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A comparative study of early vs delayed cholecystectomy was conducted on 51 patients who presented with acute cholecystitis. Ultrasonography was accurate in diagnosing all cases of acute cholecystitis. Twenty four patients were managed by early surgery performed between 24 and 72 hours of onset of symptoms. Twenty seven were managed by delayed cholecystectomy between 8 weeks and 6 months of the acute episode. Early surgery required a longer operating time (120 +/- 15 minutes vs 90 +/- 15 minutes), more skill and had a marginally higher operative blood loss (150 vs 100ml). Early surgery did not after the decision or outcome of bile duct exploration. There were no fatalities or major complications. The total hospital stay was reduced in the early surgery group (10 vs 18 days). The study confirms the advantage of early cholecystectomy for treatment of acute cholecystitis.

Delayed aneurysm surgery, once standard practice, is now followed by only a minority of neurosurgeons. We analysed the outcome of such a policy in 400 consecutive patients with ruptured aneurysms treated over a 14-year period. Despite an 'open door' admissions policy, admitting all patients immediately on referral, only 56% arrived within 24 h of the ictus (69% within 72 h). Surgery was generally delayed for 8-10 days in patients in Grades 1 and 2; for higher grade patients often for longer until their condition was stable. Two-hundred-and-eighty-seven patients (72%) underwent surgery, 93% on day 8 or later (78% on day 11 or later). Outcome was assessed at 1 year. For all patients 68% were in Glasgow Outcome Scale Grade 1, while 26% had died. Of the operated patients 88% were in GOS grade 1, while 5% had died (30-day surgical mortality was 3.5%). Fifty-one patients (12.8%) rebled, 30 in the first 10 days. Rebleeding was distributed evenly in time over the first 2 weeks. Eighty-four patients experienced non-haemorrhagic deterioration (NHD) all but 3 within 10 days. NHD peaked at days 4-9. Thirty-three patients died of rebleeding and 16 of NHD, but only 12 of the patients who died from rebleeding were fit for operation at anytime and might have been considered for early surgery. Two of these patients died so soon after admission that surgery could not have been performed leaving 10 patients who might have been saved by early surgery. We review the theoretical advantages of delayed as against early surgery and conclude that it is doubtful whether the timing of surgery has any significant effect on management outcome in line with the conclusions of the Cooperative Study.

Objective: This study compares early (≤24 hours since SCI) versus later surgical decompression of spinal cord in order to determine which approach is more cost effective in the management of patients with acute cervical SCI and to examine the potential barriers and ideal timelines for each step to early surgical decompression. Background Pre-clinical and clinical studies suggest that early surgery is potentially beneficial. Design/Methods: A cost-utility analysis was performed using data for the first year after cervical SCI. The perspective of a public health care insurer was adopted. Utilities are from the Surgical Trial in Acute SCI Study. The reasons for delays in the management steps were classified into: (a) healthcare-related (“extrinsic”) and (b) patient-related (“intrinsic”) factors. Results: When considering the late decompression as the baseline strategy, the incremental cost-effectiveness ratio is US$8,523,852 per quality-adjusted life year (QALY) for patients with complete SCI and US$275,390/QALY for patients with incomplete SCI. The probabilistic analysis indicated that there is no clearly dominant strategy. While patients who underwent early surgery had a significantly shorter time period associated with extrinsic factors than individuals who underwent later surgery (19.16 versus 71.28 hours), both groups were comparable regarding time periods related to intrinsic factors. Conclusions: The results of our economic analysis suggests that, although no strategy is clearly superior to the other, early decompression of spinal cord can be more cost effective than delayed surgery in approximately one quarter of the patients with complete SCI and one third of the individuals with incomplete SCI. Our benchmarking analysis suggests that health-related factors are key determinants of the timing from SCI to spinal cord decompression. Time in the general hospital and time of waiting for surgical decision were the most important causes of delays for surgery. Early surgery is feasible in the vast majority of the cases. Supported by: Funded by the Rick Hansen Foundation. Disclosure: Dr. Furlan has nothing to disclose. Dr. Fehlings has received personal compensation for activities with Depuy Spine as a consultant.

Among our series of 1519 cases of subarachnoid haemorrhage (SAH) due to aneurysmal rupture, 171 cases (11.3%) died of rebleeding while waiting for surgery mostly within one week after SAH. 1329 cases underwent surgery, 655 cases within one week and 674 cases later than one week after SAH. The mortality at 6 months following SAH was 14.5% in the former group of early surgery, and 3.9% in the latter group of delayed surgery. The latter, however, became 15-29%, if the above 11.3% were added to it. Scrutiny (chi 2-test and U-test) of the outcome at 6 months after SAH revealed the following: Cases of WFNS grade I (GCS: 15) just prior to surgery showed good results regardless of timing of surgery (good recovery: 87.1%, mortality: 2.9%), while WFNS grade IV (GCS: 12-7) and V (GCS: 6-3) cases showed rather poor results regardless of timing of surgery. For WNFS grades II and III cases (GCS: 14-13), surgery on Day 3-7 may better be avoided because of a higher mortality and morbidity due to vasospasm. For cases over 60 years of age, delayed surgery may be preferable especially in higher grade cases.

The aim of the present study was to verify the presence of ET-1 in CSF collected nearby an intracranial aneurysm and to discuss the relationship of cisternal CSF levels of ET-1 with different clinical aspects of the disease (vasospasm grading, Hunt and Hess grading at admission, CT classification of subarachnoid clot deposition, timing of surgery). 55 selected patients with diagnosis of intracranial aneurysms are considered. The control group is represented by 12 patients bearing an unruptured intracranial aneurysm. In all 55 patients a positivity for ET-1 was found; 12 patients were operated on for unruptured aneurysms; twenty-four patients were operated on between day 1 and 4 from last SAH episode and 19 patients were treated with delayed surgery: no statistical difference was found within the three subgroups. No statistical difference in mean cisternal CSF level of ET-1 was found on the basis of CT classification or classification of vasospasm. Mean ET-1 CSF level is significantly higher (p

In order to clarify whether the surgical timing in severely ill patients after aneurysmal subarachnoid hemorrhage is an important factor in regard to the management morbidity and mortality of these patients, the clinical data of 131 patients admitted to the Neurosurgical Clinics of the University of Essen and the Medical School of Hannover being in Grades IV and V after aneurysm rupture were analyzed. 91 patients (69.4%) were in Grades IV and 40 patients (30.6%) were in Grade V. The aneurysmall location of the 131 patients was as follows: ICA: 22 patients (16.8%), MCA. 39 patients (29.8%), ACA: 54 patients (41.2%), VBA: 16 patients (12.2%). Surgery was performed in 77 patients, 62 in Grades IV and 15 in Grade V. In Grade IV patients with surgical intervention, combined severe morbidity and mortality was 62%, while a satisfactory outcome was achieved in 34%. Of the Grade V patients, combined surgical morbidity and mortality was 93%, with only 7% of good results. In 54 patients no surgical treatment was performed (29 Grade IV, 25 Grade V). In 35 patients no surgery was undertaken, because the disastrous effect of the initial hemorrhage was judged to be too severe to attempt any surgical intervention. Of these patients 34 died and one survived in a vegetative state. 19 patients died before the scheduled delayed surgery could be performed. 8 patients died from lethal rebleeding, and 11 patients died from the sequelae of the initial hemorrhage, cerebral ischemia and/or severe medical complications. Thus mortality in Grades IV and V patients in the nonsurgical group was 98%.

Discussion: Our low 1 year mortality rate could have been due o adequate optimisation of both surgeon and patient related facors. Regular input fromOrthogeriatric teamhas improvedmedical ptimisation perioperatively. Due to complexity of these injuries, elayed surgery can be inevitable. Our experience has shown best utcomes for patients operated within 48h and patients having eplacement surgery. Patient co-morbidity did not seem to be the ain reason for delayed surgery. In contrary it was often due to urgeon related factors.

Following the initial report of Rosen in 1976 [1], a study of preoperative chemotherapy for treatment for primary osteosarcoma patients was started in our hospital in 1978.

UNLABELLED We highlight the morbidity of incarcerated inguinal hernia in very low birthweight (VLBW) infants by presenting a report of two cases. Our aim is to raise the question of the optimal timing of surgery when this common problem presents on the neonatal unit. In each of our cases the hernia was diagnosed but surgery was delayed, as per normal policy on the unit, pending growth of the baby and improvement in respiratory status. Both babies suffered significant morbidity when the hernias subsequently became acutely incarcerated. CONCLUSION In conclusion, we question whether the widespread practice of delayed surgery for inguinal hernia in VLBW infants should be reconsidered.

Ultrasound (US) findings and their significance for the clinical outcome were studied in a series of 56 patients hospitalized with a diagnosis of splenic trauma. US was abnormal in 50 cases (89.3%) on admission, revealing intraperitoneal fluid in 41 (73.2%) and a splenic parenchymal injury and/or subcapsular haematoma in 35 (62.5%). US was abnormal in 24/25 patients undergoing urgent surgery, 23/26 undergoing successful non-surgical treatment and 2/5 patients undergoing delayed surgery within 1 to 3 days of a repeat US (abnormal in all five). The presence of intraperitoneal haemorrhage preoperatively was shown accurately by US in 29 cases (96.7%), and the splenic origin of the haemorrhage in 19 (63.3%). Repeat US was of most value for confirming the diagnosis by demonstrating splenic lesions not visible initially. The need for laparotomy could not be predicted on the basis of the US findings alone, however.

The decision for early versus late surgery often is affected by factors not related to the neurological field. These factors especially occur in the period prior to admission of the patient to the neurosurgical unit and immediately thereafter.

Purpose: There are many reports that delayed operation of appendicitis in children is safe, but it is controversial whether the same principle can be applicable in adult patients. The aim of this study was to evaluate the relationship between the interval from onset of symptoms to operation and the pathologic degree of appendicitis. Methods: In this retrospective study, 783 adult patients (16 years old or more) diagnosed with appendicitis pathologically between 2004 and 2007 were included. The time from onset of symptoms to hospital arrival (patient interval) and time from hospital arrival to operation (hospital interval) were investigated. Pathologic and gross state of the appendicitis was graded as G1 (suppurative), G2 (gangrenous), G3 (ruptured), G4 (periappendiceal abscess). Results: The median time from symptom onset to operation (total interval) was 35 hours. The percentage of G1, G2, G3, and G4 was 86.3%, 11.4%, 2.4%, and 0% when total interval was ＜24 hours, 61.3%, 21.3%, 15.8%, and 1.6% when between 24 and 72 hours, and 23.8%, 13.9%, 36.9%, and 25.4% when the interval was over 72 hours. The advanced grade of appendicitis correlated with increased hospital stay (P＜0.0001). Conclusion: This study suggests that delayed appendectomy in acute appendicitis in adults is a risk factor for advanced grades, and that the sooner the operation is undertaken, the better the outcome is.

A ruptured cerebral aneurysm in a 50-year-old female with idiopathic thrombocytopenic purpura was successfully clipped after preoperative high-dose gamma-globulin therapy to control the hemorrhagic diathesis. High-dose gamma-globulin therapy with or without steroid and/or platelet transfusion is recommended for such cases if the blood pressure can be controlled and the neurological condition permits delayed surgery.

Summary Eighty-six consecutive patients with congenital diaphragmatic hernia presenting within 6 hours of birth to a regional neonatal surgical unit were reviewed. Patients were managed under a policy of delayed surgery which has evolved during the 6-year study period. Overall survival (to leave hospital) was 70.9%. There were only seven postoperative deaths (10.3% of operations). Analysis of the 25 deaths in the light of postmortem findings and published exclusion criteria indicates that the availability of extracorporeal membrane oxygenation would have made little difference to overall survival.

Introduction Despite numerous studies addressing intra-orbital traumatic optic neuropathy (TON) after facial trauma, therapeutic strategy is still unclear regarding use of corticosteroids, surgical treatment, or clinical observation alone in literature: recent studies recommend an observation period with corticoid therapy before surgical management, which is completely different from our primary urgent surgical management. Our work was designed to assess visual outcomes using this strategy. Materiels and Methods A 5-year retrospective review of surgically treated patients with TON following orbital fracture in maxillo-facial surgery and ophthalmology services in hospital. Visual acuities, visual outcomes, surgical technique and delay were recorded. Results Among 1053 patients undergoing surgery for orbital fracture, 20 patients experienced TON with dramatic visual loss and were surgically treated. Several intra-orbital mechanisms for visual loss were recorded. Complete visual recovery was reached in 80% when surgery occurred within 12 hours after amaurotic TON. Optic nerve decompression used mid-palpebral approach in all cases. Discussion After literature review, reported percentage of complete recovery after severe TON (i.e. with visual loss 80%) suggest that fast intra-orbital optic nerve decompression provides a better visual outcome as compared to clinical observation, primary 24- or 48-hours corticoid therapy, or delayed surgery. Conclusion Primary urgent orbital decompression is an efficient strategy for severe, even amaurotic, extracanalar traumatic optic neuropathy, as compared to literature review.

Twenty-three patients with 32 burned hands were studied thermographically within 48 h of injury to investigate the potential value of thermography in the assessment of the depth of hand burns. Superficial and deep partial thickness burns were treated conservatively, with excision and grafting of those which had not healed by 2–3 weeks after injury. This delayed surgery group and the healed group were retrospectively analysed to determine the predictive value of the initial clinical and thermographic assessments of the depth of the burns. Full skin thickness burns were excised and grafted within 5 days and were not included in the study. Initial thermographic assessment correctly predicted the outcome (whether healed or excised and grafted) in 33 of 36 burns. This relationship was highly significant. Initial clinical assessment of depth had no significant relationship with the time taken to heal. Thermography may help in the selection of patients who might benefit from early surgery.

EDITOR—In contrast to Bottle and Aylin,1 we found that delayed surgery alone seems not to increase mortality after hip fracture after adjustment for comorbidity, age and sex, and taking hospital level variability into account. We examined data from regional hospital discharge registers in Friuli Venezia Giulia, a region in northeastern Italy (population 1 200 000), where each year more than 2200 elderly people are admitted for hip fracture. We selected all patients aged …

An unmarried 35 years old male, who took 25mg sildenafil daily for 8 days followed by 12.5 mg daily for 4 days, with consultation with a local chemist for nocturnal emission developed priapism. He presented to an urologist after 72 hours where a corporal wash and distal shunt was tried but it did not give any relief to the patient. He had no other identified contributing factors for priapism. A proximal caverno-spongiosal shunting (Quackels cavernoso-spongiosal shunts) was done which subsequently relieved his symptoms. To our knowledge this is the first reported case of priapism resulting from supposedly safe doses of sildenafil in a healthy individual. Distal shunts are associated with high failure rates which may warrant a more proximal shunt. Even when seen after a considerable time a shunt may be useful. After the delayed surgery, relief of pain without complete detumesence suggests a role for watch-full waiting. This case also highlights the existence of unfortunate myths surrounding the omnipotence of sildenafil in all sorts of sex related problems. It points toward an urgent need for steps to prevent unauthorized prescription and misuse of this drug..

In the September 2003 issue of Pediatrics , Stege et al1 discuss the effect of new therapies for congenital diaphragmatic hernia (CDH) on survival. They point out that studies reporting improved survival using high-frequency ventilation, extracorporeal membrane oxygenation, inhaled nitric oxide, and delayed surgery are flawed by selection … Address correspondence to Patricia R. Chess, MD, Departments of Pediatrics and Biomedical Engineering, University of Rochester, Box 850, 601 Elmwood Ave, Rochester, NY 14642. E-mail: patricia_chess{at}urmc.rochester.edu

We report two patients with hypoproteinemia and finger clubbing in whom the underlying gastroesophageal reflux was only detected after symptoms of esophageal stenosis became apparent. Ignorance of gastroesophageal reflux as a possible cause of these impressive symptoms led to complications and delayed surgery.

Aims. We managed in Port-Royal (1985-96) 46 women referred for fetal CDH, and their infants. In Period 1 (< 1992), we used conventional ventilation (CMV) and “early” surgery requiring transport. Since 1992, we prospectively tested: 1) high frequency ventilation (HFO) (± NO); 2) delayed surgery, following stabilization; 3) no transport when switching to CMV was not tolerated (Period 2).

The visual results achieved after surgery in 38 patients with monocular congenital cataract and 34 with binocular congenital cataracts are reported. Thirty-two of the monocular aphakics were corrected postoperatively by contact lenses and six by intraocular lenses. Only one of the 32 eyes corrected with contact lenses achieved a visual acuity of 6/60 and 31 demonstrated a visual acuity lower than 6/60 (20/200). On the other hand, out of the six patients corrected by intraocular lenses, three whose visual acuity could be reliably recorded all achieved a visual acuity better than 6/60 and two of them reached a visual acuity of 6/12(20/40). From our group of patients with binocular congenital cataract it appears that delayed surgery beyond one year of age when the lens opacity allows undisturbed activity resulted in better visual acuity than in eyes whose opacity disturbed the child's activity and necessitated earlier surgery.