Massive hematuria due to an autogenous saphenous vein graft and urinary bladder fistula in an extra-anatomic iliofemoral bypass: a case report.

INTRODUCTION: Gross hematuria caused by rupture of an artery in the urinary tract is a rare but potentially fatal condition. Iliac artery aneurysms, pelvic surgery with radiation, vascular reconstructive surgery, surgery for stenosis of the ureteropelvic junction, and transplantation are reported to be associated with this condition. In the vascular reconstructive surgery group, the most common etiology is rupture of the degenerated artery or synthetic graft in the ureter. CASE PRESENTATION: We present a case of rupture of the small anastomotic pseudoaneurysm at the proximal anastomosis of a right iliofemoral autogenous vein extra-anatomic graft in the urinary bladder. To our knowledge, this is the first report of a rupture of an autogenous vein graft in the urinary bladder. Our patient, a 24-year-old Albanian farmer, was admitted to the emergency department in severe hemorrhagic shock induced by exsanguinating hematuria. He underwent immediate surgery, during which direct sutures to the bladder were placed and the saphenous graft was replaced with a synthetic one. The patient recovered completely, was free of hematuria, and showed no signs of pathological communication between the urinary and arterial tracts on postoperative cystoscopy and computed tomographic angiography during 2 years of follow-up. CONCLUSION: The incidence of artery-to-urinary tract fistulas is growing due to the increasing use of urologic and vascular surgery, pelvic oncologic surgery, and radiation therapy. In addition to fistulas involving a degenerated artery and ureter or synthetic grafts and ureter, they can also involve an autogenous vein graft and the urinary bladder. In our patient, the fistula was a result of erosion of the bladder from a pseudoaneurysm at the proximal anastomosis of an autogenous vein iliofemoral bypass in an extra-anatomic position. Open surgery remains the best treatment option, although there is increasing evidence of successful endovascular treatment.

A randomized trial of preoperative oral carbohydrates in abdominal surgery.

BACKGROUND: Carbohydrate-rich liquid drinks (CRLDs) have been recommended to attenuate insulin resistance by shortening the preoperative fasting interval. The aim of our study the effect of preoperative oral administration of CRLDs on the well-being and clinical status of patients. METHODS: A randomized, double blind, prospective study of patients undergoing open colorectal operations (CR) and open cholecyctectomy (CH) was conducted. Patients were divided into three groups: study, placebo, and control. Visual analogue scale (VAS) scores for seven parameters (thirst, hunger, anxiety, mouth dryness, nausea, weakness and sleep quality) were recorded and compared for two different time periods (up to 24 h postoperatively and from 36 to 48 h postoperatively). The Simplified Acute Physiology Score changes (SAPS)-II between the three groups were also studied. RESULTS: There were 142 patients American Society of Anesthesiology (ASA) I or II enrolled in the study (CR = 71 and CH = 71). There were no significant differences in postoperative SAPS-II scores or lengths of hospital stay (LOS) between the groups. However, in CR patients, the degree of thirst was partially improved by drinking CRLDs (P = 0.027). In CH patients, on the other hand, feelings of thirst, hunger, mouth dryness, nausea and weakness showed significant improvement (P < 0.05). CONCLUSION: Oral administration of carbohydrate-rich liquid drinks (CRLDs) improves the well-being in patients undergoing CH, but the effect is less evident in patients undergoing CR. No significant improvements were seen in clinical status or in length of hospital stay in either group. TRIAL REGISTRATION: ANZCTR.org.au: ACTRN12614000995673 (registered on 16/09/2014).

Maxillofacial fractures: twenty years of study in the department of maxillofacial surgery in kosovo.

THE AIM: The aim of this study was to analyze maxillofacial region fractures during the past 20 years in the Department of Maxillofacial Surgery in Prishtina. METHODS: We have analyzed the histories of all patients with trauma who were hospitalized in the Department of Maxillofacial Surgery in Prishtina since the opening of the clinic in 1983 through 2005. Narrowing the subject of our research, we concentrated on fractures of the maxillofacial region treated at the Clinic of Maxillofacial Surgery for the period 2001-2005. We have analyzed those fractures and compared them with the period from 1983 to 2005 only when it was reasonable. RESULTS: During this period, 1,945 patients were treated for trauma in the maxillofacial region by the Department of Maxillofacial Surgery. This group included 19.8% females and 80.2% males. The largest age group were those between 20 and 20 years of age. Causes of trauma for both periods were predominantly traffic accidents; however, during the period 2001-2005, interpersonal conflicts were increasingly the cause of fractures. CONCLUSION: Interpersonal conflict as a cause of maxillofacial trauma has risen in recent years. With this increase the methods of treating fractures in this region are also changing.

Intravenous lidocaine suppresses fentanyl-induced cough in Children.

OBJECTIVE: Fentanyl-induced cough is usually mild and transitory, but it can be undesirable in patients with increased intracranial pressure, open wounds of the eye, dissecting aortic aneurism, pneumothorax, and reactive airway disease. The aim of this study is to evaluate the efficacy of lidocaine in suppressing fentanyl-induced cough in children during induction in general anesthesia. METHODS: One hundred and eighty-six children of both sexes, aged between 4-10 years, ASA physical status I and II, and scheduled for elective surgery, were recruited for the study. Patients with a history of bronchial asthma, obstructive pulmonary disease, or infections of the respiratory tract were excluded. Patients were randomly allocated to three equal groups (n = 62) to receive 1.0 mg/kg lidocaine (Group I), 0.5 mg/kg lidocaine (Group II), or placebo (equal volume of 0.9% saline; Group III). Each was administered over 5 s one minute before intravenous (IV) administration of fentanyl 2-3 µg/kg during induction in general anesthesia. The severity of coughing was graded by counting the number of episodes of cough: mild (1-2), moderate (3-4) or severe (5 or more). RESULTS: Demographic information was comparable between groups. The most frequent coughing was observed in the placebo group (Group III; 43.5%), of whom 4.8% (three patients) were graded with severe cough. In Group II, 22.6% patients had cough, of which 1.6% (one patient) was graded as severe. In Group I, 16.1% patients had cough, none of whom were graded as severe. CONCLUSION: Our results demonstrate that IV lidocaine can markedly suppress fentanyl-induced cough in children, even in doses as low as 0.5 mg/kg.

Postoperative analgesia in children after propofol versus sevoflurane anesthesia.

OBJECTIVE: Postoperative analgesia remains a problem, especially in pediatric patients. We hypothesize that patients anesthetized with sevoflurane have more postoperative pain than with propofol. DESIGN: Randomized, prospective, double-blind study. SETTING: University teaching hospital. SUBJECTS: The subjects were 88 premedicated children, aged 3-6 years, and American Society of Anesthesiologists (ASA) Physical Status I or II. INTERVENTIONS: Subjectsunderwent hernia repair surgery. METHODS: Anesthesia was maintained with propofol (group P, N = 46) or sevoflurane (group S, N = 42) and fentanyl was administered during surgery. All children before surgical incision received 40 mg/kg paracetamol, rectally. Prior to wound closure, the margins were infiltrated with 0.5% bupivacaine. OUTCOME MEASURES: The primary outcome was pain score assessed by Faces Pain Scale (FPS) 2 hours postoperatively. The secondary outcomes included recovery time and adverse events within the first 2 hours. RESULTS: Group S had a significantly higher proportion of patients who exhibited postoperative pain than group P (24.3% vs 4.5%, respectively; P < 0.05). FPS score in group P was 1.2 ± 0.6, compared with 3.4 ± 1.5 in group S (P < 0.001). Mean recovery time in group S was significantly shorter than the corresponding mean for group P (10.1 ± 1.3 vs 16.5 ± 5.4 minutes, respectively; P < 0.001). CONCLUSION: In children, anesthesia maintenance with propofol was associated with a significantly lower incidence of postoperative pain than with sevoflurane.

Intrathecal clonidine added to small-dose bupivacaine prolongs postoperative analgesia in patients undergoing transurethral surgery.

INTRODUCTION: The aim of this prospective, double-blinded study was to investigate the effects of clonidine in co-administration with bupivacaine during spinal anesthesia, regarding the onset and regression of motor and sensory block, postoperative analgesia and possible side effects. METHODS: We randomly selected 66 male patients (age 35 to 70), from the American Society of Anesthesiologists (ASA) class I-II; these patients were scheduled for transurethral surgical procedures. These patients were randomly allocated into two groups of 33 patients each: group B (bupivacaine) only received 0.5% isobaric bupivacaine 7.5 mg intrathecally and group BC (bupivacaine + clonidine) received bupivacaine 7.5 mg and clonidine 25 µg intrathecally. We performed the spinal anesthesia at a level of L3-L4 with a 25-gauge needle. We assessed the sensory block with a pin-prick, the motor block using the Bromage scale, analgesia with the visual analog scale and sedation with the modified Wilson scale. We also recorded the hemodynamic and respiratory parameters. RESULTS: The groups were demographically similar. The mean time of achievement of motor block (Bromage 3) and sensory block at level T9 was significantly shorter in the BC group compared with B group (p = 0.002, p = 0.000, respeectively). The motor block regression time was not significantly different between the two groups (p = 0.237). The postoperative analgesia requirement was significantly longer in group BC compared with group B (p = 0.000). No neurological deficit, sedation or other significant adverse effects were recorded. CONCLUSION: The intrathecal application of clonidine in combination with bupivacaine improves the duration and quality of spinal anesthesia; it also provides longer duration of postoperative analgesia, without significant side effects.