Experiences with redo aortic valve surgery

Objectives and Methods: Reoperations are an integral part of a cardiac surgeon's practice. We share our experience of 546 reoperations over the last 21 years to January 2000, with the focus directed towards the timing of reoperation, reducing the mortality and morbidity of reoperation and rereplacement aortic valve surgery, and understanding the important risk factors. In addition, the precise technical steps that facilitate careful successful explantation of various devices (allograft, stented and stentless xenografts, and mechanical valves) are detailed. Results: Optimal planned reoperation before deterioration to New York Heart Association Class III/IV levels and before unfavorable cardiac and comorbidity general system failure occurs has produced low mortality and morbidity as compared with first operation results. However, unfavorable delays and late rereferral result in mortality rates of up to 22% for emergency redo AVR for degenerated bioprostheses. Conclusion: Cardiac surgical units have the opportunity to establish a closer patient-surgeon relationship, which favors, when necessary, the optimal timing of reoperation. Knowledge of the more important risk factors and adherence to specific technical steps at explantation of various devices enhances satisfactory reoperation outcomes.

Perioperative epidural analgesia and outcome after major abdominal surgery in high-risk patients

In a primary analysis of a large recently completed randomized trial in 915 high-risk patients undergoing major abdominal surgery, we found no difference in outcome between patients receiving perioperative epidural analgesia and those receiving IV opioids, apart from the incidence of respiratory failure. Therefore, we performed a selected number of predetermined subgroup analyses to identify specific types of patients who may have derived benefit from epidural analgesia. We found no difference in outcome between epidural and control groups in subgroups at increased risk of respiratory or cardiac complications or undergoing aortic surgery, nor in a subgroup with failed epidural block (all P > 0.05). There was a small reduction in the duration of postoperative ventilation (geometric mean [SD]: control group, 0.3 [6.5] h, versus epidural group, 0.2 [4.8] h, P = 0.048). No differences were found in length of stay in intensive care or in the hospital. There was no relationship between frequency of use of epidural analgesia in routine practice outside the trial and benefit from epidural analgesia in the trial. We found no evidence that perioperative epidural analgesia significantly influences major morbidity or mortality after major abdominal surgery.

Increased rates of ENT surgery among young children: Have clinical guidelines made a difference?

Objectives: To examine the association between introduction of paediatric ear, nose and throat (ENT) surgery guidelines and population procedure rates. To determine changes in children's risk of undergoing ENT surgery. Methods: Trend analysis of incidence of myringotomy, tonsillectomy and adenoidectomy among New South Wales (NSW) children aged 0-14 between 1981 and mid 1999. Poisson regression models were used to estimate annual rates of change pre and postguidelines introduction and age/gender specific rates, and lifetable methods to determine risk of undergoing an ENT procedure by age 15. Results: ENT surgery rates increased by 21% over the study period. Children's risk of surgery increased from 17.9% in 1981 to 20.2% in 1998/99. Guideline introduction was associated with moderate short-term decreases in rates. For tonsillectomy, rates decreased between 1981 and 1983, but then rose continually until the introduction of myringotomy guidelines in 1993, when they fell, only to recommence rising until the end of the study period. For myringotomy, rates rose annually from 1981 to 1992/93 and fell in the 3 years following guideline introduction, after which they rose again. Increases were almost exclusively restricted to children aged 0-4 and correspond with increased use of formal childcare. The prevalence of myringotomy by the age of 5 years rose from 5.6% of children born in 1988/89 to 6.4% of those born in 1994/95, and the prevalence of tonsillectomy from 2.4% to 2.7%. Conclusions: The risk of young Australian children undergoing ENT surgery increased significantly over the last two decades despite the introduction of guidelines and no evidence of an increase in otitis media, one condition prompting surgery. Surgery increased most among the very young. We hypothesize this is related to increasing use of childcare.

National audit of anaesthesia for major abdominal surgery

A postal survey was conducted of all hospitals in Australia known to have a department of anaesthesia and an intensive care or high dependency unit. Each hospital was asked to report the anaesthetic and postoperative analgesic techniques used for the last ten cases of four common major surgical procedures-aorto-femoral bypass, repair of an abdominal aortic aneurysm, hemicolectomy and anterior resection of the rectum. Half of 76 hospitals sent a survey form completed and returned it. Responding hospitals were larger on average, than non-responding ones, but otherwise typical of them in terms of university affiliation and metropolitan versus rural location. For each of the procedures studied the proportion of cases in which epidural block was used intra- or postoperatively varied from 0% to 100%. Depending on the procedure, between 65% and 85% of hospitals used epidural block sometimes, with between 10% and 90% of patients in these hospitals being managed with this technique. There is wide variation in the use of epidural block, intra- and postoperatively, in Australia, variation that is unlikely to be explained by systematic differences between institutions in the patients seen or their suitability for one or other technique. This pattern of practice mirrors the lack of agreement about the proper place for epidural techniques evident in the recent literature. There is a widespread belief among clinicians that this is a question of great importance. Accordingly, we believe that anaesthetists and surgeons share an ethical responsibility to enter suitable patients in an appropriately designed randomized controlled trial in order to resolve this question.

Research output of Australian general practice: A comparison with medicine, surgery and public health

Objectives: To compare the productivity of Australian general practice in terms of research publications with the productivity of other medical disciplines. Design: A survey of Australian general practice, medicine, surgery and public health publications carried out by manual searching of specific journals and an electronic search of the US National Library of Medicine's PubMed database. Main outcome measures: The number of original research publications by Australian general practitioners, physicians, surgeons and public health physicians during 1999; the relative publication rate of Australian general practice, medicine, surgery and public health over the period 1990-1999. Results: Of original research articles published in 1999, GPs authored 65% (17/26) in Australian Family Physician and 3% (3/90) in the Medical Journal of Australia; physicians published 4% and 37%, respectively. The electronic search identified 54 research articles relating to Australian general practice published in 1999 in 21 different journals, only two of which were primary care journals. Over the period 1990-1999, there was a publication rate of one general practice [discipline] article per 1000 GPs in practice per year. Corresponding rates for medicine, surgery and public health were 105/1000, 61/1000 and 148/1000, respectively. Conclusions: There is considerable disparity between the level of research output of general practice and that of the disciplines of medicine, surgery and public health. If we are to have effective general practice research, we urgently need to develop research skills, a supportive infrastructure and a culture that nurtures research.

Delayed orbital hemorrhage after routine strabismus surgery

PURPOSE: To report a case of delayed rectus muscle hemorrhage after strabismus surgery. METHODS: Case report. RESULTS: Rectus muscle hemorrhage occurred 36 hours after strabismus surgery in a 26-year-old man, causing temporary loss of vision and reduced ocular motility. Urgent lateral cantholysis and orbital exploration to restore hemostasis were undertaken. Full recovery of vision occurred and a small residual motility disturbance was present 3 months postoperatively. CONCLUSION: Delayed rectus muscle hemorrhage post-strabismus surgery is rare but can have sight-threatening effects. When vision is threatened because of optic nerve compromise, urgent orbital exploration may allow full recovery of function. (Am J Ophthalmol 2001;131: 818-819, (C) 2001 by Elsevier Science Inc. All rights reserved.).