Counsel for the coronary surgeon

Young coronary surgeons fresh out of training face challenging circumstances: fewer operations, sicker patients, and greater scrutiny. With this milieu in mind, the author offers 28 suggestions for the inexperienced surgeon performing coronary artery bypass grafting.     

Aspergilloma and the surgeon

Aspergillus fungus is a ubiquitous saprophyte that is the causative organism for the development of an aspergilloma. The most common species causing an aspergilloma is the Apergillus fumigatus. An aspergilloma is a conglomeration of mucus, inflammatory cells and altered blood elements. Aspergillomas typically form in pre-existing lung pathology, most notably and commonly in old healed tuberculosis cavities. They are classified into simple and complex types that have clinical relevance. Symptoms are very variable and it is not uncommon to incidentally find a lung aspergilloma. In most case series, the most common presenting symptom is haemoptysis which varies from mild to catastrophic bleeds. Given the limited information about the natural history of the disease, there is unfortunately no recognised factor or variable which can predict how an aspergilloma will manifest itself, hence the manner of treatment is a still a topic of debate among treating physicians. The mainstay of treatment is surgical intervention and medical options although disappointing at the current stage, require further investigation in light of the newer available anti-fungal agents. The need for surgical intervention is however not as clear-cut as one would like, since many patients have multiple co-morbidities and other diffuse or focal lung pathology, making the decision process indeterminate in certain instances. In this review, we focus on the different surgical options available for the management of aspergilloma across variable clinical settings, and we propose an approach to its management.KEYWORDS : Aspergilloma, clinical course, surgical management     

Guidelines for noninvasive vascular laboratory testing: a report from the American Society of Echocardiography and the Society for Vascular Medicine and Biology

Accompanying the rapid growth of interest in percutaneous vascular interventions, there has been increasing interest among cardiologists in performing noninvasive vascular testing using ultrasound. In an attempt to provide recommendations on the best practices in vascular laboratory testing, this report has been prepared by a writing group from the American Society of Echocardiography (ASE) and the Society for Vascular Medicine and Biology. The document summarizes principles integral to vascular duplex ultrasound--including color Doppler, spectral Doppler waveform analysis, power Doppler, and the use of contrast. Appropriate indications and interpretation of carotid artery, renal artery, abdominal aorta, and peripheral artery ultrasound imaging are described. A dedicated section summarizes noninvasive techniques for physiologic vascular testing of the lower extremity arteries--including measurement of segmental pressures and pulse volume plethysmography. The use of exercise testing in the evaluation of peripheral artery disease, ultrasound evaluation of the lower extremities after percutaneous revascularization, and the diagnosis and management of iatrogenic pseudoaneurysm (PSA) is also discussed. A section on the important topic of vascular laboratory accreditation is included. Finally, additional details regarding proper technique for performance of the various vascular tests and procedures are included in the Appendix.     

Apoptosis and the liver: Relevance for the hepato-biliary-pancreatic surgeon

Cell death by apoptosis is thought to be involved in various pathophysiological situations involving the liver. Indeed, an understanding of apoptosis is becoming increasingly helpful for understanding disease and for patients' care. In this article, we review current scientific and clinical concepts of apoptosis, including death factors such as Fas ligand and tumor necrosis factor, apoptotic signal transduction mechanisms, and the role of intracellular proteinases called caspases. We also discuss apoptosis in the liver, as related to ischemia/reperfusion injury, cholestasis, and cancer, circumstances which physicians often face in the field of the liver surgery.     

Viral hepatitis and the surgeon

BACKGROUND: Viral hepatitis is an infection of the liver caused by one or more of six known (HAV-HGV) hepatotropic viruses. It is a common problem among health care workers and their patients. Surgeons are at particular risk of both acquiring and transmitting some of these viruses from and to their patients. Unfortunately, specific immunoprophylaxis for viral hepatitis is presently limited to protecting against the spread of hepatitis A and B viral infections, leaving a high degree of vigilance and careful surgical technique as the only means available to prevent the transmission of other viruses relative to the surgeon. The purpose of this paper is to review the various forms of viral hepatitis including the nature of the virus, serologic testing, clinical features, epidemiology (with specific reference to those issues that arise in surgical practice), treatment and prevention.     

Perioperative responsibilities of the surgeon

Surgery is as effective in the elderly as in any age group and should not be denied on the basis of age. The elderly need and deserve more courtesy and respect. Meticulous attention to preoperative preparation is critical. Anticipation of problems such as hypokalemia and dependency on tranquilizers and prompt preemptive action go a long way toward the prevention of complications. Preoperative invasive monitoring in the ICU using a Swan-Ganz catheter and appropriate volume preloading will reduce operative mortality in high-risk patients. Suitable candidates are best recognized by lung function studies and blood gases in addition to a global assessment. The operation itself must be kept simple, and the surgeon needs to work swiftly but gently. The elderly require particular attention to the prevention of specific complications. Urinary catheters, nasogastric tubes, and prolonged parenteral nutrition should be avoided whenever possible. Immobility for any length of time is to be condemned. Heparin prophylaxis against thromboembolism and antibiotic prophylaxis are liberally employed. Finally, should the elderly patient develop a major complication, this complex situation must be handled with both skill and compassion. The surgeon must not lose sight of the fact that the goal is most often palliation and that quality of life is paramount.