Obstructive jaundice in young infants represents a clinical situation whose diagnostic evaluation has changed dramatically over the past few years.1-3 Biliary atresia and some forms of neonatal hepatitis are the most common diseases to be differentiated. Emphasis has shifted in recent years toward early surgical exploration for the possibility of performing some form of portoenterostomy.
Among surgically correctible lesions, the choledochal cyst, although a rare cause of obstructive jaundice during the newborn period, should be considered and actively pursued since irreversible cirrhosis is a major sequela in untreated cases.4
We describe a patient who was considered to have biliary atresia but on whom a choledochal cyst was discovered at 5½ months of age.
Patients with major cardiac risk factors have been suggested to benefit from perioperative beta-blockade. However, the scientific literature on perioperative beta-blockade needs to be interpreted carefully. So far treatment recommendations for millions of patients are based on heterogeneous data from randomized trials with divergent study results. The evidence for a beneficial effect of perioperative beta-blockers is sufficient only for a limited subpopulation of high cardiac risk patients undergoing vascular surgery. Perioperative beta-blocker treatment is not useful in patients with intermediate risk and may even be harmful in patients with low cardiac risk. Therefore, an individualized risk-benefit analysis is an important prerequisite for a rational therapy that may be based on a standardized protocol including the Revised Cardiac Risk Index. Such a protocol is presented in this article. A recently reported trial (POISE) demonstrated that perioperative treatment with high doses of oral metoprolol efficiently reduces the incidence of cardiovascular events. However, due to severe adverse effects (hypotension, bradycardia, stroke) the total mortality was increased. Thus, dose adjustments, safety aspects, and monitoring of beta-blocker therapy seem to be mandatory. So far evidence from relevant trials about how to best implement perioperative beta-blockade is lacking. This article offers a simple clinical concept for this purpose.
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