Influence of postoperative fluid management on pulmonary function after esophagectomy.

PURPOSE: The aim of this study was to investigate the effects of a restrictive vs. a liberal postoperative fluid therapy guided by intrathoracic blood volume index (ITBVI) on hemodynamic and pulmonary function in patients undergoing elective esophagectomy. Perioperative fluid therapy may influence postoperative physiology and morbidity after esophageal surgery. Definitions of adequate infusion amounts and evident rules for a fluid therapy are missing. METHODS: After esophagectomy, 22 patients were randomized either to a restrictive group (RG) with low range of ITBVI (600-800 ml/m2) or a liberal group (LG) with normal ITBVI (800-1000 ml/m2). Infusion regimen was modified twice a day according to transpulmonary thermodilution measurements until the 5th postoperative day. Primary endpoint was paO2/FIO2-ratio. Secondary endpoints were pulmonary function, fluid balance and hemodynamic as well as morbidity. RESULTS: Demographic and surgical details did not differ between both groups. The calculated sample size was not reached. There were no postoperative differences in paO2/FIO2-ratio, ITBVI, hemodynamic parameters, or morbidity either. Cumulative fluid uptake was 4.1 liter less in the RG on the 5th postoperative day (p = 0.01), and pulmonary function was better in these patients (area under curve day 2-7 for forced vital capacity (FVC), forced expiratory volume in one second (FEV1), peak expiratory flow (PEF) each <0.05). CONCLUSION: ITBVI guided restrictive infusion therapy yields a lower fluid uptake, but may not result in a difference of clinical relevant parameters. A fluid restriction after esophagectomy should always be combined with hemodynamic monitoring because additional infusions may be required.

Analysing the serum levels of tumour markers and primary tumour data in stage III melanoma patients in correlation to the extent of lymph node metastases--a prospective study in 231 patients.

BACKGROUND: Serum tumour markers correlate with biological tumour behaviour and prognosis of patients. We collected prospective data of melanoma patients in tumour stage III before radical lymph node dissection. MATERIALS AND METHODS: Between 2003 until 2007 we collected 231 tumour stage III patients and analysed the preoperative serum tumour markers S100 (S100 calcium binding protein), NSE (Neuron specific enolase, Enolase 2), Albumin, LDH (Lactate dehydrogenase) and CRP (C-reactive protein) and evaluated the correlation to clinical and pathological data. We divided patients into a group with only a positive sentinel lymph node (group 1; n = 109) and a second with further lymph node metastases (group 2; n = 122). RESULTS: Patients of group 2 had a significant higher T level (p < 0.0001) and Breslow index (p < 0.0001). Patients with a higher Breslow index had a higher S100 serum level (p = 0.021). Patients of group 2 displayed a significant higher level of serum S100. The serum level of CRP correlated with increasing number of lymph node metastases. CONCLUSIONS: A higher Breslow index in tumour stage III patients seems to have an influence on lymph node metastases and on S100 serum level. Patients with more than a positive sentinel lymph node do have a higher S100 level.

Influence of surgical complications on the level of pain after radical inguinal/iliacal lymph node dissection.

BACKGROUND: We collected the data of 288 patients with malignant skin tumours. We analysed the postoperative pain assessed by a visual analogue scale (VAS) to evaluate the quality of our standard peri-operative pain therapy after a radical inguinal and iliacal lymph node dissection (RILND) as well as the influence of postoperative surgical complications on the level of pain. MATERIALS AND METHOD: The postoperative level of pain of 85 patients with malignant skin tumours who underwent a RILND between August 2003 and December 2007 was recorded prospectively. Patients received a standardised perioperative pain therapy according to level I or II of the World Health Organisation (WHO) ladder of pain. The efficiency of our pain therapy was registered via VAS in the morning of the first three postoperative days. RESULTS: Using our standard pain therapy, we determined a VAS < 30 in rest during the first three postoperative days, but significantly more pain (VAS median 50-30) (p < 0.001) under stress. Patients with surgical complications in the postoperative period (n = 71) had significantly more pain in the postoperative period compared to patients with a regular postoperative course (p = 0.047). CONCLUSIONS: Immediately after a RILND, an analgesic therapy according to level I or II of the WHO pain ladder does not seem to be effective enough. Postoperative surgical complications lead to a higher VAS level of pain in the postoperative period.

[Surgical technique and postoperative morbidity following radical inguinal/iliacal lymph node dissection--a prospective study in 67 patients with malignant melanoma metastatic to the groin]. / Technik und Morbidität der radikalen inguinal / iliakalen Lymphknoten-dissektion--eine prospektive Untersuchung an 67 Patienten mit lymphogen metastasiertem malignen Melanom.

BACKGROUND: The surgical radical inguinal / iliacal lymph node dissection (RLND) is the procedure of choice in patients presenting with lymphatic metastasis of melanoma of the lower extremity or the lower part of the trunk. The perioperative morbidity of patients includes not only local wound complications, seroma formation or lymphatic fistula but also leg oedema, deep venous thrombosis and neuralgic disorders postoperatively. The aim of this prospective study was the evaluation of postoperative morbidity in patients undergoing radical inguinal/iliacal RLND in a standardised surgical fashion. PATIENTS AND METHODS: 67 patients suffering from malignant melanoma of the lower extremity or the lower trunk with metastatic lymph nodes in the groin or the iliacal region underwent a combined RLND of the inguinal / iliacal region or the groin alone between 2003 and 2006. All operations were performed in a standardised technique. The main criterion of the study was the incidence of postoperative wound complications. Minor endpoints included the incidence of lymphatic fistula, the length of hospital stay, and the development of temporary or permanent leg oedema. RESULTS: 64 patients underwent inguinal / iliacal and 3 patients only inguinal LND (lymph node dissection). All patients tolerated the procedure well. The overall wound complication rate was 34 %. One patient died on the 21st postoperative day due to a pulmonary embolism and a simultaneous cerebral apoplexy. Lymphatic fistula occurred in 22 (33 %) patients whereas seroma resulted in 23 (34 %) patients. The length of hospital stay was 15 (3-41) days. A relevant leg oedema was observed in 9 (13 %) patients. CONCLUSION: Even with a proper perioperative management and a precise wound care management, one-third of the patients undergoing radical inguinal / iliacal lymphadenectomy suffer from a complication requiring medical or interventional treatment. Our data demonstrate that most of these complications can be treated sufficiently by conservative treatment. A fitted surgical support hose could prevent long-term complications.

Influence of pre-operative fluid infusion on volume status during oesophageal resection--a prospective trial.

BACKGROUND: Perioperative fluid therapy is controversially debated in surgery. In malnourished and hypovolaemic patients, a restrictive fluid regimen may lead to hypoperfusion and increased incidence of complications. The present prospective cohort study was performed to assess whether pre-operative i.v. fluid administration improves intraoperative cardiac preload in patients undergoing oesophageal resection. METHODS: Intraoperatively, the intrathoracic blood volume index (ITBVI) was monitored in 44 consecutive patients undergoing elective oesophagectomies with the transthoracic thermodilution technique. Twenty-two of these patients received a pre-operative i.v. fluid loading with a balanced crystalloid solution (1 ml/kg/h over 48 h). RESULTS: After induction of anaesthesia ITBVI was low but not different between the groups [767 (512-1314) vs. 775 (531-1200) ml/m(2), P=0.81]. In the intervention group, the extravascular lung water increased above normal levels during the operation. The groups did not differ in cardiac output, blood pressure, heart rate and central venous pressure. Post-operative morbidity was not different between the cohorts. CONCLUSION: Pre-operative i.v. fluid loading with crystalloid solutions could not be shown to improve the intraoperative volume status and cardiac function in this study. Randomised trials with other volume replacement techniques are recommended.

[First clinical experience with a video presentation informing patients before surgery for inguinal hernia]. / Videoinformationsfilm vor Leistenhernienoperationen. Erste klinische Erfahrungen.

BACKGROUND: Although it is a significant part of surgical treatment, informing patients beforehand seems to be more and more neglected, mainly due to the enormous amount of work and time pressure on surgical personnel. MATERIAL AND METHODS: A video clip explaining groin hernia surgical repair was produced as additional information for patients. In it, visual material from actual practice describes the disease, the operation itself, all the perioperative aspects, and patients' own experiences. In a prospective comparison study, the length of patient education, its quality, patient satisfaction, and the duration of hospitalization and time off work were compared between patients who saw the video clip (n=50) and those who did not (n=50). RESULTS AND CONCLUSION: In summary, the time spent informing the video group was shorter (P<0.05) and their total satisfaction and evaluation of the information material were both higher (P>0.05) for comparable duration of treatment and time off work. This informative video was adopted without problems in our daily clinical life and, besides reducing the time needed to inform patients, it has significantly improved patient understanding of the operative procedure and their satisfaction with treatment.

Long-term efficacy and safety of flecainide for supraventricular tachycardia.

Eighty-three patients with paroxysmal supraventricular tachycardia (Wolff-Parkinson-White syndrome in 47 patients and atrioventricular nodal reentry in 36 patients) underwent electrophysiologic study before and after intravenous administration of flecainide. Sixty-seven of these 83 patients entered an open clinical trial to evaluate the efficacy and safety of long-term oral treatment with flecainide. Efficacy was evaluated by a patient diary of spontaneously occurring attacks during flecainide treatment and periods of withdrawal. In 24 patients, electrophysiologic study was repeated during oral therapy. During a mean follow-up of 22.8 months, the therapeutic response to flecainide (mean dose 263 mg/day) was good in 48 patients (71%) and fair in 7 patients (10%). In 8 patients (10%), an arrhythmogenic effect was seen (increased number and prolonged duration of supraventricular tachycardia episodes in 4 patients, spontaneous episodes of atrial fibrillation in 2 patients and sinoatrial block in 2 patients). No consistent abnormalities were seen in the laboratory tests. Extracardiac side effects were of minor importance and usually subsided spontaneously or disappeared after reduction of dosage. It is concluded that flecainide is a useful addition to the drugs already available for short- and long-term treatment of supraventricular tachycardia due to Wolff-Parkinson-White syndrome and atrioventricular nodal reentry.

Long term use of flecainide in patients with supraventricular tachycardia.

The acute effects of intravenous flecainide on electrically-induced paroxysmal supraventricular tachycardia and the safety and efficacy of long term prophylaxis with orally administered flecainide were assessed in 37 patients with paroxysmal supraventricular tachycardia refractory to treatment with 'conventional' antiarrhythmic drugs. Over a mean treatment period of 14.2 months, flecainide 200 to 400mg daily completely suppressed paroxysmal supraventricular tachycardia in 9 of 20 patients with paroxysmal supraventricular tachycardia due to Wolff-Parkinson-White syndrome, while 3 patients reported only transient episodes of paroxysmal supraventricular tachycardia, and 1 patient had a decreased ventricular response to chronic atrial fibrillation. Of 17 patients with paroxysmal supraventricular tachycardia due to atrioventricular nodal re-entry, flecainide 200 to 500mg daily for a mean period approaching 26 months totally prevented episodes of paroxysmal supraventricular tachycardia in 8, and reduced the frequency and duration of episodes of paroxysmal supraventricular tachycardia in 3 others. Flecainide prolonged action potential refractoriness in a few patients in each group; however, an increased frequency of occurrence of paroxysmal supraventricular tachycardia occurred due to a simultaneous decrease in the re-entry circuit conduction velocity. In both patient groups the acute electrophysiological effects of flecainide were often predictive of the long term efficacy of the drug in the prophylaxis of paroxysmal supraventricular tachycardia. Side effects usually involved the central nervous system and were most commonly manifested by disturbances in vision, balance, and taste and increased nervousness. These side effects generally subsided following 1 to 2 months' treatment with flecainide. No abnormal trends were observed in laboratory analysis of blood samples taken from patients during long term treatment with flecainide.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of clonidine on sinus node function in man.

Drugs interfering with sympathetic tone may result in depression of the function of the sinus node, especially in patients with disease of the sinus node. In 11 patients presenting with palpitations, vertigo, or syncope, the heart rate, the recovery time of the sinus node, the carotid sinus pressure slowing, and the atrioventricular conduction capacity were assessed before and every five minutes up to 30 minutes after intravenous administration of 0.15 mg of clonidine. The following significant maximal mean effects were noted at about 15 minutes after the administration of clonidine: the heart rate decreased 12 percent (59 vs 52 beats per minute); and the atrioventricular conduction capacity (ie, paced heart rate at second-degree atrioventricular block) decreased by 9 percent (132 vs 121 beats per minute), while the maximal recovery time of the sinus node increased by a factor of two (1,704 vs 3,562 msec) when atrial overdrives of 120, 150, and 200 beats per minute were used for each five minute period. In analyzing maximal carotid sinus pressure slowing after administration of clonidine, three of 11 patients developed hypersensitive carotid sinus reflex de novo, and two patients showed a decrease and three patients an increase of carotid sinus pressure slowing, while three patients had no carotid sinus pressure slowing both before and after administration of clonidine. We conclude that caution should be taken in administering clonidine to patients with signs indicative of dysfunction of the sinus node.

Thrombotic complications with pacemakers.

To analyze thrombotic complications, we performed brachial phlebographies in 100 consecutive patients (group 1), about 44 months after permanent pacemakers had been installed. Thirty-nine patients showed thrombotic lesions in the veins used to pass the stimulation electrode into the right ventricle. In 10 patients the medical history and in 12 patients clinical symptoms and signs indicated an impairment of venous flow. Fifteen of the 39 patients showed complete occlusion of one venous segment; collateral vessel formation was found dependent on the site and the extent of the occlusion. In the remaining 24 patients only partial occlusion without collateralization was demonstrated. Group 2 comprised 12 patients in whom the pacing lead originally inserted via right-sided veins had been severed and the free distal end left unsecured intraluminally when the second electrode was inserted via the left-sided cephalic vein. In all these patients phlebography about 19 months later revealed thrombotic complications, while 11 presented with clinical symptoms and signs. The incidence of thrombotic complications including segmental occlusion after the application of permanent pacer leads is only one-third of patients with segmental occlusion symptoms. However, since severed leads produce severe symptomatic complications in almost all cases their removal is mandatory.

[What is the value of the internet as a source of information for patients with inguinal hernias? First results of an observational study]. / Welchen Stellenwert hat das Internet als Informationsquelle für Patienten mit Leistenhernien? Erste Ergebnisse einer Beobachtungsstudie.

INTRODUCTION: The increasing use of the internet has led to a variety of medical web pages and an increasing amount of information about hospitals. Little is known about the extent to which this new medium is already used by patients as a source of information. For patients with inguinal hernia, for example, a frequent surgical symptom with large method variety, the value of the internet as a source of information should be examined. METHODS: One hundred patients facing an elective inguinal hernia repair at the Surgical Department Charité Berlin took part in a prospective observation study (a questionnaire with 10 questions) between July 1999 and March 2001. The questions referred to the possibility of PC/internet access, other sources of information (e.g., general practitioner, friends, internet) as well as the criteria by which the clinic was chosen. Patients were asked to answer basic questions about the development and treatment of inguinal hernia and to give a self-assessment of their knowledge of inguinal hernia (0 = no knowledge; 10 = maximum knowledge). RESULTS: The questionnaire revealed that 39% of the patients (average age 47 +/- 16 years) had a PC in their homes, 24% of those with internet access; 11% had internet access at other places. It also showed that 53% of the patients sought medical information from their general practitioner, 29% from friends, and 18% from the internet. Young patients (median age 29 years), employees and patients with private internet access use the internet with significantly more frequency. Their medical knowledge as well as their self-assessment of medical knowledge was significantly higher (median 19 versus 7 points and median 8.6 versus 5.7, respectively) and they chose the clinic because of the information from their research on the internet. CONCLUSION: At present, the internet still plays a subordinate role as a source of information for patients with an inguinal hernia. The increasing presence of this medium as well as the higher internet acceptance of future patients indicates that it has a promising future as a source of medical information.

[Trevira: a new polyester implant for the treatment of incisional hernia. Results of an experimental study]. / Trevira: une nouvelle prothèse en polyester pour la cure des éventrations. Résultats d'une étude expérimentale.

OBJECTIVE: The synthetic implant meshes in clinical use for the treatment of abdominal hernias are generally made of polyester in France and of polypropylene in Germany. Serving as an implant material for the replacement of the cruciate ligament, the Trevira is another polymer of polyester in clinical use with excellent results. This animal trial was performed to ascertain whether it offers any advantages over polypropylene for abdominal incisional hernia repair. MATERIAL AND METHODS: [corrected] In 12 pigs 10 x 10 cm of the abdominal wall preserving the peritoneum was resected and subsequently implanted a 15 x 15 cm synthetic mesh of polyethylene terephthalate (Trevira) in half of them and of polypropylene (Prolene) in the other half using a sublay technique. After two and six month the implant size was measured and the extend of the foreign body reaction determined by the microscopically presence of foreign body giant cells. RESULTS: No significant differences concerning the implant size were shown between the two groups at any of the time periods. The acute inflammatory reaction observed was significantly higher at the polypropylene than at the polyethylene terephthalate implant (number of giant cells after 2 month: Prolene 2.2 +/-0.4, Trevira: 0.8 +/-0.2, after six month: Prolene: 4.6 +/-1.3, Trevira: 1.1 +/-0.5). In contrast to the polyethylene terephthalate all polypropylene samples showed calcification areas after six month. CONCLUSION: In this animal trial Trevira mesh showed a high biocompatibility with a low foreign body reaction. It appears to be a promising new implant for the treatment of hernia.

A prospective randomized trial: the influence of intraoperative application of fibrin glue after radical inguinal/iliacal lymph node dissection on postoperative morbidity.

BACKGROUND: Effects of intraoperative application of fibrin glue following combined radical inguinal and iliacal lymph node dissection (RILND) on the amount of postoperative lymphatic secretion are discussed controversially. To detect whether fibrin glue application results in a decreased lymphatic secretion following RILND a randomized patient blinded clinical trial was conducted. METHOD: Between September 2003 and September 2006 58 patients with stage IV melanoma underwent therapeutic RILND and were randomized into two groups. 29 Patients received 4 cc fibrin glue after RILND whereas 29 patients were only irrigated with saline 0.9 percent. Postoperatively all patients received two inguinal and one iliacal closed suction drain. The main outcome criteria were the duration of drain placement in the wound. Minor criteria were the total amount of secretion and the length of hospital stay. RESULTS: There was no difference between the treatment and the control group in the duration of drain placement (fibrin group: 4 days (1-27); control group 5 days (1-26); p=0.64). The total amount of fluid was 310 cc (30-6005) in the fibrin group vs. 365 cc (30-3945 cc) in the control group (p=0.9) and the length of hospital stay 10 days (3-41) (group 1) compared to 11 days (3-41) (p=0.99) were not different between both groups either. CONCLUSION: Intraoperative application of 4 cc fibrin glue does not reduce the length of drain placement, drain output or hospitalisation of patients undergoing RILND with melanoma metastasis to the lymph node basin.

Subcutaneous gentamycin implant to reduce wound infections after loop-ileostomy closure: a randomized, double-blind, placebo-controlled trial.

BACKGROUND: After loop-ileostomy closure subcutaneous wound infection is the most frequent postoperative complication. Implantation of local antibiotics has been shown to reduce the incidence of wound infection after different surgical procedures, therefore, a subcutaneous application of a gentamycin implant may also decrease infection rate after ileostomy-closure. METHODS: We conducted a randomized, double-blind, placebo-controlled trial to evaluate the effectiveness of a subcutaneous gentamycin-collagen implant to reduce wound infection after loop-ileostomy closure. Patients had the same perioperative treatment and standardized anastomotic and closure technique. A collagen sponge with gentamycin was used in the treatment group and an identical collagen implant without antibiotics was used in the placebo group. RESULTS: Eighty patients (40 per group) were included. There was no difference between the groups with respect to demographics or in the postoperative course. The total wound infection rate was 10 percent with no difference between the gentamycin (n=4) and the collagen group (n=4) (P = 1.0). CONCLUSION: Subcutaneous implantation of a gentamycin sponge yields no clinically relevant reduction of the wound infection rate after loop-ileostomy closure so that routine use is not recommended in this procedure.

Functional properties of mahaim fibers.

Electrophysiological studies were performed in a patient with a short P-R interval and a small delta wave. The findings suggest that ventricular pre-excitation resulted from an infranodal bypass (Mahaim type). As the functional properties of the pathway were evaluated, impaired conductivity (suggested by rather long refractory periods) became apparent at frequency stress. The pathway could easily be blocked by Ajmaline. This demonstrated an unexpected early diastolic improvement in conductivity; i.e. a supernormal phase of conduction. Due to this supernormal phase, Mahaim-fiber conduction was present when block in the anterior division of the left bundle branch, or even trifascicular block occurred. Thus the effects of exclusive Mahaim-fiber conduction on ventricular activation were documented.

Coronary hemodynamics in simulated paroxysms of ventricular tachycardia: role of myocardial impairment and of extravascular resistance.

In 6 patients with healthy hearts (controls), 17 with coronary artery disease (CAD) and 6 with left ventricular hypertrophy due to aortic valvular disease, aortic pressure, coronary sinus blood flow (CSF) and lactate extraction were determined before and after the sudden onset of a paced ventricular tachycardia of 170 bpm (VT 170 = simulated paroxysmal ventricular tachycardia). Comparison to parameter changes during dipyridamol vasodilation revealed reduced coronary vascular reserve for CAD and hypertrophy. While VT induced a reduction of aortic pressure (stabilized by an average of 22%, and most excessively for CAD; p less than 0.05) and CSF remained at/or slightly above control levels (by an average of 31%; p greater than 0.05) equally for all groups (p greater than 0.05), lactate production in the groups with CAD and hypertrophy indicated myocardial impairment by ischemia. Excessively greater increases of CSF during dipyridamol vasodilation (vs. VT) for all groups suggested VTs extravascular resistance increase to have limited the extent of the potential of coronary vascular decrease. With one variable being kept constant (i.e. 'clamping' the vascular component of coronary resistance at its limit by dipyridamol), tachycardia during dipyridamol (D) vasodilation (VT 170+D and VT 140+D) in the controls and in the CAD group resulted in a linear decrease of CSF, allowing quantification of impaired coronary reserve for CAD. We concluded from the observations that: (1) paroxysmal VT demands fast therapeutic action foremost in the impaired myocardium, and (2) tachycardia per se acts as limiting factor for coronary blood flow via increase in extravascular resistance (aside from a shortened diastole).

Analysis of re-entry mechanisms in the three patients with concealed Wolff-Parkinson-White syndrome.

Three patients with recurring attacks of supraventricular tachycardia and no electrocardiographic evidence of the Wolff-Parkinson-White syndrome (WPW syndrome) were studied using intracardiac recordings and atrial stimulation. The findings are interpreted as evidence of a concealed WPW syndrome. In all patients there was antegrade block of the anomalous atrioventricular (A-V) pathway while retrograde conduction was unimpaired and allowed the initiation of the observed reciprocating tachycardias. The diagnosis was based on the assumption that the ventricular myocardium was an essential link in the re-entry circuit. The three most important findings to support this assumption are: 1) retrograde conduction time, measured by the Q-A' interval (Q in ECG to atrial echo), and the rate of tachycardia were dependent on the mode of intraventricular conduction: 2) the first Q-A' interval of the tachycardia was independent of the A-H interval (initiation of atrial impulse to first activation of the His bundle) of the initiating premature atrial depolarization (PAD); 3) there was retrograde conduction following a ventricular premature beat during tachycardia at a time when the A-V node and/or the bundle of His would be refractory.