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1/517. Treatment for empyema with bronchopleural fistulas using endobronchial occlusion coils: report of a case.

    We report herein the case of a woman with bronchopleural fistulas treated with the endobronchial placement of vascular embolization coils. She was referred to our hospital to undergo lavage of a postoperative empyema. She had undergone an air plombage operation for pulmonary tuberculosis 9 years previously. However, bronchopleural fistulas occurred postoperatively and she had to continue the use of a chest drainage tube since then. Lavage of her empyema space with 5kE of OK-432 (picibanil: Chugai) plus 100 mg minocycline was performed once every 2 weeks for 3 months, and the purulent discharge from the empyema remarkably decreased. Thereafter, the bronchopleural fistulas were occluded endobronchially by the placement of vascular embolization coils. Soon after the procedure, air leakage from the fistulas was stopped and the drainage tube was removed 2 days later. The patient remains well without any additional treatment at 20 months after this treatment. As treatment for empyema with bronchopleural fistulas, it would be worth trying to lavage the empyema space with OK-432 until it is cleaned out and to plug the fistulas by the endobronchial placement of embolization coils, before such radical operations as thoracoplasty and space-filling of the empyema are considered.
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2/517. The challenge of arteriovenous fistula formation following disk surgery: a collective review.

    Five cases of arteriovenous fistula formation are added to the 68 found in previous reports. A review of the English-language literature revealed that the L4-5 disk space was most frequently involved, the right common iliac artery injured most often, and the right and left common iliac veins and inferior vena cava injured with similar frequency.
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3/517. 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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4/517. Acute hyperkalemia associated with intravenous epsilon-aminocaproic acid therapy.

    Epsilon-aminocaproic acid (Amicar) is used to treat severe hemorrhage refractory to usual medical management. This antifibrinolytic drug has been associated with a number of renal complications. However, there are no descriptions of this medication causing hyperkalemia. This report describes the development of hyperkalemia in a patient with underlying chronic renal insufficiency treated with intravenous epsilon-aminocaproic acid. The patient, who underwent coronary artery bypass grafting, had no other obvious cause for the acute increase in serum potassium concentration. Based on data in animals and humans, the cationic amino acids lysine and arginine have been shown to enter muscle cells in exchange for potassium and lead to hyperkalemia through a shift of potassium from the intracellular to the extracellular space. Epsilon-aminocaproic acid, a synthetic amino acid structurally similar to lysine and arginine, also has been noted to cause an acute increase in serum potassium in anephric dogs infused with this medication. It is probable that the mechanism underlying the increase in serum potassium with epsilon-aminocaproic acid is also based on the shift of potassium from the intracellular to the extracellular space. Hence, it appears that intravenous epsilon-aminocaproic acid can also cause hyperkalemia in humans.
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5/517. Postoperative infection of lumbar intervertebral disk space.

    Sixteen cases of postoperative intervertebral disk space infection are reviewed. Most occurred after diskectomy, but one followed an unsuccessful attempt at a spinal anesthetic and two followed diskography. Treatment varied from aggressive surgery, either by a posterior, lateral, or anterior approach, to drain the infected disk space or spaces, to more conservative immobilization. Antibiotics were used in all cases. Needle biopsy is valuable in establishing diagnosis and identifying the organism and its antibiotic sensitivities. In some cases fusion occurred spontaneously from the infection; in others, fusion was a result of surgical fusion preceding or following the infection.
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6/517. Chronic subdural haematoma following caesarean section under spinal anaesthesia.

    Intracranial subdural haematoma is a rare complication of spinal anaesthesia. This report describes the case of a 31-year-old woman who presented with post partum headache following spinal anaesthesia for caesarean section. Bilateral haematomata were evacuated via burr-holes performed under total intravenous anaesthesia and the patient made a complete and uneventful recovery. The recognized causes of subdural haematoma are discussed.
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keywords = subdural
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7/517. Excision of spinal tumor in a patient with severe pulmonary dysfunction using combined spinal and epidural anesthesia with two epidural catheters.

    BACKGROUND AND OBJECTIVES: Combined spinal and epidural anesthesia (CSEA) has become common practice. We performed CSEA using two epidural catheters in a 69-year-old female with severe pulmonary dysfunction caused by a diaphragmatic hernia, who underwent surgical excision of a lumbar spinal tumor. methods: Combined spinal and epidural anesthesia was performed using two epidural catheters to minimize postoperative pulmonary complications. One epidural catheter was inserted above the surgical region, at the T11-12 interspace, and another one below the surgical region, via the sacral hiatus. Spinal anesthesia was produced using the L5-S1 interspace and 3 mL 0.5% bupivacaine. oxygen, 3 L/min, was administered through a face mask during surgery. RESULTS: Fifteen minutes after spinal anesthesia, analgesic level was confirmed below T7 using the pinprick method. The patient complained of pain in the surgical region 10 minutes after the dura mater was opened. We injected 5 mL 2% mepivacaine through the upper epidural catheter to relieve the pain. We also injected 10 mL 2% mepivacaine through the lower catheter when she felt pain in the right leg. The perioperative course was uneventful. oxygen saturation was maintained above 95%. CONCLUSIONS: Combined spinal and epidural anesthesia using two epidural catheters was used successfully to excise a spinal tumor in a patient with severe pulmonary dysfunction.
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8/517. Lumbar spinal subdural hematoma following craniotomy--case report.

    A 52-year-old female complained of lumbago and weakness in the lower extremities 6 days after craniotomy for clipping an aneurysm. Neurological examination revealed symptoms consistent with lumbosacral cauda equina compression. The symptoms affecting the lower extremities spontaneously disappeared within 3 days. Magnetic resonance (MR) imaging 10 days after the operation demonstrated a lumbar spinal subdural hematoma (SSH). She had no risk factor for bleeding at this site, the symptoms appeared after she began to walk, and MR imaging suggested the SSH was subacute. Therefore, the SSH was probably due to downward movement of blood from the cranial subdural space under the influence of gravity. SSH as a complication of cranial surgery is rare, but should be considered if a patient develops symptoms consistent with a lumbar SSH after craniotomy.
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keywords = subdural space, subdural, space
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9/517. Necrotizing fasciitis of the pharynx following adenotonsillectomy.

    Necrotizing fasciitis is a rare clinical entity in the head and neck region. We report a case of necrotizing fasciitis following adenotonsillectomy in a previously healthy 2-year-old girl. The child presented in a septic state with impending airway compromise. Computed tomography (CT) showed massive soft tissue widening with air in the retropharyngeal, parapharyngeal and retromandibular spaces. Intraoperative exploration showed necrosis of the posterior pharyngeal wall from the skull base to the cricoid, with extension into the parapharyngeal and retropharyngeal spaces. Cultures from the debrided tissues grew two aerobes and three anaerobes. Management involved airway support, surgical debridement, broad spectrum antibiotic coverage and nutritional support. The patient ultimately developed nasopharyngeal and oropharyngeal stenosis requiring tracheostomy and gastrostomy tube placement. This case report highlights an extremely rare complication of adenotonsillectomy.
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10/517. Developing bronchial fistulas as a late complication of extraperiosteal plombage.

    A 65-year-old male, who underwent extraperiosteal plombage for pulmonary tuberculosis 46 years ago, was referred to our hospital due to relapsing hemosputa and pneumonia. A chest computed tomography scan revealed a bronchial fistula and a fluid collection in one Lucite ball. On May 20, 1996, a right-anterior thoracotomy was performed in a supine position. Five Lucite balls were removed, and the empyema space was tightly filled with an omental pedicle flap. Although the bronchial fistulas were not sutured directly, the air leakage from the drainage tube ceased 12 days later. Two years postoperatively the patient has remained well. Our simple approach of combining an anterior thoracotomy and replacement of an empyema space with an omental pedicle flap in the same posture, without closing bronchial fistulas, would be an easy procedure, and therefore exploitable in patients who have a similar problem.
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