Surgical removal of a compressive thoracic epidural vascular malformation in a patient with Klippel-Trénaunay syndrome: illustrative case

BACKGROUND Klippel-Trénaunay syndrome (KTS) is a combined capillary-lymphatic-venous malformation disorder traditionally associated with high surgical morbidity. Although rare, pathologic involvement of the spinal cord has been reported in the literature. However, the safety of surgical intervention remains unclear. We report a case of successful decompression of a thoracic epidural lesion in an individual with KTS who presented with spastic paraparesis. OBSERVATIONS The patient is a 38-year-old male, diagnosed with KTS as an infant, who presented with spastic paraparesis secondary to a thoracic epidural lesion. He underwent laminectomies and resection of the lesion with subsequent improvement of his symptoms and without significant postoperative morbidity. Histopathology confirmed the lesion to be a benign vascular malformation. LESSONS Currently, the literature regarding management of symptomatic vascular lesions in individuals with KTS supports nonoperative management, due to the increased risk of operative morbidity associated with this syndrome. This case presents evidence for safe and appropriate surgical management of a thoracic epidural vascular malformation in a patient with KTS in the setting of progressive neurological decline, establishing a role for neurosurgical intervention in this high-risk population when no conservative management portends further neurological deterioration.

P-P18 Thoracic epidural VS intrapleural analgesia for pancreaticoduodenectomy – a study on analgesic and non-analgesic outcomes

Background Thoracic epidural analgesia (TEA) has been the traditional option for post-operative pain management for Kausch-Whipple pancreaticoduodenectomy (KWPD) via a ‘reverse L’ incision. An alternative option with inter-pleural analgesia (IPA) has become popular. However, the superior form of analgesia for KWPD regarding analgesic and non-analgesic outcomes is unclear. This study aims to establish if IPA is equivalent to TEA. Methods Retrospective study of all patients who underwent KWPD with ‘reverse L’ incision by a single surgeon between February 2014 to June 2016. All received either IPA or TEA post-operatively; patients who had rectus sheath catheter and spinal anaesthesia were excluded. To reduce bias, the Anaesthetist, rather than Surgeon, decided the choice of analgesia based on personal skill. Efficacy regarding analgesia were collected by nursing staff as patient-reported pain severity (mild, moderate or severe). Data were collected from patient case notes and electronic records. This study analysed analgesia efficacy, complications, inotrope use, and intensive treatment unit (ITU) stay. Results A total of 40 included in the study. Twenty-two patients had TEA (45% female, median age 68 years) and 18 had IPA (44% female, median age 67 years). Median Charleson Comorbidity Index (CCI) was 5 for both. Patient-reported pain was not statistically different (p = 0.15). We noted more analgesia complications with TEA (not working=4, leakage=2, haemodynamic instability=1, lower limb anaesthesia=1) than IPA (leakage=1; p = 0.027). Eleven (50%) TEA and eight (44%) IPA patients required inotropes. TEA patients required significantly longer duration (median duration 35 VS 18 hours, p = 0.047). Median ITU stay was 3 and 2 days for TEA and IPA patients, respectively. Conclusions Both TEA and IPA provide adequate pain relief for KWPD performed via a ‘reversed L’ incision. However, evidence suggests TEA was associated with significantly more analgesia-related complications and longer inotropic requirements. Furthermore, there was also a trend towards ITU stays with TEA. Therefore, we would recommend the use of inter-pleural analgesia over thoracic epidural.

Traumatic rupture of thoracic epidural capillary hemangioma resulting in acute neurologic deficit: illustrative case

BACKGROUND Thoracic epidural capillary hemangioma is exceedingly rare, with only a few reported cases. The typical presentation usually includes chronic, progressive symptoms of spinal cord compression in middle-aged adults. To the authors’ knowledge, this case is the first report in the literature of acute traumatic capillary hemangioma rupture. OBSERVATIONS A 22-year-old male presented with worsening lower extremity weakness and paresthesias after a fall onto his spine. Imaging showed no evidence of spinal fracture but revealed an expanding hematoma over 24 hours. Removal of the lesion demonstrated a ruptured capillary hemangioma. LESSONS This unique case highlights a rare occurrence of traumatic rupture of a previously unknown asymptomatic thoracic capillary hemangioma in a young adult.

Requirement of Postoperative Ventilation and analgesics during Off-Pump Coronary Artery Bypass (OPCAB) surgery – A Comparison between Combined High Thoracic Epidural Anaesthesia (HTEA) with GA and GA Alone

Beckground: This is often difficult to achieve optimal pain relief after coronary artery bypass surgery and also great challenge to choice appropriate analgesics with minimize the duration of mechanical ventilation. In the postoperative period inadequate analgesia may increase morbidity by causing adverse haemodynamic, metabolic, immunologic and haemostatic attentions and prolong mechanical ventilation with more ICU stay. High Thoracic Epidural Anaesthesia (HTEA) as an adjunct to general anaesthesia has been shown to be potentially beneficial in postoperative pain relief and the requirement of mechanical ventilationin patients with off-pump coronary artery bypass surgery (OPCAB). HTEA provides good protection from stress response, ensures hemodynamic stability, improves distribution of coronary blood flow with reducing demand of oxygen, less requirement of postoperative analgesia , mechanical ventilation and ICU stay. Objective: This study has been undertaken with a view to compare requirement of postoperative mechanical ventilation and analgesics in OPCAB surgery between HTEA with GA and GA alone. Methods: This prospective, randomized case control comparative study was carried out in sixty patients without having left main coronary artery disease, left ventricular ejection fraction <30% or contraindication of regional anaesthesia scheduled for OPCAB. They were divided into two groups, thirty in each group. Group A received GA alone and group B received high thoracic epidural anaesthesia with GA. Requirement of postoperative analgesics, pain score, consciousness score, sedation score, satisfection level and duration of ventilation with length of stay in intensive care unit were recorded in the post-operative period. Results: Rescue analgesics received and found 16(53.3%) and 6(20.0%) needed analgesia in group A and group B respectively and the difference was statistically significant (p<0.05). Regarding the pain score (VAS) during maintenance with ventilator with awareness at first fourth hour significant (p<0.05) change between two groups. After extubation at rest in different time interval and found significant (p<0.05) change between two groups in all follow-up times. Post-operative pain score (VAS) after extubation at movement in different time interval and found significant (p<0.05) change between two groups. Post-operative pain score (VAS) after extubation at during coughing in different time interval and found significant (p<0.05) change between two groups. Post-operative sedation score at first six hour (hourly) and found significant (p<0.05) change between two groups except 1st hour, which was not significant (p>0.05). The mean extubation hours were 7.4±1.09 hours in group A and 5.3±0.81 hours in group B. The mean ICU stay was 72.9±9.2 hours in group A and 57.1±12.0 hours in group B and the difference was statistically significant (p<0.05) in unpaired t-test. No postoperative complication was observed in both groups. Conclusion: HTEA with GA appeared to be most reliable postoperative pain relief, shorter mechanical ventilation, ICU stay in OPCAB surgery Bangladesh Heart Journal 2021; 36(2): 74-81