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1/16. fluoroscopy-guided retrieval of a sheared endotracheal stylet sheath from the tracheobronchial tree in a premature infant.

    Endotracheal intubation of premature infants with respiratory distress is a commonly performed procedure in the neonatal intensive care unit. We report a rare complication of this procedure, shearing of the plastic sheath that is bonded to and surrounds the stylet used to assist intubation and lodging of the sheared stylet in the tracheobronchial tree of a small premature infant. We suggest a method for removing the plastic foreign body using fluoroscopy and an Amplatz gooseneck snare directed through the existing endotracheal tube, a technique not previously reported.
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2/16. Posterior hepatic duct injury during laparoscopic cholecystectomy finally necessitating hepatic resection: case report.

    A case of bile duct injury during laparoscopic cholecystectomy finally necessitating right hepatic lobectomy is reported to re-emphasize the importance of preoperative and intraoperative assessment of the biliary tree. A 47-year-old Japanese woman underwent laparoscopic cholecystectomy for cholecystolithiasis. On postoperative day 5, fever and right hypochondralgia developed, and CT revealed fluid collection at the right hypochondrium. Percutaneous drainage was performed, and subsequent fistulography revealed a communication of the cystic cavity with the right posterior bile duct, which suggested injury of the aberrant hepatic duct. Conservative therapy, including the adaptation of fibrin glue, was performed, but closure of the fistula and cavity was not obtainable. Finally, a right hepatic lobectomy was performed four months after cholecystectomy. In this case, endoscopic retrograde cholangiopancreatography was unsuccessful preoperatively, and intraoperative cholangiography was not done. This case report re-emphasizes that the preoperative and intraoperative examination of the biliary tree is mandatory to avoid bile duct injury.
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3/16. A phylogenetic analysis elucidating a case of patient-to-patient transmission of hepatitis c virus during surgery.

    A phylogenetic hepatitis c virus (HCV) assay based on the core-Envelope 1 (C-E1) region was developed and used to elucidate a case of a patient-to-patient transmission. The index patient showed clinical symptoms of hepatitis seven weeks after surgery for hallux valgus under general anaesthesia. She progressed to a chronic persistent infection as indicated by positive HCV PCR results two years after surgery. Before her operation, a patient with HCV antibodies and positive HCV PCR had undergone surgery in the same room. There were two possibilities whereby the index patient could have been infected with hepatitis c, either through her work as a nurse or by transmission during surgery. By sequencing the 5' non-coding region PCR product, we found that both patients were infected with genotype 1a. Phylogenetic analysis with the variable C-E1 region suggested that the two patients clustered together with a bootstrap 100% in a tree with 75 sequence references. We further performed a phylogenetic analysis in this region with the genotype 1a reference sequences and an additional 25 genotype 1a sequences consecutively collected from Danish patients with HCV. The two patients still clustered together, supported by a high bootstrap 1000 value of 999. Homology analyses combined with the epidemiological findings indicate that the patient operated on in the same room before the index case was the most likely source of transmission. The mode of transmission could not be conclusively established, but a reusable part of the anaesthetic respiratory circuit is a possibility and a well known risk.
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4/16. Intracoronary retrieval of the dehisced radiopaque ring of a guiding catheter: an unusual complication of coronary angioplasty.

    The guiding catheter used in coronary intervention may be damaged or some parts could be dehisced during the procedure, producing adverse effects in the vascular tree. So much so that immediate surgery is usually indicated. We report a case with a dehisced radiopaque ring of the catheter during the procedure. It was retrieved percutaneously without thoracotomy.
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5/16. Serious complications of laparoscopic cholecystectomy in new york State.

    Serious surgical complications following laparoscopic cholecystectomy are described in a series of 17 patients who underwent the procedure in new york State in 1990 and 1991. Among the 17 cases, the most frequent complication (41.1%) was laceration of the common bile duct and/or right hepatic duct. Other serious surgical complications included perforation or laceration of the small bowel, laceration or injury of an intrahepatic bile duct, and post-operative bleeding. Some of the serious complications described here, such as laceration of the aorta and iatrogenic resection of portions of the extrahepatic biliary tree, have not been previously described. The results of this study point out the need for carefully designed retrospective and prospective studies to assess the prevalence of complications from this procedure.
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6/16. Arterial to end-tidal CO2 laparoscopic gradient reversal during pheochromocytoma resection.

    PURPOSE: We report the development of severe intraoperative hypercarbia and a pronounced arterial to end-tidal gradient reversal during laparoscopic pheochromocytoma resection. Although complex physiologic mechanisms may be responsible for this finding, anatomic alterations such as a direct communication between a capnoperitoneum and/or capnothorax and the airways resulting from prior pathology and the type of procedure should also be considered. CLINICAL FEATURES: During anesthesia for laparoscopic pheochromocytoma removal we noticed an abrupt, extensive increase of the end-tidal CO(2) accompanied by a change of the capnographic CO(2) tracing and reversal of the normal arterial-to-end-tidal gradient. These changes consistently disappeared by intermittent deflation of the abdomen and at the end of surgery. A chest x-ray revealed a right-sided loculated pneumothorax with pleural thickening. Peritoneo-thoracic CO(2) tracking and pleural scaring with pulmonary adhesions resulting in a unidirectional communication between the pleural space and airways may best explain the chest x-ray and clinical findings. CONCLUSION: Severe intraoperative hypercarbia and arterial to end-tidal CO(2) gradient reversal represents an intraoperative challenge. The possibility of a direct communication between the pleural space and the bronchial tree should be considered when other etiologies have been excluded. Simple maneuvers such as abdominal de- and re-inflation and analysis of the end-tidal capnographic tracing might aid in the differential diagnosis and management.
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7/16. A complication of transtracheal jet ventilation and use of the Aintree intubation catheter during airway resuscitation.

    We report the management of a patient requiring surgical laryngoscopy with a view to laser resection of an epiglottic recurrence of laryngeal cancer. Previous attempts at tracheal intubation and awake nasal fibreoptic intubation had failed. During a previous anaesthetic the patient had been both 'impossible to intubate and to ventilate'. neck scarring potentially complicated access for transtracheal jet ventilation. Nevertheless, a cricothyroid catheter was placed and surgery performed during low frequency 'volume' jet ventilation. Upper airway obstruction developed during the procedure, preventing exhalation, which led to raised intrathoracic pressure, cardiovascular collapse and barotrauma. The airway was re-established by insertion of an LMA Proseal. Fibreoptic placement of an Aintree intubation catheter through this allowed re-oxygenation and exchange for a cuffed tracheal tube. Some hours after the procedure, re-intubation was necessary. This was achieved using the Aintree intubation catheter as an aid to nasal fibreoptic intubation and as a tube exchanger. Novel roles of the Aintree intubation catheter and LMA Proseal in this case are discussed. Complications of transtracheal jet ventilation as well as possible methods for avoiding them are also reviewed.
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8/16. Intraoperative bronchial aspiration of ruptured pulmonary hydatid cysts.

    Ruptured pulmonary hydatid cysts are seen clinically and radiologically as persistent cavitary lesions of the lung. bronchi opening into the pericyst cavity allow for discharge of fluid matter but not the escape of solid remnants of the collapsed parasite. Operative manipulation of the involved lung in the course of surgical management of chronic ruptured pulmonary hydatids can force fragments of the laminated membrane or small daughter cysts into the bronchial tree. Such extruded solid fragments lodge in bronchi of the same or opposite lung with resulting acute obstruction of airways. Intraoperative bronchial aspiration of hydatid material was seen in 7 patients with ruptured hydatid cysts of the lung, either primary or secondary to transdiaphragmatic extension of liver hydatids. The first clinical sign can be unexplained difficulty in ventilation. Effective management consists of prompt exposure of the stem bronchus on the operative side, with bronchotomy for suction retrieval of escaped solid fragments of the parasite.
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9/16. Primary pulmonary hemangiopericytoma: early local recurrence after perioperative rupture of the giant tumor mass (two cases).

    We report two recent observations of giant hemangiopericytoma of the lung, one in a 4-year-old child and another in a 65-year-old man. There were no specific clinical signs, but the radiologic appearance was rather characteristic in both cases, as were the histologic findings. pneumonectomy was carried out, complicated in each case by rupture of the fragile, incomplete pseudocapsule and diffuse dissemination of necrotic tumor tissue in the operative field and opposite bronchial tree. Outcome was fatal in both cases within a few months, with extensive, rapidly growing metastases in the subcutaneous scar tissue of the thoracotomy and in the other lung and in one case with diffuse diaphragmatic and intraabdominal metastases. These two observations will offer some guidelines for better understanding of this rare localization of hemangiopericytoma, its natural history, and its optimal treatment, with special reference to the malignant potential and local recurrence rate.
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10/16. Intrahepatic gallbladder and obstructive jaundice.

    A case of intrahepatic gallbladder--a rare anomaly of the biliary tree which predisposes towards the formation of calculi--is reported. The special difficulties which may be encountered in the management of the complications of cholelithiasis in these circumstances are described.
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