Anaesthesia for massive retrosternal thyroidectomy in a tertiary referral centre.

BACKGROUND: Retrosternal goitre (RSG) is an uncommon problem encountered rarely by anaesthetists working outside specialized head and neck (H&N) surgical units. Traditional anaesthetic teaching warns of difficult airway management in these patients. The incidence and extent of these problems is unclear. METHODS: We have performed a retrospective review of the anaesthetic management all patients with massive RSG (extending to the aortic arch or beyond) presenting for thyroidectomy at University Hospital Aintree from January 2007 to May 2012. RESULTS: Five hundred and seventy-three patients underwent a thyroidectomy procedure at Aintree University Hospitals NHS Foundation Trust (AUH) between January 2007 and May 2012. Of these, 34 cases were documented as having a RSG. Review of each patient's preoperative computerized tomography imaging identified 19 patients with massive RSG. There was one case of failed intubation. All other patients underwent uneventful tracheal intubation via direct laryngoscopy. All glands were removed through the neck with no requirement to proceed to sternotomy. There were no instances of postoperative respiratory problems or tracheomalacia. Three patients suffered recurrent laryngeal nerve (RLN) injuries. CONCLUSION: When managed within a dedicated H&N operating theatre we have found a low incidence of difficult tracheal intubation, difficult mechanical ventilation nor postoperative respiratory difficulties in patients with massive RSG and mid-tracheal compression because of benign multi-nodular goitre. Surgical complications, however, are more frequent than those associated with cervical thyroidectomy with RLN injury and postoperative bleeding more likely.

Cardiac papillary fibroelastoma: an immunohistochemical investigation and unusual clinical manifestations.

Cardiac papillary fibroelastoma (CPF) is a morphologically distinctive, but rare, cardiac lesion that is usually found incidentally at autopsy or during open heart surgery. Because of improved diagnostic imaging techniques, the premortem or preoperative diagnosis of CPF is becoming more frequent. The histogenesis of CPF, however, remains controversial. Herein we report an immunohistochemical investigation of 11 cases of CPF; two cases showed unusual embolization phenomena, including one with histologically documented pulmonary arterial embolism. For comparison, nine cardiac myxomas (CMs) and eight examples of organizing thrombi were also studied. Immunohistochemical markers included keratin, vimentin, collagen type IV, muscle-specific actin, desmin, factor VIII-related antigen, CD34, and S-100 protein. The cells covering the surface of both CPFs and CMs were positive for vimentin, factor VIII-related antigen, and CD34, in keeping with their presumed vascular endothelial origin. Interestingly, the surface lining cells were also positive for S-100 protein in all CPF and in eight of nine CMs. In CPF, collagen type IV showed multilayered linear staining beneath the surface that was virtually identical to the staining pattern for elastic tissue. The major immunophenotypic difference between CPF and CM is the frequent presence of muscle-specific actin in the stellate cells of the stroma in CM but not in CPF. Although this study did not clarify whether CPF is a hamartomatous, neoplastic, or reparative process, it demonstrated active participation of the surface endothelial lining cells with excessive formation of basal membrane material in the formation of CPF.

Effect of epinephrine on intrathecal fentanyl analgesia in patients undergoing postpartum tubal ligation.

Eighty women receiving spinal anesthesia for postpartum tubal ligation were entered into a double-blind, randomized protocol studying the effects of epinephrine on intrathecal fentanyl-induced postoperative analgesia. All patients received 70 mg hyperbaric lidocaine with either 0.2 mg epinephrine (LE), 10 micrograms fentanyl (LF), epinephrine and fentanyl (LFE), or 0.4 ml saline (L). Onset and regression of anesthesia, degree of intraoperative comfort, incidence of pruritus, and extent of postoperative analgesia were evaluated. The simultaneous administration of epinephrine and fentanyl prolonged the duration of complete analgesia (137 +/- 47 min (LFE); 76 +/- 32 min (LE); 85 +/- 44 min (LF); 65 +/- 36 min (L)) and the duration of effective analgesia (562 +/- 504 min (LFE); 227 +/- 201 min (LE); 203 +/- 178 min (LF); 198 +/- 342 min (L)). Administration of epinephrine decreased the incidence of pruritus associated with intrathecal fentanyl (1/18 (LFE); 1/21 (LE); 8/19 (LF); 2/19 (L)).

Elastic stockings in the control of hand oedema.

Elastic support and compression in the form of an elastic finger stall or glove seems to be a simple and comfortable way to obviate and reduce oedema of the hand and fingers after surgery or trauma. It may also prove useful in inflammatory conditions such as rheumatoid arthritis, though the authors have not used it as yet for that condition.

Successful replantation of an avulsed scalp by microvascular anastomoses.

A totally avulsed scalp was replanted by microvascular anastomoses. This was feasible because suitable vessels were available in the superficial temporal region, and because the detached scalp was otherwise largely undamaged.

A method of bloodless circumcision.

A method of circumcision is described which allows accurate removal of the correct amount of tissue. The method is based on the concept of removal of a flat strp of skin rather than a fold. The removal of the correct amount of tissue with the minimal amount of bleeding and minimal risk to the frenal vessels is effected. The treatment after operation is simple and the results are invariably satisfactory. Damage to the urethra and glans is virtually impossible. Delineation of the incisions with ink before beginning is an important step in the procedure.