Beneficial effects of the n-3 long-chain polyunsaturated fatty acids in surgical patients: updating the evidence

The use of n-3 polyunsaturated fatty acids in surgical patients has risen by the fact that this may attenuate systemic and acute inflammatory responses secondary to surgical trauma through modulation of inflammatory mediators and cell membrane interactions. Moreover, the inclusion of n-3 fatty acids in clinical trials as part of the therapy in patients, who expect to undergo a surgical stress, suggests benefits on clinical progress. Therefore, the objective of this article is to review data from n-3 polyunsaturated fatty acid effects on biochemical parameters and on reduced length of hospitalization, number of infections, and mortality as main clinical outcomes in human surgical patients.     

A new method of auditing surgical mortality rates: application to a group of elderly general surgical patients.

In a prospective study of 505 patients aged 65 years or over admitted to a general surgical unit the overall hospital mortality rate was 14.5% and the postoperative mortality rate 12.0%. These rates fell to 3.6% and 5.8% respectively when deaths in non-viable patients were excluded from the analysis. An audit of surgical outcome that fails to identify non-viable patients is therefore potentially misleading. A standardised system of reporting surgical mortality is proposed to aid the comparison of results from different units. The key elements of this system are (a) the separation of the results from non-viable and potentially viable patients; (b) the consideration of both operative and non-operative mortality; (c) the differentiation between medical and surgical causes of postoperative mortality; and (d) the identification of patients who are discharged from the unit but who have residual malignancy. Data presented in such a way should be of direct relevance to surgeons and physicians who are seeking ways of improving the service provided for surgical patients of all ages.     

Distraction osteogenesis: a new surgical technique for use with the multiplanar mandibular distractor

If distraction osteogenesis is to reach its full potential and achieve the level of accuracy that is possible with orthognathic surgery, its outcomes need to be as predictable. To this end, the authors developed a planning process for distraction osteogenesis similar to that used in orthognathic surgery. However, the success of the planning process depends on the authors' ability to execute the plan at the time of surgery. As a result, the authors needed to develop a surgical technique that would enable them to precisely install the distractor as indicated in the presurgical plan. The surgical technique presented in this article was developed for this purpose. The authors used this technique in seven patients (four boys and three girls; age range, 4 to 10 years). Four patients presented with unilateral deformities, and three patients presented with bilateral deformities. The follow-up period in this group of patients ranged from 12 to 33 months. The purpose of the technique is to replicate the position of the distractor on the mandible as determined by the presurgical plan. To this purpose, a custom drill guide and a surgical template have been developed. Both of these are used following the principles of triangulation to establish the pin position and orientation of the distractor. In the authors' hands, the use of this surgical technique has resulted in outcomes close to those predicted by the planning process.     

Monitoring surgical performance using risk-adjusted cumulative sum charts

The cumulative sum (CUSUM) procedure is a graphical method that is widely used for quality monitoring in industrial settings. More recently it has been used to monitor surgical outcomes whereby it 'signals' if sufficient evidence has accumulated that there has been a change in the surgical failure rate. A limitation of the standard CUSUM procedure in this context is that since it is simply based on the observed surgical outcomes, it may signal as a result of changes in the referral pattern, such as an increased proportion of high-risk patients, rather than due to a change in the actual surgical performance. We describe a new CUSUM procedure that adjusts for each patient's pre-operative risk of surgical failure through the use of a likelihood-based scoring method. The procedure is therefore ideally suited for settings where there is a variable mix of patients over time.     

Left ventricular endocardial pacing in cardiac resynchronisation therapy: Moving from bench to bedside

In cardiac resynchronisation therapy, failure to implant a left ventricular lead in a coronary sinus branch has been reported in up to 10% of cases. Although surgical insertion of epicardial leads is considered the standard alternative, this is not without morbidity and technical limitations. Endocardial left ventricular pacing can be an alternative as it has been associated with a favourable acute haemodynamic response compared with epicardial pacing in both animal and human studies. In this paper, we discuss left ventricular endocardial pacing and compare it with epicardial surgical implantation. Ease of application and procedural complications and morbidity compare favourably with epicardial surgical techniques. However, with limited experience, the most important concern is the still unknown long-term risk of thromboembolic complications. Therefore, for now endovascular implants should remain reserved for severely symptomatic heart failure patients and patients at high surgical risk of failed coronary sinus implantation.     

Individual Management of Recurrent Intracranial Aneurysms: The Wuxi Experience

Recurrent intracranial aneurysms can occur after either surgical clipping or endovascular therapy. In this article, we present a consecutive series of 18 patients who underwent individual treatment for recurrent aneurysms after primary coil embolization or surgical clipping. During an 8-year period between May 1997 and December 2005, 18 patients underwent individual treatment for recurrent aneurysms. Clinical data and imaging studies of the patients were analyzed retrospectively. Out of the 18 patients, 13 had recurrent aneurysms located in the anterior circulation, and 5 had aneurysms of the posterior circulation. Treatment consisted of coiling in 16 patients and clipping in two patients. Of the 18 patients, 15 achieved a good or excellent recovery, two were paralyzed, and one died post-treatment. Both the surgical clipping and endovascular embolization for the treatment of recurrent intracranial aneurysms can achieve very good radiological results with low mortality rates. One of the key points for the successful treatment of this kind of lesions is the proper, individual, and interdisciplinary patient selection.     

Primary percutaneous coronary angioplasty in patients with acute coronary syndrome and concomitant cancer

The paper gives the results of X-ray surgical treatment in patients with acute coronary syndrome who have been ascertained to have concomitant cancer during their examination. Cancer was found in 11 patients in their medical history and diagnosed in 2 patients during examination after surgical treatment and 1 patient one year after his hospital discharge. The results of combination treatment showed the high efficiency of X-ray surgical treatment for acute coronary syndrome. Recovery of TIMI-III blood flow through the infarct-related coronary artery was achieved in 100% of cases; immediate clinical efficiency was 97.4%. In the concomitant cancer group, the therapeutic efficacy was 100%; there were no complications during X-ray surgery. All the patients from this group were discharged from hospital in a satisfactory state to be followed up by a cardiologist and oncologist for further treatment. The study performed suggests that concomitant cancer is not a contraindication to primary coronary angioplasty in patients with acute coronary syndrome. Primary coronary angioplasty with stenting is a safe effective treatment for acute coronary syndrome in this category of patients.     

Surgical outcomes of the brachial plexus lesions caused by gunshot wounds in adults

Background

The management of brachial plexus injuries due to gunshot wounds is a surgical challenge. Better surgical strategies based on clinical and electrophysiological patterns are needed. The aim of this study is to clarify the factors which may influence the surgical technique and outcome of the brachial plexus lesions caused by gunshot injuries.

Methods

Two hundred and sixty five patients who had brachial plexus lesions caused by gunshot injuries were included in this study. All of them were male with a mean age of 22 years. Twenty-three patients were improved with conservative treatment while the others underwent surgical treatment. The patients were classified and managed according to the locations, clinical and electrophysiological findings, and coexisting lesions.

Results

The wounding agent was shrapnel in 106 patients and bullet in 159 patients. Surgical procedures were performed from 6 weeks to 10 months after the injury. The majority of the lesions were repaired within 4 months were improved successfully. Good results were obtained in upper trunk and lateral cord lesions. The outcome was satisfactory if the nerve was intact and only compressed by fibrosis or the nerve was in-contunuity with neuroma or fibrosis.

Conclusion

Appropriate surgical techniques help the recovery from the lesions, especially in patients with complete functional loss. Intraoperative nerve status and the type of surgery significantly affect the final clinical outcome of the patients.     

Surgical treatment of liver metastases of gastric cancer: state of the art

ABSTRACT: BACKGROUND: The prognosis of patients with liver metastases from gastric cancer (LMGC) is dismal, and little is known about prognostic factors in these patients; so justification for surgical resection is still controversial. Furthermore the results of chemotherapy for these patients are disappointing. The purpose of this study was to review recent outcomes of hepatectomy for LMGC and to determine the suitable candidates for surgery, assessing the surgical results and clinicopathologic features. Moreover we compare these results with those obtained with alternative treatments.     

Managers for Medicine

For many years patients with chronic ulcerative colitis were subjected to operation as a last resort, but now, owing to improved surgical techniques and adequate preoperative preparation of the patient, mortality associated with operation has decreased and better-risk patients are being operated upon electively. The experience of the University of Alberta Hospital during the past 10 years in respect of the surgical management of chronic ulcerative colitis is reviewed, on the basis of 105 patients, 36 of whom underwent operation. The indications for surgery include obstruction, suspected carcinoma, hemorrhage, perforation, acute fulminating disease with toxic megacolon, and intractability. A variety of surgical procedures were used during this period, reflecting changing views in surgical management. Surgical complications include wound infections, bowel obstruction with ileostomy malfunction, skin excoriation, and electrolyte imbalance. In this series three of the 36 died, a mortality rate of 8%. One death was from liver failure and two were from peritonitis.     

Cutaneous leiomyosarcoma

Cutaneous leiomyosarcoma is a rare soft-tissue sarcoma with negligible metastatic potential, but local recurrence rates after surgical excision have ranged from 14 percent to 42 percent. Unlike other sarcomas, guidelines for the optimal surgical excision margin of cutaneous leiomyosarcoma are not clearly defined in the existing literature. A review of local experience with this condition revealed eight patients over 12 years, none of whom developed local recurrence or distant metastases. This is despite poor prognostic factors in seven patients and excision margins ranging from 1 to 27 mm. These findings are compared with previously published data, and conclusions are drawn based on analysis of the collective results. Complete surgical excision with a narrow margin is recommended, and patients should be observed for a minimum of 5 years after surgery.     

The application of intraoperative ultrasound during partial hepatectomy for the accurate detection and removal of intrahepatic bile duct stones

To evaluate the application of intraoperative ultrasound (IOUS) during partial hepatectomy to accurately detect and remove intrahepatic bile duct stones. Intrahepatic bile duct stones were precisely localized during surgery by using IOUS. Furthermore, guiding stone extraction, and determining the scope of liver resection and choice of surgical procedures were also evaluated using this technique. Of the 25 patients used in this study, 16 patients received a left lateral liver resection, 7 patients received a left liver resection, 1 patient had a liver resection of segments V and VI, 9 patients had common bile duct stones, and 6 patients had bile duct stones that underwent jejunal Roux-en-y anastomosis. In addition, IOUS exploration after liver resection and post-operative T-tube cholangiography showed one case with residual stones. The use of IOUS showed high diagnostic accuracy, while also rectifying the misdiagnosis and missed diagnosis of bile stones in preoperative imaging. IOUS also assisted with positioning accuracy, which is very important in determining the extent of surgical resection and choice of surgical procedure. Thus, IOUS can dynamically monitor the surgical procedure, guide the operation, and inspect the outcome of operations, therefore, effectively improving the quality of operation.     

Functional status of hip joint after surgical and conservative treatment of acetabular fracture

Both conservative and surgical treatment of acetabular fractures alter biomechanical conditions in the hip joint resulting in various degenerative changes in the acetabulum and the femur head. These changes may progress to secondary coxarthrosis, causing dysfunction of the hip joint. The aim of this paper is to compare the outcomes of both conservative and surgical treatments in different types of acetabular fractures, so that clear indications for either conservative or surgical treatment could be determined. This paper is based on retrospective study of 103 patients with acetabular fracture (21 surgically treated and 82 conservatively treated). In this study the incidence of particular types of acetabulum fractures, the treatment period, the incidence of complications and the functional status of the hip after the treatment were analyzed. In patients with anterior fracture surgical treatment lasted three times less than conservative treatment and resulted in far better functional status of the hip joint compared to conservatively treated patients. However, in patients with transverse fractures the functional status was better and the treatment period shorter after the conservative treatment. We believe that the present treatment indications should be corrected so that in anterior column fracture the surgical method should be preferred, whereas the transverse fracture should be treated conservatively. In other types of acetabular fracture, with the radiographic roof arc angle of 45 degrees or less, the surgical method should be preferred to conservative method.     

DRGs, costs, and outcome for plastic surgical patients

The purpose of this study was to analyze hospital cost, resource utilization, and outcome by age for a large group of hospitalized plastic surgical patients using the DRG format. Hospital cost per patient for all plastic surgical admissions (both inpatient and potentially ambulatory patients) treated (N = 1632) at an academic medical center increased with age and peaked for plastic surgical patients 75 to 80 years of age ($11,585 per patient). Although DRG payment would have produced an aggregate profit of $2,404,854, older plastic surgical patients (65 years of age and above) generally produced losses. Older plastic surgical patients demonstrated a longer hospital length of stay, a greater severity of illness, a higher percent of outliers, and a greater mortality than younger plastic surgical patients. In addition, older plastic surgical patients had higher clinical resource utilization based on a number of clinical parameters such as emergency admission, SICU utilization, need for blood transfusions, and need for plasma product infusions. This study suggests that the current DRG reimbursement methodology may be inequitable vis-à-vis the older plastic surgical patient. As additional pressures encourage the performance of more ambulatory procedures (previously performed as inpatients), our profit margins may decline and possibly affect our ability to provide quality plastic surgical care.     

Iterleukin 1 alpha is a marker of endothelial cellular senescent

The number of old and oldest old patients undergoing surgery of varying severity is increasing. Ageing is a process that changes the performances of most physiological systems and increases susceptibility to diseases and death; accordingly, host responses to surgical stress are altered with ageing and the occurrence of age-related increase in susceptibility to post-operative complications has been claimed. Twenty-four male patients undergoing Lichtenstein (LH) hernioplasty for unilateral inguinal hernia were included in this study and divided in two groups (Young and Old respectively), according to their age. As expression of the acute phase response, we measured changes in concentration of pro-inflammatory cytokines Tumor necrosis factor-α and Interleukin-1β, leukocytes, acute phase proteins C-reactive protein and α 1-antitrypsin. Elderly humans showed prolonged and strong inflammatory activity compared to younger subjects in response to surgical stress, indicating that the acute-phase response to surgical stress of elderly humans varies from that of the young, showing initial hyperactivity and a delayed termination of the response. Thus, the acute phase response to surgical stress is higher in old subjects, but the clinical significance of this remains unclear. It is not known whether a causal relationship exists between this stronger acute phase response and the increases in susceptibility to post-operative complications observed in aged patients.     

Evaluation of nodal patterns for melanoma of the ear

Treatment of malignant melanoma of the external ear presents unique challenges. Because of the significant debate regarding the efficacy and validity of using sentinel lymph node mapping for the treatment of ear melanomas, data for a population of patients with melanomas of the ear who underwent surgical excision and reconstruction were reviewed to determine the efficacy of sentinel node mapping. A retrospective chart review of cases treated by a single surgical oncologist was performed. All patients who were treated for malignant melanomas and required reconstruction of the external ear by the plastic surgical service between 1995 and 2001 were identified. Nineteen patients were selected, of whom nine underwent sentinel node mapping. The average age of the patients was 65.2 years. Evaluation of melanoma depth, medical history, surgical margins, lymph node metastasis, and recurrence was performed. Lymphoscintigraphy with technetium-99-sulfur colloid and 1% Lymphazurin (isosulfan blue; Zenith Parenterals, Rosemont, Ill.) demonstrated widely variable lymphatic drainage patterns. The lower tail of the parotid gland and the upper cervical area were the two most common locations. The average number of sentinel nodes identified and removed was 3.7. The average Breslow thickness for these patients was 2.3 mm. None of these patients demonstrated micrometastatic disease in their sentinel nodes. The most common reconstructive procedure after surgical resection was the use of rotational advancement flaps. Localization of radioactivity, as detected with external technetium-99 scanning, was the most reliable method for detection of the sentinel lymph node basins and the individual nodes. The average value for the primary injection site was 8375 counts per second, and the average value for the nodes removed was 973.5 counts per second. Of the nine patients who underwent sentinel lymph node mapping, only one, with an initial lesion depth of 5 mm, developed a local recurrence. The average follow-up period in this study was 21 months (range, 12 to 79 months). All patients in this study were evaluated at least 1 year after the initial surgical resection. Patients were monitored by the same surgical oncologist every 3 months for the first 2 years. Little can be found in the literature regarding the efficacy of sentinel node biopsies for ear melanomas. Larger studies are indicated; however, it seems that this method is practical for designing therapeutic methods for patients with melanoma of the ear.     

Volkmann's contracture of the extraocular muscles following blowout fracture

In the past decade there has been considerable controversy over the surgical indications for treatment of blowout fractures of the orbit. It has been well recognized that some fracture patients develop an ischemic contracture of the inferior rectus muscle. We have found that a Volkmann's type of contracture of the inferior rectus muscle does exist and is similar to that found in the distal extremities. A specific group of fracture patients is at greater risk for development of a contracture. Elderly patients, hypotensive patients, patients with small fractures, and those with high inferior rectus compartment pressures are more prone to developing a contracted extraocular muscle. We have measured compartment pressures in 18 patients who were surgical candidates following orbital fracture. Our conclusions indicate that surgical intervention following blowout fractures in these high-risk patients may be more prudent than medical management. Patients with persistent diplopia due to a contracted inferior rectus are extremely difficult to treat many months after fracture. We still believe it prudent to surgically repair orbital fractures in patients with diplopia, enophthalmos, and a risk for muscle contracture. The documentation of this additional sequela of unrepaired fractures lends more strength to this belief. There is no evidence to indicate that a Volkmann's contracture would be possible after early repair of a blowout fracture.     

Interleukin-6 and cardiac operations

Interleukin (IL)-6 is a pleiotropic inflammatory cytokine with both pro- and anti-inflammatory capacities, produced by different cells and tissues, such as leukocytes, adipocytes, and endothelium. From the viewpoint of cardiologists, this cytokine is a reliable biomarker of cardiac dysfunction, occurrence of atrial fibrillation, cardiac myxoma with recurrence, remote metastasis or embolization, and atherosclerotic processes. Although IL-6 levels were detected in patients undergoing cardiac operations and reported sporadically, the perioperative kinetics of IL-6 in cardiac surgical patients was insufficiently elaborated. The influencing factors, clinical implications, and causative effects of IL-6 on clinical outcomes and potential treatment choices among cardiac surgical patients remained to be clarified as well. The purpose of this article is to discuss these aspects of IL-6 in patients undergoing a cardiac operation.     

Optimising surgical management of elderly cancer patients

BACKGROUND: Elderly population is on rise. It is an ethical dilemma how aggressive one should be when it comes to treat cancer in elderly. Presumed fear of increased postoperative morbidity and mortality has resulted in delivery of sub-optimal cancer surgery. METHODS: In this review article we visit physiology of the aged, tools available to assess surgical risks in oncogeriatric patients, and current practice in the management of common cancers encountered in surgical oncology, with the view of increasing awareness on optimising surgical management of senior patients with cancer. A pubmed search for cancer, surgery, elderly, was carried out. RESULTS: Cancer is on rise with increasing age predominantly affecting breast, gastrointestinal tract and lung. Increasingly more surgeons are offering surgery to elderly cancer patient but selection bias is prevalent. Available data reflect short and long-term outcome of cancer surgery in elderly is not greatly different to that of younger patient. Declining physiological reserve along with inability to respond adequately to physiological stress are salient age related changes. Comprehensive Geriatric Assessment (CGA) is not tested in surgical patient. There is need for a tool to define individualised operative risk. Preoperative assessment of cancer in elderly is designed to offer this information based on functional status of an individual utilising currently available tools of risk assessment. CONCLUSION: All elderly cancer patients should be offered optimal treatment depending on their functional status not on chronological age. Oncogeriatric patient would benefit from dedicated multidisciplinary approach. Recruitment of elderly cancer patients to more clinical trials is needed to enhance our knowledge and to offer optimum treatment to this unique subgroup.     

Percutaneous Radiofrequency Trigeminal Gangliolysis in the Treatment of Tic Douloureux

The treatment of tic douloureux was dramatically altered in 1962 with the demonstration that carbamazepine (Tegretol®) alone or in combination with diphenylhydantoin sodium (Dilantin®) was effective in controlling the painful paroxysms. However, 30 percent of the patients so treated have not been successfully managed and some type of surgical therapy is required to control their pain. A wide variety of surgical alternatives are available but they all trade a sensory deficit for pain relief and have a significant risk of morbidity and mortality.Experience with percutaneous radiofrequency trigeminal gangliolysis has indicated that this new technique is capable of producing lasting relief of tic douloureux in as many as 95 percent of the patients. To date there have been no deaths from this procedure and a very low incidence of minor complications. It achieves this high success rate at the expense of only partial sensory deficits restricted to a circumscribed area of the face. No other surgical alternative carries such a high long-term success rate with a low complication rate. We believe that percutaneous radiofrequency trigeminal gangliolysis has become the surgical treatment of choice for tic douloureux.