Perianaesthetic risks and outcomes of abdominal surgery for metastatic carcinoid tumours.
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Patients with metastatic carcinoid tumours often undergo surgical procedures to reduce the tumour burden and associated debilitating symptoms. These procedures and anaesthesia can precipitate a life-threatening carcinoid crisis. To assess perioperative outcomes, we studied retrospectively the medical records of adult patients from 1983 to 1996 who underwent abdominal surgery for metastatic carcinoid tumours. Preoperative risk factors, intraoperative complications and complications occurring in the 30 days after surgery were recorded. Perioperative complications or death occurred in 15 of 119 patients (12.6%, exact confidence interval 7.2-19.9). None of the 45 patients who received octreotide intraoperatively experienced intraoperative complications compared with eight of the 73 patients (11.0%) who did not receive octreotide (P=0.023). The presence of carcinoid heart disease and high urinary output of 5-hydroxyindoleacetic acid preoperatively were statistically significant risk factors for perioperative complications. (+info)
Effects of portal triad clamping on haemodynamic conditions during laparoscopic liver resection.
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To evaluate the haemodynamic effects of portal triad clamping (PTC) during laparoscopic liver resection, 10 patients without cardiac disease were studied by invasive monitoring including a pulmonary artery catheter and were compared with a control group of 10 patients undergoing liver resection by laparotomy. During laparoscopic surgery, intra-abdominal pressure was kept below 14 mm Hg and minute ventilation was adjusted to prevent hypercapnia. Measurements were made before PTC (T1), 5 min after PTC (T2) and 5 min after clamp release (T3). During clamping with pneumoperitoneum, mean arterial pressure (MAP) remained stable (+2%; not significant), systemic vascular resistance (SVR) increased by 37% (P<0.01, T2 vs T1) and cardiac index (CI) decreased by 19% (P<0.01, T2 vs T1). During laparotomy and clamping, MAP increased by 18% (P<0.01, T2 vs T1), SVR increased by 36% (P<0.01, T2 vs T1) and CI decreased by 9% (not significant). We were unable to demonstrate a difference in haemodynamic changes during clamping with pneumoperitoneum vs the open surgical technique, but in a small number of patients this lack of difference could have been a result of inadequate statistical power. The haemodynamic changes that we found were well tolerated in these patients, who had normal cardiac function. (+info)
A randomised trial of the effect of intraoperative 5-FU on the outcome of trabeculectomy in east Africa.
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AIMS: To determine if intraoperative application of 5-fluorouracil (5-FU) improves the prognosis for trabeculectomy in east Africa. METHODS: 68 eyes with chronic open angle glaucoma were included in a randomised trial of intraoperative 5-FU versus placebo. Main outcome measures were intraocular pressures at 6 months and probability of failure at 2 years. RESULTS: 180 days after surgery the mean intraocular pressure (IOP) was 17.4 (SD 6.1) mm Hg in the placebo group and 16.9 (5.8) mm Hg in the 5-FU group. By 2 years after trabeculectomy, the probability of successful IOP control was 70.6% in the placebo group, and 88.8% in the 5-FU group. The placebo group was 2.18 times (95% CI 0.67 to 7.15) more likely to require additional IOP lowering procedures than the 5-FU group. Among patients followed for 2 years, 30% lost 0.3 logMAR units of visual acuity. CONCLUSIONS: Trabeculectomy in Africa has an acceptable success rate which may be enhanced by the use of intraoperative 5-FU. It is estimated that this would cost approximately 1.25 pounds sterling per trabeculectomy failure prevented. (+info)
Pressure measurements in closed aneurysmal sac during abdominal aortic aneurysm resection.
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PURPOSE: This study determined the relationship between closed aneurysmal sac pressure (ASP) and mean blood pressure (BP) during open abdominal aortic aneurysm (AAA) resection and evaluated the contribution of inferior mesenteric and lumbar artery blood flow to ASP after proximal and distal clamping. METHODS: We measured ASP after proximal and distal clamping by placing an 18-gauge needle connected to a BP transducer into the excluded aneurysmal sac in 25 consecutive patients from April 1999 to August 2000. Simultaneous measurement of the mean systemic BP was also recorded. The ratio of ASP to mean BP in relation to the number of actively bleeding lumbar arteries (N-LA), diameter of the AAA (D-Cm), and volume of the thrombus in the AAA (Vol-TA) were recorded. RESULTS: The mean ASP was 43.32 +/- 15.19 mm Hg, with an ASP to mean BP ratio of 0.47 +/- 0.15. The N-LA in the closed aneurysmal sac ranged from 0 to 6 (mean, 3.4 +/- 1.78). The D-Cm as determined by means of computed tomography (CT) scan of the aorta ranged from 5 to 8 cm in its largest anteroposterior/transverse diameter. The average Vol-TA was 6.15 +/- 4.49 mL. Inferior mesenteric artery blood flow contributed to ASP in three patients (12%). There was no correlation between ASP to mean BP ratios and the N-LA (P =.127), D-Cm (P =.882), or Vol-TA (P =.252). CONCLUSION: Closed ASP and ASP ratios are highly variable and do not correlate with N-LA, D-Cm, or the Vol-TA. (+info)
Intraoperative sonographic localization of breast masses: success with specimen sonography and surgical bed sonography to confirm excision.
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OBJECTIVE: To assess the use of intraoperative sonography for localization of breast masses at excisional biopsy, with specimen and surgical bed sonography to confirm excision. METHODS: A computer search of the 5-year period from January 1993 through January 1998 revealed 138 consecutive women referred for sonographically guided excisional biopsy of 148 masses; 35 masses were excluded because they had no postoperative mammograms. One hundred thirteen masses constituted the study group. Specimen sonography (n = 60) or surgical bed sonography (n = 53) was performed as the initial evaluation to confirm excision, but ultimately, surgical bed sonography may have been necessary after specimen sonography, and specimen sonography may have been necessary after surgical bed sonography. The miss rates determined by postoperative imaging were calculated for each group and compared with those of mammographically guided needle localization series from the literature. RESULTS: Follow-up physical examination and mammography showed no residual mass in the region of surgery in any patient. However, follow-up sonography had 1 miss in the initial specimen sonogram group (1 [1.7%] of 60) and 1 miss in the initial surgical bed group (1 [1.9%] of 53). As shown by the Fisher exact test, there was no significant difference between the miss rates of the 2 initial methods of confirming lesion excision or between the miss rates of these initial methods, both groups combined, and 6 mammographic localization series from the literature. CONCLUSION: Intraoperative breast sonography, using specimen sonography and scanning the surgical bed, has miss rates comparable with those of mammographic needle localization. Follow-up sonography must be performed if there is any doubt of complete excision. (+info)
Six year experience of transvenous left ventricular lead implantation for permanent biventricular pacing in patients with advanced heart failure: technical aspects.
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BACKGROUND: Biventricular pacing has been proposed as an adjuvant to optimal medical treatment in patients with drug refractory heart failure caused by chronic left ventricular systolic dysfunction and intraventricular conduction delay. OBJECTIVE: To assess the technical feasibility and long term results (over six years) of transverse left ventricular pacing with the lead inserted into a tributary vein of the coronary sinus. SUBJECTS: From August 1994 to February 2000, left ventricular lead implantation was attempted in 116 patients who were eligible for biventricular pacing (mean (SD) age 67 (9) years, New York Heart Association (NYHA) functional class III/IV, left ventricular ejection fraction 22 (6)%, QRS duration 185 (26) ms). RESULTS: The overall implantation success rate was 88% (n = 102). A learning curve was indicated by a progressive increase in success from 61% early on to 98% in the last year. The mean pacing threshold was 1.1 (0.7) V/0.5 ms at the time of implantation and increased slightly up to 1.9 (0.9) V/0.5 ms at the end of the follow up period (15 (13) months). The rate of acute and delayed left ventricular lead dislodgement decreased from 30% in the early years to 11% after 1999. During follow up, 19 patients required reoperation for delayed lead dislodgement or increase in left ventricular pacing threshold (n = 15), phrenic nerve stimulation (n = 3), or infection (n = 3). CONCLUSIONS: Transverse left ventricular pacing through the coronary sinus is feasible and safe. The rate of implantation failure and of lead related problems has decreased greatly with increasing experience and with improvements in the equipment. (+info)
I.v. ketoprofen for analgesia after tonsillectomy: comparison of pre- and post-operative administration.
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We have evaluated the safety and efficacy of ketoprofen during tonsillectomy in 106 adults receiving standardized anaesthesia. Forty-one patients received ketoprofen 0.5 mg kg(-1) at induction ('pre' ketoprofen group) and 40 patients after surgery ('post' ketoprofen group), in both cases followed by a continuous ketoprofen infusion of 3 mg kg(-1) over 24 h; 25 patients received normal saline (placebo group). Oxycodone was used for rescue analgesia. Patients in the ketoprofen groups experienced less pain than those in the placebo group. There was no difference between the study groups in the proportion of patients who were given oxycodone during the first 4 h after surgery. However, during the next 20 h, significantly more patients in the placebo group (96%) received oxycodone compared with patients in the 'pre' ketoprofen group (66%) and the 'post' ketoprofen group (55%) (P=0.002). Patients in the placebo group received significantly more oxycodone doses than patients in the two ketoprofen groups (P=0.001). Two patients (5%) in the 'pre' ketoprofen group and one (3%) in the 'post' ketoprofen group had post-operative bleeding between 4 and 14 h. All three patients required electrocautery. (+info)
Haemodynamic and renal effects of intravenous enalaprilat during coronary artery bypass graft surgery in patients with ischaemic heart dysfunction.
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Renal dysfunction occurring after open heart surgery is multifactorial in origin but activation of the renin-angiotensin system may have a prominent role. Fourteen patients with ischaemic heart dysfunction scheduled for elective coronary artery bypass graft (CABG) surgery were allocated to a treatment group [enalaprilat for 2 days; ACEI (angiotensin-converting enzyme inhibitor) group, n=7] or a control group (n=7). The cardiac index was significantly higher in ACEI-treated patients than in the controls before and after cardiopulmonary bypass (CPB) (P<0.05) and on postoperative day 2 (P<0.05). The systemic vascular resistance was significantly lower in the ACEI-treated patients than in the controls before and after CPB (P<0.05). Renal plasma flow, measured as [131I]orthoiodohippuran clearance (ClH), was higher in the ACEI group than in the control group before CPB, as was endogenous creatinine clearance after CPB (P<0.05). On post-operative day 7, ClH was significantly higher in the ACEI group than in the control group (P<0.05). Plasma renin activity and vasopressin concentration increased in both groups during CPB (P<0.05). The study demonstrates that administration of an i.v. ACEI, enalaprilat, improves cardiac output during CABG surgery in patients with ischaemic heart dysfunction. Moreover, renal perfusion was better maintained during surgery, and this effect was sustained up to post-operative day 7. (+info)