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Postoperative
Terms modified by Postoperative Selected Abstracts3 ISCHEMIC MITRAL VALVE REPAIR: THE IMPACT OF THE MECHANISM OF MITRAL REGURGITATION ON LATE POSTOPERATIVE RESULTSECHOCARDIOGRAPHY, Issue 1 2004E. Ereminien Aim: The aim of our study was to establish the anatomical-functional mechanisms of ischemic mitral regurgitation (MR) and to analyse its impact on late results after mitral valve (MV) reconstructive surgery. Methods: The study included 53 patients with ischemic MR, who underwent CABG and MV repair. MV surgery consisted of subvalvular apparatus repair and/or annuloplasty. 2D Doppler investigations performed pre-, 10,14 days, and 12 months after surgery included evaluation of MV and left ventricular (LV) geometry and function. Results: Analysis of the mechanisms of ischemic MR permitted dividing patients into two groups: group 1,29 patients with inferobasal scar and posterior papillary muscle (PM) displacement, including 22 patients with PM infarction and 7 patients without it, and group 2,24 patients with isolated mitral annulus (MA) dilation. In the case of PM infarction two different mechanisms of MR were stated: (a) P3 restriction and A3 prolapse due to chordal tethering, (b) A3 P3 (commissural) prolapse due to chordal papillary elongation. Preoperatively LV geometry and function were better preserved in group 1 and late MV repair results were better versus (vs.) group 2: LV end-systolic diameter index decreased from 22.9 ± 3.1 mm/m2 to 20.9 ± 3.6 mm/m2 at 1 year, p < 0.05, LV ejection fraction increased from 34.9 ± 8.4 to 41.8 ± 8.1%, respectively, p < 0.05. No significant changes in LV geometry and function were noted in group 2. Conclusions: The underlying mechanism of ischemic MR has an impact on MV repair results. In patients with MR due to posterobasal infarction MV repair resulted in more favorable postoperative effect-marked improvement in LV geometry and function late after surgery versus MR due to isolated MA dilation. [source] Indication of Endoscopic Papillectomy for Tumors of the Papilla of Vater and Its ProblemsDIGESTIVE ENDOSCOPY, Issue 2003HIROYUKI MAGUCHI Discussions have just started in Japan as to the indication, technique and complication of endoscopic papillectomy for tumors of the papilla of Vater. We indicate endoscopic papillectomy for tumors satisfying the following: 1exposed tumor-type adenoma, or carcinoma in adenoma; 2without invasion of duodenal muscularis; and 3no infiltration into the pancreas or the bile duct. Endoscopic papillectomy was performed on 12 patients with tumors of the papilla of Vater that satisfied the above criteria. En bloc snare excision was achieved in 11 out of 12 cases without endoscopic sphincterotomy (EST) or epinephrine injection. Pancreatic stenting was done in 8 cases for prevention of pancreatitis, and bile duct stenting in nine cases for prevention of cholangitis. Postoperative early complications were observed in 5 cases; pancreatitis in 2; pancreatitis and bleeding in 1; bleeding in 1; and bleeding and perforation in 1. Neither recurrence nor metastasis of tumor has been detected during the average postoperative period of 620 days. The treatment can be acknowledged as less invasive therapy. However, management of complications is important, for which further study needs to be accumulated. [source] Influence of psychopathological changes on quality of life after laparoscopic fundoplication for the treatment of gastroesophageal refluxDISEASES OF THE ESOPHAGUS, Issue 1 2010Á. Díaz de Liaño SUMMARY There are references in medical literature to the influence of psychopathological changes and their negative impact on the results of laparoscopic fundoplication. The objective of this study is to analyze the influence of psychological changes, as assessed by the General Health Questionnaire-28 (GHQ-28), on patients undergoing surgery for gastroesophageal reflux. This is a prospective study in a series of 103 consecutive patients (62 males and 41 females with a mean age of 40 years) undergoing laparoscopic fundoplication. In addition to functional studies, patients completed the SF-36, Gastrointestinal Quality of Life Index, and GHQ-28 before surgery. Functional tests and questionnaires were repeated 6 months after surgery. Patients were also questioned about their degree of satisfaction. Postoperative results of patients with a normal GHQ-28 and patients showing psychopathological changes as defined by the GHQ-28 questionnaire before surgery were compared. Overall, all patients experienced an improvement in their quality of life. Forty-one patients showed a pathological result in the preoperative GHQ-28 questionnaire. No differences were found in functional results and degree of satisfaction with surgery between patients with normal and pathological results in the preoperative GHQ-28 questionnaire. However, patients with a pathological result in the preoperative GHQ-28 had poorer results in all domains of the postoperative Gastrointestinal Quality of Life Index and SF36 quality of life questionnaires as compared to patients with a normal preoperative GHQ-28 questionnaire. Patients with pathological results in the preoperative GHQ-28 had poorer results in terms of postoperative quality of life despite having normal postoperative physiological studies; this decreased quality of life did not have an impact on the degree of satisfaction with surgery performed. The GHQ-28 does not therefore appear to serve as a predictor of postoperative satisfaction. [source] Postoperative intensity-modulated radiation therapy for cancers of the paranasal sinuses, nasal cavity, and lacrimal glands: Technique, early outcomes, and toxicity,HEAD & NECK: JOURNAL FOR THE SCIENCES & SPECIALTIES OF THE HEAD AND NECK, Issue 7 2008Bradford S. Hoppe MD Abstract Background Our aim was to review Memorial Sloan-Kettering Cancer Center's experience with postoperative intensity-modulated radiotherapy (IMRT) for paranasal sinus, nasal cavity, and lacrimal gland cancer and report dosimetric measures, toxicity, and outcomes. Methods Between September 2000 and June 2006, 37 patients with paranasal sinus, nasal cavity, or lacrimal gland cancer underwent postoperative IMRT. Median values were as follows: prescription dose, 60 Gy (range, 50,70); PTVD95, 99% (range, 79,101%); optic nerve Dmax, 53 Gy (range, 2,54); optic chiasm Dmax, 51Gy (range, 2,55). Acute and late toxicities were scored by Radiation Therapy Oncology Group morbidity criteria. Results Median follow-up was 28 months. Two-year local progression,free and overall survivals were 75% and 80%. No early- or late-grade 3/4 radiation-induced ophthalmologic toxicity occurred. Conclusions Preliminary results show that adjuvant IMRT in these patients is feasible, allowed for excellent planning target volume (PTV) coverage, and minimized dose delivered to optic structures. Longer follow-up is warranted to assess the extent of late effects and outcomes. © 2008 Wiley Periodicals, Inc. Head Neck, 2008 [source] Illness Representations According to Age and Effects on Health Behaviors Following Coronary Artery Bypass Graft SurgeryJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 3 2001Brooks B. Gump PhD OBJECTIVES: To determine if illness representations differ as a function of age and how these representations, in conjunction with age, predict postoperative health behaviors. DESIGN: Prospective study of patients undergoing coronary artery bypass graft (CABG) surgery. SETTING: A large metropolitan hospital providing regional cardiac care for patients in a tri-state area, located in Pittsburgh, Pennsylvania. PARTICIPANTS: All consenting patients (N = 309) from a consecutive series of patients scheduled for CABG surgery between January 1992 and January 1994. To be eligible for participation, patients could not be scheduled for any other coincidental surgery (e.g., valve replacement), and could not be in cardiac intensive care or experiencing angina at the time of the referral. Participants were predominantly male (70%) and married (80%), and averaged 62.8 years of age. MEASUREMENTS: Postoperative self-reported health behaviors. RESULTS: Older participants awaiting CABG surgery were significantly more likely to believe old age to be the cause of their coronary heart disease (CHD) and significantly less likely to believe genetics, health-damaging behaviors, health protective behaviors, and emotions to be the cause of their CHD than were younger participants awaiting surgery. Furthermore, the older participants were significantly more likely to believe they had no control over the disease and that the disease would be gone after surgery, and reported fewer postoperative health behavior changes than did younger participants. CONCLUSION: These findings demonstrate significant differences in illness representations as a function of age. Furthermore, differences in postoperative health behaviors were consistent with differing illness representations. [source] Partial Aortic Root Remodeling with an Adventitial Inversion Technique for an Acute Type A Aortic DissectionJOURNAL OF CARDIAC SURGERY, Issue 3 2010Junji Yunoki M.D. Postoperative computed tomography at six months showed no dissection or pseudoaneurysm in the aortic root.,(J Card Surg 2010;25:327-329) [source] Beating Heart Ischemic Mitral Valve Repair and Coronary Revascularization in Patients with Impaired Left Ventricular FunctionJOURNAL OF CARDIAC SURGERY, Issue 5 2003Edvin Prifti M.D., Ph.D. Materials and Methods: Between January 1993 and February 2001, 91 patients with LVEF between 17% and 35% and chronic ischemic MVR (grade III,IV), underwent MV repair in concomitance with coronary artery bypass grafting (CABG) Sixty-one patients (Group I) underwent cardiac surgery with cardioplegic arrest, and 30 patients (Group II) underwent beating heart combined surgery. Aortic valve insufficiency was considered a contraindication for the on-pump/beating heart procedure. Mean age in Group I was 64.4 ± 7 years and in Group II, 65 ± 6 years (p = 0.69). Results: The in-hospital mortality in Group I was 8 (13%) patients versus 2 (7%) patients in Group II (p > 0.1). The cardiopulmonary bypass (CPB) time was significantly higher in Group I (p < 0.001). In Groups I and II, respectively (p > 0.1), 2.5 ± 1 and 2.7 ± 0.8 grafts per patient were employed. Perioperative complications were identified in 37 (60.7%) patients in Group I versus 10 (33%) patients in Group II (p = 0.025). Prolonged inotropic support of greater than 24 hours was needed in 48 (78.7%) patients (Group I) versus 15 (50%) patients (Group II) (p = 0.008). Postoperative IABP and low cardiac output incidence were significantly higher in Group I, p = 0.03 and p = 0.027, respectively. Postoperative bleeding greater than 1000 mL was identified in 24 patients (39.4%) in Group I versus 5 (16.7%) in Group II (p = 0.033). Renal dysfunction incidence was 65.6% (40 patients) in Group I versus 36.7% (11 patients) in Group II (p = 0.013). The echocardiographic examination within six postoperative months revealed a significant improvement of MV regurgitation fraction, LV function, and reduced dimensions in both groups. The postoperative RF was significantly lower in Group II patients 12 ± 6 (%) versus 16 ± 5.6 (%) in Group I (p = 0.001). The 1, 2, and 3 years actuarial survival including all deaths was 91.3%, 84.2%, and 70% in Group I and 93.3%, 87.1%, and 75% in Group II (p = ns). NYHA FC improved significantly in all patients from both groups. Conclusion. We conclude that patients with impaired LV function and ischemic MVR may undergo combined surgery with acceptable mortality and morbidity. The on/pump beating heart MV repair simultaneous to CABG offers an acceptable postoperative outcome in selected patients. [source] Impact of environmental and hereditary risk factors on the clinical manifestation of thrombophilia in homozygous carriers of factor V:G1691AJOURNAL OF THROMBOSIS AND HAEMOSTASIS, Issue 3 2004S. Ehrenforth Summary.,Background:,Limited data exist on the clinical manifestations of homozygous factor (F)V:G1691A mutation (FV Leiden) and the impact of environmental and genetic risk factors. Objectives:,To assess the contribution of these factors on the thrombophilic phenotype. Patients and methods:,In a retrospective multicenter cohort study 165 individuals with homozygous FV:G1691A mutation, of whom 129 had previous venous thromboembolism (VTE), were included. To study the role of environmental risk factors, patients were compared by the use of a standardized questionnaire to 165 sex- and age-matched individuals (reference group A); of these, two had previous VTE. To assess the role of genetic risk factors, factor (F)II:G20210A and MTHFR:C677T were determined in individuals homozygous for FV:G1691A and in 177 healthy individuals without previous VTE (reference group B). Results:,The first VTE occurred significantly earlier in women (median age 25 years) than men (35.5 years). In 81% of women and 29% of men an environmental risk factor was present before first VTE. Oral contraceptives increased the risk of thrombosis 4-fold [odds ratio (OR) 4.0, 95% confidence interval (CI) 1.7, 10.4] in women with homozygous FV:G1691A. Postoperative and post-traumatic VTE as first manifestation occurred in 13% and 15% of surgical/traumatic events in patients and in 0.7% and 1.8% in reference group A, respectively (OR 19.7, 95% CI 2.5, 154 and OR 9.2, 95% CI 1.1, 79.4). Heterozygous FII:G20210A was more prevalent in symptomatic patients (11.7%) compared with reference group B (2.8%, OR 4.6, 95% CI 1.6, 13.2). The prevalence of homozygous MTHFR:C677T genotype was similar in patients and reference group B. Conclusions:,Our study supports the concept of thrombophilia as a multifactorial disorder. The knowledge of coexisting factors predisposing to VTE is useful for medical advice for primary and secondary prophylaxis in these patients. [source] Postoperative elevated cortisol excretion is not associated with suppression of 6-sulfatoxymelatonin excretionACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 1 2005J. Derenzo This study tests the hypothesis that elevated postoperative excretion of cortisol is associated with suppression of the nocturnal excretion of 6-sulfatoxymelatonin, the chief metabolite of the circadian hormone, melatonin. Postoperative patients demonstrate circadian rhythm disturbances and suppression of nocturnal melatonin plasma concentration. Since the nocturnal surge in melatonin concentration in normal volunteers is time-locked to the circadian nadir of cortisol concentration, perhaps the attenuation of the nocturnal melatonin surge in postoperative patients results from prolonged elevation in the plasma cortisol concentration. In this observational study performed in 21 patients having unilateral hip or knee arthroplasty, urine was collected every 4 h for the first 48 h after surgery for measurement of urinary 6-sulfatoxymelatonin (EIA) and free cortisol (RIA) excretion. The total (P < 0.05) and peak (P < 0.02) nocturnal 6-sulfatoxymelatonin excretions were lower on the first than the second postoperative night. The nocturnal cortisol nadir preceded the 6-sulfatoxymelatonin surge in 20% of the subjects on night 1 and in 75% of the subjects on night 2. The lack of a consistent relationship between the magnitude or timing of cortisol excretion and 6-sulfatoxymelatonin excretion suggests that cortisol does not mediate postoperative 6-sulfatoxymelatonin suppression. [source] Postoperative shivering in children and causative factorsPEDIATRIC ANESTHESIA, Issue 12 2005AYNUR AKIN MD Summary Background:, The aim of this study is to investigate the incidence of shivering in children and to reveal the causative factors as well as any possible clinical implications. Methods:, This study was conducted on 1507 children who underwent surgery under general anesthesia. The patients were admitted to the postanesthesia care unit after the operation and their body temperatures measured from the tympanic membrane. The type of operation, operative time, method of anesthesia induction, age, and number of cases in which caudal block had been used were recorded. Results:, Of the 1507 children, 53 (3.5%) experienced shivering. The use of intravenous induction agents, age older than 6 years, and prolonged duration of surgery were associated with shivering. The type of the operation and gender had no effect. The frequency of shivering was lower in children who underwent caudal block with a statistical significance (P < 0.05). Conclusions:, The overall incidence of shivering in children is low (3.5%). Use of intravenous induction agents, age older than 6 years, and prolonged duration of surgery were associated with shivering; prophylaxis is not necessary in children, treatment is given only when shivering occurs. [source] HP23 USE OF ANTI-REFLUX MEDICATION AFTER ANTI-REFLUX SURGERYANZ JOURNAL OF SURGERY, Issue 2007B. P. L. Wijnhoven Purpose It is thought that a substantial number of patients who undergo anti-reflux surgery use anti-reflux medication post operatively, despite no objective evidence of reflux. This study aims to determine the prevalence and underlying reasons for anti-reflux medication usage in patients after anti-reflux surgery. Methodology A questionnaire (13 questions) on the usage of anti-reflux medication was sent to 1016 patients from a prospective database of anti-reflux surgery patients. Results 852 patients (84%), (437 males & 415 females with a mean age 58 yrs) returned the questionnaire. Mean follow up was 5.9 yrs after surgery. A single or combination of medications was being taken by 319 patients (37%): 82% proton pump inhibitors, 9% H2-blockers and 34% antacids. 54 patients (18%) had never stopped taking medication, whereas 261 patients (82%) re-started medication at a mean of 2.4 yrs after surgery. Persistent or return of the same or different symptoms was the reason for taking medication by the vast majority (85%), whereas 15% were asymptomatic or had other reasons for medication use. A response of symptoms to the medication occurred for 30% of the patients, whereas 64% noticed some improvement. Postoperative 24-hour pH studies (while off medication) were abnormal in 17/62 patients (27%) on medication and in 5/73 patients (6%) not taking medication. Conclusions Anti-reflux medication is frequently taken by patients for symptoms after surgery, despite normal pH profiles in the majority. Strategies need to be employed to lower the inappropriate use of medications after surgery and to further evaluate the mechanisms underlying postoperative symptoms, which are non-responsive to anti-reflux medication. [source] Postoperative reduced dose of cisplatin concomitant with radiation therapy in high- risk head and neck squamous cell carcinoma,CANCER, Issue 11 2009Giovanni Franchin MD Abstract BACKGROUND: The role of low doses of cisplatin and concomitant postoperative radiotherapy in high risk head and neck squamous cell carcinoma has not yet been defined. METHODS: Patients treated with definitive surgery, who had histological evidence of involvement of more than 2 lymph nodes, extracapsular extension of disease, perineural and/or intravascular invasion, involved or close surgical margins, received postoperative radiotherapy plus 75 mg/m2 of cisplatin every 3 weeks during the radiotherapy cycle. The primary endpoints were to evaluate treatment compliance and overall, cause-specific, and disease-free survival. RESULTS: A total of 142 patients were enrolled. With a median follow-up of 40 months, 5-year overall survival was 68%, cause-specific survival 78% and disease-free survival 82%. At multivariate analysis surgical margins status and extracapsular lymph node invasion were the only statistically significant prognostic factors. Fifty-three percent of the patients developed severe mucositis and 14% hematologic toxicity of grade 3. The 3 planned concomitant chemotherapy cycles were delivered to 48% of the patients. CONCLUSIONS: Postoperative radiotherapy and concomitant low-dose cisplatin was an effective treatment in high risk head and neck patients. The total toxicity observed was lower compared with that reported with higher doses of cisplatin, although the delivery of all the 3 planned chemotherapy cycles was challenging. The distant failure rate was high, which was an unsatisfactory result. Cancer 2009. © 2009 American Cancer Society. [source] The effect of microplamin on wound healing after glaucoma filtration surgeryACTA OPHTHALMOLOGICA, Issue 2009T VAN BERGEN Purpose The outcome of trabeculectomy can be diminished due to a decreased bleb function secondary to blood/ fibrin clot in the aqueous outflow pathway. The aim of this study is to investigate whether the administration of Microplasmin (ThromboGenics), a recombinant protein that dissolves clot and fibrin, could lead to a better maintenance of the constructed channel, and thus improve surgical outcome after trabeculectomy. Methods The effect of Microplasmin will be investigated in vivo in a mouse model for conjunctival fibrosis and in a rabbit model for glaucoma surgery. Postoperative follow up of the animals will take place daily during the first week and two-daily until they are scarified. On specific time points animals will be sacrificed and both eyes will be enucleated. Seven-µm thin slides will be (immuno-)stained for CD45 to evaluate inflammation and for Sirius red and Trichrome to evaluate fibrosis. Results Preliminary results showed that Microplasmin significantly improved glaucoma surgery outcome in the rabbit model of aggressive scarring compared to control. Conclusion Our proposed research project will elucidate the potential role of Microplasmin in the improvement of filtration surgery outcome, and will highlight any anti-clotting, anti-inflammatory, and/or anti-fibrotic effects of this molecule. Microplasmin as an adjuvant therapy in glaucoma surgery might open new perspectives for more efficient surgery. [source] Palmaris profundus: One name, several subtypes, and a shared potential for nerve compressionCLINICAL ANATOMY, Issue 6 2009Elena Pirola Abstract The palmaris profundus is a rare, but known anatomic variation which may lead to compression of the median nerve and/or its branches. Two patients with carpal tunnel syndrome are presented in whom a palmaris profundus was discovered at operation. In these cases, median nerve compression at the wrist was attributed to the course of the extra tendon and its local mass effect on the nerve (i.e., the palmaris profundus and median nerve shared a common sheath); more commonly, the resultant decreased available space for the median nerve within the carpal tunnel due to the presence of an accessory (10th) flexor tendon is thought to be responsible. Postoperative 3 Tesla magnetic resonance imaging (MRI) was performed to demonstrate the full course of the variant muscle; despite variations in the size and longitudinal extent of the accessory musculotendinous unit, an important similarity was noted: the intimate relationship of the median nerve and the palmaris profundus. These two cases and our review of the literature highlight the fact that one name (i.e. palmaris profundus) reflects several anatomic subtypes. However, the close relationship of the palmaris profundus with the median nerve in the forearm and the palm is a common theme which emphasizes the potential pathoanatomic consequences of this relationship: nerve compression. Clin. Anat. 22:643,648, 2009. © 2009 Wiley-Liss, Inc. [source] Risk factors for anastomotic leakage after anterior resection of the rectumCOLORECTAL DISEASE, Issue 6 2004P. Matthiessen Abstract Objective Surgical technique and peri-operative management of rectal carcinoma have developed substantially in the last decades. Despite this, morbidity and mortality after anterior resection of the rectum are still important problems. The aim of this study was to identify risk factors for anastomotic leakage in anterior resection and to assess the role of a temporary stoma and the need for urgent re-operations in relation to anastomotic leakage. Patients and methods In a nine-year period, from 1987 to 1995, a total of 6833 patients underwent elective anterior resection of the rectum in Sweden. A random sample of 432 of these patients was analysed (sample size 6.3%). The associations between death and 10 patient- and surgery-related variables were studied by univariate and multivariate analysis. Data were obtained by review of the hospital files from all patients. Results The incidence of symptomatic clinically evident anastomotic leakage was 12% (53/432). The 30-day mortality was 2.1% (140/6833). The rate of mortality associated with leakage was 7.5%. A temporary stoma was initially fashioned in 17% (72/432) of the patients, and 15% (11/72) with a temporary stoma had a clinical leakage, compared with 12% (42/360) without a temporary stoma, not significant. Multivariate analysis showed that low anastomosis (, 6 cm), pre-operative radiation, presence of intra-operative adverse events and male gender were independent risk factors for leakage. The risk for permanent stoma after leakage was 25%. Females with stoma leaked in 3% compared to men with stoma who leaked in 29%. The median hospital stay for patients without leakage was 10 days (range 5,61 days) and for patients with leakage 22 days (3,110 days). Conclusion In this population based study, 12% of the patients had symptomatic anastomotic leakage after anterior resection of the rectum. Postoperative 30-day mortality was 2.1%. Low anastomosis, pre-operative radiation, presence of intra-operative adverse events and male gender were independent risk factors for symptomatic anastomotic leakage in the multivariate analysis. There was no difference in the use of temporary stoma in patients with or without anastomotic leakage. [source] Early Surgical Morbidity and Mortality in Adults with Congenital Heart Disease: The University of Michigan ExperienceCONGENITAL HEART DISEASE, Issue 2 2008Ginnie L. Abarbanell MD ABSTRACT Objectives., To review early surgical outcomes in a contemporary series of adults with congenital heart disease (CHD) undergoing cardiac operations at the University of Michigan, and to investigate possible preoperative and intraoperative risk factors for morbidity and mortality. Methods., A retrospective medical record review was performed for all patients ,18 years of age who underwent open heart operations by a pediatric cardiothoracic surgeon at the University of Michigan Congenital Heart Center between January 1, 1998 and December 31, 2004. Records from a cohort of pediatric patients ages 1,17 years were matched to a subset of the adult patients by surgical procedure and date of operation. Results., In total, 243 cardiac surgical operations were performed in 234 adult patients with CHD. Overall mortality was 4.7% (11/234). The incidence of major postoperative complications was 10% (23/234) with a 19% (45/23) minor complication rate. The most common postoperative complication was atrial arrhythmias in 10.8% (25/234). The presence of preoperative lung or liver disease, prolonged cardiopulmonary bypass and aortic cross clamp times, and postoperative elevated inotropic score and serum lactates were significant predictors of mortality in adults. There was no difference between the adult and pediatric cohorts in terms of mortality and morbidity. Conclusions., The postoperative course in adults following surgery for CHD is generally uncomplicated and early survival should be expected. Certain risk factors for increased mortality in this patient population may include preoperative presence of chronic lung or liver dysfunction, prolonged cardiopulmonary bypass and aortic cross-clamp times, and postoperative elevated inotropic score and serum lactate levels. [source] A Simple Method of Designing a Bilobed Flap Using a Triangle TemplateDERMATOLOGIC SURGERY, Issue 10 2004Li-Xing Man MSc Background. The bilobed flap is useful for the reconstruction of skin defects in which the primary closure is difficult. Proper design is paramount to achieve excellent cosmetic results, but flap design often appears unnecessarily complex and difficult. Objective. The objective was to discuss the geometry of the bilobed flap and describe a simple and practical method for constructing such flaps using a triangle template with emphasis on the pivot point. Methods. A detailed description with diagrams and an illustrative case are presented to demonstrate the technique. Results. A patient with a scalp defect was reconstructed with a triangle-template-designed bilobed flap with excellent postoperative results. Conclusion. This new method using a triangle template ensures proper placement of the pivot point and will enable practitioners to achieve superior outcomes. [source] The Laser-Assisted Neck Lift: Modifications in Technique and Postoperative Care to Improve ResultsDERMATOLOGIC SURGERY, Issue 6 2002F. Richard Noodleman MD background. Conventional submental tumescent liposuction has proved disappointing for some patients with anterior neck laxity, ptotic platysma muscles, and increased subplatysmal fat. Many of these patients are facelift candidates but are unwilling to undergo this extensive procedure. We describe our hybrid approach, which offers consistently improved results and enhanced patient satisfaction. objective. To establish a sharper cervicomental angle by more completely removing subplatysmal fat. We also wished to achieve more consistent, smoother results, minimizing ripples, folds, and hematomas with a novel postoperative dressing system. methods. Extensive tumescent liposuction of the lower face, jowls, and anterior neck was performed. Following this, subplatysmal fat was removed by dissection, the platysma muscle was imbricated, and the CO2 laser utilized in a defocused, low-power mode to partially treat the dermal undersurface and underlying muscle. Our postoperative dressing included a 10 cm mineral oil polymer gel disc in the submental location, covered by tape, silicone foam, and a lower face and neck garment to provide both support and even compression over the entire neck for at least the first 24 hours. results. Results proved uniformly satisfying for most patients, even those in their senior years. Benefits included an improved cervicomental angle, a decrease in jowling, and a marked reduction in the laxity and wrinkling of the neck skin and horizontal neck creases. Problems related to postoperative rippling or folding of the redraped skin and hematoma formation were minimized. conclusion. Laser neck tightening combined with tumescent liposuction and an advanced postoperative dressing for superior support and uniform compression has resulted in consistently excellent outcomes with improved patient satisfaction. [source] Laparoscopic Heller myotomy with Dor fundoplication for achalasia: long-term outcomes and effect on chest painDISEASES OF THE ESOPHAGUS, Issue 4 2010A. Sasaki SUMMARY The aim of the present study was to evaluate the long-term outcomes of laparoscopic Heller myotomy with Dor fundoplication (LHD) and its effect on chest pain. Between June 1995 and August 2009, a total of 35 patients with achalasia underwent an LHD. The symptom scores were calculated by combining the frequency and the severity. Pre- and postoperative evaluations included symptom score, radiology, manometry, and 24-hour pH manometry. Median total symptom score was significantly lower than the preoperative score (19 vs 4, P < 0.001) at a median follow-up of 94 months. Among the 35 patients, 18 (51%) had chest pain. The frequency of chest pain was similar for the pre- and postoperative scores, but the severity tended to be less. Median esophageal diameter (5.4 cm vs 3.5 cm, P < 0.001) and lower esophageal sphincter pressure (41 mmHg vs 8.9 mmHg, P < 0.001) were significantly reduced after surgery. Median age, duration of symptoms, esophageal diameter, and lower esophageal sphincter pressure were similar between patients with and without chest pain prior to surgery. No significant differences were observed between the two groups in terms of amplitude, duration, and frequency of contractions from the findings of postoperative 24-hour esophageal manometry. Chest pain resolved in three patients (17%) and improved in seven patients (39%) after surgery. LHD can durably relieve achalasic symptoms of both dysphagia and regurgitation, and it can be considered the surgical procedure of choice. However, achalasic chest pain does not always seem to be related with patient characteristics and manometric findings. [source] Endoscopic bougienage of benign anastomotic strictures in patients after esophageal resection: the effect of the extent of stricture on bougienage resultsDISEASES OF THE ESOPHAGUS, Issue 6 2008G. Marjanovic SUMMARY., The aim of our retrospective study was to determine the incidence of benign anastomotic strictures (BAS) in patients after esophageal resection and to examine the influence of the extent of BAS on the results of bougienage therapy. From January 2001 to July 2006, 79 patients at risk of BAS development were included in the study. BAS was diagnosed with a median delay of 8 weeks (4,26) postoperative in 23 patients (29%). A median of 4 bougienage sessions (2,20) was needed for success (success rate 100%). The mean follow-up time was 22 months [range 3,47]. There were no late recurrences of BAS. Five patients had an anastomosis diameter <5.5 mm and 14 patients >5.5 mm. There was no difference in median number of bougienage procedures in these subgroups (4.5 [2,9] vs. 4 [2,20]). Patients who presented with BAS earlier than 6 weeks postoperative had more procedures (median 8 [2,20] vs. 4 [2,9]) than those presenting later. Patients in whom first bougienage was possible to only 16 mm diameter needed more procedures than patients in whom first dilation was possible to more than 16 mm (median 5.5 [3,20] vs. 3 [2,9]). In conclusion, both early BAS development and the diameter of bougienage at first endoscopy, but not the extent of stricture, seem to be predictive factors for longer bougienage therapy. In order to influence the BAS formation early, we now routinely examine every patient after esophageal resection endoscopically in the 6th postoperative week. [source] Has the Clinical Presentation and Clinician's Index of Suspicion of Cardiac Tamponade Changed Over the Past Decade?ECHOCARDIOGRAPHY, Issue 3 2008Sachin Gandhi M.D. It remains unclear whether advances in the understanding of the pathophysiology and improvements in cardiovascular imaging over the years have impacted the clinician's recognition of cardiac tamponade (CT). We sought to evaluate signs and symptoms of CT in a present-day population and compare it to a similar group from a decade prior. We performed a retrospective analysis of two cohorts of patients presenting to a tertiary hospital with CT, all of whom underwent pericardial drainage (PD). Group 1 (Gp1) included subjects presenting from 1988 to 1991 and Group 2 (Gp2) included subjects from 2002 to 2005. Fifty-five patients comprised each group, with an average age of 55 years. Seventy-one percent of patients in Gp1 had identifiable cardiovascular symptoms 1 week prior to presentation, compared to 33% in Gp2. Dyspnea was the most common symptom in both groups, and was less frequent in Gp2. Compared with Gp1, chest pain, cough, and lethargy were also less frequent in Gp2. One day prior to PD, tachypnea and pulsus paradoxus were detected more frequently in Gp1 compared to Gp2. Large, circumferential pericardial effusions were the most frequent echocardiographic findings in both groups and the most common etiology of CT was malignancy in Gp1and postoperative bleeding in Gp2. Thus, the recognition of symptoms and physical signs in patients presenting with CT has changed over the past decade, as has etiology of pericardial effusions. However, the diagnosis of CT still remains delayed, and the present data emphasize the need for a heightened index of suspicion for recognizing this hemodynamically-important process. [source] 3 ISCHEMIC MITRAL VALVE REPAIR: THE IMPACT OF THE MECHANISM OF MITRAL REGURGITATION ON LATE POSTOPERATIVE RESULTSECHOCARDIOGRAPHY, Issue 1 2004E. Ereminien Aim: The aim of our study was to establish the anatomical-functional mechanisms of ischemic mitral regurgitation (MR) and to analyse its impact on late results after mitral valve (MV) reconstructive surgery. Methods: The study included 53 patients with ischemic MR, who underwent CABG and MV repair. MV surgery consisted of subvalvular apparatus repair and/or annuloplasty. 2D Doppler investigations performed pre-, 10,14 days, and 12 months after surgery included evaluation of MV and left ventricular (LV) geometry and function. Results: Analysis of the mechanisms of ischemic MR permitted dividing patients into two groups: group 1,29 patients with inferobasal scar and posterior papillary muscle (PM) displacement, including 22 patients with PM infarction and 7 patients without it, and group 2,24 patients with isolated mitral annulus (MA) dilation. In the case of PM infarction two different mechanisms of MR were stated: (a) P3 restriction and A3 prolapse due to chordal tethering, (b) A3 P3 (commissural) prolapse due to chordal papillary elongation. Preoperatively LV geometry and function were better preserved in group 1 and late MV repair results were better versus (vs.) group 2: LV end-systolic diameter index decreased from 22.9 ± 3.1 mm/m2 to 20.9 ± 3.6 mm/m2 at 1 year, p < 0.05, LV ejection fraction increased from 34.9 ± 8.4 to 41.8 ± 8.1%, respectively, p < 0.05. No significant changes in LV geometry and function were noted in group 2. Conclusions: The underlying mechanism of ischemic MR has an impact on MV repair results. In patients with MR due to posterobasal infarction MV repair resulted in more favorable postoperative effect-marked improvement in LV geometry and function late after surgery versus MR due to isolated MA dilation. [source] Functional MRI Predicts Memory Performance after Right Mesiotemporal Epilepsy SurgeryEPILEPSIA, Issue 2 2005Jozsef Janszky Summary:,Purpose: Anterior temporal lobe resection (ATR) is a treatment option in drug-resistant epilepsy. An important risk of ATR is loss of memory because mesiotemporal structures contribute substantially to memory function. We investigated whether memory-activated functional MRI (fMRI) can predict postoperative memory loss after anterior temporal lobectomy in right-sided medial temporal lobe epilepsy (MTLE). Methods: We included 16 patients (10 women) aged 16,54 years. The mean age at epilepsy onset was 12.5 years (range, 1,26 years). The patients' mean Wechsler IQ score was 95.2 (range, 62,125). The activation condition of fMRI consisted of retrieval from long-term memory induced by self-paced performance of an imaginative walk. All but one patient had left-sided speech dominance according to speech-activated fMRI. Outside the scanner, we evaluated the pre- and postoperative visual memory retention by using Rey Visual Design Learning Test. Results: We found a correlation between the preoperative asymmetry index of memory- fMRI and the change between pre- and postsurgical measures of memory retention. Reduced activation of the mesiotemporal region ipsilateral to the epileptogenic region correlated with a favorable memory outcome after right-sided ATR. Conclusions: In light of the postoperative results, the theoretical implication of our study is that fMRI based on a simple introspective retrieval task measures memory functions. The main clinical implication of our study is that memory- fMRI might replace the invasive Wada test in MTLE by using a simple fMRI paradigm. Predictive power, however, will be studied in larger patient samples. Other studies are required for left-sided MTLE and neocortical epilepsies to assess the clinical usefulness of memory- fMRI. [source] Effect of preoperative prophylaxis with filgrastim in cancer neck dissectionEUROPEAN JOURNAL OF CLINICAL INVESTIGATION, Issue 5 2000Wenisch Background Cancer surgery is known to lead to a deterioration in host defence mechanisms and an increase in susceptibility to infection after operation. Filgrastim enhances important antimicrobial functions of neutrophils including chemotaxis, phagocytosis and oxidative killing mechanisms. Methods The effects of additional (all patients received perioperative 3 , 25 mg kg,1 cefotiam and 1 , 20 mg kg,1 metronidazole) preoperative prophylaxis with filgrastim (5 ,g kg,1 12 h prior to surgery plus 5 ,g kg,1 0 h prior to surgery) on neutrophil phagocytosis and reactive oxygen radical production and postoperative infections in 24 patients undergoing cancer neck dissection were studied. Phagocytic capacity was assessed by measuring the uptake of fluorescein isothiocyanate-labelled Escherichia coli and Staphylococcus aureus by flow cytometry. Reactive oxygen generation after phagocytosis was estimated by determining the amount of dihydrorhodamine 123 converted to rhodamine 123, intracellularly. Results In the filgrastim-treated patients a higher neutrophil phagocytic capacity was seen intraoperatively, and 1,5 days postoperative, but not prior to surgery. Reactive oxygen radical production was significantly higher in filgrastim-treated patients prior to surgery, intraoperative and postoperative (1,5 days). 2/12 (17%) patients had postoperative infections in the filgrastim group and 9/12 (75%) patients had infections in the placebo group (P < 0.001). In particular, wound infections were recorded more often in the placebo group (1/12 vs. 6/12; P = 0.004). Conclusion We conclude that filgrastim enhances perioperative neutrophil function and could be useful in the prophylaxis of postoperative wound infections in patients undergoing cancer neck dissection. [source] Cost minimization analysis to compare activated prothrombin complex concentrate (APCC) and recombinant factor VIIa for haemophilia patients with inhibitors undergoing major orthopaedic surgeriesHAEMOPHILIA, Issue 5 2009P. O. BONNET Summary., Benefits of bypassing agents for maintaining haemostasis in major surgeries have been described in the literature; however, their use has a substantial economic impact. This study assessed the cost of FEIBA, an activated prothrombin complex concentrate and recombinant factor VIIa (rFVIIa) when used in inhibitor patients undergoing major surgeries. After reviewing published literature, a cost minimization model was developed describing dosing regimens recommended and used during major surgeries for FEIBA (pre-operative: 75,100 U kg,1; postoperative: 75,100 U kg,1 q 8,12 h days 1,5 and 75,100 U kg,1 q 12 h days 6,14) and rFVIIa (pre-operative: 90 ,g kg,1; intra-operative: 90 ,g kg,1 q 2 h; postoperative: 90 ,g kg,1 q 2,4 h days 1,5 and 90 ,g kg,1 q 6 h days 6,14). Using a 75 kg patient and US prices, total drug cost was calculated for three scenarios: use of FEIBA or rFVIIa alone and a third case combining rFVIIa pre- and intra-operative and FEIBA throughout a 14-day postoperative period. Dosage amounts of modelled bypassing agents were similar to cases in the literature. Using FEIBA instead of rFVIIa would decrease total drug cost by >50% and save over $400 000 per surgery. Sequential use of both bypassing agents would increase total drug cost by 9% when compared with FEIBA alone, but would remain >40% lower than rFVIIa alone. Univariate sensitivity analyses confirmed robustness of results. As large amounts of bypassing agents are necessary for patients with inhibitors to undergo major surgeries, cost is a major consideration. Use of FEIBA alone or in combination with rFVIIa has emerged as a cost-saving approach. [source] Total joint arthroplasty in haemophiliaHAEMOPHILIA, Issue 5 2000Beeton In severely affected haemophilic patients arthropathy is a common problem which can lead to considerable pain and functional deficit. Surgical management, including total joint arthroplasty, can be undertaken if conservative management fails. A search of the literature showed that a number of studies describing the use of total knee arthroplasty (TKA) and total hip arthroplasty (THA) in haemophilia have been published, whereas shoulder, elbow and ankle arthroplasties are confined to case reports. This paper reviews the functional outcome of arthroplasty in the different joints, the postoperative and long-term complications, and the impact of HIV. Although complications are commonly described and the surgery is technically demanding, the results suggest that arthroplasty, particularly of the hip and knee, can be a valuable option in the management of severe haemophilic arthropathy. [source] Postoperative intensity-modulated radiation therapy for cancers of the paranasal sinuses, nasal cavity, and lacrimal glands: Technique, early outcomes, and toxicity,HEAD & NECK: JOURNAL FOR THE SCIENCES & SPECIALTIES OF THE HEAD AND NECK, Issue 7 2008Bradford S. Hoppe MD Abstract Background Our aim was to review Memorial Sloan-Kettering Cancer Center's experience with postoperative intensity-modulated radiotherapy (IMRT) for paranasal sinus, nasal cavity, and lacrimal gland cancer and report dosimetric measures, toxicity, and outcomes. Methods Between September 2000 and June 2006, 37 patients with paranasal sinus, nasal cavity, or lacrimal gland cancer underwent postoperative IMRT. Median values were as follows: prescription dose, 60 Gy (range, 50,70); PTVD95, 99% (range, 79,101%); optic nerve Dmax, 53 Gy (range, 2,54); optic chiasm Dmax, 51Gy (range, 2,55). Acute and late toxicities were scored by Radiation Therapy Oncology Group morbidity criteria. Results Median follow-up was 28 months. Two-year local progression,free and overall survivals were 75% and 80%. No early- or late-grade 3/4 radiation-induced ophthalmologic toxicity occurred. Conclusions Preliminary results show that adjuvant IMRT in these patients is feasible, allowed for excellent planning target volume (PTV) coverage, and minimized dose delivered to optic structures. Longer follow-up is warranted to assess the extent of late effects and outcomes. © 2008 Wiley Periodicals, Inc. Head Neck, 2008 [source] Prognostic value of postsurgical stimulated thyroglobulin levels after initial radioactive iodine therapy in well-differentiated thyroid carcinoma,HEAD & NECK: JOURNAL FOR THE SCIENCES & SPECIALTIES OF THE HEAD AND NECK, Issue 6 2008Anna M. Sawka MD, FRCPC Abstract Background. In well-differentiated thyroid carcinoma, predictors of future positivity of stimulated thyroglobulin (>2 ,g/L) after initial radioactive iodine treatment are not known. Methods. In a retrospective study, we used logistic regression analysis to determine whether postoperative stimulated thyroglobulin measurements and pathologic stage independently predict future stimulated thyroglobulin positivity. Results. We followed 141 patients with well-differentiated thyroid carcinoma for a median of 35 months; follow-up stimulated thyroglobulin measurements were positive in 20.6% (29/141). The natural logarithm of the postsurgical stimulated thyrogolobulin was independently associated with a positive stimulated thyroglobulin at long-term follow-up (odds ratio [OR], 4.44; 95% confidence interval [CI], 2.33,8.45; p < .001); there was a trend for a positive association of TNM stage with positive follow-up stimulated thyroglobulin (p = .054). Lymph node positivity predicted a positive stimulated thyroglobulin in papillary cancer. Conclusions. Stimulated thyroglobulin measurements prior to initial radioactive iodine treatment independently predict future stimulated thyroglobulin positivity in well-differentiated thyroid carcinoma. © 2007 Wiley Periodicals, Inc. Head Neck, 2008 [source] Themes of liver transplantation,HEPATOLOGY, Issue 6 2010Thomas E. Starzl Liver transplantation was the product of five interlocking themes. These began in 1958-1959 with canine studies of then theoretical hepatotrophic molecules in portal venous blood (Theme I) and with the contemporaneous parallel development of liver and multivisceral transplant models (Theme II). Further Theme I investigations showed that insulin was the principal, although not the only, portal hepatotrophic factor. In addition to resolving long-standing controversies about the pathophysiology of portacaval shunt, the hepatotrophic studies blazed new trails in the regulation of liver size, function, and regeneration. They also targeted inborn metabolic errors (e.g., familial hyperlipoproteinemia) whose palliation by portal diversion presaged definitive correction with liver replacement. Clinical use of the Theme II transplant models depended on multiple drug immunosuppression (Theme III, Immunology), guided by an empirical algorithm of pattern recognition and therapeutic response. Successful liver replacement was first accomplished in 1967 with azathioprine, prednisone, and antilymphoid globulin. With this regimen, the world's longest surviving liver recipient is now 40 years postoperative. Incremental improvements in survival outcome occurred (Theme IV) when azathioprine was replaced by cyclosporine (1979), which was replaced in turn by tacrolimus (1989). However, the biologic meaning of alloengraftment remained enigmatic until multilineage donor leukocyte microchimerism was discovered in 1992 in long-surviving organ recipients. Seminal mechanisms were then identified (clonal exhaustion-deletion and immune ignorance) that linked organ engraftment and the acquired tolerance of bone marrow transplantation and eventually clarified the relationship of transplantation immunology to the immunology of infections, neoplasms, and autoimmune disorders. With this insight, better strategies of immunosuppression have evolved. As liver and other kinds of organ transplantation became accepted as healthcare standards, the ethical, legal, equity, and the other humanism issues of Theme V have been resolved less conclusively than the medical-scientific problems of Themes I-IV. HEPATOLOGY 2010 [source] Testicular metastasis from hepatocellular carcinomaINTERNATIONAL JOURNAL OF UROLOGY, Issue 7 2006CHIEN HSIANG WANG Abstract, We document a case of testicular metastasis from hepatocellular carcinoma. The patient suffered from bilateral testicular painful swelling for 6 months. Scrotal ultrasonography showed bilateral testicular tumors and the whole abdominal computed tomography revealed a huge tumor in the left lobe of the liver. Bilateral orchiectomy and postoperative ultrasound-guided liver biopsy were done. Pathological examination revealed metastatic hepatocellular carcinoma. Hepatocellular carcinoma with testicular metastases is a very rare disease. [source] | ||||||||||||||||||||||||||||||||||||||||