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PubMed2000

Spinal lipomas in children.

Spinal cord lipomas are a common cause of cord tethering that can lead to progressive neurological defects. The role of prophylactic surgery for spinal lipomas has recently been questioned. Between 1985 and 1999, 59 children underwent a total of 69 surgical procedures at the Birmingham Children's Hospital in Birmingham, UK. The spinal lipomas were classified into: 18 terminal, 17 transitional, 6 dorsal and 18 filum lipomas - including 12 who had a typical thickened filum terminale. At the first operation, 19 patients (32%) were asymptomatic, and 40 patients (68%) presented with symptoms. Surgical indications in the asymptomatic group included the presence of a dermal sinus tract or syrinx. Prophylactic surgery was undertaken in selected cases. The mean total follow-up for the group since the first surgical procedure was 61.8 months (range: 7.0-203.0 months). In the asymptomatic group, 26% of the patients had late neurological deterioration. Of the 14 patients with asymptomatic conus lipomas, 3 (21%) developed sphincter dysfunction and motor problems at long-term follow-up. In the symptomatic group, 68% improved, 20% remained unchanged, and 12% had late neurological deterioration. None of the 18 patients with symptomatic filum lipoma deteriorated postoperatively. However, 39% had bladder dysfunction, 54% had neuro-orthopaedic deformity, and only 15% returned to overall normal function at latest follow-up. Of the 27 patients with symptomatic conus lipomas, 67% improved, 15% remained stable, and 18% had late neurological deterioration. However, 74% had bladder dysfunction, 67% had neuro-orthopaedic deformity, and 45% had motor problems at long-term follow-up. Spinal lipomas can cause progressive neurological deficits irrespective of spinal untethering surgery. This study demonstrates that filum and conus lipomas have similar clinical presentation, but differ in their outcome following surgery. Filum lipomas are 'benign', for which surgery is safe and effective. Conus lipomas are more difficult to manage. When asymptomatic, our results suggest that prophylactic surgery does provide some protection from future neurological deterioration. When symptomatic, conus lipoma surgery is effective in stopping further deterioration. Improvement in neurological function can occur, but few patients return to normal overall function, and pre-existing sphincter dysfunction is not significantly altered by surgery.

Adolescent↗
PubMed2000

Efficacy and safety of recombinant factor VIIa in the prophylaxis of bleeding in various surgical procedures in hemophilic patients with factor VIII and factor IX inhibitors.

Patients with hemophilia may develop alloantibodies (inhibitors) directed toward the substitution factor. In the long term, this complication significantly affects around 15% of hemophilia A patients and 2-5% of hemophilia B patients suffering the severe class of disease (critical functional factor level <0.01 IU/mL). The typical consequence of a newly developed inhibitor is that the patient can no longer take advantage of the principles of modern hemophilia management, including safe and early treatment of bleeding and prophylactic use of concentrate in prevention of bleeding. Moreover, problems that are normally solved by means of a surgical procedure covered by the usual concentrate will be regarded as difficult and are likely to be associated with risk of untoward bleeding if high-titer inhibitors are present. Over the past decade, considerable experience has been collected illustrating that surgery may be performed quite safely in the patient with inhibitors if hemostasis is assisted by a new hemostatic agent, an activated recombinant factor VII molecule (rFVIIa). Although only one controlled randomized surgical study has been presented, cumulated data from this and from other, less formal studies on the use of rFVIIa in hemophilic inhibitor surgery have illustrated that a vast variety of different surgical procedures can be accomplished with none of the life-threatening bleeding complications that would be anticipated if no hemostatic treatment was administered. The aim of the present review is to present a multiplicity of surgical procedures that have been carried out during the clinical development of rFVIIa. Further, an update of 21 surgical procedures in inhibitor patients from the center of the author will be reviewed and discussed.

Autoantibodies↗
PubMed1975

Prophylactic use of hydroxyprogesterone caproate in abdominal surgery during pregnancy. A retrospective evaluation.

Abdominal surgery (unrelated to delivery) during pregnancy is not common. Review of a recent 17-year experience at our institution revealed 112 surgical procedures among 25,189 deliveries--an incidence of 0.44% (1 case for every 225 deliveries). Progestational agents have been used prophylactically in such procedures, but few studies have adequately assessed the effectiveness of these drugs to prevent onset of premature labor. The present study involved 35 gravid patients who had been treated with various doses of hydroxyprogesterone caproate before and after operations unrelated to delivery. These 35 patients were matched with 35 gravid control patients who had undergone similar operations but who had not received progestational compounds. Analysis revealed no significant difference in the abortion rate between these two groups.

Abortion, Spontaneous↗
PubMed1987

Munchausen's syndrome and prophylactic mastectomy.

A patient sought bilateral prophylactic mastectomies because of a strongly positive family history of breast cancer. Fortunately, prior to operation, this family history was discovered to be a fabrication by the patient. Few ablative plastic surgical procedures are done without objective criteria. Plastic surgeons relying on a positive family history as sufficient indication for bilateral prophylactic mastectomy need to be aware that such a history may be the contrivance of a patient with Munchausen's syndrome. A high index of suspicion may enable the plastic surgeon to recognize Munchausen's syndrome and thus avoid both contributing to the patient's illness and performing an unwarranted operation.

Adult↗
PubMed2006

Isthmus-preserving total bilobectomy: an adequate operation for C-cell hyperplasia.

BACKGROUND: Autopsy studies show that C cells deriving from the ultimobranchial body and migrating into the thyroid do not reach the isthmus region and are distributed along the vertical axes of thyroid lobes. This was confirmed in a surgical series of 58 patients (34 with preoperatively normal and 24 with elevated serum calcitonin) where no calcitonin-positive cells were demonstrable immunohistochemically within separately investigated isthmi. Consequently, isthmus-preserving total bilateral lobectomy (IPTB) may be regarded as an adequate surgical procedure for C-cell hyperplasia (CCH). PATIENTS AND METHODS: IPTB was performed from October 2001 to December 2004 in 64 patients, 59 patients with nodular goiter and slightly to moderately elevated serum calcitonin (stimulated under 500 pg/ml) (group A, apparently sporadic cases) and in 5 patients undergoing prophylactic surgery for hereditary medullary thyroid carcinoma (MTC) with intermediate- or low-risk RET mutations (non-634) (group B). The surgical procedure focused on meticulous total extracapsular resection of both thyroid lobes, preservation of an isthmus remnant of about 3 ml (smaller in children), and histologic workup of the border zones of resection in addition to that of the completely removed lobes. When malignancy could be proven intraoperatively (7 patients) or when the isthmus turned out to contain nodular lesions (4 patients), completion total thyroidectomy (plus lymphadenectomy) was performed as a one-stage procedure. Second-stage total thyroidectomy was performed in 3 cases. Thus, IPTB was the definitive surgical procedure in 50 patients (45 of group A and all 5 of group B). RESULTS: In all of the 50 definite IPTB cases, postoperative serum calcitonin was below the measurable limit (2 pg/ml); stimulated calcitonin was below the measurable limit in 47 (including all of group B) and was measurable in 3 sporadic cases in a lower-normal range between 2.4 and 3.5 pg/ml. Genetic screening of the apparently sporadic cases with CCH was positive in one (codon 791). The risk of recurrent laryngeal nerve paralysis seems not to be elevated (0% permanent); permanent hypocalcemia occurred in 1 patient (2%). Follow-up data of 37 patients, median 18 (6-36) months, showed continuously nonmeasurable serum calcitonin with one exception, where it was in the normal range after 18 months. All IPTB patients are still under substitution therapy with L-thyroxine (median 125 mug/day) with decreasing tendency in all 3 children after prophylactic operation, the latter also showing an increasing volume of well-vascularized isthmi (from 1.5 to 2.5 ml). CONCLUSION: IPTB reliably removes all C cells. There may not be need for total thyroidectomy (TTx) in cases with CCH. When necessary, completion TTx can be performed easily without additional risk. IPTB leaves a functionally relevant remnant, corresponding to that of a subtotal resection. This might be of importance especially for prophylactic surgery in children where the isthmus can compensate for the loss of thyroid function with time.

Adolescent↗
PubMedDate not supplied

The effect of prophylactic melatonin administration on reperfusion damage in experimental testis ischemia-reperfusion.

AIM: Torsion of testis, which is a urologic emergency case, is generally treated by surgical detorsion procedure. However, the resulting reperfusion and both ipsilateral and contralateral testis damage caused thereby are important problems. This study aims at investigating the administration of prophylactic melatonin in order to reduce free radical damage that is caused due to reperfusion after experimental testis torsion-detorsion procedure. MATERIAL AND METHOD: The rats used in the study were allocated to four groups, each containing 10 rats. Rats in Group I had six hours of torsion (ischemia) followed by orchiectomy. Rats in Group II had six hours of torsion, then received melatonin (10 mg/kg/IM) and after that had detorsion (reperfusion). Rats in Group III had detorsion after six hours of torsion and serum physiologic administration (the same volume as melatonin). Torsion and/or detorsion procedures were not applied in Group IV (control). Ipsilateral, contralateral testis and plasma Malondialdehyde (MDA) levels were determined in all groups. RESULTS: Tissue and plasma MDA levels in the group which had detorsion were found to be significantly higher than those in the group that had orchiectomy only (p<0.02). Ipsilateral and contralateral testis MDA levels were identified to be significantly lower in the group receiving prophylactic melatonin in comparison to the group receiving serum physiologic (p<0.02). Plasma and contralateral MDA levels correlated positively with MDA levels identified in ipsilateral testis in all groups (rs=+0.89, n=40, p=0.000). CONCLUSION: In cases where testis torsion is identified, administration of melatonin just before torsion may reduce local and systemic free radical damage.

Animals↗
PubMed1985

A retrospective study of treatment of orbital floor fractures with the maxillary sinus approach.

The Cook County Hospital, Chicago, Illinois, protocol for the management of orbital fractures is presented. Diplopia which fails to resolve in 1 week or appears after oedema subsides, enophthalmos or radiographic depression of the orbital floor, associated tripod fracture deformity, or purulent maxillary sinusitis are indications for surgery. The surgical procedure is a modification of the maxillary sinus approach, which includes the use of iodoform gauze packing, nasal antrostomy, a double layer oral closure and prophylactic antibiotics. A review of 102 patients treated surgically over a 6-year period is presented. Post-operative diplopia was 9% and there were minor complications in 3%, which were significantly lower than previously reported series of orbital fractures treated either non-operatively, or through an orbital exploration approach. No patient treated non-operatively required surgery in the future. The protocol presented can eliminate unnecessary exploration and yields excellent results with a simple surgical procedure.

Diplopia↗
PubMed1995

Gastroesophageal reflux in children.

Whereas all of these surgical modifications and new approaches are somewhat preliminary and have yet to achieve widespread clinical application, they illustrate an awareness of shortcomings in the present operative management of reflux as well as a gradual disenchantment with complications seen in many children, especially the neurologically impaired. However, the final analysis of surgical treatment for these children should not be viewed in an overly pessimistic light. Strategies for management of gastroesophageal reflux remain multifaceted, and operative intervention has a laudable role in the relief of symptoms for many afflicted children. However, the child's presentation and symptomatology should be predominant in planning therapy, operative or otherwise. It is the goal of this review to point out several points in this respect: 1. The diagnosis of gastroesophageal reflux may be difficult to pinpoint. 2. Multiple tests for reflux may offer conflicting results. 3. Clinical presentations associated with reflux do respond to treatment, which may include operative intervention. 4. The risks of anti-reflux procedures are greater than have been previously recognized, especially in the chronically ill and neurologically impaired child. 5. New approaches offer some promise to lower the risks of complications inherent in operative treatment of pathologic gastroesophageal reflux. 6. The best management plan for surgical treatment of reflux in children is evolving with less of a conviction for "prophylactic" fundoplication procedures, especially in the neurologically impaired child, and there is a recognition that underlying motility disorders may require modification of the operative approach or even the decision to operate. It is only through an awareness of the significant benefits as well as the considerable risks of operative treatment that the contemporary surgeon can best serve the interests of a child with gastroesophageal reflux. It is hoped that these guidelines will be helpful in this regard.

Adolescent↗
PubMed2001

Impact of a surgeon-trained observer on accuracy of colorectal surgical site infection rates.

PURPOSE: The aims of this study were 1) to establish accurate and reproducible baseline surgical site infection rates for our department and 2) to identify risk factors associated with surgical site infection in patients undergoing surgery on a colorectal service. METHODS: Phase I--Surgical site infection grading between the surgeon-trainer and the observer-trainee was validated using a four-point scale for wound evaluation previously used by our institution. Phase II--Patients undergoing colorectal surgery were prospectively monitored. The observed surgical site infection rate was compared with morbidity and mortality reports. Patient and perioperative variables were analyzed for their effect on surgical site infection using the chi-squared test. Risk factors approaching significance on univariate analysis (P < 0.2) were entered into a multivariate stepwise logistic regression model. RESULTS: Concordance on surgical site infection grading between the surgeon-trainer and the observer-trainee improved from an initial 79 percent to 96 percent during the validation period. The surgeon-trained observer reported a surgical site infection rate of 7.2 percent vs. a morbidity and mortality reported rate of 3.3 percent. Among the variables examined, obesity and surgical procedure category were significantly associated with surgical site infection rates. The effect of prophylactic antibiotics and prior chemotherapy, radiation, or steroid therapy on surgical site infection rates approached significance. A logistic regression analysis incorporating these risk factors for surgical site infection accurately predicted infection status 93 percent of the time. CONCLUSION: Use of a surgeon-trained observer doubles the detection rate of postoperative surgical site infection. Accurate, prospective assessment identifies risk factors significantly associated with increased surgical site infection rates in colorectal surgical patients.

Aged↗
PubMed2005

Latex sensitisation and allergy in children with myelomeningocele.

INTRODUCTION: Children with spina bifida (SB) have a high degree of exposure to latex products as a consequence of repeated surgical procedures, implantation of latex-containing materials and catheterisation. The consequence is a higher incidence of latex allergic reactions. OBJECTIVE: The aim of this study is to evaluate the prevalence of latex sensitisation and allergy in a population of children with myelomeningocele (MMC) and to assess the role of associated risk factors. RESULTS: Forty-eight percent of the patients (29 out of 60) showed a latex sensitisation with specific IgE >0.7 kU/l while 15% (9 out of 60) were allergic to latex (specific IgE >0.7 kU/l and clinical manifestations). The principal factor correlated with allergy to latex was specific serum IgE to latex (radioallergosorbent test [RAST]) values (p<0.01). Other factors were total serum IgE (paper radioimmunosorbent test [PRIST]) values, number of surgical procedures and familiarity with allergy. CONCLUSION: These results underline the importance of prophylactic measures to avoid the exposure, not only in the sanitary environment, through the institution of latex-safe routes, but also in daily life, to prevent potentially serious allergic reactions.

Adolescent↗
PubMed1996

Infected iliac pseudoaneurysm after uncomplicated percutaneous balloon angioplasty and (Palmaz) stent insertion: a case report and literature review.

Percutaneous balloon angioplasty and endovascular stent placement are becoming common techniques intended to reduce the need for surgical bypass procedures that may be more expensive or have higher morbidity rates. Prophylactic antibiotics are not currently used before stent placement in most centers even when implanted via the femoral route. Infectious complications have been rare. In the case presented here an infected common iliac pseudoaneurysm occurred after percutaneous balloon angioplasty and stent placement. The literature is reviewed.

Aneurysm, False↗
PubMedDate not supplied

Postsurgical adhesion formation in germfree and ex-germfree rats--a study using three scoring scales.

Postsurgical adhesions occur commonly after surgical procedures and are the source of substantial postoperative morbidity. No preventive or prophylactic regimen against adhesions has proven successful in all circumstances. The reasons for this are not clear. The basic mechanisms causing adhesion formation have not been elucidated fully, and furthermore, lack of accurate methods of measuring adhesions may be a contributing factor. Postoperative adhesions may occur in all kinds of surgery but are especially prominent in the abdomen, where the bowel flora may be a compromising factor. This study was undertaken to study the influence of the gastrointestinal microflora on adhesion formation. Germfree and ex-germfree DA rats were subjected to a cecal crush model, and adhesions were evaluated after 7 days using 3 different scoring scales. Germfree rats formed significantly fewer adhesions than their ex-germfree (conventionalized) counterparts. The differences were so great that all three scoring scales achieved significance (p < .005). This study corroborates that the endogenous bowel flora per se is involved in adhesion formation without causing frank infection.

Animals↗
PubMed1989

Safety of invasive procedures in patients with the coagulopathy of liver disease.

To assess the need for prophylactic fresh frozen plasma in patients with chronic liver disease before procedures, we followed 39 consecutive patients with prothrombin times (PT) of 15-29 s who had 71 invasive procedures. A total of 57 procedures was done in 30 patients receiving no blood product support, while 12 patients received blood products within 12 h of 14 procedures. Only three of the latter group received fresh frozen plasma prophylactically to improve the PT. The two groups were similar in the severity of their liver disease. There were nine surgical procedures as well as paracenteses, thoracenteses, lumbar punctures, and central venous line placement. Three bleeding episodes occurred. Two of the bleeding episodes required no further treatment. Because of the low incidence of bleeding and the ease in controlling the bleeding once it occurred, fresh frozen plasma is not recommended for prophylaxis of an elevated prothrombin time.

Blood Coagulation Disorders↗
PubMed1995

The dilemma of surgical treatment for patients with asymptomatic carotid disease.

Several case series have suggested that endarterectomy is beneficial in asymptomatic carotid artery disease. Four randomized trials have been done in this area, the most recent of which is the Asymptomatic Carotid Atherosclerosis Study (ACAS). Results of the first three trials were negative, and ACAS produced a tantalizing, statistically significant finding that does not translate into clinical importance. Disabling strokes have not been reduced by surgical therapy, and the benefit for women has not been shown. It is unclear from this study whether persons with the greatest stenosis and the highest vascular risk profiles are appropriate candidates for endarterectomy. In patients in whom carotid artery disease is incidentally discovered, the benefits of the prophylactic addition of carotid endarterectomy to coronary bypass grafting or other major surgical procedure in patients are still unknown. Excellent surgical skill is of paramount importance for the future use of this procedure. Mass population screening to detect asymptomatic carotid disease will only be justified when and if future studies identify patients in whom the risk for disabling stroke after the procedure is clearly reduced.

Carotid Stenosis↗
PubMed1997

Is incidental prophylactic oophorectomy an acceptable means to reduce the incidence of ovarian cancer?

BACKGROUND: According to previous reports, the lifetime risk of developing ovarian carcinoma is 1.4%. This figure varies with age from 6.6 per 100,000 among women aged 35 to 39 years up to 55.1 per 100,000 among women aged 75 to 79 years. Prophylactic oophorectomy remains a modality to decrease the incidence of ovarian cancer. What proportion of women diagnosed with an ovarian malignancy had a preceding laparotomy at which time a prophylactic oophorectomy could have been performed? METHODS: We reviewed the new ovarian cancer diagnoses seen in patients between August 1988 and August 1993 at the Ottawa Regional Cancer Foundation. Four hundred and four patients were identified. These patients were analyzed for preceding abdominal surgery, age, time to disease progression, time to death, time to death from other causes, and average follow-up. The previous abdominal surgeries were divided into: (1) major gynecological surgery; and (2) general surgery procedures, which were further divided into laparotomy and pelvic surgery (group A surgeries) and general surgery that included other abdominal surgeries (ie, appendectomy, cholecystectomy) where access to the pelvis could be more difficult (group B surgeries). RESULTS: A total of 270 abdominal surgeries was performed, prior to the diagnosis of ovarian cancer. The group was stratified according to the timing of the surgery (< or =40 years, 41 to 45 years, 46 to 50 years, >50 years). Based on these data, and on the grouping of general gynecologic surgeries plus the general surgical procedures of group A, 10.9% of ovarian cancers would have been prevented if prophylactic oophorectomy had been performed in patients who had surgery over 40 years of age; over 45 years this was 6.7%, over 50 years it was 4%. If one adds all major surgeries, including general surgery groups A and B, the results were 26.9% over 40 years of age, 20% over 45, and 16.6% over 50. CONCLUSION: We found that, depending on the age of the patient, prophylactic oophorectomy results in a 4% to 10.9% reduction in the incidence of ovarian carcinoma. This increases to 16.6% to 26.9% if one considers general surgery procedures in which access could be more difficult. Although we are not advocating the frequent use of this procedure, we recommend that surgeons routinely discuss this option before surgery with their postmenopausal female patients over 49 years of age. Given that the decision for prophylactic oophorectomy is multifaceted, we feel that a risk scoring for ovarian cancer and a discussion of the risk and benefit ratio should be undertaken. The ultimate goal is to heighten patient awareness of the risk factors to ensure that an informed decision is made concerning this consistently lethal disease.

Abdomen↗
PubMed1989

Antibiotic prophylaxis in surgery.

Scientific studies conducted during the last 10 years have resulted in a great improvement of our approach to the appropriate use of prophylactic antibiotics in the surgical patient. Errors of the past including faulty timing of the initial dosage as well as prolonged duration of prophylaxis have largely been remedied. Present studies are designed to define the patients within the various subsets of diseases or surgical procedures who are at greatest risk of infection. It is these patients who can be expected to benefit most from the efficacious use of prophylactic antibiotics as well as other preventative measures.

Anti-Bacterial Agents↗