Preoperative Nutritional Status of the Surgical Patients in Jeju

Background

To assess the preoperative nutritional status of patients with various disorders and to provide data for pre- and postoperative patient management plans, particularly in the elderly. There is no published information on age-matched and disease-matched preoperative nutritional/immunologic status for orthopedic patients, especially in the elderly, in Jeju.

Methods

In total, 331 patients with four categories of orthopedic conditions were assessed: 92 elective surgery patients, 59 arthroplasty patients, 145 patients with fractures, and 35 infection patients. Malnutrition was defined as body mass index (BMI) below 18 kg/m² of expected body weight (below 20% of normal), serum albumin/globulin ratio below 1.5 (normal range, 1.5 to 2.3), albumin level below 3.5 g/dL, total lymphocyte count below 1,500 cells/mm³, and lymphocyte/monocyte ratio below 5 versus 1.

Results

In 92 elective surgery patients, the average BMI was 23 kg/m², hemoglobin was 15 g/dL, lymphocytes (2,486 cells)/monocytes (465 cells) ratio was 6.1, and the albumin (4.4 g/dL)/globulin (2.5 g/dL) ratio as a protein quotient was 1.7. Among the 59 hip and knee arthroplasty patients, the average BMI was 25 kg/m², hemoglobin was 12 g/dL, lymphocytes (2,038 cells)/monocytes (391 cells) ratio was 6.6, and albumin (4.1 g/dL)/globulin (2.4 g/dL) ratio was 1.6. No subject showed malnutrition. Among the 145 fracture patients, the average BMI was 23 kg/m². The hemoglobin level was 13 g/dL, monocytes (495 cells)/lymphocytes (1,905 cells) ratio was 1 versus 4.6, and albumin (4.1 d/gL)/globulin (2.5 d/gL) ratio was 1.6. However, both ratios decreased after 70 years of age. Among the 17 of 35 infection patients, albumin levels were below 3.5 g/dL, the average BMI was 22 kg/m², lymphocytes (1,532 cells)/monocytes (545 cells) ratio was 2.4 versus 1, and albumin (3.0 g/dL)/globulin (3.3 g/dL) ratio was 0.9, while in 18 patients albumin levels were over 3.5 g/dL, the average BMI was 22 kg/m², hemoglobin was 12 g/dL, lymphocytes (1,998 cells)/monocytes (583 cells) ratio was 3 versus 1, and albumin/globulin ratio was 1.4. Thus, in the infection group, approximately 50% of the patients showed poor nutrition and immunosuppression.

Conclusions

It was found that nutritional and immune condition deteriorated gradually to some degree in elderly patients over 60 years of age.     

Favorable Effects of Preoperative Enteral Immunonutrition on a Surgical Site Infection in Patients with Colorectal Cancer Without Malnutrition

Purpose A prospective study was conducted to ascertain the effects of preoperative enteral immunonutrition on a surgical site infection (SSI) in patients with colorectal cancer without malnutrition. Methods Patients with colorectal cancer undergoing elective surgery without malnutrition, bowel obstruction, severe cardiopulmonary complications, diabetes, collagen disease, or renal failure were sequentially divided into an immunonutrition group (n = 33) and a control group (n = 34). In the immunonutrition group, an enteral diet supplemented with arginine, dietary nucleotides, and ω-3 fatty acids was administered for 5 days (750 ml/day) prior to surgery. Results The mean age was slightly higher in the immunonutrition group (69 ± 9 years) than in the control group (63 ± 11 years; P < 0.05), but no significant differences between the groups were noted for the body mass index, total protein, albumin, hemoglobin, surgical methods, operation time, or volume of intraoperative bleeding. The frequencies of superficial incisional SSI, deep incisional SSI and organ/space SSI in the immunonutrition and control groups were 0% and 11.8% (4/34; P < 0.05), 0% and 0%, and 0% and 2.9% (1/34), respectively. Conclusion Preoperative enteral immunonutrition appears to be effective for preventing SSI in patients with colorectal cancer without malnutrition.     

Local changes in cerebral energy metabolism due to brain retraction during routine neurosurgical procedures

Summary. Summary.   Patients and Interventions: Tissue damage caused by brain retraction was evaluated utilizing intracerebral microdialysis in six patients operated on subfrontally for pituitary adenoma. The microdialysis probes (membrane length 10 mm, cut-off 20 kDalton) were placed in cerebral cortex beneath the brain retractor and perfused with Ringer solution at 0.3 μl/min. The microdialysis vials were changed at intervals of 30 minutes and analysed for glucose, pyruvate, lactate, glutamate and glycerol.   Results: During brain retraction regional intracerebral glucose was within normal range in cortical tissue and the levels of lactate, glutamate, and glycerol as well as the lactate/pyruvate ratio were considerably above normal range.   Conclusion: The biochemical analysis shows a pronounced incomplete cerebral ischemia due to brain retraction. The increases in glutamate and glycerol indicate tissue damage and degradation of cell membranes. Intracerebral microdialysis may be a valuable tool in the development of optimal techniques for brain retraction during neurosurgical procedures. Published online July 18, 2002 ? Springer-Verlag 2002     

预激综合征游离壁旁路心内直视切断术（附6例报告）

自１９９０年５月以来，对６例预激综合征进行了心内直视游离壁旁路切断术，Ａ型２例，Ｂ型３例，Ａ＋Ｂ型１例，２例Ａ型均为两条旁路，合并心内畸形者３例。６例均治愈。作者就心外膜标测和手术注意事项进行了讨论。     

成人肱骨远端关节内骨折的手术治疗

目的：探讨成人肱骨远端关节内骨折的手术治疗,方法：对15例成人肱骨远端关节内骨折采用早期开放复位,运用钢板作坚强内固定及早期功能锻炼的方法进行治疗。15例均为Muller分类C型骨折。结果：术后随诊时间为6个月－3年,优良率达80％,结果：早期手术,关节内解剖复位,坚强内固定及早期功能锻炼是提高成人肱骨远端关节内骨折治疗效果的关键。     

原发性纵隔肿瘤的外科治疗：附180例报告

本文报告我院２７年外科手术治疗，并经病理证实的原发性纵隔肿瘤１８０例。男９８例，女８２例。其中神经源肿瘤的例（８６．１１％），畸胎类肿瘤５７例（３１．６７％），胸腺瘤２８例（１６．５６％），囊肿１５例（８．３３％），其它肿瘤１５例（８．３３％）。本文对纵隔肿瘤的诊断，不同纵隔肿瘤的临床特点，以及术中注意事项进行了讨论。     

The systemic inflammatory response to anaesthesia and surgery

Major surgery or trauma induces a systemic inflammatory response syndrome (SIRS). In this review the response to uncomplicated surgery is described. The inflammatory response consists of hormonal, metabolic, and immunological components. The extent of the inflammatory response correlates with the magnitude of the surgery or tissue injury. After uncomplicated major surgery a delicate balance between pro- and anti-inflammatory mediators is observed. When the injury is severe, an exaggerated response might develop and the condition progresses to organ dysfunction. In cases where patients are exposed to several events in the form of trauma and surgery immune paralysis may develop. This is associated with increased risk of infection and sepsis. The effect of anaesthetics on the inflammatory response has been studied extensively in vitro, but to a lesser extent in vivo. However, the immunosuppressive effects of anaesthetics appear to be negligible compared to the effect of the surgical trauma.     

三踝骨折及其手术治疗

从1986年5月～1996年1月收治三踝骨折24例,手法整复6例,余18例经开放整复内固定术治疗。采用螺丝钉固定内踝13例,外踝6例,后踝8例;外踝经克氏针固定5例,克氏针加钢丝固定1例。作者认为三踝骨折是复合性的踝关节骨折,应尽早手术,解剖复位和坚固内固定,才能保证踝关节功能恢复,防止创伤性关节炎发生。本文提出了先外踝,再后、内踝的整复次序,尽早整复固定下胫腓骨韧带联合分离,重视对外踝的正确处理。     

Tuberous Breast: A Surgical Challenge

Since the presentation of the tuberous breast deformity by Rees and Aston in 1976, many surgical procedures have been developed, but the correction of such a deformity still remains a surgical challenge. The authors report the last cases treated in the Department of Plastic and Reconstructive Surgery of S?o Jo?o Hospital-Porto and discuss about the ideal procedure which should be used according to the type of deformity. They emphasize the periareolar approach and the good results obtained by the Liacyr Ribeiro technique.     

Surgical Pancreatic Sphincteroplasty. Historic or History ? A Review

Background: Minimal invasive techniques represent a constantly expanding field of medicine and numerous well-established operative procedures have gradually been replaced. Likewise, surgical pancreatic sphincteroplasty, which has been the cornerstone in the management of pancreatic flow disorders for decades, has been largely replaced by endoscopy. Endoscopic pancreatic sphincterotomy however, is still not widespread and carries a significant risk of complications. In this study we attempt to review the role of the surgical approach in the modern era. Methods: Pubmed database was searched for reports concerning surgical pancreatic sphincteroplasty alone or in comparison with endoscopy, without other limitations.

Results: Initially, 44 studies were obtained. Finally, 22 full papers were selected, pertaining review articles, case series or clinical studies. Only four of them were recent (after 2002) series of surgical sphincteroplasty, pertaining 561 patients. No randomized-controlled trials or meta-analyses were revealed.

Conclusions: Pancreatic sphincterotomy, either surgical or endoscopic offers good to excellent long-term results in several disorders, like Sphincter Oddi dysfunction, especially when underlying parenchymal disease is limited. Surgical sphincteroplasty is nowadays indicated in most cases of endoscopic failure and in cases that the papilla cannot be approached. Bariatric patients with gastric by-pass and sphincter Oddi dysfunction in particular, have reported to show excellent outcome after surgery. Regardless the method, patient selection is still a very important determinant of success.     

跟距骨桥症发病原因分析与手术方法探讨

从１９９２年２月～１９９６年９月收治青年战士跟距骨桥症１４例１８足，采用骨桥楔形切除术治疗，随访５～４２个月（平均２２个月），优良率７７．８％。作者认为跟距关节创伤性关节炎是形成跟距骨桥的一种原因。踝部内外侧结构的不均衡使足易发生内翻损伤，高强度的反复足内翻致跟距关节内侧上下关节面频繁挤压、撞击是该病的发病原因。骨桥楔形切除术方法简便，保留了关节功能，是较理想的治疗方法。     

老年性腰椎管狭窄症的外科治疗

目的：探讨６０岁以上老年性腰椎管狭窄症外科治疗的方法及疗效。方法：自病变间隙切除棘间韧带,咬除部分上、下棘突和椎板（１／４～１／３）,切除黄韧带,两侧小关节突内缘有限切除（＜１／３）,前方凿除骨性凸起及摘除突出髓核,伴腰椎不稳者,行保留的上、下棘突劈开自体髂骨植入植骨。结果：２０例经１２～１８个月随访,疗效均达优。结论：腰椎管环形减压术治疗老年性腰椎管狭窄,目的性强,减压较彻底,对腰椎稳定性影响小。     

法乐四联症肺动脉瓣缺如综合征的外科治疗

手术治疗６例法乐四联症肺动脉瓣缺如综合征。除１例伴左肺动脉缺如者于术后１天死亡外，余５例恢复良好，经随访手术效果满意，作者认为对儿童型无呼吸道症状者可在３－４岁纠治，对婴幼型伴严重呼吸道症状必须早期手术治疗。     

涉及全椎骨之脊柱肿瘤的外科治疗

本文报告了4例涉及椎体及其后部结构的全椎骨肿瘤的外科治疗,介绍了全椎骨切除术的手术方法及手术注意事项。手术采用后路附件切除,上下椎体Steffee钢板内固定,前路椎体切除自体髂骨植骨融合,初步效果满意。本手术难度大、出血多、危险性高,术中采用控制性低血压,以减少出血。     

Inhibition of the arachidonic acid metabolism blocks endothelial cell migration and induces apoptosis

Summary Previous studies have demonstrated that inhibitors of the arachidonic acid metabolism block migration and sensitise human glioma cells to treatment inducing apoptosis. This paradigm may provide a new concept for anti-invasive treatment strategies targeting invasive glioma cells. However, the effect of such treatment on other cellular elements in glial tumours such as endothelial cells is unknown. In this study we have analysed the expression of metabolites of the arachidonic acid pathway in endothelial cells in vitro and in vivo and we have assessed the influence of inhibitors of this pathway on motility, capillary like tube formation, and apoptosis in human endothelial cells.Human endothelial cells (HUVEC) in culture showed expression for thromboxane synthase and both isoforms of cyclo-oxygenase, COX-1 and COX-2. Immunostaining demonstrated low levels of COX-1 expression in capillaries and larger vessels of normal brain and moderately elevated levels of this enzyme in small vessels of brain tumours of various grades. Both thromboxane synthase and COX-2 expression was limited to endothelial cells found in anaplastic gliomas and glioblastomas. Thromboxane synthase inhibitors strongly decreased endothelial cell migration in HUVEC in vitro and capillary like tube formation was strongly inhibited by the compound at a similar dose range. The non-selective cyclo-oxygenase inhibitor ASA and the selective COX-2 inhibitor sulindac only had a minor effect on endothelial cell migration, however, the COX-2 inhibitor sulindac showed a synergistic effect with the thromboxane synthase inhibitor. Thromboxane synthase inhibitors induced apoptosis in endothelial cells as demonstrated by intracellular histone-complexed DNA fragmentation.These data suggest that inhibitors of thromboxane synthase influence migration and apoptosis in both human glioma cells and human endothelial cells. An anti-invasive treatment strategy using this class of compounds may therefore not only sensitise glioma cells to conventional treatments inducing apoptosis but may also be supported by an anti-angiogenic effect.     

Surgical lessons from the lake

After circumnavigating Lake Michigan during a sabbatical in the summer of 2011, the lessons learned from this experience and the surgical parallels between boating and life as a surgeon will be discussed. Topics will include the use of surgical checklists, teamwork and communication, leadership, and surgical mentorship.     

69例骨不连原因分析及手术治疗

本文报道手术治疗骨折不愈69例,根据骨折部位、关节功能、身体状况,采用了8种不同手术方法治疗,术后随访2～8年,治愈率96％。作者对骨折不愈合原因、手术方式的选择和并发症的处理进行讨论,提出了相应的预防措施。