The role of drainage and antibiotic prophylaxis in thyroid surgery

BACKGROUND: It is our habit to employ an open drainage after thyroid surgery in our department. We have also found a large number of surgical infections in these patients (5.8% vs 2.5). Aim of the study is to evaluate prospectively if contamination happens during surgical procedure or in a later time according to the presence of the open drainage. METHODS: From October 1995 to November 1996, 113 patients who underwent a subtotal thyroidectomy were randomized into two groups: group A with antibiotic prophylaxis (57 patients) and group B without it (56 patients). RESULTS: One case (1.7%) of sepsis among 57 patients of group A and 2 cases (3.4%) among 56 patients of group B were observed. CONCLUSIONS: No statistical difference was found between the two groups despite antibiotic prophylaxis covering surgical procedure. It is personal opinion that sepsis arose after surgical procedure, due to the presence of the open drainage.     

Laparoscopic cholecystectomy during pregnancy is safe for both mother and fetus

The use of laparoscopic cholecystectomy in pregnant women has been slow to gain wide acceptance for two reasons: one is the potential for mechanical problems related to the pregnant uterus and the other is fear of fetal injury resulting from instrumentation or the pneumoperitoneum. To assess the effects of laparoscopic cholecystectomy on both the mother and the unborn fetus, we reviewed our surgical experience over a 5-year period analyzing indications for the procedure along with complications and outcome. During this 5-year period, 22 patients ranging in age from 17 to 31 years underwent laparoscopic cholecystectomy during pregnancy. Gestational ages ranged from 5 to 31 weeks with two patients being in the first trimester, 16 in the second, and four in the third. The primary indications for surgical intervention were persistent nausea, vomiting, pain, and inability to eat in 17 patients, acute cholecystitis in three, and choledocholithiasis in two. In all patients a pneumoperitoneum was established by means of a closed technique starting in the right upper quadrant of the abdomen. Two of the 22 patients also underwent successful transcystic common bile duct exploration with removal of common duct stones. All 22 patients survived the surgical procedure without complications, and there were no fetal deaths or premature births related to the procedure. Based on the preceding results, it would appear that laparoscopic cholecystectomy during pregnancy is safe for both the mother and the unborn fetus. Indications for this procedure should include stringent criteria such as unrelenting biliary tract symptoms or the complications of cholelithiasis. If at all possible, when laparoscopic cholecystectomy is indicated, it should be performed either in the second trimester or early in the third.     

Laparoscopic cholecystectomy

Traditional cholecystectomy has been the standard surgical treatment of the gallstone disease for more than 100 years. The technical development led to a new surgical procedure and its rapid acceptance. This is laparoscopic cholecystectomy. Its application is becoming widespread in therapy too. But most of the surgeons are lack of technical experiences in this field. Currently it restricts the indications those are anyway the same of standard cholecystectomy. Besides its many advantages, laparoscopic cholecystectomy has its own disadvantages and being an invasive procedure, there are possibilities of complications. The latest can be reduced by the adequate choice of patients, the careful learning of the operative technic and by turning to open surgery (conversion) when it is necessary. Its morbidity is nearly equal to complications of standard cholecystectomy, but mortality rate is lower (0.05-0.2%). Our morbidity of performed 300 laparoscopic cholecystectomies was 6.4%. We had no death. The hospitalization became as short as 4 days. Our early clinical results (90%) are the same of traditional cholecystectomy. Laparoscopic cholecystectomy as a new surgical procedure involves the efficiency of the standard cholecystectomy and the noninvasive endoscopic technic. Laparoscopic cholecystectomy performed by well trained surgeons is a safe surgical procedure, its early results are excellent and makes the choice of surgical treatment, used in bile surgery richer.     

Totally implantable systems in oncology: the cephalic vein as an elective access port

The use of totally implantable systems (TIS) has noticeably reduced risks and enhanced quality of life for cancer patients undergoing long-term chemotherapy. One aspect remains open to discussion: site of venous access and placement procedure. Opinions are divided between two techniques: percutaneous access by direct puncture of the subclavian vein or surgical access through the veins afferent to the subclavian: the cephalic, the jugular, or other minor veins. We report our experience with 63 patients undergoing surgical placement of TIS through the cephalic vein. The operatory procedure is divided into four phases: 1) Preparation of vein and cannulation; 2) X-ray control; 3) creation of subcutaneous sheath; 4) reconstruction. None of the 63 patients developed immediate complications. 46 patients are currently using TIS for a period ranging from 17 to 1862 days. 16 patients died during the time their TIS was in place. In only one patient was the TIS removed after treatment was completed. From our results it is clear that the surgical access through the cephalic vein is the most reliable method of TIS placement, with fewer risks concerning immediate and post operatory complications.     

Splenic mesothelial cysts mimicking lymphagiomas

The purpose of this prospective multicenter study of 350 consecutive patients who were accepted for mitral valve surgery because of severe regurgitation, was to assess the value of preoperative transthoracic and transesophageal echocardiography in predicting the surgical strategy in severe mitral regurgitation: repair or replacement. The cardiologist predicted the surgical strategy on the basis of the echocardiographic examination, according to predefined guidelines for repair and replacement. The predicted strategy and motivation thereof were compared with the surgical findings and procedure that was performed. Agreement on the basis of transthoracic echocardiography was reached in 86% of the repair patients and on the basis of transesophageal echocardiography in 89%. Agreement on the basis of transthoracic echocardiography was reached in 74% of the replacement patients and on the basis of transesophageal echocardiography in 75%. This study underlines the potential role of echocardiography in predicting the surgical procedure to be applied, provided that both surgeon and cardiologist use the same nomenclature and that the guidelines for replacement/repair are adhered to. Both transthoracic and transesophageal echocardiography appear to be equally accurate in predicting the optimal surgical procedure in this respect.     

Hartmann's procedure in colorectal tumors. Evolutions of the indications in a series of 46 patients

The Authors report a retrospective study of 46 cases of Hartmann's operation in order to analyze the changing indications to this procedure in the management of colo-rectal cancer. The Hartmann's is operation has been performed in 46 out of 723 patients (6.4%) with colorectal cancer treated surgically from 1973 to 1997. Data concerning the indications have been analyzed in two consecutive periods, from 1973 to 1985 and from 1986 to 1997, respectively. In the first period, the procedure has been performed in patients with neoplastic perforation (40% of Hartmann's cases), and in an elective basis in patients with locally invasive tumor or intra-abdominal metastasis (20%). Indications for the procedure in the period 1986-1997 have been locally invasive tumor and/or distant metastasis (52.8% of Hartmann's procedures), neoplastic perforation (22.2%), high surgical anaesthesiologic risk (22.2%) or intestinal obstruction (2.8%). In the second period it has been noted a decrease of the number of patients that underwent Hartmann's procedure for bowel obstruction, and an increase in the number of cases in which the operation was performed for neoplastic perforation, for local and/or distant diffusion, or for high surgical risk.     

Lumboperitoneal shunting for pseudotumor cerebri

To clarify the appropriate role of lumboperitoneal (LP) shunting in the surgical management of pseudotumor cerebri (PTC), we retrospectively analyzed the clinical data from 30 patients who underwent this procedure. We found LP shunting to be an effective means of acutely lowering intracranial pressure. Symptoms of increased intracranial pressure improved in 82% of patients. Among 14 eyes with impaired visual acuity, 10 (71%) improved by at least two lines. Worsening of vision occurred in only one eye. Of 28 eyes with abnormal Goldmann perimetry, 18 (64%) improved and none worsened. The incidence of serious complications was low. The major drawback of LP shunting was the need for frequent revisions in a few patients. The reason for poor shunt tolerance in certain individuals is unclear. In PTC, LP shunting should be considered as the first surgical procedure for patients with severe visual loss at presentation or with intractable headache (with or without visual loss). After shunting it is important to identify patients who are shunt intolerant.     

Lumbar radiofrequency sympatholysis

PURPOSE: The purpose of this article is to present a modified technique for lumbar radiofrequency sympatholysis and to compare the results with chemical sympatholysis. METHODS: Eight patients underwent the percutaneous procedure on an outpatient basis. Sympatholysis was produced with a radiofrequency lesion generator according to distinct anatomic criteria. RESULTS: Six of eight patients met previously used criteria for sympatholysis 8 weeks after the procedure. Postsympatholytic neuralgia occurred transiently in 50% of patients. CONCLUSIONS: The technique produces sympatholysis comparable to that produced by phenol 6%, while it theoretically avoids the risk of neurologic deficits associated with chemical agents. The technique may be useful in patients for whom surgical sympathectomy is undesirable.     

Laparoscopic splenectomy for idiopathic thrombocytopenic purpura. A 1-year follow-up study

BACKGROUND: Laparoscopic splenectomy is a novel approach for the treatment of idiopathic thrombocytopenic purpura (ITP) in patients requiring surgical intervention. This technique was used for treatment in 16 consecutive patients. Follow-up was initiated at a median of 13.5 months after surgery to determine whether or not laparoscopic splenectomy is a safe and successful procedure that should be used in all patients requiring splenectomy for ITP. METHODS: Sixteen patients underwent laparoscopic splenectomy for ITP between May 1994 and September 1996. They were evaluated prospectively prior to surgery, immediately following surgery, at discharge, and at 13.5 months following surgery (n = 14) to determine the short- and long-term results of the procedure. RESULTS: Mean operation time was 123.4 +/- 12.1 min, and there were no significant intra- or postoperative complications. Mean intraoperative blood loss was 437.5 +/- 73.5 ml. Autologous blood transfusion was necessary in one patient (6.3%). Mean organ weight was 202.2 +/- 47.3 g. Mean postoperative hospital stay was 4.6 +/- 0. 4 days. Before discharge, mean platelet count rose by 100.7%. At follow-up (13.5 months postoperatively), it was 77.7% above preoperative values. No additional surgery was necessary in any of the patients undergoing laparoscopic splenectomy, and hematologic success was achieved in 12 patients (85.7%). CONCLUSIONS: Our results clearly indicate that laparoscopic splenectomy is a safe and successful procedure in patients suffering from ITP. It offers the well-known advantages of minimal invasive surgery as well as the surgical effectiveness of the open approach. This surgical technique should therefore be considered in all patients requiring splenectomy for the treatment of ITP.     

Care of the patient undergoing transurethral resection of the prostate

Transurethral resection of the prostate (TURP) for benign prostatic hypertrophy is a common surgical procedure in the United States. Left untreated, benign prostatic hypertrophy can lead to detrimental consequences such as renal failure from urinary obstruction. Although TURP is a common procedure, it is not without risk. Complications can occur, and the perianesthesia nurse must be familiar with them and their treatment. Complications related to the surgical procedure and the anesthesia technique must be assessed and treated quickly to prevent morbidity and mortality in these patients. The perianesthesia nurse is instrumental in managing and preventing complications associated with transurethral resection of the prostate.     

Primary bidirectional superior cavopulmonary shunt in infants between 1 and 4 months of age

The performance of a primary bidirectional superior cavopulmonary shunt procedure in early infancy is attractive because it minimizes the number of operations needed before a Fontan procedure, avoids ventricular volume overload and its sequelae, and eliminates pulmonary artery distortion. However, concerns over elevated or labile pulmonary vascular resistance have limited its use in the first few months of life. Nine patients aged 1 to 4 months (5 patients, < 2 months) have undergone a primary bidirectional superior cavopulmonary shunt procedure between October 1992 and March 1994. Primary diagnoses were tricuspid atresia (n = 4), asplenia syndrome (n = 2), polysplenia syndrome (n = 1), double-outlet right ventricle (n = 1), and double-inlet left ventricle (n = 1). Associated lesions of immediate surgical importance were total anomalous pulmonary veins (n = 2), a restrictive atrial septum (n = 4), bilateral superior venae cavae (n = 5), and patent ductus arteriosus (n = 5). The surgical procedure consisted of unilateral (n = 4) or bilateral (n = 5) bidirectional superior cavopulmonary shunt and the repair of associated lesions. Of significance, in 4 of our first 5 patients a very limited additional source of pulmonary blood flow was provided because of a low arterial oxygen tension immediately after cardiopulmonary bypass. Pleural effusions developed in 2 of these 4 patients. In subsequent patients cardiopulmonary bypass was not used whenever possible or, if it was needed, use of an extra source of pulmonary blood flow was avoided.(ABSTRACT TRUNCATED AT 250 WORDS)     

Experiences with percutaneous endoscopic gastrostomy

Today the procedure of choice for long-term enteral tube feeding in patients with prolonged swallowing difficulties or inabilities is percutaneous endoscopic gastrostomy (PEG). The primary indications are head and neck cancers, neurologic dysphagia, cancer cachexia, and obstruction of the esophagus and pharynx with enough space for an endoscopic procedure. This technique requires no general anesthesia and is possible in patients with contraindications to surgical gastrostomy. Between September 1994 and April 1995 a total of 115 patients underwent PEG placement attempts. We employed the pull-technique with 15-Freka PEG tubes. The average procedure time, including esophagogastroduodenoscopy, was 17 minutes. In nine cases PEG insertion was impossible owing to severe obstruction of the esophagus. In 46 (40%) patients local abdominal pains started on the first or second postoperative day; 7 of these patients required surgical consultation, and no further intervention was needed. In only one patient was there a serious complication that required surgical intervention: a presumed perforation that turned out to have no correlate upon review. All patients received single-shot antibiotic prophylaxis; and only in those patients with abdominal symptoms do we recommend a prolonged antibiosis. The abdominal symptoms reported were due to a slight leak of gastric fluid causing a topical peritonitis, which required no further treatment. In our experience PEG is a useful alternative to surgical gastrostomy. The simplicity of this procedure leads to low complication rates, short hospitalization, and is possible on an outpatient basis. It is cost-efficient and has a much better psychological tolerance than nasogastric tubes.     

Minimally invasive coronary artery bypass grafting: port-access approach versus off-pump techniques

BACKGROUND: Within the past 5 years several surgical techniques have been developed for less invasive surgical treatment of coronary artery disease. The aim of this study was to define specific indications for the various minimally invasive coronary artery surgical procedures. METHODS: Minimally invasive direct coronary artery bypass grafting through a minithoracotomy was performed in 67 patients. The left internal mammary artery was anastomosed on the beating heart with the use of a pressure or suction stabilizer without the use of extracorporeal circulation. In 58 other patients with multivessel disease, the off-pump coronary artery bypass grafting technique through a sternotomy was applied with a left internal mammary artery to left anterior descending artery and additional vein grafts without extracorporeal circulation. In a third group, Port-Access (Heartport Inc, Redwood City, CA) coronary artery bypass grafting was performed through a left minithoracotomy with the use of an endovascular extracorporeal circulation system and cardioplegic arrest. Angiographic follow-up was complete in 64% of the patients. RESULTS: There was minimal perioperative or postoperative mortality (0.5%). The medium surgical procedure time for all minimally invasive and off-pump procedures was 2.5 hours; it was 4.5 hours for Port-Access procedures. The median postoperative intensive care unit stay was 1.0 days, and the median hospitalization was 5.0 days. Overall graft patency was 97.3%; in 8 patients (4.1%) a stenosis either at or distal to the graft anastomosis was dilated with coronary angioplasty. CONCLUSIONS: For single-vessel disease of the left anterior descending artery, the minimally invasive coronary artery bypass grafting procedure can be performed safely without the use of extracorporeal circulation. In case of hemodynamic instability or anatomic variation, the Port-Access procedure can be applied without additional necessity for sternotomy. For multivessel disease, the off-pump bypass grafting procedure with sternotomy can be recommended depending on the coronary arteries involved. In case of necessary grafts to the lateral marginal or circumflex branches, Port-Access grafting can be recommended and may play an important role in the future for the development of fully endoscopic robot-assisted coronary artery bypass grafting.     

Effects of blood transfusion on left ventricular output in premature babies

Tracheostomy tube insertion is periodically performed when patients with acquired immunodeficiency syndrome (AIDS) require prolonged mechanical ventilation. In this population, bedside percutaneous tracheostomy may be a better technique than conventional operating room tracheostomy because it reduces procedural cost, requires no patient transport, and requires few sharp instruments, thereby potentially decreasing risk to surgical staff. A retrospective review was conducted in the Department of Medical Records at St. Vincents Hospital and Medical Center of New York City. Nine consecutive patients diagnosed with AIDS and undergoing percutaneous tracheostomy from January 1, 1992, to December 31, 1996, were identified. All patients were males (mean age 32.1 +/- 4 years, CD4 count average 145) and were ventilator-dependent for mean of 24 +/- 3 days. The procedure was successful and without complications in all patients. Follow-up was 27 months (range 1-42 months) and in-hospital mortality was 77 per cent. The average length of survival for those patients who died in the hospital was 29 days (range, 3-120). Two patients survived the hospitalization after undergoing decannulation on postoperative days 29 and 52, respectively. Despite the poor prognosis after tracheostomy in patients with AIDS this procedure allows better oral care and may improve patient comfort. Bedside percutaneous tracheostomy can be performed with less risk to surgical personnel and patient when compared to conventional surgery. This minimally invasive procedure safely and efficiently provides prolonged tracheal access in patients with AIDS.     

Large-volume liposuction and extensive abdominoplasty: a feasible alternative for improving body shape

Forty-two female patients underwent liposuction of large volumes and extensive abdominoplasty during an 18-month period, with an average follow-up period of 9 months. Fifty-two percent of the patients underwent a third surgical procedure, which was basically aesthetic. The average age was 40 years; weight varied between 51 kg and 113 kg, with only 11 percent of the patients at their ideal weight. The tumescent technique was used for performing liposuction, which was done on the loins, trochanters, lumbar, upper scapular, and upper lateral abdominal regions, avoiding liposuction of the abdominal flap in all cases except for one. The abdominoplasty was extensive with detachment to the xiphoid process without detaching liposuctioned areas. Volumes of 1600 ml to 11,200 ml were obtained through liposuction, with an average of 4230 cc, and minimal blood loss. Fatty dermal tissue was removed through abdominoplasty and it varied between 400 g and 5000 g with an average of 1300 g. Only the two heaviest patients required an autologous blood unit, because they underwent breast reduction at the same time. All the other patients were managed exclusively with intravenous crystalloids solutions. No major complications arose, and only five patients had minor complications. Based on these results, we consider it to be feasible to combine the liposuctioning of large volumes with abdominoplasty to improve body shape, even with the addition of a third surgical procedure. Nevertheless, it is essential to use the tumescent technique for liposuction to reduce bleeding to a minimum and to allow us to perform other procedures.     

Complications associated with pectoral cardioverter-defibrillator implantation: comparison of subcutaneous and submuscular approaches. Worldwide Jewel Investigators

OBJECTIVES: The aim of this study was to compare complications in a large cohort of patients undergoing pectoral cardioverter-defibrillator implantation with a subcutaneous or submuscular approach. BACKGROUND: Pectoral placement of implantable cardioverter-defibrillator (ICD) pulse generators is now routine because of downsizing of these devices. subcutaneous implantation has been advocated by some because it is a simple surgical procedure comparable to pacemaker insertion. Others have favored submuscular insertion to avoid wound complications. These surgical approaches have not been compared previously. METHODS: The subjects for this study were 1,000 consecutive patients receiving a Medtronic Jewel ICD at 93 centers worldwide. Cumulative follow-up for all patients was 633.7 patient-years, with 64.9% of patients followed up for > or = 6 months. The complications evaluated were erosion, pocket hematoma, seroma, wound infection, dehiscence, device migration, lead fracture and dislodgment. RESULTS: Subcutaneous implantation was performed in 604 patients and submuscular implantation in the remaining 396. The median procedural times were shorter for subcutaneous implantation (p = 0.014). In addition, the cumulative percentage of patients free from erosion was greater for subcutaneous implantations (p = 0.03, 100% vs. 99.1% at 6 months). However, lead dislodgment was more common with subcutaneous implantations (p = 0.019, 2.3% vs. 0.5% at 6 months) and occurred primarily during the first month postoperatively. Overall, there were no significant differences in cumulative freedom from complications between groups (4.1% vs. 2.5%, p = 0.1836). CONCLUSIONS: Subcutaneous pectoral implantation of this ICD can be performed safely and has a low complication rate. This approach requires a simple surgical procedure and, compared with the submuscular approach, is associated with shorter procedure times and comparable overall complication rates. However, early follow-up is important in view of the increased lead dislodgment rate.     

Transthoraco-phrenic esophageal transection with paraesophago-gastric devascularization and splenectomy using a stapler

BACKGROUND/AIMS: Surgery remains the most reliable treatment for bleeding esophageal varices. The aim of this study was to introduce the operative technique of transthoraco-phrenic esophageal transection with paraesophagogastric devascularization using a stapler and to evaluate surgical results. METHODS: Forty-five patients underwent the procedure; an elective procedure was performed in 22 patients (bleeders) and a prophylactic procedure in 23 patients (nonbleeders). Twenty-nine patients were classified as Child's A, 15 as B and 1 as C. Previous sclerotherapy had been performed in 5 patients. RESULTS: No hospital deaths occurred. No patients developed postoperative anastomotic leakage, encephalopathy, or any complications related to phrenicotomy. Three patients bled postoperatively from recurrent esophageal varices. Cumulative 5-year bleeding rates were 5.0% in bleeders and 6.6% in non-bleeders. Two patients died due to bleeding varices. Cumulative 5-year survival rates were 72.1% and 78.8% in patients classified as Child's A and Child's B, respectively. CONCLUSIONS: This procedure may be indicated for a majority of Child's A or B patients. Although the advantages of this procedure must be evaluated further, it may be an alternative when injection sclerotherapy and endoscopic ligation fail.     

Technical considerations for partial left ventriculectomy (Batista operation)

The surgical technique for partial left ventriculectomy (Batista operation) as performed in two surgical centers is described. This surgical remodeling of the left ventricle restores the abnormal geometric configuration produced by the dilated failing heart. It accomplishes a reduction of the left ventricular end-diastolic diameter and end-diastolic volume with consequent increase in left ventricular function. This procedure represents the newest surgical approach in the management of patients with end-stage cardiomyopathy; it can be used as a bridge to transplantation or perhaps as a definitive form of therapy, particularly in those patients in whom heart transplantation is contraindicated. This report describes technical guidelines to avoid serious intraoperative and postoperative complications directly associated with this technique.     

An analysis of radiating pain at lumbar discography

Internal illiac and ovarian artery ligation was performed in 7 patients as a life saving measure (group I) and in 12 patients as a prophylactic procedure (group II) in 116 pelvic operations for gynaecological malignancy. The author presents own surgical technique for internal iliac and ovarian arteries ligation. The purpose of analysis was to identify a surgical complications after the ligation in the study groups. Surgical complications in the group of prophylactic ligation were statistically significant low. It is advisable to adopt this procedure as a routine in all difficult pelvic operations, particularly radical operations for gynaecological malignancy.     

Patient rights, provider rights: balancing the conflict

Laparoscopic cholecystectomy is a minimally invasive and highly effective technique for gallstone disease. The authors report their experience of laparoscopic cholecystectomy. Between September 1992 and December 1994 we performed laparoscopic operations on 212 patients with gallstone disease. Our series included 149 female and 63 male patients; 29 patients was converted intraoperatively to the open procedure. Laparoscopic cholecystectomy is the best surgical approach for the treatment of cholelithiasis: it reduces postoperative pain and hospital stay, has cosmetical and financial benefits.