Cost-effectiveness of simultaneous versus sequential surgery in head and neck reconstruction.

PubMed

Wong, Kevin K; Enepekides, Danny J; Higgins, Kevin M

2011-02-01

To determine whether simultaneous (ablation and reconstruction overlaps by two teams) head and neck reconstruction is cost effective compared to sequentially (ablation followed by reconstruction) performed surgery. Case-controlled study. Tertiary care hospital. Oncology patients undergoing free flap reconstruction of the head and neck. A match paired comparison study was performed with a retrospective chart review examining the total time of surgery for sequential and simultaneous surgery. Nine patients were selected for both the sequential and simultaneous groups. Sequential head and neck reconstruction patients were pair matched with patients who had undergone similar oncologic ablative or reconstructive procedures performed in a simultaneous fashion. A detailed cost analysis using the microcosting method was then undertaken looking at the direct costs of the surgeons, anesthesiologist, operating room, and nursing. On average, simultaneous surgery required 3 hours 15 minutes less operating time, leading to a cost savings of approximately $1200/case when compared to sequential surgery. This represents approximately a 15% reduction in the cost of the entire operation. Simultaneous head and neck reconstruction is more cost effective when compared to sequential surgery.

Comparison of vocal outcomes after angiolytic laser surgery and microflap surgery for vocal polyps.

PubMed

Mizuta, Masanobu; Hiwatashi, Nao; Kobayashi, Toshiki; Kaneko, Mami; Tateya, Ichiro; Hirano, Shigeru

2015-12-01

The microflap technique is a standard procedure for the treatment of vocal fold polyps. Angiolytic laser surgery carried out under topical anesthesia is an alternative method for vocal polyp removal. However, it is not clear whether angiolytic laser surgery has the same effects on vocal outcomes as the microflap technique because of a lack of studies comparing both procedures. In the current study, vocal outcomes after both procedures were compared to clarify the effects of angiolytic laser surgery for vocal polyp removal. Vocal outcomes were reviewed for patients who underwent angiolytic laser surgery (n=20, laser group) or microflap surgery (n=34, microflap group) for vocal polyp removal. The data analyzed included patient and lesion characteristics, number of surgeries required for complete resolution, and aerodynamic and acoustic examinations before and after surgery. In the laser surgery group, complete resolution of the lesion was achieved with a single procedure in 17 cases (85%) and with two procedures in 3 cases (15%). Postoperative aerodynamic and acoustic parameters demonstrated significant improvement compared to preoperative parameters in both the laser surgery group and the microflap surgery group. There were no significant differences in any postoperative aerodynamic and acoustic parameters between the two groups. The current retrospective study demonstrated that angiolytic laser surgery achieved complete resolution of vocal polyps within two procedures. Postoperative effects on aerodynamic and acoustic functions were similar to those after microflap surgery. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Propranolol reduces the anxiety associated with day case surgery.

PubMed

Mealy, K; Ngeh, N; Gillen, P; Fitzpatrick, G; Keane, F B; Tanner, A

1996-01-01

To find out if propranolol, a non-cardioselective beta-blocker, can reduce the anxiety associated with day case surgery. Prospective randomized double blind trial. University hospital, Ireland. An unselected group of 53 patients undergoing day case surgery. Subjects randomised to receive either propranolol (10 mg) or placebo on the morning of operation. Blood pressure; pulse, anxiety, pain score and patient satisfaction. Mean (SD) Hospital Anxiety and Depression score was significantly lower in the propranolol group than in the control group (2.5 (0.7) compared with 4.6 (0.7), p < 0.0001) before discharge. A low dose of propranolol given on the morning of day case surgery significantly reduced patients' anxiety.

Safety of minimally invasive pituitary surgery (MIPS) compared with a traditional approach.

PubMed

White, David R; Sonnenburg, Robert E; Ewend, Matthew G; Senior, Brent A

2004-11-01

Transsphenoidal hypophysectomy is becoming progressively less invasive. Recent endoscopic techniques avoid nasal or intraoral incisions, use of nasal speculums, and nasal packing. Several case series of endoscopic endonasal pituitary surgery have been reported, but relatively little data exists comparing complication rates to more traditional approaches. We compare the complications of our first 50 cases of endoscopic, minimally invasive pituitary surgery (MIPS) to our last 50 sublabial transseptal (SLTS) procedures. Retrospective case control study. Fifty consecutive MIPS procedures and 50 consecutive SLTS procedures were reviewed retrospectively. Complication rates were analyzed and compared. Total complications per patient (P = .005), postoperative epistaxis (P = .031), lip anesthesia (P = .013), and deviated septum (P = .028) occurred more often in the SLTS group. No significant difference was seen in cerebrospinal fluid leak, meningitis, ophthalmoplegia, visual acuity loss, diabetes insipidus, intracranial hemorrhage, or death. In the MIPS group, length of stay (P < .001), use of lumbar drainage (P = .007), and nasal packing (P < .001) were also significantly reduced. Endoscopic endonasal pituitary surgery provides improved complication rates when compared with SLTS approaches. In addition, we note advantages of the MIPS approach, including reduced length of hospital stay and decreased use of lumbar drainage and nasal packing.

An acute care surgery rotation contributes significant general surgical operative volume to residency training compared with other rotations.

PubMed

Stanley, Matthew D; Davenport, Daniel L; Procter, Levi D; Perry, Jacob E; Kearney, Paul A; Bernard, Andrew C

2011-03-01

Surgical resident rotations on trauma services are criticized for little operative experience and heavy workloads. This has resulted in diminished interest in trauma surgery among surgical residents. Acute care surgery (ACS) combines trauma and emergency/elective general surgery, enhancing operative volume and balancing operative and nonoperative effort. We hypothesize that a mature ACS service provides significant operative experience. A retrospective review was performed of ACGME case logs of 14 graduates from a major, academic, Level I trauma center program during a 3-year period. Residency Review Committee index case volumes during the fourth and fifth years of postgraduate training (PGY-4 and PGY-5) ACS rotations were compared with other service rotations: in total and per resident week on service. Ten thousand six hundred fifty-four cases were analyzed for 14 graduates. Mean cases per resident was 432 ± 57 in PGY-4, 330 ± 40 in PGY-5, and 761 ± 67 for both years combined. Mean case volume on ACS for both years was 273 ± 44, which represented 35.8% (273 of 761) of the total experience and exceeded all other services. Residents averaged 8.9 cases per week on the ACS service, which exceeded all other services except private general surgery, gastrointestinal/minimally invasive surgery, and pediatric surgery rotations. Disproportionately more head/neck, small and large intestine, gastric, spleen, laparotomy, and hernia cases occurred on ACS than on other services. Residents gain a large operative experience on ACS. An ACS model is viable in training, provides valuable operative experience, and should not be considered a drain on resident effort. Valuable ACS rotation experiences as a resident may encourage graduates to pursue ACS as a career. Copyright © 2011 by Lippincott Williams & Wilkins

A Comparison of the Local Flap and Skin Graft by Location of Face in Reconstruction after Resection of Facial Skin Cancer.

PubMed

Lee, Kyung Suk; Kim, Jun Oh; Kim, Nam Gyun; Lee, Yoon Jung; Park, Young Ji; Kim, Jun Sik

2017-12-01

Surgery for reconstruction of defects after surgery should be performed selectively and the many points must be considered. The authors conducted this study to compare the local flap and skin graft by facial location in the reconstruction after resection of facial skin cancer. The authors performed the study in patients that had received treatment in Department of Plastic Surgery, Gyeongsang National University. The cases were analyzed according to the reconstruction methods for the defects after surgery, sex, age, tumor site, and tumor size. Additionally, the authors compared differences of aesthetic satisfaction (out of 5 points) of patients in the local flap and skin graft by facial location after resection of facial skin cancer by dividing the face into eight areas. A total of 153 cases were confirmed. The most common facial skin cancer was basal cell carcinoma (56.8%, 87 cases), followed by squamous cell carcinoma (37.2%, 57 cases) and bowen's disease (5.8%, 9 cases). The most common reconstruction method was local flap 119 cases (77.7%), followed by skin graft 34 cases (22.3%). 86 patients answered the questionnaire and mean satisfaction of the local flap and skin graft were 4.3 and 3.5 ( p =0.04), respectively, indicating that satisfaction of local flap was significantly high. When comparing satisfaction of patients according to results, local flap shows excellent effects in functional and cosmetic aspects would be able to provide excellent results rather than using a skin graft with poor touch and tone compared to the surrounding normal skin.

Comparing the 810nm diode laser with conventional surgery in orthodontic soft tissue procedures.

PubMed

Ize-Iyamu, I N; Saheeb, B D; Edetanlen, B E

2013-09-01

To compare the use of the 810nm diode laser with conventional surgery in the management of soft tissue mucogingival problems associated with orthodontic treatment. Orthodontic patients requiring different soft tissue surgical procedures were randomly assigned to receive conventional surgery or soft tissue diode laser, (wavelength 810 nm). Parameters documented include the type of anaesthesia used, intra and post operative pain, bleeding, the use of scalpel and sutures. The chi-squared test was used to test for significance at 95% confidence level. Probability values (p-values) less than 0.05 were regarded as significant. Only 2(16.7%) of the procedures carried out with the soft tissue laser required infiltration anaesthesia compared to 10 (90.9%) with conventional surgery and this was significant (P<0.001). Post operative pain was significantly reduced in all cases treated with the diode laser (P<0.001). There was also a significant difference (P<0.05) in post operative bleeding in all cases treated with the diode laser. No sutures were used in all soft tissue cases managed with the diode laser and this was significant (P<0.001). There was no statistically significant difference in treatment time in the use of the laser compared with conventional surgery. Orthodontic patients treated with the diode laser required less infiltration anaesthesia, had reduced bleeding during and after surgery, rapid postoperative haemostasis, elimination of the need for sutures and an improved postoperative comfort and healing.

Spontaneous Endometriosis Within a Primary Umbilical Hernia

PubMed Central

Yheulon, Christopher G

2017-01-01

Umbilical hernias are rather common in the General Surgery clinic; however, endometriosis of an umbilical hernia is rare. It is especially unusual to have endometriosis of an umbilical hernia spontaneously occur compared to occurring at a site of a prior surgery. We present a case of spontaneous endometriosis of an umbilical hernia without prior surgery to her umbilicus. She had not presented with the usual symptoms of endometriosis and it was not considered as a diagnosis prior to surgery. Umbilical endometriosis is rare but usually occurs after prior laparoscopic surgery. We believe this is the second reported case in the English literature and the first such case reported from North America of spontaneous endometriosis of an umbilical hernia. This case highlights the importance of a full review of systems and qualifying the type and occurrence of pain. Additionally, it is always important to analyze surgical specimens in pathology to avoid errors in diagnosis. PMID:29164008

Spontaneous Endometriosis Within a Primary Umbilical Hernia.

PubMed

Laferriere, Nicole R; Yheulon, Christopher G

2017-11-01

Umbilical hernias are rather common in the General Surgery clinic; however, endometriosis of an umbilical hernia is rare. It is especially unusual to have endometriosis of an umbilical hernia spontaneously occur compared to occurring at a site of a prior surgery. We present a case of spontaneous endometriosis of an umbilical hernia without prior surgery to her umbilicus. She had not presented with the usual symptoms of endometriosis and it was not considered as a diagnosis prior to surgery. Umbilical endometriosis is rare but usually occurs after prior laparoscopic surgery. We believe this is the second reported case in the English literature and the first such case reported from North America of spontaneous endometriosis of an umbilical hernia. This case highlights the importance of a full review of systems and qualifying the type and occurrence of pain. Additionally, it is always important to analyze surgical specimens in pathology to avoid errors in diagnosis.

Single-Site Laparoscopic Surgery for Inflammatory Bowel Disease

PubMed Central

Bedros, Nicole; Hakiman, Hekmat; Araghizadeh, Farshid Y.

2014-01-01

Background and Objectives: Single-site laparoscopic colorectal surgery has been firmly established; however, few reports addressing this technique in the inflammatory bowel disease population exist. Methods: We conducted a case-matched retrospective review of 20 patients who underwent single-site laparoscopic procedures for inflammatory bowel disease compared with 20 matched patients undergoing multiport laparoscopic procedures. Data regarding these patients were tabulated in the following categories: demographic characteristics, operative parameters, and perioperative outcomes. Results: A wide range of cases were completed: 9 ileocolic resections, 7 cases of proctocolectomy with end ileostomy or ileal pouch anal anastomosis, 2 cases of proctectomy with ileal pouch anal anastomosis, and 2 total abdominal colectomies with end ileostomy were all matched to equivalent multiport laparoscopic cases. No single-incision cases were converted to multiport laparoscopy, and 2 single-incision cases (10%) were converted to an open approach. For single-incision cases, the mean length of stay was 7.7 days, the mean time to oral intake was 3.3 days, and the mean period of intravenous analgesic use was 5.0 days. There were no statistically significant differences between single-site and multiport cases. Conclusions: Single-site laparoscopic surgery is technically feasible in inflammatory bowel disease. The length of stay and period of intravenous analgesic use (in days) appear to be higher than those in comparable series examining outcomes of single-site laparoscopic colorectal surgery, and the outcomes are comparable with those of multiport laparoscopy. This may be because of the nature of inflammatory bowel disease, limiting the benefits of a single-site approach in this population. PMID:24960490

[Preliminary investigation on the safety and efficacy of Trabectome].

PubMed

Huang, Ping; Wang, Huaizhou; Wu, Huijuan; Sun, Yanran; Wang, Minshu; Cui, Ying; Qiu, Weiqiang; Yang, Yiquan; Ren, Zeqin; Zhang, Chun; Wang, Ningli

2015-02-01

To evaluate the safety and efficacy of ab interno trabeculectomy (Trabectome) surgery in Chinese open angle glaucoma patients. Prospective non-comparative case series study. A total of 41 cases (34 primary open angle glaucoma patients, 3 developmental glaucoma patients and 4 pigmentary glaucoma patients) were included in the study. All the cases underwent Trabectome, including 9 cases combined with phacoemulsification cataract extraction. Major outcomes include intraocular pressure (IOP), number of glaucoma medications, secondary glaucoma surgery and postoperative complications. Criteria for successful operation were defined as IOP ≤ 21 mmHg (1 mmHg = 0.133 kPa), at least 20% IOP reduction in any two consecutive visits after 3 months with or without IOP-lowering drugs and no additional glaucoma surgery. IOP and number of glaucoma medications were compared to baseline using Wilcoxon signed-rank test with Bonferroni correction. Kaplan-Meier analysis was performed to analyze the success rate of surgery. In the all 41 patients, 21 cases (51.2%) were followed up for up to 12 months. IOP was reduced from (22.5 ± 8.1) mmHg to (17.6 ± 6.4) mmHg (P = 0.02), meanwhile number of glaucoma medications was reduced from 2.0 ± 0.9 to 1.2 ± 0.9 (P = 0.02) at 12 months. The success rate at one year was 85% and 4 cases required additional glaucoma surgery. Trabectome has many advantages, such as shorter surgery time, simple post-operative care, less intraoperative and postoperative complications and clear IOP-lowering effect. But it slong-term efficacy is still need a large sample, long-term follow-up to verify.

Evaluation of a digital drainage system (Thopaz) in over 250 cases at a single site: A retrospective case-control study.

PubMed

Arai, Hiromasa; Tajiri, Michihiko; Kameda, Yohei; Shiino, Kimihisa; Ando, Kohei; Okudela, Koji; Masuda, Munetaka

2018-04-01

The aim of this study was to evaluate the efficacy of the Thopaz system, a new drainage system in management of general thoracic surgery, based on a review of our clinical practice and a comparison of the utility of the Thopaz device compared with a standard drainage system. A review of 540 thoracic surgeries at our hospital was performed. These cases were divided into 275 treated with the Thopaz system from April 2014 to March 2015 and 265 treated with a standard system from April 2013 to March 2014. The characteristics of patients and outcomes after surgery were compared in these 2 groups. The characteristics of the patients were similar in the 2 groups. Outcomes after surgery, including types of operation, period of chest tube placement, chest tube reinsertion rate and clamping test rate also did not differ significantly between the groups. The non-inferiority of the Thopaz system compared to a standard system was verified statistically. With advantages of providing objective data as a small portable system, in addition to the quietness of the unit and the ease of setup and operation, Thopaz system is likely to become mainstream in postoperative management in general thoracic surgery. © 2017 John Wiley & Sons Ltd.

Myocardial Protection and Financial Considerations of Custodiol Cardioplegia in Minimally Invasive and Open Valve Surgery.

PubMed

Hummel, Brian W; Buss, Randall W; DiGiorgi, Paul L; Laviano, Brittany N; Yaeger, Nalani A; Lucas, M Lee; Comas, George M

Single-dose antegrade crystalloid cardioplegia with Custodiol-HTK (histidine-tryptophan-ketoglutarate) has been used for many years. Its safety and efficacy were established in experimental and clinical studies. It is beneficial in complex valve surgery because it provides a long period of myocardial protection with a single dose. Thus, valve procedures (minimally invasive or open) can be performed with limited interruption. The aim of this study is to compare the use of Custodiol-HTK cardioplegia with traditional blood cardioplegia in patients undergoing minimally invasive and open valve surgery. A single-institution, retrospective case-control review was performed on patients who underwent valve surgery in Lee Memorial Health System at either HealthPark Medical Center or Gulf Coast Medical Center from July 1, 2011, through March 7, 2015. A total of 181 valve cases (aortic or mitral) performed using Custodiol-HTK cardioplegia were compared with 181 cases performed with traditional blood cardioplegia. Each group had an equal distribution of minimally invasive and open valve cases. Right chest thoracotomy or partial sternotomy was performed on minimally invasive valve cases. Demographics, perioperative data, clinical outcomes, and financial data were collected and analyzed. Patient outcomes were superior in the Custodiol-HTK cardioplegia group for blood transfusion, stroke, and hospital readmission within 30 days (P < 0.05). No statistical differences were observed in the other outcomes categories. Hospital charges were reduced on average by $3013 per patient when using Custodiol-HTK cardioplegia. Use of Custodiol-HTK cardioplegia is safe and cost-effective when compared with traditional repetitive blood cardioplegia in patients undergoing minimally invasive and open valve surgery.

Bacterial endophthalmitis after resident-performed cataract surgery.

PubMed

Hollander, David A; Vagefi, M Reza; Seiff, Stuart R; Stewart, Jay M

2006-05-01

To determine if there is an increased rate of postoperative bacterial endophthalmitis after resident-performed cataract extraction relative to the reported rates of experienced surgeons. Retrospective, observational case series. The operative reports of the resident-performed cataract surgeries at San Francisco General Hospital between 1983 and 2002 were reviewed. Cases of culture-positive bacterial endophthalmitis and vitreous loss were identified. Between 1983 and 2002, three cases (0.11%) of culture-positive bacterial endophthalmitis occurred after 2718 resident-performed cataract extractions. The overall vitreous loss rate was 6.7%. Two endophthalmitis cases were acute (Staphylococcus epidermidis, Streptococcus viridans), presenting within five days of surgeries complicated by vitreous loss, and one case was delayed-onset (Corynebacterium species) after Nd:YAG posterior capsulotomy after uncomplicated cataract extraction. Despite higher rates of vitreous loss, the rate of endophthalmitis following resident-performed cataract surgery remains comparable with the rates of more experienced surgeons.

Short-term effects of splenectomy on serum fibrosis indexes in liver cirrhosis patients.

PubMed

Kong, Degang; Chen, Xiuli; Lu, Shichun; Guo, Qingliang; Lai, Wei; Wu, Jushan; Lin, Dongdong; Zeng, Daobing; Duan, Binwei; Jiang, Tao; Cao, Jilei

2015-01-01

To determine the changing patterns of 4 liver fibrosis markers pre and post splenectomy (combined with pericardial devascularization [PCDV]) and to examine the short-term effects of splenectomy on liver fibrosis. Four liver fibrosis markers of 39 liver cirrhosis patients were examined pre, immediately post, 2 days post, and 1 week post (15 cases) splenectomy (combined with PCDV). The laminin (LN) level decreased immediately post surgery compared with the preoperative LN level (P < 0.05). The type IV collagen level decreased immediately post surgery compared with that pre surgery (P < 0.05), it significantly increased (P < 0.05) 2 days post surgery and significantly decreased 1 week post surgery (P < 0.05). Hyaluronic acid and the procollagen III N-terminal peptide levels increased significantly 2 days post surgery compared with that pre and immediately post surgery, they significantly decreased 1 week post surgery compared to 2 days post surgery (P < 0.05). In the short-term, the 4 liver fibrosis markers and the FibroScans post splenectomy showed characteristic changes, splenectomy may transiently initiate the degradation process of liver fibrosis.

Reimbursement in hospital-based vascular surgery: Physician and practice perspective.

PubMed

Perri, Jennifer L; Zwolak, Robert M; Goodney, Philip P; Rutherford, Gretchen A; Powell, Richard J

2017-07-01

The purpose of this study was to determine change in value of a vascular surgery division to the health care system during 6 years at a hospital-based academic practice and to compare physician vs hospital revenue earned during this period. Total revenue generated by the vascular surgery service line at an academic medical center from 2010 through 2015 was evaluated. Total revenue was measured as the sum of physician (professional) and hospital (technical) net revenue for all vascular-related patient care. Adjustments were made for work performed, case complexity, and inflation. To reflect the effect of these variables, net revenue was indexed to work relative value units (wRVUs), case mix index, and consumer price index, which adjusted for work, case complexity, and inflation, respectively. Differences in physician and hospital net revenue were compared over time. Physician work, measured in RVUs per year, increased by 4%; case complexity, assessed with case mix index, increased by 10% for the 6-year measurement period. Despite stability in payer mix at 64% to 69% Medicare, both physician and hospital vascular-related revenue/wRVU decreased during this period. Unadjusted professional revenue/wRVU declined by 14.1% (P = .09); when considering case complexity, physician revenue/wRVU declined by 20.6% (P = .09). Taking into account both case complexity and inflation, physician revenue declined by 27.0% (P = .04). Comparatively, hospital revenue for vascular surgery services decreased by 13.8% (P = .07) when adjusting for unit work, complexity, and inflation. At medical centers where vascular surgeons are hospital based, vascular care reimbursement decreased substantially from 2010 to 2015 when case complexity and inflation were considered. Physician reimbursement (professional fees) decreased at a significantly greater rate than hospital reimbursement for vascular care. This trend has significant implications for salaried vascular surgeons in hospital-based settings, where the majority of revenue generated by vascular surgery care is the technical component received by the facility. Appropriate care for patients with vascular disease is increasingly resource intensive, and as a corollary, reimbursement levels must reflect this situation if high-quality care is to be maintained. Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Learning curve in robotic rectal cancer surgery: current state of affairs.

PubMed

Jiménez-Rodríguez, Rosa M; Rubio-Dorado-Manzanares, Mercedes; Díaz-Pavón, José Manuel; Reyes-Díaz, M Luisa; Vazquez-Monchul, Jorge Manuel; Garcia-Cabrera, Ana M; Padillo, Javier; De la Portilla, Fernando

2016-12-01

Robotic-assisted rectal cancer surgery offers multiple advantages for surgeons, and it seems to yield the same clinical outcomes as regards the short-time follow-up of patients compared to conventional laparoscopy. This surgical approach emerges as a technique aiming at overcoming the limitations posed by rectal cancer and other surgical fields of difficult access, in order to obtain better outcomes and a shorter learning curve. A systematic review of the literature of robot-assisted rectal surgery was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The search was conducted in October 2015 in PubMed, MEDLINE and the Cochrane Central Register of Controlled Trials, for articles published in the last 10 years and pertaining the learning curve of robotic surgery for colorectal cancer. It consisted of the following key words: "rectal cancer/learning curve/robotic-assisted laparoscopic surgery". A total of 34 references were identified, but only 9 full texts specifically addressed the analysis of the learning curve in robot-assisted rectal cancer surgery, 7 were case series and 2 were non-randomised case-comparison series. Eight papers used the cumulative sum (CUSUM) method, and only one author divided the series into two groups to compare both. The mean number of cases for phase I of the learning curve was calculated to be 29.7 patients; phase II corresponds to a mean number 37.4 patients. The mean number of cases required for the surgeon to be classed as an expert in robotic surgery was calculated to be 39 patients. Robotic advantages could have an impact on learning curve for rectal cancer and lower the number of cases that are necessary for rectal resections.

Comparison of outcomes following laparoscopic and open treatment of emergent small bowel obstruction: an 11-year analysis of ACS NSQIP.

PubMed

Patel, Richa; Borad, Neil P; Merchant, Aziz M

2018-06-04

Small bowel obstruction (SBO) continues to be a common indication for acute care surgery. While open procedures are still widely used for treatment, laparoscopic procedures may have important advantages in certain patient populations. We aim to analyze differences in outcomes between the two for treatment of bowel obstruction. The American College of Surgeons National Surgical Quality Improvement Program was used to find patients that underwent emergent or non-elective surgery for SBO. Propensity matching was used to create comparable groups. Logistic regression was used to assess differences in the primary outcome of interest, return to operating room, and morbidity and mortality outcomes. Logistic regression was also used to assess the contribution of various preoperative demographic and comorbidity characteristics to 30-day mortality. A total of 24,028 patients underwent surgery for SBO from 2005 to 2011. Of those, 3391 were laparoscopic. Propensity matching resulted in 6782 matched patients. Laparoscopic cases had significantly decreased odds of experiencing any morbidity and wound complications compared to open cases in bowel-resection and adhesiolysis-only cases. There was no significant difference found for odds of returning to operating room. Laparoscopic cases resulted in significantly shorter hospital stays than open cases (7.18 vs.10.84 days, p < 0.0001). Increasing age, American Society of Anesthesiologists class greater than three, and the presence of respiratory comorbidities resulted in increased odds of mortality. Underweight body mass index (BMI) (< 18.5) increased odds of mortality while greater than normal BMI (> 25) decreased odds of mortality. Analysis of emergent SBO cases between 2005 and 2015 demonstrates that laparoscopy is not utilized as often as open approaches in surgical treatment. Laparoscopic surgery resulted in reduced postoperative morbidity and significantly shorter hospital stays compared to open intervention and was not associated with significant differences in odds of reoperation compared to open surgery.

A review of general cosmetic surgery training in fellowship programs offered by the American Academy of Cosmetic Surgery.

PubMed

Handler, Ethan; Tavassoli, Javad; Dhaliwal, Hardeep; Murray, Matthew; Haiavy, Jacob

2015-04-01

We sought, first, to evaluate the operative experience of surgeons who have completed postresidency fellowships offered by the American Academy of Cosmetic Surgery (AACS), and second, to compare this cosmetic surgery training to other surgical residency and fellowship programs in the United States. Finally, we suggest how new and existing oral and maxillofacial surgeons can use these programs. We reviewed the completed case logs from AACS-accredited fellowships. The logs were data mined for 7 of the most common cosmetic operations, including the median total number of operations. We then compared the cosmetic case requirements from the different residencies and fellowships. Thirty-nine case logs were reviewed from the 1-year general cosmetic surgery fellowships offered by the AACS from 2007 to 2012. The fellows completed a median of 687 total procedures. The median number of the most common cosmetic procedures performed was 14 rhinoplasties, 31 blepharoplasties, 21 facelifts, 24 abdominoplasties, 28 breast mastopexies, 103 breast augmentations, and 189 liposuctions. The data obtained were compared with the minimum cosmetic surgical requirements in residency and fellowship programs. The minimum residency requirements were as follows: no minimum listed for plastic surgery, 35 for otolaryngology, 20 for oral and maxillofacial surgery, 28 for ophthalmology, 0 for obstetrics and gynecology, and 20 for dermatology. The minimum fellowship requirements were as follows: 300 for the AACS cosmetic surgery fellowship, no minimum listed for facial plastic surgery and reconstruction, no minimum listed for aesthetic surgery, 133 for oculoplastic and reconstructive surgery, and 0 for Mohs dermatology. Dedicating one's practice exclusively to cosmetic surgery requires additional postresidency training owing to the breadth of the field. The AACS created comprehensive fellowship programs to fill an essential part in the continuum of cosmetic surgeons' education, training, and experience. This builds on the foundation of their primary board residency program. The AACS fellowships are a valuable option for additional training for qualified surgeons seeking proficiency and competency in cosmetic surgery. Copyright © 2015 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.

Current status of cardiovascular surgery in Japan, 2013 and 2014: A report based on the Japan Cardiovascular Surgery Database 3. Coronary artery bypass surgery.

PubMed

Saito, Aya; Hirahara, Norimichi; Motomura, Noboru; Miyata, Hiroaki; Takamoto, Shinichi

2018-01-01

Data on isolated coronary artery bypass grafting (CABG) performed in 2013 and 2014, and registered in the Japan Cardiovascular Surgery Database were reviewed for preoperative characteristics, postoperative outcomes, and choice of graft material for the left anterior descending artery (LAD). Isolated CABG was performed off-pump in 54.7% of cases, and graft material for the LAD was left internal thoracic artery in 74.3% and right internal thoracic artery in 15.6%. Operative mortality was 2.0% in elective cases, 8.2% in emergency cases, and 3.0% overall. In elective cases, operative mortality was 1.1% for off-pump CABG compared with 3.0% for on-pump CABG. Clinical results of our isolated CABG were reasonable and acceptable.

Laparoscopic surgery in the treatment of incarcerated indirect inguinal hernia in children.

PubMed

Yin, Yiyu; Zhang, Hongwei; Zhang, Xiang; Sun, Fang; Zou, Huaxin; Cao, Hui; Wen, Cheng

2016-12-01

We aimed to explore the feasibility and the safety of the laparoscopic surgery for incarcerated indirect inguinal hernia (IIH) in children. From January 2012 to December 2014, 64 children were enrolled into this study. All 64 patients received laparoscopic surgery and we reviewed their perioperative and postoperative follow-up studies. In addition, we enrolled 60 cases of children who received traditional surgery of IIH administered through minimally invasive surgery as the control group. Results from the present study showed that the mean operation time for the laparoscopic group was 41.5 min (range, 15-80 min) which was significantly shorter than the control group. Nine cases developed incarcerated intestine necrosis, expanded umbilical incision and parallel resection anastomosis. They received laparoscopic hernia sac high ligation. Only 5 cases developed scrotum edema after the surgery. The postoperative length of the stay ranged from 2 to 7 days (average, 3.2). The postoperative follow-up was from 6 months to 1 year and no relapse or secondary testicular atrophy was observed in the laparoscopic group. The operation time, incidence of postoperative complications and length of stay in the laparoscopic group were decreased compared to the control group, and differences were statistically significant (P<0.05). In conclusion, laparoscopic surgery treatment for incarcerated inguinal hernia is safe and feasible and produced better results compared with the alternative.

Laparoscopic surgery complications: postoperative peritonitis.

PubMed

Drăghici, L; Drăghici, I; Ungureanu, A; Copăescu, C; Popescu, M; Dragomirescu, C

2012-09-15

Complications within laparoscopic surgery, similar to classic surgery are inevitable and require immediate actions both to diminish intraoperative risks and to choose the appropriate therapeutic attitude. Peritonitis and hemorrhagic incidents are both part of the complications aspect of laparoscopic surgery. Fortunately, the incidence is limited, thus excluding the rejection of celioscopic methods. Patient's risks and benefits are to be analyzed carefully prior recommending laparoscopic surgery. This study presents a statistical analysis of peritonitis consecutive to laparoscopic surgery, experience of "Sf. Ioan" Emergency Hospital, Bucharest, and Department of Surgery (2000-2010). There were 180 (0,96%) complicated situations requiring reinterventions, from a total of 18676 laparoscopic procedures. 106 cases (0,56%) represented different grades of postoperative peritonitis. Most frequently, there were consecutive laparoscopic appendicectomia and colecistectomia. During the last decade, few severe cases of peritonitis followed laparoscopic bariatric surgical procedures. This study reflects the possibility of unfavorable evolution of postoperative peritonitis comparing with hemorrhagic incidents within laparoscopic surgery.

Endoscopic Endonasal Pituitary Surgery: Impact of Surgical Education on Operation Length and Patient Morbidity

PubMed Central

Dedhia, Raj C.; Lord, Christopher A.; Pinheiro-Neto, Carlos D.; Fernandez-Miranda, Juan C.; Wang, Eric W.; Gardner, Paul A.; Snyderman, Carl H.

2012-01-01

Objectives To determine the difference in operative times and associated complications for cases performed solely by attending-level surgeons versus cases assisted by surgeons-in-training for endoscopic endonasal pituitary surgeries. Design Retrospective chart review. Setting Tertiary-care academic medical center. Participants A total of 228 patients having undergone endoscopic endonasal pituitary surgery from 2005 to 2011. Main Outcome Measure Duration of surgery comparing attending only (AO) and trainee-assisted (TA) surgeries. Results Thirty-seven (19%) of 198 cases were identified as AO surgeries, the remaining 161 (81%) were TA. Operative times (minutes) for the AO group were significantly shorter than the TA group (149.1 ± 54.8 vs 219.5 ± 83.7, p < 0.001). The AO group had fewer intraoperative cerebrospinal fluid leaks (30% vs 39%, p = 0.318), decreased estimated blood loss (408 mL vs 523 mL, p = 0.176), fewer postoperative complications (27% vs 37%, p = 0.268), and shorter length of stay (3.5 vs 4.3 days, p = 0.294). Conclusions This is the first study in otolaryngology or neurosurgery to compare operative times and outcomes for AO versus TA cases at a single academic institution. Operative times were significantly decreased and a trend toward a decrease in patient morbidity was noted for cases performed solely by attendings. The valuation of teaching activities in the operating room is a necessary first step toward optimizing the allocation of resources and funding of surgical education. PMID:24294558

General surgery training without laparoscopic surgery fellows: the impact on residents and patients.

PubMed

Linn, John G; Hungness, Eric S; Clark, Sara; Nagle, Alexander P; Wang, Edward; Soper, Nathaniel J

2011-10-01

To evaluate resident case volume after discontinuation of a laparoscopic surgery fellowship, and to examine disparities in patient care over the same time period. Resident case logs were compared for a 2-year period before and 1 year after discontinuing the fellowship, using a 2-sample t test. Databases for bariatric and esophageal surgery were reviewed to compare operative time, length of stay (LOS), and complication rate by resident or fellow over the same time period using a 2-sample t test. Increases were seen in senior resident advanced laparoscopic (Mean Fellow Year = 21 operations vs Non Fellow Year = 61, P < 0.01), esophageal (1 vs 11, P < .01) and bariatric volume (9 vs 36, P < .01). Junior resident laparoscopic volume increased (P < 0.05). No difference in LOS or complication rate was seen with resident vs fellow assistant. Operative time was greater for gastric bypass with resident assistant (152 ± 51 minutes vs 138 ± 53, P < .05). Discontinuing a laparoscopic fellowship significantly increases resident case volume in laparoscopic surgery. Operative time for complex operations may increase in the absence of a fellow. Other patient outcomes are not affected by this change. Copyright © 2011 Mosby, Inc. All rights reserved.

Trauma and emergency surgery: an evolutionary direction for trauma surgeons.

PubMed

Scherer, Lynette A; Battistella, Felix D

2004-01-01

The success of nonoperative management of injuries has diminished the operative experience of trauma surgeons. To enhance operative experience, our trauma surgeons began caring for all general surgery emergencies. Our objective was to characterize and compare the experience of our trauma surgeons with that of our general surgeons. We reviewed records to determine case diversity, complexity, time of operation, need for intensive care unit care, and payor mix for patients treated by the trauma and emergency surgery (TES) surgeons and elective practice general surgery (ELEC) surgeons over a 1-year period. TES and ELEC surgeons performed 253 +/- 83 and 234 +/- 40 operations per surgeon, respectively (p = 0.59). TES surgeons admitted more patients and performed more after-hours operations than their ELEC colleagues. Both groups had a mix of cases that was diverse and complex. Combining the care of patients with trauma and general surgery emergencies resulted in a breadth and scope of practice for TES surgeons that compared well with that of ELEC surgeons.

Increasing operating room productivity by duration categories and a newsvendor model.

PubMed

Lehtonen, Juha-Matti; Torkki, Paulus; Peltokorpi, Antti; Moilanen, Teemu

2013-01-01

Previous studies approach surgery scheduling mainly from the mathematical modeling perspective which is often hard to apply in a practical environment. The aim of this study is to develop a practical scheduling system that considers the advantages of both surgery categorization and newsvendor model to surgery scheduling. The research was carried out in a Finnish orthopaedic specialist centre that performs only joint replacement surgery. Four surgery categorization scenarios were defined and their productivity analyzed by simulation and newsvendor model. Detailed analyses of surgery durations and the use of more accurate case categories and their combinations in scheduling improved OR productivity 11.3 percent when compared to the base case. Planning to have one OR team to work longer led to remarkable decrease in scheduling inefficiency. In surgical services, productivity and cost-efficiency can be improved by utilizing historical data in case scheduling and by increasing flexibility in personnel management. The study increases the understanding of practical scheduling methods used to improve efficiency in surgical services.

Effect of six sigma program on the number of surgeries cancellation.

PubMed

Gheysari, Esmat; Yousefi, Hojatollah; Soleymani, Hossain; Mojdeh, Soheila

2016-01-01

Today, the rate of surgeries is increasing, but surgeries are canceled due to various reasons. Unexpected cancellation of surgeries not only results in disorder in the operating room schedule, but also causes stress for patients and their family and increases costs. We determined the number and causes of surgery cancellations and areas for improvement. This outcome evaluation of Six Sigma program was conducted on 850 cases after the implementation of the program and compared to that of 850 cases which received routine care before the program. Cases were selected through easy sampling during the study. Before the implementation, the number of cancellations was recorded daily and their reasons were investigated. Then, Six Sigma program was implemented in accordance with the reasons for each category and necessary steps were taken to prevent the cancellation of surgeries. Data were collected for 3 months using a three-section data collection form. For data analysis, distribution and relative frequency and chi-square test were used. The three categories of patient, physician, and hospital system were identified as the main causes. The highest rate of cancellation was related to ENT surgeries (74.19%). No cancellations were made in orology surgeries. The implementation of the Six Sigma program caused a significant difference in surgery cancellation (P = 0.003); 31 (3.6%) cases of cancellation were reduced to 12 (1.4%) cases. The results showed that Six Sigma program is a pre-surgery care quality improvement program. Patient education and the implementation of the 6 sigma program can be effective in reducing the rate of cancellation of operations.

In-hospital mortality and morbidity after robotic coronary artery surgery.

PubMed

Cavallaro, Paul; Rhee, Amanda J; Chiang, Yuting; Itagaki, Shinobu; Seigerman, Matthew; Chikwe, Joanna

2015-02-01

The objective of this study was to assess the impact of robotic approaches on outcomes of coronary bypass surgery. Retrospective national database analysis. United States hospitals. A weighted sample of 484,128 patients undergoing isolated coronary artery surgery identified from the Nationwide Inpatient Sample from 2008 through 2010. Robotically assisted coronary artery bypass surgery versus conventional bypass surgery. Robotic approaches were used in 2,582 patients (0.4%). Patients undergoing robotic surgery were less likely to be female (odds ratio [OR] 0.71, 95% confidence interval [CI] 0.57-0.87), present with acute myocardial infarction (OR 0.53, 95% CI 0.38-0.73), or have cerebrovascular disease (OR 0.41, 95% CI 0.23-0.71) compared to patients undergoing conventional surgery. In 59% of robotic cases, a single bypass was performed, and 2 bypasses were performed in 25% of cases. After adjusting for comorbidity, reduced postoperative stroke (0.0% v 1.5%, p = 0.045) and transfusion (13.5% v 24.4%, p = 0.001) rates were observed in patients who underwent robotic single-bypass surgery compared to conventional surgery. In patients undergoing multiple bypass grafts, higher mortality (1.1% v 0.5%), and cardiovascular complications (12.2% v 10.6%) were observed when robotic assistance was used, but the differences were not statistically significant (p = 0.5). The mean number of robotic cases carried out annually at institutions sampled was 6. Robotic assistance is associated with lower rates of postoperative complications in highly selected patients undergoing single coronary artery bypass surgery, but the benefits of this approach are reduced in patients who require multiple coronary artery bypass grafts. Copyright © 2014 Elsevier Inc. All rights reserved.

Effect of minimally invasive surgery fellowship on residents' operative experience.

PubMed

Altieri, Maria S; Frenkel, Catherine; Scriven, Richard; Thornton, Deborah; Halbert, Caitlin; Talamini, Mark; Telem, Dana A; Pryor, Aurora D

2017-01-01

There is an increased need for surgical trainees to acquire advanced laparoscopic skills as laparoscopy becomes the standard of care in many areas of general surgery. Since the introduction of minimally invasive surgery (MIS) fellowships, there has been a continuing debate as to whether these fellowships adversely affect general surgery resident exposure to laparoscopic cases. The aim of our study was to examine whether the introduction of an MIS fellowship negatively impacts general surgery residents' experience at a single academic center. We describe the changes following establishment of MIS fellowship at an academic center. Resident case log system from the Accreditation Council for Graduate Medical Education was queried to obtain all PGY 1-5 resident operative case logs. Two-year time period preceding and following the institution of an MIS fellowship at our institution in 2012 was compared. P values less than 0.05 were considered statistically significant. Following initiation of the MIS fellowship, an MIS service was established. The service comprised of a fellow, midlevel resident, and intern. Operative experience was examined. From 2010-2012 to 2012-2014, residents logged a total of 272 and 585 complex laparoscopic cases, respectively. There were 43 residents from 2010 to 2013 and 44 residents from 2013 to 2014. When the two time periods were compared, a trend of increased numbers for all procedures was noted, except laparoscopic GYN/genito-urinary procedures. Average percent increase in complex general surgery procedures was 249 ± 179.8 %. Following establishment of a MIS fellowship, reported cases by residents were higher or similar to those reported nationally for laparoscopic procedures. Institution of an MIS fellowship had a favorable effect on general surgery resident operative education at a single academic training center. Residents may benefit from the presence of a fellowship at an academic center because they are able to participate in an increased number of complex laparoscopic cases.

Active Ankle Movement May Prevent Deep Vein Thrombosis in Patients Undergoing Lower Limb Surgery.

PubMed

Wang, Zhe; Chen, Qian; Ye, Mao; Shi, Guang-Hui; Zhang, Bo

2016-04-01

Our aim is to investigate the effect of active ankle movement to prevent deep vein thrombosis (DVT) in patients who received lower limb surgery, and to provide a theory of evidence for rehabilitation nursing of patients after orthopedic surgery. Between January 2012 and December 2013, a total of 174 patients were randomized as case group (n = 96) and control group (n = 78). Case group received routine nursing and active ankle movement (30 times/min, 1-7 days after surgery), while control group only received routine nursing. The symptoms and signs of DVT were in real-time observation during the experiment. Thigh and crus circumference, maximum venous outflow (MVO), maximum venous capacity (MVC), and MVO ratio (MVO ratio = MVO/MVC) in the two groups were measured 1-7 days after surgery. Six-month follow-up study was also conducted to observe the occurrence of DVT. Our study revealed that thigh circumference in the case group decreased compared with the control group in 5-7 days (fifth day: 39.98 ± 3.25 vs. 41.01 ± 3.38, P = 0.043; sixth day: 38.21 ± 3.81 vs. 39.49 ± 3.79, P = 0.029; seventh day: 37.13 ± 3.15 vs. 38.76 ± 3.31, P = 0.001), and crus circumference in the case group also decreased compared with the control group in 5-7 days (fifth day: 26.35 ± 2.11 vs. 27.01 ± 2.19, P = 0.045; sixth day: 25.99 ± 2.31 vs. 26.88 ± 3.12, P = 0.032; seventh day: 25.56 ± 1.99 vs. 26.38 ± 2.89, P = 0.028). MVO and MVC in the case group increased compared with the control group 7 days after surgery (MVO: 15.01 ± 2.56 vs. 14.12 ± 2.56, P = 0.024; MVC: 10.18 ± 3.15 vs. 8.91 ± 2.78, P = 0.006). Significant difference in the incidence of thrombus and DVT were found between the case group and the control group 1-7 days after surgery (thrombus: 1.0% and 7.7%, P = 0.027; DVT: 7.6% and 18.4%, P = 0.032). Our result manifested that active ankle movement can relieve the swelling of patients after lower limb surgery, and improve the MVO and MVC of patients to prevent formation of DVT after lower limb surgery. Copyright © 2016 Elsevier Inc. All rights reserved.

Arterial Stump Thrombosis after Lung Resection Surgery: Clinical Presentation, Treatment and Progress.

PubMed

López-Padilla, Daniel; Peghini Gavilanes, Esteban; Revilla Ostolaza, Teresa Yolanda; Trujillo, María Dolores; Martínez Serna, Iván; Arenas Valls, Nuria; Girón Matute, Walther Iván; Larrosa-Barrero, Roberto; Manrique Mutiozabal, Adriana; Pérez Gallán, Marta; Zevallos, Annette; Sayas Catalán, Javier

2016-10-01

To determine the prevalence of arterial stump thrombosis (AST) after pulmonary resection surgery for lung cancer and to describe subsequent radiological follow-up and treatment. Observational, descriptive study of AST detected by computerized tomography angiography (CT) using intravenous contrast. Clinical and radiological variables were compared and a survival analysis using Kaplan-Meier curves was performed after dividing patients into 3 groups: patients with AST, patients with pulmonary embolism (PE), and patients without AST or PE. Nine cases of AST were detected after a total of 473 surgeries (1.9%), 6 of them in right-sided surgeries (67% of AST cases). Median time to detection after surgery was 11.3 months (interquartile range 2.7-42.2 months), and range 67.5 months (1.4-69.0 months). Statistically significant differences were found only in the number of CTs performed in AST patients compared to those without AST or PE, and in tumor recurrence in PE patients compared to the other 2 groups. No differences were found in baseline or oncological characteristics, nor in the survival analysis. In this series, AST prevalence was low and tended to occur in right-sided surgeries. Detection over time was variable, and unrelated to risk factors previous to surgery, histopathology, and tumor stage or recurrence. AST had no impact on patient survival. Copyright © 2016 SEPAR. Publicado por Elsevier España, S.L.U. All rights reserved.

The Misconception of Case-Control Studies in the Plastic Surgery Literature: A Literature Audit.

PubMed

Hatchell, Alexandra C; Farrokhyar, Forough; Choi, Matthew

2017-06-01

Case-control study designs are commonly used. However, many published case-control studies are not true case-controls and are in fact mislabeled. The purpose of this study was to identify all case-control studies published in the top three plastic surgery journals over the past 10 years, assess which were truly case-control studies, clarify the actual design of the articles, and address common misconceptions. MEDLINE, Embase, and Web of Science databases were searched for case-control studies in the three highest-impact factor plastic surgery journals (2005 to 2015). Two independent reviewers screened the resulting titles, abstracts, and methods, if applicable, to identify articles labeled as case-control studies. These articles were appraised and classified as true case-control studies or non-case-control studies. The authors found 28 articles labeled as case-control studies. However, only six of these articles (21 percent) were truly case-control designs. Of the 22 incorrectly labeled studies, one (5 percent) was a randomized controlled trial, three (14 percent) were nonrandomized trials, two (9 percent) were prospective comparative cohort designs, 14 (64 percent) were retrospective comparative cohort designs, and two (9 percent) were cross-sectional designs. The mislabeling was worse in recent years, despite increases in evidence-based medicine awareness. The majority of published case-control studies are not in fact case-control studies. This misunderstanding is worsening with time. Most of these studies are actually comparative cohort designs. However, some studies are truly clinical trials and thus a higher level of evidence than originally proposed.

Review of Robotic Surgery in Gynecology—The Future Is Here

PubMed Central

Lauterbach, Roy; Matanes, Emad; Lowenstein, Lior

2017-01-01

The authors present a systematic review of randomized and observational, retrospective and prospective studies to compare between robotic surgery as opposed to laparoscopic, abdominal, and vaginal surgery for the treatment of both benign and malignant gynecologic indications. The comparison focuses on operative times, surgical outcomes, and surgical complications associated with the various surgical techniques. PubMed was the main search engine utilized in search of study data. The review included studies of various designs that included at least 25 women who had undergone robotic gynecologic surgery. Fifty-five studies (42 comparative and 13 non-comparative) met eligibility criteria. After careful analysis, we found that robotic surgery was consistently connected to shorter post-surgical hospitalization when compared to open surgery, a difference less significant when compared to laparoscopic surgery. Also, it seems that robotic surgery is highly feasible in gynecology. There are quite a few inconsistencies regarding operative times and estimated blood loss between the different approaches, though in the majority of studies estimated blood loss was lower in the robotic surgery group. The high variance in operative times resulted from the difference in surgeon’s experience. The decision whether robotic surgery should become mainstream in gynecological surgery or remain another surgical technique in the gynecological surgeon’s toolbox requires quite a few more randomized controlled clinical trials. In any case, in order to bring robotic surgery down to the front row of surgery, training surgeons is by far the most important goal for the next few years. PMID:28467761

Penile prosthesis implantation compares favorably in malpractice outcomes to other common urological procedures: findings from a malpractice insurance database.

PubMed

Chason, Juddson; Sausville, Justin; Kramer, Andrew C

2009-08-01

Some urologists choose not to offer penile prostheses because of concern over malpractice liability. The aim of this study was to assess whether urologists performing penile prosthesis surgery are placed at a greater malpractice risk. Percentage of malpractice suits from prosthesis surgery and other urological procedures that result in payment, average resulting payout from these cases, and category of legal issue that ultimately resulted in payout. A database from the Physician Insurers Association of America, an association of malpractice insurance companies covering physicians in North America, was analyzed to quantitatively compare penile implant surgery to other urological procedures in medicolegal terms. Compared to other common urological procedures, penile implant is comparable and on the lower end of the spectrum in terms of both the percentage of malpractice suits that result in payment and the amount ultimately paid in indemnity from those cases. Additionally, issues of informed consent play the largest role in indemnities for all urological procedures, whereas surgical technique is the most important issue for prosthesis surgery. Urologists who are adequately trained in prosthetic surgery should not avoid penile implant procedures for fear of malpractice suits. A focus on communication and informed consent can greatly reduce malpractice risk for urological procedures.

Does lamellar surgery for keratoconus experience the popularity it deserves?

PubMed

Wisse, Robert P L; van den Hoven, Célinde M L; Van der Lelij, Allegonda

2014-08-01

To analyse developments in surgical treatment for keratoconus (KC) by assessing rates and types of corneal surgery from 2005 to 2010. The Dutch Transplantation Foundation supplied data on all keratoplasty procedures for KC performed from 2005 to 2010 in the Netherlands. Registration was carried out by the eyebank at allocation and by the surgeon at the time of surgery. The type of surgery was categorized as either a penetrating or a lamellar procedure. Five hundred and seventy-five anonymized records were received, with excellent data completion (99%). Patients undergoing penetrating surgery had on average a lower visual acuity, higher k-readings and were slightly older compared with the lamellar group. A previous corneal hydrops was recorded for 19.1% of patients. Regular penetrating keratoplasty decreased in popularity from 79.7% in 2005 to 43.7% in 2010, due to the increased rate of lamellar surgery (42.5% in 2010) and 'mushroom' penetrating keratoplasty (13.8% in 2010). When hydrops cases were excluded, popularity became equal (47.6% penetrating versus 52.4% lamellar surgery, in 2010). Lamellar surgery is gaining in popularity, although regular penetrating keratoplasty is still the more commonly performed procedure. Only when hydrops cases are excluded do transplant rates become comparable. © 2013 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.

[Variability and opportunity costs among the surgical alternatives for breast cancer].

PubMed

Angulo-Pueyo, Ester; Ridao-López, Manuel; Martínez-Lizaga, Natalia; García-Armesto, Sandra; Bernal-Delgado, Enrique

2014-01-01

To analyze medical practice variation in breast cancer surgery (either inpatient-based or day-case surgery), by comparing conservative surgery (CS) plus radiotherapy vs. non-conservative surgery (NCS). We also analyzed the opportunity costs associated with CS and NCS. We performed an observational study of age- and sex-standardized rates of CS and NCS, performed in 199 Spanish healthcare areas in 2008-2009. Costs were calculated by using two techniques: indirectly, by using All-Patients Diagnosis Related Groups (AP-DRG) based on hospital admissions, and directly by using full costing from the Spanish Network of Hospital Costs (SNHC) data. Standardized surgery rates for CS and NCS were 6.84 and 4.35 per 10,000 women, with variation across areas ranging from 2.95 to 3.11 per 10,000 inhabitants. In 2009, 9% of CS was performed as day-case surgery, although a third of the health care areas did not perform this type of surgery. Taking the SNHC as a reference, the cost of CS was estimated at 7,078 € and that of NCS was 6,161 €. Using AP-DRG, costs amounted to 9,036 € and 8,526 €, respectively. However, CS had lower opportunity costs than NCS when day-case surgery was performed frequently-more than 46% of cases (following SNHC estimates) or 23% of cases (following AP-DRG estimates). Day-case CS for breast cancer was found to be the best option in terms of opportunity-costs beyond a specific threshold, when both CS and NCS are elective. Copyright © 2013 SESPAS. Published by Elsevier Espana. All rights reserved.

Robot-assisted surgery in elderly and very elderly population: our experience in oncologic and general surgery with literature review.

PubMed

Ceccarelli, Graziano; Andolfi, Enrico; Biancafarina, Alessia; Rocca, Aldo; Amato, Maurizio; Milone, Marco; Scricciolo, Marta; Frezza, Barbara; Miranda, Egidio; De Prizio, Marco; Fontani, Andrea

2017-02-01

Although there is no agreement on a definition of elderly, commonly an age cutoff of ≥65 or 75 years is used. Nowadays most of malignancies requiring surgical treatment are diagnosed in old population. Comorbidities and frailty represent well-known problems during and after surgery in elderly patients. Minimally invasive surgery offers earlier postoperative mobilization, less blood loss, lower morbidity as well as reduction in hospital stay and as such represents an interesting and validated option for elderly population. Robot-assisted surgery is a recent improvement of conventional minimally invasive surgery. We provided a complete review of old and very old patients undergoing robot-assisted surgery for oncologic and general surgery interventions. A retrospective review of all patients undergoing robot-assisted surgery in our General Surgery Unit from September 2012 to June 2016 was conducted. Analysis was performed for the entire cohort and in particular for three of the most performed surgeries (gastric resections, right colectomy, and liver resections) classifying patients into three age groups: ≤64, 65-79, and ≥80. Data from these three different age groups were compared and examined in respect of different outcomes: ASA score, comorbidities, oncologic outcomes, conversion rate, estimated blood loss, hospital stay, geriatric events, mortality, etc. Using our in-patient robotic surgery database, we retrospectively examined 363 patients, who underwent robot-assisted surgery for different diseases (402 different robotic procedures): colorectal surgery, upper GI, HPB, etc.; the oncologic procedures were 81%. Male were 56%. The mean age was 65.63 years (18-89). Patients aged ≥65 years represented 61% and ≥80 years 13%. Overall conversion rate was of 6%, most in the group 65-79 years (59% of all conversions). The more frequent diseases treated were colorectal surgery 43%, followed by hepatobilopancreatic surgery 23.4%, upper gastro-intestinal 23.2%, and others 10.4%. Robot-assisted surgery is a safe and effective technique in aging patient population too. There was no increased risk of death or morbidity compared to younger patients in the three groups examined. A higher conversion rate was observed in our experience for patients aged 65-79. Prolonged operative time and in any cases steep positions (Trendelenburg) have not represented a problem for the majority of patients. In any case, considering the high direct costs, minimally invasive robot-assisted surgery should be performed on a case-by-case basis, tailored to each patient with their specific histories and comorbidities.

Surgical Site Infections in Pediatric Spine Surgery: Comparative Microbiology of Patients with Idiopathic and Nonidiopathic Etiologies of Spine Deformity.

PubMed

Maesani, Matthieu; Doit, Catherine; Lorrot, Mathie; Vitoux, Christine; Hilly, Julie; Michelet, Daphné; Vidal, Christophe; Julien-Marsollier, Florence; Ilharreborde, Brice; Mazda, Keyvan; Bonacorsi, Stéphane; Dahmani, Souhayl

2016-01-01

Surgical site infections (SSIs) are a concern in pediatric spine surgery with unusually high rates for a clean surgery and especially for patients with deformity of nonidiopathic etiology. Microbiologic differences between etiologies of spine deformities have been poorly investigated. We reviewed all cases of SSI in spinal surgery between 2007 and 2011. Characteristics of cases and of bacteria according to the etiology of the spine disease were investigated. Of 496 surgeries, we identified 51 SSIs (10.3%) in 49 patients. Staphylococcus aureus was the most frequent pathogen whatever the etiology (n = 31, 61% of infection cases). The second most frequent pathogens vary according to the etiology of the spine deformity. It was Gram-negative bacilli (GNB) in nonidiopathic cases (n = 19, 45% of cases) and anaerobe in idiopathic cases (n = 8, 38% of cases), particularly Gram-positive anaerobic cocci (n = 5, 24% of cases). Infection rate was 6.8% in cases with idiopathic spine disease (n = 21) and 15.9% in cases with nonidiopathic spine disease (n = 30). Nonidiopathic cases were more frequently male with lower weight. American Society of Anesthesiologists score was more often greater than 2, they had more frequently sacral implants and postoperative intensive care unit stay. GNB were significantly associated with a nonidiopathic etiology, low weight, younger age and sacral fusion. SSIs were polymicrobial in 31% of cases with a mean of 1.4 species per infection cases. S. aureus is the first cause of SSI in pediatric spine surgery. However, Gram-positive anaerobic cocci should be taken into account in idiopathic patients and GNB in nonidiopathic patients when considering antibiotic prophylaxis and curative treatment.

Cosmetic Surgery Training in Plastic Surgery Residency Programs.

PubMed

McNichols, Colton H L; Diaconu, Silviu; Alfadil, Sara; Woodall, Jhade; Grant, Michael; Lifchez, Scott; Nam, Arthur; Rasko, Yvonne

2017-09-01

Over the past decade, plastic surgery programs have continued to evolve with the addition of 1 year of training, increase in the minimum number of required aesthetic cases, and the gradual replacement of independent positions with integrated ones. To evaluate the impact of these changes on aesthetic training, a survey was sent to residents and program directors. A 37 question survey was sent to plastic surgery residents at all Accreditation Council for Graduate Medical Education-approved plastic surgery training programs in the United States. A 13 question survey was sent to the program directors at the same institutions. Both surveys were analyzed to determine the duration of training and comfort level with cosmetic procedures. Eighty-three residents (10%) and 11 program directors (11%) completed the survey. Ninety-four percentage of residents had a dedicated cosmetic surgery rotation (an increase from 68% in 2015) in addition to a resident cosmetic clinic. Twenty percentage of senior residents felt they would need an aesthetic surgery fellowship to practice cosmetic surgery compared with 31% in 2015. Integrated chief residents were more comfortable performing cosmetic surgery cases compared with independent chief residents. Senior residents continue to have poor confidence with facial aesthetic and body contouring procedures. There is an increase in dedicated cosmetic surgery rotations and fewer residents believe they need a fellowship to practice cosmetic surgery. However, the comfort level of performing facial aesthetic and body contouring procedures remains low particularly among independent residents.

Cosmetic Surgery Training in Plastic Surgery Residency Programs

PubMed Central

McNichols, Colton H. L.; Diaconu, Silviu; Alfadil, Sara; Woodall, Jhade; Grant, Michael; Lifchez, Scott; Nam, Arthur

2017-01-01

Background: Over the past decade, plastic surgery programs have continued to evolve with the addition of 1 year of training, increase in the minimum number of required aesthetic cases, and the gradual replacement of independent positions with integrated ones. To evaluate the impact of these changes on aesthetic training, a survey was sent to residents and program directors. Methods: A 37 question survey was sent to plastic surgery residents at all Accreditation Council for Graduate Medical Education–approved plastic surgery training programs in the United States. A 13 question survey was sent to the program directors at the same institutions. Both surveys were analyzed to determine the duration of training and comfort level with cosmetic procedures. Results: Eighty-three residents (10%) and 11 program directors (11%) completed the survey. Ninety-four percentage of residents had a dedicated cosmetic surgery rotation (an increase from 68% in 2015) in addition to a resident cosmetic clinic. Twenty percentage of senior residents felt they would need an aesthetic surgery fellowship to practice cosmetic surgery compared with 31% in 2015. Integrated chief residents were more comfortable performing cosmetic surgery cases compared with independent chief residents. Senior residents continue to have poor confidence with facial aesthetic and body contouring procedures. Conclusions: There is an increase in dedicated cosmetic surgery rotations and fewer residents believe they need a fellowship to practice cosmetic surgery. However, the comfort level of performing facial aesthetic and body contouring procedures remains low particularly among independent residents. PMID:29062658

Myospherulosis following sinus surgery: pathological curiosity or important clinical entity?

PubMed

Sindwani, Raj; Cohen, Jacob T; Pilch, Ben Z; Metson, Ralph B

2003-07-01

Myospherulosis is a foreign body reaction to lipid material used on nasal packing at the conclusion of sinus surgery. This reaction has been associated with postoperative adhesion formation. The purpose of the study was to determine whether the occurrence of myospherulosis has an adverse effect on clinical outcome following sinus surgery. Case-control study at an academic medical center. Thirty-two cases of myospherulosis were identified in 28 patients (4 with bilateral disease) who underwent sinus surgery between 1989 and 1999. Cases were staged according to histological and radiological grading systems. Clinical outcome was compared with a control group of 28 patients who had similar surgery during the same time period. Patients with myospherulosis were found to have a significantly higher likelihood of developing postoperative adhesions compared with control subjects (50% vs. 18%, respectively [P =.023]). Histological stage, based on the extent of lipid vacuoles and spherules (erythrocyte remnants) present in the surgical specimen, was found to correlate with disease severity based on preoperative sinus computed tomography staging (P =.009). Patients with myospherulosis tended to have a shorter interval between their last two surgeries than did control subjects (2.2 +/- 2.1 vs. 4.5 +/- 7.1 y, respectively [P =.086]). Patient age, sex, comorbid conditions, CT stage, and number of previous operations were not predictive for the occurrence of myospherulosis. Patients who develop myospherulosis from lipid-based packing material used during sinus surgery are more likely to form postoperative adhesions. These adhesions appear to be clinically relevant and may hasten the need for revision surgery.

Surgery or gamma -knife for the treatment of arteriovenous malformations?

PubMed

Shigeno, T; Atsuchi, M; Tanaka, J; Goto, K; Ogata, N

2000-09-01

Decision making for either surgery or gamma-knife for the treatment of arteriovenous malformations (AVMs) cannot be uniform. The skill of the neurosurgeon in operating on AVMs is now being compared with that of the gamma-knife. The decision varies from case to case and is to be taken by the neurosurgeon. This report presents three cases in which such decision making was not easy. Case 1 was a non-ruptured cingulate AVM of 2.5 cm diameter in the cingulate cortex. The operative field was anticipated to be very narrow between the parietal bridging veins. Case 2 was a tiny ruptured AVM in the speech-motor area which was buried underneath the cortex. Case 3 was a large ruptured thalamo-stiriate-capsular AVM with feeders from the anterior and posterior choroidal arteries. All cases were operated without serious morbidity. A combination of pre-operative intravascular surgery (cases 1 and 3) or postoperative gamma-knife (case 3) was adopted. In conclusion, there is no unitary rule to decide on surgery or gamma-knife for the treatment of AVMs. It depends on what good or harm the responsible surgeon or the gamma-knife does.

Laparoscopic surgery for colorectal cancer is safe and has survival outcomes similar to those of open surgery in elderly patients with a poor performance status: subanalysis of a large multicenter case-control study in Japan.

PubMed

Niitsu, Hiroaki; Hinoi, Takao; Kawaguchi, Yasuo; Ohdan, Hideki; Hasegawa, Hirotoshi; Suzuka, Ichio; Fukunaga, Yosuke; Yamaguchi, Takashi; Endo, Shungo; Tagami, Soichi; Idani, Hitoshi; Ichihara, Takao; Watanabe, Kazuteru; Watanabe, Masahiko

2016-01-01

It remains controversial whether open or laparoscopic surgery should be indicated for elderly patients with colorectal cancer and a poor performance status. In those patients aged 80 years or older with Eastern Cooperative Oncology Group performance status score of 2 or greater who received elective surgery for stage 0 to stage III colorectal adenocarcinoma and had no concomitant malignancies and who were enrolled in a multicenter case-control study entitled "Retrospective study of laparoscopic colorectal surgery for elderly patients" that was conducted in Japan between 2003 and 2007, background characteristics and short-term and long-term outcomes for open surgery and laparoscopic surgery were compared. Of the 398 patients included, 295 underwent open surgery and 103 underwent laparoscopic surgery. There were no significant differences in the baseline characteristics between open surgery and laparoscopic surgery patients, except for previous abdominal surgery and TNM stage. The median operation duration was shorter with open surgery (open surgery, 153 min; laparoscopic surgery, 202 min; P < 0.001), and less blood loss occurred with laparoscopic surgery (median open surgery, 109 g; median laparoscopic surgery, 30 g; P < 0.001). An operation duration of 180 min or more (odds ratio, 1.97; 95 % confidence interval, 1.17-3.37; P = 0.011) and selection of laparoscopic surgery (odds ratio, 0.41; 95 % confidence interval, 0.22-0.75; P = 0.003) were statistically significant in the multivariate analysis for postoperative morbidity. Moreover, laparoscopic surgery did not result in an inferior overall survival rate compared with open surgery (log-rank test P = 0.289, 0.278, 0.346, 0.199, for all-stage, stage 0-I, stage II, and stage III disease, respectively). Laparoscopic surgery in elderly colorectal cancer patients with a poor performance status is safe and not inferior to open surgery in terms of overall survival.

Robotic surgery start-up with a fellow as the console surgeon.

PubMed

Reinhardt, Susanne; Ifaoui, Inge Boetker; Thorup, Jorgen

2017-08-01

Owing to the encouraging data on fellowship training in robotic pyeloplasty and the documented benefits of robotic pyeloplasty, the aim of this study was to test the feasibility of starting up pediatric urological robotic surgery in a center with a limited case volume. The operative parameters and clinical outcome of the first 25 robotic pyeloplasties performed were compared to data on open and laparoscopic procedures from the previous 5 year period. The fellow was the only console surgeon. An experienced non-robotic pediatric urologist was supervising at the patient site. The learning curve was in accordance with previously published data on fellows. The median operating time in robotic surgery was 182 min and was significantly shorter than in laparoscopic surgery (median 250 min) and the postoperative inpatient length of stay was significantly shorter after robotic surgery (median 1 day) than after both laparoscopic (median 2 days) and open surgery (median 3.5 days). For robotic cases, postoperative renography showed either stable or increased function of the hydronephrotic kidney. The only complication was in one case with ureteral orifice edema after JJ-stent removal, requiring nephrostomy for 6 weeks. The benefits of overall shorter postoperative hospital stay after robotic pyeloplasty and faster operating time compared to the laparoscopic procedure are clearly in accordance with data from the recent literature. The fast learning curve for robotic pyeloplasty will allow pediatric urology fellowship programs to be integrated in the start-up phase of a pediatric robotic program even though the case material is limited. Operative success rates were in accordance with the gold standard of open surgery.

Management implications for the perioperative surgical home related to inpatient case cancellations and add-on case scheduling on the day of surgery.

PubMed

Epstein, Richard H; Dexter, Franklin

2015-07-01

The American Society of Anesthesiologists has embraced the concept of the Perioperative Surgical Home as a means through which anesthesiologists can add value to the health systems in which they practice. One key listed element of the Perioperative Surgical Home is to support "scheduling initiatives to reduce cancellations and increase efficiency." In this study, we explored the potential benefits of the Perioperative Surgical Home with respect to inpatient cancellations and add-on case scheduling. We evaluated 6 hypotheses related to the timing of inpatient cancellations and preoperative anesthesia evaluations. Inpatient cancellations were studied during 26 consecutive 4-week intervals between July 2012 and June 2014 at a tertiary care academic hospital. All timestamps related to scheduling, rescheduling, and cancellation activities were retrieved from the operating room (OR) case scheduling system. Timestamps when patients were seen by anesthesia residents were obtained from the preoperative evaluation system database. Batch mean methods were used to calculate means and SE. For cases cancelled, we determined whether, for "most" (>50%) cancellations, a subsequent procedure (of any type) was performed on the patient within 7 days of the cancellation. Comparisons with most and other fractions were assessed using the 1 group, 1-sided Student t test. We evaluated whether a few procedures were highly represented among the cancelled cases via the Herfindahl (Simpson's) index, comparing it with <0.15. The rate of scheduling activity was assessed by computing the number of OR scheduling office decisions in each 1-hour bin between 6:00 AM and 3:59 PM. These values were compared with ≥1 decision per hour at the study hospital. Data from 24,735 scheduled inpatient cases were assessed. Cases cancelled after 7 AM on the day before or at any time on the scheduled day of surgery accounted for 22.6% ± 0.5% (SE) of the scheduled minutes all scheduled cases, and 26.8% ± 0.4% of the case volume (i.e., number of cases). Most (83.1% ± 0.6%, P < 10) cases performed were evaluated on the day before surgery. Most (67.6% ± 1.6%, P < 10) minutes of cancelled cases were evaluated on the day before surgery. Most (62.3% ± 1.5%, P < 10) cases were seen earlier than 6:00 PM of the day before surgery. The Herfindahl index among cancelled procedures was 0.021 ± 0.001 (P < 10 compared not only to <0.15 but also to <0.05), showing large heterogeneity among the cancelled procedures. A subsequent procedure was not performed for most cancelled cases (50.6% ± 0.9% compared with >50%, P = 0.12), implying that the indication for the cancelled procedure no longer existed or the patient/family decided not to proceed with surgery. When only cancellations on the scheduled day of surgery were considered, the cancellation rate was 14.0% ± 0.3% of scheduled inpatient minutes and 11.8% ± 0.2% of scheduled inpatient cases. There were 0.59 ± 0.02 OR schedule decisions per hour per 10 ORs between 6:00 AM and 3:59 PM (P < 10, corresponding to ≥1 decision per hour at the 36 OR study hospital). The study hospital had a high inpatient cancellation rate, despite the fact that most patients whose cases were cancelled were seen by an anesthesia resident by 6:00 PM of the day before surgery. This finding suggests that further efforts to reduce the cancellations by seeing patients sooner on the day before surgery, or seeing even more patients the day before surgery, would not be an economically useful focus of the Perioperative Surgical Home. The wide heterogeneity among cancelled cases indicates that focusing on a few procedures would not materially affect the overall cancellation rate. The relatively low rate of subsequent performance of a procedure on patients whose cases had been cancelled suggests that trying to decrease the cancellation rate might be medically counterproductive. The hourly rate of decisions in the scheduling office during regular work hours on the day of surgery highlights the importance of decisions made at the OR control desk and scheduling office throughout the day to reduce the hours of overused OR time. These data suggest that efforts of the Perioperative Surgical Home related to inpatient cancellations should focus on management decision-making to mitigate the disruptions to the planned OR schedule caused by inpatient case cancellations and add-on cases, more so than on efforts to reduce inpatient cancellation rates.

Surgical results of reoperative tricuspid surgery: analysis from the Japan Cardiovascular Surgery Database†.

PubMed

Umehara, Nobuhiro; Miyata, Hiroaki; Motomura, Noboru; Saito, Satoshi; Yamazaki, Kenji

2014-07-01

Tricuspid valve insufficiency (TI) following cardiovascular surgery causes right-side heart failure and hepatic failure, which affect patient prognosis. Moreover, the benefits of reoperation for severe tricuspid insufficiency remain unclear. We investigated the surgical outcomes of reoperation in TI. From the Japan Cardiovascular Surgery Database (JACVSD), we extracted cases who underwent surgery for TI following cardiac surgery between January 2006 and December 2011. We analysed the surgical outcomes, specifically comparing tricuspid valve replacement (TVR) and tricuspid valve plasty (TVP). Of the 167 722 surgical JACVSD registered cases, reoperative TI surgery occurred in 1771 cases, with 193 TVR cases and 1578 TVP cases. The age and sex distribution was 684 males and 1087 females, with an average age of 66.5 ± 10.8 years. The overall hospital mortality was 6.8% and was significantly higher in the TVR group than in the TVP group (14.5 vs 5.8%, respectively; P < 0.001). Incidences of dialysis, prolonged ventilation and heart block were also significantly higher in the TVR group than in the TVP group. Logistic regression analysis revealed that the risk factors of hospital mortality were older age, preoperative renal dysfunction, preoperative New York Heart Association Class 4, left ventricular dysfunction and TVR. Surgical outcomes following reoperative tricuspid surgery were unsatisfactory. Although TVR is a last resort for non-repairable tricuspid lesions, it carries a significant risk of surgical mortality. Improving the patient's preoperative status and opting for TVP over TVR is necessary to improve the results of reoperative tricuspid surgery. © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Effect of six sigma program on the number of surgeries cancellation

PubMed Central

Gheysari, Esmat; Yousefi, Hojatollah; Soleymani, Hossain; Mojdeh, Soheila

2016-01-01

Background: Today, the rate of surgeries is increasing, but surgeries are canceled due to various reasons. Unexpected cancellation of surgeries not only results in disorder in the operating room schedule, but also causes stress for patients and their family and increases costs. We determined the number and causes of surgery cancellations and areas for improvement. Materials and Methods: This outcome evaluation of Six Sigma program was conducted on 850 cases after the implementation of the program and compared to that of 850 cases which received routine care before the program. Cases were selected through easy sampling during the study. Before the implementation, the number of cancellations was recorded daily and their reasons were investigated. Then, Six Sigma program was implemented in accordance with the reasons for each category and necessary steps were taken to prevent the cancellation of surgeries. Data were collected for 3 months using a three-section data collection form. For data analysis, distribution and relative frequency and chi-square test were used. Results: The three categories of patient, physician, and hospital system were identified as the main causes. The highest rate of cancellation was related to ENT surgeries (74.19%). No cancellations were made in orology surgeries. The implementation of the Six Sigma program caused a significant difference in surgery cancellation (P = 0.003); 31 (3.6%) cases of cancellation were reduced to 12 (1.4%) cases. Conclusions: The results showed that Six Sigma program is a pre-surgery care quality improvement program. Patient education and the implementation of the 6 sigma program can be effective in reducing the rate of cancellation of operations. PMID:27095994

Improved outcomes in pediatric epilepsy surgery: the UCLA experience, 1986-2008.

PubMed

Hemb, M; Velasco, T R; Parnes, M S; Wu, J Y; Lerner, J T; Matsumoto, J H; Yudovin, S; Shields, W D; Sankar, R; Salamon, N; Vinters, H V; Mathern, G W

2010-06-01

Epilepsy neurosurgery is a treatment option for children with refractory epilepsy. Our aim was to determine if outcomes improved over time. Pediatric epilepsy surgery patients operated in the first 11 years (1986-1997; pre-1997) were compared with the second 11 years (1998-2008; post-1997) for differences in presurgical and postsurgical variables. Despite similarities in seizure frequency, age at seizure onset, and age at surgery, the post-1997 series had more lobar/focal and fewer multilobar resections, and more patients with tuberous sclerosis complex and fewer cases of nonspecific gliosis compared with the pre-1997 group. Fewer cases had intracranial EEG studies in the post-1997 (0.8%) compared with the pre-1997 group (9%). Compared with the pre-1997 group, the post-1997 series had more seizure-free patients at 0.5 (83%, +16%), 1 (81%, +18%), 2 (77%, +19%), and 5 (74%, +29%) years, and more seizure-free patients were on medications at 0.5 (97%, +6%), 1 (88%, +9%), and 2 (76%, +29%), but not 5 (64%, +8%) years after surgery. There were fewer complications and reoperations in the post-1997 series compared with the pre-1997 group. Logistic regression identified post-1997 series and less aggressive medication withdrawal as the main predictors of becoming seizure-free 2 years after surgery. Improved technology and surgical procedures along with changes in clinical practice were likely factors linked with enhanced and sustained seizure-free outcomes in the post-1997 series. These findings support the general concept that clearer identification of lesions and complete resection are linked with better outcomes in pediatric epilepsy surgery patients.

Nontrauma emergency surgery: optimal case mix for general surgery and acute care surgery training.

PubMed

Cherry-Bukowiec, Jill R; Miller, Barbra S; Doherty, Gerard M; Brunsvold, Melissa E; Hemmila, Mark R; Park, Pauline K; Raghavendran, Krishnan; Sihler, Kristen C; Wahl, Wendy L; Wang, Stewart C; Napolitano, Lena M

2011-11-01

To examine the case mix and patient characteristics and outcomes of the nontrauma emergency (NTE) service in an academic Division of Acute Care Surgery. An NTE service (attending, chief resident, postgraduate year-3 and postgraduate year-2 residents, and two physician assistants) was created in July 2005 for all urgent and emergent inpatient and emergency department general surgery patient consults and admissions. An NTE database was created with prospective data collection of all NTE admissions initiated from November 1, 2007. Prospective data were collected by a dedicated trauma registrar and Acute Physiology and Chronic Health Evaluation-intensive care unit (ICU) coordinator daily. NTE case mix and ICU characteristics were reviewed for the 2-year time period January 1, 2008, through December 31, 2009. During the same time period, trauma operative cases and procedures were examined and compared with the NTE case mix. Thousand seven hundred eight patients were admitted to the NTE service during this time period (789 in 2008 and 910 in 2009). Surgical intervention was required in 70% of patients admitted to the NTE service. Exploratory laparotomy or laparoscopy was performed in 449 NTE patients, comprising 37% of all surgical procedures. In comparison, only 118 trauma patients (5.9% of admissions) required a major laparotomy or thoracotomy during the same time period. Acuity of illness of NTE patients was high, with a significant portion (13%) of NTE patients requiring ICU admission. NTE patients had higher admission Acute Physiology and Chronic Health Evaluation III scores [61.2 vs. 58.8 (2008); 58.2 vs. 55.8 (2009)], increased mortality [(9.71% vs. 4.89% (2008); 6.78% vs. 5.16% (2009)], and increased readmission rates (15.5% vs. 7.4%) compared with the total surgical ICU (SICU) admissions. In an era of declining operative caseload in trauma, the NTE service provides ample opportunity for complex general surgery decision making and operative procedures for surgical residency education, including advanced surgical critical care management. In addition, creation of an NTE service provides an optimal general surgery case mix, including major abdominal operations, that can augment declining trauma surgery caseloads, maintain acute care faculty surgical skills, and support general and acute care surgery residency training.

Otogenic Meningitis: A Comparison of Diagnostic Performance of Surgery and Radiology.

PubMed

Bruschini, Luca; Fortunato, Simona; Tascini, Carlo; Ciabotti, Annalisa; Leonildi, Alessandro; Bini, Belinda; Giuliano, Simone; Abbruzzese, Arturo; Berrettini, Stefano; Menichetti, Francesco

2017-01-01

Development of intracranial complications from middle ear infections might be difficult to diagnose. We compared radiological and surgical findings of 26 patients affected by otogenic meningitis. Results of our analysis showed that surgery is more reliable than imaging in revealing bone defects. Therefore, suggest that surgery be performed for diagnosis and eventual management of all cases of suspected otogenic meningitis.

High field strength magnetic resonance imaging in paediatric brain tumour surgery--its role in prevention of early repeat resections.

PubMed

Avula, Shivaram; Pettorini, Benedetta; Abernethy, Laurence; Pizer, Barry; Williams, Dawn; Mallucci, Conor

2013-10-01

The purpose of this study is to compare the surgical and imaging outcome in children who underwent brain tumour surgery with intention of complete tumour resection, prior to and following the start of intra-operative MRI (ioMRI) service. ioMRI service for brain tumour resection commenced in October 2009. A cohort of patients operated between June 2007 and September 2009 with a pre-surgical intention of complete tumour resection were selected (Group A). A similar number of consecutive cases were selected from a prospective database of patients undergoing ioMRI (Group B). The demographics, imaging, pathology and surgical outcome of both groups were compared. Thirty-six of 47 cases from Group A met the inclusion criterion and 36 cases were selected from Group B; 7 of the 36 cases in Group A had unequivocal evidence of residual tumour on the post-operative scan; 5 (14%) of them underwent repeat resection within 6 months post-surgery. In Group B, ioMRI revealed unequivocal evidence of residual tumour in 11 of the 36 cases following initial resection. In 10 of these 11 cases, repeat resections were performed during the same surgical episode and none of these 11 cases required repeat surgery in the following 6 months. Early repeat resection rate was significantly different between both groups (p = 0.003). Following the advent of ioMRI at our institution, the need for repeat resection within 6 months has been prevented in cases where ioMRI revealed unequivocal evidence of residual tumour.

[Sclerotherapy and hydrocelectomy for the management of hydrocele in outpatient and day-surgery setting].

PubMed

Erdas, Enrico; Pisano, Giuseppe; Pomata, Mariano; Pinna, Giovanni; Secci, Lucia; Licheri, Sergio; Daniele, Giovanni Maria

2006-01-01

The purpose of this report was to compare two different procedures in the treatment of idiopathic hydrocele, namely, hydrocelectomy and percutaneous sclerotherapy, both of which performed in the outpatient or day surgery setting. A detailed description of the technical local anaesthesia steps is reported together with the sclerotherapy method. The study was conducted in 71 patients with a total of 77 hydroceles treated from 1993 to 2004. Surgery was carried out in 53 cases and sclerotherapy in 24. The latter was more frequently opted for elderly subjects as well as in those patients who requested it. Local or locoregional anaesthesia was reserved to patients treated surgically. The two treatments were compared on the basis of the following parameters: age, operative time, length of hospital stay, success rate and complications. The efficacy of the two procedures was comparable (sclerotherapy 95.8% vs surgery 100%), but sclerotherapy proved more favourable in terms of simplicity, rapidity of execution, shortness of hospital stay and risk of complications. However, 41.7% of patients required more than one treatment to obtain a radical cure, whereas surgery was effective in all cases in just one step. Hospital stay and morbidity were almost the same when surgery was performed under local anaesthesia. Sclerotherapy is an efficient alternative to the classic hydrocelectomy. The choice between the two treatment modalities should be made, taking into account above all the patient's individual preference.

Risk factors for unavoidable removal of instrumentation after surgical site infection of spine surgery: A retrospective case-control study.

PubMed

Tominaga, Hiroyuki; Setoguchi, Takao; Kawamura, Hideki; Kawamura, Ichiro; Nagano, Satoshi; Abematsu, Masahiko; Tanabe, Fumito; Ishidou, Yasuhiro; Yamamoto, Takuya; Komiya, Setsuro

2016-10-01

Surgical site infection (SSI) after spine instrumentation is difficult to treat, and often requires removal of instrumentation. The removal of instrumentation after spine surgery is a severe complication that can lead to the deterioration of activities of daily living and poor prognosis. Although there are many reports on SSI after spine surgery, few reports have investigated the risk factors for the removal of instrumentation after spine surgery SSI. This study aimed to identify the risk factors for unavoidable removal of instrumentation after SSI of spine surgery. We retrospectively reviewed 511 patients who underwent spine surgery with instrumentation at Kagoshima University Hospital from January 2006 to December 2014. Risk factors associated with SSI were analyzed via multiple logistic regression analysis. Parameters of the group that needed instrumentation removal were compared with the group that did not require instrumentation removal using the Mann-Whitney U and Fisher's exact tests. The posterior approach was used in most cases (453 of 511 cases, 88.6%). SSI occurred in 16 of 511 cases (3.14%) of spine surgery with instrumentation. Multivariate logistic regression analysis identified 2 significant risk factors for SSI: operation time, and American Society of Anesthesiologists physical status classification ≥ 3. Twelve of the 16 patients with SSI (75%) were able to keep the instrumentation after SSI. Pseudarthrosis occurred in 2 of 4 cases (50%) after instrumentation removal. Risk factors identified for instrumentation removal after spine SSI were a greater number of past surgeries, low preoperative hemoglobin, high preoperative creatinine, high postoperative infection treatment score for the spine, and the presence of methicillin-resistant Staphylococcus aureus. In these high risk cases, attempts should be made to decrease the risk factors preoperatively, and careful postoperative monitoring should be conducted.

Maternal and perinatal outcomes after bariatric surgery: a case control study.

PubMed

de Alencar Costa, Laura Arrais Sydrião; Araujo Júnior, Edward; de Lucena Feitosa, Francisco Edson; Dos Santos, Andréa Cavalcante; Moura Júnior, Luiz Gonzaga; Costa Carvalho, Francisco Herlânio

2016-05-01

To compare the results of maternal and perinatal pregnancies of obese women after bariatric surgery. A retrospective cross-sectional study was carried out on 63 women who had undergone bariatric surgery and 73 obese women (control). Demographic data, the characteristics of the bariatric surgery, and the maternal and perinatal results were evaluated. The Student's t-test and chi-square test (χ2) were used to compare the groups. The gestational complications of the prevalence of gestational diabetes mellitus, anemia, and preeclampsia were analyzed using simple and multivariate logistical regression and odd ratios (OD) with their respective confidence intervals (CI) of 95%. The average body mass index (BMI) at the 1st prenatal appointment of the control group was 34.6±3.3 kg/m2 and that of the post-surgical group was 26.5±4.2 kg/m2. The Roux-en-Y Gastric Bypass was used in 100% of cases; no complications were observed during or after the surgeries. The average weight loss in patients with a prior bariatric surgery was statistically significant (P=0.000). The average weight at birth of the control group was significantly higher than in the post-bariatric surgery group (P=0.017). The women who had a prior bariatric surgery had a higher chance of anemia (OR=3.5; CI 95%: 1.5-8.3) and a reduced chance of macrosomia (OR=0.2; CI 95%:0.1-0.5), and prematurity (OR=0.3; CI 95%:0.1-0.7). Those women who had been submitted to bariatric surgery presented better maternal and perinatal results when compared to obese women.

The impact of an acute care surgery team on general surgery residency.

PubMed

Hatch, Quinton; McVay, Derek; Johnson, Eric K; Maykel, Justin A; Champagne, Bradley J; Steele, Scott R

2014-11-01

Acute care surgical teams (ACSTs) have limited data in residency. We sought to determine the impact of an ACST on the depth and breadth of general surgery resident training. One year prior to and after implementation of an ACST, Accreditation Council for Graduate Medical Education case logs spanning multiple postgraduate year levels were compared for numbers, case types, and complexity. We identified 6,009 cases, including 2,783 after ACST implementation. ACSTs accounted for 752 cases (27%), with 39.2% performed laparoscopically. ACST cases included biliary (19.4%), skin/soft tissue (10%), hernia (9.8%), and appendix (6.5%). Second-year residents performed a lower percentage of laparoscopic cases after the creation of the ACST (20.4% vs 26.3%; P = .003), while chief residents performed a higher percentage (42.1 vs 37.4; P = .04). Case numbers and complexity following ACST development were unchanged within all year groups (P > .1). ACST in a residency program does not sacrifice resident case complexity, diversity, or volume. Published by Elsevier Inc.

Bar-code medication administration system for anesthetics: effects on documentation and billing.

PubMed

Nolen, Agatha L; Rodes, W Dyer

2008-04-01

The effects of using a new bar-code medication administration (BCMA) system for anesthetics to automate documentation of drug administration by anesthesiologists were studied. From October 1, 2004, to September 15, 2005, all medications administered to patients undergoing cardiac surgery were documented with a BCMA system at a large acute care facility. Drug claims data for 12 targeted anesthetics in diagnosis-related groups (DRGs) 104-111 were analyzed to determine the quantity of drugs charged and the revenue generated. Those data were compared with claims data for a historical case-control group (October 1, 2003, to September 15, 2004, for the same DRGs) for which medication use was documented manually. From October 1, 2005, to October 1, 2006, anesthesiologists for cardiac surgeries either voluntarily used the automated system or completed anesthesia records manually. A total of 870 cardiac surgery cases for which the BCMA system was used were evaluated. There were 961 cardiac surgery cases in the historical control group. The BCMA system increased the quantity of drugs documented per case by 21.7% and drug revenue captured per case by 18.8%. The time needed by operating-room pharmacy staff to process an anesthesia record for billing decreased by eight minutes per case. After two years, anesthesiologists voluntarily used the new technology on 100% of cardiac surgery patients. Implementation of a BCMA system for anesthetic use in cardiac surgery increased the quantity of drugs charged by 21.7% per case and drug revenue per case by 18.8%. Anesthesiologists continued to use the automated system on a voluntary basis after conclusion of the initial study.

Acute care surgery: impact on practice and economics of elective surgeons.

PubMed

Miller, Preston R; Wildman, Elizabeth A; Chang, Michael C; Meredith, J Wayne

2012-04-01

The creation of an acute care surgery service provides a rich operative experience for acute care surgeons. Elective surgeons typically have concerns about whether their practice volume will be restored with elective cases. Acute care surgery has financial implications for both groups. The aim of this project is to examine the impact in terms of work relative value units (wRVUs), collections, and cases in both groups with creation of an acute care surgery service at our institution. Work RVUs, collections, and case volume were examined from departmental records for 2 groups before and after acute care surgery service creation. The service began on September 1, 2008. Before this time, emergency surgical consults went to the general surgeon on call. After this date, all emergency consults were seen by acute care surgeons. The number of operations performed by the acute care surgery group increased significantly when the mean of the 2 years after institution of acute care surgery were compared with the mean of the 2 years preceding the service creation (1,639 vs 790/year; p = 0.007). There was no change in total operations done by the elective surgery group (2,763 vs 2,496/year: p = 0.13). Elective caseload, however, did increase by 23% in the elective surgery group. In the acute care surgery group, wRVUs increased by 140% and elective surgery group wRVUs decreased by 8%. Collections increased in both groups (acute care surgery 129%, elective surgery 7%) and the combined collections of the groups increased by $2,138,00 in the year after service creation. Acute care surgery service creation took emergency business from the elective surgery group, but this was almost immediately replaced with elective cases. This resulted in higher collections for both groups and a resultant significant increase in collections in aggregate. Copyright © 2012 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Retroperitoneal laparoscopic pyelolithotomy in renal pelvic stone versus open surgery - a comparative study.

PubMed

Singal, Rikki; Dhar, Siddharth

2018-01-01

The introduction of endourological procedures such as percutaneous nephrolithotomy and ureterorenoscopy have led to a revolution in the the management of urinary stone disease. The indications for open stone surgery have been narrowed significantly, making it a second- or third-line treatment option. To study the safety and efficacy of retroperitoneal laparoscopic pyelolithotomy in retroperitoneal renal stone. We compared the results of laparoscopic and open surgery in terms of easy accessibility, operative period, renal injuries, and early recovery. This prospective study was conducted on renal pelvic stone cases from January 2009 to February 2016 in Suchkhand Hospital, Agra, India. The study included a total of 1700 cases with the diagnosis of solitary renal pelvic stones. In group A - 850 cases - retroperitoneal laparoscopic pyelolithotomy was performed, while group B - 850 cases - underwent open pyelolithotomy. The mean operative time was less in group B than group A (74.83 min vs. 94.43 min) which was significant (p<0.001). The blood loss was less in the laparoscopic group than in the open group (63 mL vs. 103mL). There were statistically significant differences in the post-operative pain scores, and postoperative complications compared to group B (p<0.001). The mean hospital stay was less in group A (p<0.03), which was significant. Laparoscopic surgery reduces analgesic requirements, hospital stay, and blood loss. The disadvantages include the reduced working space, the cost of equipment and the availability of a trained surgeon.

Topical anesthesia in strabismus surgery: a review of 101 cases.

PubMed

Seijas, Olga; Gómez de Liaño, Pilar; Merino, Pilar; Roberts, Clare J; Gómez de Liaño, Rosario

2009-01-01

To analyze the results over a 10-year period with a different type of strabismus surgery performed with topical anesthesia, to describe the differences in technique compared with surgery performed with general anesthesia, and to detail current indications and technical changes made according to the experience accrued during these years. A total of 101 patients undergoing strabismus surgery with topical anesthesia in a single hospital were analyzed. These patients were randomly selected from a total of 567 patients who had undergone extra-ocular muscle surgery in the past 10 years. A good result was obtained (squint angle < 10 prism diopters and absence of diplopia) in 95% of patients immediately after surgery and in 85% at final follow-up (mean follow-up: 3.1 years). The mean operating time for each muscle was 29 minutes. Surgery was well tolerated in every patient. Conversion to general anesthesia was not necessary in any case. Atropine was used in three patients (3%) because of induction of the vagal reflex. Topical anesthesia in strabismus surgery is a useful technique in the treatment of extraocular muscle pathology, with few limitations. Appropriate monitoring by an anesthetist is vital to ensure adequate control of pain and possible side effects and to enable conversion to general anesthesia. The oculocardiac reflex is infrequent. For experienced strabismus surgeons, the total surgical time is comparable with topical and general anesthesia. Copyright 2009, SLACK Incorporated.

Association Between Surgeon Scorecard Use and Operating Room Costs.

PubMed

Zygourakis, Corinna C; Valencia, Victoria; Moriates, Christopher; Boscardin, Christy K; Catschegn, Sereina; Rajkomar, Alvin; Bozic, Kevin J; Soo Hoo, Kent; Goldberg, Andrew N; Pitts, Lawrence; Lawton, Michael T; Dudley, R Adams; Gonzales, Ralph

2017-03-01

Despite the significant contribution of surgical spending to health care costs, most surgeons are unaware of their operating room costs. To examine the association between providing surgeons with individualized cost feedback and surgical supply costs in the operating room. The OR Surgical Cost Reduction (OR SCORE) project was a single-health system, multihospital, multidepartmental prospective controlled study in an urban academic setting. Intervention participants were attending surgeons in orthopedic surgery, otolaryngology-head and neck surgery, and neurological surgery (n = 63). Control participants were attending surgeons in cardiothoracic surgery, general surgery, vascular surgery, pediatric surgery, obstetrics/gynecology, ophthalmology, and urology (n = 186). From January 1 to December 31, 2015, each surgeon in the intervention group received standardized monthly scorecards showing the median surgical supply direct cost for each procedure type performed in the prior month compared with the surgeon's baseline (July 1, 2012, to November 30, 2014) and compared with all surgeons at the institution performing the same procedure at baseline. All surgical departments were eligible for a financial incentive if they met a 5% cost reduction goal. The primary outcome was each group's median surgical supply cost per case. Secondary outcome measures included total departmental surgical supply costs, case mix index-adjusted median surgical supply costs, patient outcomes (30-day readmission, 30-day mortality, and discharge status), and surgeon responses to a postintervention study-specific health care value survey. The median surgical supply direct costs per case decreased 6.54% in the intervention group, from $1398 (interquartile range [IQR], $316-$5181) (10 637 cases) in 2014 to $1307 (IQR, $319-$5037) (11 820 cases) in 2015. In contrast, the median surgical supply direct cost increased 7.42% in the control group, from $712 (IQR, $202-$1602) (16 441 cases) in 2014 to $765 (IQR, $233-$1719) (17 227 cases) in 2015. This decrease represents a total savings of $836 147 in the intervention group during the 1-year study. After controlling for surgeon, department, patient demographics, and clinical indicators in a mixed-effects model, there was a 9.95% (95% CI, 3.55%-15.93%; P = .003) surgical supply cost decrease in the intervention group over 1 year. Patient outcomes were equivalent or improved after the intervention, and surgeons who received scorecards reported higher levels of cost awareness on the health care value survey compared with controls. Cost feedback to surgeons, combined with a small departmental financial incentive, was associated with significantly reduced surgical supply costs, without negatively affecting patient outcomes.

Single-specialty management and reconstruction of necrotizing fasciitis of the upper extremities: clinical and economic benefits from a case series.

PubMed

Mattison, Gennaya; Leis, Amber R; Gupta, Subhas C

2014-05-01

Patients with necrotizing fasciitis are managed with multiple prompt, radical surgical debridements and critical care support. Debridement and reconstruction are often provided by different surgical teams. Anecdotally, single-specialty management seemed to be a more efficient management strategy. This study aimed to investigate and compare the outcomes of management by plastic surgery versus multiple disciplines through a retrospective economic and clinical analysis of patients with necrotizing fasciitis treated over 8 years. We also present 3 index cases for which our service functioned as the primary management team. Necrotizing fasciitis cases evaluated and treated by our department, covering both Level I and Level II Trauma Centers, were reviewed for total charges, length of hospital stay, length of intensive care unit (ICU) stay, and number of procedures. The admission Acute Physiology and Chronic Health Evaluation II score was calculated for each patient. Three comparative index cases of upper extremity necrotizing fasciitis managed primarily by the plastic surgery team are presented in greater detail. Patients managed primarily by the plastic surgery service had equivalent Acute Physiology and Chronic Health Evaluation II scores to patients managed by multiple services for their necrotizing fasciitis, with the average score higher for patients managed by plastic surgery alone. In a case-matched series of upper extremity necrotizing fasciitis, the patients admitted directly to plastic surgery had shorter average lengths of hospital and ICU stays as well as decreased total number of procedures, resulting in decreased average total hospital charges. There were no amputations among the cases treated primarily by the plastic surgery. The patients also required smaller areas of reconstruction with skin grafting despite large initial areas of debridement compared to those whose reconstructive teams differed from the team performing the debridement. Improved economic and clinical outcomes-as indicated by the reduced lengths of overall and ICU stay, the reduced number of procedures, none of the cases requiring amputation, and the reduced need for skin grafting-may be attainable when the surgeon eventually performing the reconstruction is involved early in management. We propose that, in the interest of improving patient care, a closer collaboration should be established between the reconstructive and primary managing teams.

Robotic radical hysterectomy in the management of gynecologic malignancies.

PubMed

Pareja, Rene; Ramirez, Pedro T

2008-01-01

Robotic surgery is being used with increasing frequency in gynecologic oncology. To date, 44 cases were reported in the literature of radical hysterectomy performed with robotic surgery. When comparing robotic surgery with laparoscopy or laparotomy in performing a radical hysterectomy, the literature shows that robotic surgery offers an advantage over the other 2 surgical approaches with regard to operative time, blood loss, and length of hospitalization. Future studies are needed to further elucidate the equivalence or superiority of robotic surgery to laparoscopy or laparotomy in performing a radical hysterectomy.

Management of Aspergillus osteomyelitis: report of failure of liposomal amphotericin B and response to voriconazole in an immunocompetent host and literature review.

PubMed

Stratov, I; Korman, T M; Johnson, P D R

2003-05-01

Presented here is a case of Aspergillus osteomyelitis in an immunocompetent patient that progressed despite surgery and prolonged treatment with liposomal amphotericin B; the report is followed by a review of the literature. The review of this case and 41 similar cases found an overall cure rate of 69%. The importance of surgery when amphotericin B is used as first-line therapy is indicated by a 14% cure rate when amphotericin B is used alone compared to 75% when combined with surgery. When therapy is failing or surgery is contraindicated, dose escalation using a lipid formulation was not effective. On review, the addition of another agent, in particular 5-fluorocytosine, appears to be more beneficial. The patient reported here responded rapidly to voriconazole, a promising new antifungal agent for Aspergillus infections.

Impact of Soft Tissue Heterogeneity on Augmented Reality for Liver Surgery.

PubMed

Haouchine, Nazim; Cotin, Stephane; Peterlik, Igor; Dequidt, Jeremie; Lopez, Mario Sanz; Kerrien, Erwan; Berger, Marie-Odile

2015-05-01

This paper presents a method for real-time augmented reality of internal liver structures during minimally invasive hepatic surgery. Vessels and tumors computed from pre-operative CT scans can be overlaid onto the laparoscopic view for surgery guidance. Compared to current methods, our method is able to locate the in-depth positions of the tumors based on partial three-dimensional liver tissue motion using a real-time biomechanical model. This model permits to properly handle the motion of internal structures even in the case of anisotropic or heterogeneous tissues, as it is the case for the liver and many anatomical structures. Experimentations conducted on phantom liver permits to measure the accuracy of the augmentation while real-time augmentation on in vivo human liver during real surgery shows the benefits of such an approach for minimally invasive surgery.

Current Status of Laparoendoscopic Single-Site Surgery in Urologic Surgery

PubMed Central

2012-01-01

Since the introduction of laparoscopic surgery, the promise of lower postoperative morbidity and improved cosmesis has been achieved. Laparoendoscopic single-site surgery (LESS) potentially takes this further. Following the first human urological LESS report in 2007, numerous case series have emerged, as well as comparative studies comparing LESS with standard laparoscopy. However, comparative series between conventional laparoscopy and LESS for different procedures suggest a non-inferiority of LESS over standard laparoscopy, but the only objective benefit remains an improved cosmetic outcome. Challenging ergonomics, instrument clashing, lack of true triangulation, and in-line vision are the main concerns with LESS surgery. Various new instruments have been designed, but only experienced laparoscopists and well-selected patients are pivotal for a successful LESS procedure. Robotic-assisted LESS procedures have been performed. The available robotic platform remains bulky, but development of instrumentation and application of robotic technology are expected to define the actual role of these techniques in minimally invasive urologic surgery. PMID:22866213

Malignant Hyperthermia: Report of Two Cases with a Neglected Complication in Cardiac Surgery

PubMed Central

Neshati, Mahdi; Azadeh, Manizheh; Neshati, Parinaz; Burnett, Tyrone; Saenz, Ryan; Karbasi, Bahman; Shahmohammadi, Ghader; Nourizadeh, Eskandar; Rostamzadeh, Mohsen

2017-01-01

Malignant hyperthermia (MH) can develop after contact with volatile anesthetics (halothane, enflurane, isoflurane, sevoflurane, and desflurane) as well as succinylcholine and cause hypermetabolism during anesthesia, which is associated with high mortality when untreated. Early diagnosis and treatment could be life-saving. During cardiac surgery, hypothermia and cardiopulmonary bypass make the diagnosis of MH extremely challenging compared with other settings such as general surgery. We herein report 2 cases of MH, graded as “very likely” or “almost certain” based on the MH clinical grading scale. A 14-month-old infant and a 53-year-old male underwent surgery for severe pulmonary valve stenosis and mitral valve replacement, respectively. Both of them were extubated on the operation day, but they deteriorated with the development of high-grade fever, hypotension, renal failure, and acidosis. The first case had muscle spasms. Unfortunately, the delayed symptoms of MH in the early postoperative course were not diagnosed in these 2 cases, which caused permanent neurologic damage in the first case and death in the second one. However, the infant was discharged from the hospital after 2 months. PMID:29576786

Malignant Hyperthermia: Report of Two Cases with a Neglected Complication in Cardiac Surgery.

PubMed

Neshati, Mahdi; Azadeh, Manizheh; Neshati, Parinaz; Burnett, Tyrone; Saenz, Ryan; Karbasi, Bahman; Shahmohammadi, Ghader; Nourizadeh, Eskandar; Rostamzadeh, Mohsen

2017-10-01

Malignant hyperthermia (MH) can develop after contact with volatile anesthetics (halothane, enflurane, isoflurane, sevoflurane, and desflurane) as well as succinylcholine and cause hypermetabolism during anesthesia, which is associated with high mortality when untreated. Early diagnosis and treatment could be life-saving. During cardiac surgery, hypothermia and cardiopulmonary bypass make the diagnosis of MH extremely challenging compared with other settings such as general surgery. We herein report 2 cases of MH, graded as "very likely" or "almost certain" based on the MH clinical grading scale. A 14-month-old infant and a 53-year-old male underwent surgery for severe pulmonary valve stenosis and mitral valve replacement, respectively. Both of them were extubated on the operation day, but they deteriorated with the development of high-grade fever, hypotension, renal failure, and acidosis. The first case had muscle spasms. Unfortunately, the delayed symptoms of MH in the early postoperative course were not diagnosed in these 2 cases, which caused permanent neurologic damage in the first case and death in the second one. However, the infant was discharged from the hospital after 2 months.

The impact of a preloaded intraocular lens delivery system on operating room efficiency in routine cataract surgery.

PubMed

Jones, Jason J; Chu, Jeffrey; Graham, Jacob; Zaluski, Serge; Rocha, Guillermo

2016-01-01

The aim of this study was to evaluate the operational impact of using preloaded intraocular lens (IOL) delivery systems compared with manually loaded IOL delivery processes during routine cataract surgeries. Time and motion data, staff and surgery schedules, and cost accounting reports were collected across three sites located in the US, France, and Canada. Time and motion data were collected for manually loaded IOL processes and preloaded IOL delivery systems over four surgery days. Staff and surgery schedules and cost accounting reports were collected during the 2 months prior and after introduction of the preloaded IOL delivery system. The study included a total of 154 routine cataract surgeries across all three sites. Of these, 77 surgeries were performed using a preloaded IOL delivery system, and the remaining 77 surgeries were performed using a manual IOL delivery process. Across all three sites, use of the preloaded IOL delivery system significantly decreased mean total case time by 6.2%-12.0% (P<0.001 for data from Canada and the US and P<0.05 for data from France). Use of the preloaded delivery system also decreased surgeon lens time, surgeon delays, and eliminated lens touches during IOL preparation. Compared to a manual IOL delivery process, use of a preloaded IOL delivery system for cataract surgery reduced total case time, total surgeon lens time, surgeon delays, and eliminated IOL touches. The time savings provided by the preloaded IOL delivery system provide an opportunity for sites to improve routine cataract surgery throughput without impacting surgeon or staff capacity.

General surgery residents' perception of robot-assisted procedures during surgical training.

PubMed

Farivar, Behzad S; Flannagan, Molly; Leitman, I Michael

2015-01-01

With the continued expansion of robotically assisted procedures, general surgery residents continue to receive more exposure to this new technology as part of their training. There are currently no guidelines or standardized training requirements for robot-assisted procedures during general surgical residency. The aim of this study was to assess the effect of this new technology on general surgery training from the residents' perspective. An anonymous, national, web-based survey was conducted on residents enrolled in general surgery training in 2013. The survey was sent to 240 Accreditation Council for Graduate Medical Education-approved general surgery training programs. Overall, 64% of the responding residents were men and had an average age of 29 years. Half of the responses were from postgraduate year 1 (PGY1) and PGY2 residents, and the remainder was from the PGY3 level and above. Overall, 50% of the responses were from university training programs, 32% from university-affiliated programs, and 18% from community-based programs. More than 96% of residents noted the availability of the surgical robot system at their training institution. Overall, 63% of residents indicated that they had participated in robotic surgical cases. Most responded that they had assisted in 10 or fewer robotic cases with the most frequent activities being assisting with robotic trocar placement and docking and undocking the robot. Only 18% reported experience with operating the robotic console. More senior residents (PGY3 and above) were involved in robotic cases compared with junior residents (78% vs 48%, p < 0.001). Overall, 60% of residents indicated that they received no prior education or training before their first robotic case. Approximately 64% of residents reported that formal training in robotic surgery was important in residency training and 46% of residents indicated that robotic-assisted cases interfered with resident learning. Only 11% felt that robotic-assisted cases would replace conventional laparoscopic surgery in the future. This study illustrates that although the most residents have a robot at their institution and have participated in robotic surgery cases, very few residents received formal training before participating in a robotic case. Copyright © 2014 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Infant brain tumors: incidence, survival, and the role of radiation based on Surveillance, Epidemiology, and End Results (SEER) Data.

PubMed

Bishop, Andrew J; McDonald, Mark W; Chang, Andrew L; Esiashvili, Natia

2012-01-01

To evaluate the incidence of infant brain tumors and survival outcomes by disease and treatment variables. The Surveillance, Epidemiology, and End Results (SEER) Program November 2008 submission database provided age-adjusted incidence rates and individual case information for primary brain tumors diagnosed between 1973 and 2006 in infants less than 12 months of age. Between 1973 and 1986, the incidence of infant brain tumors increased from 16 to 40 cases per million (CPM), and from 1986 to 2006, the annual incidence rate averaged 35 CPM. Leading histologies by annual incidence in CPM were gliomas (13.8), medulloblastoma and primitive neuroectodermal tumors (6.6), and ependymomas (3.6). The annual incidence was higher in whites than in blacks (35.0 vs. 21.3 CPM). Infants with low-grade gliomas had the highest observed survival, and those with atypical teratoid rhabdoid tumors (ATRTs) or primary rhabdoid tumors of the brain had the lowest. Between 1979 and 1993, the annual rate of cases treated with radiation within the first 4 months from diagnosis declined from 20.5 CPM to <2 CPM. For infants with medulloblastoma, desmoplastic histology and treatment with both surgery and upfront radiation were associated with improved survival, but on multivariate regression, only combined surgery and radiation remained associated with improved survival, with a hazard ratio for death of 0.17 compared with surgery alone (p = 0.005). For ATRTs, those treated with surgery and upfront radiation had a 12-month survival of 100% compared with 24.4% for those treated with surgery alone (p = 0.016). For ependymomas survival was higher in patients treated in more recent decades (p = 0.001). The incidence of infant brain tumors has been stable since 1986. Survival outcomes varied markedly by histology. For infants with medulloblastoma and ATRTs, improved survival was observed in patients treated with both surgery and early radiation compared with those treated with surgery alone. Copyright © 2012 Elsevier Inc. All rights reserved.

The long term impact of cataract surgery on quality of life, activities and poverty: results from a six year longitudinal study in Bangladesh and the Philippines.

PubMed

Danquah, Lisa; Kuper, Hannah; Eusebio, Cristina; Rashid, Mamunur Akm; Bowen, Liza; Foster, Allen; Polack, Sarah

2014-01-01

Cataract surgery has been shown to improve quality of life and household economy in the short term. However, it is unclear whether these benefits are sustained over time. This study aims to assess the six year impact of cataract surgery on health related quality of life (HRQoL), daily activities and economic poverty in Bangladesh and The Philippines. This was a longitudinal study. At baseline people aged ≥50 years with visual impairment due to cataract ('cases') and age-, sex-matched controls without visual impairment were interviewed about vision specific and generic HRQoL, daily activities and economic indicators (household per capita expenditure, assets and self-rated wealth). Cases were offered free or subsidised cataract surgery. Cases and controls were re-interviewed approximately one and six years later. At baseline across the two countries there were 455 cases and 443 controls. Fifty percent of cases attended for surgery. Response rates at six years were 47% for operated cases and 53% for controls. At baseline cases had poorer health and vision related QoL, were less likely to undertake productive activities, more likely to receive assistance with activities and were poorer compared to controls (p<0.05). One year after surgery there were significant increases in HRQoL, participation and time spent in productive activities and per capita expenditure and reduction in assistance with activities so that the operated cases were similar to controls. These increases were still evident after six years with the exception that time spent on productive activities decreased among both cases and controls. Cataract causing visual loss is associated with reduced HRQoL and economic poverty among older adults in low-income countries. Cataract surgery improves the HRQoL of the individual and economy of the household. The findings of this study suggest these benefits are sustained in the long term.

Impact of cataract surgery in reducing visual impairment: a review.

PubMed

Khandekar, Rajiv; Sudhan, Anand; Jain, B K; Deshpande, Madan; Dole, Kuldeep; Shah, Mahul; Shah, Shreya

2015-01-01

The aim was to assess the impact of cataract surgeries in reducing visual disabilities and factors influencing it at three institutes of India. A retrospective chart review was performed in 2013. Data of 4 years were collected on gender, age, residence, presenting a vision in each eye, eye that underwent surgery, type of surgery and the amount the patient paid out of pocket for surgery. Visual impairment was categorized as; absolute blindness (no perception of light); blind (<3/60); severe visual impairment (SVI) (<6/60-3/60); moderate visual impairment (6/18-6/60) and; normal vision (≥6/12). Statistically analysis was performed to evaluate the association between visual disabilities and demographics or other possible barriers. The trend of visual impairment over time was also evaluated. We compared the data of 2011 to data available about cataract cases from institutions between 2002 and 2009. There were 108,238 cataract cases (50.6% were female) that underwent cataract surgery at the three institutions. In 2011, 71,615 (66.2%) cases underwent surgery. There were 45,336 (41.9%) with presenting vision < 3/60 and 75,393 (69.7%) had SVI in the fellow eye. Blindness at presentation for cataract surgery was associated to, male patients, Institution 3 (Dristi Netralaya, Dahod) surgeries after 2009, cataract surgeries without Intra ocular lens implant implantation, and patients paying <25 US $ for surgery. Predictors of SVI at time of cataract surgery were, male, Institution 3 (OM), phaco surgeries, those opting to pay 250 US $ for cataract surgeries. Patients with cataract seek eye care in late stages of visual disability. The goal of improving vision related quality of life for cataract patients during the early stages of visual impairment that is common in industrialized countries seems to be non-attainable in the rural India.

Unplanned Robotic-Assisted Conversion-to-Open Colorectal Surgery is Associated with Adverse Outcomes.

PubMed

Lee, Yongjin F; Albright, Jeremy; Akram, Warqaa M; Wu, Juan; Ferraro, Jane; Cleary, Robert K

2018-06-01

Laparoscopic conversion-to-open colorectal surgery is associated with worse outcomes when compared to operations completed without conversion. Consequences of robotic conversion have not yet been determined. The purpose of this study is to compare short-term outcomes of converted robotic colorectal cases with those that are completed without conversion, as well as with cases done by the open approach. The ACS-NSQIP database was queried for patients who underwent robotic completed, robotic converted-to-open, and open colorectal resection between 2012 and 2015. Propensity scores were estimated using gradient-boosted machines and converted to weights. Generalized linear models were fit using propensity score-weighted data. A total of 25,253 patients met inclusion criteria-21,356 (84.5%) open, 3663 (14.5%) robotic completed, and 234 (0.9%) conversions. Conversion rate was 6.0%. Converted cases had significantly higher 30-day mortality rate, higher complication rate, and longer hospital length of stay than completed cases. Converted patients also had significantly higher rates of the following complications: surgical site infections, cardiac complications, deep venous thrombosis, postoperative ileus, postoperative re-intubation, renal failure, and 30-day reoperation. Compared to the open approach, converted patients had significantly more cardiac complications, postoperative reintubation, and longer operating times with no significant difference in 30-day mortality. Unplanned robotic conversion-to-open is associated with worse outcomes than completed cases and outcomes that more closely resemble traditional open colorectal surgery. Patients should be counseled with regard to minimally invasive conversion rates and outcomes. The continued pursuit of technological advancements that decrease the risk for conversion in minimally invasive colorectal surgery is clearly warranted.

Risk factors for unavoidable removal of instrumentation after surgical site infection of spine surgery

PubMed Central

Tominaga, Hiroyuki; Setoguchi, Takao; Kawamura, Hideki; Kawamura, Ichiro; Nagano, Satoshi; Abematsu, Masahiko; Tanabe, Fumito; Ishidou, Yasuhiro; Yamamoto, Takuya; Komiya, Setsuro

2016-01-01

Abstract Surgical site infection (SSI) after spine instrumentation is difficult to treat, and often requires removal of instrumentation. The removal of instrumentation after spine surgery is a severe complication that can lead to the deterioration of activities of daily living and poor prognosis. Although there are many reports on SSI after spine surgery, few reports have investigated the risk factors for the removal of instrumentation after spine surgery SSI. This study aimed to identify the risk factors for unavoidable removal of instrumentation after SSI of spine surgery. We retrospectively reviewed 511 patients who underwent spine surgery with instrumentation at Kagoshima University Hospital from January 2006 to December 2014. Risk factors associated with SSI were analyzed via multiple logistic regression analysis. Parameters of the group that needed instrumentation removal were compared with the group that did not require instrumentation removal using the Mann–Whitney U and Fisher's exact tests. The posterior approach was used in most cases (453 of 511 cases, 88.6%). SSI occurred in 16 of 511 cases (3.14%) of spine surgery with instrumentation. Multivariate logistic regression analysis identified 2 significant risk factors for SSI: operation time, and American Society of Anesthesiologists physical status classification ≥ 3. Twelve of the 16 patients with SSI (75%) were able to keep the instrumentation after SSI. Pseudarthrosis occurred in 2 of 4 cases (50%) after instrumentation removal. Risk factors identified for instrumentation removal after spine SSI were a greater number of past surgeries, low preoperative hemoglobin, high preoperative creatinine, high postoperative infection treatment score for the spine, and the presence of methicillin-resistant Staphylococcus aureus. In these high risk cases, attempts should be made to decrease the risk factors preoperatively, and careful postoperative monitoring should be conducted. PMID:27787365

Outcomes of cataract surgery with residents as primary surgeons in the Veterans Affairs Healthcare System.

PubMed

Payal, Abhishek R; Gonzalez-Gonzalez, Luis A; Chen, Xi; Cakiner-Egilmez, Tulay; Chomsky, Amy; Baze, Elizabeth; Vollman, David; Lawrence, Mary G; Daly, Mary K

2016-03-01

To explore visual outcomes, functional visual improvement, and events in resident-operated cataract surgery cases. Veterans Affairs Ophthalmic Surgery Outcomes Database Project across 5 Veterans Affairs Medical Centers. Retrospective data analysis of deidentified data. Cataract surgery cases with residents as primary surgeons were analyzed for logMAR corrected distance visual acuity (CDVA) and vision-related quality of life (VRQL) measured by the modified National Eye Institute Vision Function Questionnaire and 30 intraoperative and postoperative events. In some analyses, cases without events (Group A) were compared with cases with events (Group B). The study included 4221 cataract surgery cases. Preoperative to postoperative CDVA improved significantly in both groups (P < .0001), although the level of improvement was less in Group B (P = .03). A CDVA of 20/40 or better was achieved in 96.64% in Group A and 88.25% in Group B (P < .0001); however, Group B had a higher prevalence of preoperative ocular comorbidities (P < .0001). Cases with 1 or more events were associated with a higher likelihood of a postoperative CDVA worse than 20/40 (odds ratio, 3.82; 95% confidence interval, 2.92-5.05; P < .0001) than those who did not experience an event. Both groups had a significant increase in VRQL from preoperative levels (both P < .0001); however, the level of preoperative to postoperative VRQL improvement was significantly less in Group B (P < .0001). Resident-operated cases with and without events had an overall significant improvement in visual acuity and visual function compared with preoperatively, although this improvement was less marked in those that had an event. None of the authors has a financial or proprietary interest in any material or method mentioned. Copyright © 2016 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.

[Otorhinolaryngology in the field of demography, growing outpatient care and regionalization].

PubMed

Schmidt, C E; Schuldt, T; Kaiser, A; Letzgus, P; Liebeneiner, J; Schmidt, K; Öner, A; Mlynski, R

2017-01-01

Otorhinolaryngology (ENT) departments are strongly affected by current changes in the reimbursement schemes for inpatients. The study was designed to investigate these effects on the ENT Department in Rostock and selected comparison clinics, as well as to outline solutions. We analyzed diagnosis-related group (DRG) reports of the ENT Clinic at Rostock University Medical Center from 2013 to 2015, according to the size of the outpatient potential. Comparisons were made with other surgical departments such as maxillofacial surgery and ophthalmology in terms of average length of stay and the resulting deductibles. We also compared billing as day surgery and complete outpatient surgery for the main small surgical procedures such as tonsillectomy and septum surgery. Finally, we compared the discounts with 22 ENT departments in other maximum care hospitals. The average case mix index of an ENT department in Germany is 0.75, case load average of 2,500 patients and common length of stay 4.1 days. In a typical academic ENT department as in Rostock, health plans usually discount around 500 T€ (thousand euro), which is considerably higher than comparable departments, e.g., oral and maxillofacial surgery or ophthalmology departments. However, discounts on a DRG for inpatient surgery is still approximately 1,000 € more revenue than surgery in an outpatient setting. The benchmark analysis shows that health plans in rural areas are more likely to accept inpatient surgery with discounts for small procedures than strict billing according to outpatient reimbursement schemes. These effects can result in an insufficient cost effectiveness of ENT departments in Germany. As a consequence, substantial restructuring of the in- and outpatient treatment seems necessary, also for academic ENT departments, e.g., in the form of day surgery or ambulatory surgical centers, outpatient clinics with special contracts and specialized inpatient surgery. However, this results in greater demands on the training of young physicians and management of patient flows within the department.

Risk assessment for ectasia after corneal refractive surgery.

PubMed

Randleman, J Bradley; Woodward, Maria; Lynn, Michael J; Stulting, R Doyle

2008-01-01

To analyze the epidemiologic features of ectasia after excimer laser corneal refractive surgery, to identify risk factors for its development, and to devise a screening strategy to minimize its occurrence. Retrospective comparative and case-control study. All cases of ectasia after excimer laser corneal refractive surgery published in the English language with adequate information available through December 2005, unpublished cases seeking treatment at the authors' institution from 1998 through 2005, and a contemporaneous control group who underwent uneventful LASIK and experienced a normal postoperative course. Evaluation of preoperative characteristics, including patient age, gender, spherical equivalent refraction, pachymetry, and topographic patterns; perioperative characteristics, including type of surgery performed, flap thickness, ablation depth, and residual stromal bed (RSB) thickness; and postoperative characteristics including time to onset of ectasia. Development of postoperative corneal ectasia. There were 171 ectasia cases, including 158 published cases and 13 unpublished cases evaluated at the authors' institution. Ectasia occurred after LASIK in 164 cases (95.9%) and after photorefractive keratectomy (PRK) in 7 cases (4.1%). Compared with controls, more ectasia cases had abnormal preoperative topographies (35.7% vs. 0%; P<1.0x10(-15)), were significantly younger (34.4 vs. 40.0 years; P<1.0x10(-7)), were more myopic (-8.53 vs. -5.09 diopters; P<1.0x10(-7)), had thinner corneas before surgery (521.0 vs. 546.5 microm; P<1.0x10(-7)), and had less RSB thickness (256.3 vs. 317.3 microm; P<1.0x10(-10)). Based on subgroup logistic regression analysis, abnormal topography was the most significant factor that discriminated cases from controls, followed by RSB thickness, age, and preoperative corneal thickness, in that order. A risk factor stratification scale was created, taking all recognized risk factors into account in a weighted fashion. This model had a specificity of 91% and a sensitivity of 96% in this series. A quantitative method can be used to identify eyes at risk for developing ectasia after LASIK that, if validated, represents a significant improvement over current screening strategies.

Retroperitoneal laparoscopic pyelolithotomy in renal pelvic stone versus open surgery - a comparative study

PubMed Central

DHAR, SIDDHARTH

2018-01-01

Background The introduction of endourological procedures such as percutaneous nephrolithotomy and ureterorenoscopy have led to a revolution in the the management of urinary stone disease. The indications for open stone surgery have been narrowed significantly, making it a second- or third-line treatment option. Aims and Objectives To study the safety and efficacy of retroperitoneal laparoscopic pyelolithotomy in retroperitoneal renal stone. We compared the results of laparoscopic and open surgery in terms of easy accessibility, operative period, renal injuries, and early recovery. Methods This prospective study was conducted on renal pelvic stone cases from January 2009 to February 2016 in Suchkhand Hospital, Agra, India. The study included a total of 1700 cases with the diagnosis of solitary renal pelvic stones. In group A - 850 cases - retroperitoneal laparoscopic pyelolithotomy was performed, while group B - 850 cases – underwent open pyelolithotomy. Results The mean operative time was less in group B than group A (74.83 min vs. 94.43 min) which was significant (p<0.001). The blood loss was less in the laparoscopic group than in the open group (63 mL vs. 103mL). There were statistically significant differences in the post-operative pain scores, and postoperative complications compared to group B (p<0.001). The mean hospital stay was less in group A (p<0.03), which was significant. Conclusion Laparoscopic surgery reduces analgesic requirements, hospital stay, and blood loss. The disadvantages include the reduced working space, the cost of equipment and the availability of a trained surgeon. PMID:29440956

Chiropractic care and risk for acute lumbar disc herniation: a population-based self-controlled case series study.

PubMed

Hincapié, Cesar A; Tomlinson, George A; Côté, Pierre; Rampersaud, Y Raja; Jadad, Alejandro R; Cassidy, J David

2017-10-16

Chiropractic care is popular for low back pain, but may increase the risk for acute lumbar disc herniation (LDH). Low back pain is a common early (prodromal) symptom of LDH and commonly precedes LDH diagnosis. Our objective was to investigate the association between chiropractic care and acute LDH with early surgical intervention, and contrast this with the association between primary care physician (PCP) care and acute LDH with early surgery. Using a self-controlled case series design and population-based healthcare databases in Ontario, Canada, we investigated all adults with acute LDH requiring emergency department (ED) visit and early surgical intervention from April 1994 to December 2004. The relative incidence of acute LDH with early surgery in exposed periods after chiropractic visits relative to unexposed periods was estimated within individuals, and compared with the relative incidence of acute LDH with early surgery following PCP visits. 195 cases of acute LDH with early surgery (within 8 weeks) were identified in a population of more than 100 million person-years. Strong positive associations were found between acute LDH and both chiropractic and PCP visits. The risk for acute LDH with early surgery associated with chiropractic visits was no higher than the risk associated with PCP visits. Both chiropractic and primary medical care were associated with an increased risk for acute LDH requiring ED visit and early surgery. Our analysis suggests that patients with prodromal back pain from a developing disc herniation likely seek healthcare from both chiropractors and PCPs before full clinical expression of acute LDH. We found no evidence of excess risk for acute LDH with early surgery associated with chiropractic compared with primary medical care.

Preoperative Antibiotics and Mortality in the Elderly

PubMed Central

Silber, Jeffrey H.; Rosenbaum, Paul R.; Trudeau, Martha E.; Chen, Wei; Zhang, Xuemei; Lorch, Scott A.; Kelz, Rachel Rapaport; Mosher, Rachel E.; Even-Shoshan, Orit

2005-01-01

Objective and Background: It is generally thought that the use of preoperative antibiotics reduces the risk of postoperative infection, yet few studies have described the association between preoperative antibiotics and the risk of dying. The objective of this study was to determine whether preoperative antibiotics are associated with a reduced risk of death. Methods: We performed a multivariate matched, population-based, case-control study of death following surgery on 1362 Pennsylvania Medicare patients between 65 and 85 years of age undergoing general and orthopedic surgery. Cases (681 deaths within 60 days from hospital admission) were randomly selected throughout Pennsylvania using claims from 1995 and 1996. Models were developed to scan Medicare claims, looking for controls who did not die and who were the closest matches to the previously selected cases based on preoperative characteristics. Cases and their controls were identified, and charts were abstracted to define antibiotic use and obtain baseline severity adjustment data. Results: For general surgery, the odds of dying within 60 days were less than half in those treated with preoperative antibiotics within 2 hours of incision as compared with those without such treatment: (odds ratio = 0.44; 95% confidence interval, 0.32–0.60), P < 0.0001). For orthopedic surgery, no significant mortality reduction was observed (OR = 0.85; 95% confidence interval, 0.54–1.32; P < 0.464). Interpretation: Preoperative antibiotics are associated with a substantially lower 60-day mortality rate in elderly patients undergoing general surgery. In patients who appear to be comparable, the risk of death was half as large among those who received preoperative antibiotics. PMID:15973108

Robotic Colorectal Resection With and Without the Use of the New Da Vinci Table Motion: A Case-Matched Study.

PubMed

Palmeri, Matteo; Gianardi, Desirée; Guadagni, Simone; Di Franco, Gregorio; Bastiani, Luca; Furbetta, Niccolò; Simoncini, Tommaso; Zirafa, Cristina; Melfi, Franca; Buccianti, Piero; Moglia, Andrea; Cuschieri, Alfred; Mosca, Franco; Morelli, Luca

2018-06-01

The da Vinci Table Motion (dVTM) is a new device that enables patients to be repositioned with instruments in place within the abdomen, and without undocking the robot. The present study was designed to compare operative and short-term outcomes of patients undergoing colorectal cancer surgery with the da Vinci Xi system, with or without use of the dVTM. Ten patients underwent robotic colorectal resection for cancer with the use of dVTM (Xi-dVTM group) between May 2015 and October 2015 at our center. The intraoperative and short-term clinical outcome were compared, using a case-control methodology (propensity scores approach to create 1:2 matched pairs), with a similar group of patients who underwent robotic colorectal surgery for cancer without the use of the dVTM device (Xi-only group). Overall robotic operative time was shorter in the Xi-dVTM group ( P = .04). Operations were executed fully robotic in all Xi-dVTM cases, while 2 cases of the Xi-only group required conversion to open surgery because of bulky tumors and difficult exposure. Postoperative medical complications were higher in the Xi-only group ( P = .024). In this preliminary experience, the use of the new dVTM with the da Vinci Xi in colorectal surgery, by overcoming the limitations of the fixed positions of the patient, enhanced the workflow and resulted in improved exposure of the operative field. Further studies with a greater number of patients are needed to confirm these benefits of the dVTM-da Vinci Xi robotically assisted colorectal surgery.

Intraoperative Ultrasound in Patients Undergoing Transsphenoidal Surgery for Pituitary Adenoma: Systematic Review [corrected].

PubMed

Marcus, Hani J; Vercauteren, Tom; Ourselin, Sebastien; Dorward, Neil L

2017-10-01

Transsphenoidal surgery is the gold standard for pituitary adenoma resection. However, despite advances in microsurgical and endoscopic techniques, some pituitary adenomas can be challenging to cure. We sought to determine whether, in patients undergoing transsphenoidal surgery for pituitary adenoma, intraoperative ultrasound is a safe and effective technologic adjunct. The PubMed database was searched between January 1996 and January 2016 to identify relevant publications that 1) featured patients undergoing transsphenoidal surgery for pituitary adenoma, 2) used intraoperative ultrasound, and 3) reported on safety or effectiveness. Reference lists were also checked, and expert opinions were sought to identify further publications. Ultimately, 10 studies were included, comprising 1 cohort study, 7 case series, and 2 case reports. One study reported their prototype probe malfunctioned, leading to false-positive results in 2 cases, and another study' prototype probe was too large to safely enter the sphenoid sinus in 2 cases. Otherwise, no safety issues directly related to use of intraoperative ultrasound were reported. In the only comparative study, remission occurred in 89.7% (61/68) of patients with Cushing disease in whom intraoperative ultrasound was used, compared with 83.8% (57/68) in whom it was not. All studies reported that surgeons anecdotally found intraoperative ultrasound helpful. Although there is limited and low-quality evidence available, the use of intraoperative ultrasound appears to be a safe and effective technologic adjunct to transsphenoidal surgery for pituitary adenoma. Advances in ultrasound technology may allow for more widespread use of such devices. Copyright © 2017 Elsevier Inc. All rights reserved.

Survival outcome of women with stage IV uterine carcinosarcoma who received neoadjuvant chemotherapy followed by surgery.

PubMed

Matsuo, Koji; Johnson, Marian S; Im, Dwight D; Ross, Malcolm S; Bush, Stephen H; Yunokawa, Mayu; Blake, Erin A; Takano, Tadao; Klobocista, Merieme M; Hasegawa, Kosei; Ueda, Yutaka; Shida, Masako; Baba, Tsukasa; Satoh, Shinya; Yokoyama, Takuhei; Machida, Hiroko; Ikeda, Yuji; Adachi, Sosuke; Miyake, Takahito M; Iwasaki, Keita; Yanai, Shiori; Takeuchi, Satoshi; Nishimura, Masato; Nagano, Tadayoshi; Takekuma, Munetaka; Shahzad, Mian M K; Pejovic, Tanja; Omatsu, Kohei; Kelley, Joseph L; Ueland, Frederick R; Roman, Lynda D

2018-03-01

To examine survival of women with stage IV uterine carcinosarcoma (UCS) who received neoadjuvant chemotherapy followed by hysterectomy. This is a nested case-control study within a retrospective cohort of 1192 UCS cases. Women who received neoadjuvant chemotherapy followed by hysterectomy based-surgery for stage IV UCS (n = 26) were compared to those who had primary hysterectomy-based surgery without neoadjuvant chemotherapy for stage IV UCS (n = 120). Progression-free survival (PFS) and cause-specific survival (CSS) were examined. The most common regimen for neoadjuvant chemotherapy was carboplatin/paclitaxel (53.8%). Median number of neoadjuvant chemotherapy cycles was 4. PFS was similar between the neoadjuvant chemotherapy group and the primary surgery group (unadjusted-hazard ratio [HR] 1.19, 95% confidence interval [CI] 0.75-1.89, P = 0.45). Similarly, CSS was comparable between the two groups (unadjusted-HR 1.13, 95%CI 0.68-1.90, P = 0.64). When the types of neoadjuvant chemotherapy regimens were compared, women who received a carboplatin/paclitaxel regimen had better survival outcomes compared to those who received other regimens: PFS, unadjusted-HR 0.38, 95%CI 0.15-0.93, P = 0.027; and CSS, unadjusted-HR 0.21, 95%CI 0.07-0.61, P = 0.002. Our study found that there is no statistically significant difference in survival between women with stage IV UCS who are tolerated neoadjuvant chemotherapy and those who undergo primary surgery. © 2017 Wiley Periodicals, Inc.

Outcome in dogs with advanced (stage 3b) anal sac gland carcinoma treated with surgery or hypofractionated radiation therapy.

PubMed

Meier, V; Polton, G; Cancedda, S; Roos, M; Laganga, P; Emmerson, T; Rohrer Bley, C

2017-09-01

Stage 3b anal sac gland carcinoma (ASGC) can be life-threatening. A surgical approach is not always possible or may be declined. Dogs with stage 3b ASGC treated with surgery or conformal radiation therapy (RT) with 8 × 3.8 Gy (total dose 30.4 Gy, over 2.5 weeks) were retrospectively evaluated. Patient characteristics, median progression-free interval (PFI) and median survival time (MST) were compared. Twenty-eight dogs were included; 15 underwent surgery, 13 underwent RT. At the time of presentation, 21% showed life-threatening obstipation and 25% showed hypercalcaemia. PFI and MST for surgery cases were 159 days (95% CI: 135-184 days) and 182 days (95% CI: 146-218 days), both significantly lower than for RT cases with 347 days (95% CI: 240-454 days) and 447 days (95% CI: 222-672 days), (P = 0.01, P = 0.019). Surgery as well as RT led to a fast relief of symptoms. PFI and survival of surgical patients were significantly inferior to that of a comparable patient group treated with conformal hypofractionated RT. © 2016 John Wiley & Sons Ltd.

Systematic review on mentoring and simulation in laparoscopic colorectal surgery.

PubMed

Miskovic, Danilo; Wyles, Susannah M; Ni, Melody; Darzi, Ara W; Hanna, George B

2010-12-01

To identify and evaluate the influence of mentoring and simulated training in laparoscopic colorectal surgery (LCS) and define the key components for learning advanced technical skills. Laparoscopic colorectal surgery is a complex procedure, often being self-taught by senior surgeons. Educational issues such as inadequate training facilities or a shortfall of training fellowships may result in a slow uptake of LCS. The effectiveness of mentored and simulated training, however, remains unclear. We conducted a systematic search, using Ovid databases. Four study categories were identified: mentored versus nonmentored cases, training case selection, simulation, and assessment. We performed a meta-analysis and a mixed model regression on the difference of the main outcome measures (conversion rates, morbidity, and mortality) for mentored trainees and expert surgeons. We also compared conversion rates of mentored and nonmentored. Meta-analysis of risk factors for conversion was performed using published and unpublished data sets requested from various investigators. For studies on simulation, we compared scores of surveys on the perception of different training courses. Thirty-seven studies were included. Pooled weighted outcomes of mentored cases (n = 751) showed a lower conversion rate (13.3% vs 20.5%, P = 0.0332) compared with nonmentored cases (n = 695). Compared to expert case series (n = 5313), there was no difference in conversion (P = 0.2835), anastomotic leak (P = 0.8342), or mortality (P = 0.5680). A meta-analysis of training case selection data (n = 4444) revealed male sex (P < 0.0001), previous abdominal surgery (P = 0.0200), a BMI greater than 30 (P = 0.0050), an ASA of less than 2 (P < 0.0001), colorectal cancer (P < 0.0001) and intra-abdominal fistula (P < 0.0001), but not older than 64 years (P = 0.4800), to significantly increase conversion risk. Participants on cadaveric courses were highly satisfied with the teaching value yet trainees on an animal course gave less positive feedback. Structured assessment for LCS has been partially implemented. This review and meta-analysis supports evidence that trainees can obtain similar clinical results like expert surgeons in laparoscopic colorectal surgery if supervised by an experienced trainer. Cadaveric models currently provide the best value for training in a simulated environment. There remains a need for further research into technical skills assessment and the educational value of simulated training.

Systematic review of published studies on safety and efficacy of thoracoscopic and robot-assisted lobectomy for lung cancer.

PubMed

Nakamura, Hiroshige

2014-01-01

The safety and efficacy of thoracoscopic and robot-assisted lobectomies for primary lung cancer were reviewed in the literature. Thoracoscopic surgery is less invasive compared to thoracotomy, and it has been reported to be superior with regard to the outcome. In addition, the operability of a surgical robot (da Vinci) is favorable and supplements the disadvantages of conventional endoscopic surgery. Robot-assisted lobectomy has been reported to be comparable to thoracoscopic surgery with regard to the safety and efficacy based on analysis of perioperative results and superior with regard to the operability and length of the learning curve. However, a high cost and a long operative time are of concern. Since robot-assisted surgery has been performed only in early cases, the continuation of a comparative investigation may be necessary.

Therapeutic outcomes of transsphenoidal surgery in pediatric patients with craniopharyngiomas: a single-center study.

PubMed

Yamada, Shozo; Fukuhara, Noriaki; Yamaguchi-Okada, Mitsuo; Nishioka, Hiroshi; Takeshita, Akira; Takeuchi, Yasuhiro; Inoshita, Naoko; Ito, Junko

2018-03-30

OBJECTIVE The aim of this study was to analyze the outcomes of transsphenoidal surgery (TSS) in a single-center clinical series of pediatric craniopharyngioma patients treated with gross-total resection (GTR). METHODS The authors retrospectively reviewed the surgical outcomes for 65 consecutive patients with childhood craniopharyngiomas (28 girls and 37 boys, mean age 9.6 years) treated with TSS (45 primary and 20 repeat surgeries) between 1990 and 2015. Tumors were classified as subdiaphragmatic or supradiaphragmatic. Demographic and clinical characteristics, including extent of resection, complications, incidence of recurrence, pre- and postoperative visual disturbance, pituitary function, and incidence of diabetes insipidus (DI), as well as new-onset obesity, were analyzed and compared between the primary surgery and repeat surgery groups. RESULTS Of the 45 patients in the primary surgery group, 26 (58%) had subdiaphragmatic tumors and 19 had supradiaphragmatic tumors. Of the 20 patients in the repeat surgery group, 9 (45%) had subdiaphragmatic tumors and 11 had supradiaphragmatic tumors. The only statistically significant difference between the 2 surgical groups was in tumor size; tumors were larger (mean maximum diameter 30 mm) in the primary surgery group than in the repeat surgery group (25 mm) (p = 0.008). GTR was accomplished in 59 (91%) of the 65 cases; the GTR rate was higher in the primary surgery group than in the repeat surgery group (98% vs 75%, p = 0.009). Among the patients who underwent GTR, 12% experienced tumor recurrence, with a median follow-up of 7.8 years, and recurrence tended to occur less frequently in primary than in repeat surgery patients (7% vs 27%, p = 0.06). Of the 45 primary surgery patients, 80% had deteriorated pituitary function and 83% developed DI, whereas 100% of the repeat surgery patients developed these conditions. Among patients with preoperative visual disturbance, vision improved in 62% but worsened in 11%. Visual improvement was more frequent in primary than in repeat surgery patients (71% vs 47%, p < 0.001), whereas visual deterioration was less frequent following primary surgery than repeat surgery (4% vs 24%, p = 0.04). Among the 57 patients without preoperative obesity, new-onset postoperative obesity was found in 9% of primary surgery patients and 21% of repeat surgery patients (p = 0.34) despite aggressive resection, suggesting that hypothalamic dysfunction was rarely associated with GTR by TSS in this series. However, obesity was found in 25% of the repeat surgery patients preoperatively due to prior transcranial surgery. Although there were no perioperative deaths, there were complications in 12 cases (18%) (6 cases of CSF leaks, 3 cases of meningitis, 2 cases of transient memory disturbance, and 1 case of hydrocephalus). Postoperative CSF leakage appeared to be more common in repeat than in primary surgery patients (20% vs 4.4%, p = 0.2). CONCLUSIONS The results of TSS for pediatric craniopharyngioma in this case series suggest that GTR should be the goal for the first surgical attempt. GTR should be achievable without serious complications, although most patients require postoperative hormonal replacement. When GTR is not possible or tumor recurrence occurs after GTR, radiosurgery is recommended to prevent tumor regrowth or progression.

Cost-Effectiveness Analysis of Microscopic and Endoscopic Transsphenoidal Surgery Versus Medical Therapy in the Management of Microprolactinoma in the United States.

PubMed

Jethwa, Pinakin R; Patel, Tapan D; Hajart, Aaron F; Eloy, Jean Anderson; Couldwell, William T; Liu, James K

2016-03-01

Although prolactinomas are treated effectively with dopamine agonists, some have proposed curative surgical resection for select cases of microprolactinomas to avoid life-long medical therapy. We performed a cost-effectiveness analysis comparing transsphenoidal surgery (either microsurgical or endoscopic) and medical therapy (either bromocriptine or cabergoline) with decision analysis modeling. A 2-armed decision tree was created with TreeAge Pro Suite 2012 to compare upfront transsphenoidal surgery versus medical therapy. The economic perspective was that of the health care third-party payer. On the basis of a literature review, we assigned plausible distributions for costs and utilities to each potential outcome, taking into account medical and surgical costs and complications. Base-case analysis, sensitivity analysis, and Monte Carlo simulations were performed to determine the cost-effectiveness of each strategy at 5-year and 10-year time horizons. In the base-case scenario, microscopic transsphenoidal surgery was the most cost-effective option at 5 years from the time of diagnosis; however, by the 10-year time horizon, endoscopic transsphenoidal surgery became the most cost-effective option. At both time horizons, medical therapy (both bromocriptine and cabergoline) were found to be more costly and less effective than transsphenoidal surgery (i.e., the medical arm was dominated by the surgical arm in this model). Two-way sensitivity analysis demonstrated that endoscopic resection would be the most cost-effective strategy if the cure rate from endoscopic surgery was greater than 90% and the complication rate was less than 1%. Monte Carlo simulation was performed for endoscopic surgery versus microscopic surgery at both time horizons. This analysis produced an incremental cost-effectiveness ratio of $80,235 per quality-adjusted life years at 5 years and $40,737 per quality-adjusted life years at 10 years, implying that with increasing time intervals, endoscopic transsphenoidal surgery is the more cost-effective treatment strategy. On the basis of the results of our model, transsphenoidal surgical resection of microprolactinomas, either microsurgical or endoscopic, appears to be more cost-effective than life-long medical therapy in young patients with life expectancy greater than 10 years. We caution that surgical resection for microprolactinomas be performed only in select cases by experienced pituitary surgeons at high-volume centers with high biochemical cure rates and low complication rates. Copyright © 2016 Elsevier Inc. All rights reserved.

Assessment of the incidence of GDV following splenectomy in dogs.

PubMed

Goldhammer, M A; Haining, H; Milne, E M; Shaw, D J; Yool, D A

2010-01-01

To establish if splenectomy increases the incidence of gastric dilatation and volvulus (GDV) in dogs. Two case-series studies of cases and controls were performed. Records of dogs that had undergone splenectomy (37 cases) were compared with records of dogs that had undergone other abdominal surgery (43 cases). Records of dogs that presented for non-elective gastropexy (33 cases) were compared with records of dogs presented to the hospital for unrelated reasons (39 cases). Survival following splenectomy and development of GDV in the first 12 months following surgery were retrieved from the clinical records and by questionnaire-based canvassing of the referring clinician. The incidence of GDV following splenectomy was established and the association between a current episode of GDV and previous splenectomy was assessed. There was no evidence that splenectomy was associated with an increased incidence of subsequent GDV (P=0.469). No association between a current episode of GDV and previous splenectomy was found. Splenectomy is not associated with an increase in the incidence of GDV.

Correlation of bone defect dimensions with healing outcome one year after apical surgery.

PubMed

von Arx, Thomas; Hänni, Stefan; Jensen, Simon Storgård

2007-09-01

This clinical study prospectively evaluated the healing outcome 1 year after apical surgery in relation to bony crypt dimensions measured intraoperatively. The study cohort included 183 teeth in an equal number of patients. For statistical analysis, results were dichotomized (healed versus non-healed cases). The overall success rate was 83% (healed cases). Healing outcome was not significantly related to the level and height of the facial bone plate. In contrast, a significant difference was found for the mean size of the bony crypt when healed cases (395 mm(3)) were compared with non-healed cases (554 mm(3)). In addition, healed cases had a significantly shorter mean distance (4.30 mm) from the facial bone surface to the root canal (horizontal access) compared with non-healed cases (5.13 mm). With logistic regression, however, the only parameter found to be significantly related to healing outcome was the length of the access window to the bony crypt.

REMIFENTANIL VS FENTANYL DURING DAY CASE DENTAL SURGERY IN PEOPLE WITH SPECIAL NEEDS: A COMPARATIVE, PILOT STUDY OF THEIR EFFECT ON STRESS RESPONSE AND POSTOPERATIVE PAIN.

PubMed

Sklika, Eirini; Kalimeris, Konstantinos; Perrea, Despina; Stavropoulos, Nikolaos; Kostopanagiotou, Georgia; Matsota, Paraskevi

2016-06-01

People with special needs undergoing dental surgery frequently require general anesthesia. We investigated the effect of remifentanil vs fentanyl on stress response and postoperative pain in people with special needs undergoing day-case dental surgery. Forty-six adult patients with cognitive impairment undergoing day-case dental surgery under general anesthesia were allocated to receive intraoperatively either fentanyl 50 μg iv bolus (group F, n = 23) or continuous infusion of remifentanil 0.5-1 μg/kg/min (group R, n = 23). Iintraoperative hemodynamic parameters were recorded and serum inflammatory mediators [tumor necrosis factor-α, substance-P], stress hormons (melatonin, cortisol) and β-endorphin were measured. Postoperative pain was assessed during the first postoperative 12 hours with the Wong-Baker faces pain-rating scale. Demographics were similar in two groups. The two groups did not differ regarding their effects on inflammatory mediators, stress hormons and postoperative pain scores. However, the use of remifentanil prevented intraoperative increases of arterial blood pressure and heart rate. Remifentanil and fentanyl did not affect differently stress and inflammatory hormones during day-case dental surgery, although remifentanil may render intraoperative management of hemodynamic responses easier. Both opioids are equally efficient for postoperative pain management following dental surgery in people with special needs.

The impact of operative time on complications after plastic surgery: a multivariate regression analysis of 1753 cases.

PubMed

Hardy, Krista L; Davis, Kathryn E; Constantine, Ryan S; Chen, Mo; Hein, Rachel; Jewell, James L; Dirisala, Karunakar; Lysikowski, Jerzy; Reed, Gary; Kenkel, Jeffrey M

2014-05-01

Little evidence within plastic surgery literature supports the precept that longer operative times lead to greater morbidity. The authors investigate surgery duration as a determinant of morbidity, with the goal of defining a clinically relevant time for increased risk. A retrospective chart review was conducted of patients who underwent a broad range of complex plastic surgical procedures (n = 1801 procedures) at UT Southwestern Medical Center in Dallas, Texas, from January 1, 2008 to January 31, 2012. Adjusting for possible confounders, multivariate logistic regression assessed surgery duration as an independent predictor of morbidity. To define a cutoff for increased risk, incidence of complications was compared among quintiles of surgery duration. Stratification by type of surgery controlled for procedural complexity. A total of 1753 cases were included in multivariate analyses with an overall complication rate of 27.8%. Most operations were combined (75.8%), averaging 4.9 concurrent procedures. Each hour increase in surgery duration was associated with a 21% rise in odds of morbidity (P < .0001). Compared with the first quintile of operative time (<2.0 hours), there was no change in complications until after 3.1 hours of surgery (odds ratio, 1.6; P = .017), with progressively greater odds increases of 3.1 times after 4.5 hours (P < .0001) and 4.7 times after 6.8 hours (P < .0001). When stratified by type of surgery, longer operations continued to be associated with greater morbidity. Surgery duration is an independent predictor of complications, with a significantly increased risk above 3 hours. Although procedural complexity undoubtedly affects morbidity, operative time should factor into surgical decision making.

Does cataract surgery alleviate poverty? Evidence from a multi-centre intervention study conducted in Kenya, the Philippines and Bangladesh.

PubMed

Kuper, Hannah; Polack, Sarah; Mathenge, Wanjiku; Eusebio, Cristina; Wadud, Zakia; Rashid, Mamunur; Foster, Allen

2010-11-09

Poverty and blindness are believed to be intimately linked, but empirical data supporting this purported relationship are sparse. The objective of this study is to assess whether there is a reduction in poverty after cataract surgery among visually impaired cases. A multi-centre intervention study was conducted in three countries (Kenya, Philippines, Bangladesh). Poverty data (household per capita expenditure--PCE, asset ownership and self-rated wealth) were collected from cases aged ≥50 years who were visually impaired due to cataract (visual acuity<6/24 in the better eye) and age-sex matched controls with normal vision. Cases were offered free/subsidised cataract surgery. Approximately one year later participants were re-interviewed about poverty. 466 cases and 436 controls were examined at both baseline and follow-up (Follow up rate: 78% for cases, 81% for controls), of which 263 cases had undergone cataract surgery ("operated cases"). At baseline, operated cases were poorer compared to controls in terms of PCE (Kenya: $22 versus £35 p = 0.02, Bangladesh: $16 vs $24 p = 0.004, Philippines: $24 vs 32 p = 0.0007), assets and self-rated wealth. By follow-up PCE had increased significantly among operated cases in each of the three settings to the level of controls (Kenya: $30 versus £36 p = 0.49, Bangladesh: $23 vs $23 p = 0.20, Philippines: $45 vs $36 p = 0.68). There were smaller increases in self-rated wealth and no changes in assets. Changes in PCE were apparent in different socio-demographic and ocular groups. The largest PCE increases were apparent among the cases that were poorest at baseline. This study showed that cataract surgery can contribute to poverty alleviation, particularly among the most vulnerable members of society. This study highlights the need for increased provision of cataract surgery to poor people and shows that a focus on blindness may help to alleviate poverty and achieve the Millennium Development Goals.

Cost-effectiveness of pediatric epilepsy surgery compared to medical treatment in children with intractable epilepsy.

PubMed

Widjaja, Elysa; Li, Bing; Schinkel, Corrine Davies; Puchalski Ritchie, Lisa; Weaver, James; Snead, O Carter; Rutka, James T; Coyte, Peter C

2011-03-01

Due to differences in epilepsy types and surgery, economic evaluations of epilepsy treatment in adults cannot be extrapolated to children. We evaluated the cost-effectiveness of epilepsy surgery compared to medical treatment in children with intractable epilepsy. Decision tree analysis was used to evaluate the cost-effectiveness of surgery relative to medical management. Fifteen patients had surgery and 15 had medical treatment. Cost data included inpatient and outpatient costs for the period April 2007 to September 2009, physician fee, and medication costs. Outcome measure was percentage seizure reduction at one-year follow-up. Incremental cost-effectiveness ratio (ICER) was assessed. Sensitivity analysis was performed for different probabilities of surgical and medical treatment outcomes and costs, and surgical mortality or morbidity. More patients managed surgically experienced Engel class I and II outcomes compared to medical treatment at one-year follow-up. Base-case analysis yielded an ICER of $369 per patient for each percentage reduction in seizures for the surgery group relative to medical group. Sensitivity analysis showed robustness for the different probabilities tested. Surgical treatment resulted in greater reduction in seizure frequency compared to medical therapy and was a cost-effective treatment option in children with intractable epilepsy who were evaluated for epilepsy surgery and subsequently underwent surgery compared to continuing medical therapy. However, larger sample size and long-term follow-up are needed to validate these findings. Copyright © 2011 Elsevier B.V. All rights reserved.

Enhanced cephalomedullary nail lag screw placement and intraoperative tip-apex distance measurement with a novel computer assisted surgery system.

PubMed

Kuhl, Mitchell; Beimel, Claudia

2016-10-01

The goal of this study was to evaluate the ability of a novel computer assisted surgery system to guide ideal placement of a lag screw during cephalomedullary nailing and then accurately measure the tip-apex distance (TAD) measurement intraoperatively. Retrospective case review. Level II trauma hospital. The initial 98 consecutive clinical cases treated with a cephalomedullary nail in conjunction with a novel computer assisted surgery system were retrospectively reviewed. A novel computer assisted surgery system was utilized to enhance lag screw placement during cephalomedullary nailing procedures. The computer assisted surgery system calculates the TAD intraoperatively after final lag screw placement. The ideal TAD was considered to be within a range of 5mm-20mm. The ability of the computer assisted surgery system (CASS) to assist in placement of a lag screw within the ideal TAD was evaluated. Intraoperative TAD measurements provided by the computer assisted surgery system were then compared to standard postoperative TAD measurements on PACS (picture archiving and communication system) images to determine whether these measurements are equivalent. 79 cases (80.6%) were available with complete information for a retrospective review. All cases had CASS TAD and PACS TAD measurements >5mm and<20mm. In addition, no significant difference could be detected between the intraoperative CASS TAD and the postoperative PACS TAD (p=0.374, Wilcoxon Test; p=0.174, paired T-Test). A cut-out rate of 0% was observed in all patients who were treated with CASS in this case series (95% CI: 0 - 3.01%). The novel computer assisted surgery system tested here is an effective and reliable adjunct that can be utilized for optimal lag screw placement in cephalomedullary nailing procedures. The computer assisted surgery system provides an accurate intraoperative TAD measurement that is equivalent to the standard postoperative measurement utilizing PACS images. Therapeutic Level IV. Copyright © 2016 Elsevier Ltd. All rights reserved.

Single-incision laparoscopic cecectomy for low-grade appendiceal mucinous neoplasm after laparoscopic rectectomy

PubMed Central

Fujino, Shiki; Miyoshi, Norikatsu; Noura, Shingo; Shingai, Tatsushi; Tomita, Yasuhiko; Ohue, Masayuki; Yano, Masahiko

2014-01-01

In this case report, we discuss single-incision laparoscopic cecectomy for low-grade appendiceal neoplasm after laparoscopic anterior resection for rectal cancer. The optimal surgical therapy for low-grade appendiceal neoplasm is controversial; currently, the options include appendectomy, cecectomy, right hemicolectomy, and open or laparoscopic surgery. Due to the risk of pseudomyxoma peritonei, complete resection without rupture is necessary. We have encountered 5 cases of low-grade appendiceal neoplasm and all 5 patients had no lymph node metastasis. We chose the appendectomy or cecectomy without lymph node dissection if preoperative imaging studies did not suspect malignancy. In the present case, we performed cecectomy without lymph node dissection by single-incision laparoscopic surgery (SILS), which is reported to be a reduced port surgery associated with decreased invasiveness and patient stress compared with conventional laparoscopic surgery. We are confident that SILS is a feasible alternative to traditional surgical procedures for borderline tumors, such as low-grade appendiceal neoplasms. PMID:24868331

Nationwide survey of partial fundoplication in Korea: comparison with total fundoplication.

PubMed

Lee, Chang Min; Park, Joong-Min; Lee, Han Hong; Jun, Kyong Hwa; Kim, Sungsoo; Seo, Kyung Won; Park, Sungsoo; Kim, Jong-Han; Kim, Jin-Jo; Han, Sang-Uk

2018-06-01

Laparoscopic total fundoplication is the standard surgery for gastroesophageal reflux disease. However, partial fundoplication may be a viable alternative. Here, we conducted a nationwide survey of partial fundoplication in Korea. The Korean Anti-Reflux Surgery study group recorded 32 cases of partial fundoplication at eight hospitals between September 2009 and January 2016. The surgical outcomes and postoperative adverse symptoms in these cases were evaluated and compared with 86 cases of total fundoplication. Anterior partial fundoplication was performed in 20 cases (62.5%) and posterior in 12 (37.5%). In most cases, partial fundoplication was a secondary procedure after operations for other conditions. Half of patients who underwent partial fundoplication had typical symptoms at the time of initial diagnosis, and most of them showed excellent (68.8%), good (25.0%), or fair (6.3%) symptom resolution at discharge. Compared to total fundoplication, partial fundoplication showed no difference in the resolution rate of typical and atypical symptoms. However, adverse symptoms such as dysphagia, difficult belching, gas bloating and flatulence were less common after partial fundoplication. Although antireflux surgery is not popular in Korea and total fundoplication is the primary surgical choice for gastroesophageal reflux disease, partial fundoplication may be useful in certain conditions because it has less postoperative adverse symptoms but similar efficacy to total fundoplication.

Feasibility and Learning Curve of Robotic Laparoendoscopic Single-Site Surgery in Gynecology.

PubMed

Buckley de Meritens, Alexandre; Kim, Julia; Dinkelspiel, Helen; Chapman-Davis, Eloise; Caputo, Thomas; Holcomb, Kevin M

2017-02-01

Single-site laparoscopy has proven to be a desirable option for patients undergoing gynecologic surgery, with some studies indicating improved cosmesis and less perioperative pain compared with standard approaches. This study describes the safety and feasibility of a novel robotic laparoendoscopic single-site surgery (R-LESS) platform as it is incorporated into a surgeon's practice with extensive multiport robotic surgical experience but limited LESS experience. We reviewed 83 women undergoing R-LESS by a single surgeon from September 2013 through August 2015. Operative times (total operative time, console time, docking time) were collected prospectively for the first 53 cases, and total operative time was collected retrospectively for the next 30 cases. Clinical parameters, including age, estimated blood loss, body mass index (BMI), prior abdominal surgeries, conversion to laparotomy, procedure type, uterine weight, length of hospital stay, and complications, were retrospectively collected from medical charts. Eighty-two of 83 surgeries were completed successfully with a single incision. One surgery was converted to multiport robotics for para-aortic lymph node dissection. Twelve surgeries were performed for cancer (ovary 1, uterus 8, and cervix 3). Eight patients underwent pelvic lymph node biopsy. The median total operative time for hysterectomies was 128 minutes (range, 60-275). After the first 13 hysterectomies the total operative time and the console time decreased significantly from 165.3 to 131.1 minutes (p = .032) and from 84.9 to 57.1 minutes (p = .028), respectively. Mean docking time halved from 7.8 minutes to 3.4 minutes comparing the first 10 cases to the last 10 cases. Surgical times were longer with larger BMIs, but the console time decreased with experience regardless of BMI. The mean uterine weight was 164 g (range, 30-460). Complications included 2 umbilical hernias (2.4%) and 1 conversion to multiport. In conclusion, R-LESS is a feasible and safe surgical platform for gynecologic procedures. A small number of cases are needed to significantly improve operative times when it is introduced on a surgeon's practice with limited experience in LESS but familiar with robotic surgery. Further study is needed to investigate the cost, benefits, and long-term outcomes of R-LESS. Published by Elsevier Inc.

Gynecologic surgeries and risk of ovarian cancer in women with BRCA1 and BRCA2 Ashkenazi founder mutations: an Israeli population-based case-control study.

PubMed

Rutter, Joni L; Wacholder, Sholom; Chetrit, Angela; Lubin, Flora; Menczer, Joseph; Ebbers, Sarah; Tucker, Margaret A; Struewing, Jeffery P; Hartge, Patricia

2003-07-16

In the general population, the risk of developing ovarian cancer is reduced in women who have undergone tubal ligation, hysterectomy, or oophorectomy, although peritoneal cancer can arise after bilateral oophorectomy. In studies from genetic screening clinics, women with mutations in the breast and ovarian susceptibility genes BRCA1 and BRCA2 have been found to have a low risk of peritoneal carcinoma in the first years after bilateral oophorectomy. We assessed the level and persistence of reduction of ovarian (including peritoneal) cancer risk after gynecologic surgeries for women who carry BRCA1/2 mutations but were not selected from high-risk clinics. We identified 1124 Israeli women with incident ovarian cancer or primary peritoneal cancer and tested 847 of them for the three Ashkenazi founder mutations. We compared gynecologic surgery history among all case patients, BRCA1 (n = 187) and BRCA2 (n = 64) carrier case patients, and the non-carrier case patients (n = 598) with that in control subjects drawn from a population registry (n = 2396). We estimated ovarian cancer risk (odds ratios [ORs] with 95% confidence intervals [CIs]) after gynecologic surgery in mutation carriers and non-carriers with logistic regression models. Eight women with primary peritoneal cancer and 128 control subjects reported a previous bilateral oophorectomy (OR = 0.12, 95% CI = 0.06 to 0.24). Other gynecologic surgeries were associated with a 30%-50% reduced risk of ovarian cancer, depending on the type of surgery, with surgery to remove some ovarian tissue associated with the most risk reduction (OR = 0.34, 95% CI = 0.16 to 0.74). Reduced risks were seen in BRCA1/2 carriers and non-carriers. Age at surgery and years since surgery did not affect risk reductions. Both BRCA1/2 mutation carriers and non-carriers have reduced risk of ovarian or peritoneal cancer after gynecologic surgery. The magnitude of the reduction depends upon the type and extent of surgery.

Robotic-Assisted Procedures in Pediatric Surgery: A Critical Appraisal of the Current Best Evidence in Comparison to Conventional Minimally Invasive Surgery.

PubMed

Friedmacher, Florian; Till, Holger

2015-11-01

In recent years, the use of robotic-assisted surgery (RAS) has expanded within pediatric surgery. Although increasing numbers of pediatric RAS case-series have been published, the level of evidence remains unclear, with authors mainly focusing on the comparison with open surgery rather than the corresponding laparoscopic approach. The aim of this study was to critically appraise the published literature comparing pediatric RAS with conventional minimally invasive surgery (MIS) in order to evaluate the current best level of evidence. A systematic literature-based search for studies comparing pediatric RAS with corresponding MIS procedures was performed using multiple electronic databases and sources. The level of evidence was determined using the Oxford Centre for Evidence-based Medicine (OCEBM) criteria. A total of 20 studies met defined inclusion criteria, reporting on five different procedures: fundoplication (n=8), pyeloplasty (n=8), nephrectomy (n=2), gastric banding (n=1), and sleeve gastrectomy (n=1). Included publications comprised 5 systematic reviews and 15 cohort/case-control studies (OCEBM Level 3 and 4, respectively). No studies of OCEBM Level 1 or 2 were identified. Limited evidence indicated reduced operative time (pyeloplasty) and shorter hospital stay (fundoplication) for pediatric RAS, whereas disadvantages were longer operative time (fundoplication, nephrectomy, gastric banding, and sleeve gastrectomy) and higher total costs (fundoplication and sleeve gastrectomy). There were no differences reported for complications, success rates, or short-term outcomes between pediatric RAS and conventional MIS in these procedures. Inconsistency was found in study design and follow-up with large clinical heterogeneity. The best available evidence for pediatric RAS is currently OCEBM Level 3, relating only to fundoplication and pyeloplasty. Therefore, higher-quality studies and comparative data for other RAS procedures in pediatric surgery are required.

Results of The Comparative Study of 200 Cases: One Anastomosis Gastric Bypass vs Roux-en-Y Gastric Bypass.

PubMed

Navarrete, Salvador; Leyba, José Luis; Ll, Salvador Navarrete; Borjas, Guillermo; Tapia, José León; Alcázar, Ruben

2018-05-01

Obesity has experienced worldwide increase and surgery has become the treatment that has achieved the best results. Several techniques have been described; the most popular are vertical gastrectomy (GV) and the Roux-en-Y gastric bypass (RYGB). However, mini-gastric bypass/one anastomosis gastric bypass (MGB/OAGB) has gained popularity due to its simplicity and good results. To comparatively evaluate the results of MGB/OAGB with those of RYGB with 1-year follow-up. The paper presents a comparative case and control study of 100 patients that underwent MGB/OAGB surgery and another 100 with RYGB surgery, operated between 2008 and 2016. Patients were not submitted to revision surgery and had the following pre-operative variables: age 40.46 ± 12.4 vs. 39.43 ± 10.33 years; sex 64 and 54 women, 36 and 46 men; BMI 44.8 ± 12.06 and 45.29 ± 8.82 kg/m 2 ; 50 and 54 cases with comorbidities, respectively, these being non-significant differences. The surgical time was 69.01 ± 4.62 (OAGB) vs. 88.98 ± 3.44 min; the time of hospitalization was 2 days, reaching a BMI of 27.7 ± 7.85 and 29 ± 4.52 kg/m 2 , with an excess weight loss 1 year after surgery of 89.4 vs. 85.9%, respectively. The morbidity rates are 9% for OAGB and 11% for the RYGB. There was a comorbidity resolution of 84.4 and 83.7% respectively, without mortality. The results show the benefits of both techniques, OAGB being the easiest to perform and with less surgical time.

Optical Coherence Tomography and Its Role in Mohs Micrographic Surgery: A Case Report

PubMed Central

Chan, C. Stanley; Rohrer, Thomas E.

2012-01-01

Optical coherence tomography (OCT) is an imaging technology with the potential to provide high-resolution images of the skin non-invasively. With this device, it is possible to identify a host of skin structures including tumors. In this case report, we demonstrate the use of an OCT device in delineating a lateral tumor margin of an ill-defined basal cell carcinoma prior to Mohs micrographic surgery. Following surgery, the OCT images are compared to histologic sections to confirm their accuracy. OCT technology has the potential to be a vital tool for dermatologists and particularly Mohs surgeons in identifying tumor margins and potentially reducing the number of invasive procedures needed. PMID:23341806

[Laparoscopic hysterectomy assisted with robot. Report of first case in Mexico ].

PubMed

Gallardo-Valencia, Luis Ernesto; Gallardo-Fuentes, J J; Ruz-Barros, R E

2014-10-01

Some 15 years ago since the DaVinci system is launched in the market and since then has been gaining ground in the field of surgery. There have been published case series and large casuisticals comparing the benefits from robotic surgery versus laparoscopic. In 2005 the Food & Drug Administration (FDA) approves its use for gynecological surgery. In Mexico, we have no experience in the use of this technology in this field of medicine. To describe the first laparoscopic hysterectomy case assisted with a robot (LHAR) intervened in Mexico, the results and review of the literature reported at the global level. this is a 47 year-old patient with clinical and ultrasonographic diagnosis of uterine fibroids of large items, who is scheduled for laparoscopic hysterectomy assisted with robot at Hospital Angeles del Pedregal in May of 2014. It examines the parameters of surgical time, transoperative bleeding, surgical complications, postoperative pain and hospital stay. It is also a review of the literature and compared the results obtained with what is reported in the literature world. The surgery had a duration of 2 hours 35 minutes. Blood loss was less than 50 mL. There were no complications and the patient had an EVA test of 2 at 24 hours after surgery. Hospital stay was 2 days. Laparoscopic hysterectomy assisted with a robot is a reliable procedure according to what is reported at the global level, offering benefits to both the surgeon and the patient.

[POKING REDUCTION TREATMENT OF DISPLACED SCAPULAR NECK FRACTURE WITH SHOULDER ARTHROSCOPY-ASSISTED SURGERY].

PubMed

Qu, Feng; Yuan, Bangtuo; Qi, Wei; Wang, Junliang; Shen, Xuezhen; Wang, Jiangtao; Zhao, Gang; Liu, Yujie

2014-07-01

To discuss the effectiveness of Poking reduction with shoulder arthroscopy-assisted surgery for displaced scapular neck fracture. Between January 2009 and January 2012, 9 cases of displaced scapular neck fracture underwent shoulder arthroscopy-assisted surgery for Poking reduction treatment. Of 9 cases, 6 were men, and 3 were women, aged 21-54 years (mean, 39 years). The causes were traffic accident injury in 7 cases, falling injury from height in 1 case, and hurt injury in 1 case. The shoulder abduction, flexion, and external rotation were obviously limited. X-ray films showed all cases had obvious displaced scapular neck fracture. Three-dimensional reconstruction of CT showed a grossly displaced of fracture. The time of injury to surgery was 4-27 days (mean, 11 days). Patients obtained healing of incision by first intension, without infection, neurovascular injury, or other surgery-related complications. All patients were followed up 19- 31 months (mean, 23 months). X-ray films showed scapular neck fractures healed from 7 to 11 weeks (mean, 8 weeks). At last follow-up, the shoulder abduction, flexion, and external rotation activity were improved significantly when compared with ones at preoperation (P < 0.05); the shoulder Constant score, American Shoulder and Elbow Surgenos (ASES) score, and Rowe score were significantly better than preoperative scores (P < 0.05). The reduction of displaced scapular neck fracture is necessary, and arthroscopic Poking reduction and fixation for displaced scapular neck fracture can reconstruct the shoulder stability and reduce complications.

Outcomes and Predictive Factors After Cataract Surgery in Patients With Neovascular Age-related Macular Degeneration. The Fight Retinal Blindness! Project.

PubMed

Daien, Vincent; Nguyen, Vuong; Morlet, Nigel; Arnold, Jennifer J; Essex, Rohan W; Young, Stephanie; Hunyor, Alex; Gillies, Mark C; Barthelmes, Daniel

2018-06-01

To evaluate outcomes and predictive factors of visual acuity (VA) change after cataract surgery in patients being treated for neovascular age-related macular degeneration (nAMD). Retrospective, matched case-control study. We studied eyes undergoing cataract surgery that had been tracked since they first started treatment for nAMD. These eyes were compared with a cohort of unoperated phakic eyes being treated for nAMD (3 per case) matched for treatment duration before cataract surgery, baseline VA, age, and length of follow-up. We included 124 patients that had cataract surgery and 372 matched controls. The mean (95% confidence interval) VA gained was 10.6 letters (7.8, 13.2; P < .001) 12 months after surgery; 26.0% had gained ≥3 lines and 1.6% had lost ≥3 lines of VA. Visual acuity (mean [standard deviation]) 12 months after surgery was higher in eyes that had cataract extraction compared with controls (65.8 [17.1] vs 61.3 [20.8] letters, respectively, P = .018). The proportion of visits where the choroidal neovascular (CNV) lesion was graded active and the mean number of injections were similar before and after surgery (P = .506 and P = .316, respectively), whereas both decreased in the control group, suggesting that surgery modestly increased the level of activity of the CNV lesion. Mean [SD] VA prior to surgery was lower in eyes that gained ≥15 letters compared with eyes that gained 0-14 letters (40.2 [21.4] vs 62.1 [15.1], P < .001). Patients undergoing cataract surgery within the first 6 months of anti-VEGF therapy were more likely to lose rather than gain vision (20.8% lost vision vs 12.8% and 4.4% gaining ≥15 or 0-14 letters respectively, P = .023). Age, receiving an injection at least 2 weeks before surgery, and the CNV lesion type had no discernible association with VA outcomes. We found evidence of a modest effect of cataract surgery on CNV lesion activity in eyes being treated for nAMD. Despite this, visual outcomes were reassuringly good. Cataract surgery within 6 months of starting treatment for nAMD should be avoided if possible. Copyright © 2018 Elsevier Inc. All rights reserved.

Variability of Arthroscopy Case Volume in Orthopaedic Surgery Residency.

PubMed

Gil, Joseph A; Waryasz, Gregory R; Owens, Brett D; Daniels, Alan H

2016-05-01

To examine orthopaedic surgery case logs for arthroscopy case volume during residency training and to evaluate trends in case volume and variability over time. Publicly available Accreditation Council for Graduate Medical Education surgical case logs from 2007 to 2013 for orthopaedic surgery residency were assessed for variability and case volume trends in shoulder, elbow, wrist, hip, knee, and ankle arthroscopy. The national average number of procedures performed in each arthroscopy category reported was directly compared from 2009 to 2013. The 10th and 90th percentile arthroscopy case volume was compared between 2007 and 2013 for shoulder and knee arthroscopy procedures. Subsequently, the difference between the 10th and 90th percentile arthroscopy case volume in each category in 2007 was compared with the difference between the 10th and 90th percentile arthroscopy case volume in each category in 2013. From 2007 to 2013, shoulder arthroscopy procedures performed per resident increased by 43.1% (P = .0001); elbow arthroscopy procedures increased by 28.0% (P = .00612); wrist arthroscopy procedures increased by 8.6% (P = .05); hip arthroscopy procedures, which were first reported in 2012, increased by 588.9%; knee arthroscopy procedures increased by 8.5% (P = .0435); ankle arthroscopy increased by 27.6% (P = .00149). The difference in knee and shoulder arthroscopy volume between residents in the 10th and 90th percentile in 2007 and residents in the 10th and 90th percentile in 2013 was not significant (P > .05). There was a 3.66-fold difference in knee arthroscopy volume between residents in the 10th and 90th percentile in 2007, whereas the difference was 3.36-fold in 2013 (P = .70). There was a 5.86-fold difference in shoulder arthroscopy case volume between residents in the 10th and 90th percentile in 2007, whereas the difference was 4.96-fold in 2013 (P = .29). The volume of arthroscopy cases performed by graduating orthopaedic surgery residents has significantly increased over time. There continues to be substantial variability in knee and shoulder arthroscopy case volume between residents in the 10th and 90th percentile. Variability in residency training is notable and may affect knowledge, skill, and practice patterns of surgeons. Copyright © 2016 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.

Robotic thoracic surgery: technical considerations and learning curve for pulmonary resection.

PubMed

Veronesi, Giulia

2014-05-01

Retrospective series indicate that robot-assisted approaches to lung cancer resection offer comparable radicality and safety to video-assisted thoracic surgery or open surgery. More intuitive movements, greater flexibility, and high-definition three-dimensional vision overcome limitations of video-assisted thoracic surgery and may encourage wider adoption of robotic surgery for lung cancer, particularly as more early stage cases are diagnosed by screening. High capital and running costs, limited instrument availability, and long operating times are important disadvantages. Entry of competitor companies should drive down costs. Studies are required to assess quality of life, morbidity, oncologic radicality, and cost effectiveness. Copyright © 2014 Elsevier Inc. All rights reserved.

Association between Socioeconomic Status and 30-Day and One-Year All-Cause Mortality after Surgery in South Korea.

PubMed

Oh, Tak Kyu; Kim, Kooknam; Do, Sang-Hwan; Hwang, Jung-Won; Jeon, Young-Tae

2018-03-10

Preoperative socioeconomic status (SES) is associated with outcomes after surgery, although the effect on mortality may vary according to region. This retrospective study evaluated patients who underwent elective surgery at a tertiary hospital from 2011 to 2015 in South Korea. Preoperative SES factors (education, religion, marital status, and occupation) were evaluated for their association with 30-day and one-year all-cause mortality. The final analysis included 80,969 patients who were ≥30 years old, with 30-day mortality detected in 339 cases (0.4%) and one-year mortality detected in 2687 cases (3.3%). As compared to never-married patients, those who were married or cohabitating (odds ratio (OR): 0.678, 95% confidence interval (CI): 0.462-0.995) and those divorced or separated (OR: 0.573, 95% CI: 0.359-0.917) had a lower risk of 30-day mortality after surgery. Similarly, the risk of one-year mortality after surgery was lower among married or cohabitating patients (OR: 0.857, 95% CI: 0.746-0.983) than it was for those who had never married. Moreover, as compared to nonreligious patients, Protestant patients had a decreased risk of 30-day mortality after surgery (OR: 0.642, 95% CI: 0.476-0.866). The present study revealed that marital status and religious affiliation are associated with risk of 30-day and one-year all-cause mortality after surgery.

Association between Socioeconomic Status and 30-Day and One-Year All-Cause Mortality after Surgery in South Korea

PubMed Central

Oh, Tak Kyu; Kim, Kooknam; Do, Sang-Hwan; Hwang, Jung-Won; Jeon, Young-Tae

2018-01-01

Preoperative socioeconomic status (SES) is associated with outcomes after surgery, although the effect on mortality may vary according to region. This retrospective study evaluated patients who underwent elective surgery at a tertiary hospital from 2011 to 2015 in South Korea. Preoperative SES factors (education, religion, marital status, and occupation) were evaluated for their association with 30-day and one-year all-cause mortality. The final analysis included 80,969 patients who were ≥30 years old, with 30-day mortality detected in 339 cases (0.4%) and one-year mortality detected in 2687 cases (3.3%). As compared to never-married patients, those who were married or cohabitating (odds ratio (OR): 0.678, 95% confidence interval (CI): 0.462–0.995) and those divorced or separated (OR: 0.573, 95% CI: 0.359–0.917) had a lower risk of 30-day mortality after surgery. Similarly, the risk of one-year mortality after surgery was lower among married or cohabitating patients (OR: 0.857, 95% CI: 0.746–0.983) than it was for those who had never married. Moreover, as compared to nonreligious patients, Protestant patients had a decreased risk of 30-day mortality after surgery (OR: 0.642, 95% CI: 0.476–0.866). The present study revealed that marital status and religious affiliation are associated with risk of 30-day and one-year all-cause mortality after surgery. PMID:29534463

Understanding the "Weekend Effect" for Emergency General Surgery.

PubMed

Hoehn, Richard S; Go, Derek E; Dhar, Vikrom K; Kim, Young; Hanseman, Dennis J; Wima, Koffi; Shah, Shimul A

2018-02-01

Several studies have identified a "weekend effect" for surgical outcomes, but definitions vary and the cause is unclear. Our aim was to better characterize the weekend effect for emergency general surgery using mortality as a primary endpoint. Using data from the University HealthSystem Consortium from 2009 to 2013, we identified urgent/emergent hospital admissions for seven procedures representing 80% of the national burden of emergency general surgery. Patient characteristics and surgical outcomes were compared between cases that were performed on weekdays vs weekends. Hospitals varied widely in the proportion of procedures performed on the weekend. Of the procedures examined, four had higher mortality for weekend cases (laparotomy, lysis of adhesions, partial colectomy, and small bowel resection; p < 0.01), while three did not (appendectomy, cholecystectomy, and peptic ulcer disease repair). Among the four procedures with increased weekend mortality, patients undergoing weekend procedures also had increased severity of illness and shorter time from admission to surgery (p < 0.01). Multivariate analysis adjusting for patient characteristics demonstrated independently higher mortality on weekends for these same four procedures (p < 0.01). For the first time, we have identified specific emergency general surgery procedures that incur higher mortality when performed on weekends. This may be due to acute changes in patient status that require weekend surgery or indications for urgent procedures (ischemia, obstruction) compared to those without a weekend mortality difference (infection). Hospitals that perform weekend surgery must acknowledge and identify ways to manage this increased risk.

Surgical Training and the Early Specialization Program: Analysis of a National Program.

PubMed

Klingensmith, Mary E; Potts, John R; Merrill, Walter H; Eberlein, Timothy J; Rhodes, Robert S; Ashley, Stanley W; Valentine, R James; Hunter, John G; Stain, Steven C

2016-04-01

The Early Specialization Program (ESP) in surgery was designed by the American Board of Surgery, the American Board of Thoracic Surgery, and the Residency Review Committees for Surgery and Thoracic Surgery to allow surgical trainees dual certification in general surgery (GS) and either vascular surgery (VS) or cardiothoracic surgery (CTS) after 6 to 7 years of training. After more than 10 years' experience, this analysis was undertaken to evaluate efficacy. American Board of Surgery and American Board of Thoracic Surgery records of VS and CTS ESP trainees were queried to evaluate qualifying exam and certifying exam performance. Case logs were examined and compared with contemporaneous non-ESP trainees. Opinions of programs directors of GS, VS, and CTS and ESP participants were solicited via survey. Twenty-six CTS ESP residents have completed training at 10 programs and 16 VS ESP at 6 programs. First-time pass rates on American Board of Surgery qualifying and certifying exams were superior to time-matched peers; greater success in specialty specific examinations was also found. Trainees met required case minimums for GS despite shortened time in GS. By survey, 85% of programs directors endorsed satisfaction with ESP, and 90% endorsed graduate readiness for independent practice. Early Specialization Program participants report increased mentorship and independence, greater competence for practice, and overall satisfaction with ESP. Individuals in ESP programs in VS and CTS were successful in passing GS and specialty exams and achieving required operative cases, despite an accelerated training track. Programs directors and participants report satisfaction with the training and confidence that ESP graduates are prepared for independent practice. This documented success supports ESP training in any surgical subspecialty, including comprehensive GS. Copyright © 2016 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Long-term clinical outcomes with the retropubic tension-free vaginal tape (TVT) procedure compared to Burch colposuspension for correcting stress urinary incontinence (SUI).

PubMed

Holdø, Bjørn; Verelst, Margareta; Svenningsen, Rune; Milsom, Ian; Skjeldestad, Finn Egil

2017-11-01

The retropubic tension-free vaginal tape (TVT) procedure replaced Burch colposuspension as the primary surgical method for stress urinary incontinence (SUI) and mixed urinary incontinence (MUI) in women in our department in 1998. In this study we compared the short-term and long-term clinical outcomes of these surgical procedures. Using a case series design, we compared the last 5 years of the Burch procedure (n = 127, 1994-1999) with the first 5 years of the retropubic TVT procedure (n = 180, 1998-2002). Information from the medical records was transferred to a case report form comprising data on perioperative and long-term complications as well as recurrence of UI, defined as bothersome UI or UI in need of repeat surgery. Other endpoints were rates of perioperative and late complications and the rates of prolapse surgery after primary surgery. The data were analyzed with the chi-squared and t tests and survival analysis using SPSS. The cumulative recurrence rate of SUI in women with preoperative SUI was significantly higher after the Burch procedure, but no difference was observed in women with MUI. There were no significant differences in rates of perioperative and late complications. At 12 years there was a significant increase in rates of repeat surgery for incontinence and prolapse in women after the Burch procedure. The long-term efficacy of TVT surgery was superior to that of Burch colposuspension in women with SUI. In addition, the rate of late prolapse surgery was significantly higher after the Burch procedure.

Vascular surgery research in the Gulf Cooperation Council countries.

PubMed

Jawas, Ali; Hefny, Ashraf F; Abbas, Alaa K; Abu-Zidan, Fikri M

2014-04-01

To evaluate the quantity and quality of published vascular surgery research articles from the Gulf Cooperation Council (GCC) countries so as to identify areas for improvement. Descriptive study. Published MEDLINE articles on vascular surgery from the GCC countries (1960-2010). Critical analysis of the articles. A total of 146 articles were studied, majority of which were case series/case reports (55.5%); 33% of the articles were prospective. The first author was from a university in 67.1% of the articles. Only one randomized controlled trial was found. The median (range) impact factor of the journals was 1.16 (0.16-12.64). Kuwait had the highest number of publications/country, standardized/100,000 inhabitants. There were 11 experimental studies, which were all from Kuwait. More statistically significant, experimental vascular surgery papers were published prior to 1993 (11/30 compared with 0/111 afterward, p < 0.0001; Fisher exact test). The GCC countries had the lowest vascular surgery research output compared with Turkey, Hong Kong, Singapore, and Japan when standardized by the population. The h index of the GCC countries' vascular research publications was the lowest (19) compared with the other four countries (29-97). Furthermore, the average citation of the GCC countries (5.81) was similar to Turkey (5.66), but less than Hong Kong (17.38), Singapore (12.79), and Japan (11.75). The quality and quantity of vascular surgery research in the GCC countries should be improved to answer important local questions related to vascular diseases. This needs better strategic planning and more collaboration between various institutions. Copyright © 2013. Published by Elsevier B.V.

Clinical evaluation of complete solo surgery with the "ViKY®" robotic laparoscope manipulator.

PubMed

Takahashi, Masahiro; Takahashi, Masanori; Nishinari, Naoto; Matsuya, Hideki; Tosha, Tsutomu; Minagawa, Yukihiro; Shimooki, Osamu; Abe, Tadashi

2017-02-01

Advancement in both surgical technique and medical equipment has enabled solo surgery. ViKY ® Endoscope Positioning System (ViKY ® ) is a robotic system that remotely controls an endoscope and provides direct vision control to the surgeon. Here, we report our experience with ViKY ® -assisted solo surgery. We retrospectively examined 25 cases of solo surgery TAPP with ViKY ® . ViKY ® was setup by the surgeon alone, and the setup duration was determined as the time at which the side rail was positioned and that when the endoscope was installed. For assessing the control unit, the number of false movements was counted. We compared the operative results between ViKY ® -assisted solo surgery TAPP and the conventional method with an assistant. The average time to set up ViKY ® was 7.9 min. The average number of commands for ViKY ® during surgery was 98.3, and the average number of errors and no response of control unit was 7.9. The mean duration of surgery was 136 min for the ViKY ® group, including the setup time, and 117 min for the conventional method. No case required an assistant during the operation. There was also no difference between the two groups with regard to postoperative complications and the rate of recurrence. ViKY ® proved reliable in recognizing orders with very few failures, and the operations were performed safely and were comparable to the conventional operations with assistants. Solo surgery with ViKY ® was beneficial in this clinical evaluation.

A population-based study comparing laparoscopic and robotic outcomes in colorectal surgery.

PubMed

Tam, Michael S; Kaoutzanis, Christodoulos; Mullard, Andrew J; Regenbogen, Scott E; Franz, Michael G; Hendren, Samantha; Krapohl, Greta; Vandewarker, James F; Lampman, Richard M; Cleary, Robert K

2016-02-01

Current data addressing the role of robotic surgery for the management of colorectal disease are primarily from single-institution and case-matched comparative studies as well as administrative database analyses. The purpose of this study was to compare minimally invasive surgery outcomes using a large regional protocol-driven database devoted to surgical quality, improvement in patient outcomes, and cost-effectiveness. This is a retrospective cohort study from the prospectively collected Michigan Surgical Quality Collaborative registry designed to compare outcomes of patients who underwent elective laparoscopic, hand-assisted laparoscopic, and robotic colon and rectal operations between July 1, 2012 and October 7, 2014. We adjusted for differences in baseline covariates between cases with different surgical approaches using propensity score quintiles modeled on patient demographics, general health factors, diagnosis, and preoperative co-morbidities. The primary outcomes were conversion rates and hospital length of stay. Secondary outcomes included operative time, and postoperative morbidity and mortality. A total of 2735 minimally invasive colorectal operations met inclusion criteria. Conversion rates were lower with robotic as compared to laparoscopic operations, and this was statistically significant for rectal resections (colon 9.0 vs. 16.9%, p < 0.06; rectum 7.8 vs. 21.2%, p < 0.001). The adjusted length of stay for robotic colon operations (4.00 days, 95% CI 3.63-4.40) was significantly shorter compared to laparoscopic (4.41 days, 95% CI 4.17-4.66; p = 0.04) and hand-assisted laparoscopic cases (4.44 days, 95% CI 4.13-4.78; p = 0.008). There were no significant differences in overall postoperative complications among groups. When compared to conventional laparoscopy, the robotic platform is associated with significantly fewer conversions to open for rectal operations, and significantly shorter length of hospital stay for colon operations, without increasing overall postoperative morbidity. These findings and the recent upgrades in minimally invasive technology warrant continued evaluation of the role of the robotic platform in colorectal surgery.

Tracking the Re-organization of Motor Functions After Disconnective Surgery: A Longitudinal fMRI and DTI Study

PubMed Central

Rosazza, Cristina; Deleo, Francesco; D'Incerti, Ludovico; Antelmi, Luigi; Tringali, Giovanni; Didato, Giuseppe; Bruzzone, Maria G.; Villani, Flavio; Ghielmetti, Francesco

2018-01-01

Objective: Mechanisms of motor plasticity are critical to maintain motor functions after cerebral damage. This study explores the mechanisms of motor reorganization occurring before and after surgery in four patients with drug-refractory epilepsy candidate to disconnective surgery. Methods: We studied four patients with early damage, who underwent tailored hemispheric surgery in adulthood, removing the cortical motor areas and disconnecting the corticospinal tract (CST) from the affected hemisphere. Motor functions were assessed clinically, with functional MRI (fMRI) tasks of arm and leg movement and Diffusion Tensor Imaging (DTI) before and after surgery with assessments of up to 3 years. Quantifications of fMRI motor activations and DTI fractional anisotropy (FA) color maps were performed to assess the lateralization of motor network. We hypothesized that lateralization of motor circuits assessed preoperatively with fMRI and DTI was useful to evaluate the motor outcome in these patients. Results: In two cases preoperative DTI-tractography did not reconstruct the CST, and FA-maps were strongly asymmetric. In the other two cases, the affected CST appeared reduced compared to the contralateral one, with modest asymmetry in the FA-maps. fMRI showed different degrees of lateralization of the motor network and the SMA of the intact hemisphere was mostly engaged in all cases. After surgery, patients with a strongly lateralized motor network showed a stable performance. By contrast, a patient with a more bilateral pattern showed worsening of the upper limb function. For all cases, fMRI activations shifted to the intact hemisphere. Structural alterations of motor circuits, observed with FA values, continued beyond 1 year after surgery. Conclusion: In our case series fMRI and DTI could track the longitudinal reorganization of motor functions. In these four patients the more the paretic limbs recruited the intact hemisphere in primary motor and associative areas, the greater the chances were of maintaining elementary motor functions after adult surgery. In particular, DTI-tractography and quantification of FA-maps were useful to assess the lateralization of motor network. In these cases reorganization of motor connectivity continued for long time periods after surgery. PMID:29922216

Tracking the Re-organization of Motor Functions After Disconnective Surgery: A Longitudinal fMRI and DTI Study.

PubMed

Rosazza, Cristina; Deleo, Francesco; D'Incerti, Ludovico; Antelmi, Luigi; Tringali, Giovanni; Didato, Giuseppe; Bruzzone, Maria G; Villani, Flavio; Ghielmetti, Francesco

2018-01-01

Objective: Mechanisms of motor plasticity are critical to maintain motor functions after cerebral damage. This study explores the mechanisms of motor reorganization occurring before and after surgery in four patients with drug-refractory epilepsy candidate to disconnective surgery. Methods: We studied four patients with early damage, who underwent tailored hemispheric surgery in adulthood, removing the cortical motor areas and disconnecting the corticospinal tract (CST) from the affected hemisphere. Motor functions were assessed clinically, with functional MRI (fMRI) tasks of arm and leg movement and Diffusion Tensor Imaging (DTI) before and after surgery with assessments of up to 3 years. Quantifications of fMRI motor activations and DTI fractional anisotropy (FA) color maps were performed to assess the lateralization of motor network. We hypothesized that lateralization of motor circuits assessed preoperatively with fMRI and DTI was useful to evaluate the motor outcome in these patients. Results: In two cases preoperative DTI-tractography did not reconstruct the CST, and FA-maps were strongly asymmetric. In the other two cases, the affected CST appeared reduced compared to the contralateral one, with modest asymmetry in the FA-maps. fMRI showed different degrees of lateralization of the motor network and the SMA of the intact hemisphere was mostly engaged in all cases. After surgery, patients with a strongly lateralized motor network showed a stable performance. By contrast, a patient with a more bilateral pattern showed worsening of the upper limb function. For all cases, fMRI activations shifted to the intact hemisphere. Structural alterations of motor circuits, observed with FA values, continued beyond 1 year after surgery. Conclusion: In our case series fMRI and DTI could track the longitudinal reorganization of motor functions. In these four patients the more the paretic limbs recruited the intact hemisphere in primary motor and associative areas, the greater the chances were of maintaining elementary motor functions after adult surgery. In particular, DTI-tractography and quantification of FA-maps were useful to assess the lateralization of motor network. In these cases reorganization of motor connectivity continued for long time periods after surgery.

The ACGME case log: General surgery resident experience in pediatric surgery

PubMed Central

Gow, Kenneth W.; Drake, F. Thurston; Aarabi, Shahram; Waldhausen, John H.

2014-01-01

Background General surgery (GS) residents in ACGME programs log cases performed during their residency. We reviewed designated pediatric surgery (PS) cases to assess for changes in performed cases over time. Methods The ACGME case logs for graduating GS residents were reviewed from academic year (AY) 1989–1990 to 2010–2011 for designated pediatric cases. Overall and designated PS cases were analyzed. Data were combined into five blocks: Period I (AY1989–90 to AY1993–94), Period II (AY1994–95 to AY1998–99), Period III (AY1999–00 to AY2002–03), Period IV (AY2003–04 to AY2006–07), and Period V (AY2007–08 to AY2010–11). Periods IV and V were delineated by implementation of duty hour restrictions. Student t-tests compared averages among the time periods with significance at P < .05. Results Overall GS case load remained relatively stable. Of total cases, PS cases accounted for 5.4% in Period I and 3.7% in Period V. Designated pediatric cases declined for each period from an average of 47.7 in Period I to 33.8 in Period V. These changes are due to a decline in hernia repairs, which account for half of cases. All other cases contributed only minimally to the pediatric cases. The only laparoscopic cases in the database were anti-reflux procedures, which increased over time. Conclusions GS residents perform a diminishing number of designated PS cases. This decline occurred before the onset of work-hour restrictions. These changes have implications on the capabilities of the current graduating workforce. However, the case log does not reflect all cases trainees may be exposed to, so revision of this list is recommended. PMID:23932601

Comparison of extended colectomy and limited resection in patients with Lynch syndrome.

PubMed

Natarajan, Nagendra; Watson, Patrice; Silva-Lopez, Edibaldo; Lynch, Henry T

2010-01-01

The purpose of the study was to determine the advantages and disadvantages of prophylactic/extended colectomy (subtotal colectomy) in patients with Lynch syndrome who manifest colorectal cancer. A retrospective cohort using Creighton University's hereditary cancer database was used to identify cases and controls. Cases are patients who underwent subtotal colectomy, either with no colorectal cancer diagnosis (prophylactic) or at diagnosis of first colorectal cancer; controls for these 2 types of cases were, respectively, patients who underwent no colon surgery or those having limited resection at time of diagnosis of first colorectal cancer. The Kaplan-Meier and proportional hazard regression models from the Statistical Analysis Software program was used to calculate the difference in survival, time to subsequent colorectal cancer, and subsequent abdominal surgery between cases and controls. The event-free survival of our study did not reach 50%, so we used the event-free survival at 5 years as our parameter to compare the 2 groups. The event-free survival for subsequent colorectal cancer, subsequent abdominal surgery, and death was 94%, 84%, and 93%, respectively, for cases and 74%, 63%, and 88%, respectively, for controls. Times to subsequent colorectal cancer and subsequent abdominal surgery were significantly shorter in the control group (P < .006 and P < .04, respectively). No significant difference was identified with respect to survival time between the cases and controls. Even though no survival benefit was identified between the cases and controls the increased incidence of metachronous colorectal cancer and increased abdominal surgeries among controls warrant the recommendation of subtotal colectomy in patients with Lynch syndrome.

Day case hernia repair: weak evidence or practice gap?

PubMed

Scarfe, Anje; Duncan, Joanna; Ma, Ning; Cameron, Alun; Rankin, David; Karatassas, Alex; Fletcher, David; Watters, David; Maddern, Guy

2018-06-01

Analysis of a private insurer's administrative data set revealed significant variation in the length of hospital stay following hernia surgery. This review examined factors influencing the performance of day surgery for inguinal, femoral and umbilical hernia repair in adults. A systematic literature search was conducted in the PubMed, Embase and Cochrane Library databases to identify studies and clinical practice guidelines (CPGs) comparing same day hernia surgery to surgery followed by an overnight stay. Screening of studies by abstract and full text was completed by a single researcher and checked by a second. Studies were selected for inclusion based on a step-wise approach across three phases. Limited evidence from one systematic review, and three case series studies including 3213 patients found that same day hernia surgery was as safe and effective as an overnight stay. All identified CPGs recommended a same day procedure for most patients. Two case series studies reported that 3-8% of patients were ineligible for day procedures due to medical reasons; however, the characteristics of patients, in general, which are not suitable, have not been adequately investigated. Day surgery for groin hernia repair is safe and effective for most patients. However, evidence-based support is only one of many factors that may contribute to the uptake of day surgery in Australia. There is an opportunity for key stakeholders across the private healthcare system to deliver an equally effective but more sustainable and affordable hernia care by increasing the day surgery rates. © 2018 Royal Australasian College of Surgeons.

Incidence, microbiology, and outcomes of endophthalmitis after 111,876 pars plana vitrectomies at a single, tertiary eye care hospital

PubMed Central

Raman, Rajiv; Jain, Mukesh; Shah, Pratik K.; Sharma, Tarun; Gopal, Lingam; Bhende, Pramod S.; Srinivasan, Sangeetha; Jambulingam, Malathi

2018-01-01

Purpose To describe the incidence, risk factors, clinical presentation, causative organisms, and outcomes in patients with endophthalmitis following pars plana vitrectomy (20G and minimally invasive vitrectomy surgery (MIVS). Methods Of 111,876 vitrectomies (70,585 20-G 41,291 MIVS) performed, 45 cases developed acute-onset, postoperative endophthalmitis. Results The rate of culture positive and culture negative endophthalmitis was 0.021% (2.1/10,000 surgeries) and 0.019% (1.9/10,000 surgeries) overall, 0.031% (3.1/10,000 surgeries) and 0.025% (2.5/10,000 surgeries) in 20G, and 0.005% (0.5/10,000 surgeries) and 0.007% (0.7/10,000 surgeries) in the MIVS group respectively. Potential predisposing factors were as follows: diabetes, 46.7%; vitrectomy for vascular retinopathies, 44.4%; and vitrectomy combined with anterior segment surgeries, 35.5%. The culture proven rates were 53.3% overall, 55.0% for 20G and 40.0% for MIVS. The most common organism was Pseudomonas aeruginosa for 20G. Klebsiella and Staphylococcus aureus were isolated in the two culture positive cases in MIVS group. The follow-up period for the patients with endophthalmitis was 586.14 ± 825.15 days. Seven were lost to follow up beyond one week. Of the remaining 38, 13 (34.2%) cases had a favorable visual outcome (i.e., best-corrected visual acuity [BCVA] > 5/200) and 24 (63.2%) had unfavorable visual outcome (BCVA < 5/200). Group with culture test results negative had significantly better outcomes (P < 0.05) as compared to those with positive. Conclusions MIVS does not increase the risk of endophthalmitis. Outcomes are poor despite appropriate treatment, particularly in cases with culture results positive. PMID:29338030

Variable Operative Experience in Hand Surgery for Plastic Surgery Residents.

PubMed

Silvestre, Jason; Lin, Ines C; Levin, Lawrence Scott; Chang, Benjamin

Efforts to standardize hand surgery training during plastic surgery residency remain challenging. We analyze the variability of operative hand experience at U.S. plastic surgery residency programs. Operative case logs of chief residents in accredited U.S. plastic surgery residency programs were analyzed (2011-2015). Trends in fold differences of hand surgery case volume between the 10th and 90th percentiles of residents were assessed graphically. Percentile data were used to calculate the number of residents achieving case minimums in hand surgery for 2015. Case logs from 818 plastic surgery residents were analyzed of which a minority were from integrated (35.7%) versus independent/combined (64.3%) residents. Trend analysis of fold differences in case volume demonstrated decreasing variability among procedure categories over time. By 2015, fold differences for hand reconstruction, tendon cases, nerve cases, arthroplasty/arthrodesis, amputation, arterial repair, Dupuytren release, and neoplasm cases were below 10-fold. Congenital deformity cases among independent/combined residents was the sole category that exceeded 10-fold by 2015. Percentile data suggested that approximately 10% of independent/combined residents did not meet case minimums for arterial repair and congenital deformity in 2015. Variable operative experience during plastic surgery residency may limit adequate exposure to hand surgery for certain residents. Future studies should establish empiric case minimums for plastic surgery residents to ensure hand surgery competency upon graduation. Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Comparison of open and laparoscopic pyeloplasty in ureteropelvic junction obstruction surgery: report of 49 cases.

PubMed

Umari, Paolo; Lissiani, Andrea; Trombetta, Carlo; Belgrano, Emanuele

2011-12-01

This study aimed to evaluate laparoscopic dismembered pyeloplasty compared with open surgery and to determine whether the morbidity and outcome rates are different in each of these techniques. We report our 10-year experience with open and laparoscopic pyeloplasty at one istitution. From February 1999 to October 2010, 49 patients with ureteropelvic junction obstruction were assigned into two groups. 25 patients underwent open surgical pyeloplasty (period 1999-2010) and 24 underwent laparoscopic pyeloplasty (period 2004-2010). 25 patients undergoing open pyeloplasty had a retroperitoneal flank approach. Of the 24 laparoscopic cases 18 had a transperitoneal retrocolic access, 1 had a transperitoneal transmesocolic access and 5 had a retroperitoneal access. In all 49 cases an Anderson-Hynes dismembered pyeloplasty was used. We retrospectively compared the operative time, hospital stay, perioperative complications and follow-up of the two groups. Clinical symptoms were assessed before and after surgery, subjectively. Patients dermographic data were similar between the two groups with mean age of 42 years (range 6-78) and with a male/female ratio of 1:1.45. A crossing vessel could be identified in 37.5% (9/24) with laparoscopy vs. 32% (8/25) in open surgery. Compared with open procedures, laparoscopic procedures were associated with a longer mean operating time (274 vs 143 min), a shorter mean hospital stay (9.9 vs 15.8 day) and the perioperative complication rates were 16.7% for laparoscopic pyeloplasties and 20% for open pyeloplasties. The success rates were 90.5% for laparoscopy and 90.9% for open surgery. Average follow-up was 40.9 month for the laparoscopic group and 72.3 month for the open group. Failed procedures showed no improvement in loin pain or obstruction. The efficacy (in term of success rate and perioperative complications) of laparoscopic pyeloplasty is comparable to that of open pyeloplasty, with shorter mean hospital stay and better cosmetic results. These findings may suggest, that the laparoscopic dismembered pyeloplasty has the potential to replace open surgery and may be considered the first option for the treatment of ureteropelvic junction obstruction in expert hands.

Clinical presentation and characteristics of 25 adult cases of pulmonary sequestration.

PubMed

Polaczek, Mateusz; Baranska, Inga; Szolkowska, Malgorzata; Zych, Jacek; Rudzinski, Piotr; Szopinski, Janusz; Orlowski, Tadeusz; Roszkowski-Sliz, Kazimierz

2017-03-01

Pulmonary sequestration (PS) is a rare congenital abnormality of lung tissue. Only few series of adult cases are reported. The aim was to describe clinical characteristics in adult cases of PS and to compare outcomes in different clinical situations. Using MSD engine we searched for cases of PS that have been diagnosed between Jan 1st, 2005 and Dec 31st, 2015. Clinical data was retrospectively gathered. Statistica v.12 (StatSoft, Inc.) was used for statistical analyses. We found 25 cases (18 females, 7 males), which underwent surgery and were histologically proven. There were 22 cases of intralobar PS. 7 cases were asymptomatic, 12 had infectious history (including 3 cases of lung abscess and pleural empyema), 4 presented with hemoptysis, 2 with chest pain. The average age to undergo surgery was 38.24, in the asymptomatic group 34, in symptomatic 39.89. In the latter the symptoms preceded the surgery for 2.45-year. Great majority of sequestrations was located in lower lobes (96%), 52% on the left. Symptomatic cases were at higher than expected risk of surgical complications, comparing to asymptomatic (chi 2 , P=0.04). In most cases there were surgical and histological signs of infection, only in 9 cases etiological factor was determined: in 5 cases it was A. fumigatus . A 0.53-day longer post-surgical hospital stay was observed in the symptomatic group, no statistical significance was found (U-test, P=0.45). Surgical treatment of symptomatic cases of PS is characterized by slightly longer post-surgical hospital stay and higher risk of surgical complications. Fungal infections are the most likely to occur in PS.

Virtual Surgical Planning for Inferior Alveolar Nerve Reconstruction.

PubMed

Miloro, Michael; Markiewicz, Michael R

2017-11-01

The purpose of this study was to assess the outcomes after preoperative virtual surgical planning (VSP) for inferior alveolar nerve (IAN) reconstruction in ablative mandibular surgery. We performed a retrospective evaluation of consecutive surgical cases using standard VSP for hard tissue resection and reconstructive surgery in addition to IAN VSP performed simultaneously during surgery. Cases were assessed regarding the planning time, additional costs involved, surgeon's subjective impression of the process, accuracy of the prediction during surgery, and operative time during surgery compared with cases performed without VSP. The study sample was composed of 5 cases of mandibular resection for benign disease, with bony, soft tissue, and neural reconstruction with the use of VSP. The addition of IAN reconstruction to the VSP session added no additional expense to the planning session but resulted in an additional 22.5 minutes (±7.5 minutes) for the webinar session. From a subjective standpoint, IAN VSP provided the surgeon with a discreet plan for surgery. From an objective standpoint, IAN VSP provided the exact length and diameter of nerve graft required for surgery, facilitated the surgeon's ability to visualize the actual nerve graft procedure, and limited the additional time required for simultaneous nerve reconstruction. Despite perceived prejudice against simultaneous IAN reconstruction with complex mandibular resection and reconstruction, the use of IAN VSP may facilitate the actual surgical procedure and result in considerably improved patient outcomes without considerable additional time or cost associated with this protocol. Copyright © 2017 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.

Use, cost, complications, and mortality of robotic versus nonrobotic general surgery procedures based on a nationwide database.

PubMed

Salman, Muhammad; Bell, Theodore; Martin, Jennifer; Bhuva, Kalpesh; Grim, Rod; Ahuja, Vanita

2013-06-01

Since its introduction in 1997, robotic surgery has overcome many limitations, including setup costs and surgeon training. The use of robotics in general surgery remains unknown. This study evaluates robotic-assisted procedures in general surgery by comparing characteristics with its nonrobotic (laparoscopic and open) counterparts. Weighted Healthcare Cost and Utilization Project Nationwide Inpatient Sample data (2008, 2009) were used to identify the top 12 procedures for robotic general surgery. Robotic cases were identified by Current Procedural Terminology codes 17.41 and 17.42. Procedures were grouped: esophagogastric, colorectal, adrenalectomy, lysis of adhesion, and cholecystectomy. Analyses were descriptive, t tests, χ(2)s, and logistic regression. Charges and length of stay were adjusted for gender, age, race, payer, hospital bed size, hospital location, hospital region, median household income, Charlson score, and procedure type. There were 1,389,235 (97.4%) nonrobotic and 37,270 (2.6%) robotic cases. Robotic cases increased from 0.8 per cent (2008) to 4.3 per cent (2009, P < 0.001). In all subgroups, robotic surgery had significantly shorter lengths of stay (4.9 days) than open surgery (6.1 days) and lower charges (median $30,540) than laparoscopic ($34,537) and open ($46,704) surgery. Fewer complications were seen in robotic-assisted colorectal, adrenalectomy and lysis of adhesion; however, robotic cholecystectomy and esophagogastric procedures had higher complications than nonrobotic surgery (P < 0.05). Overall robotic surgery had a lower mortality rate (0.097%) than nonrobotic surgeries per 10,000 procedures (laparoscopic 0.48%, open 0.92%; P < 0.001). The cost of robotic surgery is generally considered a prohibitive factor. In the present study, when overall cost was considered, including length of stay, robotic surgery appeared to be cost-effective and as safe as nonrobotic surgery except in cholecystectomy and esophagogastric procedures. Further study is needed to fully understand the long-term implications of this new technology.

A cost and policy analysis comparing immediate sequential cataract surgery and delayed sequential cataract surgery from the physician perspective in the United States.

PubMed

Neel, Sean T

2014-11-01

A cost analysis was performed to evaluate the effect on physicians in the United States of a transition from delayed sequential cataract surgery to immediate sequential cataract surgery. Financial and efficiency impacts of this change were evaluated to determine whether efficiency gains could offset potential reduced revenue. A cost analysis using Medicare cataract surgery volume estimates, Medicare 2012 physician cataract surgery reimbursement schedules, and estimates of potential additional office visit revenue comparing immediate sequential cataract surgery with delayed sequential cataract surgery for a single specialty ophthalmology practice in West Tennessee. This model should give an indication of the effect on physicians on a national basis. A single specialty ophthalmology practice in West Tennessee was found to have a cataract surgery revenue loss of $126,000, increased revenue from office visits of $34,449 to $106,271 (minimum and maximum offset methods), and a net loss of $19,900 to $91,700 (base case) with the conversion to immediate sequential cataract surgery. Physicians likely stand to lose financially, and this loss cannot be offset by increased patient visits under the current reimbursement system. This may result in physician resistance to converting to immediate sequential cataract surgery, gaming, and supplier-induced demand.

The Inequity of Bariatric Surgery: Publicly Insured Patients Undergo Lower Rates of Bariatric Surgery with Worse Outcomes.

PubMed

Hennings, Dietric L; Baimas-George, Maria; Al-Quarayshi, Zaid; Moore, Rachel; Kandil, Emad; DuCoin, Christopher G

2018-01-01

Bariatric surgery has been shown to be the most effective method of achieving weight loss and alleviating obesity-related comorbidities. Yet, it is not being used equitably. This study seeks to identify if there is a disparity in payer status of patients undergoing bariatric surgery and what factors are associated with this disparity. We performed a case-control analysis of National Inpatient Sample. We identified adults with body mass index (BMI) greater than or equal to 25 kg/m 2 who underwent bariatric surgery and matched them with overweight inpatient adult controls not undergoing surgery. The sample was analyzed using multivariate logistic regression. We identified 132,342 cases, in which the majority had private insurance (72.8%). Bariatric patients were significantly more likely to be privately insured than any other payer status; Medicare- and Medicaid-covered patients accounted for a low percentage of cases (Medicare 5.1%, OR 0.33, 95% CI 0.29-0.37, p < 0.001; Medicaid 8.7%, OR 0.21, 95% CI 0.18-0.25, p < 0.001). Medicare (OR 1.54, 95% CI 1.33-1.78, p < 0.001) and Medicaid (OR 1.31, 95% CI 1.08-1.60, p = 0.007) patients undergoing bariatric surgery had an increased risk of complications compared to privately insured patients. Publicly insured patients are significantly less likely to undergo bariatric surgery. As a group, these patients experience higher rates of obesity and related complications and thus are most in need of bariatric surgery.

Variable Case Detection and Many Unreported Cases of Surgical-Site Infection Following Colon Surgery and Abdominal Hysterectomy in a Statewide Validation.

PubMed

Calderwood, Michael S; Huang, Susan S; Keller, Vicki; Bruce, Christina B; Kazerouni, N Neely; Janssen, Lynn

2017-09-01

OBJECTIVE To assess hospital surgical-site infection (SSI) identification and reporting following colon surgery and abdominal hysterectomy via a statewide external validation METHODS Infection preventionists (IPs) from the California Department of Public Health (CDPH) performed on-site SSI validation for surgical procedures performed in hospitals that voluntarily participated. Validation involved chart review of SSI cases previously reported by hospitals plus review of patient records flagged for review by claims codes suggestive of SSI. We assessed the sensitivity of traditional surveillance and the added benefit of claims-based surveillance. We also evaluated the positive predictive value of claims-based surveillance (ie, workload efficiency). RESULTS Upon validation review, CDPH IPs identified 239 SSIs following colon surgery at 42 hospitals and 76 SSIs following abdominal hysterectomy at 34 hospitals. For colon surgery, traditional surveillance had a sensitivity of 50% (47% for deep incisional or organ/space [DI/OS] SSI), compared to 84% (88% for DI/OS SSI) for claims-based surveillance. For abdominal hysterectomy, traditional surveillance had a sensitivity of 68% (67% for DI/OS SSI) compared to 74% (78% for DI/OS SSI) for claims-based surveillance. Claims-based surveillance was also efficient, with 1 SSI identified for every 2 patients flagged for review who had undergone abdominal hysterectomy and for every 2.6 patients flagged for review who had undergone colon surgery. Overall, CDPH identified previously unreported SSIs in 74% of validation hospitals performing colon surgery and 35% of validation hospitals performing abdominal hysterectomy. CONCLUSIONS Claims-based surveillance is a standardized approach that hospitals can use to augment traditional surveillance methods and health departments can use for external validation. Infect Control Hosp Epidemiol 2017;38:1091-1097.

Infant Brain Tumors: Incidence, Survival, and the Role of Radiation Based on Surveillance, Epidemiology, and End Results (SEER) Data

DOE Office of Scientific and Technical Information (OSTI.GOV)

Bishop, Andrew J.; McDonald, Mark W., E-mail: mwmcdona@iupui.edu; Indiana University Health Proton Therapy Center, Bloomington, IN

2012-01-01

Purpose: To evaluate the incidence of infant brain tumors and survival outcomes by disease and treatment variables. Methods and Materials: The Surveillance, Epidemiology, and End Results (SEER) Program November 2008 submission database provided age-adjusted incidence rates and individual case information for primary brain tumors diagnosed between 1973 and 2006 in infants less than 12 months of age. Results: Between 1973 and 1986, the incidence of infant brain tumors increased from 16 to 40 cases per million (CPM), and from 1986 to 2006, the annual incidence rate averaged 35 CPM. Leading histologies by annual incidence in CPM were gliomas (13.8), medulloblastomamore » and primitive neuroectodermal tumors (6.6), and ependymomas (3.6). The annual incidence was higher in whites than in blacks (35.0 vs. 21.3 CPM). Infants with low-grade gliomas had the highest observed survival, and those with atypical teratoid rhabdoid tumors (ATRTs) or primary rhabdoid tumors of the brain had the lowest. Between 1979 and 1993, the annual rate of cases treated with radiation within the first 4 months from diagnosis declined from 20.5 CPM to <2 CPM. For infants with medulloblastoma, desmoplastic histology and treatment with both surgery and upfront radiation were associated with improved survival, but on multivariate regression, only combined surgery and radiation remained associated with improved survival, with a hazard ratio for death of 0.17 compared with surgery alone (p = 0.005). For ATRTs, those treated with surgery and upfront radiation had a 12-month survival of 100% compared with 24.4% for those treated with surgery alone (p = 0.016). For ependymomas survival was higher in patients treated in more recent decades (p = 0.001). Conclusion: The incidence of infant brain tumors has been stable since 1986. Survival outcomes varied markedly by histology. For infants with medulloblastoma and ATRTs, improved survival was observed in patients treated with both surgery and early radiation compared with those treated with surgery alone.« less

The efficiency of a dedicated staff on operating room turnover time in hand surgery.

PubMed

Avery, Daniel M; Matullo, Kristofer S

2014-01-01

To evaluate the effect of orthopedic and nonorthopedic operating room (OR) staff on the efficiency of turnover time in a hand surgery practice. A total of 621 sequential hand surgery cases were retrospectively reviewed. Turnover times for sequential cases were calculated and analyzed with regard to the characteristics of the OR staff being primarily orthopedic or nonorthopedic. A total of 227 turnover times were analyzed. The average turnover time with all nonorthopedic staff was 31 minutes, for having only an orthopedic surgical technician was 32 minutes, for having only an orthopedic circulator was 25 minutes, and for having both an orthopedic surgical technician and a circulator was 20 minutes. Statistical significance was seen when comparing only an orthopedic surgical technician versus both an orthopedic circulator and a surgical technician and when comparing both nonorthopedic staff versus both an orthopedic circulator and a surgical technician. OR efficiency is being increasingly evaluated for its effect on hospital revenue and OR staff costs. Reducing turnover time is one aspect of a multifaceted solution in increasing efficiency. Our study showed that, for hand surgery, orthopedic-specific staff can reduce turnover time. Economic/Decision Analysis III. Copyright © 2014 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

Osteo-odonto keratoprosthesis: systematic review of surgical outcomes and complication rates.

PubMed

Tan, Anna; Tan, Donald T; Tan, Xiao-Wei; Mehta, Jodhbir S

2012-01-01

Case series on osteo-odonto keratoprosthesis (OOKP) published in English from 1950-June 2010 were identified in Medline/PubMed. Indications for surgery, visual acuity, anatomical survival, complication and repeat surgery rates were compared among the different studies. Our own case series is a retrospective review of all OOKP surgeries performed in our center from February 2004-July 2011. Eight case series including our own were systematically reviewed. Sample sizes ranged from 4-181 eyes. The most common indications for surgery were severe cases of Stevens-Johnson syndrome and thermal and chemical burns that were unamenable to other forms of surgery or had had previous surgical failure. Anatomical survival rate in all the studies was 87.8% (range 67-100%) at 5 years, and three studies showed survival rates of 81.0% (range 65-98%) at 20 years. Visual acuity was more than 6/18 in 52% (range 46-72%) of the eyes with OOKP surgery. The most common intraoperative complication was vitreous hemorrhage (0-52%) and the most common long-term blinding complication was glaucoma (7-47%). Endophthalmitis rates ranged from 2-8%. The most common repeat surgical procedure was mucosal trimming due to mucosal overgrowth at the optical cylinder and mucosal grafting for extrusion of the OOKP or mucosal ulceration. Of the available biological and synthetic keratoprosthesis, OOKP appears to be an excellent option for the treatment of end-stage corneal diseases. Copyright © 2012 Elsevier Inc. All rights reserved.

A comparative analysis of readmission rates after outpatient cosmetic surgery.

PubMed

Mioton, Lauren M; Alghoul, Mohammed S; Kim, John Y S

2014-02-01

Despite the increasing scrutiny of surgical procedures, outpatient cosmetic surgery has an established record of safety and efficacy. A key measure in assessing surgical outcomes is the examination of readmission rates. However, there is a paucity of data on unplanned readmission following cosmetic surgery procedures. The authors studied readmission rates for outpatient cosmetic surgery and compared the data with readmission rates for other surgical procedures. The 2011 National Surgical Quality Improvement Program (NSQIP) data set was queried for all outpatient procedures. Readmission rates were calculated for the 5 surgical specialties with the greatest number of outpatient procedures and for the overall outpatient cosmetic surgery population. Subgroup analysis was performed on the 5 most common cosmetic surgery procedures. Multivariate regression models were used to determine predictors of readmission for cosmetic surgery patients. The 2879 isolated outpatient cosmetic surgery cases had an associated 0.90% unplanned readmission rate. The 5 specialties with the highest number of outpatient surgical procedures were general, orthopedic, gynecologic, urologic, and otolaryngologic surgery; their unplanned readmission rates ranged from 1.21% to 3.73%. The 5 most common outpatient cosmetic surgery procedures and their associated readmission rates were as follows: reduction mammaplasty, 1.30%; mastopexy, 0.31%; liposuction, 1.13%; abdominoplasty, 1.78%; and breast augmentation, 1.20%. Multivariate regression analysis demonstrated that operating time (in hours) was an independent predictor of readmission (odds ratio, 1.40; 95% confidence interval, 1.08-1.81; P=.010). Rates of unplanned readmission with outpatient cosmetic surgery are low and compare favorably to those of other outpatient surgeries.

Simultaneous Versus Sequential Ptosis and Strabismus Surgery in Children.

PubMed

Revere, Karen E; Binenbaum, Gil; Li, Jonathan; Mills, Monte D; Katowitz, William R; Katowitz, James A

The authors sought to compare the clinical outcomes of simultaneous versus sequential ptosis and strabismus surgery in children. Retrospective, single-center cohort study of children requiring both ptosis and strabismus surgery on the same eye. Simultaneous surgeries were performed during a single anesthetic event; sequential surgeries were performed at least 7 weeks apart. Outcomes were ptosis surgery success (margin reflex distance 1 ≥ 2 mm, good eyelid contour, and good eyelid crease); strabismus surgery success (ocular alignment within 10 prism diopters of orthophoria and/or improved head position); surgical complications; and reoperations. Fifty-six children were studied, 38 had simultaneous surgery and 18 sequential. Strabismus surgery was performed first in 38/38 simultaneous and 6/18 sequential cases. Mean age at first surgery was 64 months, with mean follow up 27 months. A total of 75% of children had congenital ptosis; 64% had comitant strabismus. A majority of ptosis surgeries were frontalis sling (59%) or Fasanella-Servat (30%) procedures. There were no significant differences between simultaneous and sequential groups with regards to surgical success rates, complications, or reoperations (all p > 0.28). In the first comparative study of simultaneous versus sequential ptosis and strabismus surgery, no advantage for sequential surgery was seen. Despite a theoretical risk of postoperative eyelid malposition or complications when surgeries were performed in a combined manner, the rate of such outcomes was not increased with simultaneous surgeries. Performing ptosis and strabismus surgery together appears to be clinically effective and safe, and reduces anesthesia exposure during childhood.

Bariatric surgery for the treatment of severely obese patients in South Korea--is it cost effective?

PubMed

Song, Hyun Jin; Kwon, Jin Won; Kim, Yong Jin; Oh, Sung-Hee; Heo, Yoonseok; Han, Sang-Moon

2013-12-01

In South Korea, the number of severely obese patients has increased. An economic study comparing bariatric surgery with nonsurgical interventions has not been published for Asia. This study was conducted to evaluate the cost effectiveness of bariatric surgery as compared to nonsurgical interventions for severe obese Korean people. We used the Markov model to compare the lifetime expected costs and quality-adjusted life years (QALYs) between bariatric surgery and nonsurgical interventions from Korean Healthcare system perspectives. Our target cohort consisted of severe obese people defined as having a body mass index of 30-<40 kg/m(2) in South Korea. The starting age of the cohort was 30 years old, and the cycle length was 1 year. Nonsurgical interventions included a physician visit, exercise, diet, and pharmacotherapy. A discount of 5 % was applied in cost and QALY. The incremental cost-effectiveness ratio (ICER) of bariatric surgery compared to nonsurgery interventions was calculated. The cost-utility analysis study indicated that bariatric surgery had US$1,522 incremental costs and 0.86 incremental QALYs as compared to nonsurgical interventions. Through the base case analysis, ICER was US$1,771/QALY. The sensitivity analyses were performed using a variety of assumptions, and the robustness of the study results was also demonstrated. The study indicated that bariatric surgery was a cost-effective alternative to nonsurgical interventions over a lifetime, providing substantial lifetime benefits for severely obese Korean people.

A 9-year comparison of practice profiles of candidates for primary and recertification examinations of the American Board of Plastic Surgery relative to economic indicators.

PubMed

Gosain, Arun K; Haller, Harold S; Lee, Michelle; Cullison, Terry M; Noone, R Barrett

2013-03-01

This study compared the practice profiles of plastic surgeons applying for recertification/maintenance of certification with those applying for primary certification by the American Board of Plastic Surgery between 2003 and 2011. American Board of Plastic Surgery case logs from both recertification and primary certification candidates from 2003 to 2011 were examined. Deidentified data included operative year, Current Procedural Terminology codes, and the candidate's designation of the case relative to (1) cosmetic or reconstructive and (2) the Maintenance of Certification in Plastic Surgery module (i.e., comprehensive, cosmetic, craniomaxillofacial, and hand). Department of Commerce unemployment data from 2003 to 2011 served as an economic indicator for the period studied. A negative trend in the median number of cases per candidate was observed for both groups for cosmetic, reconstructive, and total number of cases, corresponding to a rise in unemployment. With every 1 percent increase in the unemployment rate, recertification candidates demonstrated a greater loss of cosmetic cases relative to primary candidates and an accelerated decline in reconstructive cases starting in 2007. Distribution of the four Maintenance of Certification modules demonstrated a negative trend for cosmetic and comprehensive cases in both groups. Hand and craniofacial consistently constituted approximately 20 percent of cases for primary and 14 percent of cases for recertification candidates. There was a shift away from hand cases toward craniofacial cases in both groups. Both primary and recertification candidates reported a decline in overall caseload from 2003 to 2011. Negative economic trends have a greater impact on the practice profile of recertification candidates.

Effect of the 16-hour work limit on general surgery intern operative case volume: a multi-institutional study.

PubMed

Schwartz, Samuel I; Galante, Joseph; Kaji, Amy; Dolich, Matthew; Easter, David; Melcher, Marc L; Patel, Kevin; Reeves, Mark E; Salim, Ali; Senagore, Anthony J; Takanishi, Danny M; de Virgilio, Christian

2013-09-01

The 80-hour work-week limit for all residents was instituted in 2003 and studies looking at its effect have been mixed. Since the advent of the 16-hour mandate for postgraduate year 1 residents in July 2011, no data have been published regarding the effect of this additional work-hour restriction. To determine whether the 16-hour intern work limit, implemented in July 2011, has adversely affected operative experience. A retrospective review of categorical postgraduate year 1 Accreditation Council for Graduate Medical Education case logs from the intern class (N = 52) (with 16-hour work limit) compared with the 4 preceding years (2007-2010; N = 197) (without 16-hour work limit). A total of 249 categorical general surgery interns from 10 general surgery residency programs in the western United States were included. Total, major, first-assistant, and defined-category case totals. As compared with the preceding 4 years, the 2011-2012 interns recorded a 25.8% decrease in total operative cases (65.9 vs 88.8, P = .005), a 31.8% decrease in major cases (54.9 vs 80.5, P < .001), and a 46.3% decrease in first-assistant cases (11.1 vs 20.7, P = .008). There were statistically significant decreases in cases within the defined categories of abdomen, endocrine, head and neck, basic laparoscopy, complex laparoscopy, pediatrics, thoracic, and soft tissue/breast surgery in the 16-hour shift intern era, whereas there was no decrease in trauma, vascular, alimentary, endoscopy, liver, and pancreas cases. The 16-hour work limit for interns, implemented in July 2011, is associated with a significant decrease in categorical intern operative experience. If the 16-hour shift were to be extended to all postgraduate year levels, one can anticipate that additional years of training will be needed to maintain the same operative volume.

Achieving target refraction after cataract surgery.

PubMed

Simon, Shira S; Chee, Yewlin E; Haddadin, Ramez I; Veldman, Peter B; Borboli-Gerogiannis, Sheila; Brauner, Stacey C; Chang, Kenneth K; Chen, Sherleen H; Gardiner, Matthew F; Greenstein, Scott H; Kloek, Carolyn E; Chen, Teresa C

2014-02-01

To evaluate the difference between target and actual refraction after phacoemulsification and intraocular lens implantation at an academic teaching institution's Comprehensive Ophthalmology Service. Retrospective study. We examined 1275 eye surgeries for this study. All consecutive cataract surgeries were included if they were performed by an attending or resident surgeon from January through December 2010. Postoperative refractions were compared with preoperative target refractions. Patients were excluded if they did not have a preoperative target refraction documented or if they did not have a recorded postoperative manifest refraction within 90 days. The main outcome measure was percentage of cases achieving a postoperative spherical equivalent ± 1.0 diopter (D) of target spherical equivalent. We performed 1368 cataract surgeries from January through December of 2010. Of these, 1275 (93%) had sufficient information for analysis. Of the included cases, 94% (1196 of 1275) achieved ± 1.0 D of target refraction by 90 days after cataract surgery. This paper establishes a new benchmark for a teaching hospital, where 94% of patients achieved within 1.0 D of target refraction after cataract surgery. The refractive outcomes after cataract surgery at this academic teaching institution were higher than average international benchmarks. Copyright © 2014 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.

Exposure of Surgeons to Extremely Low-Frequency Magnetic Fields During Laparoscopic and Robotic Surgeries

PubMed Central

Park, Jee Soo; Chung, Jai Won; Kim, Nam Kyu; Cho, Min Soo; Kang, Chang Moo; Choi, Soo Beom; Kim, Deok Won

2015-01-01

Abstract The development of new medical electronic devices and equipment has increased the use of electrical apparatuses in surgery. Many studies have reported the association of long-term exposure to extremely low-frequency magnetic fields (ELF-MFs) with diseases or cancer. Robotic surgery has emerged as an alternative tool to overcome the disadvantages of conventional laparoscopic surgery. However, there has been no report regarding how much ELF-MF surgeons are exposed to during laparoscopic and robotic surgeries. In this observational study, we aimed to measure and compare the ELF-MFs that surgeons are exposed to during laparoscopic and robotic surgery. The intensities of the ELF-MFs surgeons are exposed to were measured every 4 seconds for 20 cases of laparoscopic surgery and 20 cases of robotic surgery using portable ELF-MF measuring devices with logging capability. The mean ELF-MF exposures were 0.6 ± 0.1 mG for laparoscopic surgeries and 0.3 ± 0.0 mG for robotic surgeries (significantly lower with P < 0.001 by Mann–Whitney U test). Our results show that the ELF-MF exposure levels of surgeons in both robotic and conventional laparoscopic surgery were lower than 2 mG, which is the most stringent level considered safe in many studies. However, we should not overlook the effects of long-term ELF-MF exposure during many surgeries in the course of a surgeon's career. PMID:25674758

Revision surgery after cervical laminoplasty: report of five cases and literature review.

PubMed

Shigematsu, Hideki; Koizumi, Munehisa; Matsumori, Hiroaki; Iwata, Eiichiro; Kura, Tomohiko; Okuda, Akinori; Ueda, Yurito; Tanaka, Yasuhito

2015-06-01

Revision surgery after laminoplasty is rarely performed, and there are few reports of this procedure in the English literature. To evaluate the reasons why patients underwent revision surgery after laminoplasty and to discuss methods of preventing the need for revision surgery. A literature review with a comparative analysis between previous reports and present cases was also performed. Case report and literature review. Five patients who underwent revision surgery after laminoplasty. Diagnosis was based on the preoperative computed tomography and magnetic resonance imaging findings. Neurologic findings were evaluated using the Japanese Orthopedic Association score. A total of 237 patients who underwent cervical laminoplasty for cervical spondylotic myelopathy from 1990 to 2010 were reviewed. Patients with ossification of the posterior longitudinal ligament, renal dialysis, infection, tumor, or rheumatoid arthritis were excluded. Five patients who underwent revision surgery for symptoms of recurrent myelopathy or radiculopathy were identified, and the clinical courses and radiological findings of these patients were retrospectively reviewed. The average interval from the initial surgery to revision surgery was 15.0 (range 9-19) years. The patients were four men and one woman with an average age at the time of the initial operation of 49.8 (range 34-65) years. Four patients developed symptoms of recurrent myelopathy after their initial surgery, for the following reasons: adjacent segment canal stenosis, restenosis after inadequate opening of the lamina with degenerative changes, and trauma after inadequate opening of the lamina. One patient developed new radiculopathy symptoms because of foraminal stenosis secondary to osteoarthritis at the Luschka and zygapophyseal joints. All patients experienced resolution of their symptoms after revision surgery. Revision surgery after laminoplasty is rare. Inadequate opening of the lamina is one of the important reasons for needing revision surgery. Degenerative changes after laminoplasty may also result in a need for revision surgery. Surgeons should be aware of the degenerative changes that can cause neurologic deterioration after laminoplasty. Copyright © 2015 Elsevier Inc. All rights reserved.

Waterless Hand Rub Versus Traditional Hand Scrub Methods for Preventing the Surgical Site Infection in Orthopedic Surgery.

PubMed

Iwakiri, Kentaro; Kobayashi, Akio; Seki, Masahiko; Ando, Yoshiyuki; Tsujio, Tadao; Hoshino, Masatoshi; Nakamura, Hiroaki

2017-11-15

MINI: Fourteen hundred consecutive patients were investigated for evaluating the utility of waterless hand rub before orthopaedic surgery. The risk in the surgical site infection incidence was the same, but costs of liquids used for hand hygiene were cheaper and the hand hygiene time was shorter for waterless protocol, compared with traditional hand scrub. A retrospective cohort study with prospectively collected data. The aim of this study was to compare SSI incidences, the cost of hand hygiene agents, and hand hygiene time between the traditional hand scrub and the waterless hand rub protocols before orthopedic surgery. Surgical site infections (SSI) prolong hospitalization and are a leading nosocomial cause of morbidity and a source of excess cost. Recently, a waterless hand rub protocol comprising alcohol based chlorhexidine gluconate for use before surgery was developed, but no studies have yet examined its utility in orthopedic surgery. Fourteen hundred consecutive patients who underwent orthopedic surgery (spine, joint replacement, hand, and trauma surgeries) in our hospital since April 1, 2012 were included. A total of 712 cases underwent following traditional hand scrub between April 1, 2012 and April 30, 2013 and 688 cases underwent following waterless hand rub between June 1, 2013 and April 30, 2014. We compared SSI incidences within all and each subcategory between two hand hygiene protocols. All patients were screened for SSI within 1 year after surgery. We compared the cost of hand hygiene agents and hand hygiene time between two groups. The SSI incidences were 1.3% (9 of 712) following the traditional protocol (2 deep and 7 superficial infections) and 1.1% (8 of 688) following the waterless protocol (all superficial infections). There were no significant differences between the two groups. The costs of liquids used for one hand hygiene were about $2 for traditional hand scrub and less than $1 for waterless hand rub. The mean hand hygiene time was 264 seconds with the traditional protocol and 160 seconds with the waterless protocol. Waterless hand rub with an alcohol based chlorhexidine gluconate solution can be a safe, quick, and cost-effective alternative to traditional hand scrub. 3.

Comprehensive comparing percutaneous endoscopic lumbar discectomy with posterior lumbar internal fixation for treatment of adjacent segment lumbar disc prolapse with stable retrolisthesis: A retrospective case-control study.

PubMed

Sun, Yapeng; Zhang, Wei; Qie, Suhui; Zhang, Nan; Ding, Wenyuan; Shen, Yong

2017-07-01

The study was to comprehensively compare the postoperative outcome and imaging parameter characters in a short/middle period between the percutaneous endoscopic lumbar discectomy (PELD) and the internal fixation of bone graft fusion (the most common form is posterior lumbar interbody fusion [PLIF]) for the treatment of adjacent segment lumbar disc prolapse with stable retrolisthesis after a previous lumbar internal fixation surgery.In this retrospective case-control study, we collected the medical records from 11 patients who received PELD operation (defined as PELD group) for and from 13 patients who received the internal fixation of bone graft fusion of lumbar posterior vertebral lamina decompression (defined as control group) for the treatment of the lumbar disc prolapse combined with stable retrolisthesis at Department of Spine Surgery, the Third Hospital of Hebei Medical University (Shijiazhuang, China) from May 2010 to December 2015. The operation time, the bleeding volume of perioperation, and the rehabilitation days of postoperation were compared between 2 groups. Before and after surgery at different time points, ODI, VAS index, and imaging parameters (including Taillard index, inter-vertebral height, sagittal dislocation, and forward bending angle of lumbar vertebrae) were compared.The average operation time, the blooding volume, and the rehabilitation days of postoperation were significantly less in PELD than in control group. The ODI and VAS index in PELD group showed a significantly immediate improving on the same day after the surgery. However, Taillard index, intervertebral height, sagittal dislocation in control group showed an immediate improving after surgery, but no changes in PELD group till 12-month after surgery. The forward bending angle of lumbar vertebrae was significantly increased and decreased in PELD and in control group, respectively.PELD operation was superior in terms of operation time, bleeding volume, recovery period, and financial support, if compared with lumbar internal fixation operation. Radiographic parameters reflect lumber structure changes, which could be observed immediately after surgery in both methods; however, the recoveries on nerve function and pain relief required a longer time, especially after PLIF operation.

Laparoscopic versus open abdominal surgery in children with sickle cell disease is associated with a shorter hospital stay.

PubMed

Goers, Trudie; Panepinto, Julie; Debaun, Michael; Blinder, Morey; Foglia, Robert; Oldham, Keith T; Field, Joshua J

2008-03-01

Limited information exists comparing the post-operative complication rate of laparoscopic or open abdominal surgeries in children with sickle cell disease (SCD). The primary objective of this study was to compare the outcomes in children with SCD who required laparoscopic or open abdominal surgery for a cholecystectomy or splenectomy. We conducted a retrospective analysis of laparoscopic and open abdominal surgeries performed in children with SCD (ages 0-20 years) at two medical centers from 1984 to 2004. The primary outcome measures were the rates of post-operative pain and acute chest syndrome (ACS) episodes following laparoscopic or open abdominal surgery. The secondary outcome was length of hospital stay following surgery. We also examined the potential contribution of pre-operative (transfusion) and intra-operative factors (operating time, estimated blood loss, and end-operative temperature) to post-operative SCD-related complications. A total of 140 cases were identified, 98 laparoscopic and 42 open. Episodes of post-operative pain and ACS episodes were comparable between laparoscopic and open procedures (pain: 4% vs. 3%, P = 0.619; ACS: 5% vs. 5%, P = 0.933). Additionally, laparoscopic surgeries were associated with a significantly shorter hospital stay (2.9 vs. 5.4 days, 95% CI -3.7 to -1.4, P < 0.001). There was no difference in the number of hospital readmissions within 1 month of the surgery. For children with SCD who need a cholecystectomy or splenectomy, laparoscopy is the preferred strategy because of a shorter hospital stay with a similar complication rate compared to open surgeries. (c) 2007 Wiley-Liss, Inc.

Protocol for concomitant temporomandibular joint custom-fitted total joint reconstruction and orthognathic surgery utilizing computer-assisted surgical simulation.

PubMed

Movahed, Reza; Teschke, Marcus; Wolford, Larry M

2013-12-01

Clinicians who address temporomandibular joint (TMJ) pathology and dentofacial deformities surgically can perform the surgery in 1 stage or 2 separate stages. The 2-stage approach requires the patient to undergo 2 separate operations and anesthesia, significantly prolonging the overall treatment. However, performing concomitant TMJ and orthognathic surgery (CTOS) in these cases requires careful treatment planning and surgical proficiency in the 2 surgical areas. This article presents a new treatment protocol for the application of computer-assisted surgical simulation in CTOS cases requiring reconstruction with patient-fitted total joint prostheses. The traditional and new CTOS protocols are described and compared. The new CTOS protocol helps decrease the preoperative workup time and increase the accuracy of model surgery. Copyright © 2013 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.

Virtual reality in the treatment of body image disturbances after bariatric surgery: a clinical case.

PubMed

Riva, Giuseppe; Cárdenas-López, Georgina; Duran, Ximena; Torres-Villalobos, Gonzalo M; Gaggioli, Andrea

2012-01-01

Bariatric surgery is an operation on the stomach and/or intestines that helps patients with extreme obesity to lose weight. Even if bariatric surgery, compared with traditional obesity treatment, is more effective in reducing BMI, this approach does not achieve equal results in every patient. More, following bariatric surgery common problems are body image dissatisfaction and body disparagement: there is a significant difference between the weight loss clinicians consider successful (50% of excess weight) and the weight loss potential patients expect to achieve (at least 67% of the excess weight). The paper discusses the possible role of virtual reality (VR) in addressing this problem within an integrated treatment approach. More, the clinical case of a female bariatric patient who experienced body dissatisfaction even after a 30% body weight loss and a 62% excess body weight loss, is presented and discussed.

Introduction of a computer-based surgical platform in the surgical care of patients with newly diagnosed uterine cancer: outcomes and impact on approach.

PubMed

Leitao, Mario M; Briscoe, Gabriel; Santos, Kevin; Winder, Abigail; Jewell, Elizabeth L; Hoskins, William J; Chi, Dennis S; Abu-Rustum, Nadeem R; Sonoda, Yukio; Brown, Carol L; Levine, Douglas A; Barakat, Richard R; Gardner, Ginger J

2012-05-01

To assess the introduction of computer-based surgery (ie, robotic surgery [RBT]) in the treatment of patients with newly diagnosed uterine cancer. We identified all patients who presented to our institution for initial surgical care of newly diagnosed uterine cancer from 5/1/07-12/31/10. Perioperative outcomes of laparotomy cases were compared to those of laparoscopic (LSC) or RBT cases. Complications within 30 days of surgery were graded. Of 752 patients, the planned approach was laparotomy in 103 (14%), LSC in 302 (40%), and RBT in 347 (46%). The rate of laparotomy for any reason (planned or converted) was 39% in 2007 compared to 18% in 2010 (P<0.001). Preoperative characteristics for LSC and RBT cases were similar, except 10% versus 15%, respectively, were morbidly obese (P=0.049). The extent of procedure, total nodal counts, and overall complications were similar between the LSC and RBT cases. The median length of stay was shorter for RBT cases (P<0.001). The median total room and operative times were longer for RBT cases (P<0.001), mainly due to cases in which the surgeon had less than ~40 RBT cases of experience. Robotics can be efficiently introduced into the surgical care of patients with newly diagnosed uterine cancers. RBT cases require the same operative times as LSC cases after accounting for the 40-case learning curve. Both approaches result in similar excellent patient outcomes and remain reasonable approaches for this disease. The introduction of robotics may lead to further reduction in the rate of laparotomy. Copyright © 2012 Elsevier Inc. All rights reserved.

[Endonasal endoscopic surgery in the treatment of spontaneous or post-traumatic cerebrospinal fluid (csf) leaks].

PubMed

Nallet, E; Decq, P; Bezzo, A; Le Lievre, G; Peynegre, R; Coste, A

1998-10-01

The incidence and the risk of meningitidis justify treatment in all cases of cerebrospinal fluid rhinorrhea with spontaneous etiology or after traumatic injury. Endonasal surgery with endoscopic instruments provides many advantages compared with transcranial or transfacial approach used by neurosurgeons. We report our experience and our surgical technique in the treatment of CSF leaks in 5 patients. Intrathecal injection of fluoresceine was very useful in all cases for detecting the CSF leak. Total or selected ethmoidectomy depended on the localization of the leakage. Wide sphenoidotomy enables detection and repair of CSF leaks from the sphenoid cavity. A free graft of inferior turbinal mucosal was used to repair the breache. This rapid low morbidity surgery offered secure closure of rhinorrhea in 4 cases after one procedure and in 1 case after two procedures with an average follow up of 22 months. Cerebrospinal fluid rhinorrhea can be managed in first line therapy with endoscopic intranasal surgical techniques when they are localized in the anterior ethmoid or in the sphenoid cavity.

Diffusion of robotics into clinical practice in the United States: process, patient safety, learning curves, and the public health.

PubMed

Mirheydar, Hossein S; Parsons, J Kellogg

2013-06-01

Robotic technology disseminated into urological practice without robust comparative effectiveness data. To review the diffusion of robotic surgery into urological practice. We performed a comprehensive literature review focusing on diffusion patterns, patient safety, learning curves, and comparative costs for robotic radical prostatectomy, partial nephrectomy, and radical cystectomy. Robotic urologic surgery diffused in patterns typical of novel technology spreading among practicing surgeons. Robust evidence-based data comparing outcomes of robotic to open surgery were sparse. Although initial Level 3 evidence for robotic prostatectomy observed complication outcomes similar to open prostatectomy, subsequent population-based Level 2 evidence noted an increased prevalence of adverse patient safety events and genitourinary complications among robotic patients during the early years of diffusion. Level 2 evidence indicated comparable to improved patient safety outcomes for robotic compared to open partial nephrectomy and cystectomy. Learning curve recommendations for robotic urologic surgery have drawn exclusively on Level 4 evidence and subjective, non-validated metrics. The minimum number of cases required to achieve competency for robotic prostatectomy has increased to unrealistically high levels. Most comparative cost-analyses have demonstrated that robotic surgery is significantly more expensive than open or laparoscopic surgery. Evidence-based data are limited but suggest an increased prevalence of adverse patient safety events for robotic prostatectomy early in the national diffusion period. Learning curves for robotic urologic surgery are subjective and based on non-validated metrics. The urological community should develop rigorous, evidence-based processes by which future technological innovations may diffuse in an organized and safe manner.

Exploring predictors of surgery and comparing operative treatment approaches for pediatric intracranial arachnoid cysts: a case series of 83 patients.

PubMed

Ali, Mohsin; Bennardo, Michael; Almenawer, Saleh A; Zagzoog, Nirmeen; Smith, Alston A; Dao, Dyda; Ajani, Olufemi; Farrokhyar, Forough; Singh, Sheila K

2015-09-01

Although intracranial arachnoid cysts are a common incidental finding on pediatric brain imaging, only a subset of patients require surgery for them. For the minority who undergo surgery, the comparative effectiveness of various surgical approaches is debated. The authors explored predictors of surgery and compared operative techniques for pediatric patients with an intracranial arachnoid cyst seen at a tertiary care center. The authors reviewed records of pediatric patients with an intracranial arachnoid cyst. For each patient, data on baseline characteristics, the method of intervention, and surgical outcomes for the initial surgery were extracted, and cyst size at diagnosis was calculated (anteroposterior × craniocaudal × mediolateral). Baseline variables were analyzed as predictors of surgery by using logistic regression modeling, excluding patients whose surgery was not related to cyst size (i.e., those with obstructive hydrocephalus secondary to the cyst compressing a narrow CSF flow pathway or cyst rupture/hemorrhage). Data collected regarding surgical outcomes were analyzed descriptively. Among 83 pediatric patients with an intracranial arachnoid cyst seen over a 25-year period (1989-2013), 27 (33%) underwent surgery; all had at least 1 cyst-attributed symptom/finding. In the multivariate model, age at presentation and cyst size at diagnosis were independent predictors of surgery. Cyst size had greater predictive value; specifically, the area under the curve for the receiver-operating-characteristic curve was 0.89 (95% CI 0.82-0.97), with an ideal cutoff point of ≥ 68 cm(3). This cutoff point had 100% sensitivity (95% CI 79%-100%), 75% specificity (95% CI 61%-85%), a 53% positive predictive value (95% CI 36%-70%), and a 100% negative predictive value (95% CI 91%-100%); the positive likelihood ratio was 4.0 (95% CI 2.5-6.3), and the negative likelihood ratio was 0 (95% CI 0-0.3). Although the multivariate model excluded 7 patients who underwent surgery (based on prespecified criteria), excluding these 7 cases did not change the overall findings, as shown in a sensitivity analysis that included all the cases. Descriptive results regarding surgical outcomes did not indicate any salient differences among the surgical techniques (endoscopic fenestration, cystoperitoneal shunting, or craniotomy-based procedures) in terms of symptom resolution within 6 months, need for reoperation to date, cyst-size change from before the operation, morbidity, or mortality. The results of these exploratory analyses suggest that pediatric patients with an intracranial arachnoid cyst are more likely to undergo surgery if the cyst is large, compresses a narrow CSF flow pathway to cause hydrocephalus, or has ruptured/hemorrhaged. There were no salient differences among the 3 surgical techniques for several clinically important outcomes. A prospective multicenter study is required to enable more robust analyses, which could ultimately provide a decision-making framework for surgical indications and clarify any differences in the comparative effectiveness of surgical approaches to treating pediatric intracranial arachnoid cysts.

Reoperative surgery: a critical risk factor for complications inadequately captured by operative reporting and coding of lysis of adhesions.

PubMed

Aloia, Thomas A; Cooper, Amanda; Shi, Weiming; Vauthey, Jean-Nicolas; Lee, Jeffrey E

2014-07-01

Reoperative surgery is suspected, but not proven, to increase postoperative complication rates. In the absence of a specific definition for reoperative surgery, the American College of Surgeons NSQIP has proposed using procedural coding for lysis of adhesions (LOA) as a surrogate for reoperative surgery to risk adjust hospitals. We hypothesized that coding of reoperative surgery will be associated with worse 30-day outcomes and, for abdominal procedures, will be more accurate than operative dictation and coding of "lysis of adhesions." Reoperative surgery was categorized at the time of data abstraction from February 2012 to December 2012 for all NSQIP cases collected at a single institution by independent surgical clinical reviewers. Reoperative surgery classification and coding of LOA were compared with each other and with 30-day outcomes. The setting was a tertiary cancer center, multispecialty NSQIP model. During the study period, 1,289 operations were classified as nonreoperative (n = 793), regionally reoperative (n = 39; prior surgery in an adjacent area of current operation), or locally reoperative (n = 457; prior surgery at same site or organ). In the multispecialty cohort, the non-risk-adjusted rates of overall 30-day morbidity, serious morbidity, and mortality were 21.5%, 17.7%, and 0.5%. Compared with nonreoperative surgery (overall 30-day morbidity 16.8%, serious morbidity 13.9%, and mortality .38%), both regionally reoperative surgery (overall 30-day morbidity 30.8%, serious morbidity 28.2%, and mortality 2.5%) and locally reoperative surgery (overall 30-day morbidity 28.9%, serious morbidity 23.4%, and mortality .66%) were associated with worse outcomes (p < 0.001). One hundred ninety-nine of the 327 gastrointestinal/laparotomy cases were recorded as reoperative, but only of 20 of these were CPT coded as LOA (sensitivity = 10%). Reoperative surgery is frequent, increases the risk of complications, and can be captured. Operative LOA coding vastly under reports reoperative surgery and, therefore, is not an adequate surrogate for this important risk factor. Copyright © 2014 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Immediate loading of four implants (BTLock®) in the maxilla and provisional restoration with guide-surgery (SimPlant, Materialise®): case report

PubMed Central

SPINELLI, D.; DE VICO, G.; SCHIAVETTI, R.; BONINO, M.; POZZI, A.; BOLLERO, P.; BARLATTANI, A.

2010-01-01

SUMMARY The severe atrophy of the jaws are a challenging therapeutic problem, since the increase in bone is necessary to allow the placement of a sufficient number of implants. Combining immediate functionalization with the concept of guided surgery they combine the advantages offered by the innovative surgical and prosthetic implant technique (All-on-Four®) with those of computer-assisted planning in cases of severe bone atrophy. The method used in this case report, combines these two concepts in a surgical and prosthetic protocol safe and effective for the immediate function of 4 implants to support a fixed prosthesis in completely edentulous subjects. The integration of technology with immediate function with the concept of computer-guided surgery for implant placement and rehabilitation of completely edentulous jaws is now a predictable treatment modality with implant survival comparable to the traditional protocols. PMID:23285381

Post-cataract Surgery Endophthalmitis in the United States: Analysis of the Complete 2003–2004 Medicare Database of Cataract Surgeries

PubMed Central

Keay, Lisa; Gower, Emily W.; Cassard, Sandra D.; Tielsch, James M.; Schein, Oliver D.

2011-01-01

OBJECTIVE To estimate endophthalmitis incidence following cataract surgery nationally and at the state level in 2003–2004 and to explore risk factors. DESIGN Analysis of Medicare beneficiary claims data. PARTICIPANTS 100% sample of Medicare recipients’ claims for endophthalmitis and outpatient cataract surgery services. METHODS Cataract surgeries were identified by procedure codes and merged with demographic information. Cataract annual surgical volume was calculated for all surgeons. Presumed post-operative endophthalmitis cases were identified by International Classification of Diseases-9 Clinical Modification Codes (ICD-9-CM) on claims within 42 days after surgery. Endophthalmitis rates and 95% confidence intervals were calculated at state and national levels. Logistic regression was used to investigate the association between developing endophthalmitis and surgery location and surgeon factors. MAIN OUTCOME MEASURES Endophthalmitis incidence and risk factors. RESULTS 4,006 cases of presumed endophthalmitis occurred following 3,280,966 cataract surgeries. The national rate in 2003 was 1.33 per 1000 surgeries (95% confidence interval [CI]: 1.27–1.38) and decreased to 1.11 per 1000 (95% CI: 1.06–1.16) in 2004. Males (relative risk [RR] 1.23, 95% CI: 1.15–1.31), older individuals (RR 1.53, 95% CI 1.38–1.69; 85+ compared to 65–74 years), Blacks (RR 1.17, 95% CI 1.03–1.33) and Native Americans (RR 1.72, 95% CI 1.07–2.77) had increased risk of disease. After adjustment, surgeries by surgeons with low annual volume (RR 3.80, 95% CI 3.13–4.61 for 1–50 compared to 1001+annual surgeries) and less experience (RR 1.41, 95% CI 1.25–1.59 1–10 compared to 30+ years) and surgeries per formed in 2003 (RR 1.20, 95% CI 1.13–1.28) had increased endophthalmitis risk. CONCLUSIONS Endophthalmitis rates are lower than previous-year US estimates, but remain higher than rates reported from a series of studies from Sweden; patient factors or methodological differences may contribute to differences across countries. Patient age, gender and race, and surgeon volume and years of experience are important risk factors. PMID:22297029

Robotic and open radical prostatectomy in the public health sector: cost comparison.

PubMed

Hall, Rohan Matthew; Linklater, Nicholas; Coughlin, Geoff

2014-06-01

During 2008, the Royal Brisbane and Women's Hospital became the first public hospital in Australia to have a da Vinci Surgical Robot purchased by government funding. The cost of performing robotic surgery in the public sector is a contentious issue. This study is a single centre, cost analysis comparing open radical prostatectomy (RRP) and robotic-assisted radical prostatectomy (RALP) based on the newly introduced pure case-mix funding model. A retrospective chart review was performed for the first 100 RALPs and the previous 100 RRPs. Estimates of tangible costing and funding were generated for each admission and readmission, using the Royal Brisbane Hospital Transition II database, based on pure case-mix funding. The average cost for admission for RRP was A$13 605, compared to A$17 582 for the RALP. The average funding received for a RRP was A$11 781 compared to A$5496 for a RALP based on the newly introduced case-mix model. The average length of stay for RRP was 4.4 days (2-14) and for RALP, 1.2 days (1-4). The total cost of readmissions for RRP patients was A$70 487, compared to that of the RALP patients, A$7160. These were funded at A$55 639 and A$7624, respectively. RALP has shown a significant advantage with respect to length of stay and readmission rate. Based on the case-mix funding model RALP is poorly funded compared to its open equivalent. Queensland Health needs to plan on how robotic surgery is implemented and assess whether this technology is truly affordable in the public sector. © 2013 The Authors. ANZ Journal of Surgery © 2013 Royal Australasian College of Surgeons.

Blended learning in surgery using the Inmedea Simulator.

PubMed

Funke, Katrin; Bonrath, Esther; Mardin, Wolf Arif; Becker, Jan Carl; Haier, Joerg; Senninger, Norbert; Vowinkel, Thorsten; Hoelzen, Jens Peter; Mees, Soeren Torge

2013-02-01

Recently, medical education in surgery has experienced several modifications. We have implemented a blended learning module in our teaching curriculum to evaluate its effectiveness, applicability, and acceptance in surgical education. In this prospective study, the traditional face-to-face learning of our teaching curriculum for fourth-year medical students (n = 116) was augmented by the Inmedea Simulator, a web-based E-learning system, with six virtual patient cases. Student results were documented by the system and learning success was determined by comparing patient cases with comparable diseases (second and sixth case). The acceptance among the students was evaluated with a questionnaire. After using the Inmedea Simulator, correct diagnoses were found significantly (P < 0.05) more often, while an incomplete diagnostic was seen significantly (P < 0.05) less often. Significant overall improvement (P < 0.05) was seen in sixth case (62.3 ± 5.6 %) vs. second case (53.9 ± 5.6 %). The questionnaire revealed that our students enjoyed the surgical seminar (score 2.1 ± 1.5) and preferred blended learning (score 2.5 ± 1.2) to conventional teaching. The blended learning approach using the Inmedea Simulator was highly appreciated by our medical students and resulted in a significant learning success. Blended learning appears to be a suitable tool to complement traditional teaching in surgery.

A comparative cost analysis of robot-assisted versus traditional laparoscopic partial nephrectomy.

PubMed

Hyams, Elias; Pierorazio, Philip; Mullins, Jeffrey K; Ward, Maryann; Allaf, Mohamad

2012-07-01

Robot-assisted laparoscopic partial nephrectomy (RALPN) is supplanting traditional laparoscopic partial nephrectomy (LPN) as the technique of choice for minimally invasive nephron-sparing surgery. This evolution has resulted from potential clinical benefits, as well as proliferation of robotic systems and patient demand for robot-assisted surgery. We sought to quantify the costs associated with the use of robotics for minimally invasive partial nephrectomy. A cost analysis was performed for 20 consecutive robot-assisted partial nephrectomy (RPN) and LPN patients at our institution from 2009 to 2010. Data included actual perioperative and hospitalization costs as well as professional fees. Capital costs were estimated using purchase costs and amortization of two robotic systems from 2001 to 2009, as well as maintenance contract costs. The estimated cost/case was obtained using total robotic surgical volume during this period. Total estimated costs were compared between groups. A separate analysis was performed assuming "ideal" robotic utilization during a comparable period. RALPN had a cost premium of +$1066/case compared with LPN, assuming actual robot utilization from 2001 to 2009. Assuming "ideal" utilization during a comparable period, this premium decreased to +$334; capital costs per case decreased from $1907 to $1175. Tumor size, operative time, and length of stay were comparable between groups. RALPN is associated with a small to moderate cost premium depending on assumptions regarding robotic surgical volume. Saturated utilization of robotic systems decreases attributable capital costs and makes comparison with laparoscopy more favorable. Purported clinical benefits of RPN (eg, decreased warm ischemia time, increased utilization of nephron-sparing surgery) need further study, because these may have cost implications.

The Black Cloud Phenomenon in Hand Surgery.

PubMed

Zhao, Emily; Tiedeken, Nathan; Wang, William; Fowler, John

2018-04-01

The term black cloud for a surgeon is generally used to describe someone who is unusually busy compared with his or her counterparts, and it is a superstition that tends to pervade the medical world. The purpose of this study is to investigate whether black clouds exist in hand surgery. We examined one academic year's worth of hand surgery-specific call at a level I trauma center and tabulated the number of hand-related patient transfers and add-on cases per surgeon. Each surgeon was given a black cloud rating by the fellows who were in training that year. Correlations were made between the black cloud rating and the surgeons' call volume. There were 12 surgeons who shared 365 days of hand call, and 5 of them are hand surgery fellowship trained. Those 5 surgeons tended to be busier on their call days, with more cases added on overnight and the next day, and also had worse black cloud ratings than the 7 non-hand fellowship trained surgeons. In regard to hand surgery, while true emergencies occur and require emergent intervention, how busy hand surgeons may be during call may be influenced by a variety of factors not related to their patients' problems but rather their daily schedules, their hospitals' ability to facilitate add-on cases, and their rapport with their fellow surgeons to share case loads.

Routine exposure of recurrent laryngeal nerve in thyroid surgery can prevent nerve injury.

PubMed

Shen, Chenling; Xiang, Mingliang; Wu, Hao; Ma, Yan; Chen, Li; Cheng, Lan

2013-06-15

To determine the value of dissecting the recurrent laryngeal nerve during thyroid surgery with respect to preventing recurrent laryngeal nerve injury, we retrospectively analyzed clinical data from 5 344 patients undergoing thyroidectomy. Among these cases, 548 underwent dissection of the recurrent laryngeal nerve, while 4 796 did not. There were 12 cases of recurrent laryngeal nerve injury following recurrent laryngeal nerve dissection (injury rate of 2.2%) and 512 cases of recurrent laryngeal nerve injury in those not undergoing nerve dissection (injury rate of 10.7%). This difference remained statistically significant between the two groups in terms of type of thyroid disease, type of surgery, and number of surgeries. Among the 548 cases undergoing recurrent laryngeal nerve dissection, 128 developed anatomical variations of the recurrent laryngeal nerve (incidence rate of 23.4%), but no recurrent laryngeal nerve injury was found. In addition, the incidence of recurrent laryngeal nerve injury was significantly lower in patients with the inferior parathyroid gland and middle thyroid veins used as landmarks for locating the recurrent laryngeal nerve compared with those with the entry of the recurrent laryngeal nerve into the larynx as a landmark. These findings indicate that anatomical variations of the recurrent laryngeal nerve are common, and that dissecting the recurrent laryngeal nerve during thyroid surgery is an effective means of preventing nerve injury.

Routine exposure of recurrent laryngeal nerve in thyroid surgery can prevent nerve injury★

PubMed Central

Shen, Chenling; Xiang, Mingliang; Wu, Hao; Ma, Yan; Chen, Li; Cheng, Lan

2013-01-01

To determine the value of dissecting the recurrent laryngeal nerve during thyroid surgery with respect to preventing recurrent laryngeal nerve injury, we retrospectively analyzed clinical data from 5 344 patients undergoing thyroidectomy. Among these cases, 548 underwent dissection of the recurrent laryngeal nerve, while 4 796 did not. There were 12 cases of recurrent laryngeal nerve injury following recurrent laryngeal nerve dissection (injury rate of 2.2%) and 512 cases of recurrent laryngeal nerve injury in those not undergoing nerve dissection (injury rate of 10.7%). This difference remained statistically significant between the two groups in terms of type of thyroid disease, type of surgery, and number of surgeries. Among the 548 cases undergoing recurrent laryngeal nerve dissection, 128 developed anatomical variations of the recurrent laryngeal nerve (incidence rate of 23.4%), but no recurrent laryngeal nerve injury was found. In addition, the incidence of recurrent laryngeal nerve injury was significantly lower in patients with the inferior parathyroid gland and middle thyroid veins used as landmarks for locating the recurrent laryngeal nerve compared with those with the entry of the recurrent laryngeal nerve into the larynx as a landmark. These findings indicate that anatomical variations of the recurrent laryngeal nerve are common, and that dissecting the recurrent laryngeal nerve during thyroid surgery is an effective means of preventing nerve injury. PMID:25206452

Closed-loop assisted versus manual goal-directed fluid therapy during high-risk abdominal surgery: a case-control study with propensity matching.

PubMed

Rinehart, Joseph; Lilot, Marc; Lee, Christine; Joosten, Alexandre; Huynh, Trish; Canales, Cecilia; Imagawa, David; Demirjian, Aram; Cannesson, Maxime

2015-03-19

Goal-directed fluid therapy strategies have been shown to benefit moderate- to high-risk surgery patients. Despite this, these strategies are often not implemented. The aim of this study was to assess a closed-loop fluid administration system in a surgical cohort and compare the results with those for matched patients who received manual management. Our hypothesis was that the patients receiving closed-loop assistance would spend more time in a preload-independent state, defined as percentage of case time with stroke volume variation less than or equal to 12%. Patients eligible for the study were all those over 18 years of age scheduled for hepatobiliary, pancreatic or splenic surgery and expected to receive intravascular arterial blood pressure monitoring as part of their anesthetic care. The closed-loop resuscitation target was selected by the primary anesthesia team, and the system was responsible for implementation of goal-directed fluid therapy during surgery. Following completion of enrollment, each study patient was matched to a non-closed-loop assisted case performed during the same time period using a propensity match to reduce bias. A total of 40 patients were enrolled, 5 were ultimately excluded and 25 matched pairs were selected from among the remaining 35 patients within the predefined caliper distance. There was no significant difference in fluid administration between groups. The closed-loop group spent a significantly higher portion of case time in a preload-independent state (95 ± 6% of case time versus 87 ± 14%, P =0.008). There was no difference in case mean or final stroke volume index (45 ± 10 versus 43 ± 9 and 45 ± 11 versus 42 ± 11, respectively) or mean arterial pressure (79 ± 8 versus 83 ± 9). Case end heart rate was significantly lower in the closed-loop assisted group (77 ± 10 versus 88 ± 13, P =0.003). In this case-control study with propensity matching, clinician use of closed-loop assistance resulted in a greater portion of case time spent in a preload-independent state throughout surgery compared with manual delivery of goal-directed fluid therapy. ClinicalTrials.gov Identifier: NCT02020863. Registered 19 December 2013.

A community-based, case-control study of childhood stroke risk associated with congenital heart disease

PubMed Central

Fox, Christine K.; Sidney, Stephen; Fullerton, Heather J.

2014-01-01

Background and Purpose A better understanding of the stroke risk factors in children with congenital heart disease (CHD) could inform stroke prevention strategies. We analyzed pediatric stroke associated with CHD in a large community-based, case-control study. Methods From 2.5 million children (< 20 years) enrolled in a Northern California integrated healthcare plan, we identified ischemic and hemorrhagic strokes and randomly selected age and facility-matched stroke-free controls (3 per case). We determined exposure to CHD (diagnosed prior to stroke) and used conditional logistic regression to analyze stroke risk. Results CHD was identified in 15/412 cases (4%) versus 7/1,236 controls (0.6%). Children (28 days – 20 years) with CHD had 19-fold (Odds Ratio [OR] 19; 95% Confidence Interval [CI] 4.2, 83) increased stroke risk compared to controls. History of CHD surgery was associated with >30-fold increased risk of stroke (OR 31; CI 4, 241 compared to controls). After excluding peri-operative strokes, a history of CHD surgery still increased childhood stroke risk (OR 13; CI 1.5, 114). The majority of children with stroke and CHD were outpatient at the time of stroke, and almost half the cases who underwent cardiac surgery had their stroke >5 years after the most recent procedure. An estimated 7% of ischemic and 2% of hemorrhagic childhood strokes in the population were attributable to CHD. Conclusions CHD is an important childhood stroke risk factor. Children who undergo CHD surgery remain at elevated risk outside of the peri-operative period, and would benefit from optimized long-term stroke prevention strategies. PMID:25516197

Postoperative intra-abdominal collections using a sodium hyaluronate-carboxymethylcellulose (HA-CMC) barrier at the time of laparotomy for uterine or cervical cancers.

PubMed

Leitao, Mario M; Byrum, Graham V; Abu-Rustum, Nadeem R; Brown, Carol L; Chi, Dennis S; Sonoda, Yukio; Levine, Douglas A; Gardner, Ginger J; Barakat, Richard R

2010-11-01

A prior analysis of patients undergoing laparotomy for ovarian malignancies at our institution revealed an increased rate of intra-abdominal collections using HA-CMC film during debulking surgery. The primary objective of the current study was to determine whether the use of HA-CMC is associated with the development of postoperative intra-abdominal collections in patients undergoing laparotomy for uterine or cervical malignancies. We retrospectively identified all laparotomies performed for these malignancies from 3/1/05 to 12/31/07. We identified cases involving the use of HA-CMC via billing records and operative reports. Intra-abdominal collections were defined as localized intraperitoneal fluid accumulations in the absence of re-accumulating ascites. We noted incidences of intra-abdominal collections, as well as other complications. Appropriate statistical tests were applied using SPSS 15.0. We identified 169 laparotomies in which HA-CMC was used and 347 in which HA-CMC was not used. The following were statistically similar in both cohorts: age, body mass index (BMI), primary site, surgery for recurrent disease, prior intraperitoneal surgery, and extent of current surgery. Intra-abdominal collections were seen in 6 (3.6%) of 169 HA-CMC cases compared to 10 (2.9%) of 347 non-HA-CMC cases (p=0.7). The rate of infected collections was similar in both groups (1.2% vs. 1.4%). In the subgroup that underwent tumor debulking, intra-abdominal collections were seen in 3 (11.5%) of 26 HA-CMC cases compared to 2 (5.4%) of 37 non-HA-CMC cases (p=0.6). HA-CMC use does not appear to be associated with postoperative intra-abdominal collections in patients undergoing laparotomy for uterine or cervical cancer. Copyright © 2010 Elsevier Inc. All rights reserved.

Comparison of soft-tissue changes in simultaneous maxillomandibular distraction with mandibular distraction with second-stage maxillary osteotomy.

PubMed

Balaji, S M; Balaji, Preetha

2016-01-01

The purpose of this study was to compare the frontal lip cant changes in common facial asymmetry (FA) cases after simultaneous maxillomandibular distraction osteogenesis (DO) and mandibular DO with maxillary orthognathic surgery. Retrospective analysis of FA cases at tertiary craniofacial referral was performed. Patients of either gender with all medical imaging records and pre- and post-operative (1 year) facial photographs in natural head position were included in the study. The lip cant change was assessed by the ratio of the linear dimension between affected and unaffected side labial commissures and the bi-pupillary reference line. Difference between the pre- and post-operative ratio was analyzed. Statistical analysis was performed for the outcome. P ≤0.05 was taken as significant. The mean preoperative measured value of the affected side was 0.845 ± 0.036 while the postoperative value was 0.95 ± 0.032. The effective change was 0.11 ± 0.044. The postoperative ratio compared with simultaneous DO case was 0.98 ± 0.06 while that of mandibular distraction with orthognathic surgery was 0.92 ± 0.08 (P = 0.048). The mean change of the simultaneous DO case was measured as 0.114 ± 0.041 while the same for the mandibular distraction with orthognathic surgery was 0.069 ± 0.035 (P = 0.013). The results indicate that the simultaneous DO yields more better frontal lip cant change between both halves than the mono-DO with orthognathic surgery. The mean change is much higher in the simultaneous DO cases indicating a more effective correction and desired result. The biological reason and lip musculature mechanism behind the response in both conditions are discussed.

[Osteoid osteoma in children: 5 cases treated with electrocoagulation].

PubMed

Gilliaux, O; de Wispelaere, J-F; Charlier, H; Bodart, E

2012-11-01

Osteoid osteoma is a benign bone tumor. Its diagnosis is often delayed despite typical symptoms: severe pain mainly situated on the lower limbs and characteristically worse at night. Once diagnosed, an antalgic treatment by aspirin is well known to be very effective in relieving pain. Osteoid osteoma will resolve spontaneously. If symptoms persist despite the use of aspirin, surgery can be performed to remove the tumor. Percutaneous electrocoagulation can be performed instead of surgical resection as a less invasive procedure. The success rate of surgery and percutaneous electrocoagulation is comparable. We reviewed the cases of 5 patients who were hospitalized in our institution for percutaneous electrocoagulation of an osteoid osteoma. We compared them to the literature. Copyright © 2012 Elsevier Masson SAS. All rights reserved.

[Potentials and limitations of the planned compulsory quality assurance program for cataract surgery (Qesü)].

PubMed

Hahn, U; Bertram, B; Krummenauer, F; Reuscher, A; Fabian, E; Neuhann, T; Schmickler, S; Neuhann, I

2013-04-01

Cataract surgery is scheduled for a federal program for quality improvement across the different sectors of care (outpatient care and hospitals). In case of implementation not only ophthalmic surgeons but all ophthalmologists would have to contribute to the documentation. Urgency, potential benefits and limitations of a compulsory compared to a voluntary quality assessment system are analyzed.

The Role of the Surgeon on Outcomes of Vaginal Prolapse Surgery With Mesh.

PubMed

Eilber, Karyn S; Alperin, Marianna; Khan, Aqsa; Wu, Ning; Pashos, Chris L; Clemens, J Quentin; Anger, Jennifer T

Adverse outcomes after surgery for pelvic organ prolapse (POP) with mesh are often attributed to the mesh material with little attention paid to the influence of surgeon factors. We used a national data set to determine whether surgeon case volume and specialty influenced vaginal prolapse surgery outcomes with mesh. Public Use File data on a 5% random national sample of female Medicare beneficiaries were obtained from the Centers for Medicare and Medicaid Services. Women with a diagnosis of POP who underwent surgery with mesh between 2007 and 2008 were identified by relevant International Classification of Diseases, 9th Revision, Clinical Modification and Current Procedural Terminology, 4th Edition procedure codes. Outcomes were compared by surgeon case volume and specialty. From 2007 to 2008, 1657 surgeries for POP were performed with mesh. Low-, intermediate-, and high-volume surgeons performed 881 (53%), 408 (25%), and 368 (22%) of the cases with mesh, respectively. The cumulative reoperation rates for low-, intermediate-, and high-volume providers were 6%, 2%, and 3%, respectively. The difference in reoperation rates between low and intermediate and low- and high-volume surgeons was statistically significant (P = 0.007 and 0.003, respectively). There was no significant difference in reoperation rates between gynecologists and urologists when vaginal mesh was implanted for POP surgery. Low-volume surgeons performed most of the vaginal prolapse repairs with mesh and had significantly higher reoperation rates. Surgeon experience must be a consideration when reporting mesh-related complications of POP surgery.

Cosmetic surgery on children - professional and legal obligations in Australia.

PubMed

Kitipornchai, Leon; Then, Shih-Ning

2011-07-01

Public awareness and concern about cosmetic surgery on children is increasing. Nationally and internationally questions have been raised by the media and government bodies about the appropriateness of children undergoing cosmetic surgery. Considering the rates of cosmetic surgery in comparable Western societies, it seems likely that the number of physicians in Australia who will deal with a request for cosmetic surgery for a child will continue to increase. This is a sensitive issue and it is essential that physicians understand the professional and legal obligations that arise when cosmetic surgery is proposed for a child. This article reviews the current professional and legal obligations that physicians have to competent and incompetent children for whom cosmetic surgery has been requested. A case study is used to highlight the factors that Australian primary care physicians must consider before referring and conducting cosmetic surgery on children.

Robot-assisted laparoscopic prostatectomy and previous surgical history: a multidisciplinary approach.

PubMed

Bernstein, Adrien N; Lavery, Hugh J; Hobbs, Adele R; Chin, Edward; Samadi, David B

2013-06-01

Previous abdominal or prostate surgery can be a significant barrier to subsequent minimally invasive procedures, including radical prostatectomy (RP). This is relevant to a quarter of prostatectomy patients who have had previous surgery. The technological advances of robot-assisted laparoscopic RP (RALP) can mitigate some of these challenges. To that end, our objective was to elucidate the effect of previous surgery on RALP, and to describe a multidisciplinary approach to the previously entered abdomen. One-thousand four-hundred and fourteen RALP patients were identified from a single-surgeon database. Potentially difficult cases were discussed preoperatively and treated in a multidisciplinary fashion with a general surgeon. Operative, pathological, and functional outcomes were analyzed after stratification by previous surgical history. Four-hundred and twenty (30 %) patients underwent previous surgery at least once. Perioperative outcomes were similar among most groups. Previous major abdominal surgery was associated with increased operative time (147 vs. 119 min, p < 0.001), as was the presence of adhesions (120 vs. 154 min, p < 0.001). Incidence of complications was comparable, irrespective of surgical history. Major complications included two enterotomies diagnosed intraoperatively and one patient requiring reoperation. All cases were performed robotically, without conversion to open-RP. There was no difference in biochemical disease-free survival among surgical groups and continence and potency were equivalent between groups. In conclusion, previous abdominal surgery did not affect the safety or feasibility of RALP, with all patients experiencing comparable perioperative, functional, and oncologic outcomes.

Comparison of long-term prognosis of laparoscopic and open adrenalectomy for local adrenal neuroblastoma in children.

PubMed

Yao, Wei; Dong, Kuiran; Li, Kai; Zheng, Shan; Xiao, Xianmin

2018-06-07

To investigate and compare long-term outcomes in children undergoing laparoscopic or open adrenalectomy for local adrenal neuroblastoma. A retrospective review was conducted of 37 children with local adrenal neuroblastoma treated between January 2005 and December 2013 in our hospital. These patients met inclusion criteria for having adrenal neuroblastoma and undergoing operative resection. All patients were successfully followed up until December 2017. The local adrenal neuroblastoma cases included 25 males and 12 females with an average age of 37.24 ± 37.55 months (range from 5 days to 158 months). Left adrenal lesions were present in 13 cases, the right in 24 cases. According to the INSS staging system, 27 patients were classified as stage I and 10 as stage II. Open adrenalectomy was performed in 24 patients. Laparoscopic adrenalectomy was performed in the other 13 patients, 2 of whom were converted to open surgery because of adhesions to renal vessels and diaphragmatic rupture. Significant differences were observed between the laparoscopic surgery and open surgery groups regarding tumor size (P = 0.005). There were two recurrence cases in open surgery, but there was no recurrence in laparoscopic surgery. The average follow-up time was 86.78 ± 24.52 months. The overall 5-year survival rate of open and laparoscopic surgery were 86.2 and 100% (P = 0.316). Laparoscopic adrenalectomy for neuroblastoma is feasible and can be performed with equivalent recurrence and mortality rates with open resection. For small tumor size and absence of vascular encasement, the adrenal neuroblastoma may be preferred laparoscopic surgery.

Maylard incision in gynecologic surgery: 4-year experience in Thammasat University Hospital.

PubMed

Manusook, Sakol; Suwannarurk, Komsun; Pongrojpaw, Densak; Bhamarapravatana, Kornkarn

2014-08-01

To present the results of Maylard incisionfor gynecologic surgery in Thammasat University Hospital during the past four years. A retrospective study of gynecologic surgery performed via the Maylard muscle cutting incision compare to Pfannenstiel muscle splitting and midline incision. Data came from subjects who underwent gynecologic surgey at Thammasat University Hospital, Pathumthani, Thailand friom January 2010 to December 2013. In the period of 4 years, there were 283 cases of elective surgery that performed via Maylard, Pfannenstiel and midline incision by the single experience gynecologic surgeon team. One hundred and six cases were performed via Maylard incision technique. The remaining 59 and 118 cases were performed via Pfannenstiel and midline incision technique, respectively. Two-thirds and one-thirds of cases underwent hysterectomy and conservative surgery, respectively. Benign conditions were the major indicationfor surgery at the percentage of 83.4. Operative results were not significantly different from well-known midline and Pfannenstiel incision in terms of blood loss, time to first meal and postoperative pain. Operative time in Maylard incision was longer than in Pfannenstiel incision. Length of stay in Maylard incision was longer than Pfannenstiel but shorter than midline incision. Overall complications (eoperation, bowel injuries, urinary bladder injuries and blood transfusion rate) were not significantly different. Maylard incision provides similar operative results with midline and Pfannenstiel technique. Even though it takes more time for abdominal entry but it gives more operative exposure than Pfannenstiel incision. In the woman with previous low transverse scar and gynaecologic surgery is needed, Maylard incision could be an optional technique that provides cosmetic and successfud results. Hand on training for Maylard incision from their mentors should be encouraged to more practice.

Audit of Cardiac Surgery Outcomes for Low Birth Weight and Premature Infants.

PubMed

Alarcon Manchego, Peter; Cheung, Michael; Zannino, Diana; Nunn, Russell; D'Udekem, Yves; Brizard, Christian

2018-01-01

The burden of disease associated with cardiac surgery in preterm and low birth weight infants is increasing. This retrospective study aimed to compare the mortality and morbidity of cardiac surgery in low birth weight and preterm infants with that of a case-matched normal population. This was a single-center audit of cardiac surgery interventions at a tertiary pediatric center in Melbourne, Australia. Subjects underwent intervention in the first 3 months of life and were preterm (<37 weeks' gestation) or <2500 g at birth. Subjects were case-matched with 2 controls of term gestation and appropriate birth weight with the same primary diagnosis and intervention. Principal outcomes were mortality and complications in the 6 months following intervention. A total of 513 participants were included for analysis in the 13-year study period. There was an increased risk of mortality (odds ratio 6.26; 95% confidence interval (3.19, 12.3)) and rate of complications (odds ratio 2.29; 95% confidence interval (1.38, 3.78)) in low birth weight and premature infants compared with the control population. Patients who did not survive were more likely to have required extracorporeal membrane oxygenation (relative risk [RR] 6.6, P < 0.001), developed postoperative sepsis (RR 2.6, P = 0.012), and undergone unplanned reintervention (RR 2.3, P < 0.001) compared with survivors. Preterm and low birth weight patients had twice the RR of developing complications and 6 times the risk of mortality in the 6 months following cardiac intervention compared with a matched population. Observed trends suggest delaying surgery in clinically stable infants beyond 35 weeks corrected gestational age and 2500-g weight may result in improved survival. Copyright © 2018 Elsevier Inc. All rights reserved.

Femtosecond laser-assisted cataract surgeries reported to the European Registry of Quality Outcomes for Cataract and Refractive Surgery: Baseline characteristics, surgical procedure, and outcomes.

PubMed

Lundström, Mats; Dickman, Mor; Henry, Ype; Manning, Sonia; Rosen, Paul; Tassignon, Marie-José; Young, David; Stenevi, Ulf

2017-12-01

To describe a large cohort of femtosecond laser-assisted cataract surgeries in terms of baseline characteristics and the related outcomes. Eighteen cataract surgery clinics in 9 European countries and Australia. Prospective multicenter case series. Data on consecutive eyes having femtosecond laser-assisted cataract surgery in the participating clinics were entered in the European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO). A trained registry manager in each clinic was responsible for valid reporting to the EUREQUO. Demographics, preoperative corrected distance visual acuity (CDVA), risk factors, type of surgery, type of intraocular lens, visual outcomes, refractive outcomes, and complications were reported. Complete data were available for 3379 cases. The mean age was 64.4 years ± 10.9 (SD) and 57.8% (95% confidence interval [CI], 56.1-59.5) of the patients were women. A surgical complication was reported in 2.9% of all cases (95% CI, 2.4-3.5). The mean postoperative CDVA was 0.04 ± 0.15. logarithm of the minimum angle of resolution. A biometry prediction error (spherical equivalent) was within ±0.5 diopter in 71.8% (95% CI, 70.3-73.3) of all surgeries. Postoperative complications were reported in 3.3% (95% CI, 2.7-4.0). Patients with good preoperative CDVA had the best visual and refractive outcomes; patients with poor preoperative visual acuity had poorer outcomes. The visual and refractive outcomes of femtosecond laser-assisted cataract surgery were favorable compared with manual phacoemulsification. The outcomes were highly influenced by the preoperative visual acuity, but all preoperative CDVA groups had acceptable outcomes. Copyright © 2017 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.

Simultaneous development of laparoscopy and robotics provides acceptable perioperative outcomes and shows robotics to have a faster learning curve and to be overall faster in rectal cancer surgery: analysis of novice MIS surgeon learning curves.

PubMed

Melich, George; Hong, Young Ki; Kim, Jieun; Hur, Hyuk; Baik, Seung Hyuk; Kim, Nam Kyu; Sender Liberman, A; Min, Byung Soh

2015-03-01

Laparoscopy offers some evidence of benefit compared to open rectal surgery. Robotic rectal surgery is evolving into an accepted approach. The objective was to analyze and compare laparoscopic and robotic rectal surgery learning curves with respect to operative times and perioperative outcomes for a novice minimally invasive colorectal surgeon. One hundred and six laparoscopic and 92 robotic LAR rectal surgery cases were analyzed. All surgeries were performed by a surgeon who was primarily trained in open rectal surgery. Patient characteristics and perioperative outcomes were analyzed. Operative time and CUSUM plots were used for evaluating the learning curve for laparoscopic versus robotic LAR. Laparoscopic versus robotic LAR outcomes feature initial group operative times of 308 (291-325) min versus 397 (373-420) min and last group times of 220 (212-229) min versus 204 (196-211) min-reversed in favor of robotics; major complications of 4.7 versus 6.5 % (NS), resection margin involvement of 2.8 versus 4.4 % (NS), conversion rate of 3.8 versus 1.1 (NS), lymph node harvest of 16.3 versus 17.2 (NS), and estimated blood loss of 231 versus 201 cc (NS). Due to faster learning curves for extracorporeal phase and total mesorectal excision phase, the robotic surgery was observed to be faster than laparoscopic surgery after the initial 41 cases. CUSUM plots demonstrate acceptable perioperative surgical outcomes from the beginning of the study. Initial robotic operative times improved with practice rapidly and eventually became faster than those for laparoscopy. Developing both laparoscopic and robotic skills simultaneously can provide acceptable perioperative outcomes in rectal surgery. It might be suggested that in the current milieu of clashing interests between evolving technology and economic constrains, there might be advantages in embracing both approaches.

Unilateral vocal fold immobility: a tertiary hospital's experience over 5 years.

PubMed

Prasad, Vyas M N; Fakhoury, Raja; Helou, Diane; Lawson, Georges; Remacle, Marc

2017-07-01

The objective of the study was to determine the etiology and subsequent management of patients with unilateral vocal fold immobility (UVFI) and compare our results with other such studies. This was a retrospective case series of all patients that were treated for UVFI at one single tertiary referral centre between 2010 and 2014. The medical records of 161 patients over a 5-year period diagnosed with UVFI were analyzed. We looked at the patient demographics, side of immobility, etiology, management and voice assessment. A total of 21 patients were excluded due to varying reasons including second presentation and incomplete data. Our results demonstrated 37.1% of cases to be due to non-thyroid surgery (mainly vascular or anterior cervical spine surgery) compared to thyroid or parathyroid (18.6%). Carotid endarterectomy was the commonest cause followed by cervical spine discectomy or fusion. Other iatrogenic causes included thoracic surgery either involving the lung or not. Our results are very much in keeping with those seen by our colleagues in North America. A better appreciation of the causes of UVFI especially in cases not performed by otolaryngologists and head and neck surgeons should be highlighted and the necessary steps should be taken to prevent this iatrogenic complication.

Reliability of skin biopsies in determining accurate tumor margins: a retrospective study after Mohs micrographic surgery.

PubMed

Koslosky, Cynthia Lynn; El Tal, Abdel Kader; Workman, Benjamin; Tamim, Hani; Durance, Michelle Christine; Mehregan, David Ali

2014-09-01

Skin biopsy reports of basal cell carcinoma and squamous cell carcinoma are often accompanied by comments on the margins. A physician's management can be influenced by such reports, particularly when the margins are reported as clear and no further interventions are pursued. To retrospectively review pathology margins on Mohs micrographic surgery (MMS) cases performed at a University Center and to compare biopsy margins with the Mohs margins found on the first stage. Data collection of 1,000 cases of Mohs surgery was obtained regarding margins on skin biopsy and compared with margins on the first stage of MMS. Overall, of the biopsies that showed only deep margin involvement, a lateral margin was seen on 32% of the first stages of MMS. Conversely, of the biopsies that showed only lateral margin involvement, a deep margin was seen on 14% of the first stages of MMS. Of the biopsies that showed clear margins, a margin was seen in 30% of the cases on the first stage of MMS. Skin biopsies processed through the "bread-loafing" technique are not reliable in detecting accurate margins, and therefore, a biopsy report should not include margin involvement within it.

[Cochlear implantation in patients with Waardenburg syndrome type II].

PubMed

Wan, Liangcai; Guo, Menghe; Chen, Shuaijun; Liu, Shuangriu; Chen, Hao; Gong, Jian

2010-05-01

To describe the multi-channel cochlear implantation in patients with Waardenburg syndrome including surgeries, pre and postoperative hearing assessments as well as outcomes of speech recognition. Multi-channel cochlear implantation surgeries have been performed in 12 cases with Waardenburg syndrome type II in our department from 2000 to 2008. All the patients received multi-channel cochlear implantation through transmastoid facial recess approach. The postoperative outcomes of 12 cases were compared with 12 cases with no inner ear malformation as a control group. The electrodes were totally inserted into the cochlear successfully, there was no facial paralysis and cerebrospinal fluid leakage occurred after operation. The hearing threshold in this series were similar to that of the normal cochlear implantation. After more than half a year of speech rehabilitation, the abilities of speech discrimination and spoken language of all the patients were improved compared with that of preoperation. Multi-channel cochlear implantation could be performed in the cases with Waardenburg syndrome, preoperative hearing and images assessments should be done.

Efficacy and safety of bariatric surgery for craniopharyngioma-related hypothalamic obesity: a matched case-control study with 2 years of follow-up.

PubMed

Wijnen, M; Olsson, D S; van den Heuvel-Eibrink, M M; Wallenius, V; Janssen, J A M J L; Delhanty, P J D; van der Lely, A J; Johannsson, G; Neggers, S J C M M

2017-02-01

Hypothalamic obesity is a devastating consequence of craniopharyngioma. Bariatric surgery could be a promising therapeutic option. However, its efficacy and safety in patients with craniopharyngioma-related hypothalamic obesity remain largely unknown. We investigated the efficacy of bariatric surgery for inducing weight loss in patients with craniopharyngioma-related hypothalamic obesity. In addition, we studied the safety of bariatric surgery regarding its effects on hormone replacement therapy for pituitary insufficiency. In this retrospective matched case-control study, we compared weight loss after bariatric surgery (that is, Roux-en-Y gastric bypass and sleeve gastrectomy) between eight patients with craniopharyngioma-related hypothalamic obesity and 75 controls with 'common' obesity during 2 years of follow-up. We validated our results at 1 year of follow-up in a meta-analysis. In addition, we studied alterations in hormone replacement therapy after bariatric surgery in patients with craniopharyngioma. Mean weight loss after bariatric surgery was 19% vs 25% (difference -6%, 95% confidence of interval (CI) -14.1 to 4.6; P=0.091) at 2 years of follow-up in patients with craniopharyngioma-related hypothalamic obesity compared with control subjects with 'common' obesity. Mean weight loss was 25% vs 29% (difference -4%, 95% CI -11.6 to 8.1; P=0.419) after Roux-en-Y gastric bypass and 10% vs 20% (difference -10%, 95% CI -14.1 to -6.2; P=0.003) after sleeve gastrectomy at 2 years of follow-up in patients with craniopharyngioma-related hypothalamic obesity vs control subjects with 'common' obesity. Our meta-analysis demonstrated significant weight loss 1 year after Roux-en-Y gastric bypass, but not after sleeve gastrectomy. Seven patients with craniopharyngioma suffered from pituitary insufficiency; three of them required minor adjustments in hormone replacement therapy after bariatric surgery. Weight loss after Roux-en-Y gastric bypass, but not sleeve gastrectomy, was comparable between patients with craniopharyngioma-related hypothalamic obesity and control subjects with 'common' obesity at 2 years of follow-up. Bariatric surgery seems safe regarding its effects on hormone replacement therapy.

Endovascular repair of descending thoracic aortic aneurysm: an evidence-based analysis.

PubMed

2005-01-01

To conduct an assessment on endovascular repair of descending thoracic aortic aneurysm (TAA). Aneurysm is the most common condition of the thoracic aorta requiring surgery. Aortic aneurysm is defined as a localized dilatation of the aorta. Most aneurysms of the thoracic aorta are asymptomatic and incidentally discovered. However, TAA tends to enlarge progressively and compress surrounding structures causing symptoms such as chest or back pain, dysphagia (difficulty swallowing), dyspnea (shortness of breath), cough, stridor (a harsh, high-pitched breath sound), and hoarseness. Significant aortic regurgitation causes symptoms of congestive heart failure. Embolization of the thrombus to the distal arterial circulation may occur and cause related symptoms. The aneurysm may eventually rupture and create a life-threatening condition. The overall incidence rate of TAA is about 10 per 100,000 person-years. The descending aorta is involved in about 30% to 40% of these cases. The prognosis of large untreated TAAs is poor, with a 3-year survival rate as low as 25%. Intervention is strongly recommended for any symptomatic TAA or any TAA that exceeds twice the diameter of a normal aorta or is 6 cm or larger. Open surgical treatment of TAA involves left thoracotomy and aortic graft replacement. Surgical treatment has been found to improve survival when compared with medical therapy. However, despite dramatic advances in surgical techniques for performing such complex operations, operative mortality from centres of excellence are between 8% and 20% for elective cases, and up to 50% in patients requiring emergency operations. In addition, survivors of open surgical repair of TAAs may suffer from severe complications. Postoperative or postprocedural complications of descending TAA repair include paraplegia, myocardial infarction, stroke, respiratory failure, renal failure, and intestinal ischemia. Endovascular aortic aneurysm repair (EVAR) using a stent graft, a procedure called endovascular stent-graft (ESG) placement, is a new alternative to the traditional surgical approach. It is less invasive, and initial results from several studies suggest that it may reduce mortality and morbidity associated with the repair of descending TAAs. The goal in endovascular repair is to exclude the aneurysm from the systemic circulation and prevent it from rupturing, which is life-threatening. The endovascular placement of a stent graft eliminates the systemic pressure acting on the weakened wall of the aneurysm that may lead to the rupture. However, ESG placement has some specific complications, including endovascular leak (endoleak), graft migration, stent fracture, and mechanical damage to the access artery and aortic wall. The Talent stent graft (manufactured by Medtronic Inc., Minneapolis, MN) is licensed in Canada for the treatment of patients with TAA (Class 4; licence 36552). The design of this device has evolved since its clinical introduction. The current version has a more flexible delivery catheter than did the original system. The prosthesis is composed of nitinol stents between thin layers of polyester graft material. Each stent is secured with oversewn sutures to prevent migration. Objectives To compare the effectiveness and cost-effectiveness of ESG placement in the treatment of TAAs with a conventional surgical approachTo summarize the safety profile and effectiveness of ESG placement in the treatment of descending TAAsMeasures of Effectiveness Primary Outcome Mortality rates (30-day and longer term)Secondary Outcomes Technical success rate of introducing a stent graft and exclusion of the aneurysm sac from systemic circulationRate of reintervention (through surgical or endovascular approach)Measures of Safety Complications were categorized into 2 classes: Those specific to the ESG procedure, including rates of aneurysm rupture, endoleak, graft migration, stent fracture, and kinking; andThose due to the intervention, either surgical or endovascular. These include paraplegia, stroke, cardiovascular events, respiratory failure, real insufficiency, and intestinal ischemia.Inclusion Criteria Studies comparing the clinical outcomes of ESG treatment with surgical approachesStudies reporting on the safety and effectiveness of the ESG procedure for the treatment of descending TAAsExclusion Criteria Studies investigating the clinical effectiveness of ESG placement for other conditions such as aortic dissection, aortic ulcer, and traumatic injuries of the thoracic aortaStudies investigating the aneurysms of the ascending and the arch of the aortaStudies using custom-made graftsLiterature Search The Medical Advisory Secretariat searched The International Network of Agencies for Health Technology Assessment and the Cochrane Database of Systematic Reviews for health technology assessments. It also searched MEDLINE, EMBASE, Medline In-Process & Other Non-Indexed Citations, and Cochrane CENTRAL from January 1, 2000 to July 11, 2005 for studies on ESG procedures. The search was limited to English-language articles and human studies. One health technology assessment from the United Kingdom was identified. This systematic review included all pathologies of the thoracic aorta; therefore, it did not match the inclusion criteria. The search yielded 435 citations; of these, 9 studies met inclusion criteria. Mortality The results of a comparative study found that in-hospital mortality was not significantly different between ESG placement and surgery patients (2 [4.8%] for ESG vs. 6 [11.3%] for surgery).Pooled data from case series with a mean follow-up ranging from 12 to 38 months showed a 30-day mortality and late mortality rate of 3.9% and 5.5%, respectively. These rates are lower than are those reported in the literature for surgical repair of TAA.Case series showed that the most common cause of early death in patients undergoing endovascular repair is aortic rupture, and the most common causes of late death are cardiac events and aortoesophageal or aortobronchial fistula.Technical Success Rate Technical success rates reported by case series are 55% to 100% (100% and 94.4% in 2 studies with all elective cases, 89% in a study with 5% emergent cases, and 55% in a study with 42% emergent cases).Surgical Reintervention In the comparative study, 3 (7.1%) patients in the ESG group and 14 (26.5%) patients in the surgery group required surgical reintervention. In the ESG group, the reasons for surgical intervention were postoperative bleeding at the access site, paraplegia, and type 1 endoleak. In the surgical group, the reasons for surgery were duodenal perforation, persistent thoracic duct leakage, false aneurysm, and 11 cases of postoperative bleeding.Pooled data from case series show that 9 (2.6%) patients required surgical intervention. The reasons for surgical intervention were endoleak (3 cases), aneurysm enlargement and suspected infection (1 case), aortic dissection (1 case), pseudoaneurysm of common femoral artery (1 case), evacuation of hematoma (1 case), graft migration (1 case), and injury to the access site (1 case).Endovascular Revision In the comparative study, 3 (7.1%) patients required endovascular revision due to persistent endoleak.Pooled data from case series show that 19 (5.3%) patients required endovascular revision due to persistent endoleak.Graft Migration Two case series reported graft migration. In one study, 3 proximal and 4 component migrations were noted at 2-year follow-up (total of 5%). Another study reported 1 (3.7%) case of graft migration. Overall, the incidence of graft migration was 2.6%.Aortic Rupture In the comparative study, aortic rupture due to bare stent occurred in 1 case (2%). The pooled incidence of aortic rupture or dissection reported by case series was 1.4%.Postprocedural Complications In the comparative study, there were no statistically significant differences between the ESG and surgery groups in postprocedural complications, except for pneumonia. The rate of pneumonia was 9% for those who received an ESG and 28% for those who had surgery (P = .02). There were no cases of paraplegia in either group. The rate of other complications for ESG and surgery including stroke, cardiac, respiratory, and intestinal ischemia were all 5.1% for ESG placement and 10% for surgery. The rate for mild renal failure was 16% in the ESG group and 30% in the surgery group. The rate for severe renal failure was 11% for ESG placement and 10% for surgery.POOLED DATA FROM CASE SERIES SHOW THE FOLLOWING POSTPROCEDURAL COMPLICATION RATES IN THE ESG PLACEMENT GROUP: paraplegia (2.2%), stroke (3.9%), cardiac (2.9%), respiratory (8.7%), renal failure (2.8%), and intestinal ischemia (1%).Time-Related Outcomes The results of the comparative study show statistically significant differences between the ESG and surgery group for mean operative time (ESG, 2.7 hours; surgery, 5 hours), mean duration of intensive care unit stay (ESG, 11 days; surgery, 14 days), and mean length of hospital stay (ESG, 10 days; surgery, 30 days).The mean duration of intensive care unit stay and hospital stay derived from case series is 1.6 and 7.8 days, respectively. ONTARIO-BASED ECONOMIC ANALYSIS: In Ontario, the annual treatment figures for fiscal year 2004 include 17 cases of descending TAA repair procedures (source: Provincial Health Planning Database). Fourteen of these have been identified as "not ruptured" with a mean hospital length of stay of 9.23 days, and 3 cases have been identified as "ruptured," with a mean hospital length of stay of 28 days. However, because one Canadian Classification of Health Interventions code was used for both procedures, it is not possible to determine how many were repaired with an EVAR procedure or with an open surgical procedure. (ABSTRACT TRUNCATED)

Contribution of MRI to clinically equivocal penile fracture cases.

PubMed

Türkay, Rüştü; Yenice, Mustafa Gürkan; Aksoy, Sema; Şeker, Gökhan; Şahin, Selçuk; İnci, Ercan; Tuğcu, Volkan; Taşcı, Ali İhsan

2016-11-01

Penile fracture is a surgical emergency defined as rupture of the tunica albuginea. Although most cases can be diagnosed with clinical evaluation, it has been stated in the literature that diagnosis in as many as 15% of cases can be challenging. In uncertain cases, imaging can help determine diagnosis. Present study included 20 cases where diagnosis could not be made with certainty and magnetic resonance imaging (MRI) was performed. MR images were examined for tunical rupture and accompanying pathologies. When rupture was observed, localization and length of rupture were noted. All patients underwent degloving surgery. All imaging findings were compared to surgical findings. MRI revealed 19 tunical ruptures. In 1 case, hematoma was seen with no sign of penile fracture. No urethral injuries were found. All MRI findings were confirmed during surgery. Performing MRI in clinically equivocal cases can provide crucial data to make precise diagnosis and improve patient management.

The Relationship Between Hospital Volume and Outcome in Bariatric Surgery at Academic Medical Centers

PubMed Central

Nguyen, Ninh T.; Paya, Mahbod; Stevens, C Melinda; Mavandadi, Shahrzad; Zainabadi, Kambiz; Wilson, Samuel E.

2004-01-01

Objective: To examine the effect of hospital volume of bariatric surgery on morbidity, mortality, and costs at academic centers. Summary Background Data: The American Society for Bariatric Surgery recently proposed categorization of certain bariatric surgery centers as “Centers of Excellence.” Some of the proposed inclusion criteria were hospital volume and operative outcomes. The volume–outcome relationship has been well established in several complex abdominal operations; however, few studies have examined this relationship in patients undergoing bariatric surgery. Methods: Using the International Classification of Diseases, 9th edition, diagnosis and procedure codes, we obtained data from the University HealthSystem Consortium Clinical Data Base for all patients who underwent Roux-en-Y gastric bypass for the treatment of morbid obesity between 1999 and 2002 (n = 24,166). Outcomes of bariatric surgery, including length of hospital stay, 30-day readmission, morbidity, observed and expected (risk-adjusted) mortality, and costs were compared between high-volume (>100 cases/year), medium-volume (50–100 cases/year), and low-volume hospitals (<50 cases/year). Results: There were 22 high-volume (n = 13,810), 27 medium-volume (n = 7634), and 44 low-volume (n = 2722) hospitals included in our study. Compared with low-volume hospitals, patients who underwent gastric bypass at high-volume hospitals had a shorter length of hospital stay (3.8 versus 5.1 days, P < 0.01), lower overall complications (10.2% versus 14.5%, P < 0.01), lower complications of medical care (7.8% versus 10.8%, P < 0.01), and lower costs ($10,292 versus $13,908, P < 0.01). The expected mortality rate was similar between high- and low-volume hospitals (0.6% versus 0.6%), demonstrating similarities in characteristics and severity of illness between groups. The observed mortality, however, was significantly lower at high-volume hospitals (0.3% versus 1.2%, P < 0.01). In a subset of patients older than 55 years, the observed mortality was 0.9% at high-volume centers compared with 3.1% at low-volume centers (P < 0.01). Conclusions: Bariatric surgery performed at hospitals with more than 100 cases annually is associated with a shorter length of stay, lower morbidity and mortality, and decreased costs. This volume–outcome relationship is even more pronounced for a subset of patients older than 55 years, for whom in-hospital mortality was 3-fold higher at low-volume compared with high-volume hospitals. High-volume hospitals also have a lower rate of overall postoperative and medical care complications, which may be related in part to formalization of the structures and processes of care. PMID:15383786

[Deep infiltrative endometriosis without digestive involvement, what is the impact of surgery on in vitro fertilization outcomes? A retrospective study].

PubMed

Mounsambote, L; Cohen, J; Bendifallah, S; d'Argent, E Mathieu; Selleret, L; Chabbert-Buffet, N; Ballester, M; Antoine, J M; Daraï, E

2017-01-01

To evaluate the impact of complete removal of endometriosis in case of deep infiltrative endometriosis without digestive involvement, on in vitro fertilization outcomes. Retrospective monocentric study. We included infertile women with deep infiltrative endometriosis without colorectal involvement that underwent IVF. Women were divided in two groups, following their history: "surgery" when they underwent complete endometriosis resection before IVF and "without surgery" when they underwent IVF without endometriosis removal. We analysed IVF outcomes considering pregnancy rates per cycle and cumulative pregnancy rates per patient. We included 72 patients: 35 in the "surgery" group and 37 in the "without surgery" group. Women in the two groups were comparable in terms of baseline characteristics (age, body mass index, anti-Müllerian hormone, antral follicular count), endometriosis localizations and in vitro fertilization parameters. Cumulative pregnancy rates per patient were similar in both groups (40 % in the "surgery" group and 41 % in the "without surgery" group; P=1). Clinical pregnancy rate per cycle were also comparable groups (24 % in the "surgery" group and 28 % in the "without surgery" group; P=0.67). Surgery performed was comparable in women that became pregnant and in women that did not. Age was lower in women that became pregnant (P=0.01) and there were more pregnancy obtained in women under 35 years. In women with deep infiltrative endometriosis without digestive involvement, in vitro fertilization outcomes were not impacted by surgery. Therapeutic choice between IVF or surgery as first-line treatment remains thus questionable and shall be guided by other influencing factors, such as pain symptomatology, age, tubal permeability, ovarian reserve, partner's sperm characteristics and woman's choice. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

Predictors of unanticipated admission following ambulatory surgery: a retrospective case-control study.

PubMed

Whippey, Amanda; Kostandoff, Greg; Paul, James; Ma, Jinhui; Thabane, Lehana; Ma, Heung Kan

2013-07-01

The primary objectives of this historical case-control study were to evaluate the incidence of and reasons and risk factors for adult unanticipated admissions in three tertiary care Canadian hospitals following ambulatory surgery. A random sample of 200 patients requiring admission (cases) and 200 patients not requiring admission (controls) was taken from 20,657 ambulatory procedures was identified and compared. The following variables were included: demographics, reason for admission, type of anesthesia, surgical procedure, length of procedure, American Society of Anesthesiologists' (ASA) classification, surgical completion time, pre-anesthesia clinic, medical history, medications (classes), and perioperative complications. Multiple logistic regression analysis was used to assess factors associated with unanticipated admissions. The incidence of unanticipated admission following ambulatory surgery was 2.67%. The most common reasons for admission were surgical (40%), anesthetic (20%), and medical (19%). The following factors were found to be associated with an increased risk of unanticipated admission: length of surgery of one to three hours (odds ratio [OR] 16.70; 95% confidence interval [CI] 4.10 to 67.99) and length of surgery more than three hours (OR 4.26; 95% CI 2.40 to 7.55); ASA class III (OR 4.60; 95% CI 1.81 to 11.68); ASA class IV (OR 6.51; 95% CI 1.66 to 25.59); advanced age (> 80 yr) (OR 5.41; 95% CI 1.54 to 19.01); and body mass index (BMI) of 30-35 (OR 2.81; 95% CI 1.31 to 6.04). Current smoking status was found to be associated with a decreased likelihood of unanticipated admission (OR 0.44; 95% CI 0.23 to 0.83), as was monitored anesthesia care when compared with general anesthesia (OR 0.17; 95% CI 0.04 to 0.68) and plastic (OR 0.18; 95% CI 0.07 to 0.50), orthopedic (OR 0.16; 95% CI 0.08 to 0.33), and dental/ear-nose-throat surgery (OR 0.32; 95% CI 0.13 to 0.83) when compared with general surgery. Other comorbid conditions did not impact unanticipated admission. Unanticipated admission after ambulatory surgery occurs mainly due to surgical, anesthetic, and medical complications. Length of surgery more than one hour, high ASA class, advanced age, and increased BMI were all predictors. No specific comorbid illness was associated with an increased likelihood of unanticipated admission. These findings support continued use of the ASA classification as a marker of patient perioperative risk rather than attributing risk to a specific disease process.

Impact of Targeted Preoperative Optimization on Clinical Outcome in Emergency Abdominal Surgeries: A Prospective Randomized Trial.

PubMed

Sethi, Ashish; Debbarma, Miltan; Narang, Neeraj; Saxena, Anudeep; Mahobia, Mamta; Tomar, Gaurav Singh

2018-01-01

Perforation peritonitis continues to be one of the most common surgical emergencies that need a surgical intervention most of the times. Anesthesiologists are invariably involved in managing such cases efficiently in perioperative period. The assessment and evaluation of Acute Physiology and Chronic Health Evaluation II (APACHE II) score at presentation and 24 h after goal-directed optimization, administration of empirical broad-spectrum antibiotics, and definitive source control postoperatively. Outcome assessment in terms of duration of hospital stay and mortality in with or without optimization was also measured. It is a prospective, randomized, double-blind controlled study in hospital setting. One hundred and one patients aged ≥18 years, of the American Society of Anesthesiologists physical Status I and II (E) with clinical diagnosis of perforation peritonitis posted for surgery were enrolled. Enrolled patients were randomly divided into two groups. Group A is optimized by goal-directed optimization protocol in the preoperative holding room by anesthesiology residents whereas in Group S, managed by surgery residents in the surgical wards without any fixed algorithm. The assessment of APACHE II score was done as a first step on admission and 24 h postoperatively. Duration of hospital stay and mortality in both the groups were also measured and compared. Categorical data are presented as frequency counts (percent) and compared using the Chi-square or Fisher's exact test. The statistical significance for categorical variables was determined by Chi-square analysis. For continuous variables, a two-sample t -test was applied. The mean APACHE II score on admission in case and control groups was comparable. Significant lowering of serial scores in case group was observed as compared to control group ( P = 0.02). There was a significant lowering of mean duration of hospital stay seen in case group (9.8 ± 1.7 days) as compared to control group ( P = 0.007). Furthermore, a significant decline in death rate was noted in case group as compared to control group ( P = 0.03). Goal-directed optimized patients with perforation peritonitis were discharged early as compared to control group with significantly lesser mortality as compared with randomly optimized patients in the perioperative period.

Solo surgery--early results of robot-assisted three-dimensional laparoscopic hysterectomy.

PubMed

Tuschy, Benjamin; Berlit, Sebastian; Brade, Joachim; Sütterlin, Marc; Hornemann, Amadeus

2014-08-01

Report of our initial experience in laparoscopic hysterectomy by a solo surgeon using a robotic camera system with three-dimensional visualisation. This novel device (Einstein Vision®, B. Braun, Aesculap AG, Tuttlingen, Germany) (EV) was used for laparoscopic supracervical hysterectomy (LASH) performed by one surgeon. Demographic data, clinical and surgical parameters were evaluated. Our first 22 cases, performed between June and November 2012, were compared with a cohort of 22 age-matched controls who underwent two-dimensional LASH performed by the same surgeon with a second surgeon assisting. Compared to standard two-dimensional laparoscopic hysterectomy, there were no significant differences regarding duration of surgery, hospital stay, blood loss or incidence of complications. The number of trocars used was significantly higher in the control group (p <.0001). All hysterectomies in the treatment group were performed without assistance of a second physician. Robot-assisted solo surgery laparoscopic hysterectomy is a feasible and safe procedure. Duration of surgery, hospital stay, blood loss, and complication rates are comparable to a conventional laparoscopic hysterectomy.

Is moderate hypothermic circulatory arrest with selective antegrade cerebral perfusion superior to deep hypothermic circulatory arrest in elective aortic arch surgery?

PubMed

Poon, Shi Sum; Estrera, Anthony; Oo, Aung; Field, Mark

2016-09-01

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether moderate hypothermia circulatory arrest with selective antegrade cerebral perfusion (SACP) is more beneficial than deep hypothermic circulatory arrest in elective aortic arch surgery. Altogether, 1028 papers were found using the reported search, of which 6 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. There were four retrospective observational studies, one prospective randomized controlled trial and one meta-analysis study. There were no local or neuromuscular complications related to axillary arterial cannulation reported. In the elective setting, four studies showed that the in-hospital mortality for moderate hypothermia is consistently low, ranging from 1.0 to 4.3%. In a large series of hemiarch replacement comparing 682 cases of deep hypothermia with 94 cases of moderate hypothermia with SACP, 20 cases (2.8%) of permanent neurological deficit were reported, compared to 3 cases (3.2%) in moderate hypothermia. Three observational studies and a meta-analysis study did not identify an increased risk of postoperative renal failure and dialysis following either deep or moderate hypothermia although a higher incidence of stroke was reported in the meta-analysis study with deep hypothermia (12.7 vs 7.3%). Longer cardiopulmonary bypass time and circulatory arrest time were reported in four studies for deep hypothermia, suggesting an increased time required for systemic cooling and rewarming in that group. Overall, these findings suggested that in elective aortic arch surgery, moderate hypothermia with selective antegrade cerebral perfusion adapted to the duration of circulatory arrest can be performed safely with acceptable mortality and morbidity outcomes. The risk of spinal cord and visceral organ complications is low with the use of this cerebral adjunct. Current studies did not identify an advantage in terms of postoperative bleeding when compared with deep hypothermia. The moderate hypothermia strategy reduced operative time without increasing the mortality and morbidity of surgery. © The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Operative shoulder instability injury management in Australian Football League players: A case series.

PubMed

Bonacci, Jason; Manson, Brent; Bowe, Steven J; Gill, Stephen; Seward, Hugh; Hoy, Greg; Page, Richard

2017-11-27

The purpose of this study was to review the surgical management procedures of shoulder instability injuries in Australian Football League (AFL) players, and determine outcomes regarding return to sport and injury recurrence. Retrospective cohort study. Elite AFL players with shoulder instability resulting in surgery were assessed in a retrospective cohort design (72 players/77 shoulders). Type of initial injury, surgical management, return to sport and injury recurrence were obtained. The mean follow-up period post-surgery was 2.9 years. Return to sport outcomes were compared between arthroscopic and open surgery using a Kaplan-Meier survival analysis. Logistic regression modelling was used to determine associations between injury recurrence, type of injury, participant age and method of surgery. Shoulder instability injuries occurred most frequently during tackling (40%). Arthroscopic surgery was preferred for primary shoulder instability. Nine (16%) recurrences occurred in those who underwent arthroscopic surgery compared to two (9%) following open surgery. Return to the elite level was slightly but significantly (2 weeks, p=0.049) longer for open compared to arthroscopic surgery. Recurrence was 5 times more likely if the primary injury was a dislocation and more likely in players who were younger at the time of surgery. Tackling was the predominant mechanism for shoulder instability injuries in AFL players and arthroscopic surgery was more commonly performed for primary injuries. Sustaining a dislocation as the primary injury and younger age increased the likelihood of recurrent instability. Careful consideration should be given to the operative management of these individuals. Copyright © 2017. Published by Elsevier Ltd.

The importance of improving the quality of emergency surgery for a regional quality collaborative.

PubMed

Smith, Margaret; Hussain, Adnan; Xiao, Jane; Scheidler, William; Reddy, Haritha; Olugbade, Kola; Cummings, Dustin; Terjimanian, Michael; Krapohl, Greta; Waits, Seth A; Campbell, Darrell; Englesbe, Michael J

2013-04-01

Within a large, statewide collaborative, significant improvement in surgical quality has been appreciated (9.0% reduction in morbidity for elective general and vascular surgery). Our group has not noted such quality improvement in the care of patients who had emergency operations. With this work, we aim to describe the scope of emergency surgical care within the Michigan Surgical Quality Collaborative, variations in outcomes among hospitals, and variations in adherence to evidence-based process measures. Overall, these data will form a basis for a broad-based quality improvement initiative within Michigan. We report morbidity, mortality, and costs of emergency and elective general and vascular surgery cases (N = 190,826) within 34 hospitals participating in the Michigan Surgical Quality Collaborative from 2005 to 2010. Adjusted hospital-specific outcomes were calculated using a stepwise multivariable logistic regression model. Adjustment covariates included patient specific comorbidities and case complexity. Hospitals were also compared on the basis of their adherence to evidence-based process measures [measures at the patient level for each case-Surgical Care Improvement Project (SCIP)-1 and SCIP-2 compliance]. Emergency procedures account for approximately 11% of total cases, yet they represented 47% of mortalities and 28% of surgical complications. The complication-specific cost to payers was $126 million for emergency cases and $329 million for elective cases. Adjusted patient outcomes varied widely within Michigan Surgical Quality Collaborative hospitals; morbidity and mortality rates ranged from 16.3% to 33.9% and 4.0% to 12.4%, respectively. The variation among hospitals was not correlated with volume of emergency cases and case complexity. Hospital performance in emergency surgery was found to not depend on its share of emergent cases but rather was found to directly correlate with its performance in elective surgery. For emergency colectomies, there was a wide variation in compliance with SCIP-1 and SCIP-2 measures and overall compliance (42.0%) was markedly lower than that for elective colon surgery (81.7%). Emergency surgical procedures are an important target for future quality improvement efforts within Michigan. Future work will identify best practices within high-performing hospitals and disseminate these practices within the collaborative.

Abortion rate during the second half of gestation of cows undergoing surgery in lateral recumbency as compared with cows of a control population.

PubMed

Hirsbrunner, G; Knutti, B; Eicher, R

1999-01-01

In a retrospective study, we compared the abortion rates of 59 cows in the second half of gestation, admitted to the Clinic for Food Animals and Horses (1993-1996) with a strictly focal problem (head region, udder and teats, locomotor system) requiring surgery in lateral recumbency, to the abortion rate of a control cow population. Before surgery, a uterus relaxant was given in 42 cases, and 17 cows were untreated as to pregnancy. Cows included in the reproduction health program of the Department of Fertility and Reproduction were used as a control population. Data of 1,736 cows pregnant in the second half of gestation per year were available for the same time period (1993-1996). Abortion rate was 5.08% for the cows undergoing surgery in lateral recumbency as compared with 5.18% for the cows of the control population. There was no significant difference between the two populations (P > 0.05). Thus, the risk for abortion in the cows in question is not elevated as compared with the control population.

Patent Ductus Arteriosus closure in preterms less than 2kg: Surgery versus transcatheter.

PubMed

Pamukcu, Ozge; Tuncay, Aydin; Narin, Nazmi; Baykan, Ali; Korkmaz, Levent; Argun, Mustafa; Ozyurt, Abdullah; Sunkak, Suleyman; Uzum, Kazim

2018-01-01

As new devices come into the market, percutaneous techniques improve and interventionalists become more experienced; percutaneous closure gets more common in preterms. In this study we aimed to compare efficacy and safety of Patent Ductus Arteriosus closure surgically versus transcatheter method in preterms <2kg. Best of our knowledge this study is the first one that compares outcomes of surgery and percutaneous Patent Ductus Arteriosus closure in preterms. Between the dates July 1997 to October 2014 in our center Patent Ductus Arteriosus of 26 patients <2kg were closed percutaneously (Group A) and 31 less than 2kg operated (Group B). Weight of patients in percutaneous Patent Ductus Arteriosus closure group was significantly more than the surgery group. Mean gestational age of the patients in Group A was 30±1.8weeks, in group B was 28.6±3.5weeks. In group A; all cases were closed successfully except 4 cases: device embolization in 2, cardiac tamponade and iatrogenic aortic coarctation were seen. Pneumomediastinum and chylothorax were the major complications of the surgery group. There was no statistically significance between complication and success rates between two groups. Percutaneous Patent Ductus Arteriosus closure is the candidate for taking the place of surgery in preterms. However, it is not applied routinely; can only be done in fully equipped large centers by experienced interventionalists. Copyright © 2017 Elsevier B.V. All rights reserved.

A critical assessment of outcomes in emergency versus nonemergency general surgery using the American College of Surgeons National Surgical Quality Improvement Program database.

PubMed

Becher, Robert D; Hoth, J Jason; Miller, Preston R; Mowery, Nathan T; Chang, Michael C; Meredith, J Wayne

2011-07-01

Emergent operations are thought to carry higher morbidity and mortality than nonemergent cases. However, there is a lack of specific outcomes data for emergent general surgery procedures. The objective of our study was to assess and quantify postoperative morbidity and mortality for emergency versus nonemergency general surgery operations. All general surgery inpatients were identified in the American College of Surgeons National Surgical Quality Improvement Program 2008 database. Preoperative, intraoperative, and postoperative clinical metrics and occurrences were assessed. A total of 25,770 emergent and 98,867 nonemergent cases were identified. Postoperative morbidity was significantly worse in the emergent group, including ventilation more than 48 hours, bleeding requiring transfusion, deep vein thrombosis, renal failure, and need for reoperation. Overall, emergent cases had significantly more postoperative complications (22.8% vs 14.2%) and higher mortality rates (6.5% vs 1.4%). General surgery patients who undergo emergent operations have significantly poorer outcomes when compared with nonemergent patients; our analysis has quantified these differences. Emergent patients seem to manifest unique clinical, pathophysiologic, and inflammatory responses to their surgical disease. This data suggests that there is a need for improvement in both methods and systems of care for the emergent population.

Effect of Preoperative Warm-up Exercise Before Laparoscopic Gynecological Surgery: A Randomized Trial.

PubMed

Polterauer, Stephan; Husslein, Heinrich; Kranawetter, Marlene; Schwameis, Richard; Reinthaller, Alexander; Heinze, Georg; Grimm, Christoph

2016-01-01

Laparoscopic surgical procedures require a high level of cognitive and psychomotoric skills. Thus, effective training methods to acquire an adequate level of expertise are crucial. The aim of this study was to investigate the effect of preoperative warm up training on surgeon׳s performance during gynecologic laparoscopic surgery. In this randomized controlled trial, surgeons performed a preoperative warm up training using a virtual reality simulator before laparoscopic unilateral salpingo-oophorectomy. Serving as their own controls, each subject performed 2 pairs of laparoscopic cases, each pair consisting of 1 case with and 1 without warm up before surgery. Surgeries were videotaped and psychomotoric skills were rated using objective structured assessment of technical skills (OSATS) and the generic error rating tool by a masked observer. Perioperative complications were assessed. Statistical analysis was performed using a mixed model, and mean OSATS scores were compared between both the groups. In total, data of 10 surgeons and 17 surgeries were available for analysis. No differences between educational level and surgical experiences were observed between the groups. Mean standard error psychomotoric and task-specific OSATS scores of 19.8 (1.7) and 3.7 (0.2) were observed in the warm up group compared with 18.6 (1.7) and 3.8 (0.2) in the no warm up group, respectively (p = 0.51 and p = 0.29). Using generic error rating tool, the total number of errors was 8.75 (2.15) in the warm up group compared with 10.8 (2.18) in the no warm-up group (p = 0.53). Perioperative complications and operating time did not differ between both the groups. The present study suggests that warm-up before laparoscopic salpingo-oophorectomy does not increase psychomotoric skills during surgery. Moreover, it does not influence operating time and complication rates. (Medical University of Vienna-IRB approval number, 1072/2011, ClinicalTrials.gov number, NCT01712607). Copyright © 2016 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Robotic bariatric surgery: a systematic review.

PubMed

Fourman, Matthew M; Saber, Alan A

2012-01-01

Obesity is a nationwide epidemic, and the only evidence-based, durable treatment of this disease is bariatric surgery. This field has evolved drastically during the past decade. One of the latest advances has been the increased use of robotics within this field. The goal of our study was to perform a systematic review of the recent data to determine the safety and efficacy of robotic bariatric surgery. The setting was the University Hospitals Case Medical Center (Cleveland, OH). A PubMed search was performed for robotic bariatric surgery from 2005 to 2011. The inclusion criteria were English language, original research, human, and bariatric surgical procedures. Perioperative data were then collected from each study and recorded. A total of 18 studies were included in our review. The results of our systematic review showed that bariatric surgery, when performed with the use of robotics, had similar or lower complication rates compared with traditional laparoscopy. Two studies showed shorter operative times using the robot for Roux-en-Y gastric bypass, but 4 studies showed longer operative times in the robotic arm. In addition, the learning curve appears to be shorter when robotic gastric bypass is compared with the traditional laparoscopic approach. Most investigators agreed that robotic laparoscopic surgery provides superior imaging and freedom of movement compared with traditional laparoscopy. The application of robotics appears to be a safe option within the realm of bariatric surgery. Prospective randomized trials comparing robotic and laparoscopic outcomes are needed to further define the role of robotics within the field of bariatric surgery. Longer follow-up times would also help elucidate any long-term outcomes differences with the use of robotics versus traditional laparoscopy. Copyright © 2012 American Society for Metabolic and Bariatric Surgery. All rights reserved.

A personal experience of 2-year general thoracic surgery training programs in Japan and the United States.

PubMed

Hamaji, Masatsugu; Tanaka, Toru

2013-03-01

The objective of the study is to review and compare two countries' thoracic surgery training programs. Retrospective review of the first author's prospectively maintained operative case logs in two countries was performed. Each training program was established in a teaching hospital for its country's board requirement. Preoperative diagnosis, operative procedures and postoperative diagnosis were reviewed. The case volume (overall and in each category) was also reviewed. The ratio of each category and overall case volume was compared between the two programs by Chi-square test. p value was considered significant if it is <0.05. The overall case volumes were 169 cases in the Japanese institution and 456 cases in the United States' institution. The number ratio of each category's procedures and overall procedures was as follows: pleural cases, Japan 19.2 % versus the Unites States 20.6 % (p = 0.782), pulmonary cases, Japan 72.7 % versus the United States 36.8 % (p < 0.0001), mediastinal cases, Japan 8.1 % versus the United States 8.6 % (p = 0.678), diaphragm cases, Japan 0.62 % versus the United States 13.2 % (p = 0.0001), chest wall cases, Japan 1.2 % versus the United States 3.5 % (p = 0.0858), tracheobronchial cases, Japan 1.2 % versus the United States 1.8 % (p = 0.583). Regarding the approach, the ratios of each approach and overall cases are as follows: minimally invasive approach, Japan 78.3 % versus the United States 45.8 % (p < 0.0001), reoperative cases, Japan 0.62 % versus the United States 3.1 % (p = 0.0411). Case variety is different between the two countries. Our findings suggest that thoracic surgery training in the United States may be beneficial for Japanese medical graduates.

Advantages of robotics in benign gynecologic surgery.

PubMed

Truong, Mireille; Kim, Jin Hee; Scheib, Stacey; Patzkowsky, Kristin

2016-08-01

The purpose of this article is to review the literature and discuss the advantages of robotics in benign gynecologic surgery. Minimally invasive surgery has become the preferred route over abdominal surgery. The laparoscopic or robotic approach is recommended when vaginal surgery is not feasible. Thus far, robotic gynecologic surgery data have demonstrated feasibility, safety, and equivalent clinical outcomes in comparison with laparoscopy and better clinical outcomes compared with laparotomy. Robotics was developed to overcome challenges of laparoscopy and has led to technological advantages such as improved ergonomics, visualization with three-dimensional capabilities, dexterity and range of motion with instrument articulation, and tremor filtration. To date, applications of robotics in benign gynecology include hysterectomy, myomectomy, endometriosis surgery, sacrocolpopexy, adnexal surgery, tubal reanastomosis, and cerclage. Though further data are needed, robotics may provide additional benefits over other approaches in the obese patient population and in higher complexity cases. Challenges that arose in the earlier adoption stage such as the steep learning curve, costs, and operative times are becoming more optimized with greater experience, with implementation of robotics in high-volume centers and with improved training of surgeons and robotic teams. Robotic laparoendoscopic single-site surgery, albeit still in its infancy where technical advantages compared with laparoscopic single-site surgery are still unclear, may provide a cost-reducing option compared with multiport robotics. The cost may even approach that of laparoscopy while still conferring similar perioperative outcomes. Advances in robotic technology such as the single-site platform and telesurgery, have the potential to revolutionize the field of minimally invasive gynecologic surgery. Higher quality evidence is needed to determine the advantages and disadvantages of robotic surgery in benign gynecologic surgery. Conclusions on the benefits and risks of robotic surgery should be made with caution given limited data, especially when compared with other routes. Route of surgery selection should take into consideration the surgeons' skill and comfort level that allows for the highest level of safety and efficiency. Ultimately, the robotic device is an additional minimally invasive surgical tool that can further the goal of minimizing laparotomy in gynecology.

[Use of surgical staplers in gastrointestinal surgery].

PubMed

Lorenz, D; Siemer, P; Maskow, G; Petermann, J

1988-01-01

Reported in this paper is the use of staplers in gastro-intestinal surgery. Three soviet-made types of staplers, UO 40/60, NShKA, and SPTU (comparable to TA 30/55/90, GIA, and EEA) were used on the upper part of the gastro-intestinal tract in 237 cases and in colorectal surgery on 66 patients. The UO stapler worked well, when used for closure of uncomplicated duodenal stumps, though no absolute indication can be claimed for such application. The SPTU type, on the other hand, proved to be an ideal solution in cases of oesophago-jejunostomy with intrathoracic localisation of the anastomosis. Another, nearly absolute indication for the use of the SPTU can be claimed for anterior rectum resection (especially in male patients) with narrow pelvis and tense pelvic floor.

Diagnostic performance of swab PCR as an alternative to tissue culture methods for diagnosing infections associated with fracture fixation devices.

PubMed

Omar, Mohamed; Suero, Eduardo M; Liodakis, Emmanouil; Reichling, Moritz; Guenther, Daniel; Decker, Sebastian; Stiesch, Meike; Krettek, Christian; Eberhard, Jörg

2016-07-01

Molecular procedures could potentially improve diagnoses of orthopaedic implant-related infections, but are not yet clinically implemented. Analysis of sonication fluid shows the highest sensitivity for diagnosing implant infections in cases of revision surgery with implant removal. However, there remains controversy regarding the best method for obtaining specimens in cases of revision surgery with implant retention. Tissue culture is the most common diagnostic method for pathogen identification in such cases. Here we aimed to assess the diagnostic performance of swab PCR analysis compared to tissue culture from patients undergoing revision surgery of fracture fixation devices. We prospectively investigated 62 consecutive subjects who underwent revision surgery of fracture fixation devices during a two-year period. Tissue samples were collected for cultures, and swabs from the implant surface were obtained for 16S rRNA PCR analysis. Subjects were classified as having an implant-related infection if (1) they presented with a sinus tract or open wound in communication with the implant; or (2) purulence was encountered intraoperatively; or (3) two out of three tissue cultures tested positive for the presence of the same pathogen. Tissue culture and swab PCR results from the subjects were used to calculate the sensitivity, specificity, accuracy, positive predictive value (PPV), negative predictive value (NPV), and area under the ROC curve (AUC) for identifying an orthopaedic implant-related infection. Orthopaedic implant-related infections were detected in 51 subjects. Tissue culture identified infections in 47 cases, and swab PCR in 35 cases. Among the 11 aseptic cases, tissue culture was positive in 2 cases and swab PCR in 4 cases. Tissue culture showed a significantly higher area under the ROC curve for diagnosing infection (AUC=0.89; 95% CI, 0.67-0.96) compared to swab PCR (AUC=0.66; 95% CI, 0.46-0.80) (p=0.033). Compared to swab PCR, tissue culture showed better performance for diagnosing orthopaedic implant-related infection. Although molecular methods are expected to yield higher diagnostic accuracy than cultures, it appears that the method of obtaining specimens plays an important role. Improved methods of specimen collection are required before swab PCR can become a reliable alternative to tissue-consumptive methods. Copyright © 2016 Elsevier Ltd. All rights reserved.

[Perforated peptic ulcer closure: laparoscopic or open?

PubMed

Alekberzade, A V; Krylov, N N; Rustamov, E A; Badalov, D A; Popovtsev, M A

To compare laparoscopic and open closure of perforated peptic ulcer (PPU). The study included 153 patients who underwent PPU suturing. 78 patients underwent laparoscopic closure (laparoscopic group) and open suturing via upper midline laparotomy was performed in 75 cases (open group). Surgery time, postoperative pain severity, time of analgesics intake, postoperative complications, hospital-stay and and cosmetic effect were compared. Laparoscopic PPU closure may be effective and accessible in experienced endoscopic surgeon. It significantly reduces postoperative pain severity, need for analgesics, incidence of postoperative complications and provides excellent cosmetic effect. However, there is greater time of surgery compared with open intervention. There were no significant differences in hspital-stay between groups. Laparoscopic PPU suturing can be considered a good alternative to open surgery. Further researches are needed for standardization, assessment of safety, real advantages and disadvantages of laparoscopic technique.

Surgical treatment of scoliosis in Marfan syndrome: outcomes and complications.

PubMed

Qiao, Jun; Xu, Leilei; Liu, Zhen; Zhu, Feng; Qian, Bangping; Sun, Xu; Zhu, Zezhang; Qiu, Yong; Jiang, Qing

2016-10-01

To investigate surgical outcomes and complications of scoliosis associated with Marfan syndrome. Inclusion criteria were patients who were 10-20 years of age, had a diagnosis of Marfan syndrome by the Ghent nosology, had scoliosis and had undergone spinal fusion, and had at least 2 years of postoperative follow-up. The medical records of all patients were reviewed for age at the time of surgery, surgical procedures performed, instrumentation type, estimated blood loss (EBL) during surgery, operation time and complications related to surgery. Health-related quality-of-life measures (obtained with the SRS-22 Questionnaire before operation and at the last clinical follow-up) were also recorded. Patients were analyzed as two different groups, Group 1 and Group 2, according to the different approaches employed. Patients receiving combined anterior and posterior surgery were assigned to Group 1 and those who received posterior-only surgery to Group 2. Group 1 consisted of 30 patients (14 males, 16 females) with a mean age at surgery of 16.8 years (range: 10-20 years). Complications in Group 1 included two cases of instrumentation loosening with one removed, one case of instrumentation breakage and one case of chylothorax and hemothorax during video assisted thoracoscopic release. 66 patients (28 males, 38 females) with a mean age at surgery of years 16.4 years (range: 10-20 years) were included in Group 2. Complications in Group 2 included six cases of cerebro-spinal fluid leak, one case of deep wound infection secondary to cerebro-spinal fluid leak, one case of leg weakness and one case of pleural rupture cause by misplacement of pedicle screw. There is no difference of age at surgery, preoperative Cobb angles, and SRS-22 total scores (3.0 vs. 3.1) between the two groups (P > 0.05). Group 1 yielded larger correction rate than Group 2 for both thoracic (62.5 % vs. 56.2 %) and lumbar scoliosis (68.3 % vs. 62.7 %). Loss of correction was similar between the two groups for both thoracic (4.1° vs. 3.6°) and lumbar (4.2° vs. 4.6°) curves (P > 0.05). EBL (1972 ml vs. 1530) and operation time (669 min vs. 419 min) were significantly increased in Group 1 than in Group 2 (P < 0.05). No difference was noted for SRS-22 total scores in the last follow-up between the two groups (3.7 vs. 3.8, P > 0.05). In conclusion, as compared to anterior release combined with posterior spinal fusion, posterior-only spinal fusion could yield comparable clinical outcomes for scoliosis associated with Marfan syndrome with lower EBL, and operation time. However, longer follow-up is needed to verify these findings.

[Comparison of the results of laparotomy and laparoscopic surgery in patients with Crohn's disease].

PubMed

Horváth, Gyula; Simonka, Zsolt; Lázár, György

2014-01-05

Crohn's disease is an inflammatory bowel disease which may affect different parts of the gastrointestinal tract. To compare retrospectively the results of laparotomy and laparoscopic surgery performed in patients with Crohn's disease between January 1, 2005 and October 31, 2012 in the Department of Surgery, University of Szeged, Hungary. Patients were divided into two groups based on the types of surgery; 103 patients underwent laparotomy and 30 patients had laparoscopic surgery programmed. 22 patients had 24 primary acute interventions. The mean age was significantly lower in the laparoscopic surgery group (p = 0.042). The laparoscopic ileocecal resections have been found significantly shorter than laparotomies (p = 0.033). When ileocecal resection was performed the operation time was significantly longer (p = 0.033) while hospitalization time (p = 0.025) and intensive care unit treatment time (p<0.001) were shorter and the bowel passage also started earlier in the laparoscopic group as compared to the laparotomy group. Laparoscopic surgery results in smaller surgical trauma, better cosmetic outcome, shorter hospitalization time and not higher complication- and morbidity-rate as well as shorter operation time in certain cases. However, it requires more qualified surgical team and the operation expenses are higher.

Bioactive glass in cavitary bone defects: a comparative experimental study in rabbits

PubMed Central

Camargo, André Ferrari de França; Baptista, André Mathias; Natalino, Renato; de Camargo, Olavo Pires

2015-01-01

OBJECTIVES: To compare bioactive glass and autograft regarding their histomorphometric characteristics. METHODS: The authors conducted a prospective case-control experimental study on animals in order to compare the histomorphometric characteristics of bioactive glass versus autograft. Eight rabbits underwent surgery in which a cavitary defect was created in both proximal femurs. One side was filled with bioactive glass granules and the other, with autograft grafted from the contralateral side. The sides were randomized. Fourteen days after surgery, the animals were euthanized. RESULTS: Histologic analysis revealed that bone neoformation was equivalent among the two groups and the osteoblasts cell-count was higher in the femurs treated with bioactive glass. The osteocytes cell-count, however, was lower. The similarity in bone formation between both groups was consistent to literature findings. CONCLUSION: Bioactive glass is similar to autograft regarding bone neoformation in this animal model of cavitary bone defects. Level of Evidence III, Case-Control Study. PMID:26327802

DOE Office of Scientific and Technical Information (OSTI.GOV)

Gavioli, Margherita; Losi, Lorena; Luppi, Gabriele

Purpose: To assess the frequency and magnitude of changes in lower rectal cancer resulting from preoperative therapy and its impact on sphincter-saving surgery. Preoperative therapy can increase the rate of preserving surgery by shrinking the tumor and enhancing its distance from the anal sphincter. However, reliable data concerning these modifications are not yet available in published reports. Methods and Materials: A total of 98 cases of locally advanced cancer of the lower rectum (90 Stage uT3-T4N0-N+ and 8 uT2N+M0) that had undergone preoperative therapy were studied by endorectal ultrasonography. The maximal size of the tumor and its distance from themore » anal sphincter were measured in millimeters before and after preoperative therapy. Surgery was performed 6-8 weeks after therapy, and the histopathologic margins were compared with the endorectal ultrasound data. Results: Of the 90 cases, 82.5% showed tumor downsizing, varying from one-third to two-thirds or more of the original tumor mass. The distance between the tumor and the anal sphincter increased in 60.2% of cases. The median increase was 0.73 cm (range, 0.2-2.5). Downsizing was not always associated with an increase in distance. Preserving surgery was performed in 60.6% of cases. It was possible in nearly 30% of patients in whom the cancer had reached the anal sphincter before the preoperative therapy. The distal margin was tumor free in these cases. Conclusion: The results of our study have shown that in very low rectal cancer, preoperative therapy causes tumor downsizing in >80% of cases and in more than one-half enhances the distance between the tumor and anal sphincter. These modifications affect the primary surgical options, facilitating or making sphincter-saving surgery possible.« less

Neuroimaging and pathological findings in a child with cerebral sparganosis. Case report.

PubMed

Bo, Gao; Xuejian, Wang

2006-12-01

The authors report the case of a 6-year-old boy with cerebral sparganosis due to infection with a plerocercoid tapeworm larva of Spirometra mansoni. Magnetic resonance imaging revealed an area of irregular long T2 signal in the right frontal lobe. When compared with images obtained 2 years earlier, the lesion appeared to have migrated into the parietal lobe. During surgery for the removal of a granuloma, the parasite was discovered and excised. Following surgery, the patient's neurological deficits markedly improved. The authors review the pathological and imaging features of cerebral sparganosis.

Do prices reflect the costs of cardiac surgery in the elderly?

PubMed

Coelho, Pedro; Rodrigues, Vanessa; Miranda, Luís; Fragata, José; Pita Barros, Pedro

2017-01-01

Payment for cardiac surgery in Portugal is based on a contract agreement between hospitals and the health ministry. Our aim was to compare the prices paid according to this contract agreement with calculated costs in a population of patients aged ≥65 years undergoing cardiac surgery in one hospital department. Data on 250 patients operated between September 2011 and September 2012 were prospectively collected. The procedures studied were coronary artery bypass graft surgery (CABG) (n=67), valve surgery (n=156) and combined CABG and valve surgery (n=27). Costs were calculated by two methods: micro-costing when feasible and mean length of stay otherwise. Price information was provided by the hospital administration and calculated using the hospital's mean case-mix. Thirty-day mortality was 3.2%. Mean EuroSCORE I was 5.97 (standard deviation [SD] 4.5%), significantly lower for CABG (p<0.01). Mean intensive care unit stay was 3.27 days (SD 4.7) and mean hospital stay was 9.92 days (SD 6.30), both significantly shorter for CABG. Calculated costs for CABG were €6539.17 (SD 3990.26), for valve surgery €8289.72 (SD 3319.93) and for combined CABG and valve surgery €11 498.24 (SD 10 470.57). The payment for each patient was €4732.38 in 2011 and €4678.66 in 2012 based on the case-mix index of the hospital group, which was 2.06 in 2011 and 2.21 in 2012; however, the case-mix in our sample was 6.48 in 2011 and 6.26 in 2012. The price paid for each patient was lower than the calculated costs. Prices would be higher than costs if the case-mix of the sample had been used. Costs were significantly lower for CABG. Copyright © 2016 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.

Minimally invasive colorectal surgery: status and technical specifications.

PubMed

Keller, D S; Ibarra, S; Haas, E M

2015-10-01

Laparoscopy was the most significant technologic advance in colorectal surgery in the last quarter century. The safety, feasibility and oncologic equivalence have been proven, and undisputed clinical benefits have also been demonstrated over open approaches. Despite proven benefits, laparoscopic has not dominated the market, especially for colon and rectal cancer cases. Adaptations in laparoscopic technique were developed to increase use of minimally invasive surgery. Concurrently, there has been a paradigm shift toward less invasive technologies to further optimize patient outcomes. From these needs, hand assisted laparoscopic surgery (HALS), single incision laparoscopic surgery (SILS), and robotic assisted laparoscopic surgery (RALS) were applied to colorectal surgery. Each platform has unique costs and benefits, and similar outcomes when likened to each other in comparative studies. However, conventional laparoscopy, HALS, SILS, and RALS actually serve a complementary role as tools to increase the use of minimally invasive colorectal surgery. The goal of this paper is to review the history, current status, technical specifications, and evolution of the major minimally invasive platforms for colorectal surgery.

The role of ovarian surgery in polycystic ovary syndrome.

PubMed

Farquhar, Cynthia M

2004-10-01

Problems in inducing ovulation in women with polycystic ovary syndrome (PCOS) and anovulation are well recognized. In 1935, Stein and Leventhal first described surgical treatment by ovarian wedge resection at laparotomy for women with anovulation and PCOS. Ovarian wedge resection was eventually abandoned because of the significant risk of postsurgical adhesion formation, which resulted in tubal adhesions, and because of the advent of medical ovulation induction with clomiphene and gonadotrophins. However, since the arrival of minimally invasive surgical techniques, laparoscopic ovarian surgery has become feasible. The potential advantages of laparoscopic ovarian surgery include repeated single ovulations and less adhesion formation. Lowered costs make ovarian surgery an attractive alternative to gonadotrophins. However, although many case series have suggested that ovarian surgery is an effective strategy, few randomized, controlled trials have been undertaken comparing the success rates of surgery with gonadotrophins. The long-term concerns with surgery include adhesion formation and premature ovarian failure.

Comparing oncologic outcomes after minimally invasive and open surgery for pediatric neuroblastoma and Wilms tumor.

PubMed

Ezekian, Brian; Englum, Brian R; Gulack, Brian C; Rialon, Kristy L; Kim, Jina; Talbot, Lindsay J; Adibe, Obinna O; Routh, Jonathan C; Tracy, Elisabeth T; Rice, Henry E

2018-01-01

Minimally invasive surgery (MIS) has been widely adopted for common operations in pediatric surgery; however, its role in childhood tumors is limited by concerns about oncologic outcomes. We compared open and MIS approaches for pediatric neuroblastoma and Wilms tumor (WT) using a national database. The National Cancer Data Base from 2010 to 2012 was queried for cases of neuroblastoma and WT in children ≤21 years old. Children were classified as receiving open or MIS surgery for definitive resection, with clinical outcomes compared using a propensity matching methodology (two open:one MIS). For children with neuroblastoma, 17% (98 of 579) underwent MIS, while only 5% of children with WT (35 of 695) had an MIS approach for tumor resection. After propensity matching, there was no difference between open and MIS surgery for either tumor for 30-day mortality, readmissions, surgical margin status, and 1- and 3-year survival. However, in both tumors, open surgery more often evaluated lymph nodes and had larger lymph node harvest. Our retrospective review suggests that the use of MIS appears to be a safe method of oncologic resection for select children with neuroblastoma and WT. Further research should clarify which children are the optimal candidates for this approach. © 2017 Wiley Periodicals, Inc.

Increased Rate of Poor Laryngoscopic Views in Patients Scheduled for Cardiac Surgery Versus Patients Scheduled for General Surgery: A Propensity Score-Based Analysis of 21,561 Cases.

PubMed

Heinrich, Sebastian; Ackermann, Andreas; Prottengeier, Johannes; Castellanos, Ixchel; Schmidt, Joachim; Schüttler, Jürgen

2015-12-01

Former analyses reported an increased rate of poor direct laryngoscopy view in cardiac surgery patients; however, these findings frequently could be attributed to confounding patient characteristics. In most of the reported cardiac surgery cohorts, the rate of well-known risk factors for poor direct laryngoscopy view such as male sex, obesity, or older age, were increased compared with the control groups. Especially in the ongoing debate on anesthesia staff qualification for cardiac interventions outside the operating room a detailed and stratified risk analysis seems necessary. Retrospective, anonymous, propensity score-based, matched-pair analysis. Single-center study in a university hospital. No active participants. Retrospective, anonymous chart analysis. The anesthesia records of patients undergoing cardiac surgery in a period of 6 consecutive years were analyzed retrospectively. The results were compared with those of a control group of patients who underwent general surgery. Poor laryngoscopic view was defined as Cormack and Lehane classification grade 3 or 4. The records of 21,561 general anesthesia procedures were reviewed for the study. The incidence of poor direct laryngoscopic views in patients scheduled for cardiac surgery was significantly increased compared with those of the general surgery cohort (7% v 4.2%). Using propensity score-based matched-pair analysis, equal subgroups were generated of each surgical department, with 2,946 patients showing identical demographic characteristics. After stratifying for demographic characteristics, the rate of poor direct laryngoscopy view remained statistically significantly higher in the cardiac surgery group (7.5% v 5.7%). Even with stratification for demographic risk factors, cardiac surgery patients showed a significantly higher rate of poor direct laryngoscopic view compared with general surgery patients. These results should be taken into account for human resource management and distribution of difficult airway equipment, especially when cardiac interventional programs are implemented in remote hospital locations. Copyright © 2015 Elsevier Inc. All rights reserved.

Does pelvic floor muscle training augment the effect of surgery in women with pelvic organ prolapse? A systematic review of randomized controlled trials.

PubMed

Zhang, Feng-Wa; Wei, Fen; Wang, Hai-Lin; Pan, Yuan-Qing; Zhen, Jie-Yu; Zhang, Jv-Xia; Yang, Ke-Hu

2016-08-01

Pelvic floor muscle training (PFMT) is often used as a treatment for pelvic organ prolapse (POP) and can improve function. However, the effectiveness of this modality as an adjunct to prolapse surgery for women with POP is unknown. To evaluate whether the use of pelvic floor muscle training as an adjunct to prolapse surgery is superior to surgery alone for women with pelvic organ prolapse. We searched PubMed, Embase, the Cochrane Library, and the Web of Science from their inception dates to June 30, 2014 for data describing randomized controlled trials (RCTs) that compare the efficacy of PFMT with or without lifestyle modification plus surgery versus surgery alone for women with POP. Additional relevant studies were identified by searching the references of retrieved articles and using Google Scholar. Two investigators independently reviewed and selected relevant studies that met the pre-specified inclusion criteria, extracted the data, and assessed the risk of bias in the included studies according to the Cochrane Handbook, version 5.1.0. Due to great heterogeneity in the choice and reporting of outcome measures and the different durations of follow-up among the studies, this analysis is confined to a qualitative systematic review. Five RCTs involving 591 women were reviewed (treatment group [TG], 292 cases; control group [CG], 299 cases). Generally, the five RCTs exhibited low risk of bias. This study indicated no significant improvement in prolapse symptoms, in quality of life, or in the degree of prolapse for women with POP in the TG compared to those in the CG. Insufficient evidence was found to support adding perioperative PFMT to surgery over the use of surgery alone in women undergoing surgery for POP. Adequately, powered RCTs with longer follow-up periods are required to evaluate the long-term effect of perioperative PFMT. Neurourol. Urodynam. 35:666-674, 2016. © 2015 Wiley Periodicals, Inc. © 2015 Wiley Periodicals, Inc.

Comparison of systematic mediastinal lymph node dissection versus systematic sampling for lung cancer staging and completeness of surgery.

PubMed

Wu, Nan; Yan, Shi; Lv, Chao; Feng, Yuan; Wang, Yuzhao; Zhang, Lijian; Yang, Yue

2011-12-01

This self-controlled prospective study was designed to investigate the efficacy of systematic sampling (SS), compared with systematic mediastinal lymph node dissection (SMLD), for pathologic staging and completeness of surgery. Over a period of 11 mo, 110 patients with lung cancer were enlisted and treated by pulmonary resection. Surgeons systematically sampled mediastinal lymph nodes prior to pulmonary resection, and after pulmonary resection SMLD was performed to each patient using Mountain's procedure [1]. After SMLD, pN status was classified as N0 in 57 cases, N1 in 27, and N2 in 26. SS detected 38.3% of pooled nodes and 37.6% of pooled positive nodes collected from SMLD. Pathologic diagnosis after SS was understaged in nine cases (8.2%) compared with staging after SMLD. However, surgery was incomplete in 24 cases (21.8%) if SMLD was not performed after sampling. Negative predictive value for SS was 86.8% on the right side, and 95.0% on the left. Three categories were generated according to pN status: negative nodes in SS and additional negative nodes from SMLD [S(-)D(-)], negative nodes in SS but additional positive nodes from SMLD [S(-)D(+)], and positive nodes in SS [S(+)D(+)]. cN2 (P=0.000) and CEA level (P=0.001) were correlated with pN status. There was significant overall survival difference between non-N2 group and N2 group (P=0.002). SMLD may harvest about three times of mediastinal lymph nodes compared with SS. SS is more likely to affect the completeness of surgery instead of underrating pathologic stage. Copyright © 2011 Elsevier Inc. All rights reserved.

Cost of Cardiac Surgery in Frail Compared With Nonfrail Older Adults.

PubMed

Goldfarb, Michael; Bendayan, Melissa; Rudski, Lawrence G; Morin, Jean-Francois; Langlois, Yves; Ma, Felix; Lachapelle, Kevin; Cecere, Renzo; DeVarennes, Benoit; Tchervenkov, Christo I; Brophy, James M; Afilalo, Jonathan

2017-08-01

Frailty is a risk factor for mortality, morbidity, and prolonged length of stay after cardiac surgery, all of which are major drivers of hospitalization costs. The incremental hospitalization costs incurred in frail patients have yet to be elucidated. Patients aged ≥ 60 years were evaluated for frailty before coronary artery bypass grafting or heart valve surgery at 2 academic centres between 2013 and 2015 as part of the McGill Frailty Registry. Total costs were summed from the date of the index surgery to the date of hospital discharge. Mutivariable linear regression was used to determine the association between preoperative frailty status and total costs after adjusting for conventional surgical risk factors. Among 235 patients included in the analysis, the median age was 73.0 years (interquartile range [IQR], 70.0-78.0 years) and 68 (29%) were women. The median cost was $32,742 (IQR, $23,221-$49,627) in 91 frail patients compared with $23,370 (IQR, $19,977-$29,705) in 144 nonfrail patients. Seven extreme-cost cases > $100,000 were identified, and all of the patients in these cases exhibited baseline frailty. In the multivariable model, total costs were independently associated with frailty (adjusted additional cost, $21,245; 95% confidence interval [CI], $12,418-$30,073; P < 0.001) and valve surgery (adjusted additional cost, $20,600; 95% CI, $9,661-$31,539; P < 0.001). Frailty is associated with a marked increase in hospitalization costs after cardiac surgery, an effect that persists after adjusting for age, sex, surgery type, and surgical risk score. Further efforts are needed to optimize care and resource use in this vulnerable population. Copyright © 2017 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.

Evaluation of day care versus inpatient cataract surgery performed at a Jiangsu public Tertiary A hospital.

PubMed

Zhuang, Min; Cao, Juan; Cui, Minglan; Yuan, Songtao; Liu, Qinghuai; Fan, Wen

2018-06-05

High cataract incidence and low cataract surgical rate are serious public health problems in China, despite the fact that efficient day care cataract surgery has been implemented in some public Tertiary A hospitals in China. In this study, we compared not only clinical outcomes, hospitalization time and total costs but also payment manners between day care and inpatient procedures for cataract surgery in a Jiangsu public Tertiary A hospital to put forward several instructional suggestions for the improvement of government medical policies. In total, 4151 day care cases and 2509 inpatient cases underwent the same cataract surgery in the day care ward and ordinary ward respectively, and were defined as two groups. General information, complications, postoperative best corrected visual acuity (BCVA), hospitalization time, total costs and especially payment method were analyzed to compare day care versus inpatient. The general data display no significant differences (P > 0.05), and no significant difference between complications and postoperative BCVA were observed between the two groups (P > 0.05). The period of stay in hospital was significantly different (P < 0.001). The total costs were lower for day care than for inpatients (P < 0.001). To avoid sampling error, we analyzed the data of payment manner for each patient among this period. Day care patients tended to pay for the procedure using the Urban Employees Basic Medical Insurance (UEBMI) method, while inpatients tended to use the Out-of-Pocket Medical Treatment (OMT) payment method (P < 0.001). Day surgery of cataract is more cost-effective and efficient than inpatient surgery with equivalent clinical outcomes. As an efficient therapeutic regimen, day care surgery should be further promoted and supported by the government policies.

Interdisciplinary Care Model Independently Decreases Use of Critical Care Services After Corrective Surgery for Adult Degenerative Scoliosis.

PubMed

Adogwa, Owoicho; Elsamadicy, Aladine A; Sergesketter, Amanda R; Ongele, Michael; Vuong, Victoria; Khalid, Syed; Moreno, Jessica; Cheng, Joseph; Karikari, Isaac O; Bagley, Carlos A

2018-03-01

Interdisciplinary management of elderly patients requiring spine surgery has been shown to improve short- and long-term outcomes. The aim of this study was to determine whether an interdisciplinary team approach mitigates use of intensive care unit (ICU) resources. A unique comanagement model for elderly patients undergoing lumbar fusion surgery was implemented at a major academic medical center. The Peri-operative Optimization of Senior Health Program (POSH) was launched with the aim of improving outcomes in elderly patients (>65 years old) undergoing complex lumbar spine surgery. In this model, a geriatrician evaluates elderly patients preoperatively, comanages daily throughout hospital course, and coordinates multidisciplinary rehabilitation, along with the neurosurgical team. We retrospectively reviewed the first 100 cases after the initiation of the POSH protocol and compared them with the immediately preceding 25 cases to assess the rates of ICU transfer and independent predictors of ICU admission. A total of 125 patients undergoing lumbar decompression and fusion surgery were enrolled in this pilot program. Baseline characteristics and intraoperative variables, as well as number of fusion levels and duration of surgery, were similar between both cohorts. There was a significant difference in the use of ICU services (ICU admission rates) between both cohorts, with the non-POSH cohort having a 3-fold increase compared with the POSH cohort (P < 0.0001). In a multivariate analysis, lack of an interdisciplinary comanagement team approach was an independent predictor for ICU transfers in elderly patients undergoing corrective surgery (odds ratio 8.51, 95% confidence interval 2.972-24.37, P < 0.0001). Our study suggests that an interdisciplinary comanagement model between geriatrics and neurosurgery is independently associated with reduced use of critical care services. Copyright © 2018 Elsevier Inc. All rights reserved.

Resident Perceptions of 2-Year Versus 3-Year Cardiothoracic Training Programs.

PubMed

Nguyen, Tom C; Terwelp, Matthew D; Stephens, Elizabeth H; Odell, David D; Loor, Gabriel; LaPar, Damien J; DeNino, Walter F; Wei, Benjamin; Aftab, Muhammad; Macke, Ryan A; Nelson, Jennifer S; Berfield, Kathleen S; Lazar, John F; Stein, William; Youssef, Samuel J; Tchantchaleishvili, Vakhtang

2015-06-01

Resident perceptions of 2-year (2Y) vs 3-year (3Y) programs have never been characterized. The objective was to use the mandatory Thoracic Surgery Residents Association and Thoracic Surgery Directors Association In-Training Examination survey to compare perceptions of residents graduating from 2Y vs 3Y cardiothoracic programs. Each year Accreditation Council for Graduate Medical Education cardiothoracic residents are required to take a 30-question survey designed by the Thoracic Surgery Residents Association and the Thoracic Surgery Directors Association accompanying the In-Training Examination with a 100% response rate. The 2013 and 2014 survey responses of residents graduating from 2Y vs 3Y training programs were compared. The Wilcoxon signed rank test was used to analyze ordinal and interval data. Graduating residents completed 167 surveys, including 96 from 2Y (56%) and 71 from 3Y (43%) programs. There was no difference in the perception of being prepared for the American Board of Thoracic Surgery examinations or amount of debt between 2Y and 3Y respondents. There was no difference in intended academic vs private practice. Graduating 3Y residents felt more prepared to meet case requirements and better trained, were more likely to pass their written American Board of Thoracic Surgery examinations, and were less likely to pursue additional training beyond their cardiothoracic residency. There was no difference in field of interest, practice type, and amount of debt between graduating 2Y vs 3Y residents. Respondents from 2Y programs expressed more difficulty in meeting case requirements, whereas residents from 3Y programs felt more prepared for independent practice and had higher American Board of Thoracic Surgery written pass rates. Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Cephalometric and three-dimensional assessment of the posterior airway space and imaging software reliability analysis before and after orthognathic surgery.

PubMed

Burkhard, John Patrik Matthias; Dietrich, Ariella Denise; Jacobsen, Christine; Roos, Malgorzota; Lübbers, Heinz-Theo; Obwegeser, Joachim Anton

2014-10-01

This study aimed to compare the reliability of three different imaging software programs for measuring the PAS and concurrently to investigate the morphological changes in oropharyngeal structures in mandibular prognathic patients before and after orthognathic surgery by using 2D and 3D analyzing technique. The study consists of 11 randomly chosen patients (8 females and 3 males) who underwent maxillomandibular treatment for correction of Class III anteroposterior mandibular prognathism at the University Hospital in Zurich. A set of standardized LCR and CBCT-scans were obtained from each subject preoperatively (T0), 3 months after surgery (T1) and 3 months to 2 years postoperatively (T2). Morphological changes in the posterior airway space (PAS) were evaluated longitudinally by two different observers with three different imaging software programs (OsiriX(®) 64-bit, Switzerland; Mimics(®), Belgium; BrainLab(®), Germany) and manually by analyzing cephalometric X-rays. A significant increase in the upper airway dimensions before and after surgery occurred in all measured cases. All other cephalometric distances showed no statistically significant alterations. Measuring the volume of the PAS showed no significant changes in all cases. All three software programs showed similar outputs in both cephalometric analysis and 3D measuring technique. A 3D design of the posterior airway seems to be far more reliable and precise phrasing of a statement of postoperative gradients than conventional radiography and is additionally higher compared to the corresponding manual method. In case of Class III mandibular prognathism treatment with bilateral split osteotomy of the mandible and simultaneous maxillary advancement, the negative effects of PAS volume decrease may be reduced and might prevent a developing OSAS. Copyright © 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

Laparoscopic surgery versus antegrade scrotal sclerotherapy: Retrospective comparison of two different approaches for varicocele treatment.

PubMed

May, Matthias; Johannsen, Manfred; Beutner, Sabine; Helke, Christian; Braun, Kay P; Lein, Michael; Roigas, Jan; Hoschke, Bernd

2006-02-01

Both laparoscopic surgery and antegrade sclerotherapy are effective treatment options in the management of varicoceles. However, very limited data comparing these two approaches are available in the literature. We present our experience regarding outcome and complications with each treatment modality. During a 10-year period, 122 cases of laparoscopic varicocelectomy (LV) and 108 cases of antegrade sclerotherapy (AS) were performed in our institution. Diagnosis and postoperative results were established clinically and using Doppler ultrasonography. Data regarding failure rate, complications, operative time and length of hospital stay of each procedure were retrospectively evaluated. Median follow-up was 59 months (5-130). Failure rates for LV and AS were 4.9% and 15.7%, respectively (p < 0.01). Complications occurred in 13.1% after LV, including 13 cases (10.7%) of hydrocele formation, and 4.6% after AS. Hydroceles following LV were significantly more frequent in patients with compared to patients without previous inguinal surgery (27.8% vs. 8.5%; p < 0.05). There was no significant difference between LV and AS regarding operative time (36 vs. 34 min, p > 0.05) and hospital stay (2.2 vs. 2.1 days, p > 0.5). In our experience, LV was more effective than AS in correcting varicoceles. Complications other than hydroceles were higher after AS. The higher incidence of postoperative hydrocele formation following LV warrants strategies such as the lymphatic sparing approach, especially in patients with previous inguinal surgery.

Operative time and cost of resident surgical experience: effect of instituting an otolaryngology residency program.

PubMed

Pollei, Taylor R; Barrs, David M; Hinni, Michael L; Bansberg, Stephen F; Walter, Logan C

2013-06-01

Describe the procedure length difference between surgeries performed by an attending surgeon alone compared with the resident surgeon supervised by the same attending surgeon. Case series with chart review. Tertiary care center and residency program. Six common otolaryngologic procedures performed between August 1994 and May 2012 were divided into 2 cohorts: attending surgeon alone or resident surgeon. This division coincided with our July 2006 initiation of an otolaryngology-head and neck surgery residency program. Operative duration was compared between cohorts with confounding factors controlled. In addition, the direct result of increased surgical length on operating room cost was calculated and applied to departmental and published resident case log report data. Five of the 6 procedures evaluated showed a statistically significant increase in surgery length with resident involvement. Operative time increased 6.8 minutes for a cricopharyngeal myotomy (P = .0097), 11.3 minutes for a tonsillectomy (P < .0001), 27.4 minutes for a parotidectomy (P = .028), 38.3 minutes for a septoplasty (P < .0001), and 51 minutes for tympanomastoidectomy (P < .0021). Thyroidectomy showed no operative time difference. Cost of increased surgical time was calculated per surgery and ranged from $286 (cricopharyngeal myotomy) to $2142 (mastoidectomy). When applied to reported national case log averages for graduating residents, this resulted in a significant increase of direct training-related costs. Resident participation in the operating room results in increased surgical length and additional system cost. Although residency is a necessary part of surgical training, associated costs need to be acknowledged.

National Trends in Surgery for Rotator Cuff Disease in Korea

PubMed Central

2017-01-01

The objective of this study was to investigate the national trends in rotator cuff surgery in Korea and analyze hospital type-specific trends. We analyzed a nationwide database acquired from the Korean Health Insurance Review and Assessment Service (HIRA) from 2007 to 2015. International Classification of Diseases, 10th revision (ICD-10) codes, procedure codes, and arthroscopic device code were used to identify patients who underwent surgical treatment for rotator cuff disease. A total of 383,719 cases of rotator cuff surgeries were performed from 2007 to 2015. The mean annual percentage change in the age-adjusted rate of rotator cuff surgery per population of 100,000 persons rapidly increased from 2007 to 2012 (53.3%, P < 0.001), while that between 2012 to 2015 remained steady (2.3%, P = 0.34). The proportion of arthroscopic surgery among all rotator cuff surgeries steadily rose from 89.9% in 2007 to 96.8% in 2015 (P < 0.001). In terms of hospital types, the rate of rotator cuff surgery increased to the greatest degree in hospitals with 30–100 inpatient beds, and isolated acromioplasty procedure accounted for a larger proportion of the rotator cuff surgeries in small hospitals and clinics compared to large hospitals. Overall, our findings indicate that cases of rotator cuff surgery have increased rapidly recently in Korea, of which arthroscopic surgeries account for the greatest proportion. While rotator cuff surgery is a popular procedure that is commonly performed even in small hospitals, there was a difference in the component ratio of the procedure code in accordance with hospital type. PMID:28049250

Hip and knee replacement in Germany and the USA: analysis of individual inpatient data from German and US hospitals for the years 2005 to 2011.

PubMed

Wengler, Annelene; Nimptsch, Ulrike; Mansky, Thomas

2014-06-09

The number of hip and knee replacement operations is rising in many industrialized countries. To evaluate the current situation in Germany, we analyzed the frequency of procedures in Germany compared to the USA, with the aid of similar case definitions and taking demographic differences into account. We used individual inpatient data from Germany (DRG statistics) and the USA (Nationwide Inpatient Sample) to study differences in the age- and sex-adjusted rates of hip and knee replacement surgery and the determinants of trends in case numbers over the years 2005 to 2011. In 2011, hip replacement surgery was performed 1.4 times as frequently in Germany as in the USA (284 vs. 204 cases per 100 000 population per year; the American figures have been adjusted to the age and sex structure of the German population). On the other hand, knee replacement surgery was performed 1.5 times as frequently in the USA as in Germany (304 [standardized] vs. 206 cases per 100,000 population per year). Over the period of observation, the rates of both procedures increased in both countries. The number of elective primary hip replacement operations in Germany grew by 11%, from 140,000 to 155 300 (from 170 to 190 per 100,000 persons); after correction for demographic changes, a 3% increase remained. At the same time, the rate of elective primary hip replacement surgery in the USA rose by 28%, from 79 to 96 per 100 000 population, with a 13% increase remaining after correction for demographic changes. There are major differences between Germany and the USA in the frequency of these operations. The observed upward trend in elective primary hip replacement operations was mostly due to demographic changes in Germany; non-demographic factors exerted a stronger influence in the USA than in Germany. With respect to primary knee replacement surgery, non-demographic factors exerted a comparably strong influence in both countries.

Sinonasal adenoid cystic carcinoma: a population-based analysis of 694 cases.

PubMed

Unsal, Aykut A; Chung, Sei Y; Zhou, Albert H; Baredes, Soly; Eloy, Jean Anderson

2017-03-01

Currently, limited literature exists about sinonasal adenoid cystic carcinoma (SNACC). In this study, we analyze the demographics, survival, and treatment efficacy of this rare entity. Our study was a retrospective population-based analysis of SNACC in the Surveillance, Epidemiology, and End Results (SEER) database assessing the 40-year time-frame of 1973 to 2013. Six hundred ninety-four SNACC patients were identified; 53.2% were female and 46.8% were male. Caucasians were most commonly affected (77.1%). SNACC most often arose from the maxillary sinuses, followed by the nasal cavity. The majority of SNACC cases presented as stage IV disease. Nodal and distant metastases were present in 3.6% and 7.1% of all cases, respectively. Overall 5-, 10-, and 20-year disease-specific survival (DSS) rates were 66.5%, 41.1%, and 17.6%, respectively. The presence of distant metastasis dropped the 5-year DSS rate from 64.5% to 20.0%. Cases treated with combined surgery and adjuvant radiotherapy had a slightly improved 5-year DSS rate compared with surgery alone (73.5% vs 72.5%). Surgery alone resulted in higher 10- and 20-year DSS rates (54.2% and 36.8%, respectively) when compared with combined therapy (44.2% and 15.5%), radiotherapy alone (10.8% and 0%), and no surgery or radiotherapy (9.3% and 0%). This study represents the largest cohort of SNACC patients to date. Factors that confer a survival benefit in SNACC include M0 disease, and presentation primarily in the nasal cavity. Overall low rates of nodal metastasis may not warrant the use of elective neck dissections, unless there is clinical suspicion. Modalities of therapy that include surgery greatly improve survival. Adjuvant radiotherapy appears to slightly improve 5-year disease-free survival but does not impact long-term survival. © 2016 ARS-AAOA, LLC.

Robotic-assisted colorectal surgery in the United States: a nationwide analysis of trends and outcomes.

PubMed

Halabi, Wissam J; Kang, Celeste Y; Jafari, Mehraneh D; Nguyen, Vinh Q; Carmichael, Joseph C; Mills, Steven; Stamos, Michael J; Pigazzi, Alessio

2013-12-01

While robotic-assisted colorectal surgery (RACS) is becoming increasingly popular, data comparing its outcomes to other established techniques remain limited to small case series. Moreover, there are no large studies evaluating the trends of RACS at the national level. The Nationwide Inpatient Sample 2009-2010 was retrospectively reviewed for robotic-assisted and laparoscopic colorectal procedures performed for cancer, benign polyps, and diverticular disease. Trends in different settings, indications, and demographics were analyzed. Multivariate regression analysis was used to compare selected outcomes between RACS and conventional laparoscopic surgery (CLS). An estimated 128,288 colorectal procedures were performed through minimally invasive techniques over the study period, and RACS was used in 2.78 % of cases. From 2009 to 2010, the use of robotics increased in all hospital settings but was still more common in large, urban, and teaching hospitals. Rectal cancer was the most common indication for RACS, with a tendency toward its selective use in male patients. On multivariate analysis, robotic surgery was associated with higher hospital charges in colonic ($11,601.39; 95 % CI 6,921.82-16,280.97) and rectal cases ($12,964.90; 95 % CI 6,534.79-19,395.01), and higher rates of postoperative bleeding in colonic cases (OR = 2.15; 95 % CI 1.27- 3.65). RACS was similar to CLS with respect to length of hospital stay, morbidity, anastomotic leak, and ileus. Conversion to open surgery was significantly lower in robotic colonic and rectal procedures (0.41; 95 % CI 0.25-0.67) and (0.10; 95 % CI 0.06-0.16), respectively. The use of RACS is still limited in the United States. However, its use increased over the study period despite higher associated charges and no real advantages over laparoscopy in terms of outcome. The one advantage is lower conversion rates.

Using length of stay data from a hospital to evaluate whether limiting elective surgery at the hospital is an inappropriate decision.

PubMed

Dexter, Franklin; Lubarsky, David A

2004-09-01

At hospitals without detailed managerial accounting data but with overall longer than average diagnosis-related groups (DRG)-adjusted lengths of stays (LOS), some administrators do not aggressively hire the nurses needed to maintain surgical hospital capacity. The consequence of this (long-term) decision is that day-of-surgery admit cases are delayed or cancelled from a lack of beds. The anesthesiologists suffer financially. In this paper, we show how publicly released national LOS data can be applied specifically to these cases. We applied the method to 1 year of data from two academic hospitals. Each case's LOS was compared to the United States national average LOS for cases with the same DRG. A total of 8,050 and 10,099 hospitalizations, respectively. Among all surgical admissions, mean LOS was 2.5 days longer than the national average for Hospital #1 (95% confidence interval [CI], 2.1 to 2.8) and 3.1 days longer for Hospital #2 (95% CI, 2.8 to 3.4). Among patients undergoing elective, scheduled surgery with day of surgery admission, mean LOS was 0.7 days less than average for Hospital #1 (0.6 to 0.9) and 1.2 days less than average for Hospital #2 (1.1 to 1.4). This method can be used by anesthesiologists to show that LOS are not longer than average among patients whose surgeries may be cancelled or delayed for a lack of hospital ward staff.

Change in fracture risk and fracture pattern after bariatric surgery: nested case-control study.

PubMed

Rousseau, Catherine; Jean, Sonia; Gamache, Philippe; Lebel, Stéfane; Mac-Way, Fabrice; Biertho, Laurent; Michou, Laëtitia; Gagnon, Claudia

2016-07-27

 To investigate whether bariatric surgery increases the risk of fracture.  Retrospective nested case-control study.  Patients who underwent bariatric surgery in the province of Quebec, Canada, between 2001 and 2014, selected using healthcare administrative databases.  12 676 patients who underwent bariatric surgery, age and sex matched with 38 028 obese and 126 760 non-obese controls.  Incidence and sites of fracture in patients who had undergone bariatric surgery compared with obese and non-obese controls. Fracture risk was also compared before and after surgery (index date) within each group and by type of surgery from 2006 to 2014. Multivariate conditional Poisson regression models were adjusted for fracture history, number of comorbidities, sociomaterial deprivation, and area of residence.  Before surgery, patients undergoing bariatric surgery (9169 (72.3%) women; mean age 42 (SD 11) years) were more likely to fracture (1326; 10.5%) than were obese (3065; 8.1%) or non-obese (8329; 6.6%) controls. A mean of 4.4 years after surgery, bariatric patients were more susceptible to fracture (514; 4.1%) than were obese (1013; 2.7%) and non-obese (3008; 2.4%) controls. Postoperative adjusted fracture risk was higher in the bariatric group than in the obese (relative risk 1.38, 95% confidence interval 1.23 to 1.55) and non-obese (1.44, 1.29 to 1.59) groups. Before surgery, the risk of distal lower limb fracture was higher, upper limb fracture risk was lower, and risk of clinical spine, hip, femur, or pelvic fractures was similar in the bariatric and obese groups compared with the non-obese group. After surgery, risk of distal lower limb fracture decreased (relative risk 0.66, 0.56 to 0.78), whereas risk of upper limb (1.64, 1.40 to 1.93), clinical spine (1.78, 1.08 to 2.93), pelvic, hip, or femur (2.52, 1.78 to 3.59) fractures increased. The increase in risk of fracture reached significance only for biliopancreatic diversion.  Patients undergoing bariatric surgery were more likely to have fractures than were obese or non-obese controls, and this risk remained higher after surgery. Fracture risk was site specific, changing from a pattern associated with obesity to a pattern typical of osteoporosis after surgery. Only biliopancreatic diversion was clearly associated with fracture risk; however, results for Roux-en-Y gastric bypass and sleeve gastrectomy remain inconclusive. Fracture risk assessment and management should be part of bariatric care. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Ankle surgery: focus on arthroscopy.

PubMed

Cavallo, M; Natali, S; Ruffilli, A; Buda, R; Vannini, F; Castagnini, F; Ferranti, E; Giannini, S

2013-12-01

The ankle joint can be affected by several diseases, with clinical presentation varying from mild pain or swelling to inability, becoming in some cases a serious problem in daily life activities. Arthroscopy is a widely performed procedure in orthopedic surgery, due to the low invasivity compared to the more traditional open field surgery. The ankle joint presents anatomical specificities, like small space and tangential view that make arthroscopy more difficult. From 2000 more than 600 ankle arthroscopies were performed at our institution. The treated pathologies were mostly impingement syndrome and osteochondral lesions, and in lower percentage instabilities and ankle fractures. In the impingement, the AOFAS scores at FU showed an increase compared to scores collected preoperatively, with improvement of symptoms in most of the cases, good or excellent results in 80 % of cases. In ligament injuries, AOFAS score significatively improved at the maximum follow-up. In fractures all patients had an excellent AOFAS score at maximum follow-up, with complete return to their pre-injury activities. In osteochondral injuries, the clinical results showed a progressive improvement over time with  the different performed procedures. Control MRI and bioptic samples showed a good regeneration of the cartilage and bone tissue in the lesion site. The encouraging obtained clinical results, in line with the literature, show how the arthroscopic technique, after an adequate learning curve, may represent a precious aid for the orthopedic surgeon and for the patient's outcome. Case series, Level IV.

Surgery or stereotactic body radiotherapy for elderly stage I lung cancer? A propensity score matching analysis.

PubMed

Miyazaki, Takuro; Yamazaki, Takuya; Nakamura, Daisuke; Sato, Shuntaro; Yamasaki, Naoya; Tsuchiya, Tomoshi; Matsumoto, Keitaro; Kamohara, Ryotaro; Hatachi, Go; Nagayasu, Takeshi

2017-12-01

The aim of this study was to compare the outcomes of surgery and stereotactic body radiotherapy (SBRT) for elderly clinical stage I non-small cell lung cancer (NSCLC) patients. Patients ≥80 years of age with clinical stage I NSCLC between August 2008 and December 2014 were treated either surgery or SBRT. Propensity score matching was performed to reduce bias in various clinicopathological factors. Surgery was performed in 57 cases and SBRT in 41 cases. In the surgery group, the operations included 34 lobectomies and 23 sublobar resections. In the SBRT group, 27 cases were given 48 Gy in 4 fractions, and 14 were given 60 Gy in 10 fractions. Similar characteristics were identified in age (82 years), gender (male:female ratio 2:1), tumor size (2.2 cm), carcinoembryonic antigen (3.6 ng/ml), Charlson comorbidity index (1), Glasgow prognostic scale (0), and forced expiratory volume in 1 s (1.7 L) after matching. Before matching, the 5-year overall survival (OS) in surgery (68.3%) was significantly better than that in SBRT (47.4%, p = 0.02), and the 5-year disease-specific survival (DSS) (94.1%, 78.2%, p = 0.17) was not significantly different between the groups. The difference in the 5-year OS became non-significant between the matched pairs (57.0%, 49.1%, p = 0.56). The outcomes of surgery and SBRT for elderly patients with the early stage NSCLC were roughly the same.

Understanding the relationship between the Centers for Medicare and Medicaid Services' Hospital Compare star rating, surgical case volume, and short-term outcomes after major cancer surgery.

PubMed

Kaye, Deborah R; Norton, Edward C; Ellimoottil, Chad; Ye, Zaojun; Dupree, James M; Herrel, Lindsey A; Miller, David C

2017-11-01

Both the Centers for Medicare and Medicaid Services' (CMS) Hospital Compare star rating and surgical case volume have been publicized as metrics that can help patients to identify high-quality hospitals for complex care such as cancer surgery. The current study evaluates the relationship between the CMS' star rating, surgical volume, and short-term outcomes after major cancer surgery. National Medicare data were used to evaluate the relationship between hospital star ratings and cancer surgery volume quintiles. Then, multilevel logistic regression models were fit to examine the association between cancer surgery outcomes and both star rankings and surgical volumes. Lastly, a graphical approach was used to compare how well star ratings and surgical volume predicted cancer surgery outcomes. This study identified 365,752 patients undergoing major cancer surgery for 1 of 9 cancer types at 2,550 hospitals. Star rating was not associated with surgical volume (P < .001). However, both the star rating and surgical volume were correlated with 4 short-term cancer surgery outcomes (mortality, complication rate, readmissions, and prolonged length of stay). The adjusted predicted probabilities for 5- and 1-star hospitals were 2.3% and 4.5% for mortality, 39% and 48% for complications, 10% and 15% for readmissions, and 8% and 16% for a prolonged length of stay, respectively. The adjusted predicted probabilities for hospitals with the highest and lowest quintile cancer surgery volumes were 2.7% and 5.8% for mortality, 41% and 55% for complications, 12.2% and 11.6% for readmissions, and 9.4% and 13% for a prolonged length of stay, respectively. Furthermore, surgical volume and the star rating were similarly associated with mortality and complications, whereas the star rating was more highly associated with readmissions and prolonged length of stay. In the absence of other information, these findings suggest that the star rating may be useful to patients when they are selecting a hospital for major cancer surgery. However, more research is needed before these ratings can supplant surgical volume as a measure of surgical quality. Cancer 2017;123:4259-4267. © 2017 American Cancer Society. © 2017 American Cancer Society.

Minimally-invasive glaucoma surgeries (MIGS) for open angle glaucoma: A systematic review and meta-analysis

PubMed Central

Maule, Milena; Ceccarelli, Manuela; Fea, Antonio Maria

2017-01-01

Background MIGS have been developed as a surgical alternative for glaucomatous patients. Purpose To analyze the change in intraocular pressure (IOP) and glaucoma medications using different MIGS devices (Trabectome, iStent, Excimer Laser Trabeculotomy (ELT), iStent Supra, CyPass, XEN, Hydrus, Fugo Blade, Ab interno canaloplasty, Goniscopy-assisted transluminal trabeculotomy) as a solo procedure or in association with phacoemulsification. Methods Randomized control trials (RCT) and non-RCT (non randomized comparative studies, NRS, and before-after studies) were included. Studies with at least one year of follow-up in patients affected by primary open angle glaucoma, pseudoexfoliative glaucoma or pigmentary glaucoma were considered. Risk of Bias assessment was performed using the Cochrane Risk of Bias and the ROBINS-I tools. The main outcome was the effect of MIGS devices compared to medical therapy, cataract surgery, other glaucoma surgeries and other MIGS on both IOP and use of glaucoma medications 12 months after surgery. Outcomes measures were the mean difference in the change of IOP and glaucoma medication compared to baseline at one and two years and all ocular adverse events. The current meta-analysis is registered on PROSPERO (reference n° CRD42016037280). Results Over a total of 3,069 studies, nine RCT and 21 case series with a total of 2.928 eyes were included. Main concerns about risk of bias in RCTs were lack of blinding, allocation concealment and attrition bias while in non-RCTs they were represented by patients’ selection, masking of participants and co-intervention management. Limited evidence was found based on both RCTs and non RCTs that compared MIGS surgery with medical therapy or other MIGS. In before-after series, MIGS surgery seemed effective in lowering both IOP and glaucoma drug use. MIGS showed a good safety profile: IOP spikes were the most frequent complications and no cases of infection or BCVA loss due to glaucoma were reported. Conclusions Although MIGS seem efficient in the reduction of the IOP and glaucoma medication and show good safety profile, this evidence is mainly derived from non-comparative studies and further, good quality RCTs are warranted. PMID:28850575

Minimally-invasive glaucoma surgeries (MIGS) for open angle glaucoma: A systematic review and meta-analysis.

PubMed

Lavia, Carlo; Dallorto, Laura; Maule, Milena; Ceccarelli, Manuela; Fea, Antonio Maria

2017-01-01

MIGS have been developed as a surgical alternative for glaucomatous patients. To analyze the change in intraocular pressure (IOP) and glaucoma medications using different MIGS devices (Trabectome, iStent, Excimer Laser Trabeculotomy (ELT), iStent Supra, CyPass, XEN, Hydrus, Fugo Blade, Ab interno canaloplasty, Goniscopy-assisted transluminal trabeculotomy) as a solo procedure or in association with phacoemulsification. Randomized control trials (RCT) and non-RCT (non randomized comparative studies, NRS, and before-after studies) were included. Studies with at least one year of follow-up in patients affected by primary open angle glaucoma, pseudoexfoliative glaucoma or pigmentary glaucoma were considered. Risk of Bias assessment was performed using the Cochrane Risk of Bias and the ROBINS-I tools. The main outcome was the effect of MIGS devices compared to medical therapy, cataract surgery, other glaucoma surgeries and other MIGS on both IOP and use of glaucoma medications 12 months after surgery. Outcomes measures were the mean difference in the change of IOP and glaucoma medication compared to baseline at one and two years and all ocular adverse events. The current meta-analysis is registered on PROSPERO (reference n° CRD42016037280). Over a total of 3,069 studies, nine RCT and 21 case series with a total of 2.928 eyes were included. Main concerns about risk of bias in RCTs were lack of blinding, allocation concealment and attrition bias while in non-RCTs they were represented by patients' selection, masking of participants and co-intervention management. Limited evidence was found based on both RCTs and non RCTs that compared MIGS surgery with medical therapy or other MIGS. In before-after series, MIGS surgery seemed effective in lowering both IOP and glaucoma drug use. MIGS showed a good safety profile: IOP spikes were the most frequent complications and no cases of infection or BCVA loss due to glaucoma were reported. Although MIGS seem efficient in the reduction of the IOP and glaucoma medication and show good safety profile, this evidence is mainly derived from non-comparative studies and further, good quality RCTs are warranted.

MRI appearance of surgically proven abnormal accessory anterior-inferior tibiofibular ligament (Bassett's ligament).

PubMed

Subhas, Naveen; Vinson, Emily N; Cothran, R Lee; Santangelo, James R; Nunley, James A; Helms, Clyde A

2008-01-01

A thickened accessory anterior-inferior tibiofibular ligament (Bassett's ligament) of the ankle can be a cause of ankle impingement. Its imaging appearance is not well described. The purpose of this study was to determine if the ligament could be identified on magnetic resonance imaging (MRI), to determine associated abnormalities, and to determine if MRI could be used to differentiate normal from abnormal. Eighteen patients with a preoperative ankle MRI and an abnormal Bassett's ligament reported at surgery were found retrospectively. A separate cohort of 18 patients was selected as a control population. The presence of Bassett's ligament and its thickness were noted. The integrity and appearance of the lateral ankle ligaments, talar dome cartilage, and anterolateral gutter were also noted. In 34 of the 36 cases (94%), Bassett's ligament was identified on MRI. The ligament was seen in all three imaging planes and most frequently in the axial plane. The mean thickness of the ligament in the surgically abnormal cases was 2.37 mm, compared with 1.87 mm in the control with a p value=0.015 (t test). Nine of the 18 abnormal cases (50%) had talar dome cartilage lesions as a result of contact with the ligament at surgery, with only 3 cases of high-grade defects seen on MRI. Fourteen of the 18 abnormal cases (78%) had of synovitis or scarring in the lateral gutter at surgery, with only 5 cases with scarring seen on MRI. The anterior-inferior tibiofibular ligament was abnormal or torn in 8 of the 18 abnormal cases (44%) by MRI and confirmed in only 3 cases at surgery. Bassett's ligament can be routinely identified on MRI and was significantly thicker in patients who had it resected at surgery. An abnormal Bassett's ligament is often present in the setting of a normal anterior-inferior tibiofibular ligament. The cartilage abnormalities and synovitis associated with an abnormal Bassett's ligament are poorly detected by conventional MRI.

Influence of the vocal cord mobility in salvage surgery after radiotherapy for early-stage squamous cell carcinoma of the glottic larynx.

PubMed

Gorphe, Philippe; Blanchard, Pierre; Temam, Stephane; Janot, François

2015-10-01

Disease relapses occur in up to 40% of cases after radiotherapy (RT) for early-stage glottic laryngeal neoplasms, and the foremost remaining treatment option is salvage total laryngectomy (STL). Our objectives were to review the outcomes of patients treated with salvage surgery after RT for early-stage carcinoma of the glottic larynx and to assess prognostic factors. We retrospectively analyzed 43 patients who underwent surgery. Overall and disease-free survival rates among subgroups were calculated and compared, stratified by preoperative stage, vocal cord mobility and postoperative histopathologic data. Recurrences occurred 22.7 months after the end of RT. Surgery was STL in 33 cases (76.8%). The main prognostic factors associated with survival rates were initial vocal cord mobility, vocal cord mobility at the diagnosis of recurrence, and changes in mobility. Vocal cord mobility is an important clinical criterion in treatment decision making for early-stage glottis carcinoma and remains important during follow-up.

How small is small enough? Role of robotics in paediatric urology

PubMed Central

Ganpule, Arvind P.; Sripathi, Venkat

2015-01-01

The well-known advantages of robotic surgery include improved dexterity, three-dimensional operating view and an improved degree of freedom. Robotic surgery is performed for a wide range of surgeries in urology, which include radical prostatectomy, radical cystectomy, and ureteric reimplantation. Robotic paediatric urology is evolving. The major hindrance in the development of paediatric robotics is, first, the differences in practice patterns in paediatric urology compared with adult urology thereby making development of expertise difficult and secondly it is challenging to conduct proper studies in the paediatric population because of the paucity of cases. The difficulties in conducting these studies include difficulty in designing a proper randomised study, difficulties with blinding, and finally, the ethical issues involved, finally the instruments although in the phase of evolution require a lot of improvement. In this article, we review the relevant articles for paediatric robotic surgery. We emphasise on the technical aspects and results in contemporary paediatric robotic case series. PMID:25598599

How small is small enough? Role of robotics in paediatric urology.

PubMed

Ganpule, Arvind P; Sripathi, Venkat

2015-01-01

The well-known advantages of robotic surgery include improved dexterity, three-dimensional operating view and an improved degree of freedom. Robotic surgery is performed for a wide range of surgeries in urology, which include radical prostatectomy, radical cystectomy, and ureteric reimplantation. Robotic paediatric urology is evolving. The major hindrance in the development of paediatric robotics is, first, the differences in practice patterns in paediatric urology compared with adult urology thereby making development of expertise difficult and secondly it is challenging to conduct proper studies in the paediatric population because of the paucity of cases. The difficulties in conducting these studies include difficulty in designing a proper randomised study, difficulties with blinding, and finally, the ethical issues involved, finally the instruments although in the phase of evolution require a lot of improvement. In this article, we review the relevant articles for paediatric robotic surgery. We emphasise on the technical aspects and results in contemporary paediatric robotic case series.

Breast cancer surgery and diagnosis-related groups (DRGs): patient classification and hospital reimbursement in 11 European countries.

PubMed

Scheller-Kreinsen, David; Quentin, Wilm; Geissler, Alexander; Busse, Reinhard

2013-10-01

Researchers from eleven countries (i.e. Austria, England, Estonia, Finland, France, Germany, Ireland, Netherlands, Poland, Spain, and Sweden) compared how their DRG systems deal with breast cancer surgery patients. DRG algorithms and indicators of resource consumption were assessed for those DRGs that individually contain at least 1% of all breast cancer surgery patients. Six standardised case vignettes were defined and quasi prices according to national DRG-based hospital payment systems were ascertained. European DRG systems classify breast cancer surgery patients according to different sets of classification variables into three to seven DRGs. Quasi prices for an index case treated with partial mastectomy range from €577 in Poland to €5780 in the Netherlands. Countries award their highest payments for very different kinds of patients. Breast cancer specialists and national DRG authorities should consider how other countries' DRG systems classify breast cancer patients in order to identify potential scope for improvement and to ensure fair and appropriate reimbursement. Copyright © 2012 Elsevier Ltd. All rights reserved.

Dedicated operating room for emergency surgery generates more utilization, less overtime, and less cancellations.

PubMed

van Veen-Berkx, Elizabeth; Elkhuizen, Sylvia G; Kuijper, Bart; Kazemier, Geert

2016-01-01

Two approaches prevail for reserving operating room (OR) capacity for emergency surgery: (1) dedicated emergency ORs and (2) evenly allocating capacity to all elective ORs, thereby creating a virtual emergency team. Previous studies contradict which approach leads to the best performance in OR utilization. Quasi-experimental controlled time-series design with empirical data from 3 university medical centers. Four different time periods were compared with analysis of variance with contrasts. Performance was measured based on 467,522 surgical cases. After closing the dedicated emergency OR, utilization slightly increased; overtime also increased. This was in contrast to earlier simulated results. The 2 control centers, maintaining a dedicated emergency OR, showed a higher increase in utilization and a decrease in overtime, along with a smaller ratio of case cancellations because of emergency surgery. This study shows that in daily practice a dedicated emergency OR is the preferred approach in performance terms regarding utilization, overtime, and case cancellations. Copyright © 2016 Elsevier Inc. All rights reserved.

Adjustable suture strabismus surgery in infants and children: a 19-year experience.

PubMed

Kassem, Ahmed; Xue, Gilbert; Gandhi, Niral B; Tian, Jing; Guyton, David L

2018-06-01

To evaluate the success rate of adjustable suture techniques in horizontal eye muscle surgery in children ≤15 years of age over a 19-year period by a single surgeon. The medical records of all consecutive patients in this age group who underwent horizontal eye muscle surgery from 1989 through 2012 were reviewed retrospectively. Patients were divided into two groups: those in whom a nonadjustable suture technique was used and those in whom adjustable sutures were used. The following data were collected: type of strabismus, preoperative measurements, postoperative results, and reoperation rates. A total of 116 cases in the nonadjustable group and 521 cases in the adjustable group were included. In the adjustable group, adjustment was performed in 63% of the cases, because of either an under- (41%) or overcorrection (22%). The adjustment procedure was performed under topical proparacaine in 15% of cases and under intravenous propofol in 85%. For the adjustable group, 3-5 minutes more per muscle intraoperatively and 15-20 minutes for adjustment were required. No complications were encountered during the adjustment procedures. Early success rate, defined as alignment within 8 Δ of straight at 3 to 6 months' postoperative follow-up, was significantly greater in the adjustable group than in the nonadjustable group (77.7% vs 64.6% [P ≤ 0.03]). Of the adjustable patients, 15% required reoperation compared with 21% of the nonadjustable patients. Use of adjustable sutures in horizontal eye muscle surgery in children ≤15 years of age provided an improved success rate and fewer reoperations compared with nonadjustable sutures. Copyright © 2018 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.

Femtosecond laser-assisted compared with standard cataract surgery for removal of advanced cataracts.

PubMed

Hatch, Kathryn M; Schultz, Tim; Talamo, Jonathan H; Dick, H Burkhard

2015-09-01

To compare effective phacoemulsification time (EPT) for the removal of brunescent cataracts treated with femtosecond laser-assisted cataract surgery with standard cataract phacoemulsification techniques. Ruhr University Eye Hospital, Bochum, Germany. Comparative prospective case study. The Lens Opacities Classification System III (LOCS III) grading system was used to measure eyes divided into 4 groups having cataract surgery. Groups 1 and 2 contained eyes with LOCS III grade nuclear opalescence (NO) 3 cataracts treated with standard cataract surgery and femtosecond laser-assisted cataract surgery, respectively. Groups 3 and 4 contained brunescent cataracts, LOCS III grades NO5, treated with standard cataract surgery and femtosecond laser-assisted cataract surgery, respectively. There were 240 eyes, with 60 eyes in each group. The EPT in Group 1 ranged from 0.46 to 3.10 (mean 1.38); the EPT in all eyes in Group 2 was 0 (P < .001). The EPT in Groups 3 and 4 was 2.12 to 19.29 (mean 6.85) and 0 to 6.75 (mean 1.35), respectively (P < .001). A comparison between EPT in Groups 1 and 4 showed that EPT in Group 4 was also lower than in Group 1 (P = .013). Groups 4 and 1 were the most statistically similar of all groups compared, suggesting that EPT for a femtosecond laser-treated grade 5 cataract was most similar to that of a standard-treated grade 3 cataract. Femtosecond laser pretreatment for brunescent cataracts allowed for a significant reduction in EPT compared with manual standard phacoemulsification techniques. Drs. Hatch, Talamo, and Dick are consultants to Abbott Medical Optics, Inc. Dr. Schultz has no financial or proprietary interest in any material or method mentioned. Copyright © 2015 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.

Primary care physician decision making regarding referral for bariatric surgery: a national survey.

PubMed

Stolberg, Charlotte Røn; Hepp, Nicola; Juhl, Anna Julie Aavild; B C, Deepti; Juhl, Claus B

2017-05-01

Bariatric surgery is the most effective treatment for severe obesity. It results in significant and sustained weight loss and reduces obesity-related co-morbidities. Despite an increasing prevalence of severe obesity, the number of bariatric operations performed in Denmark has decreased during the past years. This is only partly explained by changes in the national guidelines for bariatric surgery. The purpose of the cross-sectional study is to investigate referral patterns and possible reservations regarding bariatric surgery among Danish primary care physicians (PCPs). Primary care physicians in Denmark METHODS: A total of 300 Danish PCPs were invited to participate in a questionnaire survey regarding experiences with bariatric surgery, reservations about bariatric surgery, attitudes to specific patient cases, and the future treatment of severe obesity. Most questions required a response on a 5-point Likert scale (strongly disagree, disagree, neither agree nor disagree, agree, and strongly agree) and frequency distributions were calculated. 133 completed questionnaires (44%) were returned. Most physicians found that they had good knowledge about the national referral criteria for bariatric surgery. With respect to the specific patient cases, a remarkably smaller part of physicians would refer patients on their own initiative, compared with the patient's initiative. Fear of postoperative surgical complications and medical complications both influenced markedly the decision to refer patients for surgery. Only 9% of the respondents indicated that bariatric surgery should be the primary treatment option for severe obesity in the future. Danish PCPs express severe concerns about surgical and medical complications following bariatric surgery. This might, in part, result in a low rate of referral to bariatric surgery. Copyright © 2017 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.

Predictors of surgical revision after in situ decompression of the ulnar nerve.

PubMed

Krogue, Justin D; Aleem, Alexander W; Osei, Daniel A; Goldfarb, Charles A; Calfee, Ryan P

2015-04-01

This study was performed to identify factors associated with the need for revision surgery after in situ decompression of the ulnar nerve for cubital tunnel syndrome. This case-control investigation examined all patients treated at one institution with open in situ decompression for cubital tunnel syndrome between 2006 and 2011. The case patients were 44 failed decompressions that required revision, and the controls were 79 randomly selected patients treated with a single operation. Demographic data and disease-specific data were extracted from the medical records. The rate of revision surgery after in situ decompression was determined from our 5-year experience. A multivariate logistic regression model was used based on univariate testing to determine predictors of revision cubital tunnel surgery. Revision surgery was required in 19% (44 of 231) of all in situ decompressions performed during the study period. Predictors of revision surgery included a history of elbow fracture or dislocation (odds ratio [OR], 7.1) and McGowan stage I disease (OR, 3.2). Concurrent surgery with in situ decompression was protective against revision surgery (OR, 0.19). The rate of revision cubital tunnel surgery after in situ nerve decompression should be weighed against the benefits of a less invasive procedure compared with transposition. When considering in situ ulnar nerve decompression, prior elbow fracture as well as patients requesting surgery for mild clinically graded disease should be viewed as risk factors for revision surgery. Patient factors often considered relevant to surgical outcomes, including age, sex, body mass index, tobacco use, and diabetes status, were not associated with a greater likelihood of revision cubital tunnel surgery. Copyright © 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.

Case complexity scores in congenital heart surgery: a comparative study of the Aristotle Basic Complexity score and the Risk Adjustment in Congenital Heart Surgery (RACHS-1) system.

PubMed

Al-Radi, Osman O; Harrell, Frank E; Caldarone, Christopher A; McCrindle, Brian W; Jacobs, Jeffrey P; Williams, M Gail; Van Arsdell, Glen S; Williams, William G

2007-04-01

The Aristotle Basic Complexity score and the Risk Adjustment in Congenital Heart Surgery system were developed by consensus to compare outcomes of congenital cardiac surgery. We compared the predictive value of the 2 systems. Of all index congenital cardiac operations at our institution from 1982 to 2004 (n = 13,675), we were able to assign an Aristotle Basic Complexity score, a Risk Adjustment in Congenital Heart Surgery score, and both scores to 13,138 (96%), 11,533 (84%), and 11,438 (84%) operations, respectively. Models of in-hospital mortality and length of stay were generated for Aristotle Basic Complexity and Risk Adjustment in Congenital Heart Surgery using an identical data set in which both Aristotle Basic Complexity and Risk Adjustment in Congenital Heart Surgery scores were assigned. The likelihood ratio test for nested models and paired concordance statistics were used. After adjustment for year of operation, the odds ratios for Aristotle Basic Complexity score 3 versus 6, 9 versus 6, 12 versus 6, and 15 versus 6 were 0.29, 2.22, 7.62, and 26.54 (P < .0001). Similarly, odds ratios for Risk Adjustment in Congenital Heart Surgery categories 1 versus 2, 3 versus 2, 4 versus 2, and 5/6 versus 2 were 0.23, 1.98, 5.80, and 20.71 (P < .0001). Risk Adjustment in Congenital Heart Surgery added significant predictive value over Aristotle Basic Complexity (likelihood ratio chi2 = 162, P < .0001), whereas Aristotle Basic Complexity contributed much less predictive value over Risk Adjustment in Congenital Heart Surgery (likelihood ratio chi2 = 13.4, P = .009). Neither system fully adjusted for the child's age. The Risk Adjustment in Congenital Heart Surgery scores were more concordant with length of stay compared with Aristotle Basic Complexity scores (P < .0001). The predictive value of Risk Adjustment in Congenital Heart Surgery is higher than that of Aristotle Basic Complexity. The use of Aristotle Basic Complexity or Risk Adjustment in Congenital Heart Surgery as risk stratification and trending tools to monitor outcomes over time and to guide risk-adjusted comparisons may be valuable.

Effect of Previous Abdominal Surgery on Laparoscopic Liver Resection: Analysis of Feasibility and Risk Factors for Conversion.

PubMed

Cipriani, Federica; Ratti, Francesca; Fiorentini, Guido; Catena, Marco; Paganelli, Michele; Aldrighetti, Luca

2018-03-28

Previous abdominal surgery has traditionally been considered an additional element of difficulty to later laparoscopic procedures. The aim of the study is to analyze the effect of previous surgery on the feasibility and safety of laparoscopic liver resection (LLR), and its role as a risk factor for conversion. After matching, 349 LLR in patients known for previous abdominal surgery (PS group) were compared with 349 LLR on patients with a virgin abdomen (NPS group). Subgroup analysis included 161 patients with previous upper abdominal surgery (UPS subgroup). Feasibility and safety were evaluated in terms of conversion rate, reasons for conversion and outcomes, and risk factors for conversion assessed via uni/multivariable analysis. Conversion rate was 9.4%, and higher for PS patients compared with NPS patients (13.7% versus 5.1%, P = .021). Difficult adhesiolysis resulted the commonest reason for conversion in PS group (5.7%). However, operative time (P = .840), blood loss (P = .270), transfusion (P = .650), morbidity rate (P = .578), hospital stay (P = .780), and R1 rate (P = .130) were comparable between PS and NPS group. Subgroup analysis confirmed higher conversion rates for UPS patients (23%) compared with both NPS (P = .015) and PS patients (P = .041). Previous surgery emerged as independent risk factor for conversion (P = .033), alongside the postero-superior location and major hepatectomy. LLR are feasible in case of previous surgery and proved to be safe and maintain the benefits of LLR carried out in standard settings. However, a history of surgery should be considered a risk factor for conversion.

Trends in Primary and Revision Hip Arthroplasty Among Orthopedic Surgeons Who Take the American Board of Orthopedics Part II Examination.

PubMed

Eslam Pour, Aidin; Bradbury, Thomas L; Horst, Patrick K; Harrast, John J; Erens, Greg A; Roberson, James R

2016-07-01

A certified list of all operative cases performed within a 6-month period is a required prerequisite for surgeons taking the American Board of Orthopaedic Surgery Part II oral examination. Using the American Board of Orthopaedic Surgery secure Internet database database containing these cases, this study (1) assessed changing trends for primary and revision total hip arthroplasty (THA) and (2) compared practices and early postoperative complications between 2 groups of examinees, those with and without adult reconstruction fellowship training. Secure Internet database was searched for all 2003-2013 procedures with a Current Procedural Terminology code for THA, hip resurfacing, hemiarthroplasty, revision hip arthroplasty, conversion to THA, or removal of hip implant (Girdlestone, static, or dynamic spacer). Adult reconstruction fellowship-trained surgeons performed 60% of the more than 33,000 surgeries identified (average 28.1) and nonfellowship-trained surgeons performed 40% (average 5.2) (P < .001). Fellowship-trained surgeons performed significantly more revision surgeries for infection (71% vs 29%)(P < .001). High-volume surgeons had significantly fewer complications in both primary (11.1% vs 19.6%) and revision surgeries (29% vs 35.5%) (P < .001). Those who passed the Part II examination reported higher rates of complications (21.5% vs 19.9%). In early practice, primary and revision hip arthroplasties are often performed by surgeons without adult reconstruction fellowship training. Complications are less frequently reported by surgeons with larger volumes of joint replacement surgery who perform either primary or more complex cases. Primary hip arthroplasty is increasingly performed by surgeons early in practice who have completed an adult reconstructive fellowship after residency training. This trend is even more pronounced for more complex cases such as revision or management of infection. Copyright © 2016 Elsevier Inc. All rights reserved.

Comparison of the Wake-up Test and Combined TES-MEP and CSEP Monitoring in Spinal Surgery.

PubMed

Chen, Bailing; Chen, Yuguang; Yang, Junlin; Xie, Denghui; Su, Haihua; Li, Fobao; Wan, Yong; Peng, Xinsheng; Zheng, Zhaomin

2015-11-01

A retrospective clinical analysis. The aim of this study was to compare the effectiveness of the wake-up test with that of combined monitoring of transcranial electrical stimulation motor evoked potentials (TES-MEP) and cortical somatosensory evoked potentials (CSEP) in spinal surgery. TES-MEP/CSEP combined monitoring is being increasingly recognized as the ideal approach to detect spinal neurophysiological compromise during spinal surgery; however, as a result the merit of the wake-up test is now in doubt. TES-MEP/CSEP combined monitoring was performed simultaneously in 426 patients who underwent spinal surgery at our department, and wake-up tests were conducted on 23 patients because of positive neurophysiological monitoring results with uncertain causes or persistent positive monitoring findings after all potential causes had been resolved. Preoperative and postoperative neurological examinations were performed as the gold standard to detect irreversible spinal function compromise. All data were collected to compare the efficiency of TES-MEP/CSEP combined monitoring with that of the wake-up test. Positive results of TES-MEP/CSEP combined monitoring were recorded in 64 cases. Among them, the positive monitoring findings agreed with the results of the neurological examination in 51 cases, and the monitoring results did not match that of neurological examination in 13 cases. No false-negative result was observed. The sensitivity of TES-MEP/CSEP monitoring was 100%, the specificity was 96.5%, and the Youden index was 0.965. Wake-up tests were conducted in 23 cases. In 8 patients the positive monitoring findings completely matched the postoperative neurological examination results. In contrast, in the other 15 cases with negative neurophysiological monitoring results, only 9 patients retained intact neurological function and 6 patients suffered compromised neurological function. The sensitivity of the wake-up test was 57.1%, the specificity was 100%, and the Youden index was 0.571. Combined TES-MEP and CSEP monitoring, with its high sensitivity and specificity, is an effective method for monitoring spinal function during surgery and should be the preferred choice. The wake-up test is a useful complementary method for monitoring because of its high specificity.

Necessity of suction drains in gynecomastia surgery.

PubMed

Keskin, Mustafa; Sutcu, Mustafa; Cigsar, Bulent; Karacaoglan, Naci

2014-05-01

The aim of gynecomastia surgery is to restore a normal chest contour with minimal signs of breast surgery. The authors examine the rate of complications in gynecomastia surgery when no closed-suction drains are placed. One hundred thirty-eight consecutive male patients who underwent gynecomastia surgery without drains were retrospectively analyzed to determine whether the absence of drains adversely affected patient outcomes. Patients were managed by ultrasonic-assisted liposuction both with and without the pull-through technique. The mean age of the patients was 29 years, and the mean volume of breast tissue aspirated was 350 mL per beast. Pull-through was needed in 23 cases. There was only 1 postoperative hematoma. These results are comparable with previously published data for gynecomastia surgery in which drains were placed, suggesting that the absence of drains does not adversely affect postoperative recovery. Routine closed-suction drainage after gynecomastia surgery is unnecessary, and it may be appropriate to omit drains after gynecomastia surgery.

10 Years Later: Lessons Learned from an Academic Multidisciplinary Cosmetic Center

PubMed Central

Chen, Jenny T.; Nayar, Harry S.

2017-01-01

Background: In 2006, a Centers for Medicare and Medicaid Services-accredited multidisciplinary academic ambulatory surgery center was established with the goal of delivering high-quality, efficient reconstructive, and cosmetic services in an academic setting. We review our decade-long experience since its establishment. Methods: Clinical and financial data from 2006 to 2016 are reviewed. All cosmetic procedures, including both minimally invasive and operative cases, are included. Data are compared to nationally published reports. Results: Nearly 3,500 cosmetic surgeries and 10,000 minimally invasive procedures were performed. Compared with national averages, surgical volume in abdominoplasty is high, whereas rhinoplasty and breast augmentation is low. Regarding trend data, breast augmentation volume has decreased by 25%, whereas minimally invasive procedural volume continues to grow and is comparable with national reports. Similarly, where surgical revenue remains steady, minimally invasive revenue has increased significantly. The majority of surgical cases (70%) are reconstructive in nature and insurance-based. Payer mix is 71% private insurance, 18% Medicare and Medicaid, and 11% self-pay. Despite year-over-year revenue increases, net profit in 2015 was $6,120. Rent and anesthesia costs exceed national averages, and employee salary and wages are the highest expenditure. Conclusion: Although the creation of our academic cosmetic ambulatory surgery center has greatly increased the overall volume of cosmetic surgery performed at the University of Wisconsin, the majority of surgical volume and revenue is reconstructive. As is seen nationwide, minimally invasive cosmetic procedures represent our most rapidly expanding revenue stream. PMID:29062640

Refractive Surgery: Malpractice Litigation Outcomes.

PubMed

Custer, Benjamin L; Ballard, Steven R; Carroll, Robert B; Barnes, Scott D; Justin, Grant A

2017-10-01

To review data on malpractice claims related to refractive surgery to identify common allegations and injuries and financial outcomes. The WestlawNext database was reviewed for all malpractice lawsuits/settlements related to refractive eye surgery. Data evaluated included patient demographics, type of operation performed, plaintiff allegation, nature of injury, and litigation outcomes. A total of 167 cases met the inclusion criteria, of which 108 cases (64.7%) were found to be favorable and 59 cases (35.3%) unfavorable to the defendant. A total of 141 cases were tried by a jury with 108 cases (76.4%) favorable and 33 cases (23.6%) unfavorable to the defendant. Laser in situ keratomileusis was performed in 127 cases (76%). The most common allegations were negligence in treatment or surgery in 127 cases (76%) and lack of informed consent in 83 cases (49.7%). For all cases, the need for future surgery (P = 0.0001) and surgery resulting in keratoconus (P = 0.05) were more likely to favor the plaintiff. In jury verdict decisions, cases in which failure to diagnose a preoperative condition was alleged favored the defendant (P = 0.03), whereas machine malfunction (P = 0.05) favored the plaintiff. After adjustment for inflation, the overall mean award was $1,287,872. Jury verdicts and settlements led to mean awards of $1,604,801 and $826,883, respectively. Malpractice litigation in refractive surgery tends to favor the defendant. However, large awards and settlements were given in cases that were favorable to the plaintiff. The need for future surgery and surgery leading to keratoconus increased the chance of an unfavorable outcome.

Neurodevelopmental delay with critical congenital heart disease is mainly from prenatal injury not infant cardiac surgery: current evidence based on a meta-analysis of functional magnetic resonance imaging.

PubMed

Li, Y; Yin, S; Fang, J; Hua, Y; Wang, C; Mu, D; Zhou, K

2015-06-01

No consensus has been reached regarding whether brain injury related to congenital heart disease (CHD) is caused by infant cardiac surgery and/or prenatal injury resulting from the CHD. We performed this meta-analysis to identify the likely cause of neurodevelopmental delay in CHD patients. We carried out a literature search without language restriction in December 2013, retrieving records from PubMed, EMBASE, the Cochrane Library and the World Health Organization trials center, to identify studies applying functional magnetic resonance imaging (fMRI) evaluation of brain function before surgery and, in some cases, after surgery (both immediate term and short term postoperatively). The preoperative and postoperative fMRI results were extracted, and meta-analysis was performed using Revman 5.1.1 and STATA 11.0, according to the guidelines from the Cochrane review and MOOSE groups. The electronic search yielded 937 citations. Full text was retrieved for 15 articles and eight articles (nine studies) were eligible for inclusion: six studies (n = 312 cases) with fMRI analysis before surgery and three (n = 36 cases) with complete perioperative fMRI analysis. The overall average diffusivity of CHD cases was significantly higher than that of controls, with a summarized standard (std) mean difference of 1.39 (95% CI, 0.70-2.08), and the fractional anisotropy was lower in CHD cases, with a summarized mean difference of -1.43 (95% CI, -1.95 to -0.91). N-acetylaspartate (NAA)/choline (Cho) for the whole brain was significantly lower in CHD cases compared with healthy ones, while lactate/Cho was significantly higher in CHD cases. Immediate term postoperatively, significant changes in NAA/creatine and NAA/Cho, relative to preoperative values, were found. However, the difference did not persist at the short-term follow-up. This meta-analysis suggests that the delay in neurological development in newborns with CHD is due mainly to prenatal injury, and cardiac surgery might lead to mild brain injuries postoperatively, but fMRI shows recovery within a short period. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd.

Orthodontic camouflage versus orthognathic surgery for class III deformity: comparative cephalometric analysis.

PubMed

Martinez, P; Bellot-Arcís, C; Llamas, J M; Cibrian, R; Gandia, J L; Paredes-Gallardo, V

2017-04-01

The objective of this study was to compare different cephalometric variables in adult patients with class III malocclusions before and after treatment, in order to determine which variables are indicative of orthodontic camouflage or orthognathic surgery. The cases of 156 adult patients were assessed: 77 treated with orthodontic camouflage and 79 treated with orthodontics and orthognathic surgery. The following cephalometric variables were measured on pre-treatment (T1) and post-treatment (T2) lateral cephalograms: sella-nasion-A-point (SNA), sella-nasion-B-point (SNB), and A-point-nasion-B-point (ANB) angles, Wits appraisal, facial axis angle, mandibular plane angle, upper and lower incisor inclination, and inter-incisal angle. There were statistically significant differences in cephalometric variables before and after treatment between the two groups. The percentage of normal pre-treatment measurements in the camouflage orthodontics group was 30.7%, which worsened slightly to 28.4% post-treatment. However in the group receiving surgery, this was 24.5% pre-treatment, improving to 33.5% after surgery. SNA, SNB, Wits appraisal, lower incisor inclination, and inter-incisal angle showed differences between the two groups before and after treatment. Wits appraisal, lower incisor inclination, and inter-incisal angle were indicative of one or other treatment. Upper and lower incisor decompensation in both groups did not reach ideal values, which impeded complete skeletal correction in 52% of surgical cases. Copyright © 2016 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Alcohol and substance abuse, depression and suicide attempts after Roux-en-Y gastric bypass surgery.

PubMed

Backman, O; Stockeld, D; Rasmussen, F; Näslund, E; Marsk, R

2016-09-01

Small studies suggest that subjects who have undergone bariatric surgery are at increased risk of suicide, alcohol and substance use disorders. This population-based cohort study aimed to assess the incidence of treatment for alcohol and substance use disorders, depression and attempted suicide after primary Roux-en-Y gastric bypass (RYGB). All patients who underwent primary RYGB in Sweden between 2001 and 2010 were included. Incidence of hospital admission for alcohol and substance use disorders, depression and suicide attempt was measured, along with the number of drugs prescribed. This cohort was compared with a large age-matched, non-obese reference cohort based on the Swedish population. Inpatient care and prescribed drugs registers were used. Before RYGB surgery, women, but not men, were at higher risk of being diagnosed with alcohol and substance use disorder compared with the reference cohort. After surgery, this was the case for both sexes. The risk of being diagnosed and treated for depression remained raised after surgery. Suicide attempts were significantly increased after RYGB. The adjusted hazard ratio for attempted suicide in the RYGB cohort after surgery compared with the general non-obese population was 2·85 (95 per cent c.i. 2·40 to 3·39). Patients who have undergone RYGB are at an increased risk of being diagnosed with alcohol and substance use, with an increased rate of attempted suicide compared with a non-obese general population cohort. © 2016 BJS Society Ltd Published by John Wiley & Sons Ltd.

Video-assisted endocrine neck surgery: state of the art.

PubMed

Sessa, Luca; Lombardi, Celestino Pio; De Crea, Carmela; Raffaelli, Marco; Bellantone, Rocco

2017-06-01

During the last two decades, several minimally invasive approaches for endocrine neck surgery have been developed. Minimally invasive video-assisted approaches (minimally invasive video-assisted parathyroidectomy and minimally invasive video-assisted thyroidectomy) gained a quite large worldwide diffusion, maybe because these techniques combine the advantages related to the endoscopic magnification with those due to the close similarity with the conventional surgery that makes these surgical approaches reproducible and feasible in different surgical settings. Several comparative studies have demonstrated the advantages of minimally invasive video-assisted neck surgery in terms of reduced postoperative pain, better cosmetic result, and higher patients' satisfaction over the conventional endocrine neck surgery. An accurate patients' selection plays a key role to ensure the success of minimally invasive video-assisted approaches. To date, in selected cases and in experienced Center, minimally invasive video-assisted endocrine neck surgery could be considered the standard treatment or at least a safe and effective surgical option.

Computed tomography vs. digital radiography assessment for detection of osteolysis in asymptomatic patients with uncemented cups: a proposal for a new classification system based on computer tomography.

PubMed

Sandgren, Buster; Crafoord, Joakim; Garellick, Göran; Carlsson, Lars; Weidenhielm, Lars; Olivecrona, Henrik

2013-10-01

Digital radiographic images in the anterior-posterior and lateral view have been gold standard for evaluation of peri-acetabular osteolysis for patients with an uncemented hip replacement. We compared digital radiographic images and computer tomography in detection of peri-acetabular osteolysis and devised a classification system based on computer tomography. Digital radiographs were compared with computer tomography on 206 hips, with a mean follow up 10 years after surgery. The patients had no clinical signs of osteolysis and none were planned for revision surgery. On digital radiographs, 192 cases had no osteolysis and only 14 cases had osteolysis. When using computer tomography there were 184 cases showing small or large osteolysis and only 22 patients had no osteolysis. A classification system for peri-acetabular osteolysis is proposed based on computer tomography that is easy to use on standard follow up evaluation. Copyright © 2013 Elsevier Inc. All rights reserved.

Financial analysis of revision knee surgery based on NHS tariffs and hospital costs: does it pay to provide a revision service?

PubMed

Kallala, R F; Vanhegan, I S; Ibrahim, M S; Sarmah, S; Haddad, F S

2015-02-01

Revision total knee arthroplasty (TKA) is a complex procedure which carries both a greater risk for patients and greater cost for the treating hospital than does a primary TKA. As well as the increased cost of peri-operative investigations, blood transfusions, surgical instrumentation, implants and operating time, there is a well-documented increased length of stay which accounts for most of the actual costs associated with surgery. We compared revision surgery for infection with revision for other causes (pain, instability, aseptic loosening and fracture). Complete clinical, demographic and economic data were obtained for 168 consecutive revision TKAs performed at a tertiary referral centre between 2005 and 2012. Revision surgery for infection was associated with a mean length of stay more than double that of aseptic cases (21.5 vs 9.5 days, p < 0.0001). The mean cost of a revision for infection was more than three times that of an aseptic revision (£30 011 (sd 4514) vs £9655 (sd 599.7), p < 0.0001). Current NHS tariffs do not fully reimburse the increased costs of providing a revision knee surgery service. Moreover, especially as greater costs are incurred for infected cases. These losses may adversely affect the provision of revision surgery in the NHS. ©2015 The British Editorial Society of Bone & Joint Surgery.

Factors associated with local recurrence in operated osteosarcomas: A retrospective evaluation of 95 cases from a tertiary care center in a resource challenged environment.

PubMed

Poudel, Rishi R; Tiwari, Vivek; Kumar, Venkatesan S; Bakhshi, Sameer; Gamanagatti, Shivanand; Khan, Shah Alam; Rastogi, Shishir

2017-04-01

Local control of disease is one of the main goals of osteosarcoma management. We conducted a retrospective evaluation of 95 operated cases of osteosarcoma over 7 years to know about the factors associated with local recurrence in resource-challenged environment of the developing world. The factors which were evaluated and compared between local recurrence and non-local recurrence groups included demographic profile, site of tumor, whether biopsy done outside, type of surgery (limb salvage or amputation), presence of pathological fracture, vicinity of neurovascular bundle, tumor volume, histological subtype, chemotherapy induced necrosis, surgical margins, and delay in surgery. The time to local recurrence after surgery was also noted in the local recurrence group. At a mean follow-up of 2.8 years, biopsy done from outside the treating center and delay in surgery after completion of neo-adjuvant chemotherapy emerged as significant risk factors for local recurrence. Most of the local recurrences (80%) occurred within 12 months of the primary surgery. Lack of financial resources and availability of few tertiary care centers dealing with musculoskeletal oncology in the developing countries, lead to overburden with a long waiting list for tumor surgery making the scenario different from the Western world. © 2017 Wiley Periodicals, Inc.

Surgical Site Infections Following Pediatric Ambulatory Surgery: An Epidemiologic Analysis.

PubMed

Rinke, Michael L; Jan, Dominique; Nassim, Janelle; Choi, Jaeun; Choi, Steven J

2016-08-01

OBJECTIVE To identify surgical site infection (SSI) rates following pediatric ambulatory surgery, SSI outcomes and risk factors, and sensitivity and specificity of SSI administrative billing codes. DESIGN Retrospective chart review of pediatric ambulatory surgeries with International Classification of Disease, Ninth Revision (ICD-9) codes for SSI, and a systematic random sampling of 5% of surgeries without SSI ICD-9 codes, all adjudicated for SSI on the basis of an ambulatory-adapted National Healthcare Safety Network definition. SETTING Urban pediatric tertiary care center April 1, 2009-March 31, 2014. METHODS SSI rates and sensitivity and specificity of ICD-9 codes were estimated using sampling design, and risk factors were analyzed in case-rest of cohort, and case-control, designs. RESULTS In 15,448 pediatric ambulatory surgeries, 34 patients had ICD-9 codes for SSI and 25 met the adapted National Healthcare Safety Network criteria. One additional SSI was identified with systematic random sampling. The SSI rate following pediatric ambulatory surgery was 2.9 per 1,000 surgeries (95% CI, 1.2-6.9). Otolaryngology surgeries demonstrated significantly lower SSI rates compared with endocrine (P=.001), integumentary (P=.001), male genital (P<.0001), and respiratory (P=.01) surgeries. Almost half of patients with an SSI were admitted, 88% received antibiotics, and 15% returned to the operating room. No risk factors were associated with SSI. The sensitivity of ICD-9 codes for SSI following ambulatory surgery was 55.31% (95% CI, 12.69%-91.33%) and specificity was 99.94% (99.89%-99.97%). CONCLUSIONS SSI following pediatric ambulatory surgery occurs at an appreciable rate and conveys morbidity on children. Infect Control Hosp Epidemiol 2016;37:931-938.

Comparing disciplines: outcomes of non melanoma cutaneous malignant lesions in oral and maxillofacial surgery and dermatology.

PubMed

Thavarajah, M; Szamocki, S; Komath, D; Cascarini, L; Heliotis, M

2015-01-01

300 cases of non-melanoma cutaneous lesion procedures carried out by the Oral and Maxillofacial Surgery and Dermatology departments in a North West London hospital over a 6 month period between September 2011 and February 2012 were included in a retrospective case control study. The results from each speciality were compared. The mean age of the OMFS group was 75.8 years compared to 69.9 years in the dermatology group. There was no statistically significant difference in gender between the 2 groups. The OMFS group treated a higher proportion of atypical (17%) and malignant (64.9%) cases compared to the dermatology group (11.3% and 50.5% respectively). This could also account for the fact that the OMFS group carried out a higher number of full excisions compared to dermatology. Both groups had a similar number of false positives (a benign lesion initially diagnosed as malignant) and a similar proportion of false negatives (a malignant lesion initially diagnosed as benign). Overall, the results show that both specialities had similar outcomes when managing non-melanoma cutaneous lesions. Both groups adhere to the guidelines set out by the British Association of Dermatologists and the National Institute of Clinical Excellence when managing such lesions. Crown Copyright © 2014. Published by Elsevier Ltd. All rights reserved.

Individualized strategy for clopidogrel suspension in patients undergoing off-pump coronary surgery for acute coronary syndrome: a case-control study.

PubMed

Mannacio, Vito; Meier, Pascal; Antignano, Anita; Di Tommaso, Luigi; De Amicis, Vincenzo; Vosa, Carlo

2014-10-01

An increasing number of patients presenting for urgent coronary surgery have been exposed to clopidogrel, which constitutes a risk of bleeding and related events. Based on the wide variability in clopidogrel response and platelet function recovery after cessation, we evaluated the role of point-of-care platelet function testing to define the optimal time for off-pump coronary artery bypass graft (CABG) surgery in a case-control study. Three equally matched groups (300 patients in total) undergoing isolated off-pump CABG for acute coronary syndrome were compared. Group A were treated with clopidogrel and prospectively underwent a strategy guided by platelet function testing. Outcomes were compared with 2 propensity score matched groups: group B underwent CABG after the currently recommended 5 days without clopidogrel; group C were never exposed to clopidogrel. Patients in group A had reduced postoperative bleeding compared with those in group B (523±202 mL vs 851±605 mL; P<.001) and a lower number of units packed red blood cells (PRBCs) transfused during the postoperative hospital stay (1.2±1.6 units vs 1.9±1.8 units; P=.004). Postoperative bleeding and the number of units of PRBCs transfused were similar in group A and group C. There was no difference in blood-derived products and platelet consumption, mortality, or the need for reoperation among the groups. Patients in group A waited 3.6±1.7 days for surgery. The strategy used for group A saved 280 days of hospital stay in total. The strategy guided by platelet function testing for off-pump CABG offers improved guidance for optimal timing of CABG in patients treated with clopidogrel. This strategy significantly reduces postoperative bleeding and blood consumption, and has a shorter waiting time for surgery than current clinical practice. Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Functional Visual Improvement After Cataract Surgery in Eyes With Age-Related Macular Degeneration: Results of the Ophthalmic Surgical Outcomes Data Project.

PubMed

Stock, Michael V; Vollman, David E; Baze, Elizabeth F; Chomsky, Amy S; Daly, Mary K; Lawrence, Mary G

2015-04-01

To determine if cataract surgery on eyes with AMD confers as much functional visual improvement as surgery on eyes without retinal pathology. This is a retrospective analysis of 4924 cataract surgeries from the Veterans Healthcare Administration Ophthalmic Surgical Outcomes Data Project (OSOD). We included cases of eyes with AMD that had both preoperative and postoperative NEI-VFQ-25 questionnaires submitted and compared their outcomes with controls without retinal pathology. We excluded patients with other retinal pathologies (740 patients). The analyses compared changes in visual acuity and overall functional visual improvement and its subscales using t-tests, multivariate logistic regressions, and linear regression modeling. Preoperative and postoperative questionnaires were submitted by 58.3% of AMD and 63.8% of no retinal pathology cases (controls). Analysis of overall score showed that cataract surgery on eyes with AMD led to increased visual function (13.8 ± 2.4 NEI-VFQ units, P < 0.0001); however, increases were significantly less when compared with controls (-6.4 ± 2.9 NEI-VFQ units, P < 0.0001). Preoperative best-corrected visual acuity (preBCVA) in AMD was predictive of postoperative visual function (r = -0.38, P < 0.0001). In controls, postoperative visual function was only weakly associated with preBCVA (r = -0.075, P = 0.0002). Patients with AMD with vision of 20/40 or better had overall outcomes similar to controls (-2.2 ± 4.7 NEI-VFQ units, P = 0.37). Cataract surgery on eyes with AMD offers an increase in functional visual improvement; however, the amount of benefit is associated with the eye's preBCVA. For eyes with preBCVA of 20/40 or greater, the improvement is similar to that of patients without retinal pathology. However, if preBCVA is less than 20/40, the amount of improvement was shown to be significantly less and decreased with decreasing preBCVA.

Should Moderate-to-Severe Tricuspid Regurgitation be Repaired During Reoperative Left-Sided Valve Procedures?

PubMed

Gosev, Igor; Yammine, Maroun; McGurk, Siobhan; Ejiofor, Julius I; Norman, Anthony; Ivkovic, Vladimir; Cohn, Lawrence H

The risks vs benefits of tricuspid valve (TV) surgery in reoperative patients requiring left-sided valve surgery and moderate-to-severe tricuspid regurgitation is unclear. We compared patients with and without concomitant TV surgery. A total of 200 patients with moderate-to-severe TV regurgitation had reoperative left-sided valve procedures from January 2002 to April 2014; 75 with TV intervention (TVI) and 125 with no tricuspid intervention (TVN). Propensity-matched cohorts of 60 TVI and 60 TVN patients were compared. Outcomes included New York Heart Association class, TV regurgitation and survival. TVI patients were younger (66 ± 15 vs 72 ± 13 years, P < 0.001), had more cardiogenic shock (6 of 75, vs 0 of 125, P < 0.001) and mitral valve surgery (60 of 75 vs 69 of 125, P < 0.001). Propensity matching yielded 60 pairs of TVI cases and TVN controls. Matched groups were comparable in age (TVI = 67 ± 13 vs TVN 68 ± 14 years, P = 0.67), cardiogenic shock (2 vs 0, P = 0.50), and mitral valve surgery (15 each, P = 1.0). Operative mortality was 2 of 60 in TVI vs 10 of 60 TVN (P = 0.27). Median follow-up was 4.4 years. Follow-up rates of New York Heart Association class III-IV were similar (12 of 60 for TVI vs 16 of 60 TVN, P = 0.52). Kaplan-Meier analysis indicated improved event-free survival for TVI patients (6 years, 95% CI: 4.8-7.2 years vs 8 years, 95% CI: 6.7-9.3 years for TVN, P = 0.030). There was a trend towards increased TR at follow-up in patients with valve repair alone vs annuloplasty (P = 0.15). TV surgery was performed more often in higher-risk patients. Matched case-control analyses showed TVI was associated with improved midterm outcomes. Our data suggest that annuloplasty was preferable to TV repair alone. Copyright © 2016 Elsevier Inc. All rights reserved.

[Effects of electroacupuncture preemptive intervention on postoperative pain of mixed hemorrhoids].

PubMed

Wu, Jing; Zhao, Yu; Yang, Chun-Mei; Xue, Qi-Ming; Li, Ning

2014-03-01

To evaluate clinical efficacy of electroacupuncture at Changqiang (GV 1) and Chengshan (BL 57) 30 min before surgery on postoperative pain and discomforts in patients with mixed hemorrhoids. One hundred and twenty cases of mixed hemorrhoids who received Milligan-Morgan operation were randomly divided into an electroacupuncture group, a sham electroacupuncture group and a blank group, 40 cases in each one. At the same time of basic treatment, the electroacupuncture was applied at Changqiang (GV 1) and Chengshan (BL 57) 30 min before surgery in the electroacupuncture group, while shallow needling without electrical stimulation at sham acupoint (1 cm next to acupoint) was applied 30 min before surgery in the sham electroacupuncture group, while no treatment was given before the surgery in the blank group. The total dose of painkillers in the first 24 h after operation, the number of cases who received additional anesthetic in the operation, the self-score of most severity pain in the first 24 h after operation and sleeping time in the night of surgery were observed. The differences of the numbers of cases who received additional anesthetic in the operation had no statistical significance among the three groups (all P > 0.05), but compared with the sham electroacupuncture group and blank group, the total dose of painkillers in the first 24 h after operation was reduced in the electroacupuncture group [(2.43 +/- 1.08) tablets vs (3.23 +/- 1.33) tablets, (3.10 +/- 1.22) tablets], and the score of most severity pain was also decreased (6.65 +/- 1.00 vs 7.48 +/- 0.96, 7.25 +/- 1.19), besides, the sleeping time in the night of surgery was increased [(220.63 +/- 85.50) min vs (162.00 +/- 92.69) min, (151.50 +/- 80.01) min, all P < 0.05]. The electroacupuncture at Changqiang (GV 1) and Chengshan (BL 57) 30 min before surgery has effects of preemptive analgesia on postoperative pain for patients with mixed hemorrhoids.

Pre-operative rectal indomethacin for reduction of postoperative nausea and vomiting after laparoscopic cholecystectomy: a double-blind randomized clinical trial.

PubMed

Pazouki, Abdolreza; Cheraghali, Roozbeh; Saeedimotahhar, Hossein; Jesmi, Fatemeh; Jangjoo, Ali; Pishgahroudsari, Mohadeseh

2015-01-01

To evaluate the effect of pre-operative indomethacin suppository on postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy. A double blind placebo-controlled randomized clinical trial. Hazrat Rasoul Akram Hospital, Tehran, Iran, from February 2010 to September 2012. One hundred and thirty patients, scheduled for laparoscopic cholecystectomy, were randomly divided into case and control groups. Sixty-five patients received indomethacin suppository and 70 patients received rectal placebo in the case and control groups respectively. All patients underwent the same protocol in laparoscopic surgery and anesthesia, then nausea and vomiting was recorded after 1, 6, 12 and 24 hours postoperatively and compared between the two groups. Independent-sample t test or Mann-Whitney tests were used for statistical analysis. Level of statistical significance was set at P ² 0.05. Patients' nausea was statistically lower in the case group at the 1st hour (43.1 vs. 92.9%), 6th hour (20.0 vs. 68.6%) and 12th hour (7.7 vs. 24.3%) after surgery (for all periods, P < 0.001). Fewer patients in the case group experienced vomiting at the first (13.8 vs. 51.4%) and 6th hour (0 vs. 20%) after surgery (for both P < 0.001). The use of pethidine was also statistically less in the case group in the same hours after surgery (for all of them, P < 0.001). Rectal indomethacin before laparoscopic cholecystectomy led to lower postoperative nausea and vomiting.

Disparities in Aesthetic Procedures Performed by Plastic Surgery Residents.

PubMed

Silvestre, Jason; Serletti, Joseph M; Chang, Benjamin

2017-05-01

Operative experience in aesthetic surgery is an important issue affecting plastic surgery residents. This study addresses the variability of aesthetic surgery experience during plastic surgery residency. National operative case logs of chief residents in independent/combined and integrated plastic surgery residency programs were analyzed (2011-2015). Fold differences between the bottom and top 10th percentiles of residents were calculated for each aesthetic procedure category and training model. The number of residents not achieving case minimums was also calculated. Case logs of 818 plastic surgery residents were analyzed. There was marked variability in craniofacial (range, 6.0-15.0), breast (range, 2.4-5.9), trunk/extremity (range, 3.0-16.0), and miscellaneous (range, 2.7-22.0) procedure categories. In 2015, the bottom 10th percentile of integrated and independent/combined residents did not achieve case minimums for botulinum toxin and dermal fillers. Case minimums were achieved for the other aesthetic procedure categories for all graduating years. Significant variability persists for many aesthetic procedure categories during plastic surgery residency training. Greater efforts may be needed to improve the aesthetic surgery experience of plastic surgery residents. © 2016 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com

Effect of Endovascular Interventions on General Surgery Trainee Operative Experience; a Comparison of Case Log Reports.

PubMed

Pedersen, Rose C; Li, Yiping; Chang, Jason S; Lew, Wesley K; Patel, Kaushal Kevin

2016-05-01

Vascular surgery fellowship training has evolved with the widespread adoption of endovascular interventions. The purpose of this study is to examine how general surgery trainee exposure to vascular surgery has changed over time. Review of the Accreditation Council for Graduate Medical Education national case log reports for graduating Vascular Surgery Fellows (VF), and general surgery residents (GSR) from 2001 to 2012 was performed. The number of GSR increased from 1021 to 1098, and the number of VF increased from 96 to 121 from 2001 to 2012. The total number of vascular cases done by VF increased by 1161 since 2001 (298-762), whereas the total number of vascular cases done by GSR has decreased by 40% during this time period (186-116). Vascular fellows increase was due primarily to an increase in endovascular experience; a finding not noted in general surgery residents. Vascular fellow case log changes are due primarily to an increase in endovascular experience that has not been mirrored by general surgery trainees. Open surgery experience has decreased overall for general surgery residents in all major categories, a change not seen in vascular surgery fellows. Copyright © 2016 Elsevier Inc. All rights reserved.

Robotic surgery in gynecologic cancer.

PubMed

Yim, Ga Won; Kim, Young Tae

2012-02-01

The development of robotic technology has facilitated the application of minimally invasive techniques for complex operations in gynecologic oncology. The objective of this article is to review the published literature regarding robotic surgery and its application to gynecologic cancer. To date, 20 articles addressing radical hysterectomy, six articles of radical trachelectomy, seven articles of surgical procedure in advanced or recurrent cervical cancer, 14 articles of endometrial cancer staging, and two articles solely on ovarian cancer all performed robotically are published in the literature. The majority of publications on robotic surgery are still retrospective or descriptive in nature. However, the data for gynecologic cancer show comparable results of robotic surgery compared with laparoscopy or laparotomy in terms of blood loss, length of hospital stay, and complications. Computer-enhanced technology with its associated benefits appears to facilitate the surgical approach for technically challenging operations performed to treat selected cases of cervical, endometrial, and ovarian cancer as evidenced by the current literature. Continued research and clinical trials are needed to further elucidate the equivalence or superiority of robot-assisted surgery to conventional methods in terms of oncologic outcome and patients' quality of life.

Influence of age on the outcome of single stage reconstructive surgery for congenital dislocation of the hip joint.

PubMed

Bhatti, Anisuddin; Jamali, A R; Mehboob, Ghulam

2009-01-01

This study was conducted to assess the effect of age on the ultimate outcome measures following single stage surgical procedure of soft tissue release, relocation, capsulorrhaphy, femoral shortening with varus/derotation osteotomy and pelvic osteotomy. A case series. The study with two groups of pretest-posttest design was conducted at Department of Orthopaedic Surgery, Jinnah Postgraduate Medical Centre (JPMC), Karachi, from 1993 to January 2008. Patients included were having neglected, congenital dislocation of the hip joint, aged over 3 years. Patients with failed previous surgery, paralytic, teratological, traumatic or septic dislocations and patients with less than 5 years follow-up were excluded from the study. The patients were divided into two groups, 3-7 years (37 hip joints) and over 7 years (13 hip joints). The single stage surgical procedure of open relocation, femoral shortening/derotation/ varus osteotomy and pelvic osteotomy was the dependent variable; whereas, the final clinico-radiological results based upon Tonnis grading, Severin's clinical/radiological grading, Klisic's overall rating and acetabular index were the independent variables of the study. Pre- and postoperative data was assessed for overall improvement and the difference in outcome measures between the two age groups. Significant overall improvement on all parameters was achieved after surgery. When results were compared between two age groups, there was no significant difference in the final outcome as per Tonnis grading and Severin's clinical typing as modified by Gibson (97.3% versus 84.4% normal hip joints or Tonnis grade 1 and 78.37% versus 53.85% Severin's type 1) but the results based upon Severin's radiological grading (62.16% versus 15.38%) and Klisic's overall rating (62.16% versus 15.38%) were significantly better in 3-7 years as compared to those over 7 years. There was no significant difference between the two age groups when compared for improvement in acetabular index. On further analysis, a progressive deterioration of results with increasing age was observed, yet the results in those aged over 7 years were reasonably justified surgical correction of congenital dislocation of the hip joint. Majority of the complications were seen in children operated at the age of 4-5 years. There were 7 cases (14%) of redislocation/subluxation and 6 were in 3-7 years age group. There were 4 cases (8%) of the avascular necrosis of the femoral head. Three patients had residual coxa vara and 2 had significant limb shortening. Limb lengthening was done in these 2 cases. The final results displayed progressive deterioration of clinical, radiological and functional outcome measures with aging after single stage reconstructive surgery for the congenital dislocation of hip joint. However, despite this, the results in children over 7 years were also good/excellent in most of the cases justifying surgery.

Outcome of appendicectomy in children performed in paediatric surgery units compared with general surgery units.

PubMed

Tiboni, S; Bhangu, A; Hall, N J

2014-05-01

Appendicectomy for acute appendicitis in children may be performed in specialist centres by paediatric surgeons or in general surgery units. Service provision and outcome of appendicectomy in children may differ between such units. This multicentre observational study included all children (aged less than 16 years) who had an appendicectomy at either a paediatric surgery unit or general surgery unit. The primary outcome was normal appendicectomy rate (NAR). Secondary outcomes included 30-day adverse events, use of ultrasound imaging and laparoscopy, and consultant involvement in procedures. Appendicectomies performed in 19 paediatric surgery units (242 children) and 54 general surgery units (461 children) were included. Children treated in paediatric surgery units were younger and more likely to have a preoperative ultrasound examination, a laparoscopic procedure, a consultant present at the procedure, and histologically advanced appendicitis than children treated in general surgery units. The unadjusted NAR was significantly lower in paediatric surgery units (odds ratio (OR) 0.37, 95 per cent confidence interval 0.23 to 0.59; P < 0.001), and the difference persisted after adjusting for age, sex and use of preoperative ultrasound imaging (OR 0.34, 0.21 to 0.57; P < 0.001). Female sex and preoperative ultrasonography, but not age, were significantly associated with normal appendicectomy in general surgery units but not in paediatric surgery units in this adjusted model. The unadjusted 30-day adverse event rate was higher in paediatric surgery units than in general surgery units (OR 1.90, 1.18 to 3.06; P = 0.011). When adjusted for case mix and consultant presence at surgery, no statistically significant relationship between centre type and 30-day adverse event rate existed (OR 1.59, 0.93 to 2.73; P = 0.091). The NAR in general surgery units was over twice that in paediatric surgery units. Despite a more severe case mix, paediatric surgery units had a similar 30-day adverse event rate to general surgery units. Service provision differs between paediatric and general surgery units. © 2014 BJS Society Ltd. Published by John Wiley & Sons Ltd.

[Analysis of cataract surgical rate and its influencing factors in Shanghai, China].

PubMed

Zhu, Ming-ming; Zhu, Jian-feng; Zou, Hai-dong; He, Xian-gui; Zhao, Rong; Lu, Li-na

2013-12-17

To explore the cataract surgical rate (CSR) of Shanghai from 2006 to 2012 and examine its influencing factors. As of 2003, a cataract surgery registration form had been filled by physicians after every cataract surgery in Shanghai. The local eye disease prevention team then entered the relevant information into the Shanghai Cataract Operations Database. Based upon this database, CSR of Shanghai was calculated. And the number of cataract surgeries was compared between Shanghai urban and suburban districts as well as among different medical institutions. The overall CSR in Shanghai increased from 1741 in 2006 to 2313 in 2012. In 2012, CSR in urban districts reached 6013 while it stood at 460 and 584 in inner and outer suburb districts respectively. The number of hospitals performing cataract surgery in urban districts was much more than that in suburbs. And the average number of cataract surgeries per hospital per year in suburbs was only one third of that (748 cases) in urban areas. The number of cataract surgeries at in private hospitals increased rapidly during the past 7 years. The number of 1921 cases was nearly twice as many as that at tertiary hospitals in 2012. Phacoemulsification surgery was the most popular surgical choice for cataract removal, accounting for 98.40% of total cataract surgeries in 2012. Until 2012, CSR in Shanghai dropped below the target of World Health Organization (WHO). A low level of CSR in suburbs is a major influencing factor for the overall level of CSR in Shanghai.

Lower limb compartment syndrome following laparoscopic colorectal surgery: a review.

PubMed

Rao, M M; Jayne, D

2011-05-01

  In spite of recent advances in technology and technique, laparoscopic colorectal surgery is associated with increased operating times when compared with open surgery. This increases the risk of acute lower limb compartment syndrome. The aim of this review was to gain a better understanding of postoperative lower limb compartment syndrome following laparoscopic colorectal surgery and to suggest strategies to avoid its occurrence. A MEDLINE search was performed using the keywords 'compartment syndrome', 'laparoscopic surgery' and 'Lloyd-Davies position' between 1970 and 2008. All relevant articles were retrieved and reviewed. A total of 54 articles were retrieved. Of the 30 articles in English, five were reviews, six were original articles and 19 were case reports, of which only one was following laparoscopic colorectal surgery. The remaining 24 were non-English articles. Of these, two were reviews and 22 were case reports, of which only one was following laparoscopic colorectal surgery. The incidence of acute compartment syndrome following laparoscopic colorectal surgery is unknown. The following are believed to be risk factors for acute lower limb compartment syndrome: the Lloyd-Davies operating position with exaggerated Trendelenburg tilt, prolonged operative times and improper patient positioning. Simple strategies are suggested to reduce its occurrence. Simple preventative measures have been identified which may help to reduce the incidence of acute lower limb compartment syndrome. However, if suspected, timely surgical intervention with four-compartment fasciotomy remains the standard of care. © 2011 The Authors. Colorectal Disease © 2011 The Association of Coloproctology of Great Britain and Ireland.

Supervision by a technically qualified surgeon affects the proficiency and safety of laparoscopic colectomy performed by novice surgeons.

PubMed

Ichikawa, Nobuki; Homma, Shigenori; Yoshida, Tadashi; Ohno, Yosuke; Kawamura, Hideki; Kamiizumi, You; Iijima, Hiroaki; Taketomi, Akinobu

2018-01-01

The use of laparoscopic colectomy is becoming widespread and acquisition of its technique is challenging. In this study, we investigated whether supervision by a technically qualified surgeon affects the proficiency and safety of laparoscopic colectomy performed by novice surgeons. The outcomes of 23 right colectomies and 19 high anterior resections for colon cancers performed by five novice surgeons (experience level of <10 cases) between 2014 and 2016 were assessed. A laparoscopic surgeon qualified by the Endoscopic Surgical Skill Qualification System (Japan Society for Endoscopic Surgery) participated in surgeries as the teaching assistant. In the right colectomy group, one patient (4.3%) required conversion to open surgery and postoperative morbidities occurred in two cases (8.6%). The operative time moving average gradually decreased from 216 to 150 min, and the blood loss decreased from 128 to 28 mL. In the CUSUM charts, the values for operative time decreased continuously after the 18th case, as compared to the Japanese standard. The values for blood loss also plateaued after the 18th case. In the high anterior resection group, one patient (5.2%) required conversion to open surgery and no postoperative complication occurred in any patient. The operative time moving average gradually decreased from 258 to 228 min, and the blood loss decreased from 33 to 18 mL. The CUSUM charts showed that the values of operative time plateaued after the 18th case, as compared to the Japanese standard. In the CUSUM chart for blood loss, no distinguishing peak or trend was noted. Supervision by a technically qualified surgeon affects the proficiency and safety of laparoscopic colectomy performed by novice surgeons. The trainee's learning curve in this study represents successful mentoring by the laparoscopic surgeon qualified by the Endoscopic Surgical Skill Qualification System.

Surgical management of peptic ulcer disease today--indication, technique and outcome.

PubMed

Zittel, T T; Jehle, E C; Becker, H D

2000-03-01

The current surgical management of peptic ulcer disease and its outcome have been reviewed. Today, surgery for peptic ulcer disease is largely restricted to the treatment of complications. In peptic ulcer perforation, a conservative treatment trial can be given in selected cases. If laparotomy is necessary, simple closure is sufficient in the large majority of cases, and definitive ulcer surgery to reduce gastric acid secretion is no longer justified in these patients. Laparoscopic surgery for perforated peptic ulcer has failed to prove to be a significant advantage over open surgery. In bleeding peptic ulcers, definitive hemostasis can be achieved by endoscopic treatment in more than 90% of cases. In 1-2% of cases, immediate emergency surgery is necessary. Some ulcers have a high risk of re-bleeding, and early elective surgery might be advisable. Surgical bleeding control can be achieved by direct suture and extraluminal ligation of the gastroduodenal artery or by gastric resection. Benign gastric outlet obstruction can be controlled by endoscopic balloon dilatation in 70% of cases, but gastrojejunostomy or gastric resection are necessary in about 30% of cases. Elective surgery for peptic ulcer disease has been largely abandoned, and bleeding or obstructing ulcers can be managed safely by endoscopic treatment in most cases. However, surgeons will continue to encounter patients with peptic ulcer disease for emergency surgery. Currently, laparoscopic surgery has no proven advantage in peptic ulcer surgery.

Increased anaesthesia duration increases venous thromboembolism risk in plastic surgery: A 6-year analysis of over 19,000 cases using the NSQIP dataset.

PubMed

Mlodinow, Alexei S; Khavanin, Nima; Ver Halen, Jon P; Rambachan, Aksharananda; Gutowski, Karol A; Kim, John Y S

2015-01-01

Venous thromboembolism (VTE) is a significant cause of morbidity and mortality, particularly in the postoperative setting. Various risk stratification schema exist in the plastic surgery literature, but do not take into account variations in procedure length. The putative risk of VTE conferred by increased length of time under anaesthesia has never been rigorously explored. The goal of this study is to assess this relationship and to benchmark VTE rates in plastic surgery. A large, multi-institutional quality-improvement database was queried for plastic and reconstructive surgery procedures performed under general anaesthesia between 2005-2011. In total, 19,276 cases were abstracted from the database. Z-scores were calculated based on procedure-specific mean surgical durations, to assess each case's length in comparison to the mean for that procedure. A total of 70 patients (0.36%) experienced a post-operative VTE. Patients with and without post-operative VTE were compared with respect to a variety of demographics, comorbidities, and intraoperative characteristics. Potential confounders for VTE were included in a regression model, along with the Z-scores. VTE occurred in both cosmetic and reconstructive procedures. Longer surgery time, relative to procedural means, was associated with increased VTE rates. Further, regression analysis showed increase in Z-score to be an independent risk factor for post-operative VTE (Odds Ratio of 1.772 per unit, p-value < 0.001). Subgroup analyses corroborated these findings. This study validates the long-held view that increased surgical duration confers risk of VTE, as well as benchmarks VTE rates in plastic surgery procedures. While this in itself does not suggest an intervention, surgical time under general anaesthesia would be a useful addition to existing risk models in plastic surgery.

Assessing perioperative complications associated with use of intraoperative magnetic resonance imaging during glioma surgery - a single centre experience with 516 cases.

PubMed

Ahmadi, Rezvan; Campos, Benito; Haux, Daniel; Rieke, Jörn; Beigel, Bernhard; Unterberg, Andreas

2016-08-01

Intraoperative magnetic resonance imaging (io-MRI) improves the extent of glioma resection. Due to the magnetic field, patients have to be covered with sterile drape and are then transferred into an io-MRI chamber, where ferromagnetic anaesthesia monitors and machines must be kept at distance and can only be applied with limitations. Despite the development of specific paramagnetic equipment for io-MRI use, this method is suspected to carry a higher risk for anaesthesiological and surgical complications. Particularly, serial draping and un-draping cycles as well as the extended surgery duration might increase the risk of perioperative infection. Given the importance of io-MRI for glioma surgery, the question regarding io-MRI safety needs to be answered. We prospectively evaluate the perioperative anaesthesiological and surgical complications for 516 cases of brain tumour surgery involving io-MRI (MRI cohort). As a control group, we evaluate a cohort of 610 cases of brain tumour surgery, performed without io-MRI (control group). The io-MRI procedure (including draping/undraping, transfer to and from the MRI cabinet and io-MRI scan) significantly extended surgery, defined as "skin to skin" time, by 57 min (SD = 16 min) (p ≤ 0.01). Still, we show low and comparable rates of surgical complications in the MRI cohort and the control group. Postoperative haemorrhage (3.7% versus 3.0% in MRI cohort versus control group; p = 0.49) and infections (2.2% versus 1.8% in MRI cohort versus control group; p = 0.69) were not significantly different between both groups. No anaesthesiological disturbances were reported. Despite prolonged surgery and serial draping and un-draping cycles, io-MRI was not linked to higher rates of infections and postoperative haemorrhage in this study.

Active Ankle Movements Prevent Formation of Lower-Extremity Deep Venous Thrombosis After Orthopedic Surgery

PubMed Central

Li, Ye; Guan, Xiang-Hong; Wang, Rui; Li, Bin; Ning, Bo; Su, Wei; Sun, Tao; Li, Hong-Yan

2016-01-01

Background The aim of this study was to assess the preventive value of active ankle movements in the formation of lower-extremity deep venous thrombosis (DVT), attempting to develop a new method for rehabilitation nursing after orthopedic surgery. Material/Methods We randomly assigned 193 patients undergoing orthopedic surgery in the lower limbs into a case group (n=96) and a control group (n=97). The control group received routine nursing while the case group performed active ankle movements in addition to receiving routine nursing. Maximum venous outflow (MVO), maximum venous capacity (MVC), and blood rheology were measured and the incidence of DVT was recorded. Results On the 11th and 14th days of the experiment, the case group had significantly higher MVO and MVC than the control group (all P<0.05). The whole-blood viscosity at high shear rate and the plasma viscosity were significantly lower in the case group than in the control group on the 14th day (both P<0.05). During the experiment, a significantly higher overall DVT incidence was recorded in the control group (8 with asymptomatic DVT) compared with the case group (1 with asymptomatic DVT) (P=0.034). During follow-up, the case group presented a significantly lower DVT incidence (1 with symptomatic DVT and 4 with asymptomatic DVT) than in the control group (5 with symptomatic DVT and 10 with asymptomatic DVT) (P=0.031). Conclusions Through increasing MVO and MVC and reducing blood rheology, active ankle movements may prevent the formation of lower-extremity DVT after orthopedic surgery. PMID:27600467

[Impact of microwave dealing with the cutting surface on the hepatocellular carcinoma recurrence after hepatectomy].

PubMed

Wu, Zhengshan; Wang, Xing; Wang, Dong; Fan, Ye; Li, Donghua; Kong, Lianbao; Wang, Xuehao; Wang, Ke

2015-12-01

To explore the impact of microwave dealing with cutting surface on perioperative liver function recovery and recurrence and metastasis after hepatectomy for HCC. Clinical data of 133 patients with HCC from March 2009 to November 2010 were retrospectively analyzed. They were divided into the conventional surgery group (66 cases) and microwave treatment group (67 cases). A domestic ECO-100 microwave knife was inserted into the liver cutting surface 0.5 cm from the cutting edge, and repeated multi-point burning with an average time of 25 minutes in the microwave treatment group. Then the perioperative liver function recovery and recurrence and metastasis in the two groups were compared. The operation time of conventional surgery group was (158.0 ± 31.0) minutes, and that of microwave treatment group was significantly longer (181.0 ± 28.0) minutes (P=0.027). There were no significant differences in the liver function recovery between the two groups (P>0.05). There were 6 cases of recurrence and metastasis after 6 months and 9 cases after 12 months in the microwave treatment group, while there were 15 cases of recurrence and metastasis after 6 months and 20 cases after 12 months in the conventional surgery group, showing a significant difference (P=0.034 and 0.022, respectively). Microwave dealing with the cutting surface has no significant effect on perioperative liver function recovery in hepatectomy. However, microwave treatment can reduce the in situ recurrence in HCC patients within the first year after surgery, indicating a good clinical application value.

Piezosurgery versus conventional surgery in radicular cyst enucleation.

PubMed

Kocyigit, Ismail Doruk; Atil, Fethi; Alp, Yunus Emre; Tekin, Umut; Tuz, Hakan H

2012-11-01

This study compared the use of piezosurgery and conventional surgery in radicular cyst enucleation. The study was conducted with 29 patients who were radiologically and cytologically prediagnosed with radicular cysts in the jaw region. Nineteen patients were treated using piezosurgery, and 10 were treated using conventional surgical procedures. Surgical procedures were evaluated according to the following criteria: hemorrhage, soft-tissue damage, manipulation complexity, major perforation areas on the enucleated cyst tissue, and approximate operation duration. Patients were monitored postoperatively and evaluated for hemorrhaging at 24, 48, and 72 hours following surgery. Follow-up was conducted to check for recurrences and ranged from 5 to 24 months. No complications were observed in any of the 20 patients treated using piezosurgery, although the duration of surgery was longer than expected. Of the 10 patients treated using conventional methods, hemorrhaging that affected the operation occurred in 3 cases, perforation of the cyst epithelium and difficulties in enucleation occurred in 5 cases, postoperative hemorrhage occurred in 2 cases, and recurrence was observed in 2 cases. Piezosurgery may be considered effective in procedures such as enucleation that require sensitive manipulation, despite the increase in the length of the overall surgical procedure. Given the results of the present study and the current lack of information in the literature regarding postoperative pain, infection, and long-term success rates associated with the use of piezosurgery in cyst enucleation, further study in this area is recommended.

Endoscopic Endonasal Anterior Skull Base Surgery: A Systematic Review of Complications During the Past 65 Years.

PubMed

Borg, Anouk; Kirkman, Matthew A; Choi, David

2016-11-01

Endoscopic skull base surgery is becoming more popular as an approach to the anterior skull base for tumors and cerebrospinal fluid (CSF) fistulae. It offers the advantages of better cosmesis and improved quality of life after surgery. We reviewed the complication rates reported in the literature. A literature search was performed in the electronic database Ovid MEDLINE (1950 to August 25, 2015) with the search item "([Anterior] AND Skull base surgery) AND endoscopic." We identified 82 relevant studies that included 7460 cases. An average overall complication rate of 17.1% (range 0%-68.0%) and a mortality rate of 0.4% (0%-10.0%) were demonstrated in a total of 82 studies that included 7460 cases. The average CSF leak rate for all studies was 8.9% (0%-40.0%) with meningiomas and clival lesions having the greatest CSF leak rates. The most frequent benign pathology encountered was pituitary adenomas (n = 3720, 49.8% of all cases) and the most frequent malignant tumor was esthesioneuroblastoma (n = 120, 1.6% of all cases). Studies that included only CSF fistula repairs had a lower average total complication rate (12.9%) but a greater rate of meningitis compared with studies that reported mixed pathology (2.4% vs. 1.3%). A trend towards a lower total complication rate with increasing study size was observed. The endoscopic approach is an increasingly accepted technique for anterior skull base tumor surgery and is associated with acceptable complication rates. Increasing experience with this technique can decrease rates of complications. Copyright © 2016 Elsevier Inc. All rights reserved.

[Risk of hypocalcemia after thyroid surgery].

PubMed

Shulutko, A M; Semikov, V I; Gryaznov, S E; Gorbacheva, A V; Patalova, A R; Mansurova, G T; Kazakova, V A

2015-01-01

To reveal calcium metabolism disorders that frequently occur after thyroid surgery. The study included 202 patients who underwent thyroid surgery for different diseases and had normal calcium level in peripheral blood at baseline. Based on laboratory data postoperative hypocalcemia was diagnosed in 57 (28.8%) patients. It was not always accompanied by clinical symptoms. Clinical picture depended on degree of hypocalcemia. Symptoms was diagnosed more frequently if calcium concentration was less than 2.1 mmol/l. Clinical manifestations were absent in 64.9% of cases on background of hypocalcemia. Incidence of hypocalcemia was higher after thyroidectomy compared to organ-preserving surgery. Symptoms of hypocalcemia occurred after thyroidectomy only. Casual parathyroidectomy does not always cause hypocalcemia. Only in 14% of patients with hypocalcemia excised parathyroid was identified in specimen. At the same time 7.6% of patients with postoperative normocalcaemia also had excised parathyroids in specimens. Symptoms of hypocalcemia does not always occur at 1 day after surgery. They can appear later, for example at 5 days postoperatively and depend on severity of hypocalcemia. Thyroidectomy has high risk of postoperative hypocalcemia with clinical symptoms (19.6%) that is transient in 15.5% of cases and permanent in 4.1% of patients.

Rates of surgery for frozen shoulder: an experience in England.

PubMed

Kwaees, Tariq A; Charalambous, Charalambos P

2015-01-01

the aim of this study was to identify the incidence of surgical treatment for frozen shoulder in a western population. patients included in this study all resided within a well-defined area in the North West of England, all had surgery for frozen shoulder over a 3-year period and were identified from theatre logbooks of two local hospitals. Cases having surgery for shoulder stiffness other than frozen shoulder were excluded. Local and national population size estimates were based on data obtained from the UK Office for National Statistics. 117 patients underwent surgery for frozen shoulder during the period examined; of these 101 had arthroscopic arthrolysis and 16 had manipulation under anaesthesia. The overall incidence of frozen shoulder surgery was calculated at 2.67 procedures per 10,000 general population per year, and at 7.55 for those aged 40-60. surgical intervention for frozen shoulder is common, estimated at over 14,180 cases per year in England. Given the variation in costs associated with arthroscopic arthrolysis and manipulation under anaesthesia, comparative studies of the cost effectiveness of the two procedures would be of great value. 2C (outcome research).

Midazolam intravenous conscious sedation in oral surgery. A retrospective study of 372 cases.

PubMed

Runes, J; Ström, C

1996-01-01

In 1987 the Swedish Dental Act was amended to allow Swedish dentists who have undergone a specific accreditation course to administer intra-venous sedation. Midazolam is a benzodiazepin derivate with express sedative and hypnotic qualities, powerful amnesia, a short half-life time and few secondary effects. From 1989-1994 midazolam intravenous conscious sedation (ICS) was administered in 372 cases in the Department of Oral and Maxillofacial Surgery, County Hospital, Falun. This study presents data on the 298 patients. Although surgical removal of impacted wisdom teeth predominated, implant surgery, reduction of fractures and correction of anomalies were also carried out. Supplementary sedative premedication was rarely used. Most patients were treated under local anaesthesia. The mean dosage was 10.45 mg (range 1.25-40 mg). Mean dosage/kg was 0.15 mg (range 0.03-0.50 mg). The average duration of anaesthesia was 50 minutes. The average recovery time was 94 minutes. Three hundred and sixty-nine of 372 planned treatments were completed. No serious complications occurred. The patients were co-operative during surgery and were satisfied with the treatment. Compared with full anaesthesia this method required less resources and is a valuable complement in management of anxious patients undergoing oral surgery.

Examining the "July effect" on patients undergoing pituitary surgery.

PubMed

Bashjawish, Bassel; Patel, Shreya; Kılıç, Suat; Hsueh, Wayne D; Liu, James K; Baredes, Soly; Eloy, Jean Anderson

2018-06-15

Our aim in this study was to assess the impact of the turnover of residents in July on patients undergoing pituitary surgery. This work was a retrospective cohort study of cases from the National Inpatient Sample (NIS). Patients who underwent pituitary surgery from 2005 to 2012 were selected in the NIS. Patients undergoing surgery in July and in non-July months were compared to determine differences in demographics, comorbidities, and complications. Of the 12,939 patients, 1098 (8.5%) underwent pituitary surgery in July. Patients receiving surgery in July had similar demographics and Agency for Healthcare Research and Quality comorbidity values compared with patients receiving surgery in other months. There were no significant differences in mortality, cerebral edema, cerebrospinal fluid leakage, iatrogenic pituitary complications, iatrogenic cerebrovascular accidents, urinary tract infections, pulmonary edema, pulmonary complications, or acute cardiac complications. There were no differences in the rate of postoperative fistulas, hematomas, perforations, or infections. The use of meningeal suturing, pedicled or free-flap reconstruction, and skin reconstruction was more frequent in July. Finally, hospitalization costs in July were similar to costs in other months. The turnover of new residents in July showed no change in complication rates for patients undergoing pituitary surgery. Patient care in July is similar to care during other months, demonstrating that hospitals are adequately supervising surgical residents during this transition. © 2018 ARS-AAOA, LLC.

Immediate effects of the initial FDA notification on the use of surgical mesh for pelvic organ prolapse surgery in medicare beneficiaries.

PubMed

Reynolds, W Stuart; Gold, Karen P; Ni, Shenghua; Kaufman, Melissa R; Dmochowski, Roger R; Penson, David F

2013-04-01

Prompted by increased reports of complications with the use of mesh for pelvic organ prolapse (POP) surgery, the FDA issued an initial public health notification (PHN) in 2008. We proposed to determine if the numbers of POP cases augmented with surgical mesh performed in U.S. Medicare beneficiaries changed relative to this PHN. Using administrative healthcare claims for beneficiaries enrolled in the U.S. Medicare program from 2008 to 2009, we identified women who underwent POP surgery with and without surgical mesh by procedural and diagnosis coding. In addition to comparing cases with and without mesh, we also calculated rates (number of cases per 100,000 female beneficiaries) and compared these relative to the timing of the PHN. We identified 104,185 POP procedures, of which 27,839 (26.7%) included mesh material and 76,346 (73.3%) did not. Between the last three quarters of 2008 and the first three of 2009, the rates of mesh cases increased (40.3-42.1, P < 0.001) and those without mesh decreased (115.5-111.4, P < 0.001). Inpatient procedures decreased and outpatient procedures increased for both those with and without mesh augmentation. For inpatient procedures, the relative use of biologic graft and synthetic mesh material did not vary over the study period. A substantial number of Medicare beneficiaries underwent mesh POP procedures in 2008-2009. However, despite the PHN cautioning about potential mesh complications, the numbers of mesh cases continued to rise in the immediate period after the PHN. Copyright © 2012 Wiley Periodicals, Inc.

One-stage vs. two-stage BAHA implantation in a pediatric population.

PubMed

Saliba, Issam; Froehlich, Patrick; Bouhabel, Sarah

2012-12-01

BAHA implantation surgery in a pediatric population is usually done in two-stage surgeries. This study aims to evaluate the safety and possible superiority of the one-stage over the two-stage BAHA implantation and which one would be the best standard of care for our pediatric patients. A retrospective chart review of 55 patients operated in our tertiary care institutions between 2005 and 2010 was conducted. The actual tendency in our institutions, applied at the time of the study, is to perform a one-stage surgery for all operated patients (pediatric and adult), except for patients undergoing translabyrinthine surgeries for cerebellopontine tumor excision. These patients indeed had a two-stage insertion. 26 patients underwent one-stage surgery (group I) while 29 patients had a two-stage (group II) BAHA insertion. A period of 4 months was allowed for osseointegration before BAHA processor fitting. As for the safety assessment of the one-stage surgery, we compared both groups regarding the incidence and severity (minor, moderate and major) of encountered complications, as well as the operating time and follow-up. The operating time of the two-stage surgery includes the time of the first and of the second stage. The mean age at surgery was 8.5 years old for the group I and 50 years old for the group II patients. There was no difference in the incidence of minor (p=0.12), moderate (p=0.41) nor severe (p=0.68) complications between groups I and II. Two cases of traumatic extrusion were noted in the group I. Furthermore, the one-stage BAHA implantation requests a significantly lower operating time (mean: 54 [32-100] min) than the two-stage surgery (mean: 79 [63-148] min) (p=0.012). All pediatric cases of BAHA insertion were performed in a one day surgery. The mean postoperative follow-up was 114 and 96 weeks for groups I and II respectively (p=0.058). One-stage BAHA insertion surgery in the pediatric population is a reliable, safe and efficient therapeutic option that allows a good result in a significantly lower operating time compared to the two-stage insertion and is achieved in a one day surgery. It could therefore be considered as a standard of care for pediatric patients. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

[Cost-effectiveness analysis of laparoscopic surgery versus methotrexate: comparison of data recorded in an ectopic pregnancy registry].

PubMed

Vaissade, L; Gerbaud, L; Pouly, J-L; Job-Spira, N; Bouyer, J; Coste, J; Glanddier, P-Y

2003-09-01

To compare the cost efficacy ratios of medical therapy (methotrexate - MTX) and laparoscopic surgery for ectopic pregnancy, based on an observational study of effectiveness. Data were collected by a population register of the Auvergne area. We computed the costs before, during and after hospitalization of women who could be treated either by MTX or laparoscopic surgery. We detailed costs related to the various existing facilities. We considered the entire treatment. One hundred nine cases of ectopic pregnancy were treated by laparoscopic surgery and 46 by MTX. Second-line therapy was required in 3% of women who underwent laparoscopic surgery, and 35% of those given MTX. MTX was found to be less costly (1,342 euros) than laparoscopic surgery (2,113 euros). The efficacy threshold for MTX was 11% (giving a failure rate of 89%). MTX is much more cost effective than laparoscopic surgery but the frequent need for second-line treatment must also be assessed.

Outcome of laparoscopic ovariectomy and laparoscopic-assisted ovariohysterectomy in dogs: 278 cases (2003-2013).

PubMed

Corriveau, Kayla M; Giuffrida, Michelle A; Mayhew, Philipp D; Runge, Jeffrey J

2017-08-15

OBJECTIVE To compare outcomes for laparoscopic ovariectomy (LapOVE) and laparoscopic-assisted ovariohysterectomy (LapOVH) in dogs. DESIGN Retrospective case series. ANIMALS 278 female dogs. PROCEDURES Medical records of female dogs that underwent laparoscopic sterilization between 2003 and 2013 were reviewed. History, signalment, results of physical examination, results of preoperative diagnostic testing, details of the surgical procedure, durations of anesthesia and surgery, intraoperative and immediate postoperative (ie, during hospitalization) complications, and short- (≤ 14 days after surgery) and long-term (> 14 days after surgery) outcomes were recorded. Data for patients undergoing LapOVE versus LapOVH were compared. RESULTS Intraoperative and immediate postoperative complications were infrequent, and incidence did not differ between groups. Duration of surgery for LapOVE was significantly less than that for LapOVH; however, potential confounders were not assessed. Surgical site infection was identified in 3 of 224 (1.3%) dogs. At the time of long-term follow-up, postoperative urinary incontinence was reported in 7 of 125 (5.6%) dogs that underwent LapOVE and 12 of 82 (14.6%) dogs that underwent LapOVH. None of the dogs had reportedly developed estrus or pyometra by the time of final follow-up. Overall, 205 of 207 (99%) owners were satisfied with the surgery, and 196 of 207 (95%) would consider laparoscopic sterilization for their dogs in the future. CONCLUSIONS AND CLINICAL RELEVANCE Results suggested that short- and long-term outcomes were similar for female dogs undergoing sterilization by means of LapOVE or LapOVH; however, surgery time may have been shorter for dogs that underwent LapOVE. Most owners were satisfied with the outcome of laparoscopic sterilization.

Analysis of mortality in colorectal surgery in the Bi-National Colorectal Cancer Audit.

PubMed

Teloken, Patrick Ely; Spilsbury, Katrina; Platell, Cameron

2016-06-01

In the last decade, there has been a significant increase in interest for public reporting of outcome data and performance comparison across institutions and surgeons. This study aims at comparing postoperative mortality after colorectal cancer surgery across units and individual consultants in Australia and New Zealand using funnel plots. The Bi-National Colorectal Cancer Audit database was used. Unadjusted and adjusted funnel plots of inpatient mortality were constructed. Risk adjustment was based upon multivariable logistic regression models using purposeful covariate selection. A total of 10 008 patients undergoing surgery for colorectal cancer from 56 surgical units and 90 consultants were identified. Overall inpatient mortality was 1.51%, corresponding to 1.1% for elective and 3.9% for urgent cases. Logistic regression identified age, American Society of Anesthesiologists score, urgent surgery and open surgery to be independently associated with inpatient mortality. Unadjusted and adjusted funnel plot analysis identified three (5.3%) units exceeding the inner limit and none exceeding the outer limit. Six (6.6%) consultants had inpatient mortality between the upper inner and outer limits and one (1.1%) between the inferior inner and outer limits. Upon adjustment, seven (7.7%) consultants had inpatient mortality between the inner and outer limit. Potential limitations of this study include: residual confounding being responsible for the association of open surgery and mortality; incomplete case-mix adjustment resulting in outlier identification; and bias towards inclusion of larger institutions. Mortality figures in Australia and New Zealand are comparable to recently reported international data. The vast majority of units and consultants are performing within the expected boundaries. © 2016 Royal Australasian College of Surgeons.

Comparative use of CO₂ laser, diode laser and monopolar electrocautery for resection of the soft palate in dogs with brachycephalic airway obstructive syndrome.

PubMed

Dunié-Mérigot, A; Bouvy, B; Poncet, C

2010-10-30

Clinical results, complications and the outcome of using either a carbon dioxide (CO₂) laser, diode laser or electrocautery (ELEC) for resection of the soft palate with an extended palatoplasty technique in brachycephalic dogs with upper airway obstructive syndrome were compared. Dogs were randomly allocated into three groups (n=20 in each group): ELEC, diode and CO₂ groups. The palatoplasty was made at the rostral aspect of the tonsils. A respiratory clinical score, ranging from 0 (normal) to 4 (cyanosis), was attributed to each dog before surgery and at 0 hours, 24 hours, two weeks and six months after surgery. A favourable outcome was defined as a one point or greater decrease in score 24 hours after surgery. The proportion of dogs with a favourable outcome was significantly higher in the CO₂ (n=15) and ELEC groups (n=15) in comparison with the diode group (n=7) (OR=5.6, 95 per cent confidence interval 1.4 to 21.9). Surgical time was significantly shorter (P<0.001; mean [sd] 510 [178] seconds), and bleeding was less common (P<0.001; 30 per cent of cases) in the CO₂ group. Complications were most frequent with the diode group (two cases of death and two cases of tracheostomy). The final outcome for all groups (n=57) was considered excellent in 79 per cent of cases and was considered good in 21 per cent.

Increased incidence of patella baja after total knee arthroplasty revision for infection.

PubMed

Chen, Antonia F; Tetreault, Matthew W; Levicoff, Eric A; Fedorka, Catherine J; Rothenberg, Adam C; Klatt, Brian A

2014-12-01

The incidence of patella baja in total knee arthroplasty (TKA) revisions for aseptic and septic causes is not well defined. We retrospectively reviewed 101 mobile-bearing TKA revisions performed between 2003 and 2009. Aseptic (n=67) and septic (n=34) revisions were compared for patella baja. A nonarticulating spacer was used as the initial treatment for infected cases. The Insall-Salvati ratio was radiographically measured before surgery (preexplant for septic revisions) and at latest follow-up (postreplant for septic revisions). Mean (SD) Insall-Salvati ratio did not differ between groups before surgery, 1.00 (0.25) for aseptic and 0.96 (0.22) for septic, but differed significantly after surgery, 0.99 (0.23) for aseptic and 0.77 (0.24) for septic. After correcting for preoperative patellar height, there was a statistically significant postoperative difference between aseptic cases, 1.09 (0.19), and septic cases, 0.82 (0.21). There was also a significant difference in mean (SD) postoperative range of motion (ROM) between aseptic cases, 108.0° (20.7°), and septic cases, 92.2° (34.6°), and decreased ROM between cases with patella baja, 95.1° (31.6°) and cases without patella baja, 106.8° (23.6°). TKA revisions done for septic causes using a nonarticulating spacer resulted in a higher incidence of patella baja and decreased ROM.

[Changes in the diagnosis and therapeutic management of hepatic trauma. A retrospective study comparing 2 series of cases in different (1997-1984 vs. 2001-2008)].

PubMed

Sánchez-Bueno, Francisco; Fernández-Carrión, Jezabel; Torres Salmerón, Gloria; García Pérez, Rocío; Ramírez Romero, Pablo; Fuster Quiñonero, Matilde; Parrilla, Pascual

2011-01-01

We present a series of 146 cases of hepatic trauma (HT) treated in our hospital over a period of 8 yearsm (2001-2008), and comparing it with a previous series of 92 cases (1977-1984). The mean age in the current series was 28.6 years and the majority were male. The closed traumas were mainly penetrating, with the most frequent cause being road traffic accidents. The American Association for the Surgery of Trauma (AAST) classification was used to evaluate the grade of the hepatic injury. Associated abdominal and /or extra-abdominal injuries were seen in 79.5% of the patients, with the most frequent being chest trauma, compared to bone fractures in the previous series. The most common associated intra-abdominal injury was the spleen in both series. The most used diagnostic technique in the current series was abdominal CT. Simple peritoneal puncture and lavage (PLP) were the most used examinations used in the previous series. Non-surgical treatment (NST) was given in 98 cases and the surgery was indicated in the remaining 48. In the previous series, 97.8% of patients were operated on. In the current series, on the 15 patients with severe liver injuries, 5 right hepatectomies, 2 segmentectomies and 6 packing compressions were performed, with the remaining two dying during surgery due to hepatic avulsion. The overall mortality was 3.4%, being 1% in the NST group and 8.3% in the surgical patients. In the previous series, the overall mortality was 29.3%. The key factor for using NST is to control haemodynamic stability, leaving surgical treatment for haemodynamically unstable patients. Copyright © 2011 AEC. Published by Elsevier Espana. All rights reserved.

Otosclerosis surgery: approaches, profits and complications.

PubMed

Japaridze, Sh; Lomidze, L; Jashi, M; Kekelidze, I; Gegenava, Kh

2009-05-01

A systematic analysis of stapedoplasty output in otosclerosis cases was carried out. The operations were done during the period of 2005-2008 years at the Department of Otorhinolaryngology of the Tbilisi State Medical University. From the overall number of 107 patients, 78 were females and 29 males, 72.9% and 27.1%, respectively. The ages ranged from 16 to 57 years. The mean age was 35 years. The conductive and mixed forms of hearing losses were diagnosed in 70 and 37 cases, 65.4% and 34.6%, respectively. Right ear was operated in 46 patients, left ear in 57, and both ears in four, 43.3%, 53.0%, and 3.7%, respectively. 111 ears have been cured thus in sum. Intumescences of external ear tube were observed during the operation in 22 patients, 20.6%. In 7, 6.5%, the facial nerve was located downward. Particularly abnormal placement of the facial nerve was the case in two patients, 1.9%. The endaural approach has been proved to own advantages over the transmeatal one. The data generally confirmed that stapedotomy, as compared to stapedectomy, is a better choice for the surgery output. In beneficial cases the air/bone gaps after the operation closed totally or nearly totally. Such a proper outcome was reached in 93 out of 111 ears operated, 83.8%. In most of remainder ears the gaps after the operation narrowed significantly but far not completely. The definite surgery failure happened in one case only, 0.9%. To balance the preserved middle-ear problems in non-perfect surgery cases, the hearing aids of bone-conduction types have been recommended. In mixed otosclerosis cases, conversely, the aids of air-conduction types were advised to overcome the coexisted inner-ear pathologies.

Surgical site infection in lumbar surgeries, pre and postoperative antibiotics and length of stay: a case study.

PubMed

Khan, Inayat Ullah; Janjua, Muhammad Burhanuddin; Hasan, Shumaila; Shah, Shahid

2009-01-01

Postoperative wound infection also called as surgical site infection (SSI), is a trouble some complication of lumbar spine surgeries and they can be associated with serious morbidities, mortalities and increase resource utilization. With the improvement in diagnostic modalities, proper surgical techniques, antibiotic therapy and postoperative care, infectious complications can result in various compromises afterwards. The objective was to study the relation of surgical site infection in clean lumbar surgeries with the doses of antibiotics. This Retrospective study was conducted at Shifa International Hospital, from January 2006 to March 2008. Hundred post operated cases of lumber disc prolapse, lumbar stenosis or both studied retrospectively by tracing their operated data from hospital record section for the development of surgical site infection (SSI). The patients were divided into three groups depending upon whether they received single, three or more than three doses of antibiotics respectively. Complete data analyses and cross tabulation done with SPSS version 16. Of 100 cases, only 6% had superficial surgical site infection; only 1 case with co morbidity of hypertension was detected. Twenty-one cases had single dose of antibiotic (Group-I), 59 cases had 3 doses (Group-II) and 20 cases received multiple doses (Group-III). There was no infection in Group-I. Only one patient in Group-II and 5 patients in Group-III developed superficial SSI. While 4 in Group-II, 3 in Group-III, and none of Group-I had > 6 days length of stay (LOS). The dose of antibiotic directly correlates with the surgical site infection in clean lumbar surgeries. When compared with multiple doses of antibiotics a single preoperative shot of antibiotic is equally effective for patients with SSI.

Fecal incontinence after minor anorectal surgery.

PubMed

Zbar, A P; Beer-Gabel, M; Chiappa, A C; Aslam, M

2001-11-01

Fecal leakage after open lateral internal anal sphincterotomy for chronic anal fissure is common, but underreported. The aim of this study was to prospectively assess the physiologic and morphologic effects of sphincterotomy, comparing continent and incontinent patients after surgery. This group was further compared with an unselected group of patients presenting with incontinence after hemorrhoidectomy. Between January 1997 and June 1999, 23 patients were prospectively followed up through internal sphincterotomy with conventional and vector volume anorectal manometry, parametric assessment of the rectoanal inhibitory reflex, and endoanal magnetic resonance imaging. Fourteen continent patients were compared with 9 incontinent postoperative cases, 9 patients referred with incontinence after hemorrhoidectomy, and 33 healthy volunteers without anorectal disease. Significant differences were noted between continent and incontinent postsphincterotomy cases for all resting conventional and vector volume parameters and for some squeeze parameters. Although there was a significant reduction in postoperative high pressure zone length at rest, there were no differences between the postoperative groups. There was an increase in sphincter asymmetry of 6.7 percent (+/- 3.5 percent) in incontinent postsphincterotomy patients and a decrease of 2.8 percent (+/- 3.2 percent) in continent cases. Significant differences were noted for resting parameters between incontinent postsphincterotomy and posthemorrhoidectomy patients, with a higher resting sphincter asymmetry in the latter group. The area under the rectoanal inhibitory curve was smaller in postsphincterotomy incontinent patients when compared with continent cohorts over the distal and intermediate sphincter zones at rest with a reduced latency of inhibition. There was no difference in the magnetic resonance images of the sphincterotomy site between incontinent and continent postsphincterotomy cases and no posthemorrhoidectomy case had evidence of sphincteric damage. There are complex significant differences in the postoperative physiology of patients undergoing lateral internal sphincterotomy who become incontinent when compared with those who maintain continence. These physiologic changes are not reflected in detectable morphologic sphincteric differences. It is unknown whether these changes predict for long-term incontinence, and it is suggested that postoperative incontinence after minor anorectal surgery is not necessarily related either to a preexisting sphincter defect or inadvertent intraoperative sphincter injury.

Tranexamic Acid in cardiac surgery and postoperative seizures: a case report series.

PubMed

Bell, David; Marasco, Silvana; Almeida, Aubrey; Rowland, Michael

2010-08-01

With the recent withdrawal of the antifibrinolytic aprotinin from the market, tranexamic acid (TxA) has become more widely used. This change has led to increasing concern about the side-effect profile of TxA, particularly the incidence of postoperative seizures. In this case series, we describe 7 patients over an 18-month period who had open-chamber cardiac surgery and developed seizures in the postoperative period. This incidence is increased compared with that of a cohort of patients in the previous 36 months who did not receive TxA (0.66% versus 0%; P < .05). The exact mechanism of TxA-induced seizures is thought to be via inhibition of gamma-aminobutyric acid receptors in neurons. Data from the neurosurgical literature show a well-established link between this antifibrinolytic and seizures. There is now increasing awareness of this association in cardiac surgery, particularly when high TxA doses are used.

Pharyngoesophageal perforation 3 years after anterior cervical spine surgery: a rare case report and literature review.

PubMed

Yin, Dan-Hui; Yang, Xin-Ming; Huang, Qi; Yang, Mi; Tang, Qin-Lai; Wang, Shu-Hui; Wang, Shuang; Liu, Jia-Jia; Yang, Tao; Li, Shi-Sheng

2015-08-01

Pharyngoesophageal perforation after anterior cervical spine surgery is rare and the delayed cases were more rarely reported but potentially life-threatening. We report a case of pharyngoesophageal perforation 3 years after anterior cervical spine surgery. The patient presented with dysphagia, fever, left cervical mass and developing dyspnea 3 years after cervical spine surgery for trauma. After careful examinations, he underwent an emergency tracheostomy, neck exploration, hardware removal, abscess drainage and infected tissue debridement. 14 days after surgery, CT of the neck with oral contrast demonstrated no contrast extravasation from the esophagus. Upon review of literature, only 14 cases of pharyngoesophageal perforation more than 1 year after anterior cervical spine surgery were found. We discussed possible etiology, diagnosis and management and concluded that in cases of dysphagia, dyspnea, cervical pain, swelling and edema of the cervical area even long time after anterior cervical spine surgery, potential pharyngoesophageal damage should be considered.

Clinicopathological analysis of colorectal cancer: a comparison between emergency and elective surgical cases.

PubMed

Ghazi, Sam; Berg, Elisabeth; Lindblom, Annika; Lindforss, Ulrik

2013-06-11

Approximately 15 to 30% of colorectal cancers present as an emergency, most often as obstruction or perforation. Studies report poorer outcome for patients who undergo emergency compared with elective surgery, both for their initial hospital stay and their long-term survival. Advanced tumor pathology and tumors with unfavorable histologic features may provide the basis for the difference in outcome. The aim of this study was to compare the clinical and pathologic profiles of emergency and elective surgical cases for colorectal cancer, and relate these to gender, age group, tumor location, and family history of the disease. The main outcome measure was the difference in morphology between elective and emergency surgical cases. In total, 976 tumors from patients treated surgically for colorectal cancer between 2004 and 2006 in Stockholm County, Sweden (8 hospitals) were analyzed in the study. Seventeen morphological features were examined and compared with type of operation (elective or emergency), gender, age, tumor location, and family history of colorectal cancer by re-evaluating the histopathologic features of the tumors. In a univariate analysis, the following characteristics were found more frequently in emergency compared with elective cases: multiple tumors, higher American Joint Committee on Cancer (AJCC), tumor (T) and node (N) stage, peri-tumor lymphocytic reaction, high number of tumor-infiltrating lymphocytes, signet-ring cell mucinous carcinoma, desmoplastic stromal reaction, vascular and perineural invasion, and infiltrative tumor margin (P<0.0001 for AJCC stage III to IV, N stage 1 to 2/3, and vascular invasion). In a multivariate analysis, all these differences, with the exception of peri-tumor lymphocytic reaction, remained significant (P<0.0001 for multiple tumors, perineural invasion, infiltrative tumor margin, AJCC stage III, and N stage 1 to 2/3). Colorectal cancers that need surgery as an emergency case generally show a more aggressive histopathologic profile and a more advanced stage than do elective cases. Essentially, no difference was seen in location, and therefore it is likely there would be no differences in macro-environment either. Our results could indicate that colorectal cancers needing emergency surgery belong to an inherently specific group with a different etiologic or genetic background.

Laparoscopic and Robotic Total Mesorectal Excision in the Treatment of Rectal Cancer. Brief Review and Personal Remarks

PubMed Central

Bianchi, Paolo Pietro; Petz, Wanda; Luca, Fabrizio; Biffi, Roberto; Spinoglio, Giuseppe; Montorsi, Marco

2014-01-01

The current standard treatment for rectal cancer is based on a multimodality approach with preoperative radiochemotherapy in advanced cases and complete surgical removal through total mesorectal excision (TME). The most frequent surgical approach is traditional open surgery, as laparoscopic TME requires high technical skill, a long learning curve, and is not widespread, still being confined to centers with great experience in minimally invasive techniques. Nevertheless, in several studies, the laparoscopic approach, when compared to open surgery, has shown some better short-term clinical outcomes and at least comparable oncologic results. Robotic surgery for the treatment of rectal cancer is an emerging technique, which could overcome some of the technical difficulties posed by standard laparoscopy, but evidence from the literature regarding its oncologic safety and clinical outcomes is still lacking. This brief review analyses the current status of minimally invasive surgery for rectal cancer therapy, focusing on oncologic safety and the new robotic approach. PMID:24834429

Preoperative biological therapy and short-term outcomes of abdominal surgery in patients with inflammatory bowel disease.

PubMed

Waterman, Matti; Xu, Wei; Dinani, Amreen; Steinhart, A Hillary; Croitoru, Kenneth; Nguyen, Geoffrey C; McLeod, Robin S; Greenberg, Gordon R; Cohen, Zane; Silverberg, Mark S

2013-03-01

Previous investigations of short-term outcomes after preoperative exposure to biological therapy in inflammatory bowel disease (IBD) were conflicting. The authors aimed to assess postoperative outcomes in patients who underwent abdominal surgery with recent exposure to anti-tumour necrosis factor therapy. A retrospective case-control study with detailed matching was performed for subjects with IBD with and without exposure to biologics within 180 days of abdominal surgery. Postoperative outcomes were compared between the groups. 473 procedures were reviewed consisting of 195 patients with exposure to biologics and 278 matched controls. There were no significant differences in most postoperative outcomes such as: length of stay, fever (≥ 38.5°C), urinary tract infection, pneumonia, bacteraemia, readmission, reoperations and mortality. On univariate analysis, procedures on biologics had more wound infections compared with controls (19% vs 11%; p=0.008), but this was not significant in multivariate analysis. Concomitant therapy with biologics and thiopurines was associated with increased frequencies of urinary tract infections (p=0.0007) and wound infections (p=0.0045). Operations performed ≤ 14 days from last biologic dose had similar rates of infections and other outcomes when compared with those performed within 15-30 days or 31-180 days. Patients with detectable preoperative infliximab levels had similar rates of wound infection compared with those with undetectable levels (3/10 vs 0/9; p=0.21). Preoperative treatment with TNF-α antagonists in patients with IBD is not associated with most early postoperative complications. A shorter time interval from last biological dose is not associated with increased postoperative complications. In most cases, surgery should not be delayed, and appropriate biological therapy may be continued perioperatively.

Onyx versus nBCA and coils in the treatment of intracranial dural arteriovenous fistulas

PubMed Central

Choo, Douglas M

2016-01-01

Background and purpose Intracranial dural arteriovenous fistulas (DAVFs) with cortical venous drainage have significant morbidity and mortality. Complete closure of these lesions is necessary to reduce these risks. The purpose of our study was to compare the outcome of DAVFs treated with Onyx versus those treated with n-Butyl Cyanoacrylate (nBCA) and coil embolization in a case-control study. Compared with nBCA and coil embolization, we hypothesized that Onyx embolization for DAVF is safer and has a higher chance of complete obliteration, with no need for post-embolization surgery for the DAVF. Materials and methods From 1998 to 2015, 29 patients who had DAVFs were treated with endovascular embolization. Of these, 24 patients had imaging available for analysis. Successful closure rates, complications, and procedure time were compared between the embolization techniques. Results The chance of not requiring post-embolization surgery with Onyx (81.8%) was significantly higher (p = 0.005) than with nBCA (22.22%). The complication rate with Onyx (9.1%) tended to be lower compared with that of nBCA (22.22%; p = 0.37). Procedural time was not significantly different between Onyx (mean 267 minutes) and nBCA (mean 288 minutes) (p = 0.59). The odds ratio of a DAVF being treated with Onyx and then requiring no follow-up surgery was 17.5 (95% CI 1.97–155.4). Conclusion Our case-control study suggests that Onyx embolization is superior to nBCA and coil embolization in completely obliterating DAVFs, with higher odds of no post-embolization surgery. We also found that Onyx is safe for embolization of DAVFs, with no associated neurological mortality and morbidity. PMID:26748082

Onyx versus nBCA and coils in the treatment of intracranial dural arteriovenous fistulas.

PubMed

Choo, Douglas M; Shankar, Jai Jai Shiva

2016-04-01

Intracranial dural arteriovenous fistulas (DAVFs) with cortical venous drainage have significant morbidity and mortality. Complete closure of these lesions is necessary to reduce these risks. The purpose of our study was to compare the outcome of DAVFs treated with Onyx versus those treated with n-Butyl Cyanoacrylate (nBCA) and coil embolization in a case-control study. Compared with nBCA and coil embolization, we hypothesized that Onyx embolization for DAVF is safer and has a higher chance of complete obliteration, with no need for post-embolization surgery for the DAVF. From 1998 to 2015, 29 patients who had DAVFs were treated with endovascular embolization. Of these, 24 patients had imaging available for analysis. Successful closure rates, complications, and procedure time were compared between the embolization techniques. The chance of not requiring post-embolization surgery with Onyx (81.8%) was significantly higher (p = 0.005) than with nBCA (22.22%). The complication rate with Onyx (9.1%) tended to be lower compared with that of nBCA (22.22%; p = 0.37). Procedural time was not significantly different between Onyx (mean 267 minutes) and nBCA (mean 288 minutes) (p = 0.59). The odds ratio of a DAVF being treated with Onyx and then requiring no follow-up surgery was 17.5 (95% CI 1.97-155.4). Our case-control study suggests that Onyx embolization is superior to nBCA and coil embolization in completely obliterating DAVFs, with higher odds of no post-embolization surgery. We also found that Onyx is safe for embolization of DAVFs, with no associated neurological mortality and morbidity. © The Author(s) 2016.

Navigated transcranial magnetic stimulation for glioma removal: prognostic value in motor function recovery from postsurgical neurological deficits.

PubMed

Takakura, Tomokazu; Muragaki, Yoshihiro; Tamura, Manabu; Maruyama, Takashi; Nitta, Masayuki; Niki, Chiharu; Kawamata, Takakazu

2017-10-01

OBJECTIVE The aim of the present study was to evaluate the usefulness of navigated transcranial magnetic stimulation (nTMS) as a prognostic predictor for upper-extremity motor functional recovery from postsurgical neurological deficits. METHODS Preoperative and postoperative nTMS studies were prospectively applied in 14 patients (mean age 39 ± 12 years) who had intraparenchymal brain neoplasms located within or adjacent to the motor eloquent area in the cerebral hemisphere. Mapping by nTMS was done 3 times, i.e., before surgery, and 1 week and 3 weeks after surgery. To assess the response induced by nTMS, motor evoked potential (nTMS-MEP) was recorded using a surface electromyography electrode attached to the abductor pollicis brevis (APB). The cortical locations that elicited the largest electromyography response by nTMS were defined as hotspots. Hotspots for APB were confirmed as positive responsive sites by direct electrical stimulation (DES) during awake craniotomy. The distances between hotspots and lesions (D HS-L ) were measured. Postoperative neurological deficits were assessed by manual muscle test and dynamometer. To validate the prognostic value of nTMS in recovery from upper-extremity paresis, the following were investigated: 1) the correlation between D HS-L and the serial grip strength change, and 2) the correlation between positive nTMS-MEP at 1 week after surgery and the serial grip strength change. RESULTS From the presurgical nTMS study, MEPs from targeted muscles were identified in 13 cases from affected hemispheres. In one case, MEP was not evoked due to a huge tumor. Among 9 cases from which intraoperative DES mapping for hand motor area was available, hotspots for APB identified by nTMS were concordant with DES-positive sites. Compared with the adjacent group (D HS-L < 10 mm, n = 6), the nonadjacent group (D HS-L ≥ 10 mm, n = 7) showed significantly better recovery of grip strength at 3 months after surgery (p < 0.01). There were correlations between D HS-L and recovery of grip strength at 1 week, 3 weeks, and 3 months after surgery (r = 0.74, 0.68, and 0.65, respectively). Postsurgical nTMS was accomplished in 13 patients. In 9 of 13 cases, nTMS-MEP from APB muscle was positive at 1 week after surgery. Excluding the case in which nTMS-MEP was negative from the presurgical nTMS study, recoveries in grip strength were compared between 2 groups, in which nTMS-MEP at 1 week after surgery was positive (n = 9) or negative (n = 3). Significant differences were observed between the 2 groups at 1 week, 3 weeks, and 3 months after surgery (p < 0.01). Positive nTMS-MEP at 1 week after surgery correlated well with the motor recovery at 1 week, 3 weeks, and 3 months after surgery (r = 0.87, 0.88, and 0.77, respectively). CONCLUSIONS Navigated TMS is a useful tool for identifying motor eloquent areas. The results of the present study have demonstrated the predictive value of nTMS in upper-extremity motor function recovery from postsurgical neurological deficits. The longer D HS-L and positive nTMS-MEP at 1 week after surgery have prognostic values of better recovery from postsurgical neurological deficits.

Laparoscopic surgery for complicated diverticular disease: a single-centre experience.

PubMed

Royds, J; O'Riordan, J M; Eguare, E; O'Riordan, D; Neary, P C

2012-10-01

The role of laparoscopic surgery in the management of patients with diverticular disease is still not universally accepted. The aim of our study was to evaluate the results of laparoscopic surgery for diverticular disease in a centre with a specialist interest in minimally invasive surgery. All diverticular resections carried out between 2006 and 2010 were reviewed. Data recorded included baseline demographics, indication for surgery, operative details, length of hospital stay and complications. Complicated diverticular disease was defined as diverticulitis with associated abscess, phlegmon, fistula, stricture, obstruction, bleeding or perforation. One hundred and two patients (58 men) who had surgery for diverticular disease were identified (median age 59 years, range 49-70 years). Sixty-four patients (64%) had surgery for complicated diverticular disease. The indications were recurrent acute diverticulitis (37%), colovesical fistula (21%), stricture formation (17%) and colonic perforation (16%). Sixty-nine cases (88%) were completed by elective laparoscopy. Postoperative mortality was 0%. For elective cases there was no difference in morbidity rates between patients with complicated and uncomplicated diverticular disease. The overall anastomotic leakage rate was 1% and the wound infection rate 7%. There was a nonsignificant trend to higher conversion to open surgery in the elective group in complicated (11.4%) compared with uncomplicated patients (5.2%) (P=0.67). Electively, the rate of stoma formation was higher in the complicated (31.6%) than the uncomplicated group (5.2%) (P<0.02). Laparoscopic surgery for both complicated and uncomplicated diverticular disease is associated with low rates of postoperative morbidity and relatively low conversion rates. Laparoscopic surgery is now the standard of care for complicated and uncomplicated diverticular disease in our institution. © 2011 The Authors. Colorectal Disease © 2011 The Association of Coloproctology of Great Britain and Ireland.

The effect of expedited rotator cuff surgery in injured workers: a case-control study.

PubMed

Razmjou, Helen; Lincoln, Sandra; Boljanovic, Dragana; Gallay, Stephen; Henry, Patrick; Richards, Robin R; Holtby, Richard

2017-07-01

Expediting rotator cuff surgery is expected to facilitate recovery and return to work in injured workers. This case-control study examined the effect of expedited rotator cuff surgery on recovery and work status in injured workers. Injured workers who had undergone an expedited rotator cuff surgery funded by parallel-pay insurance (study group) were compared with workers who had used the public health insurance (control group) while adjusting for sex, age, severity of pathology, and follow-up period. Disability was measured by the American Shoulder and Elbow Surgeons (ASES) Standardized Assessment Form score. The percentage of patients who exceeded the minimal clinically important difference of 17 points in the ASES was calculated. The study group waited less time to have surgery than the control group (P < .0001), reported less disability after surgery, and had a higher number of patients whose improvement exceeded the minimal clinically important difference (119 vs. 65, P < .0001). The study group was more likely to be working at the time of the final follow-up (P < .0001). The final multivariable regressions, which adjusted for unmatched variables, such as dominant side involvement, mechanism of injury, and associated operations that were different between groups, were consistent with univariable analyses indicating superior results in the study group. Injured workers who underwent expedited rotator cuff surgery reported less disability and had a more successful return to work after surgery than injured workers who waited longer for specialist assessment and surgery within the public health system. Copyright © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.

Multimodal intraoperative neuromonitoring in corrective surgery for adolescent idiopathic scoliosis: Evaluation of 354 consecutive cases

PubMed Central

Kundnani, Vishal K; Zhu, Lisa; Tak, HH; Wong, HK

2010-01-01

Background: Multimodal intraoperative neuromonitoring is recommended during corrective spinal surgery, and has been widely used in surgery for spinal deformity with successful outcomes. Despite successful outcomes of corrective surgery due to increased safety of the patients with the usage of spinal cord monitoring in many large spine centers, this modality has not yet achieved widespread popularity. We report the analysis of prospectively collected intraoperative neurophysiological monitoring data of 354 consecutive patients undergoing corrective surgery for adolescent idiopathic scoliosis (AIS) to establish the efficacy of multimodal neuromonitoring and to evaluate comparative sensitivity and specificity. Materials and Methods: The study group consisted of 354 (female = 309; male = 45) patients undergoing spinal deformity corrective surgery between 2004 and 2008. Patients were monitored using electrophysiological methods including somatosensory-evoked potentials and motor-evoked potentials simultaneously. Results: Mean age of patients was 13.6 years (±2.3 years). The operative procedures involved were instrumented fusion of the thoracic/lumbar/both curves, Baseline somatosensory-evoked potentials (SSEP) and neurogenic motor-evoked potentials (NMEP) were recorded successfully in all cases. Thirteen cases expressed significant alert to prompt reversal of intervention. All these 13 cases with significant alert had detectable NMEP alerts, whereas significant SSEP alert was detected in 8 cases. Two patients awoke with new neurological deficit (0.56%) and had significant intraoperative SSEP + NMEP alerts. There were no false positives with SSEP (high specificity) but 5 patients with false negatives with SSEP (38%) reduced its sensitivity. There was no false negative with NMEP but 2 of 13 cases were false positive with NMEP (15%). The specificity of SSEP (100%) is higher than NMEP (96%); however, the sensitivity of NMEP (100%) is far better than SSEP (51%). Due to these results, the overall sensitivity, specificity and positive predictive value of combined multimodality neuromonitoring in this adult deformity series was 100, 98.5 and 85%, respectively. Conclusion: Neurogenic motor-evoked potential (NMEP) monitoring appears to be superior to conventional SSEP monitoring for identifying evolving spinal cord injury. Used in conjunction, the sensitivity and specificity of combined neuromonitoring may reach up to 100%. Multimodality monitoring with SSEP + NMEP should be the standard of care. PMID:20165679

Increased incidence of myelodysplastic syndrome and acute myeloid leukemia following breast cancer treatment with radiation alone or combined with chemotherapy: a registry cohort analysis 1990-2005.

PubMed

Kaplan, Henry G; Malmgren, Judith A; Atwood, Mary K

2011-06-21

Our objective was to measure myelodysplastic syndrome (MDS) and acute myelogenous leukemia (AML) risk associated with radiation and/or chemotherapy breast cancer (BC) treatment. Our study cohort was composed of BC patients diagnosed from 1990 to 2005 and followed up for blood disorders, mean length of follow up = 7.17 years, range 2-18 years. 5790 TNM stage 0-III patients treated with surgery alone, radiation and/or chemotherapy were included. Patients without surgery (n = 111), with stem cell transplantation (n = 98), unknown or non-standard chemotherapy regimens (n = 94), lost to follow up (n = 66) or 'cancer status unknown' (n = 67) were excluded. Rates observed at our community based cancer care institution were compared to SEER incidence data for rate ratio (RR) calculations. 17 cases of MDS/AML (10 MDS/7 AML) occurred during the follow up period, crude rate .29% (95% CI = .17, .47), SEER comparison RR = 3.94 (95% CI = 2.34, 6.15). The RR of MDS in patients age < 65 comparing our cohort incidence to SEER incidence data was 10.88 (95% CI = 3.84, 24.03) and the RR of AML in patients age < 65 was 5.32 (95% CI = 1.31, 14.04). No significant increased risk of MDS or AML was observed in women ≥ 65 or the surgery/chemotherapy-only group. A RR of 3.32 (95% CI = 1.42, 6.45) was observed in the surgery/radiation-only group and a RR of 6.32 (95% CI = 3.03, 11.45) in the surgery/radiation/chemotherapy group. 3 out of 10 MDS cases died of disease at an average 3.8 months post diagnosis and five of seven AML cases died at an average 9 months post diagnosis. An elevated rate of MDS and AML was observed among breast cancer patients < 65, those treated with radiation and those treated with radiation and chemotherapy compared to available population incidence data. Although a small number of patients are affected, leukemia risk associated with treatment and younger age is significant.

Impact of an Interactive Vascular Surgery Web-Based Educational Curriculum on Surgical Trainee Knowledge and Interest.

PubMed

Zayed, Mohamed A; Lilo, Emily A; Lee, Jason T

The surgical council on resident education developed an online competency-based self-study curriculum for general surgery residency trainees. Vascular surgery trainees are yet to have a similarly validated and readily accessible self-study curriculum. We sought to determine the effect of an interactive online vascular surgery curriculum on trainee knowledge and interest in vascular surgery. Over 15 months, 53 trainees (36 medical students and 16 surgical residents) performing a vascular surgery rotation were enrolled in a prospective, randomized, 2-cohort study. Before starting a 4-week rotation, trainee baseline demographics were collected, and a pretest was administered to evaluate baseline vascular surgery knowledge. During the same study period, 31 trainees (GROUP 1) were randomized to an interactive online curriculum with weekly reading assignments, and 21 trainees (GROUP 2) did not have access to the online curriculum. At the conclusion, all trainees received a posttest and survey to evaluate any change in vascular surgery knowledge and interest. Although 26.8% of trainees predicted that online computer modules would be a beneficial learning tool, most of trainees indicated textbook reading and case discussions are preferred. Analysis of GROUPS 1 and 2 revealed no significant differences in the average trainee age, training level, sex, or number of surgical cases observed during the rotation. Improvement in vascular surgery knowledge in GROUP 1 was significantly higher compared to GROUP 2 (average increase in posttest scores of 16.1% vs 6.6%, p = 0.009). New interest in vascular surgery was increased by 22.2% in GROUP 1, but was decreased by 40% in GROUP 2 (p < 0.001). Basic vascular surgery principles can be efficiently introduced through an interactive online curriculum. This type of self-study can improve trainee knowledge, and foster interest in vascular surgery. As in other specialties, a standardized and validated online vascular surgery curriculum should be developed for emerging trainees. Published by Elsevier Inc.

Pediatric epilepsy surgery: long-term 5-year seizure remission and medication use.

PubMed

Hauptman, Jason S; Pedram, Kayvon; Sison, Christia Angela; Sankar, Raman; Salamon, Noriko; Vinters, Harry V; Mathern, Gary W

2012-11-01

It is unclear whether long-term seizure outcomes in children are similar to those in adult epilepsy surgery patients. To determine 5-year outcomes and antiepilepsy drug (AED) use in pediatric epilepsy surgery patients from a single institution. The cohort consisted of children younger than 18 years of age whose 5-year outcome data would have been available by 2010. Comparisons were made between patients with and without 5-year data (n = 338), patients with 5-year data for seizure outcome (n = 257), and seizure-free patients on and off AEDs (n = 137). Five-year data were available from 76% of patients. More seizure-free patients with focal resections for hippocampal sclerosis and tumors lacked 5-year data compared with other cases. Of those with 5-year data, 53% were continuously seizure free, 18% had late seizure recurrence, 3% became seizure free after initial failure, and 25% were never seizure free. Patients were more likely to be continuously seizure free if their surgery was performed during the period 2001 to 2005 (68%) compared with surgery performed from 1996 to 2000 (61%), 1991 to 1995 (36%), and 1986 to 1990 (46%). More patients had 1 or fewer seizures per month in the late seizure recurrence (47%) compared with the not seizure-free group (20%). Four late deaths occurred in the not seizure-free group compared with 1 in the seizure-free group. Of patients who were continuously seizure free, 55% were not taking AEDs, and more cortical dysplasia patients (74%) had stopped taking AEDs compared with hemimegalencephaly patients (18%). In children, 5-year outcomes improved over 20 years of clinical experience. Our results are similar to those of adult epilepsy surgery patients despite mostly extratemporal and hemispheric operations for diverse developmental etiologies.

Robotic assisted versus pure laparoscopic surgery of the adrenal glands: a case-control study comparing surgical techniques.

PubMed

Morelli, Luca; Tartaglia, Dario; Bronzoni, Jessica; Palmeri, Matteo; Guadagni, Simone; Di Franco, Gregorio; Gennai, Andrea; Bianchini, Matteo; Bastiani, Luca; Moglia, Andrea; Ferrari, Vincenzo; Fommei, Enza; Pietrabissa, Andrea; Di Candio, Giulio; Mosca, Franco

2016-11-01

The role of the da Vinci Robotic System ® in adrenal gland surgery is not yet well defined. The goal of this study was to compare robotic-assisted surgery with pure laparoscopic surgery in a single center. One hundred and 16 patients underwent minimally invasive adrenalectomies in our department between June 1994 and December 2014, 41 of whom were treated with a robotic-assisted approach (robotic adrenalectomy, RA). Patients who underwent RA were matched according to BMI, age, gender, and nodule dimensions, and compared with 41 patients who had undergone laparoscopic adrenalectomies (LA). Statistical analysis was performed using the Student's t test for independent samples, and the relationship between the operative time and other covariates were evaluated with a multivariable linear regression model. P < 0.05 was considered significant. Mean operative time was significantly shorter in the RA group compared to the LA group. The subgroup analysis showed a shorter mean operative time in the RA group in patients with nodules ≥6 cm, BMI ≥ 30 kg/m 2 and in those who had previous abdominal surgery (p < 0.05). Results from the multiple regression model confirmed a shorter mean operative time with RA with nodules ≥6 cm (p = 0.010). Conversion rate and postoperative complications were 2.4 and 4.8 % in the LA group and 0 and 4.8 % in the RA group. In our experience, RA shows potential benefits compared to classic LA, in particular on patients with nodules ≥6 cm, BMI ≥ 30 kg/m2, and with previous abdominal surgery.

Randomized controlled trial of stereotactic 11-G vacuum-assisted core biopsy for the diagnosis and management of mammographic microcalcification

PubMed Central

Maxwell, Anthony J; Morris, Julie; Lim, Yit Y; Harake, MD Janick; Whiteside, Sigrid

2016-01-01

Objective: To compare the accuracy of 11-G vacuum-assisted biopsy (VAB) with 14-G core needle biopsy (CNB) to diagnose mammographic microcalcification (MM) and effect on surgical outcomes. Methods: Following ethical approval, VAB and CNB (control) were compared in a randomized prospective study for first-line diagnosis of MM and subsequent surgical outcomes in two breast-screening units. Participants gave written informed consent. Exclusions included comorbidity precluding surgery, prior ipsilateral breast cancer and lesions >40 mm requiring mastectomy as first surgical procedure. The final pathological diagnosis was compared with the initial biopsy result. Quality-of-life (QOL) questionnaires were administered at baseline, 2, 6 and 12 months. 110 participants were required to show a 25% improvement in diagnosis with VAB compared with CNB (90% power). Results: Eligibility was assessed for 787 cases; 129 females recalled from the National Health Service breast screening programme were randomized. Diagnostic accuracy of VAB was 86% and that of CNB was 84%. Using VAB, 2/14 (14.3%) cases upgraded from ductal carcinoma in situ to invasion at surgery and 3/19 (15.8%) using CNB. Following VAB 7/16 (44%) cases required repeat surgery vs 7/24 (29%) after CNB. Both groups recorded significant worsening of functional QOL measures and increased breast pain at follow-up. Conclusion: VAB and CNB were equally accurate at diagnosing MM, and no significant differences in surgical outcomes were observed. Advances in knowledge: The first randomized controlled study of VAB for diagnosis of microcalcification using digital mammography showed no difference in diagnostic accuracy of VAB and CNB, or in the proportion of participants needing repeat non-operative biopsy or second therapeutic operation to treat malignancy. PMID:26654214

Endoscopic Transsphenoidal Surgery Outcomes in 331 Nonfunctioning Pituitary Adenoma Cases After a Single Surgeon Learning Curve.

PubMed

Kim, Jung Hee; Lee, Jung Hyun; Lee, Ji Hyun; Hong, A Ram; Kim, Yoon Ji; Kim, Yong Hwy

2018-01-01

The outcomes of recent endoscopic surgery of nonfunctioning pituitary adenomas (NFPAs) are controversial when compared with traditional microscopic surgery. We aimed to assess the outcomes of endoscopic transsphenoidal surgeries performed by 1 surgeon with 7 years of experience and elucidate the predictive factors for surgical outcomes for NFPAs. We included 331 patients (155 men and 176 women) with clinical NFPAs who underwent transsphenoidal surgery because of visual symptoms by a single surgeon in Seoul National University Hospital from March 2010 to May 2016. We assessed the tumor removal rate, hormonal outcomes, visual outcomes, and complications. The gross total resection rate of endoscopic transsphenoidal surgery for NFPAs by a single surgeon was 74.9%. Cavernous sinus invasion, a high Knosp grade, large tumor size, previous surgery, and lack of surgical experience in the neurosurgeon elevated the risk for residual tumors. Visual deficits were improved in 73.4% of the patients, which was associated with tumor size, preoperative visual impairment score, previous radiation, and surgical experience. Hormonal status was improved in 15.4% and aggravated in 32.9% after surgery. There were no predictors for hormonal recovery. Transient diabetes insipidus (DI) was the most common complication (9.1%), and among these patients, 3.0% had persistent DI. Endoscopic transsphenoidal surgery by a well-experienced surgeon was an effective and safe treatment for NFPAs, but the hormonal outcomes were not changed compared with previous reports of microscopic surgery. Large tumor size and cavernous sinus invasion were still the barriers for achieving total resection. Copyright © 2017 Elsevier Inc. All rights reserved.

The Efficacy of Thoracic Ultrasonography in Postoperative Newborn Patients after Cardiac Surgery

PubMed Central

Ozturk, Erkut; Tanidir, Ibrahim Cansaran; Yildiz, Okan; Ergul, Yakup; Guzeltas, Alper

2017-01-01

Objective In this study, the efficacy of thoracic ultrasonography during echocardiography was evaluated in newborns. Methods Sixty newborns who had undergone pediatric cardiac surgery were successively evaluated between March 1, 2015, and September 1, 2015. Patients were evaluated for effusion, pulmonary atelectasis, and pneumothorax by ultrasonography, and results were compared with X-ray findings. Results Sixty percent (n=42) of the cases were male, the median age was 14 days (2-30 days), and the median body weight was 3.3 kg (2.8-4.5 kg). The median RACHS-1 score was 4 (2-6). Atelectasis was demonstrated in 66% (n=40) of the cases. Five of them were determined solely by X-ray, 10 of them only by ultrasonography, and 25 of them by both ultrasonography and X-ray. Pneumothorax was determined in 20% (n=12) of the cases. Excluding one case determined by both methods, all of the 11 cases were diagnosed by X-ray. Pleural effusion was diagnosed in 26% (n=16) of the cases. Four of the cases were demonstrated solely by ultrasonography, three of them solely by X-ray, and nine of the cases by both methods. Pericardial effusion was demonstrated in 10% (n=6) of the cases. Except for one of the cases determined by both methods, five of the cases were diagnosed by ultrasonography. There was a moderate correlation when all pathologies evaluated together (k=0.51). Conclusion Thoracic ultrasonography might be a beneficial non-invasive method to evaluate postoperative respiratory problems in newborns who had congenital cardiac surgery. PMID:28977200

Review analysis of medullary carcinoma of the thyroid: a 15-year Indian experience.

PubMed

Dorairajan, N; Siddharth, D; Kanna, Srinivasulu

2006-01-01

The aim of this study was to emphasize the importance of adequate primary surgery in cases of medullary carcinoma of the thyroid. We retrospectively reviewed 44 cases of medullary carcinoma of the thyroid treated in Government General Hospital, Chennai between 1987 and 2002. Patients who underwent total thyroidectomy with only central compartment dissection were compared with those who had undergone total thyroidectomy with meticulous triple compartment (bilateral lateral and central groups) nodal dissection. The group of total thyroidectomy with only central compartment dissection had a high rate of lymph nodal recurrence and persistent hypercalcitoninemia compared with the group with total thyroidectomy with meticulous triple compartment nodal dissection. (chi square, 4.503; P > 0.05). Primary surgery with total thyroidectomy with meticulous triple compartment dissection is superior to total thyroidectomy with central compartment dissection alone in terms of preventing nodal and local recurrences and achieving normal (basal and stimulated) serum calcitonin levels postoperatively.

[Reconstruction of an iatrogenic acromial pseudarthrosis: a case report].

PubMed

Liodakis, E; Kenawey, M; Petri, M; Liodaki, E; Hankemeier, S; Krettek, C; Jagodzinski, M

2011-06-01

Acromial fractures are rare but severe complications which can occur during subacromial decompression. We report a case of acromial pseudarthrosis which was discovered belatedly due to persistent pain after several operations. The pseudarthrosis was successfully treated by osteosynthesis with a distal radius plate and implantation of a monocortical bone graft from the iliac crest. Two years after surgery, the fracture has healed and the patient's pain improved significantly. In the constant score the patient achieved postoperatively 58 points compared to 25 points before surgery and 65 points compared to 25 points preoperatively in the subjective shoulder rating system (SSRS). Postoperatively, the patient had a better range of motion with active abduction/adduction of 50/0/25º (30/0/20° preoperatively), outward rotation/inward rotation of 35/0/45º (30/0/30° preoperatively) and anteversion/retroversion of 60/0/35° (35/0/20° preoperatively).

Comparison of single thickness and double thickness processed pericardium patch graft in glaucoma drainage device surgery: a single surgeon comparison of outcome.

PubMed

Lankaranian, Dara; Reis, Ricardo; Henderer, Jeffrey D; Choe, Sung; Moster, Marlene R

2008-01-01

To compare the incidence of conjuctival erosions with single thickness versus double thickness allograft processed pericardium used in mitomycin-C (MMC) augmented glaucoma drainage device (GDD) sugery. In a retrospective comparative case series, medical records of 84 consecutive glaucoma patients who underwent GDD surgery between July 1996 to December 2004 were reviewed. All surgeries were done by one glaucoma surgeon (M.R.M.). MMC was adminstered in all cases over the plate area and either single thickness processed pericardium patch graft (STPP) or double thickness processed pericardium patch graft (DTPP) was used to cover the external silicone tube of the glaucoma device at the limbus. The principal outcome measure was the incidence of conjunctival erosions associated with GDD surgery. Eighty-four patients (90 eyes) who met the eligibility criteria were enrolled in the study. Thirty-one consecutive eyes received a STPP, and 59 consecutive eyes received a DTPP. Five eyes (16.0%) in the STPP group developed conjunctival erosion. None of the eyes in DTPP group developed conjunctival erosion. The Mann-Whitney U test difference in the rate of conjunctival erosion was statistically significant between 2 groups (P=0.002). For the STPP group, the average time to conjunctival erosion was 9 months (range, 4 to 14 mo). All erosions were surgically corrected using DTPP and followed up for a mean of 8.6 months after repair with no additional conjunctival erosions. DTPP placed over the silicone tube significantly reduced the incidence of conjunctival erosion after MMC augmented GDD surgery.

The effect of a multidisciplinary regional educational programme on the quality of colon cancer resection.

PubMed

Sheehan-Dare, G E; Marks, K M; Tinkler-Hundal, E; Ingeholm, P; Bertelsen, C A; Quirke, P; West, N P

2018-02-01

Mesocolic plane surgery with central vascular ligation produces an oncologically superior specimen following colon cancer resection and appears to be related to optimal outcomes. We aimed to assess whether a regional educational programme in optimal mesocolic surgery led to an improvement in the quality of specimens. Following an educational programme in the Capital and Zealand areas of Denmark, 686 cases of primary colon cancer resected across six hospitals were assessed by grading the plane of surgery and undertaking tissue morphometry. These were compared to 263 specimens resected prior to the educational programme. Across the region, the mesocolic plane rate improved from 58% to 77% (P < 0.001). One hospital had previously implemented optimal surgery as standard prior to the educational programme and continued to produce a high rate of mesocolic plane specimens (68%) with a greater distance between the tumour and the high tie (median for all fresh cases: 113 vs 82 mm) and lymph node yield (33 vs 18) compared to the other hospitals. Three of the other hospitals showed a significant improvement in the plane of surgical resection. A multidisciplinary regional educational programme in optimal mesocolic surgery improved the oncological quality of colon cancer specimens as assessed by mesocolic planes; however, there was no significant effect on the amount of tissue resected centrally. Surgeons who attempt central vascular ligation continue to produce more radical specimens suggesting that such educational programmes alone are not sufficient to increase the amount of tissue resected around the tumour. Colorectal Disease © 2017 The Association of Coloproctology of Great Britain and Ireland.

Development of a Performance Improvement Program: A Workplace-Based Educational Intervention on Magnetic Resonance Imaging in Spinal Trauma.

PubMed

Kraus, Michael David; Mueller, Marguerite; Schmitz, Bernd; Cunningham, Michael; Gebhard, Florian

2016-01-01

Performance improvement (PI) programs are an educational tool used to analyze clinical performance of clinicians. The effect of this tool has not been fully explored in orthopedic and trauma surgery. A needs assessment was conducted in connection with a worldwide webinar on magnetic resonance imaging in spinal injuries to identify the clinical need for an educational intervention. A 3-step PI process was defined and implemented over a 6-month period in 1 hospital department. Opportunities for improvement were identified by applying a 10-item quality checklist to 26 cases. A focused educational intervention was delivered to address the identified gaps, and a set of 22 posteducation cases was compared. The department of radiology and the department of trauma surgery of a level I university hospital participated in this study. A total of 26 cases collected before the educational intervention showed several areas for potential improvement. Important information was not provided by the surgeons in their communication with the radiologist. The educational intervention outlined the data and suggested actions. Comparing the information transfer of the preintervention and postintervention data, there was a significant improvement following the intervention (p = 0.0013). Our PI program was able to demonstrate a significant influence on the behavior and the attitude of surgeons and radiologists. Copyright © 2016 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Comparison of time required for traditional versus virtual orthognathic surgery treatment planning.

PubMed

Wrzosek, M K; Peacock, Z S; Laviv, A; Goldwaser, B R; Ortiz, R; Resnick, C M; Troulis, M J; Kaban, L B

2016-09-01

Virtual surgical planning (VSP) is a tool for predicting complex surgical movements in three dimensions and it may reduce preoperative laboratory time. A prospective study to compare the time required for standard preoperative planning versus VSP was conducted at Massachusetts General Hospital from January 2014 through January 2015. Workflow data for bimaxillary cases planned by both standard techniques and VSP were recorded in real time. Time spent was divided into three parts: (1) obtaining impressions, face-bow mounting, and model preparation; (2) occlusal analysis and modification, model surgery, and splint fabrication; (3) online VSP session. Average times were compared between standard treatment planning (sum of parts 1 and 2) and VSP (sum of parts 1 and 3). Of 41 bimaxillary cases included, 20 were simple (symmetric) and 21 were complex (asymmetry and segmental osteotomies). Average times for parts 1, 2, and 3 were 4.43, 3.01, and 0.67h, respectively. The average time required for standard treatment planning was 7.45h and for VSP was 5.10h, a 31% time reduction (P<0.001). By eliminating all or some components of part 1, time savings may increase to as much as 91%. This study indicates that in an academic setting, VSP reduces the time required for treatment planning of bimaxillary orthognathic surgery cases. Copyright © 2016 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Optimal culture incubation time in orthopedic device-associated infections: a retrospective analysis of prolonged 14-day incubation.

PubMed

Schwotzer, Nora; Wahl, Peter; Fracheboud, Dominique; Gautier, Emanuel; Chuard, Christian

2014-01-01

Accurate diagnosis of orthopedic device-associated infections can be challenging. Culture of tissue biopsy specimens is often considered the gold standard; however, there is currently no consensus on the ideal incubation time for specimens. The aim of our study was to assess the yield of a 14-day incubation protocol for tissue biopsy specimens from revision surgery (joint replacements and internal fixation devices) in a general orthopedic and trauma surgery setting. Medical records were reviewed retrospectively in order to identify cases of infection according to predefined diagnostic criteria. From August 2009 to March 2012, 499 tissue biopsy specimens were sampled from 117 cases. In 70 cases (59.8%), at least one sample showed microbiological growth. Among them, 58 cases (82.9%) were considered infections and 12 cases (17.1%) were classified as contaminations. The median time to positivity in the cases of infection was 1 day (range, 1 to 10 days), compared to 6 days (range, 1 to 11 days) in the cases of contamination (P < 0.001). Fifty-six (96.6%) of the infection cases were diagnosed within 7 days of incubation. In conclusion, the results of our study show that the incubation of tissue biopsy specimens beyond 7 days is not productive in a general orthopedic and trauma surgery setting. Prolonged 14-day incubation might be of interest in particular situations, however, in which the prevalence of slow-growing microorganisms and anaerobes is higher.

Surgery or conservative treatment for rotator cuff tear: a meta-analysis.

PubMed

Ryösä, Anssi; Laimi, Katri; Äärimaa, Ville; Lehtimäki, Kaisa; Kukkonen, Juha; Saltychev, Mikhail

2017-07-01

Comparative evidence on treating rotator cuff tear is inconclusive. The objective of this review was to evaluate the evidence on effectiveness of tendon repair in reducing pain and improving function of the shoulder when compared with conservative treatment of symptomatic rotator cuff tear. Search on CENTRAL, MEDLINE, EMBASE, CINAHL, Web of Science and Pedro databases. Randomised controlled trials (RCT) comparing surgery and conservative treatment of rotator cuff tear. Study selection and extraction based on the Cochrane Handbook for Systematic reviews of Interventions. Random effects meta-analysis. Three identified RCTs involved 252 participants (123 cases and 129 controls). The risk of bias was considered low for all three RCTs. For Constant score, statistically insignificant effect size was 5.6 (95% CI -0.41 to 11.62) points in 1-year follow up favouring surgery and below the level of minimal clinically important difference. The respective difference in pain reduction was -0.93 (95% CI -1.65 to -0.21) cm on a 0-10 pain visual analogue scale favouring surgery. The difference was statistically significant (p = 0.012) in 1-year follow up but below the level of minimal clinically important difference. There is limited evidence that surgery is not more effective in treating rotator cuff tear than conservative treatment alone. Thus, a conservative approach is advocated as the initial treatment modality. Implications for Rehabilitation There is limited evidence that surgery is not more effective in treating rotator cuff tear than conservative treatment alone. There was no clinically significant difference between surgery and active physiotherapy in 1-year follow-up in improving Constant score or reducing pain caused by rotator cuff tear. As physiotherapy is less proneness to complications and less expensive than surgery, a conservative approach is advocated as the initial treatment modality to rotator cuff tears.

Surgical outcomes after epiretinal membrane peeling combined with cataract surgery.

PubMed

Yiu, Glenn; Marra, Kyle V; Wagley, Sushant; Krishnan, Sheela; Sandhu, Harpal; Kovacs, Kyle; Kuperwaser, Mark; Arroyo, Jorge G

2013-09-01

To compare functional and anatomical outcomes after idiopathic epiretinal membrane (ERM) peeling combined with phacoemulsification and intraocular lens implantation versus ERM peeling alone. A retrospective, non-randomised comparative case series study was conducted of 81 eyes from 79 patients who underwent ERM peeling at the Beth Israel Deaconess Medical Center between 2001 and 2010. Eyes that underwent combined surgery for ERM and cataracts (group 1) were compared with those that had ERM peeling alone (group 2) with respect to best-corrected visual acuity at 6 months and 1 year after surgery, postoperative central macular thickness (CMT) as measured on optical coherence tomography, and rates of complications, including elevated intraocular pressure (IOP), ERM recurrence and need for reoperation. Mean logMAR visual acuity improved significantly in both groups at 6 months (p<0.001) and 1 year (p<0.001) after surgery. There was no statistical difference between the two groups in visual acuity improvement at 6 months (p=0.108) or 1 year (p=0.094). Mean CMT of both groups also significantly decreased after surgery (p=0.002), with no statistical difference in CMT reduction between the two groups, but a trend toward less CMT reduction in group 1 (p=0.061). The rates of complications, including IOP elevation, ERM recurrence and frequency of reoperation, were similar in the two groups, with non-statistical trends toward greater ERM recurrence (p=0.084) and need for reoperation (p=0.096) in those that had combined surgery. Combined surgery for ERMs and cataracts may potentially be as effective as membrane peeling alone with respect to visual and anatomical outcomes. Further studies are necessary to determine if there may be greater ERM recurrence or need for reoperation after combined surgery.

Laparoscopic fundoplication compared with medical management for gastro-oesophageal reflux disease: cost effectiveness study.

PubMed

Epstein, David; Bojke, Laura; Sculpher, Mark J

2009-07-14

To describe the long term costs, health benefits, and cost effectiveness of laparoscopic surgery compared with those of continued medical management for patients with gastro-oesophageal reflux disease (GORD). We estimated resource use and costs for the first year on the basis of data from the REFLUX trial. A Markov model was used to extrapolate cost and health benefit over a lifetime using data collected in the REFLUX trial and other sources. The model compared laparoscopic surgery and continued proton pump inhibitors in male patients aged 45 and stable on GORD medication. Laparoscopic surgery versus continued medical management. We estimated quality adjusted life years and GORD related costs to the health service over a lifetime. Sensitivity analyses considered other plausible scenarios, in particular size and duration of treatment effect and the GORD symptoms of patients in whom surgery is unsuccessful. Main results The base case model indicated that surgery is likely to be considered cost effective on average with an incremental cost effectiveness ratio of pound2648 (euro3110; US$4385) per quality adjusted life year and that the probability that surgery is cost effective is 0.94 at a threshold incremental cost effectiveness ratio of pound20 000. The results were sensitive to some assumptions within the extrapolation modelling. Surgery seems to be more cost effective on average than medical management in many of the scenarios examined in this study. Surgery might not be cost effective if the treatment effect does not persist over the long term, if patients who return to medical management have poor health related quality of life, or if proton pump inhibitors were cheaper. Further follow-up of patients from the REFLUX trial may be valuable. ISRCTN15517081.

[Pterygium surgery and fibrin glue: avoiding dehiscence].

PubMed

Pérez-Silguero, D; Díaz-Ginory, A; Santana-Rodríguez, C; Pérez-Silguero, M A

2014-01-01

The purpose of the study is to evaluate those cases of pterygium surgery with fibrin sealant that produced dehiscence of the graft, and then apply and evaluate the efficacy of a different surgical technique in an attempt eliminate this complication in previously identified cases of high risk. The first phase is a retrospective study of 42 cases of pterygium surgery. In the second phase, the variation in the surgical technique was prospectively used in 14 cases of pterygium surgery. Cases of recurrent pterygium, broad pterygium, and complicated surgery were identified as the groups with a risk of suffering dehiscence of the graft. With the variant applied surgery no dehiscence occurred when using the variation in surgical technique, with no added complications. Copyright © 2012 Sociedad Española de Oftalmología. Published by Elsevier Espana. All rights reserved.

Direct non-medical costs double the total direct costs to patients undergoing cataract surgery in Zamfara state, Northern Nigeria: a case series.

PubMed

Ibrahim, Nazaradden; Pozo-Martin, Francisco; Gilbert, Clare

2015-04-16

Cost is frequently reported as a barrier to cataract surgery, but few studies have reported costs of accessing surgery in Africa. The purpose of this prospective, facility based study was to compare direct non-medical cost with total direct cost of cataract surgery to patients, and to assess how money was found to cover costs. Participants were those aged 17 years and above attending their first post-operative visit after first eye, subsidised, day case cataract surgery. Systematic random sampling was used to select participants who were interviewed to obtain data on socio-demographic details, and on expenditure during the assessment visit, the surgical visit, and the first follow-up visit. Costs were a) direct medical costs (patients' costs for registration, investigations, surgery, medication), and b) direct non-medical costs (patients' and escorts' costs for transport, accommodation, meals). The source of funds to pay for the services received was also assessed. Almost two thirds (63%) of the 104 participants were men. The mean age of men was 64 (± 12.5) years, being 63 (± 12.9) years for women. All men were married and 35% of women were widows. 84% of men were household heads compared with 6% of women. The median total direct cost for all visits by all participants was N8,245 (US$51), being higher for men than women (N9,020; US$56 and N7,620; US$47) (p < 0.09) respectively. Direct non-medical cost constituted 49% of total direct cost. 92% of participants had adequate money to pay, but 8% had to sell possessions to raise the money. 20% of unmarried women sold possessions or took out a loan. Despite the subsidy, cost is still likely to be a barrier to accessing cataract surgery, as the total direct costs represented at least 50 days income for 70% of the local population. Provision of transport would reduce direct non-medical costs.

Comparison of Plastic Surgery Residency Training in United States and China.

PubMed

Zheng, Jianmin; Zhang, Boheng; Yin, Yiqing; Fang, Taolin; Wei, Ning; Lineaweaver, William C; Zhang, Feng

2015-12-01

Residency training is internationally recognized as the only way for the physicians to be qualified to practice independently. China has instituted a new residency training program for the specialty of plastic surgery. Meanwhile, plastic surgery residency training programs in the United States are presently in a transition because of restricted work hours. The purpose of this study is to compare the current characteristics of plastic surgery residency training in 2 countries. Flow path, structure, curriculum, operative experience, research, and evaluation of training in 2 countries were measured. The number of required cases was compared quantitatively whereas other aspects were compared qualitatively. Plastic surgery residency training programs in 2 countries differ regarding specific characteristics. Requirements to become a plastic surgery resident in the United States are more rigorous. Ownership structure of the regulatory agency for residency training in 2 countries is diverse. Training duration in the United States is more flexible. Clinical and research training is more practical and the method of evaluation of residency training is more reasonable in the United States. The job opportunities after residency differ substantially between 2 countries. Not every resident has a chance to be an independent surgeon and would require much more training time in China than it does in the United States. Plastic surgery residency training programs in the United States and China have their unique characteristics. The training programs in the United States are more standardized. Both the United States and China may complement each other to create training programs that will ultimately provide high-quality care for all people.

A Computerized Microelectrode Recording to Magnetic Resonance Imaging Mapping System for Subthalamic Nucleus Deep Brain Stimulation Surgery.

PubMed

Dodani, Sunjay S; Lu, Charles W; Aldridge, J Wayne; Chou, Kelvin L; Patil, Parag G

2018-06-01

Accurate electrode placement is critical to the success of deep brain stimulation (DBS) surgery. Suboptimal targeting may arise from poor initial target localization, frame-based targeting error, or intraoperative brain shift. These uncertainties can make DBS surgery challenging. To develop a computerized system to guide subthalamic nucleus (STN) DBS electrode localization and to estimate the trajectory of intraoperative microelectrode recording (MER) on magnetic resonance (MR) images algorithmically during DBS surgery. Our method is based upon the relationship between the high-frequency band (HFB; 500-2000 Hz) signal from MER and voxel intensity on MR images. The HFB profile along an MER trajectory recorded during surgery is compared to voxel intensity profiles along many potential trajectories in the region of the surgically planned trajectory. From these comparisons of HFB recordings and potential trajectories, an estimate of the MER trajectory is calculated. This calculated trajectory is then compared to actual trajectory, as estimated by postoperative high-resolution computed tomography. We compared 20 planned, calculated, and actual trajectories in 13 patients who underwent STN DBS surgery. Targeting errors for our calculated trajectories (2.33 mm ± 0.2 mm) were significantly less than errors for surgically planned trajectories (2.83 mm ± 0.2 mm; P = .01), improving targeting prediction in 70% of individual cases (14/20). Moreover, in 4 of 4 initial MER trajectories that missed the STN, our method correctly indicated the required direction of targeting adjustment for the DBS lead to intersect the STN. A computer-based algorithm simultaneously utilizing MER and MR information potentially eases electrode localization during STN DBS surgery.

Magnetic resonance imaging in interventional therapy of patients with acute myocardial infarction prior to and after treatment

PubMed Central

Li, Yuzhou; Li, Chunrong; Jin, Hongrui; Huang, Wenqi

2016-01-01

The aim of the study was to investigate the cardiac magnetic resonance (CMR) imaging in interventional therapy of patients with acute myocardial infarction prior to and after treatment. Fifty-six cases of AMI patients with elective treatment by percutaneous coronary intervention (PCI) were continuously selected. Patients with an incidence of 7–10 days were treated with CMR and echocardiography to evaluate the quality of myocardial infarction, visual score method (VSM), wall motion score abnormality, left ventricular end-diastolic diameter (LVEDD), left ventricular end-systolic diameter (LVESD) and left ventricular ejection fraction (LVEF). Patients with an incidence of 10–14 days were treated with PCI, and CMR and echocardiography were evaluated after 6 months, after which the occurrence of major adverse cardiac events (MACE) were compared. The infarction quality, VSM score and wall motion abnormality (WMA) score were significantly reduced following surgery, and the difference was statistically significant (P<0.05). Ultrasound evaluation of LVEDD, LVESD, and LVEF prior to and after surgery was compared, and the difference was not statistically significant (P>0.05). Evaluation of the magnetic resonance imaging (MRI) in LVEDD prior to surgery was increased compared with that of the ultrasound in LVEDD, whereas MRI in LVESD and LVEF was decreased compared to that of the ultrasound obtained for LVESD and LVEF. Additionally, postoperative LVEDD was reduced compared with preoperative LVEDD, whereas LVEF was increased, and the difference was statistically significant (P<0.05). However, the evaluation of LVESD using the two methods exhibited no significant change. MACE occurred in 7 (12.5%) of 56 cases. The infarction quality of patients in the MACE group following surgery indicated that VSM and WMA scores were significantly higher than the group without MACE, while LVEF was lower than the MACE group following surgery, and the difference was statistically significant (P<0.05), albeit the ultrasound results of LVEF indicated no difference. In conclusion, CMR evaluation of AMI patients with elective PCI treatment in myocardial remodeling and cardiac function were more sensitive and accurate than with cardiac ultrasound. PMID:27588093

Diagnostic imaging in uterine incisional necrosis/dehiscence complicating cesarean section.

PubMed

Rivlin, Michel E; Patel, Rameshkumar B; Carroll, C Shannon; Morrison, John C

2005-12-01

To review the diagnostic imaging studies in patients with surgically proven uterine incisional necrosis/dehiscence complicating cesarean section and to compare these studies with the findings at surgery. Over a 6-year period, the records of 7 patients with imaging studies prior to surgery for uterine incisional necrosis/dehiscence complicating cesarean delivery were reviewed and compared with the findings at surgery. Four cases underwent computed tomography (CT) and sonography, 1 underwent CT only, and 2 underwent sonography only. Abnormal findings included abdominal free fluid in 4, pleural effusions in 3, dilated bowel in 3, possible bladder flap hematoma in 2 and single instances of liver abscess and retained products of conception. In no cases were all the studies normal, and necrosis/dehiscence was not demonstrated in any patient. Abdominal free fluid, bowel distension, pleural effusion and bladder flap hematoma seen on CT or sonogram in the postcesarean context suggest the possibility of uterine incisional necrosis/dehiscence. Magnetic resonance imaging (MRI) might then be indicated since MRI may be superior to CT in evaluating complications at the incisional site because of its multiplanar capability and greater degree of soft tissue contrast.

Treatment of bilateral inguinal hernia -- minimally invasive versus open surgery procedure.

PubMed

Timişescu, L; Turcu, F; Munteanu, R; Gîdea, C; Drăghici, L; Ginghină, O; Iordache, N

2013-01-01

The aim of this study is to evaluate and compare the treatment outcomes of the bilateral inguinal hernia repair in one stage using minimally invasive technique (totally extraperitoneal) and conventional surgery (Lichtenstein). Records from all hospitalized cases in our institution between 2006 and 2011 that underwent surgery having the diagnosis of bilateral inguinal hernia were analysed. The study consists of two groups selected by means of the used procedure: the study arm which is laparoscopic (234 cases) and the control arm that consists of Lichtenstein procedure (91 cases). One conversion was recorded due to difficult dissection (0.4% of cases). There were complications reported in 2.5% cases in the laparoscopic group and 27.4% complications noted in the conventional group (p less then 0.01). Reinterventions were logged in 1.7% cases in the laparoscopic group and 2.1% reinterventions in the open group (p less then 0.01). The postoperative hospital stay was 2.1 days in the laparoscopic group and 4.7 days for the open procedure. Mortality was not recorded. In our department the procedure of choice for bilateral inguinal repair is the laparoscopic approach (TEP) which has a 10 fold decrease in complications rate than Lichtenstein operation and also a shortening by half of the hospital stay. Hernia recurrence is the same for both procedures. Celsius.

MRI in patients with chronic pubalgia: Is precise useful information provided to the surgeon? A case-control study.

PubMed

Larbi, A; Pesquer, L; Reboul, G; Omoumi, P; Perozziello, A; Abadie, P; Loriaut, P; Copin, P; Ducouret, E; Dallaudière, B

2016-10-01

Recent studies described that MRI is a good examination to assess damage in chronic athletic pubalgia (AP). However, to our knowledge, no studies focus on systematic correlation of precise tendon or parietal lesion in MRI with surgery and histological assessment. Therefore, we performed a case-control study to determine if MRI can precisely assess Adductor longus (AL) tendinopathy and parietal lesion, compared with surgery and histology. MRI can determine if AP comes from pubis symphysis, musculotendinous or inguinal orifice structures. Eighteen consecutive patients were enrolled from November 2011 to April 2013 for chronic AP. To constitute a control group, we also enrolled 18 asymptomatic men. All MRI were reviewed in consensus by 2 skeletal radiologists for pubic symphysis, musculotendinous, abdominal wall assessment and compared to surgery and histology findings. Regarding pubis symphysis, we found 4 symmetric bone marrow oedema (14%), 2 secondary cleft (7%) and 2 superior ligaments lesions (7%). For AL tendon, we mainly found 13 asymmetric bone marrow oedema (46%), 15 hyperaemia (54%). Regarding abdominal wall, the deep inguinal orifice size in the group of symptomatic athletes and the control group was respectively 27.3±6.4mm and 23.8±6.3mm. The correlation between MRI and surgery/histology was low: 20% for the AL tendon and 9% for the abdominal wall. If we chose the criteria "affected versus unaffected", this correlation became higher: 100% for AL tendon and 73% for the abdominal wall. MRI chronic athletic pubalgia concerns preferentially AL tendinopathy and deep inguinal canal dehiscence with high correlation to surgery/histology when only considering the item "affected versus unaffected" despite low correlation when we try to precisely grade these lesions. III: case-control study. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

Same-Day Versus Next-Day Repair of Fovea-Threatening Primary Rhegmatogenous Retinal Detachments.

PubMed

Gorovoy, Ian R; Porco, Travis C; Bhisitkul, Robert B; de Juan, Eugene; Schwartz, Daniel M; Stewart, Jay M

2016-01-01

To evaluate the outcomes of same-day versus next-day repair of fovea-threatening rhegmatogenous retinal detachments (FT RRD). Retrospective, multi-surgeon observational case series. Operative reports and medical records were reviewed to evaluate a number of visual and anatomic outcomes, including presenting features, intraoperative complications, and postoperative results in the repair of primary FT RRD undergoing same-day versus next-day repair with scleral buckling, pars plana vitrectomy, or both procedures. A total of 96 consecutive patients (43 same-day, 45 next-day, and eight two days later) were compared. There was no statistically significant difference in visual outcomes between same-day and next-day repair at postoperative months 3 and 6 and at last follow-up (month 3 mean BCVA 20/30 same day; 20/32 next day; p = 0.82). Preoperative vision was strongly correlated with postoperative acuity. Effect of differences in length or type of visual symptoms, location of RRD, gender, or lens status on postoperative month 3 best-corrected visual acuity (BCVA) was not statistically significant. Overall, 85% of patients had a BCVA of 20/40 or better at postoperative month 3. Reoperation rate and intraoperative complications were not statistically different between the two groups. Re-attachment was achieved in all but one patient in both groups. Time in the operating room was longer for same-day surgery (2.98 ± 0.46 hours) compared to next-day surgery (2.54 ± 0.38 hours) (p < 0.001), which was statistically significant even when factoring in the type of surgery performed. However, one case did progress to a macula-off detachment in a superior RRD with breaks found in lattice degeneration. Next-day surgery provided equivalent visual outcomes. Emergent, same-day surgery has logistical and resource implications as it may be more expensive, may necessitate rescheduling of previously booked cases, and may limit preoperative examination by the surgeon and perioperative team.

Single-Docking Full Robotic Surgery for Rectal Cancer: A Single-Center Experience.

PubMed

Alfieri, Sergio; Di Miceli, Dario; Menghi, Roberta; Cina, Caterina; Fiorillo, Claudio; Prioli, Francesca; Rosa, Fausto; Doglietto, Giovanni B; Quero, Giuseppe

2018-06-01

Robotic surgery has gradually gained importance in the treatment of rectal cancer. However, recent studies have not shown any advantages when compared with laparoscopy. The objective of this study is to report a single surgeon's experience in robotic rectal surgery focusing on short-term and long-term outcomes. Sixty consecutive robotic rectal resections for adenocarcinoma, over a 4-year period, were retrospectively reviewed. Patients' characteristics and perioperative outcomes were analyzed. Oncological outcomes and surgical resection quality as well as overall and disease-free survival were also assessed. Thirty patients out of 60 (50%) underwent neoadjuvant therapy. Anterior rectal resection was performed in 52 cases (86.7%), and abdominoperineal resection was done in 8 cases (13.3%). Mean operative time was 283 (±68.6) minutes. The conversion rate was 5% (3 patients). Postoperative complications occurred in 10 cases (16.7%), and reoperation was required in 1 case (1.7%). Mean hospital stay was 9 days, while 30-day mortality was 1.7% (1 patients). The histopathological analysis reported a negative circumferential radial margin and distal margins in 100% of cases with a complete or near complete total mesorectal excision in 98.3% of patients. Mean follow-up was 32.8 months with a recurrence rate of 3.4% (2 patients). Overall survival and disease-free survival were 94% and 87%, respectively. Robotic surgery for rectal cancer proves to be safe and feasible when performed by highly skilled surgeons. It offers acceptable perioperative outcomes with a conversion rate notably lower than with the laparoscopic approach. Adequate pathological results and long-term oncological outcomes were also obtained.

Reoperation for rhegmatogenous retinal detachment as quality indicator for disease management: a register study.

PubMed

Hajari, Javad N; Christensen, Ulrik; Kiilgaard, Jens F; Bek, Toke; la Cour, Morten

2015-09-01

To establish a quality indicator that could be used in optimizing treatment for rhegmatogenous retinal detachment (RRD). The Danish National Patient Registry was used to identify surgery conducted in Denmark for RRD in the period 01 January 2001-31 December 2009. Cases were identified by diagnosis and surgical codes. A total of 6522 cases were operated for a primary RRD in the study period, and 22% (1434 patients) were reoperated for a redetachment. A Cox regression analysis showed that the risk of redetachment was equal to or less than detachment on the fellow eye 1 year after primary surgery with techniques not using silicone oil. The same was true 1.5 years after surgery for techniques using silicone oil. Based on this, we established a quality indicator defining failure as the need for operation for redetachment within 1 year from initial surgery when using techniques without oil and after 1.5 years for techniques using oil. Also the lack of oil removal within 1 year from initial surgery should be noted as an operational failure. We applied the quality indicators on the cohort of 6522 RRDs and found that in Denmark the need for redetachment surgery has decreased over time and also that high-volume departments have better outcome compared to smaller ones. The risk of reoperation for redetachment after initial surgery fulfils the criteria for a good quality indicator and can be used in RRD surgery. This indicator could aid in optimizing the management of RRD patients to minimize morbidity. © 2015 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.

Single-site multiport combined splenectomy and cholecystectomy with conventional laparoscopic instruments: Case series and review of literature

PubMed Central

Ozemir, Ibrahim Ali; Bayraktar, Baris; Bayraktar, Onur; Tosun, Salih; Bilgic, Cagri; Demiral, Gokhan; Ozturk, Erman; Yigitbasi, Rafet; Alimoglu, Orhan

2015-01-01

Introduction Conventional laparoscopic procedures have been used for splenic diseases and concomitant gallbladder stones, frequently in patients with hereditary spherocytosis since 1990’s. The aim of this study is to evaluate the feasibility of single-site surgery with conventional instruments in combined procedures. Presentation of case series Six consecutive patients who scheduled for combined cholecystectomy and splenectomy because of hereditary spherocytosis or autoimmune hemolytic anemia were included this study. Both procedures were performed via trans-umbilical single-site multiport approach using conventional instruments. All procedures completed successfully without conversion to open surgery or conventional laparoscopic surgery. An additional trocar was required for only one patient. The mean operation time was 190 min (150–275 min). The mean blood loss was 185 ml (70–300 ml). Median postoperative hospital stay was two days. No perioperative mortality or major complications occurred in our series. Recurrent anemia, hernia formation or wound infection was not observed during the follow-up period. Discussion Nowadays, publications are arising about laparoscopic or single site surgery for combined diseases. Surgery for combined diseases has some difficulties owing to the placement of organs and position of the patient during laparoscopic surgery. Single site laparoscopic surgery has been proposed to have better cosmetic outcome, less postoperative pain, greater patient satisfaction and faster recovery compared to standard laparoscopy. Conclusion We consider that single-site multiport laparoscopic approach for combined splenectomy and cholecystectomy is a safe and feasible technique, after gaining enough experience on single site surgery. PMID:26708949

[The role of computed tomography after functional surgery on the paranasal sinuses. Normal findings and an assessment of the surgical failures].

PubMed

Scribano, E; Ascenti, G; Cascio, F; Bellinvia, A; Mazziotti, S; Lamberto, S

1999-09-01

Functional endoscopic sinus surgery has become the technique of choice to treat benign or inflammatory diseases of paranasal sinuses resistant to medical therapy. The goal of this type of surgery is to open the obstructed sinus ostia and restore normal aeration and mucociliary clearance. Messerklinger's is the most widely used technique. We investigated the role of CT after functional endoscopic sinus surgery and describe CT findings of postoperative anatomical changes together with frequent complications and surgical failures. Twenty-seven patients with relapsing symptoms were examined with CT of paranasal sinuses 8-32 weeks after functional endoscopic sinus surgery. In all cases both preoperative CT and surgical reports were available: CT and surgical results were compared. In 21/27 patients nasosinusal changes were demonstrated with CT. Recurrent disease secondary to inflammation and/or fibrosis was observed in 14 cases. Residual disease was seen in 5 patients. A major orbital complication was found in 1 patient with diplopia. One patient exhibited a large interruption of cribriform plate with CSF fistula. CT permitted an accurate assessment of extension and results of functional endoscopic sinus surgery. CT is indicated in the postoperative study of the patients who a) present symptoms of cerebral and ocular complications (early after functional endoscopic sinus surgery); and b) do not respond to medical treatments 8-32 weeks after unsuccessful functional endoscopic sinus surgery. In these patients CT can demonstrate recurrent and/or residual nasosinusal disease and bony defects unintentionally caused by the surgeon during the procedure.

Veterans Affairs general surgery service: the last bastion of integrated specialty care.

PubMed

Poteet, Stephen; Tarpley, Margaret; Tarpley, John L; Pearson, A Scott

2011-11-01

In a time of increasing specialization, academic training institutions provide a compartmentalized learning environment that often does not reflect the broad clinical experience of general surgery practice. This study aimed to evaluate the contribution of the Veterans Affairs (VA) general surgery surgical experience to both index Accreditation Council for Graduate Medical Education (ACGME) requirements and as a unique integrated model in which residents provide concurrent care of multiple specialty patients. Institutional review board approval was obtained for retrospective analysis of electronic medical records involving all surgical cases performed by the general surgery service from 2005 to 2009 at the Nashville VA. Over a 5-year span general surgery residents spent an average of 5 months on the VA general surgery service, which includes a postgraduate year (PGY)-5, PGY-3, and 2 PGY-1 residents. Surgeries involved the following specialties: surgical oncology, endocrine, colorectal, hepatobiliary, transplant, gastrointestinal laparoscopy, and elective and emergency general surgery. The surgeries were categorized according to ACGME index requirements. A total of 2,956 surgeries were performed during the 5-year period from 2005 through 2009. Residents participated in an average of 246 surgeries during their experience at the VA; approximately 50 cases are completed during the chief year. On the VA surgery service alone, 100% of the ACGME requirement was met for the following categories: endocrine (8 cases); skin, soft tissue, and breast (33 cases); alimentary tract (78 cases); and abdominal (88 cases). Approximately 50% of the ACGME requirement was met for liver, pancreas, and basic laparoscopic categories. The VA hospital provides an authentic, broad-based, general surgery training experience that integrates complex surgical patients simultaneously. Opportunities for this level of comprehensive care are decreasing or absent in many general surgery training programs. The increasing level of responsibility and simultaneous care of multiple specialty patients through the VA hospital systems offers a crucial experience for those pursuing a career in general surgery. Published by Elsevier Inc.

Creation of an emergency surgery service concentrates resident training in general surgical procedures.

PubMed

Ahmed, Hesham M; Gale, Stephen C; Tinti, Meredith S; Shiroff, Adam M; Macias, Aitor C; Rhodes, Stancie C; Defreese, Marissa A; Gracias, Vicente H

2012-09-01

Emergency general surgery (EGS) is increasingly being provided by academic trauma surgeons in an acute care surgery model. Our tertiary care hospital recently changed from a model where all staff surgeons (private, subspecialty academic, and trauma academic) were assigned EGS call to one in which an emergency surgery service (ESS), staffed by academic trauma faculty, cares for all EGS patients. In the previous model, many surgeries were "not covered" by residents because of work-hour restrictions, conflicting needs, or private surgeon preference. The ESS was separate from the trauma service. We hypothesize that by creating a separate ESS, residents can accumulate needed and concentrated operative experience in a well-supervised academic environment. A prospectively accrued EGS database was retrospectively queried for the 18-month period: July 2010 to June 2011. The Accreditation Council for Graduate Medical Education (ACGME) databases were queried for operative numbers for our residency program and for national resident data for 2 years before and after creating the ESS. The ACGME operative requirements were tabulated from online sources. ACGME requirements were compared with surgical cases performed. During the 18-month period, 816 ESS operations were performed. Of these, 307 (38%) were laparoscopy. Laparoscopic cholecystectomy and appendectomy were most common (138 and 145, respectively) plus 24 additional laparoscopic surgeries. Each resident performed, on average, 34 basic laparoscopic cases during their 2-month rotation, which is 56% of their ACGME basic laparoscopic requirement. A diverse mixture of 70 other general surgical operations was recorded for the remaining 509 surgical cases, including reoperative surgery, complex laparoscopy, multispecialty procedures, and seldom-performed operations such as surgery for perforated ulcer disease. Before the ESS, the classes of 2008 and 2009 reported that only 48% and 50% of cases were performed at the main academic institution, respectively. This improved for the classes of 2010 and 2011 to 63% and 68%, respectively, after ESS creation. An ESS rotation is becoming essential in large teaching hospitals by helping to fulfill ACGME requirements and by providing emergent general surgical skills an efficient and well-supervised academic environment. Movement toward concentrating EGS on a single service can enhance resident education and may decrease the need to supplement certain aspects of general surgery education with away rotations.

Mental and physical health-related quality of life in obese patients before and after bariatric surgery: a meta-analysis.

PubMed

Magallares, Alejandro; Schomerus, Georg

2015-01-01

In this meta-analysis, we review studies that compare mental and physical health-related quality of life measured with the Short-Form 36 of obese patients before and after bariatric surgery with a follow-up measure until one year. Twenty-one studies were selected to conduct the meta-analysis about the relationship between quality of life in obesity before (2680 subjects) and after (2251 subjects) bariatric surgery. Results reveal that obese patients scored less in the mental health component of the Short-Form 36 before bariatric surgery than after (d = -9.00). The same pattern could be observed in the case of the physical health component of the Short-Form 36 (d = -22.84). The results show the strong improvement that obese patients experience in both mental and physical components of the Short-Form 36 after receiving bariatric surgery.

Medical and surgical treatment of obesity.

PubMed

Kissane, Nicole A; Pratt, Janey S A

2011-03-01

The prevalence of obesity has reached epidemic proportions. Conceptualization of obesity as a chronic disease facilitates greater understanding its treatment. The NIH Consensus Conference on Gastrointestinal Surgery for Severe Obesity provides a framework by which to manage the severely obese--specifically providing medical versus surgical recommendations which are based on scientific and outcomes data. Medical treatments of obesity include primary prevention, dietary intervention, increased physical activity, behavior modification, and pharmacotherapy. Surgical treatment for obesity is based on the extensive neural-hormonal effects of weight loss surgery on metabolism, and as such is better termed Metabolic Surgery. Surgery is not limited to the procedure itself, it also necessitates thorough preoperative evaluation, risk assessment, and counseling. The most common metabolic surgical procedures include Roux-en-Y gastric bypass, adjustable gastric band, sleeve gastrectomy, and biliopancreatic diversion. Surgical outcomes for metabolic surgery are well studied and demonstrate superior long-term weight loss compared to medical management in cases of severe obesity.

Comparison of the Incidence of Complications and Secondary Surgical Interventions Necessary in Patients with Chronic Lower Limb Ischemia Treated by Both Open and Endovascular Surgeries

PubMed Central

Janczak, Dariusz; Malinowski, Maciej; Bąkowski, Wojciech; Krakowska, Katarzyna; Marschollek, Karol; Marschollek, Paweł

2017-01-01

Background: Peripheral arterial disease (PAD) affects 3%–10% of the population before the age of 70 years and 15%–20% after that age. The aim of the study was to compare the incidence of complications and secondary interventions in patients who underwent each type of treatment. Methods: We analyzed 734 medical records of the Department of Surgery at the 4th Military Teaching Hospital in Wroclaw, In total, 394 were operated on with open surgery; an endarterectomy (59.39%), a vascular prosthesis implantation (31.01%), or both of these techniques (6.6%), and 340 patients had angioplasty with (50.59%) or without stenting (49.41%). Results: There were no statistically significant differences in the incidence of corresponding complications. The exception was the infection of the wound; significantly fewer were reported in the case of endovascular procedures (p = 0.0087). There were 12 occasions (3.53%) during endovascular surgeries when intraoperative conversion or re-operation using the open method occurred. In the case of open surgery, the mean hospital stay was 7.77 days (median: 8, mode: 8), while for endovascular management it was equal to 4.68 days (median: 4, mode: 3), p <0.0001. Conclusion: The endovascular method results in a similar re-operation rate and number of complications as open surgery. PMID:28496017

Robotics applied in laparoscopic kidney surgery: the Yonsei University experience of 127 cases.

PubMed

Lorenzo, Enrique Ian S; Jeong, Wooju; Oh, Cheol Kyu; Chung, Byung Ha; Choi, Young Deuk; Rha, Koon Ho

2011-01-01

We report our experience on 127 kidney surgeries with the da Vinci surgical system and show the feasibility of a robotics application in a variety of kidney surgeries by both a laparoscopically-trained and a laparoscopically-naïve surgeon. Clinical data of patients who underwent kidney surgery with the da Vinci surgical system from September 2006 to April 2009 were reviewed. Data acquired from medical records included patient demographics, operative time, estimated blood loss (EBL), incidence of intraoperative complication, duration of hospital stay, blood transfusion rate, oncological outcomes, and follow-up results. One-hundred twenty-seven kidney surgeries have been conducted with the da Vinci surgical system at our institution. Three urologists--1 with formal endourology training, 1 with laparoscopic experience, and 1 laparoscopically naïve--have used it for a variety of procedures involving the kidney. The cases include 65 partial nephrectomies (RPN), 38 radical nephrectomies (RRN), and 24 nephroureterectomies with bladder cuff (RNU). Results on operative time, EBL, incidence of intraoperative injury, duration of hospital stay, and blood transfusion rate are comparable with contemporary studies. Robotics application in kidney surgery is a viable option for various procedures. Our experience shows it can be safely and effectively conducted by both laparoscopically-trained and laparoscopically-naïve surgeons once they are accustomed to the robotics system. Copyright © 2011 Elsevier Inc. All rights reserved.

Impact of Resident Involvement in Neurosurgery: An American College of Surgeons’ National Surgical Quality Improvement Program Database Analysis of 33,977 Patients

PubMed Central

Kumar, Prateek; Seicean, Sinziana; Neuhauser, Duncan; Selman, Warren R.; Bambakidis, Nicholas C.

2018-01-01

Objective There is conflicting and limited literature on the effect of intraoperative resident involvement on surgical outcomes. Our study assessed effects of resident involvement on outcomes in patients undergoing neurosurgery. Methods We identified 33,977 adult neurosurgical cases from 374 hospitals in the 2006–2012 National Surgical Quality Improvement Program, a prospectively collected national database with established reproducibility and validity. Outcomes were compared according to resident involvement before and after 1:1 matching on procedure and perioperative risk factors. Results Resident involvement was documented in 13,654 cases. We matched 10,170 resident-involved cases with 10,170 attending-alone. In the matched sample, resident involvement was associated with increased surgery duration (average, 34 minutes) and slight increases in odds for prolonged hospital stay (odds ratio, 1.2; 95% confidence interval [CI], 1.2–1.3) and complications (odds ratio, 1.2; 95% CI, 1.1–1.3) including infections (odds ratio, 1.4; 95% CI, 1.2–1.7). Increased risk for infections persisted after controlling for surgery duration (odds ratio, 1.3; 95% CI, 1.1–1.5). The majority of cases were spine surgeries, and resident involvement was not associated with morbidity or mortality for malignant tumor and aneurysm patients. Training level of residents was not associated with differences in outcomes. Conclusion Resident involvement was more common in sicker patients undergoing complex procedures, consistent with academic centers undertaking more complex cases. After controlling for patient and intraoperative characteristics, resident involvement in neurosurgical cases continued to be associated with longer surgical duration and slightly higher infection rates. Longer surgery duration did not account for differences in infection rates. PMID:29656619

How much incisor decompensation is achieved prior to orthognathic surgery?

PubMed

McNeil, Calum; McIntyre, Grant T; Laverick, Sean

2014-07-01

To quantify incisor decompensation in preparation for orthognathic surgery. Pre-treatment and pre-surgery lateral cephalograms for 86 patients who had combined orthodontic and orthognathic treatment were digitised using OPAL 2.1 [http://www.opalimage.co.uk]. To assess intra-observer reproducibility, 25 images were re-digitised one month later. Random and systematic error were assessed using the Dahlberg formula and a two-sample t-test, respectively. Differences in the proportions of cases where the maxillary (1100 +/- 60) or mandibular (900 +/- 60) incisors were fully decomensated were assessed using a Chi-square test (p<0.05). Mann-Whitney U tests were used to identify if there were any differences in the amount of net decompensation for maxillary and mandibular incisors between the Class II combined and Class III groups (p<0.05). Random and systematic error were less than 0.5 degrees and p<0.05, respectively. A greater proportion of cases had decompensated mandibular incisors (80%) than maxillary incisors (62%) and this difference was statistically significant (p=0.029). The amount of maxillary incisor decompensation in the Class II and Class III groups did not statistically differ (p=0.45) whereas the mandibular incisors in the Class III group underwent statistically significantly greater decompensation (p=0.02). Mandibular incisors were decompensated for a greater proportion of cases than maxillary incisors in preparation for orthognathic surgery. There was no difference in the amount of maxillary incisor decompensation between Class II and Class III cases. There was a greater net decompensation for mandibular incisors in Class III cases when compared to Class II cases. Key words:Decompensation, orthognathic, pre-surgical orthodontics, surgical-orthodontic.

Clinical results with two different methods of root-end preparation and filling in apical surgery: mineral trioxide aggregate and adhesive resin composite.

PubMed

von Arx, Thomas; Hänni, Stefan; Jensen, Simon Storgård

2010-07-01

The aim of apical surgery is to hermetically seal the root canal system after root-end resection, thereby enabling periradicular healing. The objective of this nonrandomized prospective clinical study was to report results of 2 different root-end preparation and filling methods, ie, mineral trioxide aggregate (MTA) and an adhesive resin composite (Retroplast). The study included 353 consecutive cases with endodontic lesions limited to the periapical area. Root-end cavities were prepared with sonic microtips and filled with MTA (n = 178), or alternatively, a shallow concavity was prepared in the cut root face, with subsequent placement of an adhesive resin composite (Retroplast) (n = 175). Patients were recalled after 1 year. Cases were defined as healed when no clinical signs or symptoms were present and radiographs demonstrated complete or incomplete (scar tissue) healing of previous radiolucencies. The overall rate of healed cases was 85.5%. MTA-treated teeth demonstrated a significantly (P = .003) higher rate of healed cases (91.3%) compared with Retroplast-treated teeth (79.5%). Within the MTA group, 89.5%-100% of cases were classified as healed, depending on the type of treated tooth. In contrast, more variable rates ranging from 66.7%-100% were found in the Retroplast group. In particular, mandibular premolars and molars demonstrated considerably lower rates of healed cases when treated with Retroplast. MTA can be recommended for root-end filling in apical surgery, irrespective of the type of treated tooth. Retroplast should be used with caution for root-end sealing in apical surgery of mandibular premolars and molars. Copyright 2010 American Association of Endodontists. Published by Elsevier Inc. All rights reserved.

A national survey (NAP5-Ireland baseline) to estimate an annual incidence of accidental awareness during general anaesthesia in Ireland.

PubMed

Jonker, W R; Hanumanthiah, D; O'Sullivan, E P; Cook, T M; Pandit, J J

2014-09-01

As part of the 5th National Audit Project of the Royal College of Anaesthetists and the Association of Anaesthetists of Great Britain and Ireland concerning accidental awareness during general anaesthesia, we issued a questionnaire to every consultant anaesthetist in each of 46 public hospitals in Ireland, represented by 41 local co-ordinators. The survey ascertained the number of new cases of accidental awareness becoming known to them for patients under their care or supervision for a calendar year, as well as their career experience. Consultants from all hospitals responded, with an individual response rate of 87% (299 anaesthetists). There were eight new cases of accidental awareness that became known to consultants in 2011; an estimated incidence of 1:23 366. Two out of the eight cases (25%) occurred at or after induction of anaesthesia, but before surgery; four cases (50%) occurred during surgery; and two cases (25%) occurred after surgery was complete, but before full emergence. Four cases were associated with pain or distress (50%), one after an experience at induction and three after experiences during surgery. There were no formal complaints or legal actions that arose in 2011 related to awareness. Depth of anaesthesia monitoring was reported to be available in 33 (80%) departments, and was used by 184 consultants (62%), 18 (6%) routinely. None of the 46 hospitals had a policy to prevent or manage awareness. Similar to the results of a larger survey in the UK, the disparity between the incidence of awareness as known to anaesthetists and that reported in trials warrants explanation. Compared with UK practice, there appears to be greater use of depth of anaesthesia monitoring in Ireland, although this is still infrequent. © 2014 The Association of Anaesthetists of Great Britain and Ireland.

Impact of the viral respiratory season on postoperative outcomes in children undergoing cardiac surgery.

PubMed

Spaeder, Michael C; Carson, Kathryn A; Vricella, Luca A; Alejo, Diane E; Holmes, Kathryn W

2011-08-01

To compare postoperative outcomes in children undergoing cardiac surgery during the viral respiratory season and nonviral season at our institution. This was a retrospective cohort study and secondary matched case-control analysis. The setting was an urban academic tertiary-care children's hospital. The study was comprised of all patients <18 years of age who underwent cardiac surgery at Johns Hopkins Hospital from October 2002 through September 2007. Patients were stratified by season of surgery, complexity of cardiac disease, and presence or absence of viral respiratory infection. Measurements included patient characteristics and postoperative outcomes. The primary outcome was postoperative length of stay (LOS). A total of 744 patients were included in the analysis. There was no difference in baseline characteristics or outcomes, specifically, no difference in postoperative LOS, intensive care unit (ICU) LOS, and mortality, among patients by seasons of surgery. Patients with viral respiratory illness were more likely to have longer postoperative LOS (p < 0.01) and ICU LOS (p < 0.01) compared with matched controls. We identified no difference in postoperative outcomes based on season in patients undergoing cardiac surgery. Children with viral respiratory infection have significantly worse outcomes than matched controls, strengthening the call for universal administration of influenza vaccination and palivizumab to appropriate groups. Preoperative testing for respiratory viruses should be considered during the winter months for children undergoing elective cardiac surgery.

Long-term outcome of cochlear implant in patients with chronic otitis media: one-stage surgery is equivalent to two-stage surgery.

PubMed

Jang, Jeong Hun; Park, Min-Hyun; Song, Jae-Jin; Lee, Jun Ho; Oh, Seung Ha; Kim, Chong-Sun; Chang, Sun O

2015-01-01

This study compared long-term speech performance after cochlear implantation (CI) between surgical strategies in patients with chronic otitis media (COM). Thirty patients with available open-set sentence scores measured more than 2 yr postoperatively were included: 17 who received one-stage surgeries (One-stage group), and the other 13 underwent two-stage surgeries (Two-stage group). Preoperative inflammatory status, intraoperative procedures, postoperative outcomes were compared. Among 17 patients in One-stage group, 12 underwent CI accompanied with the eradication of inflammation; CI without eradicating inflammation was performed on 3 patients; 2 underwent CIs via the transcanal approach. Thirteen patients in Two-stage group received the complete eradication of inflammation as first-stage surgery, and CI was performed as second-stage surgery after a mean interval of 8.2 months. Additional control of inflammation was performed in 2 patients at second-stage surgery for cavity problem and cholesteatoma, respectively. There were 2 cases of electrode exposure as postoperative complication in the two-stage group; new electrode arrays were inserted and covered by local flaps. The open-set sentence scores of Two-stage group were not significantly higher than those of One-stage group at 1, 2, 3, and 5 yr postoperatively. Postoperative long-term speech performance is equivalent when either of two surgical strategies is used to treat appropriately selected candidates.

The incidence and risk factors associated with developing symptoms of hypoglycemia after bariatric surgery.

PubMed

Lee, Clare J; Brown, Todd T; Schweitzer, Michael; Magnuson, Thomas; Clark, Jeanne M

2018-06-01

Hypoglycemia after bariatric surgery is an increasingly recognized metabolic complication associated with exaggerated secretion of insulin and gut hormones. We sought to determine the incidence of hypoglycemic symptoms (hypo-sx) after bariatric surgery and characteristics of those affected compared with those unaffected. University hospital. We collected retrospective survey data from the patients who underwent bariatric surgery at a single center. Based on number and severity of postprandial hypo-sx in Edinburgh hypoglycemia questionnaire postoperatively, patients without preoperative hypo-sx were grouped into high versus low suspicion for hypoglycemia. We used multivariable logistic regression to examine potential baseline and operative risk factors for the development of hypo-sx after surgery. Among the 1119 patients who had undergone bariatric surgery who received the questionnaire, 464 (40.6%) responded. Among the 341 respondents without preexisting hypo-sx, 29% (n = 99) had new-onset hypo-sx, and most were severe cases (n = 92) with neuroglycopenic symptoms. Compared with the low suspicion group, the high suspicion group consisted of more female patients, younger patients, patients without diabetes, and those who underwent Roux-en-Y gastric bypass with a longer time since surgery and more weight loss. In multivariate analysis, factors independently associated with incidence of hypo-sx after bariatric surgery were female sex (P = .003), Roux-en-Y gastric bypass (P = .001), and absence of preexisting diabetes (P = .011). New onset postprandial hypoglycemic symptoms after bariatric surgery are common, affecting up to a third of those who underwent bariatric surgery. Many affected individuals reported neuroglycopenic symptoms and were more likely to be female and nondiabetic and to have undergone Roux-en-Y gastric bypass. Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.

Heterologous, Fresh, Human Donor Sclera as Patch Graft Material in Glaucoma Drainage Device Surgery.

PubMed

Tsoukanas, Dimitrios; Xanthopoulou, Paraskevi; Charonis, Alexandros C; Theodossiadis, Panagiotis; Kopsinis, Gerasimos; Filippopoulos, Theodoros

2016-07-01

To determine the safety and efficacy of fresh, human sclera allografts as a patch graft material in glaucoma drainage device (GDD) surgery. Retrospective, noncomparative, interventional, consecutive case series. All GDD cases operated between 2008 and 2013 in which fresh human corneoscleral rims were used immediately after the central corneal button was used for penetrating or endothelial keratoplasty. Surgery was performed by 2 surgeons at 2 facilities. The Ahmed Glaucoma Valve (FP-7) was used exclusively in this cohort. Sixty-four eyes of 60 patients were identified; demographic data were recorded along with intraocular pressure (IOP), medication requirements, visual acuity, complications, and subsequent interventions. Incidence of complications. IOP and medication requirements at the last follow-up. Quilified success utilizing Tube Versus Trabeculectomy study criteria. The mean age of the cohort was 66.2±19.1 years; the average preoperative IOP was 33.2±11.1 mm Hg on 4.2±1.3 IOP-lowering agents before GDD surgery. IOP decreased significantly to 14.1±4.7 mm Hg (P<0.001) on 1.6±1.2 IOP-lowering agents (P<0.001) after an average follow-up of 18.2±15.4 months. There were no cases of early or late blebitis or endophthalmitis, and there was 1 case of conjunctival erosion and tube/plate exposure (1.6%) occurring 30 days after surgery. Qualified success was estimated as 90.5% and 81% at 1 and 2 years, respectively, using Tube Versus Trabeculectomy study criteria. Heterologous, fresh, human donor sclera appears to be a safe material for GDD tube coverage. It provides a cost-efficient alternative compared with traditional patch graft materials associated with a low risk of pathogen transmission.

[Deeply infiltrating endometriosis and infertility: CNGOF-HAS Endometriosis Guidelines].

PubMed

Mathieu d'Argent, E; Cohen, J; Chauffour, C; Pouly, J L; Boujenah, J; Poncelet, C; Decanter, C; Santulli, P

2018-03-01

Deeply infiltrating endometriosis is a severe form of the disease, defined by endometriotic tissue peritoneal infiltration. The disease may involve the rectovaginal septum, uterosacral ligaments, digestive tract or bladder. Deeply infiltrating endometriosis is responsible for disabling pain and infertility. The purpose of these recommendations is to answer the following question: in case of deeply infiltrating endometriosis associated infertility, what is the best therapeutic strategy? First-line surgery and then in vitro fertilization (IVF) in case of persistent infertility or first-line IVF, without surgery? After exhaustive literature analysis, we suggest the following recommendations: studies focusing on spontaneous fertility of infertile patients with deeply infiltrating endometriosis found spontaneous pregnancy rates about 10%. Treatment should be considered in infertile women with deeply infiltrating endometriosis when they wish to conceive. First-line IVF is a good option in case of no operated deeply infiltrating endometriosis associated infertility. Pregnancy rates (spontaneous and following assisted reproductive techniques) after surgery (deep lesions without colorectal involvement) varie from 40 to 85%. After colorectal endometriosis resection, pregnancy rates vary from 47 to 59%. The studies comparing the pregnancy rates after IVF, whether or not preceded by surgery, are contradictory and do not allow, to date, to conclude on the interest of any surgical management of deep lesions before IVF. In case of alteration of ovarian reserve parameters (age, AMH, antral follicle count), there is no argument to recommend first-line surgery or IVF. The study of the literature does not identify any prognostic factors, allowing to chose between surgical management or IVF. The use of IVF in the indication "deep infiltrating endometriosis" allows satisfactory pregnancy rates without significant risk, regarding disease progression or oocyte retrieval procedure morbidity. Copyright © 2018. Published by Elsevier Masson SAS.

A comparison of outcomes for adults and children undergoing resection for inflammatory bowel disease: is there a difference?

PubMed

Mcmullin, Christine M; Morton, Jonathan; Vickramarajah, Saranya; Cameron, Ewen; Parkes, Miles; Torrente, Franco; Heuschkel, Robert; Carroll, Nicholas; Davies, R Justin

2014-01-01

Background. The incidence of inflammatory bowel disease (IBD) is increasing in the paediatric population. Since 2007, a single surgeon whose main practice is in the treatment of adults has performed surgery for IBD in adults and children within two dedicated multidisciplinary teams. Our aim was to assess and compare outcomes for adults and children following surgery for IBD. Methods. Analysis of a prospectively collected database was carried out to include all patients who had undergone resectional surgery for IBD between 2007 and 2012. Results. 48 adults and 30 children were included in the study. Median age for children was 14 years (range 8-16) and for adults was 33.5 years (range 17-64). Median BMI was 23 (range 18-38) and 19 (range 13-29.5) in adults and children, respectively (P < 0.001). Laparoscopic resection was performed in 27 (90%) children and 36 (75%) adults. Postoperative complication rates were comparable, 11 (23%) in adults versus 6 (20%) in children (P = 1.00). Conclusion. Resectional surgery for IBD in children has outcomes that compare favourably with the adult population, with the majority of cases being performed by a laparoscopic approach.

High-power diode laser in the circumvestibular incision for Le Fort I osteotomy in orthognathic surgery: a prospective case series study.

PubMed

Jaeger, Filipe; Chiavaioli, Gustavo Marques; de Toledo, Guilherme Lacerda; Freire-Maia, Belini; Amaral, Marcio Bruno Figueiredo; Mesquita, Ricardo Alves

2018-01-01

The incisions during orthognathic surgery are classically performed with conventional scalpel or electrocautery. Considering that the high-power diode laser surgery may provide advantages when compared to conventional incision techniques, the current study aimed to present a prospective case series of patients submitted to circumvestibular incision for Le Fort I osteotomy. Ten patients with dentofacial deformities who underwent to rapid assisted maxillary expansion or bimaxillary orthognathic surgery were enrolled in the study. All incisions were performed by a single surgeon using an 808-nm diode laser, with an optical fiber of 600 μm, at a power of 2.5 W, in a continuous-wave mode. The performance of the incision was evaluated by incision velocity, bleeding, edema, secondary infection, clinical healing, and pain. The velocity of the incision ranged from 0.10 to 0.20 mm/s (mean 0.13 ± 0.03 mm/s). Considering bleeding during the soft tissue incision, all surgeries were classified as absent bleeding. All patients presented a clinical healing of the surgical wound in a period that range from 3 to 5 weeks and experienced swelling during the follow-up period. On average, approximately 50% of the swelling had resolved after the third postoperative week, and 28.8% of swelling remained after 2 months after the surgery. The pain decreased after 2 and 3 days, and 90.0% of the patients reported no pain after 7 postoperative days. High-power diode laser is effective and safety during circumvestibular incisions for Le Fort I osteotomy in orthognathic surgery decreasing bleeding, surgery time, pain, and edema after orthognathic surgery.

Interventional Catheterization Combined with Staphylococcin Aureus Injection in 112 Cases of Ischemic Necrosis of Femoral Heads.

PubMed

Liang, Junkui; Jiang, Xiliang; Zhang, Xiulin; Cao, Wendong; Wang, Yong; Han, Jie

2015-11-01

The objective of this study was to investigate the effectiveness of interventional catheterization with staphylococcin aureus injection on ischemic necrosis of the femoral heads. By percutaneous catheterization of the femoral artery, papaverine, urokinase, compound Danshen, and anisodamine were injected intravenously into the arteries of the femoral head. Staphylococcin aureus injection was injected into the hit joint capsule on the side of the lesion to compare the conditions before and after surgery. The patients did the rehabilitation exercises of the hit joint 48 h after the surgery and had double crutches for 3-6 months. Of the 112 cases, 39 cases (34.8 %) were cured, 51 cases (45.6 %) were markedly effective, and 22 cases (19.6 %) were effective. Interventional catheterization combined with staphylococcin aureus injection given into the hit joint capsule is an effective way to treat ischemic necrosis of the femoral head by influencing the internal and external environments of the femoral head.

Aneurysmal portahepatic venous fistula: Report of two cases

DOE Office of Scientific and Technical Information (OSTI.GOV)

Chagnon, S.F.; Vallee, C.A.; Barge, J.

1986-06-01

Two cases are reported of congenital intrahepatic portacaval shunts in middle-aged women who had encephalopathy or hypoglycemia. Real-time ultrasound (US) investigations revealed vascular communication between the left portal and hepatic veins in one patient and communication between the right portal and hepatic veins in the other. These findings were confirmed using angiography with pressure measurement. One patient underwent surgery; the other received dietetic treatment. The findings in these two cases are compared with those of three previously reported cases.

Vertebral artery injuries in cervical spine surgery.

PubMed

Lunardini, David J; Eskander, Mark S; Even, Jesse L; Dunlap, James T; Chen, Antonia F; Lee, Joon Y; Ward, Timothy W; Kang, James D; Donaldson, William F

2014-08-01

Vertebral artery injuries (VAIs) are rare but serious complications of cervical spine surgery, with the potential to cause catastrophic bleeding, permanent neurologic impairment, and even death. The present literature regarding incidence of this complication largely comprises a single surgeon or small multicenter case series. We sought to gather a large sample of high-volume surgeons to adequately characterize the incidence and risk factors for VAI, management strategies used, and patient outcomes after VAI. The study was constructed as a cross-sectional study comprising all cervical spine patients operated on by the members of the international Cervical Spine Research Society (CSRS). All patients who have undergone cervical spine surgery by a current member of CSRS as of the spring of 2012. For each surgeon surveyed, we collected self-reported measures to include the number of cervical cases performed in the surgeon's career, the number of VAIs encountered, the stage of the case during which the injury occurred, the management strategies used, and the overall patient outcome after injury. An anonymous 10-question web-based survey was distributed to the members of the CSRS. Statistical analysis was performed using Student t tests for numerical outcomes and chi-squared analysis for categorical variables. One hundred forty-one CSRS members (of 195 total, 72%) responded to the survey, accounting for a total of 163,324 cervical spine surgeries performed. The overall incidence of VAI was 0.07% (111/163,324). Posterior instrumentation of the upper cervical spine (32.4%), anterior corpectomy (23.4%), and posterior exposure of the cervical spine (11.7%) were the most common stages of the case to result in an injury to the vertebral artery. Discectomy (9%) and anterior exposure of the spine (7.2%) were also common time points for an arterial injury. One-fifth (22/111) of all VAI involved an anomalous course of the vertebral artery. The most common management of VAI was by direct tamponade. The outcomes of VAIs included no permanent sequelae in 90% of patients, permanent neurologic sequelae in 5.5%, and death in 4.5%. Surgeons at academic and private centers had nearly identical rates of VAIs. However, surgeons who had performed 300 or fewer cervical spine surgeries in their career had a VAI incidence of 0.33% compared with 0.06% in those with greater than 300 lifetime cases (p=.028). The overall incidence of VAI during cervical spine surgery reported from this survey was 0.07%. Less experienced surgeons had a higher rate of VAI compared with their more experienced peers. The results of VAI are highly variable, resulting in no permanent harm most of the time; however, permanent neurologic injury or death occur in 10% of cases. Copyright © 2014 Elsevier Inc. All rights reserved.

Audit of accuracy of clinical coding in oral surgery.

PubMed

Naran, S; Hudovsky, A; Antscherl, J; Howells, S; Nouraei, S A R

2014-10-01

We aimed to study the accuracy of clinical coding within oral surgery and to identify ways in which it can be improved. We undertook did a multidisciplinary audit of a sample of 646 day case patients who had had oral surgery procedures between 2011 and 2012. We compared the codes given with their case notes and amended any discrepancies. The accuracy of coding was assessed for primary and secondary diagnoses and procedures, and for health resource groupings (HRGs). The financial impact of coding Subjectivity, Variability and Error (SVE) was assessed by reference to national tariffs. The audit resulted in 122 (19%) changes to primary diagnoses. The codes for primary procedures changed in 224 (35%) cases; 310 (48%) morbidities and complications had been missed, and 266 (41%) secondary procedures had been missed or were incorrect. This led to at least one change of coding in 496 (77%) patients, and to the HRG changes in 348 (54%) patients. The financial impact of this was £114 in lost revenue per patient. There is a high incidence of coding errors in oral surgery because of the large number of day cases, a lack of awareness by clinicians of coding issues, and because clinical coders are not always familiar with the large number of highly specialised abbreviations used. Accuracy of coding can be improved through the use of a well-designed proforma, and standards can be maintained by the use of an ongoing data quality assurance programme. Copyright © 2014. Published by Elsevier Ltd.

[A comparative study on treating femal stress urinary incontinence with TVT-Abbrevo and TVT-Obturator].

PubMed

Li, W L; Lu, Z W; Li, F P; Yu, H Y

2016-07-26

To compare the effectiveness and complications of TVT-Abbrevo (tension-free vaginal tape-Abbrevo) and TVT-Obturator (tension-free vaginal tape-obturator) for the treatment of female stress urinary incontinence (SUI). From Nov.2012 to Nov.2013, 117 patients suffering from SUI were treated with TVT-Abbrebo (n=79) or TVT-Obturator (n=38) procedure, the clinical efficacy and operation-correlated complications were observed. A total of 117 cases, 107 cases of urinary incontinence symptoms disappeared completely, 10 cases were improved. 72 cases (91.1%) were cured and 7 cases (8.9%) were improved in TVT-Abbrevo group; 35 cases (92.1%) were cured and 3 cases (7.9%) were improved in TVT-Obturator group. No significant differences could be found for the curing rates between two groups (P>0.05). Compared with the TVT-Obturator group, the TVT-Abbrevo group had less patients complaining of inner thigh pain at 24 h and 1 w after surgery (P<0.05). No significant differences were observed for the incidence of inner thigh pain at 1m and 1y after surgery between TVT-Abbrevo and TVT-Obturator group (P>0.05). No intraoperative complications such as blood vessel, nerve, bladder damage were recorded and no postoperative retropubic hematoma, tape adjustment and other complications occurred in two goups. No recurrence after 1 year follow-up. The study shows that TVT-Abbrevo procedure is safe and efficacy in treatment of SUI, and associated with low incidence of recent postoperative inner thigh pain.

Local and national trends in general surgery residents' operative experience: do work hour limitations negatively affect case volume in small community-based programs?

PubMed

Markelov, Alexey; Sakharpe, Aniket; Kohli, Harjeet; Livert, David

2011-12-01

The goals of this study were to analyze the impact of work hour restrictions on the operative case volume at a small community-based general surgery residency training program and compare changes with the national level. Annual national resident case log data from Accreditation Council for Graduate Medical Education (ACGME) website and case logs of graduating Easton Hospital residents (years 2002-2009) were used for analysis. Weighted average change in total number of cases in our institution was -1.20 (P = 0.52) vs 1.78 (P = 0.07) for the national program average with statistically significant difference on comparison (P = 0.027). We also found significant difference in case volume changes at the national level compared with our institution for the following ACGME defined subcategories: alimentary tract [8.19 (P < 0.01) vs -1.08 (P = 0.54)], abdomen [8.48 (P < 0.01) vs -6.29 (P < 0.01)], breast [1.91 (P = 0.89) vs -3.6 (P = 0.02)], and vascular [4.03 (P = 0.02) vs -3.98 (P = 0.01)]. Comparing the national trend to the community hospital we see that there is total increase in cases at the national level whereas there is a decrease in case volume at the community hospital. These trends can also be followed in ACGME defined subcategories which form the major case load for a general surgical training such as alimentary tract, abdominal, breast, and vascular procedures. We hypothesize that work hour restrictions have been favorable for the larger programs, as these programs were able to better integrate the night float system, restructure their call schedule, and implement institutional modifications which are too resource demanding for smaller training programs.

Iatrogenic Pseudoaneurysm of Superficial Temporal Artery After Surgery for Scaphocephaly: Case Report and Review of Literature.

PubMed

Anania, Pasquale; Pacetti, Mattia; Ravegnani, Marcello; Pavanello, Marco; Piatelli, Gianluca; Consales, Alessandro

2018-03-01

Iatrogenic pseudoaneurysm of the superficial temporal artery after surgery for craniosynostosis is a complication that has never been described in the pertinent literature. Although reported for other types of surgeries, no case has been described in the pediatric population. We report on a case of pseudoaneurysm of the superficial temporal artery that occurred 9 days after corrective surgery for scaphocephaly. We also describe the management of this complication. Pseudoaneurysm is an exceptional complication in surgery for craniosynostosis, but it should be considered in case of swelling in the temporal region. Copyright © 2017 Elsevier Inc. All rights reserved.

Endovascular Repair of Descending Thoracic Aortic Aneurysm

PubMed Central

2005-01-01

Executive Summary Objective To conduct an assessment on endovascular repair of descending thoracic aortic aneurysm (TAA). Clinical Need Aneurysm is the most common condition of the thoracic aorta requiring surgery. Aortic aneurysm is defined as a localized dilatation of the aorta. Most aneurysms of the thoracic aorta are asymptomatic and incidentally discovered. However, TAA tends to enlarge progressively and compress surrounding structures causing symptoms such as chest or back pain, dysphagia (difficulty swallowing), dyspnea (shortness of breath), cough, stridor (a harsh, high-pitched breath sound), and hoarseness. Significant aortic regurgitation causes symptoms of congestive heart failure. Embolization of the thrombus to the distal arterial circulation may occur and cause related symptoms. The aneurysm may eventually rupture and create a life-threatening condition. The overall incidence rate of TAA is about 10 per 100,000 person-years. The descending aorta is involved in about 30% to 40% of these cases. The prognosis of large untreated TAAs is poor, with a 3-year survival rate as low as 25%. Intervention is strongly recommended for any symptomatic TAA or any TAA that exceeds twice the diameter of a normal aorta or is 6 cm or larger. Open surgical treatment of TAA involves left thoracotomy and aortic graft replacement. Surgical treatment has been found to improve survival when compared with medical therapy. However, despite dramatic advances in surgical techniques for performing such complex operations, operative mortality from centres of excellence are between 8% and 20% for elective cases, and up to 50% in patients requiring emergency operations. In addition, survivors of open surgical repair of TAAs may suffer from severe complications. Postoperative or postprocedural complications of descending TAA repair include paraplegia, myocardial infarction, stroke, respiratory failure, renal failure, and intestinal ischemia. The Technology Endovascular aortic aneurysm repair (EVAR) using a stent graft, a procedure called endovascular stent-graft (ESG) placement, is a new alternative to the traditional surgical approach. It is less invasive, and initial results from several studies suggest that it may reduce mortality and morbidity associated with the repair of descending TAAs. The goal in endovascular repair is to exclude the aneurysm from the systemic circulation and prevent it from rupturing, which is life-threatening. The endovascular placement of a stent graft eliminates the systemic pressure acting on the weakened wall of the aneurysm that may lead to the rupture. However, ESG placement has some specific complications, including endovascular leak (endoleak), graft migration, stent fracture, and mechanical damage to the access artery and aortic wall. The Talent stent graft (manufactured by Medtronic Inc., Minneapolis, MN) is licensed in Canada for the treatment of patients with TAA (Class 4; licence 36552). The design of this device has evolved since its clinical introduction. The current version has a more flexible delivery catheter than did the original system. The prosthesis is composed of nitinol stents between thin layers of polyester graft material. Each stent is secured with oversewn sutures to prevent migration. Review Strategy Objectives To compare the effectiveness and cost-effectiveness of ESG placement in the treatment of TAAs with a conventional surgical approach To summarize the safety profile and effectiveness of ESG placement in the treatment of descending TAAs Measures of Effectiveness Primary Outcome Mortality rates (30-day and longer term) Secondary Outcomes Technical success rate of introducing a stent graft and exclusion of the aneurysm sac from systemic circulation Rate of reintervention (through surgical or endovascular approach) Measures of Safety Complications were categorized into 2 classes: Those specific to the ESG procedure, including rates of aneurysm rupture, endoleak, graft migration, stent fracture, and kinking; and Those due to the intervention, either surgical or endovascular. These include paraplegia, stroke, cardiovascular events, respiratory failure, real insufficiency, and intestinal ischemia. Inclusion Criteria Studies comparing the clinical outcomes of ESG treatment with surgical approaches Studies reporting on the safety and effectiveness of the ESG procedure for the treatment of descending TAAs Exclusion Criteria Studies investigating the clinical effectiveness of ESG placement for other conditions such as aortic dissection, aortic ulcer, and traumatic injuries of the thoracic aorta Studies investigating the aneurysms of the ascending and the arch of the aorta Studies using custom-made grafts Literature Search The Medical Advisory Secretariat searched The International Network of Agencies for Health Technology Assessment and the Cochrane Database of Systematic Reviews for health technology assessments. It also searched MEDLINE, EMBASE, Medline In-Process & Other Non-Indexed Citations, and Cochrane CENTRAL from January 1, 2000 to July 11, 2005 for studies on ESG procedures. The search was limited to English-language articles and human studies. One health technology assessment from the United Kingdom was identified. This systematic review included all pathologies of the thoracic aorta; therefore, it did not match the inclusion criteria. The search yielded 435 citations; of these, 9 studies met inclusion criteria. Summary of Findings Mortality The results of a comparative study found that in-hospital mortality was not significantly different between ESG placement and surgery patients (2 [4.8%] for ESG vs. 6 [11.3%] for surgery). Pooled data from case series with a mean follow-up ranging from 12 to 38 months showed a 30-day mortality and late mortality rate of 3.9% and 5.5%, respectively. These rates are lower than are those reported in the literature for surgical repair of TAA. Case series showed that the most common cause of early death in patients undergoing endovascular repair is aortic rupture, and the most common causes of late death are cardiac events and aortoesophageal or aortobronchial fistula. Technical Success Rate Technical success rates reported by case series are 55% to 100% (100% and 94.4% in 2 studies with all elective cases, 89% in a study with 5% emergent cases, and 55% in a study with 42% emergent cases). Surgical Reintervention In the comparative study, 3 (7.1%) patients in the ESG group and 14 (26.5%) patients in the surgery group required surgical reintervention. In the ESG group, the reasons for surgical intervention were postoperative bleeding at the access site, paraplegia, and type 1 endoleak. In the surgical group, the reasons for surgery were duodenal perforation, persistent thoracic duct leakage, false aneurysm, and 11 cases of postoperative bleeding. Pooled data from case series show that 9 (2.6%) patients required surgical intervention. The reasons for surgical intervention were endoleak (3 cases), aneurysm enlargement and suspected infection (1 case), aortic dissection (1 case), pseudoaneurysm of common femoral artery (1 case), evacuation of hematoma (1 case), graft migration (1 case), and injury to the access site (1 case). Endovascular Revision In the comparative study, 3 (7.1%) patients required endovascular revision due to persistent endoleak. Pooled data from case series show that 19 (5.3%) patients required endovascular revision due to persistent endoleak. Graft Migration Two case series reported graft migration. In one study, 3 proximal and 4 component migrations were noted at 2-year follow-up (total of 5%). Another study reported 1 (3.7%) case of graft migration. Overall, the incidence of graft migration was 2.6%. Aortic Rupture In the comparative study, aortic rupture due to bare stent occurred in 1 case (2%). The pooled incidence of aortic rupture or dissection reported by case series was 1.4%. Postprocedural Complications In the comparative study, there were no statistically significant differences between the ESG and surgery groups in postprocedural complications, except for pneumonia. The rate of pneumonia was 9% for those who received an ESG and 28% for those who had surgery (P = .02). There were no cases of paraplegia in either group. The rate of other complications for ESG and surgery including stroke, cardiac, respiratory, and intestinal ischemia were all 5.1% for ESG placement and 10% for surgery. The rate for mild renal failure was 16% in the ESG group and 30% in the surgery group. The rate for severe renal failure was 11% for ESG placement and 10% for surgery. Pooled data from case series show the following postprocedural complication rates in the ESG placement group: paraplegia (2.2%), stroke (3.9%), cardiac (2.9%), respiratory (8.7%), renal failure (2.8%), and intestinal ischemia (1%). Time-Related Outcomes The results of the comparative study show statistically significant differences between the ESG and surgery group for mean operative time (ESG, 2.7 hours; surgery, 5 hours), mean duration of intensive care unit stay (ESG, 11 days; surgery, 14 days), and mean length of hospital stay (ESG, 10 days; surgery, 30 days). The mean duration of intensive care unit stay and hospital stay derived from case series is 1.6 and 7.8 days, respectively. Ontario-Based Economic Analysis In Ontario, the annual treatment figures for fiscal year 2004 include 17 cases of descending TAA repair procedures (source: Provincial Health Planning Database). Fourteen of these have been identified as “not ruptured” with a mean hospital length of stay of 9.23 days, and 3 cases have been identified as “ruptured,” with a mean hospital length of stay of 28 days. However, because one Canadian Classification of Health Interventions code was used for both procedures, it is not possible to determine how many were repaired with an EVAR procedure or with an open surgical procedure. Hospitalization Costs The current fiscal year forecast of in-hospital direct treatment costs for all in-province procedures of repair of descending TAAs is about $560,000 (Cdn). The forecast in-hospital total cost per year for in-province procedures is about $720,000 (Cdn). These costs include the device cost when the procedure is EVAR (source: Ontario Case Costing Initiative). Professional (Ontario Health Insurance Plan) Costs Professional costs per treated patient were calculated and include 2 preoperative thoracic surgery or EVAR consultations. The professional costs of an EVAR include the fees paid to the surgeons, anesthetist, and surgical assistant (source: fee service codes). The procedure was calculated to take about 150 minutes. The professional costs of an open surgical repair include the fees of the surgeon, anesthetist, and surgical assistant. Open surgical repair was estimated to take about 300 minutes. Services provided by professionals in intensive care units were also taken into consideration, as were the costs of 2 postoperative consultations that the patients receive on average once they are discharged from the hospital. Therefore, total Ontario Health Insurance Plan costs per treated patient treated with EVAR are on average $2,956 (ruptured or not ruptured), as opposed to $5,824 for open surgical repair and $6,157 for open surgical repair when the aneurysm is ruptured. Conclusions Endovascular stent graft placement is a less invasive procedure for repair of TAA than is open surgical repair. There is no high-quality evidence with long-term follow-up data to support the use of EVAR as the first choice of treatment for patients with TAA that are suitable candidates for surgical intervention. However, short- and medium-term outcomes of ESG placement reported by several studies are satisfactory and comparable to surgical intervention; therefore, for patients at high risk of surgery, it is a practical option to consider. Short- and medium-term results show that the benefit of ESG placement over the surgical approach is a lower 30-day mortality and paraplegia rate; and shorter operative time, ICU stay, and hospital stay. PMID:23074469

The Prevalence of Body Dysmorphic Disorder in Patients Undergoing Cosmetic Surgery: a Systematic Review.

PubMed

Panayi, Andreana

2015-09-01

Body dysmorphic disorder (BDD) is a somatoform disorder characterised by a distressing obsession with an imagined or slight appearance defect, which can significantly impair normal day-to-day functioning. Patients with BDD often first present, and are hence diagnosed, in cosmetic surgery settings. Several studies have investigated the prevalence rate of BDD in the general population or have done so for patients referring to cosmetic medical centers. To date, however, no review has been undertaken to compare the prevalence in the general community versus in a cosmetic surgery setting. Despite the lack of such a review it is a commonly held belief that BDD is more common in patients seeking cosmetic surgery. The current study aims to review the available literature in order to investigate whether BDD is indeed more prevalent in patients requesting cosmetic surgery, and if that is the case, to provide possible reasons for the difference in prevalence. In addition this review provides evidence on the effectiveness of cosmetic surgery as a treatment of BDD.

Corneal polarimetry after LASIK refractive surgery

NASA Astrophysics Data System (ADS)

Bueno, Juan M.; Berrio, Esther; Artal, Pablo

2006-01-01

Imaging polarimetry provides spatially resolved information on the polarization properties of a system. In the case of the living human eye, polarization could be related to the corneal biomechanical properties, which vary from the normal state as a result of surgery or pathologies. We have used an aberro-polariscope, which we recently developed, to determine and to compare the spatially resolved maps of polarization parameters across the pupil between normal healthy and post-LASIK eyes. The depolarization distribution is not uniform across the pupil, with post-surgery eyes presenting larger levels of depolarization. While retardation increases along the radius in normal eyes, this pattern becomes irregular after LASIK refractive surgery. The maps of slow axis also differ in normal and post-surgery eyes, with a larger disorder in post-LASIK eyes. Since these changes in polarization indicate subtle structural modifications of the cornea, this approach can be useful in a clinical environment to follow the biomechanical and optical changes of the cornea after refractive surgery or for the early diagnosis of different corneal pathologies.

[LAPAROSCOPIC NERVE-SPARING RADICAL HYSTERECTOMY IN CERVICAL CANCER].

PubMed

Berlev, I V; Ulrikh, E A; Korolkova, E N; Ibragimov, Z N; Kashina, N O; Mikhailyuk, G I; Khadzhimba, A V; Urmancheeva, A F

2015-01-01

Cervical cancer is the most common cancer of the female reproductive system up to 20% of malignant tumors of the female genital organs. Surgery is the main method in treatment for local cervical cancer but postoperative complications often are associated with dysfunction of the pelvic organs. Some researchers focus their attention on the preservation of the pelvic innervation without loss of surgery's radicalism, which is represented in this survey. The paper presents the results of comparative analysis of 54 cases of surgical treatment for invasive cervical cancer.

Re-resection rates after breast-conserving surgery as a performance indicator: introduction of a case-mix model to allow comparison between Dutch hospitals.

PubMed

Talsma, A K; Reedijk, A M J; Damhuis, R A M; Westenend, P J; Vles, W J

2011-04-01

Re-resection rate after breast-conserving surgery (BCS) has been introduced as an indicator of quality of surgical treatment in international literature. The present study aims to develop a case-mix model for re-resection rates and to evaluate its performance in comparing results between hospitals. Electronic records of eligible patients diagnosed with in-situ and invasive breast cancer in 2006 and 2007 were derived from 16 hospitals in the Rotterdam Cancer Registry (RCR) (n = 961). A model was built in which prognostic factors for re-resections after BCS were identified and expected re-resection rate could be assessed for hospitals based on their case mix. To illustrate the opportunities of monitoring re-resections over time, after risk adjustment for patient profile, a VLAD chart was drawn for patients in one hospital. In general three out of every ten women had re-surgery; in about 50% this meant an additive mastectomy. Independent prognostic factors of re-resection after multivariate analysis were histological type, sublocalisation, tumour size, lymph node involvement and multifocal disease. After correction for case mix, one hospital was performing significantly less re-resections compared to the reference hospital. On the other hand, two were performing significantly more re-resections than was expected based on their patient mix. Our population-based study confirms earlier reports that re-resection is frequently required after an initial breast-conserving operation. Case-mix models such as the one we constructed can be used to correct for variation between hospitals performances. VLAD charts are valuable tools to monitor quality of care within individual hospitals. Copyright © 2011 Elsevier Ltd. All rights reserved.

Bariatric Surgery in Septuagenarians: a Comparison with <60 Year Olds.

PubMed

Parmar, Chetan; Mahawar, Kamal K; Carr, William R J; Schroeder, Norbert; Balupuri, Shlok; Small, Peter K

2017-12-01

There is reluctance amongst many healthcare professionals to offer bariatric surgery to septuagenarians. There is only one study in the scientific literature specifically describing any experience with this group of patients and none that compares the outcomes in this group with younger patients. We retrospectively examined our prospective database to identify all those who were >70 years old at the time of bariatric surgery. This group was then compared with a matched (for sex, body mass index, surgical procedure, and time of surgery) cohort of younger (<60 year old) patients. Information was obtained from our database, case notes, hospital electronic records, by interviewing team members, and from general practitioners. A total of 10 septuagenarians were compared with 10 younger patients (mean age 41 years). There were one early complication and 1 late complication in the over 70 group as opposed to no early complication and 2 late complications in the younger group. There was no mortality or early reoperation in either group. Excess weight loss of 50.4, 67.4, and 74.0% in the >70 age group at 6, 12, and 24 months, respectively, was no different to 51.3, 70.8, and 73.9% in <60 year olds. The effect on the co-morbidity resolution was similar in the two groups. In carefully selected septuagenarians, bariatric surgery can be performed with safety and efficacy comparable to those <60 years old.

A comparative analysis of minimally invasive and open spine surgery patient education resources.

PubMed

Agarwal, Nitin; Feghhi, Daniel P; Gupta, Raghav; Hansberry, David R; Quinn, John C; Heary, Robert F; Goldstein, Ira M

2014-09-01

The Internet has become a widespread source for disseminating health information to large numbers of people. Such is the case for spine surgery as well. Given the complexity of spinal surgeries, an important point to consider is whether these resources are easily read and understood by most Americans. The average national reading grade level has been estimated to be at about the 7th grade. In the present study the authors strove to assess the readability of open spine surgery resources and minimally invasive spine surgery resources to offer suggestions to help improve the readability of patient resources. Online patient education resources were downloaded in 2013 from 50 resources representing either traditional open back surgery or minimally invasive spine surgery. Each resource was assessed using 10 scales from Readability Studio Professional Edition version 2012.1. Patient education resources representing traditional open back surgery or minimally invasive spine surgery were all found to be written at a level well above the recommended 6th grade level. In general, minimally invasive spine surgery materials were written at a higher grade level. The readability of patient education resources from spine surgery websites exceeds the average reading ability of an American adult. Revisions may be warranted to increase quality and patient comprehension of these resources to effectively reach a greater patient population.

Application of an innovative computerized virtual planning system in acetabular fracture surgery: A feasibility study.

PubMed

Wang, Huixiang; Wang, Fang; Newman, Simon; Lin, Yanping; Chen, Xiaojun; Xu, Lu; Wang, Qiugen

2016-08-01

Acetabular fracture surgery is amongst the most challenging tasks in the field of trauma surgery and careful preoperative planning is crucial for success. The aim of this paper is to describe the preliminary outcome of the utilization of an innovative computerized virtual planning system for acetabular fractures. 3D models of acetabular fractures and surrounding soft tissues from six patients were constructed from preoperative CT scans. A novel highly-automatic segmentation technique was performed on the 3D model to separate each fracture fragment, then 3D virtual reduction was performed. Additionally, the models were used to assess potential surgical approaches with reference to both the fracture and the surrounding soft tissues. The time required for virtual planning was recorded. After surgery, the virtual plan was compared to the real surgery with respect to surgical approach and reduction sequence. A Likert scale questionnaire was completed by the surgeons to evaluate their satisfaction with the system. Virtual planning was successfully completed in all cases. The planned surgical approach was followed in all cases with the planned reduction sequence followed completely in five cases and partially in one. The mean time required for virtual planning was 38.7min (range 21-57, SD=15.5). The mean time required for planning of B-type fractures was 25.0min (range 21-30, SD=4.6), of C-type fracture 52.3min (range 49-57, SD=4.2). The results of the questionnaire demonstrated a high level of satisfaction with the planning system. This study demonstrates that the virtual planning system is feasible in clinical settings with high satisfaction and acceptability from the surgeons. It provides a viable option for the planning of acetabular fracture surgery. Copyright © 2016 Elsevier Ltd. All rights reserved.

[Clinical analysis on extramedullary plasmacytoma in the upper airway].

PubMed

Ge, Shenglei; Tan, Zhiqiang; Xie, Dinghua; Yi, Yan

2013-03-01

To investigate the clinical manifestation, treatment and prognosis of extramedullary plasmacytoma(EMP) in the upper airway, and to improve the diagnosis and outcome of EMP treatment. Clinical data of 26 EMP cases were reviewed retrospectively, and then compared with multiple myeloma(MM) patients presenting with lesions in upper airway. Of 26 cases, 9 cases with the tumors occurred in nasal cavities, 7 in nasal sinuses, 6 in pharyngeal, 4 in throat, mainly manifesting with local masses and relevant symptoms. The manifestations of clinical, endoscopy findings and pathologic results in EMP patients were not distinguishable from the lesions of MM patients, while MM patients often accompanied by other findings, such as anemia and bone damage. Involvement of neck lymph nodes was more common in MM patients than in EMP patients. Ten patients were treated with surgery, and 16 patients with surgery and radiotherapy. Of the seven EMP patients with involvement of neck lymph nodes, four patients received additional chemotherapy besides surgery and radiotherapy, and no local relapse and MM happened in them, while of the three patients only received surgery and radiotherapy, one local relapse were found and one progressed to MM. The diagnosis of EMPs mainly depends on pathological results. The judgment of pathologists and application of molecular biology technology are vital for the diagnosis of EMP in upper airway, and MM must be excluded very carefully in the diagnosis of EMP. Surgery combined with radiotherapy is the main treatment for EMP in the upper airway, and the prognosis is good but the follow-up should be taken. Besides surgery and radiotherapy, chemotherapy is beneficial for the EMP patients accompanied with lesions in neck lymph nodes.

Financial modelling of femtosecond laser-assisted cataract surgery within the National Health Service using a 'hub and spoke' model for the delivery of high-volume cataract surgery.

PubMed

Roberts, H W; Ni, M Z; O'Brart, D P S

2017-03-16

To develop financial models which offset additional costs associated with femtosecond laser (FL)-assisted cataract surgery (FLACS) against improvements in productivity and to determine important factors relating to its implementation into the National Health Service (NHS). FL platforms are expensive, in initial purchase and running costs. The additional costs associated with FL technology might be offset by an increase in surgical efficiency. Using a 'hub and spoke' model to provide high-volume cataract surgery, we designed a financial model, comparing FLACS against conventional phacoemulsification surgery (CPS). The model was populated with averaged financial data from 4 NHS foundation trusts and 4 commercial organisations manufacturing FL platforms. We tested our model with sensitivity and threshold analyses to allow for variations or uncertainties. The averaged weekly workload for cataract surgery using our hub and spoke model required either 8 or 5.4 theatre sessions with CPS or FLACS, respectively. Despite reduced theatre utilisation, CPS (average £433/case) was still found to be 8.7% cheaper than FLACS (average £502/case). The greatest associated cost of FLACS was the patient interface (PI) (average £135/case). Sensitivity analyses demonstrated that FLACS could be less expensive than CPS, but only if increased efficiency, in terms of cataract procedures per theatre list, increased by over 100%, or if the cost of the PI was reduced by almost 70%. The financial viability of FLACS within the NHS is currently precluded by the cost of the PI and the lack of knowledge regarding any gains in operational efficiency. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Modifications of transaxillary approach in endoscopic da Vinci-assisted thyroid and parathyroid gland surgery.

PubMed

Al Kadah, Basel; Piccoli, Micaela; Mullineris, Barbara; Colli, Giovanni; Janssen, Martin; Siemer, Stephan; Schick, Bernhard

2015-03-01

Endoscopic surgery for treatment of thyroid and parathyroid pathologies is increasingly gaining attention. The da Vinci system has already been widely used in different fields of medicine and quite recently in thyroid and parathyroid surgery. Herein, we report about modifications of the transaxillary approach in endoscopic surgery of thyroid and parathyroid gland pathologies using the da Vinci system. 16 patients suffering from struma nodosa in 14 cases and parathyroid adenomas in two cases were treated using the da Vinci system at the ENT Department of Homburg/Saar University and in cooperation with the Department of General Surgery in New Sant'Agostino Hospital, Modena/Italy. Two different retractors, endoscopic preparation of the access and three different incision modalities were used. The endoscopic preparation of the access allowed us to have a better view during preparation and reduced surgical time compared to the use of a headlamp. To introduce the da Vinci instruments at the end of the access preparation, the skin incisions were over the axilla with one incision in eight patients, two incisions in four patients and three incisions in a further four patients. The two and three skin incisions modality allowed introduction of the da Vinci instruments without arm conflicts. The use of a new retractor (Modena retractor) compared to a self-developed retractor made it easier during the endoscopic preparation of the access and the reposition of the retractor. The scar was hidden in the axilla and independent of the incisions selected, the cosmetic findings were judged by the patients to be excellent. The neurovascular structures such as inferior laryngeal nerve, superior laryngeal nerve and vessels, as well as the different pathologies, were clearly 3D visualized in all 16 cases. No paralysis of the vocal cord was observed. All patients had a benign pathology in their histological examination. The endoscopic surgery of the thyroid and parathyroid gland can be performed using the da Vinci system and offers an excellent, intra-operative, 3D visualization of the neurovascular structures. The new incision modalities, use of a new retractor, and endoscopic preparation of the access made the surgery easier and safer using the transaxillary access to the thyroid and parathyroid glands. The modified skin incisions allowed an improved movement of the da Vinci arms during operation.

Robotic assisted gastrectomy compared with open resection: a case-matched study.

PubMed

Caruso, Riccardo; Vicente, Emilio; Quijano, Yolanda; Ielpo, Benedetto; Duran, Hipolito; Diaz, Eduardo; Fabra, Isabel; Ferri, Valentina

2018-05-04

In recent years, increasingly sophisticated tools have allowed for more complex robotic surgery. Robotic gastrectomy, however, is adopted in only a few selected centers. The goals of this study were to examine the adoption of robotic gastrectomy and to compare outcomes between open and robotic gastric resections. This is a case-matched analysis of patients who underwent robotic and open gastric resection performed at Sanchinarro University Hospital, Madrid from November 2011 to February 2017. Patient data were obtained retrospectively. Clinicopathologic characteristics and perioperative and postoperative outcomes were recorded and analyzed. Two groups of demographically similar patients were analyzed: the robotic group (n = 20) and the open surgery group (n = 19). The patient characteristics of the two groups have been compared. Robotic resection resulted in less blood loss, shorter postoperative hospital stay, and a longer operating time. The two groups had similar complication rates. Pathological data were similar for both procedures. Robotic gastrectomy for locally advanced gastric carcinoma is safe, and long-term outcomes are comparable to those patients who underwent open resection. Robotic gastrectomy resulted in a shorter hospital stay, less blood loss and morbidity comparable with the outcomes of open gastrectomy.

The operating room case-mix problem under uncertainty and nurses capacity constraints.

PubMed

Yahia, Zakaria; Eltawil, Amr B; Harraz, Nermine A

2016-12-01

Surgery is one of the key functions in hospitals; it generates significant revenue and admissions to hospitals. In this paper we address the decision of choosing a case-mix for a surgery department. The objective of this study is to generate an optimal case-mix plan of surgery patients with uncertain surgery operations, which includes uncertainty in surgery durations, length of stay, surgery demand and the availability of nurses. In order to obtain an optimal case-mix plan, a stochastic optimization model is proposed and the sample average approximation method is applied. The proposed model is used to determine the number of surgery cases to be weekly served, the amount of operating rooms' time dedicated to each specialty and the number of ward beds dedicated to each specialty. The optimal case-mix selection criterion is based upon a weighted score taking into account both the waiting list and the historical demand of each patient category. The score aims to maximizing the service level of the operating rooms by increasing the total number of surgery cases that could be served. A computational experiment is presented to demonstrate the performance of the proposed method. The results show that the stochastic model solution outperforms the expected value problem solution. Additional analysis is conducted to study the effect of varying the number of ORs and nurses capacity on the overall ORs' performance.

A single-institution experience: the integrated vascular surgery residency's effect on fellowship and general surgery resident case volume and diversity.

PubMed

Carroll, Megan I; Downes, Kathryne; Miladinovic, Branko; Illig, Karl A; Armstrong, Paul A; Back, Martin R; Johnson, Brad L; Shames, Murray L

2014-01-01

To determine whether the formation of an integrated vascular surgery residency (0 + 5) has negatively impacted the case volume and diversity of the vascular surgery fellows (5 + 2) and chief general surgeons at the same institution. Operative data from the vascular integrated (0 + 5), independent (5 + 2), and general surgery residencies at a single institution were retrospectively reviewed and analyzed to determine vascular surgery case volumes from 2006-2012. National operative data (Residency Review Committee) were used for comparison of diversity and volume. Standard statistical methods were applied. During this period, the 5 + 2 fellows at our institution performed on average 741 (range, 554-1002) primary cases and 1091 (range, 844-1479) combined primary and secondary cases for the 2-year fellowship. Our integrated residency began in July 2007. Our fellows' primary case volumes remained relatively stable between 2006 and 2011, with a 4% increase in the number of cases, although their total (primary and secondary) case volumes fell 15%; by comparison, the equivalent national 50th percentile rates rose 16% during this time frame. Our institution's general surgery residents performed an average of 116 (range, 56-221) vascular cases individually during their 5-year residency from 2005-2011. From 2006-2011, the total case volume fell only 5%, while the national 50th percentile rate fell 24%. Across all years, however, resident and fellow volumes both continue to be above Accreditation Council for Graduate Medical Education minimum requirements, and the major vascular case volume at our institution in all groups studied remained statistically greater than or equal to the national 50th percentile of cases. Our first integrated resident to graduate finished in June 2012 with 931 total vascular cases and 249 general surgery cases for a total operative experience of 1180 cases during the 5-year residency. Finally, after an 8-year period (2003-2010) in which none of our general surgery residents pursued vascular training, 1 resident in each of the 2011, 2012, and 2013 graduating years has now done so. At our institution, the introduction of a 0 + 5 vascular residency has correlated with a modest drop (15%) in overall case volume for the 5 + 2 fellows, but the number of primary cases have actually increased slightly and they continue to meet or exceed Accreditation Council for Graduate Medical Education requirements and national 50th percentile rates. General surgery residents' vascular volumes, by contrast, have remained stable, and interest in vascular surgery by residents has increased. Our integrated vascular residents are projected to exceed the fellows' 50th percentile case volume and diversity targets during their residency experience. Copyright © 2014 Elsevier Inc. All rights reserved.

Practice-based learning and improvement: a two-year experience with the reporting of morbidity and mortality cases by general surgery residents.

PubMed

Falcone, John L; Lee, Kenneth K W; Billiar, Timothy R; Hamad, Giselle G

2012-01-01

The Accreditation Council for Graduate Medical Education (ACGME) core competency of practice-based learning and improvement can be assessed with surgical Morbidity and Mortality Conference (MMC). We aim to describe the MMC reporting patterns of general surgery residents, describe the adverse event rate for patients and compare that with existing published rates, and describe the nature of our institutional adverse events. We hypothesize that reporting patterns and incidence rates will remain constant over time. In this retrospective cohort study, archived MMC case lists were evaluated from January 1, 2009 to December 31, 2010. The reporting patterns of the residents, the adverse event ratios, and the specific categories of adverse events were described over the academic years. χ(2) and Fisher's exact tests were used to compare across academic years, using an α = 0.05. There were 85 surgical MMC case lists evaluated. Services achieved a reporting rate above 80% (p < 0.001). The most consistent reporting was done by postgraduate year (PGY) 5 level chief residents for all services (p > 0.05). Out of 11,368 patients evaluated from complete MMC submissions, 289 patients had an adverse event reported (2.5%). This was lower than published reporting rates for patient adverse event rates (p < 0.001). Adverse event rates were consistent for residents at the postgraduate year 2, 4, and 5 levels for all services (p > 0.05). Over 2 years, 522 adverse events were reported for 461 patients. A majority of adverse events were from death (24.1%), hematologic and/or vascular events (16.7%), and gastrointestinal system events (16.1%). Surgery resident MMC reporting patterns and adverse event rates are generally stable over time. This study shows which adverse event cases are important for chief residents to report. Copyright © 2012 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Bariatric surgery in patients with inflammatory bowel disease: an accessible path? Report of a case series and review of the literature.

PubMed

Colombo, Francesco; Rizzi, Andrea; Ferrari, Carlo; Frontali, Alice; Casiraghi, Silvia; Corsi, Fabio; Sampietro, Gianluca M; Foschi, Diego

2015-02-01

Morbid obesity is an emerging problem in the inflammatory bowel disease [IBD] population. Bariatric and IBD surgeries share technical difficulties and elevated morbidity. However, nothing is known about the possibility of performing bariatric surgery in patients with a definite diagnosis of IBD. The aim of this study was to evaluate safety and efficacy of restrictive bariatric surgical procedures in IBD patients. Six patients with morbid obesity and IBD were operated on with restrictive bariatric surgery and concomitant or deferred IBD surgery. We compared BMI, excess weight loss, and perioperative complications of restrictive bariatric surgery in IBD with a control group of 95 bariatric patients. We also evaluated clinical, biochemical, pharmacological, and endoscopic characteristics before and after surgery in IBD patients. Perioperative results, in terms of BMI, excess weight loss, and complications after restrictive bariatric surgery, were comparable between obese IBD and control patients. IBD patients experienced a significant postoperative reduction in BMI, CRP levels, WCC, and systolic blood pressure and a significant increment in hemoglobin levels. None of the patients reported signs of malabsorption. All the patients except one were able to discontinue steroids, were in endoscopic remission at 1 year, and were in clinical remission at the latest follow-up visit. Two patients halved azathioprine dosage. One patient had a postoperative clinical recurrence treated with adalimumab. Bariatric surgery seems to be safe and effective in IBD patients. Concomitant ileocolic resection does not increase perioperative complications. Relationship between IBD and obesity remains unclear, but weight loss could be useful in the pharmacological control of IBD.

Comparison of Complications Rates in Endoscopic Surgery Performed by a Clinical Assistant vs. An Experienced Endoscopic Surgeon

PubMed Central

Singhi, Aditi

2009-01-01

Study Objectives: (a) To find out the actual incidence of complications during endoscopic surgeries. (b) Comparison of complication rate between an experienced laparoscopic surgeon (> 10 years of experience in endoscopic surgery) and a clinical assistant (> 3 years of experience in endoscopic surgery). (c) How to manage complications in endoscopic surgery. (d) Concrete suggestions to reduce the complication rate. Design: Retrospective study (Canadian Task Force classification ii-2). Setting: Tertiary gynecologic endoscopic unit. Patients: A total of 3204 cases of gynecologic endoscopic surgery out of which 2001 were laparoscopic and 1203 were hysteroscopic surgeries. Interventions: Laparoscopic and hysteroscopic gynecologic surgeries in indicated cases. Measurements and Main Results: The study was carried out between April 2003 and October 2007 at a referral center for endoscopic surgery. A total of 3204 cases of gynecologic endoscopic surgery were studied. There were five significant complications in laparoscopic surgeries and four significant complications in hysteroscopic surgeries seen in four years and six months. All the complications could be managed with no mortality. Conversion to laparotomy was needed in eight cases of laparoscopic surgeries and none in hysteroscopic surgeries. Conclusion: The risk of complication reduces with the experience in endoscopic surgery. However, the proper grooming of a novice in experienced hands, for a sufficient period of time, can minimize the complication rate in the initial learning phase. The complication may be utilized as a stepping-stone to overcome any given situation without panic, but with adequate safety. PMID:22442510

Crude versus case-mix-adjusted control charts for safety monitoring in thyroid surgery.

PubMed

Duclos, Antoine; Voirin, Nicolas; Touzet, Sandrine; Soardo, Pietro; Schott, Anne-Marie; Colin, Cyrille; Peix, Jean-Louis; Lifante, Jean-Christophe

2010-12-01

Patient-safety monitoring based on health-outcome indicators can lead to misinterpretation of changes in case mix. This study aimed to compare the detection of indicator variations between crude and case-mix-adjusted control charts using data from thyroid surgeries. The study population included each patient who underwent thyroid surgery in a teaching hospital from January 2006 to May 2008. Patient safety was monitored according to two indicators, which are immediately recognisable postoperative complications: recurrent laryngeal nerve palsy and hypocalcaemia. Each indicator was plotted monthly on a p-control chart using exact limits. The weighted κ statistic was calculated to measure the agreement between crude and case-mix-adjusted control charts. We evaluated the outcomes of 1405 thyroidectomies. The overall proportions of immediate recurrent laryngeal nerve palsy and hypocalcaemia were 7.4% and 20.5%, respectively. The proportion of agreement in the detection of indicator variations between the crude and case-mix-adjusted p-charts was 95% (95% CI 85% to 99%). The strength of the agreement was κ = 0.76 (95% CI 0.54 to 0.98). The single special cause of variation that occurred was only detected by the case-mix-adjusted p-chart. There was good agreement in the detection of indicator variations between crude and case-mix-adjusted p-charts. The joint use of crude and adjusted charts seems to be a reasonable approach to increase the accuracy of interpretation of variations in outcome indicators.

[Suspension laryngoscopic surgery for laryngotracheal stenosis of 32 cases].

PubMed

Wang, Chunyan; Qin, Yong; Xiao, Shuifang

2014-08-01

To investigate the efficacy of suspension laryngoscopic surgery for benign laryngotracheal stenosis (LTS). Thirty-two patients (aged from 5 to 70 years with a median of 36 years) with benign LTS were studied retrospectively who were treated by suspension laryngoscopic surgery with or without assistance of CO₂ Laser for LTS. Stents were placed in 17 cases. Among 32 patients, 13 cases were with LST in Cotton I, 8 cases in Cotton II, and 11 cases in Cotton III; 23 were with single level narrow, and 9 cases with multi-level narrow; the average narrow length was 1.3 cm and the average diameter at maximum stenosis was 0.5 cm; and 19 cases underwent tracheostomy before surgery. Follow-up period ranged from 1 to 18 years with median time of 10 years. Twenty-six patients (81.2%) were successfully decannulated with good airway patency and effective phonation. Six cases failed and 1 case of them was changed to open surgery. Among 17 cases with stent placement, 4 cases were applied additionally with T tube (effective rate of 50.0%), 1 case with laryngeal keel, 12 cases with stents alone (effective rate of 66.7%). Stent-related complications occurred in 2 cases. Patients with cotton I-II had a successful rate of 100% (21/21), while patients with Cotton III showed poor effectiveness (5/11), with a statistical significant difference between two groups (χ² = 14.098, P = 0.001). The patients with single level LTS were successfully treated by suspension laryngoscopic surgery with 100% successful rate (23/23), while the patients with multi-level LTS showed poor effectiveness (3/9), with a statistical significant difference between two groups (χ² = 18.872, P = 0.000) . Suspension laryngoscopic microsurgery can treat single level LTS with good results and also can be used as a pre-surgery in treatment of multi-level LTS with the virtue of minimal trauma and short recovery time. Application of stents can be helpful for suspension laryngoscope surgery for LST.

[Laparoscopic surgery for malignancies of the colon, rectum, and anus in Lithuania in 2008].

PubMed

Samalavicius, Narimantas Evaldas; Rudinskaite, Giedre; Pavalkis, Dainius; Latkauskas, Tadas; Kaselis, Nerijus; Sidlauskas, Zilvinas; Sniuolis, Pranas; Poskus, Tomas; Kvedaras, Vytautas; Strupas, Kestutis; Poskus, Eligijus

2009-01-01

THE OBJECTIVE OF THIS STUDY: was to analyze data on laparoscopic surgery for malignant diseases of the colon, rectum, and anus in Lithuania during the period of January 1, 2005, to February 15, 2008. During the above-mentioned period in Lithuania, 130 laparoscopic surgeries for malignancies of colon, rectum, and anus were performed in seven different hospitals. There were 73 males and 57 females with a mean age of 68 years (range, 35-85 years). Laparoscopic procedures were attempted in 140 cases. Out of them, 130 were completed laparoscopically; 10 operations were converted to open, and conversion rate was 7.1%. Twenty-seven (20.8%) patients had stage I, 45 (34.6%) stage II, 45 (34.6%) stage III, and 13 (10%) stage IV disease. Ninety-two (70.8%) patients underwent straight laparoscopic surgery and 38 (29.2%) - hand-assisted laparoscopic surgery. Time in surgery was from 50 to 365 min, with a mean of 183 min. During 130 operations, in 11 (8.5%) cases, blood vessels were ligated through specimen retrieval site. Out of 104 operations, where anastomosis was performed (23 abdominoperineal resections and 3 Hartmann's procedures), in 68 (65.4%) cases it was done laparoscopically and in 36 (34.6%) cases using conventional extracorporal suturing. Hospital stay ranged from 7 to 59 days, with a mean of 12 days. One (0.8%) patient died. Postoperative complications occurred in 27 (20.8%) cases. Reoperation rate was 4.6% (6 cases). Complications were as follows: suture insufficiency (3 cases), eventration (3 cases), wound infection (7 cases), intraperitoneal abscess (1 case), abdominal wall phlegmon (1 case), intra-abdominal infiltrate (1 case), perineal hematoma (1 case), proctovaginal fistula (2 case), intraoperative bleeding from uterus (1 case), urinary retention (4 cases), cystitis (1 case), pneumonia (1 case), acute cardiovascular insufficiently (1 case). In histological specimens, 10 lymph nodes were found on the average (range, 2 to 27). Laparoscopic surgery for malignant diseases of the colon, rectum, and anus is dominating among laparoscopic surgeries for colorectum. Complication rate is similar to other authors. To evaluate disease relapse and outcomes, observation time is not sufficient yet.

Transgender Surgery in Denmark From 1994 to 2015: 20-Year Follow-Up Study.

PubMed

Aydin, Dogu; Buk, Liv Johanne; Partoft, Søren; Bonde, Christian; Thomsen, Michael Vestergaard; Tos, Tina

2016-04-01

Gender dysphoria is a mismatch between a person's biological sex and gender identity. The best treatment is believed to be hormonal therapy and gender-confirming surgery that will transition the individual toward the desired gender. Treatment in Denmark is covered by public health care, and gender-confirming surgery in Denmark is centralized at a single-center with few specialized plastic surgeons conducting top surgery (mastectomy or breast augmentation) and bottom surgery (vaginoplasty or phalloplasty and metoidioplasty). To report the first nationwide single-center review on transsexual patients in Denmark undergoing gender-confirming surgery performed by a single surgical team and to assess whether age at time of gender-confirming surgery decreased during a 20-year period. Electronic patient databases were used to identify patients diagnosed with gender identity disorders from January 1994 through March 2015. Patients were excluded from the study if they were pseudohermaphrodites or if their gender was not reported. Gender distribution, age trends, and surgeries performed for Danish patients who underwent gender-confirming surgery. One hundred fifty-eight patients referred for gender-confirming surgery were included. Fifty-five cases (35%) were male-to-female (MtF) and 103 (65%) were female-to-male (FtM). In total, 126 gender-confirming surgeries were performed. For FtM cases, top surgery (mastectomy) was conducted in 62 patients and bottom surgery (phalloplasty and metoidioplasty) was conducted in 17 patients. For MtF cases, 45 underwent bottom surgery (vaginoplasty), 2 of whom received breast augmentation. The FtM:MtF ratio of the referred patients was 1.9:1. The median age at the time of surgery decreased from 40 to 27 years during the 20-year period. Gender-confirming surgery was performed on 65 FtM and 40 MtF cases at our hospital, and 21 transsexuals underwent surgery abroad. Mastectomy was performed in 62 FtM and bottom surgery in 17 FtM cases. Vaginoplasty was performed in 45 MtF and breast augmentation in 2 MtF cases. There was a significant decrease in age at the time of gender-confirming surgery during the course of the study period. Copyright © 2016 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.

Working with a fixed operating room team on consecutive similar cases and the effect on case duration and turnover time.

PubMed

Stepaniak, Pieter S; Vrijland, Wietske W; de Quelerij, Marcel; de Vries, Guus; Heij, Christiaan

2010-12-01

If variation in procedure times could be controlled or better predicted, the cost of surgeries could be reduced through improved scheduling of surgical resources. This study on the impact of similar consecutive cases on the turnover, surgical, and procedure times tests the perception that repeating the same manual tasks reduces the duration of these tasks. We hypothesize that when a fixed team works on similar consecutive cases the result will be shorter turnover and procedure duration as well as less variation as compared with the situation without a fixed team. Case-control study. St Franciscus Hospital, a large general teaching hospital in Rotterdam, the Netherlands. Two procedures, inguinal hernia repair and laparoscopic cholecystectomy, were selected and divided across a control group and a study group. Patients were randomly assigned to the study or control group. Preparation time, surgical time, procedure time, and turnover time. For inguinal hernia repair, we found a significantly lower preparation time and 10 minutes less procedure time in the study group, as compared with the control group. Variation in the study group was lower, as compared with the control group. For laparoscopic cholecystectomy, preparation time was significantly lower in the study group, as compared with the control group. For both procedures, there was a significant decrease in turnover time. Scheduling similar consecutive cases and performing with a fixed team results in lower turnover times and preparation times. The procedure time of the inguinal hernia repair decreased significantly and has practical scheduling implications. For more complex surgery, like laparoscopic cholecystectomy, there is no effect on procedure time.

Economic burden of deep infiltrating endometriosis of the bowel and the bladder in Germany: The statutory health insurance perspective.

PubMed

Koltermann, Katharina C; Schlotmann, Andreas; Schröder, Helmut; Willich, Stefan N; Reinhold, Thomas

2016-12-01

Until now, there has been little discussion of the costs of the deep infiltrating endometriosis (DIE) of the bowel or the bladder. The aim of the present secondary data analysis was to describe the population affected by this disease and to determine the economic burden in Germany from a payer's perspective. Health claims data of women diagnosed with DIE of the bladder or bowel, who were surgically treated as inpatients between Jan 1, 2008 and Dec 31, 2012, were evaluated retrospectively. All data were extrapolated on a national statutory health insurance (SHI) level and normalized based on the year of surgery (index year). Case-individual information on age, comorbidities and prescribed drugs were presented for the index year. Direct medical cost data were analysed before and after the index year, differentiated by cost sector and age group. The data of 825 women with DIE were analysed. Sample size for different time points varied depending on insurance eligibility and continuous case information. The average age at surgery was 39 years. Besides DIE, 41 % of the women had at least one additional disease of the peritoneum. The mean annual total healthcare costs per DIE case were 12,868 Euros in the index year. Before surgery, mean annual costs varied between 548 and 2,475 Euros per case and after surgery between 1,739 and 2,818 Euros per case. In total, mean costs were higher in younger women as compared to older women, with a cost difference of 616 Euros over all time points. Direct costs are highest during the year of surgical treatment, but DIE of the bowel and bladder places a substantial burden on the SHI also before and after surgery. Further studies on indirect costs would be desirable to complete the knowledge on the economic burden of DIE. Copyright © 2016. Published by Elsevier GmbH.

Continuation of TNF blockade in patients with inflammatory rheumatic disease. An observational study on surgical site infections in 1,596 elective orthopedic and hand surgery procedures.

PubMed

Berthold, Elisabet; Geborek, Pierre; Gülfe, Anders

2013-10-01

Increased infection risk in inflammatory rheumatic diseases may be due to inflammation or immunosuppressive treatment. The influence of tumor necrosis factor (TNF) inhibitors on the risk of developing surgical site infections (SSIs) is not fully known. We compared the incidence of SSI after elective orthopedic surgery or hand surgery in patients with a rheumatic disease when TNF inhibitors were continued or discontinued perioperatively. We included 1,551 patients admitted for elective orthopedic surgery or hand surgery between January 1, 2003 and September 30, 2009. Patient demographic data, previous and current treatment, and factors related to disease severity were collected. Surgical procedures were grouped as hand surgery, foot surgery, implant-related surgery, and other surgery. Infections were recorded and defined according to the 1992 Centers for Disease Control definitions for SSI. In 2003-2005, TNF inhibitors were discontinued perioperatively (group A) but not during 2006-2009 (group B). In group A, there were 28 cases of infection in 870 procedures (3.2%) and in group B, there were 35 infections in 681 procedures (5.1%) (p = < 0.05). Only foot surgery had significantly more SSIs in group B, with very low rates in group A. In multivariable analysis with groups A and B merged, only age was predictive of SSI in a statistically significant manner. Overall, the SSI rates were higher after abolishing the discontinuation of anti-TNF perioperatively, possibly due to unusually low rates in the comparator group. None of the medical treatments analyzed, e.g. methotrexate or TNF inhibitors, were significant risk factors for SSI. Continuation of TNF blockade perioperatively remains a routine at our center.

A matched cohort comparison of clinical outcomes following microsurgical resection or stereotactic radiosurgery for patients with small- and medium-sized vestibular schwannomas.

PubMed

Golfinos, John G; Hill, Travis C; Rokosh, Rae; Choudhry, Osamah; Shinseki, Matthew; Mansouri, Alireza; Friedmann, David R; Thomas Roland, J; Kondziolka, Douglas

2016-12-01

OBJECTIVE A randomized trial that compares clinical outcomes following microsurgery (MS) or stereotactic radiosurgery (SRS) for patients with small- and medium-sized vestibular schwannomas (VSs) is impractical, but would have important implications for clinical decision making. A matched cohort analysis was conducted to evaluate clinical outcomes in patients treated with MS or SRS. METHODS The records of 399 VS patients who were cared for by 2 neurosurgeons and 1 neurotologist between 2001 and 2014 were evaluated. From this data set, 3 retrospective matched cohorts were created to compare hearing preservation (21 matched pairs), facial nerve preservation (83 matched pairs), intervention-free survival, and complication rates (85 matched pairs) between cases managed with SRS and patients managed with MS. Cases were matched for age at surgery (± 10 years) and lesion size (± 0.1 cm). To compare hearing outcomes, cases were additionally matched for preoperative Class A hearing according to the American Academy of Otolaryngology-Head and Neck Surgery guidelines. To compare facial nerve (i.e., cranial nerve [CN] VII) outcomes, cases were additionally matched for preoperative House-Brackmann (HB) score. Investigators who were not involved with patient care reviewed the clinical and imaging records. The reported outcomes were as assessed at the time of the last follow-up, unless otherwise stated. RESULTS The preservation of preoperative Class A hearing status was achieved in 14.3% of MS cases compared with 42.9% of SRS cases (OR 4.5; p < 0.05) after an average follow-up interval of 43.7 months and 30.3 months, respectively. Serviceable hearing was preserved in 42.8% of MS cases compared with 85.7% of SRS cases (OR 8.0; p < 0.01). The rates of postoperative CN VII dysfunction were low for both groups, although significantly higher in the MS group (HB III-IV 11% vs 0% for SRS; OR 21.3; p < 0.01) at a median follow-up interval of 35.7 and 19.0 months for MS and SRS, respectively. There was no difference in the need for subsequent intervention (2 MS patients and 2 SRS patients). CONCLUSIONS At this high-volume center, VS resection or radiosurgery for tumors ≤ 2.8 cm in diameter was associated with low overall morbidity. The need for subsequent intervention was the same in both groups. SRS was associated with improved hearing and facial preservation rates and reduced morbidity, but with a shorter average follow-up period. Facial function was excellent in both groups. Since patients were not randomly selected for surgery, different clinical outcomes may be of different value to individual patients. Both anticipated medical outcomes and patient goals remain the drivers of treatment decisions.

Initial experience using a femtosecond laser cataract surgery system at a UK National Health Service cataract surgery day care centre

PubMed Central

Dhallu, Sandeep K; Maurino, Vincenzo; Wilkins, Mark R

2016-01-01

Objectives To describe the initial outcomes following installation of a cataract surgery laser system. Setting National Health Service cataract surgery day care unit in North London, UK. Participants 158 eyes of 150 patients undergoing laser-assisted cataract surgery. Interventions Laser cataract surgery using the AMO Catalys femtosecond laser platform. Primary and secondary outcome measures Primary outcome measure: intraoperative complications including anterior and posterior capsule tears. Secondary outcome measures: docking to the laser platform, successful treatment delivery, postoperative visual acuities. Results Mean case age was 67.7±10.8 years (range 29–88 years). Docking was successful in 94% (148/158 cases), and in 4% (6/148 cases) of these, the laser delivery was aborted part way during delivery due to patient movement. A total of 32 surgeons, of grades from junior trainee to consultant, performed the surgeries. Median case number per surgeon was 3 (range from 1–20). The anterior capsulotomy was complete in 99.3% of cases, there were no anterior capsule tears (0%). There were 3 cases with posterior capsule rupture requiring anterior vitrectomy, and 1 with zonular dialysis requiring anterior vitrectomy (4/148 eyes, 2.7%). These 4 cases were performed by trainee surgeons, and were either their first laser cataract surgery (2 surgeons) or their first and second laser cataract surgeries (1 surgeon). Conclusions Despite the learning curve, docking and laser delivery were successfully performed in almost all cases, and surgical complication rates and visual outcomes were similar to those expected based on national data. Complications were predominately confined to trainee surgeons, and with the exception of intraoperative pupil constriction appeared unrelated to the laser-performed steps. PMID:27466243

Osteo-odonto-keratoprosthesis surgery: a combined ocular-oral procedure for ocular blindness.

PubMed

Tay, A B G; Tan, D T H; Lye, K W; Theng, J; Parthasarathy, A; Por, Y-M

2007-09-01

The aim of this retrospective study was to describe the oral procedures used in osteo-odonto-keratoprosthesis (OOKP) surgery, and the demographics and oral findings of candidate patients in Singapore. The OOKP procedure utilizes an autologous tooth-bone complex to mount a poly-methylmethacrylate optical cylinder, as an artificial cornea, stabilized by an overlying autologous buccal mucosal graft. Consecutive patients referred over 3 years for dental evaluation prior to OOKP surgery were included. A total of 21 patients underwent oral clinical and radiographic evaluation. The aetiology of blindness included Stevens-Johnson's syndrome (11 cases), chemical burns (9 cases) and multiple failed corneal grafts (1 case). Evaluation revealed that 12 patients were suitable for OOKP surgery, 8 were at risk of complication or failure and 1 had no usable teeth. Fourteen patients have undergone unilateral OOKP Stage 1 surgery successfully. Complications included fracture of a tooth from its lingual bone necessitating the harvesting of a second tooth (1 case), oronasal perforation (1 case), exposure of adjacent roots (5 teeth), lower lip paresthesia (2 cases) and submucosal scar band formation in the buccal mucosal graft donor site (10 cases). Thirteen patients have completed Stage 2 surgery, with attainment of their best possible visual potential following OOKP surgery.

Planning Strabismus Surgery: How to Avoid Pitfalls and Complications.

PubMed

Aroichane, Maryam

2016-01-01

Good surgical results following strabismus surgery depend on several factors. In this article, detailed steps for planning strabismus surgery will be reviewed for basic horizontal strabismus surgery, vertical, and oblique muscle surgeries. The thought process behind each case will be presented to help in selecting the best surgical approach to optimize postoperative results. The surgical planning for strabismus will be developed with clinical examples from easy cases to more complex ones. Preoperative pictures of the ocular alignment are an integral part of planning surgery and help in documenting the strabismus before and after surgery. Three cases of strabismus cases will be reviewed with several key factors for planning surgery, including visual acuity, refractive error, potential for stereovision, and risk of postoperative diplopia. The most important factor is accurate orthoptic measurements. The surgical planning for each patient is detailed along with preoperative pictures. Strabismus surgery results can be improved by careful preoperative planning. The surgeon has the ability to discern potential pitfalls that can alter the surgical outcome. Surgical planning allows a dedicated time of reflection before surgery, foreseeing potential problems, and avoiding them during the surgery. © 2016 Board of regents of the University of Wisconsin System, American Orthoptic Journal, Volume 66, 2016, ISSN 0065-955X, E-ISSN 1553-4448.

[Manufacture and application of laparoscopic extraperitoneal sigmoid colostomy].

PubMed

Jin, Hei-ying; DU, Yong-hong; Wang, Xiao-feng; Yao, Hang; Wu, Kun-lan; Zhang, Bei; Zhang, Jin-hao

2013-10-01

To investigate the safety and feasibility of laparoscopic extraperitoneal sigmoid colostomy. Thirty-six patients with low rectal cancer undergoing laproscopic abdominoperineal resection from July 2011 to July 2012 were prospectively enrolled in the study and randomly divided into extraperitoneal colostomy group(EPC, n=18) and internal peritoneal colostomy group(IPC, n=18). Follow-up period was 4-16 (median, 7) months and postoperative complications were compared between two groups. One case in EPC group was converted to IPC because of poor blood supply of the proximal sigmoid, who was eliminated from the subsequent analysis. Compared with the IPC group, the surgery time was longer in EPC group [(25.3±8.5) min vs. (14.7±6.4) min], while the difference was not statistically significant(P>0.05). Each group had 1 case of stoma ischemia, who both received the colostomy reconstructive surgery. The incidence of stoma edema was significantly higher in EPC group[35.3%(6/17) vs. 0, P<0.05). The early postoperative complications rate did not significantly different between the two groups[58.8%(10/17) vs. 27.8%(5/18), P>0.05]. The late postoperative complications rate was 22.2%(4/18) in IPC group, including 1 case of stoma prolapse, 1 case of stoma stenosis and 2 cases of parastomal hernia. No later postoperative complication occurred in EPC group. Extraperitoneal sigmoid colostomy is an easy and safe procedure with lower late complications as compared to internal peritoneal sigmoid colostomy.

Learning Curve Assessment of Robot-Assisted Radical Prostatectomy Compared with Open-Surgery Controls from the Premier Perspective Database

PubMed Central

Kreaden, Usha S.; Gabbert, Jessica; Thomas, Raju

2014-01-01

Abstract Introduction: The primary aims of this study were to assess the learning curve effect of robot-assisted radical prostatectomy (RARP) in a large administrative database consisting of multiple U.S. hospitals and surgeons, and to compare the results of RARP with open radical prostatectomy (ORP) from the same settings. Materials and Methods: The patient population of study was from the Premier Perspective Database (Premier, Inc., Charlotte, NC) and consisted of 71,312 radical prostatectomies performed at more than 300 U.S. hospitals by up to 3739 surgeons by open or robotic techniques from 2004 to 2010. The key endpoints were surgery time, inpatient length of stay, and overall complications. We compared open versus robotic, results by year of procedures, results by case volume of specific surgeons, and results of open surgery in hospitals with and without a robotic system. Results: The mean surgery time was longer for RARP (4.4 hours, standard deviation [SD] 1.7) compared with ORP (3.4 hours, SD 1.5) in the same hospitals (p<0.0001). Inpatient stay was shorter for RARP (2.2 days, SD 1.9) compared with ORP (3.2 days, SD 2.7) in the same hospitals (p<0.0001). The overall complications were less for RARP (10.6%) compared with ORP (15.8%) in the same hospitals, as were transfusion rates. ORP results in hospitals without a robot were not better than ORP with a robot, and pretreatment co-morbidity profiles were similar in all cohorts. Trending of results by year of procedure showed no differences in the three cohorts, but trending of RARP results by surgeon experience showed improvements in surgery time, hospital stay, conversion rates, and complication rates. Conclusions: During the initial 7 years of RARP development, outcomes showed decreased hospital stay, complications, and transfusion rates. Learning curve trends for RARP were evident for these endpoints when grouped by surgeon experience, but not by year of surgery. PMID:24350787

[Office surgery: organization, legislative, and medico-legal problems. Personal experience].

PubMed

Pepe, N; Actis Dato, G M; Vennarecci, G; Anselmo, A

1993-11-01

The authors approach the subject of office surgery by underlining the advantages of this procedure. In particular, they focus attention on the anesthesiological and legislative problems. Depending on the setting used for surgery and the duration of hospitalisation, ambulatorial surgery can be divided into: day-hospital, office surgery, one-day surgery, short-stay surgery, same-day surgery, The authors report their own experience relating to 103 cases with relative complications. A total of 103 operations of medium-to- major ambulatorial surgery were performed (100 females and 3 males, mean age 36.8). One week prior to surgery all patients attended a medical out-patient examination in order to fill in medical records and be prescribed routine hematochemical tests, chest X-ray and ECG. The preoperative anesthesiological evaluation was made at the time of surgery. All patients received antibiotic prophylactic treatment. Postoperative complications were reported above all following neuroleptoanalgesia and amounted to a total of 5 cases: nausea (4 cases) associated with vomit (1 case), and postural hypotension (1 case). No infective complications were observed. The authors emphasise the importance of a careful preoperative selection of patients; an out-patient structure equipped with the appropriate instrument and machinery for surgery and the constant presence of anesthetists to ensure correct anesthesia (local, neuroleptoanalgesic, peridural general), reanimation and postoperative care. The aims of ambulatorial surgery are, in broad terms, the safety of procedures, convenience for the patient and organisational and economic savings for health structures. Ambulatorial surgery has an extremely high acceptance rate by patients. Lastly, the authors also report the juridical and bureaucratic problems faced by ambulatorial surgery and look forward to its wider diffusion. In the future office surgery might represent an important contribution to surgical therapeutic strategies, allowing, if well organised, an excellent compromise between safety, convenience and reduced costs for the patient.

Cost-effectiveness of robotic surgery in gynecologic oncology.

PubMed

Xie, Yue

2015-02-01

Robotically assisted surgeries have flourished in the United States, especially in gynecological procedures. Current robotic systems have high upfront and procedure costs that have led many in the medical community to question the new technology's cost-effectiveness. Recent research continues to find that robotically assisted gynecological cancer treatments have comparable outcomes to traditional laparoscopy and similar or better outcomes than that of laparotomy in the cases studied. However, robotic surgery costs remain higher than that of traditional laparoscopy. Under the current reimbursement climate, practicing physicians and hospitals should collaborate on identifying cost-effective uses of robotic systems and pushing manufacturers to lower purchase and procedure costs to a level that may be accepted by all stakeholders.

Changing trends in barriers to cataract surgery in India.

PubMed

Vaidyanathan, K; Limburg, H; Foster, A; Pandey, R M

1999-01-01

Cataract is a major cause of blindness in Asia. Efforts in India to provide cataract surgical services have had limited success in reaching the cataract-blind population. Earlier studies identified the major barriers to cataract surgery as poverty, lack of transportation or felt need, or sex related; and the critical barriers in rural areas as lack of awareness, difficult access, and cost. Compared with these earlier data, the results of the present study in Karnataka State indicate a shift in the character of the barriers. They now appear to be more related to case selection and service provision. These shifts are analysed and alternative strategies to increase the uptake to cataract surgery are recommended.

Informed Consent as a Litigation Strategy in the Field of Aesthetic Surgery: An Analysis Based on Court Precedents.

PubMed

Park, Bo Young; Kwon, Jungwoo; Kang, So Ra; Hong, Seung Eun

2016-09-01

In an increasing number of lawsuits doctors lose, despite providing preoperative patient education, because of failure to prove informed consent. We analyzed judicial precedents associated with insufficient informed consent to identify judicial factors and trends related to aesthetic surgery medical litigation. We collected data from civil trials between 1995 and 2015 that were related to aesthetic surgery and resulted in findings of insufficient informed consent. Based on these data, we analyzed the lawsuits, including the distribution of surgeries, dissatisfactions, litigation expenses, and relationship to informed consent. Cases were found involving the following types of surgery: facial rejuvenation (38 cases), facial contouring surgery (27 cases), mammoplasty (16 cases), blepharoplasty (29 cases), rhinoplasty (21 cases), body-contouring surgery (15 cases), and breast reconstruction (2 cases). Common reasons for postoperative dissatisfaction were deformities (22%), scars (17%), asymmetry (14%), and infections (6%). Most of the malpractice lawsuits occurred in Seoul (population 10 million people; 54% of total plastic surgeons) and in primary-level local clinics (113 cases, 82.5%). In cases in which only invalid informed consent was recognized, the average amount of consolation money was KRW 9,107,143 (USD 8438). In cases in which both violation of non-malfeasance and invalid informed consent were recognized, the average amount of consolation money was KRW 12,741,857 (USD 11,806), corresponding to 38.6% of the amount of the judgment. Surgeons should pay special attention to obtaining informed consent, because it is a double-edged sword; it has clinical purposes for doctors and patients but may also be a litigation strategy for lawyers.

The general surgery model: a more appealing and sustainable alternative for the care of trauma patients.

PubMed

Roettger, Richard H; Taylor, Spence M; Youkey, Jerry R; Blackhurst, Dawn W

2005-08-01

The contemporary model of trauma care where dedicated trauma/critical care surgeons exclusively manage trauma patients has become progressively unsustainable. Little objective data, however, is available documenting that a better model exists. From September 2002 through August 2003, the trauma model at a 735-bed level I trauma teaching hospital was changed from the contemporary model to a new one where selected general surgeons with Advanced Trauma Life Support (ATLS) certification covered in-house trauma and emergency surgery call on a rotational basis. As well, each pursued elective practices, admitting all inpatients (trauma, emergent, elective) to a single teaching service (formerly the trauma service). Critical care was managed by a separate group of intensivists. The purpose of this study was to objectively compare the two models. Quantitative, financial, and qualitative data were derived from August 2001 to January 2002 (trauma/critical care model) and compared to August 2003 to January 2004 (general surgery model). During the two periods (trauma/critical care vs general surgery), the mean Revised Trauma Score (7.1 vs 7.2; P = 0.029), the mean Injury Severity Score (ISS) (10.9 vs 10.8; P = 0.84), and the percentage of penetrating trauma (12.5% vs 13.2%; P = 0.79) were similar. Differences (trauma/critical care vs general surgery, % increase/P value) included average daily census (24 vs 54, 225%), cases/attending (262 vs 543, 207%), cases/resident (54 vs 262, 485%), charges/attending (353,811 dollars vs 471,725 dollars, 133%), collections/attending (106,143 dollars vs 165,103 dollars, 156%), number of trauma patients (643 vs 748, 116%), trauma mortality (7.3% vs 4.0%; P = 0.007), trauma mortality with ISS >15 (21.7% vs 12.0%; P = 0.035), trauma complications (33.1% vs 17%; P < 0.001), and ICU morbidity (66.8% vs 43.9%; P < .001). The new general surgery model produced superior financial results and better quantitative surgical experience while exceeding trauma and ICU quality outcomes compared to the former trauma/critical care model. These data objectively support a model such as ours--one that is financially sustainable and more professionally attractive.

Should Breast Cancer Surgery Be Done in an Outpatient Setting?: Health Economics From the Perspective of Service Providers.

PubMed

Formago, Margaret; Schrauder, Michael G; Rauh, Claudia; Hack, Carolin C; Jud, Sebastian M; Hildebrandt, Thomas; Schulz-Wendtland, Rüdiger; Frentz, S; Graubert, S; Beckmann, Matthias W; Lux, Michael P

2017-08-01

The care of patients with breast cancer is extremely complex and requires interdisciplinary care in certified facilities. These specialized facilities provide numerous services without being correspondingly remunerated. The question whether breast cancer surgery should be performed in an outpatient setting to reduce costs is increasingly being debated. This study compares inpatient surgical treatment with a model of the same surgery performed on an outpatient basis to examine the potential financial impact. A theoretical model was developed and the DRG fees for surgical interventions to treat primary breast cancer were calculated. A theoretical 1-day DRG was then calculated to permit comparisons with outpatient procedures. The costs of outpatient surgery were calculated based on the remuneration rates of the AOP (Outpatient Surgery) Contract and the EBM (Uniform Assessment Scale) and compared to the costs of the 1-day DRG. The DRG fee for both breast-conserving surgery and mastectomy is higher than the fee paid in the context of the EBM system, although the same procedures were carried out in both systems. If a hospital were to carry out breast-conserving surgery as an outpatient procedure, the fee would be € 1313.81; depending on the type of surgery, the hospital would therefore only receive between 39.20% and 52.82% of the DRG fee. This was the case even for a 1-day treatment. Compared to the real DRG fees the difference would be even more striking. Carrying out breast cancer surgery as an outpatient procedure would result in a significant shortfall of revenues. Additional services from certified centers, such as the interdisciplinary planning of treatment, psycho-oncological and social-medical care with the involvement of relatives, detailed documentation, etc., which are currently provided without surcharge or adequate remuneration, could no longer be maintained. The quality of processes and excellent results which have been achieved and ultimately the care given by certified facilities would be significantly at risk.

Intraoperative costs of video-assisted thoracoscopic lobectomy can be dramatically reduced without compromising outcomes.

PubMed

Richardson, Michael T; Backhus, Leah M; Berry, Mark F; Vail, Daniel G; Ayers, Kelsey C; Benson, Jalen A; Bhandari, Prasha; Teymourtash, Mehran; Shrager, Joseph B

2018-03-01

To determine whether surgeon selection of instrumentation and other supplies during video-assisted thoracoscopic lobectomy (VATSL) can safely reduce intraoperative costs. In this retrospective, cost-focused review of all video-assisted thoracoscopic surgery anatomic lung resections performed by 2 surgeons at a single institution between 2010 and 2014, we compared VATSL hospital costs and perioperative outcomes between the surgeons, as well as costs of VATSL compared with thoracotomy lobectomy (THORL). A total of 100 VATSLs were performed by surgeon A, and 70 were performed by surgeon B. The preoperative risk factors did not differ significantly between the 2 groups of surgeries. Mean VATSL total hospital costs per case were 24% percent greater for surgeon A compared with surgeon B (P = .0026). Intraoperative supply costs accounted for most of this cost difference and were 85% greater for surgeon A compared with surgeon B (P < .0001). The use of nonstapler supplies, including energy devices, sealants, and disposables, drove intraoperative costs, accounting for 55% of the difference in intraoperative supply costs between the surgeons. Operative time was 25% longer for surgeon A compared with surgeon B (P < .0001), but this accounted for only 11% of the difference in total cost. Surgeon A's overall VATSL costs per case were similar to those of THORLs (n = 100) performed over the same time period, whereas surgeon B's VATSL costs per case were 24% less than those of THORLs. On adjusted analysis, there was no difference in VATSL perioperative outcomes between the 2 surgeons. The costs of VATSL differ substantially among surgeons and are heavily influenced by the use of disposable equipment/devices. Surgeons can substantially reduce the costs of VATSL to far lower than those of THORL without compromising surgical outcomes through prudent use of costly instruments and technologies. Copyright © 2017 The American Association for Thoracic Surgery. All rights reserved.

[Hand surgery in the German DRG System 2007].

PubMed

Franz, D; Windolf, J; Kaufmann, M; Siebert, C H; Roeder, N

2007-05-01

Hand surgery often needs only a short length of stay in hospital. Patients' comorbidity is low. Many hand surgery procedures do not need inpatient structures. Up until 2006 special procedures of hand surgery could not be coded. The DRG structure did not separate very complex and less complex operations. Specialized hospitals needed a proper case allocation of their patients within the G-DRG system. The DRG structure concerning hand surgery increased in version 2007 of the G-DRG system. The main parameter of DRG splitting is the complexity of the operation. Furthermore additional criteria such as more than one significant OR procedure, the patients' age, or special diagnoses influence case allocation. A special OPS code for complex cases treated with hand surgery was implemented. The changes in the DRG structure and the implementation of the new OPS code for complex cases establish a strong basis for the identification of different patient costs. Different case allocation leads to different economic impacts on departments of hand surgery. Whether the new OPS code becomes a DRG splitting parameter has to be calculated by the German DRG Institute for further DRG versions.

Comparison of ultra-congruent mobile- and fixed-bearing navigation-assisted total knee arthroplasty with minimum 5-year follow-up.

PubMed

Kim, Seong Hwan; Lim, Jung-Won; Ko, Young-Bong; Song, Min-Gu; Lee, Han-Jun

2016-11-01

The purpose of this study was to compare the midterm outcomes between fixed and mobile ultra-congruent (UC) bearings in total knee arthroplasty (TKA). This is a retrospective matched-pairs case-control study of patients who underwent primary navigation-assisted TKA with a minimum 5-year follow-up. A total of 182 cases involved the fixed UC bearing system as Group 1 and 101 cases involved mobile UC bearing system group as Group 2. After 1:1 matching, 73 knees in each group were enrolled. Clinical and radiographic outcomes were evaluated. The overall survival was 143 of 146 cases (97.9 %) at final follow-up, and 72 of 73 cases (96.3 %) in Group 1 and 71 of 73 cases (95.8 %) in Group 2 at final follow-up based on an endpoint of revision surgery. The reasons of revision TKA were periprosthetic fracture in Group 1, infection and bearing dislocation in Group 2. There was no statistical difference in Hospital for Special Surgery (HSS) scores, Knee Society Scores (KSS), WOMAC index score evaluations between groups. This study demonstrated that the fixed-bearing UC prosthesis could provide satisfactory performance compared with that of the mobile-bearing UC prosthesis with minimum 5-year follow-up. The fixed-bearing UC prosthesis could be considered in navigation-assisted TKA with theoretical advantages of UC design. IV.

Time to Revive the Value of the Pseudocapsule in Endoscopic Endonasal Transsphenoidal Surgery for Growth Hormone Adenomas.

PubMed

Xie, Tao; Liu, Tengfei; Zhang, Xiaobiao; Chen, Lingli; Luo, Rongkui; Sun, Wei; Hu, Fan; Yu, Yong; Gu, Ye; Lu, Zhiqiang

2016-05-01

To investigate the role of endoscopic endonasal transsphenoidal surgery and the pseudocapsule in the treatment of growth hormone adenomas. The study included 43 patients (age range, 21-64 years) with growth hormone adenomas treated with an endoscopic endonasal approach. We compared the tumor characteristics and surgical outcomes of cases with (group A, 21 cases, from November 2013 to January 2015) and without (group B, 22 cases, from October 2011 to October 2013) extra-pseudocapsule resection. The preoperative demographics, tumor characteristics, and surgical complications were not significantly different between groups A and B. Postoperative remission without adjuvant therapy was achieved in 18 of 21 cases (85.7%) in group A, which was significantly greater than that observed in group B (12 of 22 cases [54.4%]). In group A, the pseudocapsules were verified by endoscopy and histopathology. The pseudocapsule was removed en bloc with the whole adenoma in only 5 cases (23.8%). For the remaining 16 patients (76.2%), following extra-pseudocapsule dissection, incomplete pseudocapsule removals with intracapsule procedures were achieved. The combination of extra-pseudocapsule resection and endoscopy led to a high rate of gross total tumor resection and endocrinologicl remission in acromegalic patients compared with the group with intracapsular resection. Extra-pseudocapsule resection resulted in no additional postoperative complications. Copyright © 2016. Published by Elsevier Inc.

Office-based endoscopic revision using a microdebrider for failed endoscopic dacryocystorhinostomy.

PubMed

Park, Jongyeop; Kim, Hochang

2016-12-01

This article is to introduce office-based endoscopic revision surgery using a microdebrider for failed endoscopic dacryocystorhinostomy (EN-DCR). The authors conducted retrospective, non-comparative, interventional case series analysis of 27 eyes of 24 patients, treated by office-based revision EN-DCR using a microdebrider. After local anesthesia, anatomical failures (cicatrization, granuloma, synechia) after primary EN-DCR were treated with a microdebrider (Osseoduo 120, Bien-Air Surgery, Le Noirmont, Switzerland) in an office setting, and a bicanalicular silicone tube was placed. Anatomical improvement and functional relief of epiphora were evaluated at 6-months after revision. The causes of failed EN-DCR were rhinostomy site cicatrization (17/27, 63.0 %), granulomatous obstruction (7/27, 25.9 %) and synechial formation (3/27, 11.1 %). The anatomical success rate was 100 %, and 85.2 % cases achieved complete relief of epiphora. The surgery did not exceed 10 min in any case and no complications were observed. Office-based revision EN-DCR using a microdebrider provided prompt management of post-DCR epiphora. The portable nature and all-round ability of the microdebrider allowed office-based surgery, which offered advantage to work with the surgeon's own well-trained office staff. Office-based revision EN-DCR can be both time- and money-saving, and might be regarded the treatment of choice for failed EN-DCR.

Upper and lower extremity nerve injuries in pediatric missile wounds: a selective approach to management.

PubMed

Stoebner, Andrew A; Sachanandani, Neil S; Borschel, Gregory H

2011-06-01

Nerve injuries from missile and gunshot wounds often produce significant disability, and their management is controversial. The role of the surgeon in cases of missile wounds with neurologic deficits is not well defined. Enhancing the trauma team's ability to recognize treatable nerve injuries will lead to improved outcomes. Further, raising awareness of the time-sensitive nature of these injuries will also improve results in these cases. We reviewed a consecutive series of 17 pediatric patients with peripheral nerve injuries caused by missile and gunshot wounds in a tertiary care children's hospital. We examined the indications for surgery, presence of associated injuries, mechanisms of injury, demographic characteristics and clinical outcomes. Urban victims were significantly more likely to have been intentionally assaulted than rural or suburban victims and they were also less likely to have completed follow-up care. High-energy weapons were more likely to require surgery compared with low-energy weapons. Patients presenting with tendon injuries were more likely to have a high-grade nerve injury requiring surgery. Patients presenting with tendon lacerations or high-energy mechanisms were significantly more likely to require surgery. Early exploration should be undertaken in cases where transection is likely to have occurred. Early decompression of common entrapment sites distal to repairs or injuries should be performed. Because follow-up is poor in this population, treatment should be prompt and thorough.

Introduction and use of video-assisted endoscopic thyroidectomy for patients in Belarus affected by the Chernobyl nuclear disaster.

PubMed

Igarashi, Takehito; Shimizu, Kazuo; Yakubouski, Siarhei; Akasu, Haruki; Okamura, Ritsuko; Sugitani, Iwao; Jikuzono, Tomoo; Danilova, Larisa

2013-11-01

We developed video-assisted neck surgery (VANS) - a feasible, simple, and safe endoscopic thyroid procedure with cosmetic benefits - in 1998. To date, we have performed this procedure 633 times. We have also introduced the VANS method in Belarus, a country that was left contaminated by the Chernobyl nuclear disaster. From a mass screening, nine Belarusian patients, including two with papillary carcinoma of the thyroid, were selected to undergo an operation using the VANS method, performed by a single surgeon (author Shimizu). We compared indicating factors for minimally invasive surgery, specifically the operating time and blood loss, between the Belarusian cases and the 33 most recent cases performed at our institute in Tokyo. The procedures in Belarus were performed under very different working conditions than in Japan. However, operating time and blood loss improved for the Belarusian cases as the surgeon gained experience in this environment; all the cosmetic outcomes were excellent. Subsequently, over a 2-year period, surgeons in Belarus performed the VANS method, with modification, for 29 cases of thyroid tumor. The VANS method is easily learned by inexperienced surgeons without major technical problems. © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.

Does transfusion of residual cardiopulmonary bypass circuit blood increase postoperative bleeding? A prospective randomized study in patients undergoing on pump cardiopulmonary bypass

PubMed Central

Duara, Rajnish; Misra, Manoranjan; Bhuyan, Ritwick Raj; Sarma, P. Sankara; Jayakumar, Karunakaran

2008-01-01

Objective: Homologous blood transfusion after open heart surgery puts a tremendous load on the blood banks. This prospective randomized study evaluates the efficacy of infusing back residual cardiopulmonary bypass (CPB) circuit i.e., pump blood as a means to reduce homologous transfusion after coronary artery bypass surgery (CABG) and whether its use increases postoperative drainage. Materials and Methods: Sixty-seven consecutive patients who underwent elective CABGs under CPB were randomized into 2 groups: (1) cases where residual pump blood was used and (2) controls where residual pump blood was not used. Patients were monitored for hourly drainage on the day of surgery and the 1st postoperative day and the requirements of homologous blood and its products. Data were matched regarding change in Hemoglobin, Packed Cell Volume and coagulation parameters till 1st postoperative day. All cases were followed up for three years. Results: There was a marginal reduction in bleeding pattern in the early postoperative period in the cases compared to controls. The requirement of homologous blood and its products were also reduced in the cases. Conclusions: The use of CPB circuit blood is safe in the immediate postoperative period. The requirement of homologous blood transfusion can come down if strict transfusion criteria are maintained. PMID:20041077

Frozen section pathology for decision making in parotid surgery.

PubMed

Olsen, Kerry D; Moore, Eric J; Lewis, Jean E

2013-12-01

For parotid lesions, the high accuracy and utility of intraoperative frozen section (FS) pathology, compared with permanent section pathology, facilitates intraoperative decision making about the extent of surgery required. To demonstrate the accuracy and utility of FS pathology of parotid lesions as one factor in intraoperative decision making. Retrospective review of patients undergoing parotidectomy at a tertiary care center. Evaluation of the accuracy of FS pathology for parotid surgery by comparing FS pathology results with those of permanent section. Documented changes from FS to permanent section in 1339 parotidectomy pathology reports conducted from January 1, 2000, through December 31, 2009, included 693 benign and 268 primary and metastatic malignant tumors. Changes in diagnosis were found from benign to malignant (n = 11) and malignant to benign (n = 2). Sensitivity and specificity of a malignant diagnosis were 98.5% and 99.0%, respectively. Other changes were for lymphoma vs inflammation or lymphoma typing (n = 89) and for confirmation of or change in tumor type for benign (n = 36) or malignant (n = 69) tumors. No case changed from low- to high-grade malignant tumor. Only 4 cases that changed from FS to permanent section would have affected intraoperative decision making. Three patients underwent additional surgery 2 to 3 weeks later. Overall, only 1 patient was overtreated (lymphoma initially deemed carcinoma). Frozen section pathology for parotid lesions has high accuracy and utility in intraoperative decision making, facilitating timely complete procedures.

Quality assessment in head and neck oncologic surgery in a Brazilian cancer center compared with MD Anderson Cancer Center benchmarks.

PubMed

Lira, Renan Bezerra; de Carvalho, André Ywata; de Carvalho, Genival Barbosa; Lewis, Carol M; Weber, Randal S; Kowalski, Luiz Paulo

2016-07-01

Quality assessment is a major tool for evaluation of health care delivery. In head and neck surgery, the University of Texas MD Anderson Cancer Center (MD Anderson) has defined quality standards by publishing benchmarks. We conducted an analysis of 360 head and neck surgeries performed at the AC Camargo Cancer Center (AC Camargo). The procedures were stratified into low-acuity procedures (LAPs) or high-acuity procedures (HAPs) and outcome indicators where compared to MD Anderson benchmarks. In the 360 cases, there were 332 LAPs (92.2%) and 28 HAPs (7.8%). Patients with any comorbid condition had a higher incidence of negative outcome indicators (p = .005). In the LAPs, we achieved the MD Anderson benchmarks in all outcome indicators. In HAPs, the rate of surgical site infection and length of hospital stay were higher than what is established by the benchmarks. Quality assessment of head and neck surgery is possible and should be disseminated, improving effectiveness in health care delivery. © 2015 Wiley Periodicals, Inc. Head Neck 38: 1002-1007, 2016. © 2015 Wiley Periodicals, Inc.

Strategic hospital partnerships: improved access to care and increased epilepsy surgical volume.

PubMed

Vadera, Sumeet; Chan, Alvin Y; Mnatsankanyan, Lilit; Sazgar, Mona; Sen-Gupta, Indranil; Lin, Jack; Hsu, Frank P K

2018-05-01

OBJECTIVE Surgical treatment of patients with medically refractory focal epilepsy is underutilized. Patients may lack access to surgically proficient centers. The University of California, Irvine (UCI) entered strategic partnerships with 2 epilepsy centers with limited surgical capabilities. A formal memorandum of understanding (MOU) was created to provide epilepsy surgery to patients from these centers. METHODS The authors analyzed UCI surgical and financial data associated with patients undergoing epilepsy surgery between September 2012 and June 2016, before and after institution of the MOU. Variables collected included the length of stay, patient age, seizure semiology, use of invasive monitoring, and site of surgery as well as the monthly number of single-surgery cases, complex cases (i.e., staged surgeries), and overall number of surgery cases. RESULTS Over the 46 months of the study, a total of 104 patients underwent a total of 200 operations; 71 operations were performed in 39 patients during the pre-MOU period (28 months) and 129 operations were performed in 200 patients during the post-MOU period (18 months). There was a significant difference in the use of invasive monitoring, the site of surgery, the final therapy, and the type of insurance. The number of single-surgery cases, complex-surgery cases, and the overall number of cases increased significantly. CONCLUSIONS Partnerships with outside epilepsy centers are a means to increase access to surgical care. These partnerships are likely reproducible, can be mutually beneficial to all centers involved, and ultimately improve patient access to care.

Tonsillectomy in children and in adults: changes in practice following the opening of a day-surgery unit with dedicated operating room.

PubMed

Bartier, S; Gharzouli, I; Kiblut, N; Bendimered, H; Cloutier, L; Salvan, D

2018-05-30

To study the impact of the opening of a day-surgery unit on the practice of tonsillectomy in adults and children in the light of the experience of our department, and to compare complications between day-surgery and conventional admission. A retrospective review was conducted of all tonsillectomies performed since the opening of a dedicated day-surgery room, using the ENT and emergency department data-bases. Between October 2013 and December 2014, 179 tonsillectomies were performed (51 in adults, 128 in children), including 108 day-surgeries. Between 2012 and 2014, the number of tonsillectomies increased by 12.7%, with an 18.27% increase in children and stable adult rate. Within 1 year, day-surgery became predominant for children (73.19%) and equaled conventional admission for adults (47.22%). For almost all patients without same-day discharge, the reasons were organizational or due to malorientation (comorbidity, or unsuitable home environment). Day-case tonsillectomy in children showed a 30-day complications rate comparable to those reported in the literature (8.3% postoperative hemorrhage), with a higher rate in adults (35.3%). Onset of complications was at a mean 6 days in adults and 9 days in children; only 2 patients developed complications between 6 and 24hours postoperatively. The present study showed that opening a day-surgery unit led to changes in practice, with most tonsillectomies now performed on an outpatient basis, without increased complications, and notably immediate complications. Outpatient tonsillectomy thus seems to be a solution of choice compared to conventional admission, in terms of cost saving and of patient comfort, without sacrificing safety. The dedicated operating room facilitates scheduling and thereby increasing turnover by reducing wait time. Copyright © 2018. Published by Elsevier Masson SAS.

A value-based medicine cost-utility analysis of idiopathic epiretinal membrane surgery.

PubMed

Gupta, Omesh P; Brown, Gary C; Brown, Melissa M

2008-05-01

To perform a reference case, cost-utility analysis of epiretinal membrane (ERM) surgery using current literature on outcomes and complications. Computer-based, value-based medicine analysis. Decision analyses were performed under two scenarios: ERM surgery in better-seeing eye and ERM surgery in worse-seeing eye. The models applied long-term published data primarily from the Blue Mountains Eye Study and the Beaver Dam Eye Study. Visual acuity and major complications were derived from 25-gauge pars plana vitrectomy studies. Patient-based, time trade-off utility values, Markov modeling, sensitivity analysis, and net present value adjustments were used in the design and calculation of results. Main outcome measures included the number of discounted quality-adjusted-life-years (QALYs) gained and dollars spent per QALY gained. ERM surgery in the better-seeing eye compared with observation resulted in a mean gain of 0.755 discounted QALYs (3% annual rate) per patient treated. This model resulted in $4,680 per QALY for this procedure. When sensitivity analysis was performed, utility values varied from $6,245 to $3,746/QALY gained, medical costs varied from $3,510 to $5,850/QALY gained, and ERM recurrence rate increased to $5,524/QALY. ERM surgery in the worse-seeing eye compared with observation resulted in a mean gain of 0.27 discounted QALYs per patient treated. The $/QALY was $16,146 with a range of $20,183 to $12,110 based on sensitivity analyses. Utility values ranged from $21,520 to $12,916/QALY and ERM recurrence rate increased to $16,846/QALY based on sensitivity analysis. ERM surgery is a very cost-effective procedure when compared with other interventions across medical subspecialties.

Utilization of Total Joint Arthroplasty in Physician-Owned Specialty Hospitals vs Acute Care Facilities.

PubMed

Chen, Antonia F; Pflug, Emily; O'Brien, Daniel; Maltenfort, Mitchell G; Parvizi, Javad

2017-07-01

The recent emergence of physician-owned specialty hospitals has sparked controversy about overutilization. Thus, the purpose of this study was to compare utilization patterns of total joint arthroplasty (TJA) between physician-specialty hospitals (PSHs) and acute care hospitals (ACHs). A retrospective study was conducted from January 2010 to August 2014 comparing primary TJA patients between a PSH and an ACH; 103 PSH patients were matched to 103 ACH patients by age, gender, BMI, and ASA classification with similar case distribution between facilities. All surgeons in the study operated at both hospitals and were shareholders of the PSH. Information on nonoperative treatments, and timing to the initial appointment, consent, and surgery were analyzed using univariate analysis. Nonoperative treatments before surgery were similar between hospitals (P = 1.00). The time from the initial appointment to consent was longer for PSH (P = .0001). However, the time from consent to the date of surgery (P = .04) and the timing from symptoms to initial appointment (P = .006) was shorter for PSH. The time from initial appointment to the day of surgery was similar between groups (P = .20). Patients were more likely to be consented for surgery on their first clinic visit when undergoing surgery at ACH (87 of 103, 84.4%) compared to PSH (61 of 103; 59.2%; P < .001). Length of stay was significantly shorter for both total knee arthroplasty (P = .001) and total hip arthroplasty patients (P = .001) at PSH. Facility ownership in PSH resulted in similar conservative treatment before TJA. The time to surgical consent after the initial appointment was longer PSH, whereas the time from consent to the date of surgery was shorter at the PSH. Copyright © 2017 Elsevier Inc. All rights reserved.

Improving health care costing with resource consumption accounting.

PubMed

Ozyapici, Hasan; Tanis, Veyis Naci

2016-07-11

Purpose - The purpose of this paper is to explore the differences between a traditional costing system (TCS) and resource consumption accounting (RCA) based on a case study carried out in a hospital. Design/methodology/approach - A descriptive case study was first carried out to identify the current costing system of the case hospital. An exploratory case study was then conducted to reveal how implementing RCA within the case hospital assigns costs differently to gallbladder surgeries than the current costing system (i.e. a TCS). Findings - The study showed that, in contrast to a TCS, RCA considers the unused capacity, which is the difference between the work that can be performed based on current resources and the work that is actually being performed. Therefore, it assigns lower total costs to open and laparoscopic gallbladder surgeries. The study also showed that by separating costs into fixed and variable RCA allows managers to benefit from a pricing strategy based on the difference between the service's selling price and variable costs incurred in providing that service. Research limitations/implications - The limitation of this study is that, because of time constraints, the implementation was performed in the general surgery department only. However, since RCA is an advanced system that has the same application procedures for any department inside in a hospital, managers need only time gaps to implement this system to all parts of the hospital. Practical implications - This study concluded that RCA is better than a TCS for use in health care settings that have high overhead costs because it accurately assigns overhead costs to services by considering unused capacities incurred by a hospital. Consequently, this study provides insight into both measuring and managing unused capacities within the health care sector. This study also concluded that RCA helps health care administrators increase their competitive advantage by allowing them to determine the lowest service price. Originality/value - Since the literature review found no study comparing RCA with TCS in a real-life health care setting, little is known about differences arising from applying these systems in this context. Thus, the current study fills this gap in the literature by comparing RCA with TCS for both open and laparoscopic gallbladder surgeries.

[Is the use of synthetic mesh by vaginal route decrease the risk of cystocele recurrence? Clinical practice guidelines].

PubMed

Le Normand, L; Deffieux, X; Donon, L; Fatton, B; Cour, F

2016-07-01

The use of prosthetic surgery by vaginal route has been widely used to try to reduce the risk of prolapse recurrence in the surgical treatment of vaginal cystoceles. Specific complications including type of erosion have led to randomized studies comparing surgery by vaginal route with and without use of Mesh. This work is based on a systematic review of the literature (PubMed, Medline, Cochrane Library, Cochrane database of systemactic reviews, EMBASE) for meta-analyzes, randomized trials, registries, literature reviews, controlled studies and major not controlled studies, published on the subject. Its implementation has followed the methodology of the HAS on the recommendations for clinical practice, with a scientific argument (with the level of evidence, NP) and a recommendation grade (A, B, C, and professional agreement (AP)). The use of inter-vesicovaginal synthetic mesh improves the anatomical result compared to the autologous surgery for the treatment of cystocele (NP1). However, there is no difference in the functional outcome and there is an increase in the number of reoperations related to specific complications, including vaginal erosions. If the use of inter-vesicovaginal synthetic mesh improves the anatomical result compared to the autologous surgery for the treatment of cystocele (NP1), no difference in functional outcome and the increased number of related reoperations specific complications including vaginal erosions, do not argue for the systematic use of mesh in the treatment of primary cystocele. It must be discussed case by case basis taking into account a risk-benefit uncertain at long-term (grade B). Its use should be supported by additional studies focused on specific populations at risk of recurrence. © 2016 Published by Elsevier Masson SAS. © 2016 Elsevier Masson SAS. Tous droits réservés.

Does robotic assistance confer an economic benefit during laparoscopic radical nephrectomy?

PubMed

Yang, David Y; Monn, M Francesca; Bahler, Clinton D; Sundaram, Chandru P

2014-09-01

While robotic assisted radical nephrectomy is safe with outcomes and complication rates comparable to those of the pure laparoscopic approach, there is little evidence of an economic or clinical benefit. From the 2009 to 2011 Nationwide Inpatient Sample database we identified patients 18 years old or older who underwent radical nephrectomy for primary renal malignancy. Robotic assisted and laparoscopic techniques were noted. Patients treated with the open technique and those with evidence of metastatic disease were excluded from analysis. Descriptive statistics were performed using the chi-square and Mann-Whitney tests, and the Student t-test. Multiple linear regression was done to examine factors associated with increased hospital costs and charges. We identified 24,312 radical nephrectomy cases for study inclusion, of which 7,787 (32%) were performed robotically. There was no demographic difference between robotic assisted and pure laparoscopic radical nephrectomy cases. Median total charges were $47,036 vs $38,068 for robotic assisted vs laparoscopic surgery (p <0.001). Median total hospital costs for robotic assisted surgery were $15,149 compared to $11,735 for laparoscopic surgery (p <0.001). There was no difference in perioperative complications or the incidence of death. Compared to the laparoscopic approach robotic assistance conferred an estimated $4,565 and $11,267 increase in hospital costs and charges, respectively, when adjusted for adapted Charlson comorbidity index score, perioperative complications and length of stay (p <0.001). Robotic assisted radical nephrectomy results in increased medical expense without improving patient morbidity. Assuming surgeon proficiency with pure laparoscopy, robotic technology should be reserved primarily for complex surgeries requiring reconstruction. Traditional laparoscopic techniques should continue to be used for routine radical nephrectomy. Copyright © 2014 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

Reducing versus stopping antiepileptic medications after temporal lobe surgery

PubMed Central

Yardi, Ruta; Irwin, Anna; Kayyali, Husam; Gupta, Ajay; Nair, Dileep; Gonzalez-Martinez, Jorge; Bingaman, William; Najm, Imad M; Jehi, Lara E

2014-01-01

Objective To study the safety of antiepileptic drug (AED) withdrawal after temporal lobe epilepsy (TLE) surgery. Methods We reviewed patients who underwent TLE surgery from 1995 to 2011, collecting data on doses, dates of AED initiation, reduction, and discontinuation. Predictors of seizure outcome were defined using Cox-proportional hazard modeling and adjusted for, while comparing longitudinal seizure-freedom in patients for whom AEDs were unchanged after resection as opposed to reduced or stopped. Results A total of 609 patients (86% adults) were analyzed. Follow-up ranged from 0.5 to 16.7 years. Most (64%) had hippocampal sclerosis. Overall, 229 patients had remained on their same baseline AEDs, while 380 patients stopped (127 cases) or reduced (253 cases) their AEDs. Mean timing of the earliest AED change was shorter in patients with recurrent seizures (1.04 years) compared to those seizure-free at last follow-up (1.44 years; P-value 0.03). Whether AEDs were withdrawn 12 or 24 months after surgery, there was a 10–25% higher risk of breakthrough seizures within the subsequent 2 years. However, 70% of patients with seizure recurrence after AED discontinuation reachieved remission, as opposed to 50% of those whose seizures recurred while reducing AEDs (P = 0.0001). Long-term remission rates were similar in both AED discontinuation and “unchanged” groups (82% remission for AEDs withdrawn after 1 year and 90% for AEDs withdrawn after 2 years), while only 65% of patients whose recurrences started during AED reduction achieved a 2-year remission by last follow-up. Interpretation AED withdrawal increases the short-term risk of breakthrough seizures after TLE surgery, and may alter the long-term disease course in some patients. PMID:25356390

Do case-generic measures of queue performance for bypass surgery accurately reflect the waiting-list experiences of those most urgent?

PubMed

Burstein, Jason; Lee, Douglas S; Alter, David A

2006-02-01

Queue performance is typically assessed using generic measures, which capture the queue in aggregate. The objective of this study was to examine whether case-generic measures of queue performance appropriately reflected the waiting-list experiences of those patients with greatest disease severity. We examined the queue for isolated coronary artery bypass grafting (CABG) in Ontario between April 1993 and March 2000 using data obtained from the Cardiac Care Network. Our primary measure of queue performance was the proportion of patients who received their bypass surgery within their recommended maximum waiting times (%RMWTs) in any given month. We compared case-generic measures of queue performance to case-specific measures of queue performance stratified by urgency level. The queue was largely comprised of elective cases ranging from 73% (1993) to 57%(1999). Urgent patients comprised the minority of the queue ranging from 14% (1993) to 20% (1999). Case-generic month-to-month variations in the percentage of cases completed within RMWTs (an aggregated waiting list measure encompassing the characteristics of all patients in the queue) closely resembled the experiences of elective patients (R2 = 0.81), but conversely, bore little relationship to the waiting-list experiences of those most urgent (R2 = 0.15). Case-generic measures of queue performance for bypass surgery in Ontario were not reflective of the waiting-list experiences of those most urgent. Our results reinforce the concept that urgency-specific waiting list monitoring systems are required to best evaluate and appropriately respond to fluctuations in queue performance.

Quality assurance in melanoma surgery: The evolving experience at a large tertiary referral centre.

PubMed

Read, R L; Pasquali, S; Haydu, L; Thompson, J F; Stretch, J R; Saw, R P M; Quinn, M J; Shannon, K; Spillane, A J

2015-07-01

The quality of melanoma surgery needs to be assessed by oncological outcome and complication rates. There is no published consensus on complication rates for common melanoma surgeries, namely wide excision (WE), sentinel node biopsy (SNB) and regional lymph node dissection (RLND). Consequently there are no agreed standards by which surgeons can audit their practices. Surgical standards were proposed in 2008 following review of the literature and from expert opinion. Melanoma Institute Australia (MIA) self-reported audit data from 2011 and 2012 were compared with these standards. To quality check the self-reported audit, RLND data were extracted from the MIA database. Six surgeons performed a mean of 568 surgeries each quarter; with a mean of 106 major procedures. Following WE with primary closure or flap repair, wound infection or dehiscence occurred in <1% of cases. When skin grafting was required non-take of >20% of the grafted area was observed in 5.9% of cases. Following SNB wound infection and significant seroma occurred in 1.8% of cases. RLND node counts were below the 90% standard in 4 of 409 procedures. In comparison, data extraction identified 405 RLNDs, with node counts below the 90% standard in eight procedures. Two of these patients had previously undergone surgery removing nodes from the field and two had gross coalescing disease with extensive extra-nodal spread. The quality standards proposed in 2008 have been validated long-term by high volume caseloads. The data presented provide standards by which melanoma surgeons can audit their surgical performance. Copyright © 2015 Elsevier Ltd. All rights reserved.

Economic viability of stapes surgery in Germany.

PubMed

Savvas, E; Maurer, J

2009-04-01

The purpose of this study was to determine the economic viability of stapes surgery in Germany. We compared the cost of the operation to the retail value and average cost of a lifelong supply of hearing aids. Retrospective study. Tertiary referral centre. One hundred and sixty-four consecutive cases of primary stapedotomy performed on patients with otosclerosis at our institution served as the representative group for the calculation. The post-operative air-bone gap average at the frequencies 500, 1000, 2000 and 4000 Hz was less than 10 dB for 62 per cent of the patients, and less than 20 dB for 92 per cent of the patients. There was a post-operative sensorineural hearing loss in 1.2 per cent of the patients. Analysis showed that, even for an elderly patient aged 65 years with a life expectancy of 15 years, the cost of a lifelong supply of hearing aids was greater than that of a stapedotomy procedure. Based on our group of patients, the stapedotomy procedure proved to be euro 800,000 K cheaper than treatment with an averagely priced hearing aid. The economic benefit was still present when taking into account possible revision surgery in 5-10 per cent of cases, and also when, in addition to the surgery, a post-operative hearing aid was required, in for example 20 per cent of cases. Stapes surgery is economically beneficial for the individual patient as well as for the general patient cohort, irrespective of age. The stapedotomy procedure also prevents the known disadvantages of conventional hearing aids, thus improving the patient's quality of life.

Laparoscopic versus robotic surgery for hepatocellular carcinoma: the first 46 consecutive cases.

PubMed

Magistri, Paolo; Tarantino, Giuseppe; Guidetti, Cristiano; Assirati, Giacomo; Olivieri, Tiziana; Ballarin, Roberto; Coratti, Andrea; Di Benedetto, Fabrizio

2017-09-01

Hepatocellular carcinoma has a growing incidence worldwide, and represents a leading cause of death in patients with cirrhosis. Nowadays, minimally invasive approaches are spreading in every field of surgery and in liver surgery as well. We retrospectively reviewed demographics, clinical, and pathologic characteristics and short-term outcomes of patients who had undergone minimally invasive resections for hepatocellular carcinoma at our institution between June 2012 and May 2016. No significant differences in demographics and comorbidities were found between patients in the laparoscopic (n = 24) and robotic (n = 22) groups, except for the rates of cirrhotic patients (91.7% and 68.2%, respectively, P = 0.046). Perioperative data analysis showed that the operative time (mean, 211 and 318 min, respectively, P < 0.001) was the only parameter in favor of laparoscopy. Conversely, robotic-assisted resections were related to less Clavien I-II postoperative complications (22 cases versus 13 cases; P = 0.03). As regards resection margins, the two groups were similar with no statistically significant differences in rates of disease-free resection margins. A modern hepatobiliary center should offer both open and minimally invasive approaches to liver disease to provide the best care for each patient, according to the individual comorbidities, risk factors, and personal quality of life expectations. Our results show that the robotic approach is a reliable tool for accurate oncologic surgery, comparable to the laparoscopic approach. Robotic surgery also allows the surgeon to safely approach liver segments that are difficult to resect in laparoscopy, namely segments I-VII-VIII. Copyright © 2017 Elsevier Inc. All rights reserved.

First 101 Robotic General Surgery Cases in a Community Hospital

PubMed Central

Robertson, Jarrod C.; Alrajhi, Sharifah

2016-01-01

Background and Objectives: The general surgeon's robotic learning curve may improve if the experience is classified into categories based on the complexity of the procedures in a small community hospital. The intraoperative time should decrease and the incidence of complications should be comparable to conventional laparoscopy. The learning curve of a single robotic general surgeon in a small community hospital using the da Vinci S platform was analyzed. Methods: Measured parameters were operative time, console time, conversion rates, complications, surgical site infections (SSIs), surgical site occurrences (SSOs), length of stay, and patient demographics. Results: Between March 2014 and August 2015, 101 robotic general surgery cases were performed by a single surgeon in a 266-bed community hospital, including laparoscopic cholecystectomies, inguinal hernia repairs; ventral, incisional, and umbilical hernia repairs; and colorectal, foregut, bariatric, and miscellaneous procedures. Ninety-nine of the cases were completed robotically. Seven patients were readmitted within 30 days. There were 8 complications (7.92%). There were no mortalities and all complications were resolved with good outcomes. The mean operative time was 233.0 minutes. The mean console operative time was 117.6 minutes. Conclusion: A robotic general surgery program can be safely implemented in a small community hospital with extensive training of the surgical team through basic robotic skills courses as well as supplemental educational experiences. Although the use of the robotic platform in general surgery could be limited to complex procedures such as foregut and colorectal surgery, it can also be safely used in a large variety of operations with results similar to those of conventional laparoscopy. PMID:27667913

First 101 Robotic General Surgery Cases in a Community Hospital.

PubMed

Oviedo, Rodolfo J; Robertson, Jarrod C; Alrajhi, Sharifah

2016-01-01

The general surgeon's robotic learning curve may improve if the experience is classified into categories based on the complexity of the procedures in a small community hospital. The intraoperative time should decrease and the incidence of complications should be comparable to conventional laparoscopy. The learning curve of a single robotic general surgeon in a small community hospital using the da Vinci S platform was analyzed. Measured parameters were operative time, console time, conversion rates, complications, surgical site infections (SSIs), surgical site occurrences (SSOs), length of stay, and patient demographics. Between March 2014 and August 2015, 101 robotic general surgery cases were performed by a single surgeon in a 266-bed community hospital, including laparoscopic cholecystectomies, inguinal hernia repairs; ventral, incisional, and umbilical hernia repairs; and colorectal, foregut, bariatric, and miscellaneous procedures. Ninety-nine of the cases were completed robotically. Seven patients were readmitted within 30 days. There were 8 complications (7.92%). There were no mortalities and all complications were resolved with good outcomes. The mean operative time was 233.0 minutes. The mean console operative time was 117.6 minutes. A robotic general surgery program can be safely implemented in a small community hospital with extensive training of the surgical team through basic robotic skills courses as well as supplemental educational experiences. Although the use of the robotic platform in general surgery could be limited to complex procedures such as foregut and colorectal surgery, it can also be safely used in a large variety of operations with results similar to those of conventional laparoscopy.

Staged bilateral single-port thoracoscopic lung volume reduction surgery: A report of 11 cases

PubMed Central

Zhang, Miao; Wang, Heng; Pan, Xue-Feng; Wu, Wen-Bin; Zhang, Hui

2016-01-01

The aim of the present study was to investigate the feasibility and efficacy of staged bilateral single-port thoracoscopic lung volume reduction surgery (LVRS) for patients with chronic obstructive pulmonary emphysema (COPE). Eleven male patients with a mean age of 60.27±12.11 years with bilateral COPE and bullae were admitted to the Department of Thoracic Surgery, Xuzhou Central Hospital from January 2013 to June 2014. The patients underwent staged bilateral single-port thoracoscopic LVRS. The hyperinflated bullae were resected using endoscopic staplers (Endo-GIA), followed by continuous suture and biological glue for reinforcement of the margin. In addition, pulmonary function, blood gas assay, 6-min walk distance (6MWD) and life quality evaluated by a short form 36-item health survey questionnaire (SF-36) were recorded before and after LVRS, respectively. All the patients survived after surgery. The chest tube drainage time was 9.09±1.31 days and postoperative hospital stay was 15.73±2.75 days, with 5 cases of persistent air leakage and 7 cases of pulmonary infection which were finally cured. The patients were followed up for 3 to 12 months, and the pulmonary function, partial pressure of oxygen (pO2), 6MWD and life quality after unilateral or bilateral LVRS were improved compared to these parameters before surgery. However, there was no significant difference between unilateral and bilateral LVRS in terms of life quality. In conclusion, staged bilateral single-port thoracoscopic LVRS may improve the short-term life quality of patients with COPE. PMID:27882084

Robotic colorectal surgery: hype or new hope? A systematic review of robotics in colorectal surgery.

PubMed

Mirnezami, A H; Mirnezami, R; Venkatasubramaniam, A K; Chandrakumaran, K; Cecil, T D; Moran, B J

2010-11-01

Robotic colorectal surgery is an emerging field and may offer a solution to some of the difficulties inherent to conventional laparoscopic surgery. The aim of this review is to provide a comprehensive and critical analysis of the available literature on the use of robotic technology in colorectal surgery. Studies reporting outcomes of robotic colorectal surgery were identified by systematic searches of electronic databases. Outcomes examined included operating time, length of stay, blood loss, complications, cost, oncological outcome, and conversion rates. Seventeen Studies (nine case series, seven comparative studies, one randomized controlled trial) describing 288 procedures were identified and reviewed. Study heterogeneity precluded a meta-analysis of the data. Robotic procedures tend to take longer and cost more, but may reduce the length of stay, blood loss, and conversion rates. Complication profiles and short-term oncological outcomes are similar to laparoscopic surgery. Robotic colorectal surgery is a promising field and may provide a powerful additional tool for optimal management of more challenging pathology, including rectal cancer. Further studies are required to better define its role. © 2010 The Authors. Colorectal Disease © 2010 The Association of Coloproctology of Great Britain and Ireland.

Conventional (CH) vs. stapled hemorrhoidectomy (SH) in surgical treatment of hemorrhoids. Ten years experience.

PubMed

Manfredelli, Simone; Montalto, Gioacchino; Leonetti, Giovanni; Covotta, Marco; Amatucci, Chiara; Covotta, Alfredo; Forte, Angelo

2012-01-01

Interest about hemorrhoids is related to its high incidence and elevated social costs that derive from its treatment. Several comparative studies are reported in Literature to define a standard for ideal treatment of hemorrhoidal disease. Radical surgery is the only therapeutic option in case of III and IV stage haemorrhoids. Hemorrhoids surgical techniques are classified as Open, Closed and Stapled ones. We report our decennial experience on surgical treatment focusing on early, middle and late complications, indications and contraindications, satisfaction level of each surgical procedure for hemorrhoids. Four hundred forty-eight patients have been hospitalized in our department fom 1st January to 31st December 2008. Of these 241 underwent surgery with traditional open or closed technique and 207 with the SH technique according to Longo. This retrospective study includes only patients with symptomatic hemorrhoids at III or IV stage. There were no differences between CH and SH about both pre and post surgery hospitalization and intraoperative length. Pain is the most frequently observed early complication with a statistically significant difference in favour of SH. We obtain good results in CH group using anoderma sparing and perianal anaesthetic infiltration at the end of the surgery. In all cases, pain relief was obtained only with standard analgesic drugs (NSAIDs). We also observed that pain level influences the outcome after surgical treatment. No chronic pain cases were observed in both groups. Bleeding is another relevant early complication in particular after SH: we reported 2 cases of immediate surgical reintenvention and 2 cases treated with blood transfusion. Only in SH group we report also 5 cases of thrombosis of external haemorrhoids and 7 perianal hematoma both solved with medical therapy There were no statistical significant differences between two groups about fever, incontinence to flatus, urinary retention, fecal incontinence, substenosis and anal burning. No cases of anal stenosis were observed. About late complications, most frequently observed were rectal prolapse and hemorrhoidal recurrence, especially after SH. Our experience confirms the validity of both CH and SH. Failure may be related to wrong surgical indication or technical execution. Certainly CH procedure is more invasive and slightly more painfull in immediate postoperative period than SH surgery, which is slightly more expensive and has more complications. In our opinion the high risk of possible early and immediate complications after surgery requires at least a 24 hours hospitalization length. SH is the gold standard for III grade haemorrhoids with mucous prolapse while CH is suggested in IV grade cases. Hemorrhoidal arterial ligation operation (HALO) technique in III and IV degree needs further validations.

Laparoendoscopic single site in pelvic surgery

PubMed Central

Sanchez-Salas, Rafael; Clavijo, Rafael; Barret, Eric; Sotelo, Rene

2012-01-01

Laparoendoscopic single site (LESS) has recently gained momentum as feasible techniques for minimal access surgery. Our aim is to describe the current status of laparoendoscopic single site (LESS) in pelvic surgery. A comprehensive revision of the literature in LESS pelvic surgery was performed. References for this manuscript were obtained by performing a review of the available literature in PubMed from 01-01-01 to 30-11-11. References outside the search period were obtained selected manuscript΄s bibliography. Search terms included: pelvic anatomy, less in gynecology, single port colectomy, urological less, single port, single site, NOTES, LESS and single incision. 314 manuscripts were initially identified. Out of these, 46 manuscripts were selected based in their pelvic anatomy or surgical content; including experimental experience, clinical series and literature reviews. LESS drastically limit the surgeon's ability to perform in the operative field and the latter becomes hardened by the lack of space in anatomical location like the pelvis. Potential advantages of LESS are gained with the understanding that the surgical procedure is more technically challenging. Pelvic surgical procedures related to colorectal surgery, gynecology and urology have been performed with LESS technique and information available is mostly represented by case reports and short case series. Comparative series remain few. LESS pelvic surgery remain in its very beginning and due to the very specific anatomical conditions further development of LESS surgery in the mentioned area can be clearly be facilitated by using robotic technology. Standardization ad reproducibility of techniques are mandatory to further develop LESS in the surgical arena.. PMID:22557719

Multinational institutional survey on patterns of intraoperative transesophageal echocardiography use in adult cardiac surgery.

PubMed

Dobbs, Heather A; Bennett-Guerrero, Elliott; White, William; Shernan, Stanton K; Nicoara, Alina; Del Rio, J Mauricio; Stafford-Smith, Mark; Swaminathan, Madhav

2014-02-01

To assess institutional patterns of perioperative transesophageal echocardiography (TEE) usage. The authors hypothesized that TEE is performed more frequently and comprehensively in academic centers, mainly by anesthesiologists, and barriers to performing TEE are due to inadequate resources. A survey was deployed to selected participants. Collated responses were assessed for demographic patterns in TEE practice, and 2-category comparisons were made with Chi-squared association tests. Web-based survey. Practitioners in cardiovascular anesthesia/surgery in 200 institutions. None. Surveys were completed by respondents representing 200 centers in 27 countries and 1,727 anesthesiologists with a mean annual institutional volume of 924 cases. Most centers were in the USA (53%) and were defined as academic (83%). Anesthesiologists performed (85%) and also read/reported TEEs (78%) in most centers. Three-dimensional TEE is performed routinely at 40% of centers. TEE is used routinely for valve surgery in 95% of institutions compared to 68% for coronary artery bypass graft surgery. Academic institutions assessed diastolic function more often than nonacademic centers (46% v 19%; p = 0.006). The most important reason cited for not using TEE in all cases was insufficient resource availability (47%). These results suggest that TEE is performed more comprehensively in academic centers, mainly by anesthesiologists, and that lack of resources is a significant barrier to routine TEE usage. TEE is used more often for valve surgery than for coronary artery bypass graft surgery, and many centers use 3D TEE. This survey describes international TEE practice patterns and identifies limitations to universal adoption of TEE in cardiac surgery. © 2013 Elsevier Inc. All rights reserved.

Is case triaging a useful tool for emergency surgeries? A review of 106 trauma surgery cases at a level 1 trauma center in South Africa.

PubMed

Chowdhury, Sharfuddin; Nicol, Andrew John; Moydien, Mahammed Riyaad; Navsaria, Pradeep Harkison; Montoya-Pelaez, Luis Felipe

2018-01-01

The optimal timing for emergency surgical interventions and implementation of protocols for trauma surgery is insufficient in the literature. The Groote Schuur emergency surgery triage (GSEST) system, based on Cape Triaging Score (CTS), is followed at Groote Schuur Hospital (GSH) for triaging emergency surgical cases including trauma cases. The study aimed to look at the effect of delay in surgery after scheduling based on the GSEST system has an impact on outcome in terms of postoperative complications and death. Prospective audit of patients presenting to GSH trauma center following penetrating or blunt chest, abdominal, neck and peripheral vascular trauma who underwent surgery over a 4-month period was performed. Post-operative complications were graded according to Clavien-Dindo classification of surgical complications. One-hundred six patients underwent surgery during the study period. One-hundred two (96.2%) cases were related to penetrating trauma. Stab wounds comprised 71 (67%) and gunshot wounds (GSW) 31 (29.2%) cases. Of the 106 cases, 6, 47, 40, and 13 patients were booked as red, orange, yellow, and green, respectively. The median delay for green, yellow, and orange cases was within the expected time. The red patients took unexpectedly longer (median delay 48 min, IQR 35-60 min). Thirty-one (29.3%) patients developed postoperative complications. Among the booked red, orange, yellow, and green cases, postoperative complications developed in 3, 18, 9, and 1 cases, respectively. Only two (1.9%) postoperative deaths were documented during the study period. There was no statistically significant association between operative triage and post-operative complications ( p  = 0.074). Surgical case categorization has been shown to be useful in prioritizing emergency trauma surgical cases in a resource constraint high-volume trauma center.

A Review of the Ahmed Glaucoma Valve Implant and Comparison with Other Surgical Operations.

PubMed

Riva, Ivano; Roberti, Gloria; Katsanos, Andreas; Oddone, Francesco; Quaranta, Luciano

2017-04-01

The Ahmed glaucoma valve (AGV) is a popular glaucoma drainage implant used for the control of intraocular pressure in patients with glaucoma. While in the past AGV implantation was reserved for glaucoma patients poorly controlled after one or more filtration procedures, mounting evidence has recently encouraged its use as a primary surgery in selected cases. AGV has been demonstrated to be safe and effective in reducing intraocular pressure in patients with primary or secondary refractory glaucoma. Compared to other glaucoma surgeries, AGV implantation has shown favorable efficacy and safety. The aim of this article is to review the results of studies directly comparing AGV with other surgical procedures in patients with glaucoma.

Geriatric comanagement reduces perioperative complications and shortens duration of hospital stay after lumbar spine surgery: a prospective single-institution experience.

PubMed

Adogwa, Owoicho; Elsamadicy, Aladine A; Vuong, Victoria D; Moreno, Jessica; Cheng, Joseph; Karikari, Isaac O; Bagley, Carlos A

2017-12-01

OBJECTIVE Geriatric patients undergoing lumbar spine surgery have unique needs due to the physiological changes of aging. They are at risk for adverse outcomes such as delirium, infection, and iatrogenic complications, and these complications, in turn, contribute to the risk of functional decline, nursing home admission, and death. Whether preoperative and perioperative comanagement by a geriatrician reduces the incidence of in-hospital complications and length of in-hospital stay after elective lumbar spine surgery remains unknown. METHODS A unique model of comanagement for elderly patients undergoing lumbar fusion surgery was implemented at a major academic medical center. The Perioperative Optimization of Senior Health (POSH) program was launched with the aim of improving outcomes in elderly patients (> 65 years old) undergoing complex lumbar spine surgery. In this model, a geriatrician evaluates elderly patients preoperatively, in addition to performing routine preoperative anesthesia surgical screening, and comanages them daily throughout the course of their hospital stay to manage medical comorbid conditions and coordinate multidisciplinary rehabilitation along with the neurosurgical team. The first 100 cases were retrospectively reviewed after initiation of the POSH protocol and compared with the immediately preceding 25 cases to assess the incidence of perioperative complications and clinical outcomes. RESULTS One hundred twenty-five patients undergoing lumbar decompression and fusion were enrolled in this pilot program. Baseline characteristics were similar between both cohorts. The mean length of in-hospital stay was 30% shorter in the POSH cohort (6.13 vs 8.72 days; p = 0.06). The mean duration of time between surgery and patient mobilization was significantly shorter in the POSH cohort compared with the non-POSH cohort (1.57 days vs 2.77 days; p = 0.02), and the number of steps ambulated on day of discharge was 2-fold higher in the POSH cohort (p = 0.04). Compared with the non-POSH cohort, the majority of patients in the POSH cohort were discharged to home (24% vs 54%; p = 0.01). CONCLUSIONS Geriatric comanagement reduces the incidence of postoperative complications, shortens the duration of in-hospital stay, and contributes to improved perioperative functional status in elderly patients undergoing elective spinal surgery for the correction of adult degenerative scoliosis.

Robotic hysterectomy versus conventional laparoscopic hysterectomy: outcome and cost analyses of a matched case-control study.

PubMed

Sarlos, Dimitri; Kots, Lavonne; Stevanovic, Nebojsa; Schaer, Gabriel

2010-05-01

Robotic surgery, with its technical advances, promises to open a new window to minimally invasive surgery in gynaecology. Feasibility and safety of this surgical innovation have been demonstrated in several studies, and now a critical analysis of these new developments regarding outcome and costs is in place. So far only a few studies compare robotic with conventional laparoscopic surgery in gynaecology. Our objective was to evaluate our initial experience performing total robot-assisted hysterectomy with the da Vinci surgical system and compare peri-operative outcome and costs with total laparoscopic hysterectomy. For this prospective matched case-control study at our institution, peri-operative data from our first 40 consecutive total robot-assisted hysterectomies for benign indications were recorded and matched 1:1 with total laparoscopic hysterectomies according to age, BMI and uterus weight. Surgical costs were calculated for both procedures. Surgeons' subjective impressions of robotics were evaluated with a self-developed questionnaire. No conversions to laparotomy or severe peri-operative complications occurred. Mean operating time was 109 (113; 50-170) min for the robotic group and 83 (80; 55-165) min for the conventional laparoscopic group. Mean postoperative hospitalisation for robotic surgery was 3.3 (3; 2-6) days versus 3.9 (4; 2-7) days for the conventional laparoscopic group. Average surgical cost of a robot-assisted laparoscopic hysterectomy was 4067 euros compared to 2151 euros for the conventional laparoscopic procedure at our institution. For the robotic group wider range of motion of the instruments and better ergonomics were considered to be an advantage, and lack of direct access to the patient was stated as a disadvantage. Robot-assited hysterectomy is a feasible and interesting new technique with comparable outcome to total laparoscopic hysterectomy. Operating times of total laparoscopic hysterectomy seem to be achieved quickly especially for experienced laparoscopic surgeons. However, costs of robotic surgery are still higher than for conventional laparoscopy. Randomised clinical trials need to be conducted to further evaluate benefits of this new technology for patients and surgeons and analyse its cost-effectiveness in gynaecology. Copyright (c) 2010 Elsevier Ireland Ltd. All rights reserved.

Comparison of shoulder internal rotation test with the elbow flexion test in the diagnosis of cubital tunnel syndrome.

PubMed

Ochi, Kensuke; Horiuchi, Yukio; Tanabe, Aya; Morita, Kozo; Takeda, Kentaro; Ninomiya, Ken

2011-05-01

To compare the shoulder internal rotation test-a new, provocative test-with the elbow flexion test in the diagnosis of cubital tunnel syndrome (CubTS). Twenty-five patients with CubTS were examined before and after surgery with 10 seconds each of the elbow flexion and shoulder internal rotation tests. Fifty-four asymptomatic individuals and 14 neuropathy patients with a diagnosis other than CubTS were also examined as control cases. For the shoulder internal rotation test, the patient's upper extremity was kept at 90° abduction, maximum internal rotation, and 10° flexion at the shoulder, with 90° elbow flexion and neutral position of the forearm and wrist, with finger extension. Test results were considered positive if any slight symptom attributable to CubTS occurred within 10 seconds. Extraneural pressure inside the cubital tunnel was intraoperatively measured with the positions of both the elbow flexion and shoulder internal rotation tests, in 15 of the CubTS cases. Statistical analyses were performed using Student's t-test with a confidence level of 95%. The preoperative sensitivity in CubTS cases was 80% in the 10-second shoulder internal rotation test and 36% in the 10-second elbow flexion test, and these differences were significant. None of the control cases had positive results in either test. All the CubTS cases improved with surgery; after surgery, neither test provoked symptoms in any surgical patient. The extraneural pressure increased in both provocative positions with no significant difference. Positive results for the 10-second shoulder internal rotation test were more sensitive than that for the elbow flexion test of the same duration and seemed specific to CubTS. Copyright © 2011 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

Innovative practice model to optimize resource utilization and improve access to care for high-risk and BRCA+ patients.

PubMed

Head, Linden; Nessim, Carolyn; Usher Boyd, Kirsty

2017-02-01

Bilateral prophylactic mastectomy (BPM) has demonstrated breast cancer risk reduction in high-risk/ BRCA + patients. However, priority of active cancers coupled with inefficient use of operating room (OR) resources presents challenges in offering BPM in a timely manner. To address these challenges, a rapid access prophylactic mastectomy and immediate reconstruction (RAPMIR) program was innovated. The purpose of this study was to evaluate RAPMIR with regards to access to care and efficiency. We retrospectively reviewed the cases of all high-risk/ BRCA + patients having had BPM between September 2012 and August 2014. Patients were divided into 2 groups: those managed through the traditional model and those managed through the RAPMIR model. RAPMIR leverages 2 concurrently running ORs with surgical oncology and plastic surgery moving between rooms to complete 3 combined BPMs with immediate reconstruction in addition to 1-2 independent cases each operative day. RAPMIR eligibility criteria included high-risk/ BRCA + status; BPM with immediate, implant-based reconstruction; and day surgery candidacy. Wait times, case volumes and patient throughput were measured and compared. There were 16 traditional patients and 13 RAPMIR patients. Mean wait time (days from referral to surgery) for RAPMIR was significantly shorter than for the traditional model (165.4 v. 309.2 d, p = 0.027). Daily patient throughput (4.3 v. 2.8), plastic surgery case volume (3.7 v. 1.6) and surgical oncology case volume (3.0 v. 2.2) were significantly greater in the RAPMIR model than the traditional model ( p = 0.003, p < 0.001 and p = 0.015, respectively). A multidisciplinary model with optimized scheduling has the potential to improve access to care and optimize resource utilization.

Innovative practice model to optimize resource utilization and improve access to care for high-risk and BRCA+ patients

PubMed Central

Head, Linden; Nessim, Carolyn; Boyd, Kirsty Usher

2017-01-01

Background Bilateral prophylactic mastectomy (BPM) has shown breast cancer risk reduction in high-risk/BRCA+ patients. However, priority of active cancers coupled with inefficient use of operating room (OR) resources presents challenges in offering BPM in a timely manner. To address these challenges, a rapid access prophylactic mastectomy and immediate reconstruction (RAPMIR) program was innovated. The purpose of this study was to evaluate RAPMIR with regards to access to care and efficiency. Methods We retrospectively reviewed the cases of all high-risk/BRCA+ patients having had BPM between September 2012 and August 2014. Patients were divided into 2 groups: those managed through the traditional model and those managed through the RAPMIR model. RAPMIR leverages 2 concurrently running ORs with surgical oncology and plastic surgery moving between rooms to complete 3 combined BPMs with immediate reconstruction in addition to 1–2 independent cases each operative day. RAPMIR eligibility criteria included high-risk/BRCA+ status; BPM with immediate, implant-based reconstruction; and day surgery candidacy. Wait times, case volumes and patient throughput were measured and compared. Results There were 16 traditional patients and 13 RAPMIR patients. Mean wait time (days from referral to surgery) for RAPMIR was significantly shorter than for the traditional model (165.4 v. 309.2 d, p = 0.027). Daily patient throughput (4.3 v. 2.8), plastic surgery case volume (3.7 v. 1.6) and surgical oncology case volume (3.0 v. 2.2) were significantly greater in the RAPMIR model than the traditional model (p = 0.003, p < 0.001 and p = 0.015, respectively). Conclusion A multidisciplinary model with optimized scheduling has the potential to improve access to care and optimize resource utilization. PMID:28234588

Innovative practice model to optimize resource utilization and improve access to care for high-risk and BRCA+ patients.

PubMed

Head, Linden; Nessim, Carolyn; Usher Boyd, Kirsty

2016-12-01

Bilateral prophylactic mastectomy (BPM) has demonstrated breast cancer risk reduction in high-risk/ BRCA + patients. However, priority of active cancers coupled with inefficient use of operating room (OR) resources presents challenges in offering BPM in a timely manner. To address these challenges, a rapid access prophylactic mastectomy and immediate reconstruction (RAPMIR) program was innovated. The purpose of this study was to evaluate RAPMIR with regards to access to care and efficiency. We retrospectively reviewed the cases of all high-risk/ BRCA + patients having had BPM between September 2012 and August 2014. Patients were divided into 2 groups: those managed through the traditional model and those managed through the RAPMIR model. RAPMIR leverages 2 concurrently running ORs with surgical oncology and plastic surgery moving between rooms to complete 3 combined BPMs with immediate reconstruction in addition to 1-2 independent cases each operative day. RAPMIR eligibility criteria included high-risk/ BRCA + status; BPM with immediate, implant-based reconstruction; and day surgery candidacy. Wait times, case volumes and patient throughput were measured and compared. There were 16 traditional patients and 13 RAPMIR patients. Mean wait time (days from referral to surgery) for RAPMIR was significantly shorter than for the traditional model (165.4 v. 309.2 d, p = 0.027). Daily patient throughput (4.3 v. 2.8), plastic surgery case volume (3.7 v. 1.6) and surgical oncology case volume (3.0 v. 2.2) were significantly greater in the RAPMIR model than the traditional model ( p = 0.003, p < 0.001 and p = 0.015, respectively). A multidisciplinary model with optimized scheduling has the potential to improve access to care and optimize resource utilization.

Risk of transmission of sporadic Creutzfeldt-Jakob disease by surgical procedures: systematic reviews and quality of evidence.

PubMed

López, Fernando J García; Ruiz-Tovar, María; Almazán-Isla, Javier; Alcalde-Cabero, Enrique; Calero, Miguel; de Pedro-Cuesta, Jesús

2017-10-01

Sporadic Creutzfeldt-Jakob disease (sCJD) is potentially transmissible to humans. This study aimed to summarise and rate the quality of the evidence of the association between surgery and sCJD. Firstly, we conducted systematic reviews and meta-analyses of case-control studies with major surgical procedures as exposures under study. To assess quality of evidence, we used the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. Secondly, we conducted a systematic review of sCJD case reports after sharing neurosurgical instruments. Thirteen case-control studies met the inclusion criteria for the systematic review of case-control studies. sCJD was positively associated with heart surgery, heart and vascular surgery and eye surgery, negatively associated with tonsillectomy and appendectomy, and not associated with neurosurgery or unspecified major surgery. The overall quality of evidence was rated as very low. A single case-control study with a low risk of bias found a strong association between surgery conducted more than 20 years before disease onset and sCJD. Seven cases were described as potentially transmitted by reused neurosurgical instruments. The association between surgery and sCJD remains uncertain. Measures currently recommended for preventing sCJD transmission should be strongly maintained. Future studies should focus on the potential association between sCJD and surgery undergone a long time previously.

A Tourette-like syndrome following cardiopulmonary bypass and hypothermia: MRI volumetric measurements.

PubMed

Singer, H S; Dela Cruz, P S; Abrams, M T; Bean, S C; Reiss, A L

1997-07-01

We present the case of an adolescent boy who developed a variety of simple and complex motor and vocal tics (Tourette-like syndrome), along with inattentiveness and obsessive-compulsive behaviors after cardiac surgery with cardiopulmonary bypass and profound hypothermia. A single photon emission computed tomography study 2 months after surgery showed reduced uptake in the left hemisphere and 2 years later a perfusion defect in the basal ganglia. Serial magnetic resonance imaging (MRI) studies were normal. Volumetric MRI studies were obtained 4 years after surgery and compared with published values for normal individuals and children with Tourette syndrome (TS), including subsets matched for age, sex, and handedness. Measurement of basal ganglia structures showed a right-dominant asymmetry of the caudate and putamen, in part similar to findings previously reported in patients with TS. Other volumetric abnormalities included a > 2-SD reduction of cortical gray matter, a small decrease of total cerebral volume, and increase in cerebral white matter. Although a variety of neurological problems may occur after cardiopulmonary bypass, to our knowledge this case represents the first report of a chronic tic disorder following cardiac surgery with cardiopulmonary bypass and hypothermia.

Virtual Planning of a Complex Three-Part Bimaxillary Osteotomy

PubMed Central

Anghinoni, Marilena Laura

2017-01-01

In maxillofacial surgery, every patient presents special problems requiring careful evaluation. Conventional methods to study the deformities are still reliable, but the advent of tridimensional (3D) imaging, especially computed tomography (CT) scan and laser scanning of casts, created the opportunity to better understanding the skeletal support and the soft tissue structures. Nowadays, virtual technologies are increasingly employed in maxillofacial surgery and demonstrated precision and reliability. However, in complex surgical procedures, these new technologies are still controversial. Especially in the less frequent cases of three-part maxillary surgery, the experience is limited, and scientific literature cannot give a clear support. This paper presents the case of a young patient affected by a complex long face dentofacial deformity treated by a bimaxillary surgery with three-part segmentation of the maxilla. The operator performed the surgical study completely with a virtual workflow. Pre- and postoperative CT scan and optical scanning of plaster models were collected and compared. Every postoperatory maxillary piece was superimposed with the presurgical one, and the differences were examined in a color-coded map. Only mild differences were found near the osteotomy lines, when the bony surface and the teeth demonstrated an excellent coincidence. PMID:29318057

Inferior gluteal artery perforator flap: a viable alternative for ischial pressure sores.

PubMed

Kim, Young Seok; Lew, Dae Hyun; Roh, Tai Suk; Yoo, Won Min; Lee, Won Jai; Tark, Kwan Chul

2009-10-01

The ischial area is by far the most common site for pressure sores in wheelchair-bound paraplegic patients, because most of the pressure of the body is exerted on this area in the seated position. Even after a series of successful pressure sore treatments, the site is very prone to relapse from the simplest everyday tasks. Therefore, it is crucial to preserve the main pedicle during primary surgery. Several surgical procedures, such as myocutaneous flap and perforator flap, have been introduced for the treatment of pressure sores. During a 4-year time period at our institute, we found favourable clinical results using the inferior gluteal artery perforator (IGAP) procedure for ischial sore treatment. A total of 23 patients (20 males and three females) received IGAP flap surgery in our hospital from January 2003 to January 2007. Surgery was performed on the same site again in 10 (43%) patients who had originally relapsed after undergoing the conventional method of pressure sore surgery. The average age of patients was 47.4 years (range 26-71 years). Most of the patients were paraplegic (16 cases, 70%) and others were either quadriplegic (four cases, 17%) or ambulatory (three cases, 13%). Based on hospital records and clinical photographs, we attempted to assess the feasibility and practicability of the IGAP flap procedure through comparative analysis of several parameters including the size of the defective area, treatment modalities, relapses, complications, and postoperative treatments. The average follow-up duration for 23 subjects was 25.4 months (range 5-42 months). All flaps survived without major complications. Partial flap necrosis developed in one case but secondary healing was achieved and the final outcome was not impaired. Most of the cases healed well during the follow-up period. Postoperative complications such as wound dehiscence and fistula developed in some subjects, but all healed well with a secondary treatment. A total of five cases relapsed after surgery due to tissue deficit and these were treated with bursectomy and muscle transposition flap to fill the dead space. We propose that the IGAP flap should be considered a viable alternative to other methods of ischial pressure sore surgery owing to its many advantages, which include the ability to preserve peripheral muscle tissue, the variability of flap designs, relatively good durability, and the low donor site morbidity rate.

A 5-year perspective over robotic general surgery: indications, risk factors and learning curves.

PubMed

Sgarbură, O; Tomulescu, V; Blajut, C; Popescu, I

2013-01-01

Robotic surgery has opened a new era in several specialties but the diffusion of medical innovation is slower indigestive surgery than in urology due to considerations related to cost and cost-efficiency. Studies often discuss the launching of the robotic program as well as the technical or clinical data related to specific procedures but there are very few articles evaluating already existing robotic programs. The aims of the present study are to evaluate the results of a five-year robotic program and to assess the evolution of indications in a center with expertise in a wide range of thoracic and abdominal robotic surgery. All consecutive robotic surgery cases performed in our center since the beginning of the program and prior to the 31st of December 2012 were included in this study, summing up to 734 cases throughout five years of experience in the field. Demographic, clinical, surgical and postoperative variables were recorded and analyzed.Comparative parametric and non-parametric tests, univariate and multivariate analyses and CUSUM analysis were performed. In this group, the average age was 50,31 years. There were 60,9% females and 39,1% males. 55,3% of all interventions were indicated for oncological disease. 36% of all cases of either benign or malignant etiology were pelvic conditions whilst 15,4% were esogastric conditions. Conversion was performed in 18 cases (2,45%). Mean operative time was 179,4Â+-86,06 min. Mean docking time was 11,16Â+-2,82 min.The mean hospital length of stay was 8,54 (Â+-5,1) days. There were 26,2% complications of all Clavien subtypes but important complications (Clavien III-V) only represented 6,2%.Male sex, age over 65 years old, oncological cases and robotic suturing were identified as risk factors for unfavorable outcomes. The present data support the feasibility of different and complex procedures in a general surgery department as well as the ascending evolution of a well-designed and well-conducted robotic program. From the large variety of surgical interventions, we think that a robotic program could be focused on solving oncologic cases and different types of pelvic and gastroesophageal junction conditions, especially rectal, cervical and endometrial cancer, achalasia and complicated or redo hiatal hernia. Celsius.

Alfentanil and memory function. A comparison with fentanyl for day case termination of pregnancy.

PubMed

Kennedy, D J; Ogg, T W

1985-06-01

Two groups of 20 patients undergoing day case vaginal termination of pregnancy received either methohexitone and alfentanil 7.5 micrograms/kg or methohexitone and fentanyl 1.5 micrograms/kg. Their recovery times and memory function at 1 and 2 hours after surgery were compared. No difference in the recovery of the 2 groups was noted but at 2 hours after operation the alfentanil group showed impairment of memory for new facts compared with pre-operative memory function testing. This was not evident in the fentanyl group. Apart from this finding alfentanil was adjudged to be a suitable agent for day case anaesthesia.

Prospective Evaluation of Opioid Consumption Following Carpal Tunnel Release Surgery

PubMed Central

Chapman, Talia; Kim, Nayoung; Maltenfort, Mitchell; Ilyas, Asif M.

2016-01-01

Background: Postoperative pain management and opioid consumption following carpal tunnel release (CTR) surgery may be influenced by many variables. To understand factors affecting opioid consumption, a prospective study was undertaken with the hypothesis that CTR performed under local anesthesia (wide awake local anesthesia with no tourniquet [WALANT]) would result in increased opioid consumption postoperatively compared with cases performed under sedation. Methods: All patients undergoing open CTR surgery were consecutively enrolled over a 6-month period. Information collected included patient demographics, surgical technique, amount and type of narcotic prescribed, number of pills taken, and type of anesthesia. Results: 277 patients were enrolled (56% women, 44% men). On average, 21 pills were prescribed, and 4.3 pills (median = 2) were consumed. There was no difference in consumption between patients who received WALANT (78 cases) versus (198 cases) sedation (4.9 vs 3.9 pills, respectively) (P = .22). There was no difference in opioid consumption based on insurance type (P = .47) or type of narcotic (P = .85). However, more men consumed no opioids (47%) compared with women (36%) (P < .05) and older patients consumed less than younger patients (P < .05). Conclusions: Opioid consumption following CTR is more influenced by age and gender, and less influenced by anesthesia type, insurance type, or the type of opioid prescribed. Many more opioids were prescribed than needed, on an average of 5:1. Many patients, particularly older patients, do not require any opioid analgesia after CTR. PMID:28082841

Adnexal Torsion in Postmenopausal Women: Clinical Presentation and Risk of Ovarian Malignancy.

PubMed

Cohen, Aviad; Solomon, Neta; Almog, Benny; Cohen, Yoni; Tsafrir, Ziv; Rimon, Eli; Levin, Ishai

2017-01-01

To investigate the clinical presentation, operative outcome, and incidence of malignancy in postmenopausal women who were diagnosed with adnexal torsion. Retrospective cohort study (Canadian Task Force classification II-2). Tertiary university-affiliated hospital. Postmenopausal women diagnosed with adnexal torsion between 1995 and 2014 (study group) were reviewed and compared with 220 premenopausal patients diagnosed with adnexal torsion during the same time period. Demographic data, clinical signs and symptoms, and intra- and postoperative characteristics were compared between the 2 groups. During the study period 44 postmenopausal women were diagnosed with adnexal torsion. Continuous dull pain was the most common presenting symptom in the postmenopausal group (57%), whereas acute-onset sharp pain was the predominant symptom in the premenopausal group (86%). The time interval from admission to surgery was significantly longer in the postmenopausal group (24 vs 6 hours, p < .001). Laparoscopic surgery was performed in 84.5% of the cases in the premenopausal group, whereas it was carried out in only 50% of cases in the postmenopausal group (p < .001). Four women in the postmenopausal group were diagnosed with malignancy, whereas only 1 case of malignancy was found in the premenopausal group (9% vs .4%, respectively; p = .003). Adnexal torsion in postmenopausal women is an uncommon event with a unique presentation. Because ovarian malignancy is not an uncommon finding in this group of patients, preparation for more extensive surgery should be contemplated. Copyright © 2016 AAGL. Published by Elsevier Inc. All rights reserved.

Automated Whole Brain Tractography Affects Preoperative Surgical Decision Making.

PubMed

Zakaria, Hesham; Haider, Sameah; Lee, Ian

2017-09-06

Surgery in and around eloquent brain structures poses a technical challenge when the goal of surgery is maximal safe resection. Magnetic resonance imaging (MRI) has revolutionized the diagnosis and treatment of neurological disorders, but tractography still remains limited in terms of utility because of the requisite manual labor and time required combined with the high risk of bias and inaccuracy. Automated whole brain tractography (AWBT) has simplified this workflow, overcoming historical barriers, and allowing for integration into modern neuronavigation. However, current literature showing the usefulness of this new technology is limited. In this study, we aimed to illustrate the utility of AWBT during cranial surgery and its ability to affect presurgical and intraoperative clinical decision making. We performed a retrospective chart review of cases that underwent AWBT for one year from July 2016 to July 2017. All patients underwent conventional anatomic MRI with and without contrast sequences, in addition to diffusion tensor imaging (DTI) on a 3 Tesla MRI scanner (Ingenia 3.0T, Philips, Amsterdam NL). Post-hoc AWBT processing was performed on a separate workstation. Patients were subsequently grouped into those that had undergone either language or motor mapping and those that did not. We compared both sets of patients to see any differences in patient age, sex, laterality of surgery, depth of resection from cortical surface, and smallest distance between the lesion and adjacent eloquent white matter tracts. We identified illustrative cases which demonstrated the ability of AWBT to affect surgical decision making. In this single-center series, we identified 73 total patients who underwent AWBT for intracranial surgery, of which 28 patients underwent either speech or language mapping. When comparing mapping to non-mapping patients, we found no difference with respect to age, gender, laterality of surgery, or whether the surgery was a revision. The distance between the lesion and eloquent white matter tracts demonstrated a statistically significant difference between mapping and non-mapping patients, namely in the corticospinal tract (p < 0.0001), the superior longitudinal fasciculus (p < 0.0001), and the arcuate fasciculus (p < 0.004). Patients who underwent mapping were at equal risk for having a postoperative deficit (p = 0.772) but had an improved chance of recovery (p = 0.041) after surgery. We believe this phenomenon is related to increased awareness and avoidance of functional tissue during surgery, which occurs due to the combination of preoperatively identifying white matter tracts with AWBT and intraoperatively testing margins with mapping. We provide two illustrative cases that show the impact of AWBT on patient outcomes. In conclusion, AWBT is relatively simple to perform and provides vital information for surgeons about eloquent white matter tracts that can be used to help improve patient outcomes.

Cryopreservation of Autologous Blood (Red Blood Cells, Platelets and Plasma)

NASA Astrophysics Data System (ADS)

Ebine, Kunio

Prevention of post-transfusion hepatitis is still a problem in cardiovascular surgery. We initiated the cryopreservation of autologous blood for the transfusion in elective cardiovascular surgery since 1981. This study includes 152 surgical cases in which autologous frozen, allogeneic frozen, and/or allogeneic non-frozen blood were used. In the 152 surgical cases, there were 69 cases in which autologous blood only (Group I) was used; 12 cases with autologous and allogeneic frozen blood (Group II); 46 cases with autologous and allgeneic frozen plus allogeneic non-frozen blood (Group III); and 25 cases with allogeneic frozen plus allogeneic non-frozen blood (Group IV). No hepatitis developed in Groups I (0%) and II (0%), but there was positive hepatitis in Groups III (4.3%) and IV (8.0%) . In 357 cases of those who underwent surgery with allogeneic non-frozen whole blood during the same period, the incidence rate of hepatitis was 13.7% (49/357). Patients awaiting elective surgery can store their own blood in the frozen state. Patients who undergo surgery with the cryoautotransfusion will not produce any infections or immunologic reactions as opposed to those who undergo surgery with the allogeneic non-frozen blood.

Acute catecholamine cardiomyopathy in patients with phaeochromocytoma or functional paraganglioma.

PubMed

Giavarini, Alessandra; Chedid, Antoine; Bobrie, Guillaume; Plouin, Pierre-François; Hagège, Albert; Amar, Laurence

2013-10-01

Phaeochromocytomas and paragangliomas (PPGL) can cause acute catecholamine cardiomyopathy (ACC). We assessed the prevalence of ACC and compared the presentation of cases with and without ACC in a large series of PPGL. Single centre retrospective study. Hypertension Unit, University Hospital, Paris. 140 consecutive patients with PPGL, referred from January 2003 to September 2012. Left ventricular ejection fraction (LVEF), perioperative mortality. Fifteen patients (11%) had suffered an ACC, occurring in 14 cases before the diagnosis of PPGL. Precipitating factors were identified in 11 cases. Twelve patients presented with acute pulmonary oedema, including 10 with cardiogenic shock, requiring life support in eight cases. Seven patients (five with pulmonary oedema) presented with acute chest pain and cardiac dysfunction. Electrocardiographic abnormalities were present in 14 cases: ST segment elevation or pathological Q waves, ST segment depression, and/or diffuse T wave inversion. Six patients displayed classical (apical ballooning) or inverted (basal/mid ventricular stunning) takotsubo-like cardiomyopathy. Coronary arteries were always normal on angiography. In patients with ACC, median LVEF rose from 30% (IQR 23-33%) during ACC to 71% (50-72%) before surgery (n=11, p<0.001). Median LVEF before PPGL surgery was 65% (51-72%) and 65% (60-70%) in patients with and without a history of ACC, respectively (not significant). PPGL may present as ACC in 11% of cases, excluding patients dying from undiagnosed tumours. Left ventricular dysfunction is usually reversible before surgery. PPGL should be suspected in patients with acute heart failure without evidence of valvular or coronary artery disease.

Comparison of quality of life between two biliary drainage procedures in laparoscopic common bile duct exploration.

PubMed

Xin, Ying; Zhu, Xin; Wei, Qi; Cai, Xiujun; Wang, Xianfa; Huang, Diyu

2007-03-01

With various kinds of minimal access surgery being introduced, quality of life must be considered as a measure of whether minimal access surgery is good or not. We evaluate the difference in quality of life using two kinds of biliary drainage procedures in laparoscopic common bile duct exploration. Forty cases of laparoscopic common bile duct exploration with cholecystectomy were studied to compare gastrointestinal quality of life index (GIQLI) preoperatively and postoperatively at two, five and sixteen weeks in two groups using different biliary drainage procedures. There was no preoperative GIQLI difference between the two groups. Cases with biliary drainage through the cystic duct achieved earlier recovery. GIQLI of all cases reached normal sixteen weeks postoperatively. Biliary drainage through the cystic duct in laparoscopic common bile duct exploration may help to improve the postoperative GIQLI in patients.

Reversal of the Hartmann's procedure: A comparative study of laparoscopic versus open surgery.

PubMed

Melkonian, Ernesto; Heine, Claudio; Contreras, David; Rodriguez, Marcelo; Opazo, Patricio; Silva, Andres; Robles, Ignacio; Rebolledo, Rolando

2017-01-01

The Hartmann's operation, although less frequently performed today, is still used when initial colonic anastomosis is too risky in the short term. However, the subsequent procedure to restore gastrointestinal continuity is associated with significant morbidity and mortality. The review of an institutional review board (IRB)-approved prospectively maintained database provided data on the Hartmann's reversal procedure performed by either laparoscopic or open technique at our institution. The data collected included: demographic data, operative approach, conversion for laparoscopic cases and perioperative morbidity and mortality. Over a 14-year period from January 1997 to August 2011, 74 Hartmann's reversal procedures were performed (laparoscopic surgery-49, open surgery-25). The average age was 55 years for the laparoscopic and 57 years for the open surgery group, respectively. Male patients represent 61% of both groups. There was no significant difference in operative time between the two groups (149 min vs 151 min; P = 0.95), and there was a tendency to lower morbidity (3/49-7.3% vs 4/25-16%; P = 0.24) in the laparoscopic surgery group. In the laparoscopic group, eight patients (16.3%) were converted to open surgery, mostly due to severe adhesions. The length of hospital stay was significantly shorter for the laparoscopic group (5 days vs 7 days; P = 0.44). The Hartmann's reversal procedure can be safely performed in the majority of the cases using a laparoscopic approach with a low morbidity rate and achieving a shorter hospital stay.

Impact of acute care surgery to departmental productivity.

PubMed

Barnes, Stephen L; Cooper, Christopher J; Coughenour, Jeffrey P; MacIntyre, Allan D; Kessel, James W

2011-10-01

The face of trauma surgery is rapidly evolving with a paradigm shift toward acute care surgery (ACS). The formal development of ACS has been viewed by some general surgeons as a threat to their practice. We sought to evaluate the impact of a new division of ACS to both departmental productivity and provider satisfaction at a University Level I Trauma Center. Two-year retrospective analysis of annual work relative value unit (wRVU) productivity, operative volume, and FTEs before and after establishment of an ACS division at a University Level I trauma center. Provider satisfaction was measured using a 10-point scale. Analysis completed using Microsoft Excel with a p value less than 0.05 significant. The change to an ACS model resulted in a 94% increase in total wRVU production (78% evaluation and management, 122% operative; p<0.05) for ACS, whereas general surgery wRVU production increased 8% (-15% evaluation and management, 14% operative; p<0.05). Operative productivity was substantial after transition to ACS, with 129% and 44% increases (p<0.05) in operative and elective case load, respectively. Decline in overall general surgery operative volume was attributed to reduction in emergent cases. Establishment of the ACS model necessitated one additional FTE. Job satisfaction substantially improved with the ACS model while allowing general surgery a more focused practice. The ACS practice model significantly enhances provider productivity and job satisfaction when compared with trauma alone. Fears of a productivity impact to the nontrauma general surgeon were not realized.

Intraoperative intra-articular injection of gentamicin: will it decrease the risk of infection in total shoulder arthroplasty?

PubMed

Lovallo, Jeffrey; Helming, Jarrett; Jafari, S Mehdi; Owusu-Forfie, Afia; Donovan, Skye; Minnock, Christopher; Adib, Farshad

2014-09-01

Deep infection is a debilitating complication after shoulder arthroplasty. Intra-articular injection of antibiotic can give a higher concentration compared with intravenous administration. We hypothesized that a group of patients given an intra-articular, intraoperative injection of gentamicin would report a lower infection rate than a group without local antibiotics. Between 2005 and 2011, the senior author performed 507 shoulder arthroplasties. We retrospectively reviewed all of those cases. All patients were administered systemic prophylactic antibiotics. Beginning in June 2007, patients were also injected with 160 mg of gentamicin in the glenohumeral joint at the end of their surgery. Patient records were examined for preexisting medical conditions, type of surgery, and presence of infection. Patients receiving surgery before 2007 were compared with those after to determine the effect of prophylactic gentamicin administration in preventing deep infection associated with surgery. All patients were observed for a minimum of 1 year. Of the 507 surgeries, 164 were performed before 2007 (without intra-articular injection of gentamicin; group A) and 343 were performed with addition of gentamicin (group B). In group A, 5 patients presented with infection (3.0%) compared with 1 in group B (0.29%). The gender, mean age, mean body mass index, and prevalence of comorbidities were similar between the groups. The data from this study support the conclusion that intra-articular intraoperative gentamicin administration may reduce postoperative infection. Copyright © 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.

Case-mix & patients' reports of outcome in Independent Sector Treatment Centres: Comparison with NHS providers.

PubMed

Browne, John; Jamieson, Liz; Lewsey, Jim; van der Meulen, Jan; Copley, Lynn; Black, Nick

2008-04-09

There has been considerable concern expressed about the outcomes achieved in Independent Sector Treatment Centres (ISTCs) introduced in England since 2003. Our aim was to compare the case-mix and patients' reported outcomes of surgery in ISTCs and in NHS providers. Prospective cohort study of 769 patients treated in six ISTCs and 1895 treated in 20 NHS providers (acute hospitals and treatment centres) in England during 2006-07. Participants underwent one of three day surgery procedures (inguinal hernia repair, varicose vein surgery, cataract extraction) or hip or knee replacement. Change in patient-reported health status and health related quality of life (measured using a disease-specific and a generic (EQ-5D) instrument) was assessed either 3-months (day surgery) or 6-months (hip/knee) after surgery. In addition patient-reported post-operative complications and an overall assessment of success of surgery were collected. Outcome measures were adjusted (using multivariable regression) for patient characteristics (disease severity, duration of symptoms, age, sex, socioeconomic status, general health, previous similar surgery, comorbidity). Post-operative response rates varied by procedure (73%-88%) and were similar for those treated in ISTCs and NHS facilities. Patients treated in ISTCs were healthier, were less likely to have any comorbidity and, for those undergoing cataract surgery or joint replacement, their primary condition was less severe. Those undergoing hernia repair or joint replacement were less likely to have had similar surgery before. When adjustment was made for pre-operative characteristics, patients undergoing cataract surgery or hip replacement in ISTCs achieved a slightly greater improvement in functional status and quality of life than those treated in NHS facilities, while the opposite was true of patients undergoing hernia repair. No significant differences were found for the two other procedures. Patients treated in ISTCs were less likely to report post-operative problems than those treated in NHS facilities for cataract surgery (Adjusted Odds Ratio 0.35; 95% CI 0.17-0.70), hernia repair (0.42; 0.28-0.63) and knee replacement (0.44; 0.28-0.69). Most patients described the result of their operation as excellent, very good or good, regardless of where they were treated. The case-mix of patients treated in ISTCs differs from that in NHS providers, in line with the intention of the contracts. Caution is needed in interpreting the observation that patients treated in ISTCs reported slightly better outcomes as very few ISTCs participated, case-mix adjustment might have been insufficient, and patients' reports might have been biased as they were more likely to be satisfied with the way they were treated.

Case-Cohort Studies: Design and Applicability to Hand Surgery.

PubMed

Vojvodic, Miliana; Shafarenko, Mark; McCabe, Steven J

2018-04-24

Observational studies are common research strategies in hand surgery. The case-cohort design offers an efficient and resource-friendly method for risk assessment and outcomes analysis. Case-cohorts remain underrepresented in upper extremity research despite several practical and economic advantages over case-control studies. This report outlines the purpose, utility, and structure of the case-cohort design and offers a sample research question to demonstrate its value to risk estimation for adverse surgical outcomes. The application of well-designed case-cohort studies is advocated in an effort to improve the quality and quantity of observational research evidence in hand and upper extremity surgery. Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

Comparing oncoplastic breast conserving surgery with mastectomy and immediate breast reconstruction: Case-matched patient reported outcomes.

PubMed

Kelsall, Jennett E; McCulley, Stephen J; Brock, Lisa; Akerlund, Malin T E; Macmillan, R Douglas

2017-10-01

Oncoplastic breast conserving surgery (OBCS) allows women who may otherwise have mastectomy and immediate reconstruction (MxIR) the choice to conserve their breast yet avoid deformity. We compared the outcome of these options. Two cohorts meeting study criteria were identified from prospectively audited series of women undergoing OBCS or MxIR. After case matching for age, tumour size and date of surgery, stratification by breast size and controlling for radiotherapy; body image scale (BIS) scores of psychosocial function and patient reported outcome measures (PROMs) for breast appearance and return to function were analysed. A total of 567 women (286 treated by OBCS and 281 by MxIR) fulfilled inclusion criteria. Demographics were similar between the two unmatched cohorts, except for radiotherapy, age and tumour size (all p < 0.001). Overall, BIS score (p = 0.002), self-rated breast appearance, return to work and function (all p < 0.001) significantly favoured OBCS. Case-matched women with larger breasts treated by OBCS reported better BIS scores (mean 3.30 vs. 5.37, p = 0.011) and self-rated breast appearance score (p < 0.001) than MxIR, whereas no significant difference was observed for smaller breasts. BIS and appearance favoured OBCS, regardless of whether radiotherapy would have been avoided if treated by MxIR. OBCS offers suitable women the option to avoid MxIR while providing faster recovery. Better psychosocial and self-rated satisfaction with breast appearance is achieved for OBCS in all groups, regardless of the need for radiotherapy, apart from those women with smaller breasts for whom the results are comparable. Copyright © 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Usefulness of StereoEEG-based tailored surgery for medial temporal lobe epilepsy. Preliminary results in 11 patients.

PubMed

Kubota, Yuichi; Ochiai, Taku; Hori, Tomokatsu; Kawamata, Takakazu

2017-07-01

Surgical options for medial temporal lobe epilepsy (MTLE) include anterior temporal lobectomy (ATL) and selective amygdalohippocampectomy (SAH). Optimal criteria for choosing the appropriate surgical approach remain uncertain. This article reports 11 consecutive cases in which electrophysiological findings of stereoelectroencephalography (SEEG) were used to determine the optimal surgical approach. Eleven consecutive patients with MTLE underwent SEEG evaluation and were placed in either the medial or the medial+lateral group based on the findings. Patients in the medial group underwent SAH using the subtemporal approach, and patients in the medial+lateral group underwent SEEG-guided anterior temporal lobectomy. SEEG findings were also compared with other examinations including flumazenil (FMZ)-positron emission tomography (PET), fluorine-18 labeled fluorodeoxyglucose (FDG)-PET, and magnetoencephalography (MEG). Results were evaluated to determine which examinations most consistently identified the epileptogenic zone. Of the 11 cases, 4 patients were placed in the medial group, and 7 patients in the medial+lateral group. Of patients, 90.9% were classified in class I of the Engel Epilepsy Surgery Outcome Scale, while 72.7% were classified in class I by the International League Against Epilepsy (ILAE) system. Analyzed by group, 100% of the medial group experienced an Engel class I outcome in the medial group, compared to 85.7% in the medial+lateral group. SEEG findings were comparable with FDG-PET results (10 of 11, 91%). Tailored surgery guided by SEEG is an electrophysiologically feasible treatment for MTLE that can result in favorable outcomes. Although seizures are thought to originate in the medial temporal lobe in MTLE, it is important for involvement of the lateral temporal cortex to be also considered in some cases. Copyright © 2017. Published by Elsevier B.V.

Implementation of an acute care emergency surgical service: a cost analysis from the surgeon's perspective.

PubMed

Anantha, Ram Venkatesh; Parry, Neil; Vogt, Kelly; Jain, Vipan; Crawford, Silvie; Leslie, Ken

2014-04-01

Acute care surgical services provide comprehensive emergency general surgical care while potentially using health care resources more efficiently. We assessed the volume and distribution of emergency general surgery (EGS) procedures before and after the implementation of the Acute Care and Emergency Surgery Service (ACCESS) at a Canadian tertiary care hospital and its effect on surgeon billings. This single-centre retrospective case-control study compared adult patients who underwent EGS procedures between July and December 2009 (pre-ACCESS), to those who had surgery between July and December 2010 (post-ACCESS). Case distribution was compared between day (7 am to 3 pm), evening (3 pm to 11 pm) and night (11 pm to 7 am). Frequencies were compared using the χ(2) test. Pre-ACCESS, 366 EGS procedures were performed: 24% during the day, 55% in the evening and 21% at night. Post-ACCESS, 463 operations were performed: 55% during the day, 36% in the evening and 9% at night. Reductions in night-time and evening EGS were 57% and 36% respectively (p < 0.001). Total surgeon billings for operations pre- and post-ACCESS were $281 066 and $287 075, respectively: remuneration was $6008 higher post-ACCESS for an additional 97 cases (p = 0.003). Using cost-modelling analysis, post-ACCESS surgeon billing for appendectomies, segmental colectomies, laparotomies and cholecystectomies all declined by $67 190, $125 215, $66 362, and $84 913, respectively (p < 0.001). Acute care surgical services have dramatically shifted EGS from nighttime to daytime. Cost-modelling analysis demonstrates that these services have cost-savings potential for the health care system without reducing overall surgeon billing.

Effect of anterior cruciate ligament reconstruction and meniscectomy on length of career in National Football League athletes: a case control study.

PubMed

Brophy, Robert H; Gill, Corey S; Lyman, Stephen; Barnes, Ronnie P; Rodeo, Scott A; Warren, Russell F

2009-11-01

Meniscal and anterior cruciate ligament (ACL) injuries are common in college football athletes. The effect of meniscectomy and/or ACL surgery on the length of an athlete's career in the National Football League (NFL) has not been well examined. Athletes with a history of meniscectomy or ACL surgery before the NFL combine have a shorter career than matched controls. Case-control study; Level of evidence, 3. A database containing the injury history and career NFL statistics of athletes from 1987-2000 was used to match athletes with a history of meniscectomy and/or ACL surgery, and no other surgery or major injury, to controls without previous surgeries. Athletes were matched by position, year drafted, round drafted, and additional injury history. Fifty-four athletes with a history of meniscectomy, 29 with a history of ACL reconstruction, and 11 with a history of both were identified and matched with controls. Isolated meniscectomy reduced the length of career in years (5.6 vs 7.0; P = .03) and games played (62 vs 85; P = .02). Isolated ACL surgery did not significantly reduce the length of career in years or games played. Comparing the athletes with meniscectomy or ACL reconstruction to athletes with combined ACL reconstruction and meniscectomy, a history of both surgeries, resulted in a shorter career in games started (7.9 vs 35.1; P <.01), games played (41 vs 63; P = .07), and years (4.0 vs 5.8; P = .08) than a history of either surgery alone. A history of meniscectomy, but not ACL reconstruction, shortens the expected career of a professional football player. A combination of ACL reconstruction and meniscectomy may be more detrimental to an athlete's durability than either surgery alone. Further research is warranted to better understand how these injuries and surgeries affect an athlete's career and what can be done to improve the long-term outcome after treatment.

The Effect of Gender on Resident Autonomy in the Operating room.

PubMed

Meyerson, Shari L; Sternbach, Joel M; Zwischenberger, Joseph B; Bender, Edward M

Discrimination against women training in medicine and surgery has been subjectively described for decades. This study objectively documents gender differences in the degree of autonomy given to thoracic surgery trainees in the operating room. Thoracic surgery residents and faculty underwent frame of reference training on the use of the 4-point Zwisch scale to measure operative autonomy. Residents and faculty then submitted evaluations of their perception of autonomy granted for individual operations as well as operative difficulty on a real-time basis using the "Zwisch Me!!" mobile application. Differences in autonomy given to male and female residents were elucidated using chi-square analysis and ordered logistic regression. Seven academic medical centers with thoracic surgery training programs. Volunteer thoracic surgery residents in both integrated and traditional training pathways and their affiliated cardiothoracic faculty. Residents (n = 33, female 18%) submitted a total of 596 evaluations to faculty (n = 48, female 12%). Faculty gave less autonomy to female residents with only 56 of 184 evaluations (30.3%) showing meaningful autonomy (passive help or supervision only) compared to 107 of 292 evaluations (36.7%) at those levels for male residents (p = 0.02). Resident perceptions of autonomy showed even more pronounced differences with female residents receiving only 38 of 197 evaluations (19.3%) with meaningful autonomy compared to 133 of 399 evaluations (33.3%) for male residents (p < 0.001). Potential influencing factors explored included attending gender and specialty, case type and difficulty, and resident level of training. In multivariate analysis, only case difficultly, resident gender, and level of training were significantly related to autonomy granted to residents. Evaluations of operative autonomy reveal a significant bias against female residents. Faculty education is needed to encourage allowing female residents more operative autonomy. Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Severe Graves' ophthalmopathy may be a risk factor for the development of postthyroidectomy hypocalcaemia.

PubMed

Hassan, I; Danila, R; Maurer, E; Osei-Agymang, T; Zielke, A

2008-11-01

The aim of this study was to compare the rate of hypocalcaemia after thyroid resection in patients with versus patients without Graves' Ophthalmopathy (GO). 153 patients following thyroid surgery for Grave's disease were studied. Patients were divided into three groups according to the severity of GO at the time of surgery using the NOSPECS classification. Subgroup I comprised of 70 patients without GO, subgroup II comprised of 63 patients with moderate GO and 20 patients with severe GO were assigned to Subgroup III. Association between severe ophthalmopathy and postoperative hypocalcaemia after thyroidectomy was investigated. 12/70 patients complained transient and 3/70 permanent hypocalcemia within subgroup I. 14/63 patients developed transient and 4/63 patients permanent hypocalcaemia within subgroup II. There were 7/20 patients with transient and 5/20 cases with permanent hypocalcaemia in the patient group with severe GO (subgroup III). The incidence of permanent postthyroidectomy hypocalcaemia was significantly higher in the subgroup III with severe GO when compared to the subgroup I without GO (p=0.004). Although postthyroidectomy hypocalcemia seems to be a multifactorial phenomenon, this study implicates unknown role of severe GO at time of surgery in the development of hypocalcaemia after thyroid surgery for Graves' disease. Therefore, patients with GO should be considered for surgery at high volume centres specialised in thyroid and parathyroid surgery.

The risk of internal hernia or volvulus after laparoscopic colorectal surgery: a systematic review.

PubMed

Toh, J W T; Lim, R; Keshava, A; Rickard, M J F X

2016-12-01

To determine the incidence of internal hernias after laparoscopic colorectal surgery and evaluate the risk factors and strategies in the management of this serious complication. Two databases (MEDLINE from 1946 and Embase from 1949) were searched to mid-September 2015. The search terms included volvulus or internal hernia and laparoscopic colorectal surgery or colorectal surgery or anterior resection or laparoscopic colectomy. We found 49 and 124 articles on MEDLINE and Embase, respectively, an additional 15 articles were found on reviewing the references. After removal of duplicates, 176 abstracts were reviewed, with 33 full texts reviewed and 15 eligible for qualitative synthesis. The incidence of internal hernia after laparoscopic colorectal surgery is low (0.65%). Thirty-one patients were identified. Five cases were from two prospective studies (5/648, 0.8%), 20 cases were from seven retrospective studies (20/3165, 0.6%) and six patients were from case reports. Of the 31 identified cases, 21 were associated with left-sided resection, four with right sided resection, two with transverse colectomy, one with a subtotal colectomy and in three cases the operation was not specified. The majority of cases (64.3%) were associated with a restorative left sided resection. Nearly all cases occurred within 4 months of surgery. All patients required re-operation and reduction of the internal hernia and 35.7% of cases required a bowel resection. In 52.2% of cases, the mesenteric defect was closed at the second operation and 52.6% of cases were successfully managed laparoscopically. There were three deaths (0.08%). Mesenteric hernias are a rare but important complication of laparoscopic colorectal surgery. The evidence does not support routine closure for all cases, but selective closure of the mesenteric defect during left-sided restorative procedures in high-risk patients at the initial surgery may be considered. Colorectal Disease © 2016 The Association of Coloproctology of Great Britain and Ireland.

[Where do we stand with benign prostatic hyperplasia day-case surgery: A laser effect?

PubMed

Gury, L; Robert, G; Bensadoun, H

2018-06-12

Despite its feasibility has been proven, Benign Prostatic Hyperplasia (BPH) day-case surgery remains uncommon. Our objective was to describe the evolution of BPH day-case surgery in France according to the surgical technique employed. We extracted data from the Information System of Medicalization Program (PMSI) including all of the hospital stays in France from 2010 to 2016. Patients belonging to the transurethral prostatectomy homogeneous group of patients (GHM 12C04) and having as a main diagnosis prostatic hyperplasia (N40) or benign prostatic tumor (D291) were included in the analysis. From March 2016, specific codes were introduced to differentiate laser surgery and other types of surgery: JGFE023 (resection without laser), JGFE365 (laser resection) and JGNE171 (laser vaporization). We described the rates of day case surgery and the average length of stay from 2010 to 2016. From March 2016 we could study the influence of laser surgery on day-case and length of stay. Regarding the all dataset analysis we found 328,781 hospital stays (318,549 patients) for BPH surgery, of which 2.7% (9047 hospital stays) were day-case. From 2010 to 2016, the lengths of stay decreased from 5.78 to 4.29 days. In the meantime, the number of day-case procedures increased from 14 patients (0.03%) to 3035 patients (5.63%). Regarding the last 9 months of 2016, we found 38,930 hospital stays including 5.4% (2104) day-cases. In total, 92.7% of day-case procedures had been performed with a laser technique, of which 47.9% (1008) were laser vaporization and 44.8% (944) were laser resection. There were only 7.1% (151.8%) of day-case procedures performed without laser. The exponential development of the day-case procedures seems to be linked with the advent of laser technology. This tendency is expected to increase in the coming years according to the spreading of laser surgery. 3. Crown Copyright © 2018. Published by Elsevier Masson SAS. All rights reserved.

Comparison of temporomandibular joint and ramus morphology between class II and class III cases before and after bi-maxillary osteotomy.

PubMed

Iguchi, Ran; Yoshizawa, Kunio; Moroi, Akinori; Tsutsui, Takamitsu; Hotta, Asami; Hiraide, Ryota; Takayama, Akihiro; Tsunoda, Tatsuya; Saito, Yuki; Sato, Momoko; Baba, Nana; Ueki, Koichiro

2017-12-01

The purpose of this study was to compare changes in temporomandibular joint (TMJ) and ramus morphology between class II and III cases before and after sagittal split ramus osteotomy (SSRO) and Le Fort I osteotomy. The subjects were 39 patients (78 sides) who underwent bi-maxillary surgery. They consisted of 2 groups (18 class II cases and 21 class III cases), and were selected randomly from among patients who underwent surgery between 2012 and 2016. The TMJ disc tissue and joint effusion were assessed by magnetic resonance imaging (MRI) and the TMJ space, condylar height, ramus height, ramus inclination and condylar square were assessed by computed tomography (CT), pre- and post-operatively. The number of joints with anterior disc displacement in class II was significantly higher than that in class III (p < 0.0001). However, there were no significant differences between the two classes regarding ratio of joint symptoms and ratio of joint effusion pre- and post-operatively. Class II was significantly better than class III regarding reduction ratio of condylar height (p < 0.0001) and square (p = 0.0005). The study findings suggest that condylar morphology could change in both class II and III after bi-maxillary surgery. The findings of the numerical analysis also demonstrated that reduction of condylar volume occurred frequently in class II, although TMJ disc position classification did not change significantly, as previously reported. Copyright © 2017 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

Impact of integrated programs on general surgery operative volume.

PubMed

Jensen, Amanda R; Nickel, Brianne L; Dolejs, Scott C; Canal, David F; Torbeck, Laura; Choi, Jennifer N

2017-03-01

Integrated residencies are now commonplace, co-existing with categorical general surgery residencies. The purpose of this study was to define the impact of integrated programs on categorical general surgery operative volume. Case logs from categorical general, integrated plastics, vascular, and thoracic surgery residents from a single institution from 2008 to 2016 were collected and analyzed. Integrated residents have increased the number of cases they perform that would have previously been general surgery resident cases from 11 in 2009-2010 to 1392 in 2015-2016. Despite this, there was no detrimental effect on total major cases of graduating chief residents. Multiple integrated programs can co-exist with a general surgery program through careful collaboration and thoughtful consideration to longitudinal needs of individual trainees. As additional programs continue to be created, both integrated and categorical program directors must continue to collaborate to insure the integrity of training for all residents. Copyright © 2017 Elsevier Inc. All rights reserved.

Are Victorian elective surgery cases still converting from overnight to same day cases?

PubMed

Hanning, Brian W T

2005-05-01

The conversion rate on a diagnosis related group (DRG)-standardised basis of Victorian private overnight (ON) elective surgery cases to same day (SD) cases declined from 4.7% per annum over 1996-97 to 1998-99 to 2.5% per annum over 1998-99 to 2002-03. Similar analysis within the Victorian public sector shows a decline from 3.8% per annum over 1996-97 to 1998-99 to 1.9% over 1998-99 to 2002-03. Comparison on a DRG-standardised basis shows while the public sector continued to show a higher incidence of elective surgery SD cases than the private sector in 2002-03 (by 1.6%). The difference has declined since 1998-99 when it was 2.4%. DRG-based analysis suggests the conversion rate in both sectors and the difference in SD surgery cases between the two sectors will continue to decline. Future savings in recurrent and capital cost due to ON surgery cases becoming SD cases are likely to be much lower than savings in recent years.

National Emphysema Treatment Trial redux: accentuating the positive.

PubMed

Sanchez, Pablo Gerardo; Kucharczuk, John Charles; Su, Stacey; Kaiser, Larry Robert; Cooper, Joel David

2010-09-01

Under the Freedom of Information Act, we obtained the follow-up data of the National Emphysema Treatment Trial (NETT) to determine the long-term outcome for "a heterogeneous distribution of emphysema with upper lobe predominance," postulated by the NETT hypothesis to be optimal candidates for lung volume reduction surgery. Using the NETT database, we identified patients with heterogeneous distribution of emphysema with upper lobe predominance and analyzed for the first time follow-up data for those receiving lung volume reduction surgery and those receiving medical management. Furthermore, we compared the results of the NETT reduction surgery group with a previously reported consecutive case series of 250 patients undergoing bilateral lung volume reduction surgery using similar selection criteria. Of the 1218 patients enrolled, 511 (42%) conformed to the NETT hypothesis selection criteria and received the randomly assigned surgical or medical treatment (surgical = 261; medical = 250). Lung volume reduction surgery resulted in a 5-year survival benefit (70% vs 60%; P = .02). Results at 3 years compared with baseline data favored surgical reduction in terms of residual volume reduction (25% vs 2%; P < .001), University of California San Diego dyspnea score (16 vs 0 points; P < .001), and improved St George Respiratory Questionnaire quality of life score (12 points vs 0 points; P < .001). For the 513 patients with a homogeneous pattern of emphysema randomized to surgical or medical treatment, lung volume reduction surgery produced no survival advantage and very limited functional benefit. Patients most likely to benefit from lung volume reduction surgery have heterogeneously distributed emphysema involving the upper lung zones predominantly. Such patients in the NETT trial had results nearly identical to those previously reported in a nonrandomized series of similar patients undergoing lung volume reduction surgery. 2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

[The clinical analysis of instrumentation failure after corrective surgery for thoracolumbar focal kyphosis].

PubMed

Zeng, Y; Chen, Z Q; Qi, Q; Guo, Z Q; Li, W W; Sun, C G; Zhong, W Q; Jiang, Y

2016-07-01

To analyze the etiology of instrumentation failure after corrective surgery for thoracolumbar focal kyphosis, and make suggestion for treatment. Retrospective study for 8 patients with thoracolumbar focal kyphosis who underwent surgical treatment and suffered instrumentation failure from June 2005 to December 2011 was made. The surgical procedures included pedicle subtraction osteotomy (PSO), anterior opening-posterior closing osteotomy and correction (AOPC), and posterior vertebral column resection (VCR). The reasons of instrumentation failure were analyzed and revision surgeries were performed. The incidence of instrumentation failure was 6.3%. The average occurrence time was 22.5 months after surgery. Except one had failure in 3 months after surgery, all cases happened after 1 year. In this series, there were 5 cases with post-tuberculosis, 2 cases with post-traumatic kyphosis and 1 case with congenital kyphosis. For the surgical procedure, 7 cases underwent VCR and 1 case AOPC. After the instrumentation failure, all cases had back pain, and 3 of them had combined neurological symptoms. The reasons or risk factors of instrumentation failure included non-fusion of bone graft, VCR procedure, sink of the titanium mesh, insufficiency of anchor sites, and more severe kyphosis. All the 8 cases were treated with revision surgery and got good results. The instrumentation failure of thoracolumbar focal kyphosis is relatively late occurred, and can develop with various reasons. Positive revision surgery is suggested for the instrumentation failure, and good results can be expected.

5-year results comparing mineral trioxide aggregate and adhesive resin composite for root-end sealing in apical surgery.

PubMed

von Arx, Thomas; Hänni, Stefan; Jensen, Simon Storgård

2014-08-01

Recent meta-analyses of the outcome of apical surgery using modern techniques including microsurgical principles and high-power magnification have yielded higher rates of healing. However, the information is mainly based on 1- to 2-year follow-up data. The present prospective study was designed to re-examine a large sample of teeth treated with apical surgery after 5 years. Patients were recalled 5 years after apical surgery, and treated teeth were classified as healed or not healed based on clinical and radiographic examination. (The latter was performed independently by 3 observers). Two different methods of root-end preparation and filling (primary study parameters) were to be compared (mineral trioxide aggregate [MTA] vs adhesive resin composite [COMP]) without randomization. A total of 271 patients and teeth from a 1-year follow-up sample of 339 could be re-examined after 5 years (dropout rate = 20.1%). The overall rate of healed cases was 84.5% with a significant difference (P = .0003) when comparing MTA (92.5%) and COMP (76.6%). The evaluation of secondary study parameters yielded no significant difference for healing outcome when comparing subcategories (ie, sex, age, type of tooth treated, post/screw, type of surgery). The results from this prospective nonrandomized clinical study with a 5-year follow-up of 271 teeth indicate that MTA exhibited a higher healing rate than COMP in the longitudinal prognosis of root-end sealing. Copyright © 2014 American Association of Endodontists. Published by Elsevier Inc. All rights reserved.

An Empirical Comparison of Discrete Choice Experiment and Best-Worst Scaling to Estimate Stakeholders' Risk Tolerance for Hip Replacement Surgery.

PubMed

van Dijk, Joris D; Groothuis-Oudshoorn, Catharina G M; Marshall, Deborah A; IJzerman, Maarten J

2016-06-01

Previous studies have been inconclusive regarding the validity and reliability of preference elicitation methods. The aim of this study was to compare the metrics obtained from a discrete choice experiment (DCE) and profile-case best-worst scaling (BWS) with respect to hip replacement. We surveyed the general US population of men aged 45 to 65 years, and potentially eligible for hip replacement surgery. The survey included sociodemographic questions, eight DCE questions, and twelve BWS questions. Attributes were the probability of a first and second revision, pain relief, ability to participate in sports and perform daily activities, and length of hospital stay. Conditional logit analysis was used to estimate attribute weights, level preferences, and the maximum acceptable risk (MAR) for undergoing revision surgery in six hypothetical treatment scenarios with different attribute levels. A total of 429 (96%) respondents were included. Comparable attribute weights and level preferences were found for both BWS and DCE. Preferences were greatest for hip replacement surgery with high pain relief and the ability to participate in sports and perform daily activities. Although the estimated MARs for revision surgery followed the same trend, the MARs were systematically higher in five of the six scenarios using DCE. This study confirms previous findings that BWS or DCEs are comparable in estimating attribute weights and level preferences. However, the risk tolerance threshold based on the estimation of MAR differs between these methods, possibly leading to inconsistency in comparing treatment scenarios. Copyright © 2016 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.

Is radical oncosurgery justified for the treatment of primary malignant fibrous histiocytoma of the urinary bladder? Report of two cases and analyses of disease-specific survival rates based on a review of the literature.

PubMed

Gunia, Sven; May, Matthias; Koch, Stefan; Erbersdobler, Andreas

2011-01-01

Disease-specific survival (DSS) rates were evaluated in 20 patients with primary malignant fibrous histiocytoma (MFH) of the bladder. The most common pathologic finding was the pleomorphic subtype of MFH (55%) with a mean tumor size of 6.8 cm. 10 patients underwent surgery without and 6 patients with adjuvant therapy. Local and systemic rates of progression were 30 and 60% after surgery only compared with 16.7 and 50% after surgery with adjuvant therapy. Although none of the patients showed metastatic dissemination at the time of diagnosis, overall 1- and 2-year DSS rates of only 47.8 and 31.9% were observed. Hence, after the onset of clinical symptoms, the disease runs a very aggressive course regardless of the therapeutic options employed. Although distant dissemination seems to be rare at the time of diagnosis, the prognostic outcome is dismal. The rarity and inconsistency of the currently available case reports on MFH of the bladder hampers the development of therapeutic guidelines. Advanced studies enrolling a larger number of patients with appropriate clinical and pathological data are needed to compare the beneficial effects of various treatment options. Copyright © 2011 S. Karger AG, Basel.

Identification alone versus intraoperative neuromonitoring of the recurrent laryngeal nerve during thyroid surgery: experience of 2034 consecutive patients.

PubMed

Calò, Pietro Giorgio; Pisano, Giuseppe; Medas, Fabio; Pittau, Maria Rita; Gordini, Luca; Demontis, Roberto; Nicolosi, Angelo

2014-06-18

The aim of this study was to evaluate the ability of intraoperative neuromonitoring in reducing the postoperative recurrent laryngeal nerve palsy rate by a comparison between patients submitted to thyroidectomy with intraoperative neuromonitoring and with routine identification alone. Between June 2007 and December 2012, 2034 consecutive patients underwent thyroidectomy by a single surgical team. We compared patients who have had neuromonitoring and patients who have undergone surgery with nerve visualization alone. Patients in which neuromonitoring was not utilized (Group A) were 993, patients in which was utilized (group B) were 1041. In group A 28 recurrent laryngeal nerve injuries were observed (2.82%), 21 (2.11%) transient and 7 (0.7%) permanent. In group B 23 recurrent laryngeal nerve injuries were observed (2.21%), in 17 cases (1.63%) transient and in 6 (0.58%) permanent. Differences were not statistically significative. Visual nerve identification remains the gold standard of recurrent laryngeal nerve management in thyroid surgery. Neuromonitoring helps to identify the nerve, in particular in difficult cases, but it did not decrease nerve injuries compared with visualization alone. Future studies are warranted to evaluate the benefit of intraoperative neuromonitoring in thyroidectomy, especially in conditions in which the recurrent nerve is at high risk of injury.

Identification alone versus intraoperative neuromonitoring of the recurrent laryngeal nerve during thyroid surgery: experience of 2034 consecutive patients

PubMed Central

2014-01-01

Background The aim of this study was to evaluate the ability of intraoperative neuromonitoring in reducing the postoperative recurrent laryngeal nerve palsy rate by a comparison between patients submitted to thyroidectomy with intraoperative neuromonitoring and with routine identification alone. Methods Between June 2007 and December 2012, 2034 consecutive patients underwent thyroidectomy by a single surgical team. We compared patients who have had neuromonitoring and patients who have undergone surgery with nerve visualization alone. Patients in which neuromonitoring was not utilized (Group A) were 993, patients in which was utilized (group B) were 1041. Results In group A 28 recurrent laryngeal nerve injuries were observed (2.82%), 21 (2.11%) transient and 7 (0.7%) permanent. In group B 23 recurrent laryngeal nerve injuries were observed (2.21%), in 17 cases (1.63%) transient and in 6 (0.58%) permanent. Differences were not statistically significative. Conclusions Visual nerve identification remains the gold standard of recurrent laryngeal nerve management in thyroid surgery. Neuromonitoring helps to identify the nerve, in particular in difficult cases, but it did not decrease nerve injuries compared with visualization alone. Future studies are warranted to evaluate the benefit of intraoperative neuromonitoring in thyroidectomy, especially in conditions in which the recurrent nerve is at high risk of injury. PMID:24942225

[Stapler versus manual anastomosis in gastrointestinal surgery].

PubMed

Moreno-Gonzalez, E; Vara-Thorbeck, R

1987-01-01

The comparative effectiveness of manual and auto-sutured anastomoses after total gastrectomy (107 cases), low anterior rectal resection (100 cases) and right hemicolectomy (34 cases) is studied. In the stapled series the incidence of anastomotic leakage was somewhat less, although benign stenosis occurred more frequently than with hand-sutured anastomoses. However, this could not be statistically demonstrated. In the authors' view, the main advantages of the use of staplers are the shortening of operating time and the lessening of septic steps.

Cost-Benefit Performance of Robotic Surgery Compared with Video-Assisted Thoracoscopic Surgery under the Japanese National Health Insurance System.

PubMed

Kajiwara, Naohiro; Patrick Barron, James; Kato, Yasufumi; Kakihana, Masatoshi; Ohira, Tatsuo; Kawate, Norihiko; Ikeda, Norihiko

2015-01-01

Medical economics have significant impact on the entire country. The explosion in surgical techniques has been accompanied by questions regarding actual improvements in outcome and cost-effectiveness, such as the da Vinci(®) Surgical System (dVS) compared with conventional video-assisted thoracic surgery (VATS). To establish a medical fee system for robot-assisted thoracic surgery (RATS), which is a system not yet firmly established in Japan. This study examines the cost benefit performance (CBP) based on medical fees compared with VATS and RATS under the Japanese National Health Insurance System (JNHIS) introduced in 2012. The projected (but as yet undecided) price in the JNHIS would be insufficient if institutions have less than even 200 dVS cases per year. Only institutions which perform more than 300 dVS operations per year would obtain a positive CBP with the projected JNHIS reimbursement. Thus, under the present conditions, it is necessary to perform at least 300 dVS operations per year in each institution with a dVS system to avoid financial deficit with current robotic surgical management. This may hopefully encourage a downward price revision of the dVS equipment by the manufacture which would result in a decrease in the cost per procedure.

Surgical outcomes in native valve infectious endocarditis: the experience of the Cardiovascular Surgery Department - Cluj-Napoca Heart Institute.

PubMed

Molnar, Adrian; Muresan, Ioan; Trifan, Catalin; Pop, Dana; Sacui, Diana

2015-01-01

The introduction of Duke's criteria and the improvement of imaging methods has lead to an earlier and a more accurate diagnosis of infectious endocarditis (IE). The options for the best therapeutic approach and the timing of surgery are still a matter of debate and require a close colaboration between the cardiologist, the infectionist and the cardiac surgeon. We undertook a retrospective, descriptive study, spanning over a period of five years (from January 1st, 2007 to December 31st, 2012), on 100 patients who underwent surgery for native valve infectious endocarditis in our unit. The patients' age varied between 13 and 77 years (with a mean of 54 years), of which 85 were males (85%). The main microorganisms responsible for IE were: Streptococcus Spp. (21 cases - 21%), Staphylococcus Spp. (15 cases - 15%), and Enterococcus Spp. (9 cases - 9%). The potential source of infection was identified in 26 patients (26%), with most cases being in the dental area (16 cases - 16%). The lesions caused by IE were situated in the left heart in 96 patients (96%), mostly on the aortic valve (50 cases - 50%). In most cases (82%) we found preexisting endocardial lesions which predisposed to the development of IE, most of them being degenerative valvular lesions (38 cases - 38%). We performed the following surgical procedures: surgery on a single valve - aortic valve replacement (40 cases), mitral valve replacement (19 cases), mitral valve repair (1 case), surgery on more than one valve - mitral and aortic valve replacement (20 cases), aortic and tricuspid valve replacement (1 case), aortic valve replacement with a mechanical valve associated with mitral valve repair (5 cases), aortic valve replacement with a biological valve associated with mitral valve repair (2 cases), and mitral valve replacement with a mechanical valve combined with De Vega procedure on the tricuspid valve (1 case). In 5 patients (5%) the bacteriological examination of valve pieces excised during surgery was positive. In 3 cases it matched the germ identified in the hemocultures, and in 2 cases it evidenced another bacterium. The overall mortality of 5% is well between the limits presented in literature, being higher (30%) in patients who required emergency surgery. For the patients who return into our clinic with prosthetic valve endocarditis, the mortality after surgery was even higher (50%).

The Australian litigation landscape - oral and maxillofacial surgery and general dentistry (oral surgery procedures): an analysis of litigation cases.

PubMed

Badenoch-Jones, E K; White, B P; Lynham, A J

2016-09-01

There are persistent concerns about litigation in the dental and medical professions. These concerns arise in a setting where general dentists are more frequently undertaking a wider range of oral surgery procedures, potentially increasing legal risk. Judicial cases dealing with medical negligence in the fields of general dentistry (oral surgery procedure) and oral and maxillofacial surgery were located using the three main legal databases. Relevant cases were analysed to determine the procedures involved, the patients' claims of injury, findings of negligence and damages awarded. A thematic analysis of the cases was undertaken to determine trends. Fifteen cases over a 20-year period were located across almost all Australian jurisdictions (eight cases involved general dentists; seven cases involved oral and maxillofacial surgeons). Eleven of the 15 cases involved determinations of whether or not the practitioner had failed in their duty of care; negligence was found in six cases. Eleven of the 15 cases related to molar extractions (eight specifically to third molar). Dental and medical practitioners wanting to manage legal risk should have regard to circumstances arising in judicial cases. Adequate warning of risks is critical, as is offering referral in appropriate cases. Preoperative radiographs, good medical records and processes to ensure appropriate follow-up are also important. © 2015 Australian Dental Association.

Comparing multiple competing interventions in the absence of randomized trials using clinical risk-benefit analysis

PubMed Central

2012-01-01

Background To demonstrate the use of risk-benefit analysis for comparing multiple competing interventions in the absence of randomized trials, we applied this approach to the evaluation of five anticoagulants to prevent thrombosis in patients undergoing orthopedic surgery. Methods Using a cost-effectiveness approach from a clinical perspective (i.e. risk benefit analysis) we compared thromboprophylaxis with warfarin, low molecular weight heparin, unfractionated heparin, fondaparinux or ximelagatran in patients undergoing major orthopedic surgery, with sub-analyses according to surgery type. Proportions and variances of events defining risk (major bleeding) and benefit (thrombosis averted) were obtained through a meta-analysis and used to define beta distributions. Monte Carlo simulations were conducted and used to calculate incremental risks, benefits, and risk-benefit ratios. Finally, net clinical benefit was calculated for all replications across a range of risk-benefit acceptability thresholds, with a reference range obtained by estimating the case fatality rate - ratio of thrombosis to bleeding. Results The analysis showed that compared to placebo ximelagatran was superior to other options but final results were influenced by type of surgery, since ximelagatran was superior in total knee replacement but not in total hip replacement. Conclusions Using simulation and economic techniques we demonstrate a method that allows comparing multiple competing interventions in the absence of randomized trials with multiple arms by determining the option with the best risk-benefit profile. It can be helpful in clinical decision making since it incorporates risk, benefit, and personal risk acceptance. PMID:22233221

The clinical study of the optimalization of surgical treatment and the traditional Chinese medicine intervention on palmar hyperhidrosis.

PubMed

Yang, Yong; Yan, Zhikun; Fu, Xiaoqing; Dong, Liwen; Xu, Linhai; Wang, Jun; Cheng, Genmiao

2014-11-01

To analyze the efficacy of different surgical methods in treating palmar hyperhidrosis and the compensatory hyperhidrosis after surgery and to observe the efficacy of "Energy-boosting and Yin-nourishing anti-perspirant formula" on postsurgical hyperhidrosis patients. Two-hundred patients were randomly assigned to groups A (Chinese and Western medicine, T4 transection plus "Energy-boosting and Yin-nourishing anti-perspirant formula") and B (Western medicine, T4 transection). The surgical efficiency, recurrence rate, compensatory hyperhidrosis, and the long-term life quality were compared. Another 100 cases (group C, T2 transection) were analyzed as a control group. After surgery, the palmar hyperhidrosis and armpit sweating were relieved in all the three group patients and in 34 % of patients combined with plantar hyperhidrosis, the symptoms were relieved. Transient palmar hyperhidrosis was found in three cases at day 2 to day 5 postoperatively. One case of Horner's syndrome and one case recurrence were found in group C patients. The compensatory sweating of various degrees occurred in all the three groups. There were 25, 24, and 43 cases in groups A, B, and C, respectively. There is a significant difference between groups C, A, and B. The compensatory sweating in 13 cases of group A and four cases of group B had different degrees of improvement in the follow-up 6 months after surgery. There is a significant difference. Thoracoscopic bilateral T4 sympathetic chain and the Kuntz resection are the optimized surgical treatments for the palmar hyperhidrosis. "Energy-boosting and Yin-nourishing anti-perspirant formula" is effective in treating the postoperative compensatory sweating.

Treatment of hematomas after anterior cervical spine surgery: A retrospective study of 15 cases.

PubMed

Miao, Weiliang; Ma, Xiaojun; Liang, Deyong; Sun, Yu

2018-05-04

Postoperative hematoma is a rare and dangerous complication of cervical spine surgery. The aim of this study was to investigate the incidence and related factors of postoperative hematoma, and to report on 15 cases at our institution over a 6-year period. Fifteen cases of postoperative hematoma were retrospectively identified. We investigated their neurological outcomes, characteristics, and surgical data, and identified risk factors associated with postoperative (PO) hematoma. Patients with hematoma were compared to those with no hematoma, in order to identify risk factors. Retropharyngeal hematomas developed in seven cases and epidural hematomas in eight. The total incidence of postoperative hematoma was 1.2%: 0.5% retropharyngeal hematomas and 0.6% spinal epidural hematomas. At time of onset, the severity of paralysis was assessed as grade B in one case, grade C in six cases, and grade D in eight cases. Risk factors for PO hematoma were: (1) presence of ossification of the posterior longitudinal ligament (OPLL) (P<0.001); (2) longer operative duration (P=0.048); (3) greater number of surgical levels (P=0.02); and (4) higher body mass index (BMI; P=0.035). There was no significant difference in modified Japan Orthopedic Association scores between the hematoma group and non-hematoma group (P>0.05). Precise preoperative preparation and systematic evaluation are central to successful management of PO hematoma after anterior cervical surgery. Risk factors for PO hematoma include multilevel decompression, OPLL, higher BMI, and longer operation time. Copyright © 2018 Elsevier Masson SAS. All rights reserved.

e-Consultation Improves Efficacy in Thoracic Surgery Outpatient Clinics.

PubMed

Novoa, Nuria M; Gómez, Maria Teresa; Rodríguez, María; Jiménez López, Marcelo F; Aranda, Jose L; Bollo de Miguel, Elena; Diez, Florentino; Hernández Hernández, Jesús; Varela, Gonzalo

2016-11-01

The aim of this study is analysing the impact of the systematic versus occasional videoconferencing discussion of patients with two respiratory referral units along 6 years of time over the efficiency of the in-person outpatient clinics of a thoracic surgery service. Retrospective and comparative study of the evaluated patients through videoconferencing and in-person first visits during two equivalents periods of time: Group A (occasional discussion of cases) between 2008-2010 and Group B (weekly regular discussion) 2011-2013. Data were obtained from two prospective and electronic data bases. The number of cases discussed using e-consultation, in-person outpatient clinics evaluation and finally operated on under general anaesthesia in each period of time are presented. For efficiency criteria, the index: number of operated on cases/number of first visit outpatient clinic patients is created. Non-parametric Wilcoxon test is used for comparison. The mean number of patients evaluated at the outpatient clinics/year on group A was 563 versus 464 on group B. The median number of cases discussed using videoconferencing/year was 42 for group A versus 136 for group B. The mean number of operated cases/first visit at the outpatient clinics was 0.7 versus 0.87 in group B (P=.04). The systematic regular discussion of cases using videoconferencing has a positive impact on the efficacy of the outpatient clinics of a Thoracic Surgery Service measured in terms of operated cases/first outpatient clinics visit. Copyright © 2016 SEPAR. Publicado por Elsevier España, S.L.U. All rights reserved.

Primary Congenital Glaucoma Versus Glaucoma Following Congenital Cataract Surgery: Comparative Clinical Features and Long-term Outcomes.

PubMed

Neustein, Rebecca F; Bruce, Beau B; Beck, Allen D

2016-10-01

To report and compare visual and glaucoma outcomes in primary congenital glaucoma (PCG) vs glaucoma following congenital cataract surgery (GFCS). Retrospective, observational, comparative case series. Setting: Emory Eye Center, Atlanta, Georgia. Pediatric glaucoma patients (age 0-18 years) treated at Emory by 1 clinician with ≥2-year follow-up. Glaucoma was defined according to the 9th Consensus Report of the World Glaucoma Association. Snellen-equivalent logMAR visual acuity (VA) and glaucoma control (IOP ≤21, no devastating complications, no recommendation for further glaucoma surgery). Asymptotic Wilcoxon-Mann-Whitney rank sum tests were employed to compare glaucoma subgroups. Included were 72 PCG and 56 GFCS cases, with mean follow-up time of 7.4 ± 4.1 and 8.0 ± 3.8 years, respectively. At last follow-up, PCG showed better median VA than GFCS in worse-seeing eyes (20/60 [interquartile range (IQR) 20/30-20/200] vs 20/400 [IQR 20/70-hand motion], respectively, P < .0001) and in better-seeing eyes of bilaterally-affected children (20/30 [IQR 20/20-20/60] vs 20/70 [IQR 20/35-20/100], respectively, P = .024).The following variables characterized the PCG and GFCS groups' glaucoma status, respectively: mean age at diagnosis (years), 0.70 ± 1.3 vs 3.3 ± 3.5 (P < .0001); median IOP (mm Hg), 15.50 [IQR 12.1-19.4] vs 17.50 [IQR 14.9-22], P = .037; median number of glaucoma medications at last follow-up, 1.49 [IQR 0-2] vs 2.54 [IQR 1-4], P < .0001; median number of glaucoma surgeries, 1.0 [IQR 1-2] vs 1.25 [IQR 0.5-2.0], P = .09. Children with PCG (vs those with GFCS) presented earlier, had better vision, required fewer medications to control disease, and had lower IOP at last follow-up. Copyright © 2016 Elsevier Inc. All rights reserved.

[Incidence and risk factors of venous thromboembolism in major spinal surgery with no chemical or mechanical prophylaxis].

PubMed

Rojas-Tomba, F; Gormaz-Talavera, I; Menéndez-Quintanilla, I E; Moriel-Durán, J; García de Quevedo-Puerta, D; Villanueva-Pareja, F

2016-01-01

To evaluate the incidence of venous thromboembolism in spine surgery with no chemical and mechanical prophylaxis, and to determine the specific risk factors for this complication. A historical cohort was analysed. All patients subjected to major spinal surgery, between January 2010 and September 2014, were included. No chemical or mechanical prophylaxis was administered in any patient. Active mobilisation of lower limbs was indicated immediately after surgery, and early ambulation started in the first 24-48 hours after surgery. Clinically symptomatic cases were confirmed by Doppler ultrasound of the lower limbs or chest CT angiography. A sample of 1092 cases was studied. Thromboembolic events were observed in 6 cases (.54%); 3 cases (.27%) with deep venous thrombosis and 3 cases (.27%) with pulmonary thromboembolism. A lethal case was identified (.09%). There were no cases of major bleeding or epidural haematoma. The following risk factors were identified: a multilevel fusion at more than 4 levels, surgeries longer than 130 minutes, patients older than 70 years of age, hypertension, and degenerative scoliosis. There is little scientific evidence on the prevention of thromboembolic events in spinal surgery. In addition to the disparity of prophylactic methods indicated by different specialists, it is important to weigh the risk-benefit of intra- and post-operative bleeding, and even the appearance of an epidural haematoma. Prophylaxis should be assessed in elderly patients over 70 years old, who are subjected to surgeries longer than 130 minutes, when 4 or more levels are involved. Copyright © 2015 SECOT. Published by Elsevier Espana. All rights reserved.

Minimally invasive surgery for gastric cancer in Brazil: current status and perspectives—a report from the Brazilian Laparoscopic Oncologic Gastrectomy Group (BLOGG)

PubMed Central

da Costa, Wilson Luiz; Jacob, Carlos Eduardo; Cordts, Roberto de Moraes; Castro, Osvaldo Antônio Prado; Barchi, Leandro Cardoso; Cecconello, Ivan; Charruf, Amir Zeide; Coimbra, Felipe José Fernández; Cury, Antônio Moris; Diniz, Alessandro Landskron; de Farias, Igor Correia; de Freitas, Wilson Rodrigues; de Godoy, André Luis; Ilias, Elias Jirjoss; Malheiros, Carlos Alberto; Ramos, Marcus Fernando Kodama Pertille; Ribeiro, Heber Salvador de Castro; Roncon Dias, André; Thuler, Fábio Rodrigues; Yagi, Osmar Kenji; Lourenço, Laércio Gomes; Zilberstein, Bruno

2017-01-01

The minimally invasive surgery for gastric cancer in Brazil has begun about two years after the first laparoscopic gastrectomy (LG) performed by Kitano in Japan, in 1991. Although the report of first surgeries shows the year of 1993, there was no dissemination of the technique until the years 2010. At that time with the improvement of optical devices, laparoscopic instruments and with the publications coming from Asia, several Brazilian surgeons felt encouraged to go to Korea and Japan to learn the standardization of the LG. After that there was a significant increase in that type of surgery, especially after the IRCAD opened a branch in Brazil. The growing interest for the subject led some services to begin their own experience with the LG and, since the beginning, the results were similar with those found in the open surgery. Nevertheless, there were some differences with the papers published initially in Japan and Korea. In those countries, the surgeries were laparoscopic assisted, meaning that, in the majority of cases, the anastomoses were done through a mini-incision in the end of the procedure. In Brazil since the beginning it was performed completely through laparoscopic approach due to the skills acquired by Brazilian surgeons in bariatric surgeries. Another difference was the stage. While in the east the majority of cases were done in T1 patients, in Brazil, probably due to the lack of early cases, the surgeries were done also in advanced cases. The initial experience of Zilberstein et al. revealed low rates of morbidity without mortality. Comparing laparoscopic and open surgery, the group from Barretos/IRCAD showed shorter surgical time (216×255 minutes), earlier oral or enteral feeding and earlier hospital discharge, with a smaller number of harvested lymph nodes (28 in laparoscopic against 33 in open surgery). There was no significant difference regarding morbidity, mortality and reoperation rate. In the first efforts to publish a multicentric study the Brazilian Gastric Cancer Association (BGCA) collected data from three institutions analyzing 148 patients operated from 2006 to 2016. There were 98 subtotal, 48 total and 2 proximal gastrectomies. The anastomoses were totally laparoscopic in 105, laparoscopic assisted in 21, cervical in 2, and 20 open (after conversion). The reconstruction methods were: 142 Roux-en-Y, two Billroth I, and three other types. The conversion rate was 13.5% (20/148). The D2 dissection was performed in 139 patients. The mean number of harvested lymph nodes was 34.4. If we take only the D2 cases the mean number was 39.5. The morbidity rate was 22.3%. The mortality was 2.7%. The stages were: IA—59, IB—14, IIA—11, IIB—15, IIIA—9, IIIB—19, IIIC—11 and stage IV—three cases. Four patients died from the disease and 10 are alive with disease. The participating services have already begun the robotic gastrectomy with satisfactory results. The intention of this group is to begin now a prospective multicentric study to confirm the data already obtained with the retrospective studies. PMID:28616601

Minimally invasive surgery for gastric cancer in Brazil: current status and perspectives-a report from the Brazilian Laparoscopic Oncologic Gastrectomy Group (BLOGG).

PubMed

Kassab, Paulo; da Costa, Wilson Luiz; Jacob, Carlos Eduardo; Cordts, Roberto de Moraes; Castro, Osvaldo Antônio Prado; Barchi, Leandro Cardoso; Cecconello, Ivan; Charruf, Amir Zeide; Coimbra, Felipe José Fernández; Cury, Antônio Moris; Diniz, Alessandro Landskron; de Farias, Igor Correia; de Freitas, Wilson Rodrigues; de Godoy, André Luis; Ilias, Elias Jirjoss; Malheiros, Carlos Alberto; Ramos, Marcus Fernando Kodama Pertille; Ribeiro, Heber Salvador de Castro; Roncon Dias, André; Thuler, Fábio Rodrigues; Yagi, Osmar Kenji; Lourenço, Laércio Gomes; Zilberstein, Bruno

2017-01-01

The minimally invasive surgery for gastric cancer in Brazil has begun about two years after the first laparoscopic gastrectomy (LG) performed by Kitano in Japan, in 1991. Although the report of first surgeries shows the year of 1993, there was no dissemination of the technique until the years 2010. At that time with the improvement of optical devices, laparoscopic instruments and with the publications coming from Asia, several Brazilian surgeons felt encouraged to go to Korea and Japan to learn the standardization of the LG. After that there was a significant increase in that type of surgery, especially after the IRCAD opened a branch in Brazil. The growing interest for the subject led some services to begin their own experience with the LG and, since the beginning, the results were similar with those found in the open surgery. Nevertheless, there were some differences with the papers published initially in Japan and Korea. In those countries, the surgeries were laparoscopic assisted, meaning that, in the majority of cases, the anastomoses were done through a mini-incision in the end of the procedure. In Brazil since the beginning it was performed completely through laparoscopic approach due to the skills acquired by Brazilian surgeons in bariatric surgeries. Another difference was the stage. While in the east the majority of cases were done in T1 patients, in Brazil, probably due to the lack of early cases, the surgeries were done also in advanced cases. The initial experience of Zilberstein et al. revealed low rates of morbidity without mortality. Comparing laparoscopic and open surgery, the group from Barretos/IRCAD showed shorter surgical time (216×255 minutes), earlier oral or enteral feeding and earlier hospital discharge, with a smaller number of harvested lymph nodes (28 in laparoscopic against 33 in open surgery). There was no significant difference regarding morbidity, mortality and reoperation rate. In the first efforts to publish a multicentric study the Brazilian Gastric Cancer Association (BGCA) collected data from three institutions analyzing 148 patients operated from 2006 to 2016. There were 98 subtotal, 48 total and 2 proximal gastrectomies. The anastomoses were totally laparoscopic in 105, laparoscopic assisted in 21, cervical in 2, and 20 open (after conversion). The reconstruction methods were: 142 Roux-en-Y, two Billroth I, and three other types. The conversion rate was 13.5% (20/148). The D2 dissection was performed in 139 patients. The mean number of harvested lymph nodes was 34.4. If we take only the D2 cases the mean number was 39.5. The morbidity rate was 22.3%. The mortality was 2.7%. The stages were: IA-59, IB-14, IIA-11, IIB-15, IIIA-9, IIIB-19, IIIC-11 and stage IV-three cases. Four patients died from the disease and 10 are alive with disease. The participating services have already begun the robotic gastrectomy with satisfactory results. The intention of this group is to begin now a prospective multicentric study to confirm the data already obtained with the retrospective studies.

Single port laparoscopic right hemicolectomy for ileocolic intussusception

PubMed Central

Chen, Jia-Hui; Wu, Jhe-Syun

2013-01-01

A 36-year-old male was admitted with right lower abdominal pain and diarrhea for more than 3 mo. Colonoscopy and a barium enema study revealed a submucosal tumor over the cecum, but computed tomography showed an ileal lipoma. There was no definitive diagnosis preoperatively, but ileocolic intussusception was noted during surgery. Single port laparoscopic radical right hemicolectomy was performed because intra-operative reduction failed. The histological diagnosis of the resected tumor was lipoma. Single port laparoscopic surgery has recently been proven to be safe and feasible. There are advantages compared with conventional laparoscopic surgery, such as smaller incision wounds, fewer port site complications, and easier conversion. However, there are some drawbacks which need to be overcome, such as difficulties in triangulation and instrument clashing. If there are no contraindications to laparoscopy, single port laparoscopic surgery can be performed safely and should be considered for diagnosis and treatment of intussusception in adults. Here, we report the first case of ileocolic intussusception successfully treated by single port laparoscopic surgery. PMID:23538552

Ab interno trabeculectomy: patient selection and perspectives

PubMed Central

Vinod, Kateki; Gedde, Steven J

2016-01-01

Ab interno trabeculectomy is one among several recently introduced minimally invasive glaucoma surgeries that avoid a conjunctival incision and full-thickness sclerostomy involved in traditional glaucoma surgery. Ablation of the trabecular meshwork and inner wall of Schlemm’s canal is performed in an arcuate fashion via a clear corneal incision, alone or in combination with phacoemulsification cataract surgery. Intraocular pressure reduction following ab interno trabeculectomy is limited by resistance in distal outflow pathways and generally stabilizes in the mid-to-high teens. Relief of medication burden has been demonstrated by some studies. A very low rate of complications, most commonly transient hyphema and intraocular pressure elevations in the immediate postoperative period, have been reported. However, available data are derived from small retrospective and prospective case series. Randomized, controlled trials are needed to better elucidate the potential merits of ab interno trabeculectomy in the combined setting versus phacoemulsification cataract surgery alone and to compare it with other minimally invasive glaucoma surgeries. PMID:27574396

Epidemiology of Cranial Cruciate Ligament Disease Diagnosis in Dogs Attending Primary-Care Veterinary Practices in England.

PubMed

Taylor-Brown, Frances E; Meeson, Richard L; Brodbelt, Dave C; Church, David B; McGreevy, Paul D; Thomson, Peter C; O'Neill, Dan G

2015-08-01

To estimate the prevalence and risk factors for a diagnosis of cranial cruciate ligament (CCL) disease in dogs and to describe the management of such cases attending primary-care veterinary practices. Historical cohort with a nested case-control study. Nine hundred and fifty-three dogs diagnosed with CCL disease from 171,522 dogs attending 97 primary-care practices in England. Medical records of dogs attending practices participating in the VetCompass project that met selection criteria were assessed. Univariate and multivariate logistic regression methods were used to evaluate association of possible risk factors with diagnosis of CCL disease. The prevalence of CCL disease diagnosis was estimated at 0.56% (95% confidence interval 0.52-0.59). Compared with crossbred dogs, Rottweilers, West Highland White Terriers, Golden Retrievers, Yorkshire Terriers, and Staffordshire Bull Terriers showed increased odds of CCL disease diagnosis while Cocker Spaniels showed reduced odds. Increasing bodyweight within breeds was associated with increased odds of diagnosis. Dogs aged over 3 years had increased odds of diagnosis compared with dogs aged less than 3 years. Neutered females had 2.1 times the odds of diagnosis compared with entire females. Insured dogs had 4 times the odds of diagnosis compared with uninsured dogs. Two-thirds of cases were managed surgically, with insured and heavier dogs more frequently undergoing surgery. Overall, 21% of cases were referred, with referral more frequent in heavier and insured dogs. Referred dogs more frequently had surgery and an osteotomy procedure. Breed predispositions and demographic factors associated with diagnosis and case management of CCL disease in dogs identified in this study can be used to help direct future research and management strategies. © Copyright 2015 by The American College of Veterinary Surgeons.

The Auckland Cataract Study II: Reducing Complications by Preoperative Risk Stratification and Case Allocation in a Teaching Hospital.

PubMed

Kim, Bia Z; Patel, Dipika V; McKelvie, James; Sherwin, Trevor; McGhee, Charles N J

2017-09-01

To assess the effect of preoperative risk stratification for phacoemulsification surgery on intraoperative complications in a teaching hospital. Prospective cohort study. Prospective assessment of consecutive phacoemulsification cases (N = 500) enabled calculation of a risk score (M-score of 0-8) using a risk stratification system. M-scores of >3 were allocated to senior surgeons. All surgeries were performed in a public teaching hospital setting, Auckland, New Zealand, in early 2016. Postoperatively, data were reviewed for complications and corrected distance visual acuity (CDVA). Results were compared to a prospective study (N = 500, phase 1) performed prior to formal introduction of risk stratification. Intraoperative complications increased with increasing M-scores (P = .044). Median M-score for complicated cases was higher (P = .022). Odds ratio (OR) for a complication increased 1.269 per unit increase in M-score (95% confidence interval [CI] 1.007-1.599, P = .043). Overall rate of any intraoperative complication was 5.0%. Intraoperative complication rates decreased from 8.4% to 5.0% (OR = 0.576, P = .043) comparing phase 1 and phase 2 (formal introduction of risk stratification). The severity of complications also reduced. A significant decrease in complications for M = 0 (ie, minimal risk cases) was also identified comparing the current study (3.1%) to phase 1 (7.2%), P = .034. There was no change in postoperative complication risks (OR 0.812, P = .434) or in mean postoperative CDVA (20/30, P = .484) comparing current with phase 1 outcomes. A simple preoperative risk stratification system, based on standard patient information gathered at preoperative consultation, appears to reduce intraoperative complications and support safer surgical training by appropriate allocation of higher-risk cases. Copyright © 2017 Elsevier Inc. All rights reserved.

Preoperative vaginal preparation with baby shampoo compared with povidone-iodine before gynecologic procedures.

PubMed

Lewis, Linda A; Lathi, Ruth B; Crochet, Patrice; Nezhat, Camran

2007-01-01

The objective of this study was to compare the postoperative infection rates between patients receiving either povidone-iodine (PI) or baby shampoo vaginal preparations before gynecologic surgery. Cohort study (Canadian Task Force classification II-2). University referral center for gynecologic endoscopy. All patients underwent minimally invasive gynecologic surgery including hysteroscopy or laparoscopy. The agents used for vaginal preparation were either baby shampoo in a 1:1 dilution with sterile normal saline solution or PI 7.5% scrub solution. Charts were reviewed for evidence of infection within 30 days of surgery (symptoms of urinary tract infection, abdominal or vaginal wound infections, temperature > 100.4 degrees F, and fungal or bacterial vaginitis). A total of 249 cases were collected; 96 subjects underwent surgery before the change to baby shampoo and 153 subjects after. Both groups were well matched for the types of surgery performed, age, risk factors for postoperative infections, and the postoperative diagnosis. The infection rates were 14/96 (14.6%) with PI preparation versus 18/153 (11.8%) with baby shampoo (p = .52). Baby shampoo should be studied as an alternative to PI because it is a nonirritating, inexpensive mild detergent. This preliminary study suggests that baby shampoo is as effective as PI in preventing postoperative infection.

Differences in energy expenditure for conventional and femtosecond-assisted cataract surgery using 2 different phacoemulsification systems.

PubMed

Yesilirmak, Nilufer; Diakonis, Vasilios F; Sise, Adam; Waren, Daniel P; Yoo, Sonia H; Donaldson, Kendall E

2017-01-01

To compare the mean cumulative dissipated energy (CDE) in patients having femtosecond laser-assisted or conventional phacoemulsification cataract surgery using 2 different phacoemulsification platforms. Bascom Palmer Eye Institute, Miami, Florida, USA. Prospective comparative nonrandomized clinical study. Consecutive patients were scheduled to have femtosecond laser-assisted cataract surgery with the Lensx laser or conventional phacoemulsification using an active-fluidics torsional platform (Centurion) or torsional platform (Infiniti). The mean CDE and cataract grade were recorded. The study comprised 570 eyes (570 patients). There was no statistically significant difference in mean age (P = .41, femtosecond group; P = .33, conventional group) or cataract grade (P = .78 and P = .45, respectively) between the active-fluidics and gravity-fluidics platforms. In femtosecond cases (145 eyes), the mean CDE (percent-seconds) was 5.18 ± 4.58 (SD) with active fluidics and 7.00 ± 6.85 with gravity fluidics; in conventional cases (425 eyes), the mean CDE was 7.77 ± 6.97 and 11.43 ± 9.12, respectively. In both femtosecond cases and conventional cases, the CDE was lower with the active-fluidics platform than with the gravity-fluidics platform (P = .029, femtosecond group; P < .001 conventional group). With both fluidics platforms, the mean CDE was significantly lower in the femtosecond group than in the conventional group (both P < .001). The active-fluidics phacoemulsification platform achieved lower CDE values than the gravity-fluidics platform for conventional cataract extraction. Femtosecond laser pretreatment with the active-fluidics platform further reduced CDE. Copyright © 2017 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.

Performance after rotator cuff tear and operative treatment: a case-control study of major league baseball pitchers.

PubMed

Namdari, Surena; Baldwin, Keith; Ahn, Albert; Huffman, G Russell; Sennett, Brian J

2011-01-01

Little is known about pitching performance or lack of it among Major League Baseball (MLB) pitchers who undergo operative treatment of rotator cuff tears. To assess pitching performance outcomes in MLB players who needed operative treatment of rotator cuff tears and to compare performance in these athletes with that in a control group of MLB players. Case-control study. Publicly available player profiles, press releases, and team injury reports. Thirty-three MLB pitchers with documented surgery to treat rotator cuff tears and 117 control pitchers who did not have documented rotator cuff tears were identified. Major League Baseball pitching attrition and performance variables. Players who underwent rotator cuff surgery were no more likely not to play than control players. Performance variables of players who underwent surgery improved after surgery but never returned to baseline preoperative status. Players who needed rotator cuff surgery typically were more experienced and had better earned run averages than control players. Pitchers who had symptomatic rotator cuff tears that necessitated operative treatment tended to decline gradually in performance leading up to their operations and to improve gradually over the next 3 seasons. In contrast to what we expected, they did not have a greater attrition rate than their control counterparts; however, their performances did not return to preoperative levels over the course of the study.

Optical coherence tomography in guided surgery of GI cancer

NASA Astrophysics Data System (ADS)

Zagaynova, Elena V.; Abelevich, Alexander I.; Zagaynov, Vladimir E.; Gladkova, Natalia D.; Denisenko, Arkady N.; Feldchtein, Felix I.; Snopova, Ludmila B.; Kutis, Irina S.

2005-04-01

Optical Coherence Tomography (OCT) is a new high spatial resolution, real-time optical imaging modality, known from prior pilot studies for its high sensitivity to invasive cancer. We reported our results in an OCT feasibility study for accurate determination of the proximal border for esophageal carcinoma and the distal border for rectal carcinoma. The OCT study enrolled 19 patients with rectal adenocarcinoma and 24 patients with distal esophageal carcinoma (14 squamous cell carcinomas, 10 adenocarcinomas). During pre-surgery planning endoscopy we performed in vivo OCT imaging of the tumor border at four dial clock axes (12, 3, 6 and 9 o"clock). The OCT border then was marked by an electrocoagulator, or by a methylene blue tattoo. A cold biopsy (from the esophagus) was performed at visual and OCT borders and compared with visual and OCT readings. 27 post-surgery excised specimens were analyzed. OCT borders matched the histopathology in 94% cases in the rectum and 83.3% in the esophagus. In the cases of a mismatch between the OCT and histology borders, a deep tumor invasion occurred in the muscle layer (esophagus, rectum). Because of its high sensitivity to mucosal cancer, OCT can be used for pre-surgery planning and surgery guidance of the proximal border for esophageal carcinoma and the distal border for rectal carcinoma. However, deep invasion in the rectum or esophageal wall has to be controlled by alternative diagnostic modalities.