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PubMed1993

Celiac compression syndrome and liver transplantation.

OBJECTIVE: The authors assessed the prevalence and clinical significance of the celiac compression syndrome in liver transplantation patients. SUMMARY BACKGROUND DATA: Compression of the celiac axis by the median arcuate ligament of the diaphragm, causes a decrease in celiac artery blood flow which may lead to hepatic artery thrombosis in patients undergoing orthotopic liver transplantation. METHODS: From July 1991 to July 1992, 17 (10%) cases of celiac compression syndrome were identified among 164 consecutive adult patients who underwent liver transplantation. The diagnosis was confirmed by blood flow recording demonstrating a typical pattern of accentuated decrease in celiac blood flow during expiration. RESULTS: Surgical transection of the median arcuate ligament resulted in normalization of the hepatic artery blood flow. In two cases (11.7%), an interposition iliac graft from the recipient supra-celiac aorta was used for the arterial reconstruction. During the follow-up period of up to 15 months, there was no incidence of hepatic artery thrombosis. CONCLUSIONS: The clinical significance of the celiac compression syndrome is evident in liver transplantation in which the collateral circulation to the liver is compromised and the celiac artery remains the only source of arterial blood. It is imperative to identify and remove the obstruction of the celiac axis to prevent severe complications and potential graft loss.

Adult↗
PubMed1985

Intra-aortic balloon pumping: seven years' experience.

The indications for intra-aortic balloon pumping vary widely from country to country and from one cardiac surgical unit to another. Its use in Glasgow from 1976 to 1983 in 63 patients has been reviewed. Six of the patients (9.5%) had the intra-aortic balloon inserted before cardiac surgery, 43 (68.2%) at the time of surgery, and 14 (22.2%) in the postoperative period. Of the 63 patients, 11 could not be weaned from cardiopulmonary bypass despite intra-aortic balloon pumping, and died in the operating room. A further 35 patients had intra-aortic balloon pumping but died in the immediate postoperative period. Seventeen patients (27%) survived from six weeks to 3.3 years after receiving the support of intra-aortic balloon pumping. There was major morbidity in 11 patients (17%), all of whom developed degrees of ischaemia due to ileofemoral arterial obstruction in the leg in which the balloon was inserted. The conservative use of the method in this centre is reflected in the high mortality of these patients.

Adult↗
PubMed1989

Pulse oximetry during shunt surgery in pediatric patients with tetralogy of fallot.

Pulse oximetry is a noninvasive technique for measuring O2 saturation (SpO2) continuously. We applied pulse oximetry to 9 pediatric patients with tetralogy of Fallot during shunt surgery. Arterial oxygen tensions (PaO2) and saturations (SaO2) were also measured at the time of postinduction, just before the shunt, after the shunt and at the end of the operation. The SpO2 and SaO2 levels were identically changed in all 4 periods. The PaO2 was increased a little without statistical significance after the shunt procedure and at the end of the operation compared with the values before the shunt. However, SaO2 values increased with statistical significance after the shunt procedure and SpO2 values also showed similar increases with significance. In conclusion, continuous monitoring of SpO2 by pulse oximetry, instead of PaO2, is a very useful and reliable method to assess the improvement of perfusion after shunt, particularly in cyanotic cases.

Child, Preschool↗
PubMedDate not supplied

[Comparative evaluation of clinical use of cardioplegic solutions custodiol and konsol in the correction of cardiac valvular diseases].

The efficiency of myocardial protection with cold crystalloid cardioplegia (CC) during operations on the heart under total ischemia and extracorporeal circulation was studied. Two hundred and fifty patients who underwent prosthetic or plastic repair of the aortic and mitral valves or plastic repair of the tricuspid valve were examined. Group 1 comprised 218 patients in whom the myocardium was protected with Konsol solution ("Biofarm "research-and-production enterprise, Russia); Group 2 included 32 patients in whom Custodiol solution ("Dr Franz Kohler Chemia GMBH", Germany). The volume of the Konsol solution required for CC was 400-2000 ml, with the duration of myocardial ischemia (MI) being 75 +/- 33 min; that of the Custodiol was 2000-4000 ml, with the duration of MI being 80 +/- 22 min. The used algorithm of administration of the solutions provided a persistent cardioplegic effect in both groups. After aortic declamping, there was a spontaneous recovery of cardiac performance in 84 and 40% in Groups 1 and 2, respectively. In the reperfusion period (RP), no significant differences were found in the basic hemodynamic parameters (heart rate, blood pressure, and central venous pressure) in both groups. After defect correction, cardiac output equally increased in both groups. The groups did not differ in the rate of inotropic support either. In RP, transient cardiac rhythm and conduction disturbances occurred in 19 and 28% in Groups 1 and 2, respectively.

Cardioplegic Solutions↗
PubMed1995

Cytokine balance and immunosuppressive changes at cardiac surgery: contrasting response between patients and isolated CPB circuits.

In vitro work suggests that IL-10 plays a pivotal role in controlling the balance of pro- and anti-inflammatory cytokines and monocyte HLA-DR expression. In 20 patients undergoing cardiac surgery, we investigated elaboration of interleukin 10 (IL-10) and its relationship to pro- and anti-inflammatory cytokines and leucocyte expression of HLA-DR and adhesion molecules. There were small increases in pro-inflammatory cytokines (IL-1, IL-8 and tumour necrosis factor (TNF) after induction, returning to baseline on induction of cardiopulmonary bypass (CPB). After CPB another transient increase in IL-8 occurred (P < 0.05). The anti-inflammatory response began with elevated IL-10 during CPB (P < 0.001), which peaked early in recovery (P < 0.001), by which time IL-1 receptor antagonist (IL-1ra) and the TNF soluble receptors (TNFsr) had also increased (P < 0.01). The next day IL-10 and IL-1ra were decreasing but TNFsr continued to increase. Induction of anaesthesia caused HLA-DR downregulation. The IL-10 peak was associated with further monocyte HLA-DR downregulation (P < 0.001) and return towards baseline of granulocyte adhesion molecule expression which transiently increased during CPB (P < 0.001). To determine which aspects of the immune response arose from the interaction of blood with the CPB apparatus, the above variables were studied within an isolated CPB circuit and the influence of fentanyl on the magnitude of any such changes determined. Five healthy volunteers donated two, 250-ml samples of blood to which was added either fentanyl 175 micrograms with heparin 1050 u. or heparin alone 1050 u. These were used to prime two identical isolated CPB circuits and circulation was conducted under identical conditions for 90 min. Of the pro-inflammatory cytokines, only IL-8 was elevated at 90 min CPB (P < 0.05). There was no increase in anti-inflammatory cytokines and TNFsr decreased (P < 0.001). Granulocyte adhesion molecules were increased during CPB. In the fentanyl group, the CD11b increase was greater and preceded CPB. The reduction in lymphocyte HLA-DR expression, observed throughout the study period (P < 0.01), was greater with fentanyl (P < 0.05). Monocyte HLA-DR expression increased (P < 0.05), but to a lesser extent with fentanyl (P > 0.05). In contrast with the in vivo response where there was a phased anti-inflammatory response beginning with IL-10, in the isolated CPB model no anti-inflammatory cytokine response occurred.

Adult↗
PubMed2001

[Synchronous tumor of the upper urinary tract with bladder cancer. Opportunity for nephroureterectomy and block-cystectomy].

OBJECTIVE: One of the basic characteristics of urothelial carcinoma is its tendency to synchronous or metachronous multifocality. Thus the need to explore the entire urinary tract of patients with urothelial neoformations. The aim of this article is to study the tumors of the upper urinary tract that appear synchronously with infiltrating carcinoma of the bladder. The clinicopathological characteristics and the morbidity and mortality of en bloc surgery of both tumors are analyzed. METHODS: A retrospective study was carried out on 170 radical cystectomies for infiltrating bladder tumor performed in our department over a 13-year period. Patient history, clinicopathological characteristics, complementary tests, type of surgery performed, postoperative complications and follow-up were analyzed. RESULTS: Tumor of the upper urinary tract appeared in 14 (1 bilateral) of these patients and were synchronous in 10 cases. All patients were male; mean age 63 years. Three were localized in the pelvis, 2 in the proximal ureter and 6 in the distal third. Diagnosis was made by IVP in 6 patients and by US and antegrade pyelography in the other 4 patients. Nephroureterectomy and radical cystectomy were performed en bloc in 8 cases; 6 had a Bricker procedure and 2 ileal substitution. Salvage radical cystectomy + distal ureterectomy were performed in the other two patients. Two patients submitted to en bloc surgery had postoperative complications; one presented prolonged ileua and the other required surgery for retroperitoneal hemorrhage. The two patients submitted to palliative surgery died of and sepsis during the postoperative period. At 33 months' mean follow-up, 3 patients have shown tumor progression. CONCLUSIONS: There is a high proportion of synchronous tumor of the upper urinary tract in our series of patients with infiltrating carcinoma of the bladder undergoing radical cystectomy, therefore we consider it necessary to explore the entire urinary system. Surgical removal of both tumors en bloc does not increase the morbidity and mortality.

Aged↗
PubMed1980

[Problems of the diagnostic value of an urgent biopsy].

Under consideration were some aspects of the diagnostic value of urgent biopsy, based on the vast materials submitted by a pathoanatomical department of the Provincial Hospital and Oncological Dispensary for a 5-year period (1974--1978). Gross errors in the urgent diagnosis were found to be in 3.24% (216 biopsies) and in 1.41% (931 biopsies) as compared with the results obtained after the routine investigation as well as the examination mostly of the whole operation material, obtained later. The errors may be due to underestimation of some findings and overestimation of the others, an inadequately selected site for investigation as well as some objective factors, related to limitations of the urgent biopsy technic and emergency of its use.

Biopsy↗
PubMed1998

[Cardiovascular effects of anesthesia. Management of cardiovascular therapy during the perioperative period].

General anesthesia changes circulatory haemodynamics in three ways: a decrease in sympathetic tone, a decrease in VO2, and a change in baroreceptor reflex function. These effects may have important consequences in patients with cardiovascular disease whose stability depends on these different factors. In addition, the anaesthesia should be adapted to the intensity of the surgical stimuli which tend to increase sympathetic activity, produce tachycardia and increase the blood pressure which may cause decompensation of some cardiac diseases (coronary artery disease for example). Drugs used in the treatment of cardiac disease may interfere with anaesthesia but they are usually continued in order to operate patients under stable cardiovascular conditions.

Anesthesia, General↗
PubMed1990

Pulmonary artery occlusion pressure is not accurate immediately after cardiopulmonary bypass.

Elevated pulmonary vascular resistance (PVR), differential cardiac dynamics, and increased lung water following cardiopulmonary bypass (CPB) have been proposed as limitations to the accuracy of the pulmonary artery occlusion pressure (PAOP) in estimating left ventricular preload. A prospective study of 22 patients undergoing elective myocardial revascularization is described wherein PAOP was compared with directly measured left atrial pressure (LAP). The reliability of PAOP to estimate LAP in the hour immediately following CPB and at 1, 4, 8, and 12 hours post-CPB was examined with repeated measures analysis of variance. Relationships between the PAOP-LAP difference and PVR, core temperature, arterial CO2 tension, and right and left ventricular stroke work indices (RVSWI, LVSWI) were tested by linear regression analysis. There was greater variability in measurements at 15, 30, and 45 minutes immediately after CPB, demonstrated by a pooled correlation coefficient of 0.73 versus 0.90 in the postoperative period. The degree of discrepancy between PAOP and LAP lessened with time. There was no determinable relationship of the PAOP-LAP gradient to PVR, level of PCO2, temperature, RVSWI, or LVSWI. Potential sources of discrepancy include airway pressure effects, position of the measuring catheters, positive end-expiratory pressure, infusion of protamine sulfate, extremes of pulmonary artery pressures, and effects of an open pericardium.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1996

The effect of epidural blockade on gastric intramucosal pH in the peri-operative period.

Patients undergoing major surgery are at risk of developing gut ischaemia and multiple organ failure. The gastric tonometer provides a relatively non-invasive method of assessing the adequacy of gut blood flow. Patients who develop repeated episodes of splanchnic ischaemia in the postoperative period, as evidenced by a low gastric intramucosal pH, have a higher mortality than those who do not. This randomised, controlled study was conducted to assess the effect of epidural blockade with bupivacaine on gastric intramucosal pH measurements in patients undergoing major surgery. A significantly lower proportion of patients with epidural blockade developed gastric intramucosal pH values < 7.32 postoperatively compared to controls (3/15 versus 13/16, p < 0.001). The significance of these results is discussed.

Anesthesia, Epidural↗
PubMed1986

Influence of mannitol and dopamine on renal function during elective infrarenal aortic clamping in man.

The impact of elective infrarenal aortic clamping on parameters of renal function was evaluated in 27 extracellular fluid volume expanded patients. Significant transient decreases (p less than 0.05) in glomerular filtration rate were observed in all three groups either in the early or late post-clamp release period, despite maintenance of hemodynamic stability. This study documents transient decreases in glomerular filtration rate which occurred following release of the infrarenal aortic cross-clamp. No clinically important benefit from the use of mannitol and dopamine over extracellular fluid volume expansion with saline alone was demonstrated in the prevention of the changes in renal function associated with aortic cross-clamping.

Adult↗
PubMed1990

Intravenous omeprazole in patients with Zollinger-Ellison syndrome undergoing surgery.

Twenty patients with Zollinger-Ellison syndrome who were undergoing surgery were studied prospectively to assess the efficacy and safety of IV omeprazole. During the preoperative period, in 19 of 20 patients, omeprazole 60 mg administered as an IV bolus every 12 hours inhibited acid output to less than 5 mEq/h measured in the last hour before the next dose of drug. In one patient, acid output was 25 mEq/h 12 hours after omeprazole, 60 mg, and increasing the dose to 100 mg every 12 hours reduced acid output to less than 5 mEq/h. During the operative and postoperative periods, IV omeprazole controlled gastric acid hypersecretion in all patients for up to 15 days. During this time, all patients received the dose determined preoperatively. No patient developed any clinical, hematological, or biochemical toxicity that could be attributed to omeprazole therapy during the preoperative or postoperative period. The present study demonstrates that omeprazole administered by IV bolus is safe and effective for controlling gastric acid hypersecretion. In contrast to IV histamine H2-receptor antagonists, IV omeprazole has the advantages of not requiring continuous infusion or postoperative dose adjustments. Intravenous omeprazole will become the drug of choice in patients with Zollinger-Ellison syndrome undergoing surgery.

Adult↗
PubMed2003

Anesthesia for off-pump coronary artery bypass grafting.

Off-pump coronary artery bypass presents special challenges for the anesthesiologist and surgeon, who must work closely together to provide optimal care. Displacement and immobilization of the heart for exposure of the coronary arteries, as well as occlusion of these vessels, can result in periods of significant hemodynamic instability. Appropriate preparation, guided therapy, and technical maneuvers can lessen such adverse hemodynamic impact. It is important for anesthesiologists to be aware of the special problems associated with this surgery, as well as the different therapies and maneuvers that can be useful in providing the best possible care. As surgeons develop greater expertise and better devices for the management of these patients, the number of coronary revascularizations without CPB is likely to increase.

Anesthesia, General↗
PubMed2001

Quantification of relative afferent pupillary defects induced by posterior sub-Tenon's, peribulbar, and retrobulbar anaesthetics.

AIMS: The effect of local anaesthetics on optic nerve function can be investigated by quantifying the relative afferent pupillary defect (RAPD). METHODS: The study compared the depth of induced RAPD following posterior sub-Tenon's, retrobulbar, and peribulbar local anaesthetics using crossed polarising filters before cataract surgery (time 1 = 5 minutes), immediately after surgery (time 2 = 42 minutes (av)), and once again on the ward (time 3 = 107 minutes (av)). RESULTS: All patients developed a RAPD. There was no significant difference in the depth of RAPD between the groups at any one time period. The peribulbar group had a significantly steeper decay in RAPD from time 1 to time 2 (p = 0.014). This effect was reduced when the shorter operation time for this group was entered as a cofactor (p = 0.063). By time 3 the RAPDs for all groups had decayed similarly so that no differences could be detected. CONCLUSION: All three anaesthetic methods caused a similar level of disruption to optic nerve conduction immediately following administration and at the time of day case discharge.

Anesthesia, Local↗
PubMed2002

Impact of cardiopulmonary bypass management on postcardiac surgery renal function.

OBJECTIVE: Cardiac surgery on cardiopulmonary bypass (CPB) is associated with postoperative renal dysfunction and up to 4% of patients with normal preoperative renal function develop acute renal failure (ARF) requiring dialysis. According to recent investigations, CPB management is not evidence-based and, thus, current clinical CPB practice may favor renal dysfunction. The purpose of our study was to investigate if postcardiac surgery renal dysfunction is influenced by CPB management. METHODS: We selected three groups of patients with normal preoperative renal function who had been subjected to cardiac surgical procedures on CPB: 44 patients with postoperative ARF requiring hemofiltration/dialysis (ARF group), 51 patients with postoperative renal dysfunction not requiring hemofiltration/dialysis (serum creatinine increase > 0.5 mg/dl within 48 h postsurgery: CREA group), and 48 patients with normal postoperative renal function (Control group). The patients' on-line CPB records were analyzed for CPB duration, CPB perfusion pressure, CPB flow, and periods on CPB at a perfusion pressure <60 mmHg. On-CPB diuretic and vasoconstrictor medication was recorded. RESULTS: Patient demographics were similar for the three groups. In the ARF group, CPB duration was longer (166 +/- 77 [standard deviation, SD] min) compared to CREA (115 +/- 41 min; p < 0.001) and to Control groups (107 +/- 40 min; p < 0.001), and mean CPB flow was lower (2.35 +/- 0.36 l/min/m2) compared to CREA (2.61 +/- 0.35 l/min/m2; p = 0.0015) and to Control groups (2.51 +/- 0.33 l/min/m2; p = 0.09). Mean arterial pressure on CPB (ARF: 61 +/- 10; CREA: 60 +/- 7; CONTROL: 63 +/- 9 mmHg; p = 0.19) as well as furosemide and norepinephrine medication on CPB were similar for the groups. Compared to Control (46 +/- 26 min), CPB duration at arterial pressures <60 mmHg was longer in ARF (78 +/- 60 min; p = 0.034) and in CREA (62 +/- 36 min;p = 0.048). CONCLUSIONS: Our data suggest that current clinical CPB management impacts postoperative renal function. We found that patients with normal preoperative renal function who developed postoperative ARF had longer CPB duration, lower CPB perfusion flow, and longer periods on CPB at pressures < 60 mmHg compared to patients with no post CPB ARF. However, our data do not allow us to separate these CPB-related factors from the potential influence of perioperative low cardiac output syndrome as a cause for postoperative ARF. Thus, future clinical studies are required to elucidate CPB-induced ARF and to optimize CPB management for ARF prevention.

Acute Kidney Injury↗
PubMed2004

Tracheoesophageal diversion versus total laryngectomy for intractable aspiration.

This study evaluates the outcome and surgical stress associated with surgery for intractable aspiration. A retrospective review was conducted to compare the results between tracheoesophageal diversion and total laryngectomy. The operative time, intra-operative bleeding, time until drain removal, feeding conditions and surgical complications were compared between the two groups. Of the 19 patients, 31.6 per cent underwent tracheoesophageal diversion and 68.4 per cent received total laryngectomy. The operative time and drain insertion periods were statistically shorter in the tracheoesophageal diversion group, while the amount of intra-operative blood loss was smaller in the tracheoesophageal diversion group. The complication rate and the feeding conditions before and after surgery for the two groups did not show any statistically significant difference. Tracheoesophageal diversion was thus found to be a simple, safe, and reliable therapeutic modality for the control of intractable aspiration. Moreover, it induced less surgical stress than total laryngectomy.

Adult↗
PubMedDate not supplied

[Body temperature variations during laparoscopic cholecystectomies].

OBJECTIVE: To study changes over time in body temperature related to insufflation of CO2. PATIENTS AND METHOD: Fifty patients were randomly assigned to 2 groups of 25 to undergo cholecystectomy by either laparoscopy or laparotomy. Total intravenous anesthesia with propofol, pancuronium and fentanyl was used in both groups. Ventilation was maintained at 0.5 FiO2. Central temperature was continuously measured by a distal esophageal thermometer and results were recorded every 10 minutes in both groups. All operations lasted approximately 80 min. RESULTS: We found that temperature gradually decreased over time in both groups. In the laparotomy group the decrease reached 0.20 degree C (SD 0.03) at 80 min. During laparoscopy the temperature decrease was 0.43 degree C (SD 0.04) for the same time period. The differences were statistically significant. We observed no pathophysiologic repercussions associated with these results. CONCLUSIONS: Laparoscopic surgery, even when the abdominal cavity is not exposed to room air, induces a loss of temperature that is greater than that of laparotomy, because of insufflation of CO2 at 4 degrees C. The decrease was 0.4 degree C for every 50 l of CO2 insufflated during the study.

Anesthesia, Intravenous↗
PubMed1993

Intraperitoneal cisplatin with sodium thiosulfate protection in rats with intestinal anastomoses.

Intraperitoneal (IP) cisplatin administered at the time of intraabdominal malignancies such as gastric cancer may prevent or delay intraabdominal recurrence. Perioperative IP cisplatin raises concerns regarding systemic toxicity and retardation of wound healing. Systemic cisplatin toxicity may be reduced by administering its antidote, sodium thiosulfate (STS). A preclinical study of IP cisplatin in rats undergoing a small intestinal anastomosis was carried out. All animals that had received only cisplatin died in the postoperative period as a consequence of cisplatin toxicity. Tensile strength of the intestinal anastomoses was determined on the tenth postoperative day in the surviving animals. Animals that had received intravenous (IV) cisplatin with STS had significantly lower tensile strengths than both those receiving IP cisplatin with STS and STS alone. This study demonstrates the safety of perioperative cisplatin with STS protection by the avoidance of systemic toxicity and minimizing the cisplatin-related retardation of wound healing.

Anastomosis, Surgical↗