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The preoperative and perioperative evaluation of diabetic foot pathologies has been discussed. The effects of vascular and neuropathic alterations in such cases can be devastating. Only through understanding of the underlying mechanisms that contribute to the diabetic foot can progressive, appropriate care be rendered.
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OBJECTIVES: To evaluate the result of pars plana vitrectomy (PPV) and prophylactic broad encirling scleral buckle in posterior segment trauma and to define factors that lead to functional failure. DESIGN: Retrospective, noncomparative, interventional case series. INTERVENTION: Prophylactic broad encircling scleral buckle, PPV, SF6/C3F8 or silicone oil implantation if required. RESULTS: Ninety-two patients (94 eyes) with open globe ocular injuries involving posterior segment, were treated between January 1988 and December 2004. The mean age was 33.1 years Common sources of injuries were industrial and automobile accidents. After a follow up period of at least 6 months, 62 of 94 eyes (65.96%) achieved visual acuity of 20/400 or better and 6 eyes (6.38%) lost vision to no light perception. Eyes that had sharp perforating injuries with retained IOFB had better visual outcome than the others. Twenty-three of 38 eyes (60.53%) that had sharp perforating injuries with retained IOFBs achieved a visual acuity of 20/70 or better Eyes with traumatic retinal detachment had a reattachment rate of 78.18% and a functional success rate of 56.36%. The detachment rate in vitrectomized eyes with prophylactic broad encircling scleral buckle was 3.19 %. Main reasons for functional failure (V.A. <20/400) were macular damage, retinal detachment with PVR and optic nerve injury. Endophthalmitis occurred in 6.25%. CONCLUSION: Sharp perforating ocular injuries have the best visual prognosis among all types of injuries. Pars plana vtrectomy and prophylactic broad encircling scleral buckle, can salvage and prevent subsequent retinal detachment in these severely traumatized eyes.
The combination of vagotomy, of proximal and of total gastrectomy with antireflux-surgery can lead to a characteristic roentgenmorphology of the lower esophagus and the upper stomach. The fundoplication or hemifundoplication may have a tumorlike shape, may open up or may slide down. The knowledge of the preceding operation and of the symptoms allows a correct interpretation of the x-ray findings in most cases.
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Two prophylactic antibiotic regimes were compared in 129 patients who had open heart surgery for mitral and/or aortic valve replacements at Guy's Hospital. The first group were prescribed cephalothin for five days beginning with premedication. The second group were prescribed the combination of cloxacillin and gentamicin for the same time. The incidence of minor infection was low. There was no statistical difference between the two antibiotic regimes. The major infections were due predominantly to Gram negative organisms and difficult to prevent by any prophylactic regime.
The prophylactic value of gentamicin combined with either lincomycin or metronidazole in 52 patients undergoing colorectal surgery was investigated. The results confirmed the value of this practice. In a control group, the sepsis-rate was 48% with 1 death attributable to sepsis, compared with a sepsis-rate of 4% in the treated group. The combination of gentamicin and lincomycin was effective against sepsis but pseudomembranous colitis developed in 2 of the 14 patients treated with this combination of drugs. Lincomycin was discontinued, and when metronidazole was substituted the results were equally good and there were no toxic side-effects.
To analyse the prevalence of (pre) malignant lesions occurring in breast and adnexal tissue at prophylactic surgery in women at hereditary high risk of breast and/or ovarian cancers. Tissue was obtained from 85 women who underwent prophylactic bilateral salpingo-oophorectomy (pBSO) and from 59 women who underwent prophylactic mastectomy (pM). Control tissue samples were obtained from women undergoing breast reduction surgery (N = 99) or adnexal surgery for benign reasons (N = 72). In women with a BRCA1/2 mutation, the prevalence of a (pre) malignant adnexal lesion was 50% (95% CI 26-74) if older than 40 years and 14% (95% CI 0-58) if younger. The prevalences of (pre) malignant breast lesions in women older than 40 years, with and without a BRCA1/2 mutation, were 0% (95% CI 0-16) and 47% (95% CI 21-73), respectively. No association was found between (pre) malignant lesions in breast and adnexal tissue occurring in 28 women who underwent surgery on both organs (R = 0.155, p = 0.432), but the prevalence of lesions was significantly higher in adnexal tissue than in the breast (p = 0.023). Compared to controls, women at hereditary high risk had a higher chance of (pre) malignant lesions in the breast and an even higher chance of such lesions in the adnexal tissue. There was no indication for concomitant presence of such lesions in both organs at the time of prophylactic surgery. The high frequency of (pre) malignant lesions in the adnexal tissue stresses further the importance of pBSO from the age of 40 onwards in women at hereditary high risk.
BACKGROUND: Marfan syndrome is a relatively common heritable disorder of connective tissue that affects numerous organ systems, but the most severe complication is aortic aneurysm and dissection. A variety of medical and surgical approaches are available for managing the cardiovascular complications. Our objective was to compare elective composite graft surgery, elective valve-sparing surgery, and medical management for patients with both Marfan syndrome and thoracic aortic disease on the basis of life expectancy with differing diameters of the aortic root and rate of increase in the aortic root size. METHODS: A Markov decision analysis model was constructed to compare the 2 surgical options with watchful waiting with medical therapy. RESULTS: For our base-case analysis of a 20-year-old patient with Marfan syndrome and thoracic aortic aneurysm, the aortic valve-sparing option was preferred. It extended life expectancy to 73.8 years compared with the medical treatment option (71.4 years) and with the composite graft surgery (72.7 years). Our results show that there is a better outcome for a patient with an aortic root diameter between 3.0 and 3.5 cm with early prophylactic surgery than with deferred or emergency surgery. Medical treatment was preferred when the aortic root diameter was smaller than 3.0 cm. CONCLUSIONS: Although long-term follow-up data are not yet available, it appears that advances in the technique of valve-sparing surgery have made it the preferred option to composite graft, primarily to avoid the complications of anticoagulation. Our study indicates that patients who have an aortic root diameter of larger than 3.0 cm should be considered for prophylactic aortic surgery.
The management of asymptomatic cholelithiasis in patients with diabetes is controversial. We used decision analysis to compare expectant management to prophylactic cholecystectomy in asymptomatic diabetic patients. Relevant probabilities were derived from the literature or expert opinion. Hypothetical cohorts of patients were followed for their lifetimes under each strategy. Expectant management was almost always the superior course. For example, a 30-year-old diabetic man gains an average of 6.1 months of life by choosing expectant management over prophylactic surgery. The superiority of expectant management was invariant to changes in age, sex, and the extent to which major surgical complications affect the future quality of life. Prophylactic cholecystectomy was superior only with extremely high estimates of the likelihood of developing symptomatic disease, the probability of requiring emergency surgery after symptoms develop, and emergency surgical mortality rates. However, no single factor had sufficient impact to alter the optimal decision by itself; the probabilities of several untoward events had to be increased simultaneously to favor prophylactic cholecystectomy. Prophylactic surgery for silent gallstones in diabetic patients does not increase life expectancy or quality of life and may in fact reduce it. This result holds over a wide range of basic assumptions.
Thirteen papers on different aspects of cerebral cavernomas are reviewed; interest in this condition has increased since magnetic resonance imaging (MRI) became widely available. The prevalence of cavernomas is uncertain, but they are the most common of the angiographically occult vascular malformations. Some are isolated occurrences, and some are familial, with a dominant inheritance. Screening with MRI of first-degree relatives is justified. The reported annual risk of haemorrhage varies widely and is probably between 1 and 3%, with a possible increase in risk after a first haemorrhage; the risk may also be higher in deep or brain stem cavernomas. Opinions on when surgery should be offered vary, with prophylactic surgery not usually recommended. After symptomatic haemorrhages, surgery may be more justified for easily accessible lesions. For those that are more difficult to approach safely, especially in the brain stem, operation is not usually recommended unless there has been at least one clinically significant haemorrhage. Epilepsy owing to hemisphere cavernomas can often be successfully managed medically, with surgery reserved for intractable seizures. In children with epilepsy, there is a stronger argument for surgery. Radiosurgery has been used for symptomatic cavernomas that are surgically inaccessible. Strong arguments have been advanced both for and against this treatment, and the risks probably outweigh the benefits. Suggestions for a randomised trial have been made.
BACKGROUND: Women affected with breast cancer who carry a BRCA1 or BRCA2 (BRCA1/2) mutation are at risk of developing contralateral breast cancer. To reduce the risk of contralateral breast cancer, some patients opt for prophylactic surgery of the unaffected breast (contralateral prophylactic mastectomy, CPM) in addition to mastectomy of the affected breast. METHODS: We conducted the present study to determine the predictors and outcomes of CPM in the year following BRCA1/2 genetic counseling and testing. Four hundred and thirty-five women affected with unilateral breast cancer who received positive or uninformative BRCA1/2 genetic test results completed assessments prior to genetic counseling and testing and 1, 6, and 12 months after receipt of results. RESULTS: Prior to testing, 16% had undergone CPM (in conjunction with mastectomy of the affected breast). In the year following testing, 18% with positive test results and 3% with uninformative test results opted for CPM. CPM following testing was associated with a positive genetic test result, younger age at cancer diagnosis [odds ratio (OR) = 0.94], and higher cancer-specific distress at baseline (OR = 3.28). CPM was not associated with distress outcomes at 12 months. CONCLUSIONS: Following a positive test result, 18% of women previously affected with unilateral breast cancer had a CPM. Women affected with breast cancer at a younger age, particularly those with positive genetic test results and higher cancer-specific distress, are more likely to choose CPM than women who receive uninformative test results and who are less distressed and older at diagnosis. CPM does not appear to impact distress outcomes.
The management of women at high risk for breast cancer presents a clinical dilemma to the health-care provider as well as to the woman herself. Current options include surveillance, prophylactic surgery (mastectomy and/or oophorectomy), and/or chemoprevention. Prophylactic mastectomy, including bilateral prophylactic mastectomy in high-risk women or contralateral prophylactic mastectomy in women with primary breast cancer, has been a controversial clinical option. In this review, we address the efficacy of prophylactic mastectomy in reducing the risk of breast cancer in high-risk women, the use of this procedure, surgical complications, and its psychosocial impact. The decision to undergo prophylactic mastectomy is highly personal and must be preceded by an in-depth assessment of the woman's risk of breast cancer, and a thorough discussion of the benefits of the procedure weighed against its potential surgical risks and psychological impact. It is also imperative that the woman be informed of alternative options for management, including chemoprevention, close surveillance, and prophylactic oophorectomy.
To evaluate prophylactic surgery for esophageal varices, a prospective randomized controlled trial was begun in 1980 by the Japanese Research Society for Portal Hypertension. Methods of operation included selective shunts and nonshunting interruption procedures. One hundred and twelve Japanese patients, in whom endoscopic findings suggested risk of bleeding but who had no bleeding episode, were randomly allocated to the operated group of 60 patients or nonoperated group of 52 patients. Nine patients with idiopathic portal hypertension, histologically proven noncirrhotic disease, which all fell in the operated group, were excluded from the study and the remaining 103 patients (51 operated and 52 nonoperated) were analyzed. Long-term follow-up of patients for a median of 49 mo with a maximum of 73 mo showed a total of 11 (22%) deaths, including 2 operative deaths, in the operated group compared with 23 (49%) deaths in the nonoperated group. The cumulative survival rate at 5 yr in the operated group was 72%, which was significantly higher than the 45% of the nonoperated group (p less than 0.05). The cumulative variceal bleeding rate at 5 yr was 7% in the operated group, which was significantly lower than that of the nonoperated group of 46% (p less than 0.001). It was concluded that portal nondecompression surgery was effective in preventing the variceal bleeding and in improving survival.
Gastroduodenal bleeding or perforation following renal transplantation constitute a serious complication with a high lethality. 82 patients with terminal renal insufficiency were grouped in 4 categories with increasing gastroduodenal risk factors. Parameters for judging gastroduodenal risk consisted of gastric acid secretion, history and endoscopic demonstration of acute or chronic ulcer disease. 33 transplant candidates of groups I (hypochlorhydria, no ulcer) and II (normochlorhydria, no ulcer) were treated by medical prophylaxis alone. 23/33 were transplanted without prophylactic surgery, 1 patient in group II with erosive duodenitis before transplantation died from bleeding duodenal ulcer. Patients of group III (hyperchlorhydria up to 40 mval/h, MAO, no ulcer) received selective proximal vagomty, patients of group IV (hyperchlorhydria, 40 mval/h MAO and/or ulcer) underwent selective gastric vagotomy and 50% gastric resection. In 25 of 49 patients of group III and IV prophylactic operations were performed without serious complications. In 16 later on transplantated patients no gastrointestinal bleeding occurred. 2 patients of group III without gastric operation had minor bleedings out of erosive lesions in the gastric antrum and duodenal bulb, that could be managed by medical treatment. The positive experience with prophylactic gastric surgery in this limited number of patients seems to advocate a broader application of such a protocol. A considerable rise in gastric secretion was demonstrated in 19/21 patients during the first 3 years following the commencement of dialysis, BAO rose by an average of 72,2%, MAO by 41%. Thus, gastric analysis should be repeated once a year. Erosive gastritis and duodenitis seem to predispose for bleeding episodes after renal transplantation, this diagnosis should prompt prophylactic SPV.
OBJECTIVES/HYPOTHESIS: The role of prophylactic antibiotics in otologic surgery continues to be debated and perhaps misused. Prior studies have provided conflicting evidence with regard to the benefit obtained from the use of prophylactic antibiotics in surgery for chronic otitis media. The current study was designed to evaluate the role of prophylactic antibiotics in the outcomes of surgery for chronic ear disease. It was the authors' impression that there was no indication for prophylactic antibiotics in such surgery. STUDY DESIGN: Randomized prospective study performed in a tertiary care facility. METHODS: Patients who met inclusion criteria (n = 146) were randomly assigned to an antibiotic treatment group or a control group receiving no prophylactic antibiotics. Patients in the antibiotic treatment group were given preoperative intravenous antibiotics followed by oral antibiotics for 5 days after surgery. Patients were followed postoperatively and observed for clinical evidence of infection and graft failure. RESULTS: There was no statistically significant difference between the two groups with regard to the incidence of postoperative infection or graft survival. CONCLUSIONS: The use of prophylactic antibiotics in surgery for chronic ear disease cannot be recommended based on the findings of this study.
In a retrospective study of 468 patients treated with renal transplantation in Gothenburg from 1965 to 1974, gastro-duodenal perforations and/or significant bleedings were seen in a frequency of 10%. While half of these complications were seen in patients without previous history of gastro-duodenal disorder, positive history of such disorder increases the risk of post-transplant complications significantly. These complications have proved to be highly lethal, expecially when occurring early after transplantation, whereas prophylactic surgery in predisposed patients has been well tolerated by the uremic patient and followed by decreased frequency of post-transplant gastro-duodenal complications. It is concluded that gastro-duodenal complications remain a major hazard to transplanted paitents, especially with a previous history of gastro-duodenal ulcer. This increased risk can be abolished by prophylactic gastric surgery on wide indications before transplantation.