Emergency surgery after unsuccessful coronary angioplasty: a review of 15 years' experience.

BACKGROUND: Emergency coronary artery bypass grafting (CABG) is occasionally necessary for failed percutaneous transluminal coronary angioplasty (PTCA). The aim of this study was to assess the outcome of patients receiving emergency CABG after unsuccessful PTCA over a 15-year study period. METHODS: From January 1982 through December 1996, 74 patients underwent emergency CABG after unsuccessful PTCA (crash group). This group was compared with a matched group of 74 patients having primary elective CABG (control group). RESULTS: All 74 crash group patients were to have PTCA of one coronary system. After PTCA failure, 58 patients (78.3%) developed electrocardiographic changes of evolving acute myocardial infarction (AMI). The overall rate of AMI was 8.1% for the crash group and 2.7% for the control group. Two patients in the crash group died, with no deaths in the control group. There was no significant difference between mean in-hospital length of stay. CONCLUSIONS: With prompt, aggressive, and complete myocardial revascularization, patients who required emergency CABG after PTCA failure had an outcome not significantly different from that of patients having elective CABG.

Total thyroidectomy is now the preferred option for the surgical management of Graves' disease.

PURPOSE: Subtotal thyroidectomy has been advocated as the standard treatment for Graves' disease because of the possibility of avoiding thyroxine therapy as well as the assumed lower risk of complications compared to total thyroidectomy. However, the long-term results of subtotal thyroidectomy are not as good as they were previously believed to be, as evidenced by the increasing incidence of hypothyroidism. If the risk of complications from total thyroidectomy is no higher,then that procedure offers significant advantages in the surgical management of Graves' disease. The aim of this study therefore was to compare the complication rate of the two procedures in patients with Graves' disease. METHODS: This was a retrospective case control study in a tertiary referral hospital. Information was obtained from an endocrine surgery database over the study period from January 1957 to December 2000. During that period 1246 patients with Graves' disease underwent subtotal thyroidectomy and 119 patients underwent total thyroidectomy. RESULTS: Prior to 1987 total thyroidectomy was rarely if ever performed whereas in the last 12 months total thyroidectomy comprised 95% of all procedures. There was no significant difference in the rate of permanent complications between the two procedures although temporary hypocalcaemia was significantly more common following total thyroidectomy. Permanent hypoparathyroidism resulted in one patient each who underwent total thyroidectomy (0.8%) and subtotal thyroidectomy (0.1%). Permanent recurrent laryngeal nerve palsy occurred in one patient who underwent total thyroidectomy (0.8%) and 5 patients undergoing subtotal thyroidectomy (0.4%). CONCLUSION: Given that subtotal thyroidectomy provides an unpredictable outcome and that the risk of permanent complications is no greater than with total thyroidectomy, there appears little logical reason to continue to recommend subtotal thyroidectomy for the surgical management of Graves' disease. We believe that Graves' disease should join the increasing list of thyroid conditions for which total thyroidectomy is the preferred option.

Management of acute superior mesenteric artery occlusion.

BACKGROUND: This review examines the surgical management of acute superior mesenteric artery (SMA) occlusion and the impact of interventional radiology techniques. METHODS: Eight consecutive patients with SMA occlusion were treated at the Lismore Base Hospital, Lismore, NSW, Australia, from 1996 through to 2001 and of these, one patient was managed successfully with catheter-directed lytic therapy. The study group included five male and three female patients with a mean age of 71.3 (range 57-88) years. The records of these patients were reviewed to determine demographic characteristics, clinical features, predisposing factors and the duration of symptoms before intervention, management details and final outcome. RESULTS: Embolic phenomena due to atrial fibrillation were the most frequently identifiable cause of acute SMA occlusion, present in six of eight patients. Seven patients were managed with open surgery in the first instance and of these, four died. Three patients remain alive and well at a mean 2.8 years follow-up. Patient number eight developed acute SMA occlusion from embolism secondary to atrial fibrillation and was managed initially with SMA urokinase thrombolysis. This patient's pain was relieved 1 h after initiation of the procedure. Delayed films after 18 h from initiation of thrombolysis demonstrated re-opening of all the ileo-colic branches and at 6 weeks' follow-up the patient remains well with normal bowel function. CONCLUSIONS: There is a role for selective SMA cannulation and urokinase thrombolysis in the management of patients with acute SMA thrombosis.

Mastoiditis in a paediatric population: a review of 11 years experience in management.

OBJECTIVE: This study explores the experience at Sydney Children's Hospital (SCH) managing children with acute mastoiditis and establishes a robust treatment algorithm. METHODS: Retrospective review of all patients admitted to SCH with an ICD-10 coding of "Mastoiditis" from 1 January 1996 through 31 December 2006 inclusive. Criteria assessed included demographic characteristics, clinical features, symptom duration and treatment initiated by the general practitioner. The results of investigations at SCH were reviewed including white blood cell count, microbiology and imaging. The presence of complications was determined and the results of medical and surgical treatment were assessed. RESULTS: Seventy-nine episodes of acute mastoiditis were managed in 76 patients. Treatment prior to SCH was commenced by the family practitioner or district hospital doctor in 53/79 patients. The mean duration of community initiated treatment before presentation to SCH was 3.7 days. In 33 episodes a previous history of acute otitis media was noted (42%). In the remaining 46 episodes (58%) mastoiditis was the initial diagnosis. Complications were found in 30 episodes (38%) and 36 episodes (46%) required surgical treatment. CONCLUSIONS: Mastoiditis often develops rapidly but may be treated very effectively. The potential for significant morbidity remains high but excellent outcomes can be expected for those who are managed without delay. Children with acute mastoiditis should be managed in centres where timely and complete medical and surgical treatment is available.

Atypical presentation of intramedullary spinal cord lesion.

We report a patient who presented with atypical clinical manifestations including worsening abdominal pain from an intramedullary spinal cord lesion. It is important to consider non-abdominal causes of abdominal pain for patients with an atypical presentation. The described case demonstrates the challenges facing the physician with the early diagnosis of acute abdominal pain. Spinal cord lesions, although uncommon, remain a potentially disabling and life-threatening cause of abdominal pain.