Thursday, September 16, 2010

Prayer Sign and relation to difficult laryngoscopy.

Thickened waxy skin with joint contractures

This 30 year old juvenile onset insulin dependent diabetic developed diffuse subtle joint contractures of the hands with decreased ability to fully extend the fingers typical of limited joint mobility syndrome(LJM). Her skin was thickened and waxy especially on the tops of her hands. Skin biopsy showed increased dermal collagen. Cutaneous findings are postulated to result from accumulations of glycosylated proteins in the collagen matrix and fibroblast proliferation.

If patient shows inability to place palms flat together, it suggests difficult intubation. It is a reflection of generalised joint and cartilage immobility and tight waxy skin, particularly in diabetic patients. About 33% of diabetic patients are prone to difficult intubations. One study from Istanbul, Turkey compared 80 diabetic patients (D) with 80 non-diabetic patients (ND) undergoing elective surgery under general anaesthesia. The incidence of difficult laryngoscopy was 18.75% in Group D and 2.5% in Group ND. The incidence of the prayer sign was 31.25% in Group D and 13.75% in Group ND......

Relationship of difficult laryngoscopy to long-term non-insulin-dependent diabetes and hand abnormality:
About one-third of long-term insulin-dependent (type I) diabetics present with laryngoscopic difficulties.This is due, at least in part, to diabetic stiff joint syndrome characterized by a short stature, joint rigidity, and tight waxy skin.The fourth and fifth proximal phalangeal joints are most commonly involved. Patients with diabetic stiff joint syndrome have difficulty in approximating their palms and cannot bend their fingers backwards (the prayer sign).This is due to non enzymatic glycosylation of collagen and its deposition in joints. When the cervical spine is involved, limited atlanto-occipital joint motion may make laryngoscopy intubation difficult.

The incidence of difficult laryngoscopy was 18.75% in Group D (diabetic patients) and 2.5% in Group ND(non-diabetic patients). A statistically significant increase in difficult laryngoscopy was noted in patients in Group D. The incidence of the prayer sign was 31.25% in Group D and 13.75% in Group ND. A statistically significant increase in the incidence of the prayer sign was noted in patients in Group D . Four patients in Group D with the prayer sign had a difficult laryngoscopy. There was no significant association between difficult laryngoscopy and the prayer sign .

Hand abnormalities such as thickened tight waxy skin, and limitation of small joint mobility are common manifestations of diabetes. Although small joint mobility is usually limited to the hand, other joints might be involved. The term limited joint mobility (LJM) describes this phenomenon. It is seen more frequently in type I and type II diabetic patients than in the general population.
The prayer sign is a more simple bedside test for interphalangeal joint involvement. However, it can be detected in normal individuals.In the study, 13.75% of non-diabetic patients had the prayer sign

In the hands of diabetic patients, we have demonstrated a significant increase in LJM compared with non-diabetic patients as assessed by the prayer sign. The incidence of difficult laryngoscopy in long-term diabetic patients is high (27–31%). In our study it was 18.75%. The incidence of difficult laryngoscopy has been shown to be high in diabetic patients with LJM diagnosed using the palm print test. In this study, however, there was no relation between the prayer sign and difficult laryngoscopy.

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Surgery Algorithm: Post-Operative fever

This topic is post operative fever. Topics included:
-Deep Thrombophlebitis
-Wound Infection
-Deep Abcess



A 65-year-old man presents with squamous cell carcinoma of the esophagus extending from 34 to 40 cm from the incisors. On EUS there are several hypoechoic ,non homogenous ,sharply delineated paraesophageal lymphnodes within the mediastinum,which are 2cm in diameter.There are no signs of disseminated
disease on this or a...dditional staging studies. Which organ is most commonly used for reconstruction ?

The Correct Answer Is....STOMACH
The type of reconstructive surgery that is recommended for it will depend upon how much esophagus remains after the operation. The surgeon often has to pull the stomach up into the chest. This surgery is called gastric pull up with esophagogastric anastomosis. (Usually a surgeon specialist called a thoracic surgeon performs this type of surgery).

If only a small amount of the esophagus remains then a new esophagus needs to be formed. A new esophagus is usually created by resecting a portion of the colon (large intestine) and using the resected colonic segment as the new esophagus. This is called colon interposition. The colon is considered the organ of choice for patients who require an esophageal substitute and are potential candidates for long survival. This is a major operation with a thirty-day mortality rate of about 13.7%.

Stomach Versus Colon :
If the stomach is intact, most surgeons would use it for esophageal reconstruction. On the contrary,we prefer to use the colon, if available and of suitable quality, particularly if the replacement must last a decade or longer.
A gastric advancement is without doubt the best esophageal replacement.

Jejunal Interposition and Free Graft:
Some authors have advocated the use of jejunum as the esophageal substitute of choice. In our experience, the ability to ingest has been better with a colon than with a jejunal graft. Based on a postoperative questionnaire, patients with colon interpositions were able to eat more and were more likely to experience normal transit and less satiety than those with jejunal interpositions.

These differences probably relate to the greater reservoir capacity of the colon, consistent with its native function. The greater motility in the jejunal graft does little to improve transit and is more likely to cause nausea and bloating. Furthermore, the loss of a segment of colon does not result in more frequent stools.

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Radiation Proctitis

A 70-year-old man presented with a 2-month history of intermittent hematochezia. Ten years earlier, he had undergone 6 months of radiation therapy for the treatment of prostate cancer. The total dose of radiation was 64 Gy, and the prostate cancer was cured.

On physical examination, the temperature was 36.5°C, the blood pressure was 150/90 mm Hg, the pulse was 90 beats per minute, and the respiration was 14 breaths per minute. The abdomen was soft, with normal bowel sounds and without tenderness.
On rectal examination, there were blood clots and friable mucosa that bled easily but no hemorrhoids or palpable masses. The results of analyses of blood and urine were normal.

Colonoscopy revealed fine, tortuous blood vessels and telangiectasias in the rectum (figure). Histopathological evaluation revealed telangiectatic blood vessels with adjacent hyalinization of the lamina propria. Radiation proctitis was diagnosed, and the patient was given argon plasma coagulation therapy.
During 15 months of follow-up, he had mild tenesmus and infrequent, small amounts of hematochezia that did not require further intervention.

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