Uncomplicated Operation Research Articles

Outcome measures after lower extremity bypass surgery: there is more than just patency.

Arterial occlusive disease is a generalized, progressive, and disabling condition that can significantly influence the quality of a patient’s life. When it affects peripheral vessels this chronic disease may cause considerable morbidity, particularly when it progresses to gangrene. At other sites it is responsible for an increased mortality from myocardial infarction and stroke. To improve some of this unfavourable outlook lower extremity bypass surgery down to the level of the ankle and foot has been recommended, even in elderly patients with extensive disease. Such procedures, however, are associated with a high failure rate leading to further surgical interventions and hospital stays. The traditionally reported outcomes of bypass operations are graft patency, limb salvage and patient survival 1 , but these indicators of surgical success are limited as measurements of outcome because they do not tell the whole story from the patient’s perspective. All vascular surgeons know that major amputation may sometimes be necessary in spite of graft patency, and that graft occlusion is not always associated with a reduction in quality of life. For a proper appreciation of the situation many factors must be considered, particularly delayed wound healing, residual postoperative pain and leg swelling, episodes of recurrent ischaemia, number of reoperations, maintenance of ambulation and residential status, opposite leg problems and cardiovascular events. Moreover, increasing emphasis has been placed in recent years on assessment of perception of well being, functional capacity and life quality 2 . Nicoloff et al. 3 found that only 14 per cent of patients who had limb salvage surgery achieved the ideal result of an uncomplicated operation with long-term symptom relief, preservation of functional status, and no recurrence or repeat operations. This disappointing picture occurred in spite of an excellent assisted primary graft patency rate of 77 per cent and a limb salvage rate of no less than 87 per cent at 5 years. To allow a more comprehensive view of the effectiveness of bypass surgery, including its impact on daily life and life satisfaction, outcome measurements of vascular interventions must reflect a more complete array of endpoints than those commonly applied. An important issue in the effectiveness of vascular surgery is the need for repeat operative intervention. From recent studies it is evident that many patients who had bypass surgery for limb salvage require ongoing reoperations for persistent or recurrent symptoms until their death, implying significant morbidity, discomfort, and additional costs 3,4 . We believe that additional interventions for a graft-related complication, recurrent leg ischaemia or delayed wound healing should be used as a principal outcome measure in clinical studies. It is also recognized that over time many patients treated for ischaemic symptoms in one leg will return with similar symptoms in the opposite leg 5 . The risk that symptoms will develop in the contralateral limb varies from 8 to 21 per cent per annum and emphasizes that peripheral arterial occlusive disease is essentially a two-limb problem. This information is important for patients, in particular for those with contralateral claudication, and should be discussed in full when considering surgery. Since atherosclerotic disease is

Prediction of postoperative cardiac surgical morbidity and organ failure within 4 hours of intensive care unit admission using esophageal Doppler ultrasonography.

To compare esophageal Doppler ultrasonography with standard hemodynamic variables used in postoperative care for the prediction of postoperative complications after cardiac surgery. Prospective, observational pilot study. University hospital, multidisciplinary intensive care unit Postoperative cardiac surgical patients. Standard postoperative management as guided by routinely measured hemodynamic variables. An esophageal Doppler ultrasound probe was inserted for measurement of stroke volume (SV), cardiac output (CO), and other flow-related variables. Both these and routine hemodynamic variables (mean arterial pressure, central venous pressure, heart rate, arterial base deficit, urine output, core-toe temperature difference) were recorded at half-hourly intervals for the first 4 postoperative hrs. The incidence of systemic inflammatory response syndrome at 24 hrs, Acute Physiology and Chronic Health Evaluation II, and multiple organ failure scores, postoperative complications, and length of ICU and hospital stays were recorded. Twenty consecutively admitted patients were studied: eight after emergency bypass grafting and 12 after elective bypass grafts and/or valve replacement. Of the nine patients who developed postoperative complications, two died. At admission, significant differences were seen between patients with a complicated and those with an uncomplicated surgical procedure for SV, heart rate, and standard base excess, but not for cardiac output. By using receiver operator characteristic curves, SV was the best marker for predicting postoperative complications during the initial postoperative period. A low SV and a high heart rate, both at ICU admission and during the subsequent 4 hrs, were the best prognostic factors for development of complications after cardiac surgery. Cardiac output values were not useful. This pilot study suggests that the minimally invasive technique of esophageal Doppler ultrasonography may be a useful tool to assist early prognostication.

Patient recovery after infrainguinal bypass grafting for limb salvage

Purpose: The outcome of infrainguinal bypass surgery for limb salvage has traditionally been assessed by graft patency rates, limb salvage rates, and patient survival rates. Recently, functional outcome of limb salvage surgery has been assessed by patient ambulatory status and independent living status. These assessments fail to consider the adverse long-term patient effects of delayed wound healing, episodes of recurrent ischemia, and need for repeat operations. An ideal result of infrainguinal bypass surgery for limb salvage includes an uncomplicated operation, elimination of ischemia, prompt wound healing, and rapid return to premorbid functional status without recurrence or repeat surgery. The present study was performed to determine how often this ideal result is actually achieved. Methods: The records of 112 consecutive patients who underwent initial infrainguinal bypass surgery for limb salvage 5 to 7 years before the study were reviewed for operative complications, graft patency, limb salvage, survival, patient functional status, time to achieve wound healing, need for repeat operations, and recurrence of ischemia. Results: The mean patient age was 66 years. The mean postoperative follow-up was 42 months (range, 0 to 100.1 months). After operation 99 patients (88%) lived independently at home and 103 (92%) were ambulatory. There were seven perioperative deaths (6.3%), and wound complications occurred in 27 patients (24%). By life table, the assisted primary graft patency and limb salvage rates of the index extremity 5 years after operation were 77% and 87%, respectively, and the patient survival rate was 49%. At last follow-up or death, 73% of the patients (72 of 99) who lived independently at home before the operation were still living independently at home, and 70% (72 of 103) of those who were ambulatory before the operation remained ambulatory. Wound (operative and ischemic) healing required a mean of 4.2 months (range, 0.4 to 48 months), and 25 patients (22%) had not achieved complete wound healing at the time of last follow-up or death. Repeat operations to maintain graft patency, treat wound complications, or treat recurrent or contralateral ischemia were required in 61 patients (54%; mean, 1.6 reoperations/patient), and 26 patients (23.2%) ultimately required major limb amputation of the index or contralateral extremity. Only 16 of 112 patients (14.3%) achieved the ideal surgical result of an uncomplicated operation with long-term symptom relief, maintenance of functional status, and no recurrence or repeat operations. Conclusions: Most patients who undergo infrainguinal bypass surgery for limb salvage require ongoing treatment and have persistent or recurrent symptoms until their death. A significant minority have major tissue loss despite successful initial surgery. Clinically important palliation is frequently achieved by bypass surgery, but ideal results are distinctly infrequent. (J Vasc Surg 1998;27:256-66.)

Energy requirements of surgical newborn infants receiving parenteral nutrition.

The energy requirement for mature newborn infants receiving total parenteral nutrition is approximately 100 kcal.kg-1.d-1. There is no necessity to increase the caloric intake after an uncomplicated operation. Energy requirements are affected by the maturity of the infant, the degree of operative stress, opioid medication, and the presence or absence of sepsis. In general, glucose intake should not exceed the resting energy expenditure. Glucose administration exceeding 18 g.kg-1.d-1 is associated with lipogenesis and reduced oxygenation of exogenous lipid. Resting energy expenditure varies widely between infants, and energy intake, based on clinical and biochemical monitoring, should be adjusted for individual patients.

Cardiovascular monitoring of elective aortic aneurysm repair using methods of chaos analysis.

Biological signals like arterial blood pressure (ABP) and electrocardiograms are usually displayed in a linear fashion. The often very complex structure may, however, be better described by phase space plots and time-delayed vectors, enabling an advantageous display of the dynamics contained in the signal. The potentials of such a display were investigated during elective aortic aneurysm repair, where profound haemodynamic changes frequently occur. The peripheral volume pulse was recorded at a digit using noninvasive near infrared photoplethysmography (NIRP). All patients (n = 20, mean age 72.8 years) were invasively monitored using arterial and Swan Ganz catheters. The ABP signal was continuously recorded with a computer (sample rate 128 Hz). Two different phase space plots, [x(t), y(t + 8/128 s) and x(t), d(x(t + 8/128 s) - x(t))/dt] were calculated for the NIRP and the ABP signals and continuously displayed. The stability was subjectively assessed and the fractal dimension calculated using the 'Hausdorff dimension'. The correlation between stability, fractal dimension and frequently used parameters of patient monitoring were investigated. All patients included in the study had an uncomplicated operation. Cardiac index (CI) and oxygen delivery (DO2) increased, and systemic vascular resistance (SVR) decreased following declamping of the aorta. The ABP signal was generally more stable. After declamping of the aorta, 14 of 16 NIRP signals became unstable, and 9 of 14 ABP signals destabilised. The time required for stabilisation of the signal varied between the individual patients. Thirty minutes after declamping, 11 of 12 ABP signals were stable, whereas 3 out of 9 NIRP signals still revealed an unstable pattern. A fractal dimension was calculated by box counting, which revealed a linear regression over two orders of magnitude in a log-log plot (Hausdorff dimension between 1.19 and 1.71). The mean fractal dimension for NIRP was significantly higher than that of the ABP signal. On clamping and declamping of the aorta, a trend to a higher fractal dimension (p = 0.08) was observed for both signals analysed. No correlation was observed between the fractal dimension and ABP, SVR index, CI, DO2 index and oxygen consumption. The dynamic changes of the signals were emphasised when they were displayed as phase space plots calculated by time-delayed vectors. The time series of the signal revealed a fractal dimension, and the observed increase at the critical time points of the operation, where the need for cardiovascular regulation is most pronounced, support the contention that a physiological system based on non-linear behaviour may enable a rapid response to haemodynamic challenges. An on-line display of phase space plots calculated by time-delayed vectors may in future provide a valuable method of monitoring for high-risk patients.

Peyronie curvature treated by plication of the penile fasciae.

To evaluate the results of plication of the penile fascia in patients with penile curvature secondary to Peyronie's disease. Twenty-eight men with Peyronie curvature underwent plication of the penile fascia. Before operation, the deviation of the penis was so severe (median 60 degrees) in 24 men that they were unable to perform sexual intercourse. Follow-up was based on hospital records, one postal questionnaire sent to all patients and a clinical evaluation of the men in the out-patient clinic. After an uncomplicated operation and a median follow-up of 34 months, 20 of the 28 men were able to perform sexual intercourse and 23 were satisfied with the result of the operation. The most frequent reasons for dissatisfaction with the outcome of the operation were insufficient straightening, pain from sutures and uncharacteristic pain related to the penis and/or scrotum. The technique is simple to perform and the method gives functional and cosmetic results equal to those of more invasive procedures. The provision of adequate information to patients before the operation is important to ensure their satisfaction with the outcome.

Time course of beta 2-integrin CD11b/CD18 (Mac-1, alpha M beta 2) upregulation on neutrophils and monocytes after coronary artery bypass grafting. CD11b upregulation after CABG surgery.

Although upregulation of CD11b/CD18 receptor, i.e. activation of neutrophils and monocytes, during cardiopulmonary bypass is well documented, the duration of the active state after uncomplicated operation is less understood. We therefore investigated CD11b expression of phagocytes in blood samples collected 2-4, 24, 48 and 72 h after coronary artery bypass grafting. CD11b expression on neutrophils was significantly elevated at 2-4 and 24 hours after operation as compared with baseline. On monocytes, expression peaked at 24 h and returned to baseline by 72 h. Because CD11b is a sensitive marker, effects of different sampling techniques on its expression were also studied. CD11b expression was similar in samples collected with a syringe from arterial or central venous catheter or with open technique from cubital vein. On neutrophils from healthy subjects, sampling with syringe caused small (10%) but statistically significant increase of expression. We conclude that activated neutrophils disappear from circulation within hours after CABG surgery while activated monocytes may continue circulating for 2-3 days, and that CD11b sampling can be done with a syringe.

The effect of recombinant BPI21 on endotoxin-induced mortality in rats with bile duct ligation

In a prospective study of 248 consecutive patients undergoing cardiopulmonary bypass surgery, early postoperative "post-pump" jaundice (PPJ) developed in 49 (20%). Development of PPJ was strongly associated with a bad outcome; 25% of jaundiced patients and 1% of non-jaundiced patients died in the postoperative period. The jaundice was a conjugated hyperbilirubinaemia, and was detectable in 48 out of 49 patients by postoperative day 2. Hypotension, hypoxia, and hypothermia ("shocked liver") were not associated with the development of PPJ, nor was evidence of haemolysis or heart-failure. Although PPJ was significantly associated with multiple valve replacement, higher transfusion requirements, and longer cardiopulmonary bypass time, it also occurred in patients undergoing uncomplicated operations. It is suggested that PPJ is caused by a defect in hepatic excretion of bilirubin.

The immunological effects of trauma

Trauma, both surgical as occurs during an elective operation, and accidental as in the burn or road traffic accident victim, is associated with a relative state of immunosuppression. Why this apparently deleterious response should happen remains unexplained, but our understanding of the interactions within the immune system during trauma is increasing dramatically. The use of monoclonal antibodies, recombinant DNA technology and highly sensitive assays has permitted the dissection of much of the immune system to be carried out. The present review will examine recent findings on the immunological consequences of trauma. For many years surgeons have been aware that patients who have short, uncomplicated operations recover much quicker than those who have lengthy, complex procedures (Buckman, 1976). The metabolic (Gill et al. 1975) and endocrine (Johnston, 1972) responses to trauma are well known. Recent interest in the immune system (which has an important role in response to infection, allograft rejection and probably malignancy) and trauma has developed because of the exciting possibility of using drugs or cytokines to block or augment certain immunological events. The immunological response can be seen as an orderly progression of cellular activity and protein production to control injury and modulate healing. This includes haemostasis, production of growth factors, changes in the microcirculation, the inflammatory response and wound repair. The inflammatory response can be subdivided into an innate response and an adaptive one. The innate response includes such factors as secreted enzymes and proteins, acute-phase proteins, activation of the alternate pathways of complement, the interferons (IFN) and non-specific immunological activity such as phagocytosis and natural killer (NK) cell activity. None of the factors previously described require previous ‘programming’ or cooperation with specific antigen-primed cells to be effective. The adaptive immune response, in contrast, is a highly specific response occurring as a result of directed antibodies, targeted cytokine-mediated lymphocyte activity and the classical pathway of complement activation (Lennard, 1991). The typical cascade reaction to antigen is shown in Fig. 1.

Absence of hypermetabolism after operation in the newborn infant.

This study was designed to assess the effect of operative stress on resting energy expenditure (REE) in the newborn infant. In 13 neonates who had an uncomplicated abdominal, thoracic, or spinal operation, REE was measured both preoperatively and on the third postoperative day. The mean preoperative REE of 43.19 +/- 7.95 kcal/kg per day was not significantly different from the mean postoperative REE of 41.70 +/- 7.94 kcal/kg per day. Sixteen neonates had REE measured on the first, second, and seventh postoperative days. The mean postoperative REE values of 43.12 +/- 6.92, 42.41 +/- 7.58, and 46.33 +/- 6.89 kcal/kg per day at 1, 2, and 7 days, respectively, were not significantly different from the preoperative REE. There was no significant difference in oxygen consumption, carbon dioxide production, and respiratory quotient between the preoperative and postoperative groups. In this study, an uncomplicated operation did not increase REE in the neonate.

C-Reactive Protein (CRP) Levels After Elective Orthopedic Surgery

The levels of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were determined by serial measurements after four types of uncomplicated elective orthopedic surgery. The type of operations chosen for this study were total hip arthroplasty (primary, n = 109; and revisions caused by aseptic loosening, n = 9), unicondylar knee arthroplasty (n = 39), and lumbar microdiskectomy (n = 36). In all patients, CRP levels increased after surgery, reaching peak levels on the third day after hip arthroplasties (primary, 116 +/- 43 mg/l; revisions, 136 +/- 58 mg/l) and on the second day after knee arthroplasties (140 +/- 46 mg/l) and lumbar microdiskectomy (48 +/- 27 mg/l). C-reactive protein levels usually dropped to normal (less than 10 mg/l) within 21 days after surgery. No correlations were found between CRP response and the type of anesthesia, amount of bleeding, transfusion, operation time, administered drugs, age, or gender. Erythrocyte sedimentation rate increased to peak levels about five days after surgery, followed by a slow and irregular decrease. Still, 42 days after uncomplicated operations ESR often remained elevated. In conclusion, the level of CRP must be considered a better diagnostic aid for the early detection of postoperative infections than ESR. It can be assumed that the rapid decline in CRP after uncomplicated orthopedic surgery will be interrupted by a second rise or by a persisting elevated level if infectious complications occur.

Correction of Myopia by Implantation of a Concave Worst-Iris Claw Lens Into Phakic Eyes

The Worst-Fechner Biconcave Lens for the correction of myopia in phakic eyes is fixated to the anterior iris. Of the 125 eyes implanted between November 1986 and November 1990, 109 eyes ("core group") had a follow-up period of at least 12 months (mean, 25.0; range, 13 to 51). Sixty-eight of these eyes were reexamined at Giessen University Eye Clinic by an independent investigator using a laser flare cell meter; 23 of the eyes also were examined by iris fluorescence angiography. Seventy-five of the 109 eyes (68.8%) were corrected within 1.00 diopters of the desired refraction, and only 10 eyes (9.2%) deviated more than 2.00 D from the calculated correction. The anatomical results were characterized by good fixation, absence of glaucoma, inflammation, and leak from iris vessels. However, the corneal endothelium was damaged in five eyes by surgical trauma, three resulting in corneal edema. In addition, in five eyes the endothelial density decreased during the follow-up period despite an uncomplicated operation, resulting in corneal edema in one eye. These eyes may have had anterior chambers that were too shallow.

Operation does not increase resting energy expenditure in the neonate

This study was designed to assess the effect of operative stress on resting energy expenditure (REE) in surgical newborn infants. REE was measured in 15 neonates who had had an abdominal or thoracic operation. The findings were compared with the REE predicted from Talbot's data for unstressed neonates. The mean measured postoperative REE of 39.18 ± 6.44 was not significantly different from the mean predicted REE of 40.98 ± 8.83 kcal/kg/d. We conclude that an uncomplicated operation does not increase REE in the neonate.

Surgical and prosthesis-related complications using the Groningen button voice prosthesis

Prosthesis-assisted tracheoesophageal speech has advanced speech rehabilitation appreciably. However, the surgical technique and the use of a prosthesis may give rise to complications. In a retrospective study on 132 consecutive patients rehabilitated with a Groningen button voice prosthesis, the complications were assessed, the average follow-up being 21 months. Surgical complications were not observed. Prosthesis-related complications, which were encountered in 28%, were all of a minor nature and mainly consisted of granulation formation and hypertrophic scarring; these appeared to be easily treatable. The complications found were few and insignificant in comparison with reports in the literature. This may be attributed to the uncomplicated surgical procedure for the insertion of the Groningen button. Moreover, the prosthesis is self-retaining and requires hardly any care from the patient. Permanent removal of the prosthesis usually requires surgical closure, which is a simple procedure performed under local anaesthesia.

Homologous replacement of the cruciate ligament in the animal experiment

A homologous cruciate ligament transplantation was effected in 20 Alsation dogs. Clinical, pathologico-anatomical and histological results were obtained from 16 animals after 3, 6 and 9 months, respectively, proving metaplasia of the transplant to endogenous body tissue. The clinical conclusion of this finding is that an anatomically optimally-structured ligament replacement can be inserted by means of a relatively uncomplicated operation--possibly even by using arthroscopy. The low amount of traumatization due to this type of surgery will be of advantage especially to sportsmen, who, as is well known, not only suffer from frequent cruciate ligament ruptures but also have remarkably long-term deficits by large operation wounds both in regaining their proprioceptive performance ability and their muscular power.

Carotid endarterectomy. Current indications for elective and emergency surgery.

PreviewCarotid endarterectomy has evolved from a radical procedure involving excision of the diseased segment with end-to-end anastomosis of the parent vessel to a routine and uncomplicated operation for patients at high risk for impending stroke. But exactly which patients are these? And what are the risks and complications of the procedure? Dr Loftus reviews the recent findings.

The Case of Baby Fae

Appearing in this issue ofThe Journalis the first full scientific report of the "case of Baby Fae"—cardiac xenotransplantation in a neonate. Many emotional editorial comments about this case have appeared in the lay press and in respected scientific publications. Critical editorial commentary by peers, based on an impartial analysis of the scientific gathering of the facts, is now appropriate. The infant, born prematurely with hypoplastic left heart syndrome, an invariably fatal form of congenital heart disease, received the heart of a young female baboon in an uncomplicated surgical procedure on Oct 26, 1984. At the time of transplantation the infant was critically ill, and urgent surgical intervention was required if she was to survive even for a brief interval. Based on his own evaluation of the alternatives, Dr Bailey had offered xenotransplantation to the mother. The alternatives were three: a risky palliative surgical procedure, the Norwood procedure, 1

Delayed Cerebral Vasospasm after Uncomplicated Operation on an Unruptured Aneurysm: Case Report

We present the case of a patient who developed significant vasospasm on the 9th postoperative day after the uneventful clipping of an unruptured asymptomatic berry aneurysm. We discuss the literature and potential mechanisms for vasospasm in the absence of subarachnoid hemorrhage.

Delayed cerebral vasospasm after uncomplicated operation on an unruptured aneurysm

Delayed cerebral vasospasm after uncomplicated operation on an unruptured aneurysm

Spinal cord injury associated with hyperthermia during aortic coarctation repair

Three infants with coarctation of the thoracic aorta, patent ductus arteriosus (PDA), and ventricular septal defect (VSD) underwent repair of the coarctation in three different institutions. Despite a technically uncomplicated operation, each was noted to have significant paraplegia postoperatively. Retrospective analysis revealed that each patient had been hyperthermic during the time of aortic cross-clamping. It is possible that the hyperthermia, either alone or in combination with other factors, contributed to the development of paraplegia in these three infants.