Surgical outcomes of macular hole and epimacular membrane treatment in patients with intraoperative amaurosis under sub-Tenon's anesthesia.

OBJECTIVE: Some patients have been found to develop intraoperative amaurosis under sub-Tenon's anesthesia. We explored whether these patients have poor surgical outcomes during mid- to long-term postoperative follow-up. METHODS: In this case series, 74 of 85 patients with macular diseases who underwent phacoemulsification combined with vitrectomy under sub-Tenon's anesthesia developed intraoperative amaurosis. The surgical outcomes at the 2- and 4-month follow-ups in these patients were investigated and compared with the outcomes in patients without amaurosis using best-corrected visual acuity (BCVA), optical coherence tomography (OCT), and pattern visual evoked potential (PVEP). RESULTS: Both BCVA and the OCT-based macular structure in patients with intraoperative amaurosis showed significant postoperative improvement comparable with that of patients without amaurosis. The presence of intraoperative amaurosis was not associated with either macular hole closure or macular edema regression. PVEP revealed no significant changes in the wave latency or amplitude before and after surgery. CONCLUSION: Intraoperative amaurosis following sub-Tenon's block is commonly seen but does not predict a poor surgical prognosis. When a patient develops amaurosis during surgery, the surgeon should increase patient comfort through verbal communication rather than perform an additional intervention to help relieve the patient's anxiety.

Clinical outcomes of medial collateral ligament injury in total knee arthroplasty.

Intraoperative injury to the medial collateral ligament (MCL) during total knee arthroplasty (TKA) is a rare but severe complication. The main treatment methods are primary repair and revision with a more constrained implant; however, the clinical outcomes of primary reconstruction without a constrained implant have rarely been reported.A retrospective study was performed to evaluate the prevalence of iatrogenic injury to the MCL during primary TKA, and to report the clinical outcomes of MCL reconstruction without the use of a constrained device.A total of 1749 patients (2054 knees) underwent primary TKA between 2007 and 2013 and were retrospectively evaluated. Seventeen patients (0.83%) experienced an MCL injury intraoperatively, and the remaining 1732 patients (2037 knees) were considered as the controls. We attempted to reconstruct the MCL with an unconstrained prosthesis in all patients. The Knee Society Score (KSS) was used to evaluate knee function after an average 51-month follow-up (range, 36-72 months).No patients were lost during the follow-up period. In the MCL injury group, the mean KSS was 84.7 for function and 87.7 for pain, while the scores were 87.9 and 90.6, respectively, in the control group. No patient treated with MCL reconstruction without increased prosthetic constraint experienced knee instability requiring revision.MCL reconstruction without a constrained implant achieved excellent results for MCL injury during TKA. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Daño medular intraoperatorio en cirugía de escoliosis idiopática: reinstrumentar y cuándo / Spinal cord injury as a complication of idiopathic scoliosis surgery: when to plan a new surgical procedure

La lesión medular es una complicación temida y devastadora del tratamiento quirúrgico de la escoliosis idiopática. Su prevención requiere una técnica quirúrgica y anestésica depurada y potenciales evocados somatosensoriales (PESS) y motores (PEM) intraoperatorios para poder instaurar rápidamente medidas neuroprotectoras, entre ellas la desinstrumentación vertebral. Es esperable que la escoliosis continúe progresando posteriormente. Presentamos el caso de una niña de 12 años, con una escoliosis juvenil grave y progresiva, que en la cirugía correctora sufre una lesión medular espinal. A pesar de la buena evolución neurológica, la deformidad vertebral sigue progresando y se replantea la reinstrumentación vertebral, con su inherente riesgo de relesión medular y secuelas finales más graves. En conclusión, el manejo de las escoliosis progresivas graves que coexisten con daño medular debe individualizarse. La gravedad de las secuelas neurológicas parece aumentar la progresión de la deformidad ortopédica y hacer más incierta la respuesta a cualquier tratamiento posterior (AU)

Spinal cord injury (SCI) is a dreaded and devastating complication of the surgical treatment of idiopathic scoliosis. Its prevention requires meticulous surgical and anaesthetic procedures and combined monitoring of somatosensory (SEPs) and motor (PEM) evoked potentials to quickly establish neuroprotective measures such as pedicle screw removal. It is expected that the scoliosis keeps progressing afterwards. We report the case of a 12-year-old girl who had a spinal cord injury during scoliosis corrective surgery. Despite the good neurological outcome, the spinal deformity continues to progress and a new surgical procedure might be considered, with its inherent risk of a second SCI and more serious neural damage. In conclusion, the management of progressive scoliosis that coexists with an SCI must be individualized. The severity of neurologic sequelae seems to worsen the progression of spinal deformity and make the response to any subsequent treatment more uncertain (AU)

Facial nerve repair after operative injury: Impact of timing on hypoglossal-facial nerve graft outcomes.

PURPOSE: Reanimation of facial paralysis is a complex problem with multiple treatment options. One option is hypoglossal-facial nerve grafting, which can be performed in the immediate postoperative period after nerve transection, or in a delayed setting after skull base surgery when the nerve is anatomically intact but function is poor. The purpose of this study is to investigate the effect of timing of hypoglossal-facial grafting on functional outcome. MATERIALS AND METHODS: A retrospective case series from a single tertiary otologic referral center was performed identifying 60 patients with facial nerve injury following cerebellopontine angle tumor extirpation. Patients underwent hypoglossal-facial nerve anastomosis following facial nerve injury. Facial nerve function was measured using the House-Brackmann facial nerve grading system at a median follow-up interval of 18months. Multivariate logistic regression analysis was used determine how time to hypoglossal-facial nerve grafting affected odds of achieving House-Brackmann grade of ≤3. RESULTS: Patients who underwent acute hypoglossal-facial anastomotic repair (0-14days from injury) were more likely to achieve House-Brackmann grade ≤3 compared to those that had delayed repair (OR 4.97, 95% CI 1.5-16.9, p=0.01). CONCLUSIONS: Early hypoglossal-facial anastomotic repair after acute facial nerve injury is associated with better long-term facial function outcomes and should be considered in the management algorithm.

Is the anesthesiologist actually prepared for loss of airway or respiratory function? A cross-sectional study conducted in a tertiary hospital.

OBJECTIVE: To identify compliance with the procedures for securing the airway of patients submitted to anesthesia, defined as highly recommended in the World Health Organization Surgical Safety Checklist. METHODS: A prospective, cross-sectional, observational study was conducted with 87 patients aged 18 to 60 years, classified as ASA grade 1 or 2 according to the American Society of Anesthesiologists' Physical Status Classification. The study variables consisted of: whether the Mallampati test had been performed, whether equipment was readily available for orotracheal intubation, whether the correct placement of the endotracheal tube was verified, whether patient ventilation was monitored and whether fasting was confirmed. Prevalence ratios and their respective 95% confidence intervals were calculated as measures of relative risk. Statistical significance was defined at 5%. RESULTS: It was found that in 87.4% of patients, the airway was not evaluated using the Mallampati classification and in 51.7% of cases, preoperative fasting was not confirmed. In 29.9% of cases, the ready availability of equipment for orotracheal intubation was not verified. In all of the cases in which the availability of this equipment was not checked, the patient was submitted to regional anesthesia, with a statistically significant difference compared to the cases in which the patient was submitted to general anesthesia. CONCLUSION: Measures considered essential for the safety of the patient during surgery are still being ignored.

Is the anesthesiologist actually prepared for loss of airway or respiratory function? A cross-sectional study conducted in a tertiary hospital / O anestesiologista está efetivamente preparado para perda da via aérea ou da função respiratória? Um estudo de corte transversal em hospital terciário

Objective To identify compliance with the procedures for securing the airway of patients submitted to anesthesia, defined as highly recommended in the World Health Organization Surgical Safety Checklist. Methods A prospective, cross-sectional, observational study was conducted with 87 patients aged 18 to 60 years, classified as ASA grade 1 or 2 according to the American Society of Anesthesiologists’ Physical Status Classification. The study variables consisted of: whether the Mallampati test had been performed, whether equipment was readily available for orotracheal intubation, whether the correct placement of the endotracheal tube was verified, whether patient ventilation was monitored and whether fasting was confirmed. Prevalence ratios and their respective 95% confidence intervals were calculated as measures of relative risk. Statistical significance was defined at 5%. Results It was found that in 87.4% of patients, the airway was not evaluated using the Mallampati classification and in 51.7% of cases, preoperative fasting was not confirmed. In 29.9% of cases, the ready availability of equipment for orotracheal intubation was not verified. In all of the cases in which the availability of this equipment was not checked, the patient was submitted to regional anesthesia, with a statistically significant difference compared to the cases in which the patient was submitted to general anesthesia. Conclusion Measures considered essential for the safety of the patient during surgery are still being ignored. .

Objetivo Identificar a realização de procedimentos altamente recomendados para assegurar a via aérea de pacientes submetidos a anestesia, previstos no manual de segurança anestésica da Organização Mundial da Saúde. Métodos Realizou-se um estudo prospectivo do tipo transversal observacional, envolvendo 87 pacientes com idade entre 18 e 60 anos, ASA 1 e 2 de acordo com a classificação do Estado Físico pela Sociedade Americana de Anestesiologia. Variáveis estudadas: realização do teste de Mallampati, disponibilidade de material para intubação orotraqueal, confirmação do posicionamento do tubo endotraqueal, monitoração da ventilação do paciente e confirmação do jejum. Calculou-se a Razão de Prevalência (RP) e o seu Intervalo de Confiança a 95% (IC 95%) como medida do risco relativo. Adotou-se o nível de significância de 5%. Resultados Em 87,4% dos pacientes a via aérea não foi avaliada pelo teste de Mallampati e 51,7% não tiveram seus jejuns pré-operatórios confirmados, e em 29,1% das anestesias não se verificou a disponibilidade de material para intubação orotraqueal. Todos os casos em que não ocorreu esta verificação o paciente foi submetido à anestesia regional, com diferença significativa entre os grupos (p = 0.00). 95,8% dos pacientes tiveram a intubação orotraqueal confirmada pela capnografia e 68% tiveram esta confirmação realizada pela ausculta. Conclusão Medidas consideradas essenciais para a segurança do paciente durante a cirurgia ainda são negligenciadas. .

Anestesia para la craneotomía en el paciente consciente / Anesthesia for craniotomy in the conscious patient

La craneotomía en el paciente consciente (CPC) permite valorar los cambios neurológicos durante la obtención de mapas neurológicos en la cirugía de la epilepsia, la localización de los electrodos durante la cirugía de estimulación cerebral profunda y la extirpación tumoral en áreas elocuentes del cerebro. La CPC consciente es útil para realizar cirugía radical, minimizando el daño en las zonas funcionales del cerebro. El anestesiólogo debe asegurar un adecuado bienestar al paciente, una óptima analgesia y garantizar su colaboración. Se debe realizar una adecuada selección conjunta de los posibles candidatos con todos los profesionales implicados en el caso. El conocimiento de las distintas fases de esta forma de craneotomía, la coordinación y comunicación entre los especialistas, el dominio de la farmacología y de las técnicas anestésicas específicas, junto con la capacidad de comunicación psicoemocional con el paciente, son los determinantes del éxito del procedimiento, que debe someterse, además, a la cultura de seguridad. El objetivo de esta revisión es describir el tratamiento anestésico integral, las consideraciones neurofisiológicas y las complicaciones intraoperatorias de la CPC(AU)

Craniotomy in the conscious patient (CPC) enables the neurological changes to be assessed during the mapping in epilepsy surgery, the location of the electrodes during deep brain stimulation surgery, and tumor resection in eloquent areas of the brain. CPC is a useful technique for radical surgery in order to minimize the damage to the functional areas of the brain. The anesthesiologist must ensure, adequate patient comfort, analgesia and ensure optimal collaboration. The appropriate selection of potential candidates for CPC should be made jointly with all professionals involved in the case. Knowledge of the different phases of CPC, coordination and communication among specialists, the right management of the pharmacology, and anesthetic techniques specific to CPC, along with the ability of psycho-emotional communication with the patient, determine the success of the procedure to be performed in the culture of patient safety. The aim of this review was to describe the anesthetic management, comprehensive considerations, and intraoperative neurophysiological tests for CPC(AU)

Laparoscopic gastric surgery in an enhanced recovery programme.

BACKGROUND: Laparoscopy is associated with less pain and organ dysfunction than open surgery. Improved perioperative care (enhanced recovery programmes, fast-track methodology) has also led to reduced morbidity and a shorter hospital stay. The effects of a combination of laparoscopic resection and accelerated recovery have not been examined previously in the context of gastric surgery. METHODS: This was a prospective study of 32 consecutive patients undergoing laparoscopic gastric resection combined with an enhanced recovery protocol (early oral intake, no drains or nasogastric tubes, no epidural analgesia, use of a urinary catheter for less than 24 h and planned discharge 72 h after surgery). Outcomes included length of hospital stay, intraoperative and postoperative complications, readmission rate and 30-day mortality. RESULTS: Operative procedures were elective distal or subtotal gastrectomy (22 patients) and total gastrectomy (10). Median length of hospital stay was 4 (range 2-30) days. There were two major complications: postoperative bleeding requiring reoperation and pulmonary embolism. Two patients required readmission, one for a wound abscess and one for treatment of a urinary tract infection. There were no deaths within 30 days. CONCLUSION: Minimally invasive gastrectomy with enhanced postoperative recovery results in a short hospital stay and low morbidity rate.

Lesión vascular durante cirugía discal. Caso clínico y revisión de la literatura / Vascular injury during intervertebral surgery. Case report and review of the literature

Las lesiones viscerales (intestinales y ureterales) y vasculares durante la cirugía discal son infrecuentes por lo que, en ocasiones, se omiten en los protocolos de consentimiento informado. Sin embargo, estas lesiones son potencialmente muy graves y tienen un alto porcentaje de mortalidad. A pesar de su rareza, los anestesistas y cirujanos deben tenerlas en cuenta, ya que, en el caso de presentarse, un diagnóstico precoz resulta de vital importancia. Normalmente, los pacientes que logran sobrevivir presentan una recuperación completa sin secuelas de ningún tipo. Se presenta un caso clínico de una rotura de arteria y vena ilíaca común derechas producidas en el transcurso de una discectomía L4-L5 por vía posterior, que requirieron dos intervenciones vasculares. En los meses siguientes la paciente presentó como secuela una plexopatía lumbosacra que afectó a una extremidad y de la que se recuperó parcialmente (AU)

Introduction Visceral (intestinal, uretheral) and vascular damage during intervertebral disk surgery is uncommon; therefore sometimes is excluded of informed consents; however those damages, are potentially life-threatening with high risk of mortality; hence, in spite of their rarity, anaesthetists and surgeons should be watchful since in case of showing up, early diagnosis is vitally important. Usually, patients who survived restore completely without sequels. Clinical case A clinical case of common right iliac artery and vein disruption during posterior L4-L5 discectomy is here discussed. The patient required two vascular interventions. After the surgeries the patient presented a postoperative lower extremity neurologic deficit due to a lumbosacral plexopathy from which she partially recovered during the following months (AU)

[Attention and executive processes in neuropsychological rehabilitation of the visuospatial processes]. / Atencion y funcionamiento ejecutivo en la rehabilitacion neuropsicologica de los procesos visuoespaciales.

INTRODUCTION AND OBJECTIVE: Cognitive deficits following lesions in parieto occipital areas tend to cause, among others, visuospatial and visuoperceptive alterations. The aim of this article is to examine the influence of others possible deficit over its rehabilitation. DEVELOPMENT: We discuss several patients who present visuospatial impairment after different brain injuries, not only those affecting the areas typically involved in these deficits, such as parieto occipital cortex. Rehabilitation was conducted on an individual basis in the brain injury unit of Beata Maria Ana hospital. Neuropsychological evaluation showed some difficulties not previously described together with these deficits, related to attention, working memory and executive functions, as well as topographic disorientation, lack of visuospatial coordination, distances perception disorders and difficulty to mentally rotate objects. The rehabilitation was AIMed not only at restoration but also compensation of visuospatial deficits, successfully achieved after treatment: patients were capable of returning to their daily activities, including their jobs. CONCLUSION: In patients with visuospatial deficits, a compressive neuropsychological evaluation seem to be essential to define the influence of the other cognitive domains over the rehabilitation of visuospatial problems. In particular, the reinforcement of processes related to attention control and executive functions could very important, give their contribution to the learning of compensatory strategies and assuming that those functions pay key role in the organization and supervision demanded for perceptual skills.

Femoral, saphenous nerve palsy after tourniquet use: a case report.

Persistent motor and sensory abnormalities after surgery may affect the rehabilitation process. Patients with continued weakness may be perceived as lacking motivation by health care providers. However, there may be an underlying pathophysiologic abnormality preventing patients from progressing through their rehabilitation programs. We report a case of a 20-year-old man who underwent surgical repair of multiple knee structures with the use of a pneumatic tourniquet. Several weeks after surgery, electromyographic evaluation was done because he was having difficulty in his rehabilitation because of persistent weakness. An electromyography and nerve conduction study (NCS) revealed femoral and saphenous nerve palsies. Our report is the first on tourniquet-induced saphenous nerve injury as well as on abnormal femoral NCSs caused by tourniquet use. A review of the literature indicates that tourniquet-induced nerve palsies are not a rare event. Further evaluation should be considered if patients who are having persistent weakness or sensory findings after surgery have used a tourniquet.

Ureteral injury after anterior lumbar interbody fusion. A case report.

STUDY DESIGN: This case report presents a patient with ureter injury after anterior spinal fusion and its management. OBJECTIVES: To present possible causes, symptoms, diagnostic approach, and management of this rare complication. SUMMARY OF BACKGROUND DATA: The reported complications of anterior surgical approaches to the lumber spine have been predominantly vascular or neurologic. The susceptibility of the ureter to injury is emphasized by the description of an as-yet-unreported case of ureter laceration after anterior lumbar fusion. METHODS: Ureter injury was diagnosed using computed axial tomography, ultrasonography-guided aspiration, and chemical analysis of the aspirate after anterior spinal fusion. RESULTS: Early diagnosis of this injury prompted a ureter stent placement and prevented additional deterioration of renal function and infection. CONCLUSIONS: The ureter is prone to injury if not identified and protected when sharp and pointed instruments are used for retraction. Abdominal mass, low-grade fever, and leukocytosis should prompt use of computed tomography or ultrasonography-guided aspiration.

Complicaciones trans y postoperatorias en la extracción dental: estudio de 81 casos / Trans-operative and post-operative complications for dental extraction a review of 81 cases

Estudio prospectivo que se realizó en 81 pacientes adultos de ambos sexos, a los cuales por indicaciones terapéuticas se les practicaron extracciones dentales por vía alveolar o disección según el caso, con un seguimiento clínico y radiográfico de 12 días a partir de la cirugía. Los procedimientos quirúrgicos se realizaron con instrumental y técnica convencionales, sutura no absorbible y medicamentos sólo en casos indispensables, encontrándose que las complicaciones más frecuentes aunque poco severas fueron la hemorragia leve y el dolor moderado en el postoperatorio inmediato, así como la inflamación y osteítis alveolar aguda pero en menor proporción, en el postoperatorio mediato

[The use of infrared laser radiation in the rehabilitation of IHD patients after the surgical revascularization of the myocardium]. / Ispol'zovanie infrakrasnogo lazernogo izlucheniia v reabilitatsii bol'nykh IBS posle khirurgicheskoi revaskuliarizatsii miokarda.

Application of epicutaneous infrared laser radiation early in the course of postoperative aftercare of patients with coronary heart disease who have undergone myocardial revascularization contributes to improved functioning of the cardiorespiratory system. The laser therapy is indicated in the absence of serious intra- and postoperative myocardial infarctions, postoperative arrhythmia and mediastinitis.

Evaluation and treatment of complications of thyroid and parathyroid surgery.

The major complications of thyroid and parathyroid surgery include hemorrhage, respiratory obstruction, hyperthyroid storm, hypoparathyroidism, and laryngeal nerve injury. In this article, the incidence, diagnosis, and treatment of various complications are reviewed, with emphasis on hypoparathyroidism and vocal cord paralysis, either bilateral or unilateral. Thyroplastic phonosurgery and carbon dioxide laser arytenoidectomy, two recent surgical additions to the rehabilitation of vocal cord paralysis, are described in depth.

Burn care: symposium proceedings, 1988-1989

Burn injuries form a major part of the spectrum of trauma which absorbs so much of the health care resources in developing countries. The Jamaica Burn Programme was established to address this problem, through the collection and analysis of local information about burns and through the education of health and other interested professionals in the prevention and care of burn injuries. The first step was the establishment of a Burn Unit in May 1986 at the 500 bed University Hospital of the West Indies. The following year, a Post Basic Course for nurses was introduced and, to date three groups have graduated from this programme. In June 1988, a three day international symposium was held at the Medical Faculty of the University of the West Indies. One year later, a smaller meeting was held.The papers at both of these covered many relevant areas of burn care and were of excellent quality. The editors consider themselves fortunate to have been able to collect the majority of them for publication. This text is provided for the benefit of those who have the responsibility for promoting burn prevention or for caring for those with burn injuries (AU)

Complications of intra-articular anterior cruciate reconstruction.

Intra-articular reconstruction of the ACL is a powerful technique, but is associated with a variety of potential complications. Careful patient selection, precise intraoperative technique, and aggressive rehabilitation can help minimize these problems. Our most common complication, postoperative limitation of motion, was nearly eliminated by a change to arthroscopic surgical technique and early motion.