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Making your mark again in surgery.

Accurate, durable pre-operative skin marking that withstands the necessary vigorous surgical skin preparation on the theatre table minimises confusion and the risk of mistakes occurring perioperatively, as well as assisting the surgeon with the technicalities of required skin incisions. Felt-tipped marker pens vary widely in achieving these objectives. A selection of markers, including a number used by junior surgical staff on the wards, was investigated.

Humans↗

Surgical recurrence of perforating and nonperforating Crohn's disease. A study of 101 surgically treated Patients.

PURPOSE: This is a study of the long-term course of surgically treated Crohn's disease designed to identify prognostic factors predictive of the time course and probability of surgical recurrence. PATIENTS AND METHODS: The study is based on the records of 101 patients admitted to our institution for surgical treatment of Crohn's disease from January 1, 1970 to December 31, 1985. Follow-up was complete in 97 (96 percent) and incomplete in 4 patients. Median follow-up from the date of first operation was 13.25 years. The cumulative probability of requiring surgical treatment for recurrent disease was calculated using the life table method and further analyzed with the log-rank test and Cox regression. RESULTS: The time to reoperation in this series was not significantly influenced by sex, age at onset of symptoms, age at diagnosis, age at first operation, anatomic location, and number of sites involved at the time of first operation. The only variable that had a statistically significant effect on the time to reoperation was characterization of disease at the time of operation as being perforating (P) opposed to nonperforating (NP). Median interval between the first and second intestinal operation was 1.7 years for the P group and 13 years for the NP group (P value, 0.005), and the median time between any two operations undergone during the study period was 2 years for the P group and 9.9 years for the NP group (P = 0.0002). The risk of having to undergo reoperation for recurrence was greatest during the first two years after an operation, and this was mainly because of a short time to surgical recurrence in the P group of indications. Therefore, the yearly hazard of requiring further surgery was maintained at approximately 5 percent. CONCLUSION: The cumulative probability of requiring a reoperation for patients undergoing surgery for the P type of Crohn's disease is significantly different from that of patients with NP indications. The risk of having to undergo further surgery is particularly high during the first two years following an operation for perforating disease. The concept of a relatively aggressive perforating type of Crohn's disease and a more indolent nonperforating type is confirmed by the results of this study.

Adult↗

End stage coronary disease treated with the transmyocardial CO2 laser revascularization: a chance for the 'inoperable' patient.

OBJECTIVE: The aim of this study is to evaluate the short and mid-term efficacy of the Transmyocardial High Power CO2 Laser Revascularisation (TMLR) as a last resource method for end-stage coronary disease patients. METHOD AND PATIENTS: The High Power CO2 Laser 800 W Heart Laser (PLC Medical Systems) was used since February 1994 to treat 268 patients. In 52% of the cases (140) the indication for TMLR treatment was virtual inoperability by the classical bypass revascularisation. In the other 128 patients (48%), where only an incomplete revascularisation was expected, the TMLR was combined with a feasible bypass revascularisation (CABG). Of all patients, 71% were operated on 1-5 times before and or treated by several percutaneous transluminal coronary angioplasty (PTCA). All patients were sufferers of angina pectoris and most were classified Canadian Cardiac Society (CCS) 3-4, despite the maximal medical treatment. The ejection fraction was normal in 13% of patients only, and in 47% of them it was below 40% (10-68%). RESULTS: The operation itself was generally well tolerated. We lost only one patient at the table. The hospital survival was 89.2%; 88.2% in the combined group and 90.3% in the TMLR only group. After the routine follow up screening 3, 6 and 12 months postoperatively (262 patients--131 TMLR and 131 TMRL/CABG), 40% of the TMLR patients upgraded into the functional class CCS 0-1; the combined group of patients scored up even in 84%. All considering their quality of life to be 'better than years ago'. The ergometry stress test, impossible for most of them before, became feasible and better in 80% of the patients. In the follow up period of the combined group, another 6 (4.7%), and in the TMLR only group, 12 (9.4%) patients died. CONCLUSION: The short and middle term results of this--until now the largest single institution series of TMLR treated patients--were that patients almost without exception were refused for any kind of surgery by several other centres; this shows an acceptable survival rate and a surprising level of pain relief, increased activity and better quality of life then ever expected. In our experience, TMLR is a suitable method for treatment of end stage coronary disease, if all standard measures, medical therapy, PTCA and redo coronary revascularisation possibilities are exhausted. The favourable results imply the question as to whether this method will become an alternative for a second bypass operation in the future. The TMLR as an alternative for heart transplant is already a reality for some of our patients.

Cohort Studies↗

Beam characteristics of the therapax DXT300 orthovoltage therapy unit.

The operating performance and beam characteristics of a new orthovoltage unit, the Therapax DXT300, have been evaluated. Percentage depth-dose and backscatter tables are presented for several applicator sizes, at 30 cm and 50 cm focal skin distances (FSDS) and for multiple x-ray beam qualities with the tube operating between 100 and 300 kVp accelerating potential. The unit has been found to provide beam characteristics similar to those reported for other orthovoltage therapy machines. The linearity and short- and long-term stability/reproducibility of the unit's internal dosimetry system have also been studied, and results indicate a very stable beam output of better than 1% standard deviation. The data presented in this work should provide the basis for comparison with other units and act as a reference for clinics commissioning the Therapax DXT300 in the future.

Equipment Failure Analysis↗

Batteries: from alkaline to zinc-air.

There is no perfect disposable battery--one that will sit on the shelf for 20 years, then continually provide unlimited current, at a completely constant voltage until exhausted, without producing heat. There is no perfect rechargeable battery--one with all of the above characteristics and will also withstand an infinite overcharge while providing an equally infinite cycle life. There are only compromises. Every battery selection is a compromise between the ideally required characteristics, the advantages, and the limitations of each battery type. General selection of a battery type to power a medical device is largely outside the purview of the biomed. Initially, these are engineering decisions made at the time of medical equipment design and are intended to be followed in perpetuity. However, since newer cell types evolve and the manufacturer's literature is fixed at the time of printing, some intelligent substitutions may be made as long as the biomed understands the characteristics of both the recommended cell and the replacement cell. For example, when the manufacturer recommends alkaline, it is usually because of the almost constant voltage it produces under the devices' design load. Over time, other battery types may be developed that will meet the intent of the manufacturer, at a lower cost, providing longer operational life, at a lower environmental cost, or with a combination of these advantages. In the Obstetrical Doppler cited at the beginning of this article, the user had put in carbon-zinc cells, and the biomed had unknowingly replaced them with carbonzinc cells. If the alkaline cells recommended by the manufacturer had been used, there would have been the proper output voltage at the battery terminals when the [table: see text] cells were at their half-life. Instead, the device refused to operate since the battery voltage was below presumed design voltage. While battery-type substitutions may be easily and relatively successfully made in disposable applications (for example, zinc-air for alkaline--if it is cost-effective), this is absolutely forbidden for secondary cells. Because of the differing cell voltages, charge characteristics and overcharge tolerance between different types of secondary cells, substituting a nickel-cadmium battery pack for the more expensive lithium-ion pack (if it is physically able to fit into the battery compartment), might appear to save money (e.g. $50 vs. $100) but it would be very ill advised. Since the cell characteristics are very different, it would be downright fatal to anyone within the 'kill radius' when the pack explodes. Those outside the kill radius would receive chemical burns from the electrolyte. Substitutions of secondary cell battery packs are generally not a good idea for biomeds to engage in. These are engineering decisions best left to either aftermarket battery pack manufacturers or the medical device manufacturer as a design engineering change.

Air↗

[A prospective controlled study of vagotomy in the treatment of duodenal ulcer. Results after 11-15 years].

A prospective, randomized, controlled trial was conducted to compare truncal vagotomy and drainage (TV), selective vagotomy and drainage (SV) and parietal cell vagotomy (PCV) as elective treatment for duodenal ulcer. Between 11 and 15 years post-operatively, 248 patients were available for study of the recurrent ulceration rate by a life table method and 197 patients could be studied with regard to post-vagotomy symptoms. The recurrent ulcer rates were TV 28.5%, SV 37.4% and PCV 39.3%. These differences were not statistically significant. There was no significant difference in the Visick gradings among the three groups either before or after treatment of the failures. About two-thirds of the patients in each group were finally satisfied with their operation, often after second operations or prolonged medical treatment.

Clinical Trials as Topic↗

Long-term results of biliary reconstruction after laparoscopic bile duct injuries.

HYPOTHESIS: The Hepp-Couinaud approach to biliary enteric reconstruction for laparoscopic bile duct injuries provides a durable, long-term result in most patients. DESIGN: Retrospective study of patients who underwent operative repair of laparoscopic bile duct injuries from January 1990 through December 1997. SETTING: Academic tertiary referral center. MAIN OUTCOME MEASURES: Outcome was assessed using a grading system based on clinical symptoms, liver function tests, and need for reintervention for anastomotic stricture. The Kaplan-Meier method was employed to estimate stricture-free survival. RESULTS: Fifty-nine consecutive patients underwent operative repair of the following laparoscopic bile duct injuries (Strasberg classification): B: n = 2 (3%), C: n = 1 (1%), D: n= 2 (3%), E1: n= 5 (8%), E2: n= 16 (27%), E3: n= 25 (42%), E4: n = 5 (8%), and E5: n = 3 (5%). Forty-seven patients (80%) had 1 or more interventions prior to the index repair. The extrahepatic left bile duct (Hepp-Couinaud approach) was used in 46 of 53 patients who underwent a Roux-en-Y hepaticojejunostomy. Follow-up (mean+/-SEM, 3.7+/-0.3 years) was complete in 54 of the 57 patients still alive. Five patients developed subsequent anastomotic strictures and were treated with percutaneous transhepatic dilation (n = 3), endoscopic dilation (n = 1), and operative revision (n= 1). Excellent to good long-term results were achieved in the remaining 49 patients (91%). Life-table analysis yielded 95% and 88% chances of stricture-free survival at 2 and 5 years, respectively. CONCLUSIONS: Complex iatrogenic proximal bile duct injuries and strictures are amenable to operative repair using the extrahepatic left bile duct. The Hepp-Couinaud approach offers a durable result in more than 90% of patients, even after previous interventions have failed.

Bile Ducts↗

Staged resection or primary anastomosis for obstructing lesions to the left colon.

The management of obstructing left-sided colonic and rectal lesions has traditionally been by a staged procedure. The introduction of 'on-table lavage', has made primary resection and anastomosis of the large bowel feasible for patients presenting as emergencies. We have studied the perioperative course of 28 patients who presented with left colonic obstruction to determine whether primary anastomosis conferred additional morbidity. The patients ranged in age from 29 to 89 years (mean 66 years) at presentation. The ASA status of patients was comparable in both groups (Table 1). Fourteen patients underwent resection, on-table lavage, and primary anastomosis (PA) and 14 a Hartmann's procedure (HP). The mean operative time for the PA procedure was 200 minutes compared to 110 minutes for the HP group. There was no significant difference in the postoperative complication rate nor mean hospital stay rate for the primary procedures between the two groups. There was no clinical anastomotic leak in patients undergoing primary anastomosis. However secondary surgery for patients undergoing colorectal reconnection conferred added morbidity for patients who had a HP. We conclude that resection, on-table lavage, and primary anastomosis is safe in the management of left-sided colonic obstruction and in most cases is the treatment of choice.

Aged↗

Percutaneous nephrostomy for deflation and stone treatment, I.

A simple technique of percutaneous nephrostomy and renal calculus treatment is reported. The pertaining equipment and method are so highly accomplished today that the majority of stones can be removed percutaneously, largely dispensing with the need for surgical operation. The method has proved particularly efficient in secondary operations. It can be put to work at every urologic department where an X-ray table with closed-circuit TV is available and a surgical team is at hand, ready to cope at once with complications, presenting themselves rarely in the form of secondary bleeding, injury of a nearby organ, etc. Therefore the urologist should be advised to perform the renal puncture himself. Endoscopic removal of the stone, the easier part of the operation, can be carried out in a single session; but for larger stones which are less easy to cope with, it should be done a few days after creation of the fistula, when the tunnel has sufficiently indurated to permit effortless work. The percutaneous method, since it removes the stone at once, is usually superior to the more expensive extracorporeal nephrolithotripsy but the two may complement each other.

Humans↗

Polycystic ovarian disease treated by laparoscopic argon laser capsule drilling: comparison of vaporization versus perforation technique.

Forty-four anovulatory women with polycystic ovarian disease (PCOD) were laparoscopically treated with the argon laser. Eighty percent of them were previously resistant to clomiphene citrate therapy. After surgery spontaneous ovulation occurred in 80% of the women. Spontaneous conception occurred in 55% of patients, and another 18% of the women who were previously resistant to clomiphene citrate conceived post-operatively after clomiphene citrate therapy. This gives an overall conception rate of 73% after 18 months (using life table analysis). Two different drilling techniques were used: classical vaporization of the ovarian capsule (22 women), and simple perforation of the ovarian capsule with subcapsular destruction of the ovarian stroma (22 women). No different ovulation or pregnancy rates were observed post-operatively between the two techniques. These results suggest that patients with PCOD can be induced to ovulate, and subsequently conceive, by laparoscopic argon laser treatment. The technique with minimal trauma to the ovarian capsule seems preferable.

Adult↗

An evaluation of ergonomic improvements in the woodworking industry.

A survey was conducted among operators in the woodworking industry to study the effect of machine characteristics on exposure to mechanical load. The 28 subjects worked in five small factories and operated four-sided planing machines. Work postures and external load were analysed with the Ovako working posture analysis system. Among the operators awkward postures regularly occurred, such as a bent or twisted back (25%), outstretched arms (25%) and a twisted head (28%). The average percentage of time spent with lifting and carrying wooden boards and planks was 41%. The statistical analysis indicated that beneficial effects on postural load were achieved by various ergonomic improvements, such as rising platforms and roller paths. Work time with external load was reduced by 10% as a result of the presence of rising platforms and tables. The type of analysis presented may guide towards the improvement of work conditions of operators of planing machines by reducing mechanical load on the body.

Biomechanical Phenomena↗

Patient monitoring in the operating theatre.

Anaesthetised patients are monitored to ensure their safety. Simple clinical observations must not be replaced by electronic instruments--these provide an extension of the clinical senses. The choice of parameters for monitoring is discussed. The design of the Ninewells main operating theatre suite is described. An 8-channel bourne in the base of the theatre table conveys patient signals to a 4-channel recorder in a monitoring laboratory. Outputs are displayed on a wall mounted display in theatre. Two-way speech intercommunication exists with monitoring technician and students.

Anesthesia↗

Pre-operative aspirin decreases platelet aggregation and increases post-operative blood loss--a prospective, randomised, placebo controlled, double-blind clinical trial in 100 patients with chronic stable angina.

Aspirin has an established benefit in reducing the incidence of coronary events and vein graft occlusion. We have now assessed the risk of pre-operative aspirin in a prospective, randomised, double-blind clinical trial in 100 patients scheduled for elective coronary artery surgery. Any prescribed aspirin and non-steroidal anti-inflammatory drugs were discontinued 2 weeks pre-operatively and these were replaced by a randomly assigned tablet of either aspirin 300 mg daily or placebo taken until the day of surgery. Patient compliance was confirmed by serum and urinary salicylate analysis. The two groups were similar in demographic characteristics, bypass time, number of grafts placed and number of internal mammary arteries used. All patients survived to be discharged home (see Table). Aspirin decreases platelet aggregation to arachidonic acid and to collagen both pre- and post-operatively. The benefit of pre-operative aspirin has to be balanced against the risk of increasing post-operative blood loss, re-exploration for excessive bleeding and transfusion requirements.

Aspirin↗

Remediation of NAPL below the water table by steam-induced heat conduction.

Previous experimental studies have shown that NAPL will be removed when it is contacted by steam. However, in full-scale operations, steam may not contact the NAPL directly and this is the situation addressed in this study. A two-dimensional intermediate scale sand box experiment was performed where an organic contaminant was emplaced below the water table at the interface between a coarse and a fine sand layer. Steam was injected above the water table and after an initial heating period the contaminant was recovered at the outlet. The experiment was successfully modeled using the numerical code T2VOC and the dominant removal mechanism was identified to be heat conduction induced boiling of the separate phase contaminant. Subsequent numerical modeling showed that this mechanism was insensitive to the porous medium properties and that it could be evaluated by considering only one-dimensional heat conduction.

Environmental Monitoring↗

Permanent Dipole Moments of Methane-Type Molecules: Calculation of the DeltaJ = 0 Matrix Elements in the l = 1 Vibrational State

We examined permanent dipole moments (PDMs) of methane-type molecules induced by molecular internal motions which are expanded in terms of the vibrational coordinate operator q , total angular momentum operator J , and vibrational angular momentum operator l . The qq -, JJ -, Jl -, and ll -type quadratic terms of these operators contribute to the production of PDMs. The DeltaJ = 0 matrix elements of the four PDMs are calculated for the first excited state of the triply degenerate vibrational mode; a portion are numerically given in a table for the J </= 6 levels. We have also compared them with the PDM represented by the rotational angular momentum operator R = J - l and discussed an application of the present calculations to the v 3 = 2 state of methane.

Journal Article↗

[Surgery of the extracranial cerebral vessels. (Indication and results)].

Surgery of the extracranial cerebral vessels nowadays under right indication and operative technique is one of the most satisfying areas of vascular surgery. Our present status of indication is shown in table 1; it should be pointed out that the classical indication is a lesion of the internal carotid artery with a Transitoric Ischemic Attack, but also in cases of progressive stroke with acute carotid occlusion the operation will be successful relentless of any time limit as long as the patient is conscious. For the extrathoracal bypass procedure we now prefer the subclavio-subclavian bypass to the formerly performed carotio-subclavian bypass.

Carotid Artery Diseases↗

Intravenous fluids for abdominal aortic surgery.

BACKGROUND: Surgery on the abdominal aorta, for aneurysmal and occlusive disease is a major undertaking which requires intensive support and fluid management. Blood products are often used, but the major fluid replacement is with crystalloids or colloids. There has been controversy for many years over which fluid is optimal and a number of studies have examined this subject, without any systematic review. OBJECTIVES: The objective of this review was to determine the effectiveness of different non-blood replacement fluids used in surgery on the abdominal aorta with a view to identifying the optimal fluid for use in such surgery. SEARCH STRATEGY: All publications describing (or which might describe) randomised controlled trials of non-blood replacement fluids in abdominal aortic surgery were sought using the search strategy described by the Cochrane Review Group on Peripheral Vascular Diseases. This strategy includes hand searching of relevant medical journals and extensive MEDLINE and EMBASE searches. In addition, trials have been identified from searches of references included in those trials already retrieved. SELECTION CRITERIA: Randomised controlled trials assessing the effects of one or more specific non-blood fluids used for replacement therapy in operations on, and confined to, the abdominal aorta. DATA COLLECTION AND ANALYSIS: Data were extracted to pre-prepared tables and then entered into the Review Manager software where statistical analysis and descriptive subjective analysis were performed. MAIN RESULTS: Nine trials, involving 412 patients were included. Patients undergoing aortic surgery had various physiological parameters measured before and after their operation (cardiac, respiratory, biochemical, haematological and protein). Ten fluids were studied: Ringer lactate, 5% dextrose in Ringer lactate, 5% dextrose in 0.45% saline, 5% dextrose in water, 1.8% saline, human albumin solution in Ringer lactate, human albumin solution in water, 5% dextrose with human albumin solution, Dextran 60, Hetastarch. Patients were randomised to fluid type. This review demonstrates that no single fluid has been shown to affect any outcome measure significantly more than any other across a range of outcome measures. However, each trial compared different fluids, and each fluid has not been compared against all others. The death rate in these studies was 2.9% (12 patients). REVIEWER'S CONCLUSIONS: Further studies are required, with sufficient sample size and power, to draw any further conclusions. There are no studies examining the effects of combination fluid therapy.

Aorta, Abdominal↗