A 26-year-old man presented following blunt abdominal trauma to a regional major trauma centre for emergency embolisation of a retroperitoneal bleed from a presumed renal laceration. Imaging had also revealed a large right suprarenal mass. Embolisation resulted in a hypertensive crisis raising the suspicion of a metabolically active adrenal tumour. The course was further complicated by the development of ischaemic bowel requiring emergency laparotomy. Intraoperatively he became haemodynamically unstable from an actively haemorrhaging lesion. Emergency laparotomy and adrenalectomy was performed as a life-saving procedure. Histology confirmed a phaeochromocytoma. The patient made a gradual recovery and was discharged home with no sequelae. Definitive management of phaeochromocytoma is surgical resection which requires prolonged preoperative optimisation with alpha receptor blockers to adequately control blood pressure and prevent hypertensive crises. Parenteral alpha receptor blockers, such as phentolamine, are optimal treatment for intraoperative hypertensive emergencies, yet they are currently not available in the UK.
Letters to the editor We suggest that there are two additional learning points from this case. Firstly, phaeochromocytoma crisis with sustained hypotension is notoriously difficult to manage and there is normally a significant component of myocardial dysfunction due to catecholamine toxicity. An effective treatment (along with aggressive volume replacement) is some form of mechanical circulatory support such as cardiopulmonary bypass or veno-arterial extracorporeal membrane oxygenation. 3,4 The use of this type of circulatory support is strongly associated with improved survival in hypotensive phaeochromocytoma crisis. 2 If required, urgent surgery can be performed whilst on mechanical support. 5 Secondly, the authors correctly point out that intravenous alpha blockade (phentolamine and phenoxybenzamine) is currently difficult to access in UK. In preference to using no alpha blocking agents, clinicians who find themselves in these circumstances should consider using intravenous magnesium for medical stabilisation. 2,6 There is an evidence base for intravenous magnesium 7,8 as an alternative to alpha blockade and importantly the drug is familiar to many intensivists due to its critical role in eclampsia treatment. ■
Objective: 1. To compare Laparoscopic sterlisation with "Essure" hysteroscopic sterilisation in terms of safety and failure rate 2. To review the value of imaging following hysteroscopic sterilisation with the Essure Setting: Outpatient interventional setting in Birmingham Women's Hospital Methods: Retrospective study of reproductive age women requesting permanent sterilisation in a tertiary centre, measuring patient's demographics, safety outcome, unintended pregnancies, and reoperation within one year of the procedure. Women who underwent placement of the Essure were assessed for appropriate positioning of the Essure micro-insert coil using USS as well as HSG when indicated.Results: We identified 314 patients undergoing hysteroscopic sterilisation and 493 undergoing laparoscopic sterilisation between 2010 and 2015. The use of hysteroscopic sterilisation increased during this period. Hysteroscopic sterilisation was not associated with higher rate of unintended pregnancy (0.96% vs 0.82%), but was associated with higher rate of re-operation (5.2% vs 1.4%). 252 women who underwent hysteroscopic sterilisation returned for USS follow up at 3 months following insertion, adequate micro insert positioning and bilateral tubal occlusion was confirmed in (63%) of the cases. (13.8%) of patients required HSG to confirm proper placement.Conclusion: Patients undergoing hysteroscopic sterilisation have a similar risk of unintended pregnancy but higher risk of reoperation. USS is a rapid and safe method of confirming satisfactory placement and tubal occlusion. HSG should be reserved for the cases that demonstrate unsatisfactory ultrasound results. http://dx.
No preference
Pelvic floor disorders and urinary incontinencePrimary Anterior vaginal site specific repair (VSSR) with non-crosslinked xenograft splinting: surgical technique and perioperative review
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.