The risk of infection and peritoneal catheter loss from implant procedure exit-site trauma.
OBJECTIVE: To evaluate the role of skin and subcutaneous tissue trauma at the time of catheter implant procedure as a determinant of catheter loss from infectious complications. DESIGN: Nonrandomized study with prospective collection of data. PATIENTS: Consecutive patients were divided into three groups based upon how the catheter was exited through the skin: group 1, procedure involved pulling tubing, with a permanently bonded catheter adapter, through the exit-site wound (n = 43); group 2, same as group 1 except exit wounds were closed around the catheter with a suture (n = 20); group 3, procedure involved pulling only tubing through the exit wound (n = 61). SETTING: Primary medical center for a health maintenance organization. MAIN OUTCOME MEASURES: Log rank comparisons of Kaplan-Meier analyses of first occurrences of infectious events and overall catheter survival. RESULTS: The risk of first exit-site infection (p < 0.001), tunnel infection (p < 0.001), catheter infection-related peritonitis (p < 0.001), and catheter loss (p < 0.01) were greatest in group 1 with large exit wounds, and lowest in group 3 with small exit wounds. CONCLUSIONS: The study demonstrates the importance of careful dissection and exit-site construction. The exit site should consist of the smallest hole possible that permits passage of only the tubing and leaves the skin snug around the catheter. The present report incriminates catheter designs employing permanently bonded adapters that result in large pericannular wounds that are prone to infection and catheter loss. (+info)
Randomized prospective comparison of laparoscopic and open peritoneal dialysis catheter insertion.
OBJECTIVE: To compare laparoscopic and conventional peritoneal dialysis catheter insertion with respect to post operative discomfort, complication rates, and catheter survival. DESIGN: Randomized prospective study. SETTING: Tertiary referral renal unit. PATIENTS: Fifty patients commencing peritoneal dialysis. INTERVENTION: Catheters were implanted laparoscopically or by a conventional surgical technique. MAIN OUTCOME MEASURES: The duration of surgery, hospital stay, pain scores, and analgesic requirements were recorded. Complications (early/late) and catheter survival were compared. RESULTS: The conventional procedure was faster than the laparoscopic (14.3 vs 21.9 minutes, p < 0.0001). There was no difference in any other parameter assessed. CONCLUSIONS: The data suggest that the insertion techniques are equivalent, and that laparoscopic insertion does not reduce early complication rates. (+info)
Endovascular management of ureteroarterial fistula.
Ureteroarterial fistulas, although rare, appear to be increasing in frequency. Because open surgical repair may be difficult and associated with significant risk for complications, endovascular intervention may provide an attractive treatment alternative. We review the diagnosis and management of a ureteroarterial fistula and iliac pseudoaneurysm that presented with massive hematuria during ureteral stent removal. The patient was treated by means of the percutaneous embolization of the right hypogastric artery and placement of an expanded polytetrafluoroethylene stent-graft. Endovascular stent-graft placement may serve as a safe and practical alternative in the treatment of these patients, whose cases are challenging. (+info)
Effect of a remifentanil bolus dose on the cardiovascular response to emergence from anaesthesia and tracheal extubation.
We have examined the effect of remifentanil on the haemodynamic response to emergence from anaesthesia and tracheal extubation in 40 ASA I-II female patients undergoing diagnostic laparoscopy, in a randomized, double-blind study. All patients received a standard general anaesthetic comprising propofol, vecuronium and 1% isoflurane with 66% nitrous oxide in oxygen. At the end of surgery, a bolus dose of remifentanil 1 microgram kg-1 (n = 20) or saline placebo (n = 20) was given and tracheal extubation was performed when standard criteria were achieved. Arterial pressure and heart rate were recorded non-invasively at 1-min intervals from the end of surgery. Remifentanil attenuated the increase in both mean arterial pressure (P < 0.001) and heart rate (P < 0.05) at extubation. Mean time to extubation was 7.2 (SEM 0.6) min and 4.0 (0.5) min in the remifentanil and saline groups, respectively (P < 0.001). There was no difference in the incidence of coughing at extubation, time to recovery from anaesthesia or time to fitness for discharge from the recovery room. (+info)
Day-case percutaneous endoscopic gastrostomy: a viable proposition?
The aim of our study was to evaluate the success rate, complications, and long term outcomes following day-case percutaneous endoscopic gastrostomy (PEG). This retrospective study was carried out in a 650-bed District General hospital in Northamptonshire, UK. Thirty-six patients, aged 28-90 years, were included in the study, 21 males (58%) and 15 females (42%). Indications for PEG insertion included head and neck cancer, dysphagia as a result of primary disease, and AIDS-related malnutrition. Data were collected from the medical and dietetic records. The PEG procedure was successful in 33 patients (92%). In 32 cases (97%) the patient was discharged home. Twenty five of the patients (76%) suffered no complications whilst seven (21%) suffered complications within a month of the procedure. No patient required further surgical intervention. Five patients (15%) died of their primary disease within a month of the procedure. Patients had had their PEG tubes in situ for up to 2.5 years at the end of data collection. We conclude that PEG can be performed as a day-case procedure in stable patients with no increase in complication rate, morbidity, or mortality. (+info)
Internal biliary stenting in orthotopic liver transplantation.
Biliary complications account for significant morbidity in orthotopic liver transplantation (OLT), with a reported incidence ranging from 6% to 47%, and many centers are reassessing the need and options available for stenting the biliary anastomosis. We report on our experience using a 6F Silastic, double-J, ureteral stent as an internal biliary stent in OLT. From October 15, 1995, to September 30, 1998, a total of 99 patients at our institution underwent 108 OLTs. Of these, 77 patients received an end-to-end choledochocholedochostomy over an internal stent. Three patients died within 1 week post-OLT, leaving 74 patients for evaluation (follow-up, 2 to 38 months). Stents were placed transanastomotic and transsphincteric at the time of OLT and secured with a dissolvable suture. At 4 to 6 weeks post-OLT, stents visible within the biliary tree on kidney, ureters, and bladder radiograph were removed endoscopically. Graft and patient survival rates were 92% and 96%, respectively. There were 12 biliary complications (18%): anastomotic leak in 6 patients (9%), anastomotic stricture in 5 patients (7.6%), and stent migration in 1 patient (1.5%). Thirty-two patients (43%) passed the biliary stent without intervention, whereas 42 patients (57%) underwent esophagogastro duodenoscopy (EGD) stent removal at 4 to 6 weeks without incident. Treatment of the complications included percutaneous drainage, endoscopic dilatation with stenting, and/or conversion to Roux-en-Y choledochojejunostomy. The use of the 6 F Silastic, double-J, ureteral stent provides a safe and effective means of stenting the biliary anastomosis in OLT. Major advantages to this method are that it: (1) is completely internal, (2) is biliary decompressive, (3) is radiopaque, (4) can be spontaneously passed, and (5) is easily accessible for EGD extraction. (+info)
Long-term outcome after treatment of aortic graft infection with staged extra-anatomic bypass grafting and aortic graft removal.
OBJECTIVE: The purpose of this study was to determine long-term outcome in patients with infected prosthetic aortic grafts who were treated with extra-anatomic bypass grafting and aortic graft removal. METHODS: Between January 1989 and July 1999, 36 patients were treated for aortic graft infection with extra-anatomic bypass grafting and aortic graft removal. Extra-anatomic bypass graft types were axillofemoral femoral (5), axillofemoral (26; bilateral in 20), axillopopliteal (3; bilateral in 1) and axillofemoral/axillopopliteal (2). The mean follow-up was 32.3 +/- 4. 8 months. RESULTS: Four patients (11%) died in the postoperative period, and two patients died during follow-up as a direct consequence of extra-anatomic bypass grafting and aortic graft removal (one died 7 months after extra-anatomic bypass graft failure, one died 36 months after aortic stump disruption). One additional patient died 72 months after failure of a subsequent aortic reconstruction, so that the overall treatment-related mortality was 19%, whereas overall survival by means of life table analysis was 56% at 5 years. No amputations were required in the postoperative period, but four patients (11%) required amputation during follow-up. Twelve patients (35%) had extra-anatomic bypass graft failure during follow-up, and six patients underwent secondary aortic reconstruction (thoracobifemoral , iliofemoral , femorofemoral ). However, with the exclusion of patients undergoing axillopopliteal grafts (primary patency 0% at 7 months), only seven patients (25%) had extra-anatomic bypass graft failure, and only two patients required amputation (one after extra-anatomic bypass graft removal for infection, one after failure of a secondary aortic reconstruction). Furthermore, primary and secondary patency rates by means of life table analysis were 75% and 100% at 41 months for axillofemoral femoral grafts and 64% and 100% at 60 months for axillofemoral grafts. Only one patient required extra-anatomic bypass graft removal for recurrent infection, and only one late aortic stump disruption occurred. CONCLUSIONS: Staged extra-anatomic bypass grafting (with axillofemoral bypass graft) and aortic graft removal for treatment of aortic graft infection are associated with acceptable early and long-term outcomes and should remain a primary approach in selected patients with this grave problem. (+info)
Apoptosis in shed human corneal cells.
PURPOSE: To determine whether shear forces applied to the corneal epithelium by the repeated insertion and removal of a hydrogel contact lens alter the size and number of cells removed and to determine the contribution of apoptosis to this process. METHODS; Human corneal cells were collected from eight healthy subjects by sequential contact lens cytology (20 lens insertions and removals). Collected cells were stained with acridine orange for counting and measurement of cell size. In a separate experiment, collected cells were fixed and stained with TdT-mediated dUTP nick-end labeling (TUNEL) or labeled immediately after collection using annexin V. Hoechst stain and propidium iodide (PI) were used as nuclear counterstains. The proportion of cells labeled with acridine orange, TUNEL, and annexin V was quantified by fluorescence microscopy. RESULTS; The number of cells increased in later collections, and cells were smaller. The mean number of positively stained cells using TUNEL was 57%. Annexin V labeling on unfixed fresh samples showed a mean of 64%, with an increase in later collections. Apoptotic bodies were observed in very few cells. In most cells the nucleus and cytoplasmic membrane were intact. Structures were observed in which nuclei were missing (Hoechst negative) but in which cytoplasm had the size and appearance of whole, nucleated cells. These structures (cell ghosts) increased in number along with the increase in nucleated cells in later collections. CONCLUSIONS: The sequential removal of a soft contact lens caused a progressive increase in the number of cells collected from the surface and a progressive decrease in their size. The majority of nucleated cells removed by a contact lens were apoptotic in the sense of being positively labeled by TUNEL and annexin V. Morphologically they differed from classically apoptotic cells, in that cells showed an intact nuclear structure and no discernible apoptotic bodies. They could represent a last stage in a pathway of cell differentiation in which frictional forces induced by the removal of the contact lens activate the apoptotic program and cause the cell to be shed. There is also a pathway in which cells lose their nuclei before leaving the epithelial surface. (+info)