Pain relief following thoracoscopic sympathectomy for palmar hyperhidrosis: a prospective randomised double-blind study.

BACKGROUND: Acute pain management following thoracoscopic sympathectomy (TS) has been described in the literature. The combination of interpleural (IP) injection of bupivacaine and intramuscular injection. (I.M) NSAIDs has not been reported. Therefore we conducted this randomized controlled trial to compare this technique to other reported techniques described for postoperative analgesia following TS. METHODS: 40 patients scheduled to have TS under general anesthesia for the treatment of hyperhidrosis were randomly allocated into 4 groups. Group 1 received 1.5 mg/kg b.w I.M pethidine at end of surgery. Group 2 received ketoprofen 100 mg I.M at end of surgery. Group 3 received 0.4 ml/kg b.w interpleural bupivacaine 0.5%. Group 4 received a combination of I.M ketoprofen (100 mg) in addition to interpleural bupivacaine (0.4 ml/kg). Postoperative pain was assessed using the 11- point numeric rating score (NRS) at 7 different intervals. First, immediately on admission to PACU, every 2 hours for the next 8 hours then at 12 and at 24 hours. Pain was assessed at rest, during deep inspiration and while coughing. ANOVA was used for statistical analysis and Chi-square test for comparing of the data where P values <0.05 were considered significant. RESULTS: The NRS at rest was 3.2 (1.9), 2.4 (1.6), 3 (1.9) and 0.7 (0.9) at Groups 1, 2, 3 and 4 respectively with significant difference in Group 4 versus other Group (P < 0.05) at 2 hours postoperatively and up to 24 hours postoperatively. The same trend was also found during maximal inspiration and while coughing. Opioid consumption in 24 hours was significantly reduced in Group 4 compared to other Groups. CONCLUSIONS: Combination of IP bupivacaine and I.M ketoprofen provided superior analgesia when compared to each modality alone and was better than intramuscular pethidine injection in terms of NRS and the consumption of rescue morphine postoperatively. Further studies are needed on large sample size to confirm our results.

Anaesthesia for morbidly obese patients: a study of haemodynamic changes during bariatric surgery.

BACKGROUND AND AIMS: Morbid obesity with body mass index (BMI) > 40 kg/m2 requires surgical correction if the diet program fails. Laparoscopic adjustable gastric banding (LAGB) (bariatric surgery) is the standard surgical procedure. The haemodynamic effects of the typical pneumoperitoneum had been studied but, the additional effects of morbid obesity and the consequences of LAGB surgery had not. Therefore, we conducted this study to determine the haemodynamic changes under anaesthesia during bariatric surgery. MATERIALS AND METHODS: Under general anaesthesia, 7 patients (4 males) were studied. Their mean age was 36.2 yr (range 25-50 yr) and mean BMI was 49.7 kg/m2 (range 39.3-67.3). Besides routine monitoring of vital signs, non invasive cardiac output monitor (NICO, Novametrix, Wallingford, CT, USA) was used to monitor cardiac output (CO), cardiac index (CI) and stroke volume (SV). All the haemodynamic variables were taken at three phases: A) after induction of anaesthesia, B) during pneumoperitoneum and C) after gas deflation. RESULTS: The mean HR and BP showed significant high values during phase B compared to phase A. The mean values of CO were 7.2 +/- 1.1 and 9.06 +/- 2.6 L/min during phases A and B respectively with significant differences. The mean values of SV were 91.1 +/- 12.3 and 123.2 +/- 42.6 ml during phases A and B respectively with significant differences. The mean values of CI during phases A and B were 3.1 +/- 0.7 and 3.4 +/- 1.09 L/min/m2 respectively with significant differences. CONCLUSIONS: We have reported high CO and CI during pneumoperitoneum, which may be due to increased heart rate induced by sympathetic stimulation.

Right vs left side thoracoscopic sympathectomy: effects of CO2 insufflation on haemodynamics.

BACKGROUND AND AIMS: Currently, few reports of the haemodynamic impact of intrapleural CO2 insufflation in the clinical setting are available. Therefore, we conducted the present study to compare the haemodynamic changes between right and left side thoracoscopic sympathectomy (TS) for treatment of palmar hyperhidrosis (PH) under general anaesthesia. MATERIALS AND METHODS: 20 adult patients (17 males) undergoing TS were randomly allocated to two groups (each 10); group A, right side and group B, left side TS procedures were performed under general anaesthesia with single-lumen endotracheal tube. Besides the routine monitoring of vital signs, non-invasive cardiac output monitor (NICO) was used to record the stroke volume (SV), cardiac output (CO) and cardiac index (CI). Intrapleural CO2 insufflation was used. Anaesthesia was maintained with 1 MAC sevoflurane in 50% nitrous oxide in oxygen with incremental doses of sufentanil and atracurium when required. Haemodynamic parameters were obtained every 3 min then averaged over the time of surgery at phases; I) after tracheal intubation, II) after CO2 insufflation and III) after CO2 deflation. RESULTS: The CO, CI and SV showed decreased trend in both groups during phase II compared to phase I with significant differences (P < 0.05). Comparing the CO and CI variables revealed lower values in group A compared to group B but with non-significant differences (P > 0.05). While the SV variable showed significant low value in group A compared to group B (P < 0.05). CONCLUSIONS: Compared to left side TS, direct compression by CO2 against the venae cava and right atrium and ventricle during right side TS caused reduction of the venous return and hence low CO, CI and SV.

Invasive mucormycosis in benign gastric ulcer.

Fungal elements are frequently noted overlying the base of chronic peptic ulcers of the stomach and it has been suggested that the fungi enhance the degree of necrosis and that these cases have protracted disease and deeper ulcers with more perforations. It has also been postulated that the number of fungal elements might be increased in the stomach of patients who are receiving potent medications such as H2-receptor antagonists to reduce gastric acidity, but there have not been adequate control studies, and the deleterious effects from the presence of the fungi in these cases have not been substantiated. We present a very rare case of invasive mucormycosis (phycomycosis) occurring in the base of a chronic gastric ulcer in a 55 years old diabetic male. This case was clinically and radiologically been mistaken for a gastric carcinoma. In addition, the ulcer was complicated by perforation and fungal septicemia with subsequent fatal outcome. The clinical, radiological and histopathological features are described together with a literature review of other reported fungal gastric ulcers.

Laparoscopic placement of peritoneal dialysis catheter (same day dialysis).

BACKGROUND AND OBJECTIVE: Peritoneal dialysis (PD) remains the generally accepted method for management of renal failure in chronic and acute renal failure. Despite the rapidly increasing use of continuous ambulatory peritoneal dialysis (CAPD) since its introduction, controversy persists as to the efficacy and exact role of the modality in the treatment of end stage renal failure. The aim of this paper is to present the experience with laparoscopic placement of a peritoneal dialysis catheter and starting the peritoneal dialysis on the same day. METHODS: The laparoscopic placement of a peritoneal dialysis catheter was performed on 11 patients (10 males and 1 female) with an average age of 35 years, over a 12-month period. The procedure was done using two 5 mm abdominal trocars. The precise position of the catheter on the pelvis was ensured laparoscopically. One to two liters exchange dialysis was used for every patient, and no leakage was recorded. RESULTS: The patients tolerated the procedure well. The peritoneal dialysis was started immediately. Patients were discharged after an overnight stay, and PD was carried out routinely. CONCLUSION: The results of laparoscopic placement of a peritoneal dialysis catheter show the following advantages: minimal incision; less surgical trauma; the procedure hastens the early start of peritoneal dialysis and has no complications.

Transaxillary thoracoscopic sympathectomy experience in a hot climate: management of the dominant hand.

Primary palmar hyperhydrosis is a functionally and socially disabling problem of unknown etiology, affecting adolescents and young adults, especially in hot climates. Thoracoscopic sympathectomy is the most effective treatment for palmar hyperhydrosis. Postsympathectomy rebound hyperhydrosis may limit its success, especially in hot climates. The aim of this study is to report experience with thoracoscopic sympathectomy in a hot climate, managing the dominant hand (unilateral), followed by the other hand at a later date, based on the patient's choice. One hundred twenty patients were operated on during a 3 year period. The mean operative time was 25 minutes. The procedure was successfully completed in 169 operated limbs and was abandoned in one limb because of severe pleural adhesions. The procedure was done for the dominant hand (unilateral) in 120 patients. Fifty patients returned for contralateral thoracoscopic sympathectomy. There were 18 postoperative complications. Most of the patients (95%) were discharged after an overnight stay. The early observed cure rate was high (97%). During the mean follow-up period of 300 days, there was no recurrence of the original symptoms, except for one patient in whom the nerve of Kuntz was found and diathermized on the second thoracoscopy with symptomatic relief. Rebound hyperhydrosis occurred in 40 patients (33% of the total; 21% in the unilateral group and 42% in the bilateral group). In conclusion, it seems that transaxillary endoscopic sympathectomy of the dominant hand is an alternative method of treatment for patients with hyperhydrosis. Managing the dominant hand first and giving the patient the chance to observe the severity of the rebound hyperhydrosis may facilitate the decision for contralateral sympathectomy.

The beneficial effect of alpha-tocopherol on liver regeneration after partial hepatectomy on rats.

Liver, a unique organ, is the only organ which has the ability to regenerate after partial hepatectomy. It can return to normal mass several weeks after 70% partial hepatectomy. The exact mechanism responsible for regeneration is yet to be known. This needs further investigation. The aim of this study is to examine the role of oxygen free radicals (OFRs) such as superoxide (O(-)2), hydroxyl radicals (H2O2 or OH(-)) in liver regeneration after partial hepatectomy (< 70%). To evaluate the effect of antioxidant on liver regeneration, rats were pre-treated intramuscularly with alpha-tocopherol (vitamin E) daily for 3 weeks, and continued for 3 weeks post partial hepatectomy (< 70%) liver weight, rat body weight were determined in both control (untreated) and treated groups. The present results showed significant increase in liver weight in vitamin E treated group compared to control. The results of this paper might be useful in throwing some light on the role of oxygen free radical scavengers and antioxidants upon liver regeneration. This would have a therapeutic utilization in patients with liver problems.

Effect of previous sclerotherapy on the outcome of gastro-oesophageal devascularization and oesophageal transection in bleeding oesophageal varices.

This retrospective analysis studied the effect of sclerotherapy on subsequent oesophageal transection in the management of patients with bleeding oesophageal varices and compared the result with that in those who did not receive sclerotherapy as the primary treatment. Fifty patients were treated by gastro-oesophageal devascularization and oesophageal transection for bleeding oesophageal varices over a 4-year period. Twenty-six patients did not receive sclerotherapy (group 1) and 24 received between one and four sessions of sclerotherapy (group 2) before surgery. Oedema and thickness of the lower end of the oesophagus and some adhesions were noted during surgery in patients who had had previous sclerotherapy; however, stapled oesophageal transection and anastomosis could be performed in all these patients. There was no oesophageal leak in any patient, although there was a higher rate of chest complications (nine versus six patients) in group 2. Six patients (12 per cent) died (three in each group) during the postoperative period; three had Child grade C disease. It is concluded that the decision to operate to control bleeding varices should be made early. One or two sessions of sclerotherapy before surgery does not increase intraoperative difficulty or the postoperative leak rate following oesophageal transection. The outcome of surgery is directly related to the state of liver reserve (Child grade).

The potential synergistic effect of calcium channel blockers and alpha-tocopherol on gastric mucosal injury induced by ischaemia-reperfusion.

METHODS AND RESULTS: Acute oral administration of various doses of alpha-tocopherol (100, 600, 1200 mg/kg by mouth) produced a dose dependent and significant protection of mucosal injury induced by ischaemia-reperfusion injury in experimental animals. In addition, intraperitoneal administration of calcium channel blockers, nifedipine (0.5, 1, 3 mg/kg), diltiazem (1.25, 2.5 mg/kg) and verapamil (1.25, 2.5, 5, 10 mg/kg) protected gastric mucosa in ischaemia-reperfusion. alpha-Tocopherol (100 mg/kg by mouth), when given in combination with either nifedipine (0.5 mg/kg intraperitoneally), diltiazem (1.25 mg/kg intraperitoneally) or verapamil (1.25 mg/kg intraperitoneally), significantly reduced gastric mucosal injury. The protective effect of calcium channel blockers and the antioxidant agent was synergistic. CONCLUSION: The results showed that calcium channel blockers potentiate the protective effect of the antioxidant activity of alpha-tocopherol on gastric mucosal injury induced by ischaemia-reperfusion in experimental animals.

Role of oxygen-derived free radicals on gastric mucosal injury induced by ischemia-reperfusion.

A free radical is an unstable and highly-reactive chemical species capable of independent existence that contained one or more unpaired electrons in its outer orbital. A number of oxygen-derived free radicals (ODFRs) have been identified. However, superoxide (O(-)(2) and hydroxyl (OH*) radicals are extensively studied. The univalent reduction of oxygen to water produces a number of highly-reactive chemical intermediates such as O(-)2 and OH*, which are commonly-known as oxygen-derived free radicals. ODFRS may be formed from several sources as follows: a) mitochondrial cytochrome oxidase, b) xanthine oxidase, c) neutrophils and d) transitional metals. There are several important defense mechanisms to limit or to prevent the damage caused by excessive ODFRs activity. These antioxidant defenses can be divided into a) enzymatic defense mechanisms such as: superoxide dismutase (SOD): catalase: selenium-containing glutathione peroxidase and b) non-enzymatic defense mechanisms including: alpha-tocopherol; ascorbic acid; glutathione and any sulfhydryl-containing compounds.

The pattern of respiratory burst of leucocytes in patients with Echinococcus granulosus.

The function of polymorphonuclear leucocytes (PMN) of patients with hydatidosis was investigated. The patients were divided into three categories according to the characteristics of the cyst (calcified, alive and dead cyst). Healthy blood donors were used as a control group. The oxidative activity of PMN was determined by chemiluminescence (CL) assay. Reduction of ferricytochrome C was used to measure the superoxide (O2-) production. Phagocytosis was monitored by opsonized yeast uptake. The results showed that the CL response, O2- production and phagocytic index of PMN, significantly increased in patients with dead cysts compared with healthy subjects while in patients with live cysts there was a marked reduction. No significant changes were noticed in patients with calcified cysts. These data indicate that the PMN of infected patients were in an activated state both functionally and metabolically.

Acute appendicitis complicating pregnancy.

Appendicitis occurring during pregnancy presents a difficult problem for both the treating gynecological and the surgeon. We studied retrospectively the cases of 52 consecutive patients seen during a four-year period at Riyadh Central Hospital, a large and busy general hospital. The incidence of appendicitis in various stages of pregnancy, along with its symptomatology, physical signs, laboratory results, and operative findings, were analyzed. The rates of complications, especially maternal and fetal mortality, were also analyzed and findings compared with those reported elsewhere. There was no maternal morbidity and a 4% fetal mortality. We concluded that an aggressive approach in the diagnosis and surgical management of these patients reduces the maternal and fetal mortality.