Mostafa Abdelkhalek

Does Preprocedural Ultrasound Increase the First-Pass Success Rate of Epidural Catheterization Before Cesarean Delivery? A Randomized Controlled Trial.

BACKGROUND: Preprocedural ultrasound may improve the efficacy and safety of epidural catheterization, especially in difficult cases. Most studies of ultrasound-assisted epidural catheterization in the obstetric population are dated and nonblinded with inconsistent designs. This double-blind, randomized controlled study aimed to compare the ultrasound-assisted with the conventional palpation techniques for epidural catheterization in parturients undergoing cesarean delivery. We hypothesized that the use of preprocedural ultrasound would increase the success rate of epidural catheterization at the first needle pass. METHODS: Eligible subjects were American Society of Anesthesiologists physical status II parturients with full-term singleton pregnancy undergoing elective cesarean delivery using double-interspace combined spinal–epidural anesthesia. Exclusion criteria were age <19 or >40 years, body mass index ≥35 kg/m2, women presenting in labor or having any contraindication to neuraxial anesthesia, marked spinal deformity, previous spinal surgery, or impalpable anatomical landmarks. One hundred ten patients were randomly allocated into 2 equal groups (palpation and ultrasound groups). All procedures were performed by a single experienced anesthesiologist. Patients and investigators assessing the outcome data were blinded to group allocation. A systematic spinal ultrasound assessment and a sham procedure were performed in the ultrasound and palpation groups, respectively, before attempting epidural catheterization. The primary outcome was the rate of successful epidural catheterization at the first needle pass. Secondary outcomes were the rate of successful epidural catheterization at the first skin puncture, number of performed needle passes and skin punctures, duration of the epidural procedure, patient satisfaction from the procedure, and complications of the procedure (incidence of unintentional dural and vascular punctures, failed block, unilateral or patchy block, and backache). RESULTS: Data from 108 patients (55 patients in the palpation group and 53 patients in the ultrasound group) were analyzed. The rate of successful epidural catheterization at the first needle pass was 60% in the palpation group and 58.5% in the ultrasound group (95% confidence interval of the difference in proportions between groups is −18.5% to 21.6%; P > 0.99). There were no significant differences between the 2 groups in the success rate at the first skin puncture, the number of needle passes and skin punctures, or patient satisfaction. The median (range) duration of the epidural procedure was 185 (57–680) seconds in the ultrasound group and 215 (114–720) seconds in the palpation group (P = 0.036 with the Mann-Whitney U test and P = 0.083 with the Student t test with unequal variances). The overall rate of complications of the procedure was low in both groups. CONCLUSIONS: For experienced anesthesiologists, it remains unclear whether preprocedural ultrasound improves the epidural catheterization technique in parturients with palpable anatomical landmarks undergoing cesarean delivery.

Transversus Abdominis Plane Block Versus Wound Infiltration for Analgesia After Cesarean Delivery: A Randomized Controlled Trial.

BACKGROUND: Transversus abdominis plane (TAP) block and local anesthetic wound infiltration provide analgesia after cesarean delivery. Studies comparing the 2 techniques are scarce, with conflicting results. This double-blind, randomized controlled trial aimed to compare bilateral ultrasound-guided TAP block with single-shot local anesthetic wound infiltration for analgesia after cesarean delivery performed under spinal anesthesia. We hypothesized that the TAP block would decrease postoperative cumulative fentanyl consumption at 24 hours. METHODS: Eligible subjects were American Society of Anesthesiologists physical status II parturients with full-term singleton pregnancies undergoing elective cesarean delivery under spinal anesthesia. Exclusion criteria were: <19 years of age or >40 years of age; height <150 cm, weight <60 kg, body mass index ≥40 kg/m2; contraindications to spinal anesthesia; history of recent opioid exposure; hypersensitivity to any of the drugs used in the study; significant cardiovascular, renal, or hepatic disease; and known fetal abnormalities. Eighty subjects were randomly allocated to 2 equal groups. In the infiltration group, participants received 15 mL of bupivacaine 0.25% in each side of the surgical wound (total 30 mL); and in the TAP group, participants received 20 mL of bupivacaine 0.25% bilaterally in the TAP block (total 40 mL). The TAP block and wound infiltration were performed by the primary investigator and the operating obstetrician, respectively. All participants received postoperative standard analgesia (ketorolac and paracetamol) and intravenous fentanyl via patient-controlled analgesia. Patients and outcome assessors were blinded to the study group. The primary outcome was the cumulative fentanyl consumption at 24 hours. Secondary outcomes were the time to the first postoperative fentanyl dose, cumulative fentanyl consumption at 2, 4, 6, and 12 hours, pain scores at rest and on movement at 2, 4, 6, 12, and 24 hours, the deepest level of sedation, the incidence of side effects (nausea and vomiting and pruritis), and patient satisfaction. RESULTS: Data from 78 patients (39 patients in each group) were analyzed. The mean ± SD of cumulative fentanyl consumption at 24 hours was 157.4 ± 63.4 &mgr;g in the infiltration group and 153.3 ± 68.3 &mgr;g in the TAP group (difference in means [95% confidence interval] is 4.1 [−25.6 to 33.8] &mgr;g; P = .8). There were no significant differences between the 2 groups in the time to the first postoperative fentanyl dose, cumulative fentanyl consumption at 2, 4, 6, and 12 hours, pain scores at rest and on movement at 2, 4, 6, 12, and 24 hours, the deepest level of sedation, and patient satisfaction. The incidence of side effects (nausea and vomiting and pruritis) was low in the 2 groups. CONCLUSIONS: TAP block and wound infiltration did not significantly differ regarding postoperative fentanyl consumption, pain scores, and patient satisfaction in parturients undergoing cesarean delivery under spinal anesthesia.

Ilizarov bone transport versus fibular graft for reconstruction of tibial bone defects in children.

The aim of this study was to compare the results of treatment of segmental tibial defects in the pediatric age group using an Ilizarov external fixator versus a nonvascularized fibular bone graft. This study included 24 patients (age range from 5.5 to 15 years) with tibial bone defects: 13 patients were treated with bone transport (BT) and 11 patients were treated with a nonvascularized fibular graft (FG). The outcome parameters were bone results (union, deformity, infection, leg-length discrepancy) and functional results: external fixation index and external fixation time. In group A (BT), one patient developed refracture at the regenerate site, whereas, in group B (FG), after removal of the external fixator, one of the FGs developed a stress fracture. The external fixator time in group A was 10.7 months (range 8–14.5) versus 7.8 months (range 4–11.5 months) in group B (FG). In group A (BT), one patient had a limb-length discrepancy (LLD), whereas, in group B (FG), three patients had LLD. The functional and bone results of the Ilizarov BT technique were excellent in 23.1 and 30.8%, good in 38.5 and 46.2, fair in 30.8 and 15.4, and poor in 7.6 and 7.6%, respectively. The poor functional result was related to the poor bone result because of prolonged external fixator time resulting in significant pain, limited ankle motion, whereas the functional and bone results of fibular grafting were excellent in 9.1 and 18.2%, good in 63.6 and 45.5%, fair in 18.2 and 27.2%, and poor in 9.1 and 9.1%, respectively. Segmental tibial defects can be effectively treated with both methods. The FG method provides satisfactory results, with early removal of the external fixator. However, it had a limitation in patients with severe infection and those with LLD. Also, it requires a long duration of limb bracing until adequate hypertrophy of the graft. The Ilizarov method has the advantages of early weight bearing, treatment of postinfection bone defect in a one-stage surgery, and the possibility to treat the associated LLD. However, it has a long external fixation time.

Ultrasound-guided spinal anesthesia for cesarean section in a parturient with spinal metastases

Preprocedural spinal ultrasound appears to decrease the failure rate and complications of neuraxial anesthesia compared to the conventional landmark technique. It is especially beneficial in difficult cases where conventional palpation technique may fail. We recently encountered a parturient with multiple lumbar and cervical spinal metastatic lesions presenting for cesarean section in the third trimester. We used spinal ultrasound to define the appropriate intervertebral space and measure the distance to the ligamentum flavum-dura mater complex. This greatly helped in administering a safe spinal anesthetic and avoiding general anesthesia which might have been hazardous in this patient.

Internal hernia of the small intestine around biliary catheter after living-donor liver transplantation: A case report

Highlights • Biliary reconstruction is a cornerstone of LDLT.• The use of trans-anastomotic biliary catheters is controversial.• We describe a rare case of intestinal obstruction due to internal herniation around biliary catheter.• Awareness of this complication plus early surgical intervention can prevent postoperative morbidity and mortality.

Primary versus secondary calcar replacement hip arthoplasty for treatment of unstable trochanteric fractures

Background Harris and Allen had modified and described a calcar replacement femoral component, which is necessary for the conventional femoral components, as a part of total hip replacement to address many problems related to proximal femoral deficiency. The aim of this study was to compare the clinical and radiological outcomes of a primary salvage calcar replacement hip arthroplasty with secondary salvage calcar replacement hip arthroplasty for treatment of new (group 1, prospective) or failed osteosynthesis or end prosthesis treatment (group 2, retrospective) of unstable trochanteric fractures. Patients and methods Fifteen patients were included in each group, with a mean age of 67.3 years for group 1 patients and 65.8 years for group 2 patients. The female-to-male ratio was 8 : 7 in group 1 and 10 : 5 in group 2. Incidence of preoperative comorbidities was 2.2 per patient in group 1 and 2.0 per patient in group 2. The mean time from the initial unstable trochanteric fracture to the time of calcar replacement hip arthroplasty was 4.2 days and 12.4 months in group 1 and group 2, respectively. The posterolateral approach using the posteriorKocher–Langenbeck proximally and the posterolateral approach distally for the proximal femur without trochanteric osteotomy. All patients were followed up clinically and radiologically, and at the end of the follow-up period (1–3 years) the Merle d’Aubigne and Postel score was used for functional evaluation. Results The mean operative time was 105 and 155 min, the mean amount of blood loss was 550 and 850 ml, and the mean period of hospital stay was 11 and 21 days for group 1 and group 2 patients, respectively. Two patients in group 2 had required postoperative ICU admission. Postoperative complication(s) were reported in one patient (6.6%) in group 1 and in five patients in group 2. Postoperative psychological problems and mortality during the first year were reported in three patients (20%). The Merle d’Aubigne and Postel functional outcome score by the end of the first year was found to be satisfactory (above 14 points) in 100 and 93.3% of patients in group 1 and group 2, respectively. After 3 years of follow-up it was satisfactory in 83.3 and 66.7% of patients in group 1 and group 2, respectively. Conclusion Primary cemented calcar replacement hip arthroplasty for treatment of unstable trochanteric fractures is associated with lesser pain, better walking ability without mortality or psychological problems, and with measurable better overall functional outcomes compared with salvage calcar replacement hip arthroplasty.