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ABSTRACTS OF PAPERS AT THE 87TH RESEARCH MEETING OF THE MEDICAL RESEARCH CENTRE OF BOMBAY HOSPITAL ON MONDAY, 11TH JUNE, 2001, 2.30 PM SP JAIN CAFETERIA (CONVENOR DR. HL DHAR)
1. URETERONEOCYSTOSTOMY - EVALUATION AND COMPARISON OF SURGICAL TECHNIQUES
Samir Trivedi, HM Punjani
Ureteroneocystostomy for refluxing and obstructed ureters is a widely performed procedure in paediatric urologic practice. A variety of techniques have been described for ureteroneocystostomy. They can be categorized as Transvesical, Extravesical, or Combined depending on the approach to the ureter, or as suprahiatal or infrahiatal depending on the position of the new ureteric orifice. In this retrospective study, we reviewed the records of 90 patients who have undergone ureteroneocystostomy in 140 ureters for various indications by different techniques. We have analysed the operative techniques used and their results.
Between Jan 1996 and Dec. 2000, 70 male and 20 female patients underwent ureteroneocystostomy at our institution. Of these 15 males and 4 females presented in adulthood with a mean age of 34.6 yrs. at presentation. 71 patients belonged to Paediatric age group with 55 male and 16 female children. The mean age at operation in this group was 4.9 yrs. The most common diagnosis was primary Vesico-Ureteric Reflux (47 patients and 74 Ureters) followed by Megaureters, posterior urethral valves, ureterocoele, neurogenic bladder and giant para ureteral diverticulae.
Cohen’s technique for reimplantation was used in 40 patients (73 ureters), Leadbetter-Politano Technique in 31 patients (41 ureters), Lich-Gregoir Technique in 11 patients (15 ureters), and Paquin’s Technique in 9 patients (11 ureters). Ureteric tailoring was performed in 27 ureters while ureteric plication was done in 11 ureters. Ureteric stents were placed post-operatively in 94 ureters.
Post-operative followup ranged from 6 months to 4 yrs. with a mean of 1.8 yrs. Post-operative complications were seen in 14 patients. 2 patients developed ureteral obstruction after Lead better-Politano technique and re-do surgery had to be performed. Two other patients (3 ureters) showed transient obstruction of the upper tracts following Cohen’s reimplantation which settled in 4-6 weeks without intervention. Persistent Vesico-Ureteric Reflux was seen in 7 ureters (5 after Cohen’s and 2 after Lead better-Politano Technique) of whom 3 required re-reimplantation, 2 were treated by Teflon Injections, and 2 settled by conservative management. Post operative sepsis was encountered in 4 patients who required parenteral antibiotics for an extended period. 2 patients developed urinary leakage post operatively, 1 of which was settled by passage of a D-J stent while the other required a second operation for the associated obstruction. Post operative evaluation included urine cultures, voiding cystourethrography, intravenous urography, renal sonography, and renal radionuclide scans. The overall success rate for Lead better-Politano Technique was 93-94% while for Cohen’s technique it was 92-93%.
Ureteroneocystostomy is a reasonably safe procedure with high degree of success irrespective of the technique used. The key to the success of the operation lies in judicious selection of the patients for surgery and in the choice of surgical technique for individual patients. Ureteric stenting post operatively does not affect the results of surgery in patients with primary Vesico-Ureteric Reflux.
2. NO REFLOW AFTER CORONARY ANGIOPLASTY AND REPERFUSION INJURY AFTER THROMBOLYTIC THERAPY IN ACUTE MYOCARDIAL INFARCTION
Cynthia, K Punamiya, KH Ayyer, Anil Kumar
This is an interesting case of a 48 yr. old gentleman who presented with acute Anterior wall MI within 2 hours duration of chest pain. His CPK levels were high with normal CPK-MB.
He was thrombolysed with Urokinase. After 1 hour of thrombolysis patient had ventricular tachycardia/ventricular fibrillation and Stoke Adams syndrome. He was successfully cardioverted with DC shock.
Due to ongoing symptoms of chest pain he was given a second bolus of Urokinase. After 8 hrs. of thrombolytic therapy, in view of persistent ST elevation a coronary angiography was performed.
Coronary angiography showed a 95% stenosis in the LAD, so a stent was deployed in the LAD. After implantation of the stent the patient had no reflow phenomenon with haemodynamic instability. He was resuscitated but there was no flow through the implanted stent. The patient was taken up for an emergency coronary artery bypass surgery, with LIMA graft to the LAD. Post operative recovery was uneventful.
A check coronary angiography done after a week showed patent LAD with good flow. This phenomenon of no reflow is rare and may be related to re-perfusion injury post thrombolytic therapy in acute myocardial infarction.
3. MANAGEMENT OF INTUBATION AND BRONCHIAL BLOCKADE IN A CASE OF PNEUMONECTOMY
S Karthik, Tillotama Mangeshikar
A 29 year old female was admitted under Dr. JC Kothari for complaints of fever, cough and breathlessness of 8 months duration. Breathlessness was present at rest and was incapacitating. Her past history revealed that she had suffered from pulmonary Koch’s in 1993 and had been treated for the same with a full course of AKT. In 1996, she was re-admitted and treated for pneumonitis. She had no other medical illnesses like hypertension, diabetes mellitus, bronchial asthma or IHD. Significant physical findings included a decreased chest expansion of the left side which on auscultations revealed diminished breath sounds, bronchial breath sounds and left basal rhonchi with crepitations. Her investigations included a complete blood picture (H - 11.1%, Hct - 34%, MCh - 21 and MCV-67). Her differential count did not show any significant lymphocytosis (20%). Other routine investigations included blood sugar, blood urea, serum creatinine and a 12-lead ECG which were within normal limits. A spirometry showed severe restrictive lung disease. A CT of the chest revealed fibrocavitary and bronchiectatic changes in the left upper lobe with peri-bronchiolar nodular masses. The right lung was relatively normal.
The clinical impression was fibrocavitation and bronchiectasis of the left upper lobe of lung due to resistant Kochs. She was referred to Dr. CA Somaya and was posted for a left pneumonectomy on 10th April 2001. She was anaesthetised by Dr. Tillotama Mangeshikar.
Anaesthetic Management
A routine pre-anaesthetic check was performed. Airway assessment showed an adequate mouth opening with a Mallampatti Grade I and a slight tracheal deviation to the left side. She was assigned to Class IV of American Society of Anaesthesiologists’ (ASA) grading.
All routine monitoring devices were used. A 16G intravenous cannula, a triple lumen central line in the right IJV ad a left radial arterial line were taken. General Anaesthesia with controlled ventilation to the right lung and a bronchial blockade of the left bronchus was intended in order to prevent soiling of the relatively healthy right lung due to infected material from the left lung.
The patient was preoxygenated with 100% oxygen and induced using a combination of fentanyl, midazolam and thiopentone and relaxed with norcuron. We decided to intubate with a 37F left-sided Portex double lumen tube. This wouldn’t even negotiate the vocal cords. Then it was tried with a 35F. This negotiated the vocal cords but not beyond that. Since these were the only standard sizes available at our disposal, we had to abandon the idea of using a double lumen tube and intubated with a 7 size Portex single lumen cuffed endotracheal tube (ETT). But, we had to somehow block the left bronchus. In the interest of the patient, we tried to block it using a balloon of a Foley’s catheter. An infant Foley’s catheter (8F) was used. The cuff of the endotracheal tube was first deflated with ventilation continuing through the tube. Then the Foley’s catheter was passed along the left of the ETT under direct laryngoscopic vision with the aid of a Magill’s forceps. It was directed along its left and when the full length was in, the cuff of the Foley’s was inflated with 3 cc of air. The tracheal cuff (ETT) was inflated and checked. Air entry was maintained on the right chest whereas there was a considerable loss of air entry on the left chest implying that the Foley’s cuff had effectively blocked the left bronchus. The vital signs like oxygen saturation, heart rate and BP showed no significant changes. The left lung collapsed further giving a good surgical field. The final confirmation of successful bronchial blockade came when the pneumonectomy was completed when the ventilator showed that there was a mere leak of 6-8 cc of air. This implied that the whole tidal volume was going to the right lung with almost no leak at all into the left bronchus which had been blocked by the balloon of the Foley’s. This had caused a good bronchial blockade saving the healthy right lung from any soiling.
The surgery was completed and the patient was ventilated post-operatively. She had a fairly uneventful recovery and is now attending to all her activities.
The aim of using a double lumen tube in this case was to isolate the two lungs and prevent contamination of the healthy lung. In such cases of unanticipated difficulty in intubation and passage of a DLT, this method can be tried for bronchial blockade. Usually, a Fogarty’s balloon or a Univent tube with a bronchial blocker is used to accomplish the same. This method could be improvised and made more Fail safe by the use of a fibreoptic bronchoscope to direct the bronchial blocker into the correct site. Hence, though this method has its own merits and demerits, the method used by us was timely, inexpensive and above all, had served the purpose of a bronchial blocker.
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