Intraoperatively Research Articles

PIGMENTED VILLONODULAR SYNOVITIS OF HIP: A RARE CASE

Pigmented villonodular synovitis (PVNS) is a rare disease that can affect any joint, bursa or tendon sheath. The hip is less frequently affected than the knee.1 We report a case of a 46 years old male presented with history of pain and limp over right hip since 6months associated with difculty in sitting cross legged and squatting to performing day today activity. There was no history of fever, weight loss, and long term drug intake. Radiological assessment showed secondary arthritis of right hip with features of avascular necrosis (AVN). The provisional diagnosis was Arthritis of right hip secondary to AVN/ Inammatory arthritis and the patient underwent uncemented right total hip replacement(THA), Intra operatively the articular erosion was noted with reddish gray abnormal synovial growth. Histological assessment showed diffuse expansive sheets of histiocytes admixed with hemosiderin laden macrophages and alveolar spaces lined by synovial cells and collagenized stroma. A short term follow up of 18months did not show any clinical recurrence. We conclude that, from our observation, complete excision of lesion combined with THA is an effective treatment for PVNS of Hip.

Incidental Multifocal Peritoneal Adenomatoid Tumors Presenting Intra Operatively as Possible Metastatic Disease in a 73 Year Old Woman

Adenomatoid tumour is a benign entity which occurs most commonly in the female and male genital tract. In females they cannot be distinguished clinically or radiologically from other entities such as leiomyoma; histology is required and intra-operative frozen section can be considered. Resection can be challenging when the growth pattern is diffuse.

Cecal volvulus in an elderly male: Rare case report of cause of intestinal obstruction

Introduction: Colonic volvulus represents 1.9% of cases of large bowel obstruction in the United States and up to 10% to 50% of cases in Africa, the Middle East, and South America. Volvulus occurs when a segment of colon undergoes torsion along its own mesentery (Mesenteroaxial) resulting in obstruction. Case History: A 70 year old male presents to the Emergency Department with 3 days history of worsening abdominal pain, distension, nausea, vomiting and cessation of flatus and bowel movements. As soon as patient presented to our emergency department, brief history was noted and examination was done, resuscitative measures were taken and patient was planned for emergency laparotomy. INTRA Operatively: Small bowel dilatation noted with cecal volvulus with multiple perforations over the dilated cecum along with discoloration of ascending colon. Discussion: The management of cecal volvulus requires emergency diagnosis and emergency surgical intervention. Any delay in diagnosis may lead to intestinal necrosis or perforation and worsening the prognosis in patients who are generally elderly. Several authors reported a high mortality rate of cecal volvulus due to delay to diagnosis and surgical intervention. Conclusion: It is rare case of intestinal obstruction needs emergency operative management. Despite advancement in radiological imaging preoperative diagnosis is challenge.

Quantum of cortico-cancellous bone safe for harvest from anterior iliac wing of pediatric patients: a finite element analysis with clinical correlation

Background: Objective was to assess the maximum quantum of cortico- cancellous bone that can be harvested from the Anterior Iliac Wing (AIW) of paediatric population.Methods: All patients reporting to the unit for the correction of bilateral cleft alveolus were included. A Computed Tomogram (CT) of the hip was recorded and the volume of cancellous bone available for harvest was assessed. Finite element model of the hip was generated using D2P and Geomagic Free form software and the impact of bone harvest on stress distribution along the anterior iliac wing was assessed by substituting the muscle forces (hip abductors and sartorius group) and was clinically correlated to volume harvested and donor site morbidities.Results: 10 patients were enrolled, 5 patients were excluded. CT volumetric evaluation revealed an average 0.5 cc to 4.7 ccof cancellous bone and 6.7 cc to 11 cc of cortical bone was available for harvest. Harvest of 50% of available graft volume was safe with minimal stress distributed along the line joining the tuberosity to the area between Antero Superior and Inferior spines (4.2 MPa at rest and 18.5 MPa at stance). The stress levels increased with increase in volume of bone harvested. Intra operatively 1.9 cc to 6.2 cc of cortico cancellous graft was harvested, which was equivalent to 60% of the graft available with no long-term morbidities.Conclusions: The volume of bone graft harvest should be restricted (up to 6 cc) to avoid long term morbidities.

Comparative Study of Volume Controlled Ventilation Mode (VCV) and Pressure Controlled Ventilation Mode (PCV) Intra Operatively in Patient Undergoing Coronary Artery Bypass Graft Surgery

Comparative Study of Volume Controlled Ventilation Mode (VCV) and Pressure Controlled Ventilation Mode (PCV) Intra Operatively in Patient Undergoing Coronary Artery Bypass Graft Surgery

A Rare Case of Polypoidal Cystitis in Adult without History of Prolong Catheterization

Introduction: Polypoidal cystitis is a rare lesion of the bladder mucosa characterized by benign exophytic inflammation,epithelial proliferation and development of polypoid mass without evidence of neoplasm histologically. Polypoid cystitis is rarely seen in patient without prolong used of indwelling catheter. Other cases of polypoidal cystitis are associated with post-radiation, post chemotherapy bladder reaction, colovesicular fistula are extremely rare. Case Report: 66 year old Malay male ,underlying hypertension and Benign Prostatic Hyperplasia (BPH) on treatment, complaining of difficulty in urination, straining on voiding for the past 6 months and on and off  hematuria for the past 2 months. He denied any history of CBD insertion or prolong cataheterization. Blood investigations are Normal. X-Ray KUB showed unremarkable. Ultrasound KUB revealed Prostatomegaly, no evidence of renal or ureteric calculi or evidence of Obstructive uropathy,No obvious bladder mass. Cystoscopy Examination (CE) showed enlarged occlusive prostate and noted bladder growth at base of bladder. The growth is malignant looking however no active bleeding seen. No bladder stone seen. Patient subsequently underwent TransUrethral Resection of Bladder Tumor (TURBT) and Trans-Urethral Resection of Prostate (TURP) in same setting. Intra operatively was uneventful. HistoPathological Examination (HPE) from TURBT specimens showed in favour of Polypoidal Cystitis and TURP revealed Nodular Hyperplasia. Discussion: Polypoidal Cystitis is a form or chronic cystitis characterized by exophytic inflammatory  lesion of bladder mucosa. The polypoidal mass is mimicking neoplasm. At the initial evaluation, it may be confused with transitional cell carcinoma of the urinary bladder, especially in patient without an indwelling catheter. The most common aetiology of this condition is long-standing indwelling catheterization.. There is also reported that any factors that irritates the bladder mucosa may result in Polypoidal Cystitis.  In our patient ,there was no history of such other causes, including prolong catheterization, fistula, urinary calculi or radiation therapy.

Evaluation of Intraoperative Versus Postoperative Adjuvant Mitomycin C with Nephroureterectomy for Urothelial Carcinoma of the Upper Urinary Tract.

Background:Results of randomized trials support a single dose of intravesical chemotherapy following radical nephroureterectomy (RNU) for urothelial carcinoma.Objective:To evaluate the impact of the timing of intravesical mitomycin C (MMC) administration on the rate of bladder tumor recurrence (BTR) following RNU.Methods:We performed a retrospective review of patients who underwent RNU for upper tract urothelial carcinoma (UTUC) and received intravesical MMC between 2008 and 2016. Patients were categorized into two separate groups based on the timing of MMC administration: patients who received MMC intraoperatively (IO) and patients who received MMC on post-operative day 1 or later (PO). Our primary endpoint was BTR rate within the first year after surgery.Results:Fifty-one patients met our inclusion criteria: (IO: n = 30; PO: n = 21). There were no statistically significant differences in baseline characteristics of age, gender, race, surgical approach, tumor grade, tumor stage, surgical margins, nodal status, concomitant CIS, or history of bladder cancer. The median length of follow-up for each group was 22 months for IO and 12 months for PO (P = 0.10). The estimated probability of 1-year BTR rates for the IO and PO groups were 16% and 33%, respectively (p = 0.09). Cox analysis noted that the IO patients had a significantly lower rate of BTR in the first year postoperatively (HR = 0.113, 95% CI = 0.28–0.63, p = 0.01).Conclusions:The use of intraoperative MMC at the time of RNU was associated with a decrease in the risk of 1-year recurrence within the bladder.

Comparative Study of Intra Operative Blood Sugar Level in Spinal Anesthesia and General Anesthesia in Patients undergoing Elective Surgery

Introduction: The aim of the study was to carry out the comparative study of variations in blood glucose levels intra operatively in patients undergoing surgical procedures in Spinal Anesthesia and General Anesthesia by capillary blood glucose level.Objective: To compare intra operative blood glucose level in Spinal and General Anesthesia.Methodology: Sixty non diabetic patients (30 in each group) aged between 20 – 60 years belonging to ASA I and ASA II status were enrolled for this prospective comparative study. Capillary blood glucose was measured preoperatively and thereafter at 15 minutes interval after incision in Spinal Anesthesia and after induction of General Anesthesia till one hour of surgery. For statistical analysis paired sample t – test was used for comparing mean of quantitative data. Difference was considered statistically significant if p < 0.05.Results: Blood sugar level was well controlled in patients receiving spinal anesthesia. General anesthesia produced more increase in blood sugar level compared to base line value which was statistically significant (P<0.05). Similarly, Glycaemia was significantly higher in the General anesthesia group (p < 0.05) when compared with Spinal Anesthesia group suggesting poor control of stress response during general anesthesia.Conclusion: Based on capillary blood glucose level, spinal anesthesia proved more effective in suppressing stress response as compared to general anesthesia in elective surgical patients. BJHS 2018;3(2)6: 458-462

Study of Changes in Cholesterol 7 Alpha Hydroxylase in Patients with Gall Stone in Babylon Province

The gallbladder (GB) is an assistant organ of the digestive system, It is located under the liver and attached to the biliary system, And it is responsible for controlling release of bile and the storage. Gallstone disease a major health problem worldwide. In 10–15% of adults contain gallstone disease. This study (case control) consists of one hundred sixty (160) patients are included in this study randomly selected and consisted of 130 females and 30 males. All patients are examined 24 hr. Before operation, Intra operatively and 24hr post operatively. Decreased gallbladder motility and the decrease of cholesterol 7 –alpha hydroxylase activity, which regulate the novo bile salt synthesis. The rate-limiting step of bile acid synthesis is acting between the liver-specific CYP 7A1 (CYP450). Thus, Alteration in CYP gene control also has an impact on bile acid synthesis and lipid metabolism.

Intraoperative air leak measured after lobectomy is associated with postoperative duration of air leak.

To verify the association between the air leak objectively measured intraoperatively (IAL) using the ventilator and the air leak duration after pulmonary lobectomy. Prospective analysis on 111 patients submitted to pulmonary lobectomy (33 by video-assisted thoracic surgery). After resection, objective assessment of air leak (in milliliter per minute) was performed before closure of the chest by measuring the difference between a fixed inspired and expired volume, using a tidal volume of 8 ml/kg, a respiratory rate of 10 and a positive-end expiratory pressure of 5 cmH2O. A multivariable analysis was performed for identifying factors associated with duration of postoperative air leak. Average IAL was 158 ml/min (range 0-1500 ml/min). The best cut-off (receiver-operating characteristics analysis) associated with air leak longer than 5 days was 500 ml/min. Nine patients had IAL >500 ml/min (8%). They had a longer duration of postoperative air leak compared with those with a lower IAL (mean values, 10.1 days, SD 8.8 vs 1.5 days, SD 4.9 P < 0.001). The following variables remained associated with days of air leak duration after multivariable regression: left side resection (P = 0.018), upper site resection (P = 0.031) and IAL >500 ml/min (P < 0.001). The following equation estimating the days of air leak duration was generated: 1.7 + 2.4 × left side + 2.2 × upper site + 8.8 × IAL >500. The air leak measurement using the ventilator parameters after lung resection may assist in estimating the risk of postoperative prolonged air leak. An IAL > 500 ml/min may warrant the use of intraoperative preventative measures, particularly after video-assisted thoracic surgery lobectomy where a submersion test is often unreliable.

Radiotherapy-induced miR-223 prevents relapse of breast cancer by targeting the EGF pathway

In breast cancer (BC) patients, local recurrences often arise in proximity of the surgical scar, suggesting that response to surgery may have a causative role. Radiotherapy (RT) after lumpectomy significantly reduces the risk of recurrence. We investigated the direct effects of surgery and of RT delivered intraoperatively (IORT), by collecting irradiated and non-irradiated breast tissues from BC patients, after tumor removal. These breast tissue specimens have been profiled for their microRNA (miR) expression, in search of differentially expressed miR among patients treated or not with IORT. Our results demonstrate that IORT elicits effects that go beyond the direct killing of residual tumor cells. IORT altered the wound response, inducing the expression of miR-223 in the peri-tumoral breast tissue. miR-223 downregulated the local expression of epidermal growth factor (EGF), leading to decreased activation of EGF receptor (EGFR) on target cells and, eventually, dampening a positive EGF–EGFR autocrine/paracrine stimulation loop induced by the post-surgical wound-healing response. Accordingly, both RT-induced miR-223 and peri-operative inhibition of EGFR efficiently prevented BC cell growth and reduced recurrence formation in mouse models of BC. Our study uncovers unknown effects of RT delivered on a wounded tissue and prompts to the use of anti-EGFR treatments, in a peri-operative treatment schedule, aimed to timely treat BC patients and restrain recurrence formation.

Anaesthetic Management of an Adult Patient with Diaphragmatic Eventration

This case report presents the anaesthetic management of an adult male, who had epidermal inclusion cyst of neck with incidental findings of diaphragmatic eventration, dextro position of heart and pituitary macro adenoma, but the patient was clinically asymptomatic, planned for neck exploration and excision of cyst. Induction of anaesthesia was uneventful, Intra operatively patient became hypoxic and hypotensive probably due to increase in shunting fraction, norepinephrine infusion was started; blood pressure and oxygen saturation improved, at the end of surgery patient was successfully extubated, rest of the course was unremarkable.

術中に腫瘍塞栓に気付き治癒切除が得られた胃肝様腺癌の１例

術中に腫瘍塞栓に気付き治癒切除が得られた胃肝様腺癌の１例

Ancient Cervical Vagal Schwannoma: A Diagnostic Challenge

Sir, Nerve sheath tumors arising from the cervical vagus nerve are extremely rare and difficult to diagnose. We report a case of a 33-year-old male who presented to us with a two year history of an asymptomatic left sided cervical swelling. Clinical examination revealed a firm, well circumscribed 14x6cm neck mass with minimal transverse mobility along the nodal levels II to IV. Clinical examination of the rest of the neck, the upper aero digestive tract and the cranial nerves were unremarkable. A computerized tomography scan revealed an irregular hetero dense well enhancing mass with multiple calcifications in the left neck extending from the level of the C2 vertebra to the level of the D2 vertebral level measuring 14 × 5.9 × 4.6cm, displacing the carotid artery anteriorly and severely compressing the left internal jugular vein. A digital subtraction angiography revealed the mass to be mainly supplied from one of the branches of the external carotid artery (Fig. 1a, b). Fine needle aspiration cytology of the mass repeated twice was inconclusive. The patient was therefore taken up for a surgical exploration with a provisional clinical diagnosis of a soft tissue tumor. Fig. 1 a A computerized tomography scan revealed an irregular hetero dense well enhancing mass with multiple calcifications in the left neck extending from the level of the C2 vertebra to the level of the D2 vertebral level measuring 14 × 5.9 × 4.6 cm, ... Intra operatively an encapsulated yellowish white mass was seen in close proximity to the vagus nerve (Fig. 2a, b). The tumor was meticulously separated from the trunk of the vagus nerve, the carotid artery and was removed en-bloc along with the internal jugular vein using micro surgical dissection techniques. The patient made an uneventful clinical and neurological recovery. Fig. 2 a Intra operative photograph showing an encapsulated yellowish white mass was seen in close proximity to the vagus nerve. b The post operative specimen photograph The post operative histopathology revealed a 15x8x5cm encapsulated mass, the cut surface of which appeared yellowish white with myxoid areas. Microscopic examination revealed a tumor composed of spindle cells with vesicular nuclei surrounded by a markedly hyalinized stroma. Most of the areas show marked myxoid degeneration and hyalinization (Antoni B) and focal cellular spindle cell areas with dark staining nuclei. (Antoni A) Scattered calcifications are seen Scattered calcific spherules, hyalinized blood vessels and lymphoid aggregates were also seen, suggesting a diagnosis of an Ancient Schwannoma (Fig. 3). Fig. 3 a, b H&EX10: Most of the areas show marked myxoid degeneration and hyalinization (Antoni B) marked as B and focal cellular spindle cell areas with dark staining nuclei(Antoni A) marked as A. Scattered calcifications are seen (C). Few blood vessels ... Schwannoma is a rare benign neural tumor, arising from the neural sheath schwann cells of the peripheral, cranial or autonomic nerves. Ackerman and Taylor in 1951 [1] coined the term “ancient” schwannoma to describe a long standing degenerative schwannoma that presented with wide areas of hyalinized matrix. Despite the degenerative changes ancient schwannomas are believed to have a clinical behavior similar to that of a conventional schwannoma. Schwannoma originating from the cervical vagus nerve is an extremely rare neoplasm. They usually occur between the third and fifth decades of life, with no definite sex predilection. The pre-operative diagnosis of schwannoma is a clinical challenge and is aided by imaging. MRI scan with gadolinium contrast is said to be the preferred technique of choice for imaging. The imaging findings are also useful in providing a clue as to the nerve of origin of a cervical schwannoma. The vagal schwannomas displaces and separates the internal jugular vein and the carotid artery, whereas schwannomas from the cervical sympathetic chain displaces both the carotid artery and internal jugular vein without separating them [2]. Complete surgical excision is the treatment of choice of cervical vagal schwannomas. Transecting and re-anastomosing the vagus nerve invariably results in significant morbidity, hence attempts at nerve preservation should be made whenever possible considering the benign nature of a majority of the cervical vagal schwannomas [3, 4]. Some series have reported the incidence of post operative vocal cord paralysis as high as 85%, citing difficulty in separately identifying the trunk of the vagus nerve from the tumor [5]. This was however not the case in a few other series [3, 4] as also our patient, who had an uneventful neurological recovery.

Pancreatoblastoma – A Rare Pediatric Pancreatic Tumor.

A 12-year-old male child, who was previously well, complained of pain and lump in abdomen. Physical and radiological investigations revealed a mass in Histopathological examination of the resected specimen showed pancreatoblastoma. Pancreatoblastoma is an unusual malignant tumour seen in infants and children although rare cases have also been reported in adults. They are clinicopathologically distinct from adult pancreatic ductal carcinoma. The histogenesis, clinical features and treatment options are discussed along with presentation of the case. Pancreatoblastoma is a rare distinct neoplasm that is most commonly encountered in infants and young children, although rare cases have been reported in adults. They comprise 0.5- 1% of pancreatic tumors. Pancreatoblastoma was first described by Frantz in 1959. Subsequently, Frable et al in 1971 described the histological and ultrastructural findings and called it as infantile carcinoma of pancreas. These tumors are considered to be embryonic in origin, based on the histological appearance. Evidence of endocrine component, acinar cells containing zymogen granules and the presence of alpha-foetoprotein, suggests that this neoplasm arises from multipotential stemcells. A potential molecular association between pancreatoblastoma and hepatoblastoma is suggested by the occurrence of both tumors in young patients with Beckwith-Wiedemann syndrome, raising the possibility that genetic events on chromosome 11p might play a role. The clinical presentations of these tumors are varied. They can present as abdominal pain, abdominal mass, diarrhoea, or upper gastrointestinal bleeding. Most of the time, they are asymptomatic. The presenting features are highly non-specific and this leads to diagnostic dilemmas. The tumor is slightly more frequent in males, with the median age of presentation being five years. Though malignant, these tumors have an indolent course. They can be cured by complete resection alone and in cases of unresectable tumors, incomplete resection and in those with metastatic lesions, radiotherapy or chemotherapy may be given. The prognosis is worse in the presence of synchronous or metachronous metastasis and non-resectable disease at presentation, (1). II. Case Report A 12-year-old boy presented with pain and swelling in the upper abdomen and had vomitings. The vomitus contained only ingested food particles. Patient also had few episodes of loose stools. Physical examination revealed a slightly tender lump in the epigastrium and left hypochondriac region. The rest of the abdomen was soft and non-tender. Bowel sounds were sluggish. Ultrasonography of the abdomen showed a well-defined heterogeneous mass in the epigastric region measuring 6.4x5.5x2 cm. This mass was situated medial to the spleen and was compressing the stomach. Computed tomography (CT) of abdomen showed a well- defined cystic mass in the region of pancreatic tail.(Fig. 1 & 2). The contents antigen, serum amylase and alpha- foetoprotein were all within normal limits. The patient underwent exploratory laprotomy for resection of the mass in the Intra operatively, there was a well-defined encapsulated firm mass arising from the body of pancreas adherent to mesocolon and lesser sac of stomach. The mass was adherent to retroperitoneum and surrounding structures except spleen This cystic mass was resected piecemeal. Grossly, the resected tumor was globular and encapsulated, measuring 7x6x3 cm and weighing 180g. The surface was bossellated and the tumour was soft in consistency. Serial cut sections revealed a greyish white solid tumor with central area of haemorrhage and necrosis. Microscopical examination of this resected tumor showed pancreatic tissue and a tumor that was arranged in glandular and acinar pattern with interspersed focal solid areas. In the solid areas, whorled nests of spindle cells and islands of plump epithelioid cells were seen (Fig. 3 & 4). Extensive tumor necrosis was also present. The tumor cells showed diffuse strong positivity for alpha-foetoprotein .After surgery, the patient was referred to our Deptt. for further management. He was started on PLADO (Cisplatinum &Doxorubicin) based chemotherapy .He received one cycle of PLADO based chemotherapy and later was lost to follow up.

Visual acuity after trabeculectomy

In this study we compared the two groups of glaucoma patients who had underwent trabeculectomy, with or without intraoperative application of antimetabolite 5-Fluorouracile (5 FU). We followed up 50 glaucoma patients (group I) in a four-years period after trabeculectomy alone (antimetabolites were not applied), and 50 patients in whom antimetabolite 5 FU was applied (group II). We followed up intraocular pressure (IOP), visual acuity (VA), lens transparency, optic disc changes, visual fields (VF perimetry). The IOP at the time of the surgery, and the period of the treatment before the surgery were the important data for the follow-up. The results that we got in the first group were: in 8 patients (16%) there was no change of VA, and of optic disc with a mild VF deterioration; in 18 patients (33%) the worsening of VA by 1 Snellen line (3 years after the surgery) with no change of the disc and a mild VF progressing; in 10 patients (20%) VA decreased by 2 Snellen lines with the progressive VF changes and cataract appearance, (cataract and VA worsening appeared mainly 3 years after the surgery); in 6 patients (12%) by 3 Snellen lines, and in 4 patients (8%) by 4 Snellen lines. In 4 patients (8%), the highest worsening of VA--(0.2) and the best (0.9) at the time of the surgery were observed. The VA ranging from 0.4-0.6 at the time of the surgery yielded the longest preservation of vision. In the group II (5 FU applied intra-operatively): in 5 patients (10%) there was no change of VA and of optic disc with a mild VF deterioration; in 20 patients (40%) the worsening of VA by 1 Snellen line, with no change of the disc and a mild VF progressing. In 14 patients (28%) VA decreased by 2 Snellen lines with the progressive VF changes and cataract appearance; in 7 patients (14%) by 3 Snellen lines, and in 4 patints (8%) by 4 Snellen lines. All of the checked parameters were better in the group II of the patients, (5 FU applied intraoperatively). Also, in the group of the patients with the longest treatment before the surgery and with the good VA, and in the patients with the shorter treatment and with the bad VA, the quickest progression of the vision losts was observed. The best preservation of VA was recordered in the patients with a mild IOP, and in those who had not been treated more than 1 or 2 years with the drops before the surgery. The VA ranging from 0.4-0.6 at the time of the surgery allowed the longest preservation of vision.

Long-term effects of postoperative subconjunctival injections of mitomycin-C in the rabbit eye.

Single or multiple subconjunctival injections of mitomycin-C (MMC) may offer one way of establishing the total dosage of MMC more accurately. The method also allows re-applications later postoperatively. In this experimental, randomized prospective study we compared the effects of a single intraoperative application of MMC at the filtering site and a single postoperative subconjunctival injection of the drug. The left eyes of 32 pigmented rabbits were divided into two groups. In the first group we applied MMC intraoperatively (IO) with a 4 x 1 mm surgical sponge soaked in a MMC solution (0.5 mg/ml). In the second group we injected 0.4 ml of the same solution subconjunctivally (SC) immediately after (conjunctival) suture. Post-operative evaluation was carried out every day during the first week, then every three days until day 58. Survival analyses were done for intraocular pressure (IOP) and bleb failure. Log-rank tests were used to compare survival differences between the groups. The IO group showed longer survival parameters than the SC group (p < 0.05), both in the control of IOP and as regards blebs. The histological persistence of fistulas was similar. The IO group, however, had a higher incidence of undesirable side effects. Our findings suggest IO application of MMC is more effective in reducing fibroblast ingrowth. However, subconjunctival application offers certain advantages such as the possibility of repeating the treatment postoperatively and, therefore, using a smaller initial dose.

Crystalloid Vs. Colloid Resuscitation

The effects of hemodynamic resuscitation with protein-containing or balanced salt solution were studied prospectively in 29 patients undergoing abdominal aortic surgery. Blood loss was replaced with packed red cells and extracellular volume with either Ringer's Lactate (RL) or 5% albumin in Ringer's lactate (ALB). Fluids were given to maintain the pulmonary capillary wedge pressure (PCWP) equal to or within 5 torr above preoperative (PO) levels, the cardiac output (CO) equal to or greater than preoperative values, and the urine output at least 50 ml/hr. Serum colloid osmotic pressure (COP), CO, PCWP, the gradient between COP and PCWP (COP-PCWP), and intrapulmonary shunt (Qs/Qt) were measured PO, intraoperatively (IO), and daily for 3 days. The measured variables were similar PO in both groups. Operation time, estimated blood loss, and transfusions were similar. Total fluids received for resuscitation (day of operation) was 11.3 +/- 0.8 liters (RL) and 6.2 +/- 0.4 liters (ALB). Fluid balance at the end of resuscitation was 8.4 +/- 0.8 liters (RL) and 3.4 +/- 0.5 liters (ALB). Maximum decrease in COP was 40% (P less than 0.001) in the RL group and was insignificant in the ALB group. The COP-PCWP decreased from 11 +/- 1 to 2 +/- 1 in RL (P less than 0.001) and insignificantly in ALB. Qs/Qt increased slightly in both groups following operation but was not different between groups. Fluid balance, total fluid infused, sodium balance, total sodium infused, COP, or COP-PCWP did not significantly correlate with Qs/Qt. Two patients in the ALB group experienced pulmonary edema associated with normal COPs and elevated PCWPs. There were no cases of pulmonary edema associated with low COPs and normal PCWPs in the crystalloid group. These data seriously question the necessity to maintain COP by using protein-containing solutions during acute hemodynamic resuscitation. When titrated to physiological end points, even large volumes of balanced salt solutions are tolerated well.