The selective beta 1-blocking agent metoprolol compared with antithyroid drug and thyroxine as preoperative treatment of patients with hyperthyroidism. Results from a prospective, randomized study.

Despite the increasing use of beta-blocking agents alone as preoperative treatment of patients with hyperthyroidism, there are no controlled clinical studies in which this regimen has been compared with a more conventional preoperative treatment. Thirty patients with newly diagnosed and untreated hyperthyroidism were randomized to preoperative treatment with methimazole in combination with thyroxine (Group I) or the beta 1-blocking agent metoprolol (Group II). Metoprolol was used since it has been demonstrated that the beneficial effect of beta-blockade in hyperthyroidism is mainly due to beta 1-blockade. The preoperative, intraoperative, and postoperative courses in the two groups were compared, and patients were followed up for 1 year after thyroidectomy. At the time of diagnosis, serum concentration of triiodothyronine (T3) was 6.1 +/- 0.59 nmol/L in Group I and 5.7 +/- 0.66 nmol/L in Group II (reference interval 1.5-3.0 nmol/L). Clinical improvement during preoperative treatment was similar in the two groups of patients, but serum T3 was normalized only in Group I. The median length of preoperative treatment was 12 weeks in Group I and 5 weeks in Group II (p less than 0.01). There were no serious adverse effects of the drugs during preoperative preparation in either treatment group. Operating time, consistency and vascularity of the thyroid gland, and intraoperative blood loss were similar in the two groups. No anesthesiologic or cardiovascular complications occurred during operation in either group. One patient in Group I (7%) and three patients in Group II (20%) had clinical signs of hyperthyroid function during the first postoperative day. These symptoms were abolished by the administration of small doses of metoprolol, and no case of thyroid storm occurred. Postoperative hypocalcemia or recurrent laryngeal nerve paralysis did not occur in either group. During the first postoperative year, hypothyroidism developed in two patients in Group I (13%) and in six patients in Group II (40%). No patient had recurrent hyperthyroidism. The results suggest that metoprolol can be used as sole preoperative treatment of patients with hyperthyroidism without serious intra- or postoperative complications. Although the data indicate that the risk of postoperative hypothyroidism is higher after preoperative treatment with metoprolol than with an antithyroid drug, a longer follow-up period than 1 year is needed to draw conclusions regarding late results.     

Effect of restrictive fluid management and acute normovolemic intraoperative hemodilution on transfusion requirements during living donor hepatectomy

The aim of this study was to evaluate the safety and effectiveness of a restrictive fluid management strategy and acute normovolemic intraoperative hemodilution (ANIH) to decrease transfusion requirements among living-donors for liver transplantation (LDLT). We retrospectively reviewed the data of 114 consecutive LDLT donors. The patients were divided into 2 groups based on whether (Group I; n = 73) or not (Group II; n = 41) a restrictive fluid management strategy with ANIH was used during the procedure. For each group we recorded demographic features, intraoperative and postoperative transfusions, amount of administered intraoperative crystalloid and colloids, intraoperative hemodynamics, preoperative and postoperative laboratory values (renal and liver functions), intraoperative and postoperative urine output, and length of hospital stay. Demographic features and preoperative laboratory values were similar for the 2 groups, except for age (Group I, 36 +/- 9 vs Group II, 33 +/- 8; P = .04). Intraoperatively, 7 patients (10%) in Group 1 and 9 (22%) in Group II required blood transfusions (P = .06). The respective amount of heterologous blood transfusion for Groups I and II was 96 +/- 321 mL vs 295 +/- 678 mL (P = .06). Postoperative renal and liver functions were not different between the 2 groups (P > .05). Patients in Group I had a shorter hospital stay than those in Group II (8.2 +/- 4.6 days vs 10.1 +/- 4.9 days; P = .03). In conclusion, a restrictive fluid management strategy with ANIH was a safe blood-salvage technique for LDLT. This approach was also associated with decreased length of hospital stay and a trend toward decreased transfusion requirements.     

Delayed resolution of residual hemifacial spasm after microvascular decompression operations

OBJECTIVE: After microvascular decompression to treat hemifacial spasm (HFS), resolution of the HFS is often gradual. We carefully investigated the course of the gradual resolution of HFS and examined the differences between patients with and without postoperative HFS. METHODS: One hundred seventy-five patients with HFS were monitored, for observation of 1) whether postoperative HFS occurred, 2) when it occurred, and 3) when it disappeared after microvascular decompression. For two groups of patients, with (Group I) and without (Group II) postoperative HFS, we investigated age, sex, spasm side, preoperative facial nerve block (botulinum toxin treatment), decompression material, preoperative HFS period, offender (compressing vessel), temporary and permanent postoperative complications, and electromyographic findings. RESULTS: In Group I (88 patients), postoperative HFS began within 4 days after surgery, a period that we have termed the silent period of postoperative HFS; the median value for the time to resolution was 28 days. The other 87 patients exhibited no postoperative HFS (Group II). There was a significantly higher incidence of postoperative facial weakness in Group II (Group II, 41.3%; Group I, 25.5%; P = 0.02 by logistic regression analysis). In Group I, there was no statistically significant relationship between the investigated parameters and the silent period or the postoperative HFS period, as determined by Cox proportional-hazards regression analysis, except for the number of preoperative facial nerve blocks. Electromyographic investigation of F waves revealed facial paresis during the silent period in a patient. CONCLUSION: Approximately 50% of patients with HFS exhibited residual spasm postoperatively. An immediate postoperative silent period of 4 days without spasm was characteristic. One-quarter, one-half, and 90% of the residual spasm resolved by 1 week, 1 month, and 8 months after surgery, respectively.     

Preoperative endoscopic sphincterotomy versus laparoendoscopic rendezvous in patients with gallbladder and bile duct stones

OBJECTIVE: To compare success rate, length of hospital stay, clinical results, and costs of sequential treatment (endoscopic retrograde cholangiopancreatography followed by laparoscopic cholecystectomy) versus the laparoendoscopic Rendezvous in patients with cholecysto-choledocholithiasis. BACKGROUND: The ideal management of common bile duct (CBD) stones in the era of laparoscopic cholecystectomy (LC) remains controversial. METHODS: A total of 91 elective patients with cholelithiasis and CBD stones diagnosed at magnetic resonance cholangiography (MRC) were included in a prospective, randomized trial. The patients were randomized in 2 groups. Group I patients (45 cases) underwent a preoperative endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES) followed by LC in the same hospital admission. Group II patients (46 cases) underwent LC associated with intraoperative ERCP and ES according to the rendezvous technique. RESULTS: The rate of CBD clearance was 80% for Group I and 95.6% for Group II (P = 0.06). The morbidity rate was 8.8% in Group I and 6.5% in Group II (P = not significant). No deaths occurred in either group. Hospital stay was shorter in Group II than in Group I: 4.3 days versus 8.0 days (P < 0.0001). There was a significant reduction in mean total cost for group II patients versus group I patients: 2829 euro versus 3834 euro (P < 0.05). CONCLUSIONS: When compared with preoperative ERCP with ES followed by LC, the laparoendoscopic rendezvous technique allows a higher rate of CBD stones clearance, a shorter hospital stay, and a reduction in costs.     

Incidence and significance of lobar atelectasis in thoracic surgical patients

Lobar atelectasis, defined by complete lobar collapse and mediastinal shift on chest roentgenogram, represents one extreme form of postoperative atelectasis. We have evaluated the incidence and clinical significance of lobar atelectasis in a thoracic surgical patient group. A retrospective review was done of patients who underwent pulmonary resection over a 2-year period to determine patient characteristics, contributing comorbidities, and associated perioperative care factors. Lung resections were performed for both benign and malignant disease through open or video-assisted techniques. One hundred eighty patients had pulmonary resection, 101 males and 79 females, and they were divided into three groups: I, no complications (112 patients, 62%); II, complications unrelated to lobar atelectasis (60 patients, 33%); and III, complications of lobar atelectasis (8 patients, 5%). There was one death in the series, in the lobar atelectasis group (III). Mean age for the entire group was 64.5 +/- 12.5 years; however, patients in Groups II (67.3 years) and III (69.6 years) were significantly older than in Group I (P < 0.02). Mean hospital length of stay in Group I was 6 +/- 3 days, whereas that in Group II was 13 +/- 12 days (P < 0.001), and in Group III it was 27 +/- 31 days (P < 0.001). In addition, patients who developed lobar atelectasis were more likely to be male (88% vs 48%, P = 0.034), had a longer ICU length of stay (P < 0.001), were more likely to have two or more comorbidities (P < 0.05), and had a lower forced expiratory volume in 1 second (2.34 +/- 0.90 vs 1.96 +/- 0.63). All patients in the lobar atelectasis group were operated on for malignancy, but this was not significantly different from the other groups. None of the 16 patients who had thoracoscopy developed lobar atelectasis, but this also was not a significant finding. We conclude that severe postoperative atelectasis occurs as lobar atelectasis in approximately 5 per cent of patients who undergo pulmonary resection and significantly adds to the intensive care unit and hospital length of stay. The etiology of lobar atelectasis appears to be multifactorial and warrants further study to define mechanisms of occurrence and their prevention.     

Below-knee physiologic cryoanesthesia in the critically ill patient

Controversy has surrounded the role of local hypothermia as a preoperative treatment in amputations of the lower extremity. A study was undertaken to determine the effectiveness of amputation under cryoanesthesia in decreasing postoperative morbidity and mortality in below-knee (BK) amputations. Of 154 BK amputations, only 91 with unreconstructable vascular disease, gangrene, or both, were included in this study. Group I consisted of 48 patients (mean age 63.9 years) who had undergone a routine BK amputation; group II consisted of 43 patients (mean age 65.7 years) who were acutely ill and too unstable to undergo a major surgical procedure. Group II patients were treated by amputation while under cryoanesthesia before any definitive operative intervention. The patients in group II were significantly (p less than 0.05) more ill preoperatively than those in group I. Group II patients had a higher prevalence of previous myocardial infarction, previous stroke, diabetes mellitus, osteomyelitis, and wet gangrene. Seventy percent of the patients in group II had three or more risk factors vs. 46% in group I. Early postoperative mortality rates did not differ significantly between groups (group I, 8%; group II, 9%); the average length of hospital stay for group I patients was 24.2 days compared with 17.7 days in group II. Group II patients sustained slightly more postoperative complications. Amputation under cryoanesthesia appears to be of value in reducing postoperative morbidity and mortality and length of hospital stay in the acutely ill patient with unreconstructable vascular disease, gangrene, or both.     

Early cavopulmonary anastomosis in very young infants after the Norwood procedure: impact on oxygenation, resource utilization, and mortality

BACKGROUND: The optimal timing of second-stage palliation after Norwood operations remains undefined. Advantages of early cavopulmonary anastomosis are early elimination of volume load and shortening the high-risk interstage period. Potential disadvantages include severe cyanosis, prolonged pleural drainage and hospitalization, and excess mortality. We reviewed our recent experience to evaluate the safety of early cavopulmonary anastomosis. METHODS: Eighty-five consecutive patients undergoing post-Norwood operation cavopulmonary anastomosis were divided into group I (cavopulmonary anastomosis at <4 months; n = 33) and group II (cavopulmonary anastomosis at >4 months; n = 52). Groups were compared for age; size; early and late mortality; preoperative, initial postoperative, and discharge oxygen saturation; and duration of mechanical ventilation, intensive care unit stay, pleural drainage, and hospitalization. RESULTS: Group I patients were younger than group II patients (94 +/- 21 days vs 165 +/- 44 days, respectively; P <.001) and smaller (4.8 +/- 0.8 kg vs 5.8 +/- 0.9 kg; P <.001). The preoperative oxygen saturation was not different (group I, 75% +/- 10%; group II, 78% +/- 8%; P =.142). The oxygen saturation was lower immediately after surgery in group I compared with group II (75% +/- 7% vs 81% +/- 7%, respectively; P <.001) but not by discharge (group I, 79% +/- 4%; group II, 80% +/- 4%). Younger patients were ventilated longer (62 +/- 86 hours vs 19 +/- 42 hours; P =.001), in the intensive care unit longer (130 +/- 111 hours vs 104 +/- 94 hours; P =.049), hospitalized longer (12.5 +/- 11.5 days vs 10.3 +/- 14.8 days; P =.012), and required longer pleural drainage (106 +/- 45 hours vs 104 +/- 93 hours; P =.046). Hospital survival was 100% in both groups. Actuarial survival to 12 months was 96% +/- 4% for group I and 96% +/- 3% for group II. CONCLUSIONS: Early cavopulmonary anastomosis after the Norwood operation is safe. Younger patients are more cyanotic initially after surgery and have a longer duration of mechanical ventilation, pleural drainage, intensive care unit stay, and hospitalization.     

Routine pulmonary artery catheterization does not reduce morbidity and mortality of elective vascular surgery: results of a prospective, randomized trial.

OBJECTIVE: The authors determined whether the preoperative placement of a pulmonary artery catheter (PAC) with optimization of hemodynamics results in outcome improvement after elective vascular surgery. SUMMARY BACKGROUND DATA: The PAC commonly is used not only in patients who are critically ill, but also perioperatively in major elective surgery. Few prospective studies exist documenting its usefulness. METHODS: One hundred four consecutive patients were randomized to have a PAC placed the morning of operation (group I) or to have a PAC placed only if clinically indicated (group II). Group I patients were resuscitated to preestablished endpoints before surgery and kept at these points both intraoperatively and postoperatively. Group II patients received standard care. RESULTS: There was one death in each group. An intraoperative or postoperative complication developed in 13 patients in group I versus 7 patients in group II (p = not significant). Group I patients received more fluid than did group II patients (5137 +/- 315 mL vs. 3789 +/- 306 mL; p < 0.003). There was no significant difference in either overall or surgical intensive care unit length of stay. Only one patient in group II required a postoperative PAC. CONCLUSIONS: Routine PAC use in elective vascular surgery increases the volume of fluid given to patients without demonstrable improvement in morbidity or mortality.     

Laparoscopic versus open appendectomy: which factors influence the decision between the surgical techniques?

BACKGROUND: Although in hospitals focussing on minimal invasive surgery laparoscopic appendectomy (LA) is widely practiced as method of choice in patients with acute appendicitis, the decision for the laparoscopic or the conventional technique (OA) is usually ensued by individual viewpoints. Aim of this prospective observation study was to analyse the decision algorithm for both procedures in patients with the presumptive diagnosis "appendicitis". PATIENTS AND METHODS: Between January 1996 and July 2001 512 patients with the presumptive diagnosis "acute appendicitis" underwent surgery and, assigned by intention-to-treat, were subdivided in a laparoscopic (I) and a conventional group (II). The choice of surgical procedure was analysed with regard to patient characteristics (age, gender, comorbidity), severity of appendicitis (clinical manifestation, preoperative inflammation signs), surgeon (clinical experience) and daytime (during the day, in the evening, at night). Furthermore, the outcome of either method was related to postoperative diagnosis, perioperative morbidity, analgesia, length of hospital stay and cosmetic results. RESULTS: In group I 265 patients and in group II 247 patients underwent surgery. Conversion from LA to OA was necessary in 6.4 %. Group I consisted of significantly more female (67.9 % vs. 45.7 %) and younger patients (21 yrs. vs. 30 yrs.) with less medical history as well as minor severity of tissue inflammation and significantly lower preoperative serum inflammation parameters (leukocytes (1000/ml): 10.6 +/- 4.3 vs. 13.5 +/- 4.9; CRP (mg/l): 2.3 +/- 3.3 vs. 5.6 +/- 7.5, I vs. II: p < 0.001). In group I more patients underwent surgery during day-time as well as by more laparoscopic-experienced surgeons. In the postoperative histopathologic evaluation there were significantly fewer cases with complicated appendicitis (33.2 % vs. 52.2 %, p < 0.001). Additionally, patients after LA revealed a lower postoperative complication rate (9.3 % vs. 18.3 %), length of hospital stay (median 3 vs. 4 days) and duration of analgesia (2.1 +/- 1.8 vs. 4.1 +/- 7.1 days). CONCLUSIONS: Important factors for decision algorithm between a laparoscopic or an open appendectomy include severity of appendicitis, gender, day-time as well as the surgeon's individual laparoscopic experience. With appropriate indication for each technique, both procedures are of equal value in the treatment of acute appendicitis. Furthermore the positive patient selection for laparoscopic appendectomy contributed to a better postoperative outcome in this study.     

The change of extra vascular lung water volume in patients undergoing surgery for esophageal cancer

In 27 operations on esophageal cancer, extra vascular lung water (EVLW) was used as pre- and postoperative parameter in the control of the respiratory function. The cases were divided into 2 groups. Group I consisted of 6 cases with pulmonary complications and group II, 21 cases without them. The changes of EVLW and the circulatory and respiratory parameters were compared between 2 groups. Preoperative EVLWs were 5.56 +/- 0.67 ml/kg in group I and 5.76 +/- 0.41 ml/kg in group II. The immediate postoperative EVLWs were 6.65 +/- 1.90 ml/kg in group I and 4.86 +/- 0.31 ml/kg in group II, but the difference was insignificant. Beyond the 12th hour of the postoperative period there was no significant difference in the EVLW levels of groups I and II. In group II the immediate postoperative EVLW was significantly less than the preoperative value. Only 2 cases had pulmonary edema. The immediate postoperative EVLWs of these patients were extremely elevated as compared with the preoperative value. Many reports said EVLW correlated with colloid osmotic pressure-pulmonary wedge pressure gradient or PaO2, but in our cases EVLW did not correlate with any parameter. From these results, it was assumed EVLW was the good parameter for early diagnosis and management of pulmonary complication after surgery for esophageal cancer.     

Efficacy of low-dose propranolol in preventing postoperative supraventricular tachyarrhythmias: a prospective, randomized study.

A prospective, randomized study was performed in 100 consecutive patients undergoing coronary artery bypass surgery to assess the efficacy of the early reinstitution of propranolol in reducing the incidence of postoperative supraventricular tachyarrhythmias (SVT). Patients were randomized to receive propranolol 10 mg every 6 hours enterally starting the morning after surgery (Group I, 50 patients) or to serve as controls (Group II, 50 patients). No patient was excluded because of poor ventricular function, need for urgent revascularization, or transient necessity for ionotropic support. Both groups had a comparable incidence of risk factors, previous infarction, unstable angina, and abnormal ventricular function. The extent of coronary disease, preoperative propranolol dose, and number of grafts performed were also similar. SVT occurred in 3/50 (6%) patients in Group I compared with 14/50 (28%) in Group II (p less than 0.01). There were no preoperative or intraoperative discriminators to predict the occurrence of SVT. In addition, perioperative infarction and the need for mechanical or pharmacologic circulatory support did not predispose to SVT. The data indicate that early administration of propranolol should be given to all patients after myocardial revascularization to decrease the incidence of these postoperative rhythm disturbances.     

Effect of reduction of postoperative days in the intensive care unit after coronary artery bypass

The high cost of medical care prompted us closely to evaluate our practice of keeping all coronary artery bypass patients in the postoperative intensive care unit a minimum of 2 days. Thirty-seven patients were randomly assigned to a 1 or 2 day postoperative stay in the intensive care unit after routine bypass grafting. Nineteen patients in Group I stayed 1 day and 18 in Group II stayed 2 days. Eighteen Group I and 17 Group II patients were evaluated. No differences in type or rate of complications occurred in either group. No deaths occurred. Total hospital costs were $340 less for Group I (not statistically significant, p greater than 0.4), room costs were $361 less for Group I (p less than 0.01), total laboratory costs were $165 less for Group I (p greater than 0.5), and costs for arterial blood gases were $325 less for Group I (p less than 0.001). No adverse effect on patient safety was found by reducing the stay in the intensive care unit from 2 days to 1 day. This and other economies can significantly reduce hospital costs for this group of patients.     

Analyzing the outcome of early versus prolonged extubation following cardiac surgery

OBJECTIVES: This study considered the factors associated with prolonged ventilation and the effects of reduced extubation times on patient recovery, intensive care unit stay, and overall hospital stay. MATERIALS AND METHODS: A retrospective study was performed, including 86 consecutive patients who underwent cardiac surgery from August 2006 to January 2007. The patients were divided into two groups following intensive care unit admission: Group A, duration of intubation <4 h (n=34); Group B, duration of intubation >4 h (n=52). RESULTS: Two deaths occurred in 86 patients, and overall hospital mortality was 2.32%. Patients in Group A were younger (33.2+/-12 versus 45.8+/-13 years; p=0.001) and had better preoperative left ventricular ejection fraction (LVEF) (62.4+/-9.8 versus 44.6+/-9.4; p=0.003) than those in Group B. Moreover, Group A patients had a shorter intensive care unit length of stay (1.7+/-0.5 versus 2.2+/-0.8 days; p=0.006) and were discharged earlier than Group B patients (2.7+/-2.4 versus 4.01+/-3.96; p=0.014). CONCLUSIONS: Early extubation offers a substantial advantage in terms of accelerated recovery, shorter intensive care unit, and hospital stay, suggesting that efforts to reduce extubation times are cost-effective.     

Efficacy and safety of percutaneous nephrolithotomy (PCNL): a prospective and randomized study comparing regional epidural anesthesia with general anesthesia

Objective: To compare the efficacy and safety of regional epidural anesthesia and general anesthesia in patients who underwent PCNL. Materials and Methods: Fifty patients submitted to percutaneous nephrolithotomy (PCNL) were randomized into two groups: Group I (N = 26) received general anesthesia and Group II (N = 24) received regional epidural anesthesia. Demographic and operative data including age, BMI, stone position, stone size, postoperative pain, amount of postoperative analgesic usage, length of hospital stay, patient satisfaction, preoperative and postoperative hemoglobin and hematocrit, adverse effects and surgical complications were compared between both groups. Results: Average pain score at 1 hour. was 6.88 in group I and 3.12 in group II (p < 0.001), at 4 hours. 5.07 in group I and 3.42 in group II (p = 0.025). Less morphine was required in the regional epidural anesthesia group compared to the general anesthesia group. Higher satisfaction was found in the regional epidural group. 6 (23.07 %) patients in Group I and 1 patient (4.19 %) in Group II had postoperative nausea and vomiting, respectively (p = 0.05). Pain score at 12 hours, 24 hours, 48 hours, 72 hours, preoperative and postoperative hemoglobin and hematocrit, length of hospital stay, and adverse effects were no different between the two groups. Conclusion: Regional epidural anesthesia is an alternative technique for PCNL which achieves more patient satisfaction, less early postoperative pain and less adverse effects from medication with the same efficacy and safety compared to general anesthesia.     

Betablockers compared with antithyroid drugs as preoperative treatment in hyperthyroidism: drug tolerance, complications, and postoperative thyroid function

Subtotal thyroid resection or hemithyroidectomy was performed for hyperthyroidism on two groups of patients: 84 treated before surgery with antithyroid drugs and thyroxin and 111 given only beta-blocking agents before surgery. These two patient groups were compared with reference to preoperative medication, operation, immediate postoperative course, and late results, with follow-up for 3 to 7 years. The advantages of beta-blockers compared with conventional antithyroid medication were lack of adverse reactions, rapid effect of treatment, considerably shortened preoperative treatment time, and fewer outpatient visits, with consequent financial benefit. No disadvantages of beta-blockers were found except that 18% of the patients required additional propranolol in the immediate postoperative period. There were no surgical complications in either group other than a mild persistent hypocalcemia in two patients from the beta-blocked group. The serum thyrotropin levels during the first 6 postoperative months were significantly higher in the patients treated with antithyroid drugs. The frequency of postoperative thyroid dysfunction showed no intergroup difference during the observation period. Signs of hypofunction, necessitating thyroxin supplementation, were observed in 28.6% of patients in the antithyroid drug/thyroxin group and in 25.7% in the beta-blocker group. Toxic recurrence occurred in 1.8% of the group that received beta-blockers and in 1.2% of the other patients. The study demonstrated that beta-adrenoceptor blockade is a safe method for preoperative treatment in hyperthyroidism, with advantages for patients and regarding costs.     

Der Einfluss des Versorgungszeitpunktes von Frakturen der Brustwirbelsäule auf die perioperative respiratorische Funktion

BACKGROUND: Proper timing of stabilization for spine injuries is discussed controversially. Whereas early repair of long bone fractures is known to reduce complications. PATIENTS AND METHODS: We investigated retrospectively 48 patients who were stabilized in a ventrodorsal approach for fractures of the thoracic spine. Patients were divided into three groups. All patients in groups I and II presented radiological or clinical signs of lung contusion. Patients were stabilized in the prone position via single-step dorsal stabilization with internal transpedicular fixation and ventral fusion with titanium cage or autologous bone graft using a minimally invasive video-assisted thoracotomy. RESULTS: The average duration of the procedures in group I was 213+/-40 min, in group II 250+/-75 min, and in group III 255+/-65 min (p: n.s.). Intraoperative blood loss did not differ significantly between the three groups. The PaO(2)/FiO(2) ratio improved in groups I and III, whereas in group II an significant impairment of lung function occurred perioperatively. Postoperative ICU stay was comparable in groups I and II (I: 10+/-5 days; II: 9+/-7 days); overall ICU stay tended to be shorter in group I versus II. The postoperative dependence on ventilator support did not differ significantly among the three groups. The mortality rate was 0% in this series. CONCLUSION: Our data provide further evidence that early stabilization of combined thoracic and thoracic spine injuries is safe, does not alter perioperative lung function, and results in a reduced overall ICU stay.     

Aggressive blood conservation in coronary artery surgery: impact on patient care

Data on 100 consecutive non-emergency coronary artery bypass (CABG) patients were analyzed retrospectively. Sixty-nine patients received no homologous blood (Group I). Thirty-one patients received a total of 118 units of blood products averaging 2.23 units of red cells (Group II). The average red cell transfusion rate for all patients was 0.7 units per patient. The median age for Group I was 61 and Group II was 68 years (p less than 0.05). The average number of grafts was the same for both (3 per patient) with 75% of Group I and 58% of Group II receiving internal mammary artery (IMA) grafts (p less than 0.05). Twelve of the Group II patients who received intraoperative transfusions on cardiopulmonary bypass to maintain adequate hemoglobin levels were older and had lower admission hematocrits: 36 +/- 0.8% compared to 41 +/- 0.5% for all other patients (p less than 0.05). Average postoperative blood loss was 889 +/- 38 ml for Group I and 1077 +/- 104 ml for Group II (p less than 0.05). Increased hemorrhage was correlated with bypass time and IMA use but not with preoperative heparin administration, pre-existing risk factors (diabetes, hypertension, etc.), bleeding time, post-bypass clotting time, age or number of grafts. Two patients in Group II and none in Group I required exploration for excessive postoperative hemorrhage. Mortality rate was 2% (both in Group II, neither transfusion related). Discharge hematocrits were the same for all at 29.4 +/- 0.4%. Among anemia-related postoperative symptoms, only sinus tachycardia was significantly higher in Group I (20%) compared to Group II (6.5%).(ABSTRACT TRUNCATED AT 250 WORDS)     

Introduction of laparoscopic splenectomy for the treatment of immune thrombocytopenic purpura

AIM OF THE STUDY: Was to evaluate retrospectively the outcomes and efficacy of the laparoscopic splenectomies for ITP patients, performed at our institution over a period of 7 years and to compare these results with those after open splenectomies. PATIENTS AND METHODS: We collected and analyzed data of 22 consecutive adult patients with ITP who underwent either laparoscopic (LS gr., n = 9) or open (OS gr., n = 13) splenectomy at Hospital of Kaunas University of Medicine between the years 1996 and 2002. The indications for splenectomy in these patients were unsuccessful treatment with corticosteroids or other medications and/or the requirement of high dosages of steroids for prolonged periods of time to maintain platelet count > 50 G/L before operation. Prior to surgery, all patients were treated with corticosteroids and/or intravenous immunoglobulin to raise the platelet count and to minimize the risk of intraoperative bleeding. The efficacy of the operation was evaluated by counting platelets one day before surgery and on the first and fifth postoperative day. Data chosen for analysis included age, gender, weight, height, American Society of Anaesthesiologists (ASA) score, number of converted patients, estimated blood loss during operation, operating time, postoperative secretion through the drains, morbidity, mortality and postoperative hospital stay. RESULTS: There were no significant differences between LS and OS groups according patients age, weight, height, gender and ASA score. The mean operative time was 138.8 +/- 50.1 min in LS group and was significantly longer than operative time in OS group (102.3 +/- 21.3 min). One patient was converted to open splenectomy because of severe bleeding from splenic hilum. Postoperative complications occurred in one patient from each group. The mean intraoperative blood loss was 460 +/- 125 ml in LS group and 510 +/- 140 ml in OS group (p > 0.05). Postoperative secretion through the drains and postoperative secretion time in LS group was significantly lower and shorter than in OS group. Postoperative hospital stay in LS group (5 +/- 1.1 days) was significantly shorter than in OS group (8 +/- 1.4 days). After splenectomy, there was an immediate increase in the platelet count of all patients in both groups. Between the day before surgery and the first postoperative day, the mean platelet count rose significantly from 75 +/- 57.0 G/L to 117 +/- 84.2 G/L in LS group and from 64 +/- 60.1 G/L to 122 +/- 79.3 G/L in OS group. Between the first postoperative day and the fifth postoperative day, the mean platelet count also rose significantly in both groups: from 117 +/- 84.2 G/L to 259 +/- 151.0 G/L in LS group and from 122 +/- 79.3 G/L to 258 +/- 158.4 G/L in OS group. In the immediate postoperative period (five days after operation), all LS group and OS group patients responded to the splenectomy. CONCLUSIONS: Laparoscopic or open splenectomy are equally efficacious in patients with ITP, with an immediate response rate of 100 % in our study. Our study results show that open splenectomy appears superior to laparoscopic procedure in terms of shorter operative time. Laparoscopic splenectomy appears superior to open procedure in terms of postoperative hospital stay, postoperative drainage time, less postoperative secretion through the drains. These two approaches are similar with regard to blood loss during operations and the rate of postoperative complications.     

Autologous blood transfusion with recombinant human erythropoietin in heart surgery--studies on the volume of preoperative donation and postoperative administration]

Recombinant human erythropoietin (rHuEPO) was administered to 42 elective heart surgery patients, and the volume of autologous blood donated within the preoperative short period and effects of improving anemia by postoperative rHuEPO administration were studied. rHuEPO (100 U/kg/day) and chondroitin sulfate-iron (40 mg/day) were given intravenously for preoperative 14 days, and each 400 ml of autologous blood was donated on the 14th and 4th day before operation. Reticulocytes increased significantly 3 days after administration (p less than 0.01). The hemoglobin level, 13.4 +/- 1.0 g/dl before the first donation, returned to 13.4 +/- 1.1 g/dl just before operation. 800 ml of autologous blood, needed for usual open heart surgery, may possibly have been donated within 14 days without making patients anemic by intravenous rHuEPO administration. For postoperative rHuEPO administration, the patients were divided into 3 groups: Group I (10 cases): given for 14 days, Group II (12 cases): for 7 days, Group III (20 cases): no administration. Reticulocytes decreased rapidly after termination of rHuEPO administration in each group, and on the 7th day after termination, they returned to the level before administration. The hemoglobin level in Group I was maintained after termination of rHuEPO, and was +2.2 +/- 1.1 g/dl on the 21st postoperative day compared with the level of 1st postoperative day. The hemoglobin level in Group II fell after termination and was +0.9 +/- 0.7 g/dl on the 21st day, this being comparable to the level of Group III. There were significant differences between Group I and II (p less than 0.05), and between Group I and III (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)     

The effect of cisapride on the success of early feeding after elective open colon resection

Early postoperative feeding after open colon resection has been shown to be safe and effective. However, approximately 13 per cent of patients fail to tolerate it. We hypothesized that the use of promotility agents may decrease failure of early postoperative feeding after elective open colectomy. As part of a consecutive case series metoclopramide or cisapride was administered to patients undergoing open colectomy as part of an early feeding protocol. The early feeding protocol consisted of instituting a clear liquid diet on postoperative day (POD) 2, followed by a regular diet on POD 3. One hundred fifty-one patients received early-feeding without promotility agents (Group I). The next 49 patients were treated with metoclopramide (Group II), and 31 patients received cisapride (Group III). In Group I 20 of 151 patients (13.2%) failed early feeding, and the mean hospital stay was 3.77 days (range 3-11 days). In Group II seven of 49 patients (14.2%) failed early postoperative feeding, and the mean hospital stay was 3.67 days (range 3-8 days). Group III had no patients who failed to tolerate early feeding, and the mean hospital stay was 3.32 days (range 3-5 days). There were no anastomotic leaks or abdominal abscesses in any group. No cardiac arrhythmias were associated with cisapride. A decrease in early feeding failure was observed with cisapride, administration.