Reoperation for failed antireflux surgery

The management of patients with an unsatisfactory result following antireflux surgery is often problematical. Ten such patients with failed antireflux surgery, for whom medical management had also subsequently failed, underwent reoperation via a thoraco-abdominal approach. The anatomical cause of the surgical failure was determined pre-operatively in most cases by endoscopy, radiology, manometry and 24-hour pH monitoring. The most common reason for failure was a slipped Nissen fundoplication. A tight wrap, a disrupted wrap and a fundoplication hernia were less common causes. At follow-up, only one patient had a poor result. Reoperation for failed antireflux surgery can yield good results and is facilitated by pre-operative definition of the cause of failure and wide operative exposure.     

Renal insufficiency after cardiac surgery

The new millennium ushered in a number of changes in cardiac surgery. Off-pump coronary artery bypass surgery became technically easier so that multivessel surgery became less of a challenge and cardiologists were supplied with new catheters that accessed lesions that were previously thought of as being unapproachable. New drugs were introduced that made the management of heart failure patients feasible on an outpatient basis, and new devices extend the bridging period to transplantation. However, these advances have not necessarily been attended by significant improvements in outcome, possibly because the less challenging a procedure becomes, the sicker the patients that can be managed. This observation is particularly true with the incidence and outcome of renal failure after cardiac surgery. Bypass factors have been manipulated without much effect, and the traditional drugs that were found to increase renal blood flow in animal experiments did not translate into clinical improvement in renal outcome. Recent research has given us insight into the pathophysiology of ischemic acute renal failure, and it has been found that the paradigm was not as simple as previously thought, possibly accounting for the failure of the more traditional renal drugs (dopamine, mannitol and diuretics). However, these new insights open up the possibility of novel targets for renal protection and repair.     

Anaesthesia for open-heart surgery in haemodialysis-dependent patients: A report of two cases

Two cases are presented in which patients in chronic renal failure underwent successful open heart surgery. The additional problems chronic renal failure imposes on the anaesthetic management of patients requiring cardiac surgery are discussed, with recommendations on choice of agents and techniques.     

Principles of anaesthesia in urological surgery

Anaesthesia for urological surgery poses particular challenges for the anaesthetist related to the patient population and procedure type. The aim of this article is to cover the general principles of anaesthesia, with dedicated sections relevant to practising urological surgeons. This represents vast amounts of knowledge that cannot be covered in one article. We will focus upon preoperative preparation for surgery and anaesthesia, perioperative management including monitoring and analgesia, and postoperative management including fluid balance, critical care and recovery. Significant proportions of urological surgical patients have some degree of renal failure and this may be related to the surgery required. Anaesthetic care of patients with chronic renal impairment and transplant surgery will be covered in a future review.     

Anaesthesia for reconstructive surgery

Reconstructive surgery is aimed at the restoration of shape and function following tissue loss due to trauma, oncological surgery, burns and infection. Techniques range from simple primary wound closure at the bottom to complex microvascular free tissue transfer at the top rung of the reconstructive ladder.Free flap surgery involves separation of the flap from its original vascular supply and microvascular reanastomosis at a distant site and is associated with substantial transient ischaemia of the transferred tissue. Anaesthetic management plays an important role in successful free flap surgery.All factors promoting vasoconstriction need to be eliminated in order to facilitate blood flow through the transferred tissue.In this respect, maintenance of an adequate arterial blood pressure, normothermia and normocarbia, institution of moderate hypervolaemic haemodilution and effective pain management are the main principles.In spite of studies describing the effects of particular drugs on the microcirculation no single ideal anaesthetic agent has yet been identified for this type of surgery.Free flap failure occurs mainly during the first 48 hours postoperatively with venous thrombosis being more common than arterial occlusion. Prompt surgical revision is the mainstay of flap salvage. The overall success rate of microvascular free tissue transfer in high volume centres exceeds 90%.     

Acid-base problems in surgery

The identification and treatment of various clinical states of acid-base imbalance assume particular significance in major surgery and in patients with multiple organ failure. Metabolic acidosis, metabolic alkalosis, respiratory acidosis, respiratory alkalosis, and mixed disorders of acid-base balance are described and a management plan for each entity is defined.     

脊柱畸形手术失败原因与对策

目的探讨脊柱矫形手术失败原因、预防措施、处理方法及翻修手术适应证。方法31例患者,男18例,女13例;翻修手术时年龄4～35岁,平均14.7岁;既往平均手术史1.5次。初次手术距翻修手术时间平均47.9个月(13～114个月)。术前出现腰背部酸困疼痛、活动后加重16例,内植物并发症(断裂、松脱或外露等)5例,畸形进行性加重21例,下肢部分肌力和感觉障碍5例。翻修术前平均侧凸角75.3°,脊柱柔韧性9.8%;后凸角76°,柔韧性25.2%。分别采用脊椎截骨、椎弓根螺钉固定,原位固定和分期手术治疗。结果20例患者平均随访31.8个月,侧后凸平均矫正率分别为55.2%和67.5%。手术并发症:出现暂时性神经功能障碍4例(12.9%),经脱水、激素和电脉冲刺激等治疗,均在术后1～3周内得到完全恢复;内植物断裂2例,无其他严重并发症。结论正确掌握脊柱矫形手术治疗原则、良好的植骨融合、对先天性侧凸进行必要的内固定以及避免过早拆除内固定等,是防止矫形手术失败的有效手段。对有顽固性腰背痛、脊柱假关节和术后畸形进行性加重者,应根据患者年龄、畸形程度和脊柱柔韧性,采用不同的治疗方法。     

Anaesthesia for a patient with Leigh's syndrome undergoing surgery for scoliosis

Anaesthesia for patients with Leigh's syndrome has rarely been reported. Leigh's syndrome or subacute necrotizing encephalomyelopathy is a neurodegenerative disorder of infancy or childhood. Acute exacerbation with respiratory failure may accompany surgery and general anaesthesia. In this case report we describe the anaesthetic management of a 17 year old patient scheduled for spine surgery.     

Prevention of acute renal failure in major vascular surgery

The aim of this study was to analyse the main problems which involve renal function in major vascular surgery and can lead to postoperative acute renal failure. The factors responsible for renal damage in this surgical branch are at first analysed, then followed by the physiological changes which characterize the renal injury, the techniques employed to detect and monitor them and finally the therapeutic tools available to prevent acute renal failure. The most significant data of personal experience on the use of nifedipine and low-dose dopamine during abdominal aortic surgery are then presented. It is concluded that: a) an ischemic attack is the main cause of acute renal failure in mayor vascular surgery; b) prevention of ischemic renal damage is far superior to treatment; c) the optimal management of the cardiovascular function by means of the invasive hemodynamic monitoring, is the main tool to protect the kidneys and prevent acute renal failure; d) the pharmacological protection by diuretics and low-dose dopamine is of minor importance and anyway subordinate to the maintenance of adequate hemodynamics, as well as for calcium antagonist whose employment however seems to protect the kidneys better against an ischemic attack.     

Anesthesia for ruptured cerebral aneurysm surgery associated with chronic renal failure.

The management of patients with chronic renal failure (CRF) undergoing cerebral aneurysm surgery has been documented on only a few occasions. We report a 58-year-old man with CRF and subarachnoid hemorrhage (SAH) due to aneurysm rupture. We describe the patient's perioperative anesthetic management, discussing the current methods for maintaining an appropriate cerebral perfusion pressure and for preventing rehemorrhage from the aneurysm. We suggest that heparin-aided hemodialysis be avoided in these cases.     

Anaesthesia and critical care for scheduled infrarenal abdominal aortic aneurysm surgery

OBJECTIVES: Patient scheduled for infrarenal abdominal aortic aneurysm surgery carries a high risk of cardiac or respiratory comorbidity. To outline the perioperative management for these patients. METHODS: Review of the literature using MesH Terms "abdominal aortic aneurysm", "anesthesia", "analgesia" "critical care" and/or "surgery" in Medline database. RESULTS: Cardiac preoperative evaluation and management have recently been reviewed. Intermediate and high-risk patients should undergo non-invasive cardiac testing to decide between a preoperative medical strategy (using betablocker+/-statin and aspirin) and an interventional strategy (coronary angioplasty or cardiac surgery). Perioperative myocardial ischaemia should also be investigated by clinical, electrocardiographic and biologic monitoring such as plasmatic troponin Ic dosage. Specific score could also assess the respiratory failure risk preoperatively. Epidural analgesia decreases this risk. There is no evidence that a pharmacological treatment decreases the incidence of acute renal failure after aortic surgery. Endovascular repair is actually recommended for older, higher-risk patients or patients with a hostile abdomen or other technical factors that may complicate standard open repair.     

Perioperative management of the morbidly obese adolescent with heart failure undergoing bariatric surgery

The incidence and prevalence of adolescent obesity and adolescent heart failure are increasing, and anesthesiologists increasingly will encounter patients with both conditions. A greater understanding of the physiologic challenges of adolescent heart failure as they relate to the perioperative stressors of anesthesia and bariatric surgery is necessary to successfully manage the perioperative risks faced by this growing subpopulation. Here, we present a representative case of a morbidly obese adolescent with heart failure who underwent a laparoscopic bariatric operation and review the limited available literature on perioperative management in this age group. Specifically, we review evidence and offer recommendations related to preoperative evaluation, venous thromboembolism prophylaxis, positioning, induction, airway management, monitoring, anesthetic maintenance, ventilator management, and adverse effects of the pneumoperitoneum, rhabdomyolysis, and postoperative care.     

Preoperative evaluation for thoracic surgery

The goal of the preoperative evaluation for thoracic surgery is to assess and implement measures to decrease perioperative complications and prepare high-risk patients for surgery. Major respiratory complications, such as atelectasis, pneumonia, and respiratory failure, occur in 15% to 20% of patients and account for most of the 3% to 4% mortality rate. Development of pulmonary complications has been associated with higher postoperative mortality rates. Strategies aimed at preventing postoperative difficulties have the potential to reduce morbidity and mortality, decrease hospital stay, and improve resource use. One lung ventilation leads to a significant derangement of gas exchange, and hypoxemia can develop due to increased intrapulmonary shunting. Recent advances in anesthetic management, monitoring devices, improved lung isolation techniques, and improved critical care management have increased the number of patients who were previously considered inoperable. In addition, there is a growing tendency to offer surgery to patients with significant lung function impairment; hence a higher incidence of intraoperative gas-exchange abnormalities can be expected. The anesthesiologist must also consider the risks of denying or postponing a potentially curative operation in patients with lung cancer. Detailed consideration of the information provided by preoperative testing is essential to successful outcomes following thoracic surgery.     

Protection of the liver during hepatic surgery

Very few areas in medicine have seen as many controversies as the evaluation and treatment of patients with liver diseases. Many novel therapies, often marketed before conclusive demonstration of their efficacy, have been developed to enable selective destruction of liver tumors to minimize the risk of liver failure associated with major surgery. Whether these techniques are effective and result in lesser complications often remains speculative. Persisting challenges in selecting the optimal therapy are the evaluation of the risk of surgery in patients with normal or diseased liver and the preparation for surgery. A panel of hepato-biliary surgeons experienced in the management of complex cases convened at the annual meeting of the American Hepato-Pancreato-Biliary Association in Boston, MA, to address the rapidly evolving field of protective strategies for hepatic surgery.     

Natriuretic peptides in the perioperative management of cardiac surgery patients

Both heart failure (HF) and cardiac surgery with cardiopulmonary bypass result in a release of neurohormones, with a variety of physiologic effects. Administration of exogenous B-type natriuretic peptide (BNP) has beneficial hemodynamic effects and reduces the level of several neurohormones in HF patients. BNP is currently being investigated in the perioperative management of cardiac surgery patients and may be especially beneficial for patients with ventricular dysfunction, pulmonary hypertension, or renal dysfunction. Using a neurohormonal approach to supportive therapy may enhance future strategies for patients undergoing cardiac surgery, especially those at greatest risk for complications.     

Hypophosphataemia causing profound cardiac failure after cardiac surgery

We report the case of a patient who developed severe cardiac failure after cardiac surgery and required high-dose inotrope infusion. The patient was found to have significant hypophosphataemia and high insulin requirements immediately after surgery. On giving intravenous phosphate, there was a rapid decrease in inotrope requirement and improved glycaemic control. This occurrence raises questions about the cause of hypophosphataemia after cardiac surgery, the possible need for pre-operative plasma phosphate measurement and whether phosphate replacement should be part of the standard management of postoperative hypophosphataemia.     

Intermittent claudication should not be treated by surgery.

This debate examines the proposition that surgery is unnecessary or obsolete in the management of intermittent claudication. The case for this argument is that many patients have stable disease or respond well to conservative measures, that claudication is an expression of a systemic cardiovascular illness and that surgery can be replaced by endovascular techniques with equal success, and less disadvantage in the event of treatment failure. The case against the motion is that claudication is associated with repeated cycles of ischaemia and reperfusion, and that these contribute to excess cardiovascular mortality states and, furthermore, that surgery is the only option to relieve symptoms for many patients, especially those with distal disease.     

Prevention and treatment of thrombosis in microvascular surgery

Microvascular free tissue transfer is associated with a 1 to 5% failure rate, most commonly as a result of thrombosis in the region of the vascular anastomosis or the distal flap microcirculation. Although many laboratory and clinical studies have been performed, there is no consensus on the efficacy and optimal dosage of various pharmacological agents available for the prevention and treatment of thrombosis in microvascular surgery. Some agents have potentially serious side effects; and all agents carry the risks of undesirable bleeding and hematoma formation. We review the current experimental and clinical evidence regarding the agents commonly used to prevent and treat thrombosis in microvascular surgery and make practical recommendations for the management of vascular compromise in free flaps.     

The current role of laparoscopic surgery for gastroesophageal reflux disease in infants and children

Background The benefits of surgery for gastroesophageal reflux disease (GERD) in infants and children have been questioned in the recent literature. The goal of this review was to determine the best current practice for the diagnosis and management of this disease. Methods The literature was reviewed for all recent English language publications on the management of GERD in 8- to 10-year-old patients. Results In infants and children, GERD has multiple etiologies, and an understanding of these is important for determining which patients are the best surgical candidates. Proton pump inhibitors (PPIs) have become the mainstay of current treatment for primary GERD. Although laparoscopic surgery appears to be better than open surgery, there remains some morbidity and complications that careful patient selection can minimize. Conclusion Surgery for GERD should be performed only after failure of medical management or for specific problems that mandate it.     

Anesthetic management of a patient with multiple system atrophy undergoing adrenal gland tumor surgery

We report anesthetic management of a 61-year-old man with multiple system atrophy undergoing adrenal grand tumor surgery. Before surgery, he was sufficiently hydrated and an elastic bandage had been applied to the legs. After epidural catheterization for the postoperative analgesia, general anesthesia was induced with midazolam 7 mg and remifentanil 0.25 microg x kg(-1) x min(-1) and his trachea was intubated. During surgery, general anesthesia was maintained with sevoflurane and remifentanil 0.12-0.25 microg x kg(-1) x min(-1). Hemodynamics was almost stable although transient hypotension occurred during surgery because of bleeding and partial clamping of the inferior vena cava. After surgery, he emerged from anesthesia and tracheal tube was removed uneventfully. However, on the first postoperative day, hypotension and respiratory failure occurred. Noradrenaline infusion was needed to treat hypotension due to vasodilation and reintubation was performed. After several days, hypotension and respiratory failure improved and he was discharged from ICU.