Patients In Preoperative Period Research Articles

Nonalcoholic fatty liver disease and its association with metabolic syndrome in the preoperative period in patients undergoing bariatric surgery

ObjectiveTo investigate the association between nonalcoholic fatty liver disease (NAFLD) and metabolic syndrome (MS) in the preoperative period in patients undergoing bariatric surgery. MethodsA total of 68 medical records of patients from a center for advanced treatment of obesity in the city of Caxias do Sul, state of Rio Grande do Sul, Brazil, were reviewed. The variables analyzed were gender, age, biochemical parameters (fasting glucose, HDL-cholesterol and triglycerides), abdominal ultrasound, blood pressure, and anthropometric data (weight, height, waist circumference, and body mass index [BMI]). The diagnosis of NAFLD was obtained by abdominal ultrasonography; the diagnosis of of MS was obtained according to the protocol described by the National Cholesterol Education Program's Adult Treatment Panel III, updated by the American Heart Association; and the National Heart, Lung, and Blood Institute. Results72.1% (n=49) of the sample consisted of females, and the mean age for the sample was 37.57±10.29 years. The mean weight was 123.14±25.40kg, mean height was 1.67±0.09 m, and mean BMI was 56.24±9.30kg/m2. A total of 60% (n=27) of patients with MS (p=0.008), 63.4% (n=26) of patients with hypertension (p=0.013), and 66.7% (n=18) of patients with altered glucose levels (p=0.028) were diagnosed with NAFLD. ConclusionThe results of this study showed that the diagnosis of MS, as well as the presence of disorders associated with this syndrome (obesity, hypertension, and high blood glucose levels) are strongly associated with the presence of NAFLD.

Self-expanding metal stents for preoperative biliary drainage in patients receiving neoadjuvant therapy for pancreatic cancer.

Improving outcomes in management of pancreatic cancer remains a challenge, owing to advancement of the disease at presentation. Only 15-20% patients are diagnosed at a resectable or borderline resectable stage (1). During the past 1-2 decades, adjuvant chemotherapy with surgery first approach did not bring a significant survival benefit (2-4). Recent studies have shown that neoadjuvant chemoradiation therapy results in better post surgical outcomes for potentially resectable pancreatic cancer (5-7). This has led to change in management strategy in many pancreatic cancer centers from initial surgery to now neoadjuvant therapy followed by surgery, especially in borderline resectable pancreatic cancer. In this approach, preoperative therapy lasts approximately 3 months and is followed by a 1-month recovery period before surgery. Therefore, patients who have biliary obstruction due to cancer in the head of the pancreas need drainage while receiving the treatment and waiting to undergo surgery. Effective biliary drainage is essential to prevent liver toxicity due to chemotherapeutic agents. Furthermore, during the period of neoadjuvant chemoradiation, patients may become immuno-compromised, and the patients may not tolerate recurrent biliary obstruction with cholangitis, or any complications from repeated endoscopic procedures. Therefore, it is crucial to avoid unnecessary interventions including endoscopic procedures during this period. Among various kinds of biliary stents, self-expanding metal stents (SEMS) have been increasingly used in treating malignant distal biliary obstruction because of their long duration of patency. By design, SEMS have a large diameter and minimal surface area on which bacterial biofilm can form, thus reducing the risk of obstruction. In the study by Adams et al. published in this issue of Journal of Gastrointestinal Oncology, the authors have compared outcomes of placing self-expanding metal stents (SEMS) vs. plastic stents for pancreatic cancer patients undergoing neoadjuvant therapy. In this retrospective study, 52 patients with pancreatic cancer underwent ERCP and had placement of either SEMS or plastic stents before or during the treatment. Keeping in line with prior studies, the complications were 7 times higher among patients with plastic stents than with metal stents. Not only the complications were more common, their occurrence was also significantly earlier in the plastic stent group. In addition, the study showed a higher rate of hospitalization in patients with plastic stent group. Finally, the authors concluded that SEMS, not plastic stents, should be used in this setting, due to a lower rate of complications, hospitalizations, and longer stent patency. Similarly, multiple retrospective and prospective studies have proven superiority of SEMS to plastic stents in drainage of malignant bile duct obstruction. Three studies published by our group found that, compared with plastic stents, SEMS placement reduced the number of ERCPs and the episodes of cholangitis in patients who underwent preoperative chemoradiation (8-10). We found no increase in pancreaticoduodenectomy related morbidity or mortality among patients who underwent SEMS placement for pre-operative drainage. Likewise, other centers have published their experience comparing the outcomes of biliary SEMS to plastic stents. In a retrospective study of 29 patients with pancreatic cancer undergoing pre-operative biliary drainage, authors found no stent dysfunction or complications during the pre-operative period in patients who underwent SEMS placement compared to 39% patients requiring re-interventions in the plastic stent group (11). Congruently, in a prospective study evaluating the outcomes of SEMS in 55 patients receiving neoadjuvant therapy for pancreatic cancer, stent malfunction occurred only in 15% of patients by 260 days (12). There were 27 patients in the study who later underwent pancreaticoduodenectomy, and the presence of stent did not interfere with surgery in any patient. SEMS has also been proven to be more cost-effective. In summary, with recent advances in neoadjuvant chemoradiation therapy, there seems to be a significant improvement in overall survival among potentially resectable patients who undergo pancreaticoduodenectomy after the treatment. Consequently, the approach for neoadjuvant chemoradiation therapy prior to pancreaticoduodenectomy is gaining wider acceptance and more patients with pancreatic cancer will require pre-operative biliary drainage in the future. Current data unequivocally supports the use of SEMS for patients presenting with malignant biliary obstruction due to potentially resectable pancreatic cancer undergoing neoadjuvant chemoradiation therapy. On the other hand, for patients who have resectable pancreatic cancer, many centers may consider to proceed with curative surgery upfront. In such cases where patients may be undergoing curative surgery without neoadjuvant therapy, SEMS or any other stents may not be warranted. Lastly, when the stage of disease and treatment plan are not completely defined at the time of diagnosis, the vast majority of patients with symptomatic malignant distal bile duct obstruction may be best served by placement of SEMS rather than a plastic stent at the initial endoscopic intervention, due to the superior patency, lower rate of complications, and cost-effectiveness of SEMS.

Прогнозування перебігу пневмоперитонеуму та тактика хірургічого лікування хворих на гострий і хронічний холецистит із супутньою патологією серцево-судинної системи

The share of elderly and senile patients with acute cholecystitis concomitant cardiovascular pathology whom the laparoscopic cholecystectomy has been provided is increased. The heightened intraabdominal pressure has negative influence at the cardiovascular system, so the alternative ways for treatment of this group of patients are used in clinic. We propose the pneumoperitoneum model using the pneumatic belt which is fixed at the abdomen in preoperative period in patients with an acute and chronic cholecystitis. This model is useful to forecast cardiovascular disorders during future laparoscopic cholecystectomy. The arterial pressure level, pulse score and ECG are monitored during the test (90 min). Myocardial ischemia appearance seems that the risk of laparoscopic cholecystectomy with pneumoperitoneum is high. The alternative method of surgery in such group of patients (no pneumoperitoneum is applied) is laparoscopic assisted cholecystectomya from miniaccess. This method allows to reducing frequency of intra- and postoperative complications connected with pneumoperitoneum negative influence at the patients with concomitant pathology of cardiovascular system.

MODERN ASPECTS OF DIABETIC RETINOPATHY AND DIABETIC MACULAR OEDEMA TREATMENT

Main reasons of eyesight deterioration in diabetic patients are diabetic retinopathy (DR) and diabetic macular oedema (DMO). International multicenter studies have shown that retinal laser coagulation in the event of DMO decreases the risk of eyesight loss in 50%, though only in 16% patients it was also possible to improve their eyesight. Use of vascular endothelial growth factor inhibitor--Ranibizumab--have opened a new era in DMA treatment. It's efficacy and safety have been proven in several international studies. This article contains our own data upon the use of Lucentis in patients with DMO. Intravitreal Luzentis injections and subsequent retinal lasercoagulation in the macular zone were performed on 43 eyes; follow up period--6 months. Additional injections were required in 19 cases, average amount of injections--1,4. Mean corrected visual acuity before the treatment was 0,37 +/- 0,06, after 7 days, 1, 3 and 6 months. - respectively 0,41 +/- 0,06, 0,49 +/- 0,06, 0,51 +/- 0,07 and 0,52 +/- 0,07(p<0,05). Mean retina thickness in central zone was 428 +/- 125 mkm before treatment, 391 +/- 24 mkm 7 days after the last injection 349 +/- 23, 313 +/- 21 and 308 +/- 20 mkm (p<0,05) after 1, 3 and 6 months. In addition to that Luzentis use in preoperative period in patients with non-complicated proliferative DR allowed to decrease the risk of hemorrhagic complications. Thereby, intravitreal injections of Luzentis improve functional result of treatment of patients with DMO, increase efficacy and safety of surgical interventions in patients with complicated forms of proliferating DR.

Correlation analysis of compromised immune function with perioperative sepsis in HIV-positive patient

Objective: To investigate the relationship between immune function and perioperative sepsis in HIV-positive patients. Methods: Retrospective analysis of 144 HIV-positive patients surgically treated from Oct 2008 to Dec 2010 in Shanghai Public Health Clinical Center. The patients were divided into four groups based on their CD4+ T cells counts in preoperative period: group A (0 – 99 cell/ul), group B (100 – 199 cell/ul)，group C (200 – 349 cell/ul)，group D (≥350 cell/ul). All patients had received standardized surgical procedures, careful surgical routines were applied. To reduce operational damage, conventional antibi-otics, anti-TB, anti-fugal, antiretroviral therapies were used to prevent infection and promptly treatment of complications. Results among 144 HIV-positive patients (male 133 and female 11, aged 42.6 ± 12.5), 80 patients got perioperative sepsis (14 cases in preoperative period and 66 cases in postoperative period). 64 cases did not get sepsis. The average CD4+ T cell count was 276.97 ± 137.91 in preoperative period of patients without sepsis, which was significant higher than the patients with preoperative sepsis (151.29 ± 110.64) and patients with postope- rative sepsis(161.14 ± 128.45) (F = 13.91, P χ2 = 23.680, P +T cells (r = –0.987, P = 0.013). Conclusions With the decrease of preoperative CD4+T cells, the risk of perioperative sepsis had notable increase. Complete evaluation of surgical risk and suitable perioperative treatments may obtain better effect for the patients infected HIV.

Consensual Validation of the Nursing Diagnoses Fear and Anxiety Identified at the Immediate Preoperative Period in Patients Undergoing Elective Surgery

To identify the most frequent defining characteristics (DCs) for the diagnoses fear and anxiety in Brazilian patients in the immediate preoperative period following elective cardiac surgery; to develop conceptual and operational definitions for the DCs; to develop consensual validation. Clinical and observational, descriptive study developed in two phases. Forty DCs were identified for fear and 19 for anxiety. One expert judged it necessary to include "altered bowel motility" as a DC for fear. There was 100% agreement among the five experts in relation to the DCs. To add "altered bowel motility" to the DCs for the nursing diagnosis fear. To enable nurses to more accurately assess patients for these diagnoses.

P02-241 - Depressiveness in preoperative period and postoperative recovery of orthopedic patients - preliminary results of prospective study

IntroductionDepression is often occurred after surgical interventions and may have serious consequences on postoperative recovery. The treatment of early discovered depressive symptoms may have strong influence on the recovery of operated orthopedic patients.Simple and quick instrument for detection and evaluation of depressive symptoms could be of great use to doctors.Work objectives are1) determine the prevalence of depressiveness in preoperative period in patients with scheduled surgical interventions, and2) validation of Geriatric Depression Scale - short form (GDS-SF) in detection of depressiveness.MethodA sample of 120 orthopedic patients is the part of larger sample in prospective research of depressiveness in patients in preoperative period with scheduled surgical interventions (except cardio-surgical). For estimation of depressiveness we used battery of tests (GDS-SF, BDI - Beck's depression scale, MDI - major depressive disorder questionnaire), and patients were tested 3 times: to 14 days prior the surgery, 7 and 90 days after the surgery. Validation of GDS-SF was examined compared to BDI according to age and gender of examinees.ResultsIn preliminary sample of 120 orthopedic patients with scheduled orthopedic interventions, prevalence of depressiveness is greater than prevalence of depressiveness in general population (p &lt; 0.001). Depressiveness is much more present in women than in men (p &lt; 0.001). Correlation of depressive scores in BDI and in GDS-SF is satisfactory for all age groups.ConclusionPreliminary results indicate on further research of depressiveness in preoperative period in order to confirm validation of GDS-SF as simpler alternative for early detection of depressiveness.

Pain management in the pre-operative period for patients with a fractured neck of femur (Concurrent)

der, friend Sancho, thirty or forty hulking giants? I intend to do battle with them and slay them.’’ ‘‘What giants?’’ asked Sancho Panza. ‘‘Those you see over there,’’ replied his master, ‘‘with their long arms. Some of them have arms well nigh two leagues in length.’’ ‘‘Take care, sir,’’ cried Sancho. ‘‘Those over there are not giants but windmills.’’ During his odyssey, Don Quixote fights windmills perceiving the sails to be the arms of a giant and persistently engages in seemingly unwinnable battles. The analogy can be drawn with today’s healthcare practitioner encountering seemingly unwinnable battles between optimal care delivery, resources, quality, technology, bureaucracy and financial constraints. In going beyond mere storytelling, whatever our own interpretation, the application of Don Quixote’s knightly virtues of courage, justice, mercy, generosity, faith, nobility, hope, strength and humility to contemporary healthcare is inspirational. The symbiotic relationship between Sancho Panza and Quioxte may be viewed in terms of mentorship with the simple (novice) companion gaining experience, self knowledge and wisdom along the journey developing into protector, friend and eventually assuming the role of mentee as his learning overtakes that of his Master. The very diverse and encompassing nature of mentoring makes it a difficult role and concept to define but it is pivotal helping novices fit into systems and acquire contextually appropriate skills and knowledge (Hazelton, 1999). Thus mentorship builds relationships, enabling each professional to realise their potential. The aim of this presentation is to demonstrate how the use of reflective practice and mentorship can enhance care delivery by decreasing the theory practice gap and developing today’s practitioners as lifelong learners.

Medical treatment of insulinomas: The role of diphenylhydantoin

Surgical removal of the insulinoma continues to be the treatment of choice. Medical therapy should be considered in patients who cannot undergo surgery. We are reporting our experience with regard to the efficacy of Diphenylhydantoin (DPH) in controlling hypoglycemia and suppressing insulin release in patients with insulinomas. DPH was administered orally at a dose of 300–400mg/day to three patients with documented endogenous insulin excess. The first two patients received the drug temporarily during the preoperative period, with resolution of the hypoglycemic attacks, normalization of blood glucose, and reduction of insulin levels. Subsequent surgery confirmed the presence of insulin-secreting pancreatic tumor. Cure was achieved after excision of the tumor. The third patient represented a diagnostic and threrapeutic challenge. An insulin-secreting tumor located in the body of the pancreas was diagnosed in a patient with type 2 diabetes and end stage renal disease. The patient’s poor cardiac function contraindicated surgery. DPH resulted in an excellent sustained control of his blood sugar and a fall in insulin levels for several months. We believe that DPH is a potent inhibitor of insulin secretion and, thus, is suitable as a temporary therapeutic measure in the preoperative period of patients with insulinoma, as well as an alternative to surgery for those who are not surgical candidates.

Stan odżywienia chorych z rakiem krtani i gardła dolnego

The meaning of proper nutritional state in the group of cancer patients in preoperative period was noticed already over 40 years ago. In spite, that treatment of malnutrition is easy, many patients are not diagnosed and not treated, what has obvious consequences. The aim of this study was to evaluate nutritional status of patients with cancer of larynx and hypopharynx before the treatment. 223 men and 29 women with diagnosed squamous cell cancer of larynx and hypopharynx, who were classified to surgical treatment, were included into study. The evaluated population was divided into groups depending on location and local extend of the tumor. The nutritional state was assessed using: body mass index (BMI) and total lymphocyte count (TCL). Using BMI the malnutrition was diagnosed in 41% of all patients. The level of malnutrition increases while increases stage of local extend of tumor. The least numerous group of malnutritioned patients were those with tumor of glottis, but also in this group was the largest percentage of patients with local extend of tumor: T1 and T2. The state of considerable malnutrition was diagnosed in 34% patients with tumor of the piriform recess. Using TLC the malnutrition characterized 37% of all patients. In the group with tumor of glottis and epiglottis the level of malnutrition increases while increases stage of local extend of tumor. All the patients with tumor T4 with unclassified origin location were classified to the group of malnutritioned. The malnutrition is diagnosed in considerable percentage of patients with cancer of larynx and hypopharynx. The diagnosis of poor nutritional state will permit to apply suitable, controlled nutrition before surgical treatment. This will contribute in decrease of complication frequency and improve the tolerance of treatment.

A study of pulmonary embolism after abdominal surgery in patients undergoing prophylaxis

To determine risk factors for pulmonary embolism and estimate effects and benefits of prophylaxis. We included 78 patients who died subsequently to a pulmonary embolism after major abdominal surgery from 1985 to 2003. A first, retrospective analysis involved 41 patients who underwent elective surgery between 1985 and 1990 without receiving any prophylaxis. In the prospectively evaluated subgroup, 37 patients undergoing major surgery between 1991 and 2003 were enrolled: all of them had received a prophylaxis consisting in low-molecular weight heparin, given subcutaneously at a dose of 2850 IU AXa/0.3 mL (body weight < 50 kg) or 5700 IU AXa/0.6 mL (body weight > or = 50 kg). A higher incidence of thromboembolism (43.9% and 46.34% in the two groups, respectively) was found in older patients (> 60 years). The incidence of pulmonary embolism after major abdominal surgery in patients who had received the prophylaxis was significantly lower compared to the subjects with the same condition who had not received any prophylaxis (P < 0.001, OR = 2.825; 95% CI, 1.811-4.408). Furthermore, the incidence of pulmonary embolism after colorectal cancer surgery was significantly higher compared to incidence of pulmonary embolism after other abdominal surgical procedures. Finally, the incidence of pulmonary embolism after colorectal cancer surgery among the patients who had received the prophylaxis (11/4316, 0.26%) was significantly lower compared to subjects undergoing a surgical procedure for the same indication but without prophylaxis (10/1562, 0.64%) (P < 0.05, OR = 2.522; 95% CI, 1.069-5.949). Prophylaxis with low molecular weight heparin is highly recommended during the preoperative period in patients with diagnosis of colorectal cancer due to high risk of pulmonary embolism after elective surgery.

Abdominal compartment syndrome in patients with strangulated hernia

Intestinal obstruction (IO) leads to increased intra-abdominal pressure and abdominal compartment syndrome. The purpose of this study was to investigate the characteristics of abdominal compartment syndrome in patients with IO secondary to strangulated hernia. We studied 81 consecutive unselected patients presenting complicated hernias and IO. We measured intra-abdominal pressure using the intra-vesicular pressure method. Preoperative (15 min) intra-abdominal pressure was higher in patients with strangulated hernias. Postoperative (15 min) intra-abdominal pressure in both groups decreased to similar values. Intra-abdominal pressure was measured during the preoperative period in patients with strangulated hernias and during the postoperative period at 15 min (13.8 +/- 6.4 mmHg), 24 h (9.8 +/- 3.2 mmHg) and 48 h (7.4 +/- 2.4 mmHg). Abdominal compartment syndrome developed in 47% cases with strangulated hernias with a mortality of five patients. Serial measurements of intra-abdominal pressure evidenced the clinical severity of strangulated hernia. Intra-abdominal pressure measurement may be used as a predictor of intestinal strangulation in patients presenting acute abdominal compartment syndrome secondary to complicated hernia.

Hemolytic-uremic syndrome and myocardial dysfunction in a 9-month-old boy

Cardiovascular dysfunction in patients with hemolytic-uremic syndrome (HUS) may be related to secondary issues such as volume overload, hypertension or electrolyte disturbances including hyperkalemia. Additionally, primary myocardial involvement has been increasingly recognized as a potential comorbid feature of HUS. We report a 9-month-old child with HUS who developed clinical signs of poor myocardial function with depressed myocardial function noted by echocardiography. Supportive care including mechanical ventilation and inotropic agents were necessary for approximately 10 days. Follow-up echocardiography revealed return of normal ventricular function. Previous reports of primary cardiac involvement with HUS have included thrombotic microangiopathy of the coronary vasculature resulting in myocardial ischemia, myocardial infarction or depressed myocardial function, myocarditis, congestive heart failure with dilated cardiomyopathy and pericardial effusion with tamponade. Given the potential for morbidity and mortality during the preoperative period in patients with HUS, anesthesiologists involved in the care of such patients should be aware of the potential for myocardial involvement in this disease process. Preoperatively, the routine evaluation of myocardial function may be indicated.

Constipação intestinal em pacientes com tumores intracranianos

O esforço que ocorre durante a manobra de Valsalva gera aumento da pressão intracraniana e pode descompensar pacientes com hipertensão intracraniana. Os objetivos deste estudo foram avaliar a incidência de constipação intestinal no pré-operatório de pacientes com tumores intracranianos e relacionar a constipação intestinal com a descompensação da hipertensão intracraniana. O estudo foi realizado na unidade de neurocirurgia do Hospital São Paulo, de agosto a outubro de 2003, com a avaliação de 37 pacientes. O tempo médio de pré-operatório foi de 12 dias, variando de 2 a 34 dias. Durante esse período, 6 (16,2%) pacientes apresentaram constipação, sendo que todos receberam dieta laxativa e lactulose, e destes, 2 (33,3%) necessitaram de enema. Todos os pacientes realizaram manobra de Valsalva durante a evacuação, e não foi observada descompensação da hipertensão intracraniana nos pacientes que apresentaram ou não constipação intestinal.

Significados e atitudes de pacientes de cirurgia cardíaca: influência de variáveis sociodemográficas

Este estudo verificou a influência das variáveis sociodemográficas sobre os significados e atitudes relativos à cirurgia cardíaca, em 125 pacientes no período pré-operatório. Para análise dos dados coletados por meio dos instrumentos SPCC (Significados dos Pacientes frente à Cirurgia Cardíaca) e CVSCC (Crenças, Valores e Sentimentos sobre a Cirurgia Cardíaca), foram empregados o coeficiente de correlação de Pearson e os testes de Mann-Whitney e Kruskal-Wallis. Foram encontradas correlações significativas entre idade, número de filhos, renda mensal e os fatores positivos do instrumento CVSCC. Sexo, grau de escolaridade, vivência de eventos marcantes anteriores, co-habitação e cor foram associados aos significados e atitudes dos pacientes sobre cirurgia cardíaca. Conclui-se que os significados e atitudes dos pacientes sofrem influência de algumas variáveis sociodemográficas, achados que podem ser de grande valia no planejamento e implementação de práticas educativas.

&lt;![CDATA[&lt;b&gt;Importance of cardiac troponin-I in the preoperative period of patients without prior cardiac events but suffering from left coronary branch obstruction&lt;/b&gt;]]&gt;

&lt;![CDATA[&lt;b&gt;Importance of cardiac troponin-I in the preoperative period of patients without prior cardiac events but suffering from left coronary branch obstruction&lt;/b&gt;]]&gt;

Adverse Emotional Responses after Mitral Valvotomy

Out of 45 patients who had mitral valvotomy 19 developed postoperative adverse emotional responses. When these cases were compared to those without post-operative psychiatric disorders, statistically significant differences were found in the post-operative personality characteristics of ego strength and denial mechanisms and in the duration of preoperative period in patients in the cardiac surgery unit. In patients developing post-operative psychiatric disturbances the clinical severity of lesions was at discrepancy with the severity of lesions found at operation and this may be due to psychogenic symptomatic overlay in patients who subsequently develop psychiatric difficulties.