Clinical use of a dacron wool filter during perfusion for open-heart surgery.
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Blood Cell Count↗
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Effectiveness of an inferior vena caval filter as a preventive measure against pulmonary thromboembolism after abdominal surgery.
In three patients with a previous history of pulmonary thromboembolism, inferior vena caval filters were inserted before elective laparotomies to prevent a recurrent pulmonary thromboembolism. Two patients had colon cancer and underwent colectomies, while the other had myoma uteri, which might have been the cause of deep vein thrombosis, and thus a hysterectomy was performed. In spite of their poor risks, their postoperative courses were fairly good owing to perioperative management including anticoagulant therapy, and no recurrence has been observed since the operation in every case. A pulmonary thromboembolism is a fatal complication which follows deep vein thromboses. In patients with such a previous history, the risk is much higher after a laparotomy because of long-term bed rest, hypercoagulability, and so on. The mortality rate after a recurrence of pulmonary thromboembolism is reported to reach 30% without adequate therapy, whereas it is reduced to 8% with anticoagulant therapy, and to 0.8% with additional inferior vena caval filter placement. Considering the feasibility of insertion and the low incidence of complications, preoperative inferior vena caval filter placement is thus recommended for patients having a previous history of either pulmonary thromboembolism or deep vein thrombosis.
Aged↗
[Diagnosis and therapy of a fluttering thrombus in the open foramen ovale].
The finding of an extremely mobile thrombus in a patent foramen ovale (i.e., transit thrombus) without arterial embolism is rare. In our case-report diagnosis was made by routine-echocardiography. Clinically nonapparent deep vein thrombosis was documented by phleography and was thought to be the origin of the embolus. After implantation of a caval filter device cardiac surgery was performed and the embolus was removed without complications.
Heart Septal Defects, Atrial↗
Accidental dislocation of an intracaval temporary filter into the heart in a case of renal cell carcinoma extending into the vena cava.
In a case of renal cell carcinoma extending into the vena cava, a temporary intracaval filter was applied before surgery to prevent pulmonary artery thrombosis. Two days later, the filter accidentally migrated into the right ventricle during defecation. Fortunately, it was successfully removed without damaging cardiac musculature under fluoroscopy.
Carcinoma, Renal Cell↗
Duodenocaval fistula: a life-threatening condition of various origins.
We report on two cases of duodenocaval fistula. The first patient, a 73-year-old man, had sepsis and occult digestive bleeding. We diagnosed a fistula that resulted from a right nephrectomy and subsequent radiotherapy for a urothelial tumor 20 months earlier. The second patient, a 60-year-old woman, complained of right abdominal pain. A duodenocaval fistula that was caused by duodenal perforation by a migrating caval filter placed 10 years earlier was revealed by means of endoscopy. Both patients had a successful operation to treat the condition. An extensive review of the literature disclosed 35 other cases and identified two factors of good prognosis: duodenocaval fistulas caused by migrating caval filters and early surgery.
Aged↗
Ultrasound biomicroscopy for the assessment of zonules after ocular trauma.
PURPOSE: To evaluate the role of ultrasound biomicroscopy (UBM) as a method for assessing the zonules after trauma to the anterior segment. These patients might develop traumatic cataract or glaucoma requiring surgery. If occult zonular defects can be identified preoperatively, this might lead to a modified surgical technique and improved outcomes. DESIGN: Retrospective observational case series. PARTICIPANTS: Fifty-nine patients who were referred for UBM after anterior segment trauma. METHODS: UBM examinations were performed using the Humphrey Instruments Ultrasound Biomicroscope equipped with a 50-mHz transducer. A plastic eyecup filled with 2% methylcellulose solution was used in each case. The chart and UBM images of all anterior segment trauma patients examined between 1995 and 2000 were reviewed. The age, gender, and mechanism of injury were recorded for each patient. Follow-up data were obtained from the referring physician in patients who subsequently underwent ocular surgery. MAIN OUTCOME MEASURES: The number of studies judged to be of adequate quality to evaluate zonules was noted, and the number of cases in which zonular defects were found was recorded. The number of cases in which surgery was subsequently performed was noted, and postoperative results were obtained. RESULTS: Fifty-nine charts and 60 UBM studies were reviewed. Forty-nine studies were judged to be adequate for imaging zonules. Most poor-quality studies were in the early years of the study. Further analysis was carried out on the reliable studies. Occult zonular defects were identified in 21 of 49 patients (42.9%). Thirty-one patients went on to have cataract, filtering, and/or vitreoretinal surgery. One surgeon (ACS) performed 25 of the surgical cases, for which a summary is provided. Referring surgeons found the information helpful in surgical planning and anticipating complications in reliable study cases. CONCLUSIONS: UBM is an effective method for identifying occult zonular damage in patients with anterior segment trauma. There is a significant learning curve in the examination technique. The ability to diagnose zonular rupture preoperatively is of significant benefit to the surgeon and might reduce the chance of intraoperative complications.
Adolescent↗
Clinical benefits of leukocyte filtration during valve surgery.
BACKGROUND: The accumulation of activated leukocytes in the pulmonary circulation plays an important role in the pathogenesis of lung dysfunction associated with cardiopulmonary bypass (CPB). Patients undergoing valve surgery have prolonged CPB owing to the complexity of the surgery. The goal of this study is to determine if arterial leukocyte filters during CPB improve clinical outcomes after valve surgery. METHODS: A prospective analysis of all patients receiving only valve surgery with leukocyte arterial filters from June 1999 to June 2002 was compared with a case matched cohort during the same time period. Two hundred fifty patients were identified and compared with a cohort who did not have leukocyte filters used during CPB. The following study points were evaluated preoperatively and postoperatively: white blood cell count, platelet count, arterial blood gas, time to extubation, intensive care unit stay, and total length of hospital stay. RESULTS: There were 500 patients in the study. The following valve operations were performed: 92 mitral valve replacements, 168 aortic valve replacements, 152 mitral valve repairs, 80 combined valve repair/replacements, and 8 tricuspid valve repairs, all evenly divided between the two treatment limbs. Patients with leukocyte filters had the following findings compared with nonfilter patients: The time to extubation 10.3 versus 16.2 hours (P = 0.009), postoperative respiratory quotient 407 versus 320 (P = 0.02), total length of stay 5.4 versus 7.2 days (P = 0.04). CONCLUSIONS: The use of arterial leukocyte filters in patients undergoing valve surgery leads to earlier extubation, improved oxygenation, and a decreased length of stay. Leukocyte filters should be used during CPB for patients having valve surgery.
Adolescent↗
A cardiologist in the carotids.
Carotid endarterectomy for stroke prevention has been the standard of care for 50 years in patients with extra-cranial carotid bifurcation disease. Over the past decade, carotid stenting has emerged as a viable alternative to surgery. Combined with filter embolic protection devices, both a randomized control trial (Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy registry [SAPPHIRE]) as well as registry data (ACCULINK for Revascularization of Carotids in High Risk Patients registry [ARCHeR] and Registry Study to evaluate the Neuroshield Bare-Wire Cerebral Protection System and X-Act Stent in patients at high risk for Carotid Endarterectomy [SECuRITY]) have compared favorably to endarterectomy in patients at high risk for operative revascularization. Conditions associated with high operative risk included patients with significant cardiac, pulmonary, and renal disease; previous neck operation; previous radiation; and anatomically difficult surgical access. On the basis of these results, a carotid stent system approved by the Food and Drug Administration (FDA) is anticipated in 2004. Although this will be a welcome addition to endarterectomy in the armamentarium of therapeutic options for patients with carotid disease, several challenges lie ahead. Coverage and reimbursement for the carotid stenting has been severely restricted to include only those procedures performed as part of an FDA investigational device exemption trial protocol, and a national noncoverage decision will have to be reckoned with before broader coverage can be put into place (assuming FDA approval). In addition, the level of national expertise in carotid endovascular intervention is limited, and training will need to be tailored to the three specialties likely to perform the procedure: cardiology, radiology, and vascular surgery. Each of these specialties will have specific, and different, requirements for their training, further complicating the task of education.
Blood Vessel Prosthesis Implantation↗
Ultraclean air for prevention of postoperative infection after posterior spinal fusion with instrumentation: a comparison between surgeries performed with and without a vertical exponential filtered air-flow system.
STUDY DESIGN: This study retrospectively compared infection rates between adult patients after posterior spinal instrumentation procedures performed in a conventional versus an ultraclean air operating room. OBJECTIVE: To evaluate if the use of ultraclean air technology could decrease the infection rate after posterior spinal arthrodesis with instrumentation. SUMMARY OF BACKGROUND DATA: Postoperative wound infection after posterior arthrodesis remains a feared complication in spinal surgery. Although this frequent complication results in a significant problem, the employment of ultraclean air technology, as it is commonly used for arthroplasty, has not been reported as a possible alternative to reduce the infection rate after complex spine surgery. METHODS: One hundred seventy-nine patients having posterior spinal fusion with instrumentation were divided into 2 groups: group I included 139 patients operated in a conventional operating room, and group II included 40 patients operated in a vertical laminar flow operating room. Patient selection was performed favoring ultraclean air technology for elective cases in which high infection risk was considered. A statistical analysis of the infection rate and its associated risk factors between both groups was assessed. RESULTS: We observed 18 wound infections in group I and 0 in group II. Comparison of infection rates using the chi-squared test showed a statistically significant difference (P <0.017). CONCLUSION: The use of ultraclean air technology reduced the infection rate after complex spinal procedures and appears to be an interesting alternative that still needs to be prospectively studied with a randomized protocol.
Adolescent↗
Postoperative application of mitomycin for trabeculectomies.
BACKGROUND: Persistent hypotony is a severe complication following trabeculectomy with intraoperative application of mitomycin. OBJECTIVE: To reduce this rate of hypotony by using a lower concentration of mitomycin and applying the mitomycin only topically to the filtering bleb following surgery. METHODS: Patients were enrolled on a consecutive basis and prospectively followed up. Standard trabeculectomies were performed and mitomycin applied postoperatively on the 3 days following surgery (group 1). For comparison, data from previous studies were used for control eyes with intraoperative mitomycin application (group 2) and no mitomycin application (group 3). Preoperative and postoperative data, complications, and the need for further surgical procedures were evaluated. RESULTS: The study group (group 1) consisted of 22 cases. The mean follow-up was 13.4 and 13.5 months for groups 1 and 2, respectively. Average intraocular pressure values decreased from 33. 6 and 31.0 mm Hg (P =.32; t test) to 16.0 and 12.5 mm Hg in the 2 groups (P =.03; t test). The average number of medications decreased from 2.5 and 2.5 to 0.6 and 0.4 (P =.35; t test) in groups 1 and 2, respectively, at the last visit. Hypotony lasting for more than 3 months occurred only in eyes with intraoperative mitomycin application (14/22). Choroidal detachment (3/22) and hypotony maculopathy (2/22) also were only noted in eyes from group 2. In group 3, success rates were much lower. CONCLUSIONS: This is the first clinical study, to our knowledge, to evaluate the efficacy of this new technique of mitomycin application. From the results, it appears that the postoperative application of mitomycin following trabeculectomy is associated with a lower risk of severe and long-standing hypotony. This technique may be promising in eyes at low risk for failure.
Adolescent↗
Using an autoregressive model to detect departures from steady states in unequally spaced tumour biomarker data.
A new method, based on a continuous time autoregressive [CAR(1)] model of time series data, is provided for detecting departures of tumour markers from steady states in breast cancer patients following surgery. A Kalman filter recursive algorithm is used to calculate the likelihood function arising from the CAR(1) model and to calculate recursive residuals, which are monitored by a Shewhart-Cusum scheme. This approach can be used to monitor the serial marker data of large numbers of patients even when the series are short and the data are serially correlated and unequally spaced. Further, the methodology can be used to recommend appropriate testing intervals.
Algorithms↗
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↗
[Effectiveness of potassium adsorption filter during intraoperative blood transfusion in patients with chronic renal failure].
Two patients with chronic renal failure on hemodialysis, received rapid transfusion of packed red blood cells (PRBCs) because of massive intraoperative bleeding. To eliminate the excessive potassium in PRBCs, a potassium adsorption filter (Kawasumi KPF-4, Kawasumi Laboratories, INC., Tokyo, Japan) was applied during surgery. The potassium adsorption filter successfully reduced the potassium concentration from 14.4-22.0 mEq x l(-1) to 1.9-3.7 mEq x l(-1). A potassium adsorption filter is a simple and useful alternative for removal of excessive potassium in PRBCs.
Adsorption↗
[Complications of deep nonpenetrating sclerectomy].
The typical complications related to nonpenetrating surgery are the rupture of the trabeculodescemetic membrane; postoperative ocular hypertension, which requires a laser goniopuncture; fibrosis of the filtering bleb, which is best cured by local antimetabolite application; or the development of a polycystic bleb, which is efficiently resolved by needling. While small perforation of the trabeculodescemetic membrane can be handled using simple countermeasures, large breaks ultimately result in converting the surgery into a penetrating procedure akin to trabeculectomy. Other classical complications can arise that comprise shallow anterior chamber, positive Seidel, hyphema, severe inflammation, choroidal detachment, or prolonged hypotony with associated maculopathy. They can occur in other types of filtering surgery as they are not specific to the nonpenetrating procedure and they differ only in prevalence.
Glaucoma↗
Topical cyclosporine and glaucoma drainage implant surgery in rabbits.
BACKGROUND AND OBJECTIVE: To assess the effect of topical cyclosporine on the function of filtering blebs and fibroblast proliferation after glaucoma drainage implant surgery in rabbits. MATERIALS AND METHODS: Intraocular pressure, flow resistance through the implant capsule, and fibroblast density in the capsule were compared between 12 eyes that received implant surgery only (group A) and 11 eyes treated with topical 2% cyclosporine twice a day for 2 weeks after implant surgery (group B). RESULTS: There were significantly larger decreases in intraocular pressure at 1,2,4, and 8 weeks postoperatively in group B than in group A (n = 12, P < .05). Flow resistance was significantly lower in group B than in group A (n = 5, P < .05) at 8 weeks postoperatively. Fibroblast density was not significantly different between the two groups (n = 3, P > .05). CONCLUSION: These results suggest that topical 2% cyclosporine may enhance the effectiveness of glaucoma drainage implant surgery.
Administration, Topical↗
Endophthalmitis in aphakic patients with unplanned filtering blebs wearing contact lenses.
Four female patients with known unplanned filtering blebs following cataract surgery developed endophthalmitis, two weeks to 30 months after being fit with corneal contact lenses. Three patients were wearing hard contact lenses and one wore a soft lens. Significant blepharoconjunctivitis was present and treated in two patients, but intraocular infection was not averted. When endophthalmitis was diagnosed, all patients had clinical evidence of a bleb infection as well as hypopyon. Despite aggressive medical therapy, two eyes required enucleation while two eyes survived with good vision. We recommend that eyes that have unplanned filtering blebs following cataract surgery should not have a contact lens inserted until the blebs have been closed.
Aged↗
HLA and RBC immunization after filtered and buffy coat-depleted blood transfusion in cardiac surgery: a randomized controlled trial.
BACKGROUND: WBC reduction of all blood components is being introduced in many countries. Prevention of immunologic side effects of transfusions is part of the motivation. To compare the immunogenicity of before- or after-storage WBC-reduced RBCs with RBCs without buffy coat, a randomized clinical trial was performed. STUDY DESIGN AND METHODS: Cardiac surgery patients were randomly assigned to receive either RBCs without buffy coat (PCs), WBC-reduced RBCs that were filtered before storage (FFs), or WBC-reduced RBCs that were filtered after storage (SFs). Serum samples for antibody analyses were collected before and after surgery. RESULTS: Sera of 404 patients were tested. Of the 317 patients with negative preoperative screening, 12.6 percent developed anti-WBC antibodies (PC, 14.5%; FF, 9.6%; SF, 13.3%). Of the 87 patients with preoperative anti-WBC antibodies, 28.7 percent showed a marked increase in panel reactivity (PC, 31.3%; FF, 29.0%; SF, 25.0%). ELISA showed the newly formed antibodies to be of IgG class and directed against HLA class I in more than 90 percent of the samples tested. Newly formed anti-RBC antibodies appeared in 5.3 percent (PC, 7.1%; FF, 3.4%; SF 5.4%). Alloimmunization against WBCs and RBCs was strongly correlated (p < 0.01). The differences in newly formed anti-WBC antibodies and anti-RBC antibodies between the trial arms did not show significance. CONCLUSION: Buffy coat removal, and additional WBC reduction by filtration, either before or after storage, result in similar posttransfusion alloimmunization frequencies after a single transfusion event with multiple RBCs.
Cardiac Surgical Procedures↗
Suramin inhibits wound healing following filtering procedures for glaucoma.
BACKGROUND: Trabeculectomies are the most frequently performed procedures in surgically treating eyes with glaucoma. Failures are caused by fibrosis in the external ostium of the filtering procedure. In order to inhibit the fibrotic wound healing reaction, a new pharmacological approach using suramin, which inhibits a variety of important growth factors was used. METHODS: Pigmented rabbits were used and filtering procedures performed. Suramin was applied with concentrations ranging from 10 mg/ml to 333 mg/ml once during surgery and four times following surgery. The success of the filtering procedure was assessed by intraocular pressure measurements. To evaluate possible intraocular toxic effects, treated eyes were histopathologically evaluated after 4 weeks, and the ciliary body adjacent to the site of application was examined using electron microscopy. RESULTS: With concentrations of suramin of 200 mg/ml and 333 mg/ml, the trabeculectomies were patent longer than in the controls and in eyes operated with mitomycin C, which currently is the most frequently used antiproliferative drug to enhance the outcome of surgery in humans. No severe toxic effects to the ciliary epithelium were seen in suramin treated eyes. CONCLUSIONS: This study demonstrates for the first time the efficiency of a substance that broadly inhibits the action of growth factors on target cells in the setting of ocular wound healing. In this in vivo model, suramin has been shown to be highly effective in preventing scarring and in having fewer toxic side effects than usually used antimetabolites. These results therefore may suggest a new approach to the surgical treatment of glaucoma.
Animals↗