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Immediate Postoperative Period (immediate + postoperative_period)
Selected AbstractsStent Dilatation of a Right Ventricle to Pulmonary Artery Conduit in a Postoperative Patient with Hypoplastic Left Heart SyndromeCONGENITAL HEART DISEASE, Issue 2 2008Rowan Walsh MD ABSTRACT A 10-day-old child with hypoplastic left heart syndrome (HLHS) underwent first-stage palliation for HLHS, Norwood procedure with a Sano modification, i.e., placement of a right ventricular to pulmonary artery (RV-PA) conduit. The patient developed progressively worsening systemic oxygen desaturation in the immediate postoperative period. Stenosis of the proximal RV-PA conduit was diagnosed by echocardiography. In the catheterization laboratory stent placement in the conduit was performed. This resulted in increased systemic oxygen saturation. The patient was eventually discharged from the hospital with adequate oxygen saturations. [source] Repair of a Large Wound of the Back, Post-Mohs Micrographical Excision, Using Chronic Skin ExpansionDERMATOLOGIC SURGERY, Issue 6 2003Ron M. Shelton MD Background. Large defects not otherwise closed primarily may be closed after chronic skin expansion. Objective. If chronic expansion were deemed indicated for the closure of a proposed defect expected to result from Mohs micrographic surgery, can it be performed before Mohs surgery, avoiding the increased chance of expander extrusion via the defect when done postoperatively? Methods. A team approach of a Mohs surgeon and a plastic surgeon coordinated scheduling an insertion of and staged infiltration of a tissue expander before Mohs surgical removal of a large basal cell carcinoma on the back of a young woman. The reconstruction after Mohs surgery was scheduled for the immediate postoperative period. Results. The Mohs surgery completed removed the carcinoma, and the expander was removed, enabling the surgeon to perform a side-to-side closure. Conclusion. Provided that there is not a great probability of the neoplasm extending significantly deeper or wider than expected and that the skin expander is placed so as not to disturb the plane of Mohs excision, this is a useful technique to close large Mohs defects. [source] Conservative management of an extensive renal graft subcapsular hematoma arising during living donor nephrectomy.JOURNAL OF CLINICAL ULTRASOUND, Issue 3 2010Role of Doppler sonographic posttransplant follow-up Abstract We report a case of subcapsular hematoma (SH) of a kidney graft arising during minimal-incision living-donor nephrectomy. SH covered at least two-thirds of the cortical surface. Capsulotomy was not done because it was deemed too risky. In the immediate postoperative period, a rapid deterioration of graft function was observed associated with Doppler sonographic evidence of graft compression. However, in the following days, spontaneous resolution of SH and progressive improvement of Doppler findings was observed, which preceded full recovery of graft function. Conservative management seemed a valid approach of this complication in this case where Doppler sonography proved essential for the follow-up. © 2009 Wiley Periodicals, Inc. J Clin Ultrasound, 2010 [source] Evaluation of hernia repair operation in Child,Turcotte,Pugh class C cirrhosis and refractory ascitesJOURNAL OF GASTROENTEROLOGY AND HEPATOLOGY, Issue 3 2007Joo Kyung Park Abstract Background and Aim:, Abdominal wall hernia is a common feature of decompensated liver cirrhosis and frequently causes life-threatening complications or severe pain. However, there have been no data reported on postoperative mortality, hepatic functional deterioration and recurrence rate according to Child,Turcotte,Pugh (CTP) class and to the presence of refractory ascites. Methods:, The study population comprised 53 liver cirrhosis patients who underwent hernia repair operation. Comparisons were made of 30-day mortality among the different CTP classes, and between those with or without refractory ascites. Liver function was also analyzed just before the operation, in the immediate postoperative period, and in the remote postoperative period. Results:, Seventeen patients were in CTP class A, 27 patients in class B, and 9 patients in class C. The median follow-up duration was 24 months. There was single 30-day postoperative mortality in class C, and no CTP class deterioration after 30 days of operation. There was no mortality or recurrences in 17 patients with medically refractory ascites. The difference in 30-day mortality according to CTP class and the presence of refractory ascites did not show statistical significance (P = 0.17 and 0.97, respectively). Conclusion:, Hernia operation could be done safely in CTP class A and B with low rate of recurrences, and there was no definitive increase in the operative risk in class C. In addition, refractory ascites did not increase operative risk and recurrence rate. Therefore, surgical repair might be recommended even in patients with refractory ascites and poor hepatic function to prevent life-threatening complications or severe pain. [source] Platelet activation, myocardial ischemic events and postoperative non-response to aspirin in patients undergoing major vascular surgeryJOURNAL OF THROMBOSIS AND HAEMOSTASIS, Issue 10 2007S. RAJAGOPALAN Summary.,Objectives:,Myocardial ischemia is the leading cause of postoperative mortality and morbidity in patients undergoing major vascular surgery. Platelets have been implicated in the pathogenesis of acute thrombotic events. We hypothesized that platelet activity is increased following major vascular surgery and that this may predispose patients to myocardial ischemia.Methods:,Platelet function in 136 patients undergoing elective surgery for subcritical limb ischemia or infrarenal abdominal aortic aneurysm repair was assessed by P-selectin expression and fibrinogen binding with and without adenosine diphosphate (ADP) stimulation, and aggregation mediated by thrombin receptor-activating peptide and arachidonic acid (AA). Cardiac troponin-I (cTnI) was performed.Results:,P-selectin expression increased from days 1 to 3 after surgery [median increase from baseline on day 3: 53% (range: ,28% to 212%, P < 0.01) for unstimulated and 12% (range: ,9% to 45%, P < 0.01) for stimulated]. Fibrinogen binding increased in the immediate postoperative period [median increase from baseline: 34% (range: ,46% to 155%, P < 0.05)] and decreased on postoperative day 3 (P < 0.05). ADP-stimulated fibrinogen binding increased on day1 (P < 0.05) and thereafter decreased. Platelet aggregation increased on days 1,5 (P < 0.05). Twenty-eight (21%) patients had a postoperative elevation (> 0.1 ng mL,1) of cTnI. They had significantly increased AA-stimulated platelet aggregation in the immediate postoperative period and on day 2 (P < 0.05), and non-response to aspirin (48% vs. 26%, P = 0.036).Conclusions:,This study has shown increased platelet activity and the existence of non-response to aspirin following major vascular surgery. Patients with elevated postoperative cTnI had significantly increased AA-mediated platelet aggregation and a higher incidence of non-response to aspirin compared with patients who did not. [source] Hepatitis A acute liver failure: follow-up of paediatric patients in southern BrazilJOURNAL OF VIRAL HEPATITIS, Issue 2008C. T. Ferreira Summary., We retrospectively analysed 33 children and adolescents who had been hospitalized in a liver transplant unit within the previous 10 years for acute liver failure (ALF). The patients' age varied between 2 months and 15 years of age (median 6.2 ± 5.3), and 21 (63%) were male. Thirteen patients (39%) were immunoglobulin-M anti-hepatitis A virus (HAV) sero-positive. Eleven cases (33%) had an undetermined aetiology. The 13 children with HAV ALF were between 17 months and 15.6 years of age (median 5.8 ± 4.6) and eight were male (61.5%). All were on a list for urgent liver transplant. Of these, five (38%) died while waiting for a liver. Only one patient recovered spontaneously. Seven patients received a liver transplant; three died in the immediate postoperative period and one died 45 days after transplant. Three children are alive 1, 2 and 5 years after transplant. We conclude that HAV was the most frequent cause of ALF, which had high mortality even when a liver transplant was possible. The results support universal HAV vaccination in this area. [source] Outcome of the use of pediatric donor livers in adult recipientsLIVER TRANSPLANTATION, Issue 1 2001Motohiko Yasutomi The prolonged waiting time caused by the lack of donor livers leads to an increasing number of terminally ill patients waiting for lifesaving liver transplantation. To rescue these patients, transplant programs are accepting donor organs from the expanded donor pool, using donors of increasingly older age, as well as from the pediatric age group, often despite significant mismatch in liver size. We investigated the outcome of 102 consecutive liver transplantations using pediatric donor livers in adult recipients. One-year graft survival using donors aged 12 years or younger (group 1, n = 14) and donors aged 12 to 18 years (group 2, n = 88) was compared. In addition, risk factors for graft loss and vascular complications were analyzed. The 1-year graft survival rate in adult transplant recipients in group 1 was 64.3% compared with 87.5% in those in group 2 (P = .015). The main cause of graft loss was arterial complications, occurring in 5 of 16 transplant recipients (31.3%). Major risk factors for graft loss and vascular complications were related to the size of the donor: age, height and weight, body surface area of donor and recipient, and warm ischemic time. We conclude that the outcome of small pediatric donor livers in adult recipients is poor, mainly because of the increased incidence of arterial complications. When a pediatric donor is used in an adult recipient, ischemic time should be kept to a minimum and anticoagulative therapy should be administered in the immediate postoperative period to avoid arterial complications. However, because small pediatric donors are the only source of lifesaving organs for the infant recipient, the use of small pediatric donor livers in adults should be avoided. [source] Significance of detecting epstein-barr,specific sequences in the peripheral blood of asymptomatic pediatric liver transplant recipientsLIVER TRANSPLANTATION, Issue 1 2000Nancy R. Krieger Pediatric allograft recipients are at increased risk for Epstein-Barr virus (EBV)-associated illnesses. The early identification and diagnosis of EBV-associated disorders is critical because disease progression can often be curtailed by modification of immunosuppression. We have previously shown that detection of EBV-specific sequences in the circulation by polymerase chain reaction (PCR) correlated well with the clinical symptoms of EBV infection. The purpose of the current study is to determine the significance of detecting EBV-specific sequences by PCR in asymptomatic pediatric liver transplant recipients. Peripheral-blood DNA was analyzed for the EBV genes, coding from the nuclear antigen 1 (EBNA-1) and the viral capsid antigen (gp220) by PCR. Samples from asymptomatic pediatric liver transplant recipients were analyzed from the immediate postoperative period and at 2- to 4-month intervals thereafter. We followed up 13 of these asymptomatic recipients who tested positive for EBV compared with 7 asymptomatic recipients who tested negative for EBV during the early posttransplantation period. Follow-up ranged from 1.5 to 4 years posttransplantation. Nine patients (69%) initially positive for EBV and asymptomatic ultimately developed symptoms of EBV infection, including fever, lymphadenopathy, rash, respiratory and gastrointestinal symptoms, and/or hepatitis. Five of these patients (56%) went on to develop posttransplant lymphoproliferative disorder based on histological examination of biopsied tissue and immunohistochemical identification of the EBV antigen/DNA in tissue. This is the first report suggesting that detection of EBV-specific sequences in the absence of symptoms may herald impending EBV-associated disorders. Thus, routine monitoring for circulating EBV sequences in asymptomatic recipients may be useful in the early identification of those at risk for developing EBV-associated disease and its ultimate prevention. (Liver Transpl 2000;6:62-66.) [source] Autologous fat grafting: A technique for stabilization of the microvascular pedicle in DIEP flap reconstructionMICROSURGERY, Issue 7 2008Eran D. Bar-Meir M.D. Proper orientation of the microvascular pedicle is essential to ensure a high success rate in microvascular surgery. The inset of a deep inferior epigastric perforator (DIEP) flap breast reconstruction can sometimes be problematic given the long vascular pedicle, the acute takeoff from an internal mammary anastomosis, and the positioning of the flap on top of the vascular pedicle. In the postoperative period, the flap can also shift as the patient's activity level increases. We present a technique where nonvascularized autologous fat grafts are used to stabilize and cushion the vascular pedicle. Over a 14-month period, 117 consecutive DIEP flaps were performed to the internal mammary vessels with autologous fat grafting to the microvascular pedicle. Six flaps (5.1%) were explored during the immediate postoperative period for anastomotic compromise. Only one total flap failure (0.8%) was observed during this time. We had no direct complications related to the fat grafts. The use of nonvascularized autologous fat grafts is a simple and safe technique for stabilization of a microvascular pedicle. It should be considered in DIEP flap breast reconstruction and other microvascular cases where the vascular pedicle might be compressed by adjacent structures. © 2008 Wiley-Liss, Inc. Microsurgery, 2008. [source] Sequential clot strength analyses following diclofenac in pediatric adenotonsillectomyPEDIATRIC ANESTHESIA, Issue 11 2007MAIREAD HEANEY FCARCSI FJFICM Summary Background:, Tonsillectomy is a common pediatric surgical procedure resulting in significant postoperative pain. There is ongoing controversy as to the most satisfactory analgesic regimen. Nonsteroidal antiinflammatory drugs (NSAIDs) are an alternative to opioids in this setting. NSAID use in tonsillectomy has been shown to be opioid sparing in the recovery period and to have similar analgesic effects to opioids in pediatric patients. Because of their nonspecific action on the enzyme cyclo-oxygenase there is potential for increased bleeding which has led many practitioners to avoid NSAIDs completely in this patient population potentially resulting in suboptimal pain control. Our aim in this study was to assess the effect of preoperatively administered diclofenac on the blood clot strength in children undergoing (adeno-) tonsillectomy. Methods:, Twenty patients undergoing (adeno-) tonsillectomy were recruited into this prospective observational study. All patients received 2 mg·kg,1 of diclofenac rectally immediately preoperatively. Blood was taken for thromboelastograph analysis pre-diclofenac and 1 and 4 h post-diclofenac administration. Results:, There was a statistically significant increase in maximal clot strength (MA) at 1 and 4 h after diclofenac. Similarly there was a statistically significant reduction in time to initial fibrin formation (R time) post-diclofenac. There was no primary or secondary hemorrhage. Conclusions:, Diclofenac when given preoperatively does not adversely affect clot strength in the immediate postoperative period when the risk of primary hemorrhage is greatest. [source] Postoperative complications after extracapsular dissection of benign parotid lesions with particular reference to facial nerve functionTHE LARYNGOSCOPE, Issue 3 2010Nils Klintworth MD Abstract Objectives/Hypothesis: The desirable extent of surgical intervention for benign parotid tumors remains a matter of controversy. Superficial or total parotidectomy as a standard procedure is often said to be the gold standard; however, with it the risk of intraoperative damage to the facial nerve cannot be ignored. For some time now, extracapsular dissection without exposure of the main trunk of the facial nerve has been favored as an alternative for the treatment of discrete parotid tumors. Data on the incidence of facial nerve lesions and other acute postoperative complications of extracapsular dissection have been lacking until now. Study Design: Retrospective analysis. Methods: We performed a retrospective analysis of the data from patients in whom extracapsular dissection of a benign parotid tumor had been performed under facial nerve monitoring and as a primary intervention in our department between 2000 and 2008. Results: A total of 934 patients were operated on for a newly diagnosed benign tumor of the parotid gland. Three hundred seventy-seven patients (40%) underwent extracapsular dissection as a primary intervention. The most common postoperative complication was hypoesthesia of the cheek or the earlobe, as reported by 38 patients (10%). Eighteen patients (5%) developed a seroma and 13 patients (3%) a hematoma. A salivary fistula formed in eight patients (2%). Secondary bleeding occurred in three patients (0.8%). In 346 patients (92%) facial nerve function was normal (House-Brackmann grade I) in the immediate postoperative period, whereas 23 patients (6%) showed temporary facial nerve paresis (House-Brackmann grade II or III) and eight patients (2%) developed permanent facial nerve paresis (seven patients House-Brackmann grade II, one patient House-Brackmann grade III). Conclusions: Extracapsular dissection of benign parotid tumors is associated with a low rate of postoperative complications, a fact that is confirmed by the available literature. We therefore recommend that use of this technique always be considered as a means of treating benign parotid tumors as conservatively, that is, as uninvasively, as possible. Laryngoscope, 2010 [source] Etiology of Late Free Flap Failures Occurring After Hospital Discharge,THE LARYNGOSCOPE, Issue 11 2007Mark K. Wax MD Abstract Objectives: Vascular compromise of free flaps most commonly occurs in the immediate postoperative period in association with failure of the microvascular anastomosis. Rarely do flaps fail in the late postoperative period. It is not well understood why free flaps can fail after 7 postoperative days. We undertook a case review series to assess possible causes of late free flap failure. Study Design: Retrospective review at two tertiary referral centers: Oregon Health Sciences University and University of Alabama at Birmingham. Methods: A review of 1,530 flaps performed in 1,592 patients between 1998 and 2006 were evaluated to identify late flap failure. Late flap failure was defined as failure occurring after postoperative day 7 or on follow-up visits after hospital discharge. A prospective database with the following variables was examined: age, medical comorbidities, postreconstructive complications (fistula or infection), hematoma, seroma, previous surgery, radiation therapy, intraoperative findings at the time of debridement, nutrition, and, possibly, etiologies. Results: A total of 13 patients with late graft failure were identified in this study population of 1,530 (less than 1%) flaps; 6 radial forearm fasciocutaneous flaps, 2 rectus abdominis myocutaneous flaps, 4 fibular flaps, and 1 latissimus dorsi myocutaneous flap underwent late failure. The time to necrosis was a median of 21 (range, 7,90) days. Etiology was believed to possibly be pressure on the pedicle in the postoperative period in four patients (no sign of local wound issues at the pedicle), infection (abscess formation) in three patients, and regrowth of residual tumor in six patients. Loss occurring within 1 month was more common in radial forearm flaps and was presented in the context of a normal appearing wound at the anastomotic site, as opposed to loss occurring after 1 month, which happened more commonly in fibula flaps secondary to recurrence. Conclusion: Although late free flap failure is rare, local factors such as infection and possibly pressure on the pedicle can be contributing factors. Patients presenting with late flap failure should be evaluated for residual tumor growth. [source] A new instrument for pain assessment in the immediate postoperative period,ANAESTHESIA, Issue 4 2009A. M. Machata Summary Perceptual-cognitive impairment after general anaesthesia may affect the ability to reliably report pain severity with the standard visual analog scale (VAS). To minimise these limitations, we developed ,PAULA the PAIN-METER®' (PAULA): it has five coloured emoticon faces on the forefront, it is twice as long as a standard VAS scale, and patients use a slider to mark their pain experience. Forty-eight postoperative patients rated descriptive pain terms on PAULA and on a standard VAS immediately after admission and before discharge from the postanaesthesia care unit. Visual acuity was determined before both assessments. The values obtained with PAULA showed less variance than those obtained with the standard VAS, even at the first assessment, where only 23% of the patients had regained their visual acuity. Furthermore, the deviations of the absolute VAS values in individual patients for each descriptive pain term were significantly smaller with PAULA than with the standard VAS. [source] Recovery from neuromuscular blockade: a survey of practice,ANAESTHESIA, Issue 8 2007M. Grayling Summary At present in the UK there is no consensus regarding the parameters anaesthetists use to indicate adequacy of reversal from neuromuscular blockade. In an attempt to determine current practice, we carried out a survey covering 12 anaesthetic departments throughout the UK. Individuals were asked to give details regarding their usage of available monitors or, alternatively, to list those clinical parameters which they felt offered the best guidance as to the adequacy of recovery from neuromuscular blockade. There was no consensus among anaesthetists as to the most reliable clinical signs of recovery from neuromuscular blockade. There was an apparent lack of understanding of the limitations of some clinical signs used to determine recovery, as well as inappropriate application of others. In all departments where monitors (quantitative or qualitative) were available, there was limited knowledge regarding the current minimum recommended train-of-four ratio which should be observed prior to extubation. There is an apparent overall confusion among clinicians as to the best method to confirm recovery from neuromuscular blockade. This is probably due to the lack of a single reliable clinical test which can be applied in the immediate postoperative period. Insufficient reliance is placed upon the use of quantitative monitors. There is a lack of clarity in national anaesthetic guidelines with respect to monitoring of neuromuscular function. Current standards need to be re-assessed in the light of recent improvements in nerve stimulators. [source] Glycinothorax: a new complication of transurethral surgeryANAESTHESIA, Issue 2 2000J. A. L. Pittman A 76-year-old woman sustained inadvertent perforation of her posterior bladder wall during transurethral resection of a bladder tumour. In the immediate postoperative period, she developed life-threatening respiratory failure following the formation of a large, unilateral pleural effusion. After therapeutic drainage, biochemical analysis of the effusion revealed that it had a high concentration of glycine. The fluid used for intra- and postoperative bladder irrigation had leaked from the perforated bladder and collected in the pleural cavity. This type of hydrothorax complicating endoscopic urological surgery has not been described previously. [source] Surgical treatment of carpal flexural deformity in 72 horsesAUSTRALIAN VETERINARY JOURNAL, Issue 5 2008RE Charman Carpal flexural deformities (CFD) are frequently encountered in the horse, with both congenital and acquired forms described. The success of surgical correction of CFD, both in terms of the ability to achieve a straight palmar carpal angle and the impact on future athletic performance, requires further investigation. Objective To report the surgical management and outcome of treatment of flexural deformity of the carpus in 72 horses up to 12 months of age. Method Information was obtained from the medical records of horses surgically treated for CFD and through follow-up contact with owners. At the time of examination each case was graded on the severity of the flexural deformity as grade 1, 2, or 3, in order of ascending severity. Surgical treatment consisted of tenotomy of the ulnaris lateralis and flexor carpi ulnaris muscles. Re-assessment of the palmar carpal angle was made in the immediate postoperative period and again from at least 8 months after surgery via telephone contact with owners and/or breeders. A successful outcome was defined as achievement of a straight palmar carpal angle. Long term outcome was assessed in terms of fulfilment of intended use for horses reaching 3 years of age at the time of the study. Results A total of 135 surgical procedures were performed on 72 horses. A successful outcome was recorded in 111 limbs (82%). Excluding cases lost to follow-up, surgical correction was more successful in restoring a straight palmar carpal angle in grade 1 limbs (25/25, 100%) compared to grade 2 limbs (78/87, 89%) and grade 3 limbs (8/14, 57%). For those horses that had reached 3 years of age, 26 of 36 Thoroughbreds started in a race (72%) and 12 of 14 non-Thoroughbreds fulfilled their intended use (86%). Conclusion Tenotomy of the ulnaris lateralis and flexor carpi ulnaris tendons for treatment of grade 1 and 2 CFD's has an excellent prognosis for restoration of a straight palmar carpal angle and for intended athletic pursuit of the horse. In cases of grade 3 CFD, the prognosis following surgery is guarded, especially in neonates. Horses treated in this study were up to 12 months of age, indicating that this deformity may not always be self-limiting as previously thought, and treatment may be required for successful resolution of flexural deformity of the carpus in older animals. The results of this study will help veterinarians to make recommendations regarding the surgical treatment of CFDs. [source] Preoperative but not postoperative systemic inflammatory response correlates with survival in colorectal cancer,BRITISH JOURNAL OF SURGERY (NOW INCLUDES EUROPEAN JOURNAL OF SURGERY), Issue 8 2007J. E. M. Crozier Background: The aim of the present study was to evaluate the relationship between the preoperative and postoperative systemic inflammatory response and survival in patients undergoing potentially curative resection for colorectal cancer. Methods: One hundred and eighty patients with colorectal cancer were studied. Circulating concentrations of C-reactive protein (CRP) were measured before surgery and in the immediate postoperative period. Results: The peak in CRP concentration occurred on day 2 (P < 0·001). During the course of the study 59 patients died, 30 from cancer and 29 from intercurrent disease. Day 2 CRP concentrations were dichotomized. In univariable analysis, advanced tumour node metastasis stage (P = 0·002), a raised preoperative CRP level (P < 0·001) and the presence of hypoalbuminaemia (P = 0·043) were associated with poorer cancer-specific survival. Conclusion: Preoperative but not postoperative CRP concentrations are associated with poor tumour-specific survival in patients undergoing potentially curative resection for colorectal cancer. Copyright © 2007 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [source] Fibrin glue for preventing immediate postoperative hypotony following glaucoma drainage implant surgeryACTA OPHTHALMOLOGICA, Issue 3 2006Juha Välimäki Abstract. Purpose:,To prevent a leak of aqueous around the tube in the immediate postoperative period after glaucoma drainage implant (GDI) surgery. Methods:,A total of 42 eyes of 34 consecutive patients with refractory glaucoma requiring single-plate Molteno implantation were retrospectively reviewed. Peritubular filtration was checked intraoperatively in all filtered eyes. Fibrin glue was used over the scleral flap intraoperatively in every eye with peritubular leakage. All Molteno tubes were completely closed with an absorbable ligature. Results:,Peritubular filtration was detected in 11 eyes of 11 patients. All 11 eyes maintained intraocular pressure (IOP) ,,16 mmHg in the immediate postoperative phase. The mean IOP on the first postoperative day was 30.5 ± 10 mmHg. After an average follow-up of 6 months, the mean IOP in these 11 eyes was 19.1 ± 6 mmHg. No complications or Seidel-positive aqueous leak were observed during the follow-up period. Conclusions:,Results suggest that intraoperative use of fibrin glue is a viable option for reducing peritubular filtration and preventing immediate postoperative hypotony after GDI surgery. [source] Long-term remission rates after pituitary surgery for Cushing's disease: the need for long-term surveillanceCLINICAL ENDOCRINOLOGY, Issue 5 2005A. Brew Atkinson Summary Objective, There have been a few reports on long-term remission rates after apparent early remission following pituitary surgery in the management of Cushing's disease. An undetectable postoperative serum cortisol has been regarded as the result most likely to predict long-term remission. Our objective was to assess the relapse rates in patients who underwent transsphenoidal surgery in order to determine whether undetectable cortisol following surgery was predictive of long-term remission and whether it was possible to have long-term remission when early morning cortisol was measurable but not grossly elevated. Endocrinological factors associated with late relapse were also studied. Patients, We reviewed the long-term outcome in 63 patients who had pituitary surgery for the treatment of Cushing's disease between 1979 and 2000. Measurements, Case notes were reviewed and the current clinical and biochemical status assessed. Our usual practice was that early after the operation, an 08:00 h serum cortisol was measured 24 h after the last dose of hydrocortisone. This was followed by a formal low-dose dexamethasone suppression test. Current clinical status and recent 24-h urinary free cortisol values were used as an index of activity of the Cushing's disease. If there was evidence suggesting relapse, a low-dose dexamethasone suppression test was performed. In many patients, sequential collections of early morning urine specimens for urinary cortisol to creatinine ratio were also performed in an attempt to diagnose cyclical and intermittent forms of recurrent hypercortisolism. We did this if there was conflicting endocrine data, or if patients were slow to lose abnormal clinical features. Results, Mean age at diagnosis was 40·3 years (range 14,70 years). Mean follow-up up time was 9·6 years (range 1,21 years). Forty-five patients (9 males/36 females) achieved apparent remission immediately after surgery and were subsequently studied long term. Of these 45 patients, four have subsequently died while in remission from hypercortisolism. Ten of the remaining 41 patients have relapsed. Of those 10, six demonstrated definite cyclical cortisol secretion. Two of the 10 had undetectable basal serum cortisol levels in the immediate postoperative period. Thirty-one patients are still alive and in remission. Fourteen (45%) of the 31 who remained in remission had detectable serum cortisol levels (> 50 nmol/l) immediately postoperatively, and remain in remission after a mean of 8·8 years. Our relapse rate was therefore 10/45 (22%), after a mean follow-up time of 9·6 years, with mean time to relapse 5·3 years. Conclusions, The overall remission rate of 56% (35/63) at 9·6 years follow-up is disappointing and merits some re-appraisal of the widely accepted principle that pituitary surgery must be the initial treatment of choice in pituitary-dependent Cushing's syndrome. Following pituitary surgery, careful ongoing expert endocrine assessment is mandatory as the incidence of relapse increases with time and also with increasing rigour of the endocrine evaluation. A significant number of our patients were shown to have relapsed with a cyclical form of hypercortisolism. [source] A prospective single-blind randomized-controlled trial comparing two surgical techniques for the treatment of snoring: laser palatoplasty versus uvulectomy with punctate palatal diathermyCLINICAL OTOLARYNGOLOGY, Issue 3 2004S. Uppal The aim of this study was to compare laser palatoplasty with uvulectomy with punctate palatal diathermy as treatment modalities for snoring. The study design was a prospective, single-blind, randomized-controlled trial. Eighty-three patients entered the trial. After a mean follow-up period of more than 18 months there was no statistically significant difference between the two groups regarding the patient perception of benefit from surgery or the subjective improvement in snoring. However, there was a statistically significant difference in the degree of pain in the immediate postoperative period (mean difference = 22.14, 95% CI = 7.98,36.31, P = 0.003), with the pain being worse in the laser palatoplasty group. Relative risk of complications for laser palatoplasty was 1.42 (95% CI = 0.93,2.17). The snoring scores and Glasgow Benefit Inventory scores decreased with time in both the groups but there was no statistically significant difference between the two groups. [source] Conservation surgery in the management of T1 and T2 oropharyngeal squamous cell carcinoma: the Birmingham UK experienceCLINICAL OTOLARYNGOLOGY, Issue 6 2002J.C. Watkinson The aim of this paper was to evaluate our experience using conservation surgery in the management of T1 and T2 oropharyngeal squamous cell carcinoma. Eighteen patients underwent conservation surgery between 1993 and 2000 and were analysed retrospectively. The mean age was 54 years and the male to female ratio was 8:1. There were 14 tonsil and 4 tongue base tumours and 83% of cases presented with neck nodes, thereby classifying them as having advanced disease (stages 2,4). All patients received postoperative radiotherapy. All patients were followed up to December 2001. The median follow-up time was 3.8 years (minimum was 1.5 years). The 2-year and 5-year survival rates were 100% and 92% respectively. Approximately 66% of patients returned the EORTC and GHQ/12 quality-of-life questionnaires. Of these, seventy-five percent had a high healthy level of general functioning in accordance with the EORTC general health section. These results show that conservation surgery techniques are effective in the treatment of T1 and T2 oropharyngeal squamous carcinoma associated with significant metastatic neck disease. The techniques are well tolerated, produce minimal functional deficit and do not have a negative impact on the patients quality of life in either the immediate postoperative period or up to 4 years post-treatment. [source] | |||||||||||||||||||||||||