Transurethral resection in patients with cardiac pacemakers (author''s transl)

Problems of transurethral resection in patients with cardiac pacemakers are discussed. Various complications caused by interference of cutting and coagulating currents with the pacemaker system and their possible prevention are pointed out. It is concluded that transurethral resection by cold punch technique has significant advantages over electroresection in patients with a cardiac pacemaker.     

Changes in right ventricular hemodynamic function by unilateral pulmonary arterial occlusion test

We performed unilateral pulmonary arterial occlusion test (UPAO) for the preoperative evaluation of lung function in patients undergoing lung resection. In this test, the main pulmonary artery of either side is occluded to simulate postoperative functional status. In order to evaluate the right ventricular hemodynamic function, we measured right ventricular ejection fraction (RVEF) and right ventricular end-diastolic volume index (RVEDVI) throughout UPAO by thermodilution method. We investigated the relationships between changes in right ventricular hemodynamic function and postoperative complications related to cardiac functions, namely arrhythmias or heart failure. Thirty-four patients without heart disease prior to lung resection were examined by UPAO, and RVEF and RVEDVI were measured. Analyses demonstrated that changes in RVEF were inversely correlated with changes in RVEDVI. In 6 cases, RVEDVI increased from control by over 20% during UPAO. All of these patients had postoperative cardiac complications. The hypothetical ventricular function curves showed a large increase in RVEDVI relative to right ventricular stroke work index (RVSWI), suggesting a decrease in right ventricular function. In conclusion, these results suggest that changes in RVEDVI during UPAO may predict postoperative cardiac complications in patients undergoing pulmonary resection.     

Escherichia coli meningitis in a 16-month old infant revealing a posterior fossa epidermoid cyst

Surgical management of patients with simultaneous coexisting malignancy of the digestive organs and an abdominal aortic aneurysm (AAA) remains controversial. In the five patients who underwent the aneurysmectomy first, no complications developed after an aneurysmectomy and a resection of malignancy could be performed within 4 weeks, whereas postoperative complications after the resection of malignancy developed in two of them. Two patients underwent a one-stage operation, in which one was unable to tolerate the two procedures, and no postoperative complications were seen; however, one patient with cardiac dysfunction who first underwent an aneurysmectomy died 3 months after operation due to cardiac and renal failure. These results indicate that the aneurysmectomy first is preferred, when such patients do not have absolute indications of malignancy or AAA; however, a one-stage operation should be chosen when the patients show a disturbance of key organs.     

Rectal submucosal tumor-like lesion originating from intestinal tuberculosis

BACKGROUND: Laparoscopically-assisted resection for large bowel cancer is technically feasible. Sixty-six patients who had resection of the colon or rectum for cancer have been audited prospectively. METHODS: Clinical and pathological data were collected prospectively as part of the ongoing Concord Hospital colorectal cancer project. Patients were followed up for a median of 29 months. RESULTS: In 57 of 66 patients in whom laparoscopic resection was attempted the operation was completed laparoscopically. Three patients died from perioperative myocardial infarction. The median postoperative stay was 14 days. There was a high incidence of postoperative respiratory and cardiac complications. One patient developed a port-site metastasis. CONCLUSION: There was no obvious benefit from laparoscopically-assisted resection of large bowel cancer in these patients.     

Preoperative evaluation of the limitation of hepatic resection using 99mTc-GSA (galactosyl human serum albumin) scintigraphy

Preoperative evaluation of the operative indication of hepatic resection using the parameters obtained by 99mTc-GSA scintigraphy has been done. In particular, the accurate evaluation of the postoperative hepatic functional reserve essentially depends on these parameters. In the present study, a preoperative evaluation of postoperative hepatic functional reserve using 99mTc-GSA scintigraphy was performed in our operated cases retrospectively. PATIENTS AND METHODS: Thirty-eight patients who underwent hepatic resection were studied on 99mTc-GSA scintigraphy before and after operation. These patients were divided into two groups. Group A; had no postoperative complications (n = 31). Group B; had some postoperative complications (n = 7). Preoperative parameters of 99mTc-GSA liver scintigraphy (HH15, LU15) were calculated from the activities of liver and cardiac ROIs at 5 and 15 minutes after injection. The resection ratio (RR) was obtained by comparing the liver volumes which were calculated from the pre- and postoperative SPECT studies. The resectability indices (Res) were as follows: Res (LU15) = LU15 x (100-RR(%)/100, Res (HH15) = (1/HH15) x (100-RR (%)/100. RESULTS: There were statistically significant differences in the distribution of Res between A and B groups (p = 0.002, Mann-Whitney test). The values of Res, of which half of patients have complication, were 1.10 (Res (HH15)) and 16.4 (Res (LU15)). CONCLUSION: The resectability indices using 99mTc-GSA liver scintigraphy are useful for the preoperative evaluation of the limitation of hepatic resection.     

Surgical treatment of colonic diverticulitis: a report of 205 cases

In a series of 205 patients treated for colonic diverticulitis, 101 presented acute complications, 35 chronic complications and 69 attacks of diverticulitis without complications. The treatment prescribed for the acute septic complications (generalized peritonitis, perisigmoidic abscess) as well as for acute occlusions consists of two-stage surgery: drainage and emergency colostomy, then secondary colectomy in elective conditions. Massive incoercible hemorrhages were treated by emergency hemostatic resection, guided by selective mesenteric arteriography. Chronic complications (inflammatory stenosing tumor, external or internal fistulas) are ideally treated by a one-stage colic resection. As postoperative mortality and morbidity rates are high and caused by acute conditions, it is justifiable to perform a prophylactic colic resection.     

Inability to perform bicycle ergometry predicts increased morbidity and mortality after lung resection

The ability to successfully exercise has been used to assess the cardiopulmonary risk of thoracotomy for lung cancer. Because of musculoskeletal, neurologic, peripheral vascular, or behavioral problems, not all patients presenting for pulmonary resection are capable of exercising. Using a multifactorial cardiopulmonary risk index (CPRI) consisting of a cardiac risk index (CRI) and a pulmonary risk index, we studied 74 patients (60 capable of exercising and 14 incapable of exercising) who underwent thoracotomy for lung cancer resection. The groups were similar in reference to history of pulmonary disease, preoperative pulmonary function, and pulmonary risk index score. The no-exercise patients were more likely to have a history of cardiac disease (64 vs 28%; p < 0.01) and had a higher CRI score (2.0 +/- 0.2 vs 1.4 +/- 0.1; p < 0.05). Cardiopulmonary postoperative complications (POCs) and mortality were more likely among those in the no-exercise group vs those in the exercise group (POCs, 79 vs 35%, p < 0.01; mortality, 21 vs 2%, p < 0.05). Among the eight no-exercise patients with a CPRI of 4 or more, all eight suffered a POC (100%) and three died (38%). Using multiple logistic regression analysis, both the CPRI score and the inability to exercise were independently associated with increased risk for POCs. We conclude that patients unable to perform even minimal preoperative exercise are at substantially increased risk for morbidity and mortality after lung resection. This results both from greater identifiable preoperative cardiopulmonary risk factors (as assessed by the CPRI) and from an independent effect related to the inability to exercise.     

Loss of cardiopulmonary function in lung-resection surgery and post-operative complications

The items, mentioned as postoperative complications in lung-resection surgery in the newest reports, are much the same to those in patients undergone general surgery. Dealing with perioperative complications in lung-resection surgery, it must be taken into account that lung resection always results in, more or less, loss of cardiopulmonary function and that most perioperative complications are caused by accidental circumstances. Perioperative risk must be assessed based upon the predicted postoperative cardio-pulmonary function, but not the frequency of perioperative complications. The role of unilateral pulmonary artery occlusion test and exercise test in lung-resection surgery, and their pathophysiological implications are discussed.     

Cervicothoracic tumors: results of resection by the "hemi-clamshell" approach

OBJECTIVES: Our goal was to describe the "hemi-clamshell" approach for the resection of primary and metastatic tumors of the cervicothoracic junction, evaluate its morbidity and mortality, and present survival data on a series of 42 patients who underwent resection with the use of this technique. METHODS: We conducted a retrospective review of the records of all patients of a single surgeon undergoing resection of tumors of the cervicothoracic junction. Data collected includes tumor type and involvement, type of resection, complications, and survival. RESULTS: Forty-two patients underwent resection of various primary (n = 28) and metastatic (n = 14) tumors of the cervicothoracic junction over 6.5 years by means of the hemi-clamshell approach. En bloc resection of the tumor and invaded structures was successful in all but two patients (5%), who required an additional posterolateral thoracotomy to facilitate removal of tumor invading the posterior chest wall. Invaded structures that were resected included lung (n = 22), vertebral body (n = 7), chest wall (n = 8), central veins (n = 10), thyroid (n = 3), carotid artery (n = 1), and cervical esophagus (n = 1). Four major complications occurred in three patients, and nine minor complications occurred in eight patients. There were no deaths. The overall 5-year actuarial survival was 67.4%. CONCLUSIONS: Tumors of the cervicothoracic junction are represented by a variety of histologic types and can be both primary and metastatic. The hemi-clamshell approach is a successful technique for the exposure and resection of these tumors. This approach has significant advantages over other previously reported techniques. The complication rate is low and the mortality rate is zero in this series, the largest yet reported. Long-term survival is acceptable if complete resection can be performed.     

Veterinary dentistry (15). Apex resection in the horse

Periapical disorders in horses can be treated by resection of the apex. The indications, contraindications, diagnosis, treatment and complications of the intervention are discussed. Four case reports of horses in which apicoectomy with retrograde endodontic treatment was performed are reviewed.     

Surgical treatment of coronary artery aneurysm with rupture into the right atrium

Considering the increasing number of patients with chest pain who undergo routine coronary artery arteriography, coronary artery aneurysm may be found more frequently. To know how to manage these aneurysms, we must understand their possible complications. The aneurysms can produce symptoms of angina or acute myocardial infarction by total thrombosis of the aneurysm and vessel, embolism to the distal vessel, or progressive enlargement and encroachment upon the distal vessel until it is occluded. Moreover, the aneurysm may enlarge and rupture into the free pericardium or produce a fistula by eroding into a chamber of the heart. The case described herein may represent the first reported case of a coronary artery aneurysm eroding into a cardiac chamber and causing an arteriovenous fistula. The treatment of choice is resection of the aneurysm, closure of the fistula, and re-establishment of continuity of the distal coronary artery with a saphenous vein bypass graft.     

Testing to predict outcome after transurethral resection of the prostate

PURPOSE: We assessed the ability of routine clinical tests to predict outcome following transurethral resection of the prostate. MATERIALS AND METHODS: A total of 556 men randomized into a trial of surgery versus watchful waiting was evaluated preoperatively with symptom interview, quality of life assessment, uroflowmetry, urinalysis, standard chemistry panel, post-void residual urine determination and cystoscopy. The ability to predict avoidance of postoperative complications, and improvement in quality of life and genitourinary symptoms was assessed in the 249 men randomized to undergo transurethral resection of the prostate. RESULTS: Patients with the highest symptom scores were most likely to have symptom improvement and those most bothered by the symptoms were most likely to have improvement in quality of life. No objective tests measuring physiological parameters made clinically significant contributions toward predicting these outcomes. Lower obstructive symptom scores and larger perioperative infusions of intravenous fluids were associated with a greater chance of complications. CONCLUSIONS: Symptom analysis and quality of life assessment are most useful in selecting patients for transurethral resection of the prostate. Objective diagnostic tests are of limited additional benefit.     

Hereditary persistence of alpha-fetoprotein. Case report and review of the literature

BACKGROUND: The issue of performing simultaneous pulmonary resection and cardiac surgery in patients with coexisting lung carcinoma and ischaemic heart disease remains controversial. We report our experience and review the literature. METHODS: Thirteen patients (male ten, female three; mean age 65 years) underwent simultaneous cardiac surgery and pulmonary resection. Lung pathology consisted of primary lung carcinoma (n = 10), benign disease (n = 2) and carcinoid (n = 1). Lung resections included pneumonectomy (n = 3), lobectomy (n = 4), segmentectomy (n = 1) and local excision (n = 5). Cardiac procedures consisted of coronary artery bypass grafting (CABG) in 11, aortic valve replacement in one and mitral valve repair with CABG in one patient. In all but one case the lung resection was performed prior to heparinization and cardiopulmonary bypass (CPB). In two patients, with suitable coronary anatomy, myocardial revascularization without CPB was performed to reduce morbidity. RESULTS: There was no hospital mortality. Postoperative blood loss and ventilation requirements were reduced in the patients who were operated on without CPB. Prolonged ventilatory support was required in two cases. All patients with benign pathology are alive. In the lung cancer group there have been five late deaths: disseminated metastatic disease (n = 3), anticoagulant related haemorrhage (n = 1) and broncho-pleural fistula (n = 1). Of the remaining five patients four are alive and disease free 7-23 months post-operatively; one patient has recurrent disease 40 months post-operatively. CONCLUSIONS: Simultaneous pulmonary resection and cardiac surgery is associated with acceptable operative morbidity and mortality. In patients with lung carcinoma long-term survival was determined by tumour stage. The avoidance of CPB may be advantageous by decreasing blood loss and ventilation requirements.     

Right ventricular ejection fraction in the preoperative risk evaluation of candidates for pulmonary resection

The major determinants of postoperative morbidity and mortality after lung resection are the physiologic and functional statuses of the pulmonary and cardiac systems. In our previous study, serial measurements of right ventricular performance after pulmonary resection demonstrated significant right ventricular dysfunction in the postoperative period. This study evaluates the preoperative measurement of right ventricular ejection fraction as a predictor of postoperative complications. In addition to conventional cardiopulmonary functional tests, right ventricular function was assessed with a thermodilution technique at rest and during exercise in 18 patients before and 3 weeks after lobectomy or pneumonectomy. The patients were grouped according to severity of right ventricular functional defect: right ventricular ejection fraction of at least 45% (group Ia, n = 8), right ventricular ejection fraction less than 45% (group Ib, n = 10), exercise-induced increases in right ventricular ejection fraction (group IIa, n = 8), and exercise-induced decreases in right ventricular ejection fraction (group IIb, n = 10). Postoperative cardiopulmonary morbidity was recorded for two patients (25%) in group Ia, three patients (30%) in group Ib, no patients (0%) in group IIa, and five patients (50%) in group IIb. Postoperative hospital stay was 28.9 +/- 8.5 days in group Ia, 29.9 +/- 20.2 days in group Ib, 19.4 +/- 8.0 days in group IIa, and 37.5 +/- 15.9 days in group IIb (p < 0.05, group IIa vs group IIb). Although resection-induced changes in forced expiratory volume in 1 second did not differ significantly between group Ia and group Ib, these values appeared to be increased in groups IIa (not statistically significant) and IIb (significantly, p < 0.05). The measured postoperative values of forced expiratory volume in 1 second and vital capacity were significantly higher than the predicted postoperative values (p < 0.05) in group IIa, but not in groups Ia, Ib, and IIb. We conclude that evaluation of right ventricular performance is useful in determining which patients are at increased risk for medical complications after lung resection. Exercise-induced change in right ventricular ejection fraction may be a better indicator of high risk among candidates for pulmonary resection than the absolute value of this parameter.     

Resident mast cells are important for eotaxin-induced eosinophil accumulation in vivo

Cryosurgery may be considered for patients whose hepatic lesions are not amenable to surgical resection, i.e., patients with multiple hepatic lesions and/or lesions abutting major vascular structures. Because the size of the iceball created during the procedure can be carefully controlled, cryosurgery has the advantage of being a focal technique that spares much more noncancerous liver tissue than surgical resection. The major complications of hepatic cryosurgery are the same as those of hepatic resection: hemorrhage, pleural effusion, bile leak fistula, perihepatic abscess, and hepatic failure. In addition, there is a risk of coagulopathy when large tumors are frozen using multiple freeze-thaw cycles. In general, operative morbidity is related to the volume of frozen tissue, the number of freeze-thaw cycles, and number of cryoprobes. Further experience and accrual of long-term data should better define the indications for hepatic cryosurgery and minimize the incidence of complications.     

Angiosarcoma of the liver in children

The clinico-pathological features of four cases of pediatric hepatic angiosarcomas are described. One case was initially diagnosed in infancy and underwent resection of a left-sided benign hemangioendothelioma of the liver. Further resection of a lesion in the right liver was followed by malignant transformation. Primary hepatic resection of the tumor was not possible in three other cases, and all received courses of chemotherapy without significant tumor shrinkage. One child underwent liver transplantation but died 4 months later of immunosuppression complications. The remaining three children died of disseminated malignancy. Histological verification of malignancy was difficult in three cases in which there was discrepancy between the rapid growth of the liver tumor and the microscopic features of benign hemangioendothelioma.     

Therapy of ventricular tachyarrhythmia with implantable cardioverters/defibrillators--mortality and complications using epicardial electrodes

Technical improvements of third generation implantable cardioverter defibrillators (ICD) like antitachycardia pacing modalities lead to an extended use of ICDs, not only in patients with aborted sudden cardiac death, but also in patients with hemodynamically tolerable ventricular tachycardia. In addition, anticipated results of current prospective studies might indicate the prophylactic use of ICDs in patients with high risk for sudden cardiac death, but without documented ventricular tachyarrhythmias. This report reviews mortality and complications associated with the ICDs with epicardial defibrillation leads. Mortality is separated in cardiac death, sudden cardiac, arrhythmogenic "not so sudden" cardiac death, and overall mortality. Pulmonary complications and infections are related to the underlying disease and the surgical procedure. Device- and lead-related complications, high defibrillation thresholds, pacemaker interactions, inappropriate shocks, arrhythmic effects, syncope, and psychosocial problems are reported, respectively.     

Chain elongation in the isoprenoid biosynthetic pathway

PURPOSE: To investigate the associations between specific preoperative 12-lead electrocardiogram (ECG) abnormalities, perioperative ischemia, and postoperative myocardial infarction or cardiac death in major vascular surgery. METHODS: Two prospective studies on perioperative myocardial ischemia performed in two tertiary university hospitals were combined to include 405 patients. All preoperative ECGs were analyzed according to the Sokolow-Lyon criteria for left ventricular hypertrophy by investigators who were blinded to the patients' perioperative clinical course. Perioperative myocardial ischemia was detected by continuous ECG recording, and postoperative cardiac complications included myocardial infarction and cardiac death. RESULTS: A total of 19 postoperative cardiac complications occurred (two cardiac deaths and 17 myocardial infarctions). Voltage criteria for left ventricular hypertrophy (78 patients, 19%) and ST segment depression greater than 0.5 mm (98 patients, 24.2%) on preoperative ECGs were both significantly associated with postoperative myocardial infarction or cardiac death (odds ratio, 4.2 and 4.7; p = 0.001 and 0.0005, respectively) and with longer intraoperative and postoperative myocardial ischemia. In each of the two study groups, a preoperative ECG abnormality that involved voltage criteria, ST segment depression, or both (134 patients, 33.1%) was more predictive of postoperative cardiac complications than any other preoperative clinical variable, including a history of myocardial infarction or angina pectoris, diabetes mellitus, pathologic Q-wave by ECG, or preoperative myocardial ischemia. The combined duration of intraoperative and postoperative ischemia and the preoperative ECG with either voltage criteria or ST segment depression were the only independent factors associated with adverse cardiac events by multivariate analysis (p < or = 0.0001 and p = 0.02, respectively). CONCLUSION: Left ventricular hypertrophy and ST segment depression on preoperative 12-lead ECGs are important markers of increased risk for myocardial infarction or cardiac death after major vascular surgery.     

Adverse effects of calcium binding contrast agents in diagnostic cardiac angiography. A comparison between formulations with and without calcium binding additives

RATIONALE AND OBJECTIVES: The authors compared complications and hemodynamic and electrophysiologic effects of two formulations of diatrizoate, one with additives that bind calcium and one without, in diagnostic cardiac angiography. METHODS: Two hundred twenty-three consecutive low-risk patients alternately received Hypaque 76 (group 1, little calcium binding effect), and MD 76 (group 2, significant calcium binding). Electrocardiographic and hemodynamic changes related to coronary angiography and left ventriculography were measured, and complications requiring treatment were recorded. RESULTS: There were more complications in patients in group 2 than in group 1 (18 versus 8, P = 0.04). Arterial pressure fell more, the QT interval increased more, and the heart rate fell more in group 2 after coronary angiography. CONCLUSIONS: Formulations of diatrizoate that minimize calcium binding are advocated for cardiac angiography when using high osmolality contrast media. The more detrimental effects that calcium binding has on myocardial function and cardiac conduction may lead to the higher incidence of complications.     

Gastrointestinal complications after cardiac surgery

OBJECTIVE: Gastrointestinal (GI) complications after cardiac surgery with cardiopulmonary bypass (CPB) are uncommon complications with significant morbidity and mortality rates. METHODS: From 1988 to 1995, 36 GI complications were identified in 3158 patients who underwent cardiac surgery (1.14% incidence). The mortality rate was 13.9%. Complications included hemorrhage in the GI tract in 22, perforated ulcer in 3, acute cholecystitis in 3, pancreatitis in 2, mesenteric ischemia in 3, diverticulitis in 1 and liver failure in 2 patients. RESULTS: Clinical risk factors included advanced age, combined coronary artery bypass grafting (CABG)-valve operation, postoperative low cardiac output (LCO), prolonged ventilation time, re-exploration of the chest, sternal infection and a positive history of peptic ulcer. Patients with a prolonged pump time had an increased risk of GI complications (P < 0.001). CONCLUSIONS: Gastrointestinal complications, although of low incidence, carry a significantly high mortality, and the clinician must be alert to institute early appropriate treatment.