Andrew L. Tambyraja

Patterns and clinical outcomes associated with routine intravenous sodium and fluid administration after colorectal resection.

Excess intravenous water and sodium may be associated with postoperative complications and an adverse outcome. However, the effect of the magnitude of the surgery on such a relation has not been studied. This study assesses current practice in intravenous fluid and sodium administration after colonic and rectal resection and its relation to the postoperative outcome. A series of 100 consecutive patients undergoing elective colonic (n = 44) or rectal resection (n = 56) were included in a retrospective case-cohort study. The volumes of water and sodium from intravenous fluid and antibiotic administration on the day of surgery and the next 5 days were recorded together with the clinical outcome. The mean ± SEM fluid and sodium administration on the day of operation was greater after rectal than colonic resection (4.6 ± 0.2 vs. 3.6 ± 0.2 liters and 507 ± 34 vs. 389 ± 22 mmol, respectively (p < 0.05). The mean ± SEM rate of daily fluid and sodium administration for the 5 subsequent days was greater following rectal than colonic resection (2.1 ± 0.1 vs. 1.8 ± 0.1 L/day and 155 ± 8.7 vs. 128 ± 8.0 mmol/day; p < 0.05). For all resections, there were no differences in fluid and sodium administration on the day of surgery in patients with or without postoperative complications. During the subsequent 5days, patients with complications after colonic resection had a higher postoperative mean rate of intravenous sodium administration than those who did not (149 ± 12 vs. 115 ± 10 mmol; p < 0.05). A similar pattern was not observed following rectal resection. Current postoperative intravenous fluid prescription delivers approximately 2 liters of fluid and 140 mmol of sodium per day. Complications after colonic, but not rectal, resection are associated with more early postoperative daily intravenous sodium administration. Because colonic resection poses less of a physiologic insult than rectal resection, the overall outcome in the former group may be more sensitive to the interplay between fluid and sodium overload and patient co-morbidity.

Validity of the Glasgow Aneurysm Score and the Hardman Index in predicting outcome after ruptured abdominal aortic aneurysm repair

The Glasgow Aneurysm Score and the Hardman Index have been recommended as predictors of outcome after repair of ruptured abdominal aortic aneurysm (AAA). This study aimed to assess their validities.

Prognostic scoring in ruptured abdominal aortic aneurysm: A prospective evaluation

BACKGROUND Prospective validation of prognostic scoring systems for ruptured abdominal aortic aneurysm (AAA) is lacking. This study assesses the validity of three established risk scores and a new prognostic index. METHOD Patients admitted with ruptured AAA during a 26-month period (August 2002-December 2004) were recruited prospectively. The Glasgow Aneurysm Score (GAS), Hardman Index, Physiological and Operative Severity Score for enUmeration of Mortality and Morbidity (POSSUM) scores, and the Edinburgh Ruptured Aneurysm Score (ERAS) were recorded and related to outcome. RESULTS During the study period, 111 patients were admitted with ruptured AAA. Of these, 84 (76%) underwent attempted operative repair and were included in the study; 37 (44%) died after operation. The GAS, Hardman Index, and the ERAS were statistically related to mortality. However, analysis by receiver-operator characteristic curve revealed the ERAS to have an area under the curve (AUC) of 0.72 (95% confidence interval [CI], 0.61-0.83). The vascular (V)-POSSUM and ruptured AAA (RAAA)-POSSUM models had an AUC of 0.70 (95% CI, 0.59-0.82). The Hardman Index and GAS had an AUC of 0.69 (95% CI, 0.57-0.80) and 0.64 (95% CI, 0.52-0.76), respectively. Although the V-POSSUM equation predicted mortality effectively (P = .086), the RAAA-POSSUM derivative demonstrated a significant lack of fit (P = .009). CONCLUSION Prospective validation shows that the Hardman Index, GAS, and V-POSSUM and RAAA-POSSUM scores do not perform well as predictors for death after ruptured AAA. The ERAS accurately stratifies perioperative risk but requires further validation.

Attitudes of medical students toward careers in general surgery

BackgroundChanges to general surgical undergraduate curricula, alongside changes in work force and postgraduate training, may be associated with a decline in interest in surgical careers. This study examines the attitudes of students toward surgical training and their career intentions.MethodsA prospective, questionnaire-based survey was submitted to final year students at the end of their general surgery attachment over a single academic year at a UK medical school. Career ambitions and reasoning were assessed.ResultsOf 223 eligible students, 193 (87%) completed the questionnaire. There were 118 (61%) females and 75 (39%) males with a median (range) age of 23 (21–41) years. Ninety-eight (51%) respondents undertook their placement at a Teaching Hospital, whereas 93 (41%) were attached to a District General Hospital. One-hundred forty-three (74%) students felt that a four-week attachment had given them a satisfactory exposure to General Surgery, and 36 (19%) disagreed. Sixty-eight (53%) students were unable to select a single specialty that they would most like to pursue as a future career. Of the remainder, 23 (12%) chose general surgery, 24 (12%) chose general medicine, and 22 (11%) chose general practice. Seventy-eight (40%) students would consider a career in general surgery, and 75 (39%) would not; 40 (29%) were undecided. The two most popular attractions to general surgery were challenging postgraduate training and highly regarded career esteem. The two most common disincentives were family considerations and the sacrifice of personal time.ConclusionsFewer than half of the final year medical students surveyed were willing to consider general surgery as a future career choice. Potential disincentives should be targeted to promote recruitment into the specialty

POSSUM scoring for laparoscopic cholecystectomy in the elderly

Background:  Physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) scoring is a validated scoring system in the audit of surgical outcomes; however, evaluation of this system has mostly been applied to open surgical techniques. The present study examines the validity of POSSUM in predicting morbidity and mortality in patients undergoing laparoscopic cholecystectomy (LC) with the recognized risk factor for postoperative mortality of advanced age.

Natural history of thoraco-abdominal aneurysm in high-risk patients.

INTRODUCTION There is considerable interest in the role of novel endovascular techniques for the treatment of patients with complex aneurysms who are unsuitable for standard interventions. Knowledge of the natural history of these lesions, as well as other co-morbidities, is required in order that these techniques may be applied correctly in this high-risk group. METHOD This study reviews the outcome of patients deemed to be unfit for surgery following assessment under the Scottish National Thoraco-abdominal aneurysm service (TAAA) service (2002-2008). RESULTS Of 216 patients assessed, 89 (41%) patients were considered to be unfit for intervention. The median (interquartile range, IQR) age of patients was 75 (70-80) years and there were 39 men (44%). Median (IQR) aneurysm size was 6 (5.6-7.0) cm. The median (IQR) follow-up time was 12 (7-26) months. There were 49 (55%) deaths during the follow-up period of which 23 (47%) cases were due to ruptured TAAA and 26 (53%) were not aneurysm-related. Comparing patients with aneurysms <6 cm (33 patients) with those aneurysms > or =6 cm (56 patients) there was no difference in aneurysm-related death (p = 0.32) or all-cause mortality (p = 0.147). CONCLUSION Aneurysm-related mortality amongst patients unsuitable for open TAAA surgery is considerable and evolving endovascular techniques may permit intervention in selected patients. However any intervention can only be justified if the patients life expectancy is sufficient to allow benefit to accrue.

Cardiac troponin I predicts outcome after ruptured abdominal aortic aneurysm repair

Cardiac troponin I (cTnI) is a highly sensitive and specific marker for myocardial injury that predicts mortality in patients with acute coronary syndromes. This study examined the relationship between perioperative cTnI levels and clinical outcome in patients with ruptured abdominal aortic aneurysm (AAA).

Non-operative Management of High-Risk Patients with Abdominal Aortic Aneurysm

OBJECTIVES to determine the risk of rupture in patients with large non-operated abdominal aortic aneurysms (AAAs). METHODS in 128 patients admitted over a 5-year period with an intact AAA, and who did not have a surgical repair were included, initial maximum antero-posterior AAA diameter was related to survival and cause of death. RESULTS at the end of follow-up 27/52 (52%) patients with AAA <55 mm were alive compared to 17/62 (27%) patients with AAA > or =55 mm. Six (12%) in the former and 18 (29%) in the latter group had an AAA-related death. However, non-AAA-related death was commoner in both groups. CONCLUSION these findings support a role for non-operative management in high-risk patients with large AAAs.

Systemic Inflammation and Repair of Abdominal Aortic Aneurysm

BackgroundInflammation is integral to the pathogenesis of abdominal aortic aneurysm (AAA). This study examines preoperative biomarkers of systemic inflammation in patients undergoing open repair of intact and ruptured AAA.MethodsOne-hundred twelve patients were entered into a prospective observational study. Preoperative POSSUM physiology score, C-reactive protein (CRP), white blood count (WBC), platelet count, fibrinogen, and albumin were recorded and related to clinical variables using univariate analysis.ResultsSixty-one patients with a ruptured AAA, 39 with an asymptomatic intact AAA, and 12 with an acutely symptomatic intact AAA underwent attempted repair. There were two inflammatory asymptomatic aneurysms and one inflammatory ruptured aneurysm. No patient had clinical evidence of coexistent inflammatory disease. Patients with a symptomatic intact AAA had a significantly greater level of CRP and fibrinogen, higher WBC, and lower serum albumin, than those with an asymptomatic intact AAA. Patients with a ruptured aneurysm had a significantly greater level of CRP, higher WBC, and lower serum albumin than those with an asymptomatic intact aneurysm. Patients with a symptomatic intact AAA had a significantly higher CRP level, but lower WBC, than those with a ruptured AAA. There was no difference in CRP level, WBC, or serum albumin between survivors and non-survivors of attempted repair of asymptomatic, symptomatic and ruptured AAA.ConclusionsAcutely symptomatic and ruptured AAAs are associated with an early elevation in systemic inflammatory biomarkers. This early activation of the inflammatory response might influence perioperative outcome.

Autologous deep vein reconstruction of infected thoracoabdominal aortic patch graft

Graft infection remains a serious complication of prosthetic aortic repair. Infection of thoracoabdominal aortic prosthetic grafts, in particular, is a significant clinical challenge and is associated with high mortality. We report successful in situ reconstruction of an infected thoracoabdominal aortic prosthetic patch graft with autogenous superficial femoral vein. To our knowledge, this is the first such case described in the North American and English language surgical literature. At 24-month follow-up the patient remains well, with no evidence of sepsis or graft complication at clinical and radiologic assessment.