Percutaneous dilational tracheostomy: report of 356 cases.

OBJECTIVE: To evaluate the procedure time, complications, and percutaneous dilational tracheostomy (PDT) charges. DESIGN: Operative data were prospectively collected for 356 PDTs including the initial series of 141 PDTs reported in 1994. Short- and long-term complications were retrospectively identified by review of medical records and patient telephone interviews. MATERIALS AND METHODS: PDT was performed using the "Ciaglia" method of serial dilation over a Seldinger guidewire. Discharged patients (n = 258) were followed for a mean (+/-SD) of 10 +/- 7 months. MEASUREMENTS AND MAIN RESULTS: The mean procedure time was 15 +/- 8 minutes; operative mortality rate, 0.3% (1/356); overall complication rate, 19% (69/356); long-term symptomatic tracheal stenosis rate, 3.7% (8/214). The mean total patient charge for bedside PDT was $1,370; for open tracheostomy in the operating room, $2,675. CONCLUSIONS: Surgeons can rapidly perform PDT at the bedside with a lower risk of complications than open tracheostomy and at a significantly reduced patient charge.

The structured clinical instruction module: a novel strategy for improving the instruction of clinical skills.

We have previously shown that both medical students and residents demonstrate numerous important deficits when evaluating patients with abdominal complaints. To address these deficits, we implemented a pilot instructional program derived from the Objective Structured Clinical Examination. Fifty third-year medical students were presented with a 1-hr Structured Clinical Instruction Module (SCIM) of five stations, each station addressing a different aspect of the surgical evaluation of the abdomen. Simulated patients were present at two of the stations. Faculty from appropriate disciplines were present at the stations to provide standardized instruction according to predetermined curricular objectives. The medical students evaluated the SCIM for its specific characteristics, and they evaluated each of the five stations for its efficacy in increasing their clinical skills. All the specific aspects of the SCIM were given a rating significantly higher than neutral (P < 0.0001). Students agreed most strongly that the faculty were well prepared for the SCIM and that the faculty were enthusiastic. All of the SCIM stations were given a rating significantly higher than average (P < 0.0001). When compared to a conventional workshop, the SCIM scored significantly higher on all three common evaluation items. The SCIM was very well received by medical students as a format for clinical instruction. This unique modification of the Objective Structured Clinical Examination has potential for teaching important clinical skills that are not consistently mastered within current surgical curricula.

Percutaneous dilational tracheostomy in children and teenagers.

Percutaneous dilational tracheostomy (PDT) is a new technique that has been successfully performed in adult patients who required long-term mechanical ventilation, but it has not been used in children. The authors report their initial experience with PDT in 11 children and teenagers. The procedure is as follows. Using Seldinger's technique, the trachea is cannulated with a guide-wire. It is then progressively dilated, to an appropriately sized tract, with dilators from a commercially available kit. Then, a tracheostomy tube can be inserted into the trachea, loaded over a dilator. Eleven children, aged 10 to 20 years, underwent PDT in an average of 20 minutes. In eight cases, PDT was performed at the bedside. One intraoperative and one postoperative complication developed in the same patient; both complications were easily recognized and treated. Tracheal stenosis has not developed in eight decannulated patients at an average of 43 +/- 30 weeks after decannulation. PDT appears to be a safe, potentially cost-effective alternative to open tracheostomy in young patients.

One-stage gastrostomy button: an assessment.

Several types of gastrostomy tube are available. The gastrostomy button (GB) is a skin-level device that is easily used and acceptable to ambulatory patients. Previously, GB required the presence of a mature gastrocutaneous tract, necessitating a two-stage procedure for placement. We report our experience with one-stage GB placed in 24 patients. No difficulties with placement and no periprocedural complications occurred. GBs remained in place from 14 to 148 days (mean 71 days). Thirteen GBs were in place at follow-up. Four patients died from primary disease. Seven GBs were no longer needed, and were removed. No stomal infections occurred; no GBs were inadvertently removed; all GBs were convenient to use. Four complications occurred (17%): two tubes clogged, one colocutaneous fistula developed, and one tube migrated from the stomach into the abdominal wall. Complications were corrected without sequelae. One-stage GB is safe and feasible with comparable complication rates to standard PEG.

Pentobarbital coma in neurosurgical patients: nutrition considerations.

Neurosurgical patients in pentobarbital coma are a complex nutrition support population. Physiologic changes associated with the primary injury to the brain, combined with the pharmacodynamic influences of barbiturate therapy, contribute to the difficulties of initiating aggressive nutrition support. Early nutritional repletion is important to the overall outcome of traumatically injured patients. Consequently, factors that influence nutrition support decisions must be understood to assure appropriate intervention. The metabolic changes associated with traumatic head injury, pentobarbital therapy, and nutrition support strategies are reviewed.

Nonfunctioning cystic neuroendocrine neoplasms of the pancreas.

BACKGROUND: Three types (functioning solid, nonfunctioning solid, and functioning cystic) of neuroendocrine neoplasms (benign and malignant) of the pancreas have been reported. PATIENTS: We report three patients with nonfunctioning neuroendocrine neoplasms of the pancreas with cystic components, a type of neoplasm not previously reported. One of the neoplasms we report was benign; the other two were malignant. The patients were admitted with abdominal pain. In each case an abdominal computed tomography scan defined a large multicystic pancreatic mass. RESULTS: In all instances, immunochemical staining was positive for neuroendocrine markers, confirming the neuroendocrine nature of the tumors. The nonfunctional nature of the neoplasms was confirmed by (1) the absence of clinical symptoms traditionally attributed to neuroendocrine secretagogues and (2) the lack of gastroenteropancreatic peptide serum levels. CONCLUSIONS: Two of these three cases represent another subset of pancreatic neuroendocrine pathology: a nonfunctional cystic neoplasm. Increased clinical awareness, appropriate operation, and better immunohistochemical staining techniques may yield more, heretofore unrecognized, subtypes. These cases reemphasize the need for proper surgical exploration and biopsy of all unexplained pancreatic cystic lesions, particularly if they are multicystic.

Percutaneous dilational tracheostomy: report of 141 cases.

Tracheostomy is indicated frequently in the treatment of critically ill patients who require prolonged mechanical ventilation. The purpose of this prospective study was to evaluate our initial experience with 141 cases of percutaneous dilational tracheostomy (PDT) performed over a 2-year period. One hundred twenty PDTs (85%) were placed at the bedside, and 21 (15%) were performed in the operating room in conjunction with other procedures. The procedural complication rate was 11% (16 of 141). Most complications were easily recognized and did not preclude the completion of PDT. One death occurred secondary to severe bronchospasm. The postoperative complication rate was 8% (11 of 141). The most frequent complication was peristomal oozing. The average duration of follow-up after decannulation for patients discharged alive and decannulated was 36 +/- 27 weeks. There were 3 recognized cases of clinically symptomatic tracheal stenosis. We conclude that PDT is comparable with the open method and can be performed rapidly and safely at the patient's bedside.

Mirizzi's syndrome.

Mirizzi's syndrome is a partial obstruction of the biliary tree caused by a stone impacted in the cystic duct, with or without development of a cholecysto-biliary fistula. We report our experience with five cases and review current methods of diagnosis and management. Preoperative diagnosis greatly facilitates management. Diagnosis may require a combination of ultrasonography, computed tomography, and cholangiography (percutaneous or endoscopic retrograde). At surgery, dissection in the triangle of Calot should be minimized to avoid injury to the common bile duct. Often, a partial cholecystectomy is the only safe option. Defects in the common bile duct can be repaired by a variety of methods. The morbidity and mortality associated with this rare syndrome can be relatively high. A number of patients may have late biliary strictures.

Perforated gastric and duodenal ulcer: an analysis of prognostic factors.

A review of patients treated operatively for perforated ulcer was undertaken to determine factors that independently predict mortality and morbidity. From 1980 to 1989 84 patients were treated with operative mortality and morbidity rates of 18 and 37 per cent, respectively. Patients with gastric ulcer were significantly older and were more likely to have concomitant medical problems, to use steroids, and be hospitalized at time of their perforation. They also had a higher perioperative mortality rate when compared to patients with gastroduodenal ulcers (P < 0.05 for each). Patients treated with definitive operation (n = 51) had a significantly lower recurrent ulcer rate when compared to an equivalent group treated with simple closure (n = 33) (mean follow-up, 47 months). Multivariate analysis confirmed a patient's likelihood of complication or death could be predicted using three variables (P < 0.03); age greater than 42 years, hospitalization at time of perforation, concomitant medical illness. While the relative distribution of these three factors in patients with gastric versus peptic ulcers appears to account for the difference in outcome between these two groups, the distribution of these factors between patients treated with patch closure and definitive operation was not significantly different. Patient outcome from operation for perforated ulcer is dependent on preoperative conditions and appears to be independent of surgical procedure performed. There was no benefit to simple closure of a perforated ulcer. Definitive procedures of perforated ulcers are associated with lower ulcer recurrence and therefore are advocated to treat perforation.

Recovery of the neonatal heart after normothermic ischemia. Effect of oxygen and catalase.

The objective of this study was to determine the effect of oxygen and the oxygen radical-scavenging enzyme catalase on the neonatal rabbit heart exposed to global ischemia. The experiments were performed with an isolated neonatal (7 to 10 days of age) working heart model in which normothermic (37 degrees C) ischemia was produced for 60 minutes. Left ventricular developed pressure, ratio of change of ventricular pressure to change in time, and aortic flow were measured before ischemia and 30 minutes after reperfusing the hearts with physiologic saline solution. In the control group (ischemia only), developed pressure and ratio of change of ventricular pressure to change in time recovered to 27% +/- 3% (mean +/- standard error of the mean) and 24% +/- 7% of baseline; the hearts were incapable of ejecting (aortic flow = 0). Treatment of hearts before and after ischemia with catalase (150 units/ml of perfusate) was studied in a second group (control plus catalase), but functional recovery (developed pressure = 32% +/- 1%; ratio of change of ventricular pressure to change in time = 24% +/- 2%, and aortic flow = 0) was not significantly different from the control group. The effect of washout midway through the ischemic period with a low oxygen (oxygen concentration less than 35 mm Hg) solution was measured in a third group (hypoxic physiologic saline solution). Functional recovery (developed pressure = 13% +/- 3%; ratio of change of ventricular su pressure to change in time = 13% + 2%; aortic flow = 0) was not significantly different from the control and control plus catalase groups. In marked contrast were the effects of washout with an oxygenated (oxygen concentration greater than 500 mm Hg) solution (oxygenated physiologic saline solution) in which functional recovery (developed pressure = 78% +/- 3%; ratio of change of ventricular pressure to change in time = 80% +/- 3%; aortic flow = 39% +/- 9%) was significantly better than in the control, control plus catalase, and hypoxic physiologic saline solution groups. Use of modified St. Thomas' Hospital cardioplegic solution (cardioplegic solution group) during the ischemic period also resulted in substantial functional recovery (developed pressure = 80% +/- 3%; ratio of change of ventricular pressure to change in time = 78% +/- 5%; aortic flow = 64% +/- 7%) that did not differ significantly from that in the oxygenated physiologic saline solution group.(ABSTRACT TRUNCATED AT 400 WORDS)

Hemodynamic monitoring and pulse oximetry during percutaneous gastrostomy and jejunostomy: necessity or nuisance?

Hemoglobin desaturation and arrhythmias have been reported during diagnostic gastroscopy and colonoscopy. During endoscopic placement of percutaneous gastrostomy tubes (PEG), the gastroscope is inserted twice and the stomach is markedly distended, thus increasing the potential risk of complications. Also, the procedure is frequently performed in patients exhibiting underlying systemic disease or little respiratory reserve. Patients undergoing PEG or percutaneous endoscopic jejunostomy (PEJ) were studied prospectively. Blood pressure, pulse, pulse oximetry, and lead II ECG tracings were obtained. Measurements were made before sedation, after sedation, at gastroscope insertion, at gastrostomy placement, at gastroscope reinsertion, and at 5 min after the procedure. In all, 50 patients (mean age, 56.8 years; 16 women, 26 men) underwent PEG only (39 cases) or PEG/PEJ (11 cases). The endoscopy suite was the site for the procedure in 38 cases and the intensive care unit was used in 12 cases. The mean time required for PEG and PEG/PEJ was 14.7 +/- 1.1 and 18.9 +/- 2 min, respectively. Blood pressure remained stable throughout the procedure. Sinus tachycardia was observed in 72% of patients. Arterial oxygen saturation decreased after the administration of intravenous sedation but remained constant during the procedure. We reached the following conclusions: (1) desaturation occurs during sedation, (2) saturation remains constant during PEG/PEJ, (3) the mean blood pressure remains constant during PEG/PEJ, and (4) PEG/PEJ are safe procedures and monitoring should be individualized.

The concentration of calcium in neonatal cardioplegia.

The optimal calcium concentration in cardioplegia for the newborn has not been determined. Therefore, the effect of 0, 0.6, 1.2, 1.8, and 2.4 mmol/L calcium in modified St. Thomas cardioplegia was evaluated in isolated working hearts of 7- to 10-day-old rabbits. Functional recovery was determined by comparing aortic flow, developed pressure, and first derivative of left ventricular pressure (dP/dt) before and after 1 hour of normothermic (37 degrees C) ischemia. As percentages of baseline values, recovery of developed pressure and dP/dt averaged 10% +/- 1% (mean +/- standard error of the mean) and 10% +/- 1% with 0 mmol/L, 46% +/- 7% and 44% +/- 8% with 0.6 mmol/L, 79% +/- 2% and 76% +/- 2% with 1.2 mmol/L, 67% +/- 2% and 61% +/- 5% with 1.8 mmol/L, and 65% +/- 5% and 65% +/- 7% with 2.4 mmol/L calcium, respectively. Significant improvement in recovery of developed pressure and dP/dt was detected when the calcium concentration was increased from 0 to 0.6 mmol/L and from 0.6 to 1.2 mmol/L, but the groups with 1.2, 1.8, and 2.4 mmol/L did not differ from one another significantly in terms of developed pressure and dP/dt recovery. There was no recovery of aortic flow when 0 mmol/L calcium was used; at calcium concentrations of 0.6, 1.2, 1.8, and 2.4 mmol/L, recovery of aortic flow averaged 16% +/- 7%, 63% +/- 10%, 23% +/- 10%, and 36% +/- 11% of baseline values, respectively. Recovery of aortic flow with 1.2 mmol/L calcium was significantly higher than at concentrations of 0.6 and 1.8 mmol/L.(ABSTRACT TRUNCATED AT 250 WORDS)

Ejection- and isovolumic contraction-phase wall thickening in nonischemic myocardium during coronary occlusion.

During acute regional ischemia in open-chest anesthetized dogs, contraction is augmented in nonischemic myocardium. The effectiveness of enhanced contraction, however, has been questioned based on recent studies (using midwall segment length measurements) that reported that most of the increase occurred only during the isovolumic contraction phase (ICP) and not the ejection phase (EP) of systole. We evaluated this issue retrospectively using a different means of measuring regional myocardial function, systolic wall thickening (measured with sonomicrometers). In open-chest anesthetized dogs we observed a significant increase in both ICP and EP wall thickening. With circumflex occlusion, ICP and EP thickening each contributed an average of 50% to the augmentation in total thickening. With left anterior descending occlusion, ICP thickening contributed a significantly greater proportion (71%) to the total increase, but the change in EP thickening was also significant (29%). Therefore, in open-chest dogs we observed evidence of intraventricular unloading (in that ICP thickening increased), but we also observed an increase in effective (EP) thickening. In a series of conscious dogs, however, we observed no significant change in total nonischemic thickening after circumflex coronary occlusion. There was a statistically significant increase in the ICP component acutely after coronary occlusion, but its contribution to total wall thickening was small. In a group of dogs studied at intervals for 2 wk after circumflex occlusion, there was no evidence of intraventricular unloading beyond 3-5 days postocclusion. Therefore, we conclude that significant intraventricular unloading is restricted to the acute phases of myocardial infarction, and we suggest that its functional importance is smaller in conscious closed-chest chest dogs than in open-chest dogs.

Mitral valve replacement in the first 5 years of life.

Between 1976 and 1986, 19 children aged 1 month to 5 years underwent replacement of the mitral (systemic atrioventricular) valve. Indications for valve replacement included isolated congenital mitral stenosis (n = 2), valve dysfunction associated with a more complex procedure (n = 15), and failed valvuloplasty (n = 2). Seven different valve types were used; nine were mechanical valves and ten were bioprosthetic valves. There were 6 hospital deaths (32%; 70% confidence limits, 20% to 47%). Among the 13 survivors there were 3 late deaths at a mean of 14 months after operation. The late deaths were unrelated to valve malfunction. Thromboembolic events occurred in 2 patients, both with mechanical valves. One minor bleeding complication occurred among 10 patients on a regimen of Coumadin (crystalline warfarin sodium). Five patients, all with bioprostheses, required a second valve replacement. Indications for reoperation included prosthetic valve regurgitation (n = 1) and calcific stenosis (n = 4). No early or late deaths occurred after second valve replacement. Survival was 51% +/- 12% (standard error) at 112 months after valve replacement. Analysis failed to identify age, weight, sex, previous operation, underlying cardiac lesion, or prosthesis size and type as significant risk factors for mortality. Mechanical valves had a lower reoperation rate compared with bioprostheses. These data suggest that although mitral valve replacement within the first 5 years of life is associated with a high operative and late mortality, satisfactory long-term palliation for many patients can be achieved. Mechanical valves are superior to bioprosthetic valves, and offer the best long-term results.

Protection of the neonatal heart following normothermic ischemia: a comparison of oxygenated saline and oxygenated versus nonoxygenated cardioplegia.

Optimal methods of myocardial preservation in the neonate remain unknown. Hypothermia and cardioplegia have been shown to protect neonatal hearts, but few studies have examined the effects of cardioplegia when administered at normothermia. Accordingly, the role of 37 degrees C St. Thomas' cardioplegic solution in protecting the neonatal heart during 1 hour of ischemia in an isolated working rabbit heart model was examined. Both oxygenated and nonoxygenated cardioplegic solutions (CSs) were evaluated and compared with an oxygenated physiological saline solution (PSS). Following ischemia, control hearts were characterized by severely impaired left ventricular function, whereas all three treatment groups recovered well, indicating that the treatments provided substantial protection. Aortic flow recovered to 62, 63, and 57% of preischemic values for the oxygenated CS, nonoxygenated CS, and oxygenated PSS groups, respectively. Similarly, rate of change of pressure recovered to 76, 80, and 76% of preischemic values for oxygenated CS, nonoxygenated CS, and oxygenated PSS groups. All values were significantly greater than those for the control group. Recovery of developed pressure was significantly improved in all three groups. End-diastolic pressure rose markedly following ischemia in control hearts, was not increased after ischemia in hearts receiving oxygenated and nonoxygenated CS, but was increased in the oxygenated PSS group. These data indicate that crystalloid cardioplegia and oxygenated PSS provide substantial protection in neonatal rabbit hearts, even when delivered at 37 degrees C. No additional benefit was seen when the cardioplegic solution was oxygenated. Therefore, either method of balancing the oxygen supply/demand ratio appears to be beneficial: supplying oxygen intermittently during ischemia (oxygenated PSS group) or decreasing oxygen demand during the ischemic period (cardioplegia groups).