueous humor of eyes with proliferative vitreoretinopathy, clearly point to an involvement of sensory peptides in the pathobiology of the disease. The source of the elevation is not clear, but we hypothesize that it originates from a neurogenic mechanism, i.e. an acceleration of the peptides by their enhanced release from the iris/ciliary body complex subsequent to sensitization of sensory neurons, thus representing a very interesting epiphenomenon of proliferative vitreoretinopathy. Our results constitute novel aspects in the pathophysiological concept of proliferative vitreoretinopathy and extend the knowledge about the pathobiology of the disease process.

Adolescent↗

Laparoscopic extirpation of a giant ovarian cyst.

BACKGROUND: The differential diagnosis of unilocular intraabdominal cysts includes ovarian, gastrointestinal, urological, and lymphatic processes. They occur at all ages and can be benign or malignant. METHODS: We present a case of a 17-year-old female with asymptomatic abdominal distension. Ultrasonography (US) revealed a 20 x 21-cm unilocular cystic mass with smooth surface lining. Paracentesis was performed during diagnostic laparoscopy, recovering more than 7 L of clear fluid. The cyst and left adnex were completely removed laparoscopically and diagnosis of ovarian cystadenoma was made. The patient made a quick and uneventful recovery. CONCLUSIONS: In all cases of abdominal distension, US must be performed and a tumor marker profile consisting of AFP, LDH, testosterone, estradiol, and CA-125 must be established in order to differentiate between benign and malignant processes. When the latter is suspected, additional computerized tomographic scanning must be performed. In this case, a normal tumor marker profile and benign ultrasonographic appearance excluded the possibility of malignancy. Conventional treatment in these large cysts is laparotomy. We propose that complete laparoscopic drainage and extirpation should be the treatment of choice, regardless of cystic size.

Adolescent↗

Laparoscopically assisted treatment of acute abdomen in systemic lupus erythematosus.

The incidence of abdominal pain in patients with systemic lupus erythematosus (SLE) is very high. Most patients do not require surgical treatment (serositis). Some cases such as appendicitis, perforated ulcer, cholecystitis or, rarely, intestinal infarction are surgical. Differential diagnosis is difficult, partly because noninvasive examinations do not provide enough evidence to rule out a diagnosis. On the other hand, in patients with SLE who have acute abdomen, it is dangerous to delay surgery by attempting conservative therapy. In fact, a better survival rate has been associated with early laparotomy. We report a case of acute abdomen in a patient affected by SLE, in which the diagnostic problem was solved by means of laparoscopy and the treatment was laparoscopically assisted. A 45-year-old woman with a 25-year history of SLE was admitted with abdominal pain and fever. Her physical examination revealed a painful right iliac fossa with rebound tenderness. Her WBC count was normal. Abdominal x-ray, ultrasonography, paracentesis, and peritoneal lavage did not provide a diagnosis. A diagnostic laparoscopy was performed, showing segmentary small bowel necrosis. The incision of the umbilical port site was enlarged to allow a small laparatomy, and a small bowel resection was performed. The histopathologic finding was "leucocytoclasic vasculitis, with infarction of the intestinal wall." The patient recovered uneventfully. In conclusion, this case report shows that emergency diagnostic laparoscopy is feasible and useful for acute abdomen in SLE. Currently, this diagnostic possibility could be considered the technique of choice in these cases, partly because, when necessary, it also can allow for mini-invasive treatment therapy.

Abdomen, Acute↗