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PubMed2002

Hysterectomy in Denmark. An analysis of postoperative hospitalisation, morbidity and readmission.

INTRODUCTION: The aim of this study was to describe the incidence of "standard" hysterectomy in Denmark, including surgical procedure, postoperative hospitalisation, morbidity, mortality and readmission rate within 30 days. MATERIAL AND METHODS: Analysis of data from the Danish National Patient Register for a two-year period (1998-2000) concerning hysterectomies for benign indications, carcinoma in situ cervicis uteri and endometrial carcinoma stage I. A stratified sample of 821 discharge resumés was reviewed for detection of complications. RESULTS: During the two years 10,171 women underwent "standard" hysterectomy followed by a median postoperative hospitalisation of 4 days. In departments performing more than 100 operations per year, the median hospital stay varied from 3 to 5.5 days. Eighty per cent were performed by laparotomy, 6% laparoscopically assisted and 14% by the vaginal route with marked regional variation in the choice of surgical approach. The number of vaginal hysterectomies varied from 0-67% in departments with a surgical activity of more than 100 per year. The mortality rate was 0.06% and 8% were readmitted within 30 days after the operation. If allowing extrapolation from the random sample to the entire population the complication rate was estimated to a minimum of 18%. CONCLUSION: "Standard" hysterectomy in Denmark is associated with considerable morbidity and marked regional variation in choice of surgical approach. The present study emphasizes the need for a national hysterectomy database with the possibility of evaluating surgical activity, reducing morbidity rates and developing homogeneous guidelines.

Adolescent↗
PubMed1999

Use of somatosensory evoked potentials for thoracic and thoracoabdominal aortic resections.

BACKGROUND: Despite tremendous development in surgical and anesthetic techniques, resection of the thoracic and thoracoabdominal segments of the aorta remain associated with the risk of paralysis. Routine use of somatosensory-evoked potential (SEP) monitoring in patients undergoing surgery of the thoracic aorta has become a standard intra- and postoperative procedure at our institution since its first use in 1993. METHODS: One hundred forty nine (149) thoracic aortic operations were performed during January 1993 through January 1998 using SEP-directed serial sacrifice of paired intercostal arteries. Full, partial, or no cardiovascular bypass was variably used, dictated by anatomy; 49 patients required deep hypothermic circulatory arrest (DHCA). Patients were monitored during both the intraoperative procedure as well for the post-anesthesia period until neurologic stability and/or ability to reproducibly demonstrate lower extremity neurologic competency was established. Postoperative neurologic function was compared to ischemic intervals, extent of aortic resection, number of intercostal arteries sacrificed, type of perfusion, and underlying aortic pathology. RESULTS: Overall mortality in the group was 13 patients (8.7%), with no one cause predominating. Nine patients sustained permanent paraplegia, only 1 of whom lost SEPs during the procedure. Abnormal SEPs were seen in 19 patients, 14 of whom had normal neurologic function after awakening. Three of 19 (15.8%) developed late paraplegia that resolved with medical therapy. Eleven patients (7.4%) developed cerebrovascular accidents (CVA), with the majority (8) appearing in the group undergoing DHCA. The risk of CVA was significantly higher in DHCA patients (p < 0.01) than other patients. No patient with CVA had abnormal SEPs; 4 DHCA patients developed abnormal SEPs, 1 with permanent paralysis. CONCLUSIONS: The routine use of SEP monitoring during thoracic and thoracoabdominal aortic surgery as well as during the postoperative period may be useful in decreasing the observed incidence of paraplegic events associated with these procedures.

Adolescent↗
PubMed1983

Functional surgery of bullous emphysema.

Multiple large and small emphysematous bullae were resected in 27 patients with chronic obstructive lung disease (COLD). Twenty-two patients were operated on one side, and 5 patients underwent bilateral consecutive operations. Twenty-five patients were male, 2 female, and they were between 22 and 67 years old (mean 49.5 years). All patients had a follow-up examination between 3 and 48 months postoperatively. As operative techniques, resection by means of a clamp, plication of cysts according to Nissen, resection with homologous dura plasty (7 patients) and pericardial plasty (7 patients) were used. In 19 patients preoperative and postoperative pulmonary function was compared. Functional improvement occurred in 17 patients - including all of the 5 bilateral procedures. Postoperative improvement was more pronounced with decreasing preoperative pulmonary function, measured as VC, RV, IGV and Raw. Partial pulmonary insufficiency could be improved in 9 patients and global pulmonary insufficiency was improved in 5. In 16 cases physical work capacity was increased. The hemodynamics of the pulmonary circulation were improved in all patients with increased preoperative pulmonary artery pressure (latent pulmonary hypertension in 7 patients, overt pulmonary hypertension in 5). FEV1 was least influenced by surgery, especially in patients more than 50 years old. The long-term prognosis, thus has to be judged cautiously. One patient died postoperatively (mortality 4%). The technique of dura and pericardial plasty, aiming at functional adaptation, is described. Sutures inverting or folding pulmonary tissue are avoided. The aspect of at least temporary (up to 3 years) functional improvement leads us to advocate the use of extended criteria of operability.

Adult↗
PubMed2002

Fetal therapy: state of the art.

OBJECTIVE: To review our experience with the use of sonography in evaluating potential candidates for in utero fetal therapy performed at The Center for Fetal Diagnosis and Treatment at The Children's Hospital of Philadelphia. METHODS: This review article was designed to discuss open hysterotomy for the 4 fetal surgical procedures that have been performed at our institution. The procedures included surgical repair of myelomeningocele, resection of sacrococcygeal teratoma in fetuses with nonimmune hydrops, resection of an enlarging congenital cystic adenomatoid malformation that is not amenable to thoracoamniotic shunting, and tracheal clip occlusion for severe left congenital diaphragmatic hernia. RESULTS: For each surgical procedure, the use of sonography in the prenatal diagnosis of the congenital anomaly was detailed, as were indications for surgery and surgical procedures, postoperative monitoring and finally delivery, postnatal treatment, and long-term follow-up. Three of the procedures have been reasonably successful with rather dramatic results in some cases such that these techniques are still being performed. The 1 exception was open hysterotomy for the tracheal clip procedure for congenital diaphragmatic hernia, which has been abandoned. CONCLUSIONS: Fetal therapy is a rapidly evolving specialty, which is being practiced at several centers in this country. Sonography is an integral part of this specialty practice and has been used extensively in the diagnosis of some congenital anomalies that have debilitating or lethal consequences for the fetus. Technologic improvements in both sonography and magnetic resonance imaging have assisted tremendously in the many advances herein reported in the diagnosis and treatment of the above-described 4 congenital anomalies.

Cystic Adenomatoid Malformation of Lung, Congenita↗
PubMed1996

Reduction mammaplasty: a comparison of outpatient and inpatient procedures.

A review of the procedure, postoperative outcome, and expense of outpatient inferior pedicle reduction mammaplasty was compared with inpatient hospital treatment. Twenty outpatient procedures were compared with an equal number of inpatient procedures. Medical and social backgrounds of the two patient populations were similar. The findings indicate that bilateral breast reduction can be performed safely and cost-effectively as an outpatient procedure.

Adolescent↗
PubMed2000

Comparative study of perioperative management of hepatic resection.

In an attempt to identify the factors that influence outcome after hepatic resection, patient background was reviewed and operative morbidity and mortality rates were assessed during two periods: 1985-1988 (group I: N = 96) and 1995-1998 (group II: N = 109). There were no differences in patient background factors between the two groups, but intraoperative blood loss, operative morbidity, and mortality were significantly reduced in group II compared to group I. There has been a significant reduction in postoperative complications, even in cases complicated by liver cirrhosis or obstructive jaundice. As a result of appropriate surgical procedures, postoperative complications in cirrhosis have been markedly decreased. After preoperative percutaneous biliary drainage in obstructive jaundice, attempts have been made to reduce the volume of blood loss even in extensive hepatectomy, the extent of liver resection in poor risk cases has been reduced without sacrificing radicality, and, by minimizing surgical stress, perioperative management has been greatly improved.

Adult↗
PubMed1989

Electrophrenic respiration in patients with high quadriplegia.

After determining that 15 patients with high spinal cord injuries who were permanently apneic had viable phrenic nerves, electrophrenic respiration units were implanted. Thirteen of the patients (86%) achieved full-time respiration and two more achieved half-time respiration. Despite the loss of 8 patients to unrelated problems, 7 now use electrophrenic respiration continuously, one having done so for 16 years. The patient selection criteria, neurophysiological evaluation method, surgical procedure, postoperative care, and methods for diagnosis of system failures are presented. A comparison of the cervical and thoracic procedures is made. The cervical approach is preferred. Complications consisted primarily of equipment failures. For the external components there were several cases of antenna connection and battery connection failures. The implanted receivers failed in 6 cases with an average lifetime of 48 months, ranging from 24 to 108 months. In one case fibrosis around the electrode resulted in failure to stimulate the phrenic nerve effectively. In another case, infection required removal of the system which was reimplanted later and has continued to provide successful ventilation.

Adolescent↗
PubMed2004

[Reconstruction of insufficient anterior cruciate ligament].

AIM: Reconstruction of insufficient anterior cruciate ligament (ACL) has become a standard operative procedure. Still, graft choice and fixation technique are discussed controversially. The objective of this study was to ascertain the current treatment of ACL reconstruction in german orthopedic surgery and trauma centers. METHODS: A total of 250 trauma and 220 orthopedic surgery centers were asked for their treatment strategy and postoperative procedure of ACL reconstruction in an anonymous German-wide survey. RESULTS: 230 questionnaires (48.9 %) were returned for evaluation. 90.4 % of the surgeons reconstruct the anterior cruciate ligament. Patellar tendon is used by 73 % of orthopedists and 80.7 % of trauma surgeons. Reconstruction with semitendinosus tendon transplant is performed by 71.6 % of the orthopedists and 41.6 % of trauma surgeons. For tibial fixation the interference screw is as well of the semitendinosus tendon as of the patellar tendon the most common technique. In about 30 % each the femoral fixation results from interference screw and endo-button. CONCLUSION: There is still no generally accepted intra- and postoperative strategy for reconstruction of ACL. Reconstruction with semitendinosus tendon becomes more common.

Analgesics↗
PubMed2005

Preoperative intravenous morphine sulfate with postoperative osteopathic manipulative treatment reduces patient analgesic use after total abdominal hysterectomy.

CONTEXT: Administration of opioids for treatment of pain after total abdominal hysterectomy (TAH) is a common postoperative procedure, providing an excellent parameter for evaluating the efficacy of postsurgical osteopathic manipulative treatment (OMT). OBJECTIVE: To determine whether a combination of preemptive morphine sulfate and postoperative OMT could provide improved analgesic effects. DESIGN: Randomized double-blind controlled trial. SETTING AND PATIENTS: Thirty-nine hospitalized patients assigned to one of four treatment groups: (1) preoperative saline and postoperative sham manipulative treatment; (2) preoperative saline and postoperative OMT; (3) preoperative morphine and postoperative sham manipulative treatment; or (4), preoperative morphine and postoperative OMT. INTERVENTION: Saline (control) or morphine, 10 mg, delivered intravenously (IV) 10 minutes before surgical incision. All patients received a postoperative patient-controlled IV analgesia pump containing morphine. At specified intervals following preoperative IV injections, blood was drawn and analyzed for morphine concentrations. Subjects were also asked to rate their postoperative levels of pain, nausea, and vomiting. RESULTS: There were no differences in either pain, or nausea and vomiting scores among the four study groups. Patients in Group 4 used less morphine than those in the Group 3 for the first 24 hours (P=.02) and from 25-48 hours (P=.01) after elective TAH. Morphine blood concentrations were lower after 24 hours in Group 4 compared with Group 2 (P=.04). CONCLUSION: Administration of postoperative OMT enhanced pre- and postoperative morphine analgesia in the immediate 48-hour period following elective TAH, demonstrating that OMT can be a therapeutic adjunct in pain management following this procedure.

Analgesia, Patient-Controlled↗
PubMedDate not supplied

Postoperative evaluation of C-tube drainage after hepatectomy.

BACKGROUND/AIMS: In spite of recent advances in liver surgery, biliary complications remain a common cause of major morbidity after hepatectomy. METHODOLOGY: We studied the postoperative evaluation of 28 hepatectomied patients with transcystic duct tube (C-tube) drainage (C-group), compared with 38 hepatectomied patients without C-tubes (NC-group), in terms of preoperative clinical profiles of patients, intraoperative findings and procedures, postoperative management and bile leakage, daily output of bile, liver function and postoperative infections. RESULTS: There were no significant differences in the preoperative clinical profiles of patients and postoperative management between the two groups. In intraoperative findings and procedures, the tumor size, weight of the resected liver, operation time and operative blood loss were higher in the C-group than those in the NC-group. Therefore, the operative procedure was more serious in the C-group than that in the NC-group. However, bile leakage was observed in only one of 28 patients (3.6%) in the C-group and 10 of 38 patients (26.3%) in the NC-group, that is, bile leakage occurred less frequently in the C-group than in the NC-group. The daily output of bile in the C-group was thought to be enough to decompress the biliary tree. In liver function, aspartate aminotransferase and alanine aminotransferase had lower levels in the C-group than those in the NC-group with bile leakage. White blood cell count, C-reactive protein and body temperature were closer to the normal range in the C-group than those in the NC-group with bile leakage. CONCLUSIONS: C-tube drainage after hepatectomy is thought to be useful for decreasing postoperative complications, especially bile leakage.

Aged↗
PubMedDate not supplied

Factors predicting postoperative pain in children and adolescents following spine fusion.

Despite advances in research and technology, investigators around the world acknowledge the continued undertreatment and unnecessary suffering of children in pain. The dilemma of inadequate relief of children's pain may relate to the complexity of the pain phenomenon. Using the Gate Control Theory as the foundation for this work, the purpose of my study was to determine the extent to which selected variables (severity of operative procedure, postoperative use of pharmacological agents, prior experience with pain, pain tolerance, gender, and age) predicted children's and adolescents' pain following spine fusion. Using a descriptive correlational design, data were collected from 93 children (ages 8 to 21 years) who had undergone spine fusion. For four consecutive postoperative days, children were asked to rate the intensity of their pain using the Adolescent Pediatric Pain Tool and observed pain behaviors were recorded using the Child Pain Scale. Repeated measures MANOVA revealed that children continued to experience moderate to severe pain throughout the four days. Stepwise multiple regression analyses were conducted for each postoperative day on each of the dependent variables. A modest amount of variance in children's pain was explained by the variables studied. R square values suggested that age, pain tolerance, and severity of operative procedure have the greatest potential as predictors of children's postoperative pain and warrant future research.

Adolescent↗
PubMed2001

Severe hemorrhage complicating tension-free vaginal tape (TVT): a case report.

A 59-year-old non-obese woman with genuine stress incontinence underwent an uneventful TVT procedure. Postoperatively a hemorrhage in the space of Retzius became more and more prominent, and a secondary laparotomy was performed. Large clots as well as the TVT tape were removed. No active bleeding was found. She recovered uneventfully but needed 10 units of blood. A coagulation defect could not be diagnosed.

Female↗
PubMed2004

Experience with primary laparoscopy-assisted endorectal pull-through for Hirschsprung's disease.

From October 1996 to July 2001, 61 patients received primary laparoscopy-assisted endorectal pull-through (LAERPT) for biopsy-proven Hirschsprung's disease (HD) at Mackay Memorial Hospital. The patients' ages at operation ranged from 7 days to 8 years. The patients were followed up for an average of 3.8 years (range 1-5.5 years). Major complications occurred in five (8.1%) patients, of whom four had surgical complications (two instances of anastomotic leakage, one colon perforation, and one delayed formation of colovesical fistula) and one had postoperative Salmonella infection-induced colonic stricture. The five patients required a diverting colostomy and a redo-pull-through procedure. Postoperative enterocolitis developed in 13 (21%) infants. All of them had enterocolitis before the diagnosis of HD was established. The majority of the episodes of postoperative enterocolitis were mild and resolved spontaneously, but four neonates were hospitalized with significant systemic manifestations, and two of them needed a second operation to solve the problem. After primary LAERPT, stooling frequency in young infants declined rapidly from 10.5+/-3.2 to 4.4+/-1.6 bowel movements per day in the first 3 months and more slowly thereafter. Most of these infants had regular bowel movements one to two times per day 1 year after operation. Continence evaluation of the 43 patients over 3 years of age was graded as normal in 24 (56%) patients and good in 19 (44%) patients. Of the 13 patients between 1 and 3 years of age, 11 (85%) had regular normal stools, and two (15%) had occasional soiling. From the current study, the authors concluded that primary LAERPT is a safe and effective method of managing HD with excellent continence results. Considering the complications of surgery and postoperative enterocolitis, patients with long segment aganglionosis, severe enterocolitis, or prominently dilated colon are not good candidates for primary LAERPT.

Anastomosis, Surgical↗
PubMed2003

Refractive changes following scleral buckling surgery in juvenile retinal detachment.

PURPOSE: To examine the effects of scleral buckling on the eye growth of children after retinal detachment repair according to the degree of refractive change. METHODS: Thirty-five eyes of 35 patients (mean age, 11.5 years; range, 7-15 years) were treated using a silicone implant scleral buckling procedure. Postoperative refractive change in the treated eyes was analyzed statistically, with the fellow eyes used as controls. The effects of age at the time of surgery, length of the silicone tire, postoperative visual acuity, and postoperative refraction were also examined. RESULTS: The mean refractive change in treated eyes from 1 to 4 years after the procedure was -0.6 diopter (D), whereas the mean change in fellow eyes was -1.3 D. The treated eyes became less myopic than the fellow eyes (P=0.024), particularly in patients younger than 10 years (-0.1 D versus -1.6 D, respectively; P=0.003) or when the scleral buckle extended beyond two quadrants (-0.4 D versus -1.3 D, respectively; P=0.020). CONCLUSIONS: Scleral buckling resulted in significantly less myopia, particularly in younger patients and in those receiving longer buckling tires. This finding suggests that scleral buckling in children might impede ocular growth.

Adolescent↗
PubMed1994

[Structure and organization of ambulatory and day treatment in a non-university facility].

Though German hospitals are normally not built for day case surgery, this became a new challenge based on changed legal regulations. A stepwise adaptation of the present facilities to the altered necessities seems to be a relatively simple way to realise day case surgery also in hospitals. Preoperatively surgeons and anaesthetists offer office hours during the same time to avoid patients having to wait. On the day of surgery patients are admitted to the hospital and treated like inpatients with regular transport to the operating room for anaesthesia and surgery, followed by recovery room stay and transmission to the normal ward. At a fixed time in the afternoon patients are visited by the surgeon and the anaesthetist to clear the conditions for dismission. While anaesthesia, surgery and recovery take the same time as for inpatients, the pre- and postoperative procedures are more time consuming. With a rising number of outpatients a separate department for outpatient surgery with its own administration, operating theaters and day case ward should be developed.

Ambulatory Surgical Procedures↗
PubMed1997

[Evaluation of stomach emptying under extreme obstruction of gastrointestinal transit treated with gastro-intestinal or duodenal-intestinal anastomosis].

The purpose of the present study was to compare gastric emptying in two groups of dogs in which a gastrojejunal or duodenojejunal Roux-en-Y anastomosis was performed over the site of an experimental obstruction in the distal duodenum. The experiment was carried out on 10 mongrel dogs. Gastric emptying was assessed twice in each dog before the experiment (control examination); the solid phase of the test meal was labelled with 99mTc. Following a control examination, the dogs were divided into two groups of 5 animals each, and subjected to the above mentioned surgical procedures. Postoperative gastric emptying was carried out 3 weeks after the operation, and then at 3 and 6 months following the procedure. The following parameters describing quantitatively gastric emptying were determined: mean transit time MTT0-60. MTT0-120 and total mean transit time MTT0-180. The comparison of these parameters revealed statistically significant differences confirming delay of gastric emptying in dogs with a gastrojejunal anastomosis.

Anastomosis, Roux-en-Y↗
PubMed2005

No-clamp technique for valve repair or replacement in patients with a porcelain aorta.

BACKGROUND: Patients requiring valvular heart surgery may have circumferential calcification of the ascending aorta. A variety of creative procedures have been described for managing this "porcelain aorta." We describe a technique based on replacement of the ascending aorta and proximal arch under profound hypothermic circulatory arrest, followed by the valve procedure. METHODS: Twenty-five consecutive patients with a porcelain aorta were referred for heart valve surgery. In every case the aorta was replaced under circulatory arrest before the valve procedure. Postoperative morbidity, mortality, and univariate risk factors for death were calculated. Fisher's exact test defined significant perioperative variables with a p value less than 0.05. RESULTS: Of 25 patients, 23 (92%) survived the surgery to hospital discharge. One patient had a stroke (4%) and 2 patients (8%) required reexploration for bleeding. Risk factors for perioperative death by univariate analysis included age more than 78 years (p < 0.009), cardiopulmonary bypass time longer than 200 minutes (p < 0.0001), reexploration for bleeding (p < 0.02), need for intra-aortic balloon pump support (p < 0.001), and postoperative gastrointestinal complications (p < 0.001). CONCLUSIONS: Valve replacement or repair in the patient with a porcelain aorta can be safely accomplished with a technique based on aortic replacement under circulatory arrest. Elderly patients requiring extensive procedures and prolonged periods on bypass have a substantially increased risk for postoperative complications and death.

Aged↗
PubMed1998

[A case report: right ventricular outflow tract (RVOT) reconstruction using homograft for RVOT restenosis after Jatene's procedure of transposition of the great arteries (TGA)].

A 7-year-old boy was admitted for RVOT restenosis. The patient was born following an unremarkable pregnancy and delivery. He was carried out Jatene's procedure for TGA at 23rd day after birth. At 19 month of age, he was removed pulmonary stenosis using patch angioplasty with mono cusp. When he was 6 year of age, the onset of edem, ascites and hepatomegaly were pointed out. At 7 year of age, he was admitted for edema, hypoproteinemia and protein loosing enteropatchy. After he was treated medical therapy, cardiac catheterization showed markedly right atrial and right ventricular hypertension and ventricular septal defect (VSD). Cine angiography suggested the right ventricular outflow tract stenosis, pulmonary valve and tricuspid valve insufficiency. On August 1, 1996, the patient underwent surgical repair: direct closure of VSD, aortic homograft (20mm) replacement for RVOT stenosis and tricuspid valve annuloplasty by DeVega's procedure. Postoperative course was uneventful. At 23rd postoperative day, cardiac catheterization and cine angiography showed no problems. He was not treated with anticoagulation.

Aorta↗