Early Postsurgical Period Research Articles

Impact of a second FDG PET scan before adjuvant therapy for the early detection of residual/relapsing tumours in high-risk patients with oral cavity cancer and pathological extracapsular spread

Extracapsular spread (ECS) to the cervical lymph nodes is a major adverse prognostic factor in oral cavity squamous cell carcinoma (OSCC). We prospectively examined the value of FDG PET immediately before postoperative radiotherapy/concurrent chemoradiotherapy (pre-RT/CCRT PET) to detect residual/relapsing disease in the early postsurgical follow-up period in high-risk OSCC patients with ECS. We examined 183 high-risk OSCC patients with ECS who underwent preoperative FDG PET/CT for staging purposes. Of these patients, 29 underwent a second pre-RT/CCRT FDG PET/CT scan. The clinical utility of the second FDG PET/CT was examined using Kaplan-Meier curve analysis. Patients who underwent the second FDG PET/CT scan had baseline clinicopathological characteristics similar to those who did not undergo a second scan. Of the patients who underwent the second scan, seven (24 %) had unexpected, newly discovered lesions. Five eventually died of the disease, and two had no evidence of recurrence after a change in RT field and dose. In an event-based analysis at 2 months, rates of neck control (6/29 vs. 6/154, p = 0.001), distant metastases (3/29 vs. 4/154, p = 0.046), and disease-free survival (7/29 vs. 10/154, p = 0.003) were significantly higher in patients who received a second PET scan than in those who did not. The second pre-RT/CCRT PET scan was of particular benefit for detecting new lesions in OSCC patients with both ECS and lymph node standardized uptake value (SUV) of ≥ 5.2 in the first PET scan. The present findings support the clinical value of pre-RT/CCRT FDG PET for defining treatment strategy in OSCC patients with both ECS and high nodal SUV, even when FDG PET had already been performed during the initial staging work-up.

Surgical Management of Cardiac Valvular Lesions in a Tertiary Sub-Saharan Centre

The aim of the study was to investigate the pattern of valvular lesions, the early post surgical mortality, and challenges in the care of operated patients in St. Elizabeth Catholic General hospital, cardiac centre. Patients and methods: This retrospective analysis included 116 patients aged between 6 and 64 years old who underwent mitral repair or replacement and/or aortic valve replacement or repair in the cardiac centre from its inauguration in November 2009 through June 2011. Data from patients’ records, operative intervention, and preoperative and postoperative two-dimensional echocardiographic studies were reviewed. Patients and their family were contacted a month, and three months after been discharged from the hospital and later every three months. The duration of the follow-up was from 3 months to 20 months. Results: 116 patients aged between 6 and 64 years old with a mean age of 45 ± 6.5 years old underwent surgical correction of mitral and or aortic valvulopathy. Mitral regurgitation was the commonest echocardiographic diagnosis present in 51.7% patients; 13.3% patients had mixed mitral valve disease, 35% had pure mitral stenosis. Before surgery, 3 patients were in class IV, 10 in class III, 12 in class II and 4 in class I according to the New York Heart Association’s classification. Patients were extubated from 5-10 hours after surgery with low doses of inotropes. The mean stay in intensive care unit was 1.5 ± 0.5 days. The drains were removed at the 3rd ± 1.5 post surgical days in the ward. In the early post surgical period, the ejection fraction (EF) changed from 45.3 ± 1.5% to 56.1 ± 1.4% (p 0.05); at nine months it was 55.1 ± 1.8% (p>0.05), at 12 months – 58.4 ± 1.7% (p>0.05), at the latest patient’s check up, the EF was 56.2 ± 1.3% (p>0.05); however the basal part of the interventricular septum was hypokinetic. The changes of the left ventricular diastolic diameter (LVIDD) were as follow: from 57.2 ± 1.5 mm to 55.3 ± 1.1 mm (p 0.05) after six months; after nine months, it was 55 ± 1.8 mm (p>0.0). We could not identify the real cause of death in the patients because of lack of human resources and logistics however according to the relatives, we could think of sudden death, as the first cause, infectious diseases. The challenges faced are patients’ negligence and poor discipline, wrong beliefs, poverty. Conclusion: Post rheumatic mitral valve regurgitation is the pathology the most encountered. The study showed very good early results in the post surgical follow-up of patients with valve replacement for the correction of post rheumatic valvulopathy. Post surgical echocardiogram is characterised by motion abnormalities of the basal part of the interventricular septum. Due to financial limitation poverty and illiteracy of parents, the post surgical follow up of patients is challenging.

Late surgical treatment of tetralogy of Fallot

To study early post-operative results and follow up of patients over a year old, operated on for tetralogy of Fallot (ToF). This retrospective analysis included 22 patients (14 male and eight female) with a mean age of 9.18 ± 6.5 years (range 13.5 months to 26 years), who underwent complete repair of ToF between April 2003 and June 2009. Data from patients' records, pre-operative cardiac catheterisation studies, operative intervention, and pre-operative and postoperative two-dimensional echocardiographic studies were reviewed. All patients underwent complete repair including closure of ventricular septal defect (VSD). A trans-annular patch was used in 12 patients while an infundibular patch was used in 10 others. Patients were evaluated one, three, six and 12 months after surgery, and annually thereafter. The duration of follow up was from eight months to six years post surgery. Classical ToF was found in 10 patients. Twelve cases had associated anomalies: two patients with hypoplastic pulmonary artery branches, two with arterial duct malformations, and eight had proximal stenosis of the left branch of the pulmonary artery. NHYA class distribution was as follows: class I: two patients; class II: five subjects; class III: 10 patients; class IV: five subjects. The mean stay in hospital was 15 ± 7 days. Two patients (9%) died during the early post-surgical period. At a mean follow-up interval of 32 ± 9 months, all patients were asymptomatic and in NYHA class I. No late deaths occurred. In three patients, we registered isolated monomorphic ventricular extrasystoles. The right ventricle outflow tract (RVOT) pressure gradient was 29 ± 1.5 mmHg in the acute post-surgical period and it did not change significantly during follow up. The right ventricular function was defined as normal in 95% of the patients in the study and was mildly depressed in 5%. Even if treated later in life, our study showed very good surgical results of patients with ToF.

Effect of A2 Pulley Release on Repaired Tendon Gliding Resistance and Rupture in a Chicken Model

Release of part of the A2 pulley has been suggested to improve function after zone II primary flexor tendon repairs. The purpose of this study was to measure the effect of A2 pulley release compared with pulley preservation on repaired tendon gliding resistance and rupture in the early postoperative period in a chicken model. We divided 104 long toes from 52 Leghorn chickens into 2 experimental groups. In group 1, the flexor digitorum profundus tendons were cut completely and repaired surgically with either release or preservation of the A2 pulley. The tendon laceration was positioned so that the repair had to glide through the pulley with toe flexion. The toes were subjected to simulated active flexion at the end of the 2nd and 4th postsurgical weeks. The rupture rates of the tendons were recorded. In group 2, the volar two thirds of the tendons were cut and repaired, also in the region of the A2 pulley, with the pulley released or preserved. The force resisting tendon motion and the work of digital flexion with simulated active digital flexion were tested 3, 5, 7, and 14 days after surgery. At the end of the 2nd and 4th weeks, the tendon repairs showed significantly higher rates of rupture in the presence of an intact A2 pulley compared with those with the pulley released. Tendon gliding resistance was significantly increased with preservation of the pulley on postsurgical days 3, 5, 7, and 14; these toes required a greater number of motion cycles to reach steady levels of resistance and showed significantly higher steady resistance after digital motion. Release of the A2 pulley decreases the rate of repair rupture and the resistance to tendon gliding when the site of tendon repair has to glide through the pulley in the early postsurgical period. The findings of this study support partial release of the A2 pulley to favor successful tendon repair.

Combined Pancreatic Islet-Lung Transplantation With Islet Percutaneous Portal Embolization in Cystic Fibrosis

Combined Pancreatic Islet-Lung Transplantation With Islet Percutaneous Portal Embolization in Cystic Fibrosis

Prosthetic joint replacement for long bone metastases: analysis of 154 cases

Metastatic bone disease is the most common cause of malignancies to the skeleton in adults. The treatment of bone metastases is frequently palliative aiming to achieve a satisfactory control of pain and to prevent or to treat pathological fractures. In selected cases the resection of a single bone metastasis may improve the survival of the patients. Our experience with bone metastases located in the appendicular skeleton, between 1992 and 2004, is retrospectively reviewed here. We report a series of 154 patients (95 females and 59 males) treated with prosthesis for metastatic bone disease. Lower limb localization was more frequent with 117 cases, while upper limb was affected in 37 cases. Metastatic breast and renal carcinoma predominated and accounted for 66% of the lesions. Indications to surgery were reported, oncologic outcome was evaluated and functional results were obtained by the Musculoskeletal Tumor Society scoring system. Follow up ranged from 6 months to 12 years (median 26 months). One-year survival was 69.5%, 2-years survival was 44.8%, 5-years survival was 19.5%; and 5 (3.2%) died in the early post surgical period. Functional results were good or higher in 73.8% of patients for the proximal femur, in 50% of patients for the knee and 30.6% of patients for the proximal humerus. In this series, satisfactory results were achieved with few complications. We emphasized the importance of giving the patient a definitive treatment and preventing pathological fractures as they determine disability and a spreading of the tumor in the soft tissues, leading to an increased probability of local recurrence. Prosthetic replacement contributes to an improved quality of life and limb functionality and, in selected cases; this radical surgical approach is indicated as it may improve patient's life expectancy.

Evaluation of Physical Activity Participation during the Early Post-Gastric Bypass Surgery Period

Physical activity (PA) participation is thought to be an important contributor to weight loss and maintenance following gastric bypass surgery (GBS). However, PA patterns during the early post-surgical period and perceived PA obstacles have not been evaluated. PURPOSE: The purpose of this study was to evaluate pre-surgical PA barriers and PA participation before and 3-mos after GBS. METHODS: The International Physical Activity Questionnaire (IPAQ) was administered to 128 GBS patients (89.8% female, 79.7% Caucasian) to assess 1) time spent sitting (min/day), 2) time spent in vigorous, moderate, and walking activities (min/wk), and 3) total PA (MET-min/wk) before and 3-mos post-GBS. Patients rated the importance of individual PA barriers on a scale of 0 (never) to 4 (very often). Average ratings were calculated for each barrier based on response frequency. PA participation was analyzed using paired-samples t-tests. RESULTS: There was a significant increase by paired t-test (p<0.05) in vigorous (+45.0 min/wk), moderate (+118.8 min/wk), and walking (+111.6 min/wk) activities and in total PA (+1209.5 MET-min/wk) at 3-mos. A significant decrease (p<0.05) in time spent sitting (−127.2 min/d) was seen at 3-mos. Four PA barriers (“lack of equipment”, “bad weather”, “afraid in my neighborhood”, and “do not know how”) averaged a rating >3.0 (often) with “do not know how” having the highest average rating (3.6 ± 0.7). CONCLUSIONS: While time spent in PA was increased and sedentary time was decreased after surgery, patients perceived their knowledge of how to exercise as a primary pre-surgical PA barrier. These data support inclusion of pre- and post-surgical educational/intervention programs to specifically address appropriate PA behaviors.

The Effect of Digit Amputation or Arthrodesis Surgery on Culling and Milk Production in Holstein Dairy Cows

The objectives of the study were to evaluate the effects of digit amputation and arthrodesis surgery performed in the field on culling and milk production during the early postsurgical period. Cows from 3 commercial dairy farms in New York State were recruited for the study. A total of 49 cows on which digit amputation (AMP) was performed were matched with 68 controls (MC-AMP), and 17 cows on which arthrodesis surgery (ARTHRO) was performed were matched with 20 controls (MC-ARTHRO) according to lactation, DIM, and lactation at the time of surgery. Performance was not directly comparable between the AMP and ARTHRO groups because cows were not randomly assigned to the 2 treatment groups. Therefore, each surgical group was evaluated relative to its respective matched control group. Cows with AMP had a significantly lower estimated median survival of 68 d (95% confidence interval; lower = 35 d, upper = 156 d) compared with 585 d (95% confidence interval; lower = 469 d, upper = 699 d) for the MC-AMP group. Total milk production for the first 60 d postsurgery was significantly lower for the AMP (1,533±SE = 101kg) group compared with the MC-AMP (2,121±101kg) group and for the ARTHRO (1,883±86kg) group compared with the MC-ARTHRO (2,250±88kg) group. Septic arthritis of the distal interphalangeal joint was the most common condition treated by surgery, accounting for 70.5% of ARTHRO cases and 73.5% for AMP. Toe necrosis accounted for 14.3% of AMP cases, and retroarticular abscess made up the rest of the AMP (12.2%) cases and 29.5% of the ARTHRO cases. Results suggest that cows that had undergone ARTHRO had a lower culling rate and a faster return to production compared with those that had undergone AMP. Arthrodesis should be considered as a treatment option for deep sepsis of the bovine foot.

Strictures of biliary tracts during opisthorchosis

1170 patients with chronic opisthorchosis have been operated by surgeons of Tomsk hepatology center for 35 years, 4756 patients have been treated. In 730 operated patients different strictures of biliary tracts have been revealed, strictures of cystic duct have been observed in 372 patients (51%), strictures of choledoch distal section and major duodenal papilla (MDP) of expanded character — in 124 patients (17%), stricture combination — in 205 patients (28%) and sclerosing cholangitis — in 29 (4%). The treatment of opisthorchosis strictures of biliary tracts is surgical. In case of any its localization a cholecystectomy is necessary, in case of strictures of choledoch distal section and MDP a supraduodenal choledochoduodenostomy is necessary. In early postsurgical period it is prescribed an anthelmintic therapy with iodinol through external drainage of bile ducts. Good farther results have been marked at 79,4% of patients.

Reduction of Surgery-Induced Peritoneal Adhesions by Continuous Release of Streptokinase from a Drug Delivery System

Postoperative abdominal adhesions may lead to intestinal obstruction and infertility. The effect of continuous release of streptokinase to the peritoneal cavity on postoperative adhesions was examined under experimental conditions. Peritoneal adhesions were induced in rats and the animals were further treated by intraperitoneal administration of streptokinase solution, polyhydroxybutyrate-co-hydroxyvalerate (PHBV) membrane alone and streptokinase loaded PHBV membrane and compared to sham operated and untreated groups. Formation of adhesions was evaluated by quantitative macroscopic grading, histopathologically with light microscopy, on the following week. Streptokinase loaded PHBV prevented postoperative adhesion formation in 90% of the cases. PHBV membrane alone also reduced the severity of adhesions due to its anti-adhesive properties. Histopathological examination revealed limited foreign body reaction due to PHBV. Continuous streptokinase activity in the peritoneal cavity during early post-surgical period prevents postoperative adhesion.

Loss of the innate cortical engram for action patterns used in skilled reaching and the development of behavioral compensation following motor cortex lesions in the rat

Damage to the motor cortex of the rat ( Rattus norvegicus) impairs skilled movements used in reaching for food with the contralateral forepaw. Nevertheless, there is substantial recovery in success over a two-week postsurgical period. The profile of behavioral recovery is believed to reflect the eventual normalization of behavior, but this idea has not been explicitly examined. The present experiments examined postsurgical reaching success and reaching movements as a function of (1) lesion type, (2) lesion size, (3) lesion location, (4) depletion of forebrain noradrenaline, and (4) presurgical and postsurgical experience. The results show that at least two separate processes contribute to recovery in postsurgical performance. The early postsurgical period was characterized by extreme difficulties in making reaching movements. The experiments suggest that this initial impairment was due to the loss of the innate cortical engram that supports the action patterns used for skilled movements. Subsequent recovery in reaching success was not due to the reacquisition of normal movements, but was due rather to the use of compensatory movements. The results are discussed in relation to the idea that true recovery from motor cortex injury will require that damaged neurons and their connections be rescued or replaced.

Hemorheological Profile in Chronic Venous Insufficiency after Surgery

In recent years, there have been rheological abnormalities reported in chronic venous insufficiency (CVI), mainly an increase of erythrocyte aggregability (EA), which probably take part in the pathophysiology of the disease. The aim of this study was to analyze the hemorheological profile after stripping in 45 patients suffering from CVI. Follow-up included laboratory tests on the 7th, 60th and 180th day after surgery. EA was assessed with a photometric aggregometer (MA1, Myrenne) in stasis and low shear (3 s^–1). The results show an increase of EA on the 7th day after surgery (p < 0.001). Two and 6 months later, EA values returned to those found prior to surgery. The plasma fibrinogen level changes in a way parallel to EA. The association between rheological disturbances and thrombogenesis is well known, so the hyperaggregability found supports the antithrombotic prophylaxis in the early postsurgical period. On the other hand, the hemorheological abnormalities persist after stripping, so postsurgical treatment to inhibit EA may be beneficial.

Time-dependent effect of tolmetin sodium in a rabbit uterine adhesion model.

Tolmetin is a nonsteroidal anti-inflammatory drug (NSAID) that reduces adhesion formation in several animal models after a single intraperitoneal (i.p.) dose delivered at the time of surgery. We set out to determine the period during which tolmetin could prevent adhesions. Adhesions were induced in New Zealand White rabbits (2-3 kg) by abrading the uterine horns and removing their mesouterine vasculature. Tolmetin sodium (1 mg/5 ml saline) was given at various times relative to the start of surgery as a single dose i.p. One week later adhesions were assessed using a standard scoring system (0 = no adhesions; 1 = light adhesions involving both uterine horns; 2 = more tenacious adhesions to bowel or bladder; 3 = tenacious adhesions to bowel and bladder partly immobilizing the uterus; 4 = completely fixed horns adherent to bowel and bladder). Scores were arranged in ascending rank order. Mean rank positions were calculated for each group and compared against controls (Dunnett's multiple comparison). Tolmetin sodium was most effective when administered within 1 hour of surgery. Mild effects could still be observed after 4 hours and the effect diminished after 24 hours. When these effects are compared to the temporal biochemical and cellular effects of tolmetin obtained in related studies, the data support the hypothesis that tolmetin reduces adhesions at least in part by modulating fibrinolytic activity of resident macrophages and macrophages present in the early postsurgical period.

Modulation of postsurgical macrophage function by early postsurgical polymorphonuclear leukocytes.

Surgical trauma to the peritoneum, in the absence of infection, elicits a rapid and transient influx of polymorphonuclear leukocytes (PMNs) into the peritoneal cavity prior to the accumulation of macrophages. The aim of this study was to characterize the effects of these PMNs on macrophage function in the early postsurgical period. Rabbits underwent intestinal reanastomosis and peritoneal exudate cells were collected at various times after surgery. Macrophage-enriched preparations were incubated with spent media from cultures of PMNs obtained at the corresponding times after surgery. Superoxide anion (O2-) release by macrophages in response to phorbol myristate acetate was determined by cytochrome c reduction. Fibrinolytic and protease inhibitory activities in macrophage-spent media were also evaluated. The release of O2- had already increased at 2 hr, reached peak levels at 6 hr, and decreased by 24 hr after surgery. Spent media from PMNs harvested 6 hr after surgery suppressed, whereas spent media from postsurgical 12- or 24-hr PMNs increased O2- release from macrophages harvested at 6 and 12 hr after surgery. PMN-spent media had no effect on the secretion of plasminogen activator (PA) from macrophages harvested within 12 hr after surgery. In contrast, PA activity in the spent media from macrophages harvested 24 hr after surgery was elevated after exposure to PMN-spent media. PA inhibitory activity was reduced in macrophage-spent media at 2 hr after surgery and increased by 24 hr, while PMN-spent media had no effect on the level of PA inhibitory activity. Thus, soluble factors secreted into the culture medium by PMNs modulate macrophage function as soon as 6-12 hr after surgery.

Inaccuracy of pulmonary capillary wedge pressure when compared to left atrial pressure in the early postsurgical period

Simultaneous measurements of pulmonary capillary wedge pressure (PCWP) and left atrial pressure (LAP) were obtained before and after cardiopulmonary bypass and for a period of 16 hours postoperatively in 20 consecutive patients undergoing electric cardiac operations. In contrast to several previous reports that PCWP accurately reflects left-sided hemodynamics, we found that the PCWP significantly exceeded the LAP in the early postbypass period and was most significantly in error at 4, 8, and 12 hours after operation (p less than .02) (95% confidence limit). The magnitude of this discrepancy differed in individual patients; however, it was consistent for each patient for the time period studied and independent of the procedure performed. The disparity between PCWP and LAP may be due to an increase in lung interstitial water as a result of hemodilution, or it may be related to the differing effects of afterload reducing agents on the pulmonary versus the systemic circulation. We conclude from these data that LAP more accurately reflects left ventricular filling and performance in the early postoperative period and should be used instead of PCWP to monitor the hemodynamics of postsurgical patients.

Radionuclide cisternography in subdural hematomas.

Radionuclide cisternography in a group of 11 patients with subdural hematomas showed decidedly abnormal patterns of flow. The most common finding was a localized area of decreased uptake, indicating arrested or reduced flow in the subarachnoid spaces of the cerebral convexity underlying the hematoma. Control postoperative cisternograms demonstrated that the localized area of reduced radionuc1ide flow persists after evacuation of the hematoma, at least in the early postsurgical period. The diagnostic value and limitations of cisternography and its usefulness as compared to other diagnostic procedures in suspected subdural hematoma are discussed.

Management of total anomalous pulmonary venous drainage in early infancy.

Ten consecutive babies ranging in age from two weeks to five months, with total anomalous pulmonary venous drainage and pulmonary artery hypertension, have undergone surgical correction. Seven have survived, including five of six with supracardiac type and two of three with pulmonary venous drainage to the coronary sinus. Six of the last seven operations have been successful, and there have been no late deaths in the series. Factors considered to be important in successful management include: (1) early cardiac catheterization and surgical intervention; (2) high-flow buffered blood perfusion at normothermia; (3) surgical technique aimed at wider common pulmonary vein-left atrial anastomosis; (4) use of indwelling nasotracheal tube with respiratory support for the initial 24 to 48 hours postoperatively; (5) restricted fluid administration in the early postsurgical period; and (6) detailed attention to acid-base balance.