[Prevention of motility disorders of the gastrointestinal tract after surgery on the organs of the abdominal cavity].
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Abdomen↗
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Results for “Autonomous surgery”
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[The implementation of endoscopic sinus surgery in Spain].
The purpose of this study is to find out more about the implementation of functional endoscopic sinus surgery (FESS) in our country. To do that, we designed a survey which was sent to 160 public hospitals (June 2002). We received the answers of 111 hospitals. 82.9% of hospitals and 58% of surgeons performed FESS, with some differences among autonomic regions. The percentage of surgeons who performed FESS was higher in small hospitals and their mean experience time was 6.2 years. We consider the implementation of endoscopic sinus surgery very high, this can reflect that there are evident advantages for those who specialists who use it.
Endoscopy↗
Malignant thymoma with dysautonomia and disordered neuromuscular transmission.
A 42-year-old man had prominent dysautonomia accompanied by clinical and electrophysiological features of both myasthenia gravis and the Lambert-Eaton myasthenic syndrome. Antiacetylcholine receptor antibodies were present in high titer. Invasive thymoma was found at thymectomy; later, a solitary metastasis to the spleen required a splenectomy. Complete remission followed surgery. There was evidence of antibody activity directed against postsynaptic acetylcholine receptors, presynaptic somatic motor terminals, and autonomic effector junctions. To our knowledge, the association of thymoma with a myasthenia gravis-Lambert-Eaton overlap syndrome has not been reported previously.
Adult↗
Intact parathyroid hormone in primary hyperparathyroidism.
In 49 patients with primary hyperparathyroidism, intact parathyroid hormone (PTH) was measured with a recently developed immunoradiometric assay, and midregional PTH fragments (sequence 44-68) were measured with an established radioimmunoassay technique. In 47 normal subjects, the concentration of intact PTH ranged from 2.0 to 6.8 pmol/l, and in 49 patients with primary hyperparathyroidism it ranged from 6.4 to 80.0 pmol/l. In contrast, midregional PTH fragments were normal in seven of 49 patients with primary hyperparathyroidism. In five healthy controls and in 12 patients with surgically confirmed primary hyperparathyroidism and serum calcium levels below 3.0 mmol/l, a rapid calcium loading test was performed. In healthy controls, intact PTH was in the low normal to subnormal range within 2.5-5.0 min, and had recovered within 15 min of calcium infusion. In patients with primary hyperparathyroidism, the calcium infusion also led to a 30-50 per cent decrease in intact PTH levels within 5.0-7.5 min after injection, with a slow recovery after 10-15 min. In six of the patients with only slightly elevated basal intact PTH, a suppression to the normal range was observed. In 24 patients (16 patients with a solitary adenoma and eight patients with four-gland hyperplasia) the intact PTH levels were followed intraoperatively during parathyroidectomy, revealing a significantly different rate of decline for single adenomas compared with hyperplasia during the first 15 min after removal of the primary enlarged gland. Intact PTH values remained constantly elevated in one patient with primary hyperparathyroidism and an unsuccessful neck exploration. These results confirm that (a) the measurement of intact PTH in patients with primary hyperparathyroidism is superior to the measurement of midregional fragments; (b) PTH secretion in primary hyperparathyroidism is not totally autonomous; and (c) intraoperative monitoring of intact PTH values could be used to monitor the success of surgery.
Adenoma↗
Post-prostatectomy incontinence. A urodynamic and fluoroscopic point of view.
Sixty-three male patients suffering from post-prostatectomy incontinence were studied by urodynamics and fluoroscopy. In almost half the patients (49%) the sole cause of incontinence was detrusor instability. Incontinence due to damage of the sphincter mechanism was present in less than half of the patients (47%). However, almost half of these patients (53%) had concomitant detrusor instability. Only a small number of patients (4%) had incontinence due to other causes. It appears that post-prostatectomy incontinence is not always due to a surgical misadventure. Many older patients may have preexisting neurologic disorders (e.g., Parkinson disease, diabetic autonomic neuropathy, alcoholic neuropathy, and various spinal cord disorders) which can profoundly affect the outcome of prostatic surgery. Detrusor instability should be considered when evaluating post-prostatectomy incontinence.
Adult↗
Anatomy of cavernous nerves distal to prostate: microdissection study in adult male cadavers.
Retrograde and antegrade dissections from the penile hilum to the prostatic area and the glans penis were performed in 4 formalin-preserved adult male cadavers. In addition to the medial branches accompanying the urethra, the lateral branches of the cavernous nerves pierced the urogenital diaphragm 4 to 7 mm from the striated muscles of the external sphincter. At the penile region, multiple communications between the cavernous and dorsal nerves were noted that suggest that either the cavernous nerves use the dorsal nerve as a carrier to the distal portion of the penis or the dorsal nerve may itself contain autonomic fibers. These findings will improve our ability to preserve erectile function during pelvic, urethral, and penile surgery.
Adult↗
[Anatomic and clinical evidence of intrapelvic pudendal nerve and its relation with striated sphincter of the urethra].
OBJECTIVE: To demonstrate that somatic innervation of the urethrae striate sphincter is intrapelvic and not through an internal pudendal nerve, an extrapelvic nerve in its entire path. To study the relationship of the pelvic plexus with genito-urinary organs and its surgical implications. METHODS: 6 embryos and 2 fetuses, sliced and stained with techniques suitable for nervous structures were studied. Sequential observation of the pelvic plexus structures and the internal pudendal nerve was carried out using light microscopy. Three-dimensional reconstruction of the two fetuses was performed to study the relationships of these structures with the genito-urinary organs. RESULTS: A nervous branch was identified in the 19, 25 and 30 mm long specimens that started at the internal pudendal nerve and joined the hypogastric ganglion close to the site of pelvic nerves binding. Hypogastric ganglion efferent branches penetrating the striate sphincter after a short descendent run were seen in the 30 and 39 mm embryos. CONCLUSIONS: Our findings confirm that the urethrae striate sphincter received the autonomous and somatic innervation from the pelvic plexus and, therefore, is susceptible to damage during cancer related surgery of the pelvic organs. An improved knowledge of these structures and the use of nerve preservation surgical techniques can reduce the incidence of post-operative incontinence in this type of surgery.
Humans↗
A single-centre experience of retroperitoneoscopy using the balloon technique.
OBJECTIVE: To report the experience in one centre of the efficacy and safety of retroperitoneal laparoscopic procedures (RLPs). PATIENTS AND METHODS: During 1991-2000, 351 RLPs using the balloon technique were undertaken in 340 patients (mean age 34.9 years, range 4-74); the details and outcome were reviewed. Initial access was by the mini-open digital dissection technique in 152 and by the closed percutaneous technique in the remaining 199 procedures. Patients had not undergone previous retroperitoneal procedures, except for nine who had a percutaneous nephrostomy and eight ipsilateral abdominal surgery. There were 172 renal, seven adrenal, 97 ureteric, 50 gonadal, 13 lymphatic system, three vesical, two autonomic nervous system and seven vertebral RLPs. Nitrous oxide was used for pneumo-insufflation in 103 procedures, instead of CO2. RESULTS: The RLP was successful in 318 of the 351 procedures (90.6%). The operative duration was 0.5-5.5 h, depending on the difficulty of the procedure and the presence or absence of adhesions. The overall incidence of complications was 12.9%, but decreased to 9% for the last 100 procedures. There were only five major complications, e.g. avulsion of the ureter, torn renal pelvis, colonic injury and severe hypotension, but none were related to balloon dissection. The mean blood loss was 37.7 mL and the reason for transfusion in three patients was not operative blood loss but displacement of the ligature in two and severe hypotension after removing a phaeochromocytoma in one. The mean duration of analgesic use was 2.5 days, the hospital stay 3 days and return to work 14 days. CONCLUSION: Retroperitoneal laparoscopy using the balloon technique is a reasonably safe, efficient and reliable minimally invasive procedure. The efficiency, efficacy and safety of RLPs depend more on experience than on the type of access technique, type of balloon or medium used to inflate the balloon. Balloon rupture causes no tissue damage, and expansion to approximately 800 mL in adults is safe if the retroperitoneal space has not previously been invaded. The use of nitrous oxide for pneumo-insufflation in the retroperitoneal space is safe if proper precautions are taken.
Adolescent↗
[The neck -- a sonographically interesting region for many medical fields].
The soft tissues of the neck can be examined at the highest resolution with ultrasound probes of high frequencies due to their superficial position. There are many clinically important diagnostic issues concerning the thyroid gland, the parathyroid, lymph nodes, vessels of the neck, salivary glands and other structures of the field of ENT and even the nerves of this region. Numerous different medical departments therefore work in this field either together or I a parallel fashion. In addition to different sub-specialties of internal medical and surgical departments, radiologists, neurologists, ENT doctors, gnathologists and radio-oncologists are all active here. Even intensive care personnel and anaesthesiologists use ultrasound for sonographically guided punctures. It is therefore obvious that the cervical region is of special importance for an interdisciplinary journal, constituting a large part of publications. In the last 2 (1/2) years, we published two articles about cervical lymph nodes , eight concerning the topic of vessels , two articles about salivary glands and three dealing with the parathyroid glands . The present issue again contains three publications concerning this area, characteristically from three different medical specialties, each of great significance for various medical fields. An important article deals with deQuervain thyroiditis . Albeit this is not a common disease, any clinician working on the cervical region should be well aware of this entity, as the patients concerned often go through a medical "odyssey" with different specialists before the right diagnosis is made. An important addition to sonographical interventional techniques is percutaneous instillation therapy for focal autonomous adenomas of the thyroid : it is fast acting and effective, representing a genuine therapeutic alternative to surgery or radioactive iodine treatment in many cases. The case report on a - fortunately non-permanent - partial laryngeal necrosis resulting from the instillation of 96 % alcohol demonstrates the potential damage an established method can cause if applied without expertise. It is therefore mandatory to be aware of potential side effects and carry out the intervention proficiently, strictly keeping in mind the indication for therapy. A further case report demonstrates in an impressive way the importance of cervical sonography for the detection and landmarking of parathyroid adenomas. The fact that the author is a surgeon might serve as valid proof, as the surgery of parathyroid glands almost solely depended on the experience and the explorative skill of the surgeon until recently.
Humans↗
[Biological and developmental aspects of macronodular adrenal hyperplasia in Cushing's disease].
The pathophysiology of macronodular adrenocortical hyperplasia (MNH) associated with Cushing's diseases remains debatable. Some authors have claimed that MNH represents an autonomous condition that has to be treated by surgical adrenalectomy while others advocate the use of pituitary surgery. We have compared the biochemical features, before and after pituitary surgery, between 7 cases of MHN and 22 cases of diffuse hyperplasia (DH) associated with Cushing's disease. In addition, the diameter of the adrenal nodules after surgery was evaluated in 6 cases. The mean ACTH level in MNH and DH subjects was similar. Dexamethasone suppressibility and the stimulatory effect of metyrapone on ACTH secretion were less in MNH than in DH subjects, suggesting a greater degree of adrenal autonomy in the former. The cortisol responses to metyrapone and CRF tests suggested an increased responsiveness of the adrenals to endogenous ACTH in the MNH group. Only one MNH patient had biochemical features suggesting a primary adrenal disease. The use of a sensitive ACTH assay and the results of inferior petrosal sinus sampling identified the ACTH-dependency of the disease. A short to medium term remission of the disease was obtained in all cases of MNH and in 87% of cases of DH after surgery. The diameter of the adrenal nodules significantly decreased in only 43% of cases. Our results suggest that the adrenal autonomy in MNH is incomplete and that, despite the persistence of the adrenocortical nodules, the disease can be cured with pituitary microsurgery in most cases.
Adrenal Glands↗
[Physiopathology of combined peridural and general anesthesia].
General anaesthesia alters self-regulation of arterial pressure by lowering the sympathetic tone to his baseline level. More important is the sympathetic stimulation before general anaesthesia, more important will be the decrease in arterial pressure after induction. Epidural anaesthesia always leads to a sympathetic blockade. The extent and the speed of appearance of this blockade condition the magnitude of the decrease of arterial pressure. So, general anaesthesia and epidural anaesthesia both modifying deeply the autonomic nervous system, their association can only be performed on hemodynamically stable patients for a non hemorrhagic surgery. Correcting a deep arterial hypotension demands first of all the use of vasoconstricting agents the choice of which depends on the site of the epidural anaesthesia and on the cardiovascular condition of the patient. However, although the combined use of the two techniques is attractive, it does not seem to improve cardiovascular nor respiratory morbidities in high risk patients compared with classical general anaesthesia. Nevertheless, the high value of epidural analgesia may improve the postoperative course.
Anesthesia, Epidural↗
[Surgery of rectal carcinoma: 1997 status assessment].
The rectum and mesorectum are enclosed in a fascial sheath, the fascia propria, and represent an anatomical entity of abdominal origin. This package is a well-known anatomical and oncological base for radical rectal cancer excision. It is at present under discussion again under new aspects: The surgical and oncological quality of rectal cancer excision is largely surgeon-dependent. Modern rectal surgery is refined, with sharp, very precise dissection respecting the relevant fascial planes, identifying and protecting the autonomous pelvic nerves and achieving radical locoregional tumor clearance, thus virtually eliminating the serious problem of pelvic recurrence. In this overview the concept of total mesorectal excision (TME) is explained and open questions are discussed. It remains to be determined whether a refined and anatomically precise operative technique or the oncologic concept of TME are of primary importance, and also whether patient selection influences the results to some degree.
Anastomosis, Surgical↗
Management of a patient with familial amyloid polyneuropathy type I with lumbar epidural anaesthesia.
Familial amyloid polyneuropathy (FAP) type I is a rare disease characterized by sensorimotor polyneuropathy, and autonomic nervous system and cardiac conduction system dysfunction. Severe bradyarrhythmia and hypotension may occur during anaesthesia and surgery in patients with the FAP type I. Only one report has been published of a patient with FAP type I who was managed with epidural anaesthesia. The present authors report a 38-year-old Japanese man with a permanent pacemaker because of advanced FAP type I who underwent rotation flap of the gluteus maximus muscle to cover a trophic ulcer in the sacral region under lumbar epidural anaesthesia. Ten millilitres of adrenaline (1:200,000) was injected around the ulcer prior to surgical manipulation. Neither bradycardia nor hypotension developed during the procedures. The haemodynamic changes under lumbar epidural anaesthesia in FAP type I are discussed.
Adult↗
[Anesthetic management for urological surgery of patients with chronic spinal cord injury].
We evaluated retrospectively the anesthetic management and perioperative complications of 47 patients with chronic spinal cord injury for genitourinary procedures. Of the 69 cases, 38 were performed under general anesthesia, 21 cases under spinal anesthesia, one case under epidural anesthesia, four cases under axillary block, and five cases under either sedation or standby. In preoperative laboratory findings, anemia was observed in 41%, hypoproteinemia in 38%, renal insufficiency in 23%, and restrictive pulmonary dysfunction in 69%. Hypotension and bradycardia were seen in 25% and 16% of patients, respectively. Autonomic hyperreflexia was seen in four cases with cervical cord injury: two under spinal anesthesia and two under either sedation or standby. Patients with chronic spinal cord injury have disorders of various organ systems. Careful preoperative evaluation and anesthetic management are required for prevention and prompt treatment of perioperative complications related to the disorders. Autonomic hyperreflexia can be successfully prevented by either general anesthesia or spinal anesthesia. The increased anesthesia safety can be obtained by the successful management of the cardiovascular instability during surgery.
Adolescent↗
Factors influencing heart rate variability in patients with severe aortic valve disease.
BACKGROUND AND HYPOTHESIS: Heart rate variability (HRV) is an accepted tool for the assessment of cardiovascular autonomic tone. There are no sufficient data concerning its application to patients with severe aortic valve disease (AVD) requiring cardiac surgery. METHODS: It was the aim of this study to examine HRV and its physiologic correlates in patients with severe aortic valve disease requiring cardiac surgery. The correlates of time domain indices of HRV obtained from 24-h Holter electrocardiographic recordings were analyzed in 36 consecutive patients (23 men and 13 women, mean age 62 +/- 11 years) with AVD prior to cardiac surgery (aortic stenosis: 17 patients, aortic valve regurgitation: 3 patients, combined aortic valve disease: 16 patients). RESULTS: Low values of HRV were found in the entire study group: SDNN 96.8 +/- 30.9 ms, SDNNI 39.3 +/- 14.4 ms, SDANN 86 +/- 28.9 ms, and RMSSD 30 +/- 18.1 ms. In a univariate analysis, there was no significant correlation between the time domain measures of HRV and age, gender, medication, left ventricular ejection fraction, peak aortic pressure gradient, fraction of aortic valve regurgitation, and left ventricular mass assessed by echocardiography. Patients in advanced functional classes of heart failure [New York Heart Association (NYHA) III or IV] had significantly lower values for SDNN (83.8 +/- 33.6 vs. 107.3 +/- 24.7 ms; p < 0.05) and SDANN (72.7 +/- 29.4 vs. 96.6 +/- 24.3 ms; p < 0.05) than patients in NYHA class I or II. Reassessment of HRV 1 week after aortic valve replacement was performed in 17 patients and showed a significant further decrease of SDNN (102.4 +/- 29.7 vs. 61.5 +/- 23.5 ms; p < 0.001), SDNNI (40.7 +/- 13.6 vs. 23.4 +/- 12.4 ms; p < 0.001) and SDANN (91.8 +/- 29.2 vs. 54.2 +/- 22.8 ms; p < 0.001). CONCLUSION: Patients with AVD requiring cardiac surgery reveal reduced time domain indices of HRV. This observation is pronounced in patients with a progressed clinical class of heart failure, whereas hemodynamic and echocardiographic parameters seem to have no significant influence on HRV parameters in this population. In addition, there is evidence of a further reduction of HRV time domain indices 1 week after uncomplicated aortic valve replacement.
Aortic Valve↗
[Endoscopic nasal surgery for pterigopalatine fossa schwannoma].
Schwannomas are tumors of nerve sheath origin, the lesion being derived from the Schwann cells surrounding neural tissue in most of the peripheral, cranial and autonomic nerves. Schwannomas occurring in the head and neck represent 25-35% of all reported schwannomas, and most commonly arise from the acoustic or the neumogastric nerves. In the nose and paranasal sinuses these tumors are very uncommon (fewer than 4% of all schwannomas). In the pterygopalatine fossa they are very rare, and arise in this case from the ophthalmic and maxillary branches of the trigeminal nerve. In this exceptional site, the tumor is classically approached through a Caldwell-Luc incision. In this case, we report the removal of a schwannoma of the pterygopalatine fossa by endoscopic sinus surgery.
Adult↗
Surgery is the procedure of choice for the treatment of patients with toxic adenoma in an endemic goitre area.
PURPOSE: Toxic adenoma is one of the main causes of hyperthyroidism. We investigated the efficacy of surgery in the treatment of toxic adenoma. METHODS: Serum thyroid stimulating hormone (TSH) measurement, ultrasound and scintigraphy of the thyroid were made for diagnostic purpose. The safety of surgery was evaluated by postoperative clinical course of patients. The efficacy of surgery was determined by the function of the remaining thyroid tissue. RESULTS: The incidence of hyperthyroidism was 53% in surgically treated patients with nodular goitre in our iodine deficient region. The cause of thyrotoxicosis was toxic adenoma in 15 patients (14%). Suppressed serum TSH levels indicated the hyperthyroidism in all of 15 patients. Solitary solid adenoma was found by ultrasonographic examination, and solitary autonomous hot nodule by thyroid scintigraphy. Surgical treatment consisted of unilateral total lobectomy. It was the primary treatment in 13 patients. Two patients had surgery as secondary treatment after unsuccessful primary radioactive iodine application. The early postoperative clinical course of all patients was uneventful. Thirteen patients who had surgery as primary treatment had normal thyroid function postoperatively contrary to other two patients who became hypothyroid after having unsuccessful radioiodine therapy, and surgery as the secondary treatment. CONCLUSIONS: The incidence of hyperthyroidism and toxic adenoma is high in our surgically treated patients with nodular goitre. The diagnosis of toxic adenoma is not difficult by serum TSH measurements, and ultrasound and nuclear imaging of the thyroid. Surgery is effective and safe, and the treatment of choice for patients with toxic adenoma in order to control radically the hyperthyroidism and to achieve the goal of providing the euthyroid status.
Adenoma↗
A prospective study of genito-urinary dysfunction after surgery for colorectal cancer.
OBJECTIVE: To establish the incidence of impotence and urinary dysfunction after different forms of pelvic and colorectal surgery. PATIENTS AND METHODS: Over a period of one year, 78 consecutive patients, mean age 66.8 years (range 43-91 years), underwent surgery for colorectal cancer. Genito-urinary function was studied by clinical assessment and a postoperative questionnaire. RESULTS: Pre-operatively all males except one claimed to be potent. Of the 56 patients who had operations on the sigmoid colon and rectum, 12 (21.4%) developed urinary dysfunction; 6 (5 males, 1 female) had increased frequency while 6 (4 females, 2 males) had stress incontinence. Four (12.9%) of the 31 male patients became impotent. Of the control 22 patients who had had operations on the ascending colon, one female developed stress incontinence and none of the male patients developed impotence. CONCLUSION: Although the introduction of autonomic nerve sparing techniques and total mesorectal excision (TME) may have lowered the incidence of genito-urinary dysfunction after rectal surgery, there remains a degree of morbidity compared to procedures where the rectum is not mobilized.
Journal Article↗