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PubMed2003

A review of mechanical adjuncts in wound healing: hydrotherapy, ultrasound, negative pressure therapy, hyperbaric oxygen, and electrostimulation.

Chronic or non-healing wounds may develop in the setting of many diseases and are the source of considerable morbidity as well as health costs. These wounds demand an aggressive, multifactorial approach including surgical debridement, revascularization, antibiotics and dressings. In addition several adjuvant treatment methods have been developed to further stimulate healing. Whirlpool, although used frequently, has not been proven to be of benefit. However, pulsed lavage does show a promising future. Ultrasound has demonstrated beneficial effects but further controlled studies are needed. Subatmospheric pressure therapy is associated with few complications and is fast becoming a mainstay of adjuvant therapy. Hyperbaric oxygen therapy has been shown to be effective for many types of wounds. Unfortunately, cost and access to chambers may prohibit its use on a routine basis. Finally, electrostimulation may be one of the up and coming therapies for the future. Though, more studies are needed to determine the mode of delivery for various types of wounds.

Electric Stimulation Therapy↗

PubMed2005

Does physician benchmarking improve performance of laparoscopically assisted vaginal hysterectomy?

BACKGROUND: Benchmarking techniques were implemented to optimize operating time and charges associated with laparoscopically assisted vaginal hysterectomy (LAVH). MATERIALS AND METHODS: The baseline LAVH profile over a period of 4 years (167 cases) was compared with 1-year data (47 cases) after a benchmarking educational program (disseminating data ranking performance by each surgeon plus suggestions for improvement). Preintervention and postintervention profiles were compared by means of Student t test and wilcoxon rank sum analysis. Hierarchical multiple regression was used to identify additional sources of variation for operative charges and time. RESULTS: Mean operating times after implementing benchmarking were lower, averaging 182 versus 197 minutes in the control subjects (P = 0.05). We found no significant difference in total or operative charges. After adjusting for potential confounders, benchmarking remained associated with decreased operating time in the multivariate model (P = 0.01). CONCLUSIONS: LAVH operating times decreased after a surgical benchmarking and education intervention, but operating charges did not.

Benchmarking↗

PubMed2002

Gastroscopic-assisted laparoscopic cystogastrostomy in the management of pseudocysts of the pancreas.

Once pancreatic pseudocysts become persistent, unresolving, and symptomatic, surgical drainage is mandatory. Between January 1998 and December 2001, we performed five laparoscopic cystogastrostomies for such pseudocysts with the simultaneous use of the gastroendoscope. The mean cyst diameter was 20 cm (range, 18.5-24). In the first four cases, the anterior wall of the stomach was entered through two 10-mm balloon cannulae under gastroscopic guidance. By introducing the laparoscope through one port and a harmonic scalpel through the other, a wide cystogastrostomy was performed. In the fifth case, a modification of the above technique was carried out. A single 10-mm cannula was used to enter the stomach and, with the use of a side-viewing gastroduodenoscope as the camera source, the harmonic scalpel was used to create the cystogastrostomy. The punctures in the wall of the stomach were repaired with endosutures. The gallbladder was removed in all cases. The mean operating time was 110 minutes (range, 92-128) for the combined procedure. There were no postoperative complications, and the mean hospital stay was 4 days. Postoperative follow-up with ultrasonography over a period of 1 year in each case revealed complete resolution of the cyst. Laparoscopic cystogastrostomy using harmonic scalpel under gastroscopic control is an effective and rapid method of surgically managing such lesions.

Adult↗

PubMed1983

Movement of personnel and wound contamination.

We studied the association between the movement of operating room personnel and bacterial contamination of the operative field during 12 clean operations. Settle plates placed on the patient's chest and instrument table were exposed during the operation. As a control, settle plates were exposed in the same locations when no personnel and patients were in the room. Bacterial contamination of the aseptic field was categorized as disseminating (Group A: greater than 42 combined movements) and nondisseminating (Group B: less than 42 combined movements). There were 24 persons in each group. There was a highly significant difference between the two groups in the colony counts on settling plates. More vigorous movement was associated with increased bacterial contamination of the operative field. Low bacterial colony counts were found in the control plates, ruling out environmental sources of contamination. Bacterial fallout correlated with the movement of personnel. Measures to reduce excessive movement in the OR are recommended.

Air Microbiology↗

PubMed1984

Suppression of residual oestrogen production with aminoglutethimide in women following surgical hypophysectomy or adrenalectomy.

In postmenopausal women with breast carcinoma, plasma and urinary oestrogens remain detectable following surgical adrenalectomy or hypophysectomy. These residual oestrogens could result from absorption of exogenous steroids, from endogenous production, or from a combination of these two sources. To determine whether endogenous production contributes to this oestrogen pool, we administered a potent steroidogenesis inhibitor, aminoglutethimide (AG), to women with breast carcinoma following hypophysectomy or adrenalectomy. Plasma and urinary oestrogens were measured with radioimmunoassays developed to provide appropriate sensitivity. In five women treated after initial hypophysectomy (hypox), plasma oestrone fell from 66 + 28 pg/ml (hypox) to 9.1 +/- 2.4 pg/ml (hypox and AG) and oestradiol decreased from 8.3 +/- 1.8 pg/ml to 2.5 +/- 0.69 pg/ml. Similar decrements in urine oestrone (U-E1) and ostradiol (U-E2) were observed (U-E1 hypox: 2.25 +/- 0.71 microgram/24 h 0.071 +/- 0.015 microgram/24 h hypox and AG; U-E2 0.47 +/- 0.12 micrograms/24 h hypox to 0.124 +/- 0.015 hypox and AG, P less than 0.05 for all). Similar significant reductions in plasma oestrone and oestradiol were observed in four women treated with aminoglutethimide following surgical adrenalectomy. While the levels of urinary oestrogens also fell in these patients, the differences were not statistically significant. In response to the decrements in oestrogen levels induced by AG, 2/5 women in the post-hypophysectomy group and 2/4 in the post-adrenalectomy group experienced partial objective tumour regression. These observations indicated that the residual oestrogens produced after surgical adrenalectomy or hypophysectomy, even though made in small quantities, were nonetheless biologically active. We conclude that endogenous production of oestrogens in extragonadal and extra-adrenal sites occurs after major surgical endocrine ablation in women with breast carcinoma. Additional exogenous oestrogen sources can not be excluded.

Adrenalectomy↗

PubMed1996

Three-piece inflatable penile prosthesis implantation: a comparison of the penoscrotal and infrapubic surgical approaches.

Patient satisfaction with the three-piece inflatable penile prosthesis was evaluated in two surgical subgroups following randomized implantation: those who underwent implantation via an infrapubic (IP) approach and those via a penoscrotal (PS) incision. Follow-up questionnaires were mailed to 86 patients who had undergone implantation of a Mentor alpha-1 or AMS 700CX inflatable penile prosthesis between August 1989 and November 1992. The questionnaire (54 items) was designed to elicit both factual and perceptual information in the areas of general medical information, prosthesis usage, erectile quality, postoperative complications, and general satisfaction. Questionnaire data was enhanced by a review of the clinic and hospital records of each patient who returned the questionnaire. Patients were followed postoperatively at regular intervals for a minimum of 6 months. Results demonstrate an overall patient satisfaction of 85%. Breakdown into the two surgical subgroups revealed similar rates of satisfaction by both groups. Analysis of the 42 questionnaires returned demonstrated no statistical differences in the replies of the two groups in either the factual or perceptual data. The most common sources of dissatisfaction related to penile length, girth, and difficulty with usage. This study demonstrates no compelling advantages in employing one surgical approach over the other.

Humans↗

PubMed2005

Critical issues in the clinical management of complicated intra-abdominal infections.

Intra-abdominal infections differ from other infections through the broad variety in causes and severity of the infection, the aetiology of which is often polymicrobial, the microbiological results that are difficult to interpret and the essential role of surgical intervention. From a clinical viewpoint, two major types of intra-abdominal infections can be distinguished: uncomplicated and complicated. In uncomplicated intra-abdominal infection, the infectious process only involves a single organ and no anatomical disruption is present. Generally, patients with such infections can be managed with surgical resection alone and no antimicrobial therapy besides perioperative prophylaxis is necessary. In complicated intra-abdominal infections, the infectious process proceeds beyond the organ that is the source of the infection, and causes either localised peritonitis, also referred to as abdominal abscess, or diffuse peritonitis, depending on the ability of the host to contain the process within a part of the abdominal cavity. In particular, complicated intra-abdominal infections are an important cause of morbidity and are more frequently associated with a poor prognosis. However, an early clinical diagnosis, followed by adequate source control to stop ongoing contamination and restore anatomical structures and physiological function, as well as prompt initiation of appropriate empirical therapy, can limit the associated mortality. The biggest challenge with complicated intra-abdominal infections is early recognition of the problem. Antimicrobial management is generally standardised and many regimens, either with monotherapy or combination therapy, have proven their efficacy. Routine coverage against enterococci is not recommended, but can be useful in particular clinical conditions such as the presence of septic shock in patients previously receiving prolonged treatment with cephalosporins, immunosuppressed patients at risk for bacteraemia, the presence of prosthetic heart valves and recurrent intra-abdominal infection accompanied by severe sepsis. In patients with prolonged hospital stay and antibacterial therapy, the likelihood of involvement of antibacterial-resistant pathogens must be taken into account. Antimicrobial coverage of Candida spp. is recommended when there is evidence of candidal involvement or in patients with specific risk factors for invasive candidiasis such as immunodeficiency and prolonged antibacterial exposure. In general, antimicrobial therapy should be continued for 5-7 days. If sepsis is still present after 1 week, a diagnostic work up should be performed, and if necessary a surgical reintervention should be considered.

Abdominal Abscess↗

PubMed2000

Surgical approaches to pediatric defecatory disorders.

Defecation is one of the most basic of human activities. Problems with evacuation of feces have plagued people since the beginning of time. In modern society, defecatory disorders are the source of embarrassment, discomfort, and stress. Society's lack of openness on this subject forces many people to endure their affliction silently. Nevertheless, although these conditions consume significant medical resources, little research has been done on their causes and treatment. This review summarizes recent developments in surgical treatment of children with these disorders, either in the ability to pass stool or the ability to control defecation.

Anus, Imperforate↗

PubMed1994

Sound localization in hemispherectomized patients.

In order to precisely evaluate the consequences of cortical damage on free-field sound localization in humans, the present study examined response accuracy to auditory targets in three hemispherectomized patients and IQ-matched controls. Listeners reported sound location by pointing with their dominant hand to the apparent sound location in an anechoic chamber. Two conditions were tested: (i) localization of a fixed-sound source and (ii) localization of the beginning and the end of a simulated moving stimulus. In both conditions, the responses of the patients were less accurate than those of the controls in the hemifield contralateral to their removed hemisphere. Moreover, the single-case analyses revealed that the performances obtained with fixed sources were generally more precise than those obtained with moving sources. This result is discussed in terms of a differential involvement of cortical and subcortical pathways in the processing of stationary and moving sounds. Finally, the age at surgery and the post-surgical interval were related with the magnitude of the deficits, suggesting the possible influences of functional reorganization and cerebral plasticity.

Adolescent↗

PubMed1984

Impairment in T-maze reinforced alternation performance following nucleus basalis magnocellularis lesions in rats.

Rats were trained on a reinforced alternation paradigm using an elevated T-maze. After pre-surgical training subjects received either ibotenic acid (4 micrograms/0.4 microliter) or vehicle (pH 7.4, 0.4 microliter) bilaterally into the region of the nucleus basalis magnocellularis--an important source of neocortical acetylcholine projections. Acetylcholinesterase staining of sectioned brains revealed a loss of neocortical, but not hippocampal staining in lesioned animals. On the T-maze task, lesioned rats showed significantly impaired choice performance relative to controls. They also demonstrated significant side biases, the degree of which was correlated with choice performance deficit.

Acetylcholine↗

PubMed1999

Evaluation of soluble CD44v6 as a potential serum marker for head and neck squamous cell carcinoma.

In recent years, the measurement of soluble CD44 levels in the circulation of patients with malignant diseases has been introduced as a new and simple diagnostic tool for the detection of human cancer. The high CD44v6 expression in head and neck squamous cell carcinoma (HNSCC) would enable the use of soluble CD44v6 proteins present in the circulation of HNSCC patients as a marker of disease. In the present study, we determined CD44v6 plasma levels using a domain-specific ELISA in healthy volunteers, non-cancer patients, and HNSCC patients before and after surgical removal of the tumor. A difference between the CD44v6 plasma levels of HNSCC patients and controls could not be observed. Moreover, surgical removal of the tumor did not result in a reduction of the CD44v6 plasma level in the HNSCC patients. In addition, the spectrum of soluble v6-containing CD44 proteins present in the plasma of HNSCC patients and controls was determined by immunoprecipitation experiments, but again, tumor-related isoforms could not be distinguished in patient samples. Additional experiments to unravel the biological source of these circulating proteins indicated surprisingly that the v6-containing proteins present in the circulation of healthy individuals are only released in part, if at all, by activated lymphocytes or other nucleated blood cells. Most circulating CD44v6 proteins seem to be derived from the normal epithelial cell compartments, including breast cells, colon cells, and squamous cells. Taken together, these data do not support the use of soluble CD44v6 as a tumor marker in HNSCC or any other tumor type that has developed from tissues producing soluble isoforms.

Antibodies, Monoclonal↗

PubMed1990

Quality assurance in anatomic pathology. An information system approach.

Quality assurance (QA) is the outcome-oriented process by which the performance of a complex production operation is evaluated. It is strongly focused on the use of resources and the end product, and is closely related to marketing. The pathologist's product is information, and the practice of anatomic pathology is evaluated as a system for producing and effectively communicating information. Our integrated program for QA in surgical pathology, autopsy pathology, and cytopathology recognizes that several discrete elements make up the sequence leading to communication of the diagnostic opinion. These are control and processing of the specimen, accuracy of diagnosis, timely and clear communication, efficiency in production of information, coherence with institutional programs in QA, and relation to licensing and accreditation agencies. Each of these elements may be tested separately and sources of error reduced so that the validity and cost of the pathologist's prediction will ultimately be limited only by the state of the art and not by any failure of the information system. Several components of QA, especially resource utilization by pathologists, are potentially productive areas for operations research.

Clinical Laboratory Information Systems↗

PubMed1978

Angiography in determining the cause and treatment of gastrointestinal bleeding.

Angiography is useful in the diagnosis of active gastrointestinal bleeding if the rate is greater than 0.5 mL/min. For upper gastrointestinal bleeding, endoscopy is the preferred initial investigation and angiography is used for diagnosis only if the site of bleeding is still obscure. Angiography is the preferred method for investigation of massive lower gastrointestinal bleeding if results of sigmoidoscopy are negative. Vasopressin infusion is most useful for control of bleeding from esophageal varices, erosive gastritis and diverticular disease of the colon. Embolization with Gelfoam or clot is possible for massive hemorrhage from a single source in poor-risk patients. This is most successful for gastric or duodenal bleeding since the collateral blood supply prevents infarction. Some of the methods and complications of embolization are discussed and examples are given. Standard surgical principles should still apply in most cases.

Adult↗

PubMed1984

Progress in carotid artery surgery at the base of the skull.

From 1977 to 1984, 752 reconstructions of the supra-aortic arteries were performed at our service. In a group of 31 patients presenting with transient ischemic attacks (13) or minor strokes (15), preoperative multiplane angiograms identified lesions from various causes in extremely high locations (fibromuscular dysplasia, 10; atherosclerosis, 6; traumatic changes, 10; spontaneous dissection, 3; and mycotic aneurysms and others, 4) in 34 internal carotid arteries (aneurysms, 10; and stenosis, 24). Surgery was performed on 30 patients. Flow restoration was achieved by resection and vein graft replacement (20), gradual dilatation (5), thromboendarterectomy (6), and tangential clip for exclusion of a lateral aneurysm (1). Only one patient was treated with an extracranial-intracranial anastomosis because the stenosis extended into the carotid siphon. One patient was treated with heparin. Exposure of the internal carotid artery (ICA) at the base of the skull required dissection of the digastric muscle, careful mobilization of the cranial nerves, and detachment of the styloid process in 29 patients. Partial resection of the mastoid process was helpful in two patients. The carotid bone canal was opened from the lateral side in four cases to allow the most distal anastomosis 1 cm within the carotid canal. Back-bleeding was controlled by a balloon catheter. A shunt was impossible to use and clamping time averaged 62 +/- 40 minutes. Except for one recurrent stroke and two transient ischemic attacks no other neurologic deficits occurred. Cranial nerve damage could not be avoided in 21 cases (nervus recurrens, 7; nervus glossopharyngeus, 16; and nervus facialis, 4) but disappeared clinically within a 1- to 6-month period in all but two. Each surgical patient underwent control angiography, which demonstrated 30 arteries to be patent, two became occluded, and one had an insignificant stenosis. We conclude that standard surgical techniques are unsuitable for repair of highly located lesions of the ICA. Although extracranial-intracranial anastomosis has been proposed in patients with planned ligation of the ICA, the anatomic reconstruction remains advantageous because flow is restored to normal and the source of emboli is eliminated. With the use of a special approach, graft replacement can be performed up to the base of the skull.

Adolescent↗

PubMed1976

Multiple arterial occlusions and hypertension probably caused by an oral contraceptive: a patient in whom the development of renovascular hypertension has been followed.

An 18-year-old woman taking an oral contraceptive was admitted to hospital because of a stroke due to occlusion of three branches of the right middle cerebral artery. She later developed renovascular hypertension due to occlusion of one of two renal arteries on the right side. Occlusion of the ceoliac artery was also found. The circumstances suggest that the occlusions were caused by multiple emboli, the source of which could not be identified. The kidney with the circulatory disturbance was shown to have a persistent abnormal renin secretion three and six months after the stroke, but the peripheral renin level was lower at the second investigation. Cardiac function studies revealed an alarming degree of left ventricular hypertrophy, and satisfactory blood pressure control could not be maintained despite increasing antihypertensive therapy. Surgical corrrction of the circulatory disturbance promptly led to normotension without drugs, and the patient has remained normotensive during the postoperative observation period of twelve months. The oral contraceptive was probably responsible for precipitating the vascular occlusions, but no predisposing factors or warning symptoms were present to identify this patient as being at risk.

Adolescent↗

PubMed2006

Factors affecting recovery and discharge following ambulatory surgery.

PURPOSE: Recovery and discharge following ambulatory surgery are important components of the ambulatory surgery experience. This review provides contemporary perspectives on the issues of discharge criteria, fast-tracking, patient escort requirements, and driving after ambulatory anesthesia. SOURCE: A search was performed in the Cochrane Central Register for Controlled Trials, MEDLINE(R), EMBASE(R), CINAHL, and PsycINFO, to review factors delaying discharge following ambulatory surgery. The following subject headings were used: "ambulatory surgery, discharge, recovery, car driving, escort, transport, fast tracking, patient discharge, recovery, transportation of patients, hospital discharge, recovery room, patient transport, hospital discharge, recovery room, anesthetic recovery, patient transport, ambulatory surgical procedures, patient discharge, recovery of function, automobile driving, patient escort service, recovery room". Using the same search engines, the following keywords were used: "fast tracking, recovery, and discharge". PRINCIPAL FINDINGS: The current literature supports that discharge scoring systems may be useful to guide discharge following ambulatory surgery. While fast-tracking has become common in some centres, further studies are required to justify more routine implementation of this practice in the management of patients undergoing ambulatory surgery. Patients at low risk for urinary retention can be discharged home without voiding. Patients should not drive until at least 24 hr postoperatively. CONCLUSIONS: Ensuring rapid postoperative recovery and safe discharge following ambulatory surgery are important components of the ambulatory surgical program. A clearly defined process should be established for each ambulatory surgical unit to ensure the safe and timely discharge of patients after anesthesia, in accordance with current best evidence.

Ambulatory Surgical Procedures↗

PubMed1994

Acute vaginal bleeding in women undergoing liver transplantation.

OBJECTIVES: Our aim was to define the nature of acute vaginal bleeding problems in women undergoing liver transplantation and to determine the efficacy of treatments given. STUDY DESIGN: We performed a retrospective chart review of 24 patients undergoing liver transplantation in whom consultation was requested for vaginal bleeding. RESULTS: Twenty-four liver transplant patients were seen for evaluation of acute vaginal bleeding. Two patients were seen before transplantation, and 16 women were evaluated for bleeding after transplantation (8 within the first 15 postoperative days). In the other eight women abnormal uterine bleeding developed between 2 months and 5 years after transplantation. Five of these women had compromised liver function. In six other women vaginal bleeding originated from extrauterine sources. Six of seven endometrial biopsy specimens revealed proliferative endometrium, and the other showed adenomatous hyperplasia. Three of four patients had a response to progestational agents, bleeding stopped spontaneously in three patients, two required hysterectomy, and three died of other causes. The other five patients were not seen again by us before or after discharge from the hospital. CONCLUSIONS: Medical or surgical therapy can effectively control acute vaginal bleeding in liver transplant patients.

Acute Disease↗

PubMed2001

First trimester surgical abortion practices: a survey of National Abortion Federation members.

The objective of this study was to survey first trimester surgical abortion practices of North American providers. A survey was mailed to the 310 active member clinics of the National Abortion Federation, the professional organization of abortion providers in North America. The 236 respondents (76%) comprising the study group provided approximately 30% and 33% of all first trimester abortions in the US and Canada, respectively. Of the 529 practitioners who perform most abortions at the clinics, 68% are obstetrician-gynecologists, and 18% are family physicians; 51% are at least 50 years old. The majority of respondents (156 of 236, 66%) confirm gestational age with ultrasonography. Of the 202 clinics that favor one method of anesthesia, 58% use local cervical block with or without oral pre-medication, 32% combine local anesthesia with intravenous sedation, and 10% use general anesthesia. Most clinics open the cervix with tapered dilators (207 of 233, 89%), evacuate the uterus by using curved rigid plastic cannulas (157 of 229, 69%) and an electric vacuum source (191 of 233, 82%), and explore the uterus with a metal curette following aspiration (133 of 232, 57%). A large majority of respondents examine the uterine aspirate on-site (91%), prescribe antibiotics (91%), and offer oral contraceptives (95%) when requested. Although variations exist, surgical techniques and postoperative practices are quite uniform among clinics. Local anesthesia is presently the most frequent method of pain control. Ultrasonographic dating before abortion is common practice. The "graying" of skilled practitioners raises concerns about the future availability of abortion.

Abortion, Legal↗