Clinical assessment of a new computerised objective method of measuring facial palsy.

OBJECTIVE: To compare the results using a new computerised objective method of assessing the degree of facial palsy with the results obtained using traditional clinical methods. DESIGN: Prospective computerised pixel change analysis and clinical evaluation of videos. SETTING: Tertiary referral centre. PARTICIPANTS: Subjects with varying degrees of unilateral facial palsy. METHODS: Comparison of the results obtained from an objective computerised method, the Glasgow Facial Palsy Scale, with the standard subjective clinical methods of the House-Brackmann Scale, Yanagihara, Sunnybrook Grading Scales and the objective clinical Stennert-Limberg-Frentrup Scale. RESULTS: Statistical analysis of the results from the objective computerised system indicated that there is an averagely strong correlation with the results from the House-Brackmann (Spearman's coefficient of 0.64), Sunnybrook (Pearson coefficient of 0.7) and Stennert-Limberg-Frentrup Scale (Pearson coefficient of 0.65), and it therefore has the ability to produce consistent results that agree with traditional clinical methods. It has a strong correlation with the Yanagihara Grading Scale (Pearson coefficient of 0.72) indicating that it may also have the ability to detect and record variations in the different regions of the face. CONCLUSION: This new computerised objective method of assessing the degree of facial palsy shows promise as a standardised objective method of assessing the degree of facial palsy.

Esophageal replacement using cryopreserved tracheal graft.

Esophageal replacement using artificial material is not a new concept. Prior experiences with prostheses, allografts and composite grafts have not proved particularly successful. The aim of this study is to investigate whether cryopreserved animal trachea is suitable for the replacement of the esophagus. In 12 beagle dogs a 6-cm-long segment of the cervical esophagus was removed, and was replaced with cryopreserved trachea, which had been stored for 21 days on -86 degrees C. The proximal and distal ends of the esophagus were joined together with the graft by simple continuous suture (Biosyn 3/0) and covered with the sternohyoid flap. Postoperatively 16 hematological parameters were measured. The dogs were planned to be euthanized at random on days 28, 42 and 56 after the operation. Tests for air leak were performed and the inner diameter of the graft was measured to detect shrinkage. The microscopic structure of the graft was analyzed using haematoxylin and eosin staining. There was no indication of insufficiency. Based on the air leak test the sutures withheld properly. The inner diameter of the graft narrowed from an average 19 mm (+/- 1 mm) to 15.8 mm (+/- 0.6 mm). In length, the graft shortened from an average 60 mm to 47 mm (+/- 3 mm). No feeding difficulty was observed. In two cases wound suppuration was found involving only the cutaneous and subcutaneous layers. Concerning the laboratory parameters, only the fibrinogen level and white blood cell count showed temporary although significant changes. Histology findings on the 56th day showed absolute integration of the trachea with the esophagus, with disintegration of the tracheal cartilages. Cryopreserved trachea seems to be suitable for the replacement of a 5-6-cm-long esophageal segment.

Gauze swabs left intrapericardially following cardiac surgery.

The occurrence of surgical gauze swabs left in the body following operations is not as rare as one would suspect, however the actual incidence is difficult to estimate. This accident seems to be occurring most frequently in general and gastro-intestinal surgery followed by operations in gynaecology and obstetrics and orthopaedics. There have been only a few papers in the literature dealing with the topic of foreign bodies left in place after cardiac surgical procedures. In this paper two cases of gauze swabs left intrapericardially following cardiac surgery are presented. The issue goes far beyond professional significance alone, but raises important and critical questions of medical ethics let alone legal implications.

[Simultaneous heart valve implantation and coronary bypass following kidney transplantation]. / Egy ülésben végzett mübillentyü implantáció és coronaria bypass mütét vesetranszplantáció után.

The authors report simultaneous aortic valve replacement and coronary artery bypass grafting surgery successfully performed in a patient with functioning transplanted kidney. The patient's cardiac status was classified as NYHA class III. The indication of the cardiac operation was a heavily calcified, stenotic and insufficient aortic valve and severe coronary artery disease. Renal function and blood biochemistry tests did not show significant changes in the postoperative period. The patient was discharged on the 15. postoperative day after an uneventful postoperative period. He remained asymptotic for two and a half years after operation. His cardiac status judged by postoperative treadmill stress was NYHA class I. The outcome of this case in accordance with results found in the literature further confirms that, if the clinical indications are appropriate, a kidney transplant patient can survive and benefit from cardiac surgery. To our knowledge our patient has been the only one who has survived aortic valve replacement and double coronary artery bypass grafting after kidney transplantation, and this is the first case that has ever been reported in Hungary.

[Adult respiratory distress syndrome after open heart surgery]. / Adult respiratory distressz-szindróma nyitott szívmútétek után.

Cardiopulmonary bypass used in open heart surgery is responsible for nearly 15% of adult respiratory distress syndrome. The condition has a high mortality rate and still today we do not have a specific therapy for it. The aim of this study was to reveal the factors that are responsible for the adult respiratory distress syndrome developing after open heart operations. A retrospective statistical analysis of the database of 837 consecutive open heart operations was performed. Those patients in whom the adult respiratory distress syndrome has not developed have served as control group. chi 2 probe, Student t test and the Mann-Whitney test were used for the analysis. The authors applied logistic regression analysis for the multivariate investigation. Adult respiratory distress syndrome has developed in 10 patients (1.2%) in the postoperative period. One patient in whom the adult respiratory distress syndrome was accompanied by multiorgan failure has been lost. Between the two subgroups the authors found significant difference in the amount of blood and fresh frozen plasma transfusion, in the duration of ischaemic period and cardiopulmonary bypass, in anaesthesia time, and also in the occurrence of postoperative low cardiac output syndrome and acute myocardial infarction. Fresh frozen plasma can be a risk factor in the development of postoperative adult respiratory distress syndrome. In order to avoid the occurrence of this syndrome a great emphasis must be put on the pulmonary prevention.

[Low cardiac output following open heart surgery and catecholamine therapy]. / Nyitott szívmütéteket követö alacsony perctérfogat szindróma és katecholamin terápia.

The authors have studied the possible risk factors and complications of low cardiac output (LCO) following open heart operations. A retrospective analysis of 537 consecutive open heart operations has been performed with regards to the patients past medical and perioperative data. For statistical analysis the authors have applied the Chi-square test, T-probe, Mann-Whitney-test and logistical regression analysis by means of the SPSS software. Occurrence of various types of operations was as follows: coronary bypass (CABG): n = 266, 49.5%, combined CABG: n = 62, 11.5%, aortic valve replacement (AVR): n = 73, 13.6%, mitral valve replacement (MVR): n = 59, 11%, multiple valve replacement: n = 39, 7.3%, adult congenital surgery: n = 25, 4.7%. Aortic dissection repair: n = 6, 1.1%, miscellaneous: n = 7, 1.3%. LCO has developed in 7.3% (n = 39) of the patients. The authors have concluded that in the studied group of patients the independent risk factors of postoperative LCO are as follows: atrial fibrillation in the patient history, mitral valve disease, perioperative myocardial infarction, length of anaesthesia, NYHA stage, number of transfused units of blood, and the perioperative LDH value. Beyond these variables the cause of LCO in some cases was surely an intra or perioperative myocardial necrosis. At least a certain part of this perioperative myocardial damage must have been or might have been caused by the catecholamines given under compulsion for the treatment of LCO.

[Surgical resection of tumors in the distal duodenum]. / Distalis duodenum tumorok rezekciójával szerzett tapasztalataink.

We present six cases of successfully resected primary tumors of the distal part of duodenum (third and fourth segment). Average age of the four male and two female patients was 59 years (47-80). Distal segmental resection were performed in four, pylorus-preserving pancreatoduodenectomy in two cases. Histologically the tumors were five adenocarcinomas, and one gastrointestinal stromal tumor. This tumor causing massive bleeding. In two patients, local lymph nodes were tumor positive, and in one patient synchronous metastasis of the greater omentum was excised during a palliative resection. There was no operative mortality. During a mean follow-up period of 17 months two patients died. Our results support the fact, that radical surgical resection of these tumors, even by segmental resection, provides a more favorable prognosis for duodenal carcinoma than for pancreatic tumors.

Synchronous spontaneous perforation of the esophagus and a duodenal ulcer.

SUMMARY: Although 41% of patients with spontaneous rupture of the esophagus also suffer from gastro duodenal ulcer disease, cases of synchronous spontaneous esophageal and duodenal ulcer perforation have thus far not been reported in the literature. We report on the case of a 61-year-old man who presented with a 72-hour history of esophageal rupture and duodenal ulcer perforation. Following appropriate circulatory resuscitation we performed double resection; involving the esophagus, cardia and the distal part of the stomach, followed by substitution by means of gastro-jejunal transposition as a one-stage procedure. With reference to this case with a favorable outcome, we are presenting an analysis of indications for resectional surgery in advanced spontaneous esophageal perforation.

Immunological and histopathological changes in the atrial tissue during and after cardiopulmonary bypass.

BACKGROUND: Ischemia and reperfusion injury occur in cardiac operations using cardiopulmonary bypass (CPB). Little is known about the immunological and histopathological changes in the atrial tissue under these conditions. OBJECTIVES: To investigate and compare multiple right atrial biopsy specimens by means of a self-developed pathological and immunohistochemistry panel. PATIENTS AND METHODS: Thirty-six nonselected adult patients (mean age 59+/-11.6 years, range 34 to 75) who had undergone different types of heart surgery (26 with and 10 without the use of CPB). RESULTS: Circumscribed necrosis was not found in any of the samples. Contractile bundle necrosis deteriorated only moderately with CPB. The share of hibernated myocardium seemed to increase during CPB, reaching 30% regardless of the basic disease. From the subepicardial toward the subendocardial surface, the amount of contractile proteins decreased continuously. Features similar to those seen with the phenomenon of 'stunning', which develops due to acute ischemia, were also noted. The apoptosis index did not exceed 1%. Apoptotic cells were generally randomly spread. It was very characteristic that with the use of CPB neither pro- nor antiapoptotic peptides (Bax, Bcl-2) were seen. In samples taken from patients who underwent surgery performed without the use of CPB both proteins were detected. The occurrence of cellular stress (heat shock protein 70 reaction) was rather variable in the samples. CONCLUSIONS: These investigations should be continued on homogeneous patient populations with the inclusion of proinflammatory cytokine determination.