An evaluation of routine operative cholangiography

The value of routine use of operative cholangiography was evaluated in 225 patients. In 65 patients (29%), there was one or more clinical or operative indications for common duct exploration and only 21 cases showed positive cholangiographic findings and were explored. There were four negative explorations in this group. In the remaining 160 patients who had no indication for common duct exploration, 157 had a normal cholangiogram and three had false positive cholangiographic findings and were explored unnecessarily. If operative cholangiography had been performed only on those patients with clinical or operative indications for common duct exploration, no ductal stone would have been missed. A selective use of operative cholangiography is advocated and the investigation should be restricted to those patients with clinical or operative indications for exploration of the common bile-duct.     

Hepatic resection in the elderly.

Between July 1, 1970 and December 31, 1988, 453 patients underwent hepatic resection by the senior author. Ninety of these patients were more than 64 years old and are the subject of this review. The 30-day operative mortality rate for all patients undergoing hepatic resection was 3.3%: major hepatic resection was 4.4% and subsegmental resection was 1.4%. The operative mortality rate for patients undergoing major hepatic resection increased incrementally with age: for patients up to age 55 years it was 0.70%, for those between 55 and 64 years it was 3.6%, and for patients older than 64 years it increased to 11.1%. This higher operative mortality rate in the elderly reflects the mortality rate for extended right hepatic lobectomy in this age group of 30.7%. If this procedure is excluded, the operative mortality rate for patients older than age 64 was 7.6%. Sixty per cent of the operative deaths were due to hepatic insufficiency. The data presented demonstrate that major hepatic resection can be performed in the elderly with a low but somewhat increased mortality risk. However, because of its markedly increased operative risk, extended right hepatic lobectomy should be performed in elderly patients only in selected cases until better methods of estimating hepatic reserve are available.     

“隐蔽瘢痕”的改良三孔技术

腹腔镜手术已成为妇科手术的选择之一。然而经典的腹腔镜手术仍会留下3～4个切口瘢痕。瘢痕是手术的标志，因此，没有手术是没有“瘢痕”的。即使是代表内镜技术最新改进和进展的单孔腹腔镜手术（single incision laparoscopic surgery，SILS）仍然会产生瘢痕。虽然只有单一切口，瘢痕数量减少，且不明显，但对医生和病人而言并非如此。     

Identification of bile duct stones in patients undergoing laparoscopic cholecystectomy.

To identify patients with common bile duct stones, all patients considered for laparoscopic cholecystectomy in this unit undergo intravenous cholangiography (IVC) with tomography and, more recently, operative cholangiography. To date 100 consecutive patients with symptomatic gallstones have undergone laparoscopic cholecystectomy with no specific exclusion criteria. Eight patients of 100 were found to have duct stones on IVC with one false-positive. These IVC data were compared with data from 52 patients who also had operative cholangiograms performed. One stone was detected on operative cholangiography that was not identified on IVC. No additional information was gained from operative cholangiography. These data suggest that preoperative IVC is adequate for the detection of duct stones in patients considered for laparoscopic cholecystectomy.     

Impact of unstable angina on operative mortality with coronary revascularization at varying time intervals after myocardial infarction

We have performed a retrospective study of patients undergoing coronary artery bypass grafting for postinfarction angina in an effort to determine the influence of recency of myocardial infarction and unstable angina on operative mortality. Time from myocardial infarction to bypass was arbitrarily divided into five intervals. Nine hundred ninety-three patients having isolated coronary bypass for postinfarction angina were analyzed, and a significant trend of increased operative mortality with recency of myocardial infarction was found (p less than 0.001). When patients were operated on during the time interval zero to 24 hours after infarction, the operative mortality rate was 18.6%. In the interval from 1 day to 1 week after infarction, the operative mortality rate was 7.4%; 1 week to 3 weeks, 5.9%; and 3 weeks to 3 months, 2.7%. In patients operated on more than 3 months after infarction, the operative mortality rate was 3.9%. The operative mortality rate in 360 patients with postinfarction stable angina was 0.83% compared with 7.3% in 633 patients with postinfarction unstable angina (p less than 0.001). Of 18 risk factors tested, 12 were found by univariate analysis to be independent predictors of operative mortality, including recency of myocardial infarction and unstable angina. Stepwise logistic regression analysis of independent predictive variables revealed that unstable angina, previous surgical revascularization, preoperative hypotension, nonelective surgery, preoperative cardiac arrest, and female sex were the strongest predictors of mortality; recency of myocardial infarction was not a factor. When acute surgical reperfusion is not the primary treatment strategy for patients with myocardial infarction, operative mortality with coronary bypass is increased with the recency of myocardial infarction. The reason for this increase in operative mortality is a patient selection process in which those with persistent or intermittent myocardial ischemia, as reflected in the clinical syndrome of unstable angina, are selected for operation. Unstable angina is a major determinant of operative mortality after myocardial infarction. In patients with stable angina, operative mortality is not increased by the recency of myocardial infarction.     

Thoracic outlet syndrome: a comprehensive evaluation

Using various modalities, 480 patients were evaluated for thoracic outlet compression syndrome. Of this group, 300 patients were eventually diagnosed as having thoracic outlet syndrome after extensive evaluation. Ninety of these patients underwent a total of 103 operative procedures for thoracic outlet decompression. Nerve conduction velocities and directional Doppler studies were the most useful adjuncts in making the diagnosis. Surgical therapy after proper selection yielded an 80.6 per cent long-term "good" operative result and an additional 6.9 per cent long-term "fair" operative result in follow-up to 12 years.     

Prevention of fat embolism syndrome in patients with femoral fractures--immediate or delayed operative fixation?

From January 1976 until August 1980, femoral fractures in our department were initially stabilized with tibial traction and fixed operatively after 4-7 days. From August 1980 the fractures were treated with immediate operative fixation. In this retrospective study, we compared the incidence of fat embolism syndrome in 106 patients treated with delayed operative fixation to the incidence in 114 patients treated with immediate operative fixation. Eleven patients (10.4%) developed fat embolism syndrome in the group treated with delayed fixation, compared with two patients (1.8%) in the immediate osteosynthesis group (p less than 0.02). We concluded that early operative fixation of femoral fractures seems beneficial for the prevention of fat embolism syndrome.     

Is operative cholangiography always necessary?

To determine whether operative cholangiography could be performed on a selective basis, 272 consecutive patients undergoing cholecystectomy and routine operative cholangiography were studied prospectively. Appropriate clinical, biochemical and operative data were recorded and the surgeon was asked to estimate the likelihood of common bile duct stones. These factors were correlated with the subsequent cholangiographic and operative findings. From this information, four criteria were selected as indications for performing an operative cholangiogram: an abnormal common bile duct, a wide cystic duct, or elevated levels of alkaline phosphatase or bilirubin documented in the previous six months. Operative cholangiograms would have been indicated by the presence of one or more of these criteria in only 139 of the 272 patients in the study (51 per cent). Only one unsuspected stone would have been missed. It is concluded that a policy of selective cholangiography could have been safely adopted in this series of patients.     

老年患者髋部骨折治疗方法的选择与预后探讨

目的分析比较老年患者,尤其脑血管病后遗症不全瘫患者的股骨近端骨折手术与非手术治疗方法的预后。方法 回顾分析1994年1月~2002年9月获得随访的髋部骨折住院患者310例,年龄60~91岁,伤前有脑血管病后遗症不全瘫者49例,其中222例接受手术治疗,88例非手术治疗。对照分析手术治疗与非手术治疗患者功能恢复、并发症的发生及死亡等情况。结果老年髋部骨折手术治疗组并发症及死亡率均低于非手术组(P值均<0.01),即使合并脑血管病后遗症,其术后死亡率及并发症发生率亦明显低于非手术组。结论 除非患者生命垂危,老年髋部骨折均应手术治疗,尤其对并存较严重疾病者手术治疗有积极意义。     

Perioperative heart failure in coronary surgery and timing of intra‐aortic balloon pump insertion

Background: Perioperative heart failure (HF) in coronary operations is accompanied by a high operative mortality rate. An intra‐aortic balloon pump (IABP) is often used to treat this syndrome. The correct timing for IABP insertion after completion of the operation has not yet been investigated. The aim of this study was to investigate the operative mortality in perioperative HF patients who had undergone coronary operations with respect to the early or the late use of IABP. Methods: This is a retrospective study including 7,270 patients who had undergone coronary surgery with or without associated procedures. A population of patients with perioperative HF was extracted and analyzed with respect to the use of drugs, intra‐operative or post‐operative IABP to treat this condition. Results: A total of 1,051 (14.5%) patients had perioperative HF. The mortality rate in this group was 13.5%. Early (intra‐operative) IABP insertion was performed in 123 patients. In contrast, 928 patients were treated with inotropic drugs only, and, of these patients, 59 developed a drug‐refractory HF requiring late IABP insertion. Operative mortality was significantly (P=0.001) higher in patients requiring late (64.4%) vs. early (41.5%) IABP insertion. Independent risk factors for developing a drug‐refractory HF were age, pre‐operative serum creatinine value and an associated mitral valve procedure. Conclusions: Postponing the use of IABP may be deleterious in patients with drug‐refractory HF. In the presence of the three factors independently associated with the risk of a drug‐refractory HF, early IABP insertion is suggested.     

Prediction of operative mortality by a discriminant analysis for organ functions in patients with esophageal cancer--organ function index

An "organ function index" (OFI) predicting the risk of operative mortality was presented. OFI was estimated on the basis of dysfunction of the systemic organs in patients with esophageal cancer. The pulmonary, cardiac, hepatic and renal functions were assessed by 23 parameters in 108 patients when they were admitted. Operative death was defined as death due to operative complications occurring within 120 days after esophagectomy or by-pass operation. For a discriminant analysis, patients were limited to those in the early period (from October 1981 until December 1985) when the incidence of operative mortality was relatively higher and the parameters were also limited to statistically evaluable ones. Then, a discriminant analysis was performed using data on 18 parameters of four organs in 35 patients each of whom had no deficit in these data. Operative death occurred in 8 out of these 35 patients. Based on the data, an equation to calculate OFI was generated. It consisted of 7 parameters regarding pulmonary, hepatic and renal functions. The values of OFI less than zero predicted no operative death while those more than zero did predict operative death. The prediction rate on presence or absence of operative mortality by this equation was 91.4% in 35 patients. For clinical application, the predictable risk of operative mortality based on OFI was classified as high (OFI less than 1.4), intermediate (0 less than OFI less than 1.4), or low (OFI less than 0).(ABSTRACT TRUNCATED AT 250 WORDS)     

手术时间对接受腹腔镜辅助胃癌根治术老年患者预后的影响分析

目的:分析手术时间对接受腹腔镜辅助胃癌根治术的老年患者预后的影响,以探讨亚群预后的影响因素.方法:回顾分析70岁以上接受腹腔镜辅助胃癌根治术患者的临床资料.结果:X-tile软件证明手术时间影响患者预后的截断值为230 min,相较短手术时间组,长手术时间组的患者总体生存期较差(P=0.043);且肿瘤较大、TNM分期...     

Diagnostic pathways and delays on route to operative intervention in acute appendicitis

The purpose of this study was to determine the elements associated with delay in the evaluation of acute appendicitis at a community teaching hospital. We performed a retrospective chart review of patients undergoing operative exploration for presumed appendicitis in a 12-month period. Cases were categorized by the presence or absence of advanced radiographic imaging. Demographic information and time intervals from triage to operative incision were compared. One hundred twenty-four patients underwent operative exploration for presumed appendicitis. Forty-one patients had no advanced imaging, 67 had a CT scan, 8 had a sonogram, and 8 had both CT/sonogram. Patients using advanced radiographic imaging prior to operative exploration were no less likely to have a normal appendix at surgery. Diagnostic imaging significantly increased the preoperative emergency department length of stay. Two-thirds of patients with presumed acute appendicitis were imaged before operative exploration. The use of abdominal CT and sonogram resulted in significantly increased preoperative emergency department length of stay with no apparent improvement in diagnostic accuracy.     

Mitral valve replacement versus reconstruction. An analysis of indications and results of mitral valve procedures in a consecutive series of 80 patients

Case histories of 80 patients undergoing mitral valve procedures over a 2 year period were analyzed to determine the preoperative and intraoperative factors favoring reconstruction. Of 34 patients undergoing valve reconstruction, 31 (90 per cent) were women, and the average age of patients undergoing reconstruction was 41 versus 51 for patients who underwent replacement. Absence of calcification on fluoroscopic study and at operation favored reconstruction, as did the finding of good leaflet mobility by preoperative echocardiograms and operative assessment. Pure lesions, i.e., stenosis or insufficiency, favored reconstruction. In this regard, the use of new annuloplasty techniques has facilitated the surgeon's ability to reconstruct regurgitant mitral valves. No operative deaths and excellent functional and clinical results obtained in 80 per cent of patients undergoing mitral reconstruction justify the aggressive application of this technique in properly selected patients.     

Utility of operative ultrasound in the surgical management of liver tumors.

In this study the utility of operative ultrasound in the surgical management of 98 consecutive patients with liver and gastrointestinal tumors was assessed. All patients had preoperative work-up including ultrasound study of the liver as well as selective hepatic arteriography (50 patients) and computerized tomography of the liver (45 patients). At surgery, inspection and palpation of the liver as well as operative ultrasound examination were performed in all cases. Fifty-six patients were known to have liver tumors before operation, while 42 patients had their liver examined as part of the treatment of a primary gastrointestinal malignancy. A total of 126 liver tumors were found in 58 patients, all of whom were confirmed histologically. Eighteen nodules unsuspected before operation were found at surgery--nine by inspection and palpation of the liver, and nine others that were nonpalpable were found by operative ultrasound only. Eighteen lesions that were missed by all diagnostic modalities were found as secondary lesions on pathologic examination of the resected specimens. In addition to diagnostic applications, operative ultrasound was useful in localizing nodules and permitting guided biopsies deep in the hepatic parenchyma. In eight cases, segmental resections were performed with operative ultrasound to localize the plane of section and to catheterize the intrahepatic portal vein branch afferent to the tumor in order to perform balloon catheter occlusion of the vessel for control of bleeding. Operative ultrasound was found to be important in the surgical management of 19 of 98 patients (19%).     

Does viewing of surgical specimen improve patient satisfaction? A cohort study

The purpose of this study was to assess a cohort of patients who underwent elective gynecologic surgery to determine whether viewing of intraoperative photographic images by patients played a role in patient satisfaction. Three hundred and eighteen patients participated in this study, out of which 159 patients were assigned to view the operative photographic pictures and 159 were not. According to the results obtained in this study, a greater number of women who viewed their operative photographic pictures, expressed satisfaction in comparison to those who did not. In addition, this difference was significantly greater in those who encountered intra- and/or postoperative complications.     

Clinical and functional results after floating shoulder injuries

BACKGROUND: Good results have been reported with both operative and nonoperative treatment of floating shoulder, and discussions about an appropriate therapy of this rare entity are controversial because of small numbers of patients. METHODS: Seventeen patients with a floating shoulder were retrospectively evaluated. The treatment was nonoperative in eight patients and operative in nine. All patients were clinically examined and standard shoulder radiographs were obtained at the time of follow-up. RESULTS: All fractures healed. Five patients in the nonoperative and five patients in the operative group showed good to excellent results. The associated injuries influence the outcome of these patients significantly. CONCLUSION: Nondisplaced or less displaced floating shoulders are expected to give good results after nonoperative treatment. If mostly heavy associated injuries allow it, significantly displaced fractures should be treated operatively.     

Quantitative assessment of myelopathy patients using motor evoked potentials produced by transcranial magnetic stimulation

Motor evoked potentials (MEPs) study using transcranial magnetic stimulation (TMS) may give a functional assessment of corticospinal conduction. But there are no large studies on MEPs using TMS in myelopathy patients. The purpose of this study is to confirm the usefulness of MEPs for the assessment of the myelopathy and to investigate the use of MEPs using TMS as a screening tool for myelopathy. We measured the MEPs of 831 patients with symptoms and signs suggestive of myelopathy using TMS. The MEPs from the abductor digiti minimi (ADM) and abductor hallucis (AH) muscles were evoked by transcranial magnetic brain stimulation. Central motor conduction time (CMCT) is calculated by subtracting the peripheral conduction time from the MEP latency. Later, 349 patients had surgery for myelopathy (operative group) and 482 patients were treated conservatively (nonoperative group). CMCTs in the operative group and nonoperative group were assessed. MEPs were prolonged in 711 patients (86%) and CMCTs were prolonged in 493 patients (59%) compared with the control patients. CMCTs from the ADM and AH in the operative group were significantly more prolonged than that in the nonoperative group. All patients in the operative group showed prolongation of MEPs or CMCTs or multiphase of the MEP wave. MEP abnormalities are useful for an electrophysiological evaluation of myelopathy patients. Moreover, MEPs may be effective parameters in spinal pathology for deciding the operative treatment.     

Gastrointestinal tuberculosis: resurgence of an old pathogen

Thirteen patients with gastrointestinal tuberculosis (GITB) were treated at our hospitals from 1977-1987. Ten of these patients were seen during the last four years. Three patients required operative intervention for management of complications of their disease. This review discusses the presentation, diagnosis, and operative management of GITB. The authors feel that the increasing prevalence of GITB noted in their institution is primarily the result of the growing prevalence of mycobacterium tuberculosis pneumonia across the nation. With the recent influx of patients from areas of endemic tuberculosis and the increasing number of immunosuppressed patients, a surge in the number of patients presenting with GITB is likely to occur in the United States. Surgeons must be conversant with the diverse clinical features and operative management of this disease.     

Treatment of Patent Ductus Arteriosus in Infancy

Twenty-six infants less than 1 year of age were treated with duct ligation. In 2 patients recanalization or incompleie occlusion of the duct occurred. Two patients died. Early operative treatment is indicated in symptomatic patients. A dramatic change in an otherwise hopeless situation is feasible, and this greatly outweighs operative risks.