Search

Byline: Ali. Keles, Emine. Sen, Fatma. Altas, Ufuk. Elgin Purpose: To identify the risk factors predisposing posterior capsule rupture (PCR) during mature cataract surgery. Methods: A total of 1302 consecutive [...]

2022 JUN 18 (NewsRx) -- By a News Reporter-Staff News Editor at Obesity, Fitness & Wellness Week -- Research findings on Graves disease are discussed in a new report. According [...]

Byline: Yinghui. Xin, Qingwei. Liu, Jie. Zhang, Jun. Lu, Xie. Song, Haiyu. Zhan, Xinyi. Chen, Zhixin. Cao, Yan. Li, Zhaoqin. Huang Objectives: The objective is to assess the accuracy of [...]

A detailed history and physical exam can pinpoint problems like coronary artery and lung disease, which are most likely to lead to serious perioperative complications. These experts offer pre-op testing [...]

Injecting an anesthetic into the skin of a woman's abdomen before she has abdominal surgery does not appear to be beneficial, according to a study of 68 women. The anesthetic was injected at the place where the incision would be made. This injection did not seem to prevent postoperative pain because women who got the injection used as much patient-controlled morphine after the operation as women who did not receive the injection.

Abstract Objective To determine whether preoperative assessments carried out by appropriately trained nurses are inferior in quality to those carried out by preregistration house officers. Design Randomised controlled equivalence/ non-inferiority [...]

Background: Prophylaxis of venous thromboembolism with low-molecular-weight heparins in patients undergoing major orthopedic surgery is currently initiated according to at least 3 different regimens. In Europe, traditionally, prophylaxis is started 12 hours before surgery, whereas in North America it is initiated 12 to 48 hours postoperatively. The third regimen (perioperative) begins prophylaxis either earlier than 12 hours before or 12 hours after surgery. Unfortunately, the optimal regimen is uncertain because direct comparisons among these regimens with sufficiently large sample sizes are not available. Objective: To assess, in a systematic review, the relative efficacy and safety of the 3 low-molecular-weight heparin regimens used to prevent thrombosis after total hip replacement. The incidence of postoperative thrombosis detected by contrast venography was used as the measure of efficacy and the rate of major bleeding was used as the measure of safety. Methods: We pooled the results of all published studies, which met the following criteria: (1) inclusion of in at least 1 arm of the study of a dose of low-molecular-weight heparin that is approved for both preoperative and postoperative initiation of prophylaxis; (2) the use of mandatory bilateral contrast venography, performed between days 6 and 15 postoperatively; (3) thromboprophylaxis continued until venography; (4) independent reading of venograms; and (5) assessment of clinically overt major bleeding by predefined criteria. Articles were excluded if no separate data could be obtained for patients undergoing elective hip surgery (in case of patient mix), or if they were reported more than once. Results: In the 1926 patients who used a preoperative regimen, the incidence of postoperative deep vein thrombosis was 19.2% (95% confidence interval [CI], 17%-21%). In the cohort of 925 patients who received a perioperative regimen, the rate of deep vein thrombosis was 12.4% (95% CI, 10%-14%), whereas in the group of 694 patients who received a postoperative regimen, it was 14.4% (95% CI, 12%-17%). The rate of major bleeding was 1.4% (95% CI, 1%-2%) in the preoperative group, 6.3% (95% CI, 5%-7%) in the perioperative group, and 2.5% (95% CI, 1%-3%) in the postoperative group. Conclusions: We find no convincing evidence that starting prophylaxis preoperatively is associated with a lower incidence of venous thromboembolism than starting postoperatively. Perioperative regimens may lower the risk of postoperative thrombosis, but if so, this positive effect is offset by an increase in postoperative major bleeding. Arch Intern Med. 2002;162:1451-1456

National Surgical Adjuvant Breast and Bowel Project (NSABP) Protocol B-18 was initiated in 1988 to determine whether four cycles of doxorubicin/cyclophosphamide given preoperatively improve survival and disease-free survival (DFS) when compared with the same chemotherapy given postoperatively. Secondary aims included the evaluation of preoperative chemotherapy in downstaging the primary breast tumor and involved axillary lymph nodes, the comparison of lumpectomy rates and rates of ipsilateral breast tumor recurrence (IBTR) in the two treatment groups, and the assessment of the correlation between primary tumor response and outcome. Initially published findings were based on a follow-up of 5 years; this report updates results through 9 years of follow-up. There continue to be no statistically significant overall differences in survival or DFS between the two treatment groups. Survival at 9 years is 70% in the postoperative group and 69% in the preoperative group (P = .80). DFS is 53% in postoperative patients and 55% in preoperative patients (P = .50). A statistically significant correlation persists between primary tumor response and outcome, and this correlation has become statistically stronger with longer follow-up. Patients assigned to preoperative chemotherapy received notably more lumpectomies than postoperative patients, especially among patients with tumors greater than 5 cm at study entry. Although the rate of IBTR was slightly higher in the preoperative group (10.7% versus 7.6%), this difference was not statistically significant. Marginally statistically significant treatment-by-age interactions appear to be emerging for survival and DFS, suggesting that younger patients may benefit from preoperative therapy, whereas the reverse may be true for older patients. [J Natl Cancer Inst Monogr 2001;30:96-102]

Background: in publicly funded health care systems, a waiting period for such services as coronary artery bypass graft surgery (CABG) is common. The possibility of using the waiting period to improve patient outcomes should be investigated. Objective: To examine the effect of a multidimensional preoperative intervention on presurgery and postsurgery outcomes in low-risk patients awaiting elective CABG. Design: Randomized, controlled trial. Setting: A regional cardiovascular surgery center in a tertiary care hospital, southwestern Ontario, Canada. Patients: 249 patients on a waiting list for elective CABG whose surgeries were scheduled for a minimum of 10 weeks from the time of study recruitment. Intervention: During the waiting period, the treatment group received exercise training twice per week, education and reinforcement, and monthly nurse-initiated telephone calls. After surgery, participation in a cardiac rehabilitation program was offered to all patients. Measurements: Postoperative length of stay was the primary outcome. Secondary outcomes were exercise performance, general health-related quality of life, social support, anxiety, and utilization of health care services. Results: Length of stay differed significantly between groups. Patients who received the preoperative intervention spent 1 less day [95% CI, 0.0 to 1.0 day] in the hospital overall (P = 0.002) and less time in the intensive care unit (median, 2.1 hours [CI, -1.2 to 16 hours]; P = 0.001). During the waiting period, patients in the intervention group had a better quality of life than controls. Improved quality of life continued up to 6 months after surgery. Mortality rates did not differ. Conclusion: The waiting period for elective procedures, such as CABG, may be used to enhance in-hospital and early-phase recovery, improving patients' functional abilities and quality of life while reducing their hospital stay.

BACKGROUND: Preoperative cardiac evaluations have been advocated prior to major vascular procedures to reduce the incidence of postoperative cardiac complications. This study was undertaken to evaluate the efficacy and predictive value of routine dobutamine echocardiography (DE) in the screening of patients undergoing elective aortic surgery. METHODS: Dobutamine echocardiography was performed preoperatively on all patients having elective aortic procedures by our university surgical group from June 1995 to August 1996. The cardiac morbidity and mortality from this group were compared with that of a similar group undergoing elective aortic procedures from June 1993 to May 1995 with no dobutamine echocardiography (NDE). RESULTS: Although there was no statistically significant difference in either overall mortality (4.4% in NDE vs. 2.3% in DE) or cardiac mortality (2.9% in NDE vs. 0% in DE) between the two groups, cardiac events occurred only in those patients with previous coronary artery disease. In addition, dobutamine echocardiography had a negative predictive value of 97% CONCLUSIONS: Although routine screening is not necessary, selective screening of patients using dobutamine stress echocardiography is justified because of its high negative predictive value. Am J Surg. 1997;174:121-125. [C] 1997 by Excerpta Medica Inc.

The preoperative evaluation of the cardiac patient having noncardiac surgery offers an opportunity to identify occult and further define known cardiovascular disease to modify both perioperative and long-term care. The baseline probability of cardiovascular disease should initially be assessed using clinical variables and identifying unstable symptoms, including unstable angina and congestive heart failure. The decision about whether to obtain noninvasive testing to further define cardiovascular status should be made on the basis of the testing's potential to modify perioperative care, the prior probability of advanced coronary disease based on clinical history, and the magnitude of the surgical procedure. Noninvasive testing is best done in selected patients who are at moderate clinical risk. Otherwise, testing loses its predictive value because of a high incidence of false-negative and false-positive results. Quantitative imaging can also be used to identify those patients in whom coronary angiography is indicated. The value of coronary revascularization before noncardiac surgery has not been studied in a randomized, prospective manner, but several cohort studies have suggested that patients who survive coronary artery bypass grafting have decreased risk during subsequent noncardiac surgery. Given the potential short-term increase in morbidity from two surgical procedures, it is prudent to reserve coronary revascularization before noncardiac surgery for those patients in whom it is associated with improved long-term survival. If coronary revascularization is reserved for these patients, then the overall evaluation should prove cost-effective from the perspective of both perioperative and long-term cardiovascular care., Extensive heart condition examinations before non-heart surgery may be most appropriate for patients at moderate or high risk for heart attack. Most studies have shown that the number of risk factors per patient better predicts the risk for heart attack following major surgery as opposed to the results from pre-testing. Patients with unstable heart pain or function or those with heart conditions who can not exercise may be appropriate targets for extensive pre-testing. Guidelines established by the American Heart Association and American College of Cardiology can help calculate the risk for heart attack in a patient following non-heart surgery and determine the value of pre-testing in selected patients. It may be more cost-effective to select appropriate patients for pre-testing as opposed to routinely testing patients before non-heart surgery.

Before having major noncardiac surgery, patients with known or suspected coronary artery disease frequently have noninvasive cardiac testing to better define their cardiac risk. The rationale for this approach is that prophylactic coronary revascularization will significantly reduce the number of adverse cardiac events. No randomized studies support this conclusion. Furthermore, recent studies have suggested that adverse cardiac events result from postoperative stress and excess catecholamine levels, which cause an imbalance between myocardial oxygen supply and demand. Plaque rupture in this setting, if it occurs, is secondary and not primary, in contrast to its pivotal role, in spontaneous myocardial infarction. Therefore, improved clinical outcomes are more likely to result from preventing excess oxygen demand after surgery rather than from deciding which tests optimally predict adverse events. The exception is the patient with a clinical syndrome consistent with existing plaque rupture who requires active therapy for the cardiac disease independent of the need for noncardiac surgery. Otherwise, the tests should be skipped and the patient cleared., Specialized heart condition testing before non-heart surgery may be unnecessary except for in high-risk patients with a history of heart disease. Among a group of 1487 men with heart disease, only 4.1% of the patients identified as high risk had a heart attack following non-heart surgery. Patients with heart conditions that are susceptible to vessel rupture should receive thorough testing before considering any major surgery. Doctors should minimize stress on a patient's heart following major surgery in patients with manageable heart conditions but probably do not need to perform extensive and specialized heart tests on these patients before surgery.

BACKGROUND: Since 1977, we have studied preoperative treatments using 5-fluorouracil (5-FU) suppositories alone or in combination with radiation to reduce local recurrence and improve survival of patients with rectal cancer. PATIENTS AND METHODS: We developed a novel preoperative therapy combining radiation, intraluminal hyperthermia, and 5-FU suppositories. Thirty-five patients with rectal cancer underwent surgery after this treatment, and 41 patients underwent surgery without pretreatment. RESULTS: The patients who underwent preoperative combination treatment showed significant tumor reduction; 2 achieved microscopically complete regression. In comparison with the patients who underwent surgery without pretreatment, the preoperative treatment group had a 16.7% lower local recurrence rate (10.4% versus 27.1%) and an improved survival rate (81.8% versus 67.6%). CONCLUSIONS: Preoperative combination therapy is a promising modality for the patients with resectable advanced cancer in the lower rectum. Am J Surg. 1996; 1 71:346-350.

A careful preoperative assessment of patients with lung cancer is essential for identifying those at high risk for morbidity and mortality related to the surgical procedure. The clinician must assess [...]

The preop evaluation: How much is enough? Too much reoperative testing can foster a false sense of security, waste money, ana expose patients to needless risk. Use the history and [...]

Preoperative serum levels of the tumor markers CA 50, CA 19-9, CA 19-9 TruQuant, CA 72-4, CA 195, carcinoembryonic antigen (CEA), and tissue polypeptide antigen (TPA) were measured in 94 patients with well-staged adenocarcinoma of the stomach and in 15 patients with benign gastric diseases. In all patients with carcinoma, a laparotomy was done. The serum levels were correlated with the stage of disease, the location of the primary tumor, and the resectability and grade of differentiation. The marker CA 50 was the best, with an overall positivity of 59.5%. For CA 19-9, this figure was 34%; for CA 19-9 TruQuant, 22%; for CA 72-4, 34%; for CA 195, 29%; for CEA, 33%; and for TPA, 50%. The best combination of two markers was CA 50 and TPA; this combination gave a positivity of 81%. There was no evident correlation with stage of disease and the percentage of positive serum levels or the median serum levels. The marker CA 50 gave the widest range of elevated serum levels between the cutoff level and the 90th percentile (54%). Patients with carcinoma of the cardia had higher preoperative serum levels than those with a tumor in other parts of the stomach. There was no correlation with the resectability of the tumor and the preoperative serum level. Patients with an undifferentiated tumors did not have significantly lower serum levels than those with more differentiated tumors. Currently, preoperative determination of serum tumor marker levels in patients with gastric carcinoma has no significance in clinical practice. Cancer 1992; 69:2036-2041.

Peripheral vascular diseases are diseases of the arteries and veins of the extremities. They are usually characterized by inadequate blood flow and narrowing of the arterial lumen as a result of atherosclerosis, cholesterol plaque formation on the inner layer of the artery wall. Patients who require surgery for peripheral vascular disease are frequently elderly, may have diabetes, and are at high risk for the development of cardiovascular complications. It has been suggested that the cardiovascular status of these patients may be improved by using a pulmonary artery catheter to enhance their cardiovascular status before surgery. The pulmonary artery catheterization carefully monitors the patient's hemodynamics (blood flow), permitting initiation of various interventions to optimize the function of the heart's left ventricle and oxygen transport. Although routine use of pulmonary artery catheterization has been recommended for this group of patients, it has not yet become standard practice. A study was undertaken to evaluate pulmonary artery catheterization prior to surgery to determine if it improves the outcome of patients who undergo vascular surgery to save a leg. There were 89 patients who were randomly assigned to receive a pulmonary artery catheter in the surgical intensive care unit, 12 hours prior to surgery; in the pre-anesthesia unit, less than three hours before surgery; or in the operating room, at the time of anesthesia (control group). The patients who underwent pulmonary artery catheterization had significantly fewer intraoperative complications, less postoperative heart complications, and less early graft clotting than did the control group. The death rate in the control group was 9.5 percent, compared with 1.5 percent in the catheter groups. There were no differences in overall hospital costs among the groups, but higher percentage of the control group's costs were due to complications. It is concluded that preoperative pulmonary artery catheter placement and heart assessment can improve the results of peripheral vascular surgery. (Consumer Summary produced by Reliance Medical Information, Inc.)

Carotid endarterectomy is a surgical procedure to remove fatty plaque that has accumulated along the inner lining of the carotid artery, one the main blood supplies to the brain. Computed tomographic (CT) scanning, used to evaluate patients prior to carotid endarterectomy, has been able to identify patients with clinically undetectable cerebral infarction (death of brain tissue due to loss of blood supply). Patients with such ''silent'' cerebral infarcts have increased incidence of neurologic complications. This finding has prompted some authors to recommend routine CT scanning prior to endarterectomy. A study over a five-year period of 469 patients about to undergo endarterectomy was undertaken to ascertain the usefulness of routine CT scans in preoperative evaluation. Prior to surgery all patients underwent CT scan and carotid duplex scan (a type of ultrasound study that is useful in monitoring blood flow). Of the patients in the study, 237 had suffered transient ischemic attacks (TIAs, or episodes of cerebrovascular insufficiency usually with partial occlusion of an artery); 109 had prior stroke (a sudden loss of consciousness followed by paralysis); and 122 patients were without symptoms. Sixty-two percent of the stroke patients had abnormal CT scan results. CT scan did not reveal any unsuspected cerebral infarctions or tumors. Twenty-three percent of the patients who were operated upon had abnormal CT findings, which did not influence any surgical decisions. Among the patients who were not operated on, 27 percent had abnormal CT scans, which were not the reason surgery was not performed. There were three perioperative stokes. Postoperative neurologic complications were correlated with CT findings. In this study, routine use of CT scanning (costing half a million dollars) was not cost-effective. It is concluded that CT scanning prior to carotid endarterectomy should not be performed on a routine basis. (Consumer Summary produced by Reliance Medical Information, Inc.)

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.amjmed.2005.07.068 Byline: David H. Wesorick (a), Kim A. Eagle (b) Keywords: Perioperative care; Preoperative care; Risk assessment; Adrenergic beta-antagonists; Exercise test; Myocardial revascularization Abstract: The intermediate-risk preoperative patient can be defined as a patient without severely symptomatic or unstable heart disease who, nonetheless, has clinical predictors of adverse perioperative cardiovascular events. Newer data have created an awareness of competing considerations in managing these patients. There is still debate about how to appropriately select patients for noninvasive cardiac testing, invasive coronary testing, coronary revascularization, beta-blockers, or a combination of these. In this article, we review the evidence pertaining to these issues. We conclude that intermediate-risk preoperative patients are best managed by an approach that emphasizes the following points: intermediate-risk patients should be identified and risk stratified using a clinical tool (eg, the Revised Cardiac Risk Index); noninvasive cardiac testing should be reserved for those patients with multiple clinical predictors of risk or the presence of other modifying factors; preoperative coronary revascularization does not appear to reduce perioperative risk in patients with significant but stable coronary artery disease; and medical therapy should be optimized for these patients, including the application of beta-blockers in all intermediate-risk patients that do not have contraindications. Author Affiliation: (a) Division of General Medicine, Department of Internal Medicine, University of Michigan (b) Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Mich Article Note: (footnote) Dr. Eagle has research grants from NIH, Aventis, Pfizer, Mardigian Foundation, Varbedian Fund for Aortic Research, Hewlett Fund for Cardiovascular Research in Women, Biosite, and Cardiac Sciences, and he is a consultant for NHLBI and Sanofi.

An older adult undergoing a surgery has to take special care due to his age-related challenges. Being an older adult may have preexisting chronic conditions that need to be taken into account before going for an operation. The ways of preventing perioperative complications in an older adult are mentioned.

The current status of general surgery in older patients with a special focus on emergency procedures, major abdominal surgery, biliary disease, endocrine disease, and breast cancer are described. The basic principles like meticulous assessment and preparation of the patient, delicate and efficient surgery, compassionate p re operative care is same for all problems.

ABSTRACT & COMMENTARY Synopsis: Routine preoperative testing before elective cataract surgery did not improve patient outcomes. Tests should be ordered only when the history or physical examination indicate a need [...]

* Schein OD, Katz J, Bass EB, et al. The value of routine preoperative medical testing before cataract surgery. N Engl J Med 2000; 342:168-75. CLINICAL QUESTION Does routine medical [...]

Routine preoperative medical testing performed before elective cataract surgery does not reduce the incidence of patient complications--including hypertension, bradycardia, and death--during or after the procedure. That's what researchers from the [...]