Orbital emphysema post laparoscopic Nissen fundoplication in an adult with ventriculoperitoneal shunt. Case report.

INTRODUCTION: Currently there is controversy with regard to safety of laparoscopic surgery performed in patients with a ventriculoperitoneal shunt (VPS). An increased intra-abdominal pressure and eventually impaired shunt function may possibly increase intracranial pressure. Although no report of pneumocephalus due to retrograde valve failure has been published, other complications may not be neglected. PRESENTATION OF CASE: A 72-year-old woman was scheduled for a laparoscopic Nissen fundoplication due to a large intrathoracic gastric hernia. Her medical history revealed a gait disorder, requiring a VPS for normotensive hydrocephalus, set up in the right lateral ventricle 11 years earlier. No neurological symptoms were revealed preoperatively. Surgery was uneventful. Postoperatively, important right palpebral emphysema was noticed. Her Glasgow score was 15. She presented no headache, no impairment of the visual acuity, with normal sensitivity and motricity. After multidisciplinary discussion, a chest and neck x-ray were performed. No other complications were noticed. The palpebral emphysema completely disappeared 3 days later. The patient was discharged uneventfully at day 5. DISCUSSION: Orbital emphysema is an uncommon clinical occurrence of subcutaneous emphysema. It may lead to compressive orbital emphysema when air enters the orbit but cannot leave it freely. The increase of intra-orbital pressure followed by intrabulbar hypertension may cause an occlusion of central retinal artery and optic nerve ischaemia. Tension pneumocephalus must concomitantly be excluded. CONCLUSION: Although orbital emphysema is often a benign finding, it may result in serious and life threatening complications that must be excluded in patients with a VPS.

A Low-dose human fibrinogen is not effective in decreasing postoperative bleeding and transfusion requirements during cardiac surgery in case of concomitant clinical bleeding and low FIBTEM values: A retrospective matched study.

BACKGROUND: Studies evaluating the hemostatic effects of fibrinogen administration in cardiac surgery are not conclusive. AIMS: We investigated whether the use of a low-dose human fibrinogen in case of clinical bleeding after protamine administration and concomitant low FIBTEM values is effective in reducing postoperative bleeding. Secondary end-point was to investigate the consumption of allogeneic blood products. SETTING AND DESIGN: This was a retrospective matched study conducted at university hospital. MATERIALS AND METHODS: Among 2257 patients undergoing surgery with cardiopulmonary (CPB) bypass, 73 patients received a median dose of 1 g human fibrinogen (ROTEM-Fibri group). This group was matched with 73 patients who had not received human fibrinogen (control group) among 390 patients having undergone surgery at the moment FIBTEM analysis was unavailable. STATISTICAL ANALYSIS: Matching was performed for the type and the presence of redo surgery. McNemar and Wilcoxon paired tests were used to respectively compare the categorical and quantitative variables. RESULTS: The CPB bypass time was significantly higher in the ROTEM-Fibri group (P = 0.006). This group showed significantly higher bleeding in the first 12 and 24 h postoperatively (P < 0.001) and required significantly more transfusion of blood products (P < 0.001) and surgical revision (P = 0.007) when compared with the control group. There was no significant difference in the number of thromboembolic complications. CONCLUSIONS: These results show that the administration of 1 g of fibrinogen based on low-FIBTEM values and clinical bleeding after protamine administration does not stop bleeding and the need for transfusion of allogeneic blood products.

Sinonasal non-Hodgkin's malignant lymphoma - review of a clinical case.

Malignant lymphomas represent one of the most important problems of modern medicine, with a constant increase in the last decades, becoming the most frequent tumor among young people. Sinonasal localization is a particular site of malignant lymphomas, representing the second most frequent among ear, nose and throat (ENT) tumors. In this paper, authors present the clinical, diagnostic and therapeutic aspects of a malignant sinonasal lymphoma, which despite an aggressive histological subtype and important regional extension had a favorable clinical outcome. The patient presented to the ENT specialist with an important deformity of the nasal pyramid developed in the last two months. The anatomopathological exam and immunohistochemical analysis were conclusive for non-Hodgkin's lymphoma. The therapeutic course was cytostatic chemotherapy (in spite of the surgical approach) with beneficial oncological outcomes, which determined complete remission of the tumor. Computed tomography (CT) scan revealed a nasoethmoidal tumor with destruction of the nasal pyramid.