Enteral nutrition following total laryngectomy

Body composition was measured in patients who underwent total laryngectomy for carcinoma and who were enterally fed throughout the postoperative period with full liquid artificial mixtures. The intestinal complications were very mild and required no changes in the nutritional program. Body sector sizes remained essentially unchanged until the end of the support, malnutrition did not occur and the postoperative local infection rate was very low. On the contrary, in patients fed with blenderized food, the amount of enteral infusion had to be reduced because of poor tolerance or abdominal discomfort; in this case caloric intake was largely inadequate. Fall in BW and BCM size and increase of TBNa/TBK ratio demonstrated a postoperative impairment of the nutritional status. Furthermore, the postoperative infection rate, the number of days with fever and the length of antibioticotherapy were higher than those observed in patients fed with full liquid mixtures.     

Dynamic radiographic imaging following total laryngectomy

Cinepharyngoesophograms of the pharynx were obtained in 51 patients after total laryngectomy for squamous cell carcinoma. The radiological findings were correlated with operative reports and follow-up findings in 47 patients. Postoperative anatomic changes were well-demonstrated radiographically. A spectrum of radiographic findings were observed and included narrowing at the superior surgical closure site in 52% and pseudodiverticula in 47% of all patients. Cricopharyngeal prominence was observed in 15%, fistulae in 10%, and pharyngeal pouches in 6% of all cases. Increased retropharyngeal soft tissue thickness was not found to be indicative of tumor recurrence. We conclude that cineradiography is a useful method for demonstrating both functional and structural changes following laryngectomy for carcinoma.     

Vocal restoration following laryngectomy

Methods of vocal restoration after laryngectomy are summarized and a new approach briefly described. It is emphasized that surgical procedures should only be contemplated when a satisfactory esophageal voice has not been achieved.     

Therapeutic suggestions given during neurolept-anaesthesia decrease post-operative nausea and vomiting

BACKGROUND: Data on prevalence of cigarette smoking by hospital employees are limited in Australia, but anecdotal evidence suggests that many health sector employees continue to smoke despite abundant evidence regarding the harmful effects of this habit. Nicotine is an addictive drug and arguably this should be known better in the health industry than in any other industry. Despite having this knowledge at their disposal, health sector employers rarely provide assistance to employees, relying instead on restrictive policies to reduce smoking in the workplace. METHODS: To assist employees to quit smoking, we instituted a medium intensity Stop Smoking Programme, run by a clinical pharmacist offering nicotine patches and support on a weekly basis. A principal aim of the service was to redress the imbalance between the availability of cigarettes and the most effective nicotine replacement therapy, the trandermal nicotine patch. Following 18 months operation of this service, we surveyed hospital employees to ascertain smoking rates and views on smoking cessation in this South Australian teaching hospital. RESULTS: In the first 18 months of operation, 111 staff members availed themselves of the service. At the first follow up period (three months), 21 were not contactable, 29 were successful in not smoking and 61 were still smoking. Six of the 29 who were not smoking at three months resumed smoking by six months, and a further four resumed smoking by 12 months. At the time of this report, 12 of the remaining 19 non smokers had completed two years since quitting and a further three of these had resumed regular smoking by this time. The cost of providing the service was modest at approximately $180.00 per known successful quitter. Results from the survey showed that 12.4% of hospital employees were regular smokers. Smoking prevalence was not equally distributed with female employees being twice as likely to smoke as their male counterparts and employees in the catering department having the highest smoking prevalence (23.8%). CONCLUSIONS: Although the prevalence of cigarette smoking by employees of this teaching hospital is lower than for the general community, health sector employers can reduce smoking prevalence further by providing assistance to their employees to quit smoking. The Stop Smoking Programme we describe is effective and could be replicated by other hospitals and similar organisations.     

Sustained release metoclopramide for prophylaxis of post-operative nausea and vomiting

BACKGROUND: Eclampsia remains a serious complication of pregnancy and childbirth and factors related to morbidity require continued evaluation. DESIGN: Retrospective case-control study on the incidence and outcome of eclampsia. SETTING: A defined total island population over 20 years. METHODS: All centrally collected birth registration returns in Iceland for the years 1972-1991 were reviewed to identify women with the diagnosis of eclampsia, selecting women delivering immediately before and after the eclamptic case as controls. Information from all places where women had delivered was obtained to ensure that no case was missed. Maternity records were reviewed to verify the diagnosis and obtain maternal and neonatal data. RESULTS: Forty women had eclampsia (0.046% of deliveries). The incidence diminished between the decades 1972-81 and 1982-91 (p < 0.05), as did the incidence of eclamptic convulsions before delivery. Eclamptic women were more often primiparous, younger and delivered earlier than controls. Preterm delivery and a low ponderal index were more common among offspring of the eclamptic mothers and the male/female ratio was lower. CONCLUSION: The incidence of eclampsia in the population is falling. Common features related to the condition were confirmed. Severe maternal illness is rare, but the babies often appear growth-retarded and are delivered preterm.     

Epidural buprenorphine and epidural droperidol for post-operative nausea or vomiting

For 120 young patients who had undergone reconstruction of anterior cruciate ligament of the knee, we investigated the effect of epidural administration of buprenorphine on the incidence of nausea or vomiting, and the anti-emetic effect of epidural administration of droperidol. In the group who had received bolus injection of buprenorphine 0.1 mg, nausea or vomiting occurred early most often, and the injection was not useful to prolong analgesic effect. In the another group who had received continuous epidural infusion of buprenorphine 0.3 mg, nausea or vomiting occurred late. Bolus injection of droperidol 2.5 mg was not useful to prevent nausea or vomiting caused by continuous epidural infusion of buprenorphine. While, continuous infusion of droperidol 5 mg was effective in decreasing nausea or vomiting caused by continuous epidural infusion of buprenorphine. In conclusion, continuous epidural administration of droperidol is useful to prevent nausea or vomiting.     

Voice prostheses mechanisms in total laryngectomy

Familial combined hyperlipidemia is a common inherited disorder characterized by a hepatic overproduction of apo B particles and an elevated risk for the development of atherosclerosis. LDL particles are smaller and denser and are more prone to oxidation. The exact pathogenesis of familial combined hyperlipidemia is unclear at present. Treatment should aim to reduce the synthesis of atherogenic lipoproteins and to increase the clearance of triglyceride-rich lipoproteins.     

Improvements in respiratory and psychosocial functioning following total laryngectomy by the use of a heat and moisture exchanger

A prospective clinical study in 61 patients was undertaken to investigate the subjective and objective influence of a heat and moisture exchanger (HME) on the respiratory and psychosocial problems following total laryngectomy. Although statistical comparisons failed to detect significant differences between the experimental and the control groups, there was a clear trend toward improvements in respiratory and psychosocial functioning in the experimental group. Analyses of differences over time within the HME user group showed significant reductions in the incidence of coughing, the mean daily frequency of sputum production, forced expectoration, and stoma cleaning. Significant improvements were also found in shortness of breath, fatigue and malaise, sleep problems, levels of anxiety and depression, and perceived voice quality. Pulmonary function tests showed significant improvements in inspiratory flow and volume values following use of the HME. This objective improvement in inspiratory pulmonary function reflects the decrease in sputum production reported by the patients.     

Evaluation of voice and speech following subtotal reconstructive laryngectomy

Subtotal reconstructive laryngectomy (SRL) can be used to preserve voice in the treatment of selected laryngeal carcinomas. This study was designed to analyze both voice and speech results achieved after SRL in 14 male patients, aged from 48 to 73 years. Surgery was performed between 1983 and 1993. Fundamental frequencies, ranges of frequency, intensities, and intensity ranges were established using an S.I. 80 Philips AAC 600 Audio Active Comparative Language System. Five prolonged vowels and six phonetically balanced sentences were recorded on a tape positioned at a distance of 30 cm from the mouth of each patient during a 3-min recording time. The recorded material was then evaluated by a panel of ten trained listeners who were asked to consider the qualitative parameters and perceptual characteristics of voice and speech according to a scorecard modified from one devised by Voiers and Formigoni. Although a decrease was determined in Fundamental Frequency and intensity of the voice when compared to normal values, the quality and perception of speech were found to be satisfactory. The verbal message could be understood almost exactly by means of constant sonority, correct articulation and improved pneumophonic coordination. These values demonstrate that the new voice achieved after SRL is less sonorous and allows for understandable and socially acceptable speech.     

The techniques of nonmuscular closure of hypopharyngeal defect following total laryngectomy: the assessment of complication and pharyngoesophageal segment

The usual method of reconstructing a hypopharyngeal defect during total laryngectomy includes pharyngeal muscle layer closure, which may result in high pharyngoesophageal pressure. We hypothesize that nonclosure of the pharyngeal muscle can reduce the pressure of the pharyngoesophageal segment which can reduce the chances of the formation of pharyngocutaneous fistulae. A technique of nonmuscular closure of a hypopharyngeal defect is presented. The differences in the rate of fistula formation and swallowing function between patients with usual and nonmuscular closure were also studied. Sixty consecutive laryngectomees were enrolled in this study. Thirty patients received usual closure after total laryngectomy, whereas the other 30 patients underwent non closure of their pharyngeal muscles. One patient (3.3 per cent) in the nonmuscular closure group and three patients (10 per cent) in the usual closure group developed a pharyngocutaneous fistula. The pharyngoesophageal pressures of the nonmuscular closure group were significantly lower than those of the usual closure group. We conclude that the technique of nonclosure of the pharyngeal constrictor muscle after total laryngectomy is relatively more simple and is not associated with a higher rate of fistula formation. Furthermore, nonclosure of the pharyngeal constrictor muscle is preferable to muscular closure because it reduces the spasm of the pharyngoesophageal segment which limits voice rehabilitation.     

Nausea and vomiting following thyroid and parathyroid surgery

The human serotonin transporter gene (hSERT) is a strong candidate for involvement in the pathogenesis of mood disorder and, using a UK Caucasian case-control sample, Collier et al found a significant association between bipolar disorder and the 12 allele of the VNTR polymorphism in intron 2 of this gene. In a European collaborative sample, Collier et al found a significant association between affective disorder and a functional deletion polymorphism in the promoter of hSERT. We have undertaken association studies using these polymorphisms in a British Caucasian sample comprising 171 DSM-IV bipolar probands, 80 DSM-IV major depression probands and 121 unrelated controls matched to bipolar probands for age, sex and ethnicity. We found no association between the promoter deletion and affective disorder but our findings with the VNTR polymorphism are similar to those of Collier and colleagues: we found a significant excess of the 12 repeat allele in bipolar probands (P = 0.031, one-tall) with a suggestion of a gene dosage effect (using genotypes bearing no 12 repeat allele as baseline, the increased risks conferred by genotypes bearing 12 repeat alleles were: heterozygote, OR = 1.24; homozygote, OR = 1.76). Our findings add to the evidence that variation at or near hSERT influences susceptibility to bipolar disorder in the British Caucasian population.     

Postoperative vomiting. A score for prediction of vomiting risk following inhalation anesthesia

Despite numerous factors are thought to affect postoperative vomiting (PV) recent studies demonstrated that the risk of PV can be predicted by considering just the most important ones. Therefore, the aim of this study was to present the clinically most relevant factors, a risk score based upon those factors and its clinical applicability for other types of surgery. METHODS: In a prospective study 2220 adult inpatients scheduled for elective surgery were monitored for PV after inhalational anaesthesia over 24 hours. None of the patients received prophylactic antiemetic treatment. Multivariate analyses were performed with data of patients who underwent otolaryngological procedures to identify the major risk factors and to derive a risk score. The applicability of the score in surgical and ophthalmological procedures was tested by linear regression analysis of expected and observed incidences. RESULTS: In the multivariate model, clinically most important risk factors for PV were female gender, young age, a positive history of postoperative nausea and vomiting or motion sickness, non-smoking and a long duration of anaesthesia, whereas the relative impact of the "type of operation itself" was small. Expected and observed incidences in patients undergoing other types of surgery were strongly correlated (R2 = 0.99, P < 0.001). CONCLUSION: The risk for PV after inhalational anaesthesia in adults can be predicted using a score which is based on individual risk factors and the duration of anaesthesia only.     

Pouch-related fistula following restorative proctocolectomy

Prognostic factors and outcome of pouch-related fistula were analysed from a series of 21 patients, 20 of whom had an ileal J pouch manually anastomosed to the dentate line following mucosectomy. Fistula occurred more often after pouch formation for ulcerative colitis than for familial adenomatous polyposis. In 6 patients the fistula occurred more than 5 months after closure of the diverting loop ileostomy. The origin of the leak was the anastomosis in 14 patients, the vertical staple line in two and the end of the efferent limb in five. Nine forms of treatment were utilized and these were successful in 11 patients and unsuccessful in ten including three pouch excisions. Adverse prognostic factors were late fistula, the presence of an enterocutaneous or a pouch-vaginal fistula track, and diagnosed or suspected Crohn's disease. Resolution of the fistula followed none of six diverting loop ileostomies performed alone, three of 33 attempted drainage procedures, four of ten direct closures, and four of five repeat ileal pouch-anal anastomoses. It is concluded that an aggressive therapeutic approach using repeat ileal pouch-anal anastomosis increases the success rate.     

An arteriovenous fistula following laminectomy--sonographic diagnosis

In a 36-year-old woman, 10 years after laminectomy, a tentative diagnosis of arteriovenous shunt between the right iliac artery and vein, a rare complication of this procedure, was made on the basis of ultrasonographic findings. The signs consisted of dilatation of the iliac vein and of the inferior vena cava, a vascular bruit and tactile fremitus in the abdomen. In addition, cardiac enlargement and slight tricuspid and mitral incompetence in the absence of cardiac insufficiency were noted. After angiographic verification of the diagnosis the anomaly was corrected surgically.     

A new method of achieving total continence in vesico-urethro-vaginal fistula (circumferential fistula) with total urethral destruction--surgical technique

Twelve (12) cases of urethral reconstruction from the anterior bladder wall combined with primary urethropexy to achieve total continence in 67% circumferential fistulae in women is presented. These operations were performed transvaginally and the technique is described.     

Evaluation of post-operative analgesia following laparoscopic application of Filshie clips

OBJECTIVE: To evaluate the efficacy of injecting 1% lignocaine into the subserosal aspect of the cornual end of the fallopian tubes to control post-operative pain after laparoscopic Filshie clip application. DESIGN: A double blind, randomised controlled trial. SETTING: The day surgery unit of the Dunedin Public Hospital, Otago, New Zealand. PARTICIPANTS: Fifty-nine women attending the public hospital requesting sterilisation. INTERVENTIONS: The experimental group received an infiltration of 1% lignocaine into the subserosal aspect of the cornual end of the fallopian tubes. The control group received an infiltration of normal saline in the same site. MAIN OUTCOME MEASURES: The use of post-operative pethidine and the scores obtained on a modification of the McGill present pain intensity score, a visual analogue scale of present pain, a pain relief score and comparisons of time to first analgesia use. RESULTS: The use of pethidine in the experimental group was significantly reduced [P = 0.001] Pain relief scores indicated significant benefit from the intervention. The time to first analgesic use was significantly greater in the experimental group. CONCLUSION: Lignocaine infiltration at the cornual end of the fallopian tubes during laparoscopic Filshie clip application is highly effective in producing post-operative pain relief.     

Complications following total knee replacement

Forty-two months follow-up examinations on 30 total knee arthroplasties revealed the following significant complications: phlebothrombosis, 13 knees (46%); pulmonary embolism 3 patients (11%); asymptomatic loosening, 8 knees (11.4%); symptomatic loosening, 3 knees (4.8%); superficial infections, 4 knees (5.4%); deep infections, 4 knees (5.4%); peroneal palsy, 3 patients (4.3%). Early detection of thrombophlebitis by 125I fibrinogen scan and possible aspirin prophylaxis were evaluated. In view of the limited number of encouraging results, e.g. excellent 58.6 per cent; good 28.5 per cent; fair 5.4 per cent and poor 7.1 per cent, caution is advocated until extensive time elapses for more clinical experience with total knee arthroplasty.     

A-V fistula following use of a Fogarty catheter

Using metallic microelectrodes, intracellular measurements were performed of changes in O2 concentration for spherical oocytes of hens by their replacement from normal (PO2=150 torr) to hyperoxic (to 600 torr) conditions, and vice versa. The curves of O2 influx and efflux were recorded in pulse regime of the working electrode polarization. The character of these curves can be expressed by the following equations: m(t)==c==e=y1t+y0 and m (t) =e-y1t+v0+c, where v1 is determined by the coefficient of cell membrane permeability for O2. Valid differences were shown between values of v1 for oxygen influx and efflux which vanish after the action of cyanides. It is suggested that O2 transport into the cell involves a base component which may be physical diffusion, and an additional component which can be depressed by cyanides.