Unplanned splenectomy during oesophagectomy does not affect survival.

OBJECTIVE: There are limited and conflicting data available concerning the incidence of inadvertent splenectomy and its impact on the outcome in patients who have undergone oesophagectomy. The aim of this study is to identify the factors associated with a likelihood of inadvertent splenectomy and its influence on early and long-term outcome in patients having oesophagectomy for oesophageal carcinoma. METHODS: A consecutive series of 738 oesophagectomies performed between 1991 and 2004 was analysed. In our practice, the spleen was removed only if damaged intraoperatively. Routine chemo- and immunoprophylaxis would subsequently be used. Multivariate analysis with logistic and Cox models determined significant variables. RESULTS: Of the 738 oesophagectomies, 48 (6.5%) had splenectomy. Neoadjuvant chemotherapy was administered to a minority of patients; none subsequently had splenectomy. There were significant differences between types of operation (Ivor-Lewis 18 (9.0%), left thoracolaparotomy 14 (9.9%) and left thoracophrenotomy 15 (3.9%), p=0.01). Splenectomy was more common with advanced N stage disease (OR=0.44 [0.20-0.95]; p=0.04). Splenectomy resulted in more blood transfusions (median, 2 units vs 0 units; p=0.03) more anastomotic leaks (7 [14.6%] vs 42 [6.1%]; p=0.02) but not an increase in pulmonary complications (p=0.64) or in-hospital mortality (1 [4.6%] vs 37 [5.4%]; p=0.30). Splenectomy did not significantly affect median survival (551 [332-770] days vs 627 [554-700] days; p=0.63). CONCLUSION: Although inadvertent splenectomy increased the morbidity of oesophagectomy, it did not impair survival. Type of operation and advanced N stage are important risks for splenectomy. Though best avoided, most of the consequences of splenectomy can be managed. An unexpected relationship between splenectomy and anastomotic leaks needs further investigation.     

Right ventricle-to-pulmonary artery shunt versus modified Blalock-Taussig shunt in the Norwood procedure for hypoplastic left heart syndrome - influence on early and late haemodynamic status.

OBJECTIVE: The aim of this study was to assess changes in early and late haemodynamic status after the Norwood procedure (NP), caused by the implementation of right ventricle-to-pulmonary artery shunt (RV-PA). METHODS: A consecutive series of 68 children with hypoplastic left heart syndrome underwent NP: Group 1 (n=31) with the application of a modified Blalock-Taussig shunt and Group 2 (n=37) with RV-PA. Haemodynamic data from the early postoperative period (72 h after the operation) and cardiac catheterisation data, as well as blood tests before the hemi-Fontan procedure (HF) were analysed. Univariate (chi(2) test, Mann-Whitney's and Student's t-tests) and multiple regression analysis were carried out. RESULTS: In Group 1, circulatory collapse requiring resuscitation occurred in 15 (48.4%) children, within 72 h after the procedure. The resuscitation was unsuccessful in nine (29%) cases. The operative mortality (30 days) was 35%. In Group 2, two (5%) children died within the early and two (5%) within the late postoperative period. The postoperative course in the remaining children from Group 2 was uneventful. In Group 2 there was a significantly higher mean diastolic pressure after NP (P<0.05). The arterial pulse pressure after NP was significantly lower in Group 2 (P<0.05). Before HF, the application of RV-PA was associated with a lower Qp:Qs ratio (P=0.020), lower aortic pulse pressure (P=0.004) and lower aortic oxygen saturation (P=0.039). CONCLUSIONS: A stable haemodynamic status due to independent coronary perfusion, higher diastolic and lower pulse pressure is the most advantageous effect of RV-PA, resulting in a lower mortality and morbidity after NP. A lower Qp:Qs ratio eliminates the danger of the ventricular volume overload and ensures good conditions for the development of the pulmonary circulation before HF.     

Matrix Metalloproteinases

Drugs & Aging - Matrix metalloproteinases (MMPs), or matrixins, are a family of zinc endopeptidases that play a key role in both physiological and pathological tissue degradation. Normally,...     

Prediction of Remission of Acute Posttraumatic Stress Disorder in Motor Vehicle Accident Victims

One hundred forty five individuals who sought medical attention as a result of a motor vehicle accident (MVA), and who were initially assessed 1 to 4 months post-MVA, were followed up prospectively for 6 months to determine how many of the 55 with posttraumatic stress disorder (PTSD) and the 43 with sub-syndromal PTSD would remit and what variables would predict remission. Thirty (55%) of those with initial PTSD had remitted at least in part by 6 months while 67% of those with sub-syndromal PTSD had remitted (and 5% had worsened). Four variables, including severity of initial symptoms, degree of initial physical injury, relative degree of physical recovery by 4 months and whether a close family member suffered a trauma during the follow-up interval, combined to classify 6-month clinical status of 84% of those with initial PTSD secondary to MVAs.     

Coronary artery and saphenous vein graft remodeling: A review of histologic findings after various interventional procedures—part V

Catheter balloon angioplasty is a well accepted form of nonsurgical treatment of acutely and chronically obstructed coronary artery vessels. It is also the centerpiece for various new intervention techniques. Their morphologic effect on the site of obstruction has been termed “remodeling.” Part V of this six-part series focuses on remodeling effects of balloon angioplasty on obstructed young (≤ 1 year) and old (> 1 year) saphenous vein bypass grafts.     

Autoamputation of the foot caused by untreated gas gangrene: a case report

Gas-producing diabetic foot infections are limb-threatening emergencies commonly encountered by foot and ankle surgeons. Appropriate treatment includes aggressive surgical debridement, parenteral antibiotics, and postoperative wound care. The authors present a unique case of a patient who refused treatment for a deep-space gas-producing infection, resulting in autoamputation of the foot. The authors also discuss the confusion surrounding the definition of gas gangrene.     

Effect of different phospholipid-cholesterol membrane compositions on liposome-mediated formation of calcium phosphates

Summary The present report compares the effects of different membrane phospholipid (PL)-cholesterol compositions on the kinetics of liposome-mediated formation of calcium phosphates from metastable solutions (2.25 mM CaCl₂; 1.5 mM KH₂PO₄) at 22°C, pH 7.4 and 240 mOsm. In most experiments, the liposomes were composed of 7:2:X mixtures of phosphatidylcholine (PC), neutral or acidic phospholipids, and cholesterol (Chol, X=0, 10, 35, or 50 mol%). The neutral phospholipids (NPL) examined, in addition to PC, were phosphatidylethanolamine (PE) and sphingomyelin (Sph), and the acidic phospholipids (APL) examined were dicetylphosphate (DCP), dioleolylphosphatidylglycerol (DOPG), dioleolylphosphatidic acid (DOPA), phosphatidylserine (PS) and phosphatidylinositol (PI). The 7:2:X liposomes did not initiate mineralization in metastable external solutions per se or, with the exception of DOPA, show extensive Ca-PL binding. However, solution Ca²⁺ losses due to precipitation occurred when the liposomes were encapsulated with 50 mM KH₂PO₄ and made permeable to external Ca²⁺ with X-537A. The extent of these Ca²⁺ losses was sensitive to both the phospholipid and Chol makeup of the membrane. Moderate-to-extensive intraliposomal precipitation occurred in all 7PC:2APL and 7PC:2NPL liposomes containing 0 or 10 mol% Chol. In contrast, at 50 mol% Chol, mineralization inside all liposomes was negligible. The only significant discriminating effect on internal mineralization among the different phospholipids was observed at 35 mol% Chol, where mineral accumulations ranged from negligible to moderate. At 0 or 10 mol% Chol, extraliposomal precipitation was extensive in all but DOPA- and PS-containing liposomes. However, onece intraliposomal yields declined at the higher Chol levels, external mineralization was either delayed or totally blocked in all liposome preparations. Other experiments showed that Sph substituted for PC in 7NPL:2DCP:1Chol liposomes totally blocked both intra- and extraliposomal precipitaiton. PE substituted in this manner, however, blocked only extraliposomal precipitation. The results of this study suggest that interference of the membrane transport processes controlling intraliposomal precipitation [15] by high (50 mol%) Chol levels is not significantly compromised by the specific APL or NPL incorporated in the membrane. Similarly, the data suggest that Chol does not directly affect the specfic interactions of the different membrane APLs with the mineral phase. On the other hand, the substitution of other NPLs for PC can affect the role of APLs such as DCP in liposome-mediated mineralization.     

Criteria for Selective Utilization of the Intensive Care Unit following Carotid Endarterectomy

n = 62, p < 0.05), emergent CEA (n= 2, p= 0.01), and need for postoperative anticoagulation (n= 2, p= 0.01). Only 56 (15%) of patients had indications for ICU admission, 57 (16%) would have been admitted to an EKG-monitored nursing unit, and 252 (69%) would have been admitted to a standard nursing unit. Immediate admission to the ICU after CEA is indicated for patients undergoing emergent CEA, those requiring anticoagulation postoperatively, those with intraoperative stroke or major cardiac complication, and possibly those with chronic renal failure. All other patients should be admitted to the RR. Patients experiencing stroke, major cardiac events, significant wound hemorrhage, or reintubation in the RR, and those requiring vasoactive medication more than 3 hours after surgery should be transferred to the ICU. Patients with indications of cardiac disease within 6 months prior to CEA but no indications for ICU admission may be discharged from the RR to an EKG monitored unit. All others may be discharged to a standard nursing unit.