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The usefulness of fine needle aspiration (FNA) as a preoperative diagnostic procedure was studied in 43 patients with salivary gland tumors. Nine of the tumors were malignant and 34 benign. The diagnostic sensitivity of FNA was 88.9% (8/9), the specificity 94.1% (32/34) and the accuracy 93.0% (40/43). These results indicate that FNA is a highly sensitive and specific screening procedure.
For preoperative localization of enlarged parathyroid glands, several imaging techniques have been used. In this study we demonstrate the feasibility of using ultrasonography with fine needle aspiration for parathyroid hormone assay as a preoperative localization procedure in 21 patients with primary hyperparathyroidism. A single adenoma was found in 18 patients while 3 patients had multiglandular disease. Ultrasonically guided fine needle biopsy was possible in 11 cases. In 8 of these aspirates, a high parathyroid hormone content was found. In all 8 cases the localization was confirmed at surgery. We conclude that the efficiency to preoperatively localize enlarged parathyroid glands is enhanced by fine needle aspiration.
Thirty-two patients with histologically confirmed cervical carcinoma were preoperatively investigated using MRI; in addition, a CAT-scan was performed on 15 of these patients. The diagnostic results using both modalities were compared with the histological findings (after hysterectomy according to Wertheim-Meigs, including lymph node dissection in the pelvic and, in part, in para-aortal regions). Determination of tumour volume was possible with high accuracy using MRI. Accuracy in assessing the parametria was 86%, vagina 90%, bladder and rectum 97%. The shortcoming of MRI is still the detection of infiltrated lymph nodes. The accuracy of 69% achieved for lymph nodes is equal to results with computed tomography. The general accuracy for our patients in staging was 81% for MRI versus 47% for CT. MRI-based diagnosis enables us to determine a correct tumour staging preoperatively, and is therefore very helpful in planning an adequate therapy. If MRI were used more widely it would contribute to simplification and shortening of the preoperative diagnostic procedure in patients with cervical carcinoma.
Forty-eight women with genuine stress incontinence and low urethral closure pressure were treated with a suburethral sling procedure using polytetrafluoroethylene. All patients underwent a preoperative clinical evaluation and multichannel urodynamic testing. The clinical examination included a "Q-tip" test to determine the presence or absence of urethral hypermobility. Urethral hypermobility was defined as a maximal angle change of greater than or equal to 30 degrees from the horizontal, measured during straining or coughing in the lithotomy position. Thirty-four patients underwent repeat multichannel urodynamic testing three months postoperatively to determine the objective surgical success. Ninety-three percent of patients (27/29) with a positive preoperative Q-tip test were cured. Of patients with a negative preoperative Q-tip test, only 20% (1/5) were cured. Preoperative urethral hypermobility was a good prognostic indicator of operative success when a suburethral sling procedure was used to treat genuine stress incontinence and low urethral closure pressure.
Symptomatic pancreas tumors are diagnosed in general by ERCP, transabdominal ultrasonography, and computed tomography. Endoscopic ultrasonography, angiography (facultative) and video laparoscopy in combination with laparoscopic sonography and peritoneal lavage are providing preoperatively important additional information about the spreading of the tumor. Preoperative diagnostic procedures should allow the surgeon to exclude patients with an unresectable tumor from extended resection. In most of these patients satisfactory palliation can be achieved endoscopically. The indication for surgical treatment of resectable pancreatic tumors is based on the mortality of pancreaticoduodenectomy far beyond 5% in experienced centers. Improved surgical techniques and improved perioperative management together with the implementation of accurate preoperative analysis of risk factors allow resection of primary pancreatic tumors with a low morbidity and mortality.
BACKGROUND: Modern delicate microcatheters allow intranidal embolization of cerebral arteriovenous malformations (AVM). The aim of the current analysis was to assess effects of preoperative intranidal deployment of embolic material on surgical time and blood loss in cerebral arteriovenous malformations of 3-6 cm in diameter. METHODS: The case records of 38 cerebral AVM between 3 and 6 cm in maximum diameter were reviewed, that had been embolized intranidally with N-butyl 2-cyanoacrylate (Histacryl) and subsequently operated on. Surgical time and blood loss as well as particular intraoperative findings such as a congested nidus and thrombosis of draining veins were registered and correlated with the extent of embolization and the time interval between embolization and surgery. FINDINGS: Preoperative embolization occluded an estimated range of 10 to 90% of the nidus. Minor embolization related bleeding without clinical relevance occurred in 5 patients. Significant embolization related bleeding resulting in earlier than planned surgery occurred in another 5 patients. All embolization related haemorrhages occurred within 24 hours. Average total operating time was 343+/-106 min and average blood loss was 684+/-858 ml. Unequivocal bleeding difficulty from the nidus and a total blood loss of more than 1000 ml were encountered in 7 instances and dissection was tedious due to a bleeding AVM core in 5 other cases. A congested AVM core was the source of bleeding in 11 patients and paraventricular neovascularization in one. 6 of the 11 cases with a congested AVM core had suffered minor or substantial haemorrhage after a preoperative endovascular procedure. Intraoperative nidus congestion was noted in this series after an interval as long as 2 weeks after the last embolization. Combined management resulted in permanent morbidity in 6 of the 38 cases. In 4 of them the neurological deficit was associated with an intraoperative bleeding problem, in all due to congested nidus. Morbidity had to be correlated with major haemorrhage resulting from preoperative embolization in 2 instances. CONCLUSIONS: Intranidal embolization prior to surgical removal of AVM can lead to a congested residual nidus and intraoperative bleeding. Minor leakage after preoperative embolization is an inconsistent warning sign of nidus congestion. Nidus outflow after intranidal embolization appears to require a few weeks for normalization. Delay of surgery after embolization should be considered in cases of suspected congested residual nidus. The danger of major haemorrhage or arterial revascularization during this waiting period appears small.
OBJECTIVE: To evaluate the efficacy of oral granisetron for the prevention of postoperative vomiting in children undergoing strabismus surgery. DESIGN: Prospective, randomized, double-masked, placebo-controlled study. PARTICIPANTS: A total of 120 children, 4-10 years of age, scheduled for elective strabismus surgery. INTERVENTION: Patients received oral placebo or granisetron at three different doses (20 microg/kg, 40 microg/kg, 80 microg/kg) 1 hour before surgery. MAIN OUTCOME MEASURES: A complete response, defined as no vomiting, no retching, and no need for rescue antiemetic medication, during the first 24 hours after anesthesia was recorded. RESULTS: A complete response during 0-24 hours after anesthesia occurred in 33% of those who received placebo, 40% who received granisetron 20 microg/kg, 83% who received granisetron 40 microg/kg, and 87% who received granisetron 80 microg/kg (P < 0.05, overall Fisher's exact probability test). CONCLUSION: Preoperative oral granisetron, in doses more than 40 microg/kg, is effective for preventing vomiting after strabismus surgery in children.
OBJECTIVE: To describe the preoperative assessment procedures currently used in hospitals in Catalonia (Spain). SUBJECTS AND METHODS: The study population consisted of all heads of departments of anesthesiology, general and gastrointestinal surgery, orthopedic surgery and traumatology of hospitals and clinics in Catalonia with active operating theaters. Information was obtained by self-administered questionnaire prepared by an interdisciplinary team. RESULTS: Of the 227 questionnaires sent, 139 (61%) were answered and returned. A preoperative assessment visit was programmed according to 112 (81%) of the respondents and 123 (89.8%) reported following a protocol that included ordering preoperative tests. The same tests were ordered for all patients by 25% of the respondents. A chest film and an ECG were always ordered according to 61 and 65%, respectively, and always when the patient was over a certain age according to 36 and 32%, respectively. Coagulation and blood sugar tests and a complete blood workup were always ordered according to 94%, 95% and 89%, respectively. Tests were considered valid for less than six months by most. CONCLUSIONS: This survey provides evidence of widespread use of preoperative assessment, although application falls short of including all scheduled patients. According to these results, selective protocols for ordering complementary preoperative tests are rarely applied.
INTRODUCTION AND OBJECTIVE: Improving preoperative hemoglobin levels reduces transfusion requirements. The availability in Spain of iron sucrose formulas with good safety profiles has added a new therapeutic option for treating anemia. The aim of this study was to demonstrate the usefulness of preoperative intravenous infusion of iron for improving hemoglobin level before elective major orthopedic surgery. PATIENTS AND METHODS: From the beginning of 2003 until July 2004, 27 consecutive patients scheduled to undergo major orthopedic surgery were given preoperative intravenous iron infusions because of intolerance to oral iron administration, poor intestinal absorption, chronic inflammatory anemia, or functional iron deficit. Twenty patients received preoperative intravenous epoetin alfa and iron and 7 received only intravenous iron because epoetin alfa therapy was ruled out due to cardiovascular or thromboembolic disease or because they had pure iron deficiency. Variables studied were age, sex, weight, type of surgery, iron dose, duration of treatment, reason for treatment, blood parameters, hemoglobin levels, and use of transfusions. RESULTS: The preoperative increase in hemoglobin was 1.7 g dL(-1) (range, 10.8-12.5) for patients who received only intravenous iron therapy and half of them were transfused, although inappropriately in 1 case. The increase in the intravenous epoetin alfa plus iron group was 1.7 g dL(-1) (range, 10.9-12.6) and only 25% were transfused. CONCLUSIONS: Intravenous iron therapy improved the preoperative hemoglobin levels in anemic patients scheduled for major orthopedic surgery. This is a new intravenous treatment approach to evaluate.
PURPOSES: The purposes of this study were to determine (a) the relationship between preoperative uncertainty and anxiety of orthopaedic surgical patients in three adult developmental stages (young, middle, older) and (b) the differences in uncertainty and anxiety among the adult developmental stages, gender, and acuity levels of the disorder. DESIGN: Correlational and comparative with descriptive survey. SAMPLE: 106 adult orthopaedic surgical patients. METHODS: Subjects were contacted 1 to 2 weeks preoperatively during their preadmission visit or upon early admission the day of surgery. FINDINGS: All patients responded similarly in terms of having moderate levels of preoperative uncertainty and anxiety. There were no statistically significant differences among developmental stages, gender, or acuity levels for these orthopaedic patients. IMPLICATIONS FOR NURSING PRACTICE: Nurses need to be aware that adult orthopaedic patients such as these subjects may have moderate levels of uncertainty and anxiety prior to surgery. In addition to physical preparation for surgery, nurses need to help patients with their emotional concerns. The incorporation of preoperative psychoeducational interventions and improved communication into plans of care for all orthopaedic surgical patients is recommended.
A volume rendering (VR) three-dimensional reconstruction method was applied to magnetic resonance angiography (MRA), to investigate its usefulness for surgical planning of unruptured cerebral aneurysms (ANs). Twelve cases with anterior communicating artery (Acom) ANs and 16 cases with middle cerebral artery (MCA) ANs underwent MRA VR, preoperatively. There were 10 male and 18 female patients, whose ages were ranged from 37 to 73 (mean 58) years old. Appearance of ANs and surrounding vascular structures on MRA VR was compared with that on maximum intensity projection (MIP) image, three-dimensional digital subtraction angiogram (3D-DSA), and intraoperative findings. In all cases, MRA VR delineated aneurysms more clearly compared to MIP. In MCAANs, MRA VR provided enough information for surgical planning, compatible with 3D-DSA. In Acom ANs, MRA VR delineated bilateral A1, A2 and Acom complex simultaneously without temporary vascular occlusion. MRA VR may have a complementary role in preoperative evaluation of unruptured ANs with other modalities such as 3D-DSA.
BACKGROUND: Children with chronic cyanotic heart disease often develop systemic-to-pulmonary collateral arteries that can be deleterious at the time of a Fontan procedure due to excessive pulmonary blood flow. We therefore occlude all significant collaterals during cardiac catheterization. METHODS: From June 1993 to May 1998, 93 children aged 1.5 to 15.8 years (median 2.5 years) underwent a fenestrated lateral tunnel Fontan procedure. Eighty-nine (96%) had a previous bidirectional Glenn anastomosis, including 31 (33%) with a Norwood procedure. RESULTS: Preoperatively, 33 children (35%) required occlusion of 1 to 11 (mean 3.6) collateral vessels. Two of the three perioperative deaths (operative survival 97%) were due to excessive pulmonary blood flow from unrecognized collaterals in one and uncontrollable collaterals in the other. Postoperatively, 19 children (20%) required coil occlusion of 1 to 21 (mean 5.6) collaterals for elevated pulmonary artery pressures, heart failure, or prolonged chest tube drainage. Duration of inotropic support, postoperative ventilation, intensive care unit stay, and postoperative hospitalization were all significantly longer in the patients who had postoperative occlusion of collaterals. On follow-up of 2 to 67 months (mean 35 months), there have been four late deaths (two infections, two heart failures); 6 patients underwent successful cardiac transplantation for refractory heart failure. All 8 patients with ventricular failure required occlusion of significant collaterals postoperatively. CONCLUSIONS: Hemodynamically significant collaterals are not uncommon in Fontan candidates, and aggressive control can result in good operative and medium-term survival. After the Fontan, significant collaterals may be a marker for eventual cardiac failure because 8 of 18 patients requiring postoperative coils went on to transplantation or died of heart failure.
A total of 39 patients who had undergone microdiscectomy or percutaneous nucleotomy for lumbar disc herniation were examined after a follow-up of 5 years. The overall outcome was satisfactory in 80% of the patients treated, and only 1 (3%) patient had been reoperated during the follow-up. Clinical signs and symptoms of lumbar instability were detected in 10 (26%) patients. All these 39 patients had been examined with lumbar magnetic resonance imaging (MRI) on the day preceding the operation; the presence of disc degeneration was graded as severe, mild or non-existent depending on the visual brightness of the discs on T2-weighted images, as compared to the signal intensity of the lumbar vertebrae. None of the 12 patients with no preoperative disc degeneration in MRI suffered from postoperative clinical signs and symptoms of instability as compared to 10 (37%) of the 27 patients with mild or severe disc degeneration suffering from instability (p = 0.04). Thus, the results of the present study imply that the grade of the disc degeneration in preoperative T2-weighted MR images significantly predicted the occurrence of postoperative clinical instability.
Surgical exposure of intradural lesions in the thoracic spine requires intraoperative landmarks to identify the vertebral level. If spinal neuronavigation is not available, the surgeon must rely on alternative localizing methods. Intraoperative fluoroscopy is traditionally used to count the vertebrae throughout the whole spine. In the high thoracic spine, counting the vertebrae is often hampered by the scapular shadows. In these cases, a preoperative marking procedure seems preferable. Magnetic resonance imaging (MRI) based techniques have been increasingly reported, but they share an intrinsic risk of error due to the skin shift occurring at the time of surgery. We describe here a simple technique for unequivocal identification of the vertebral target. In six patients undergoing surgery for intradural lesions of the high thoracic spine, the spinous process of the vertebra corresponding to the lesion was preoperatively identified on an anteroposterior radiograph view and marked infiltrating its tip with a blue dye. At surgery, the vertebral target was identified easily and immediately. No errors occurred. No complications related to the technique were observed. Preoperative marking of the vertebral spinous process with a coloured dye is a simple and unequivocal guide to expose intradural lesions in the high thoracic spine.
AIM: To estimate the frequency of secondary glaucoma appearance and the influence of surgical treatment on intraocular pressure (IOP) in patients with posterior lens dislocation. MATERIAL AND METHODS: The study concerned 152 patients (57 females and 95 males, age range: 19 to 91 years, mean--58 years). Secondary glaucoma was found in 62 patients (41%). Trauma was the cause of lens dislocation in 81% of these cases, while it was the cause in only 69% of cases in the whole material. Pars plana vitrectomy with limbal intracapsular lens extraction or lentectomy were performed in all cases. In 24 cases perfluorocarbon liquid was used. Scleral fixation PC IOLs were implanted in 85 eyes (group A), AC IOLs in 27 eyes (group B), and 40 eyes remained aphakic (group C). The follow-up time ranged from 6 months to 5 years, mean 22 months. RESULTS: Raised IOP was found preoperatively in 46 cases (30.3%). It was raised in 21 (24.7%) eyes in group A (24-60 mm Hg, mean 37.1 mm Hg), and it has normalized postoperatively in 14 eyes, while topical medication was necessary in 7 remaining cases. In group B raised IOP (26-60 mm Hg, mean 41.4 mm Hg) was found preoperatively in 8 (29.6%) eyes. It has normalized postoperatively in 5 eyes, while topical medication was necessary in 3 eyes. The respective values in group C were: 17 (42.5%), 24-80 mm Hg, mean 43.2 mm Hg. In 7 eyes IOP was normal after surgery, 10 patients required topical treatment, and in 3 of these cases trabeculectomy had to be performed. In 16 eyes with normal preoperative IOP it has raised postoperatively in different periods of time (from 1 week to 6 months). CONCLUSIONS: Secondary glaucoma is a frequent complication of the posterior lens dislocation, and it is more often related with traumatic cases. The dislocated lens removal with the use of vitrectomy causes IOP normalization in most of the cases. The periodical examination of IOP is necessary after the dislocated lens removal also in cases with normal preoperative IOP, because secondary glaucoma may appear in different time after surgery.
BACKGROUND: An imaging-guided unilateral surgical approach in patients with primary hyperparathyroidism (HPTH) requires reliable preoperative localization procedures. Using present imaging techniques, 60% to 80% of patients with primary HPTH can be treated successfully with limited surgery. Thus, further improvement of diagnostic accuracy is required. Computed axial tomography (CAT)-MIBI image fusion was introduced as a new technique for localizing enlarged parathyroid glands. We describe the new method and present its first results. METHODS: Six consecutive patients with primary HPTH underwent CAT-MIBI image fusion for preoperative parathyroid localization. CAT and technetium-99m-sestamibi scan were performed separately. The patient's head and neck were fixed with the noninvasive Vogele-Bale-Hohner Head Holder (VBH HeadFIX; Medical Intelligence, Schwabmünchen, Germany) and the BodyFIX (Medical Intelligence) vacuum cushion. Radiographic and scintigraphic markers were mounted at the head holder and the patient. CAT and MIBI images were fused by overlaying radiographic markers using a commercial software and workstation. RESULTS: In 5 patients, localization and dimension of the solitary adenomas were exactly predicted. In 1 patient with multiglandular disease (3 enlarged glands), CAT-MIBI image fusion was not able to predict multiple gland involvement. However, in a retrospective analysis of the localization study, the other two enlarged parathyroid glands could be correctly identified regarding their site and size. CONCLUSIONS: First results of CAT-MIBI image fusion are promising. The new technique provides a higher image resolution and better delimitation of enlarged parathyroid glands and adjacent anatomic structures than conventional scintigraphic methods.
Preoperative evaluation of parotid tumors still poses difficult problems for the head and neck surgeon. The complex anatomy of the parotid space leads to difficulty in localizing these tumors. In addition, physical examination will rarely determine whether a parotid lesion is benign or malignant. High resolution CT scanning with contrast and fine needle aspiration can provide enough preoperative information to enable the surgeon to counsel his patient concerning possible risks and the extent of surgery that may be indicated. We are able to determine tumor location, multiple or bilateral masses, associated adenopathy, and often specific tumor histology. Forty-two parotid aspirates and 26 CT scans were reviewed and correlated with their postoperative pathology specimen. Parotid aspiration cytology was found to be a highly accurate and safe procedure for preoperative determination of parotid pathology. However, the CT scan was specific only in defining the anatomic localization and extent of a parotid mass.
Infection after open heart surgery is a serious complication since eradication of infection in these cases is difficult even with appropriate antibiotic therapy. In the attempt to avoid this problem, prophylactic administration of antibiotics is common. Their relative safety and their broad spectrum of activity make cephalosporin antibiotics popular choices for prophylaxis prior to and during operations, including cardiovascular procedures. METHODS. Preoperative antibiotic prophylaxis with 2 g cefamandole was performed in a prospective randomized study including 62 male patients divided into three groups. All patients gave informed consent, and the study was approved by the ethics committee of the hospital. Patients in group 1 (n = 21) and group 2 (n = 21) underwent aortocoronary bypass (ACVB) with extracorporeal circulation (ECC), while patients in group 3 (n = 20) had carotid surgery. Anaesthesia, coronary-bypass procedures and infusion regime were standardized. The flow rate during ECC was maintained at 2.41/min/m2 and the rectal temperature between 33 degrees and 34 degrees C. Arterial and urine specimens for the determination of plasma and urine levels of cefamandole were taken at definite times. Autologous blood salvage during operation was performed with haemofiltration techniques (HF) in group 1 (HF 80, Fresenius, Bad Homburg, Germany) and with cell separation techniques (CS) in group 2 (Hemonetics III, Hemonetics). Plasma and urine cefamandole levels were measured by high-pressure liquid chromatography (HPLC). RESULTS. After administration of 2 g cefamandole mean peak levels of 404.6 +/- 141.7 micrograms/ml were seen. Because of haemodilution at the beginning of extracorporeal circulation, group 1 and 2 showed much lower cefamandole plasma levels, 22.1 +/- 11.6 micrograms/ml and 24.3 +/- 14.4 micrograms/ml, than group 3 (after the same time course), with 47.4 +/- 19.1 micrograms/ml. For all patients in group 1 and 2 prebypass time (70.3 +/- 22.4 min) and the duration of the ECC (72.3 +/- 17.7 min) were comparable. There was a significant correlation between prebypass time and cefamandole plasma levels at the beginning of extracorporeal circulation (P < 0.001). No correlation could be seen for the plasma concentration after discontinuation of the extracorporeal circulation and the duration of extracorporeal circulation. The volume of autologous red packed cells and the enclosed amount of cefamandole showed a significant difference (P < 0.001) between group 1 (1120.0 +/- 296.8 ml, 27.5 +/- 17.1 mg) and group 2 (734.3 +/- 186.6 ml, 2.9 +/- 3.2 mg). The plasma cefamandole level after transfusion of autologous blood displayed a significant correlation (p < 0.01) with cefamandole concentration in the autologous red packed cells. Transfusion of the autologous blood produced no significant increase in plasma cefamandole levels. With an operation time of more than 2.5 h during ECC the cefamandole plasma level decreased below the necessary minimal inhibitory concentration (MIC90), particularly for gram-negative bacteria. CONCLUSION. Additional administration of 1 g cefamandole shortly before the beginning of cardiopulmonary bypass is recommended, particularly for surgical procedures with ECC of more than 2.5 h. Adjustment of drug dosage prior to or during surgery may be required to optimize therapy, but before this can be achieved precisely, more information on drug disposition during the operative procedures is needed.