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Study Objectives: To determine the patency of standard and modified Portex tracheostomy tubes inserted by the percutaneous dilatational technique.Design: Prospective observational study.Setting: Medical-surgical ICUs in a tertiary care community hospital.Patients: Medical-surgical ICU patients requiring tracheostomy.Interventions: Consecutive medical-surgical ICU patients requiring tracheostomy were eligible for the study. Percutaneous tracheostomy tubes were inserted using the percutaneous dilatational technique with bronchoscopic guidance. The study population consisted of the following two groups: group 1 (receiving the standard Portex Per-fit percutaneous tracheostomy tube); and group 2 (receiving the modified Portex Per-fit percutaneous tracheostomy tube). Patients underwent daily fiberoptic evaluation to assess tracheostomy tube patency following the first 72 h after the tracheostomy tube placement. Demographic data and clinical signs or symptoms of airway obstruction were recorded.Measurements and Results: Thirty-seven patients received the standard percutaneous tracheostomy tube (group 1), and 17 patients received the modified percutaneous tracheostomy tube (group 2). Partial tracheostomy tube occlusion (> 25%) was observed in 21 of 37 group 1 patients (57%) and in 1 of 17 group 2 patients (6%; p < 0.005). Fifteen of 37 group 1 patients (41%) and none of the group 2 patients sustained a > or = 40% occlusion of the distal tracheostomy tube opening (p < 0.005). One patient from group 1 had clinical manifestations of tracheostomy tube obstruction. None of the patients in group 2 experienced signs or symptoms of airway obstruction.Conclusions: The standard Portex Per-fit percutaneous tracheostomy tubes used in this study were associated with partial airway obstruction. Modifications of the standard Portex percutaneous tracheostomy tube markedly decreased the airway obstruction. Due to the findings in this study, the authors recommend abandoning the continued use of the Portex Per-fit percutaneous tracheostomy tube in its current configuration and replacing it with the modified tracheostomy tube described in this study. [ABSTRACT FROM AUTHOR]

Simultaneous intrauterine and extrauterine pregnancy is called heterotopic pregnancy. It is a rare complication of pregnancy, especially in the absence of predisposing factors. It is known to present with a variety of symptoms and signs often leading to a delay in establishing the correct diagnosis. We report the case of a 29-year-old woman, known to be 14 weeks pregnant, presenting with acute abdominal pain. The confirmation of a viable intrauterine pregnancy led to a general surgery consultation. A heterotopic ruptured right ectopic tubal pregnancy was found. Right salpingectomy was performed. The patient recovered uneventfully. The intrauterine pregnancy was not affected. This case illustrates the variable presentation of heterotopic pregnancy and the need for general surgeons to be suspicious of pregnancy related complications, even in the presence of a viable intrauterine pregnancy.

Objectives: Part 1: To describe the complication of posterior tracheal wall injury and perforation associated with the percutaneous dilational tracheostomy (PDT). Part 2: To determine the mechanism of posterior tracheal wall injury during PDT., Design: Prospective observational study., Subjects: Part 1: Medical-surgical ICU patients requiring tracheostomy. Part 2: Swine and cadaver models., Interventions: Part 1: Consecutive medical-surgical ICU patients undergoing tracheostomy tube insertion via the percutaneous dilation technique with bronchoscopic guidance were enrolled in the study. Demographic data and complications were recorded. Part 2: Tracheostomy tubes were inserted via the percutaneous dilational technique in the swine model with concomitant bronchoscopic video recording from the proximal and distal airways. Tracheostomy tubes were inserted via the percutaneous dilational technique in the cadaver model followed by anatomic inspection of the airway., Results: Part 1: Seven (29%) of 24 medical-surgical ICU patients sustained complications associated with PDT. Three patients (12.5%) sustained posterior tracheal wall perforations followed by the development of tension pneumothoraces. Part 2: The swine model demonstrated that posterior tracheal wall perforation may occur during PDT when the guiding catheter is withdrawn into the dilating catheters. Five-centimeter posterior tracheal wall mucosal lacerations occurred when the guidewire and the guiding catheter were not properly stabilized during PDT., Conclusion: Percutaneous dilational tracheostomy was associated with a 29% complication rate in this observational study. Of concern was the high rate (12.5%) of posterior tracheal wall perforation. The swine and cadaver models suggest that posterior tracheal wall injury or perforation may occur if the guidewire and guiding catheter are not properly stabilized. To avoid posterior tracheal wall injury, the guidewire and guiding catheter should be firmly stabilized during PDT.