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PubMed2005

[A minimally invasive approach in the treatment of complicated anal fistula through spatium intermuscular of anal sphincter].

OBJECTIVE: To investigate the optimal operative approach for the complicated anal fistula. METHODS: One hundred and ninety-two cases with complicated anal fistula were randomly divided into minimally invasive operation group (through spatium intermuscular of anal sphincter) and fistula resection group. The operation time, bleeding time during and after operation, pain lasting time, healing time of incision, area of anal scar, anal malformation and function and post operative recurrence were observed and compared between the two groups. RESULTS: Compared to those of fistula resection group, the operative time was (36.5+/- 15.3)min, bleeding time during and after operation (2.0+/- 0.5)d, postoperative pain lasting time (1.5+/- 0.5)d, healing time of incision (18.5+/- 5.5)d in minimally invasive operation group. All were shortened (P< 0.05), and the incidence of anal malformation (5.2%, P< 0.01) and partial anal incontinence (2.1%, P< 0.01) was lower. There was no significant difference in postoperative recurrence between the two groups. CONCLUSIONS: The minimally invasive operation through spatium in termuscular of anal sphincter is superior to fistula resection on the management of complicated fistula.

Adult↗

PubMed1999

Evolution of the modified Rossetti fundoplication in children: surgical technique and results.

OBJECTIVE: To compare the modified Rossetti fundoplication with the classic Nissen. SUMMARY BACKGROUND DATA: The traditional surgical treatment of gastroesophageal reflux in children has been the classic Nissen fundoplication, defined by liver mobilization, crural repair, takedown of short gastric vessels, and floppy wrap. The authors have progressed in our technique of fundoplication and now perform a modified Rossetti fundoplication, defined by liver retraction without mobilization, no crural repair, short gastric vessels left intact, and 2-cm floppy wrap. METHODS: A retrospective chart review was performed on 407 pediatric patients who had open fundoplications (Jan. 13, 1993, to Feb. 25, 1998). Two groups were analyzed: the Nissen group (171 patients) and the Rossetti group (236 patients). Groups were compared for incidence of recurrent reflux, dysphagia, hiatal hernia, need for esophageal dilation, revision of fundoplication, time to discharge, and operative time. RESULTS: Incidence of dysphagia (3.7% vs. 3.3%), postoperative hiatal hernia (1.9% vs. 1.4%), need for esophageal dilation (1.2% vs. 0.5%), and need for fundoplication revision (2.5% vs. 2.3%) were similar between the groups. The mean operative time was significantly decreased in the Rossetti group (65 +/- 25 minutes) versus the Nissen group (73 +/- 33 minutes). Recurrent reflux occurred significantly more often in the Nissen group (11.2%) than in the Rossetti group (5.1 %). CONCLUSION: The modified Rossetti fundoplication has a low complication rate and is the authors' preferred method for the surgical treatment of gastroesophageal reflux in children.

Child, Preschool↗

PubMed1996

Randomised, prospective, single-blind comparison of laparoscopic versus small-incision cholecystectomy.

BACKGROUND: We report a prospective randomised comparison between laparoscopic and small-incision cholecystectomy in 200 patients which was designed to eliminate bias for or against either technique. METHODS: Patients were randomised in the operating theatre and anaesthetic technique and pain-control methods were standardised. Four experienced surgeons did both types of procedure. Identical wound dressings were applied in both groups so that carers could be kept blind to the type of operation. FINDINGS: There was no significant difference between the groups for age, sex, body mass index, and American Society of Anaesthesiologists grade. Laparoscopic cholecystectomy took significantly longer than small-incision cholecystectomy (median 65 [range 27-140] min vs 40 [18-142] min, p<0.001). The operating time included operative cholangiography which was attempted in all patients. We found no significant difference between the groups for hospital stay (postoperative nights in hospital, median 3-0 [1-17] nights for laparoscopic vs 3-0 [1-14] nights for small-incision, p=0.74), time back to work for employed persons (median 5-0 weeks vs 4.0 weeks; p=0.39), and time to full activity (median 3-0 weeks vs 3.0 weeks; p=0.15). INTERPRETATION: Laparoscopic cholecystectomy takes longer to do than small-incision cholecystectomy and does not have any significant advantages in terms of hospital stay or postoperative recovery.

Analgesia, Patient-Controlled↗

PubMed1994

Laparoscopic cholecystectomy in biliary pancreatitis.

Laparoscopic cholecystectomy has emerged as the treatment of choice for uncomplicated cholelithiasis. Despite early concerns, many surgeons have applied this new technique to more complicated biliary tract disease states, including biliary pancreatitis. To evaluate the safety of laparoscopic cholecystectomy in this setting, we retrospectively reviewed 29 patients with clinical and laboratory evidence of biliary pancreatitis who underwent this procedure between March 1990 and December 1992. The severity of pancreatitis was determined by Ranson's criteria. Two patients had a Ranson's score of 6, one of 5, one of 4, five scored 3, nine scored 2, nine also scored 1, and two patients scored 0. The mean serum amylase level on admission was 1,610 (range 148 to 7680). All patients underwent laparoscopic cholecystectomy during the same hospital admission for biliary pancreatitis, with the mean time of operation being 5.5 days from admission. Operative time averaged 123 minutes (range 60-220 minutes). Intraoperative cholangiography was obtained in 76 per cent of patients. Three patients had choledocholithiasis on intraoperative cholangiography and were treated with choledochoscopy, laparoscopic common bile duct exploration, and saline flushing of the duct. The mean length of hospital stay was 11 days (range 5-32 days). There were seven postoperative complications requiring prolonged hospitalization with all but one treated non-operatively. One patient with a preoperative Ranson score of 6 developed necrotizing pancreatitis and subsequently required operative pancreatic debridement and drainage. There were no deaths in this series and no postoperative wound infections. The average recovery period for return to work was 2 weeks. These statistics compare favorably with literature reports for open cholecystectomy in biliary pancreatitis.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed1994

Hypertension perioperative splenectomy in thalassemic children.

We retrospectively studied the intraoperative hemodynamic changes in 100 thalassemic children undergoing general anesthesia for elective splenectomy. They were divided into 2 groups owing to the postoperative hemodynamic response. Eighty-four patients who had an unremarkable postoperative course were group 1, while 16 patients who developed immediate postoperative hypertension were group 2. There were no differences between the groups regarding age, body weight, sex, anesthetic time and operation time, except for the preoperative hematocrits of group 1 patients were slightly but significantly higher. Both groups similarly showed significant increase of the systolic as well as diastolic blood pressure throughout the anesthetic course. The heart rate was significantly increased at the beginning but declined to normal toward the end of the operation. Although none of the patients died postoperatively, all of group 2 patients needed aggressive treatment with diuretic and antihypertensive drugs. Despite the proper management, 3 of 16 patients developed convulsion and one of them had persistent neurological deficit. Since intraoperative and postoperative hypertension which commonly occur in these patients may lead to more serious neurological complications, the authors suggest that careful hemodynamic monitoring must be considered for all thalassemic children undergoing general anesthesia for splenectomy.

Child↗

PubMed1998

Plasma concentration of cytokine antagonists in patients with infection following liver resection.

BACKGROUND: The interactions between endogenous cytokine antagonists, surgical injury and perioperative infection are poorly understood. METHODS: Perioperative plasma concentrations of soluble tumour necrosis factor receptor p55 (STNFR p55), interleukin (IL) 1 receptor antagonist (IL-1ra) and IL-6 were measured by immunoassay in 29 consecutive patients undergoing liver resection. RESULTS: Plasma concentrations of STNFR p55, IL-1ra and IL-6 showed a striking increase immediately after operation (day 0) and on postoperative day 1. STNFR p55 concentrations correlated significantly with operating time (P< 0.05); IL-1ra levels with operating time, blood loss and weight of resected liver (P < 0.05); and IL-6 concentrations with operating time and blood loss (P< 0.05). Eight of the 29 subjects developed postoperative infections, of whom four had positive cultures of enteric organisms. Plasma STNFR p55 and IL-6 concentrations were significantly higher in the infected group than in the uninfected group (P < 0.05). STNFR p55 and IL-6 concentrations on day 0 differentiated between the two groups with a diagnostic accuracy of 79 and 83 per cent respectively. CONCLUSION: These results suggest that STNFR p55, IL-1ra and IL-6 are produced during operation in response to surgical stress. This production of STNFR p55 and IL-6 may be enhanced further by intraoperative bacterial translocation. Measurement of plasma STNFR and IL-6 concentrations may predict the development of postoperative infectious complications.

Adult↗

PubMed2001

Transperitoneal laparoscopic adrenalectomy: experience in 72 procedures.

PURPOSE: To evaluate the safety and effectiveness of transperitoneal laparoscopic adrenalectomy for a variety of adrenal diseases. PATIENTS AND METHODS: Seventy-two patients underwent laparoscopic adrenalectomy from January 1995 until March 1999. The indications for the treatment were limited to either functioning or nonfunctioning adrenal masses without radiologic evidence of involvement of the surrounding tissues. The indication for bilateral adrenalectomy was Cushing's disease after the failure of other therapies or Cushing's syndrome secondary to ectopic ACTH secretion without the discovery of a primary neoplasm. RESULTS: Thirty-five of the adrenalectomies were performed on the left side and 33 on the right side, and 4 were performed bilaterally. The right-sided procedures required a mean operating time of 130 minutes (range 85-200 minutes), the left-sided procedures required a mean operating time of 140 minutes (range 95-200 minutes), and the bilateral procedures required a mean operating time of 240 minutes (range 210-290 minutes). A conversion from laparoscopy to laparotomy was necessary for 3 patients (4%). Intraoperative complications were reported in 6 patients (8%). Postoperative complications likewise occurred in six patients. CONCLUSIONS: These procedures proved to be safe and able to remove the majority of either functioning or nonfunctioning benign adrenal masses. Some controversy remains regarding the safety of laparoscopic adrenalectomy for large lesions and the safety of bilateral laparoscopic adrenalectomy because of bleeding risks, anesthetic risks, and long operative times. The effectiveness of laparoscopic adrenalectomy for nonfunctioning adrenal masses with histologic findings of carcinoma has not yet been proved.

Adolescent↗

PubMed2005

Laparoscopically-assisted resection rectopexy for rectal prolapse: ten years' experience.

PURPOSE: This study has been undertaken to audit a single-center experience with laparoscopically-assisted resection rectopexy for full-thickness rectal prolapse. The clinical outcomes and long-term results were evaluated. METHODS: The data were prospectively collected for the duration of the operation, time to passage of flatus postoperatively, hospital stay, morbidity, and mortality. For follow-up, patients received a questionnaire or were contacted. The data were divided into quartiles over the study period, and the differences in operating time and length of hospital stay were tested using the Kruskal-Wallis test. RESULTS: Between March 1992 and October 2003, a total of 117 patients underwent laparoscopic resection rectopexy for rectal prolapse. The median operating time during the first quartile (representing the early experience) was 180 minutes compared with 110 minutes for the fourth quartile (Kruskal-Wallis test for operating time = 35.523, 3 df, P < 0.0001). Overall morbidity was 9 percent (ten patients), with one death (<1 percent). One patient had a ureteric injury requiring conversion. One minor anastomotic leak occurred, necessitating laparoscopic evacuation of a pelvic abscess. Altogether, 77 patients were available for follow-up. The median follow-up was 62 months. Eighty percent of the patients reported alleviation of their symptoms after the operation. Sixty-nine percent of the constipated patients experienced an improvement in bowel frequency. No patient had new or worsening symptoms of constipation after surgery. Two (2.5 percent) patients had full-thickness rectal prolapse recurrence. Mucosal prolapse recurred in 14 (18 percent) patients. Anastomotic dilation was performed for stricture in five (4 percent) patients. CONCLUSIONS: Laparoscopically-assisted resection rectopexy for rectal prolapse provides a favorable functional outcome and low recurrence rate. Shorter operating time is achieved with experience. The minimally invasive technique benefits should be considered when offering rectal prolapse patients a transabdominal approach for repair, and emphasis should now be on advanced training in the laparoscopic approach.

Adult↗

PubMed2002

Carpal tunnel release in the United States and Sweden: reimbursement patterns, cost for treatment, and return to work.

Cost containment plays an increasingly important role in health care, affecting providers and recipients. The present investigation addressed a limited number of factors that relate to the total cost for surgical treatment of carpal tunnel syndrome. The purpose of this study was to compare socioeconomic factors in two different societies and how worker's compensation plays a role in the cost, rehabilitation, and operative practices. To that purpose, the authors studied hospital and insurance records from a total of 123 female patients treated in two tertiary referral centers (University of Pittsburgh, Pa., and University of Umea, Sweden). The 123 patients were referred to three subgroups. Group A comprised patients from the University of Pittsburgh with worker's compensation (n = 34), group B comprised patients from the University of Pittsburgh without worker's compensation (n = 47), and group C comprised patients from the University of Umea (n = 42). The analyzed data showed a tendency toward longer duration of postoperative sick leave for those with worker's compensation than those without worker's compensation for patients from the University of Pittsburgh. However, operating room times and operating times, operative cost, use of postoperative therapy, and duration for sick leave were substantially less for patients treated at the University of Umea. There was no statistically significant difference in time off work between group A and group B. The results may indicate that the effect of compensation on a patient's ability or willingness to recover after treatment for carpal tunnel syndrome may be less important than factors that do not primarily relate to the patient or the surgical procedure.

Carpal Tunnel Syndrome↗

PubMed1997

Staffing the operating room. Time and space factors.

Staffing the operating room requires a different approach than staffing inpatient units. Of course, there are similarities, namely: assuring safe, cost-effective care; dealing with fluctuating workloads; using various types of caregivers; and maximizing and maintaining resources in a responsible manner. However, many differences also exist. This article details the fundamental requirements for determining operating room staffing.

Anesthesiology↗

PubMed2006

Revision Nissen fundoplication can be completed laparoscopically with a low rate of complications: a single-institution experience with 72 children.

PURPOSE: Recurrent gastroesophageal reflux is a common complication after fundoplication and is often treated with revision fundoplication. We report our experience with laparoscopic redo fundoplication. METHODS: The medical records of all patients in whom laparoscopic revision fundoplication was attempted over a 7 1/2-year period were reviewed. RESULTS: Redo laparoscopic fundoplication was attempted in 72 pediatric patients. Ten patients had undergone initial open fundoplication, and 9 additional patients had prior abdominal surgery. Fifty-one percent of patients were neurologically impaired. Laparoscopic fundoplication was completed in 89% of first-time redo operations and 68% of second revisions with average operative times of 2.2 +/- 1.0 and 2.6 +/- 0.9 hours, respectively. Herniation of the fundoplication through the hiatus was common (75%) and the fundoplication was intact in 49%. Conversions to laparotomy were because of difficulties with dissection or visualization. No patients required intraoperative transfusion. No patients required reoperation in the perioperative period. There were no perioperative deaths. Twenty-six percent of the 72 patients went on to a third operation for gastroesophageal reflux, and 4 of these had a fourth. CONCLUSION: Revision laparoscopic fundoplication is a technically challenging operation but can usually be completed and is characterized by a low rate of complications.

Adolescent↗

PubMedDate not supplied

Radical hysterectomy for cervical cancer: the effect of shorter length of stay on outcome.

BACKGROUND: The surgical treatment for limited cervical cancer (radical hysterectomy and pelvic lymph node dissection) has remained essentially the same for 40 years, but economic pressures have resulted in shorter length of hospital stay, and precautions against infectious diseases have resulted in less use of blood products. PURPOSE: To determine if recent changes in hospital practices have affected outcomes, and if obese patients are at greater risk of complications. METHODS: Retrospective review of 100 surgical cases grouped by time period (1981 through 1987 and 1988 through 1993) and by patient weight (< 80 kg and > or = 80 kg). RESULTS: Comparing the two time periods, the mean operative time remained the same (199 minutes), but use of blood products declined (mean 2.1 vs 1.5 units; P < .01), as did the mean length of hospital stay (10.6 vs 7.4 days, P < .01). The rate of postoperative complications decreased significantly (P < .01), and the 5-year survival rate remained 91%. Obese patients received more blood transfusions than did nonobese patients (2.6 vs 1.6 units; P = .02), but their mean operative time and hospital stay did not significantly differ. The rate of postoperative and long-term complications did not differ significantly between the two weight groups. CONCLUSIONS: Surgical treatment of limited cervical carcinoma continues to be safe and effective.

Adenocarcinoma↗

PubMed1999

Midterm results after aortic valve replacement with the autologous tissue cardiac valve.

OBJECTIVE: To assess midterm results after aortic valve replacement (AVR) with an autologous tissue cardiac valve (ATCV). This new technique was developed to construct a tissue prosthesis for AVR using the patients pericardium, harvested at the time of operation with negligible effect on operating time. METHODS: Briefly, glutaraldehyde tanned pericardium is mounted on a stent requiring no suturing. Between March 1994 and December 1996, 87 patients, 44/43 M/F and aged 70 +/- 6 years had AVR for aortic stenosis (80%), aortic insufficiency (6%) and combined lesions (14%), one patient suffered from endocarditis. Additional coronary artery bypass was done in 25%, aortic root enlargement in 7%. Aortic cross clamp and cardiopulmonary bypass times were 69 +/- 21 and 93 +/- 29 min. All patients were followed by clinical examination and color flow Doppler echocardiography in 3-12 months interval. Follow up was 99% complete. RESULTS: There were five perioperative deaths (6%), none of them valve related. Eighty-one patients were followed up to a period of 52 months (mean interval 37.5 +/- 1.3 months), one patient was lost for follow up. Overall survival was 86, 81, 79 and 71% at 12, 24, 36 and 48 months, respectively. There were 14 late deaths with eight (10%) valve related (four cerebral deaths, four sudden deaths). Sixteen patients (20%) had to be re-operated due to severe valve incompetence. Freedom from reoperation was 98, 97, 90 and 63% at 12, 24, 36, and 48 months, respectively. Valve incompetence occurred suddenly, without previous signs in the follow-up examinations. Selection and preparation of the pericardium, the way of fixation of the tissue--brief immersion in glutaraldehyde--and engineering problems might be responsible for this disastrous outcome. CONCLUSION: Due to these results we must state, that the ATCV did not fulfill our expectations and presently we can not recommend it as an aortic valve substitute.

Aged↗

PubMedDate not supplied

Laparoscopic-assisted vaginal hysterectomy with uterine artery ligation through retrograde umbilical ligament tracking.

STUDY OBJECTIVE: To evaluate the clinical outcomes of uterine artery ligation through retrograde tracking of the umbilical ligament (RUL) in laparoscopic-assisted vaginal hysterectomy (LAVH). DESIGN: Prospective study (Canadian Task Force classification II-3). SETTING: University-affiliated hospital. PATIENTS: Two hundred twenty-five women with myomas or adenomyosis. INTERVENTION: Laparoscopic-assisted vaginal hysterectomy with uterine artery identification and ligation through RUL. MEASUREMENTS AND MAIN RESULTS: The median age of the patients was 46 years, and the median weight of the extirpated uteri was 340 g, with 26.2% of uteri weighing more than 500 g. The median operation time was 135 minutes, and the median blood loss was 50 mL. The median intramuscular meperidine requirements were 1 ampoule (50 mg), and the median hospital stay was 3 days. It took approximately 10 minutes from identification of the umbilical ligament to ligation of the uterine artery. Uterine weight of 500 g or more required a significantly longer operation time compared with uteri weighing less than 500 g (164 min vs 127 min median, p <.001), and there was more blood loss (100 mL vs 50 mL median, p <.001). There were no differences in the median intramuscular meperidine requirements or hospital stay between the two groups. No blood transfusion was needed in either group, even in patients with a uterine weight of more than 1000 g. By regression analysis, uterine weight was significantly related to blood loss and operation time. A linear relationship was found among uterine weight, operation time, and blood loss: Uterine weight = 87.589 + 1.881 x operation time + 0.48 x blood loss (R = 0.531, F = 35.694, degrees of freedom 184, p <.001). No complications related to RUL were observed, although two bladder injuries related to severe pelvic adhesion with endometriosis and previous cesarean section occurred. CONCLUSION: Minimal blood loss and a low complication rate were noted in LAVH by uterine artery ligation through RUL. This technique should be a valid approach, especially in patients in whom minimal blood loss must be achieved.

Adult↗

PubMed1997

[Left atrial isolation for chronic atrial fibrillation associated with valvular disease and coronary artery disease in an 82-year-old man].

An 82-year-old man suffering from chronic atrial fibrillation associated with valvular and coronary artery diseases was admitted to our hospital. Preoperative examination revealed that mitral and aortic valve replacement with tricuspid annuloplasty and coronary artery bypass were required, in addition to surgery for chronic atrial fibrillation. In order to shorten the aortic cross-clamp time and operative time, we performed left atrial isolation, which is a simpler procedure than maze procedure and the left sided maze procedure, because it requires incision of the posterior left atrium only. Since aortic stenosis was severe and the aortic annulus was small, we used a St. Jude Medical Hemodynamic Plus valve as the aortic valve prosthesis, which spares the surgical stress of the aortic annulus. Careful investigation of the patient disorder and selection of optimal surgical procedure makes possible an extended operation of complicated valvular disease even in a high elderly patient over 80 years old.

Age Factors↗

PubMedDate not supplied

Mini-open thoracoscopically assisted thoracotomy versus video-assisted thoracoscopic surgery for anterior release in thoracic scoliosis and kyphosis: a comparison of operative and radiographic results.

BACKGROUND CONTEXT: Combining anterior release and interbody fusion with posterior instrumented fusion is an accepted treatment for severe rigid spinal deformity. Video-assisted thoracoscopic surgery (VATS) and mini-open thoracoscopically assisted thoracotomy (MOTA) are two minimally invasive approaches to the thoracic spine. Both reduce surgical trauma, improve cosmesis and provide effective exposure for release and fusion. Published data and the authors' surgical experience have demonstrated that both techniques are equivalent in degree of release to traditional open thoracotomy, but no comparison between these two minimally invasive alternatives has been published to our knowledge. PURPOSE: This study compared MOTA and VATS under the hypothesis that both result in similar corrections and comparable operative parameters when used in conjunction with posterior instrumented fusion. STUDY DESIGN/SETTING: Retrospective chart review of consecutive case series by two surgeons. PATIENT SAMPLE: Twenty-one (13 female, 8 male) patients underwent MOTA and 24 patients (17 female, 7 male) underwent VATS for anterior release, discectomy and fusion prior to posterior instrumented fusion. OUTCOME MEASURES: Outcomes were measured at a minimum of 1-year follow-up and included radiographic Cobb measurements and operative parameters. METHODS: The indications for surgery included rigid and severe scoliosis or thoracic kyphosis. Data collection included preoperative demographics, number of levels released, primary curve correction, operative time and blood loss. Data were normalized per number of levels released anteriorly. Statistical analysis of results was done using a two-sample t test assuming equal variances with two-tail p values less than .05. RESULTS: More anterior levels were operated on average in the VATS group (6.33 vs. 4.38 levels). Curve correction per anterior level released was similar in both groups (8.7 and 8.8 degrees/level for MOTA and VATS, respectively). There was a significant difference in operative time with MOTA averaging 131.7 minutes and VATS averaging 162.8 minutes. However, a comparison of the operative time per anterior level operated, approached statistical significance in favor of VATS (33.0 vs. 28.4 minutes, p=.08). There was no significant difference in estimated blood loss during the anterior portion of the surgeries. There was a trend toward decreased blood loss per operated level favoring VATS (68.4 vs. 38.9 cc, p=.09). CONCLUSIONS: Both approaches resulted in corrections that compare favorably with open thoracotomy. We suggest that a factor in choosing between these two minimally invasive techniques is the number of thoracic levels requiring release. For four levels or less, MOTA provides an excellent alternative to standard thoracotomy. For five or more levels, VATS provides for excellent exposure of additional levels with the advantages of less operative time and blood loss per operated level.

Adult↗

PubMed1998

Increased serum interleukin-8: correlation with poor prognosis in patients with postoperative multiple organ failure.

This study investigated whether cytokines and colony-stimulating factors can predict prognosis in patients with postoperative multiple organ failure (MOF). We evaluated 14 patients with postoperative MOF who underwent operation for cardiovascular disease. Seven patients recovered from MOF (survivors) and seven did not recover and died (nonsurvivors). The white blood cell (WBC) count, granulocyte colony-stimulating factor, monocytic colony-stimulating factor, interleukin-6 (IL-6), and IL-8 were measured on the day the patients were judged to be in MOF and each week thereafter until the patients recovered or died. Survivors and nonsurvivors were equivalent in terms of age, gender, proportion of use of extracorporeal circulation, operation time, volume of blood transfusion, time from operation to the onset of MOF, the MOF score, proportion of bacteremia, duration of MOF, and number of failed organs. The mean duration of MOF was less than 2 weeks in both groups; therefore the measurements were compared on the first day of MOF and 1 week later. No significant differences between the two groups in terms of WBC counts, colony-stimulating factors, and IL-6 levels were noted. However, the serum level of IL-8 was significantly higher in nonsurvivors than in survivors. Patients with a high serum levels of IL-8 at the time of MOF had a poor prognosis.

Aged↗

PubMed2005

Damage control orthopedics in patients with multiple injuries is effective, time saving, and safe.

BACKGROUND: Although early fracture fixation is expedient in patients with multiple injuries, early total care (ETC) may be associated with posttraumatic systemic complications. This study was conducted to prospectively evaluate the concept of damage control by immediate external fracture fixation (damage control orthopedics [DCO]) and consecutive conversion osteosynthesis with regard to time savings, effectiveness, and safety. METHODS: In a prospective controlled trial, a cohort of 1,070 patients with an Injury Severity Score (ISS) of 20.7 were admitted to a Level I trauma center over a 3.5-year period. Patients with an ISS > 15, survival of more than 24 hours, and without interhospital transfer were included. In all patients with major fractures requiring immediate stabilization, external fixation was performed (DCO). Conversion was executed at the earliest possible time as a one-stage procedure after stabilization of organ functions. TRISS was calculated for patients requiring DCO (DCO group) and for patients without major fractures (control group). Time spent on particular and all surgical procedures, blood loss, and complications of DCO were compared with data of consecutive conversion osteosyntheses which were considered as hypothetical ETC procedures (h-ETC) in identical patients. RESULTS: Four hundred nine patients fulfilled the inclusion criteria. Seventy-five (ISS of 37.3) required DCO for 135 fractures, whereas 334 patients (ISS of 30.4) did not require immediate fracture fixation. Mean surgical time was 62 +/- 30 minutes (SEM, 3.5) for DCO. Because of fracture consolidation with external fixation (n = 3) and injury-related death (n = 15), conversion (h-ETC) was performed in 57 patients for 101 fractures. Duration of external fixation averaged 13.7 days (range, 3-46 days). Fifty-five patients (96.5%) required intensive care treatment and 42 patients (73.7%) required mechanical ventilation at the time of conversion. Mean operation time for conversion was 233 +/- 19 minutes (SEM, 18.7) with a value of p < 0.001. Also, blood loss was significantly (p < 0.001) different for DCO (<50 mL) and h-ETC (472 mL; SEM, 63). Pin-track infections were identified in five patients, two patients with acetabular plate osteosynthesis had deep wound infection, and one patient died related to bacterial sepsis with infections of all wound sites. Overall mortality in DCO patients was significantly lower than predicted by TRISS (20% vs. 39.3%), as it was in the 334 patients without immediate fracture fixation (29.5% vs. 24.3%). CONCLUSION: DCO appears to provide a major reduction of operation time and blood loss in the primary treatment period in severely injured patients compared with h-ETC. In addition, we found that DCO is not associated with an increased rate of procedure-related complications. So far, DCO with early and one-stage conversion seems to be a safe strategy of primary fracture treatment in patients with multiple injuries.

Adult↗