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In a well-pneumatized delicate venous channels; the cavernous part of the internal sphenoid sinus purchase viagra sublingual master card, the pterygoid canal and a segment of the carotid artery; the third order 100 mg viagra sublingual visa, fourth proven viagra sublingual 100 mg, and sixth cranial nerves; maxillary division of the trigeminal nerve may be identifed and fbrofatty tissue. The internal carotid artery is the most in the lateral recess of the sphenoid sinus. The trigeminal medial structure within the cavernous sinus and forms a ganglion and the frst and third trigeminal divisions are discernible prominence on the posterolateral aspect of the separated from the lateral wall of the sphenoid sinus by the lateral wall of the sphenoid sinus. The roof of the sphenoid, the planum sphenoidale ante- The carotid prominence can be divided into three parts: the riorly, is in continuum with the roof of the ethmoid sinus. The frst part, At the junction of the planum sphenoidale and the poste- the retrosellar segment, is located in the posterolateral part rior wall of the sphenoid, the sphenoid bone is thickened to of the sinus. Inferior to the tuberculum sella, in well-pneumatized sellar-type sinuses in which the air on the posterior wall, is the sella foor, which forms a mid- cavity extends laterally in the area below the dorsum. The thickness of the anterior sellar wall ranges second part, the infrasellar segment, is located below the from 0. Of the 50 specimens the dura may be visible through this thin bone, impart- examined, Rhoton13 reported 98% had presellar, 80% had in- ing a bluish hue to the sellar foor that aids in its recogni- frasellar, and 78% had retrosellar prominences. Removal of the sellar foor provides access to the sella the prominence may be present and the others absent. The bone separating the artery and the sphenoid sinus is The diaphragma sella forms the roof of the sella turcica. It thinner over the anterior than the posterior parts of the ca- covers the pituitary gland except for a small central open- rotid prominence and is thinnest over the part of the artery ing in the center, which transmits the pituitary stalk. A layer of bone less than diaphragma is more rectangular than circular, tends to be 0. The proximity frequently a thin, tenuous structure that would not be an of the carotid prominences to the midline is an important adequate barrier for protecting suprasellar structures during consideration in pituitary surgery. In front of the infundibulum, the upper aspect of the level of the foor of the sella in 20%, and at the clivus in the gland is related directly to the arachnoid and pia mater. There are areas where no bone separates the struments during tumor removal, causing cerebrospinal fuid 170 Endoscopic Pituitary Surgery leakage. Specialists from these departments Venous sinuses that interconnect the paired cavernous are actively involved in perioperative care of patients with sinuses may be found in the margins of the diaphragma and pituitary tumors. The intercavernous connections anesthesiologist, interventional radiologist, neuropatholo- within the sella are named on the basis of their relationship gist, and radiation oncologist form important members of to the pituitary gland; the anterior intercavernous sinuses the team. In our institution, we have formed a pituitary ser- pass anterior to the hypophysis, and the posterior inter- vice that consists of dedicated specialists involved in the care cavernous sinus pass behind the gland. In addition to the neuro- ous connections may occur at any site along the anterior, surgeon, otolaryngologist, endocrinologists, ophthalmolo- inferior, or posterior surface of the gland, or all connections gist, radiologist, radiation oncologist, and interventional between the two sides may be absent. The anterior intercav- radiologist, the board also includes representatives from the ernous sinus may cover the whole anterior wall of the sella. Pituitary board meetings are The anterior sinus is usually larger than the posterior sinus, held on a 3-month or ad hoc basis. If the anterior and pos- erative results, and complications are audited during these terior connections coexist, the whole structure constitutes meetings. However, this usually stops with temporary compression of the channel with hemostatic foam or with Surgery for pituitary tumors has proven to be efective ther- light coagulation, which serves to glue the walls of the chan- apy for both endocrine active and nonfunctioning pituitary nel together. Indications for surgery include all nonsecreting and most secreting pituitary tumors except for prolactino- mas, which are usually well controlled by medical therapy with a dopamine antagonist. In the current era, the accumulated experience Nonsecretory tumors may vary in size, expanding the of endoscopic trained otolaryngologists may be used by sella and extending along the paths of least resistance, lat- neurosurgeons in providing endonasal access to the sphe- erally into the cavernous sinuses, superiorly into the su- noid sinus and the foor of the sella. These tumors are best managed surgically with wide midline sphenoidotomy and assist the neurosurgeon a combined endonasal and transcranial approach either in in tumor removal. Although it is possible for a single sur- the same setting or as staged operations. In some situ- or adjuvant stereotactic radiation therapy, depending on the ations it is important for the two surgeons to work together, evaluation of the patient. Most secretory tumors, present- the otolaryngologist providing manual manipulation of the ing with features of acromegaly and Cushing’s disease, are endoscope to optimize visualization, particularly when an- an indication for surgery. For prolactin-secreting tumors, gled scopes are used and the feld of the view is constantly surgery is considered for those tumors that do not respond changing. Pituitary apoplexy may require emergent surgery, as these patients usually present with sudden and rapid deterioration of vi- I Working as Part of a Pituitary Service sion. For a surgeon embarking on pituitary surgery, it is Management of pituitary tumors requires a dedicated multi- recommended to start with small and soft tumors and after disciplinary treatment team. Inappropriate pituitary hormone attaining adequate experience to advance to larger tumors secretion and visual feld defcits are the most characteristic with signifcant suprasellar extension or cavernous sinus presenting features of pituitary adenomas. The digital endoscopic video camera system (Karl Storz, Tuttlingen, Germany) is placed at the cephalic end of the Nasal Endoscopy and Identifcation of table to enable both surgeons to view surgery on the video Sphenoid Ostia monitor. The neuroanesthesiologist is at the caudal end of After the nose has been adequately decongested, an endo- the table. The scrub nurse and the instrument trolley are at scopic examination is performed using a 0- or 30-degree the left cephalic end. The ostium lies just above the sphenoethmoid re- side of the operating table and the neurosurgeon on the left cess, approximately 1. The digital video camera is attached to the eyepiece of size of the sphenoid ostia may vary but its location is almost the telescope, and the entire procedure is monitored on a constant. Video documentation of the supreme turbinate, which can be gently retracted laterally surgical procedure is routinely done on a digital video re- or resected if necessary. A powered sinus dissection device is used for the sphenoid ostium cannot be identifed, entry into the sphe- sphenoidotomy. A 4-mm bit with a serrated tip to exert controlled pressure to the anterior wall at the outer shaft is used for mucosal dissection. Midline Sphenoidotomy I Surgical Technique Surgery is started on the side on which the sphenoid os- Patient Positioning and Preparation tium is better visualized. Most of the time, we start on The nasal cavity is decongested by placing two neuropat- the right side. The microdebrider with a 4-mm bit with a ties soaked in 4% cocaine in each side approximately 20 serrated outer shaft is used to debride the mucosa in the minutes prior to induction. The patient is placed under sphenoethmoid recess around the sphenoid ostium, taking general anesthesia and administered antibiotics, glucocor- care not to traumatize the mucosa on the superior turbi- ticoids, and antihistamines. The serrated blade of the microdebrider is directed (2 g, intravenous), dexamethasone (10 mg, intravenous), medially and the outer sheath laterally, protecting the and diphenylhydramine (50 mg, intravenous). The sphenoid ostium is dotracheal intubation is used, and a pharyngeal pack is widened inferiorly and medially down to the foor of the placed in the pharynx. Care is taken to avoid the septal branch inserted to monitor urinary output intraoperatively and of the sphenopalatine artery by not going too inferolater- postoperatively. Brisk bleeding may result if the septal branch of the shoe slightly extended, and turned slightly to the right. This may be con- The head is elevated by approximately 30 degrees above trolled by cauterizing the vessel with bipolar diathermy.

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Alternative approaches to abdominal wound closure in severely injured patients with massive visceral edema purchase 100 mg viagra sublingual otc. The open abdomen: defnitions cheap viagra sublingual 100 mg with visa, management principles order 100 mg viagra sublingual with mastercard, and nutrition support con- siderations. Early enteral feeding, compared with parenteral, reduces postoperative septic complications. Enteral versus parenteral feeding effects on septic morbidity after blunt and penetrating abdominal trauma. Early enteral nutrition can be successfully implemented in trauma patients with an “open abdomen”. Early enteral nutrition improves outcomes of open abdo- men in gastrointestinal fstula patients complicated with severe sepsis. Effect of immediate enteral feeding on trauma patients with an open abdomen: protection from nosocomial infections. Is it feasible to implement enteral nutrition in patients with enteroatmospheric fstulae? Metabolic and nutritional support of the enterocutaneous fstula patient: a three-phase approach. Early enteral nutrition after abdominal trauma: effects on septic morbidity and practicality. Effcacy and safety of active negative pressure peritoneal therapy for reducing the systemic infammatory response after damage control laparotomy (the intra-peritoneal vacuum trial): study protocol for a randomized con- trolled trial. Systematic review and evidence based recommendations for the use of negative pressure wound therapy in the open abdomen. Systematic review and meta-analysis of the open abdomen and temporary abdominal closure techniques in non-trauma patients. High risk of fstula formation in vacuum-assisted clo- sure therapy in patients with open abdomen due to secondary peritonitis-a retrospective analy- sis. Long-term vacuum-assisted closure in open abdomen due to secondary peritonitis: a retrospective evaluation of a selected group of patients. Independent predictors of enteric fstula and abdominal sepsis after damage control laparotomy: results from the prospective aast open abdomen registry. What is the effectiveness of the negative pressure wound therapy (Npwt) in patients treated with open abdomen technique? Systematic review and meta-analysis of the role of somatostatin and its analogues in the treatment of enterocutaneous fstula. Open abdomen treatment for septic patients with gastrointestinal fstula: from fstula control to defnitive closure. Negative pressure wound therapy man- agement of the “open abdomen” following trauma: a prospective study and systematic review. Temporary closure of open abdominal wounds by the modifed sandwich-vacuum pack technique. A novel approach to the problem of intestinal fstulization arising in patients managed with open peritoneal cavities. Biological dressings for the management of enteric fstulas in the open abdomen: a preliminary report. The foating stoma: a new technique for control- ling exposed fstulae in abdominal trauma. The “Fistula Vac” a technique for management of enterocutaneous fstulae arising within the open abdomen: report of 5 cases. D’hondt M, Devriendt D, Van Rooy F, Vansteenkiste F, D’hoore A, Penninckx F, Miserez M. Treatment of small-bowel fstulae in the open abdomen with topical negative-pressure therapy. A modifed “Fistula-Vac” tech- nique: management of multiple enterocutaneous fstulas in the open abdomen. The use of negative-pressure wound therapy to manage enteroatmo- spheric fstulae in two patients with large abdominal wounds. Vacuum assisted closure (Vac) therapy(Tm) as a swiss knife multi-tool for enteric fstula closure: tips and tricks: a pilot study. Open abdomen with concomitant enteroatmospheric fstula: validation, refnements, and adjuncts to a novel approach. Collapsible enteroatmospheric fstula isolation device: a novel, simple solution to a com- plex problem. Single-stage closure of enterocutaneous fstula and stomas in the presence of large abdominal wall defects using the components sepa- ration technique. A novel method for managing enterocutaneous fstu- lae in the open abdomen using a pedicle fap. A new technique of closing a gastroatmospheric fstula with a rectus abdominis muscle fap. Autologous reconstruction of massive enteroatmospheric fstulation with a pedicled sub- total lateral thigh fap. Di Saverio S, Tarasconi A, Inaba K, Navsaria P, Coccolini F, Costa Navarro D, Mandrioli M, Vassiliu P, Jovine E, Catena F, Tugnoli G. Open abdomen with concomitant enteroatmospheric fstula: attempt to rationalize the approach to a surgical nightmare and proposal of a clinical algorithm. Classifcation, prevention and management of entero-atmospheric fstula: a state-of-the-art review. Intra-abdominal hypertension and the abdominal compartment syndrome: updated consensus defnitions and clinical practice guide- lines from the World Society of the Abdominal Compartment Syndrome. Distribution assessment comparing continuous and peri- odic wound instillation in conjunction with negative pressure wound therapy using an agar- based model. Comparison of outcomes between early fascial closure and delayed abdominal closure in patients with open abdomen: a systematic review and meta-analysis. Eastern association for the surgery of trauma: a review of the management of the open abdomen—part 2 “management of the open abdomen”. Comparative study of the microvas- cular blood fow in the intestinal wall, wound contraction and fuid evacuation during negative pressure wound therapy in laparostomy using the V. Microvascular blood fow response in the intestinal wall and the omentum during negative wound pressure therapy of the open abdomen. Management of the open abdomen: a national study of clinical outcome and safety of nega- tive pressure wound therapy. Planned ventral hernia following damage control laparotomy in trauma: an added year of recovery but equal long-term outcome. Outcomes of simultaneous large complex abdominal wall reconstruction and enterocutaneous fstula take- down. Dionigi G, Dionigi R, Rovera F, Boni L, Padalino P, Minoja G, Cuffari S, Carrafello G.

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Several fac- tors associated with higher risk of embolism or neurological complications have been identified including presence effective viagra sublingual 100mg, size and mobility of vegetations on echocardiog- raphy order cheap viagra sublingual online, S purchase 100 mg viagra sublingual overnight delivery. The clinical picture, however, is often is characterised by one type of neurological sign U. Snygg-Martin 12 Neurological Complications in Infective Endocarditis 151 or even the absence of neurological symptoms, i. Encephalopathy with impaired consciousness and meningism has also been argued to be of septic embolic origin [8, 19]. Embolic risk is reported to be age dependent by some authors [24], but results are conflicting and different risk estimates can be explained in a time-dependent manor with lower risk of embolic events in older patients in the pre- diagnostic and early treatment phase counteracted by higher risk in the late treat- ment and follow up period, relative to an age-dependent and comorbid related risk of stroke [13 ]. Studies not primarily focusing on neurological complications [25 , 26] or with a narrow definition of neurological complications as strictly of embolic cerebrovascu- lar origin, e. Higher numbers are reported in criti- cally ill patients requiring intensive care admission [28]. Snygg-Martin attention and in three out of four patients suffering neurological symptoms, these are evident at the time of presentation [5 , 20 , 31]. Although neurological complications with clinical symptoms are pre-treatment manifestations in most patients, new neurological symptoms, first time or recurrent, during antibiotic therapy occur in a substantial proportion of patients. Any type of clinically evident embolic manifestation is an important risk factor for a subsequent neurological complication, thus warranting close follow up with antibiotic optimi- sation if possible, new echocardiographic investigation and a surgical re-evaluation. Growing evidence also supports the predictive value of silent cerebral lesions to predict embolic risk [32]. Regardless of type of neurological symptoms most abnormalities are small isch- aemic lesions being more frequent than large infarctions [29]. Multifocal infarctions are also common and frequently involve the end arterial territories of cerebral vessels [2 , 33, 34]. It is, however, surprisingly uncommon that these infected emboli give rise to intracerebral infections such as meningitis, infectious aneurysms or brain abscesses, possibly related to the effective protection the blood-brain barrier exhibits to haematogenous bacterial seeding. The clinical syndromes seen with punctuate cerebral infarctions are variable and often referred to as an altered level of consciousness or embolic encephalopathy without reported incidence of concomitant focal or multifocal neu- rological signs [35]. The three underlying mechanisms of haemorrhage are pyogenic arteritis and erosion of the arterial wall causing intracerebral bleed- ing, haemorrhagic transformation of an initially purely ischaemic infarction and rupture of infectious (mycotic) aneurysm with subarachnoidal and/or intracere- bral bleeding [38, 39]. In studies detecting silent cerebral complications, the inci- dence of haemorrhagic complications is higher [21] and also in neurologically 154 U. However, when cerebral bleeding occurs in antico- agulated patients, the prognosis is poor also in contemporary studies [5 , 42 ]. Intracranial haemorrhage can also rarely complicate bacterial meningitis with poor outcome and this is more often seen in anticoagulated patients [46]. Intracranial infectious aneurysms are most com- monly located in the distal branch points of the middle cerebral artery, while con- genital aneurysms tend to be central [51, 52]. Infectious aneurysms arise from either septic microemboli to the vasa vasorum or bacterial escape from a septic embolus to the intraluminal arterial space, resulting in destruction of the vessel wall. Infectious aneurysms are actually pseudo-aneurysms in a pathological defini- tion due to the involvement of the muscular arterial wall layer. Infectious aneu- rysms are thin-walled and friable, typically fusiform with a wide or absent neck, and are feared to exhibit a high tendency to rupture and haemorrhage. On the other hand, it is well known that these aneurysms may resolve with antibiotic therapy as documented in several case series [50, 53]. Consequently, when silent aneurysms are taken into account, the risk profile for rupture is less evident but probably smaller than when only symptomatic aneurysms are studied. Further tech- nical development as well as availability and local expertise will influence the diagnostic algorithm in different centres. Additional to rupture, which is the main risk and consequence of intracranial infectious aneurysms, these can cause minor focal deficits in combination with systemic infection related symptoms. However, the clinical presentation of an infectious aneurysm is related to rupture in 80% of patients [51, 52]. Symptoms constitutes severe head- aches with sudden onset, visual loss, seizures, impaired consciousness, hemipare- sis or other focal neurological deficits related to subarachnoidal or intraparenchymal haemorrhage. Intraparenchymal haemorrhage is relatively more common after rupture of infectious aneurysms compared to after rupture of congenital intracra- nial aneurysm. The size of the infectious aneurysm does not reliably predict potential to rupture but can be used to guide treatment in unruptured aneurysms as described in one recent review, suggesting the use of antibiotics and serial imaging for stable, small (<10 mm) unruptured aneurysms and endovascular treatment for large, enlarging, or symptomatic unruptured aneurysms [50]. This recommendation has also been adopted in international endocarditis guidelines [55], but controversy remains and physicians will increasingly encounter this problem as improved imaging tech- niques visualize more asymptomatic unruptured aneurysms. If early cardiac sur- gery is required in patients with known intracranial aneurysms, preoperative endovascular intervention must be considered and is preferred to surgical intracra- nial intervention. Treatment of ruptured intracranial aneurysms requires immediate surgical or endovascular intervention, the choice of which depending on a large variation of factors not possible to cover algorithmically. Ruptured intracranial aneurysms with large intraparenchymal hematomas or those requiring occlusion of an artery supplying an eloquent territory should be treated with open microsurgery, the former to allow concomitant clot evacuation [51]. Surgical clipping can also be preferred in young, symptomatic patients without significant comorbidity who exhibit large and accessible aneurysms. In contemporary reviews endovascular techniques are favoured in a majority of patients but no specified endovascular approach (balloon occlusion, embolization, stent therapy) is shown to be superior [51]. The risks of procedure related complications and postoperative intracranial infections seem to be low. Given the heterogeneity of published studies, mostly case series or reviews [50–53], these conclusions are based low level evidence (Fig. A conventional angiography verifies an intracranial infectious aneu- rysm on the left arteria cerebri media (b). The detected rate of men- ingitis in different studies depends on the frequency of lumbar punctures performed in the specific study setting. The availability of non-invasive brain imaging methods have reduced this proportion, since meningism seldom is the only neurological symptom presented [19 , 56]. This is illustrated by two studies including patients from different time periods by Pruitt et al. While underlying endocarditis is uncommon in pneumo- coccal meningitis, the growth of S. Brain Abscess Bacterial brain abscesses are rare complications of endocarditis affecting 0. Small multiple abscesses are more commonly detected than a single large abscess, which only occasionally is caused by underly- ing endocarditis. Brain abscesses are defined as focal infection within the paren- chyma starting in a localized area of cerebritis subsequently transformed to an encapsulated collection of pus. Evidence that detection of silent complications improve patient outcome is, however, still lacking. Risk Factors for Neurological Complications Several factors associated with a higher occurrence of neurological complications have been identified but the most consistent finding is that S.