Schoeb Sohawon

A Study to Determine the Correlation Between Clinical, Fiber-Optic Endoscopic Evaluation of Swallowing and Videofluoroscopic Evaluations of Swallowing After Prolonged Intubation

BACKGROUND Clinical evaluation of swallowing disorders postextubation is often neglected. Videofluoroscopy is the gold standard with fiber-optic endoscopic evaluation of swallowing (FEES) having a high sensitivity. The aim of this study was to analyze the correlations between clinical, FEES, and videofluoroscopic evaluations in the intensive care unit. METHODS Twenty-one patients extubated after prolonged intubation were subjected to a clinical evaluation of swallowing and FEES within 24 hours. This was repeated at 48 hours with a videofluoroscopic evaluation with identical swallowing-namely, boluses of liquid and thickened water. The patients were scored from 0 (normal) to 3 (worst). RESULTS There was no correlation between the oral phase (bedside evaluation) and FEES. The correlation between pharyngeal phase (palatal and laryngeal elevation, pharyngeal rales, and gag reflex) before and after swallowing at 24 and 48 hours was statistically significant (liquid water P = .025 [24 hours] vs P < .001 [48 hours]; thickened water P < .001 [24 and 48 hours]). Clinical assessment, although not statistically significant, failed to detect silent aspiration (P = .58). There was a good correlation between FEES and videofluoroscopy as opposed to clinical assessment and videofluoroscopy (P < .001 vs P = .762). CONCLUSION Cough is a reliable sign of swallowing disorder but does not exclude silent aspiration and contraindicates oral feeding. Cough induced by liquid water should lead to modification of diet in terms of consistency and viscosity with cough reassessment.

Late onset of Aspergillus aortitis presenting as femoral artery embolism following coronary artery bypass graft surgery.

Aspergillus sp. are ubiquitous mould infections and in most patients, the source is presumed to be air-borne infections during surgical procedures. Prevention of these infections requires special attention of ventilation systems in operating rooms. Post-operative aspergillosis occurs mainly in immunocompromised patients as well as those who receive corticosteroids temporarily. We report a case of a 71-year-old immunocompromised patient who developed multiple lower limb embolisms due to Aspergillus niger originating from an aortitis of the ascending aorta nine months following coronary artery bypass graft (CABG) surgery.

A LATE COMPLICATION OF PERCUTANEOUS RADIAL ARTERY CANNULATION

Abstract Radial artery pseudoaneurysms occurring as a late complication of percutaneous radial artery cannulation are rare, while those which are infected are exceptional. Known risk factors are age-related with patients being in their seventies and onwards, the duration of the radial artery catheter and staphylococcal catheter-related infections. We report the case of an 82-year-old patient who developed a mycotic radial artery pseudoaneurysm as a late complication of arterial catheterization.

Tongue necrosis as a complication of vasoconstrictor agents in the intensive care setting

The tongue is well irrigated by the lingual and submandibular arteries along with numerous collaterals that are invariably present. This rich vascular supply makes tongue necrosis exceptional. Tongue necrosis has been reported in giant cell arteritis, Wegener’s granulomatosis, malignant tumors, previous radiation to the neck, intraarterial injections, emboli, ergotism, essential thrombocytosis, and calciphylaxis [1–3, 5]. We report a case of tongue necrosis due to a combination of different vasoconstrictive agents in the intensive care setting.

Volvulus of an ileoanal J pouch

Dear Editor: Ileoanal J pouch is confectioned after proctocolectomy by the establishment of continuity with the terminal bowel mainly for oncologic, inflammatory, or vascular reasons. Early complications include anastomotic leaks, pelvic sepsis and abscess, pouch bleeding, and bowel obstruction. The latter is frequently due to postoperative adhesions in the pelvis or at the site of the covering ileostomy. Late complications consist of ileoanal anastomotic stricture, pouchitis leading to pouch failure, fecal incontinence, and genitourinary dysfunctions but rarely result from volvulus which is a surgical emergency. Small bowel volvulus is a recognized entity in neonates and adults, but ileoanal J or W pouch volvulus is exceptional. A 35-year-old patient was admitted to the emergency department in the evening for abdominal pain which started in the morning. Her past medical history revealed a familial adenomatous polyposis treated by total proctocolectomy with an ileoanal J pouch with closure of the ileostomy 3 months later, 13 years ago. She also had bilateral ovariectomy for multiple ovarian cysts 5 years ago. On physical examination, the abdomen was enlarged, diffusely painful, and guarding with no peristaltism and gas. She was pyrexic with 39.5°C, an arterial pressure of 70/50 mmHg with a regular heart rate of 110 min. Digital rectal examination brought melena. Blood sample analysis showed raised inflammatory parameters. A clinical diagnosis of bowel obstruction with septic shock was retained. Lower abdominal obstruction at the level of the surgical staples was confirmed by abdominal CT scan. Primary differential diagnosis workup was that of either bowel obstruction on fibrous stricture or volvulus. The patient underwent an emergency laparotomy. A hemorrhagic peritoneal liquid and a 2-m small-bowel dilatation of which 1 m showed necrosis up to the superior pole of the ileoanal reservoir were found as well as a volvulus of the small bowel surrounding a stricture around the J pouch. The stricture was removed and the upper part of the J pouch was resected by means of the linear stapler GIA 55. Resection of necrotic small bowel was performed with a remnant small-bowel length of 3 m from the duodenojejunal junction. Initially, a right terminal ileostomy was performed and continuity was re-established 3 months later by an ileo-ileal anastomosis on the remaining J pouch. Volvulus of the ileoanal J pouch is a life-threatening surgical emergency. Although the incidence of short bowel volvulus has been reported in Western countries to be 1.7–5.7/100,000 of the population, the actual incidence of volvulus of an ileoanal J pouch is unknown, with few cases being reported. Diffuse abdominal pain refractory to narcotic analgesia together with the patient’s history is highly suggestive of the diagnosis. Small bowel infarction is suggested on abdominal CT scan by the presence of bowel wall thickening, intramucosal air, and intra-peritoneal fluid. The whirl sign and the peacock tail sign are additional CT scan findings due to the torsion of small bowel around the mesenteric axis. L. Choughari Divisions of Surgery, Brugmann University Hospital, Free University of Brussels, Brussels, Belgium

Painful true aneurysm in a brachio-basilic arterio-venous fistula

A 70-year-old male underwent an optical urethrotomy in 2010 for treatment of a dense 3-cm anastomotic urethral stricture. His history is significant for Gleason 9 T2b prostate cancer treated with an uncomplicated prostatectomy in 1998 and external beam radiotherapy in 2003 secondary to local recurrence. His urethral catheter was removed day 3 post-optical urethrotomy. He developed right groin pain radiating to the inner thigh and had difficulty weight bearing on the right leg over the subsequent days. His symptoms intermittently worsened and he presented 5 weeks post-optical urethrotomy to the emergency department with a fever, right groin pain and inability to walk. His C-reactive protein was elevated at 137 mg/L and a urine culture positive for pseudomonas aeruginosa. A contrast-enhanced computed tomography scan of his abdomen and pelvis revealed a hypoechoic lesion in his obturator externus muscle. An initial bone scan showed no area of increased uptake to suggest osteomyelitis. On day 3 of admission, a magnetic resonance imaging showed an extensive collection within the right obturator externus measuring 3.7 ¥ 2.1 cm as well as osteomyelitis of the pubis (Fig. 1). Ultrasound-guided drainage of the collection aspirated 3 mL of purulent material which grew Pseudomonas aeuroginosa. Optical urethrotomy is considered a safe and effective treatment for urethral strictures. The most common complications are fever, bleeding, urinary tract infection, epididymitis, urinary incontinence, urinary extravasation and recurrence of stricture. We postulate that a disruption of the anatomical planes secondary to radiotherapy resulted in the extravasation of urine, from a breach in the corpus spongiosum at time of urethrotomy, into the superficial perineal space which then tracked deep to Colles’ fascia into the medial compartment of the thigh. Pyomyositis is a rare but possible complication of optical urethrotomy, with patients previously treated with local radiotherapy at particular risk.

A comparison of mixed and central venous oxygen saturation in patients during and after cardiac surgery

Monitoring of mixed venous oxygen saturation (Sv̄O2) allows assessment of the global balance between oxygen supply and demand. Sv̄O2 measurement requires the insertion of a pulmonary artery catheter (PAC) whereas central venous oxygen saturation (ScvO2) monitoring only requires a central venous catheter. The aim of this study was to assess how continuous measurements of ScvO2 relate to simultaneous measurements of Sv̄O2 during and after cardiac surgery. Continuous Sv̄O2 and ScvO2 measurements in 15 patients undergoing elective cardiac surgery were recorded each minute for 24 hours. Bland-Altman analysis of 9,382 paired data points for Sv̄O2 and ScvO2 revealed a mean bias of 4.4% (95% Cl +22.3, −13.6%). Considerable inter- and intra-individual variability was noted. Based on these data and previous studies, ScvO2 and Sv̄O2 are not interchangeable variables.

Bilateral common carotid artery dissection following aortic dissection type A repair

A 62-year-old male patient was admitted to our hospital for sudden acute constrictive thoracic pain with electrocardiogram showing acute anterior ST elevation myocardial infarction. Physical examination revealed a significant differential blood pressure in both upper arms. A thoracic computed tomography (CT)-scan showed a DeBakey type A aortic dissection, starting from the aortic valve and extending to the aorto-iliac junction encompassing the aortic arch. Essential hypertension was his sole cardiovascular co-morbidity. His carotid arteries were unconcealed in this aortic dissection. He had urgent aortic repair surgery with a 28 mm aortic prosthesis under extracorporeal circulation. Eight days post-operatively, after weaning from sedation, he remained comatose. Electroencephalogram tracing showed bilateral cerebral dysfunction and cerebral CT-scan showed bilateral lacunar lesions with bilateral frontal hypodensities. Doppler ultrasound of the common carotid arteries showed bilateral dissection with the left common carotid artery extending towards the ostium of the internal carotid artery (Fig. 1). Both his vertebral arteries were patent. The clinical course progressed towards brain stem death and the patient died. Extracranial or common bilateral carotid artery dissections are rare with an unknown prevalence, usually attributed to major trauma and nearly all of common carotid dissections are a result of aortic dissection. We report a case of late onset of bilateral carotid dissection in a post-aortic dissection repair setting in a sedated patient. This late onset could be due to a pre-existing undetectable, subclinical dissection present before surgery. The precipitating factor could be due to hypertensive bouts in the post-operative period. In effect, 2 days prior to the cervical ultrasound, the patient presented systolic hypertensive bouts up to 214 mm Hg despite continuous intravenous nicardipine. Our patient did not have any known connective tissue disorders. Extra care should be taken to avoid hypertensive bouts and maintain tight control of blood pressure in sedated patients in the post-operative period in dissecting diseases of the aorta.

Coexistence of renal malakoplakia and myelodysplastic syndrome

Malakoplakia is a protean systemic chronic granulomatous disease that usually targets the genito‐urinary system and most particularly the bladder. Only in rare occasions do the kidneys get involved. Myelodysplastic syndrome is a heterogeneous clonal haematopoietic disorder characterised by either a hyper‐ or hypocellular bone marrow dysmyelopoiesis and peripheral blood pancytopenia. The synchronous association of these two unrelated disorders has never been reported. We report a 62‐year‐old woman who initially developed vague, relapsing gastrointestinal symptoms synchronous with renal malakoplakia and myelodysplastic syndrome.

A pulsatile and painful buttock

packing, the wound was re-closed with a suction drain left in situ. Following a total hospital stay of 18 days, the patient was discharged with regular follow-up. Having the mass removed permitted and motivated the patient to exercise more frequently. With dietician review, he began to improve his diet. The most crucial differential diagnosis of MLL is welldifferentiated liposacroma which has a significantly worse prognosis. Raising awareness of the existence of MLL will improve diagnosis and management. It is likely that MLL is more prevalent than the current world literature suggests and cases are likely to increase in proportion with the level of obesity seen in society.