Multidirectional shoulder instability and open surgical procedures

The principles and procedures for multidirectional instability do not substantially differ from those for anterior instability. Correct diagnosis is difficult, but it is important for a successful treatment. Conservative treatment should be attempted before surgery. Open surgical treatment using the inferior capsular shift procedure is the gold standard. It can be carried out either anteriorly or posteriorly. We prefer a laterally-based capsular shift because it facilitates capsular plication.     

Aortic assessment for cardiac surgical procedures

Aortic atheromatous disease is associated with stroke in both the ambulatory and perioperative setting. In addition to atheromatous deposits, a reduction in the compliance of the aorta takes place as elastin fibers are replaced by collagen fibers. Both of these distinct processes, termed atherosclerosis, can easily be measured using transesophageal echocardiography during cardiac surgery. A review of the literature demonstrates many studies supporting the benefit of transesophageal echocardiography examination of the aorta for reducing stroke following cardiac surgery, through modification of surgical techniques. There have also been attempts by surgeons to remove atheromatous lesions from the aorta during cardiac surgery. Unfortunately, these procedures currently have a high perioperative mortality. Finally, medical therapy such as warfarin or statins may help reduce the incidence of stroke following heart surgery.     

General surgical procedures after heart transplantation

Seventy-eight cardiac transplantations were performed between July 1982 and March 1989. The perioperative death rate was 10%. Overall survival was 86%. Among the long-term survivors, 14 patients underwent 16 noncardiac surgical procedures. Seven of them required emergency laparotomy, four for biliary tract disease, one for ruptured abdominal aortic aneurysm, one for suspected abdominal sepsis and one for enterocolitis. Elective surgical interventions included repair of symptomatic abdominal wall hernia, treatment of hemorrhoids or perianal condylomas, total hip arthroplasty, maxillary sinus drainage and resection of a duodenal villous adenoma. Preoperatively, all patients received cyclosporine orally. Ten of the 14 patients were on triple-drug immunosuppression (cyclosporine, azathioprine and low-dose prednisone [less than 0.20 mg/kg daily]). The remaining four patients took cyclosporine with either azathioprine or prednisone. There were no deaths. Complications were limited to residual choledocholithiasis treated by percutaneous removal, two cases of wound infection and an incisional hernia. The authors' experience indicates that noncardiac surgical procedures may be safely performed in patients who have received a heart transplant.     

The incidence, morbidity, and mortality of surgical procedures after orthotopic heart transplantation.

OBJECTIVE: The authors present their experience with patients having undergone orthotopic heart transplantation (OHT) in whom surgical conditions subsequently developed that required operative intervention. The incidence, morbidity, and mortality of these procedures are reported. SUMMARY BACKGROUND DATA: Several studies have evaluated the management options of biliary tract disease after OHT. Multiple reports of patients having undergone OHT who subsequently underwent peripheral vascular reconstructions, plastic reconstructive, and thoracic procedures also have been published. METHODS: A chart review of 349 patients who underwent OHT between 1985 and 1996 was conducted to identify surgical procedures that were required in the post-transplant period. Their outcomes are reported. RESULTS: Of 349 patients who underwent OHT, conditions requiring 94 surgical procedures developed in 54 patients (15%). Biliary tract disease developed in 17 patients (5%) who required cholecystectomy, 2 of the 5 patients with acute cholecystitis died. Eight patients (2%) underwent orthopedic procedures with no operative mortality. Flap advancements for sternal wound infections were performed in five patients and four deaths occurred. Seventeen thoracic procedures were performed in 11 patients with an overall mortality of 45%. Twenty-one vascular procedures were performed on 17 patients with 1 delayed death due to a malignancy. Seven patients underwent procedures of the colon and rectum with no mortality. Seven patients underwent repair of inguinal or incisional hernias with no mortality. Various infections occurred with one resultant death after operative intervention. Six procedures were performed for diseases of the small intestine with no resultant mortalities. CONCLUSIONS: Patients having undergone OHT and chronic immunosuppression are at increased risk of having complications develop from infection. Acute cholecystitis and sternal wound infection caused an inordinate risk of complications and death. Malignancies developed in four patients who required surgical intervention. A heightened awareness of coexisting peripheral vascular disease in patients transplanted for ischemic cardiomyopathy should exist. Close screening before surgery and surveillance after surgery to identify risk factors for infection and vascular disease and to screen for malignancies are essential.     

Use of a Bayesian statistical model for risk assessment in coronary artery surgery

A computerized statistical model based on the theorem of Bayes was developed to predict mortality after coronary artery bypass grafting. From January, 1984, to April, 1987, at our hospital, 700 patients underwent isolated coronary artery bypass grafting. The presence or absence of 20 risk factors was determined for each patient. The first 300 patients formed the initial database of the Bayesian predictive model, and the remaining 400 patients were prospectively evaluated in four groups of 100 each. Each group was prospectively evaluated and then incorporated into the database to update the model. There was good agreement between predicted and observed results. Bayesian theory is particularly suited to this task because it (1) accommodates multiple risk factors, (2) is tailored to one's specific practice, (3) determines individual, rather than group, prognosis, and (4) can be updated with time to compensate for a changing patient population. These flexible attributes are especially valuable in light of recent changes in the coronary artery bypass graft patient profile.     

Use of a Bayesian statistical model for risk assessment in coronary artery surgery

A computerized statistical model based on the theorem of Bayes was developed to predict mortality after coronary artery bypass grafting. From January, 1984, to April, 1987, at our hospital, 700 patients underwent isolated coronary artery bypass grafting. The presence or absence of 20 risk factors was determined for each patient. The first 300 patients formed the initial database of the Bayesian predictive model, and the remaining 400 patients were prospectively evaluated in four groups of 100 each. Each group was prospectively evaluated and then incorporated into the database to update the model. There was good agreement between predicted and observed results. Bayesian theory is particularly suited to this task because it (1) accommodates multiple risk factors, (2) is tailored to one's specific practice, (3) determines individual, rather than group, prognosis, and (4) can be updated with time to compensate for a changing patient population. These flexible attributes are especially valuable in light of recent changes in the coronary artery bypass graft patient profile.     

Alterations in respiratory mechanics after laparoscopic and open surgical procedures

Objective

To compare the effects of laparoscopic and open surgical procedures on postoperative strength and respiratory mechanics.

Design

Prospective cohort study.

Setting

Adult university hospital.

Participants

Fifty-one women aged 21 to 62 years scheduled to undergo elective cholecystectomy or hysterectomy (or related procedures), otherwise in good health.

Intervention

Open or laparoscopic cholecystectomy or hysterectomy (or related procedures).

Main Outcome Measures

Maximum voluntary handgrip strength (HGS), forced vital capacity (VC), forced expiratory volume in 1 second (FEV₁), and maximal inspiratory pressure (MIP) were each measured preoperatively and on the first postoperative morning. A visual analogue pain scale score was evaluated in relation to performance of the postoperative strength and respiratory measurements.

Results

VC, FEV₁ and MIP, but not HGS, were decreased after surgery. Postoperative VC, FEV₁ and MIP were lower after open procedures than after laparoscopic procedures and after cholecystectomy than after hysterectomy (all p < 0.001). Pain scores were lower after laparoscopic than after open procedures (p < 0.005) and could account in part for differences in postoperative respiratory mechanics.

Conclusions

Cholecystectomy and hysterectomy do not result in generalized muscle weakness, unlike more major abdominal procedures. Postoperative alterations in respiratory mechanics are related to the site of the surgery, the use of an open versus a laparoscopic approach and postoperative pain.     

双足鼠脊柱侧凸模型手术方法改良

目的 双足鼠脊柱侧凸模型是一种理想的脊柱侧凸动物模型.目前建模手术方法死亡率较高.本研究拟从手术方法上探究提高建模手术成功率的方法.方法 在15只1个月龄大鼠中,采用双上肢去神经和右侧肋骨栓系(4-0无创缝线)法建模,术中不分离脊旁肌.观察死亡率.结果 术中肋骨栓系时,所有大鼠膈肌活动良好,未出现气胸或大血管损伤.无大鼠在手术中或术后一周内死亡.结论 建模术中不分离脊旁肌、右侧肋骨栓系和栓系用4-0无创缝线,成功使得建模手术死亡率降为零,是一种较好的手术方法.     

Interleukin-8 serum levels in patients with various types of open heart surgical procedures performed under extracorporeal circulation

Serum concentrations of proinflammatory cytokine interleukin-8 (IL-8) in 15 patients with surgically revascularized myocardium by triple venous cardiopulmonary bypass (CPB x 3) and in 10 patients with implanted artificial aortic valves (AV) were measured. Average IL-8 concentrations in (CPB x 3) patients and in those with artificial aortic valve were 7.3 +/- 11.6 pg/mL 24 hours before surgery, i.e. 3.3 +/- 3.4 pg/mL; six hours after surgical procedure 32.7 +/- 71.4 pg/mL, i.e. 8.9 +/- 9.9 pg/mL; and 24 hours after surgery 10.9 +/- 9.7 pg/mL, i.e. 8.3 +/- 4.6 pg/mL. Extracorporeal circulation (ECC) caused significant increase of IL-8 serum concentration in both investigated groups six hours after surgery. Comparing preoperative values of the both groups, as well as those of 6 and 24 hours after surgery, no significant values of IL-8 were found. Various types of open heart surgical procedures had no influence on the extent of the production and secretion of proinflammatory IL-8 cytokine measured in patients during 24 hours after surgery.     

Intraoperative thermal regulation in patients undergoing laparoscopic vs open surgical procedures

BACKGROUND: Although perioperative hypothermia is a well-known consequence of general anesthesia, it has been hypothesized that laparoscopic surgery exacerbates hypothermia to a greater extent than open surgery. The aim of this study was to demonstrate that laparoscopic surgery does not represent an increased risk for hypothermia. METHODS: A case-controlled retrospective study was conducted on 45 patients, 25 undergoing laparoscopic cholecystectomy and 20 undergoing parathyroid surgery under endotracheal general anesthesia. Data were collected regarding age, sex, weight, height, American Society of Anesthesiologists (ASA) status, length of surgery, and anesthesia. In addition, we analyzed the type of intraoperative intravenous fluids, anesthetics and perioperative drugs, and temperature, blood pressure, and heart rate recordings during anesthesia. RESULTS: There was no significant difference between the two groups with respect to age, sex, body mass index (BMI), ASA status, type or amount of intravenous fluids infused, length of anesthesia or surgery, changes in mean blood pressure, or heart rate. Core body temperatures in both groups decreased significantly over time (p 0.05). There was no difference between the groups in terms of maximum drop in temperature (lowest temperature recorded vs baseline temperature) (1.1 +/- 0.7 vs 1.0 +/- 0.7 degrees C, p > 0.05). CONCLUSION: This study demonstrates that patients who undergo laparoscopic and open procedures of similar duration under endotracheal general anesthesia have similar profiles in terms of perioperative hypothermia.