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PubMed1995

Laparoscopic appendicectomy: a trainee's perspective.

Minimally invasive surgery is rapidly becoming an integral part of general surgery. Many general surgeons have been trained to undertake laparoscopic cholecystectomy. It has been recommended that laparoscopic appendicectomy should be the training operation for junior surgeons. The aim of our study was to assess whether laparoscopic appendicectomy training can safely be introduced to junior surgeons in a district general hospital. During the 11 month study period, 27 laparoscopic and 38 open appendicectomies were performed. The median anaesthetic time was 80 min for laparoscopic and 52.5 min for open appendicectomies. Laparoscopic appendicectomies cost, on average, 618 pounds and open appendicectomies 770 pounds per case. The complication rate between the two procedures was equal. We therefore showed that laparoscopic appendicectomy by junior surgeons is both safe and cost-effective. Although the registrar did most of the laparoscopic appendicectomies, with resultant less operating for the SHO, laparoscopic appendicectomy provided the SHO with training in diagnostic laparoscopy and laparoscopic dissection. We conclude that basic laparoscopic training should be introduced early in surgical training, after which laparoscopic appendicectomy is a safe procedure for surgical trainees.

Adolescent↗
PubMed1990

Blood transfusion and survival following surgery for prostatic carcinoma.

Blood transfusion in the perioperative period has been reported to have a detrimental effect on survival in many types of cancer. Other studies have failed to confirm this. We have examined retrospectively the records of 246 patients with prostatic carcinoma who underwent transurethral resection of the prostate (TURP) in Aberdeen Royal Infirmary between 1977 and 1982. Bilateral orchiectomy (BLO) was performed in 193 patients. Of these patients, 71 of 246 (29 per cent) received perioperative blood transfusion. After controlling for differences due to a number of variables, transfusion of non-autologous blood was shown to be associated with a significant negative effect on survival. Perioperative transfusion of non-autologous blood should be avoided in patients with malignancy, unless there are clear overriding clinical indications. Prospective trials are needed urgently.

Aged↗
PubMed1992

Shunt implantation: reducing the incidence of shunt infection.

Shunt infection remains the foremost problem of shunt implantation after mechanical malfunctions. Diversionary cerebrospinal fluid shunt implantation has a high complication rate, with 5% to 15% of such shunts becoming infected. Of these infections, 70% are diagnosed within 1 month after surgery and more than 90% within 6 months. Shunt infection in the vast majority of cases is therefore a complication of shunt surgery. The authors review their experience with shunt implantation during two time periods. From January, 1978, to December, 1982, 302 children with hydrocephalus underwent 606 operations. Among these children, 47 (15.56%) developed a proven shunt infection, with an incidence of infection per procedure of 7.75%. As a result of this study, a new protocol for shunt procedures involving modifications in the immediate pre-, intra-, and postoperative management of children undergoing shunt implantation was initiated. With this new protocol, 600 children underwent a total of 1197 procedures between January, 1983, and December, 1990. The incidence of shunt infection decreased dramatically, with two infections (0.33%) in 600 patients and a per-procedure rate of 0.17%. The overall annual risk of a shunt infection in the pediatric neurosurgical unit is currently 1.04%.

Bacterial Infections↗
PubMed1982

[Fluid loading in the surgical care of pheochromocytoma. Hemodynamic study].

Collapse following removal of pheochromocytoma can be usually prevented by fluid loading. Fluid infusion is administered at the early beginning of the surgical procedure and is accelerated just after removal. Some authors prefer to start the fluid infusion in the preoperative period. In every cases preload measurements are of primary importance for a safely fluid administration. Problems of fluid loading in course of pheochromocytoma surgery are studied in six patients. Hemodynamic data are collected during pre, per and postoperative periods. Pre and post operative rapid fluid loading was performed in three patients in order to obtain a left ventricular function curve. Before any fluid treatment, two groups of patients are distinguished: 1) five hypovolemic patients who are about to receive 1 000 +/- 300 ml to normalize pulmonary wedge pressure, 2) one patient with high pulmonary wedge pressure and with alterated myocardial performance observed during rapid fluid loading. Combined use of sodium nitroprusside and fluid loading allowed to control hypertensive accesses and preload elevations and to prevent collapse following tumor removal. Hypovolemia and myocardial lesions are not necessarily present in all cases of pheochromocytoma. The routine use of a pulmonary artery catheter is warranted to improve cardiac pump function by combined fluid and vasodilator management.

Adrenal Gland Neoplasms↗
PubMed1991

Biphasic changes in hypothalamo-pituitary-adrenal function during the early recovery period after major abdominal surgery.

Regulatory mechanisms of the hypothalamo-pituitary-adrenal (H-P-A) axis during and after major abdominal surgery were studied in a group of patients who underwent upper abdominal surgery. We first examined the general profile of the changes of the H-P-A axis from the day before surgery to the seventh day after surgery. On the day of surgery, plasma levels of CRH, ACTH, and cortisol were all significantly elevated after skin incision (phase I). During the next 2 days, plasma cortisol levels remained significantly elevated, and the both plasma CRH and ACTH levels were suppressed below the control levels obtained on the day before surgery (phase II). Several additional studies, carried out to analyze the mechanism that maintains the high plasma cortisol levels, revealed the following features of the H-P-A axis during phase II. Plasma free cortisol levels in this phase were higher than those during the preoperative period. The exogenously administered hydrocortisone clearance rate in phase II did not differ from that observed on the day before surgery. Dexamethasone administration resulted in a decrease in plasma cortisol levels similar to that observed preoperatively. Conversely, the ACTH-stimulated cortisol increase was significantly greater in phase II than that observed preoperatively. These results suggest that during and after major surgical stress, the H-P-A axis undergoes a biphasic change in the pattern of the stress response and during the second phase, not the continuous hypothalamo-pituitary drive but the increased adrenal responsiveness to ACTH is responsible at least in part for maintaining the elevated plasma cortisol level.

Abdomen↗
PubMed1986

Myocardial protection by perioperative diltiazem drip: a clinical evaluation.

This study was undertaken to evaluate the potential role of a perioperative calcium-channel blocker (Diltiazem) infusion in improving myocardial preservation. Forty consecutive CAD patients were randomly assigned to a control (C; n = 20) and a treated (D; n = 20) group. In patients in the latter group diltiazem was continuously infused at 0.5 to 2.0 mcg/kg/min i.v. from anesthesia induction until the aortic cross-clamping, and from myocardial reperfusion till the 48th postoperative hour. During the preCPB phase hypertension occurred less frequently in group D (3 vs 12 cases, p = 0.0033). In the immediate postischemic period, depression of contractility and the need for inotropic support were observed in 3 cases in group D and in 9 in group C (p = 0.0384). Postoperatively, group D patients had a lower incidence rate of hyperkinetic arrhythmias or conduction disturbances (p = 0.0218), as well as of ECG signs of ischemia (p = 0.0016). Significant CK enzyme level increase was noted in 13 patients in group C versus 4 in group D (p = 0.0040). Two perioperative myocardial infarctions were diagnosed, both in group C. These clinical data show that continuous perioperative infusion of diltiazem can effectively increase myocardial preservation during ischemic arrest, without unfavorable effects on the hemodynamics, electrical activity or mechanical performance of the heart.

Benzazepines↗
PubMed1994

Sonographic evaluation of dermis and subcutaneous tissue during and after skin expansion.

Soft-tissue thickness modifications were evaluated by high-resolution ultrasound sonography in six patients undergoing skin expansion, with the aim of investigating the possible use of this noninvasive method in the routine monitoring of soft tissues during and after skin expansion. Both during expansion (decrease) and in the postoperative period (increases up to 100 percent or more of the baseline preoperative value), changes in fat thickness occurred faster and were greater in magnitude than those in dermal tissue, overall gradual and limited. In our series, the values of fat thickness ranged between 44 (at full-expansion time) and 140 percent (2 months after expander removal), with a highly significant difference (p = 0.0003), while dermis thickness values ranged between 83 and 114 percent, respectively, showing no significant difference (p = 0.71). Some echo-structural dermal modifications were found by the 20-MHz probe at full skin expansion only. High-resolution ultrasound sonography may be proposed as a noninvasive method in the routine monitoring of soft tissues during and after skin expansion.

Adipose Tissue↗
PubMed1986

Adverse effects of vancomycin administered in the perioperative period.

Indications for the administration of vancomycin in the perioperative period have expanded in recent years. Used in this situation, vancomycin has caused adverse reactions, the most serious of which is hypotension. We describe five patients who had adverse reactions to vancomycin perioperatively. Vancomycin-induced hypotension usually results from a negative inotropic and vasodilator effect produced in part by a histamine-release phenomenon, which occurs most commonly with rapid intravenous infusion of the drug. Such a release of histamine may also produce an acute urticarial flushing of the upper torso (the "red neck syndrome") and symptoms of pain and muscle spasm in the chest or paraspinal muscles, which may mimic myocardial infarction. These effects usually abate promptly when the infusion of vancomycin is discontinued, and their resolution may be expedited by administration of an antihistamine.

Adult↗
PubMed1997

Perioperative maintenance of normothermia reduces the incidence of morbid cardiac events. A randomized clinical trial.

OBJECTIVE: To assess the relationship between body temperature and cardiac morbidity during the perioperative period. DESIGN: Randomized controlled trial comparing routine thermal care (hypothermic group) to additional supplemental warming care (normothermic group). SETTING: Operating rooms and surgical intensive care unit at an academic medical center. SUBJECTS: Three hundred patients undergoing abdominal, thoracic, or vascular surgical procedures who either had documented coronary artery disease or were at high risk for coronary disease. OUTCOME MEASURE: The relative risk of a morbid cardiac event (unstable angina/ischemia, cardiac arrest, or myocardial infarction) according to thermal treatment. Cardiac outcomes were assessed in a double-blind fashion. RESULTS: Mean core temperature after surgery was lower in the hypothermic group (35.4+/-0.1 degrees C) than in the normothermic group (36.7+/-0.1 degrees C) (P<.001) and remained lower during the early postoperative period. Perioperative morbid cardiac events occurred less frequently in the normothermic group than in the hypothermic group (1.4% vs 6.3%; P=.02). Hypothermia was an independent predictor of morbid cardiac events by multivariate analysis (relative risk, 2.2; 95% confidence interval, 1.1-4.7; P=.04), indicating a 55% reduction in risk when normothermia was maintained. Postoperative ventricular tachycardia also occurred less frequently in the normothermic group than in the hypothermic group (2.4% vs 7.9%; P=.04). CONCLUSION: In patients with cardiac risk factors who are undergoing noncardiac surgery, the perioperative maintenance of normothermia is associated with a reduced incidence of morbid cardiac events and ventricular tachycardia.

Aged↗
PubMed1984

Effects of peroperative myocardial ischemia on early and late hemodynamic response to hypertonic sodium bicarbonate in dogs.

Because hypotension induced by the administration of hypertonic sodium bicarbonate is more severe when cardiac performance is impaired, the authors evaluated the hemodynamic consequences of peroperative myocardial ischemia upon the response of conscious dogs to an intravenous bolus of sodium bicarbonate. Twenty-two control dogs (group 1) were equipped with an electromagnetic flow probe positioned around the ascending aorta. Seventeen dogs (group 2), equipped in the same manner, were subjected to 1 hour of myocardial ischemia combined with topical cardiac hypothermia. Hemodynamic studies were performed daily for 1 month before and during the administration of sodium bicarbonate. Baseline hemodynamic values in group 1 were always within normal limits. In group 2, cardiac failure was evident in the immediate postoperative period but hemodynamic values reached normal limits 24 hours postoperatively. For both groups, the peak hypotensive response to sodium bicarbonate was combined with a substantial reduction in all hemodynamic values reflecting the left ventricular performance. However, this response is significantly (p less than 0.01) more pronounced in group 2 during the first 4 postoperative days, being maximal 3 and 24 hours after operation. Afterwards, the hemodynamic response to sodium bicarbonate was similar in both groups. These results indicated that an intravenous bolus of sodium bicarbonate decreases left ventricular performance and that this decrement is greater when cardiac performance is impaired following peroperative myocardial ischemia. Long-term hemodynamic studies show that this temporary myocardial ischemia is not deleterious to cardiovascular adaptability to hypertonic sodium bicarbonate administration.

Animals↗
PubMed1983

Endocardial mapping by simultaneous recording of endocardial electrograms during cardiac surgery for ventricular aneurysm.

A technique was developed for the simultaneous recording of 30 endocardial electrograms during cardiac surgery in patients undergoing aneurysmectomy or endocardial resection, or both, for medically intractable ventricular tachycardia. An inflatable balloon covered with 30 terminals at distances of 1.5 to 2 cm was used to record from the entire endocardial surface; a smaller silicone rubber sheet with 30 terminals at distances of 0.7 cm was used to obtain a better spatial resolution. The multielectrodes were inserted into the left ventricular cavity by way of an incision in the aneurysm. A transportable minicomputer was used for the acquisition and analysis of the signals. After initiation of ventricular tachycardia by programmed stimulation, signals of a 1.5 second period were stored and analyzed. The earliest activated terminal could be determined within 2 to 5 minutes. The technique was applied in 32 patients and proved especially useful in those patients in whom sustained tachycardia could not be evoked and in whom conventional mapping with a roving electrode would have been impossible or very time consuming. In all patients, the isochronic maps showed that the ectopic impulses originated from a rather localized area and no evidence was found for large endocardial circus movements, thereby excluding these as a mechanism underlying the tachycardia. Isochronic maps, depicting activation sequences during consecutive ectopic beats with the same QRS morphologic features, showed the same site of origin in all but six patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiac Catheterization↗
PubMedDate not supplied

[Nocturnal sleep patterns during treatment of hydrocephalus].

By polygraphic methods the authors studied the sleep patterns during treatment of patients with subtentorial tumours causing hydrocephalus. Sleep recording was carried out in three stages of treatment: 1) before insertion of ventriculo-atrial valve, (7 investigations), 2) on the 7th day after valve insertion (7 investigations), 3) two months after removal of the posterior fossa tumour (3 investigations). The control group included patients with peripheral nerve injury in whom sleep recording was done before and after surgical treatment. In cases with hydrocephalus and raised CSF pressure before valve insertion the cyclic pattern of sleep was disintegrated, showing long periods of light sleep (phase 1 + 2) interrupted by long periods of alertness, during sleep, mostly with elimination of the remaining sleep components. The decrease of CSF pressure after valve implantation was parallelled by partial normalization of sleep pattern, that is shortening of the light sleep phase and reduction of the number of alertness during sleeping hours, as well as prolongation of the phases of deep sleep and appearance of paradoxical sleep. However, only removal of the tumour from the posterior fossa made possible approximation of sleep elements to those in the control group. Sleep disintegration of varying intensity in patients with hydrocephalus may be reversible, the rate of normalization of sleep depends on the intensity of sleep disturbances in the initial stage of the disease, but return to nearly normal sleep is possible only after removal of the subtentorial tumour.

Adult↗
PubMed1982

Urinary tract injury during cesarean section.

Lower urinary tract injury at the time of cesarean section is an uncommon complication. During a 5-year period, the incidence of bladder and ureter injuries at the Los Angeles County/University of Southern California Medical Center was .31 and .09%, respectively. When bladder injury occurs, it usually is due to surgical difficulty encountered while developing the bladder flap over the lower uterine segment. The difficulty is caused usually by scar tissue from previous surgery. Ureteral injury is a rare complication of cesarean section. It is attributable most often to ureteral transection or ligation associated with uterine incision extensions in the lower uterine segment or the vagina, and to attempts to achieve hemostasis. The data presented in this report indicate that cystotomy, when adequately repaired, is not associated with any complications. Furthermore, diagnostic cystotomy with intravenous injection of indigo carmine is a rapid, safe method of evaluating ureteral patency.

Cesarean Section↗
PubMed1985

The end of the crystalloid era? A new approach to peri-operative fluid administration.

The metabolic response to surgery causes sodium and water retention. It does not seem logical to pour crystalloid solutions into patients in the peri-operative period, particularly when these solutions can cause deterioration in lung function. Plasma volume must be maintained to prevent a decreased blood flow to vital organs such as the kidneys. Blood or colloid solutions, not crystalloid solutions, should be used for this purpose, since the latter are distributed throughout the whole extracellular space and are less effective in maintaining plasma volume. Water given as 5% dextrose should be given in minimal quantities to maintain intracellular hydration. Patients undergoing minor to moderate surgery when they are likely to be drinking within 24 hours do not usually require any intravenous infusion. Moreover, to administer intravenous fluids to these patients may cause harm. No fluid regimens should be inflexible and the patient's size, age and fluid losses should be taken into account.

Aldosterone↗
PubMedDate not supplied

[The efficacy of droperidol, metoclopramide, propofol, and ondansetron for the prevention of nausea and vomiting following middle ear surgery].

OBJECTIVES: The efficacy and reliability of prophylactic antiemetic therapy with low dose propofol, droperidol, metoclopramide, and ondansetron were evaluated in a randomized, double-blind, and prospective design. PATIENTS AND METHODS: A total of 101 ASA I-II patients (34 females, 67 males; age range 16 to 53 years) undergoing middle ear surgery for chronic otitis media or its sequelae were randomly assigned to receive prophylactic antiemetic therapy with propofol (n=21, 0.5 mg/kg), droperidol (n=19, 20 mg/kg), metoclopramide (n=23, 0.2 mg/kg), ondansetron (n=21, 4 mg), and placebo (n=20, 0.9% NaCl). All drugs were administered intravenously five minutes before extubation. RESULTS: In the early postoperative period (0 to 3 hours), the percentages of patients free from nausea and vomiting were 100% with droperidol, 71.4% with ondansetron and propofol, 52.1% with metoclopramide, and 35% with placebo. Ondansetron (90.4%) was found the most effective to prevent and control nausea and vomiting during the postoperative 3 to 24 hours, followed by droperidol (84.2%), propofol (57.1%), metoclopramide (47.8%), and placebo (40%). Compared with controls, the number of patients without nausea and vomiting was significantly greater in each treatment group but metoclopramide (p<0.05). No significant differences were detected with respect to adverse effects. CONCLUSION: Droperidol and ondansetron seem to exert the highest efficacy to prevent nausea and vomiting during the postoperative 0 to 3 hours and 3 to 24 hours, respectively.

Adolescent↗
PubMed2005

Local anaesthetic flush reduces postoperative pain and haematoma formation after great saphenous vein stripping--a randomised controlled trial.

OBJECTIVES: To observe the effect of local anaesthetic flush through the great saphenous vein (GSV) tunnel on postoperative pain and haematoma formation following saphenous vein stripping operations. DESIGN: Prospective, double-blind, randomised, control trial. METHODS: One hundred patients were randomized to receive 20 ml of local anaesthetic (bupivacaine 0.25% + adrenaline) or saline control flush through the GSV tunnel after stripping in a double-blind study. Visual analogue pain scores were used to measure postoperative pain daily for the 1st week, then at 3 weeks and 6 weeks. Patients were examined during the 1st, 3rd and 6th week for haematoma formation. RESULTS: In the control group the median postoperative pain score was 4 (range 0-7) in the immediate postoperative period compared to a median of 1 (range 0-4) in the LA group (p<0.001). The median pain score on day-4 was 4 (range 1-6) (control) vs. 1 (range 0-3) (LA group) (p<0.001, Mann-Whitney Utest) and on day-6 it was 1 (range 0-5) (control) vs. 0 (range 0-5) (LA group) (p<0.001, Mann-Whitney). Twelve patients (24%) developed a haematoma in the GSV tunnel in the control group compared to three patients (6%) in the LA group (p = 0.007). CONCLUSION: Flushing of the GSV tunnel with bupivacaine plus adrenaline significantly reduces postoperative pain and haematoma formation in patients undergoing GSV stripping for varicose veins.

Adult↗
PubMed2000

Intra- and post-operative assessment of renal cortical perfusion by laser Doppler flowmetry in renal transplantation in the rat.

Renal blood flow (RBF) in the period immediately following transplantation has an important prognostic value. Here we report for the first time on the use of laser Doppler flowmetry (LDF) for the measurement of renal cortical perfusion (RCP) during all the important steps in renal transplantation. Left orthotopic kidney transplantation was performed in Lewis rats (n = 14) after 2 h of cold ischaemia and preservation in EuroCollins solution. Under baseline conditions, RCP in the donor and recipient kidneys were similar with a coefficient of variability of 11 and 12%, respectively. There was a progressive increase in RCP during the first 60 min after transplantation with a return to normal values 2 weeks later. In conclusion, LDF provides a rapid and continuous measure of RCP without interference to the operative site and may prove a useful tool for the measurement of RBF during kidney transplantation.

Animals↗
PubMedDate not supplied

The impact of laparoscopic cholecystectomy on the operative experience of surgical residents.

The impact of laparoscopic cholecystectomy (LC) on the operative experience of surgical residents was assessed in a series of 787 cholecystectomies. During an initial 18-month period, residents participated in LC as operating surgeon and as first assistant or camera operator in 33% and 97% of cases, respectively. Operative time, cholangiography rate, conversion rate, and complications were not adversely affected by resident operators. Residents performed 87% of concurrent planned open cholecystectomies (OC). In comparison to the 6 months preceding LC: (1) The mean number of resident OCs decreased significantly while the total number of resident cholecystectomies was unchanged; (2) the proportion of OCs performed by PGY5 residents significantly increased at the expense of junior resident cases. LC can be safely integrated into surgical resident training by standard methods as for open procedures. Although resident operative experience has been redistributed, initial experience does not suggest that qualification in open biliary surgery has been compromised.

Cholangiography↗