Early postoperative feeding after elective colorectal surgery is not a benefit unique to laparoscopy-assisted procedures

Previous analyses of non-prospectively randomized trials have suggested that early oral postoperative feeding might be a benefit unique to laparoscopic surgery. However, some authors have indicated that early feeding can be tolerated by the majority of patients after elective open surgery. Aim: This prospective randomized study was undertaken to assess whether the time prior to oral intake of food after laparoscopy-assisted surgery is shorter than that after standard laparotomy. Methods: This trial included 40 patients who were divided randomly into two groups before operation. Group I included 20 patients (mean age, 52 years; range , 15 – 77 years) who underwent a laparoscopy-assisted colon or rectal procedure (LAP). Group II consisted of 20 patients (mean age, 56 years, range, 41 – 74 years) who underwent surgery with a standard midline incision (SMI). On the evening after surgery, patients were allowed clear liquids ab libitum. This regimen was continued until the first postoperative day at which time they could elect to start eating a regular diet. If a patient had two episodes of vomiting, a nasogastric tube was inserted. Results: Five laparoscopic procedures were converted to SMI because of adhesions (25%) and an equal number of patients was excluded from the group that was treated in the traditional manner. Therefore, only 30 patients were included in the analysis. There were no deaths in this trial. Complications appeared in four of the patients in the LAP group and in two of the patients in the SMI group (no significant difference). There were no statistically significant differences between the two groups in terms of the ability to tolerate the early oral intake of food, in the frequency of vomiting or in the incidence of insertion of a nasogastric tube. The time to the first bowel movement was 5.4 days in LAP and 5.5 days in SMI, and the difference was not significant. Conclusion: This study invalidates the claim by laparoscopic surgeons that earlier oral intake of food is tolerated by their patients than by patients who undergo standard procedures.

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Résumé. Des études randomisées non prospectives ont suggéré que la reprise précoce de l'alimentation orale peut être un bénéfice particulier à la chirurgie laparoscopique. Certains auteurs ont indiqué que la reprise précoce de l'alimentation orale peut être bien tolérée par la plupart des patients après chirurgie élective ouverte. Cette étude prospective randomisée a été entreprise pour déterminer si la reprise orale de l'alimentation après chirurgie laparoscopique peut être plus précoce qu'après une laparotomie standard. Quarante patients ont été inclus dans cette étude et ont été divisés de manière randomisée en deux groupes avant chirurgie. Le groupe 1 comporte 20 patients (15 à 77 ans, moyenne d'age 52 ans) qui ont subi une résection colique ou rectale laparoscopique (LAP). Le groupe II comporte 20 patients (41 à 74 ans, moyenne d'age 56 ans) qui ont subi une chirurgie par une incision médiane standard (SMI). Le soir de l'intervention chirurgicale, les patients ont été autorisés à boire librement. Ce régime a été continué le premier jour postopératoire à partir duquel les patients pouvaient débuter une alimentation normale. Si un patient présente deux épisodes de vomissements, une sonde naso-gastrique a été mise en place. Cinq interventions laparaoscopiques ont d?être converties en chirurgie ouverte en raison d'adhérences (25%) et un nombre égal de patients ont été exclus du groupe qui a été traité de manière traditionelle. En conséquence, 30 patients ont été inclus dans l'analyse. Aucun décès n'est à déplorer. Quatre complications sont survenues chez des patients du groupe laparoscopique et deux dans le collectif des patients ayant subi un chirurgie ouverte (pas de différence statistique significative). Il n'y a pas de différence statistique significative entre les deux groupes en ce qui concerne la tolérance à la reprise orale de l'alimentation, à la fréquence des vomissements ou à la nécessité de réinsérer un tube naso-gastrique. La première exonération est survenue au 5.4 jour dans le groupe laparoscopique et au 5,5 jour dans le groupe de chirurgie ouverte sans que la différence ne soit significative. En conclusion: Cette étude infirme l'idée que la chirurgie laparoscopique permet une reprise précoce et bien tolérée de l'alimentation en comparaison à la chirrugie ouverte.

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Accepted: 20 June 1996     

Nursing licensure. Learning from the American experience

The author describes how academic professional development in Nursing has evolved in the United States and the role which different institutions, organizations and associations have played in it. Based on this experience, one can observe operating patterns which can contribute to discovering strategies applicable to the circumstances that we are undergoing in our country. The author reviews the situation regarding a licentiate for nursing in Spain, right now, while trying to learn from the American experience.     

Chylothorax after Myocardial Revascularization with Internal Mammary Graft

Chylothorax following an intrapericardial cardiac operation is rare, and we are aware of only 12 reported cases. Nine followed median sternotomy for treatment of congenital heart disorders or acquired valvular disease; more than expected were reoperations (23%). This report documents that this complication may also occur following myocardial revascularization with internal mammary graft and describes the anatomy that makes this possible. This rare complication is important because of the high morbidity of prolonged tube drainage and the fact that nearly half of the affected patients underwent reoperation (5 of 13). Dilated lymphatics exuding chyle have been found at operations undertaken to control lymph fistulas and were located in anterior thymic tissue previously divided by electrocautery. Awareness of the significance of lymph encountered during cardiac operations, particularly during reoperation and near the origin of the internal mammary artery, may alert the surgeon that the stage is set for a disabling complication. Electrocautery may be an unreliable means of control as lymph contains little coagulable material; suture is recommended instead.     

Support groups in oncology. How does the nurse intervene?

Participation by nurses in support groups are beneficial for oncology patients and their families since they improve their degree of adaptation and they promote effective mechanisms to confront one's illness. This improvement in quality of life is reflected in patients emotional, physical, social and spiritual state; furthermore, in some cases this leads to an increase in their survival. Due to a nurse's role, oncology patients' families improve their adaptation to the situation; moreover, nurse's aid provides the necessary support to patients during their medical treatment. The authors review the existing literature about nurses' participation in support groups in order to improve a patient's and his/her family's adaptation to cancer and all it entails. With this objective in mind, the authors present the conceptual and empirical concepts of a support group along with their overall objectives and possible benefits. Finally, the authors document the role of nursing in support groups for oncology patients and their families. This study was financed by the Carlos III Health Institute as part of the Evaluation Studies of Health Technologies, reference FIS 00/10107.     

Ovarian pure leiomyosarcoma: case report

We report a case of a pure ovarian leiomyosarcoma, a rare tumor that comprises less than 0.1% out of all the ovarian malignant tumors.     

Repair of Sinus of Valsalva Aneurysm Associated with Aortoventricular Discontinuity

The case of a patient with unruptured sinus of Valsalva aneurysm with absence of the intervalvular lamina fibrosa is presented. The association of Valsalva aneurysm and aortic subvalvular defects has been explained as a deficiency of elastic tissue at the aortic root or maldevelopment of the fibrous trigone. Valvular aortic insufficiency with histological evidence of myxoid changes required prosthetic replacement. Myxomatous changes in the fibrous trigone and aortic annulus can explain this unusual, complex anomaly. Accurate preoperative diagnosis may require special views and simultaneous left and right injections at cineangiography. Techniques of repair that have been successful are reviewed, and the essential features of adequate correction are outlined.     

Coronary bypass with Gore-Tex graft.

The case is presented of a 68-year-old man who previously had undergone aorta-coronary bypass. During a 3 year interval the coronary disease progressed, so that a once insignification lesion necessitated reoperation. A Gore-Tex vascular graft was chosen as a substitute because of the lack of saphenous vein. Three months posoperatively the patient's recatheterization study showed patency of the Gore-Tex graft placed in the distal righ coronary artery, and there was a satisfactory clinical result. No anticoagulants have been given to the patient after the operation.     

Why cardioverter-defibrillator implantation might not be the best idea for your elderly patient

Over the last decade, implantable cardioverter-defibrillators (ICDs) have become a part of mainstream clinical practice, with improvements in survival in a broad range of patients. Given the overall limited life expectancy of elderly patients, their frequent comorbidities, and the complications associated with ICD implantation, it may not be reasonable to expect results with ICD implantation in the elderly to be comparable to that found in the clinical trials. In this paper, the authors review the available scientific literature and discuss why mainstream ICD use in the elderly may not be advisable.