Incidence Of Systemic Complications Research Articles

Perioperative complications and cost of posterior decompression with fusion in thoracic spine for ossification of the posterior longitudinal ligament and ossification of the ligamentum flavum -a comparative study using a national inpatient database

BackgroundAlthough posterior decompression with fusion (PDF) are effective for treating thoracic myelopathy, surgical treatment has a high risk of various complications. There is currently no information available on the perioperative complications in thoracic ossification of the longitudinal ligament (T-OPLL) and thoracic ossification of the ligamentum flavum (T-OLF). We evaluate the perioperative complication rate and cost between T-OPLL and T-OLF for patients underwent PDF.MethodsPatients undergoing PDF for T-OPLL and T-OLF from 2012 to 2018 were detected in Japanese nationwide inpatient database. One-to-one propensity score matching between T-OPLL and T-OLF was performed based on patient characteristics and preoperative comorbidities. We examined systemic and local complication rate, reoperation rate, length of hospital stays, costs, discharge destination, and mortality after matching.ResultsIn a total of 2,660 patients, 828 pairs of T-OPLL and T-OLF patients were included after matching. The incidence of systemic complications did not differ significantly between the T-OPLL and OLF groups. However, local complications were more frequently occurred in T-OPLL than in T-OLF groups (11.4% vs. 7.7% P = 0.012). Transfusion rates was also significantly higher in the T-OPLL group (14.1% vs. 9.4%, P = 0.003). T-OPLL group had longer hospital stay (42.2 days vs. 36.2 days, P = 0.004) and higher medical costs (USD 32,805 vs. USD 25,134, P < 0.001). In both T-OPLL and T-OLF, the occurrence of perioperative complications led to longer hospital stay and higher medical costs. While fewer patients in T-OPLL were discharged home (51.6% vs. 65.1%, P < 0.001), patients were transferred to other hospitals more frequently (47.5% vs. 33.5%, P = 0.001).ConclusionThis research identified the perioperative complications of T-OPLL and T-OLF in PDF using a large national database, which revealed that the incidence of local complications was higher in the T-OPLL patients. Perioperative complications resulted in longer hospital stays and higher medical costs.

Usefulness of frailty to predict short- and long-term outcomes in patients who have undergone major hepatectomy for perihilar cholangiocarcinoma.

The influence of frailty on outcomes after hepatectomy for perihilar cholangiocarcinoma (PHCC) remains unclear. This study aimed to investigate the impact of frailty on the incidence of postoperative complications and survival after major hepatectomy for PHCC. A total of 87 patients who had undergone surgery for PHCC between 2007 and 2020 were enrolled in this study. Frailty was scored retrospectively using the Clinical Frailty Scale (CFS). The survival and incidence of postoperative complications were compared based on the degree of frailty, and their risk factors were analyzed. The overall survival of the CFS score 1-2 group was significantly higher than that of the CFS score 3-7 group (P=.01). The survival benefit was especially observed in stage I or II PHCC. Furthermore, there were significant differences between the CFS score 1-3 group and the CFS score 4-7 group in the incidence of Clavien-Dindo classification grade ≥ IIIa (39.4% vs 70.6%; P=.03). Frailty was an independent risk factor for severe postoperative complications (odds ratio, 4.11; 95% confidence interval, 1.18-15.20; P=.03) and the incidence of systemic complications (P < .01). Frailty is a predictive factor for short- and long-term outcomes in patients who have undergone major hepatectomy for PHCC.

The Value of Routine Tests before Pediatric Eye Surgery: A 10-Year Experience at a Tertiary Care Hospital.

Routine tests before ophthalmologic surgery in adult patients are no longer recommended. However, there are limited data on the utility of routine preoperative tests for children. We aimed to describe the effect of routine preoperative tests on systemic perioperative complications by hospital discharge or by day 30 following eye surgery. This was a single-center, observational, and descriptive study. We examined all patients ≤ 17 years old for whom ophthalmologists consulted with anesthesiologists before eye surgery under general anesthesia in an academic teaching tertiary care hospital from January 2010 to December 2019. A total of 708 pediatric patients were analyzed. The mean patient age was 8.5 ± 4.6 years. The most frequently performed procedure was strabismus surgery in 433 patients (61.2%). Following anesthetic consultations, 15 patients (2.1%) underwent surgery postponed due to abnormalities at the physical examination. Routine tests identified that the two patients (0.3%) required additional evaluations due to elevated serum creatine kinase and electrocardiographic abnormalities. However, further examinations found that these abnormalities were unremarkable. The remaining 691 patients (97.6%) underwent surgery as scheduled. Substantial intraoperative blood loss was observed only in three patients with malignant tumors or trauma. The incidence of systemic complications was 0 (0%; 95% confidence interval, 0%-0.05%). These data indicated that the development of systemic perioperative complications following pediatric ophthalmic surgery is rare. Preoperative tests should be requested only if they are clinically indicated or before potentially bleeding procedures, such as malignancy or trauma surgery.

Intolerability to postoperative early oral nutrition in older patients (≥70 years) undergoing gastrectomy for gastric cancer: A case-control study.

BackgroundPostoperative early oral nutrition has increasingly been adopted for patients undergoing gastrectomy. However, intolerability to early oral nutrition remains a major concern, especially in older patients. This study aimed to investigate early oral nutrition intolerability in older patients who had undergone gastrectomy.MethodsWe retrospectively reviewed 825 patients who had undergone gastrectomy for gastric carcinoma between 2017 and 2019. All patients received an oral diet on postoperative day 1. Patients were divided into older (≥70 years) and younger (<70 years) adult groups, and short-term outcomes and intolerability to oral nutrition were compared. Intolerability to early oral nutrition was defined as oral diet cessation due to adverse gastrointestinal symptoms.ResultsAmong the 825 patients (≥70 years, n = 286; <70 years, n = 539), 151 (18.3%) developed intolerability to early oral nutrition, of whom 100 patients were < 70 years old and 51 were ≥70 years old. The most common symptom causing intolerability was abdominal distension. The mean duration of fasting after developing intolerability was 2.8 ± 2.4 days. The incidence of intolerability in the older and younger adult groups was 17.8% and 18.6%, respectively (p = 0.799). In terms of sex, operative approach, gastric resection, lymph node dissection, reconstruction, and tumor stage subgroups, the older adult group did not exhibit a significant increase in intolerability. Postoperatively, the older adult group showed a higher incidence of systemic complications; however, anastomotic complications did not significantly differ between the two groups.ConclusionsPostoperative early oral nutrition can safely be adopted for older patients undergoing gastrectomy, with acceptable intolerability and surgical outcomes.

Safety and feasibility of laparoscopic surgery for elderly rectal cancer patients in Japan: a nationwide study

BackgroundThis study aimed to analyse the perioperative results from a national dataset of rectal cancer resections in elderly patients.MethodsThe clinical records of patients undergoing rectal cancer surgery between 2012 and 2014 were retrieved from the Japanese National Clinical Database and analysed retrospectively. Patients were categorized according to age and those 80 years or older were defined as elderly. Subgroups were also defined according to the surgical approach (laparoscopy versus open surgery). The short-term outcomes, including mortality, anastomotic leak, surgical site infections and medical complications were compared between subgroups.ResultsOf 56 175 patients undergoing rectal cancer surgery, some 6717 patients were elderly and laparoscopy was performed in 46.8 per cent of the sample. When comparing laparoscopy and open surgery in elderly patients, the operative mortality rate (1.5 versus 2.8 per cent; P < 0.001), the incidence of anastomotic leakage (5.2 versus 6.5 per cent; P = 0.026), surgical site infections (6.0 versus 8.0 per cent; P = 0.001), pneumonia (1.4 versus 2.5 per cent; P = 0.001), renal failure (0.7 versus 1.3 per cent; P = 0.016) and cardiac events (0.3 versus 0.8 per cent; P = 0.008) were lower for laparoscopy than for open surgery. The overall complication rate in elderly patients (19.5 per cent) was comparable to that in the younger group (P = 0.07). However, incidence of systemic complications was significantly higher in elderly than in younger patients (all P < 0.001).ConclusionLaparoscopy was safe and feasible in elderly patients compared with open surgery. However, the rates of systemic complications were significantly higher than in younger patients.

IMPROVEMENT OF TECHNOLOGIES OF DIAGNOSTICS AND TREATMENT OF INTRA-ABDOMINAL HYPERTENSION IN ACUTE SURGICAL PATHOLOGY OF ABDOMINAL CAVITY

Relevance. The article is devoted to the problem of diagnosis and treatment of intra-abdominal hypertension (IAH) in acute abdominal pathology. Acute surgical diseases and abdominal injuries are accompanied by an increase in intra-abdominal pressure (IAP) in 83.6% of cases, and cause an abdominal compartment syndrome (ACS) in 16.8% of the observations.&#x0D; Objective. This review seeks to improve the results of treatment of patients with acute abdominal pathology by improving the methods of diagnosis, prevention and treatment of IAH.&#x0D; Materials and methods. The results of treatment of 187 patients with acute pathology of abdominal organs, which was accompanied by high IAP, were analyzed. Among the 187 patients, 98 (52.4%) were men, 89 (47.6%) women. The patients were divided into two groups depending on the diagnostic and therapeutic tactics chosen: the comparison group (85 (45.5%) persons) and the main group (102 (54.5%) persons). The treatment of them were carried out in accordance with our harmonized diagnostic and treatment algorithm of the correction of IAH. 149 (79.7%) patients were operated: 82 patients in the main group and 67 persons in comparison group. Our own method for the long-term determination of IAP by measuring it in the bladder was used for long-term diagnostics of IAP. Advanced laparolifting system was used in the complex conservative treatment of patients with acute pancreatitis accompanied by IAH. Methods for predicting the possibility of performing laparoscopic intervention in urgent surgery and postoperative pain after laparoscopic surgery were improved.&#x0D; Results. Implementation of the improved method of measuring IAP through prolonged monitoring of BP allowed to timely select and start the necessary therapeutic tactics, aimed to overcome intra-abdominal hypertension, and to avoid the development of abdominal compartment syndrome (sensitivity of the technique was 95.2%, specificity - 85.7%). The use of our advanced diagnostic and treatment algorithm for the prevention and treatment of IAH allowed to limit the measures to the first level in 67,6% of cases, to the second level - in 22,5% and to avoid the decompression laparostomy. At the same time, the need for such intervention arose in 11.1% of patients who had conservative treatment.&#x0D; Use of the proposed laparolifting system in the complex conservative treatment of IAH of patients with acute pancreatitis allowed to normalize IAP in the vast majority of patients, preventing the occurrence of ACS by reducing the frequency of complications associated with IAH, from 52.9% to 16.7% (p = 0.03 ), as well as overall mortality - from 35.3% to 5.6% (p = 0.03). Implementation into clinical practice the method of predicting the possibility of performing laparoscopic intervention in the conditions of urgent surgery by registering the initial values ​​of IAP, allowed to expand the indications for the implementation of this type of surgery in treatment of acute surgical pathology of the abdominal cavity organs (sensitivity of the technique was 85.7%, specificity - 95.5%). Local use of stereoselective NSAIDs (original dexketoprofen) at the end of the laparoscopic intervention followed by their intramuscular administration has a higher analgesic effect in comparison with other classes of analgesic agents, which is reliably confirmed by pain assessment indicators (visual analogue scales, blood plasma cortisol and external respiration function) (p &lt;0.0001), and has a significantly higher degree of safety (p &lt;0.001). Application of the proposed diagnostic and treatment algorithm in the complex treatment of patients with acute surgical pathology of the abdominal cavity, which is accompanied by IAH, allowed to achieve the intended goal for improving the treatment results of this category of patients by reducing the incidence of systemic complications from 54.1% to 11.8% ( p &lt;0.0001), total mortality from 21.2% to 1.96% (p &lt;0.0001), and postoperative lethality from 22.4% to 2.4% (p = 0.0001).&#x0D; Conclusions. The method of measuring IAP by prolonged monitoring of BP is effective and practical (sensitivity of the technique was 95.2%, specificity - 85.7%). The use of the laparolifting system in patients with acute pancreatitis accompanied by IAH allowed to reduce the frequency of complications from 52.9% to 16.7% (p = 0.03), and the overall mortality - from 35.3% to 5.6% (p = 0,03). The introduced method of predicting the possibility of performing laparoscopic intervention in urgent surgery demonstrates high sensitivity (85.7%) and specificity (95.5%). The local use of stereoslective NSAIDs at the end of the laparoscopic intervention has a high analgesic effect and has a significantly higher safety degree (p &lt;0.001). The use of the advanced diagnostic and treatment algorithm for treatment of IAH allows to apply only the first level measures in 67,6% of cases, the second level measures in 22,5%, to avoid the implementation of decompression laparostomy and to reduce the incidence of systemic complications from 54,1% to 11,8% (p &lt;0.0001), to reduce total mortality from 21.2% to 1.96% (p &lt;0.0001) and postoperative lethality from 22.4% to 2.4% (p = 0.0001).

Study on the Causes of Discontinue Treatment in Treated Patients with Cutaneous Leishmaniasis with Muscle Glucantime Injection based on the Type of Medicine (Treatment) Side Effects

Background and objective: Cutaneous leishmaniasis is considered as an endemic disease in not only Iran but also all over the world. Since cutaneous leishmaniasis is not mainly fatal, therefore it has not been considered seriously by researchers as such as fatal and hard diseases, therefore due to lack of studies in this area in Iran territory, Cutaneous leishmaniasis has been focused to be studied in the current study. Methods: The current research is a cross-sectional descriptiveanalytic study. The studied patients were the 54 cases who were the candidates of the treatment by systematic glucantime muscle injection in Sabzevar city at 2016 based on the country protocol. The relations among the parameters including demographic, systemic symptoms, pancreatic enzyme alterations, liver enzyme alterations, CBC, BUN, Cr by the incidence of complications during the 3-week treatment period were studied by systemic Glucantime injection. To analyze the obtained data, Chi-squared test of SPSS program version 16 was applied. Findings: Regarding the achieved results, 31 males (57.4%) and 23 females (42.6%) were selected as candidates of systemic treatment. 22 candidates (40.7%) were under the age of 60 years. Refractive index treatment was 50%, that all of the candidates have shown systemic complications with significant relations with incidence of time (P<0.0001). 14.7% of the candidates along with systemic symptoms, showed enhancements in pancreatic enzymes 3 times high, presenting significant differences with incidence of time (P<0.006). The highest complications occurred during the first week of treatment. Results: In the present research, the causes of the treatment ending was the incidence of systemic complications and incremental changes in pancreatic enzymes due to glucantime muscle injection occurs mostly in the first weeks of treatment period that finally may lead to the use of alternative methods including cryotherapy for patients treatment.

MELD and living donor liver transplantation outcome

Introduction: MELD score was validated as a predictor of mortality for a wide variety of liver diseases,8 including cirrhotic patients awaiting liver transplantation (LT).9 we try to assess the impact of MELD score on patient survival and morbidity post living donor liver transplantation (LDLT) . Design: Retrospective study. Methodology: Between February 2007 and December 2011, 80 adults patients, randomly selected with ESLD, had living donor liver transplantation. Nine patients were excluded, the remaining 71 patients were divided into two groups. Group 1 included 38 patients with MELD 20. We compared both groups as regard operative data (including operative time and intra-operative blood requirement), early post­ operative course (including JCU stay, hospital stay, incidence of infection and other morbidity like renal impairment, cardiovascular, respiratory and neurological complications) and patient survival up to 1 July 2012. Results: Eleven patients died during this study (15.2%): three out of 38 patients (7.8%) in group 1 and 8 outof33 patients (24.2%) [P=0.02]. Mean hospital stay was 30±14 and 29±18 days in 1st and 2nd group respectively [P=0.937]. The mean JCU stay in group 1 and 2 was 7±3 and 9± 4 days [P=0.315]. Mean operative time in group 1 and 2 was 11.1±2 and 10.6±1.4 hours [P=0.292]. Mean volume of blood transfusion and cellsaver re-transfusion were 8±4 unit and 1668±202 ml respectively in group 1 in comparison to 10±6 unit and 1910±679 ml respectively in group 2 [ P = 0.09 and 0.167]. The incidence of infection was 39.4% and 45.4% in group 1 and 2 respectively [P=0.48]. The incidence of systemic complications (renal, respiratory, cardiovascular and neurological complications) in group 1 and 2 were 36.8% and 45.5% [P =0.3] Conclusion: MELD score more than 20 can predict poor overall survival post living donor liver transplantation. No significant relation between MELD score and intra-operative blood requirement, hospital, and JCU stay or post LDLT morbidity was noted.

Overweight Is an Additional Prognostic Factor in Acute Pancreatitis: A Meta-Analysis

Background/Aims: It is generally accepted that there is a correlation between obesity and poor outcome in acute pancreatitis (AP); however, the relationship between overweight and the prognosis of AP is unknown. The aim of this study was to determine the correlation between overweight and the prognosis of AP. Methods: MEDLINE and PubMed were searched using the terms ‘acute pancreatitis’, ‘obesity’, ‘overweight’, and ‘body mass index’ (‘BMI’). All prospective clinical studies correlating BMI and AP were included. Obesity and overweight were defined as BMI ≥30 and from 25 to 30, respectively. A meta-analysis was performed with the endpoints severe AP (SAP), local complications, systemic complications, and mortality. Results: Eight studies including 939 patients were found. The incidence rates of SAP (OR 2.48,95% C11.34–4.60), local complications (OR 2.58, 95% CI 1.20–5.57), and mortality (OR 3.81, 95% CI 1.22–11.83) were increased in overweight patients with AP. No difference was detected in the incidence of systemic complications between the normal-weight and overweight patients (OR 1.62, 95% CI 0.76–3.43). In addition, the correlation between obesity and poor prognosis was again confirmed. Conclusion: Overweight is an additional prognostic factor of severity, local complications, and mortality in AP.

The Role of Age in Predicting the Outcome of Caustic Ingestion in Adults: A Retrospective Analysis

BackgroundAlthough the outcomes of caustic ingestion differ between children and adults, it is unclear whether such outcomes differ among adults as a function of their age. This retrospective study was performed to ascertain whether the clinical outcomes of caustic ingestion differ significantly between elderly and non-elderly adults.MethodsMedical records of patients hospitalized for caustic ingestion between June 1999 and July 2009 were reviewed retrospectively. Three hundred eighty nine patients between the ages of 17 and 107 years were divided into two groups: non-elderly (< 65 years) and elderly (≥ 65 years). Mucosal damage was graded using esophagogastroduodenoscopy (EGD). Parameters examined in this study included gender, intent of ingestion, substance ingested, systemic and gastrointestinal complications, psychological and systemic comorbidities, severity of mucosal injury, and time to expiration.ResultsThe incidence of psychological comorbidities was higher for the non-elderly group. By contrast, the incidence of systemic comorbidities, the grade of severity of mucosal damage, and the incidence of systemic complications were higher for the elderly group. The percentages of ICU admissions and deaths in the ICU were higher and the cumulative survival rate was lower for the elderly group. Elderly subjects, those with systemic complications had the greatest mortality risk due to caustic ingestion.ConclusionsCaustic ingestion by subjects ≥65 years of age is associated with poorer clinical outcomes as compared to subjects < 65 years of age; elderly subjects with systemic complications have the poorest clinical outcomes. The severity of gastrointestinal tract injury appears to have no impact on the survival of elderly subjects.

Outcomes of Reintervention for Recurrent Disease After Percutaneous Iliac Angioplasty and Stenting

To evaluate the outcomes of percutaneous therapy for symptomatic >50% angiographic restenosis after iliac intervention versus outcomes of the primary procedure. A retrospective analysis was performed of 937 patients (733 men; mean age 65 years) who underwent 1532 endovascular interventions for symptomatic atherosclerotic iliac artery obstruction and were followed by duplex ultrasound between 1990 and 2009. In this population, 374 vessels restenosed (>50% on duplex); about half (176, 47%) were associated with recurrent symptoms. In 102 symptomatic patients (58 men; mean age 61 years), 147 limbs (84%) had repeat angioplasty/stenting and were compared to the primary treatment group. Thirty-day mortality was <1% in both primary and recurrent treatment groups, but morbidity was doubled in the reintervention group (4% versus 8%; p<0.05). While the incidence of systemic complications was low in both groups, the drivers for increased morbidity in the recurrent group were lesion-specific and access-site complications. In the 937-patient cohort, the rate of >50% restenosis on duplex was 15%±1% at 5 years. Gender (p = 0.03), diabetes (p = 0.04), metabolic syndrome (p = 0.001), symptoms (p<0.001), angioplasty alone (p = 0.04), concurrent superficial femoral artery occlusion (p = 0.02), and increasing complexity of the iliac intervention (p = 0.02) were associated with primary failure. Patency rates at 10 years for primary versus recurrent treatment were 73%±2% versus 66±8% for primary patency (p = 0.004); 88%±2% versus 74%±7% for assisted primary patency (p = 0.005); and 90%±2% versus 78%±10% for secondary patency (p = 0.002). Female gender (p = 0.01), continued smoking (p = 0.02), eGFR <60 mL/min/1.73m(2) (p = 0.03), lesion length (p = 0.02), lesion calcification (p = 0.005), and TASC II category (p = 0.04) negatively influenced patency of recurrent lesions. Sustained clinical success (absence of recurrent symptoms) was 74%±2% in the primary group and 66%±8% in the restenotic group (p = 0.014) at 10 years. Symptoms (p = 0.04), female gender (p = 0.002), hypertension (p = 0.004), eGFR <60 mL/min/1.73 m(2) (p = 0.02), external iliac artery disease (p = 0.02), lesion length (p = 0.02), and poor immediate clinical outcome (p<0.001) negatively influenced clinical success of recurrent lesions. Percutaneous reintervention for recurrent iliac artery disease has a higher procedure-related morbidity compared to primary intervention. Longer-term outcomes are also poorer than for primary lesions. The patients who present with restenosis are more likely to be younger and of female gender than patients presenting for primary intervention. Both patency and functional outcomes after reintervention are worse than those for primary interventions.

Safety and Efficacy of Damage Control External Fixation Versus Early Definitive Stabilization for Femoral Shaft Fractures in the Multiple-Injured Patient

Optimal timing and treatment of patients with concomitant head, thoracic, or abdominal injury and femoral shaft fracture remain controversial. This study examines acute patient outcomes associated with early total care with intramedullary nailing (ETC group) versus damage control external fixation (DCO group) for multiple-injured patients with femoral shaft fractures. We propose DCO as a safe initial treatment for the multiple-injured patient with femur shaft fractures. This study was a retrospective review of the trauma registry and multisystem organ failure registry data at a Level I trauma center. Two cohorts were identified to compare multiple-injured patients with femoral shaft fractures treated with early total care and damage control orthopaedic surgery. Primary outcome measures included mortality, pulmonary complications (adult respiratory distress syndrome [ARDS] score), transfusion requirements, and multiple organ failure (MOF score). Operative time, estimated blood loss, intensive care unit length of stay (LOS), and hospital length of stay (LOS) were also compared. During the study period, 462 patients with 481 femoral shaft fractures were identified. Of 462 patients with femoral shaft fractures, 97 met the inclusion criteria (42 ETC and 55 DCO). The DCO group had a significantly shorter operative time (22 minutes vs. 125 minutes) and less estimated blood loss from their operative procedure (37 mL vs. 330 mL). There was no significant difference between the groups for ARDS, lung scores, MOF, MOF score, intensive care unit LOS, or hospital LOS. Fracture fixation method did not have an impact on the incidence of systemic complications in multiple-injured patients with femoral shaft fractures. Although minimal differences were noted between DCO and ETC groups regarding systemic complications, DCO is a safer initial approach, significantly decreasing the initial operative exposure and blood loss.

Protocolo combinado de fijación externa y arteriografía en fracturas de pelvis con inestabilidad hemodinámica asociada: estudio retrospectivo sobre 79 casos

Purpose Frequently pelvic fractures are associated with arterial and/or venous intrapelvic bleeding, resulting in a high mortality rate ranging between 10 and 50%. Numerous treatment protocols have been published for the early control of hemorrhage. All of them agree on the need of a determined and multi-disciplinary approach that combines various therapeutic methods. The purpose of this study is to determine the applicability, clinical evolution and results of a therapeutic diagnostic algorithm used with a group of 79 patients with a pelvis fracture and a related hemodynamic instability. Materials and methods This is a retrospective study of a series of patients with a pelvic fracture associated to hemodynamic instability, who were admitted to our hospital between 1994 and 2004. The inclusion criteria were as follows: patients with a high-energy pelvic fracture and hemodynamic instability. The criteria used to define hemodynamic instability were a systolic blood pressure < 90 mmHg on admission or transfusion needs higher than 2 units of red cell concentrate in the first 12 hours. Results External fixation was used for 45 patients (57%). 48 patients (61%) were subjected to an arteriography, which revealed active arterial intrapelvic bleeding in 44 cases (56%). Twenty-one patients required an arterography plus external fixation, one after the other. twenty-four patients underwent a laparotomy. The incidence of systemic complications was high and mortality stood at 19%. The application of the algorithm was fairly widespread, except for patients requiring a laparotomy and presenting with an open-book type fracture. This group had a high mortality rate. Conclusions The incidence of arteriography-validated arterial lesions was very high. The use of a combined external fixation and arteriography protocol, adapted to the specific health-care characteristics of each hospital makes it possible to check intrapelvic bleeding in quite a large number of cases. Indications for laparotomy should be restricted to the treatment of the hemoperitoneum and of open fractures, and should always be accompanied by some external fixation device.

Management of Patients with Extended Pancreatic Necrosis

Background: Extended pancreatic necrosis pose a considerable therapeutic problem in patients with necrotizing pancreatitis. Aim: Factors that limit conservative treatment in patients with extended pancreatic necrosis were analyzed. Methods: The clinical course of 61 patients with an extent of necrosis of more than 50% of the gland (according to contrast-enhanced CT scan) were analysed with special regard to systemic complications. Indications for surgical treatment were either persistent organ failure or pancreatic infection. Results: 10 patients were managed by conservative treatment, 51 (84%) patients underwent operation. Indications for surgery were sepsis with or without organ failure in 17 patients, persistent organ failure in another 17 patients, persistent SIRS in 13 patients and local complications in 4 patients. Pancreatic infection was present in 25 patients. The incidence of systemic complications did not differ between infected and sterile necrosis, but they occurred earlier in sterile necrosis. Conclusions: Persistent organ failure is limiting conservative treatment during the early course in patients with sterile necrosis. The latter course is characterized by a high incidence of pancreatic infection and septic organ failure.

A heparin bonding of the extracorporeal circuit reduces clot formation during prolonged lung assist in goats

Purpose of Study: This study investigated whether heparin bonded artificial lungs with non-microporous polyolefin hollow fibber combined with low dose systemic heparinization could reduce the thrombus formation during prolonged, veno-arterial extracorporeal lung assist (V-A ECLA) in goats. Methods Used: We compared heparin-bonded (HB, 5 goats) and non-heparin bonded circuits (NHB, 5 goats) in ECLA of one week. ACT was kept below 130 s by systemic infusion with a small dose of heparin in the HB group, and 180 to 230 s in the NHB group. Clot formation was assessed by both microscopic and visual examination the circuit after the experiments, and the incidence of systemic complications. Summarize Results: The mean heparin dose give during ECLA was 20.4 ± 3.6U/kg/hr iin HB group, 50.9 ± 14.2 U/kg/hr in NHB group, significantly less in HB group than in NHB group (P < 0.01). The bypass flow rate, platelet aggregation activity, platelet counts, and fibrin monomer test, antithrobin - III activity did not differ between two groups. Macroscopic examinations revealed a lot of clot in all the oxygenators of the NHB group. A goat of NHB group of NHB group developed convulsions and cerebral hemorrhage. The HB artificial membrane lung consisted of those fibers showed a good anticoagulation advantage to decrease clot formations nevertheless a small dose of heparin in ECLA of 7 in goats.

A new heparin-bonded dense membrane lung combined with minimal systemic heparinization prolonged extracorporeal lung assist in goats.

Heparin was covalently bonded to a new hollow-fiber dense membrane artificial lung and extracorporeal circuit using a silane coupling agent and polyethyleneimine. This study investigated whether prolonged, venoarterial bypass extracorporeal lung assist (V-A bypass ECLA) could be sustained in a goat by the combination of the new membrane lung and minimal systemic heparinization. We maintained ECLA with the hollow-fiber lungs (surface area, 0.8 m2) and circuits by titrating the activated clotting time (ACT) to below 150 s with minimal systemic heparinization in 5 goats. The outcome was assessed from the function of the artificial lung via macro and microscopic examinations after the experiments and the incidence of systemic complications. The 5 goats were maintained on ECLA for 6 to 27 days. The bypass flow rate, blood gases at the return and drainage sites, platelet counts, and platelet aggregation activity were well maintained. Although the hemoglobin concentration, hematocrit, and plasma protein at the start of the ECLA were significantly lower than the pre-ECLA values due to hemodilution, the values remained stable during ECLA. A cerebral infarction occurred in 1 goat. However, in the other 4 goats, no complications such as bleeding, thrombosis, or plasma leakage from the artificial lung were observed. Although several thrombi were observed in the stagnant area of the artificial lung, these local thrombi did not cause the function of the artificial lung to deteriorate. We found that this new type of highly biocompatible, dense membrane artificial lung, when combined with minimal systemic heparinization, prolonged ECLA without the deterioration of the artificial lung function and was suitable for prolonged ECLA.

Microcirculation and hemorheology in shock

All types of circulatory shock result in a severe hypotensive state at some stage in their development and virtually all involve an early splanchnic vascular hypoperfusion and a later impairment of cardiac function. One important and consistent feature of circulatory shock is a fundamental insufficiency of microcirculatory flow leading to inadequate perfusion of the somatic cells of many of the important organs of the body. If the cellular hypoxic insult can be limited by fluid therapy with colloids and crystalloids, then the incidence of systemic complications in the post-shock period will also be reduced.

Total hip replacement with M�ller Pprosthesis and ICLH double cup

A prospective comparative study was made of patients in the age-group 60-79 years with osteoarthritis of the hip treated with the Müller total hip prosthesis (n = 155) and the ICLH double-cup prosthesis (n = 149). The patients were comparable with regard to sex, mean age, and body weight, and the preoperative radiographic appearance of the hips was th same in the two groups. The mean operating time was significantly shorter in the Müller group, whereas the operative blood loss and the operative complications were statistically equal. No deep infections occurred in either group. The incidence of systemic complications was low and no difference between the two groups was seen. The patients are followed up for an average of 48.5 months (range: 27-75 months). Dramatic improvement in hip function was seen postoperatively in both prosthetic groups. The Müller group had more favorable ratings than the ICLH group for pain, walking ability, hip motion, and total hip score at all follow-ups, from 3 weeks to 5 years after the operation. However, the differences were rather small and did not reach a significant level at any registration. The acetabular radiolucent zones and heterotopic bone formation were statistically equal in the two groups. No revision operations have been done in the Müller group. Two Müller prostheses have shown radiographic signs of mechanical loosening. Thirteen ICLH prostheses (8.7%)--all in female patients--have been reoperated (P less than 0.001), 12 owing to mechanical loosening and one because of pain and stiffness.(ABSTRACT TRUNCATED AT 250 WORDS)

Rationale for the Use of Colloids in the Treatment of Shock and Hypovolemia

The question, "Are colloids or crystalloids to be preferred for resuscitation in hypovolemic shock conditions?" is detailed in this review. The effects of these two types of fluid regimes on restitution of circulating blood volume, interstitial rehydration, microvascular blood flow, cellular metabolic recovery and on the incidence of systemic complications such as adult respiratory distress syndrome (ARDS), disseminated intravascular coagulation (DIC) and multiple organ failure are considered. Colloid containing solutions seem superior to crystalloids due to efficient reexpansion of circulating blood volume and enhancement of capillary blood flow. Resuscitation times and thereby the cellular hypoxic insult are considerable reduced while at the same time the formation of excessive tissue oedema is prevented. Colloids do not seem to adversely affect pulmonary function. Dextran has considerable advantages over other types of colloids for the initial shock treatment due to its antithrombotic properties whereby cell aggregability is prevented and the incidence of systemic complications (microembolism syndromes) is convincingly reduced.

Pathophysiology of shock-induced disturbances in tissue homeostasis.

A survey is given on disturbances in tissue homeostasis induced by hypovolemic shock conditions. Fluid shifts taking place between the extra- and intravascular fluid compartments are important early compensatory responses following hypovolemia. Usually the supply-to-demand ratio of oxygen in most tissues can however, not be kept up if the hypovolemic insult is severe due to deterioration of the microcirculation. Cellular hypoxia will ensue and may with time affect the integrity of the cells. Cellular functional disturbances occur earlier and are more pronounced in peripheral non-vital tissues such as e.g. skeletal muscle than in central organs, the blood flow of which is more favoured during shock. Anaerobically produced cellular metabolites as well as intracellular components released from hypoxically injured cells in peripheral tissues may be of importance for the initiation of decompensatory reactions. Cellular components reaching the central circulation may induce direct effects on organs or systemic effects due to activation of the cascade systems. Thereby reactions leading to severe complications such as adult respiratory distress syndrome (ARDS), disseminated intravascular coagulation (DIC) and multiple organ failure may be started. The aim of shock treatment should be to reverse as rapidly and as efficiently as possible the pathophysiological disturbances induced by a shock state. If the cellular hypoxic insult can be limited then the incidence of systemic complications in the post-shock period will also be reduced.