The relation between EEG and mental development following cardiac surgery performed under simple deep hypothermia in children

In order to assess the accuracy of electroencephalography (EEG), in children who have undergone cardiac surgery under simple deep hypothermia, the relation between IQ or schoolwork achievement and the duration of circulatory arrest was investigated in 75 such children. Abnormal preoperative EEG's were found in 16 per cent of the children while abnormal postoperative EEG's were found in 17 per cent. The children were divided into 4 groups, according to pre- and postoperative EEG results. Schoolwork achievement scores ranged between 3.0 and 3.2, the difference among the groups being insignificant. Moreover, no significant shift in IQ was found among the groups. Finally, regarding the number of children who were able to go on to a higher level of education, including high school then college or university, again no significant differences were found among the 4 groups. In a comparison with the number of such children in neighboring Nagasaki prefecture able to continue on to a higher level of education, no significant differences were seen either. The findings and statistics of this investigation therefore indicate that pre- and postoperative EEG's are not always a reliable reference for assessing the prognosis of cerebral activity.     

Atracurium versus vecuronium: a comparison of recovery in outpatient arthroscopy

Atracurium 0.5 mg.kg-1 and vecuronium 0.1 mg.kg-1 were compared as neuromuscular relaxants for outpatient arthroscopy of the knee under general anaesthesia. In 40 unpremedicated patients divided at random into two groups, anaesthesia was induced with methohexitone, atracurium (Group A) or vecuronium (Group B), three per cent isoflurane prior to intubation and 0.9 per cent during maintenance with nitrous oxide 66 per cent in oxygen. Neuromuscular function was recorded by a Datex Relaxograph. Recovery was assessed by the time the patients took to open their eyes, to be able to answer five questions correctly, the time to recovery of ocular balance (Maddox Wing test) and by comparing pre- and postoperative performance of a paper and pencil test (the p-deletion test). Recovery tests showed no significant differences between groups. After three hours all the patients were fit for discharge. The patients were interviewed one month after the procedure. All were satisfied with their anaesthetic. "Full recovery" took 1.5 days with a range of 1 h-7 days. The only significant difference (p less than 0.01) between the groups was the need for pharmacological reversal of residual paralysis. In a procedure with a mean duration of 45.6 minutes, and using isoflurane, all but one patient (95 per cent) in the atracurium group required neostigmine versus nine patients in the vecuronium group (45 per cent).     

Splanchnic hemodynamic changes after the distal spleno renal shunt

Marked changes in preoperative to postoperative corrected sinusoidal pressures (CSP) occurred in 51 per cent of a series of 51 patients undergoing the distal splenorenal shunt. Twenty patients who had the highest incidence of partial portal vein thrombosis, (48%--Group I), showed minimal pre- to postoperative changes in CSP. Twelve patients (Group II) who increased their CSP to 4 mm Hg or greater had marked postoperative hyperbilirubinemia and decreased portal blood flow. Fourteen patients who decreased their CSP 4 mm Hg or more postoperatively also showed moderate portal blood flow decrease without significant changes in liver enzymes. Morbidity and mortality were not significantly different among the three groups. The significance of these hemodynamic changes is not known.     

Using the spectral analysis of the EEG for prognosis of severe brain injuries in the first post-traumatic week.

Fifty adult patients with severe brain injuries were examined with the EEG on the 1st, 2nd, 3rd, 5th, and 7th postoperative days. In 40 of these 50 cases a prognosis was given after 7 days as a result of the Fourier analysis of the EEG: 23 patients survived, 17 died. There are significant differences in the EEG's for these two groups: an increase of the absolute and relative amplitudes in the alpha and theta bands for the survivors, and a decrease or no change in the alpha and theta bands for the others, all during the first week. In 10 cases the correct prognosis could not be given: 5 patients showed spindle or alpha activity (alpha pattern coma) in the EEG; 4 cases had to be treated with barbiturates for focal seizures, and one suffered from secondary bleeding. In these cases computer tomography did not yield additional prognostic information.     

Radical mastectomy with parasternal node dissection or radiation to the parasternal region for breast cancer of medial or central location

In order to establish a therapeutic approach for primary breast cancer of medial and central origin, we reviewed 183 patients who had been treated by one of the following three modalities at the Second Department of Surgery, Osaka University Medical School between January, 1965 and December, 1980. Group A (n=70): standard radical mastectomy alone; Group B (n=34): standard radical mastectomy followed by postoperative irradiation to the parasternal and supraclavicular regions, and; Group C (n=62): extended radical mastectomy that included removal of the parasternal lymph nodes. The background factors of the three groups were not significantly different. The overall survival five and ten years following surgery in the three groups were 91 per cent and 79 per cent in group A, 82 per cent and 67 per cent in group B, and 82 per cent and 70 per cent in group C, respectively, showing no significant difference in overall survival among the three groups. When the patients were classified according to the extent of axillary lymph node involvement, there was no difference in survival among the three treatments in patients who had less than three lymph node metastases in the axilla. However, treatment of the parasternal lymph nodes improved survival in the patients who had more than four lymph node metastases in the axilla. Parasternal lymph node involvement definitely worsened the prognosis, showing it to be a good prognostic factor. Thus, extended radical mastectomy should be considered for patients with breast cancer of medial or central location, when extended axillary lymph node involvement is found.     

Central nervous system toxicity of cyclosporine in a rat model

The central nervous system toxicity of cyclosporine, which is known to be neurotoxic clinically, was investigated in a rat model. Munich-Wistar rats were divided into 3 groups for a 2-week protocol. After baseline EEG and behavioral testing, group 1 (control) received a weight-adjusted volume of parenteral cyclosporine vehicle i.p., group 2 (low-dose) received 5 or 10 mg/kg/day i.p., and group 3 (high-dose) received 20 mg/kg/day i.p. Spontaneous behavior was observed, simple sensorimotor testing performed daily, and awake EEG's recorded 3 times per week. Four of 12 high-dose animals died during study, one after a witnessed tonic-clonic seizure, and two after recording of frankly epileptiform EEG's; there were no deaths in control or low-dose animals. Significant EEG abnormalities developed only at high-dose, with frankly epileptiform EEG's and/or seizures seen in 58 +/- 15% of these rats (P = 0.005, different from controls by life-table analysis). Although some high-dose animals demonstrated hyperirritability and dystonic posturing, behavioral changes were subtle, and animals were often still or rocking slightly during recording of frankly epileptiform EEG's. Walking latency and alley escape behaviors were delayed in high-dose rats, the latter correlating with abnormal EEG's. Serum urea nitrogens were mildly elevated in high-dose animals, but serum creatinine, electrolytes, bilirubin, body magnesium stores, and blood pressure remained normal in all groups. Kidneys showed only mild vacuolation histologically. The brain showed only very focal cortical injury sites related to electrode placement, which did not correlate with EEG changes or mortality. These results suggest that there may be a direct effect of cyclosporine on the central nervous system. This model system should prove useful in defining mechanisms of cyclosporine-related neurotoxicity.     

Complications of low-dose heparin prophylaxis following pelvic lymphadenectomy

All patients who underwent pelvic lymphadenectomy for prostatic carcinoma over a five-year period were reviewed to evaluate the effect of minidose heparin prophylaxis on lymphocele formation and postoperative complications. The overall incidence of complications was found to be consistent with that reported in the current literature. However, when the rate of lymphocele occurrence was correlated with perioperative minidose heparin therapy, the incidence rose from 2.5 per cent in those receiving no heparin to 38 per cent in patients receiving both pre- and postoperative prophylactic heparinization. Other major postoperative complications were also significantly increased when minidose heparin was pre- or postoperatively administered. A strong recommendation is made for caution in the routine use of prophylactic low-dose heparin during pelvic surgery.     

Surgical treatment for poor-risk patients with carcinoma of the esophagus

During the period between 1979 and 1988, 145 patients with cancer of the esophagus were admitted to our department. They were examined for the preoperative risk factors associated with multiple organ function and classified into three groups according to the risk score. Special attention was paid to postoperative pulmonary complications, mortality and the long term results of surgery in the poor-risk patients and the findings analyzed in reference to the operative procedures. The resection rate for the poor-risk group was 41 per cent, however, esophagectomy was only able to be combined with a right thoracotomy and abdominal approach in 26 per cent of the patients in this group. Postoperative pulmonary complications developed in 64 per cent of the poor-risk patients who underwent a transthoracic esophagectomy and in only 25 per cent of those who received a transhiatal esophagectomy, although there was no significant difference in the overall survival rate beteeen these two subgroups. The present observations therefore raised the possibility that transhiatal esophagectomy may improve the results of surgical treatment for poor-risk patients with esophageal cancer.     

Surgical treatment for poor-risk patients with carcinoma of the esophagus

During the period between 1979 and 1988, 145 patients with cancer of the esophagus were admitted to our department. They were examined for the preoperative risk factors associated with multiple organ function and classified into three groups according to the risk score. Special attention was paid to postoperative pulmonary complications, mortality and the long term results of surgery in the poor-risk patients and the findings analyzed in reference to the operative procedures. The resection rate for the poor-risk group was 41 per cent, however, esophagectomy was only able to be combined with a right thoracotomy and abdominal approach in 26 per cent of the patients in this group. Postoperative pulmonary complications developed in 64 per cent of the poor-risk patients who underwent a transthoracic esophagectomy and in only 25 per cent of those who received a transhiatal esophagectomy, although there was no significant difference in the overall survival rate between these two subgroups. The present observations therefore raised the possibility that transhiatal esophagectomy may improve the results of surgical treatment for poor-risk patients with esophageal cancer.     

Transderm scopolamine for the control of perioperative nausea.

A randomized prospective study of 201 patients in two institutions was performed to evaluate the efficacy of a transderm scopolamine patch in the control of postoperative nausea. Of 201 patients, 180 successfully completed the protocol. Demographically, the groups were similar in age, sex, and surgical procedures. Adverse effects were noted in both treatment and control groups. Forty-seven per cent of the placebo and 49 per cent of the transderm scopolamine group did not experience postoperative side effects. The most common adverse reactions were urinary retention, dry mouth, agitation, nausea, and vomiting. There was a reduction in the number of vomiting episodes in the transderm scopolamine treatment group from the control group (21% transderm scopolamine vs. 36% placebo). These differences became more significant among the subgroups in surgery, especially after orthopedic procedures. Thirty-five per cent of the transderm scopolamine group experienced nausea compared with 65 per cent from the placebo, 11 per cent of the transderm scopolamine experienced vomiting compared to 26 per cent. Transderm scopolamine was effective in reducing but not eliminating postoperative nausea.     

Significance of the Preoperative Intravesical Instillation of Doxorubicin and the Oral Administration of 5-Fluorouracil in Preventing Recurrence After a Transurethral Resection of Superficial Bladder Cancer

Background : The postoperative intravesical instillation of doxorubicin (ADM) has a preventative effect on recurrence after a transurethral resection (TUR) of superficial bladder cancer. However, the significance of preoperative ADM instillation remains unclear. Although the oral administration of 5-fluorouracil (5-FU) has been observed to show some clinical response against bladder cancer, its preventative effect on the recurrence of superficial bladder cancer after TUR is unknown. Methods: Patients were randomized into 4 groups. All 4 groups received postoperative ADM instillation. In addition, patients in groups C and D received preoperative ADM instillation, whereas patients in groups B and D additionally received oral 5-FU postoperatively. The nonrecurrence rate and side effects were both compared among the 4 groups.
Results : Of the 282 patients registered, 200 were evaluable, with a median follow-up period of 21.4 months. There were no significant differences in the characteristics of the patients among the 4 groups. Group C (pre- and postoperative ADM) showed a significantly longer disease-free interval than group A (postoperative ADM alone). However, there was no significant difference in the disease-free interval between groups A and B (postoperative ADM plus 5-FU), or between groups C and D (pre- and postoperative ADM plus 5-FU). Bladder irritation symptoms were the most frequently noted side effect encountered in all groups, but the severity was generally mild.
Conclusions : Preoperative ADM instillation was found to prevent recurrence to a greater extent than the usual postoperative instillation alone, whereas oral 5-FU was found to have no additional beneficial effect on the disease-free interval in patients with superficial bladder cancer.     

Cognitive functioning and school performance in children with renal failure

Although previous studies have documented neuropsychological deficits in children with end-stage renal disease, few have evaluated and compared the cognitive functioning and the school performance of children with renal failure. The current study evaluated the influence of chronic renal failure on cognitive functioning and school performance in children and adolescents with end-stage renal disease undergoing dialysis and after renal transplantation. Participants were given standardized IQ and achievement tests to assess cognitive functioning and ability. Academic performance was determined by evaluating grades for the semester in which the testing was performed; a grade point average (GPA) was calculated based on a 4.0-point scale. The 11 dialysis patients and 13 transplant patients were comparable in age, race, sex, and socioeconomic status. Overall IQ and subtest scores demonstrated no differences between the two groups. Performance on the Woodcock-Johnson achievement tests showed that the transplant patients did better on achievement tests of written language (P=0.04) and in school performance in English compared with dialysis patients (P<0.05). Furthermore the dialysis patients tended to be below age and grade level in all areas, whereas the transplant patients were achieving at or above these levels. There were significant differences in the age equivalent scores between the dialysis and transplant patients in the areas of mathematics and written language (P<0.05). However, when grades were evaluated there were no differences in overall GPA or in the mathematics GPA. Days absent were not different between the two groups. These data demonstrate that both groups of patients were of similar intellectual ability; the achievement of the dialysis patients was behind that of the transplant patients and this lag was not necessarily reflected in school grades. Patients with chronic renal failure should have cognitive and achievement testing on a regular basis, and areas of deficit should be addressed by the schools.     

The influence of gender on postoperative PROMIS physical function outcomes following minimally invasive transforaminal lumbar interbody fusion

PurposeOur aim is to examine the gender performance of Patient-Reported Outcome Measurement Information System Physical Function (PROMIS-PF) scores among patients undergoing minimally invasive transforaminal lumbar fusion (MIS TLIF).MethodsA prospectively collected surgical dataset was retrospectively assessed for eligible patients from March 2015–June 2019. We included patients if they underwent primary MIS TLIF procedures on one or two vertebral levels. We collected baseline demographics, perioperative characteristics, and PROMIS-PF scores for each subject at pre and postoperative timepoints (e.g., 6-weeks, 3-months, 6-months, and 1-year). Chi-squared analyses were utilized to assess categorical variables and a Student’s t-tests analyzed continuous variables. A linear regression was used to analyze PROMIS-PF scores from baseline through all postoperative time points. Finally, we evaluated the PROMIS PF achievement of minimal clinically important difference (MCID) among gender.Results192 patients were included: 77 were females and 115 were males. No significant differences were observed among gender subgroups for PROMIS-PF scores at pre- or postoperative evaluations. Compared to males, females experienced significantly greater postoperative improvement with PROMIS-PF scores at the 3-month assessments, though no significant gender differences were observed during later follow-up evaluations at 6-months or one year. Females were observed to have significant PROMIS-PF score improvement from their preoperative evaluation to each postoperative score. Males were assessed to have statistically significant postoperative (e.g., at 3-months, 6-months, and 1-year) PROMIS-PF score improvement from their preoperative PROMIS-PF scores. There were no significant differences among gender in achieving MCID at any postoperative time interval.ConclusionAmong gender, we observed no statistically significant difference in PROMIS-PF scores during the pre- or postoperative evaluations. Additionally, with no difference in the rate of achieving PROMIS-PF MCID postoperatively, this study established that both genders should experience similar functional outcomes following MIS TLIF.     

A randomized study of a semisynthetic heparin analogue and heparin in prophylaxis of deep vein thrombosis

The prophylactic effect of a semisynthetic heparin analogue (SSHA) on deep vein thrombosis was investigated in a prospective double-blind multicentre trial. 440 major general surgical and gynaecological patients were randomized to one of three treatment groups: 50 mg SSHA, 37.5 mg SSHA and 5000 units sodium heparin subcutaneously 12-hourly. Deep venous thrombosis (DVT) was diagnosed with the fibrinogen uptake test and verified with phlebography. Bleeding complications and other side-effects were carefully monitored. There were no significant differences between the three treatment groups of patients in age, sex, type of operation or risk factors. A DVT was diagnosed in 16 patients (12 per cent) in the SSHA 50 mg group, in 21 patients (15 per cent) in the SSHA 37.5 mg group and 21 patients (14 per cent) in the heparin-treated group. No significant differences were found in the number of patients who bled unexpectedly in the postoperative period, required transfusion or developed wound haematomas. Blood loss at operation was similar in all three groups. Three pulmonary emboli were diagnosed by pulmonary scintigraphy, one in each group.     

Esophageal cancer from the German point of view

Although there are no differences worth mentioning between esophageal cancer in Japan and in Europe regarding epidemiology, tumor stages at the beginning of therapy and surgical selection. In Japan, early esophageal squamous cell carcinoma is more often diagnosed than in Europe where esophageal adenocarcinoma, especially that of the endobrachyesophagus, is becoming more and more relevant. For a long time, the limiting factor for the prognosis of esophageal cancer was the postoperative lethality. However, by carefully analysing the factors influencing this operative lethality over the last few years, the lethality following esophagectomy has been decreased to approximately 15 per cent. In fact, in some specialized centers, the lethality is now less than 10 per cent and in selected patient groups even 3 per cent has been reached. It is only through this achievement that the prognosis for esophageal cancer has been able to be markedly improved. The results of this analysis can be detailed as follows: 1) The preoperative definition of tumor stage by CT or MRI is not reliable, the validity being between 45 per cent and 73 per cent. Therefore, no therapeutical decision can be made on the basis of these diagnostic procedures. Hopefully the intraluminal ultrasound will improve this situation in the future. 2) The analysis of preoperative nutritional status did not allow a definition of risk groups. 3) Decisive improvements were able to be achieved by the standardising of surgical procedures and indications. Enbloc resection is indicated for all intrathoracic squamous cell carcinomas and accounts for a high percentage of RO-resections. The blunt dissection is especially appropriate for distal adenocarcinomas. 4) Endobronchial one-sided ventilation during the operation and prophylatic assisted ventilation have both decreased the pulmonary risk considerably. A further improvement in the prognosis of esophageal carcinoma can possibly be achieved by the preoperative identification of advanced tumors (T3/T4) and preoperatively treating these tumor types accordingly. From our own experience, we believe combined radio-chemotherapy could be successful.     

Impact of neoadjuvant therapy on postoperative complications in patients undergoing resection for rectal adenocarcinoma

Surgical resection continues to be the mainstay of treatment for rectal cancer. Neoadjuvant therapy (chemotherapy and radiation) has also been shown to be efficacious. The impact of preoperative chemotherapy and radiation on postoperative complications is unclear. The purpose of this study is to evaluate the relationship of neoadjuvant therapy on postoperative complications in patients undergoing a resection of rectal cancer. A total of 325 patients who underwent curative resection for rectal cancer from 1984 to 2001 were retrospectively reviewed. Only cases with complete data sets who had undergone surgery at this institution were evaluable (257). The patients were divided into groups based on the operative procedure performed; abdominoperineal resection (APR) versus sphincter-sparing (SS) procedures (LAR/Transanal) and whether or not preoperative chemotherapy or radiation was administered. There was no significant difference between complication rates for APR and SS with 19 per cent and 14 per cent, respectively. The preoperative therapy had no effect on complications after APR. However, the SS group showed 21 per cent of the patients who received radiation had complications compared to 11 per cent in those who did not (P = 0.087). Complications in the SS group included leaks, wound infections, abscess, embolism, cardiac dysrhythmias, and myocardial infarctions. The 30-day mortality was 1.9 per cent for the entire cohort with no clear difference between groups. There was no significant difference in complication rate between APR and SS. In the APR group, neoadjuvant therapy had no impact on the incidence of complications. However, the SS group did show a trend between preoperative chemotherapy and radiation and complication rate. However, this may not outweigh the advantages of preoperative therapy in this setting.     

Pain and activity disturbance after paediatric day case adenoidectomy

Over the past two decades outpatient surgery has become standard practice in paediatric surgery. Adenoidectomy is a common surgical procedure in children. In this prospective survey pain and pain-related outcomes such as sleep and activity disturbance were evaluated in 167 children aged 1–7 years who had undergone adenoidectomy as a day case in Kuopio University Hospital. The survey questionnaire consisted of 76 structured questions about pain, pain medication, adverse effects and daily activities during first week after the operation. Eighty-three per cent of children had pain at home and 17% of them had moderate or severe pain on a four point verbal rating scale. Eighty per cent of children used pain medication at home. Pain medication did not cause any major adverse effects. Over 90% of children were back to normal daily activities during the first three postoperative days and nearly all were able to drink during the whole postoperative period. We conclude that pain is a common problem after adenoidectomy in children but most of the children return to normal activities within three days.     

The prevalence of obesity and postoperative complications in a Veterans Affairs Medical Center general surgery population

Patients who are obese are believed to be at greater risk of developing intraoperative and postoperative complications than their nonobese counterparts. Many studies have shown that there is a higher prevalence of obesity among the Veterans Affairs patient population. We performed a retrospective review of 941 patients presenting to a single Veterans Affairs Medical Center. We aimed to determine the incidence of obesity among the Veterans Affairs Medical Center general surgery patient population as well to compare the frequency of postoperative complications between patients who are obese and nonobese patients undergoing elective general surgery. Body mass index was calculated for all patients; of the 941 patients seen in the clinic, 547 underwent elective surgery. Thirty-three per cent of all clinic patients had a body mass index greater than 30 kg/m2. Twenty-eight per cent of patients who underwent surgery had a body mass index greater than 30 kg/m2. Postoperative complications developed among 5.5 per cent of all surgical patients; 23.3 per cent were obese and 76.7 per cent were nonobese. There was no statistically significant difference between these two groups (P = 0.54). This study illustrates the increased prevalence of obesity among the Veterans Affairs Medical Center general surgery patient population. In addition, our study suggests that obesity is not an independent risk factor for postoperative complications in patients undergoing elective general surgery.     

Ocular aspects of learning disabilities in children

A total of 160 children were investigated to establish the role of ocular problems in children with learning disabilities. Thirty-eight per cent were found to have associated ocular problems. Eight per cent (8%) of these showed improvement in scholastic achievement after the elimination of the ocular defect. When there was evidence of brain dysfunction, correction of errors of refraction or muscle balance problems failed to improve scholastic achievement. A multidisciplinary approach to the problem is mandatory.     

Acute stress disorder in the paediatric surgical children and adolescents injured during the Wenchuan earthquake in China

The aim of the present study was to investigate the prevalence and symptoms of acute stress disorder (ASD) in the paediatric surgical children and adolescents injured during the Wenchuan earthquake in China. One hundred eighteen children and adolescent inpatients were surveyed by the ASD scale (ASDS) within 1 month of the earthquake. Using the validated ASDS score above cut‐off threshold levels, the incidence of ASD in this sample was 54.3 per cent. The morbidity of ASD were 56.1, 24.6 and 19.3 per cent in the child, in the early adolescent and in the middle adolescent, respectively. There was no significant difference among the three age groups about the severity of ASD symptom. The proportions of ASD positive were 44.0 per cent in boys and 63.6 per cent in girls that showed significant difference. The exposure risk factors were being buried in the earthquake, injury of parent, injury of relatives, amputation and operation. These results indicated that ASD was widely prevalent among the children and adolescents wounded in the earthquake, which needed an effective psychosocial intervention. Copyright © 2009 John Wiley & Sons, Ltd.