Neonatal brain abscess development following fetal scalp electrode placement: a rare complication.

A fetal scalp electrode (FSE) is a frequently used investigation during labor. However, it is an invasive procedure which can lead to complications. Our patient developed a very large brain abscess after initial superficial infection of the skin site due to an FSE. The patient was admitted to the hospital after an asymmetric growth of the skull was noticed with no further signs of clinical illness. MRI showed a very large brain abscess which was aspirated and treated with antibiotics for 10 weeks. A 2-year follow-up showed only a slight developmental delay in gross motor skills. Only once before a similar case has been described at which the patient developed a brain abscess after superficial infection of the scalp following an FSE. In both cases, the brain abscess was noticed due to an asymmetric growth of the skull without any further signs of clinical illness. A brain abscess has a high mortality and morbidity rate, and early diagnosis is vital for the optimal outcome. We therefore recommend to organize an out-patient clinical follow-up for every infant with a superficial infection of the skin site after placement of an FSE.

Holographic patient tracking after bed movement for augmented reality neuronavigation using a head-mounted display.

BACKGROUND: Holographic neuronavigation has several potential advantages compared to conventional neuronavigation systems. We present the first report of a holographic neuronavigation system with patient-to-image registration and patient tracking with a reference array using an augmented reality head-mounted display (AR-HMD). METHODS: Three patients undergoing an intracranial neurosurgical procedure were included in this pilot study. The relevant anatomy was first segmented in 3D and then uploaded as holographic scene in our custom neuronavigation software. Registration was performed using point-based matching using anatomical landmarks. We measured the fiducial registration error (FRE) as the outcome measure for registration accuracy. A custom-made reference array with QR codes was integrated in the neurosurgical setup and used for patient tracking after bed movement. RESULTS: Six registrations were performed with a mean FRE of 8.5 mm. Patient tracking was achieved with no visual difference between the registration before and after movement. CONCLUSIONS: This first report shows a proof of principle of intraoperative patient tracking using a standalone holographic neuronavigation system. The navigation accuracy should be further optimized to be clinically applicable. However, it is likely that this technology will be incorporated in future neurosurgical workflows because the system improves spatial anatomical understanding for the surgeon.

Recurrence and survival after abdominoperineal and low anterior resection for rectal cancer, without adjunctive therapy.

Sphincter-saving operations for rectal cancer are performed with increasing frequency. In the present study outcome after low anterior resection (LAR) was compared with outcome after abdominoperineal resection (APR). Morbidity, mortality, local and distant failure and survival were retrospectively studied in 68 patients, surgically treated for rectal cancer without adjunctive therapy between 1980 and 1985. APR was performed in 29 patients (27 for cure) and LAR in 39 (32 for cure). Mean follow-up time was 60 months (range 39-95 months). Groups were comparable with regard to age and Dukes' staging, but not for location of the tumour. Anastomotic leakage was present in 15% after LAR; morbidity was otherwise similar in both groups. Hospital mortality was 5% after LAR and 0% after APR. Local recurrence occurred after a mean period of 17 months: in 15% after curative APR and in 13% after curative LAR. Distant recurrence was detected after a mean period of 28 months: in 30% after curative APR and in 26% after curative LAR. Estimated cumulative 5-year survival was not statistically different, with 72% after LAR and 59% after APR. These findings confirm that LAR does not lead to higher recurrence than APR in the treatment for rectal cancer.

Continuous intravenous ammonia infusion as a model for the study of hepatic encephalopathy in rabbits.

To obtain a more precise pathophysiological evaluation of the role of ammonia in acute hepatic encephalopathy, we compared the plasma ammonia concentrations and electroencephalographic recordings (EEGs) of rabbits with surgically induced acute hepatic failure (AHF, n = 10) and normal rabbits administered an infusion of ammonium acetate (NH4-Ac, n = 7) over a 10-hr period. AHF was surgically induced by portocaval shunting followed by hepatic artery ligation 48 hr later. In the infusion group the dose of NH4-Ac, initially 0.78 mmol/kg/hr, was increased every 2 hr by 0.13 mmole/kg/hr during a 10-hour period to simulate the arterial NH3 concentrations observed in AHF. Ammonia levels in rabbits administered the NH4-Ac infusion were identical to those observed in AHF, with the exception of the higher initial value in the AHF group. Moreover, the mean rates of increase in grade of encephalopathy in the two groups were similar, although the EEG grades in the infusion group were significantly less at all time points. In conclusion, this study demonstrates that a more pathophysiological approach to identification of the putative toxins in hepatic encephalopathy is feasible. Some of the EEG abnormalities of acute hepatic encephalopathy in rabbits are presumably due to hyperammonemia; the encephalopathy observed in AHF at zero time is probably caused by the previously constructed portocaval shunt via an undefined, but possibly also ammonia-related, mechanism.

Pneumoperitoneum without peritonitis.

Usually, pneumoperitoneum is due to perforation of a hollow abdominal organ. In the absence of peritoneal symptoms, pneumoperitoneum may be due to other causes. Two patients with an unnecessary laparotomy for pneumoperitoneum without peritonitis are presented. More knowledge of the less frequent causes of pneumoperitoneum without peritonitis can possibly contribute to refraining from exploratory laparotomy in these cases.

Recurrent bleeding from cutaneous venous collaterals in portal hypertension.

In portal hypertension, three types of cutaneous portosystemic collaterals may develop: the 'classical' caput Medusae, enterostomal varices and scar or adhesion-related abdominal collaterals. Two patients were treated with severe and recurrent bleeding from adhesion-related collaterals, a complication not reported previously. In the first patient bleeding was only controlled by mesocaval shunt operation; the second patient suffered no further recurrence after local sclerotherapy.

A simple technique for endotracheal intubation in rabbits.

A technique for endotracheal intubation in rabbits, which eliminates the need for tracheostomies, special devices, laryngoscopes and guide wires, is described. Inhalation anaesthesia with controlled ventilation for major surgical procedures in rabbits is easier to perform than previous reports in the literature suggest.

A surgical model of fulminant hepatic failure in the rabbit: different effects of end-to-side versus small-diameter side-to-side portacaval shunt.

We developed a rabbit model of fulminant hepatic failure by way of a two-staged total liver devascularisation procedure. For the first-stage procedure (portosystemic shunting), the clinical, biochemical and electro-encephalographic courses in 6 rabbits (group I) with an end-to-side portacaval shunt (ETS-PCS), 6 rabbits (group II) with a small-diameter side-to-side portacaval shunt (STS-PCS) and 6 rabbits (group III) with the same STS-PCS and 48 h of pretreatment with oxytetracycline were investigated and compared to 6 sham rabbits (group IV). The limited survival, the fall in clotting factors and the rapid development of hyperammonaemia with encephalopathy within 48 h in group I point to ETS-PCS-associated ischaemic liver necrosis. Group II showed improved survival, but was associated with portosystemic encephalopathy. Rabbits in group III survived portosystemic surgery without development of marked encephalopathy. In all animals of group III, the second-stage procedure (tightening of the loose ligature around the afferent hepatic vessels) could be performed, and a suitable model of fulminant hepatic failure was obtained.

A nonelemental versus an elemental diet for early postoperative enteral feeding by needle catheter jejunostomy.

In a prospective randomised study the use of an elemental versus a nonelemental diet for early postoperative enteral feeding by needle catheter jejunostomy was investigated. After extensive gastrointestinal surgery, 25 patients received an elemental and 24 patients a nonelemental diet. The incidence of diarrhoea, the effects of the feeding and the costs were evaluated. The occurrence of diarrhoea was observed more frequently in the elemental diet group (14 25 ) compared to the nonelemental diet group (7 24 ), although this difference was statistically not significant (p > 0.05). No difference was found between the two groups in postoperative restoration of total protein and serum albumin levels and the extent of the postoperative weight loss. The costs showed a clear difference: the nonelemental diet was three times cheaper than the elemental diet. For early postoperative enteral feeding by needle catheter jejunostomy we therefore recommend the use of a nonelemental diet.

A procedure for arterial blood sampling in the rabbit.

The ear vessels in the rabbit appear to be easily accessible for blood puncturing. Several measures are described to overcome problems of vascular spasm and uncontrolled movements of the animal during injection.

Intermittent bleeding from anorectal varices.

A patient with anorectal varices is reported. Anorectal varices are a rare cause of rectal bleeding and are often erroneously diagnosed as bleeding hemorrhoids. However, the subcutaneous extension of the varices should alert the clinician. Although local treatment such as ligation of the varices has been advocated, in the presence of portal hypertension a more radical operation is recommended. A portosystemic shunt, preferably between the inferior mesenteric vein and the vena cava or renal vein, is then the treatment of choice.

In vivo experiments with powder charcoal haemoperfusion (filmadsorber) in a pig model of hepatic failure.

The filmadsorber, an experimental haemoperfusion column containing activated powder charcoal embedded in a colloidal film, has been tested in pigs with ischaemicnecrosis of the liver. Haemoperfusion with a flow of 200 ml/min was performed for a duration of 4 to 6 hours. Bile acid clearances varied between +/- 52 ml/min (1st hour) and +/- 23 ml/min (6th hour). Clearances for aromatic amino acids were initially even higher (phenylalanine 115, tyrosine 112 and methionine 46 ml/min). No ammonia was removed. Side-effects were minimal, although platelets fell 24 +/- 15%. We conclude that haemoperfusion with the filmadsorber is well tolerated and associated with high clearances for bile acids and some amino acids, particularly in the first hours of treatment.