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1/135. Transcatheter occlusion of a post-Fontan residual hepatic vein to pulmonary venous atrium communication using the Amplatzer septal occluder.

    A residual hepatic vein to left atrial communication may result in progressive cyanosis after the fontan procedure. This problem has usually been treated surgically by ligation or re-inclusion of the residual hepatic vein in the Fontan circulation. Previous attempts at transcatheter closure of such veins have been unsuccessful. An Amplatzer septal occluder was successfully used for transcatheter closure of a post-Fontan hepatic vein to pulmonary venous atrium fistula in an 8 year old boy.
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2/135. Delayed postoperative CSF rhinorrhea of intrasellar arachnoid cyst.

    CSF rhinorrhea due to a transsphenoidal approach usually follows accidental or intentional arachnoid opening. We report a patient with an intrasellar arachnoid cyst, who developed delayed onset of CSF rhinorrhea. A sixty-two-year-old man presented with bitemporal type visual field defect for the last 3 years. With the diagnosis of arachnoid cyst or Rathke's cleft cyst, based on MRI findings of intra-and supra-sellar cyst with CSF intensity, he successfully underwent transsphenoidal surgery without evidence of intra-operative CSF leakage. He developed CSF rhinorrhea one week later. This needed another operation for sellar floor repair. The pathomechanism of this delayed onset is explained as follows. Incomplete or oneway communication of subarachnoid space to cyst cavity, unrecognized during surgery, might cause delayed onset of CSF rhinorrhea. By using MRI, identification of the residual gland, which was compressed posteriorly, is useful for differentiating an arachnoid cyst from other cystic lesions. In highly suspect cases, even without evidence of intra-operative CSF leakage, peri-operative measures to prevent occurrence of postoperative CSF rhinorrhea are required.
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3/135. Stent implantation to create interatrial communications in patients with complex congenital heart disease.

    A restrictive interatrial communication can complicate the management of complex congenital heart disease. The purpose of this report is to present a new technique to achieve a patent and reliable interatrial communication by using an endovascular stent. A stent was successfully implanted across a fenestrated extracardiac conduit in two patients with low cardiac output after Fontan operations and across the interatrial septum in a patient with double inlet left ventricle and severe left atrioventricular stenosis. The procedures were uncomplicated and all patients showed immediate hemodynamic improvement. Cathet. Cardiovasc. Intervent. 47:310-313, 1999.
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4/135. Postoperative alveolar hydatid disease with cutaneous-subcutaneous involvement.

    The first Japanese case of alveolar hydatid disease with cutaneous-subcutaneous lesions is reported. The patient, a 58-year-old man who developed an indurated subcutaneous tumor on the right side of the abdomen, had had partial hepatectomy of the right lobe for echinococcosis thirteen years earlier. Clinically, the tumor was adherent with a fistulosis communication to deeper structures. Histopathologically, multiple PAS-positive cuticular layers with foreign body granulomas and fibrosis were observed between the dermis and subcutaneous fatty tissue. Surgical excision of the swelling provided the patient with temporary relief. To our knowledge, only eight cases of subcutaneous alveolar hydatid disease have been reported throughout the world. Ours, the ninth case, highlights the importance and difficulty of treating of alveolar hydatid disease.
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5/135. Right ventricular thrombosis early after bidirectional Glenn shunt.

    thrombosis in the right ventricle occurred early after bidirectional superior cavopulmonary shunt in 2 patients with pulmonary atresia with intact ventricular septum and major right ventricular coronary artery communication, and perioperative brain infarction occurred in 1 patient. Clinicians should be aware of the hazards of this potentially lethal complication, and transfusion of platelets and fresh plasma should be minimized. Although the hemodynamic state is good, echocardiography should be performed frequently and strict anticoagulation should be started as early as possible.
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6/135. A large coronary artery saphenous vein bypass graft aneurysm with a fistula: case report and review of the literature.

    We describe a patient who developed a large aneurysm of saphenous vein graft to the right coronary artery with a fistulous communication to the right atrium. The presence of a fistulous communication of a saphenous vein graft aneurysm after coronary bypass surgery to one of the heart chambers is extremely rare. The diagnosis was made by coronary angiography and confirmed by CT and MRI. At surgery the aneurysm was ligated and excised. The fistula to the right atrium was closed. Repeat coronary artery bypass surgery with aortic valve replacement was performed at the same time without complications. Cathet. Cardiovasc. Intervent. 48:214-216, 1999.
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7/135. Management of a patient with hepatic-thoracic-pelvic and omental hydatid cysts and post-operative bilio-cutaneous fistula: a case report.

    In humans, most hydatid cysts occur in the liver and 75% of these are single. Our patient was a 31 year-old male. His magnetic resonance imaging (MR) showed one cyst (15 x 20 cm) in the right lobe and three cysts (5 x 6 cm, 8 x 6 cm, and 5 x 5 cm) in the left lobe of the liver, two cysts (4 x 5 cm and 5 x 5 cm) on the greater omentum, and two cysts (15 x 10 and 10 x 10 cm) in the pelvis. The abdomen was entered first by a bilateral subcostal incision and then by a Phennenstiel incision. Partial cystectomy capitonnage was done on the liver cysts; the cysts on the omentum were excised, and the pelvic cysts were enucleated. The cyst in the right lobe of the liver was in communication with a thoracic cyst. An air leak developed from the thoracic cyst which had underwater drainage and bile drainage from the drain in the cavity of the right lobe cyst. Sphincterotomy was done on the seventh post-operative day by endoscopic retrograde cholangiopancreatography (ERCP). No significant effect on mean bile output from the fistula occurred. octreotide therapy was initiated, but due to abdominal pain and gas bloating the patient felt and could not tolerate, it was stopped on the fourth day; besides, it had no decreasing effect on bile output during the 4 days. Because air and bile leak continued and he had bile stained sputum, he was operated on on post-operative day 18. By right thoracotomy, the cavity and the leaking branches were closed. By right subcostal incision, cholecystectomy and T-tube drainage of the choledochus were done. On post-operative day 30, he was sent home with the T-tube and the drain in the cavity. After 3 months post-operatively, a second T-tube cholangiography was done, and a narrowing in the distal right hepatic duct and a minimal narrowing in the distal left hepatic duct were exposed. Balloon dilatation was done by way of a T-tube. bile drainage ceased. There was no collection in the cavity in follow-up CT scanning, so the drain in the cavity, and the drainage catheter in the right hepatic duct were extracted. Evaluation of the biliary ductal system is important in bilio-cutaneous fistulas, and balloon dilatation is very effective in fistulas due to narrowing of the ducts.
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8/135. Iatrogenic main pulmonary artery-left atrial fistula in a child.

    A 14-month-old boy who underwent operation for ventricular septal defect patch closure and debanding of the pulmonary artery presented with arterial desaturation in the early postoperative period. Angiography confirmed the echocardiographic findings of hemodynamically significant main pulmonary artery-left atrial fistula. This communication was successfully closed surgically.
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9/135. Expression of keratan sulfate at the arthroplasty surface after cup arthroplasty.

    Fibrous tissue which regenerated on the acetabular arthroplasty surface was obtained from a 52-year-old woman who underwent total hip replacement after cup arthroplasty. The histological features of this newly formed fibrous tissue and expression of keratan sulfate, which is a characteristic matrix component of articular cartilage, were studied. Microscopic observation revealed that the arthroplasty surface consisted mainly of fibrous tissue which did not show metachromasia with toluidine blue staining, but there were many nodular structures communicating with the bone marrow. Immunostaining for keratan sulfate revealed clear positive staining around the cells of the nodular structures communicating with the bone marrow, while only weakly positive staining was observed in the superficial layer of the loose fibrous tissue. The present study revealed marked formation of articular cartilaginous tissue in areas having good communication with the bone marrow, which indicates that maintenance of this communication may be necessary to improve the outcome of cup arthroplasty.
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10/135. Iatrogenic left ventricular-right atrial fistula following mitral valve replacement and tricuspid annuloplasty: diagnosis by transthoracic and transesophageal echocardiography.

    Acquired left ventricle-to-right atrium communications are a known complication of valvular heart surgery. Previous reports have described the clinical features and diagnosis using cardiac catheterization. We report two cases of acquired left ventricle-to-right atrium fistula following mitral valve replacement. Particular emphasis is placed on the diagnosis using transthoracic and transesophageal echocardiography, obviating the need for cardiac catheterization before repair.
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