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PubMed2005

Endoscopic adrenalectomy: an analysis of the transperitoneal and retroperitoneal approaches and results of a prospective follow-up study.

BACKGROUND: Endoscopic adrenalectomy is currently performed using either a retroperitoneal or transperitoneal approach. The aim of this study was to determine which of these is the optimal surgical technique in a prospectively designed analysis of a large series of patients operated on by a single team over a 10-year period. METHODS: From February 1994 to March 2004, 267 endoscopic adrenalectomies (retroperitoneal in 132 patients and transperitoneal in 135 patients) were performed in 245 consecutive patients. There were 102 right lateral and 121 left lateral procedures (22 patients had a bilateral procedure). The most prevalent indication was incidentaloma (35.9%), followed by pheochromocytoma and Conn's adenoma. RESULTS: The endoscopic procedure was performed in 238 of 245 patients (97.1%). The conversion rate was 1.5% for the transperitoneal approach and 3.8% for the retroperitoneal approach. No statistically significant influence was noted for the parameters of intraoperative blood loss, rate of postoperative complications, and duration of hospital stay with regard to the surgical technique. The operative time and the learning curve proved to be significantly longer for the retroperitoneal adrenalectomy. In addition, a variance analysis identified tumor size (>5 cm) as a significant factor influencing the operative time, whereas body mass index and localization (right/left lateral) did not prove significant. CONCLUSION: Independent of the underlying pathology, endoscopic adrenalectomy using either the trans- or retroperitoneal approach can be performed in 96-98% of all patients. Differences between the two techniques in operative time and learning curves clearly favor the transperitoneal adrenalectomy.

Adrenal Cortex Neoplasms↗
PubMed1990

Effect of combined infusion of nitroglycerin and nicardipine on femoral-to-radial arterial pressure gradient after cardiopulmonary bypass.

Nitrates and calcium channel blockers are frequently administered during cardiac surgery. We simultaneously measured femoral arterial pressure and radial arterial pressure to investigate whether nitrates, in conjunction with calcium channel blockers, would influence the central-to-peripheral arterial pressure gradient. Combined nitroglycerin and nicardipine infusion during cardiac surgery involving coronary artery bypass grafting or valve replacement resulted in a significant increase above baseline levels in the femoral-to-radial arterial pressure gradient at 60 min after cardiopulmonary bypass. In control patients there was no significant increase in the femoral-to-radial arterial pressure gradient at 60 min after completion of cardiopulmonary bypass. A subsequent study in patients given nitroglycerin and nicardipine identified that the difference in the systolic arterial pressure between femoral and radial arteries was observed 15, 60, and 120 min after completion of cardiopulmonary bypass. However, there was no difference in the mean arterial pressure between femoral and radial arteries throughout the same period. We conclude that combined infusion of nitroglycerin and nicardipine, a new calcium channel blocker, intensifies the magnitude and duration of the femoral-to-radial arterial pressure gradient after cardiopulmonary bypass.

Adult↗
PubMed1994

The hospital cost (fiscal year 1991/1992) of a simple perioperative allogeneic red blood cell transfusion during elective surgery at Duke University.

We sought to determine the actual cost to Duke University Medical Center of a perioperative red blood cell transfusion. A recent audit at Duke University Medical Center determined the base average direct and indirect hospital costs for providing a unit of red blood cells. The Transfusion Service's base cost for providing an allogeneic unit of red blood cells was $113.58. To obtain the actual hospital cost of transfusing a unit of red blood cells in the perioperative period, associated costs were calculated and added to the Transfusion Service's base cost. These associated costs included compatibility tests on multiple units per each unit transfused in the perioperative period, performing ABO and Rh typing and antibody screening on samples from patients who were not subsequently transfused, compatibility tests on units not issued, handling costs of units issued but not used, physically administering the blood, and the cost of the recipient contracting an infectious disease or developing a transfusion reaction. These associated costs increased the cost of transfusing an allogeneic unit of red blood cells in the perioperative period to $151.20. Perhaps the techniques described in the study can be used to quantify cost/benefit ratios associated with future changes in transfusion practice.

Blood Banks↗
PubMed1987

Continuous monitoring of mixed venous oxygen saturation during aortic surgery.

The correlation between mixed venous oxygen saturation (SvO2) and hemodynamic measurements was studied in 13 patients undergoing descending thoracic aortic aneurysm resection (DTAAR). A significant correlation (p less than 0.05) was found between cardiac index (CI) and SvO2 after the induction of anesthesia and at the end of surgery. However, no significant correlation could be found between SvO2 and CI during the most critical periods of the surgery that included the collapse of the left lung, the aortic clamping, and the aortic declamping. During DTAAR, continuous SvO2 monitoring is useful, but it cannot substitute for intermittent cardiac output and oxygen consumption (VO2) determinations.

Adult↗
PubMed1994

Reasons for conversion from laparoscopic to open cholecystectomy in an urban teaching hospital.

BACKGROUND: Although laparoscopic cholecystectomy has replaced open cholecystectomy for the majority of patients, it is clear that a substantial minority will require laparotomy for safe and successful removal of the gallbladder. PATIENTS AND METHODS: Seven hundred forty-six laparoscopic cholecystectomies performed at LAC+USC Medical Center for January 1991 to May 1993 were retrospectively reviewed. Hospital stay, laboratory values, and complications, as well as the need for and reason for conversion to open cholecystectomy were recorded. There were 661 females and 85 males, with a mean age of 38 years (range 15 to 92). RESULTS: One hundred one (14%) of the 746 patients were converted to open cholecystectomy. Difficult dissection secondary to inflammation or adhesions and the need to treat common-bile-duct stones were the most common reasons for conversion. Patients requiring conversion to open cholecystectomy were more likely to have been admitted through the emergency department (72% versus 46%, P < 0.0001), have had prolonged hospital stays prior to surgery (mean time from admission to surgery 4.4 days versus 2.8 days, P < 0.0001), and to have had a thickened gallbladder wall on preoperative ultrasound (54% versus 20%, P < 0.001). CONCLUSIONS: The most common reasons for conversion to open cholecystectomy are inflammation and adhesions secondary to severe acute and chronic disease and/or the need for clearance of the common bile duct. Patients who were admitted to the emergency department, particularly if they were managed nonoperatively for a period of time and had a preoperative diagnosis of acute cholecystitis, were more likely to require conversion to open cholecystectomy.

Adolescent↗
PubMed1989

Rectal anticonvulsants in seizure patients undergoing gastrointestinal surgery.

Gastrointestinal (GI) surgery in children with seizure disorders is often complicated by difficulties in administering oral anticonvulsant medications in the preoperative and postoperative periods. Because many newer anticonvulsants do not have parenteral formulations, intravenous phenobarbital, phenytoin, and benzodiazepines may appear necessary in the perioperative period. Eight children with neurologic disease with severe seizure disorders underwent gastrostomy placement and Nissen fundoplication. Perioperatively, their anticonvulsants were given successfully via the rectum. Rectal administration of anticonvulsants is a useful alternative route for drug therapy in seizure patients who are undergoing GI surgery.

Administration, Rectal↗
PubMed1983

Changes in body heat during transvesical prostatectomy. A comparison of general and epidural anaesthesia.

The superficial and deep body temperatures of 15 patients were measured before, during and for 6 hours after transvesical prostatectomy. The patients were divided randomly into two groups who received either a standard general anaesthetic or epidural analgesia. Total body heat and mean body temperature fell more rapidly in the epidural group, reaching statistical significance in the early postoperative period. Both groups showed a net heat gain 6 hours postoperatively. One patient in each group became hypothermic (core temperature less than 35 degrees C). Warming of both intravenous and bladder irrigation fluids to body temperature is recommended for patients receiving epidural or general anaesthesia.

Aged↗
PubMed2007

[Alteration in serum cytokines of patients with multiple organ dysfunction syndrome after liver transplantation].

OBJECTIVE: To explore the serum cytokine fluctuation in those adult patients with multiple organ dysfunction syndrome (MODS) during the post-operation stage of orthotopic liver transplantation (OLT) to guide the clinical treatment. METHODS: Serum levels of tumor necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6), IL-8 and IL-10 were determined in 53 MODS patients who had received OLT. They were divided into two groups as control group and experimental group, according to whether continuous blood purification (CBP) had been performed or not. The levels of serum cytokines and intensive care unit (ICU) stay time, intubation time, mortality and ICU expenses were compared between the two groups. RESULTS: The levels of serum TNF-alpha, IL-6 and IL-8 rose, while that of IL-10 increased dramatically compared with normal values (all P<0.05). After CBP, the serum levels of TNF-alpha, IL-6 and IL-8 all dropped to certain extent and became lower than those before the treatment (all P<0.05). IL-10's serum level was not changed compared with that before treatment. Those who received CBP stayed in the ICU for a longer period compared with control group, and the ICU expenses increased evidently with significant differences (P<0.05 or P<0.01). However, there was no difference in mortality between the two groups. CONCLUSION: Under the effect of immunosuppressant in the post-OLT period, the excessive release of the anti-inflammatory mediators may become dominant leading to imbalance between proinflammatory and anti-inflammatory mediators leading to MODS. CBP may remove serum proinflammatory cytokines to act as an effective supportive treatment.

Adult↗
PubMedDate not supplied

[Lipid peroxidation in open-heart operations].

The intensity of lipid peroxidation (LPO) and antioxidant system activity (ASA) have been studied using chemiluminescent technique in 15 patients with ischemic heart disease subjected to surgery under moderate hypothermia. Two types of responses to surgical intervention and cardiopulmonary bypass have been demonstrated depending on baseline LPO intensity. Low baseline intensity of free-radical reactions at the beginning of perfusion is first enhanced and then attenuated by the end of perfusion, which is accompanied by ASA activation. This indicates adequate protective and adaptation body reactions. The same group of patients was characterized by a significant correlation between the parameters studied in venous blood and blood outflowing from the myocardium prior to and following the aorta clamping. With high LPO intensity that remained unchanged in the course of the intervention no correlation between LPO and ASA parameters has been observed in venous and coronary sinus blood. These patients develop various cardiovascular complications in the postperfusion period. It has been concluded that high baseline LPO level is prognostically unfavourable, with no correlations between the parameters under study observed in venous blood and blood outflowing from the myocardium.

Adult↗
PubMed1997

Releasable suture technique for trabeculectomy.

A retrospective review of 154 trabeculectomies with releasable sutures was performed to assess the effect of suture release on intraocular pressure (IOP) at various postoperative periods. Release of the suture was necessary in 38% of cases. The immediate reduction in IOP was significant (p < 0.01) when the suture was released during the first three postoperative weeks. Seventy percent of eyes had a reduction in IOP more than 5 mmHg if released within the first week compared to 20% after the third week. With suture release after the third postoperative week, there was no clinically significant decrease in IOP. The decrease in IOP was similar in eyes undergoing trabeculectomy alone or when cataract extraction through a separate corneal incision was undertaken simultaneously. The period during which release of suture was effective was not prolonged by use of antimetabolites. Complications included a typical windshield-wiper keratopathy (18 eyes), failure to release the suture (13 eyes), epithelial abrasion (6 eyes) and a sub-conjunctival bleed (1 eye).

Cataract Extraction↗
PubMed2005

Extended pulmonary resections of advanced thoracic malignancies with support of cardiopulmonary bypass.

OBJECTIVE: Complete resection of advanced pulmonary malignancies infiltrating the heart or the great vessels may require the application of cardiopulmonary bypass (CPB). Extracorporal circulation, however, is known to cause lung injury and may be harmful especially in pneumonectomies. METHODS: Over a period of 10 years extended pulmonary resections requiring cardiopulmonary bypass were analyzed in a retrospective study. RESULTS: From August 1993 to August 2003, 13 patients underwent an extended pulmonary resection for curative indications, requiring support by CPB. Underlying diseases were sarcomas (n=8), non-small cell lung carcinomas (n=3), and others (n=2). Pneumonectomies were performed in nine and lobectomies in four cases. In the majority of cases, several cardiac structures, predominantly the left atrium (n=9), were affected. In four patients (31%), the indication for a CPB-supported procedure was not electively planned, but made intraoperatively. Complete en-bloc resection (R0) was achieved in 12 of 13 cases (92%). The 30-day mortality rate was 15% (n=2). Major complications observed were acute lung injury (n=4), right heart failure (n=1), and multi-organ failure (n=1). The cumulative survival at 1, 3, and 5 years in patients presenting with sarcomas was 62.5% compared to 33%, 0%, and 0%, respectively, in patients with non-small cell carcinoma (n=3). CONCLUSIONS: Our results encourage the application of CPB in extended pulmonary resections to achieve complete resections. In carefully selected patients, especially those with sarcomas, the radical surgical procedure associated with increased pulmonary complications allows for significantly prolonged survival and quality of life.

Adult↗
PubMed1998

Cerebral oxygenation during paediatric cardiac surgery: identification of vulnerable periods using near infrared spectroscopy.

OBJECTIVE: Neurologic sequelae remain a well recognised complication of paediatric cardiac surgery. Monitoring of cerebral oxygenation may be a useful technique for identifying vulnerable periods for the development of neurologic injury. We sought to measure regional cerebral oxygenation in children undergoing cardiac surgery using near infrared spectroscopy to ascertain such vulnerable periods. METHODS: Observational study of 18 children (median age 1.3 years) undergoing cardiac surgery (17 with cardiopulmonary bypass, 8 with circulatory arrest). Regional cerebral oxygenation was monitored using the INVOS 3100 cerebral oximeter and related to haemodynamic parameters at each stage of the procedure. RESULTS: Prior to the onset of bypass, 10 patients had a decrease in regional cerebral oxygenation of > or = 15% points, reaching an absolute haemoglobin saturation less than 35% in 5 cases. The most common cause was handling and dissection around the heart prior to and during caval cannulation. With institution of bypass, regional cerebral oxygenation increased by a mean 18% points to a mean maximum of 75%. During circulatory arrest regional cerebral oxygenation decreased with rate of decay influenced by temperature at onset of arrest (0.25%/min at < 20 degrees C; 2%/min at > 20 degrees C). Reperfusion caused an immediate increase in regional cerebral oxygenation followed by a decrease during rewarming. Discontinuation of bypass caused a precipitous decrease in regional cerebral oxygenation in 5 patients, reaching less than 50% in 3 patients. CONCLUSIONS: These observations suggest that the pre- and early post-bypass periods are vulnerable times for provision of adequate cerebral oxygenation. Near infrared spectroscopy is a promising tool for monitoring O2 supply/demand relationships especially during circulatory arrest.

Brain↗
PubMed1999

End-tidal sevoflurane concentration for tracheal extubation (MACEX) in adults: comparison with isoflurane.

Sevoflurane has a non-pungent odour and provides smooth induction of anaesthesia. In contrast, isoflurane is irritating to the airway when used for induction, and this may also be evident during emergence from anaesthesia. We measured the end-tidal concentration of anaesthetic that prevented response to extubation in 50% of patients (MACEX) in adults receiving either sevoflurane or isoflurane. Airway complications during emergence from anaesthesia were also noted. We studied 51 adult patients, ASA 1, aged 36-59 yr. Patients received sevoflurane (n = 29) or isoflurane (n = 22) for elective intraocular surgery. The concentration at which extubation was attempted was determined by a modification of Dixon's up-and-down method. When tracheal extubation was accomplished without coughing and gross purposeful muscular movements within 1 min after extubation, it was considered a smooth tracheal extubation. Patients who developed breath-holding or laryngospasm immediately after tracheal extubation were regarded as not having been extubated smoothly. In addition, patients were observed for respiratory events during the remainder of the emergence period. MACEX values for sevoflurane and isoflurane were 1.07% and 0.83%, respectively. ED95 values of sevoflurane and isoflurane were 2.04% and 1.19%, respectively. In 12 patients in the isoflurane group, extubation was smooth but six patients had coughing episodes during the remainder of the emergence period. In contrast, one of 15 patients in the sevoflurane group in whom tracheal extubation was smooth coughed later (P = 0.035). Airway obstruction was frequent when tracheal extubation was performed at end-tidal concentrations exceeding 1 MACEX for each anaesthetic.

Adult↗
PubMed1991

[Transesophageal echocardiography. Evaluation of the technique and clinical indications. Experience at the Center of Thoracic Surgery of the S. João-Porto Hospital].

The purpose of this paper is to report the early experience with Transesophageal Echocardiography (TEE) after its availability at Thoracic Surgery, Hospital S. João, Oporto, Clinical advantages of the esophageal acoustic window over other approaches and technical development background of the procedure are reviewed. Updated clinical indications of the procedure and illustrative clinical cases from daily practice are presented. From October 1990 to February 1991, 75 examinations have been performed, 59 in awake patients and 16 in unconscious patients, either in the operating theatre or in intensive care unit. The examination protocol was similar to the one followed at Mayo Clinic. All patients accepted to undergo the study when indicated. No technical difficulties were found and no complications were reported during the study period. Finally, based on this introductory experience, a comment is made on main indications for using TEE complemented by few notes on future perspectives with this using ultrasound technique.

Aged↗
PubMed1993

Thrombin production, inactivation and expression during open heart surgery measured by assays for activation fragments including a new ELISA for prothrombin fragment F1 + 2.

Activation of coagulation was studied during the peri-operative period in patients undergoing cardiopulmonary bypass (CPB) surgery using activation markers which have recently become available: prothrombin fragment F1 + 2 (F1 + 2), which is a measure of total thrombin generation, and thrombin-antithrombin complex, which is a measure of inactivation of free thrombin by antithrombin. Levels of the specific marker of fibrin breakdown, D-dimer, were also determined. F1 + 2 levels were assessed using a newly developed ELISA described herein which employs a neoantigen-specific capture antibody raised using a synthetic peptide; the latter antibody has been pre-adsorbed against prothrombin to ensure high specificity for F1 + 2. Increased generation of thrombin during surgery was clearly demonstrated despite maintenance of a high concentration of heparin during the period of extracorporeal blood circulation. There was a close association (r = 0.882) between the generation of thrombin (F1 + 2 levels) and its inhibition (TAT levels). Differences were noted, however, between the information provided by F1 + 2 and TAT, which are interpreted with regard to the different in vivo fates of F1 + 2 and thrombin. The enhanced activation and inhibition of coagulation observed during CPB was suppressed once physiological blood circulation was restored, with F1 + 2 returning to pre-surgical levels within 24 h after surgery. During the post-operative period D-dimer levels, which rose in concert with F1 + 2 and TAT levels, remained highly elevated, suggesting that not all of the generated thrombin was inactivated by antithrombin.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed2004

Risk factors, morbidity, and mortality associated with atrial fibrillation in the postoperative period of cardiac surgery.

OBJECTIVE: To determine the incidence of atrial fibrillation in the postoperative period of cardiac surgery, its impact on morbidity, mortality, and hospital stay, and to analyze the risk factors in the pre, trans, and postoperative periods. METHOD: Contemporary cohort study with 158 adult patients undergoing cardiac surgery, of whom those with atrial fibrillation in the preoperative period were excluded. The patients were assessed with continuous cardiac monitoring and daily electrocardiograms. Any episode of irregular rhythm with the presence of f waves of variable morphology and amplitude was considered atrial fibrillation. RESULTS: The general incidence of atrial fibrillation was 28.5%, being 21.6% for revascularized patients and 44.3% for those undergoing valvular repair. Factors independently associated with atrial fibrillation were left heart failure in the preoperative period (p=0.05; RC=2.2), total fluid balance (p=0.01; RC=1.0), duration of surgery (p=0.03; RC=1.01) [and other associated factors, age > 70 years, aortic valvular disease, psychomotor agitation, length of installation of the drains, pulmonary congestion and respiratory insufficiency in the postoperative period]. The use of beta-blockers (p=0.01; RC=0.3) was a protective factor. Atrial fibrillation in the postoperative period was associated with an increase in the length of hospital stay (16.9+/-12.3 days versus 9.2+/-4.0 days, p<0.001) and a greater incidence of stroke or postoperative death (p=0.02). CONCLUSION: The incidence of atrial fibrillation in the postoperative period of cardiac surgery was high and caused a significant increase in morbidity, mortality, and the length of hospital stay. Among the independent risk factors, excessive fluid balance is significant. The use of beta-blockers was identified as a protective factor.

Adult↗
PubMed2000

Peri-operative aspirin can prevent post-operative ischemia and thrombosis.

Of the 30 million patients in the USA who undergo non-cardiac surgery every year, approximately 1.5 million suffer post-operative cardiovascular events. Surgical trauma and associated catecholamine release leads to platelet activation in the immediate post-operative period, as evidenced by a rise in circulating platelet release products. Platelet activation promotes platelet aggregation and hypercoagulability. Aspirin is widely used for its platelet inhibiting effects to prevent myocardial infarction and stroke. However, aspirin is not routinely started in the immediate peri-operative period, and even in high-risk patients already taking aspirin, aspirin is generally discontinued before elective surgery to improve intra-operative hemostasis. The risk-to-benefit ratios of administering vs withholding aspirin in the immediate peri-operative period have never been assessed and compared. We hypothesize that aspirin given pre-, intra- or immediately post-operatively will reduce post-operative ischemia and thrombotic events, including myocardial infarction and stroke, and that risk-benefit analysis would favor the administration of aspirin. This hypothesis can and should be tested in a prospective, randomized trial.

Aspirin↗
PubMed1984

Repeated coronary artery bypass grafting in patients with patent atherosclerotic grafts: a special challenge.

The operative risk and results of reoperations in patients with long-standing atherosclerotic vein grafts are not well-known. We have had 38 such patients among our last 102 cases of repeated revascularization procedure (37.2%). Six out of those 38 patients were operated taking special measures to avoid atheromatous material displacement and they were compared to the remaining 32 operated on in a conventional way. In addition, all patients, as a group, were compared to another 64 patients undergoing the same procedure in the same time interval but presenting either healthy or occluded grafts. Perioperative myocardial infarction was specially studied. It was more frequent in those with atherosclerotic grafts (23.7 % versus 9.4%) and, among them, in those operated on in a conventional way (25% versus 16.7%). Operative mortality was also higher in the same groups: 13.2% versus 3.1% for atherosclerotic versus non atherosclerotic graft carriers and 15.6% versus none of those operated on in a conventional way versus those in whom special measures were taken. The late results so far are also suboptimal in the same risk groups, although a mean follow-up of 6 months is too brief a period of time. We can therefore conclude that patients with patent atherosclerotic vein grafts have a higher operative risk and worse long-term results, mainly related to a greater perioperative myocardial infarction rate. Special measures to avoid the latter event are warranted.

Adult↗