Postoperative analgesia reduces mortality and morbidity after esophagectomy

INTRODUCTION: Recently, a visually driven neck reflex was identified as causing head tilt toward the horizon during VMC flight. If this is the case, then pilots orient about a fixed rather than moving horizon, implying current attitude instruments inaccurately present spatial information. The purpose of this study was to determine if the opto-kinetic cervical neck reflex has an effect dependent on passive (autopilot) or active control of the aircraft. Further, findings could help determine if the opto-kinetic cervical reflex is characteristic of other flight crewmembers. METHODS: There were 16 military pilots who flew two 13-min VMC low-level routes in a large dome flight simulator. Head position in relation to aircraft bank angle was recorded by a head tracker device. During one low-level route, the pilot had a supervisory role as the autopilot flew the aircraft (passive). The other route was flow manually by the pilot (active). RESULTS: Pilots consistently tilted the head to maintain alignment with the horizon. Similar head tilt angles were found in both the active and passive flight phases. However, head tilt had a faster onset rate in the passive condition. CONCLUSION: Results indicate the opto-kinetic cervical reflex affects pilots while actively flying or in a supervisory role as the autopilot flies. The consistent head tilt angles in both conditions should be considered in attitude indicator, HUD, and HMD designs. Further, results seem to indicate that non-pilot flight crewmembers are affected by the opto-kinetic cervical reflex which should be considered in spatial disorientation and airsickness discussions.     

Abnormal left ventricular filling after neonatal repair of congenital heart disease: association with increased mortality and morbidity

BACKGROUND: The presence of mid-diastolic flow reversal on the mitral valve Doppler inflow indicates abnormal left ventricular filling. To determine whether mid-diastolic flow reversal predicts outcome in patients undergoing repair or palliation of neonatal congenital heart disease, we reviewed the echocardiograms and medical records of 40 patients with either left ventricular outflow obstruction or transposition of the great arteries. METHODS: All patients underwent surgical repair; transposition of the great arteries (TGA) = 17, coarctation of the aorta (CoA) = 14, interrupted aortic arch (IAA) = 8, and aortic stenosis (AS) = 1. The presence of mid-diastolic flow reversal was determined by pulsed Doppler interrogation of the mitral valve on preoperative and postoperative echocardiograms. RESULTS: Preoperative echocardiograms showed diastolic flow reversal in only 5 patients; 1 of 1 with AS and 4 of 14 with CoA. Twenty-one of 40 patients showed postoperative diastolic flow reversal; 1 of 1 with AS, 8 of 8 with IAA, 1 of 14 with CoA, and 11 of 17 with TGA. Postoperative mid-diastolic flow reversal 1 to 3 days after surgery was associated with higher mortality rate: 7 of 21 patients with diastolic flow reversal and 0 of 19 without diastolic flow reversal died. Patients with diastolic flow reversal who survived had longer intensive care unit (26.2 +/- 13.5 days vs 7.1 +/- 4.1 days, P <.001) and hospital (57.4 +/- 38.8 days vs 14.8 +/- 5.2 days, P <.05) stays. CONCLUSION: Mid-diastolic flow reversal is an indicator of prolonged hospital stay and mortality in patients with left ventricular outflow tract obstruction or TGA.     

Maternal morbidity and mortality related to delivery

OBJECTIVES: To describe the patterns of growth, nutritional status, body composition, and resting energy expenditure (REE) in prepubertal children with Alagille syndrome (AGS) before the onset of end-stage liver disease. STUDY DESIGN: Thirteen prepubertal subjects with AGS (8 male; mean age, 6.8 2.8 years) were evaluated for growth parameters, body composition by skinfolds and by dual-energy x-ray absorptiometry, and REE by indirect calorimetry. The children with AGS were compared with a healthy, age-matched reference group of 37 prepubertal children. RESULTS: Compared with healthy children, children with AGS had significantly reduced (P <. 05) growth (weight, weight z score, height, height z score), nutritional status (midarm circumference, triceps skinfold, and midarm muscle area), and body composition (fat mass and fat-free mass). Subscapular thickness, percent body fat, and REE were not different. The AGS subgroup (n = 4) with REE greater than 110% predicted value had a reduced percent body fat (P <.02). CONCLUSIONS: Growth and body composition abnormalities are common in prepubertal children with AGS.     

Contralateral pneumothorax after lung resection

Nine hundred and seventy-three consecutive patients were referred to our hospital for thoracotomy to treat chest diseases between January 1, 1981, and December 31, 1995. Of these patients, 20 males were readmitted within a mean of 20 months with a diagnosis of contralateral pneumothorax. Sixteen of the patients with a mean age of 28.5 years (range 16-76 years of age) had been operated on for bullous lung disease. The remaining four, with a mean age of 60.8 years (range 54-71), had been operated on for lung cancer. All of the 20 patients had received unilateral thoracotomy for lung resection. One patient had undergone pneumonectomy for lung cancer; three had undergone lobectomy; and 16 had been treated by partial lung resection. The patient who had undergone pneumonectomy was found to have contralateral pulmonary metastasis of lung cancer. In the other 19 patients, emphysematous bulla was the origin of the contralateral pneumothorax. The mean value of body mass index (BMI) of the group was 18.4 as compared to 21.7 in the patients who did not go on to develop contralateral pneumothorax, a significant difference (p < 0.05). In conclusion, postoperative contralateral pneumothorax was correlated to the existence of emphysematous changes of the lung and a significantly lower BMI. We conclude that patients with BMIs less than 20 may be at increased risk of developing postoperative contralateral pneumothorax.     

Female sex is associated with increased mortality and morbidity early, but not late, after coronary artery bypass grafting

OBJECTIVE: To describe mortality and morbidity during a period of 2 years after coronary artery bypass grafting in relation to gender. DESIGN: Prospective follow-up study. SETTING: Two regional cardiothoracic centres which performed all the coronary artery bypass operations in western Sweden at the time. SUBJECTS: A total of 2129 (1727 (81%) men and 402 (19%) women) consecutive patients undergoing coronary artery bypass surgery between June 1988 and June 1991 without concomitant procedures. RESULTS: Females were older and more frequently had a history of hypertension, diabetes mellitus, congestive heart failure, renal dysfunction and obesity. In a multivariate analysis, taking account of age, history of cardiovascular diseases and renal dysfunction, female sex appeared as a significant independent predictor of mortality during the 30 days after coronary artery bypass grafting (P < 0.05), but not thereafter. Various postoperative complications including neurological deficit, hydro- and pneumo-thorax, perioperative myocardial damage and the need for assist devices and prolonged reperfusion were more common in females than males. CONCLUSION: Females run an increased risk of early death and the development of postoperative complications after coronary artery bypass surgery as compared with males. Late mortality does not appear to be influenced by gender and the long-term benefit of the coronary artery bypass graft operation is similar in men and women.     

Diabetes mellitus and morbidity and mortality risks after coronary artery bypass surgery

Of 1025 patients (912 men, 113 women) who underwent coronary artery bypass grafting and were followed up for a mean of 7.4 years, 45 (4.4%) had diabetes mellitus. Norwegian population is 1.8-2%). Early mortality was not significantly greater among diabetics than in non-diabetics (2.2 vs. 3.1%, odds ratio--OR-0.44, confidence interval--CI- 0.05-3.56). Diabetic patients had no increased risk of perioperative myocardial infarction (OR = 0.87, CI 0.36-2.10) or of low-output syndrome necessitating intraortic balloon pumping (OR = 0.42, CI 0.55-3.05), and no excess incidence of late non-fatal myocardial infarction (relative risk = 0.69, CI 0.10-1.28) or late chronic heart failure (OR = 2.50, CI 0.5-11.0). Long-term mortality was increased in the diabetic patients (relative risk 1.87, CI 1.60-2.14). Thus diabetes did not entail heightened risk of early mortality, perioperative myocardial infarction or low-output syndrome. Nor was there excess risk of recurrent angina pectoris, late non-fatal myocardial infarction or chronic heart failure among the diabetic patients, but the late mortality risk was increased.     

Improved early morbidity and mortality after Fontan operation: the Mayo Clinic experience, 1987 to 1992

OBJECTIVES: This study sought to evaluate changes in early morbidity and mortality as well as predictors of outcome in our most recent 339 patients undergoing modified Fontan operations. BACKGROUND: The Fontan operation is the preferred definitive palliation for patients with functional single ventricles. Previously reported early mortality rates after Fontan operation have been substantial. METHODS: Records of 339 consecutive patients who had a Fontan operation at the Mayo Clinic between 1987 and 1992 (recent cohort) were reviewed. This cohort was compared with the previous 500 patients who had Fontan operations performed between 1973 and 1986 (early cohort). RESULTS: Recently, overall early mortality after Fontan has decreased significantly compared with that for the early cohort (from 16% to 9%, p = 0.002). This decline occurred despite increased anatomic complexity of patients. Short-term posthospital survival has also improved significantly in recent patients. One-year survival improved to 88% from 79%, and 5-year survival to 81% from 73% (p = 0.006). Patients with common atrioventricular valves and those who took daily preoperative diuretic medication or had either postoperative renal failure or elevated postbypass right atrial pressure were at increased risk for early mortality. Young age was not found to be a risk factor for early mortality. Early mortality for patients with heterotaxia decreased dramatically: recent 30-day mortality was 15% compared with 41% in the early heterotaxy cohort. CONCLUSIONS: Many factors may have contributed to decreased early mortality after Fontan. Improved patient selection, younger age at time of operation, refinements in surgical techniques and postoperative management may all have had important roles. Proposed technical modifications of the Fontan operation must be evaluated in light of these improved results.     

Physiotherapy after lung resection (author's transl)

Physiotherapy for lung resection begins well before the operation and should serve to improve the respiratory function and to prevent complications. The whole training programme should be carried out in an automated manner, this is especially important for the time immediately after the operation. Postoperative physiotherapy aimsat thorough cleaning of the bronchi, adaption of the ventilation, good peripheral circulation and helps to diminish would pain. In a later period physiotherapy should help to rehabilitate the patient's external respiratory function to train the respiratory stereotype and to improve cardiopulmonary effiency.     

Inability to work after surgical removal of mandibular third molars

This series presents six cases of a rare variant of dermatofibroma, characterized by marked clear cell change. All lesions occurred on the lower extremities of middle-aged adults (four women, two men), mostly with the clinical diagnosis of fibrohistiocytic lesion. Histological examination revealed well circumscribed, faintly stained dermal to subcutaneous lesions which were due to the overwhelming presence of clear cells (> 90%), some with prominent PAS-positive cytoplasmic granulation. Overlying epidermal hyperplasia as well as storiform arrangement of spindle cells, sclerotic collagen and some interspersed lympho-histiocytic infiltrate at the periphery of the lesion indicated the fibrohistiocytic origin. Individual histopathological peculiarities included: bizarre giant cells in two cases, perifollicular arrangement and haemangiopericytoma-like features with iron deposition in one case each. Immunohistochemically three of four lesions showed moderate reactivity for factor XIIIa and two of four with an anti-metallothionen marker E9, but were otherwise negative with a broad panel of markers. Electronmicroscopy in two cases revealed large pools of glycogen beside focal, prominent endoplasmic reticulum and lysosomes in some granular cells, but only optically translucent cells in cases of clear cells. Recognition of clear cell dermatofibroma is important as the differential diagnosis includes some entities with more serious outcome/considerations such as metastases of renal cell carcinoma, xanthogranulomatous reactions, balloon cell naevus/melanoma and clear cell sarcoma.     

The incidence, morbidity, and mortality of surgical procedures after orthotopic heart transplantation

OBJECTIVE: The authors present their experience with patients having undergone orthotopic heart transplantation (OHT) in whom surgical conditions subsequently developed that required operative intervention. The incidence, morbidity, and mortality of these procedures are reported. SUMMARY BACKGROUND DATA: Several studies have evaluated the management options of biliary tract disease after OHT. Multiple reports of patients having undergone OHT who subsequently underwent peripheral vascular reconstructions, plastic reconstructive, and thoracic procedures also have been published. METHODS: A chart review of 349 patients who underwent OHT between 1985 and 1996 was conducted to identify surgical procedures that were required in the post-transplant period. Their outcomes are reported. RESULTS: Of 349 patients who underwent OHT, conditions requiring 94 surgical procedures developed in 54 patients (15%). Biliary tract disease developed in 17 patients (5%) who required cholecystectomy, 2 of the 5 patients with acute cholecystitis died. Eight patients (2%) underwent orthopedic procedures with no operative mortality. Flap advancements for sternal wound infections were performed in five patients and four deaths occurred. Seventeen thoracic procedures were performed in 11 patients with an overall mortality of 45%. Twenty-one vascular procedures were performed on 17 patients with 1 delayed death due to a malignancy. Seven patients underwent procedures of the colon and rectum with no mortality. Seven patients underwent repair of inguinal or incisional hernias with no mortality. Various infections occurred with one resultant death after operative intervention. Six procedures were performed for diseases of the small intestine with no resultant mortalities. CONCLUSIONS: Patients having undergone OHT and chronic immunosuppression are at increased risk of having complications develop from infection. Acute cholecystitis and sternal wound infection caused an inordinate risk of complications and death. Malignancies developed in four patients who required surgical intervention. A heightened awareness of coexisting peripheral vascular disease in patients transplanted for ischemic cardiomyopathy should exist. Close screening before surgery and surveillance after surgery to identify risk factors for infection and vascular disease and to screen for malignancies are essential.     

Neonatal morbidity and mortality associated with triplet pregnancy

OBJECTIVE: To compare neonatal morbidity and mortality in a large cohort of triplet pregnancies with singleton and twin neonates managed at a single tertiary center over a short time. METHODS: Records from all triplet pregnancies managed and delivered from 1992 to 1996 were reviewed for neonatal outcome data. Pregnancies delivered before 20 weeks' gestation and neonates with lethal congenital anomalies were excluded. The comparison group comprised all singleton and twin neonates managed in the same neonatal intensive care unit (NICU) during the same period. RESULTS: During the 5-year period, 55 triplet pregnancies and their resulting 165 neonates were managed and delivered at this center. Their outcomes were compared with those of 959 singleton and 357 twin neonates born at similar gestational ages. The median gestational age at delivery for triplets was 32.1 weeks, and 149 of the 165 infants were admitted. Sixteen triplet neonates were not admitted to our neonatal intensive care unit, 12 because of previable gestational age, three because of stillbirth, and one because of a lethal congenital anomaly. The crude perinatal mortality rate in triplets was 121 per 1000 births, and there was no significant difference in outcome based on triplet birth order. There were no significant differences in survival rates between singleton, twin, and triplet neonates, with an overall neonatal survival of 95%, 95%, and 97%, respectively. The only significant differences in morbidity were an increased incidence of mild intraventricular hemorrhage (relative risk [RR] 6.20; 95% confidence interval [CI] 2.64, 14.61), mild retinopathy of prematurity (RR 20.05; 95% CI 3.59, 111.79), and severe retinopathy of prematurity (RR 46.69; 95% CI 6.25, 348.85) in triplets compared with singletons, and severe retinopathy of prematurity (RR 6.83; 95% CI 1.24, 37.56) in triplets compared with twins. CONCLUSION: When stratified by gestational age, triplet neonates delivered at 24-34 weeks' gestation have similar outcomes as singleton and twin neonates, with the only clinically significant difference being an increased incidence of retinopathy of prematurity in triplets.     

Estimation of AIDS morbidity and mortality in Spain

BACKGROUND: To obtain corrected estimates of the cumulative incidence and mortality, as well as prevalence of AIDS in Spain on June 1992. METHODS: The number of cases in the National Register of AIDS by December 1992 was adjusted for reporting delays to estimate the cumulative incidence by June 1992. The prevalence and mortality in this date were obtained using this figure and the probabilities of survival after diagnosis from the AIDS Register of Madrid. This methodology was used for Spain as all, and for each Autonomous Community. RESULTS: The estimated cumulative incidence of AIDS in Spain by June 1992 was 16,486 cases, 13.4% greater than that reported by the same date. The prevalent cases were 6,351 (95% CI, 5,996-6,708) and the remaining 10,135 (61.5%) would have died. This number of deaths is 69.6% greater than the reported figure. There were considerable differences among Autonomous Communities. Some of them exhibited rates more than six times greater than others. CONCLUSIONS: The adjusted estimations provide a view of the actual situation more accurate than the raw figures from the register. These great differences should be taken into account for appropriate allocation of health care resources.     

Perioperative morbidity and mortality of high-dose-rate gynecologic brachytherapy

PURPOSE: To determine the 30-day morbidity and mortality rates for patients with an intact uterus undergoing high-dose-rate (HDR) brachytherapy, and to assess risk factors which may predict for these potentially life-threatening complications. METHODS AND MATERIALS: From August 1989 to December 1994, 128 cervical and 41 medically inoperable endometrial cancer patients were treated with 5 outpatient weekly HDR brachytherapy insertions. Patients with cervical cancer also were treated with external beam radiotherapy. Acute events that resulted in either hospitalization (morbidity) or death (mortality) within 30 days of the implant were analyzed. Univariate and multivariate analyses were performed to identify risk factors. RESULTS: Overall there were 16 acute events in 169 patients (9.5%). The overall morbidity and mortality rates for the cervical and endometrial patients were 5.5%, 1.6%, 7.3%, and 9.8%, respectively. The following factors were significant by univariate analysis: age per decade, American Society of Anesthesiologists (ASA) score, Karnofsky Performance Status (KPS), significant medical history, diagnosis of cervical vs. endometrial cancer, and mean time exceeding 160 minutes for the procedure. Since age was the most significant predictive factor (p = 0.0003), bivariate analyses were performed by adjusting for age. In these analyses only ASA and KPS maintained significance, while a positive medical history was of borderline significance (p = 0.07). CONCLUSION: The morbidity and mortality rates observed in gynecologic patients selected for HDR brachytherapy were similar to low-dose-rate, but higher than other HDR reports. Reasons for this include a higher risk population, especially those with medically inoperable endometrial cancer. In the cervical cancer patients, some of the complications may have also been a result of the external beam portion of the radiation. In order to minimize the acute complications observed in the present HDR brachytherapy system, the following changes have been implemented: appropriate patient selection, anesthesiology involvement to monitor conscious sedation for high-risk patients, external beam radiotherapy alone in patients at extremely high risk, deep vein thrombosis (DVT) prophylaxis, use of intraoperative ultrasound, shorter duration in the brachytherapy suite, and preradiation treatment plans (plans executed prior to the insertion) if applicable. Finally, this analysis suggests that these procedures should be performed in a hospital-based setting where appropriate support is available.