Postoperative venous thromboembolism prophylaxis by general surgeons in a developing country: a survey.

Venous thromboembolism (VTE) is the most common preventable cause of hospital death. Several audits in the west have demonstrated that appropriate thromboprophylaxis is not being offered to a large number of surgical patients. Similar audits are lacking in the Indian population, and a perception exists among Indian surgeons that Indian patients are not susceptible to VTE. Hence we undertook a survey to analyze the existing knowledge and practice of VTE prophylaxis amongst general surgeons in India. A questionnaire-based survey was conducted on 100 active general surgeons. We found that 97% of surgeons had encountered VTE in their practice, and 49% had encountered mortality from pulmonary embolism. 64% of surgeons do not routinely score patients preoperatively for their VTE risk, and only 33% reported the presence of an institute-based protocol for the same. There was a wide disparity in the prophylaxis methods used for each risk group, particularly in the moderate-risk group. These findings suggest the need for adoption of institute-based protocols for prophylaxis and the evolution of Indian guidelines for VTE prophylaxis.

Cardiac herniation following completion pneumonectomy for bronchiectasis.

Sporadic reports on cardiac herniation are available in the literature; most of them had followed intrapericardial pneumonectomies for malignant pulmonary tumors. We present an uncommon event of heart herniation after a completion pneumonectomy indicated for chronic bronchiectasis. A 35-year-old male patient was operated for left completion pneumonectomy. A 6 cm x 4 cm area of adherent pericardium near the obtuse margin of heart was removed during surgery. During head-end elevation of the bed in postoperative intensive care unit, patient got accidentally tilted to the left side, which resulted in ventricular fibrillation. Chest cavity was re-opened for cardiopulmonary resuscitation. Left ventricle was found herniating through the pericardial deficiency into the left-thoracic cavity with the cardiac apex touching chest wall. During surgical re-exploration, the pericardial deficiency was closed with a synthetic Dacron patch. Hemodynamic condition remained stable in the immediate postoperative period. Patients had infection of the left thoracic cavity after 5 weeks, for which he was subjected to thoracoplasty and omentopexy. Prompt recognition with timely intervention is life saving from cardiac herniation. Strategy of closing the pericardial defect after pneumonectomy should be followed routinely, irrespective of the indication for pneumonectomy.

Experiences with carotid endarterectomy at Sree Chitra Tirunal Institute.

BACKGROUND: Atherosclerotic carotid artery disease poses a grave threat to cerebral circulation, leading to a stroke with its devastating sequelae, if left untreated. Carotid endarterectomy has a proven track record with compelling evidence in stroke prevention. OBJECTIVES: a) To confirm that carotid endarterectomy (CEA) is safe and effective in preventing stroke at both short and long term. b) to demonstrate long term patency of internal carotid artery when arteriotomy repair is performed using autologous saphenous vein patch. MATERIALS AND METHODS: During ten years, from September 1997 to February 2008, thirty nine patients who underwent consecutive carotid endarterectomy at our institute, form the basis of this report. Their age ranged from thirty to seventy eight years, with a mean age of 56. There were four women in this cohort. Thirty seven patients were symptomatic with >70% stenosis and two were asymptomatic with >80% stenosis, incidentally detected. Imaging included Duplex scan and MRA for carotid territory and brain, and non-invasive cardiac assessment. Co-morbidities included smoking, hypertension, diabetes, and coronary artery disease. Carotid Endarterectomy was performed under general anaesthesia, using carotid shunt and vein patch arteriotomy repair. RESULTS: All the patients made satisfactory recovery, without major adverse cerebral events in this series. Morbidities included Transient Ischemic Attack (TIA) in two, needing only medications in one, and carotid stenting in the other. Minor morbidities included neck hematoma in two and transient hypoglossal paresis in three patients. Yearly follow-up included duplex scan assessment for all the patients. Two patients died of contralateral stroke, two of myocardial events and two were lost to follow up. Thirty three patients are well and free of the disease during the follow up of three to 120 months. CONCLUSION: Carotid endarterectomy provided near total freedom from adverse cerebral events and its catastrophic sequelae, leading to excellent outcome, both short as well as long term.