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PubMed1997

[Is a preoperative evaluation program in treatment of patients with chronic lumbar syndrome useful?].

The Pre-Operative Evaluation Program (PEP) in the USA is a 1-week outpatient program for patients who have physical pathology which could be improved with surgical intervention. Patients are prepared for surgery and their hospital stay through an education process that includes educational groups, understanding of anatomy, pain and stress management, psychological testing and exercises to improve strength and spine techniques to improve functional abilities. The orthopedic clinic in Kassel developed a 14-days inpatient preoperative evaluation and education program (PEP) for potential surgical candidates with chronic back or neck pain.

Adaptation, Psychological↗
PubMed2004

[Asymptomatic carotid stenoses. A cardiologist's viewpoint].

Cardiologist work is undergoing profound changes. He is in charge of the prevention and treatment of atherothrombotic disease. Preoperative evaluation of global cardiovascular risk is of paramount importance to choose between medical, surgical or interventional treatment. Furthermore, because the cardiologist has extensive experience with coronary angioplasty, he will have an essential role in carotid angioplasty.

Angioplasty↗
PubMed1996

Radiology of pulmonary emphysema and lung volume reduction surgery.

Lung volume reduction surgery (LVRS), which involves the bilateral wedge resection of 20% to 30% of the most diseased lung through a median sternotomy, is emerging as a promising treatment option for select patients with severe, debilitating emphysema. This article details our observations and preliminary investigations related to the imaging evaluation of patients including selection criteria, postoperative findings, and structural changes in the thorax after surgery. Routine preoperative evaluation includes inspiratory and expiratory chest radiographs, computed tomography (CT) examination, and nuclear medicine lung scan. Investigational studies include quantitative CT to assess disease severity and dynamic magnetic resonance imaging to study respiratory movements. Postoperative improvement in FEV1, oxygenation, and exercise tolerance correlate with the degree of heterogeneity, hyperinflation, lung compression, upper lobe severity, and percentage of retained mildly diseased lung shown on preoperative imaging studies. Postoperative radiographic monitoring is important for detection of complications. Postoperative follow-up examinations show reduced thoracic distention, improved coordination of respiratory movement, and increased diaphragm curvature and excursion, supporting the hypothesis of improved respiratory mechanics as a major contributing factor to the success of LVRS.

Follow-Up Studies↗
PubMed1990

Aortocoronary bypass surgery for coronary arterial lesions resulting from Kawasaki disease.

To establish the indications for aortocoronary bypass surgery on coronary artery lesions caused by Kawasaki disease, we analyzed surgical outcome in 26 patients. Ages at operation ranged from 1 to 17 years. All patients were followed up with selective coronary arteriography, thallium myocardial imaging, electrocardiography at rest, and the Master "two-step" and treadmill exercise tests for coronary insufficiency. Surgical outcome was analyzed by comparing results of patient examinations made preoperatively with those both at 1 month and 1 year postoperatively. One month after the operation, 25 (93%) of 27 internal mammary artery grafts and 6 (86%) of 7 saphenous vein grafts were patent; 1 year after the operation, 19 (86%) of 22 internal mammary artery grafts and 6 (67%) of 9 saphenous vein grafts were patent. By comparing the preoperative findings of myocardial imaging with those obtained 1 month after surgery, we found that 17 (68%) of 25 showed improvement and 3 (12%) of 25 were worse. At 1 year, 6 (29%) of 21 showed further improvement than at 1 month, suggesting increased development of the coronary bed after internal mammary artery graft anastomosis. Thus an internal mammary artery graft has proved to be satisfactory in the management of children with coronary artery obstruction caused by Kawasaki disease; it appears that both the quality of life and the life expectancy of those patients can be improved by the surgery.

Adolescent↗
PubMed1993

Rehabilitation after coronary bypass surgery: coping strategies predict metabolic improvement and return to work.

Thirty-six consecutive male patients who underwent coronary bypass surgery were investigated before and repeatedly up to 5 years after surgery. We followed the patients' physical capacity, dietary and exercise habits, mood, perception of health and return to work. Discriminant analysis identified four variables from the preoperative interview and the psychological tests which correctly classified 22 out of 24 patients into either metabolic responders--who were characterized by favourable changes in their lipoprotein profile, related to a successful clinical outcome--or non-responders. Responders were found to acknowledge subjective, emotional aspects of their situation whereas non-responders minimised their disease. Six preoperative variables successfully predicted the classification of all but one patient into full-time workers or not, one year after surgery. Full-time workers were more frequent among minimizers. The results suggest that whereas minimising of disease is adaptive in a short-term perspective, acknowledgement may be successful in the long run.

Adaptation, Psychological↗
PubMed1991

Dipyridamole perfusion scintigraphy.

Dipyridamole is one of several agents that may be infused intravenously to nonivasively evaluate coronary perfusion without dynamic exercise. Among such agents it is the most investigated, and it is associated with the greatest clinical experience. Its mechanism of action utilizes intrinsic adenosine and does not require the induction of ischemia. Rather, the method tests the coronary flow reserve by dilating the precapillary and arteriolar capillary beds. Vessels with a limited coronary flow reserve demonstrate reduced responsiveness with relative flow reduction and a resultant defect on perfusion scintigraphy. Side effects are common and generally benign, but deaths have been reported and they generally relate to severe hypotension, prolonged dense ischemia and resultant infarction, or bronchospasm. Severe complications are rare and can be avoided by the prompt administration of aminophylline, the dipyridample antedote. Diagnostic accuracy for the identification of coronary disease appears similar to that for exercise perfusion scintigraphy. It should be applied to patients with known or suspected coronary disease who require coronary evaluation, but who cannot exercise adequately for diagnostic or prognostic purposes. In such patients, the method is useful for the preoperative assessment of risk at peripheral vascular and other major noncardiac surgery. It may be of value as well in the assessment of the otherwise uncomplicated patient postinfarction. Not yet established is its application to the patient with unstable angina or in the acute setting, after coronary reperfusion. Similarly, its comparison with direct adenosine infusion or with pharmacological agents whose mechanism rests entirely on ischemia induction, as does dobutamine, has until now been limited. Unlike its use with perfusion scintigraphy, the application of dipyridamole with echocardiography and other functional ischemic indicators is totally dependent on the induction of ischemia. This is likely less frequent than the induction of nonischemic perfusion heterogeneity. The agent is now commonly available and will make a significant beneficial impact on patient evaluation and management.

Coronary Disease↗
PubMed1993

Comparative prognostic value of clinical risk indexes, resting two-dimensional echocardiography, and dipyridamole stress thallium-201 myocardial imaging for perioperative cardiac events in major nonvascular surgery patients.

The relative prognostic value of widely accessible resting two-dimensional echocardiographic ventricular function data has not been compared with recognized clinical and scintigraphic risk markers in patients who are unable to exercise before major nonvascular surgery. To this end, 53 consecutive patients aged 67 +/- 13 years undergoing preoperative evaluation (intraabdominal, 23%; orthopedic, 30%; thoracic, 9%; other, 38%) for known or suspected coronary artery disease were followed up to evaluate the prognostic value of these studies for the perioperative cardiac events (cardiac death [n = 4], myocardial infarction [n = 2], unstable angina [n = 3], and pulmonary edema [n = 8]) that occurred in 13 of the 53 patients (25%). Dipyridamole thallium-201 myocardial redistribution defects occurred in 15 (28%) patients. Resting echocardiographic left ventricular dysfunction was present in 21 (40%) patients. Multivariate analysis of clinical, echocardiographic, and scintigraphic risk predictors revealed that cardiac events were not predicted by clinical variables, including Goldman class or score. Cardiac events were independently predicted only by the presence of significant left ventricular dysfunction on resting two-dimensional echocardiography (p < 0.042) and dipyridamole thallium-201 defect redistribution (p < 0.026). A dipyridamole-induced reversible thallium-201 perfusion defect was predictive of subsequent cardiac death or myocardial infarction (p < 0.02), whereas left ventricular dysfunction on resting echocardiography was predictive of perioperative pulmonary edema (p < 0.023). We conclude that stress thallium-201 perfusion imaging and resting two-dimensional echocardiography provide independent prognostic information in patients undergoing major nonvascular surgery who are at significant risk for ischemic cardiac events and who are unable to perform standard exercise stress tests.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1980

Results after resection of postinfarction left ventricular aneurysms.

Although left ventricular aneurysmectomy (LVA) is a common surgical procedure, the late functional and hemodynamic results have not been well defined. This presentation describes our results with LVA in 135 patients operated between 1969 and 1979. Associated procedures were performed in 57 (42%) including coronary bypass grafting in 50, valve replacement in 5, closure of ventricular septal defect in 2, or combinations of these in 3 patients. One hundred four of the 122 hospital survivors were followed from 2 to 107 months (mean = 37 months). There were 13 hospital deaths (9.6%), 12 late deaths (9.8%) and an actuarial 5-year survival rate of 77%. Clinical improvement of preoperative heart failure occurred in 82%, and of angina in 70%. Only 33 patients (30%) returned to normal work. Bicycle exercise testing in 70 patients showed normal working capacity in 41 (59%). Recatheterization in 49 patients showed no significant changes in left ventricular end-diastolic pressure or cardiac index, and a borderline reduction of the total ejection fraction. Ventricular arrhythmias were detected by long-term ECG in 70% of all patients after surgery. Of those with preoperative life-threatening arrhythmias, rhythm improvement was noted in 50%, but only 2 of 13 patients were free of arrhythmias after operation. This study demonstrates a greater frequency of postoperative symptomatic and functional improvement as compared to hemodynamic and ECG improvement. Ventricular tachyarrhythmias originating from post-infarct scars increased intra- and postoperative risk and aneurysmectomy alone is considered insufficient for treatment of these disturbances. Further electrophysiologic investigations are needed and additional surgical measures may be necessary to improve the subset of patients with life-threatening arrhythmias.

Adult↗
PubMed2006

Ventriculocordectomy as the sole treatment for recurrent laryngeal neuropathy: long-term results from ninety-two horses.

OBJECTIVE: To evaluate the effect ventriculocordectomy (VC) for treatment of recurrent laryngeal neuropathy (RLN) on exercise performance and owner satisfaction in a mixed-breed population of horses. STUDY DESIGN: Retrospective study. ANIMALS: Adult horses (n=92) with a history of abnormal respiratory noise and RLN. METHODS: Retrospective analysis of horse that had unilateral VC (and contralateral ventriculectomy in 63 horses) for treatment of idiopathic RLN. Owners/trainers completed a questionnaire about complications and outcome at least 1 year after surgery. Performance index was determined using race records for previously raced Thoroughbreds to evaluate outcome. RESULTS: Clinical signs included abnormal exercise-induced respiratory noises (noises; 52%), poor performance (11%), and noises and poor performance (37%). The median preoperative resting endoscopic grade of laryngeal function was Havemeyer grade III.1 (mild asymmetry). No discharge from the laryngotomy 1 week postoperatively occurred in 62% horses, 22% coughed after surgery, 66% made no noises, 9% continued to make noises at the canter, 21% made noise at the gallop, and 4% of owners were unsure whether noises were present. Ninety-three percent of horses returned to full work after surgery. Overall, 86% of owners considered the surgery worthwhile, 3% did not consider it worthwhile, and 11% were unsure. Surgery had a significantly beneficial effect on the racing performance index in Thoroughbreds (P=.004). CONCLUSIONS: VC is a useful alternative to laryngoplasty for selected cases of RLN and is associated with a positive effect on exercise performance, a low postoperative complication rate, and a high rate of owner satisfaction. CLINICAL RELEVANCE: Unilateral VC should be considered as a sole treatment in horses with low grades of RLN.

Animals↗
PubMed1995

Bilateral pneumectomy (volume reduction) for chronic obstructive pulmonary disease.

We undertook surgical bilateral lung volume reduction in 20 patients with severe chronic obstructive pulmonary disease to relieve thoracic distention and improve respiratory mechanics. The operation, done through median sternotomy, involves excision of 20% to 30% of the volume of each lung. The most affected portions are excised with the use of a linear stapling device fitted with strips of bovine pericardium attached to both the anvil and the cartridge to buttress the staple lines and eliminate air leakage through the staple holes. Preoperative and postoperative assessment of results has included grading of dyspnea and quality of life, exercise performance, and objective measurements of lung function by spirometry and plethysmography. There has been no early or late mortality and no requirement for immediate postoperative ventilatory assistance. Follow-up ranges from 1 to 15 months (mean 6.4 months). The mean forced expiratory volume in 1 second has improved by 82% and the reduction in total lung capacity, residual volume, and trapped gas has been highly significant. These changes have been associated with marked relief of dyspnea and improvement in exercise tolerance and quality of life. Although the follow-up period is short, these preliminary results suggest that bilateral surgical volume reduction may be of significant value for selected patients with severe chronic obstructive pulmonary disease.

Adult↗
PubMed1984

Objective clinical evaluation of function. Gait analysis.

Automated gait analysis allows us to document and quantify objectively normal gait, functional deficits, and patient response to therapeutic intervention. Instrumentation for this analysis at the Mayo Clinic Gait Laboratory includes three-dimensional electrogoniometers for measurement of relative joint rotation at the hip, knee, and ankle; footswitches that record foot-floor contact sequences; instrumented mats that measure step length and width; piezoelectric force plates for measurement of floor reaction forces; and two walkways that simulate a variety of ground conditions. We use a DEC-PDP 11/34 computer for acquisition, storage, and analysis of data and for generation of a gait report form that displays a patient's results relative to normal and previous evaluations. Applications of these techniques include assessment of function preoperative and postoperative total joint arthroplasty, quantification of gait faults, and documentation of effectiveness of exercise and gait training techniques. We have demonstrated the reliability of the techniques, accumulated a sizeable normal data bank, and developed a concise, effective data summary for communication with referring practitioners.

Amputees↗
PubMedDate not supplied

Considerations in prevention of surgical site infections following cardiac surgery: when your patient is diabetic.

The incidence of surgical site infections among patients with diabetes continues to occur at a greater rate when compared with their nondiabetic counterparts. Preexisting vascular changes, delayed wound healing, and impaired immune factors contribute. Adult patients with diabetes likely possess comorbid coronary artery disease, thus increasing the need for cardiac surgery. The resultant potential for infection can be combated with supplementary interventions above those universally taken. Modifiable risk factors of hyperglycemia and obesity are targeted preoperatively. Glycemic control, adequate tissue perfusion, and adjunct use of nasal mupirocin are addressed intraoperatively. Lastly, focus is placed on nutrition, exercise, and continued glucose control postoperatively and beyond discharge.

Bandages↗
PubMed1996

Rehabilitation after autogenous bone-patellar tendon-bone ACL reconstruction.

In the past decade, changes in the rehabilitation of patients with ACL injuries have made a dramatic impact on the management of the surgically treated ACL-deficient knee. Our rehabilitation program following the ACL reconstruction has been developed over the past 12 years. With close follow-up of our patients, we have modified the rehabilitation program in an attempt to eliminate postoperative complications, ensure long-term knee stability, and allow a safe and rapid return to athletic activities. Our present rehabilitation protocol is divided into four phases. The initial phase encompasses the preoperative period. The second phase involves the first 2 weeks after ACL reconstruction. The third phase extends from 2 to 5 weeks postoperation, and the final phase (> than 5 weeks postoperation) involves a safe return to athletic activities. An aggressive preoperative phase and close attention to full hyperextension, control of swelling, and good leg control during the first postoperative phase are the cornerstones of the rehabilitation program. We continue to evaluate our results closely and to advance our rehabilitation program guided by our patients and continuous follow-up evaluations. We propose that the avoidance of immediate surgery and appropriate preoperative patient preparation, along with postoperative rehabilitation program that emphasizes extension and closed chain function exercises, will optimize the final result.

Adult↗
PubMed1977

Diagnosis of perioperative myocardial infarction after coronary artery bypass.

The diagnosis of perioperative myocardial infarction (POMI) in patients undergoing coronary artery bypass is uncertain because the criteria of infarction are unclear. Fifty patients who underwent coronary artery bypass were evaluated preoperatively and postoperatively with serial ECGs, creatine phosphokinase (CPK), isoenzyme determinations, and technetium pyrophosphate myocardial scans. Clinical evaluation correlated with exercise testing and postoperative angiography supported the diagnosis in questionable cases. Thirty-five patients (70%) had no evidence of POMI by any criteria, and 2 patients (4%) had unequivocal evidence of infarction by all criteria. Our studies indicate the complexities of diagnosing POMI. We believe that the serially recorded ECG is the most useful diagnostic technique. CPK isoenzyme determinations may be useful but are difficult to interpret in the operative setting. Preoperative cardiac scans are necessary so as to avoid a high incidence of false-positive scans postoperatively. In doubtful cases, postoperative coronary arteriography and left ventricular angiography may provide the most definitive information.

Adult↗
PubMed2003

[Preoperative risk assessment and ambulatory management].

Evidence and practical approach of Coronary Risk Assessment in noncardiac surgery are reviewed. Growing literature suggests a benefit of perioperative b-blockade. Therefore, risk stratification and management are described in algorithms in order to provide a useful tool for practitioners both in the hospital and ambulatory setting.

Adrenergic beta-Agonists↗
PubMed1985

Qualitative and quantitative evaluation of the exercise electrocardiogram in assessing the degree of coronary heart disease.

Exercise-induced changes in the ST segments of the electrocardiogram were compared with the results of coronary arteriography in 73 consecutive patients referred for preoperative evaluation of coronary artery disease. Eighteen patients had single-, 25 double-, and 30 triple-vessel disease. Thirteen were taking digitalis alone, 28 were taking beta blockers alone, 21 had beta blockers and digitalis and 11 had no cardiac drugs. Exercise induced elevation of the ST segment in 11 patients, all with a predominant lesion in the left anterior descending coronary artery. ST depression with an upsloping ST segment was observed in patients with one-, two-, and three-vessel disease and it was the most common type of ST change in patients with single-vessel disease. Horizontal ST depression was most common in two-vessel disease and downsloping ST segment in three-vessel disease. There was a good correlation between the number of stenosed vessels and ST changes caused by exercise, expressed as the sum of ST segment displacements in twelve leads recorded immediately after the end of exercise (sigma/ST/) or as ST depression per unit increase in heart rate during exercise ("m" (ST/HR]. The latter was obtained by linear regression of ST displacement and heart rate measured at three or four different workloads in the lead with the greatest displacement of the ST segment. The mean values of sigma/ST/ were 0.58 +- 0.030 mV in single-vessel, 0.97 +- 0.41 mV in double-vessel and 1.58 +- 0. 46 mV in triple-vessel disease. The mean values of "m" (ST/HR) were 0.0024 +- 0.0013 mV X min-1 X beat-1 in single-vessel, 0.0042 +- 0.0012 in double-vessel, and 0.0078 +- 0.0033 in triple-vessel disease. These differences were highly significant (p less than 0.01 - 0.001) and there was only minimal overlap between the single- and triple-vessel groups. Digitalis caused a slight (statistically nonsignificant) increase in sigma/ST/ but not in "m" (ST/HR).

Adrenergic beta-Antagonists↗