Late Postoperative Course Research Articles

Intracellular Staphylococcus aureus: the Trojan horse of recalcitrant chronic rhinosinusitis?

BackgroundDespite recent evidence suggesting that Staphylococcus aureus exists within the sinonasal epithelium of chronic rhinosinusitis (CRS) patients, certain questions remain. The intracellular environment may provide a protective niche for pathogenic bacteria to evade host immunity and yet provide a reservoir for reinfection. To date, no studies have examined the impact of this bacterial phenotype; therefore, this study was designed to evaluate the role of intracellular S. aureus on postsurgical outcomes.MethodsThis study included 51 patients undergoing endoscopic sinus surgery (ESS) for medically‐recalcitrant CRS. Sinonasal mucosa harvested at the time of surgery was dually stained with fluorescent molecular probes and imaged using confocal scanning laser microscopy for biofilm and intracellular status. Patients were followed in their early and late postoperative course for evidence of ongoing disease and signs of clinical relapse.ResultsIntracellular S. aureus was identified in 20 of 51 (39%) patients, and all were associated with surface biofilm. Biofilm alone was found in 16 of 51 (31%) patients and 15 of 51 (29%) patients had no evidence of S. aureus. Intracellular positive patients had a significantly higher risk of late clinical and microbiological relapse (p = 0.014). In this study, biofilm status without coexisting intracellular bacteria did not appear to impact on outcomes.ConclusionClinical and microbiological relapse of disease following ESS is significantly associated with intracellular S. aureus. Evidence suggests that this disease association is independent to surface biofilm status. Intracellular bacteria should be taken into consideration when designing novel treatment strategies to lessen the chance of reinfection.

Lebertransplantation

Liver transplantation is the only curative therapy for many liver diseases, mostly chronic liver diseases, occasionally also in acute or fulminant liver failure. Currently, about 100 liver transplantatations are performed each year in Switzerland. Clichy criteria are used for acute liver failure. Liver transplantation for liver cirrhosis improves survival if the Meld-Score is above 15. 5- and 10-year-survival after liver transplantation are 71% and 61%, respectively. With increasing survival after liver transplantation, the management of drug side effects in the late postoperative course becomes important.

Roux-en-Y Reconstruction at Greater Curvature in Biliopancreatic Diversion: Effects on Early Postoperative Functional Recovery

Delayed gastric emptying after distal gastrectomy and reconstruction of alimentary tract with a gastroenteric anastomosis can significantly influence early and late postoperative course and the length of hospital stay. The purpose of this study was to compare the effect on postoperative functional recovery of two different Roux-en-Y reconstructions: at the gastric greater curvature and at the transected gastric staple line in the Scopinaro's biliopancreatic diversion. We conducted comparative study; 80 patients were enrolled and divided in two groups: group A (RY-GC) and group B (RY-SL) with 40 patients in each group. We compared the early postoperative functional recovery for both groups measuring four parameters: gastric stasis indicated with the volume of the gastric fluid collected per 24 h, day of removal of the nasogastric tube, day of starting the oral intake, and day of hospital discharge. There was statistically significant (p < 0.001) reduction in gastric fluid volume in favor of the RY-GC group starting from the first postoperative day resulting in earlier removal of nasogastric tube with earlier starting of oral feeding than RY-SL group, with no symptoms of stasis required nutrition suspension; while three patients in RY-SL group experienced persistence of nausea and vomiting and needed nutrition suspension for several days. There was statistically significant (p < 0.001) reduction in the hospital stay for RY-GC group. Roux-en-Y reconstruction at the greater curvature ensures a rapid functional recovery with early hospital discharge. The use of stapler devices made this method easier and safer and no complications have arisen with mechanical anastomoses.

Novel mechanism of mitral regurgitation after lung transplantation in a patient with scleroderma and pulmonary hypertension

Valvular complications after lung transplantation (LTx) are rare. Mitral regurgitation (MR) after LTx has been associated only with acute endocarditis in immunosuppressed patients.1,2 We report an unusual case of severe MR diagnosed in the late postoperative course of LTx, in the absence of infection.

Heart valve surgery in patients with the antiphospholipid syndrome: analysis of a series of nine cases

Antiphospholipid syndrome (APS) is a rare coagulation disorder associated with recurrent arterial and venous thrombotic events. Heart valve abnormalities are commonly found in patients with APS. From March 1998 to March 2007, nine patients with APS underwent heart valve surgery using cardiopulmonary bypass. We retrospectively reviewed their clinical data, operative and postoperative courses and the long-term results. The mean age was 43.6+/-10.4 years, six were female and three male. Four patients underwent mitral valve replacement, three went through aortic valve replacement, one underwent combined mitral-aortic valve replacement and another aortic valve plasty. The syndrome was primary in seven patients and associated with systemic lupus erythematosus (SLE) in two. Follow-up was 8 days to 8 years (median 66 months). Two patients died in the early postoperative period: both due to an acute cerebrovascular accident. Four patients presented an uneventful late postoperative course. One patient experienced an ischaemic stroke 5 years after mitral valve replacement (MVR) and developed refractory congestive heart failure requiring heart transplantation three years postoperatively. Heart valve surgery in patients with antiphospholipid syndrome may carry considerable early and late mortality and morbidity. Thrombo-embolic complications are the most common complications. Mechanical prostheses have been used at our Institution in the previous years; however, today, after reviewing our historical results, we reconsider our general strategy and believe that tissue heart valve prostheses are the possible ideal substitutes, minimising the risks of morbidity and mortality due to the hypercoagulable state of APS.

Treatment of Gastrogastric Fistula after Roux-en-Y Gastric Bypass: Surgery Combined with Gastroscopy

A 53-year-old male who had previously undergone an open gastric bypass (Capella-Fobi) developed a gastrogastric fistula during the late postoperative course. Because he regained weight and had a stomal ulcer difficult to control, it was decided to submit him to revisional surgery. At laparotomy, a retrogastric approach plus gastroscopy permitted easy identification and closure of the fistula. The patient is doing well and losing weight after this reoperation.

Surgically Treated Intraoperative Coronary Embolism

We report a case of intraoperative coronary embolism in a 52-year-old male patient undergoing mitral valve replacement. The patient had persistent atrial fibrillation and was treated with oral anticoagulants and, in spite of well controlled anticoagulation, he suffered a transient ischemic attack. No intracardiac thrombus was found by transthoracic echocardiography. Three weeks later open heart surgery was performed. During valve surgery no thrombus was found in the left atrium. When cardiopulmonary bypass was discontinued the heart function rapidly deteriorated and the heart swelled up, became bluish, with left atrial pressure rising to 40 mm Hg. It was noticed that the anterior surface of the left ventricle was not moving. Coronary embolism was considered. Multiple thrombi were found and removed from the left anterior coronary artery. After successful thrombectomy the patient came off the pump easily. Early and late postoperative course were uneventful. Intraoperative coronary embolism should be considered when cardiac function is deteriorating and there is an inability to wean the patient from the pump. Early and correct diagnosis is lifesaving.

Giant Intrasellar Carotid Aneurysm - an Unusual Cause of Panhypopituitarism

Carotid artery aneurysms represent a very rare cause of pituitary failure. We describe the case of a female patient harbouring a giant aneurysm of the left carotid artery that subsequently led to panhypopituitarism. Interestingly, the late postoperative course was complicated by severe hyponatremia, whose origin may have been due to inappropriate ADH secretion. This case illustrates the problems of diagnosis and postoperative handling of panhypopituitarism due to an intrasellar aneurysm.

Endovascular Repair of an Aorto–Left Renal Vein Fistula Due to a Ruptured Abdominal Aortic Aneurysm After EVAR

To report an unusual late complication of endovascular aneurysm repair: an arteriovenous fistula between the aneurysm sac and a retro-aortic left renal vein following sac expansion due to a type III endoleak. A 79-year-old man developed an arteriovenous fistula between the aneurysm sac and a retro-aortic left renal vein 67 months after endovascular aneurysm exclusion (EVAR). Aneurysm rupture was due to disconnection between the right iliac limb and an extender cuff. The problem was repaired percutaneously with another endograft bridging the two prostheses. At 16 months, the aneurysm sac diameter was decreased; there was no evidence of the AV fistula, and the patient was free from any complication related to the EVAR. This case emphasizes the need of close surveillance even in the late postoperative course of these patients. Moreover, this rare event confirmed that endovascular techniques can play an important role in treating emergent complications.

Reduction in Slippage with 11-cm Lap-Band® and Change of Gastric Banding Technique

Slippage occurs after 2-18% of gastric bandings performed by the perigastric technique (PGT). We investigated the slippage-rate before and after the introduction of the pars flaccida technique (PFT) and the 11-cm Lap-Band, and the long-term results of the re-operated patients. Between Dec 1996 and Feb 2004, 360 patients with a mean BMI of 44 kg/m2 were operated. The PGT (n=168) and PFT9.75 (n=15) groups received the 9.75-cm Lap-Band, and the PFT11 group (n=177) received the new 11-cm Lap-Band. Follow-up rate was 99%. Slippage occurred in a total of 31 patients from all groups (PGT, n=28, or 17%; PFT9.75, n=1, or 7%; PFT11, n=2, or 1%). Average yearly re-operation rate for slippage in the first 3 years postoperatively was 3.8%, 2.2% and 0.9%, respectively. Laparoscopic re-banding was necessary for posterior (n=19) or lateral (n=12) slippage. The late postoperative course after re-banding was: uneventful 58%, weight regain 35% and/or esophageal motility disorder 23%, secondary band intolerance 20%, and one persistent posterior slippage. 8 patients (26%) needed biliopancreatic diversion. Since the introduction of the PFT and the 11-cm Lap-Band, we observed a significant reduction in slippage rate and no posterior slippage. Re-banding had a less favorable long-term result than did first-procedure banding.

Influence of intraoperatively applied current of coagulation on the postoperative course in tonsillectomy

Postoperative pain after tonsillectomy is greater using diathermy compared to the use of ligatures for hemostasis. In the present paper, the influence of coagulation current on the postoperative course is assessed quantitatively. The applied coagulation current was registered in Watt per second (Ws) in 63 patients. Intraoperative blood loss, operation time, experience of the surgeon, postoperative pain and the consumption of analgesics were registered. The mean intraoperative blood loss was correlated to the amount of applied coagulation current. Operation time was reduced with increased coagulation current. The energy of the applied coagulation current correlated significantly with pain in the late postoperative period. There was no influence in the amount of coagulation current on the consumption of analgesics or postoperative hemorrhage. Blood loss was less and operation time was shorter with more experienced surgeons. Six secondary postoperative hemorrhages were observed. Hemorrhage occurred more often with inexperienced surgeons. The applied coagulation current was, however, not dependent on the surgeon's experience but on his individual technique for intraoperative control of hemostasis. Pain following tonsillectomy is related to the amount of intraoperatively applied coagulation current, especially in the late postoperative course (days 10 - 14). This may be explained by tissue damage and increased eschar due to coagulation. Careful and reserved use of intraoperative coagulation will reduce postoperative pain.

Laparoscopic splenectomy in patients with refractory or relapsing thrombotic thrombocytopenic purpura.

Thrombotic thrombocytopenic purpura (TTP) is a rare and serious hematological disease. First-line therapy is plasma exchange, often used in combination with corticosteroids, vincristine, aspirin, and dipyridamole. The role of splenectomy for patients resistant to or dependent on plasma therapy and for the prevention of TTP relapses is not yet determined. Laparoscopic splenectomy (LS) is effective and safe for the treatment of the chronic relapsing form of TTP. We performed LS in 8 patients with refractory or relapsing TTP. The operative as well as the early and late postoperative course and complications were recorded. The mean duration of LS was 70 minutes (range, 35-180 minutes). There were no serious bleeding complications during or after surgery. Convalescence was rapid, and the mean hospital stay was 2.5 days (range, 1-9 days). Patients were followed up for a mean of 32 months (range, 19-54 months). Seven patients are in remission with no relapse of TTP. One patient with familial TTP had multiple relapses before and after surgery. Laparoscopic splenectomy for refractory or relapsing TTP is safe and associated with low morbidity and fast recovery. It is effective in the long-term prevention of TTP relapses in most patients, and it should probably be considered early in the course of chronic, relapsing TTP.

Laparoscopic Splenectomy in Patients With Refractory or Relapsing Thrombotic Thrombocytopenic Purpura—Invited Critique

Hypothesis: Thrombotic thrombocytopenic purpura (TTP) is a rare and serious hematological disease. First-line therapy is plasma exchange, often used in combination with corticosteroids, vincristine, aspirin, and dipyridamole. The role of splenectomy for patients resistant to or dependent on plasma therapy and for the prevention of TTP relapses is not yet determined. Laparoscopic splenectomy (LS) is effective and safe for the treatment of the chronic relapsing form of TTP. Intervention: We performed LS in 8 patients with refractory or relapsing TTP. The operative as well as the early and late postoperative course and complications were recorded. Results: The mean duration of LS was 70 minutes (range, 35-180 minutes). There were no serious bleeding complications during or after surgery. Convalescence was rapid, and the mean hospital stay was 2.5 days (range, 1-9 days). Patients were followed up for a mean of 32 months (range, 19-54 months). Seven patients are in remission with no relapse of TTP. One patient with familial TTP had multiple relapses before and after surgery. Conclusions: Laparoscopic splenectomy for refractory or relapsing TTP is safe and associated with low morbidity and fast recovery. It is effective in the long-term prevention of TTP relapses in most patients, and it should probably be considered early in the course of chronic, relapsing TTP.

Pathogenetic mechanisms of venous congestion after the Fontan procedure.

The hemodynamic status after a Fontan type procedure for definitive palliation of functionally univentricular hearts is dominated by a high central venous pressure, which seems to be one of several factors responsible for venous congestion appearing as a frequent complication in the early and late postoperative course. The purpose of our study was to find other hemodynamic parameters correlating with the presence of venous congestion and effusions in these patients. We compared the hemodynamic data of 18 patients who had an uneventful long-term course after a Fontan type procedure with the respective data of 10 patients who developed symptoms of venous congestion in the immediate postoperative period. Based on a theoretical model, we developed an algorithm to calculate mean hydrostatic capillary pressure from mean arterial pressure, systemic vascular resistance index and central venous pressure. Pulmonary vascular resistance index (2.1 +/- 1.0 mmHg L-1 min m2), mean left atrial pressure (9.7+/-4.0 mmHg) and cardiac index (3.6+/-0.6 l/min/m2) are mainly normal in patients with venous congestion in the immediate postoperative period, but mean hydrostatic capillary pressure is significantly higher compared to patients without venous congestion (24.3+/-3.1 vs 18.3+/-4.0 mmHg). Lower mean hydrostatic capillary pressures in these patients are due to a highly significant increase of systemic vascular resistance index (18.6+/-4.2 versus 33.6+/-6.6 mmHg L-1 min m2) and a concomitant decrease of cardiac index to 2.4+/-0.3 l/min/m2. The increase of mean hydrostatic capillary pressure, caused by high central venous pressures but also by relatively low systemic vascular resistance indexes, seems to be the hemodynamic key parameter responsible for venous congestion and effusions in patients after a Fontan type procedure in the immediate postoperative period.

Increased Susceptibility to Postoperative Sepsis in Patients with Impaired Monocyte IL-12 Production

IL-12 is a potent immunoregulatory cytokine that is essential for the development of protective immunity, as demonstrated by numerous animal models of infection. Here, we provide evidence for a critical role of IL-12 in human sepsis. The results of a prospective study of 184 patients undergoing major elective surgery of the upper and lower gastrointestinal tract revealed that, in contrast to patients showing uneventful recovery, monocyte IL-12 production was severely and selectively impaired in patients developing postoperative sepsis. Moreover, the extent of monocyte IL-12 suppression correlated with the severity of postoperative sepsis. Monocyte IL-12 secretion was suppressed before surgery and remained low until the onset of sepsis. Therefore, the suppression of IL-12 secretion preceded the onset of postoperative sepsis but did not occur as a consequence of major surgery. In contrast, IL-1beta production was only reduced during the late postoperative course in patients developing postoperative sepsis, and TNF-alpha release was even increased at different time intervals before the onset of sepsis. Thus, reduced IL-12 release does not reflect a general defect in monocyte cytokine production. Consequently, these results establish a critical role for IL-12 in early resistance to postoperative infection and may allow for the development of novel therapeutic strategies designed to stimulate host defense mechanisms and to reduce the incidence and severity of septic complications.

Improvements in parathyroid surgery in the intact 1-84 PTH assay era.

Measurement of intact 1-84 parathormone (PTH) level by immunometric assays has been an important tool in the medical management of hypercalcaemia. The aim of the present study was to evaluate its practical contribution in the diagnosis and surgical treatment of primary hyperparathyroidism. The results of surgery were compared (number of failed and inadequate cervicotomies, number of overlooked cervical glands) in two groups of primary hyperparathyroid patients operated on without (group I, n = 624) and with (group II, n = 360) intact PTH evaluation. The postoperative intact PTH level was measured 1-50 months after surgery in 109 unselected normocalcaemic patients. The benefit of intact PTH assay was studied in borderline patients. We tried to settle a correlation between parathyroid resected weight and intact PTH pre-operative level in different subsets of the disease. The sensitivity for the diagnosis of primary hyperparathyroidism was 86.6% for intact PTH level alone, and 95.9% when plotted with synchronous serum total calcium. Hyperfunctional adenoma was incidentally discovered in 14 asymptomatic normocalcemic normo-PTH patients. The predictive positive value of intact PTH assay for the diagnosis of primary hyperparathyroidism was 99.3%. Intact PTH assay often affirmed the diagnosis of primary hyperparathyroidism in borderline cases. The postoperative intact PTH measurement was not a good indicator for evaluating the late outcome in seemingly cured patients. Sharp but statistically significant correlation was found between the resected weight and the intact PTH level. The discovery of a small adenoma in a patient with high intact PTH level, bone disease and low vitamin D level should raise suspicion of a second hyperfunctioning gland. Intact PTH assay was a main contributor to the surgical management of primary hyperparathyroidism, reducing the number of unnecessary cervicotomies and enabling the cure of all cases of primary hyperparathyroidism except those due to mediastinal glands. It raised unanswered problems in the late postoperative course.

Obstructive total anomalous pulmonary venous drainage.

Obstructive total anomalous pulmonary venous drainage (TAPVD) has a florid presentation in the neonatal period from the resulting pulmonary edema. A complete anatomical and functional diagnosis is usually possible by transthoracic color Doppler echocardiography, and cardiac catheterization with its attendant risks can usually be avoided in the sick neonate. Currently balloon atrial septostomy has a limited role in palliation of these neonates. Corrective surgery on urgent basis has gratifying results and prevents progression of pulmonary vascular occlusive disease. Pulmonary hypertensive crisis in the early post-operative course needs to be avoided and treated vigorously if it were to develop. Late post-operative course can be complicated by anastomotic obstruction or progressive narrowing of the individual pulmonary veins. Although the former can be dealt successfully by re-operation, surgical treatment of the latter is not satisfactory. Balloon dilatation of the obstructed pulmonary venous pathways, native and post-operative, has been reported with equivocal results. Infant heart-lung transplant is a viable option in patients with diffusely narrow pulmonary veins or complex TAPVDs.

Distinct mechanisms of immunosuppression as a consequence of major surgery.

Altered host defense mechanisms after major surgery or trauma are considered important for the development of infectious complications and sepsis. In the present study, we demonstrate that major surgery results in a severe defect of T-lymphocyte proliferation and cytokine secretion in response to coligation of the antigen receptor complex and CD28. During the early postoperative course, reduced cytokine secretion was observed for interleukin-2 (IL-2), gamma interferon, and tumor necrosis factor alpha, which are associated with the Th1 phenotype of helper T lymphocytes, and for IL-4, the index cytokine of Th2 cells. During the late postoperative course, T-cell cytokine secretion increased to normal levels. Production of the anti-inflammatory cytokine IL-10 was altered, with different kinetics being selectively elevated during the late postoperative course. In contrast, the capacity of peripheral blood monocytes to present bacterial superantigens and to stimulate T-cell proliferation was normal or enhanced after surgery despite a significant loss of cell surface HLA-DR molecules. Thus, the level of major histocompatibility complex class II protein expression does not appear to predict the antigen-presenting capacity of monocytes obtained from surgical patients with uneventful postoperative recovery. Secretion of IL-1beta and IL-10 by endotoxin-stimulated peripheral blood monocytes was increased at different time points after surgery. Major surgery therefore results in a distinct pattern of immune defects with a predominant defect in the T-cell response to T-cell receptor- and CD28 coreceptor-mediated signals rather than an impaired monocyte antigen-presenting capacity. Suppression of T-cell effector functions during the early phase of the postoperative course may define a state of impaired defense against pathogens and increased susceptibility to infection and septic complications.

Dumping syndrome following Nissen fundoplication, diagnosis, and treatment.

We evaluated the prevalence, diagnosis, and treatment of dumping syndrome (DS) following Nissen fundoplication in 50 consecutive infants and children who underwent the operation for gastroesophageal reflux. Examination included a preoperative dietary assessment with emphasis on specific postprandial clinical symptoms and technetium scintigraphy to evaluate gastric emptying. In the immediate postoperative period, postprandial glucose levels were examined in all patients with symptoms clinically suggestive of DS. In the late postoperative period (6 months to 5.5 years), all patients with more than one specific clinical symptom of DS were further evaluated by glucose tolerance test (GTT), HbA1C levels, and gastric technetium scintigraphy. DS was diagnosed in 15 patients (30%). Five patients had immediate severe DS (SDS), and 10 in the late postoperative course had latent postoperative DS (LDS). In all patients with DS, preoperative and postoperative gastric emptying scan T1/2 did not show any statistical significance. High levels of HbA1C ranging from 7.9 to 9% (mean, 8.25 +/- 0.5) were found in only three patients. Treatment included parenteral nutrition in one patient. All the others were successfully managed with nutritional manipulation alone, using a combination of lactose-free formula and fat emulsion. In patients whose postprandial symptoms persisted, pectin 5-15 g/day divided into six doses was added to the diet. Following 6 months of dietary treatment, the postprandial normoglycomic response was restored. Eleven patients experienced complete resolution of symptoms (78.5%), and three patients (21.4%) showed significant clinical improvement. This study indicates that DS is a common complication following Nissen fundoplication. The GTT is the most reliable examination for establishing the diagnosis. Treatment is simple and effective. The technetium gastric emptying scan and HbA1C level do not play a significant role in the diagnosis.

Pulmonary sling: morphological findings. Pre- and postoperative course.

Pulmonary sling (PS) is a congenital condition in which the left pulmonary artery (LPA) arises from the right pulmonary artery (RPA), forming a sling around the trachea causing tracheal compression. The incidence is not so rare as initially thought. Symptoms of severe airway obstruction often begin in the newborn or young infant. Echo-colour-Doppler may reveal the PS but emphysema can mask the typical findings. Deviation of fluid-filled lungs may be detected prenatally. Chest radiographs show unusual air distribution, deviation of heart and mediastinum and altered tracheobronchial angles. Bronchography and bronchoscopy demonstrate the high incidence of associated tracheal anomalies such as cartilagenous rings and long tracheal stenosis. Anterior oesophageal indentation is not always seen in the oesophogram. Magnetic resonance imaging (MRI) and computed tomography (CT) reveal the PS, but cautious interpretation is necessary because of different levels of the anomalous LPA. PS and associated cardiovascular malformations can be clearly detected by angiography. Associated extrathoracic anomalies are common. Early diagnosis and therapy of PS is mandatory and consists of reimplantation of the LPA into the pulmonary trunk and division of the ligamentum arteriosum. The postoperative course may be cumbersome necessitating bronchological interventions. Tracheal resection may be necessary but restenosis is frequent. A one-stage repair has been proposed in such cases and was successfully done in a few reported cases. Relief of respiratory obstruction is often complete when there are no associated tracheobronchial anomalies. Late postoperative course is favourable but respiratory obstructive attacks may occur with decreasing incidence over time and tracheal growth.