Distribution by Scientific Domains
Distribution within Medical Sciences

Kinds of Post-operatively

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  • Selected Abstracts

    Gastric myoelectrical activity post-chemoradiotherapy and esophagectomy: a prospective study using subscapular surface recording

    P. M. Lawlor
    SUMMARY., The aims of this study were to prospectively evaluate gastric function in esophageal cancer patients after chemoradiotherapy and following surgery, using cutaneous electrogastrography (EGG). Twenty-three patients with esophageal adenocarcinoma were recruited to the study. A subset of patients (n = 11) underwent neoadjuvant chemoradiotherapy and were also studied at 14 days after treatment. All patients underwent EGG studies prior to and following surgery, at 3 months postoperatively. Ten of these patients were also studied at medians of 6 months and 12 months after surgery. Twenty normal volunteers were used as controls. Post-operative EGG studies were monitored with a modified technique; the electrodes being placed in the subscapular region in the area of the transposed stomach. Following neoadjuvant treatment there was a significant increase in abnormal gastric myoelectrical activity involving changes in tachygastrias and decreased motility as measured by power ratio. Post-operatively there was a significant increase in bradygastria which persisted at 6 months but not at 12 months. There was a corresponding decrease in normogastria which persisted at 6 months and to a lesser extent at 12 months. Dominant frequency remained significantly depressed at 3, 6 and 12 months. Gastric myoelectrical activity is normal in untreated esophageal cancer. Neoadjuvant chemoradiotherapy causes a disruption to normal myoelectrical activity involving reduced motility and tachygastrias. Surgery causes a depression in dominant frequency with a reduced incidence of normogastria at 3 months and 6 months but with a tendency towards normality at 12 months. [source]

    Barrett's esophagus: combined treatment using argon plasma coagulation and laparoscopic antireflux surgery

    M. Pagani
    SUMMARY, The treatment of Barrett's esophagus is still controversial. Actually, the only method to prevent the development to cancer is endoscopic surveillance, which ensures good results in terms of long-term survival. An ideal treatment capable of destroying columnar metaplasia, followed by squamous epithelium regeneration could potentially result in a decrease of the incidence of adenocarcinoma. Recently most ablative techniques were used, such as photodynamic therapy, ablation therapy with Nd-YAG laser or argon plasma coagulation and endoscopic mucosal resection. We started a prospective study in January 1998, enrolling 94 patients affected by Barrett's esophagus and candidates for antireflux repair in order to assess the effectiveness and the results of endoscopic coagulation with argon plasma combined with surgery in the treatment of uncomplicated Barrett's esophagus. All patients underwent endoscopic treatment with argon plasma; we observed complete response in 68 patients (72.34%), 27 of them (39.7%) underwent antireflux surgery and the other 41 continued medical therapy. Post-operatively 19 patients (70%) underwent regular surveillance endoscopies and in two cases metaplasia recurred. The final objective of these combined treatments should be the complete eradication of metaplastic mucosa. Our experience was that argon plasma coagulation combined with antireflux surgery or proton pump inhibitor therapy gave satisfactory results, even if follow-up is too short to evaluate the potential evolution of metaplasia to cancer. For this reason, we recommend that this technique should be done only in specialized centres and that these patients continue their endoscopic surveillance program. [source]

    Intravascular papillary endothelial hyperplasia of the lower lip: surgical approach and review of the literature

    GERODONTOLOGY, Issue 4 2009
    A. Cohen
    Objective:, A review of the literature for intravascular papillary endothelial hyperplasia is presented along with a case report of a geriatric patient. Review of the literature:, Intravascular papillary endothelial hyperplasia (IPEH) is a reactive benign lesion of vascular origin, which is caused by an excessive proliferation of endothelial cells. Only a few cases with IPEH in the oral cavity have been recorded in the literature, reporting the lower lip as the main site. The treatment of choice mentioned in the literature is simple excision. Case report:, In this case, an IPEH of the lower lip of a 79-year-old male was treated by a sclerosing agent, which was injected into the lesion, causing compression and fibrosis of the blood vessels, followed by a careful dissection and excision. Intra-operatively no bleeding occurred. Post-operatively an excellent aesthetic result was achieved, without recurrence. Conclusion:, The use of sclerotherapy followed by surgery in mixed type intravascular papillary endothelial hyperplasia can provide an acceptable aesthetic result with minimal intra-operative bleeding. [source]

    Anaesthesia for endoscopic sinus surgery

    A. R. BAKER
    Endoscopic sinus surgery is commonly performed and has a low risk of major complications. Intraoperative bleeding impairs surgical conditions and increases the risk of complications. Remifentanil appears to produce better surgical conditions than other opioid analgesics, and total intravenous anaesthesia with propofol may provide superior conditions to a volatile-based technique. Moderate hypotension with intraoperative , blockade is associated with better operating conditions than when vasodilating agents are used. Tight control of CO2 does not affect the surgical view. The use of a laryngeal mask may be associated with improved surgical conditions and a smoother emergence. It provides airway protection equivalent to that provided by an endotracheal tube in well-selected patients, but offers less protection from gastric regurgitation. Post-operatively, multimodal oral analgesia provides good pain relief, while long-acting local anaesthetics have been shown not to improve analgesia. [source]

    Development of anti-VWF antibody in a patient with severe haemophilia A following the development of high-grade non-Hodgkin's lymphoma

    K. Ghosh
    A 9-year-old-boy with severe haemophilia A (factor VIII < 1%) developed colicky abdominal pain with swelling in the left iliac fossa for 4 weeks. His LDH level was 1423 IU/l (normal range < 220 IU/l) and his uric acid, 6.8 mg/dl. A computerised tomography (CT) scan of the abdomen demonstrated a tumour of the terminal ileum and mild hepatosplenomegaly. Pre-operative screening for factor VIII inhibitor was negative. Post-operatively, the patient needed high doses of factor VIII to maintain haemostasis. The tumour was found to be a high-grade lymphoma of Burkitt's type. He recovered from his operation and chemotherapy was commenced. Investigations demonstrated an anti-von Willebrand factor (VWF) antibody. He subsequently relapsed and died of progressive disease. Development of anti-VWF antibody in lymphoma is well known, but development of this antibody in a haemophilia A patient developing lymphoma has not been reported. The present case shows that antibody to VWF should be considered as a possible reason for an increased factor VIII requirement in such patients. [source]

    Use of perioperative dialogues with children undergoing day surgery

    Berith Wennström
    Abstract Title.,Use of perioperative dialogues with children undergoing day surgery Aim., This paper is a report of a study to explore what it means for children to attend hospital for day surgery. Background., Hospitalization is a major stressor for children. Fear of separation, unfamiliar routines, anaesthetic/operation expectations/experiences and pain and needles are sources of children's negative reactions. Method., A grounded theory study was carried out during 2005,2006 with 15 boys and five girls (aged 6,9 years) scheduled for elective day surgery. Data were collected using tape-recorded interviews that included a perioperative dialogue, participant observations and pre- and postoperative drawings. Findings., A conceptual model was generated on the basis of the core category ,enduring inflicted hospital distress', showing that the main problem for children having day surgery is that they are forced into an unpredictable and distressful situation. Pre-operatively, the children do not know what to expect, as described in the category ,facing an unknown reality'. Additional categories show that they perceive a ,breaking away from daily routines' and that they are ,trying to gain control' over the situation. During the perioperative period, the categories ,losing control' and ,co-operating despite fear and pain' are present and intertwined. Post-operatively, the categories ,breathing a sigh of relief' and ,regaining normality in life' emerged. Conclusion., The perioperative dialogue used in our study, if translated into clinical practice, might therefore minimize distress and prepare children for the ,unknown' stressor that hospital care often presents. Further research is needed to compare anxiety and stress levels in children undergoing day surgery involving the perioperative dialogue and those having ,traditional' anaesthetic care. [source]

    Endotracheal tube size and sore throat following surgery: a randomized-controlled study

    Background: Sore throat following endotracheal intubation is a common problem following surgery and one of the factors that affects the quality of recovery. This study was carried out with the primary aim of assessing whether the size of the endotracheal tube (ETT) affects the risk of sore throat in women following anaesthesia. Methods: One hundred healthy adult women undergoing elective surgery were randomly allocated to oral intubation with either ETT size 6.0 or 7.0. Anaesthesia was based on either inhalation or total intravenous anaesthesia according to standardized routines. Pre- and post-operatively, sore throat and discomfort were assessed on a four-graded scale and for hoarseness on a binary scale (yes or no). Post-operatively, the assessments were performed after 1,2 and 24 h, and if there was discomfort at 24 h, a follow-up call was made at 72 and 96 h. Results: After 1,2 h post-operatively, there were a higher proportion of patients with sore throat in ETT 7.0 vs. ETT 6.0 (51.1% vs. 27.1%), P=0.006. This difference between the groups was also evident, P=0.002, when comparing changes between the pre- and the post-operative values. The severity of discomfort from sore throat was also higher in ETT 7.0 (38.8%) compared with ETT 6.0 (18.8%), P=0.02. No differences were found in the incidence of hoarseness between the groups. The remaining symptoms lasted up to 96 h post-operatively in 11%, irrespective of the tube size. Conclusion: Use of a smaller-sized ETT can alleviate sore throat and discomfort in women at the post-anaesthesia care unit. [source]

    Post-operative anxiety and depression levels in orthopaedic surgery: a study of 56 patients undergoing hip or knee arthroplasty

    Richard S. J. Nickinson
    Abstract Objective, To investigate the presence and rates of anxiety and depression in postsurgical patients. Methods, The Hospital Anxiety and Depression Scale was used to measure anxiety and depression levels. Patients completed the questionnaire on the day prior to surgery, then on each post-operative day up to and including their day of discharge. Statistical analysis using logistic regression was performed to determine whether any variables were risk factors for developing anxiety or depression. Fifty-six patients undergoing lower limb arthroplasty agreed to take part. Results, Post-operatively 17 patients became anxious prior to discharge. No variables were significant predictors of anxiety. Post-operatively 28 subjects (50%) became depressed at some point prior to discharge. Females were more likely to become depressed than males odds ratio (OR) = 3.48 [95% confidence interval (CI) 1.01,11.88]. Those who had had a previous lower limb arthroplasty were more likely to develop post-operative depression, OR = 3.92 (95% CI 1.05,14.6). Site of operation was not found to be significant, OR = 0.67 (95% CI 0.20,2.22). Age and anaesthetic method were not predictive of depression. The mean time point for development of depression was 2.43 days (SD = 1.40 days) and the time of deepest depression was 2.93 days (SD = 1.72 days). The mean length of depression was 1.93 days (SD = 1.21 days). The mean length of stay for depressed patients was 5 days (SD = 1.72), compared with 4 days for the non-depressed patients (SD = 1.62 days). Conclusion, The results suggest that post-operative depression does occur in orthopaedic surgery. The prevalence may be higher than that reported in other surgical specialities. These findings emphasize the need for evaluation of patients' psychiatric state post-operatively. [source]

    Influence of diet complexity on intestinal adaptation following massive small bowel resection in a preclinical model

    Julie E Bines
    Abstract Aims: To investigate the effect of dietary complexity on intestinal adaptation using a preclinical model. Methods: Four-week-old piglets underwent a 75% proximal small bowel resection or transection operation (control). Post-operatively, animals received either pig chow (n = 15), polymeric formula (n = 9), polymeric formula plus fiber (n = 6), or elemental formula (n = 7). Results: The weight gain of all groups was reduced compared with controls that were fed the same diet. Animals that had a resection, which were fed elemental formula, had significantly reduced weight gain compared with the other groups (4.7 4.2 vs 30.7 7.1 kg chow and 11.5 1.3 kg polymeric formula). Villus height was increased in the jejunum, ileum and terminal ileum of resected animals compared with controls in animals fed with pig chow, polymeric formula and elemental formula. The animals that had a resection had a significant reduction in the transepithelial conductance (10.4 5.5 vs 25.4 6.5 mS/cm2) and 51Chromium-EDTA flux (2.8 1.9 vs 4.8 4.9 µL/h per cm2) compared with the controls. Conclusions: A complex diet was found to be superior to an elemental diet in terms of the morphological and functional features of adaptation following massive small bowel resection. © 2002 Blackwell Publishing Asia Pty Ltd [source]

    Safety of laryngeal mask airway and short-stay practice in office-based adenotonsillectomy

    Background: It is still disputed whether laryngeal mask airway (LMA) is safe and convenient for adenotonsillectomy, and whether these procedures can be safely undertaken in an office-based short-stay ambulatory setting. We report the result of this practice in 1126 consecutive children <16 years of age. Methods: The patients received general anaesthesia with propofol and remifentanil. For analgesic prophylaxis, they received paracetamol, fentanyl and local anaesthetic administration. NSAIDs were given to patients weighing above 15 kgs. A surgical technique with elevation, scissors and electrocoagulation was used. Post-operatively, the tonsillectomies were observed in the unit for at least 1.5 h and the adenoidectomies for at least 15,20 min. Results: Conversion from LMA to an endotracheal tube was carried out in six patients (0.5%), mostly due to airway leakage during ventilation. One patient had a pulmonary atelectasis and was re-intubated. No re-operation was needed in the clinic after surgery, and all patients, except for the one with atelectasis (0.1%), were discharged home as planned. In 122 patients answering a questionnaire, after discharge, two patients (1.6%) were admitted to hospital and re-operated due to bleeding; a further six patients (4.9%) were admitted for observation. In 25% of the patients, nausea and vomiting occurred after discharge, including 21% vomiting of swallowed blood during home travel. Only 5.6% reported significant post-discharge pain. Conclusion: With a well-trained team, adenotonsillectomy on children can be carried out safely in an office-based setting with LMA and a short post-operative stay. [source]

    Prediction of post-operative pain by an electrical pain stimulus

    P. R. Nielsen
    Background:, Treatment of post-operative pain is still a significant problem. Recently, interest has focused on pre-operative identification of patients who may experience severe post-operative pain in order to offer a more aggressive analgesic treatment. The nociceptive stimulation methods have included heat injury and pressure algometry. A simple method, Pain Matcher® (PM), using electrical stimulation, is validated for pain assessment, but has not been evaluated as a tool for prediction of post-operative pain. Our aim was to assess the predictive value of pre-caesarean section pain threshold on intensity of post-caesarean section pain using the PM. Patients and methods:, Thirty-nine healthy women scheduled for elective caesarean section were studied. The anaesthetic/analgesic procedures included spinal anaesthesia, paracetamol, diclofenac, controlled-release (CR) oxycodone and morphine on request. Pre-operatively, the sensory and pain thresholds were measured using the PM. Post-operatively, a midwife, blinded for pre-caesarean pain threshold assessments, assessed the pain at rest and during mobilization every 12 h for 2 days. Consumption of analgesics was also recorded. Results:, Pre-operative pain threshold correlated significantly with post-caesarean pain score (VAS) at rest and mobilization: [Spearman's rho =,0.65 (,0.30 to ,0.75), P < 0.01] and [Spearman's rho =,0.52 (,0.23 to ,0.72), P < 0.01], respectively. There was no significant correlation between pre-operative PM assessment of sensory threshold and post-operative pain. Conclusion:, Electrical pain threshold before caesarean section seems to predict the intensity of post-operative pain. This method may be used as a screening tool to identify patients at high risk of post-operative pain. [source]

    Surgical complications and medium-term outcome results of tension-free vaginal tape: A prospective study of 313 consecutive patients

    Ishai Levin
    Abstract Objective A prospective study was undertaken to examine the incidence of surgical complications and medium-term outcomes of tension-free vaginal tape (TVT) surgery in a large, heterogeneous group of stress-incontinent women. Methods Surgery was tailored according to preoperative clinical and urodynamic findings: stress-incontinent women underwent TVT surgery, whereas those with concomitant urogenital prolapse underwent combined TVT and prolapse repair. Post-operatively the patients were scheduled for evaluation at 1, 3, 6, and 12 months, and annually thereafter. All underwent urodynamics at 3 months post-operatively. Results Three hundred and thirteen consecutive patients were prospectively studied. The mean follow-up period was 21.4,±,13.5 months. Sixteen (5.1%) cases of intravesical passage of the prolene tape occurred in our series, two of which were diagnosed at 3 and 15 months post-operatively. Eight (2.5%) patients had post-operative voiding difficulties, necessitating catheterization for more than 7 days. However, transvaginal excision of the tape was required in one case only. Vaginal erosion of the tape was diagnosed in four (1.3%) patients, all of whom were successfully treated by local excision of the eroded tape. Outcome analysis was restricted to 241 consecutive patients with at least 12 months of follow-up. Subjectively, 16 (6.6%) patients had persistent mild stress urinary incontinence, although urodynamics revealed asymptomatic sphincteric incontinence in 17 (7%) other patients. De-novo urge incontinence developed post-operatively in 20 (8.3%) patients. Conclusions The TVT procedure is associated with good medium-term cure rates, however, it is not free of troublesome complications and the patients should be informed accordingly. Only well-trained surgeons, familiar with pelvic anatomy, surgical alternatives, and endoscopic techniques should perform the operation. Neurourol. Urodynam. 23:7,9, 2004. © 2003 Wiley-Liss, Inc. [source]

    Surgical management of benign duodenal tumours,

    ANZ JOURNAL OF SURGERY, Issue 7-8 2010
    Ji-Qi Yan
    Abstract Background:, While benign duodenal tumours are rare compared with malignant tumours, they comprise a wide variety of pathologies. Despite their diagnostic challenge, the optimal management of benign duodenal tumours remains undefined. We aimed to review the diagnosis and surgical treatment of benign duodenal tumours. Methods:, Records of all patients with post-operative pathological diagnosis of benign duodenal tumour were retrieved. Information on clinical presentations, diagnostic methods, tumour locations, surgical approaches, pathological results and patient outcomes were analysed. Results:, The operative spectrum included local resection in 8 cases, segmental duodenectomy in 1 case, subtotal gastrectomy in 1 case, papilla resection with sphincteroplasty in 3 cases and pancreaticoduodenectomy in 5 cases. The post-operative pathology results indicated 5 cases of adenoma, 2 cases of tubular adenoma, 2 cases of villous adenoma, 2 cases of tubulovillous adenoma, 2 cases of hamartoma and 1 case each of hamartomatous polyp, Brunner's adenoma, adenomyoma, fibromatosis and ectopic pancreas. Post-operatively, one patient died of unrelated disease, one case was lost in follow-up and the remaining patients survived recurrence-free with a good quality of life. Conclusion:, The presentation of benign duodenal tumours is non-specific, with upper abdominal discomfort and upper gastrointestinal bleeding as common symptoms. Surgical resection is the preferable therapeutic choice with satisfactory prognosis. [source]

    Minilaparotomy abdominal aortic aneurysm repair in the era of minimally invasive vascular surgery: preliminary results

    ANZ JOURNAL OF SURGERY, Issue 11 2009
    Chris N. Bakoyiannis
    Abstract Background:, This study aimed to evaluate the early post-operative clinical impact of minimal incision aortic surgery (MIAS) for infrarenal abdominal aortic aneurysm (AAA) repair in comparison with the standard open repair. Methods:, A case-control study was conducted. Patients of groups A (19 patients) and B (18 patients) were treated with the MIAS technique and the standard open method, respectively. Results:, There were significant differences between the two groups in fluid resuscitation during the operation. Post-operatively, there were significant differences between groups A and B in the time until starting liquid diet (2 ± 0.74 versus 3.55 ± 0.85 post-operative days (PD), respectively; P < 0.05), the time until starting the solid diet (3.05 ± 0.77 versus 5.11 ± 0.75 PD, respectively; P < 0.05), the time of ambulation (2 ± 0.74 versus 3.4 ± 0.98 PD, respectively; P < 0.05) and in the hospital length of stay (4 ± 0.81 versus 9.7 ± 2.66 days, respectively; P < 0.05). Conclusions:, The MIAS technique, for repair of infrarenal aortic aneurysms, is a safe and feasible procedure that combines the early advantages of endovascular repair with the long-term advantages of the traditional open repair. [source]

    Peri-operative management of anti-platelet agents

    ANZ JOURNAL OF SURGERY, Issue 7-8 2009
    Samer Hermiz
    Abstract Background:, Increasing numbers of patients treated with anti-platelet agents are presenting for non-cardiac surgery. We examined the peri-operative management of anti-platelet therapy in patients undergoing elective non-cardiac surgery and the process by which patients received instructions. Methods:, We interviewed and collected outcome data on 213 consecutive patients aged ,45 years presenting for elective non-cardiac surgery at our institution over a 6-week period regarding the peri-operative management of anti-platelet and warfarin therapy. Results:, Anti-platelet therapy was prescribed in 22.5% and warfarin in 5.2% of the study subjects. Aspirin was stopped peri-operatively in 55.3%, while clopidogrel was stopped in the sole patient treated with this. The frequency of anti-platelet agent discontinuation was similar for major and minor surgery. Warfarin was discontinued prior to surgery in all cases. Only 54.2% of those treated with anti-platelet therapy recalled being given instruction regarding pre-operative management of their anti-platelet therapy compared with 90.9% of patients treated with warfarin (P= 0.04). In the absence of instructions, a number of patients made their own decision to stop their aspirin pre-operatively. Post-operatively, only 37% recalled receiving instructions regarding restarting anti-platelet therapy. As a result, three patients failed to do so. In contrast, all those treated with warfarin received clear post-operative instructions. Conclusion:, Peri-operative anti-platelet management and communication with patients appears to be sub-optimal. There is a need for standardized processes whereby informed decisions regarding peri-operative anti-platelet therapy are made and communicated clearly to the patients. [source]


    K. C. Wong
    Purpose: , The laparoscopic mini gastric bypass (LMGB) is purportedly a technically simpler, yet equally effective operation to the laparoscopic Roux-en-Y gastric bypass as treatment for morbid obesity. This study reports the early results of LMGB in a major New Zealand bariatric centre. Methodology: , Clinical data was prospectively collected on all patients undergoing LMGB over a two year period. Results: , 142 patients were studied. 77% were females. Mean age was 43.8. Pre-operative mean body weight and body mass index (BMI) were 121.3 kg and 45.4 kg/m2 respectively. Mean BMI at one and two years follow up had decreased to 27.35 and 25.72 kg/m2 respectively. 83% of patients reported obesity associated co-morbidities pre-operatively. Post-operatively, 78% of patients reported a reduction in medication requirement. All surgery was performed laparoscopically. There were no anastomotic leaks and zero mortality. 8% of patients required further operations for complications or revision to a Roux-en-Y gastric bypass. 20% of patients required subsequent endoscopic interventions, the majority for investigation of vomiting and/or pain. 22% of patients required re-admission. 14% of patients reported new onset reflux or worsening of pre-existing reflux after LMGB. 82% of patients reported increased exercise capability post LMGB. 54% of patients required vitamin supplementation. Conclusion: , LMGB achieves significant weight loss and resolution of obesity related co-morbidities with a low short term complication rate. LMGB should be considered as a safe and simple surgical option for morbid obesity. [source]

    Development of a Disposable Magnetically Levitated Centrifugal Blood Pump (MedTech Dispo) Intended for Bridge-to-Bridge Applications,Two-Week In Vivo Evaluation

    ARTIFICIAL ORGANS, Issue 9 2010
    Eiki Nagaoka
    Abstract Last year, we reported in vitro pump performance, low hemolytic characteristics, and initial in vivo evaluation of a disposable, magnetically levitated centrifugal blood pump, MedTech Dispo. As the first phase of the two-stage in vivo studies, in this study we have carried out a 2-week in vivo evaluation in calves. Male Holstein calves with body weight of 62.4,92.2 kg were used. Under general anesthesia, a left heart bypass with a MedTech Dispo pump was instituted between the left atrium and the descending aorta via left thoracotomy. Blood-contacting surface of the pump was coated with a 2-methacryloyloxyethyl phosphorylcholine polymer. Post-operatively, with activated clotting time controlled at 180,220 s using heparin and bypass flow rate maintained at 50 mL/kg/min, plasma-free hemoglobin (Hb), coagulation, and major organ functions were analyzed for evaluation of biocompatibility. The animals were electively sacrificed at the completion of the 2-week study to evaluate presence of thrombus inside the pump, together with an examination of major organs. To date, we have done 13 MedTech Dispo implantations, of which three went successfully for a 2-week duration. In these three cases, the pump produced a fairly constant flow of 50 mL/Kg/min. Neurological disorders and any symptoms of thromboembolism were not seen. Levels of plasma-free Hb were maintained very low. Major organ functions remained within normal ranges. Autopsy results revealed no thrombus formation inside the pump. In the last six cases, calves suffered from severe pneumonia and they were excluded from the analysis. The MedTech Dispo pump demonstrated sufficient pump performance and biocompatibility to meet requirements for 1-week circulatory support. The second phase (2-month in vivo study) is under way to prove the safety and efficacy of MedTech Dispo for 1-month applications. [source]

    Subcutaneous administration of hepatitis B immune globulin in combination with lamivudine following orthotopic liver transplantation: effective prophylaxis against recurrence

    James J. Powell
    Abstract:, Prophylaxis against recurrent hepatitis B virus (HBV) infection with hepatitis B immune globulin (HBIG), in combination with antiviral agents such as lamivudine, has allowed transplantation for this condition to become feasible and accepted. Current protocols allow for HBIG administration either intravenously or intramuscularly. To date, there has been no reported experience with the subcutaneous route of post-transplant HBIG delivery. We report our experience of a 60-yr-old man for whom liver transplantation was performed for chronic HBV. HBIG was administered intramuscularly during the anhepatic phase of surgery. The finding of a portal vein thrombosis requiring repeated thrombectomy necessitated chronic anticoagulation. Post-operatively, HBIG was administered subcutaneously, in four separate injections, for a daily dose of 2170 IU along with continued lamivudine dosing. Hepatitis B surface antibody (anti-HBs) titres reached a serum concentration of >500 IU/L by seven d post-transplant and approximately 1000 IU/L by nine d post-transplant. Five months post-transplant, with continued combination of subcutaneous HBIG and lamivudine, there has been no recurrent HBV infection and anti-HBs titres have been at target levels. Our experience suggests that subcutaneous delivery of HBIG may be a feasible consideration when intramuscular/intravenous dosing is not possible. [source]

    Simultaneous pancreas,kidney transplantation in Jehovah's Witness patients

    Jose Figueiro
    Abstract:, The safety and efficacy of renal and liver transplantation has been reported for Jehovah's Witness (JW) patients, with patient, and graft survival similar to that of non-JW patients. We report our experience in five JW recipients of simultaneous pancreas,kidney transplants. None of the patients received transfusion of blood or blood products, either before or after transplant. Like the other solid organ transplants, patient, and graft survival was similar to that of the non-JW group. Specific technical issues related to the operative procedure include the use of the cell saver until the donor duodenum is opened (enteric contamination). Post-operatively, care should be taken to minimize drawing of blood and optimize erythrocyte synthesis with erythropoetin, folic acid, vitamin B12, and iron. Finally, it is critical that the pre-operative evaluation demonstrates sufficient cardiac reserve to allow the JW patient to tolerate a possible temporary anemic state. [source]

    Effect of gender on acute pain prediction and memory in periodontal surgery

    Ilana Eli
    Pain is a complex experience that is affected by factors such as gender, stress, anxiety and cognitions. The purpose of this study was to investigate the inter-relationship between gender and acute pain prediction and memory under periodontal surgery treatment. The study was conducted on 15 male and 22 female dental patients (mean age 34 yr, mean education level 14.7 yr), who were scheduled for periodontal surgery. Patients were evaluated during four consecutive appointments: at initial check-up, immediately pre-operatively, 1 wk post-operatively, and at 4 wk post-operative follow-up. Patients were requested to complete questionnaires concerning their anxiety at each appointment and to indicate their subjective evaluations concerning pain (on a visual analogue scale). Evaluations concerning expectation to experience pain during the planned surgery (pain prediction) were made at the first two appointments and evaluations of the experienced pain as remembered from the surgery (pain memory) were made at the last two appointments. Gender had a significant effect on pain prediction and pain memory. Men expected to experience more pain pre-operatively than women but remembered less pain post-operatively. It was concluded that cognitive pain perception in clinical situations differs between genders. [source]

    Endonasal Endoscopic Management of Contact Point Headache and Diagnostic Criteria

    HEADACHE, Issue 2 2010
    Alireza Mohebbi MD
    (Headache 2010;50:242-248) Background., Some types of headaches with sinonasal origin may be present in the absence of inflammation and infection. The contact points between the lateral nasal wall and the septum could be the cause of triggering and sustained pain via trigeminovascular system. Objective., The aim of this study was to evaluate the feasibility and effectiveness of endoscopic surgery in the sinonasal region for treatment of headache with special attention paid to specific diagnostic methods and patient selection. Methods., This was a prospective, non-randomized and semi-quasi experimental research study. Thirty-six patients with chronic headaches who had not previously responded to conventional treatments were evaluated by rhinoscopy and/or endoscopy, local anesthetic tests and computed tomography scans as diagnostic criteria. These patients were divided into 4 groups based on the diagnostic methods utilized. The intensity of headaches pre- and post-operatively were recorded by utilizing the visual analog scale scale and performing analysis with analysis of variance test comparison and Statistical Package for Social Sciences. Average follow-up was 30 months. Results., Our overall success rate approximated 83% while the complete cure rate was 11%. Patients in group 4 achieved the best results. In this group all diagnostic criteria were positive. In addition, patient responses were statistically significant in groups with more than one positive criteria compared with group 1 who only had positive examination. The positive response of 14 migrainous patients diagnosed with migraine prior to treatment was 64%. Conclusion., Surgery in specific cases of headaches with more positive evidence of contact point could be successful, particularly if medical therapy has failed. [source]

    The impact of pre-operative serum creatinine on short-term outcomes after liver resection

    HPB, Issue 8 2009
    Thomas Armstrong
    Abstract Background:, The aim of the present study was to determine whether raised pre-operative serum creatinine increased the risk of renal failure after liver resection. Method:, Data were studied from 1535 consecutive liver resections. Outcomes in patients with pre-operative creatinine ,124 µmol/l (Group 1) were compared with those with pre-operative creatinine ,125 µmol/l (Group 2). Results:, The median age of the 1446 (94.3%) patients resected in Group 1 was 62 years compared with 67 years in the 88 (5.7%) patients in Group 2 (P < 0.0001). Similarly this latter group had double the number of patients who were American Society of Anesthesiologists (ASA) III or IV (34.1% vs. 15.2%, P= 0.00004). Overall, the incidence of post-operative renal failure requiring haemofiltration was low (0.9%) but significantly more in Group 2 patients (5.7% vs. 0.6, P= 0.0007). In addition, patients in Group 2 were more likely to suffer acute kidney injury post-operatively (18.2% vs. 4.3%, P < 0.0001). Patients with acute kidney injury had significantly higher blood loss. Although there was no difference in mortality, patients in Group 2 had higher post-operative morbidity (37.5%) than Group 1 (21.7%, P= 0.0006), with the incidence of cardiorespiratory complications being higher in Group 2 (25.9% vs. 8.9%, P= 0.0025). Conclusions:, After liver resection, renal failure is rare but patients with an elevated creatinine pre-operatively are at an increased risk of both renal and non-renal complications. [source]

    Randomized clinical trial of root-end resection followed by root-end filling with mineral trioxide aggregate or smoothing of the orthograde gutta-percha root filling , 1-year follow-up

    R. Christiansen
    Abstract Aim, To compare healing after root-end resection with a root-end filling of mineral trioxide aggregate (MTA) or smoothing of the orthograde gutta-percha (GP) root filling. Methodology, Forty-four patients (consisting of 52 teeth with periapical infection), average age of 54.6 years (range 30,77) participated in a randomized clinical trial (RCT) comparing the MTA and GP treatment methods. Radiographs produced 1-week and 12 months post-operatively were compared after blinding for treatment method, and healing was assessed as complete, incomplete, uncertain, or unsatisfactory. Results, Six teeth were not available for the 12-month follow-up: three teeth (GP) had been re-operated because of pain and two teeth (one GP, one MTA) had been extracted because of root fracture (these five teeth were classified as failures). One patient (GP) was not available for recall. In the GP group, seven teeth (28%) showed complete healing, six teeth (24%) incomplete healing, six teeth (24%) uncertain healing and two teeth (8%) unsatisfactory healing after 1 year. In the MTA group, 22 teeth (85%) showed complete healing, three teeth (12%) incomplete healing, and none were scored as uncertain or unsatisfactory healing after 1 year. The difference in healing between the GP and the MTA groups was significant (P < 0.001). Conclusions, The results from this RCT emphasize the importance of placing a root-end filling after root-end resection. Teeth treated with MTA had significantly better healing (96%) than teeth treated by smoothing of the orthograde GP root filling only (52%). [source]

    Varicocelectomy reduces reactive oxygen species levels and increases antioxidant activity of seminal plasma from infertile men with varicocele

    T. Mostafa
    Several theories have been advanced to explain the mechanisms by which varicocele impairs male fertility. These theories include scrotal hyperthermia, retrograde flow of adrenal or renal metabolites, Leydig cell dysfunction and hypoxia. Varicocele is reported to be associated with elevated reactive oxygen species (ROS) production in spermatozoa and diminished seminal plasma antioxidant activity. The aim of this study was to investigate whether surgical correction of varicocele might reduce ROS or increase the antioxidant capacity of seminal plasma from infertile patients with varicocele. The study group consisted of 68 infertile males, selected from patients scheduled for varicocelectomy at Cairo University Hospital during the year 1999. Seminal plasma levels of two ROS [malondialdehyde (MDA), hydrogen peroxide (H2O2)] and one ROS radical [nitric oxide (NO)] were estimated as well as six antioxidants [superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GPx), vitamin C (Vit C), vitamin E (Vit E), albumin) on the day prior to varicocelectomy. For comparison, the same parameters were measured again 3 and 6 months post-operatively. A statistically significant reduction in the 3 month post-operative levels of MDA, H2O2 and NO was observed when compared with the pre-operative values. A further significant reduction took place during the following 3 months. Four of the six antioxidants tested (SOD, CAT, GPx, and Vit C) showed a significant increase in seminal levels when comparing 3-month post-operative with pre-operative values. A further significant increase of the four antioxidant levels took place during the following 3 months. No significant change in the level of seminal plasma albumen took place during the first 3 months after varicocelectomy, however, a significant increase was noted during the next 3 months. In contrast to other antioxidants, seminal plasma levels of Vit E showed a significant decrease when comparing 3-month post-operative with pre-operative values. A further significant decrease took place during the following 3 months. It is concluded that varicocelectomy reduces ROS levels and increases antioxidant activity of seminal plasma from infertile men with varicocele. [source]

    Prophylactic steroids for paediatric open-heart surgery: a systematic review

    Suzi Robertson-Malt BHSc PhD
    Background, The immune response to cardiopulmonary bypass in infants and children can lead to a series of post-operative morbidities and mortality, that is, hemodynamic instability, increased infection and tachyarrhythmias. Administration of prophylactic doses of corticosteroids is sometimes used to try and ameliorate this pro-inflammatory response. However, the clinical benefits and harms of this type of intervention in the paediatric patient remain unclear. Objectives, To systematically review the beneficial and harmful effects of the prophylactic administration of corticosteroids, compared with placebo, in paediatric open-heart surgery. Search strategy, The trials registry of the Cochrane Heart Group, the Cochrane Central Register of Controlled Trials in The Cochrane Library (Issue 4, 2006), MEDLINE (1966 to January 2007), EMBASE (1980 to January 2007) were searched. An additional hand-search of the EMRO database for Arabic literature was performed. Grey literature was searched, and experts in the field were contacted for any unpublished material. No language restrictions were applied. Selection criteria, All randomised and quasi-randomised controlled trials of open-heart surgery in the paediatric population that received corticosteroids pre-, peri- or post-operatively, with reported clinical outcomes in terms of morbidity and mortality. Data collection and analysis, Eligible studies were abstracted and evaluated by two independent reviewers. All meta-analyses were completed using RevMan4.2.8. Weighted mean difference (WMD) was the primary summary statistic with data pooled using a random-effects model. Main results, All cause mortality could not be assessed as the data reports were incomplete. There was weak evidence in favour of prophylactic corticosteroid administration for reducing intensive care unit stay, peak core temperature and duration of ventilation (WMD (95% confidence intervals) ,0.50 h (,1.41 to 0.41); ,0.20°C (,1.16 to 0.77) and ,0.63 h (,4.02 to 2.75) respectively). [source]

    Testing whether the epidural works: too time consuming?

    Background: When using epidural anaesthesia (EDA) for pain relief after major surgery, a failure rate of 10% is common. A crucial step in improving the care of patients with EDA is to define the position of the epidural catheter. The aim of this study was to investigate how much time it takes to determine whether the block is sufficient by assessing the extent of loss of cold sensation before induction of anaesthesia. Methods: One hundred patients listed for abdominal surgery were included in the study. After an epidural catheter had been inserted and an intrathecal or an intravenous position had been made unlikely by the use of a test dose, the patient was given a bolus dose of local anaesthetic plus an opioid in the epidural catheter. The epidural block was tested every 2 min, starting at 5 min and ending at 15 min. When at least four segments were blocked bilaterally, the testing was stopped, the time was noted and the patient was anaesthetised. Results: An epidural block was demonstrated after 5,6 min in 37 patients, after 7,8 min in 43 additional patients and after 9,10 min in 15 patients. In one patient, it took 12 min and in three patients, it took 15 min. In two patients, no epidural block could be demonstrated. Conclusion: Testing an epidural anaesthetic before the induction of anaesthesia takes only 5,10 extra minutes. Knowing whether the catheter is correctly placed means better quality of care, giving the anaesthetist better prerequisites for taking care of the patient post-operatively. [source]

    Analgesic efficacy of subcutaneous local anaesthetic wound infiltration in bilateral knee arthroplasty: a randomised, placebo-controlled, double-blind trial

    Background: High-volume wound local infiltration analgesia is effective in knee arthroplasty, but the analgesic efficacy of subcutaneous wound infiltration has not been evaluated. Methods: In a randomised, double-blind, placebo-controlled trial in 16 patients undergoing bilateral knee arthroplasty with high-volume local infiltration analgesia in the deeper layers, saline or ropivacaine 2 mg/ml was infiltrated into the subcutaneous part of the wound in each knee along with the placement of multi-fenestrated catheters in the subcutaneous wound layers in both knees. Pain was assessed for 6 h post-operatively and for 3 h after a bolus injection given through the catheter 24 h post-operatively. Results: Visual analogue scale (VAS) pain scores were significantly lower from the knee infiltrated with ropivacaine compared with the knee infiltrated with saline in the subcutaneous layer of the wound, at rest (P<0.02), with flexion of the knee (P<0.04) and when the leg was straight and elevated (P<0.04). Twenty-four hours post-operatively, a decline in the VAS pain scores was observed in both groups, with no statistically significant difference between injection of ropivacaine or saline in the subcutaneously placed catheters (P>0.05). Conclusion: As part of a total wound infiltration analgesia intraoperative subcutaneous infiltration with ropivacaine in bilateral total knee arthroplasty is effective in early post-operative pain management, while a post-operative subcutaneous bolus administration through a multiholed catheter 24 h post-operatively did not show improved analgesia compared with the administration of saline. [source]

    Impact of chronic advanced aortic regurgitation on the perioperative outcome of noncardiac surgery

    H.-C. LAI
    Background: Whether and how chronic advanced aortic regurgitation (AR) impacts the perioperative outcome of noncardiac surgery remains unclear. Methods: From November 1999 to December 2006, all patients undergoing noncardiac operations and ever examined by echocardiography within the last 6 months were screened. Those with chronic moderate,severe or severe AR were enrolled, provided they were not already trachea-intubated or aortic valve operated, and the surgery was not performed under local anesthesia. Case-matched subjects without significant AR served as controls. The perioperative outcomes of these patients were analyzed, and independent prognostic correlates were investigated by multivariate logistic regression analysis. Results: A total of 167 patients (male 131, mean age of 75 years) complying with the enrollment criteria were studied. Compared with the other 167 case-matched control peers, patients with advanced AR risked potential hazards of serious hemodynamic instability (0.6%) and circulatory collapse (1.2%) during surgery despite the similar incidence of overall cardiac adverse events, and were further distressed with more cardiopulmonary complications (16.2% vs. 5.4%, P=0.003) and in-hospital deaths (9% vs. 1.8%, P=0.008) post-operatively. Multivariate regression analysis confirmed the correlation of advanced AR with perioperative mortality, and identified depressed left ventricular function, renal dysfunction, high surgical risk, and lack of cardiac medication as predictors of in-hospital death. Conclusion: Chronic advanced AR complicates the perioperative outcome of noncardiac surgery as reflected by frequent cardiopulmonary morbidities and in-hospital deaths, especially when coexisting with specified high-risk clinical and surgical characteristics. [source]

    Evaluation of renal function after laparoscopic partial nephrectomy with renal scintigraphy using 99mtechnetium-mercaptoacetyltriglycine

    Aim: We evaluated the functions of an affected kidney after laparoscopic partial nephrectomy (LPN) using renal scintigraphy with 99mtechnetium-mercaptoacetyltriglycine (99mTc-MAG3). Methods: Split renal function of 10 patients who underwent LPN for renal tumors was assessed using renal scintigraphy with 99mTc-MAG3 before surgery, and 1 week and 3 months post-surgery. Results: Median operating time was 196.5 min, median tumor diameter was 2.3 cm, mean blood loss was 64 mL and mean ischemic time was 38.5 min. Median change in serum creatinine level pre- to post-surgery was 0.15 mg/dL. Median contribution of the affected kidney to total renal function (calculated using 99mTc-MAG3) was 50.0%, 41.7% and 36.1% before surgery, 1 week and 3 months after LPN, respectively. In one patient, the tumor was resected after cooling of the affected kidney with ice slush for 15 min, and the split renal function ratio remained as high as 50% at 3 months post-operatively despite a total ischemic time of 61 min. Conclusions: This paper evaluated renal function on the affected side before and after surgery by measuring split renal function with renal scintigraphy using 99mTc-MAG3. Risk factors for renal dysfunction in the affected kidney after LPN include age over 70 years with more than 30 min warm ischemic time, re-clamping of the renal artery procedure, and a warm ischemic time greater than 60 min. We believe that renal cooling with slush ice prevents renal dysfunction of the affected kidney after LPN with longer warm ischemic times. However, an easier renal cooling technique should be sought for regular use of cooling procedures in LPN. [source]

    Infusion of hypertonic saline/starch during cardiopulmonary bypass reduces fluid overload and may impact cardiac function

    Objective: Peri-operative fluid accumulation resulting in myocardial and pulmonary tissue edema is one possible mechanism behind post-operative cardiopulmonary dysfunction. This study aimed to confirm an improvement of cardiopulmonary function by reducing fluid loading during an open-heart surgery. Materials and methods: Forty-nine elective CABG patients were randomized to an intraoperative infusion of hypertonic saline/hydroxyethyl starch (HSH group) or Ringer's solution (CT group). Both groups received 1 ml/kg/h of the study solution for 4 h after baseline values were obtained (PICCO® transpulmonary thermodilution technique). Net fluid balance (NFB), hemodynamic and laboratory parameters were measured. Results: NFB was four times higher in the CT group compared with the HSH group during the first 6 h post-operatively. The total fluid gain until the next morning was lower in the HSH group, 2993.9 (938.6) ml, compared with the CT group, 4298.7 (1059.3) ml (P<0.001). Normalized values (i.e., %-changes from the baseline) of the cardiac index and the global end diastolic volume index increased post-operatively in both groups. Both parameters were significantly higher at 6 h in the HSH group compared with CT group (P=0.002 and 0.005, respectively). Normalized values of the intrathoracic blood volume index were lower in the HSH group at 6 h post-operatively when compared with the CT group. The PaO2/FiO2 ratio decreased similarly in both groups early post-operatively, but recovery tended to be more rapid in the HSH group. Although serum-sodium and serum-chloride levels were significantly higher in the HSH group, the acid,base parameters remained similar and within the normal range. Conclusions: An intraoperative infusion of HSH during cardiac surgery contributes to reduced fluid loading and an improvement in the post-operative cardiac performance. No adverse effects of the HSH infusion were observed. [source]