Determination of blood loss in bimaxillary surgery: does the formula and the time point affect results?

The amount of blood loss determined in orthognathic surgery differs greatly among studies. This can be attributed to the inhomogeneity in study cohorts analysed, but may also be a result of the varying methodologies used for blood loss determination. However, this has yet to be explored. Thus, the aim of this study was to investigate the extent to which the formula and time point used to measure blood loss affect the blood loss volume, determined in a homogeneous cohort undergoing bimaxillary surgery. Blood loss was calculated at 24 and 48 hours postoperatively using the haemoglobin balance method and the formula of Hurle et al. The estimated total blood volume was established based on the formulae of Nadler et al. and Choi et al. Differences in blood loss volume with respect to time point and formula were analysed and compared. Fifty-four patients were included in the final analysis. Statistically significant differences in blood loss were observed: a significant increase in the blood loss volume from 24 hours to 48 hours postoperatively was detected. When comparing the formulae used, blood loss differed significantly at 24 hours after surgery; however no such difference resulted at 48 hours postoperatively. These findings imply that the time point of measuring blood loss is highly relevant, whereas the formulae applied seem to have less of an impact on the blood loss volumes calculated.

The postpartum abdomen: psychology, surgery and quality of life.

PURPOSE: The postpartum abdomen presents significant challenges to the surgeon. It is anatomically complex, with often substantial symptomatic divarication of the rectus abdominis, affecting all anterior abdominal wall layers. This may lead to profound functional sequelae, and often, of more importance to patients, a significant physical deformity. The complex interplay of functional/physical symptoms can result in reduced quality of life (QoL) as well as negative body image/self-esteem. Postpartum women may seek abdominoplasty to address the whole scope of these concerns. Whilst techniques have evolved achieving such goals operatively, the impact of such surgery on QoL/mental health has yet to be established. METHODS: We perform a comprehensive review of potential options of validated patient-reported outcome measures (PROMs) for consideration of use in postpartum women seeking abdominoplasty; in addition to discussing current driving factors for seeking surgery and associated ethics. RESULTS: Pressure on postpartum women to return their abdominal wall contour to a pre-pregnant state is high. This poses important ethical considerations for surgeons. There are several well-established/validated PROMs used in body contouring in massive weight loss/bariatric population groups, including Body-Q and Body-QoL scales, but none yet specific to postpartum women. CONCLUSION: PROMs use to enable establishment of the true value of abdominoplasty in postpartum women, not just in terms of functional/physical restoration, but also in terms of delivering a positive impact on patients' mental health and QoL, are important. Further research is needed to determine if those already developed are appropriate or whether a postpartum-specific PROM would be beneficial.

Influence of different techniques of secondary cleft lip revision surgery on upper lip projection.

Patient dissatisfaction with labial appearance in the adult cleft lip is frequently linked to poor upper lip projection. Other areas of concern include asymmetry and impaired upper lip height. Different surgical techniques are available to address volumetric deficiencies, according to extent and localization. However, data comparing outcomes in these different areas are limited. The main aim of this study was to assess the relative gains in upper lip projection. An evaluation of upper vermilion height and symmetry was also performed. Thirty-seven consecutive patients treated by a single surgeon had their pre- and postoperative results measured using standardized photographs; these were analysed using subjective and objective outcome measures. Seven examiners evaluated anonymized pre- and postoperative side and front views for subjective evaluation. The objective analysis was performed using Adobe Photoshop. Fifteen lip revisions, four Abbe flaps, 12 dermal grafts, and six PermaLip implants were performed. In bilateral cleft lip and palate patients, Abbe flaps showed the most significant improvement in labial projection, followed by PermaLip implants and dermal grafts. In unilateral cleft lip and palate patients, PermaLip implants best addressed impaired lip projection, followed by dermal grafts. Overall, functional lip revisions showed excellent outcomes for upper lip symmetry; however, only minor changes in labial projection were found.

Phaeochromocytoma and Paraganglioma Excision Involving the Great Vessels.

OBJECTIVE/BACKGROUND: Phaeochromocytomas and paragangliomas are vascular neuroendocrine tumours distributed between the neck and the pelvis and may be associated with catecholamine secretion. The aim of the study was to describe the complex surgical management required to excise these tumours when in close proximity to the great vessels (aorta and vena cava). METHODS: This was a retrospective case series. Patients included those undergoing surgical excision of a phaeochromocytoma or paraganglioma involving the great vessels. Data on clinical presentation; genetic mutations; tumour location; catecholamine/metanephrine secretion; surgical strategy; pre-, intra-, and post-operative course were collated. RESULTS: Five patients (age range 16-60 years) were identified; three had thoracic paragangliomas located under the arch of the aorta, one had an abdominal paraganglioma invading the aorta, and one had a massive phaeochromocytoma invading the inferior vena cava via the adrenal vein. Three patients had predisposing germline mutations. All patients had adrenergic blockade prior to surgery. A diverse range of complex surgical techniques were employed to excise tumours, including cardiopulmonary bypass, aortic resection, grafting and venotomy of the vena cava. Early post-operative complications were limited. CONCLUSIONS: Excision of phaeochromocytomas and paragangliomas involving the great vessels is high risk surgery optimally undertaken within a multidisciplinary setting in a tertiary referral centre. Comprehensive radiological and biochemical assessment, meticulous pre-operative preparation and close intra- and post-operative monitoring are essential. Radiological imaging may be unable to resolve the tumour extent and anatomy pre-operatively and direct visualisation of the tumour may be the only way to clarify the surgical strategy. Pre-operative knowledge of the genetic predisposition may influence surgical management.

Na+/H+ exchanger activity does not contribute to protection by ischemic preconditioning in the isolated rat heart.

BACKGROUND: Despite evidence that pharmacological inhibition of the Na+/H+ exchanger (NHE) is cardioprotective, activation of NHE has been proposed as a protective mechanism of ischemic preconditioning (PC). METHODS AND RESULTS: In isolated rat ventricular myocytes (n=8 to 11 per group) loaded with the fluorescent pH indicator C-SNARF-1, we showed that HOE-642 (HOE) was a potent inhibitor of the sarcolemmal NHE (80% inhibition at 1 micromol/L); such inhibition was readily reversible by washout of the drug. We confirmed that 1 micromol/L HOE produces significant and reversible inhibition of NHE activity in isolated rat hearts as well (n=4), and in this model, we tested (n=8 per group) whether the presence of the drug during (1) the prolonged period of ischemia (40 or 60 minutes) or (2) the preceding brief periods of PC ischemia (3 minutes plus 5 minutes) modulates the protective efficacy of PC. In protocol 1, HOE was infused for 5 minutes immediately before the prolonged ischemic period. With 40 minutes of prolonged ischemia, the postischemic recovery of left ventricular developed pressure (LVDP) was 15+/-2% in controls and was improved to 45+/-7% with HOE (P<.05), 55+/-5% with PC (P<.05), and 68+/-2% with PC+HOE (P<.05 versus all groups). When the prolonged ischemic period was extended to 60 minutes, an additive effect of PC and HOE was readily apparent and LVDP recovery with PC+HOE (66+/-2%) was almost double that observed with HOE (37+/-4%) or PC (34+/-5%) alone (P<.05). In protocol 2, HOE was infused for 3 minutes immediately before each episode of PC ischemia and was subsequently washed out before a 40-minute prolonged ischemic period (HOE+PC). LVDP recovery was 34+/-4% in controls and was improved to 57+/-2% with PC (P<.05) and 55+/-3% with HOE+PC (P<.05). Improved recovery of LVDP was matched by reduced creatine kinase leakage in all cases. CONCLUSIONS: Because coadministration of HOE (at a concentration sufficient to inhibit NHE activity) did not reduce the efficacy of PC in either protocol, we conclude that NHE activity does not contribute to the cardioprotective actions of PC. On the contrary, NHE inhibition during the prolonged ischemic period may enhance the protection afforded by PC.

Na+/H+ exchanger inhibitor HOE-642 improves cardioplegic myocardial preservation under both normothermic and hypothermic conditions.

BACKGROUND: The sarcolemmal Na+/H+ exchanger has been implicated in the pathogenesis of myocardial injury during ischemia/reperfusion. We determined the cardioprotective efficacy of the Na+/H+ exchanger inhibitor HOE-642 (HOE) as an alternative, adjunct, or additive to cardioplegia (CP). METHODS AND RESULTS: In isolated working rat hearts (n=6 per group) subjected to 25 minutes of ischemia at 37 degrees C, the postischemic recovery of aortic flow (AF) was 5+/-3% in controls; this was improved to 18+/-4% by the preischemic infusion of 1 micromol/L HOE (P<.05 versus control) and to 53+/-7% by CP (P<.05 versus control and HOE). In hearts subjected to CP and 35 minutes of ischemia at 37 degrees C, AF recovered to 9+/-3% with CP alone; this was improved to 18+/-3% by the adjunctive administration of HOE during early reperfusion (CP+repHOE, P<.05 versus CP) and to 27+/-4% by the use of HOE as an additive to CP (CP+HOE, P<.05 versus CP and CP+repHOE). With 120 minutes of ischemia at 28 degrees C, AF recoveries were 16+/-3% in CP, 32+/-3% in CP+repHOE (P<.05 versus CP) and to 50+/-4% in CP+HOE (P<.05 versus CP and CP+repHOE). With 300 minutes of ischemia at 7.5 degrees C, the corresponding values were 30+/-4% 45+/-5% (P<.05 versus CP), and 63+/-5% (P<.05 versus CP and CP+repHOE). Improved recovery of pump function was often accompanied by a reduction in creatine kinase leakage during reperfusion. CONCLUSIONS: (i) HOE alone affords significant protection at normothermia but is not a superior alternative to CP, and (ii) the use of HOE as an adjunct or additive to CP provides significant benefit at normothermia, moderate hypothermia, and severe hypothermia.

A surgical approach to coexistent coronary and carotid artery disease.

OBJECTIVE: To assess the early results of combined coronary artery bypass graft surgery and carotid endarterectomy. DESIGN: Retrospective and ongoing analysis of patients who underwent combined coronary artery bypass graft surgery and carotid endarterectomy. SETTING: Cardiothoracic unit in a London teaching hospital. PATIENTS: From June 1987 to March 1995, 64 patients were identified. They were patients who were scheduled to have coronary artery bypass graft surgery or required urgent coronary revascularisation and who were found to have significant coexistent carotid disease. (Unilateral carotid stenosis > 70%, bilateral carotid stenosis > 50%, or unilateral carotid stenosis > 50% with contralateral occlusion.) INTERVENTIONS: Both procedures were performed during one anaesthesia: the carotid endarterectomy was performed first without cardiopulmonary bypass. After completion of carotid endarterectomy, coronary artery bypass graft surgery was performed. MAIN OUTCOME MEASURES: The incidence of stroke, transient ischaemic attack, and myocardial infarction in the early postoperative period was analysed. RESULTS: Myocardial revascularisation was successful in all 64 patients. There were no perioperative infarcts. In three patients (4.7%) a new neurological deficit developed postoperatively: two recovered fully before hospital discharge. CONCLUSIONS: Combined coronary artery bypass graft surgery and carotid endarterectomy were performed safely and with good results.

Myocardial revascularisation in elderly patients with refractory or unstable angina and advanced coronary disease.

BACKGROUND: Elderly patients with ischaemic heart disease are often treated more conservatively and for longer than younger patients, but this strategy may result in subsequent invasive intervention of more advanced and higher risk coronary disease. METHODS: We performed a retrospective analysis of 109 patients aged > or = 70 years (mean age 74 years, 66% men), who presented with angina refractory to maximal medical treatment or unstable angina over a 2-year period (1988-1990), to compare the relative risks and benefits of myocardial revascularisation [coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA)] in this higher-risk age group. RESULTS: Sixty patients underwent CABG and 49 patients PTCA. There were eight periprocedural deaths in total (six in the CABG group, and two in the PTCA group, P = 0.29). Six patients in the CABG group suffered a cerebrovascular accident (two fatal). Acute Q-wave myocardial infarction occurred in one patient in the CABG group and in two patients in the PTCA group. The length of hospital stay was longer for the CABG group (CABG group 11.4 +/- 5.4 days, range 7-30 days, PTCA group 7.4 +/- 7.6 days, range 1-39 days, P = 0.01). Outcome was assessed using the major cardiac event rate (MACE; i.e. the rate of death, myocardial infarction, repeat CABG or PTCA). The cumulative event-free survival in the CABG group in 1, 2 and 3 years was 87, 85 and 85%, respectively. In contrast, in the PTCA group it was 55, 48 and 48% (P = 0.0001). Age, sex, number of diseased vessels, degree of revascularisation and left ventricular function were not predictive of the recurrence of angina in both groups. Actuarial survival (total mortality, including perioperative mortality) was lower at 1 year in the CABG group due to the higher perioperative mortality, but similar in both groups after the second year (P = 0.62). CONCLUSIONS: Elderly patients with refractory or unstable angina who are revascularised surgically have a better long-term outcome (less frequent event rate of the composite end-point--myocardial infarction, revascularisation procedures and death) compared with those who are revascularised with PTCA. This benefit is been realised after the second year. Total mortality is similar in both groups after the second year. Therefore elderly patients who are fit for surgery should not be denied the benefits of CABG. PTCA may be regarded as a complementary and satisfactory treatment, especially for those whose life expectancy is limited to less than 2 years. The use of stents may improve outcome in the PTCA group and this needs to be evaluated.

Dobutamine echocardiography and thallium-201 imaging predict functional improvement after revascularisation in severe ischaemic left ventricular dysfunction.

OBJECTIVES: To evaluate the concordance between thallium-201 uptake and echocardiographic wall thickening, which are both indicators of potentially reversible myocardial dysfunction, in patients with chronic ischaemic left ventricular failure and to assess their relative contribution to predicting improvement in regional function after revascularisation in a subgroup. PATIENTS AND METHODS: 45 patients with chronic ischaemic left ventricular dysfunction (mean (SD) ejection fraction 25 (8)%) underwent echocardiography before and after dobutamine infusion (10 micrograms/kg/min). Of these, 22 patients underwent rest echocardiography at a mean (SD) of 9 (1) weeks after revascularisation. 201Tl imaging was performed during dobutamine echocardiography and at rest, 1, and 4 h after treatment with sublingual glyceryl trinitrate on two separate days. Potentially reversible dysfunction was thought to be present when a myocardial segment contained a Tl score of > or = 3 (ascending score 1-4), or showed improved wall thickening of a dysynergic segment during dobutamine stimulation. RESULTS: Of the 201Tl protocols, the redistribution scan 1 h after treatment with glyceryl trinitrate best demonstrated myocardial viability. Concordance between 201Tl and dobutamine induced wall thickening was 82% (kappa = 0.59) for detecting potentially reversible myocardial dysfunction before revascularisation (n = 45). Regional function improved in 18 of 22 patients after revascularisation. There were 168 dysynergic segments before intervention. The sensitivity of echocardiography and 201Tl imaging for detecting "recoverable" or viable segments after revascularisation was 87% and 92% respectively and specificity was 82% and 78% respectively (P = NS). CONCLUSIONS: Dobutamine echocardiography and 201Tl imaging may be used to predict mechanical improvement in dysynergic segments after revascularisation in patients with chronic ischaemic left ventricular dysfunction.

Dynamics of early postischemic myocardial functional recovery. Evidence of reperfusion-induced injury?

BACKGROUND: The present study was designed to explore the relation between the duration of ischemia and the rate and extent of myocardial functional recovery after reperfusion. METHODS AND RESULTS: Isolated rat hearts were perfused with blood from a support animal for 15 minutes (flow rate, 2.5 mL/min; perfusion pressure, 60.1 +/- 1.3 mm Hg). Control left ventricular developed pressure (LVDP) was measured, and the hearts (six per group) were subjected to 10, 20, 30, 40, 50, 60, 70, or 80 minutes of global ischemia (37 degrees C) and 60 minutes of reperfusion. Pacing (320 beats per minute) was instituted before and after ischemia. In all groups, transient arrhythmias occurred at the onset of reperfusion, to be followed by an early phase of recovery that peaked after 2 to 3 minutes of reperfusion. The relation between the extent of this initial recovery and the duration of preceding ischemia was described by a bell-shaped curve. Thus, the maximum initial mean recovery after 10, 20, 30, 40, 50, 60, 70, or 80 minutes of ischemia was 97%, 108%, 145%, 154%, 118%, 34%, 41%, and 24%, respectively, of preischemic LVDP. Possibly indicative of reperfusion-induced injury, LVDP then declined in all groups so that after 20 minutes of reperfusion, the mean recovery was 63%, 53%, 48%, 50%, 56%, 12%, 9%, and 5%, respectively. In the 10-, 20-, 30-, and 40-minute ischemia groups, there then was a secondary increase in LVDP, possibly indicating the start of recovery from stunning. After 60 minutes of reperfusion, the mean recovery of LVDP was 82%, 65%, 59%, 54%, 47%, 9%, 7%, and 4%, respectively; this second phase of recovery was inversely proportional to the duration of ischemia. To define the early phase of recovery that had been obscured by reperfusion-induced arrhythmias, we repeated the experiments with the inclusion of a cardioplegic infusion (St Thomas' solution for 2 minutes before ischemia). This significantly reduced the incidence of ventricular fibrillation during early reperfusion. The extent of the initial postischemic recovery of LVDP was similar to that observed without cardioplegia; however, the mean secondary recovery was greater in all groups. Again, the relation of early transient (2 to 5 minutes) recovery to the duration of ischemia was represented by a bell-shaped curve, whereas the secondary recovery was inversely related. CONCLUSIONS: Although the results of the present study confirm the protective properties of cardioplegia, they also shed some light on the nature of reperfusion-induced injury and myocardial stunning and their complex relation to the severity of the preceding ischemia.

Surgery for radiation-induced valvular disease.

The effects of radiation on the heart have been well described including acute and chronic pericarditis, myocardial fibrosis, accelerated arteriosclerosis of the coronary arteries. However, valvular dysfunction secondary to mediastinal irradiation has received less attention. We report two cases who developed valvular dysfunction associated with coronary artery disease possibly caused by mediastinal irradiation and a review of the literature regarding surgery for radiation induced valvular disease. Both patients underwent aortic valve replacement and coronary artery bypass graft surgery. With increasingly prolonged survival following mediastinal irradiation, we believe that long term follow up in patients who receive mediastinal irradiation is indicated.

Coronary artery anastomotic contour--a method for individual surgeons to assess their suture techniques.

A method is described whereby individual surgeons may monitor their coronary graft suturing techniques. The coronary artery anastomotic contour is measured quantitatively in corrosion resin cast models made of anastomoses between long saphenous vein and the left anterior descending coronary artery of a pig's heart. The relevant parameter assessing the contour is the mean anastomotic narrowing expressed as a percent (MAN%). To provide an example of the potential of the method, a single surgeon compared a continuous suture technique (n = 30) with an interrupted one (n = 30) using corrosion resin models. There was significantly less (P < 0.05) narrowing of the anastomotic contour with the interrupted technique (mean MAN% = 0.3 +/- 2.9) than with the continuous (mean MAN% = 10.5 +/- 3).

Teratoma associated with endodermal sinus tumor.

A 3-1/2-year-old girl was diagnosed as having a mediastinal endodermal sinus tumor with pulmonary, bony, and hilar lymph node metastases. Following 7 months of treatment with chemotherapy, thoracic CT (computerized tomogram) scan showed the presence of a residual mass. Upon further surgical exploration the residual mass, which was found to be intrapericardial and arising from the ascending aorta, was resected. This second lesion was shown to be a benign cystic teratoma. The combination of an intrapericardial teratoma and a mediastinal endodermal sinus tumor in a female child is probably unique. The possible etiology for the combination of these two pathologies is discussed.

Significance of plasma fibrinogen in coronary arterial disease: marker or causative risk factor for arterial thrombosis?

The relationship between fibrinogen and severity of disease was measured in patients with coronary arterial disease (n = 301) prior to surgical coronary revascularisation. Platelet reactivity (shear-induced haemostasis) was measured from non-anticoagulated blood, in vitro. Coagulation was assessed by the clotting time of flowing native blood (dynamic) and by the conventional (stagnant) tube tests. Significantly enhanced platelet reactivity to shear-stress was observed when patients with one-vessel disease were compared to those with two- or three-vessel disease (P = 0.003). Neither coagulation nor fibrinogen were significantly related to the severity of disease. Furthermore, patients who had myocardial infarction (n = 144) showed enhanced platelet reactivity (P = 0.02) as compared to those who had not (n = 157). Again, neither coagulation nor fibrinogen discriminated between these groups of patients. Relationship between plasma fibrinogen and platelet reactivity was also investigated in vitro. Identical blood samples with normal (220-280 mg/dl) and elevated plasma fibrinogen (approximately 500 mg/dl) were compared by measuring platelet reactivity and coagulation from native blood and platelet aggregation in whole blood. The in vitro studies suggested that plasma fibrinogen and platelet reactivity are inversely associated. Furthermore, increased fibrinogen prolonged dynamic coagulation. These findings do not support the assertion that elevated plasma fibrinogen is a true causative factor for coronary arterial disease and arterial thrombosis.

Chronic traumatic aneurysm of the aorta: to resect or not. The role of exploration operation.

A case is reported of a chronic traumatic aneurysm of the aorta believed to be of 24 years duration in an asymptomatic 43 years old male. At operation the aneurysm was found to be fusiform, rigidly calcified and extending for approximately 8 cm beyond the left subclavian artery. In view of its extent and apparent rigidity of its walls resection and grafting did not proceed. The role of exploratory thoracotomy in the management of chronic traumatic aneurysms of the aorta is discussed.

Contamination of underwater seal drainage systems in thoracic surgery.

The incidence of bacteriological contamination of drainage fluid (water constituting the underwater seal plus drainage effluent) was studied in 38 patients (50 chest drains), up to 6 days after thoracotomy. No bacteriological contamination was demonstrated in any of the samples taken during this period of time. We conclude that the underwater seal drainage system may be left for up to 6 days postoperatively without change of any of its components and without risk of contamination.

Bullet pulmonary embolus and the role of surgery.

A case report is described of a 33-years-old male who suffered a bullet pulmonary embolus following an abdominal gunshot injury. The literature of this rare occurrence is discussed together with the role of surgery in its treatment. Operative removal is advocated in all cases and the optimal time for removal is 1-2 weeks following the initial embolus to allow pulmonary induration, which can prevent peroperative embolus migration.

Quantitative measure of small vessel anastomotic contour using corrosion resin cast models: an aid to surgical training.

A surgeon who had not previously carried out a small vessel anastomosis performed 20 consecutive anastomoses between human long saphenous vein and the left anterior descending artery of a pig's heart. Corrosion resin cast models were made of the anastomoses and subjected to a quantitative analysis of the anastomotic contour. A trend of improvement in contour parameters was found with increasing experience. This model may be useful for surgeons in training.

Modified technique of internal mammary artery harvest.

A simple method of internal mammary artery harvesting is described. Hydrostatic pressure is used as an aid to dissection of the tissues including the internal mammary artery from the chest wall. The technique minimizes trauma to the mammary artery and allows for a rapid harvest.