Perioperative growth hormone treatment and functional outcome after major abdominal surgery: a randomized, double-blind, controlled study.
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OBJECTIVE: To evaluate short- and long-term effects of perioperative human growth hormone (hGH) treatment on physical performance and fatigue in younger patients undergoing a major abdominal operation in a normal postoperative regimen with oral nutrition. SUMMARY BACKGROUND DATA: Muscle wasting and functional impairment follow major abdominal surgery. METHODS: Twenty-four patients with ulcerative colitis undergoing ileoanal J-pouch surgery were randomized to hGH (12 IU/day) or placebo treatment from 2 days before to 7 days after surgery. Measurements were performed 2 days before and 10, 30, and 90 days after surgery. RESULTS: The total muscle strength of four limb muscle groups was reduced by 7.6% in the hGH group and by 17.1% in the placebo group at postoperative day 10 compared with baseline values. There was also a significant difference between treatment groups in total muscle strength at day 30, and at the 90-day follow-up total muscle strength was equal to baseline values in the hGH group, but still significantly 5.9% below in the placebo group. The work capacity decreased by approximately 20% at day 10 after surgery, with no significant difference between treatment groups. Both groups were equally fatigued at day 10 after surgery, but at day 30 and 90 the hGH patients were less fatigued than the placebo patients. During the treatment period, patients receiving hGH had reduced loss of limb lean tissue mass, and 3 months after surgery the hGH patients had regained more lean tissue mass than placebo patients. CONCLUSIONS: Perioperative hGH treatment of younger patients undergoing major abdominal surgery preserved limb lean tissue mass, increased postoperative muscular strength, and reduced long-term postoperative fatigue. (
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Hepatectomy for hepatocellular carcinoma: toward zero hospital deaths.
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OBJECTIVE: The authors report on the surgical techniques and protocol for perioperative care that have yielded a zero hospital mortality rate in 110 consecutive patients undergoing hepatectomy for hepatocellular carcinoma (HCC). The hepatectomy results are analyzed with the aim of further reducing the postoperative morbidity rate. SUMMARY BACKGROUND DATA: In recent years, hepatectomy has been performed with a mortality rate of <10% in patients with HCC, but a zero hospital mortality rate in a large patient series has never been reported. At Queen Mary Hospital, Hong Kong, the surgical techniques and perioperative management in hepatectomy for HCC have evolved yearly into a final standardized protocol that reduced the hospital mortality rate from 28% in 1989 to 0% in 1996 and 1997. METHODS: Surgical techniques were designed to reduce intraoperative blood loss, blood transfusion, and ischemic injury to the liver remnant in hepatectomy. Postoperative care was focused on preservation and promotion of liver function by providing adequate tissue oxygenation and immediate postoperative nutritional support that consisted of branched-chain amino acid-enriched solution, low-dose dextrose, medium-chain triglycerides, and phosphate. The pre-, intra-, and postoperative data were collected prospectively and analyzed each year to assess the influence of the evolving surgical techniques and perioperative care on outcome. RESULTS: Of 330 patients undergoing hepatectomy for HCC, underlying cirrhosis and chronic hepatitis were present in 161 (49%) and 108 (33%) patients, respectively. There were no significant changes in the patient characteristics throughout the 9-year period, but there were significant reductions in intraoperative blood loss and blood transfusion requirements. From 1994 to 1997, the median blood transfusion requirement was 0 ml, and 64% of the patients did not require a blood transfusion. The postoperative morbidity rate remained the same throughout the study period. Complications in the patients operated on during 1996 and 1997 were primarily wound infections; the potentially fatal complications seen in the early years, such as subphrenic sepsis, biliary leakage, and hepatic coma, were absent. By univariate analysis, the volume of blood loss, volume of blood transfusions, and operation time were correlated positively with postoperative morbidity rates in 1996 and 1997. Stepwise logistic regression analysis revealed that the operation time was the only parameter that correlated significantly with the postoperative morbidity rate. CONCLUSION: With appropriate surgical techniques and perioperative management to preserve function of the liver remnant, hepatectomy for HCC can be performed without hospital deaths. To improve surgical outcome further, strategies to reduce the operation time are being investigated. (
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A policy of quality control assessment helps to reduce the risk of intraoperative stroke during carotid endarterectomy.
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OBJECTIVES: A pilot study in our unit suggested that a combination of transcranial Doppler (TCD) plus completion angioscopy reduced incidence of intra-operative stroke (i.e. patients recovering from anaesthesia with a new deficit) during carotid endarterectomy (CEA). The aim of the current study was to see whether routine implementation of this policy was both feasible and associated with a continued reduction in the rate of intraoperative stroke (IOS). MATERIALS AND METHODS: Prospective study in 252 consecutive patients undergoing carotid endarterectomy between March 1995 and December 1996. RESULTS: Continuous TCD monitoring was possible in 229 patients (91%), while 238 patients (94%) underwent angioscopic examination. Overall, angioscopy identified an intimal flap requiring correction in six patients (2.5%), whilst intraluminal thrombus was removed in a further six patients (2.5%). No patient in this series recovered from anaesthesia with an IOS, but the rate of postoperative stroke was 2.8%. CONCLUSIONS: Our policy of TCD plus angioscopy has continued to contribute towards a sustained reduction in the risk of IOS following CEA, but requires access to reliable equipment and technical support. However, a policy of intraoperative quality control assessment may not necessarily alter the rate of postoperative stroke. (
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Gastric emptying after elective abdominal aortic aneurysm surgery: the case for early postoperative enteral feeding.
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OBJECTIVE: To assess gastric emptying with a view to early postoperative enteral nutrition after elective abdominal aortic aneurysm (AAA) surgery. METHODS: The paracetamol absorption test was used to assess gastric emptying in 13 consecutive patients at 6, 18 and 32 h following elective AAA surgery. All patients received postoperative analgesia with marcaine given via an epidural catheter during the first 48 postoperative hours. Normal emptying was defined as an area under the plasma paracetamol concentration curve at 60 min (AUC-60) of > 600 mg/min/l. RESULTS: The median time to normal gastric emptying was 18 +/- 7.7 h. One patient (7.6%) had normal emptying at 6 h, nine (69%) at 18 h and 12 (92%) at 32 h. The nasogastric tubes were removed at a median of 3.2 days after surgery, and enteral feeding was commenced on day 4. CONCLUSIONS: Gastric emptying was normal 18 h post-AAA surgery as assessed by the paracetamol absorption test. In view of the importance of maintaining an intact gastrointestinal mucosa, enteral nutrition may be commenced on the second postoperative day. (
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Effects of aggressive early rehabilitation on the outcome of anterior cruciate ligament reconstruction with multi-strand semitendinosus tendon.
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To evaluate the effects of aggressive early rehabilitation on the clinical outcome of anterior cruciate ligament reconstruction using semitendinosus (and gracilis) tendon, 103 of 110 consecutive patients who underwent ACL reconstruction using multistrand semitendinosus tendon (ST) or the central one-third of patellar tendon with bony attachments (BTB) were analyzed prospectively. Subjectively, the Lysholm score was not different among the groups. The Lachman test indicated a trend of less negative grade in the ST men's group than that in the BTB men's group. On the patellofemoral grinding test, only women patients of both groups showed pain, with less positive crepitation in the ST group than in the BTB group. KT measurements at manual maximum showed more patients with more than 5 mm differences in the ST group than in the BTB group. The results of this study suggest that aggressive early rehabilitation after the ACL reconstruction using the semitendinosus (and gracilis) tendon has more risk of residual laxity than with the BTB. (
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Predictive value of perioperative gastric acid tests.
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Preoperative acid studies and early postoperative insulin tests in 275 patients undergoing various forms of vagotomy have been related to recurrent ulceration. Follow-up time has been from two to nine years, mean 4-3 years. Recurrence is directly related to basal acidity in both tests but is not related to stimulated acid levels preoperatively. In the insulin tests higher levels of acidity after insulin are associated with a higher incidence of recurrence. When positive, Hollander's and multiple criteria are both associated with a higher recurrence rate. (
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Evaluation of routine tracheal extubation in children: inflating or suctioning technique?
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We studied prospectively the effects of the technique of tracheal extubation on arterial haemoglobin oxygen saturation (SpO2) in 120 ASA I-III children, mean age 5.3 (range 0.25-16.9) yr. At completion of surgery, tracheal extubation was performed when spontaneous ventilation had resumed, children were fully awake and SpO2 was 99-100%. Children were allocated randomly to receive a single lung inflation manoeuvre with 100% oxygen before tracheal extubation (group I; n = 59) or to have the tracheal tube removed while applying suction through the tube (group S; n = 61). SpO2 was monitored during the first 5 min after tracheal extubation in the operating room. Supplementary oxygen was given if SpO2 decreased to less than 92%. The time between tracheal extubation and decrease in SpO2 to 92% (T92) was recorded. Children in group S required oxygen administration more frequently after tracheal extubation than those in group I (65.6% vs 45.8%; P = 0.04), and had a three-fold shortening of T92 (mean 25 (SD 19) s vs 85 (63) s; P = 0.0001). These effects were more pronounced in children less than 4 yr of age compared with older children. We conclude that tracheal extubation greatly impaired oxygenation and therefore administration of oxygen was appropriate. This impairment was more marked when suction was used, and in young children. Lung inflation with 100% oxygen before removal of the tracheal tube is advised before routine tracheal extubation in children. (
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Intra-articular morphine and/or bupivacaine after total knee replacement.
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The postoperative analgesic effects of intra-articular injections of bupivacaine and/or morphine were examined prospectively in 437 patients who had total knee replacement for osteoarthritis. They were divided randomly into four groups. Group I received 10 mg of morphine (1 ml) and 9 ml of saline, group II received 10 ml of bupivacaine (2.5 mg/ml), group III received 10 ml of saline, and group IV received 10 mg of morphine (1 ml) and 9 ml of bupivacaine (2.5 mg/ml). All analgesics administered in the first 24 hours after operation were recorded. The patients rated their pain on the McGill-Melzack scale at 1, 6, 12 and 24 hours. No significant differences were found between any of the groups in the use of Demoral and/or Toradol in 24 hours, the length of stay in hospital or the pain rating at 1, 6, 12 or 24 hours. Patients in groups I and IV, whose injections included morphine, used significantly more morphine in the first 24 postoperative hours than did groups II or III. (
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