Eighth Postoperative Day Research Articles

Resting Energy Expenditure in Cancer Patients Before and After Gastrointestinal Surgery

The aim of this study was to assess the impact of surgical trauma on energy metabolism in cancer patients. Therefore, resting energy expenditure (REE) was determined before and after surgery in patients with newly detection gastric and colorectal cancer. Preoperative REE was measured in 104 patients. In 65 of these 104 patients REE was also measured on the seventh or eighth postoperative day. Postoperative REE was significantly higher than preoperative REE (mean +/- SD: 1471 +/- 238 vs 1376 +/- 231 kcal; p less than 0.001). After surgery 22 patients were hypermetabolic (REE greater than or equal to 115% predicted energy expenditure) compared with seven hypermetabolic patients before surgery. This hypermetabolism in the postoperative state can be explained by the administration of total parenteral nutrition (TPN), by an increased body temperature mainly as a consequence of postoperative complications and by the surgical trauma itself. Patients who received preoperative TPN (n = 12) showed a 10% increase in REE. Thirteen patients suffered from minor and major postoperative complications; postoperative REE in this group was increased by 10%. Forty patients who had undergone uncomplicated surgery showed a slight but significant increase of 3% in REE after operation. We conclude from this study that the increase in REE resulting from surgical trauma itself is modest at the seventh to eighth postoperative day. Therefore, energy requirements for patients undergoing major elective surgical stress are lower than generally presumed.

Microlymphography of spontaneous lymph vessel anastomosis in small bowel transplantation in the rat

Following small bowel transplantation, new lymph vessel anastomoses form spontaneously. Surgical anastomoses of the lymphatic vessels are unnecessary. The formation occurs in three stages. To the second postoperative day, lymph stays within the lymphatic vessels of the transplant. Following the fourth postoperative day, lymph flows within preexistent adventitial lymphatic vessels along the transplanted mesenteric artery to the arterial anastomosis at the aorta and stops there. From the sixth postoperative day on, lymph crosses the arterial anastomosis for the first time and flows along the recipient's aorta. To the eighth postoperative day a new lymph anastomosis is formed between the adventitia of the aorta and the neighbouring major lymphatic vessels. In the experiments presented here, these are represented by the vasa lymphatica testicularia sinistra of the recipient. Thus, the new anastomosis between lymphatic vessels is complete on the eighth postoperative day. These new vessels gradually dilate with time.

Prevention of Thromboembolic Disease Following Total Knee Arthroplasty

Seventy-two patients were randomized into a prospective clinical trial to evaluate the effects of epidural (EA) versus general anesthesia (GA) on the incidence of thromboembolic disease (TED) following total knee arthroplasty (TKA). Males received aspirin 650 mg po bid and females low-dose warfarin daily to maintain the prothrombin time at 15 to 16 seconds for pharmacologic prophylaxis against TED. Thirty-four patients had EA and 38 GA for their primary TKA. Contrast venography and ventilation-perfusion scanning were performed on the sixth, seventh, and eighth postoperative days, and these were interpreted in a blinded fashion. The mean age of the 45 males and 27 females was 64 years (range, 42-84 years). There were no significant differences between the two groups with respect to hematocrit, operative time, blood loss, number of units transfused, or hospital stay. Twelve of the 34 patients (35%) receiving an EA and 10 of the 38 patients (26%) receiving GA developed TED, an overall incidence of 31% (p greater than 0.05) Fifty-three percent of the clots were located in the popliteal vein above the trifurcation or more proximal. However, the incidence of proximal vein thrombosis was significantly less in patients receiving an EA (46%) rather than a GA (64%). The incidence and distribution of clots was not affected by the type of pharmacologic prophylaxis, gender, or use of methylmethacrylate. Ten percent of the patients had a positive scan by strict criteria and were thought to have a pulmonary embolism (PE). In patients with a femoral vein clot, the incidence of PE was 67%. One bleeding complication occurred in a patient who took double the appropriate warfarin dose.(ABSTRACT TRUNCATED AT 250 WORDS)

A Case of ‘in-the-bag’ Hyphaema after Posterior Chamber Lens Implantation

A very rare postoperative complication following posterior chamber lens (PCL) implantation, ‘in-the-bag’ hyphaema, is reported. A 64-year-old female with senile cataract underwent PCL implantation using an intercapsular technique without removal of the anterior capsule. On the third postoperative day, a hyphaema developed, and extended on the PCL and the intact anterior capsule. On the eighth postoperative day, the blood accumulated in the capsular bag between the PCL and posterior capsule and formed a niveau. It disappeared 3.5 months after topical anticoagulant application without any complications. This unusual hyphaema was caused by the capsular bag with the upper wide opening.

Postoperative mediastinitis: A comparison of two electrocautery techniques on presternal soft tissues

Postoperative mediastinitis remains a serious surgical problem, complicating 0.4% to 5% of all cases. In an experiment designed to address this problem, 36 mongrel dogs underwent a median sternotomy incision. In group I (n = 18) all layers to the sternum were opened by a scalpel, and electrocautery was used only for pinpoint hemostasis. In group II (n = 18) the skin was opened by a scalpel and the remaining layers to the sternum were opened by electrocautery. Total kilojoules of electrical energy delivered to the tissues was 9.4 +/- 5.7 for group I and 44.1 +/- 7.0 for group II (p less than 0.001). Each group was randomly divided into three subgroups (n = 6): Ia and IIa were noninoculated controls; Ib and IIb were inoculated just before skin closure; Ic and IIc were inoculated and given one preoperative dose of cefonicid. The inoculum contained Staphylococcus intermedius in a 0.5 ml suspension of 10(8) organisms. Each animal was observed and the wounds were scored daily until death or until all survivors were put to death on the eighth postoperative day. Pleural fluid was cultured at autopsy. Ten dogs died of mediastinitis (four in IIa and six in IIb), but none from group I (p less than 0.01). Positive cultures from pleural fluid in matching subgroups (n = 6) occurred as follows: one in Ia and five in IIa (p less than 0.05); one in Ib and six in IIb (p less than 0.01); zero in Ic and two in IIc. We conclude that pinpoint hemostasis on the soft tissues of the sternotomy incision significantly reduces the severity and frequency of penetrating mediastinitis.

Dissecting thoracic aortic aneurysm in a 22-year-old man

A 22-year-old man presented with a 12-hour history of acute epigastric pain associated with hematochezia. Emergency echocardiography and aortography were diagnostic of a bicuspid aortic valve and dissection of the thoracic aortic aneurysm. Surgical intervention included repair of the aneurysm, partial small bowel resection, and revascularizations of the superior mesenteric artery. An eventful hospital course ended in the patient's death on the eighth postoperative day. Dissecting aortic aneurysm is a rare condition in young adults. Prompt diagnosis with aggressive medical management and urgent surgical consultation affords the best outcome.

Small-bowel perforation complicating the open treatment of generalized peritonitis.

Fourteen patients were found to have developed 53 small-bowel perforations in the absence of pathogenic factors during "open abdominal treatment" for generalized peritonitis. They occurred after three to 17 laparotomies, on average at the eighth postoperative day (one to 120 days). Forty-nine lesions were located superficially. A relation with organ system failure, routine blood tests, type of nutrition, or microorganisms could not be demonstrated. The etiology of the lesions remains uncertain, but the open abdominal treatment must play some important role in its pathophysiology. Five patients survived. The therapy of choice appears to be mobilization of the bowel with resection of the affected part and primary anastomosis.

Effect of Collagen Shields on Corneal Epithelialization Following Penetrating Keratoplasty

To evaluate the effects of collagen shields on corneal epithelial healing following keratoplasty, we conducted a prospective study of 89 consecutive penetrating keratoplasty patients over a 9-month period, applying collagen shields in alternate cases. Eyes were evaluated on the first and on the eighth postoperative day. The appearance of the epithelium was graded on a scale from 0 to 4. Independent variables, such as donor age, patient age, patient and donor sex, death to preservation time, and donor time in K-Sol media prior to surgery, were also evaluated. Donor corneas treated with collagen demonstrated less epithelial staining and smaller epithelial defects on the first day following surgery. The results were evaluated with a Student's t test and were found to be significant (P less than 0.001). We conclude that the application of porcine collagen shields following keratoplasty is an effective means of encouraging reepithelialization of the graft.

Renal cytochrome P-450-related arachidonate metabolism in rabbit aortic coarctation.

Cells of the medullary segment of the thick ascending limb of Henle's loop (TALH) convert arachidonic acid (AA) via the cytochrome P-450 monooxygenase pathway to biologically active metabolites: P1, a vasorelaxant, and P2, an inhibitor of Na+-K+-ATPase activity. These AA metabolites may contribute to the renal vascular and metabolic adjustments in response to renal hypoperfusion and the attendant elevation of blood pressure produced by suprarenal aortic coarctation. On the eighth postoperative day, the blood pressures of hypertensive and sham-operated control rabbits were 105 (90-115) and 63 (60-64) mmHg (medians with semiquartile values), respectively (P less than 0.01). Formation of P1 and P2 was increased twofold in TALH cells obtained from hypertensive rabbits: 2.35 (1.79-4.83) and 1.28 (1.56-4.56) micrograms AA converted.mg protein-1.30 min-1 compared with sham-operated rabbits: 1.27 (1.03-1.53) and 0.64 (0.58-1.10) micrograms AA converted.mg protein-1.30 min-1 (P less than 0.05). The profile of biological activity of AA metabolites contained within P1 and P2 was unaffected by aortic coarctation. The cytochrome P-450 monooxygenase-derived AA metabolites may exert a defensive function to limit the degree of TALH cell injury in response to renal hypoperfusion and associated zonal anoxia by reducing energy-dependent Na+-K+-ATPase activity and affecting local vasodilatation.

Intussusception following abdominal trauma.

We reviewed the charts of 21 patients on the Trauma Service who were operated on for intestinal obstruction for the years 1983 through 1985. Six (28.6%) of the 21 patients had intussusception as the cause of their obstruction post-laparotomy for trauma. All were males ages 17 to 25 years. The mechanisms of injury were gunshot wounds in three, stab wounds in two, and blunt trauma in one. Five patients were hypotensive on admission with systolic BP less than 70, and two patients received uncrossmatched blood preoperatively. Injuries at exploration included liver laceration (six patients), gastric perforation (two patients), and diaphragmatic lacerations, splenic laceration, renal injury, and ventricular injury, one each. No patient suffered small intestinal injuries and we cannot explain the occurrence of intussusception. Intussusception occurred in the first 8 postoperative days in four patients and at 21 days, and 10 months, in the remaining two. The diagnosis was made twice by CT scan preoperatively. Jejunojejunal intussusception was common (five patients), jejunoileal in one and ileocolic in one (who also had a jejunojejunal intussusception). All patients were treated with manual reduction alone and none recurred. There were no postoperative complications and all patients were discharged by the eighth postoperative day. Our study suggests that early postoperative obstruction is caused by intussusception with unexpected frequency in trauma patients, and can be diagnosed by CT scan in some cases. Treatment with operative reduction has an excellent prognosis.

Early normalization of luteinizing hormone pulsatility after successful transsphenoidal surgery in women with microprolactinomas.

In eight hyperprolactinemic amenorrheic women who had a microprolactinoma, LH secretion was examined by measuring its concentration in blood samples collected every 15 min for 6 h before and 8 days after successful selective adenomectomy. Computer analysis was used for LH peak evaluation. In both circumstances, serum PRL and basal estradiol (E2) levels were also determined. Before operation, the number of LH peaks ranged from zero to one per 6 h in seven patients and was two per 6 h in the eighth patient. In all patients, serum PRL was normal on the eighth postoperative day, while E2 levels remained low, similar to the values usually found in the early follicular phase of the cycle in normal women. Postoperatively, mean LH levels were similar to preoperative levels, but there was a dramatic increase in the number of LH peaks (three to five per 6 h) in five of the eight patients. These observations confirm the impairment of LH pulsatility in hyperprolactinemia and demonstrate that normalization of PRL levels by surgery can restore LH pulsatile secretion in certain women as early as the eighth day after operation in the absence of a significant change in serum E2 levels. Thus, the preoperative impaired pulsatility of LH secretion was probably a central effect of hyperprolactinemia.

Thrombopénie post-transfusionnelle traitée par les gammaglobulines

Thrombopaenia and a haemorrhagic syndrome occurring on the eighth postoperative day were probably related to a post-transfusion purpura, confirmed by the decovery of antiplatelet antibodies not belonging to the PLA1 antigen system. The stabilization of this haemorrhage and a full recovery were obtained by giving high doses of intravenous human gammaglobulins. Blood replacement only rarely induces postoperative immunoallergologic thrombopaenia; heparin is the best known causative agent. It is concluded that platelets should never be given so long as the responsible agent is not formally identified.

TWO CASES OF PORTAL VEIN THROMBOSIS FOLLOWING SPLENECTOMY

Splenectomy was performed in the past four years in 13 cases of portal hypertension and blood disorder. Two of the patients subsequently experienced portal vein thrombosis. Case 1, a 63-year-old woman, underwent splenctomy due to polycythemia vera. Ultrasonography revealed numerous portal vein thromboses on the second postoperative day. Emergency thrombectomy and ligation of the splenic vein was performed with good results. Case 2, a 46-year-old man, underwent splenectomy and transabdominal esophageal dissection for esophageal varices. Portal vein thrombosis was detected by ultrasonography on the eighth postoperative day with the increase in thromboses, hepatic failure, numerous ascites and intestinal hemorrhage were noted. Anticoagulant-fibrinolytic therapy resulted in the disappearance of the thromboses. Portal vein thrombosis following splenctomy for portal hypertension and blood disorder occurs with an unusually high frequency. Early diagnosis by ultrasonography is the key to handling this complication, and thrombectomy or anticoagulant-fibrinolytic therapy should readily be undertaken for good results. As the principal cause is thought to be the blood stasis in the residual splenic vein, this disease should be preventable if the splenic vein is ligated just proximal to the junction of the inferior mesenteric vein.

Electrohydraulic Lithotripsy for Treatment of a Cystic Calculus in a Mare

Electrohydraulic lithotripsy performed through a nephroscope was used to fragment an ammonium urate, triple phosphate calculus in a mare. Calculus fragments were lavaged from the bladder. The mare recovered uneventfully and returned to work on the eighth postoperative day.

Skin grafting on the lower leg as an out-patient ambulatory procedure

Skin mobility on the lower leg is relatively poor. Excisional procedures often produce defects that are difficult or impossible to close by primary suture. Suturing under excessive tension predisposes to infection and frequently leads to wound dehiscence. The placement of skin grafts on the lower leg is usually considered to require post-operative immobilization in bed for several days. In the present series, split skin grafts were successfully used to repair 13 lower leg wounds of up to 4.5 cm in diameter in 12 patients aged 53–84 years (mean 67). All were treated under local anaesthesia as out-patients and all returned home immediately and remained ambulatory post-operatively. The lesions excised included squamous carcinoma, basal cell carcinoma and Bowen's disease. Haemostasis of the recipient site was achieved with diathermy. Donor skin from the ipsilateral thigh was sutured around the circumference with 4/0 monofilament polyamide overlapping the wound edges by 1–2 mm. After covering with paraffin gauze the graft was further immobilized with a tie-over sponge dressing. A stockinette tube was placed over the lower leg and foot and a firm crepe bandage applied which was fixed to the skin with tape. The donor site was covered with Opsite. Sutures were removed on the eighth post-operative day and the Opsite was removed from the donor site after 3–4 weeks. All grafts showed at least an 80% take and in most this was virtually complete. A seroma requiring aspiration developed beneath one graft and in another a minor staphylococcal infection developed. Skin grafting on the lower leg is feasible as an out-patient procedure. This is more convenient for the patient and greatly reduces the cost to the Health Service compared with conventional hospital treatment.

Splenectomy for thrombocytopenia.

AbstractThe effects of splenectomy in 49 thrombocytopenic patients managed since 1979 were assessed and compared with our previous experience of 174 patients. Idiopathic thrombocytopenic purpura (ITP) constitutes a common indication for splenectomy, which effects a cure in 86% of these patients. The platelet count rises above 100,000/mm3 by the eighth postoperative day in 88% of responders. Urgent splenectomy is indicated for patients with thrombotic thrombocytopenic purpura (TTP) because it is associated with the highest cure rate. Splenectomy in patients with myeloproliferative disorders causing thrombocytopenia effectively raises the platelet count but has been followed by the greatest incidence of complications among the hematologic disorders studied. In patients with chronic lymphatic or hairy cell leukemia, splenectomy almost always returns platelet counts to normal levels and there is an impressive improvement in the quality of life. A wide variety of disorders characterized by thrombocytopenia is responsive to splenectomy. Accessory spleens have been removed in 17% of ITP patients and are often present in patients with myeloproliferative disease, but only rarely noted in other patients with thrombocytopenia.

Adhesion formation after tubal surgery: results of the eighth-day laparoscopy in 188 patients

First-look laparoscopy (FL) on the eighth day after salpingostomy, fimbrioplasty, or adhesiolysis was performed in 188 patients. Behavior of postoperative adhesions and the occurrence of pregnancy after tubal surgery were compared with a similar group of 127 patients in whom no FL was performed. In greater than 50% of the cases (104/188), adhesions were found on the eighth postoperative day around both adnexa or the only remaining adnexum. Adhesions were mainly located between the ampulla and the ovary and between the ovary and the lateral pelvic wall or broad ligament. More than half of the adhesions that were separated at FL did not recur. It was concluded that FL significantly diminished the occurrence of permanent pelvic adhesions. The incidence of ectopic pregnancy after salpingostomy was significantly lower when FL was performed. FL on the eighth postoperative day can be regarded as a well-accepted procedure with few complications.

Sleep in the cat: raphe dorsalis and vasotocin.

To determine the relationship between the raphe nuclei and the sleep-inducing pineal peptide arginine vasotocin (AVT), we investigated the hypnogenic effects of intraventricularly administered AVT in adult cats with electrolytic lesions performed either in the raphe dorsalis nucleus (RDN) or the raphe pontis nucleus (RPN). The following results were observed: (a) RDN lesions produced a quantitative decrease in NREM sleep and a transitory increase in REM sleep and narcoleptic-like alterations of REM sleep in the first 2-5 postoperative days. On the eighth postoperative day, normal (prelesion) sleep parameters were restored. (b) RDN lesions prevented AVT from inducing its hypnogenic effects during the first 5 postoperative days, but the AVT hypnogenic effects reappeared when sleep parameters reached prelesion levels. (c) Although the RPN lesions produced a slight but statistically significant REM sleep decrease, this did not prevent AVT from inducing its hypnogenic effects. We conclude that (a) the anatomic site of AVT action within the brain may be related to RDN; (b) at least some of the sleep disturbances observed after RDN lesions (narcolepsy) may be due to damage of the AVT site of action or to modifications of AVT synthesis or release; (c) RDN belongs to a large neural circuit that includes the pineal gland and habenula, a circuit that may play an important role in the sleep-wake cycle by "fine-tuning" sleep mechanisms. We hypothesize that AVT could be the specific inhibitory neuromodulator of this neural circuit.

Changes in the systolic time intervals of the fetal heart after surgical manipulation of the fetus

The fetal cardiac systolic time intervals are potentially an important indicator of fetal well-being. Because experimental studies with the use of animal models are being carried out to evaluate the effects of abnormal antenatal factors on fetal myocardial function, it is important to establish the changes in the systolic time intervals that can occur as a result of the surgical preparation of the animal model and also to determine the time required for the recovery of myocardial function. After the appropriate catheters have been placed in fetal sheep, the ratio of preejection time to ejection time was followed in six maternal-fetal sheep models for 3 days postoperatively. The mean values obtained from the animals were then compared to the data obtained and were considered to be normal on the eighth postoperative day. In spite of acid-base data within the physiologic limits, the ratio of preejection period/ejection time was elevated postoperatively and reached normal values between 2 to 3 days postoperatively. The study demonstrates that 3 days are required for the recovery of fetal myocardial function before baseline preexperimental conditions are reached.

Surgical management of severe coarctation of the aorta in the first month of life: Review of 48 consecutive cases

Between March, 1978, and April, 1982, 48 neonates under 4 weeks of age were operated upon for severe coarctation of the aorta in our unit. Of these, 36 babies were in severe congestive cardiac failure and 11 had renal failure. Angiocardiography and echocardiography demonstrated intracardiac lesions in 29 patients. All had a patent ductus arteriosus. Surgical relief of the coarctation was effected within 48 hours of diagnosis. Those in severe cardiac and renal failure were intubated and ventilated in the intensive care unit before the operation. Continuous monitoring of the central venous and arterial pressures and rectal and skin temperature and periodic checks on the acid-base status were instituted, and acidosis was corrected carefully with a 4.2% solution of sodium bicarbonate. A dopamine infusion (4 to 8 micrograms/kg/min) was used to assist the renal and cardiac functions. Five babies were treated with prostaglandin E for 24 to 46 hours before the operation. Forty-five patients had subclavian flap repair of the coarctation and the other three had repair by polytetrafluoroethylene (PTFE) patch angioplasty. The patients were ventilated for 1 to 8 days postoperatively. Dopamine support was given to all the immediate postoperative period. Three patients with associated cardiac lesions died in the first 48 hours after operation. Three other patients died on the sixth, eighth, and eleventh postoperative days of noncardiac causes. Of the 42 survivors, three required revision of the repair because of restenosis 3 to 18 months later. Three patients with ventricular septal defect had closure of the defect within 8 months after birth. We believe that coarctation of the aorta presenting soon after birth should be treated by a combination of active resuscitation and early surgical relief, and that continuous monitoring for early detection and correction of hypoxia and acidosis is essential to achieve satisfactory results.