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PubMed1989

Acid phosphatase levels in serum during transurethral prostatectomy.

Serum prostatic acid phosphatase (S-PAP), serum electrolytes, blood loss and volume of irrigating fluid absorbed were measured during 10-min periods in the course of 35 transurethral prostatic resections. Elevation of the S-PAP concentration occurred in association with a large blood loss, with absorption of irrigant followed immediately by hyponatraemia, and with a sudden drop in systolic blood pressure. The volume of blood lost during irrigant absorption was the most important index of the S-PAP level. A model for the transfer of PAP to the circulation during TURP is presented.

Acid Phosphatase↗
PubMed2000

Colonic inflammation found at diagnosis of juvenile retention polyps in pediatric patients.

OBJECTIVE: The finding of colonic inflammation concurrently with a juvenile retention polyp (JRP) may have prognostic value. However, the significance of abnormal mucosal histology with JRP has not been evaluated. We evaluated the significance of mucosal histology at the time of JRP removal with respect to future development of inflammatory bowel disease (IBD) and polyp recurrence. METHODS: The medical records of patients who had an endoscopic polypectomy performed at the Children's Hospital of Philadelphia (CHOP) from 1/1/87 through 4/30/98 were retrospectively reviewed. RESULTS: JRP was histologically identified in 96 patients. A total of 54 patients had colonic mucosal biopsies: 30 (55.6%) had normal histology and 24 (44.4%) had colitis. Of the 24 patients with colitis, 14 patients (58.3%) had inflammation at the polyp site. Twelve of these patients had additional inflammation elsewhere in the colon. Nine (37.5%) had inflammation elsewhere in the colon; however, biopsies around the polyp site were not obtained. One patient with inflammation did not have the location of the polyp documented. Four patients (16.7%) had IBD at the time of polypectomy; two were diagnosed prior and two coincident with JRP. None have subsequently been diagnosed with IBD. There was no difference in polyp recurrence between those with or without inflammation (16.7% [4/24] vs 10.0% [3/30]). The mean follow-up period was 72.4 months (range, 5-142 months). CONCLUSIONS: In our experience, histological mucosal inflammation is a common finding with JRP. This inflammation may be a precursor for the development of JRP but has no predictive value for polyp recurrence. This colitis does not seem to be associated with IBD.

Adolescent↗
PubMed2006

Effect of cold blood cardioplegia enriched with potassium-magnesium aspartate during coronary artery bypass grafting.

AIM: The aim of this investigation is to evaluate the effect of enriched with potassium-magnesium aspartate cold-blood cardioplegia on early reperfusion injury and postoperative arrhythmias in patients with ischemic heart disease undergoing coronary artery bypass grafting (CABG), using measurements of cardiac troponin I (CTnI), hemodynamic indexes and clinical parameters. METHODS: Forty patients with three-vessel coronary artery disease (CAD) and stable angina, receiving first-time elective CABG, were randomly divided into 2 groups: patients in control group (C group n=20) received routine institutional cold blood cardioplegia (4 degrees C) concentration of Mg2+4 mmol/L, Ca2+1.2 mmol/L and K+ 24mmol/L during myocardial arrest. Patients in P group (n=20) received modified cold blood cardioplegia enriched with potassium-magnesium aspartate and maintained concentration of Mg2+10 mmol/L, Ca2+1.2 mmol/L and K+20mmol/L in the final blood cardioplegia solution. Clinical outcomes were observed during operation and postoperatively. Serial venous blood samples for CTnI were obtained before induction, after cardiopulmonary bypass (CPB), and postoperative 6, 24, and 72 hours. Hemodynamic indexes were obtained before and after bypass by the radial catheter and Swan-Ganz catheter. RESULTS: In both groups, there were no differences regarding preoperative parameters. There were no cardiac related deaths in either group. The time required to achieve cardioplegic arrest after cardioplegia administration was significantly shorter in P group (47.5+/-16.3 s) than in C group (62.5+/-17.6 s) (P<0.01). The number of patients showing a return to spontaneous rhythm after clamp off was significantly greater in P group (n=20, 100%) than in C group (n=14, 70%) (P<0.01). Eight patients in C group had atrial fibrillation (AF) compared with two patients in P group (P<0.05) in the early of postoperative period. The level of CTnI increased 6 hours and 12 hours postoperatively, and there was a significant difference between groups (P<0.05). P group also shortened the time of postoperative mechanical ventilation (P<0.05) after surgery. CONCLUSIONS: Cold blood cardioplegia enriched with potassium-magnesium aspartate is beneficial on reducing reperfusion injury.

Aged↗
PubMed1984

Ventilation during laryngoscopy in chronic obstructive lung disease.

Many patients requiring direct examination of the upper airway and gastrointestinal tract under general anesthesia have chronic obstructive lung disease, yet virtually no work has been done to assess the adequacy of their ventilation during laryngoscopy and in the early postoperative period. This study demonstrates that, using the Carden tube, their blood gases are well maintained even when areas outside the endolarynx, such as the upper esophagus, are examined. The Carden tube is shown to be easy to insert and remove as well as permitting a superior view of the larynx. Also, this study pinpoints the period of maximum danger of respiratory failure as occurring postoperatively in the recovery room. This should be independent of the method of ventilation employed at surgery and indicates the need for cocainization of the vocal cords before extubation, as well as careful, early postoperative monitoring. The problems of ventilation during direct examination of the upper airway and gastrointestinal tract are discussed and alternative methods evaluated.

Adult↗
PubMed2002

Joel-Cohen or Pfannenstiel incision at cesarean delivery: does it make a difference?

OBJECTIVE: To evaluate whether the technique to open the abdomen might influence the operative time and the maternal and neonatal outcome. METHODS: All consecutive women who underwent a cesarean section at a gestational age greater than or equal to 32 weeks were randomly allocated to have either the Joel-Cohen or the Pfannenstiel incision. Exclusion criteria were two or more previous cesarean sections and previous longitudinal abdominal incision. During the study period 366 patients underwent a cesarean delivery. Of these patients, 56 did not meet the inclusion criteria. The remaining patients were allocated to the Joel-Cohen (n = 152) group and to the Pfannenstiel (n = 158) group. Extraction time was defined as the time interval from skin incision to the clamping of the umbilical cord. RESULTS: The total operative time was similar in both groups [Joel-Cohen 32 min (12-60) vs. Pfannenstiel 33 min (18-70)]. The extraction time was shorter in the Joel-Cohen group than in the Pfannenstiel group [190 s (60-600) vs. 240 s (50-600), p = 0.05]. This remained statistically significant after adjustment for confounding variables (Hazard = 1.26, p = 0.05). No difference was found between groups in terms of intraoperative and postoperative complications. No difference was found in the neonatal neurodevelopmental assessment at 6 months of age in relation to the abdominal incision performed. CONCLUSION: The Joel-Cohen method of opening the abdomen at cesarean delivery is faster then the Pfannenstiel technique at delivering the fetus. However, considering the absence of benefits to the mother and the fetus there is no clear indication for performing a Joel-Cohen incision.

Abdomen↗
PubMed2005

Timing of intra-aortic balloon pump support and 1-year survival.

OBJECTIVE: The relationship between the timing of intra-aortic balloon pump (IABP) support and surgical outcome remains a subject of debate. Peri-operative mechanical circulatory support is commenced either prophylactically or after increasing inotropic support has proved inadequate. This study evaluates the effect timing of IABP support on the 1-year survival of patients undergoing cardiac surgery. METHODS: From April 1997 to September 2002, 7698 consecutive cardiac surgical procedures were performed. This included 5678 isolated coronary artery bypasses (CABGs), 1245 isolated valve procedures and 775 simultaneous CABG and valve procedures. IABP support was required in 237 patients (3.1%). Twenty-seven patients (0.35%) were classed as high-risk and received preoperative IABP support, 25 patients (0.32%) were haemodynamically compromised and required preoperative IABP support, 120 patients (1.56%) required intra-operative IABP support, and 65 patients (0.84%) required post-operative IABP support. Multiple variables were offered to a Cox proportional hazards model and significant predictors of 1-year survival were identified. These were used to risk adjust Kaplan-Meier survival curves. RESULTS: 1-year follow-up was complete and 450 deaths (5.8%) were recorded. The significant independent predictors of increased mortality at 1-year (P<0.05, HR=hazard ratio) were post-operative renal failure (HR=3.5), increasing EuroSCORE (HR=1.2), post-operative myocardial infarction (HR=3.7), post-operative IABP (HR=4.1) intra-operative IABP (HR=2.8), post-operative stroke (HR=2.5), increasing number of valves (HR=1.6), ejection fraction <30% (HR=1.3) and triple-vessel disease (HR=1.3). After risk-adjustment, 1-year survival for patients who required intra-operative IABP support was significantly greater than for those patients who required IABP support in the post-operative period. CONCLUSIONS: Patients who warrant IABP support in the post-operative setting have a significantly increased mortality at 1-year when compared to any other group. Therefore, earlier IABP support as part of surgical strategy may help to improve the outcome.

Aged↗
PubMed2003

Oxygen metabolism during and after cardiac surgery: role of CPB.

BACKGROUND: Cardiopulmonary bypass (CPB) has been reported to increase oxygen metabolism and to influence the relation between oxygen consumption (VO(2)) and delivery (DO(2)) in the early hours after cardiac surgery. To investigate the role of CPB, we studied oxygen metabolism in coronary artery bypass procedures performed on-pump (CABG) and off-pump (OPCAB). METHODS: Twenty-five patients were randomized to undergo CABG (n = 14) or OPCAB (n = 11). All patients received the same anesthetic management. Oxygen metabolism variables were assessed before induction of anesthesia and up to 18-hours after surgery. RESULTS: At baseline, before induction of anesthesia, there were no differences between CABG and OPCAB in oxygen consumption (VO(2)), delivery (DO(2)), or extraction (ExO(2)). After surgery VO(2) and ExO(2) increased in both groups, while DO(2) decreased. No significant differences between CABG and OPCAB were detected in postoperative VO(2), DO(2), and ExO(2) levels. The relation between VO(2) and DO(2) was very similar in CABG and OPCAB patients throughout the study, and no significant differences were detected in slopes and intercepts of the regression lines between CABG and OPCAB at all time points. There was, however, a significant effect of time on the relation between VO(2) and DO(2): this relation was stronger in the postoperative period, and the slope of this relation increased over time as well. CONCLUSIONS: A hypermetabolic state and progressive and significant increases in the strength of the relationship between VO(2) and DO(2) and in the slope of this relationship occur after both CABG and OPCAB. Cardiopulmonary bypass is not responsible for these changes in oxygen metabolism.

Cardiopulmonary Bypass↗
PubMed1984

Midazolam as adjunct to high-dose fentanyl anaesthesia for coronary artery bypass grafting operation.

The usefulness of midazolam as an adjunct during high-dose fentanyl anaesthesia was studied by following the changes in the haemodynamics and total body oxygenation after an intravenous injection of 0.075 mg/kg and 0.15 mg/kg of midazolam during the induction of fentanyl (75 micrograms/kg)-oxygen anaesthesia for a coronary artery bypass operation. These responses were then compared to the changes seen in patients receiving the same fentanyl anaesthesia without the midazolam. A rapid decline after the midazolam injection was seen in the mean systemic arterial pressure (24-32%--the lowest individual value was 45 mmHg (6.0 kPa)) and in the systolic and diastolic pulmonary arterial pressures (29-33% and 30-31%) in 1-3 min. As measured 10 min after the midazolam injection, a decrease from the baseline was seen in the stroke index (25-30%), in the left ventricular stroke work index (46-42%) and in the right ventricular stroke work index (48-61%). These haemodynamic variables remained on a lower level throughout the study period (40 min) in the midazolam patients as compared to the controls. The tissue oxygenation seemed to be sufficient in all groups during the study period. An intravenous injection of a relatively low dose of midazolam during the induction of high-dose fentanyl anaesthesia seems to be followed by rapidly increased venous pooling and a moderately to severely decreased systemic arterial pressure. Based on the results of this study, midazolam cannot be recommended as an adjunct during high-dose fentanyl anaesthesia.

Adult↗
PubMed2004

Does intraoperative evaluation of left ventricular contractile reserve predict myocardial viability? A clinical study using dobutamine stress echocardiography in patients undergoing coronary artery bypass graft surgery.

To determine the contractile reserve of the left ventricle during reperfusion as a predictor of myocardial viability in patients undergoing coronary artery bypass graft surgery, we measured the response of left ventricular regional wall motion and thickening by using dobutamine stress echocardiography (DSE) after myocardial revascularization. All patients were monitored with radial and pulmonary arterial catheters, transesophageal echocardiography, standard five-lead clinical electrocardiography, and three-channel Holter electrocardiography. Immediately after separation from cardiopulmonary bypass, dobutamine was administered IV starting at 5 microg. kg(-1). min(-1), with increases in rate every 3 min to 10, 20, 30, and 40 microg. kg(-1). min(-1). Within 1 wk after surgery, resting and redistribution thallium-201 myocardial perfusion imaging (thallium studies) was performed to assess the relationship between the intraoperative contractile response and myocardial viability. One-hundred patients completed DSE up to 10 microg. kg(-1). min(-1), and 85 patients received the larger escalating doses of the DSE. Seventy-two patients had postoperative thallium studies. At the completion of the small-dose dobutamine infusion, 689 (97.7%) of 705 segments had a normal response (improvement), and 16 segments (2.3%) had a positive response (deterioration). During large-dose dobutamine infusion, 577 (95.8%) of 602 segments had a normal response, and 25 segments (4.2%) had a positive response. Myocardial segments that had a positive response during large-dose DSE (48%) were more likely to be considered as nonviable on postoperative thallium studies compared with segments that had a normal response (14.7%) (P < 0.00001). By using thallium studies as the reference standard, the sensitivity of DSE was low (31% and 48% for small- and large-dose DSE, respectively) in predicting nonviable myocardium. However, the specificity was higher (86% and 85% for small- and large-dose DSE, respectively). In a separate analysis of patients who developed new regional wall motion abnormalities (RWMA) in the early intraoperative reperfusion period, 15 (75%) of 20 abnormally contracting myocardial segments had normal postoperative thallium studies. Our results demonstrate that a normal response to DSE is highly specific for viable myocardium; however, a positive response to DSE has low sensitivity in predicting nonviable myocardium. The majority of new postbypass regional wall motion abnormalities appear to be related to stunned myocardium.

Adult↗
PubMed1998

[Hemostatic changes in children treated with heart surgery with cardiopulmonary bypass].

PURPOSE: We evaluated hemostasic changes in children undergoing open heart surgery with cardiopulmonary bypass (CPB). METHODS: We studied 17 children before, during surgery, in the immediate, first and between the 4th and 7th postoperative days, measuring hematocrit, prothrombin time, activated partial thromboplastin time, fibrinogen, platelet count, factor V and euglobulin lysis time. Children were divided in those with and without excessive bleeding in the postoperative period. RESULTS: We observed significant prolongation of prothrombin time and activated partial thromboplastin time, reduction of fibrinogen and factor V, and shortening of euglobulin lysis time. Six (35%) children bled excessively. Platelet count reduction was greater in the intra operative period in these cases and the duration of CPB was longer in this group. CONCLUSION: Changes in hemostasis during open heart surgery are due to coagulation cascade disorders as well as fibrinolysis. The incidence of excessive bleeding is higher in the pediatric group. Prolonged CPB time and greater reduction in platelet count differentiated both groups.

Cardiac Surgical Procedures↗
PubMed1986

Internal mammary artery grafting. Clinical results, patency rates, and long-term survival in 833 patients.

This report reviews 833 patients who underwent internal mammary artery grafting alone or with vein grafts between 1968 and 1981. Use of the internal mammary artery was indicated in young or middle-aged patients with the following characteristics: a significant lesion of the proximal left anterior descending artery or its diagonal branch alone (70.1%) or combined with diffuse atherosclerosis (19.9%) or a small caliber (3.4%); absent or unsuitable veins for grafting (5.5%); atherosclerosis or an aneurysm of the ascending aorta (0.6%); and failure of previous vein grafts (0.5%). The left anterior descending artery system was grafted by the left internal mammary artery in 53.2%, and the arterial graft was complimented by vein grafts in 2.6%. In 45.2% of the patients, grafts of the left anterior descending artery by the left internal mammary artery were supplemented by vein grafts to the right coronary artery (23.8%), to the circumflex artery (15.2%), or to both (6.2%). The overall operative mortality was 2.2%. It rose to 16.7% with associated cardiac procedures and to 18.5% in patients who were in New York Heart Association Class IV. If these two high-risk categories of patients are excluded, the perioperative death rate in the remaining 750 was only 0.4%. Of the 815 patients who survived the perioperative period (mean 53.1 months follow-up), 63.1% were relieved of angina and 83.4% were in Class I or II of the New York Heart Association, as compared to 27.4% before the operation. At cardiac recatheterization (mean 18.9 months), 87.9% of the internal mammary artery grafts and 63.3% of the vein grafts were patent (p less than 0.05). The cumulative actuarial 10 year survival rate was 88.6% +/- 1.3%.

Actuarial Analysis↗
PubMedDate not supplied

Effect of fresh gas flow on isoflurane concentrations during low-flow anaesthesia.

The effect of fresh gas flow (FGF) on isoflurane concentrations at given vaporizer settings during low-flow anaesthesia was investigated. Ninety patients (American Society of Anaesthesiologists physical status I or II) were randomly allocated to three groups (FGF 1 l/min, FGF 2 l/min and FGF 4 l/min). Anaesthesia was maintained for 10 min with vaporizer setting isoflurane 2 vol% and FGF 4 l/min for full-tissue anaesthetic uptake in a semi-closed circle system. Low-flow anaesthesia was maintained for 20 min with end-tidal isoflurane 1.5 vol% and FGF 2 l/min. FGF was then changed to FGF 1 l/min, FGF 2 l/min or FGF 4 l/min. Measurements during the 20-min period showed that inspired and end-tidal isoflurane concentrations decreased in the FGF 1-l/min group but increased in the FGF 4-l/min group compared with baseline values. No haemodynamic changes were observed. Monitoring of anaesthetic concentrations and appropriate control of vaporizer settings are necessary during low-flow anaesthesia.

Adult↗
PubMed1998

[Aspects of the transplantation of kidneys from relatives].

104 transplantations of the kidney from living relative donors (LRD) in patients with an end-stage of chronic renal insufficiency (CRI) were carried out in Research Center of Surgery from April 15, 1965 to November, 1993. Donors of the kidneys were: mother (55), father (21), sister (18), brother (10). Analysis of the accumulated data showed, that the results of LRD transplantations (one year survival of recipients 84 +/- 6%) are much better than those from cadaver donors (one year survival of recipients 33 +/- 6%). The examination of the relative donors in long-term periods after the operation has demonstrated, that nephrectomy in them entails small risk, because it does not negatively influence their psycho-emotional sphere and social status. The reserved (retained) kidney is able to support homeostasis of donor organism during all his life. Therefore the operation of kidney transplantation from living relative donors is the most effective method of treatment of patients with an end-stage of chronic renal insufficiency.

Adolescent↗
PubMed1987

Is high potassium solution necessary for reinfusions in "multidose" cold cardioplegia? A randomized prospective study using computerized Holter system.

Multidose potassium cardioplegia is a common method of myocardial preservation. Although initial potassium arrest conserves high-energy phosphates, there is conflicting evidence that repeat high potassium boluses augment this protection. Fifty-six patients were prospectively randomized to receive multidose cold high potassium cardioplegia (27 mEq of KCl/L) both in the initial and subsequent infusions (Group 1) or an initial cold high potassium (27 mEq/L) cardioplegia followed by boluses of cold low potassium (7 mEq, of KCl/L) solution (Group 2). The two groups were compared in terms of postoperative myocardial electrical stability and hemodynamic performance. Electrocardiograms were recorded by continuous Holter monitor, and the data were analyzed by computer. The duration of aortic cross-clamping and cardiopulmonary bypass did not differ between groups. Group 1, who received more total KCl than Group 2 (p less than .005), experienced more high-grade ventricular ectopia during both reperfusion (p less than .001) and the immediate postoperative period (p less than .001), and required more lidocaine hydrochloride (p less than .001) for arrhythmias. There was no significant difference in hemodynamic performance between the two groups. This study fails to show an advantage to multidose "high potassium" cardioplegia and found a significant increase in ventricular ectopia associated with its use. We advocate using low potassium solutions after initial cold high potassium arrest.

Adult↗
PubMed1998

Low T3 syndrome with asynchronous changes of TT3 and rT3 values in laparoscopic cholecystectomy.

Non-thyroidal illnesses, such as surgical stress, are associated with abnormal metabolism of thyroid hormones. However, the potential impact of variable surgical procedures remain to be elucidated. In order to evaluate the effect of mild surgical stress upon thyroid function, TT4, TT3, rT3 and TSH were measured in twenty-two patients undergoing laparoscopic cholecystectomy before (Stage 1), during (Stages 2-5), at the recovery room (Stage 6) and 24h postoperatively (Stage 7). The values of TSH remained within the normal limits with transient changes during the study period. Similarly, TT4 values displayed normal variations within the normal range without reaching a statistically significant difference during the study period. A decrease of TT3 values was detected early at stage 2 during induction of anaesthesia. TT3 remained at low levels during the perioperative period, and a further decrease was observed 24 h postoperatively. The above profile of thyroid hormone metabolism, reflects a low-T3 syndrome in patients undergoing laparoscopic cholecystectomy. Interestingly, there was a tendency for rT3 to increase and it reach its highest value 24h postoperatively with the difference being statistically significant (p<0.05). The asynchronous distribution of rT3 and TT3 might be attributed to multifactorial influences.

Adult↗
PubMed1996

[Incidents and complications of therapeutic thoracoscopy. Apropos of 898 operated patients].

The exceptional interest in endoscopic surgery, both in laparoscopic surgery and video-assisted thoracoscopic surgery have led many teams to widen their indications. This movement has developed into a revolution in techniques demanded by patients, the public, and the medias, requiring many practicians to use these techniques more and more often and consequently to attempt very delicate operations. This "explosion" of endoscopic techniques has largely benefited from advances in equipment development (optics, video instrumentation) but has also required that operators acquire rigorous procedures for the proposed techniques. With the development of new thoracoscopic techniques for therapeutic indications, there are an unavoidable number of incidents and complications. These incidents and complications are related both to the use of instruments undoubtedly not well enough adapted to the procedures used and also to "forced" indications. We humbly recognize that a certain number of incidents are related to the necessarily inadequate experience of the operators during the "run in" period. We emphasize that video-assisted thoracoscopic surgery is a complementary technique among the available therapeutic armamentarium. We evaluated the mid and long term results of cancerology exeresis with these two techniques and underscore that morbidity and complications are rare but sometimes unacceptable. In conclusion, whatever the form of the technique used, it is an important evolution in surgery which must abide by the classical rules, in particular for indications in cancer surgery.

Endoscopy↗
PubMed1998

Intraoperative non-puncture laparoscopic examination of contralateral internal inguinal rings is feasible in children with unilateral hydrocele.

BACKGROUND: Intraoperative non-puncture laparoscopic examination using the hernia sac as the scope entrance has been successfully conducted in children with unilateral inguinal hernia. This technique selects patients for contralateral inguinal exploration. In spite of the thin and narrow processus vaginalis, children with unilateral hydrocele encounter the same problem of subsequent contralateral inguinal hernia or hydrocele. In this study, we discuss the feasibility of this technique in children with unilateral hydrocele. METHODS: From July 1993 to September 1995, 91 children with unilateral hydrocele were examined during surgery at our institution. The results, including success rate, complications, patent rate of contralateral internal ring and contralateral subsequent hernia or hydrocele, at at least one year follow-up, were compared with those of 329 children with unilateral hernia undergoing the same examination during this period. RESULTS: A patent contralateral processus vaginalis was recognized in 31 children and all were confirmed by surgical exploration. The examination failed in three patients, of whom two had a tear in the processus vaginalis and one had retroperitoneal air dissection as a result of false insertion of the laparoscopic sheath. One patient had a postoperative wound infection. No patient with contralateral obliterated processus vaginalis developed inguinal hernia or hydrocele during follow-up of at least one year. The results were similar to those of the 329 children with hernia who underwent the same procedure in the same period. CONCLUSIONS: Intraoperative non-puncture laparoscopic examination is feasible in children with unilateral hydrocele.

Child↗
PubMed1990

[Excretory function of the kidneys during artificial circulation in patients operated on for acquired heart defects].

The authors have shown that the suppression of the excretory function of the kidneys during the period of artificial circulation is considerably dependent on the concentration of vasopressin in blood and the associated spasm of renal vessels. The use of morphine as the main medicine for general anesthesia with the dose of 3 mg/kg as compared with the dose 2 mg/kg, gives less level of vasopressin in blood and thus reduces symptoms of antidiuresis in response to the action of strong stressogenic factors.

Adolescent↗