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PubMed1999

Physiologic consequences of pneumonectomy. Consequences on the esophageal function.

Esophageal and upper gastrointestinal dysmotility occur after both pneumonectomy without pulmonary replacement and recipient pneumonectomy for thoracic organ transplantation. After pneumonectomy without pulmonary replacement, there is a shift of the esophagus to the side of pneumonectomy and disturbance of esophageal peristalis. After recipient pneumonectomy for thoracic organ transplantation, esophageal dysmotility and delayed gastric emptying are common. Injury of the vagal nerves, local ischemia, postoperative scarring of the esophagus and mediastinum, and disturbance of the autonomic nervous systems are the major causes of the abnormality. To reduce the incidence of esophageal dysmotility after pneumonectomy, every effort should be made during surgery to prevent direct injury of the esophagus or the vagal nerves.

Esophageal Motility Disorders↗
PubMed1990

[Treatment of priapism with intracavernous injection of etilefrine hydrochloride].

A case of priapism following epidural anesthesia was reported. A 67 year old man received epidural anesthesia for the transurethral resection of a malignant bladder tumor. Epidural anesthesia which he had wanted to receive was given through the L3 to L4 intervertebral space with 18 ml of 2% lidocaine. The penile erection occurred while he was prepared and draped. Additional 8 ml of 1% lidocaine failed to overcome it and the operation cancelled. After this episode, he had anesthesia on 5 occasions in 2 years. General anesthesia was given 3 times without penile erection, but epidural block was tried on 2 occasions, which was followed by penile erection. For the penile erection, intracavernous injection of etilefrine hydrochloride was effective and surgical procedure could be done smoothly. The mechanism of priapism remained unclear but imbalance of the autonomic nervous system may be a involved. This case suggests that intracavernous injection of etilefrine hydrochloride is effective for treatment of penile erection during transurethral surgery.

Aged↗
PubMed1988

[Clinical study of extracorporeal shock-wave lithotripsy (ESWL) for renal and ureteral stones. The first report: end-results of 1,000 cases].

Between April, 1985 and May, 1987, we experienced 1,000 cases of extracorporeal shock-wave lithotripsy (ESWL) using a Dornier HM3. In the treatment of smaller stones, no auxiliary treatment was required. On the other hand, endourological treatments such as percutaneous nephrostomy, percutaneous nephroureterolithotomy, transurethral ureterolithotripsy or double J catheterization were combined in the treatment of larger stones. Sixteen percent of the cases were stone-free at the time of discharge from hospital but after more than 3 months 58.4% were stone-free, and including cases with insignificant residual fragments, the outcome was good in 84.2%. As major complications, cerebral bleeding due to autonomic nerve hyperreflexia was observed in one spinal cord injury patient, but generally speaking, the frequency of complications after ESWL was lower than after open surgery and the post ESWL period was rather comfortable for the patient. Surgical therapy for renal and ureteral stones will be performed mainly by ESWL. Manipulations of post-ESWL stone street or residual fragments are important, and detection of late complications is also important.

Adolescent↗
PubMed2005

[Cardiac surgery in octogenarians: a six-year follow-up with a multidimensional intervention].

BACKGROUND: Elderly subjects frequently experience a decline in function following hospitalization and surgery. Specific changes in the provision of acute hospital care can improve the ability of acutely ill older patients to perform activities of daily living at the time of discharge and the quality of life. The aim of this study was to investigate outcomes of older (age > or =80 years) cardiac surgery patients managed with multicomponent intervention. METHODS: Between 1998 and 2004, we studied records of 193 octogenarian patients who underwent cardiac surgery and were treated with a multicomponent intervention that included: specially designed environment, patient-centered care, planning for patient discharge at home, and an interdisciplinary approach that incorporates in- and out-of-hospital health professionals. RESULTS: Mean follow-up was 26.4 months and 100% complete. Mean age of patients was 82.3 +/- 2 years. Eighty-nine patients had myocardial revascularization (CABG), 40 aortic valve replacement (AVR), 34 AVR + CABG, 8 mitral valve replacement (MVR), 11 MVR + CABG and 11 other interventions. Rates of hospital death, major complications and prolonged stay (> 14 days) were as follows: CABG 4 (4.4%), 3 (3.3%), 6 (6.4%); AVR 1 (2.5%), 3 (7.5%), 2 (5%); AVR + CABG 1 (2.9%), 2 (5.8%), 4 (11.7%); MVR 0 (0%), 0 (0%), 1 (12.5%); MVR + CABG 2 (18.1%), 2 (18.1%), 3 (27.2%). Multivariate predictors of hospital deaths were NYHA class, cardiopulmonary bypass and cross-clamping time, urgent procedure and ischemic mitral valve procedures. The actuarial 6-year survival was as follows: CABG 91%,AVR 92.5%, AVR + CABG 88.2%, MVR + CABG 81.8%. Total survival rate, free from rehospitalization and redo surgery, was 89.7, 69.8 and 99% respectively. Multivariate predictors of late death were urgent procedure and ischemic mitral valve procedures. At follow-up NYHA classification had improved a median of two classes. Global patients' satisfaction was excellent in 76.7% of survivors; 95.7% were autonomous, 40.5% live at home, 64% had a light-moderate physical activity, and 70% of patients had good social relationships and quality of life. Medical therapy was reduced in 29.3% and level of anxiety improved in 76%. CONCLUSIONS: An interdisciplinary approach and multicomponent intervention with an appropriate postoperative care, provides beneficial effects on outcome in geriatric cardiac surgery patients.

Age Factors↗
PubMed1996

Cardiovascular and autonomic effects of sevoflurane.

This review focuses on the effects of the newest volatile anesthetic, sevoflurane, on the cardiovascular system. In general, the cardiovascular effects of sevoflurane are quite similar to isoflurane but quite different from desflurane. Sevoflurane is not associated with increases in heart rate in adult patients and volunteers whereas higher MAC of isoflurane and desflurane and rapid increases in the inspired concentrations of these two agents have been associated with increased heart rates in unstimulated volunteers. Increasing concentrations of sevoflurane progressively decrease blood pressure and this decrease appears similar to isoflurane and desflurane. Sevoflurane is a less potent coronary vasodilator than isoflurane in rodents and it has not been associated with coronary steal in a dog model. Sevoflurane decreases myocardial contractility similar to equi-MAC concentrations of isoflurane and desflurane and does not potentiate epinephrine-induced cardiac arrhythmias. In several multi-center studies where patients with coronary artery disease or patients at high risk for coronary artery disease were randomized to receive either sevoflurane or isoflurane for cardiac or noncardiac surgery, the incidence of myocardial ischemia and infarction did not differ between treatment groups. Thus, sevoflurane has not been associated with untoward cardiovascular changes in volunteers and patients undergoing elective surgery and may have less potent effects on the vascular smooth muscle of select circulations.

Anesthetics, Inhalation↗
PubMed2001

[Results of coronary artery surgery in octogenarians].

Over an 11 year period from January 1990 to December 2000, 3282 patients underwent isolated or combined surgical myocardial revascularisation. In this group, 42 were aged 80 or over (maximum 87 years), 1.3% of the total patient population. The mean age of this subgroup was 81.8 +/- 1.75 years) with a male predominance (61.9%). All patients were autonomous and considered to be in good general and psychological health. Preoperative coronary angiography showed 33.3% of left main stem lesions either alone or associated with a right coronary lesion. The ejection fraction was over 50% in 78.6% of cases. Saphenous vein grafts were used in all but 5 patients who also had left internal mammary artery grafts. Thirteen patients (31%) underwent combined valvular surgery (11 aortic and 2 mitral valve) and 2 patients underwent combined vascular surgery. Three patients were operated as an emergency. A total of 5 patients died in the first 30 postoperative days, a hospital mortality of 11.9%. There were 2 postoperative hemiplegias and 2 cases of renal failure which were aggravated in the postoperative period. The other patients were discharged from hospital with a satisfactory cardiac and functional status. The global mortality was 14% at 3 years and 18% at 5 years. The main bad prognostic factor for survival was the association of aortic valve surgery. In selected octogenarians in good general and psychological health without severe co-morbid conditions, surgical myocardial revascularisation may be considered with an acceptable operative risk.

Aged↗
PubMed2001

Surgery in Italy.

During the past 15 years, surgery in Italy has undergone significant developments in health care services at the teaching and organizational levels. In 1987, the new teaching regulations of medical and surgical schools came into force with the introduction of integrated courses that converge into educational and training areas with precise objectives. For more than a decade, postgraduate schools have had a common guideline throughout the European community--becoming real "residencies." Surgical activity is provided by university hospital facilities and hospitals with a business administration that is completely autonomous as far as organization, income, management, technique, and accounts are concerned. Research guidelines for future developments are mainly addressed toward optimization of organization and use of the most recent technology. The widespread application of day surgery and video-assisted surgery substantiates this evolution of surgery in Italy.

Ambulatory Surgical Procedures↗
PubMed1984

Corticotropin production by tumors of the autonomic nervous system.

Cushing's syndrome in association with a tumor of the autonomic nervous system (ANS) has been reported occasionally. We studied a patient who had an intra-adrenal paraganglioma (pheochromocytoma), and whose plasma corticotropin level was elevated prior to surgery but dropped to a low value following removal of the tumor. Catecholamine levels were elevated preoperatively and catecholamines were extracted from the tumor tissue. Corticotropin was identified in the tumor by immunoperoxidase staining. We also compared the endocrine data of 16 previously reported cases of Cushing's syndrome secondary to the release of ectopic corticotropin from ANS tumors. We concluded that in these patients, the plasma corticotropin level is only modestly elevated but indexes of steroid production frequently are markedly elevated. Also, discrepant responses to dexamethasone suppression tests occur, perhaps via sporadic release of corticotropin. These factors complicate evaluation of the cause of Cushing's syndrome in these patients.

Adrenalectomy↗
PubMed2002

Baroreceptor-related dysrhythmias in piglets with selective autonomic denervation of the heart.

This study was carried out to determine whether selective cardiac autonomic denervation performed on neonatal swine would evoke dysrhythmias later in development. Piglets (n = 27; 5-10 days old) underwent unilateral stellate ganglion ablation, or right cardiac vagotomy, or sham surgery. Fifty to sixty days after denervation, acute experiments were performed to evaluate responses to baroreceptor activation. Of all animals who exhibited prolonged R-R intervals, only those with right stellate ganglion ablation had prolonged corrected QT intervals. Despite findings suggesting an arrhythmogenic state (predominance of left-sided cardiac innervation), dysrhythmias occurred in all animals with stellate ganglion ablation, regardless of laterality, but in few vagotomized or control animals. Our results suggest that partial sympathetic innervation may alter cardiac function so that dysrhythmias are more likely to occur during baroreceptor activation.

Animals↗
PubMed2001

Postoperative management of the diabetic patient.

Diabetic patients are at increased risk for adverse outcomes of surgery. These adverse outcomes are related to pre-existing complications of diabetes, especially atherosclerotic disease, nephropathy (and perhaps increased susceptibility to other renal toxins), and peripheral and autonomic neuropathy. Hyperglycemia is associated with likely risks for poorer wound healing, increased susceptibility to infection, and probable loss of administered nutrients through glycosuria. Insulin use has the flexibility of timing and dose in the postoperative management of most diabetic patients. The combinations of intermediate-acting and long-acting insulins and short-acting insulins usually are related to the experience and preferences of the treating physicians and allied health professionals. Intravenous insulin (always R) may be limited to administration in the ICU because of the need for frequent blood glucose monitoring and rapidity of glucose response to intravenous insulin. The use of short-acting insulin analogues has been shown to work well as premeal insulin or for rapidly treating marked hyperglycemia in the outpatient setting. Meal delivery in the hospitalized patient may not be timed as precisely as in the home situation. Nurses may be responsible for many patients. The rapid-acting analogues may be associated with increased risk for hypoglycemia in the hospitalized patient if insulin cannot be given immediately before a meal. These rapid-acting insulin analogues usually are limited to circumstances in which the patient can determine the dose and self-administer just before ingestion of the meal. The long-acting insulin analogues may not afford enough flexibility in many situations in which daily dosages changes are occurring in intermediate-acting and long-acting insulins. Oral glucose-lowering agent use in the postoperative state usually is limited to selected patients, including patients who have been on such agents before surgery, who have only mild elevations of blood glucose, who are able to ingest oral medications, and who do not have significant comorbid conditions (or significant risk for such conditions) that may be contraindications to use of such agents (see Table 3). Sulfonylureas and other insulin secretagogues (e.g., meglitinide, nateglinide) lower glucoses acutely. The risk for hypoglycemia is slightly less with the nonsulfonylurea agents. Efficacy and side effects limit the use of carbohydrase inhibitors for hospitalized patients. The glucose-lowering effects of biguanides and thiazolidinediones usually are not rapid enough for hospitalized patients who have never taken these medications. For patients who have been on a biguanide or thiazolidinedione before admission, these agents often are restarted in the postoperative period when oral intake of medications is possible and hepatic and renal function are stable. The hospital period affords an opportunity to review long-term management issues related to diabetes and its complications. Instruction on the importance of medical nutrition therapy, glycemic control, management of hypertension, dyslipidemia, and aspirin use as well as basic guidelines for foot care should be carried out during the hospitalization and at the time of discharge. Similarly, appropriate arrangements for medical nutrition therapy, general diabetes education (especially for newly diagnosed diabetic patients), and regular medical follow-up are important to ensure long-term, excellent surgical and medical outcomes.

Adult↗
PubMed1982

Changes in human forearm blood flow after intravenous regional sympathetic blockade with guanethidine.

The effect of intravenous regional sympathetic blockade with guanethidine on total forearm blood flow and on muscle and skin blood flow in the forearm was studied in healthy humans, using venous occlusion plethysmography, 133Xe-clearance technique and skin temperature recordings. The total blood flow tripled in response to the blockade and the rise persisted for 2-3 days. The increase in blood flow was confined to the skin, with no demonstrable steal effect on muscle blood flow. The observations imply that this type of sympathetic blockade may be of therapeutic value in some vascular disorders of the hand, and as supportive treatment in vascular surgery on the extremities.

Adult↗
PubMed1995

Contributions of anterior cingulate cortex to behaviour.

Assessments of anterior cingulate cortex in experimental animals and humans have led to unifying theories of its structural organization and contributions to mammalian behaviour. The anterior cingulate cortex forms a large region around the rostrum of the corpus callosum that is termed the anterior executive region. This region has numerous projections into motor systems, however, since these projections originate from different parts of anterior cingulate cortex and because functional studies have shown that it does not have a uniform contribution to brain functions, the anterior executive region is further subdivided into 'affect' and 'cognition' components. The affect division includes areas 25, 33 and rostral area 24, and has extensive connections with the amygdala and periaqueductal grey, and parts of it project to autonomic brainstem motor nuclei. In addition to regulating autonomic and endocrine functions, it is involved in conditioned emotional learning, vocalizations associated with expressing internal states, assessments of motivational content and assigning emotional valence to internal and external stimuli, and maternal-infant interactions. The cognition division includes caudal areas 24' and 32', the cingulate motor areas in the cingulate sulcus and nociceptive cortex. The cingulate motor areas project to the spinal cord and red nucleus and have premotor functions, while the nociceptive area is engaged in both response selection and cognitively demanding information processing. The cingulate epilepsy syndrome provides important support of experimental animal and human functional imaging studies for the role of anterior cingulate cortex in movement, affect and social behaviours. Excessive cingulate activity in cases with seizures confirmed in anterior cingulate cortex with subdural electrode recordings, can impair consciousness, alter affective state and expression, and influence skeletomotor and autonomic activity. Interictally, patients with anterior cingulate cortex epilepsy often display psychopathic or sociopathic behaviours. In other clinical examples of elevated anterior cingulate cortex activity it may contribute to tics, obsessive-compulsive behaviours, and aberrent social behaviour. Conversely, reduced cingulate activity following infarcts or surgery can contribute to behavioural disorders including akinetic mutism, diminished self-awareness and depression, motor neglect and impaired motor initiation, reduced responses to pain, and aberrent social behaviour. The role of anterior cingulate cortex in pain responsiveness is suggested by cingulumotomy results and functional imaging studies during noxious somatic stimulation. The affect division of anterior cingulate cortex modulates autonomic activity and internal emotional responses, while the cognition division is engaged in response selection associated with skeletomotor activity and responses to noxious stimuli. Overall, anterior cingulate cortex appears to play a crucial role in initiation, motivation, and goal-directed behaviours.(ABSTRACT TRUNCATED AT 400 WORDS)

Animals↗
PubMed1990

[Is visceral surgery justified in patients over 90 years of age?].

The objective of this study was to evaluate the results of visceral surgery in patients over the age of 90 years by defining the indications, prognostic factors and short-term and intermediate results. This study was based on 50 patients operated between 1983 and 1987, consisting of 46 women and 4 men with a mean age of 92 years and a range of 90 to 98 years. 74% of the patients lived in long-stay hospitals, 26% lived at home, 28% were autonomous, 30% were semi-autonomous and 42% were bed-ridden. The majority of the patients were classified as ASA III. The mean number of visceral lesions was 3. 20% suffered from a malignant disease and 80% from a benign disease. 60% underwent emergency surgery and 40% underwent elective surgery. Postoperative complications were observed in 48% of cases, 58% of which had a fatal outcome. Sixteen patients (32%) died during the first postoperative month. The factors with a significant influence on mortality were: emergency in institutionalized patients (p less than 0.05), the ASA classification (ASA III and more, p less than 0.05), autonomy (bed-ridden patients, p less than 0.05), medical history (more than 4 associated organ defects, p less than 0.01) and malignant disease (p less than 0.001). The most pejorative complications in terms of mortality appeared to be postoperative septic shock, a pulmonary complication or a neurological complication. Cardiovascular disease, frequently reported in the history of theses patients, did not appear to specifically affect mortality. Surgery in patients over the age of 90 years appears to be justified in active patients in good general health presenting with a benign disease likely to become complicated if not treated, which should be preferably operated electively.

Aged↗
PubMed2001

Endoscopic clipping in video-assisted thoracoscopic sympathetic blockade for axillary hyperhidrosis. An analysis of 26 cases.

BACKGROUND: Endoscopic thoracic sympathectomy or sympathicotomy is the standard method for the treatment of axillary hyperhidrosis. But postoperative compensatory sweating may be troublesome in some patients. Therefore, we use endoclips to perform the T3 and T4 sympathetic blockade instead of permanently interrupting the transmission of nerve impulses from the sympathetic trunk. METHODS: Between May 1997 and June 1998, a total of 26 patients with axillary hyperhidrosis underwent video-assisted thoracoscopic sympathetic blocking of the T3 and T4 ganglia at our hospital. There were 10 men and 16 women with a mean age of 31.7 years (range, 16-47). All patients were placed in a semi-sitting position under single-lumen intubated anesthesia. We performed the sympathetic blockade by clipping the T3 and T4 ganglia at the level of the third, fourth, and fifth rib beds using an 8-mm 0 degree thoracoscope. RESULTS: Bilateral T3 and T4 sympathetic blockade was achieved in all 26 patients. The operation was usually completed within 30 min (range, 20-42). Most patients were discharged within 4 h after the operation. Surgical complications were minimal, with only one case of segmental atelectasis (3.8%). There were no deaths. The mean postoperative follow-up period was 31.3 months (range, 24-37). Twenty-three patients (88.5%) developed compensatory sweating of the trunk and lower limbs. Twenty-four patients (92.3%) were satisfied with the results of the operation. Improvement of axillary hyperhidrosis was obtained in all patients. One patient underwent a reverse operation to remove the endoclips due to intolerable compensatory sweating; improvement was seen 25 days after removal of the clips. CONCLUSION: Video-assisted thoracoscopic T3 and T4 sympathetic blockade by clipping is a safe and effective method for the treatment of patients with axillary hyperhidrosis. Patients who experience excessive compensatory sweating may require a reverse operation for endoclip removal.

Adolescent↗