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PubMed2002

Current status of prophylactic mastectomy.

The management of women at high risk for breast cancer presents a clinical dilemma to the health-care provider as well as to the woman herself. Current options include surveillance, prophylactic surgery (mastectomy and/or oophorectomy), and/or chemoprevention. Prophylactic mastectomy, including bilateral prophylactic mastectomy in high-risk women or contralateral prophylactic mastectomy in women with primary breast cancer, has been a controversial clinical option. In this review, we address the efficacy of prophylactic mastectomy in reducing the risk of breast cancer in high-risk women, the use of this procedure, surgical complications, and its psychosocial impact. The decision to undergo prophylactic mastectomy is highly personal and must be preceded by an in-depth assessment of the woman's risk of breast cancer, and a thorough discussion of the benefits of the procedure weighed against its potential surgical risks and psychological impact. It is also imperative that the woman be informed of alternative options for management, including chemoprevention, close surveillance, and prophylactic oophorectomy.

Breast Neoplasms↗

PubMed1977

Eisenmenger's syndrome in pregnancy: does heparin prophylaxis improve the maternal mortality rate?

Seven consecutive patients with Eisenmenber's syndrome, cared for by the obstetric team in conjunction with the cardiology service, were reviewed to assess the possible role of prophylactic heparin therapy and intensive care on the outcome of these patients. In each patient, the diagnosis of Eisenmenger's syndrome was established by the demonstration of equal pulmonary arterial and aortic pressures with a predominantly right-to-left shunt at cardiac catheterization. Five of the seven patients died as follows: Three patients died between the fifth and eighth post-partum days, one patient died during the twenty-sixth week of pregnancy, and one patient died on the fifth postoperative day following tubal ligation. All of these five patients received prophylactic heparin therapy. In three patients, heparin therapy was complicated by excessive bleeding during the postoperative or postpartum period. Autopsy examination in two patients revealed no evidence of thrombosis in the main pulmonary arteries and no pulmonary infarction, contrary to the antemortem clinical suspicion. The two survivors did not receive prophylactic heparin. They comprised one patient who had normal delivery and one patient who underwent tubal ligation and induction of abortion. We conclude that the prohibitive mortality rate of Eisenmenger's syndrome during pregnancy, puerpurium, or surgical procedures probably cannot be modified with prophylactic heparin therapy. Anticoagulant treatment does not prevent deterioration of patients and probably compounds the problem by causing significant bleeding.

Adolescent↗

PubMed1992

Perioperative antibiotic prophylaxis: the importance of timing.

1. Although prophylactic antibiotics have demonstrated efficacy in surgical procedures, they can fail because, generally, an inappropriate agent is used or the agent is inappropriately administered. 2. The timing of administration is important. Studies indicate that to reduce the risk of infection, high levels of antibiotic must be present in the bloodstream and tissues at the time of the incision. 3. Nurses play a central role in ensuring the proper timing of the administration of prophylactic antibiotics. Improvement in the timing of administration will reduce both morbidity and institutional costs.

Anti-Bacterial Agents↗

PubMed1992

Issues in gastrointestinal endoscopy: oesophageal varices: inject, band, medicate, or operate.

Injection sclerotherapy is the most widely used definitive treatment of acute variceal bleeding and is increasingly performed at the time of the first emergency endoscopy. Direct endoscopic ligation of varices by banding is a new technique under evaluation for both acute bleeding varices and long-term management. Repeated injection sclerotherapy is one of the major options for long-term management after variceal bleeding. More major surgical procedures are usually reserved for the failures of sclerotherapy in the management of acute variceal bleeding, whereas portosystemic shunts, particularly the distal splenorenal shunt, or an extensive devascularization and transection operation are commonly used alternative forms of therapy in long-term management. All patients with variceal bleeding should be assessed for liver transplantation, although only a few will ultimately receive a liver transplant. Medication with propranolol is widely recommended in long-term management, but its use in this context remains controversial. The most controversial area of management is prophylactic treatment before variceal bleeding. Major surgical procedures and injection sclerotherapy are not justified at present because it is difficult to identify those patients with a high likelihood of a first variceal bleed. Although medical therapy with propranolol has proved the most successful therapy to date, a case is made for treating most patients conservatively until their first variceal bleed occurs or until better predictive indices for patients at high risk of a first bleed are identified.

Esophageal and Gastric Varices↗

PubMed1997

Prophylactic antibiotic project.

This project evaluated the use of prophylactic antibiotics within two hours prior to selected surgical procedures. Even with knee arthroplasty, for which there is essentially universal agreement on the need for prophylactic antibiotics, there is room for improvement in antibiotic delivery. This is true both in the percent of patients receiving antibiotics and the timeliness of administration. Although there is some difference of opinion about the advisability of prophylactic antibiotics for certain procedures, the preponderance of recent literature advocates its use and this is a quality indicator evaluated by JCAHO.

Antibiotic Prophylaxis↗

PubMed2005

Complications following bilateral prophylactic mastectomy.

BACKGROUND: Bilateral prophylactic mastectomy significantly decreases breast cancer risk, but complications of the procedure have only been described in single-site studies. We describe the frequency and type of complications in women who underwent bilateral prophylactic mastectomy in a multisite community-based cohort. METHODS: Women aged 18-80 years undergoing bilateral prophylactic mastectomy without a personal history of breast cancer at one of six health plans were eligible. We identified women from automated data sources, then reviewed hospital data, ambulatory notes, and other chart elements to confirm eligibility and obtain all charted information about complications and surgeries performed after prophylactic mastectomy, including reconstructive procedures. Reconstructions were characterized by type (implant vs. tissue graft). Complications were noted for a 1-year period after any surgical procedure. RESULTS: We identified 269 women with prophylactic mastectomy who were followed for a mean of 7.4 years. Their mean age was 44.9 years. Nearly 80% undertook reconstruction, most with prosthetic implants. One or more complications occurred in 64%. The most common complications were pain (35% of women), infection (17%), and seroma (17%). Women with no reconstruction had fewer complications (mean of .93) than women who had implant (2.0) or tissue graft (2.4) reconstruction procedures (differences from no reconstruction: 1.07 [95% confidence interval = 0.36 to 1.77] and 1.50 [95% confidence interval = 0.44 to 2.56] respectively). Delay of reconstruction after mastectomy was associated with a borderline-significant higher risk of complications (80.6%) compared to simultaneous reconstruction (64.0%, P = .055). CONCLUSION: We found that almost two-thirds of women undergoing bilateral prophylactic mastectomy had at least one complication following surgery. Further work should be done to minimize and to understand the effect of complications of bilateral prophylactic mastectomy.

Adolescent↗

PubMed1988

Survey of sterile technique used by dermatologic surgeons.

A survey was made of the sterile technique practices of dermatologists interested in dermatologic surgery. The steam autoclave is the most popular method for sterilizing surgical instruments. Dry heat sterilization is often used, as is cold, chemical sterilization. The most popular agent for chemical sterilization continues to be quaternary ammonium compounds despite warnings to the contrary. Gas sterilization is rarely used. Alcohol is the most popular agent for prepping the skin and iodophors are also quite popular. Dermatologists are now wearing gloves for most procedures. Prophylactic antibiotics are used minimally in surgical cases, as is recommended by established standards.

Dermatology↗

PubMed2003

Orthopaedic surgery in persons with haemophilia.

The orthopaedic problems of haemophilia and the surgical techniques most frequently performed by orthopaedic surgeons on haemophilia patients are summarised in this review article. Sometimes it can be recommendable to carry out two or three orthopaedic surgical procedures in a single operative session, with the aim of solving the functional problem in a more global way, which usually is polyarticular. There is no doubt that such an undertaking implies a greater anaesthetic risk, but also avoids the repetition of surgical procedures and saves factor consumption. Close cooperation between haematologists, orthopaedic surgeons, rehabilitation physicians, paediatricians, psychologists, physiotherapists and nurses is paramount for the satisfactory result of any orthopaedic surgical procedure. There is no doubt that continuous prophylactic clotting factor replacement (prophylactic therapy) is the optimal way to avoid the orthopaedic problems of haemophilia that can still be seen today. Until such a goal can be reached, the orthopaedic surgeon will continue performing arthrocentheses, synoviortheses, synovectomies, tendon lengthenings, débridements, osteotomies, joint replacements, osteosynthesis of fractures and other less frequent surgical procedures on persons with haemophilia.

Hemarthrosis↗

PubMed2005

Melanoma of the penis, scrotum and male urethra: a 40-year single institution experience.

PURPOSE: Genitourinary melanoma is rare and classically associated with a poor prognosis. We describe our experience with 10 patients with penile or urethral involvement. In addition, we present what is to our knowledge the largest reported series of melanoma of the scrotum (6 cases). MATERIALS AND METHODS: We reviewed the records of 16 men who presented consecutively to our institution with genitourinary melanoma between 1962 and 2000. Clinical and pathological characteristics were assessed, including Breslow thickness, primary surgical intervention and clinical course. RESULTS: Of 10 patients with penile or urethral melanoma 1997 American Joint Committee on Cancer melanoma pathological stage was T1 (depth less than 0.75 mm) in 4, T2 (0.75 to 1.5 mm) in 3 and T3 (1.51 to 4 mm) in 3. Only 1 of 4 patients with clinically palpable inguinal nodes had inguinal metastases at lymphadenectomy (BILND) and 3 who underwent prophylactic superficial BILND had negative findings. In 7 patients with T1-2N0M0 disease there were no local recurrences after wide local excision (WLE) or partial penectomy at a median followup of 35 months. Six of 7 men were rendered disease-free. One patient died of melanoma that developed at a second primary site. The 3 patients with T3 tumors who underwent partial (2) or radical (1) penectomy with or without BILND died of disease (2) or had progression (1). In all patients with penile melanoma the 5-year actuarial disease specific and recurrence-free survival rates were 80% and 60%, respectively, at a median followup of 39 months (range 20 to 210). Six patients with scrotal melanoma were treated with WLE without local recurrences. Three of the 6 patients had palpable inguinal nodes, of whom 2 died after chemotherapy for unresectable disease and 1 died of other causes 51 months after negative BILND. The 3 men with clinically negative groins who did not undergo prophylactic BILND had distant (1) or regional (2) metastases and died of disease. In patients with scrotal melanoma the 5-year actuarial disease specific and recurrence-free survival rates were 33.3% and 33.3%, respectively, at a median followup of 36 months. CONCLUSIONS: Partial penectomy or WLE provided effective local control for low stage penile or urethral melanomas and all scrotal lesions. Patients showing clinically positive, proven metastasis died despite appropriate surgical procedures and multi-agent chemotherapy. Prophylactic modified inguinal lymphadenectomy should be considered in select patients with penile, scrotal and anterior urethral melanoma.

Adult↗

PubMed2000

Pharmacokinetics of ofloxacin enantiomers after intravenous administration for antibiotic prophylaxis in biliary surgery.

The pharmacokinetics of S-(-)- and R-(+)-ofloxacin, enantiomers of the fluoroquinolone ofloxacin, were characterized after prophylactic administration in 15 patients undergoing elective biliary surgery. A single dose of ofloxacin 400 mg given intravenously as an infusion was administered 1 hour before surgery. Plasma levels of S-(-)- and R-(+)-ofloxacin showed very small differences between both enantiomers, although the ratio of S-(-)- to R-(+)-enantiomer concentration in plasma showed significant differences (p < 0.05) at 4 and 12 hours. Adequate S-(-)-ofloxacin (levofloxacin, the active enantiomer) plasma levels (> or = minimum inhibitory concentration [MIC90] for Escherichia coli) were found throughout the procedure. For pharmacokinetic parameters, the authors found small but statistically significant differences (p < 0.05) in the area under the concentration-time curve, AUC0-infinity (22.30 +/- 2.72 mg h/L for S-(-)-ofloxacin vs. 20.50 +/- 2.06 mg h/L for R-(+)-ofloxacin), and in the clearance (0.15 +/- 0.04 L/h/Kg for S-(-)-ofloxacin vs. 0.16 +/- 0.04 L/h/Kg for R-(+)-ofloxacin). To test the penetration of ofloxacin enantiomers into tissues, the authors measured levels in subcutaneous cell tissue and gall-bladder cell tissue. They did not observe statistical differences between the two isomers, which means that distribution is not an estereoselective process. Enantiomer levels in these two tissues decreased rapidly, but the highest concentrations were reached during the 4 first hours (i.e., when the surgical procedure was being performed). In conclusion, with the prophylactic treatment used, levofloxacin plasma and tissue levels are high enough to prevent surgical infections.

Adult↗

PubMedDate not supplied

Escherichia coli sternal osteomyelitis after open heart surgery.

Deep-seated infections after open-heart surgical procedures, fortunately, are uncommon with appropriate prophylactic antibiotics and careful aseptic technique. When serious infection, such as sternal osteomyelitis, does occur, the effects are devastating and usually require one or more debridement procedures. The organisms usually implanted in postoperative sternal infections are primarily Staphylococcus aureus and aquatically based gram-negative bacilli. Common gram-negative pathogens such as Escherichia coli are very unusual in this setting. We report a case of E. coli sternal osteomyelitis in a diabetic patient after coronary artery bypass grafting.

Aged↗

PubMed1989

Severe hyponatremia after repeated intravenous administration of desmopressin.

Desmopressin (DDAVP) has recently been found to improve hemostasis in patients with congenital or acquired disorders of coagulation and to reduce operative blood loss in patients with normal hemostasis undergoing certain surgical procedures. Despite its potent antidiuretic effect, severe hyponatremia after the intravenous administration of DDAVP is felt to be rare. We report four cases of severe hyponatremia with serious clinical sequelae occurring in patients with underlying coagulopathies who were treated prophylactically with DDAVP to improve hemostasis prior to surgical procedures. Each patient received multiple (3-22) doses of DDAVP and was given intravenous hydration with hypotonic solutions before developing clinical signs and laboratory evidence of hyponatremia. We believe that the risk of significant hyponatremia after treatment with intravenous DDAVP may be higher than is generally appreciated and that patients undergoing surgical procedures, who often receive multiple doses of DDAVP and intravenous hydration, are at particular risk for this complication. Hypotonic intravenous solutions should be avoided and serum sodium levels should be monitored frequently in those patients receiving multiple doses of DDAVP.

Adenoidectomy↗

PubMed1983

Antibiotic prophylaxis in surgical procedures. A critical analysis of the literature.

The use of prophylactic antibiotics in surgery is widespread and often inappropriate. The lack of well-designed clinical studies partially explains the present confusion regarding the subject. We reviewed the literature in English on antibiotic prophylaxis through June 1982. Antibiotic prophylaxis reduces the incidence of wound infection after colorectal surgery, vaginal hysterectomy, and laryngeal and oropharyngeal resection for carcinoma, and in high-risk patients undergoing gastroduodenal or biliary surgery. In clean operations such as cardiac surgery, vascular procedures, and orthopedic surgery with placement of prostheses, the high morbidity associated with an infection justifies the use of antibiotics even though the risk of infection is small. There are conflicting data on the usefulness of prophylaxis in abdominal hysterectomy, cesarean section, noncardiac thoracic procedures, and urologic surgery. The effectiveness of prophylaxis in neurosurgery cannot be evaluated at the present time.

Administration, Oral↗

PubMedDate not supplied

Present status of sclerotherapy and surgical treatment for esophageal varices in Japan. Japanese Research Society for Portal Hypertension and Japanese Research Society for Sclerotherapy of Esophageal Varices.

A nationwide survey on the treatment for esophageal varices was performed in 1990 jointly by the Japanese Research Society for Portal Hypertension and the Japanese Research Society for Sclerotherapy of Esophageal Varices to clarify the present status and strategy of this treatment in Japan. A total of 12,675 cases, including 4,159 cases of nonshunting procedures and 7,612 cases of sclerotherapy, were collected from 101 institutions. The number of patients had greatly increased in the first half of the 1980s. With regard to the therapeutic strategy, surgical procedures were not recommended in either emergency or prophylactic cases in terms of the timing of the operation, or in Child C cases in terms of the degree of hepatic insufficiency. Endoscopic injection sclerotherapy became the leading method of treatment and in 1988 only 16% of 1,528 cases were treated by surgical procedures. The strategy for the same group of patients differed between medical and surgical institutions. With regard to sclerotherapy, repeated intravariceal injection and combined intra- and paravariceal injection were the two main techniques and 10-year cumulative survival rates were 62.8% in Child A cases, 47.7% in Child B cases, and 13.2% in Child C cases. With regard to surgical procedures, 10-year survival rates were 50.6% in esophageal transection, 42.5% in gastric transection, 53.1% in cardiectomy, and 43.0% in selective shunt procedures. We are quite convinced that this report will prove useful in determining the future strategy for treating esophageal varices.

Esophageal and Gastric Varices↗

PubMed1999

Early discharge after external anal sphincter repair.

PURPOSE: The aim of this study was to describe an accelerated-stay program for repair of the external anal sphincter. METHODS: Twenty consecutive patients undergoing overlapping repair of the external anal sphincter were included in the study. Effect parameters were length of hospitalization and complications within 30 days after the operation. Surgery was performed during the period of March 1993 to May 1997. The accelerated-stay program included preoperative information, no premedication, a surgical procedure without colostomy, single-dose prophylactic antibiotics, paracetamol for analgesia, free oral fluid and food immediately after the operation supplemented by laxatives, and enforced mobilization. Follow-up by questionnaire was performed at a median of 14 (range, 4-52) months after the operation. RESULTS: Median hospital stay was one day. Fifteen patients were discharged the day after surgery and 5 patients stayed for 48 hours after the operation. There was no 30-day morbidity, and no patient received a colostomy in conjunction with the sphincter repair. Fourteen of 19 patients available for follow-up reported a significantly improved functional result compared with preoperative state. CONCLUSION: We have described a safe accelerated-stay program (24 to 48 hours) for overlapping repair of external anal sphincter.

Anal Canal↗

PubMed1989

Comparison of intravenous ciprofloxacin and intravenous cefotaxime for antimicrobial prophylaxis in transurethral surgery.

Intravenous ciprofloxacin has been investigated in the treatment of serious infections, including those of the urinary tract. In this double-blind, randomized study, its effectiveness as a prophylactic agent in men undergoing transurethral surgical procedures was compared with that of another intravenous agent, cefotaxime. One hundred six men with genitourinary tract obstruction were enrolled in the study. The 102 men evaluable for determination of efficacy (53 in the ciprofloxacin group and 49 in the cefotaxime group) received a single intravenous infusion of either 300 mg ciprofloxacin or 1,000 mg of cefotaxime prior to resection of the prostate for benign prostatic hypertrophy and prostatic carcinoma or internal urethrotomy for urethral stricture. A mean of 32.1 and 40.3 minutes for the ciprofloxacin and cefotaxime groups, respectively, elapsed between the end of the intravenous infusion and the onset of surgery; all but one patient in the ciprofloxacin group underwent catheterization after surgery, of which the mean duration was 3.7 days for both groups. At the time of hospital discharge, patients were evaluated clinically; 50 patients in the ciprofloxacin group (94 percent) and 45 in the cefotaxime group (92 percent) had no bacteriologic evidence of genitourinary tract infection. At follow-up two to six weeks after surgery for the patients with no bacteriologic evidence of genitourinary tract infection, fewer patients in the ciprofloxacin group (8 percent) than in the cefotaxime group (16 percent) remained without evidence of infection. Both drugs were well tolerated. This study demonstrated that a single intravenous dose of ciprofloxacin was as effective as a single dose of cefotaxime in reducing the incidence of infection following transurethral surgical procedures.

Adult↗

PubMed1990

Experience with Ommaya reservoir in 120 consecutive patients with meningeal malignancy.

The Ommaya Reservoir plays an important role in a select group of neuro-oncology patients with meningeal malignancy. The benefits derived must be balanced against potential complications associated with insertion and use of the apparatus. Side effects may be minimized by careful attention to patient selection, pre-operative CAT scan (or MRI), precise surgical technique, perioperative prophylactic antibiotics and meticulous procedure during use of the reservoir.

Adolescent↗

PubMed1982

[Antibiotic therapy in bacterial infections in gynaecology].

A brief review of the special aspects concerning the use and selection of chemotherapeutic agents and antibiotics in bacterial infections occurring in gynaecology both specifically and generally. In case of severe bacterial infections such as sepsis it is recommended to combine two antibodies (e.g. beta-lactam antibiotics with aminoglycosides or several beta-lactam antibiotics together). Special attention is given to the particularly effective broad-spectrum penicillins and cephalosporins as well as to the aminoglycoside antibiotics etc. Individual well-tried antibiotics are briefly characterised in respect of their anti-bacterial efficacy (sensitivity and resistance), their field of application, and their dosage. In particular, the possibilities of the therapy of infections by anaerobic microorganisms and fungi are pointed out. In addition, a brief description is given of antibacterial chemotherapy of pneumonias of urinary tract infections and specifically gynaecological infections (such as adnexitis, endometritis, parametritis, pelveoperitonitis) under the aspects of rational antibiotic treatment. The article includes by pointing out the possibilities of prophylactic administration of antibiotics especially in surgical procedures in the sense of a perioperative short-term prophylaxis.

Anti-Bacterial Agents↗