Early Surgical Referral Research Articles

Long-term outcomes of valve replacement with modern prostheses in young adults

To examine the multiple impacts of valve replacement on the lives of young adults. Patients (N=500) between age 18 and 50 who had aortic valve replacement (AVR) and/or mitral valve replacement (MVR) with contemporary prostheses were followed annually. Events, functional status, and quality of life were examined with regression models. Median follow-up was 7.1+/-5.3 years (maximum 26.7 years). Five, 10, and 15-year survival was 92.7+/-1.7, 88.3+/-2.4 and 80.1+/-4.7% after AVR, and 93.1+/-2.3, 79.5+/-4.3 and 71.5+/-5.4% after MVR, respectively. Survival decreased with concomitant coronary disease (hazard ratio (HR): 4.5) and preoperative LV grade (HR: 2.0/grade increase) in AVR patients, and with atrial fibrillation (HR: 5.5), coronary disease (HR: 5.7), preoperative left atrial diameter (HR: 3.0/cm increase) and NYHA class (HR: 2.1/class increase) in MVR patients. Despite reoperation, late survival was equivalent between bioprostheses and mechanical valves in both implant positions. The ten-year cumulative incidence of embolic stroke was 6.3+/-2.4% for mechanical AVR patients, 6.4+/-2.9% for bioprosthetic AVR patients, 12.7+/-3.9% for mechanical MVR patients, and 3.1+/-3.1% for bioprosthetic MVR patients. Atrial fibrillation (HR: 2.8) and smoking (HR: 4.0) were risk factors for stroke in MVR patients. In AVR patients, SF-12 physical scores, freedom from recurrent heart failure, and freedom from disability were significantly higher in bioprosthetic than mechanical valve patients. Career or income limitations were more often subjectively linked to a mechanical prosthesis in both implant positions. Late outcomes of modern prosthetic valves in young adults remain suboptimal. Bioprostheses deserve consideration in the aortic position, as mechanical valves are associated with lower physical capacity, a higher prevalence of disability, and poorer disease perception. Early surgical referral and atrial fibrillation surgery may improve survival after MVR.

Is early surgical referral for children with persistent otitis media with effusion (OME) appropriate?

Is early surgical referral for children with persistent otitis media with effusion (OME) appropriate?

Small bowel intussusception in symptomatic pediatric patients: experiences with 19 surgically proven cases.

Nineteen cases of surgically proven symptomatic pediatric small bowel intussusceptions (SBI) were retrospectively reviewed. Clinical presentations included vomiting (89.5%), abdominal pain and/or irritable crying (89.5%), fever (52.6%), bloody stools (26.3%), palpable abdominal masses (15.8%), hematemesis (10.5%), jaundice (5.3%), and seizures (5.3%). The duration between symptom onset and hospitalization ranged between 20 and 336 hours (average 75.8 hours). Two patients with suspected appendicitis and small bowel obstruction were operated on promptly. Sonograms revealed target lesions (average diameter 2.9 cm) suggestive of intussusception in 13 out of 17 patients, with 10 lesions located in the paraumbilical or left abdominal regions. Barium enemas in 12 of these 13 patients demonstrated no colonic lesions. Diagnosis and surgery were delayed in 16 patients (average delay = 32 hours). The remaining 1 patient with positive sonographic findings underwent early surgery after computed tomographic (CT) confirmation of SBI. Surgery revealed ileoileal intussusceptions in 11 patients, jejunojejunal in 4, jejunoileal in 3, and duodenojejunal in 1. Eight patients had lead points. Bowel complications (ischemia, necrosis, or perforation) occurred in 8 patients. The duration between symptom onset and surgery in patients with bowel complications was significantly longer than for patients without complications (p = 0.0026). In conclusion, delayed diagnosis and surgical treatment in symptomatic pediatric patients with SBI were common, leading to a high rate (42%) of bowel complications. Sonographic demonstration of a 2-3 cm target lesion, especially if paraumbilical or left abdominal, is suggestive of SBI and may obviate the need for a barium enema; however, CT is helpful for confirming SBI. In symptomatic SBI, once diagnosed, early surgical referral is strongly recommended.

The Surgical Management of Severe Gastroparesis in Heart/Lung Transplant Recipients

This article describes the use of gastric bypass surgery for severe gastroparesis in two lung transplant recipients. In addition to feeding intolerance, both our patients suffered from severe erosive esophagitis, transfusion-dependent upper GI hemorrhage, and recurrent aspiration pneumonia. They responded poorly to promotility agents and were eventually treated with Roux-en-Y esophagojejunostomy-one patient with subtotal gastrectomy, and one with gastric bypass without distal gastric resection. Both cases were improved by surgery. Early surgical referral may be indicated in the management of lung transplant recipients with severe symptomatic gastroparesis in whom medical management has failed. On the basis of our experience, gastric bypass with esophagojejunostomy is a worthwhile option in lung transplant recipients with severe gastroparesis.

Pneumothorax in AIDS: case reviews and proposed clinical management.

Pneumothorax is a not uncommon complication of advanced HIV infection, and may prove difficult to manage in view of its recalcitrant and recurrent nature. In this group where immunosuppression and reduced life expectancy are a feature, standard protocols are often abandoned in favour of a more conservative approach. This is often unsuccessful. Patients attending the Department of Genitourinary Medicine, Chelsea and Westminster Hospital who sustained pneumothorax between 1988 and 1992 were identified retrospectively and their notes reviewed. Fifteen patients were identified of whom three had post-procedural pneumothoraces. In the remaining 12 patients, 10 had previously had Pneumocystic carinii pneumonia (PCP), whilst all 12 had some evidence to suggest current PCP (seven proven, five presumptive). In those six patients with a single, unilateral pneumothorax, four were managed successfully with intercostal drainage alone (one patient died early, one required pleurectomy). In those with recurrent pneumothoraces or pneumothoraces that did not respond to prolonged intercostal drainage, failure of medical treatment was judged to have occurred and surgery was performed. Overall, conservative management failed in 7/11 patients. Conversely surgery resulted in resolution in 7/7 with recurrence seen in one individual. Median survival was similar in the two groups. Pneumothorax in patients with AIDS is associated with a high rate of intercurrent PCP; a low threshold for treating this infection presumptively is indicated. Intercostal drainage was successful in patients with a single, unilateral pneumothorax. However, in patients with recurrent or bilateral pneumothorax extended periods on intercostal drainage were uniformly unsuccessful. Early surgical referral should be considered in this group.

Medical audit of community screening for undescended testes in Halton district

To evaluate the quality of screening in the community for undescended testis and to determine the percentage of boys referred for surgery before their second birthday. Population-based retrospective study of hospital and community clinic records of boys resident in Halton Health District who underwent surgery for undescended testicle during 1987-89. Community Child Health Clinics. Medical Records Department of referral hospitals surrounding Halton district. During 1987-89, 76 boys from Halton district underwent surgery for undescended testis in the neighbouring hospitals: 64 (84%) of these boys had attended at least one screening examination in the community clinics; 12 (16%) did not attend any. Among the 64 who attended 18 (28%) were not considered to have undescended testis. Of the 30 boys diagnosed to have undescended testis after school entry, six were diagnosed incidentally in hospital and 24 were detected by general practitioners and School Medical Service. The age range for surgical referral varied from six months to 12.5 years. The percentage of boys referred for surgery before their second birthday was only 13%. Many cryptorchid boys were not picked up in community screening and many of these did not receive early surgery. This audit report suggested the following recommendations: (a) increased awareness of the condition amongst doctors and health visitors performing screening examination; (b) early surgical referral. These recommendations have been implemented in the district. Our further plan is to repeat the audit in three years to assess changes.