Single-incision versus four-incision laparoscopic transfistulous bile duct exploration for Mirizzi syndrome type II.

BACKGROUND: We developed laparoscopic transfistulous bile duct exploration (LTBDE) for Mirizzi syndrome (MS) McSherry type II in September 2011. Then, single-incision LTBDE (SILTBDE) was adopted as a preferred technique since August 2013. This retrospective study aims to analyze the outcome of LTBDE in 7.7 years and to compare SILTBDE with four-incision LTBDE (4ILTBDE). METHODS: Seventeen consecutive patients underwent LTBDE for MS McSherry type II from September 2011 to May 2019. Transfistulous removal of the impacted stone(s), choledochoscopic bile duct exploration, and primary closure of the gallbladder remnant were performed without biliary drainage. RESULTS: The sex ratio is 12:5 (male: female) with an average age of 39.4 ± 10.3 (24-56) years. Ten patients (58.8%) had their diagnoses of MS established by preoperative imaging. According to the Csendes classification, three type II (17.6%), nine type III (52.9%), and five type IV (29.4%) were identified. The operative time was 264.8 ± 60.3 min (156-358 min). The stone clearance rate was 100%. The postoperative hospital stay was 4.7 ± 1.9 (2-10) days. No procedure was converted to an open operation. Two postoperative transient hyperamylasemia (11.8%) and one superficial wound infection (5.9%) occurred and all recovered well under conservative treatment (Clavien-Dindo grade I). During an average 2.2-year follow-up period, no biliary stricture or stone recurrence occurred. No significant difference exists between the SILTBDE and 4ILTBDE groups. Nevertheless, an insignificant trend of shorter postoperative hospital stay was observed in the former. A diagnosis of MS Csendes type IV implicates prolonged total and postoperative hospital stays (p < 0.01). CONCLUSIONS: LTBDE is safe and efficacious for MS McSherry type II. It provides a simple solution for various types of MS and avoids undesirable complications following bilioenteric anastomosis. SILTBDE is comparable to 4ILTBDE for selected patients. Patients with MS Csendes type IV need more time to recover after surgery.

Preoperative measurement of maternal abdominal circumference relates the initial sensory block level of spinal anesthesia for cesarean section: An observational study.

OBJECTIVE: Lumbosacral cerebrospinal fluid volume is decreased as the enlarging uterus compresses the inferior vena cava during pregnancy. A subsequent greater cephalad spread of sensory blockade is observed. Gravid uterus plays a crucial role in affecting the spinal anesthesia level. We hypothesized that maternal abdominal circumference can reflect compressive effect of the uterus and investigated the relationship between abdominal circumference and the level of sensory blockade, and incidence of hypotension following spinal anesthesia with hyperbaric bupivacaine in term parturients. MATERIALS AND METHODS: Forty-two term parturients scheduled for elective cesarean section were studied. Abdominal circumference was measured before spinal anesthesia; 0.5% hyperbaric bupivacaine (2 mL, 2.2 mL, or 2.4 mL) was injected in to the subarachnoid space at the L3-L4 intervertebral level according to the parturient's height. The level of sensory blockade was assessed using an ice cube 1 minute, 5 minutes, 10 minutes, and 15 minutes after the spinal injection. The level of sensory blockade at the 15th minute was defined as the level of maximum sensory blockade. Statistical correlation coefficients were evaluated with Spearman's rank correlation. RESULTS: The correlation coefficient between the abdominal circumference and spinal level measured by cold sensation loss at 5 minutes after spinal anesthesia was significantly positive (right side ρ=0.43, p=0.005; left side ρ=0.46, p=0.003). No significant correlation was found between abdominal circumference and the level of maximum sensory blockade, the incidence of hypotension, ephedrine dosage, nausea, and vomiting after spinal anesthesia. CONCLUSION: Parturients with greater abdominal circumference value have a higher level of sensory blockade at 5 minutes after spinal anesthesia. Abdominal circumference cannot predict the maximum sensory blockade level and the incidence of hypotension.

The effect of hemodynamic changes induced by propofol induction on cerebral oxygenation in young and elderly patients.

STUDY OBJECTIVE: To investigate the difference of regional cerebral oxygen saturation (rSo2) decrease in response to the decrease in mean arterial blood pressure (MAP) in young and elderly patients. DESIGN: Prospective clinical study. SETTING: Medical center hospital. PATIENTS: Twenty-four American Society of Anesthesiologists physical status I and II patients, 12 of whom were young and the other 12 elderly, scheduled for elective surgery requiring general anesthesia. Patients received propofol 2 mg/kg (young patient group) and propofol 1.5 mg/kg (elderly patient group) as an induction drug. MEASUREMENTS: MAP and rSo2 were recorded continuously for 5 minutes after propofol administration. MAIN RESULTS: MAP values at the second to fifth minutes and rSo2 at the second minute after propofol administration were significantly lower than baseline in both groups (P<.05). The rSo2 decrease was minimal, and the slopes of the rSo2 decrease in response to the MAP decrease in the young and elderly groups were 0.093+/-0.012 (P<.001) and 0.112+/-0.016 (P<.001) (mean+/-SEM), respectively. CONCLUSIONS: After propofol induction, there was no difference between young and elderly patients in rSo2 decrease in response to the decrease in MAP.

Cardiovascular collapse after labetalol for hypertensive crisis in an undiagnosed pheochromocytoma during cesarean section.

Pheochromocytoma is a catecholamine-producing tumor but rarely delayingly diagnosed until during pregnancy. We reported a pregnant woman who underwent emergent cesarean section because of intrauterine growth retardation, oligohydramnios, and hypertension. The existence of an undiagnosed pheochromocytoma was suspected by the unusual hemodynamic response to spinal anesthesia, abdominal compressions, and operative stimulus. Hypertensive crisis occurred during the operation and she was sent to the intensive care unit for postoperative care. In the intensive care unit, cardiovascular collapse occurred after nonselective ß-adrenergic blockade. Unexpected hypertensive crisis during the perioperative period should alert clinicians to the possibility of a pheochromocytoma. For the treatment of choice, nonselective ß-adrenergic blockade should not be used before the α-blockade.

Postoperative delayed respiratory failure caused by Guillain-Barré syndrome--a case report.

Postoperative respiratory failure caused by Guillain-Barré syndrome (GBS) is a rare complication after general anesthesia. We report a GBS patient who after receiving an operation for polycystic liver disease under general anesthesia developed weakness of upper and lower extremities on the 3rd postoperative day, with decreased deep tendon reflex, which ultimately evolved into respiratory failure. Slurred speech and bilateral ptosis were also noted. All these manifested an acute peripheral polyneuropathy combined with bulbar involvement. According to the clinical picture, CSF examination and results of nerve conduction tests, Guillain-Barré syndrome was diagnosed. Plasmapheresis was immediately arranged and her motor weakness problem was soon improved after treatment. No neurological sequelae were found two months after discharge. Postoperative muscle weakness is usually caused by residual effects of anesthetic agents or surgical complications. But it may sometimes be related to some rare neurological diseases. To prompt an accurate diagnosis of Guillain-Barré syndrome is important because it can help forestall fatal complications. In addition, the prognosis will be encouraging with early treatment.