Postoperative therapy

Brekke, J. H., Bresner, M., and Reitman, M. J., Polylactic acid surgical dressing material. Postoperative therapy for dental extraction wounds. Can. Dent. Assoc. J., 52, 599,... 

The 5-yr survival rate after curative resection for gastric cancer is only 30-40%. Treatment failure in these cases stems from a combination of local or regional recurrence and distant metastasis. This has stimulated interest in adjuvant and postoperative therapy in the hope of improving treatment results. 

Wide local excision and selective postoperative therapy have been used in patients with early-stage distal carcinomas. Retrospective studies have identified patients with tumors less than 3 cm in size, limited to the superficial muscularis propria, and favorable... 

Pre and postoperative therapy in postmenopausal women undergoing vaginal surgery. 

Postoperative analgesia from morphine has been shown to be the most effective if administered at the completion of the procedure (Brandsson et al 2000, Reuben et al 2001, Tetzlaff et al 2000). In these cases, it appears that the postoperative use of morphine allows the clinician to reduce both the level and the duration of other analgesics. This is not to say that the only potential benefit of morphine is in the postoperative patient. Morphine has also been shown to be of equivalent effect to corticosteroid administration in other forms of chronic arthritides (Keates et al 1999, Stein et al 1999). The reductions in inflammatory cell influx, reduced edema formation and analgesia provided with minimal systemic effects make intraarticular morphine a very attractive postoperative therapy. I most commonly use a combination of 5-15 mg morphine with 6 mg lidocaine for postoperative analgesia and have seen no untoward effects. The beneficial effects with respect to improved analgesia and ability to reduce the usage of NSAIDs remains to be proven. 

Danazol has been proven effective as empirical therapy as well as postoperative therapy. Symptomatic improvement has been reported in up to 80% to 90% of women using the drug, with the best results seen in women achieving amenorrhea. A systematic review concluded that 6 months of danazol therapy is superior to placebo in relieving painful symptoms. " Therapy for only 3 months has not been as successful, especially when used postoperatively. ... 

Figure 6. Surgical placement of the flexible hinge finger joint implant. The metacarpal head is removed to create an appropriate joint space and the intramedullary canals are then prepared to accept the implant stems. When the implant is placed in position the stems fit securely in the intramedullary canals with the flexible hinge permitting 90° active motion. Joint space is maintained by transfer of the compressive forces of joint motion across the implant to cortical bone. Careful attention to reconstructions of tendons, ligaments, and joint capsules and postoperative therapy are very important in this procedure.

Vasopressin and its derivatives are used in die treatment of diabetes insipidus, a disease resulting from die failure of the pituitary to secrete vasopressin or from surgical removal of die pituitary. Diabetes insipidus is characterized by marked increase in urination (as much as 10 L in 24 hours) and excessive tiiirst by inadequate secretion of die antidiuretic hormone or vasopressin. Treatment with vasopressin therapy replaces die hormone in the body and restores normal urination and thirst Vasopressin may also be used for die prevention and treatment of postoperative abdominal distention and to dispel gas interfering with abdominal roentgenography. 

Finally, a Cochrane review of antiplatelet therapy following CEA found no evidence of a difference in mortality when antiplatelets were compared with placebo. However, treatment with antiplatelet agents following CEA decreased the risk of postoperative stroke (OR 0.58, 95% Cl 0.34-0.98). ... 

Subtotal thyroidectomy is indicated in patients with very large goiters and thyroid malignancies and those who do not respond or cannot tolerate other therapies. Patients must be euthyroid prior to surgery, and patients often are administered iodide preoperatively to reduce gland vascularity. The overall surgical complication rate is 2.7%. Postoperative hypothyroidism occurs in 10% of patients who undergo subtotal thyroidectomy. 

Empirical therapy for postoperative infections in neurosurgical patients (including patients with CSF shunts) should include vancomycin in combination with either cefepime, ceftazidime, or meropenem. Linezolid has been reported to reach adequate CSF concentrations and resolve cases of meningitis refractory to vancomycin.35 However, data with linezolid are limited. The addition of rifampin should be considered for treatment of shunt infections. When culture and sensitivity data are available, pathogen-directed antibiotic therapy should be administered. Removal of infected devices is desirable aggressive antibiotic therapy (including high-dose intravenous antibiotic therapy plus intraventricular vancomycin and/or tobramycin) may be effective for patients in whom hardware removal is not possible.36... 

Brain abscesses are localized collections of pus within the cranium. These infections are difficult to treat due to the presence of walled-off infections in the brain tissue that are hard for some antibiotics to reach. In addition to appropriate antimicrobial therapy (a discussion of which is beyond the scope of this chapter), surgical debridement is often required as an adjunctive measure. Surgical debridement also may be required in the management of neurosurgical postoperative infections. 

In patients with peritonitis, hypovolemia is often accompanied by acidosis, so large volumes of a solution such as lac-tated Ringers may be required initially to restore intravascular volume. Maintenance fluids should be instituted (after intravascular volume is restored) with 0.9% sodium chloride and potassium chloride (20 mEq/L) or 5% dextrose and 0.45% sodium chloride with potassium chloride (20 mEq/L). The administration rate should be based on estimated daily fluid loss through urine and nasogastric suction, including 0.5 to 1.0 L for insensible fluid loss. Potassium would not be included routinely if the patient is hyperkalemic or has renal insufficiency. Aggressive fluid therapy often must be continued in the postoperative period because fluid will continue to sequester in the peritoneal cavity, bowel wall, and lumen. 

Another unique aspect of rectal cancer is the use of neoadjuvant therapy. Preoperative radiation with or without chemotherapy is given to downstage the tumor prior to surgical resection to improve sphincter preservation by making the surgical procedure easier to perform. The issue of preoperative versus postoperative radiation is a subject of debate and investigation in the United States and will require further data to determine the superiority of one method over the other. 

Patients must be monitored to assess their response to treatment and to detect recurrent diseases. PSA as a specific marker for prostate cancer is most useful in monitoring patients who have been treated with radical prostatectomy, radiation therapy, or endocrine therapy. The concentration of PSA falls to undetectable levels following a radical prostatectomy because all prostate tissue has been removed. Generally, PSA is measured at periodic intervals. In studies, the extent of disease at the time of surgery correlated well with the postoperative PSA concentration. A significant measurable PSA concentration after prostatectomy indicates that residual tumor may be present. PSA concentrations decline gradually after radiation therapy (36). 

An increasing number of both clinical and laboratory-derived observations support the importance of luminal components in driving the inflammatory response in ulcerative colitis and Crohn s disease. Although its role is unclear, antibiotic therapy is commonly used in clinical practice for the treatment of moderately to severely active ulcerative colitis. Metronidazole and/or ciprofloxacin are currently employed in active Crohn s disease, particularly in patients with colonic involvement and with perianal disease. Rifaximin, a rifamycin-derived antibiotic, is characterized by a wide range of antibacterial activity and a very low systemic absorption. Some preliminary data show its efficacy in severe active ulcerative colitis, pouchitis and prevention of postoperative recurrence in Crohn s disease. 

Venous thrombectomy may be performed to remove a massive obstructive thrombus in a patient with significant iliofemoral venous thrombosis, particularly if the patient is either not a candidate for or has not responded to thrombolysis. Full-dose anticoagulation therapy is essential during the entire operative and postoperative period. These patients need indefinite oral anticoagulation therapy targeted to an INR of 2.5 (range 2.0 to 3.0). 

Initiation of therapy - App y one system to the postauricular skin (ie, behind the ear) at least 4 hours before the antiemetic effect is required. To prevent postoperative nausea and vomiting, apply the patch the evening before scheduled surgery. To minimize exposure of the newborn baby to the drug, apply the patch 1 hour prior to cesarean section. Scopolamine approximately 1 mg will be delivered over 3 days. Wear only one disc at a time. Do not cut the patch. 

Analgesia, adjunctive therapy (parenteral only) - As pre- and postoperative and pre- and postpartum adjunctive medication to permit reduction in narcotic dosage. 

Hepatic/Renal function impairment Because of the potential for nephrotoxicity, give patients with renal or hepatic impairment doses at the lowest value of the recommended IV and oral dosing ranges. Therapy may need to be delayed by up to 48 hours or longer in patients with postoperative oliguria. 

Initial dose 5 to 6 mg/kg/day given 4 to 12 hours prior to transplantation as a single IV dose. Continue this daily single dose postoperatively until the patient can tolerate the oral doseforms. Switch patients to oral therapy as soon as possible. 

---