Postoperative Nadir Research Articles

Subtle changes in renal function are associated with differences in late survival following adult cardiac surgery

To determine the predictors of post-operative renal function following adult cardiac surgery, and to assess the influence of this on late survival. Prospectively collected data were analysed on 8032 patients who underwent coronary artery bypass grafting, valve surgery or combined procedures from 1 January 1998 until 31 December 2008, who did not require preoperative renal replacement therapy. The estimated glomerular filtration rate (eGFR) was calculated by the Modification of Diet in Renal Disease formula accounting for ethnicity pre-operatively, post-operatively on the fourth post-operative day, and the post-operative nadir based upon the peak post-operative creatinine within 30 days of surgery. Late survival data were obtained from the UK Central Cardiac Audit Database (CCAD). Appropriate frailty analyses were conducted in R and model fit was compared using Aikaike's Information Criterion. Initial analysis intended to determine predictors of post-operative renal function including pre-operative eGFR, EuroSCORE and surgical procedure including the operative procedure and bypass time. Further analysis examined its influence on late survival. Median follow-up was 72 months (IQR 48-105) during which there were 904 late deaths. The most powerful predictor of the day 4 eGFR was the pre-operative eGFR but other factors contributed including increasing EuroSCORE and bypass time. The pre-operative eGFR was shown to be a strong and independent predictor of late outcome (P = 0.0001, HR 0.497 95%CI 0.434-564); however, model fit was significantly improved using the day 4 eGFR (P = 0.0001, HR 0.43 95%CI 0.385-0.482). No specific change in individual renal function was identified as a predictor of adverse late survival, and neither the pre-operative nor day 4 eGFR was predictive of the nadir of renal function. Subtle early changes in renal function at the time of surgery are powerful predictors of adverse late outcome and can be predicted by pre-operative renal function.

Evaluation outcomes of donors in living donor liver transplantation: a single-center analysis of 132 donors

Donor safety has always been a major concern, and potential risk to the donor must be balanced against recipient benefit. However, lack of a standardized and uniform evaluation of perioperative complications is a serious limitation of the evaluation of donor morbidity. This study was designed to evaluate the outcomes of donors in adult living donor liver transplantation (LDLT) using the newer Clavien classification system in a single center in China. We prospectively analyzed the outcomes of 132 consecutive living liver donors from 2005 to 2008 using the newer Clavien classification system. The preoperative, intraoperative and postoperative data of the donors were collected and analyzed. Ordinal regression was used to analyze the ordered grades of complications. Ninety-four (71.2%) of the donors developed postoperative complications of grade I (n=45, 34.1%), grade II (n=39, 29.5%) and grade III (n=10, 7.6%). There was no death or grade IV morbidity. Hepatic functional impairment and pleural effusion were the most frequent morbidities for living donors. Fifty-three donors (40.1%) developed hepatic functional impairment of grade I (n=40, 31.1%) and grade II (n=13, 10.0%). The ICU stay (7.8+/-1.8 days) and length of hospital stay (17.7+/-4.6 days) were significantly longer in donors with grade III than others. Furthermore, ordinal logistic regression revealed that donor's older age (>40 years) and right hepatectomy were associated with morbidity. In addition, only preoperative total bilirubin (within the normal range) and postoperative nadir serum phosphorus were independently associated with hepatic functional impairment. The receiver operator characteristic curve revealed that preoperative total bilirubin >18.0 μmol/L and postoperative nadir of serum phosphorus <1 mg/dL may lead to more severe hepatic functional impairment. Despite the fact that donors are relatively safe to undergo hepatectomy, many living donors still experience postoperative morbidity. Meticulous technical and preoperative donor evaluation and treatment are sure to reduce the incidence of complications.

Usefulness of postoperative nadir prostate-specific antigen value by ultrasensitive assay as a predictor of prostate-specific antigen relapse for pathological T3 or positive surgical margins after radical prostatectomy for prostate cancer

Our aim was to identify prognostic factors and examine the usefulness of postoperative nadir prostate-specific antigen (PSA) value obtained by ultrasensitive assay for prediction of PSA relapse in prostate cancer patients with pathological T3 (pT3) or positive surgical margins. We analyzed 102 patients who were pathological T2 with positive surgical margins or pT3 without pathological lymph node metastasis or neoadjuvant hormonal therapy. Patients were classified into three groups according to postoperative nadir PSA value: <0.01 ng/ml, ≥0.01 ng/ml but <0.02 ng/ml, and ≥0.02 but <0.10 ng/ml. PSA relapse-free rate was compared according to postoperative nadir PSA. Univariate and multivariate analyses with the Cox proportional hazards regression model identified prognostic factors for PSA relapse. Of the 102 patients, 22 (21.6%) developed PSA relapse within a median follow-up time of 31.3 months. PSA relapse-free rate at 30 months was 81.2%. Univariate and multivariate analyses revealed that postoperative nadir PSA was the only statistically significant risk factor: postoperative nadir PSA ≥0.01 ng/ml but <0.02 ng/ml (P = 0.009, HR: 4.502, 95% CI: 1.457-13.916); ≥0.02 ng/ml but <0.10 ng/ml (P < 0.001, HR: 15.126, 95% CI: 4.738-48.292). PSA relapse-free rates at 30 months in patients with postoperative nadir PSA <0.01 ng/ml, ≥0.01 ng/ml but <0.02 ng/ml, and ≥0.02 ng/ml but <0.10 ng/ml were 91.9, 57.1, and 20.0%, respectively. Postoperative nadir PSA value obtained by ultrasensitive assay was useful as a predictor of PSA relapse among patients with adverse pathological features. Patients with postoperative nadir PSA of <0.01 ng/ml may have low risk of PSA relapse.

Prediction of a high-risk group based on postoperative nadir CA-125 levels in patients with advanced epithelial ovarian cancer

ObjectiveWe aimed to determine the ideal cut-off of nadir serum CA-125 level for prediction of progression free survival.MethodsAmong 267 patients who achieved complete remission after chemotherapy, the correlation between nadir CA-125 and progression free survival were compared among the subgroups classified according to the distribution of CA-125. The diagnostic odds ratio and area under the receiver operator characteristics curve were compared at various cut-off points.ResultsThe nadir CA-125 levels did not have prognostic value under 12 U/mL (to 75 percentile). In contrast, they were significantly correlated with progression free survival only when the CA-125 level was greater than 12, which was 75 percentile (p=0.034). In predicting progression free survival <6 and 12 months, the cut-off value of 18 (90 percentile) showed superior diagnostic performance over 10 or 12 U/mL. Compared with patients who showed nadir levels between 0 and 12 U/mL (0 to 75 percentile), those with nadir >18 U/mL showed a hazard ratio of 2.85 (95% confidence interval, 1.70 to 4.76; p<0.001); patients with nadir levels between 18 and 12 U/mL showed a the hazard ratio of 1.68 (95% confidence interval, 1.11 to 2.56; p=0.015) compared with those whose nadir levels were under 12 U/mL.ConclusionThe predictive power of the traditional cut-off of 10 U/mL to classify a risk group or to identify high risk patients was unsatisfactory. The optimal diagnostic performance was observed at the cut-off of 18 U/mL and this can be proposed to dichotomize cut-off values to predict outcomes among individual patients.

Hepatectomy-Related Hypophosphatemia May Predict Donor Liver Dysfunction in Live-Donor Liver Transplantation

Background Hypophosphatemia after living-donor liver donation was recently reported to not be linked to donor morbidity. However, few studies have examined the relationship between hypophosphatemia and hepatic function after hepatectomy in live liver donors. In this study, we investigated the relationship between postoperative hypophosphatemia and hepatic function in living donors after hepatectomy. Methods We collected data from 102 live-donor hemihepatectomy cases. The severity of hypophosphatemia was categorized as mild (1.5–2.5 mg/dL), moderate (1.1–1.5 mg/dL), or severe (<1.0 mg/dL). We compared complications among the groups and factors possibly related to the postoperative nadir phosphorus levels. Results One hundred cases (98%) developed mild (n = 56), moderate (n = 25), or severe (n = 19), hypophosphatemia. Serum phosphate levels began to fall on postoperative day (POD) 2, reaching a nadir (1.89 ± 0.72 mg/dL) on POD 3. There was a significant difference in the incidence of postoperative liver dysfunction among the 3 groups ( P = .027). Moreover, a correlation was identified between the incidence and the hypophosphatemia severity ( r = 0.549; P = .023). The nadir phosphorous level significantly and negatively correlated with the peak of total bilirubin ( P = .001) and international normalized ratio ( P = .004). Patients with intravenous phosphorus replacement showed better hepatic function and a lower incidence of hepatic dysfunction among the severely hypophosphatemic group. Conclusion Hypophosphatemia was predictive of hepatic dysfunction after hepatectomy in living donors. Phosphorus replacement may improve recovery of hepatic function among living liver donors.

C-Index is Associated With Functional Outcomes After Laparoscopic Partial Nephrectomy

The C-index is a morphometric descriptor of renal masses that incorporates tumor size and site. We examined associations of the C-index with kidney function after laparoscopic partial nephrectomy. We retrospectively reviewed the records of 131 patients who underwent laparoscopic partial nephrectomy for a single kidney tumor. We calculated the C-index from preoperative contrast enhanced computerized tomography images. Estimated glomerular filtration rate was calculated using the modification of diet in renal disease 2 equation. Nadir estimated glomerular filtration rate was calculated using peak serum creatinine within 7 days of surgery. The median C-index was 2.7 (range 0.7 to 9.6). The median preoperative and nadir estimated glomerular filtration rate was 78 (range 23 to 148) and 54 ml/minute/1.73 m2 (range 15 to 127, p<0.001). The mean±SD total glomerular filtration rate decrease was 28%±16%. On univariate analysis we noted a positive correlation between log C-index and the nadir estimated glomerular filtration rate (r=0.29, p=0.002), and a negative correlation between log C-index and the percent decrease in the estimated glomerular filtration rate (r=-0.4, p<0.001). On multivariate analysis the estimated glomerular filtration rate percent decrease was significantly associated with log C-index (p=0.005) and warm ischemia time (p<0.001) but not with tumor diameter or the preoperative estimated glomerular filtration rate. Of patients with a C-index of 2.5 or less 70% showed a 30% or greater decrease in the estimated glomerular filtration rate vs 32% of those with a C-index of greater than 2.5 (RR 2.2, p<0.001). The C-index is associated with the postoperative nadir estimated glomerular filtration rate and the percent decrease in the estimated glomerular filtration rate after laparoscopic partial nephrectomy. A C-index of less than 2.5 correlated with a 2.2-fold increased risk of a 30% or greater estimated glomerular filtration rate decrease after laparoscopic partial nephrectomy.

Medications and Surgical Interventions for Benign Prostatic Hyperplasia Are Potential Confounders of Prostate-Specific Antigen

Prostate-specific antigen (PSA) is the most widely used marker for prostate cancer (CaP) screening and monitoring benign prostatic hyperplasia (BPH) progression. However, lack of an established abnormal threshold and the presence of other benign processes confound the interpretation of PSA levels. Many factors besides inflammation, trauma, and instrumentation can influence PSA levels; specifically, BPH and its associated medical and surgical therapies frequently complicate the interpretation of this serum blood test. For example, the commonly used 5 alpha reductase inhibitor (5ARI) medications directly affect PSA levels by decreasing prostate volume. The amount of time and potentially even the 5ARI formulary a patient is administered has been implicated to directly impact the degree of reduction in PSA (a proxy for prostate volume). In addition, each of the currently available surgical procedures for BPH appears to remove varying amounts of prostatic adenoma. This directly confounds CaP screening because each procedure is associated with a relatively specific postoperative nadir PSA level, and PSA kinetics are not well described in the literature. Taken together, it is important for clinicians to comprehend that BPH and its associated medical and surgical interventions should directly influence their interpretation of PSA and PSA velocity when screening for CaP or following BPH progression.

Postoperative Hypocalcemia after Parathyroidectomy for Renal Hyperparathyroidism in the Era of Cinacalcet

Chronic kidney disease is often accompanied by hyperparathyroidism. Cinacalcet, a recent addition to the medical armamentarium, has proven efficacious. It is unclear whether cinacalcet use has any impact on the postoperative course in patients progressing to surgery. The records of 77 patients operated on for renal hyperparathyroidism were reviewed. Sixty-three were treated before the use of cinacalcet and 14 after. Ten subtotal and 67 total parathyroidectomies were performed. Mean nadir serum calcium was similar (6.6 +/- 1.3 vs 6.2 +/- 1.4 mg/dL). More patients taking cinacalcet preoperatively required intravenous calcium postoperatively (62%) than those treated before its use (41%), although this did not reach statistical significance (P = 0.09). In those undergoing total parathyroidectomy, cinacalcet use preoperatively (n = 11) led to a lower postoperative nadir calcium (5.8 +/- 1.7 vs 6.6 +/- 1.3 mg/dL) as compared with those who did not receive it (n = 56) (P = 0.05). This translated to a greater need for intravenous calcium infusion postoperatively (72 vs 38%) (P = 0.03). These data suggest a somewhat more aggressive postoperative course in patients who fail calcimimetic and require surgery. This may be useful to inform physicians and patients of expectations postoperatively, although it is not likely to alter management.

Early salvage radiotherapy for patients with PSA relapse after radical prostatectomy

To assess the effectiveness of early salvage radiotherapy (RT) for patients with prostate-specific antigen (PSA) relapse after radical prostatectomy (RP) retrospectively. Fifty-one patients underwent salvage RT for biochemical relapse of prostate cancer initially treated with RP. All patients had persistent or rising PSA >0.20 ng/ml at some point after surgery, or three successive PSA elevations after a postoperative nadir if PSA was < or =0.20 ng/ml. Most (96%) of pre-RT PSA were less or equal to 0.50 ng/ml, and median value was 0.25 ng/ml (range, 0.05-0.90 ng/ml). Median RT dose was 60 Gy (range, 50-66 Gy). Multivariate Cox regression analysis was performed for PSA before RP and salvage RT, margin status, seminal vesicle involvement, extracapsular invasion, Gleason score, PSA doubling time (PSADT), and RT dose to identify significant predictors of biochemical outcome. Median follow-up was 36 months. The 3-year biochemical no evidence of disease rate (bNED) was 55.1%. On multivariate analysis only the following factors were significantly associated with improved bNED: PSADT >3.0 months (P = 0.008), Gleason score < or =7 (P = 0.01), and RT dose > or =60 Gy (P = 0.028). Although a total dose of 60 Gy was effective at a low pre-RT PSA levels with short follow-up, an RT dose > or =60 Gy resulted in superior biochemical outcomes even in patients with a pre-RT PSA < or =0.50 ng/ml.

Factors Predicting Renal Functional Outcome After Partial Nephrectomy

Compared to radical nephrectomy, partial nephrectomy better preserves renal parenchyma and function. Although several clinical factors may impact renal function after partial nephrectomy including preoperative function, age, gender and comorbidities, the contributions of tumor and surgical factors have not been well studied. We evaluate independent factors predicting functional outcomes after partial nephrectomy. Preoperative and all postoperative serum creatinine values for 1,169 patients undergoing partial nephrectomy were used to estimate glomerular filtration rate. Postoperative nadir glomerular filtration rate and ultimate glomerular filtration rate were analyzed using multiple pertinent covariates. Median preoperative, postoperative nadir and ultimate glomerular filtration rates were 77, 57 and 71 ml per minute per 1.73 m(2), respectively. Increasing age, gender, lower preoperative glomerular filtration rate, solitary kidney, tumor size, ischemia time and longer time to nadir glomerular filtration rate significantly predicted postoperative nadir glomerular filtration rate and ultimate glomerular filtration rate. Acute loss of renal function predicted lower ultimate glomerular filtration rate. In the entire cohort, in patients with normal preoperative renal function, and in those with baseline stage 3 and those with stage 4 chronic kidney disease the incidence of postoperative acute kidney injury after partial nephrectomy was 3.6%, 0.8%, 6.2% and 34%, and the incidence of chronic end stage renal disease after partial nephrectomy was 2.5%, 0.1%, 3.7% and 36%, respectively. Lower preoperative glomerular filtration rate, solitary kidney, older age, gender, tumor size and longer ischemic interval all predicted lower glomerular filtration rate after partial nephrectomy. Therefore, duration of renal ischemia is the strongest modifiable surgical risk factor for decreased renal function after partial nephrectomy, and efforts to limit ischemic time and injury should be pursued in open and laparoscopic partial nephrectomy.

Preserved vision without growth retardation after laparoscopic Roux-en-Y gastric bypass in a morbidly obese child with pseudotumor cerebri: 36-month follow-up

A 12-year-old boy presented with a weight of 136 kg and a history of progressive vision loss associated with unremitting pseudotumor cerebri requiring bilateral optic nerve sheath decompression. He underwent laparoscopic Roux-en-Y gastric bypass (RYGBP) without complication. At 36 months post-RYGBP, he has grown 5 cm since the time of surgery, his weight is 6.8 kg above his postoperative nadir weight of 68.2 kg, and his visual acuity has improved with OD 20/100 (preoperative, 20/200) and OS 20/70 (preoperative, 20/100). This case suggests that RYGBP can be performed safely and without stopping linear growth in carefully selected children.

Significance of Erythrocyte Sedimentation Rate and C-reactive Protein as Predictive Factors for Prognosis in Non-metastatic Renal Cell Carcinoma

Purpose: This study was performed to investigate the significance of preoperative erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) and postoperative ESR and CRP nadir as predictive factors for prognosis in patients with non-metastatic renal cell carcinoma (RCC). Materials and Methods: In 66 patients with non-metastatic RCC for whom ESR and CRP could be measured before radical nephrectomy and during follow-up, the preoperative ESR, preoperative CRP, postoperative ESR nadir and postoperative CRP nadir were compared with the clinicopathological variables. Results: Patients with elevated preoperative ESR or CRP levels were more likely to have tumors with adverse features, including larger tumor size, higher T stage, higher nuclear grade and more frequent metastasis at follow-up, as compared to those patients with lower preoperative ESR or CRP levels, respectively. Patients with an elevated postoperative CRP nadir developed metastasis more frequently at follow-up as compared to those patients with a lower level of postoperative CRP nadir. The univariate analyses identified tumor size, T stage, preoperative ESR, preoperative CRP and postoperative CRP nadir as significant prognostic factors for recurrence-free survival. Conclusions: Elevated preoperative ESR, preoperative CRP and postoperative CRP nadir are associated with a worse prognosis and a higher recurrence rate in patients with non-metastatic RCC, suggesting that ESR and CRP are valuable prognostic indicators in RCC. (Korean J Urol 2006; 47:1059-1064) ꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏ

PSA elevation during prostate cryosurgery and subsequent decline

Purpose To determine the immediate effect of prostate cryosurgery on PSA and the subsequent decline. Methods and materials PSA level was measured in 14 patients who underwent cryosurgery for prostate cancer. Blood samples were taken immediately before and after cryosurgery and 1, 2, 4, 6 weeks and 3 months postoperatively. A confidence interval for the elevation from baseline to maximal PSA was calculated. PSA decline was assessed in patients with a nadir PSA ≤0.5 ng/mL. Patients with a postoperative nadir PSA >0.5 ng/mL were considered to harbor viable cancer and were excluded from the decline analysis. The observed PSA levels during the postoperative period were compared with the expected levels that were calculated according to the maximal PSA level and a serum half-life of 2.5 days. Student t-test was used to compare expected and observed PSA levels. Results PSA increased from an average of 9.23 ng/mL preoperatively to a maximum average of 155 ng/mL (maximal PSA ranges: 18.9–490.5 ng/mL). The 95% CI for the increase in PSA from baseline level was 63.4 to 224.14. PSA nadir ≤0.5 ng/mL was achieved in 10 patients. The observed PSA decline course was slower than expected according to its half-life. Average observed and expected PSA levels at 2,4 and 6 weeks after cryosurgery were 10.4 versus 3.57ng/mL ( P = 0.005), 0.65 versus 0.07 ( P = 0.007) and 0.09 versus 0.001 (P = 0.03), respectively. Conclusion PSA levels increase steeply following cryosurgery, and decline slower than expected according to the serum half-life.

Post-splenectomy thrombocytopenia: implications for regional analgesia.

Hospital computerised records were reviewed to identify patients who had undergone splenectomy, then chart their platelet count before and for the 5 days after the operation. A pre-operative platelet count less than 100 x 10(9).l-1 occurred in 66% of leukaemia (n = 35), 56% of lymphoma (n = 41) and 5% of solid tumour (n = 39) patients. Platelet supplementation prior to epidural catheter insertion may reduce the risks of spinal bleeding. However, accidental catheter removal during a postoperative period of thrombocytopenia may lead to formation of an epidural haematoma. The lowest postoperative platelet count was less than 100 x 10(9).l-1 in 66% of leukaemia, 27% of lymphoma and 13% of solid tumour patients. Platelet counts varied considerably, so predicting an individual patient's postoperative nadir from the pre-operative count would be impossible. Consequently, placement of an epidural catheter in many of these patients could expose them to an increased risk of spinal bleeding if the catheter is removed accidentally.

Complications of adenotonsillectomy in children with OSAS younger than 2 years of age

The most common sleep disorder in children is obstructive sleep apnea syndrome (OSAS). The majority of children with OSAS improve following tonsillectomy and adenoidectomy (T&A). T&A as an outpatient procedure in children is very common. Young age in considered risk factors for postoperative respiratory complications. The purpose of this study is to analyze our experience with postoperative T&A complications in patients younger than 2 years of age. A total of 39 T&A were performed in children younger than 2 years of age. OSAS diagnosis was confirmed by overnight polysomnography (PSG). All the patients were hospitalized and monitored by overnight pulse oximetry monitoring. Post-operatively there was marked improvement in respiratory function in all the patients comparing pre- and post-operative nadir oxygen saturation ( P<0.05). Complications were documented in seven patients (20%). Five of the complications occurred in children older than 1 year of age. Bleeding occurred in two patients (5.7%). Three patients (8.6%) had dehydration, one patient (2.9%) had hypercarbia and one patient had laryngospasm. In this study there was a low incidence of peri- and post- operative respiratory complications in children younger than 2 years of age who undergo T&A for OSAS. Identification of OSAS severity may be an important factor in determining the risk of T&A in a young child.

SERUM C-REACTIVE PROTEIN LEVEL AND THE IMPACT OF CYTOREDUCTIVE SURGERY IN PATIENTS WITH METASTATIC RENAL CELL CARCINOMA

The prognosis of metastatic renal cell carcinoma is extremely poor. In this type of metastatic tumor cytoreductive surgery of the primary tumor is often performed to confirm the histological type or improve the response to immunotherapy with agents such as interferon or interleukin-2. However, the timing and impact of cytoreductive surgery on the success of immunotherapy require further study. We determined the type of metastatic renal cell carcinoma for which cytoreductive surgery is beneficial. We retrospectively reviewed the records of 58 patients in whom metastatic renal cell carcinoma was diagnosed at our hospital between 1986 and 1997. Three patients were excluded from study because they were judged to be poor candidates for surgery due to poor performance status. Of the remaining 55 patients 34 consented to cytoreductive surgery of the primary tumor and 21 did not. All except 1 patient were treated with interferon therapy. We evaluated the association of pretreatment serum C-reactive protein and the effect of surgery. We noted no significant difference in age at diagnosis, pretreatment serum immunosuppressive acidic protein, site of metastasis or performance status in 34 patients who underwent cytoreductive surgery and 21 who did not. Of the 21 patients in whom pretreatment serum C-reactive protein was within normal limits (less than 1.0 ng./ml.) no significant difference in disease specific survival was observed in those who did and did not undergo surgery (p = 0.4133). On the other hand, of 34 patients in whom pretreatment serum C-reactive protein was elevated (1.0 ng./ml. or greater) the prognosis was significantly better in those who did versus those who did not undergo surgery (p = 0.0054). Particularly the prognosis in patients in whom postoperative nadir C-reactive protein decreased to within normal limits was markedly better than in those in whom it remained elevated (p = 0.0025). Our study suggests that cytoreductive surgery is beneficial to patients in whom pretreatment serum C-reactive protein is elevated. Particularly, those in whom serum C-reactive protein decreases to within normal limits may expect longer survival when surgery is combined with postoperative immunotherapy. Currently to our knowledge the prognostic factor that predicts postoperative nadir C-reactive protein has not been identified, indicating that cytoreductive surgery of the primary tumor should be performed in patients with elevated pretreatment C-reactive protein and as performance status permits.

Transfusion guidelines for cardiovascular surgery: lessons learned from operations in Jehovah's Witnesses.

Patients undergoing cardiovascular surgery are among the top users of homologous blood transfusion (HBT). Awareness of the risks of disease transmission and immune system modulation from HBT has prompted us to find alternatives such as autologous predonation (APD) and intraoperative autotransfusion (IAT). However, these latter options are not appropriate for all patients. We reviewed our experience with 59 Jehovah's Witness patients who underwent 63 elective cardiovascular procedures without either HBT or APD to determine the safety of operation without these modalities and to develop revised maximum surgical blood-ordering schedule guidelines for cardiovascular surgery. Estimated blood loss averaged 870 ml, but one third to one half of losses were replaced by IAT. IAT was not needed in lower extremity bypass operations in which the estimated blood loss was less than 150 ml. Three of 59 patients died (5.1%), but only one died of operative bleeding complications. We conclude that (1) elective cardiovascular operations can be done safely without the use of either HBT or APD, (2) HBT is not necessary in leg bypass procedures, and (3) maximum surgical blood-ordering schedule guidelines for HBT in major cardiovascular operations can be reduced to near zero by the use of intraoperative autotransfusion and acceptance of a postoperative hemoglobin nadir of 7.0 gm/dl.

Serial Determinations of Serum CEA in Monitoring Management of Patients with Colorectal Carcinoma

Serum concentrations were determined serially in two groups of patients with colorectal carcinoma: in 123 after curative resection and in 34 with residual cancer. Of the first group, in 98 serum CEA fluctuated within the normal range or with a 2-fold larger amplitude evidencing effective surgery because only 9 had recurrence; in 25 serum CEA rose persistently from a postoperative nadir indicating relapse, mostly liver metastases. Of the 34 patients with relapse, 3 had clinically and 7 CEA-directed second-look laparotomy; although 7 had operation with curative intent, only 3 remained disease-free. In the second group, there were 26 patients after palliative surgery and 8 during nonsurgical treatment. Serum CEA fluctuated within the normal range in 2 patients in remission and in 3 with progressive cancer, and rose in parallel to cancer progression in 29. Thus, serum CEA within or slightly above the normal range was 88% predictive that the patient might be free of disease or in remission; whereas elevated or rising level indicated disease progression. Accordance between serum CEA and clinical status occurred in 145 of 157 (92%) patients.

Value of serum levels of carcinoembryonic antigen, CEA, and gastrointestinal cancer antigen, GICA or CA 19-9, for preoperative staging and postoperative monitoring of patients with colorectal carcinoma.

Serum levels of gastrointestinal cancer antigen (GICA) and carcinoembryonic antigen (CEA) were determined in 167 patients with colorectal carcinoma. Eighty-eight patients were studied preoperatively, and 79 postoperatively, before, at the time of, and after the diagnosis of relapse. The authors aimed to assess how often the GICA test failed, i.e., was false-negative in patients in whom the CEA test was true-positive and, more importantly, whether it could give diagnostic information in patients in whom the CEA test failed. Before surgery, serum GICA gave similar information to serum CEA in 56 percent of the patients: true-positive in 18 percent and false-negative in 38 percent; less information in 42 percent; and more information in only 2 percent. During the postoperative follow-up, serum GICA gave similar information to serum CEA in 55 percent of the patients: true-positive (i.e., rising persistently from a postoperative nadir) in 27 percent and false-negative in 28 percent; less information in 44 percent; and more information in only 1 percent. Therefore, this test in its present version, where both the catcher and the tracer antibody are the same, NS 19-9, is redundant.

Left ventricular systolic and diastolic function in coronary artery disease: effects of revascularization on exercise-induced ischemia.

Left ventricular systolic and diastolic function were studied before and after surgical revascularization in a group of 24 patients with stable angina who all had an excellent clinical response to surgery. With use of micromanometer left ventricular pressure measurements and ventricular volumes, calculated from biplane cineangiograms, left ventricular function at rest and during exercise before and after surgery was compared. Before surgery all patients had exercise-induced ischemia with new asynergy, a fall in ejection fraction from 57% to 49% (p less than .001), and a rise in left ventricular end-diastolic pressure from 23 to 37 mm Hg (p less than .001). Postoperative exercise resulted in no new asynergy and ejection fraction rose from 59% to 61% (p less than .05). Left ventricular end-diastolic pressure still rose from 17 to 25 mm Hg (p less than .01). Left ventricular pressure decay during exercise was greatly improved after revascularization and allowed maintenance of reduced early diastolic pressures. The early diastolic pressure nadir before surgery rose from 9 to 21 mm Hg (p less than .001); the postoperative nadir was 5 mm Hg at rest and 6 mm Hg during exercise. All patients had an upward shift in the diastolic pressure-volume relationship during preoperative exercise. After revascularization there was no upward shift in some patients and a much smaller shift in others. The postoperative increase in left ventricular end-diastolic pressure was due to increased end-diastolic volume, not altered compliance. There was an increase in mean right atrial pressure during exercise either before (6 to 11 mm Hg) or after surgery (4 to 10 mm Hg). These increases were quite variable, suggesting no consistent role of pericardial restraint during exercise. Early diastolic peak filling rate during exercise was greater after surgery (1260 vs 950 ml/sec, p less than .001). In fact, during postoperative exercise early diastolic filling rates were greater than normal, reflecting the persistence of abnormally high atrial pressures for filling. As at preoperative study, late diastolic filling during exercise was restricted after revascularization when compared with that in a control group. Postoperatively patients undergoing bypass procedures with a good clinical result showed significantly improved left ventricular diastolic and systolic function. Persistent elevation of end-diastolic and atrial pressures and other abnormalities of diastolic function may reflect chronic structural changes and need to be taken into account when evaluating patients after bypass surgery.