Why Do Patients Bleed?

PubMed Central

Curnow, Jennifer; Pasalic, Leonardo; Favaloro, Emmanuel J.

2016-01-01

Patients undergoing surgical procedures can bleed for a variety of reasons. Assuming that the surgical procedure has progressed well and that the surgeon can exclude surgical reasons for the unexpected bleeding, then the bleeding may be due to structural (anatomical) anomalies or disorders, recent drug intake, or disorders of hemostasis, which may be acquired or congenital. The current review aims to provide an overview of reasons that patients bleed in the perioperative setting, and it also provides guidance on how to screen for these conditions, through consideration of appropriate patient history and examination prior to surgical intervention, as well as guidance on investigating and managing the cause of unexpected bleeding. PMID:28824979

Medical versus surgical abortion methods for pregnancy in China: a cost-minimization analysis.

PubMed

Xia, Wei; She, Shouzhang; Lam, Tai Hing

2011-01-01

Both medical and surgical abortions are popular in developing countries. However, the monetary costs of these two methods have not been compared. 430 women seeking abortions were recruited in 2008. Either a medical or surgical method was used for the abortion. We adopted the perspective of a third-party payer. Cost-minimization analysis was used based on all charges for the overall procedures in an out-patient clinic in Guangzhou, China. 219 subjects (51%) chose a medical method (mifepristone and misoprostol), whereas 211 subjects (49%) chose a surgical method. The efficacy in the surgical group was significantly higher than in the medical group (100 vs. 90%, p < 0.001). Surgical abortion incurred much more costs than medical abortion on average after initial treatment. When the subsequent costs were accumulated within the 2-week follow-up, the mean total cost in the medical group increased significantly due to failure of abortion and persistent bleeding. Patients undergoing medical abortion eventually incurred equivalent expenses compared to patients undergoing surgical abortion (p = 0.42). There was no difference in the mean final costs between the two abortion methods. Complications of persistent bleeding and failure to abort (requiring surgical intervention) in the medical treatment group increased the final mean total cost substantially. Copyright © 2011 S. Karger AG, Basel.

Perioperative management of antiplatelet therapy in patients with coronary stents undergoing cardiac and non-cardiac surgery: a consensus document from Italian cardiological, surgical and anaesthesiological societies.

PubMed

Rossini, Roberta; Musumeci, Giuseppe; Visconti, Luigi Oltrona; Bramucci, Ezio; Castiglioni, Battistina; De Servi, Stefano; Lettieri, Corrado; Lettino, Maddalena; Piccaluga, Emanuela; Savonitto, Stefano; Trabattoni, Daniela; Capodanno, Davide; Buffoli, Francesca; Parolari, Alessandro; Dionigi, Gianlorenzo; Boni, Luigi; Biglioli, Federico; Valdatta, Luigi; Droghetti, Andrea; Bozzani, Antonio; Setacci, Carlo; Ravelli, Paolo; Crescini, Claudio; Staurenghi, Giovanni; Scarone, Pietro; Francetti, Luca; D'Angelo, Fabio; Gadda, Franco; Comel, Andrea; Salvi, Luca; Lorini, Luca; Antonelli, Massimo; Bovenzi, Francesco; Cremonesi, Alberto; Angiolillo, Dominick J; Guagliumi, Giulio

2014-05-01

Optimal perioperative antiplatelet therapy in patients with coronary stents undergoing surgery still remains poorly defined and a matter of debate among cardiologists, surgeons and anaesthesiologists. Surgery represents one of the most common reasons for premature antiplatelet therapy discontinuation, which is associated with a significant increase in mortality and major adverse cardiac events, in particular stent thrombosis. Clinical practice guidelines provide little support with regard to managing antiplatelet therapy in the perioperative phase in the case of patients with non-deferrable surgical interventions and/or high haemorrhagic risk. Moreover, a standard definition of ischaemic and haemorrhagic risk has never been determined. Finally, recommendations shared by cardiologists, surgeons and anaesthesiologists are lacking. The present consensus document provides practical recommendations on the perioperative management of antiplatelet therapy in patients with coronary stents undergoing surgery. Cardiologists, surgeons and anaesthesiologists have contributed equally to its creation. On the basis of clinical and angiographic data, the individual thrombotic risk has been defined. All surgical interventions have been classified according to their inherent haemorrhagic risk. A consensus on the optimal antiplatelet regimen in the perioperative phase has been reached on the basis of the ischaemic and haemorrhagic risk. Aspirin should be continued perioperatively in the majority of surgical operations, whereas dual antiplatelet therapy should not be withdrawn for surgery in the case of low bleeding risk. In selected patients at high risk for both bleeding and ischaemic events, when oral antiplatelet therapy withdrawal is required, perioperative treatment with short-acting intravenous glycoprotein IIb/IIIa inhibitors (tirofiban or eptifibatide) should be taken into consideration.

Endoscopic duodenal perforation: surgical strategies in a regional centre

PubMed Central

2014-01-01

Background Duodenal perforation is an uncommon complication of endoscopic retrograde cholangio-pancreatography (ERCP) and a rare complication of upper gastrointestinal endoscopy. Most are minor perforations that settle with conservative management. A few perforations however result in life-threatening retroperitoneal necrosis and require surgical intervention. There is a relative paucity of references specifically describing the surgical interventions required for this eventuality. Methods Five cases of iatrogenic duodenal perforation were ascertained between 2002 and 2007 at Cairns Base Hospital. Clinical features were analyzed and compared, with reference to a review of ERCP at that institution for the years 2005/2006. Results One patient recovered with conservative management. Of the other four, one died after initial laparotomy. The other three survived, undergoing multiple procedures and long inpatient stays. Conclusions Iatrogenic duodenal perforation with retroperitoneal necrosis is an uncommon complication of endoscopy, but when it does occur it is potentially life-threatening. Early recognition may lead to a better outcome through earlier intervention, although a protracted course with multiple procedures should be anticipated. A number of surgical techniques may need to be employed according to the individual circumstances of the case. PMID:24461069

Oral Surgical Procedures Performed Safely in Patients With Head and Neck Arteriovenous Malformations: A Retrospective Case Series of 12 Patients.

PubMed

Karim, Abdul Basit; Lindsey, Sean; Bovino, Brian; Berenstein, Alejandro

2016-02-01

This case series describes patients with head and neck arteriovenous malformations who underwent oral and maxillofacial surgical procedures combined with interventional radiology techniques to minimize blood loss. Twelve patients underwent femoral cerebral angiography to visualize the extent of vascular malformation. Before the surgical procedures, surgical sites were devascularized by direct injection of hemostatic or embolic agents. Direct puncture sclerotherapy at the base of surgical sites was performed using Surgiflo or n-butylcyanoacrylate glue. Surgical procedures were carried out in routine fashion. A hemostatic packing of FloSeal, Gelfoam, and Avitene was adapted to the surgical sites. Direct puncture sclerotherapy with Surgiflo or n-butylcyanoacrylate glue resulted in minimal blood loss intraoperatively. Local application of the FloSeal, Gelfoam, and Avitene packing sustained hemostasis and produced excellent healing postoperatively. Patients with arteriovenous malformations can safely undergo routine oral and maxillofacial surgical procedures with minimal blood loss when appropriate endovascular techniques and local hemostatic measures are used by the interventional radiologist and oral and maxillofacial surgeon. Copyright © 2016 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.

Surgery Versus Transcatheter Interventions for Significant Paravalvular Prosthetic Leaks.

PubMed

Millán, Xavier; Bouhout, Ismail; Nozza, Anna; Samman, Karla; Stevens, Louis-Mathieu; Lamarche, Yoan; Serra, Antonio; Asgar, Anita W; El-Hamamsy, Ismail; Cartier, Raymond; Pellerin, Michel; Noble, Stephane; Demers, Phillipe; Ibrahim, Reda; Jolicœur, E Marc; Bouchard, Denis

2017-10-09

This study sought to assess the relative merit of surgical correction (SC) versus transcatheter reduction on long-term outcomes in patients with significant paravalvular leak (PVL) refractory to medical therapy. PVL is the most frequent dysfunction following prosthetic valve replacement. Although repeat surgery is the gold standard, transcatheter reduction (TR) of PVL has been associated with reduced mortality. From 1994 to 2014, 231 patients underwent SC (n = 151) or TR (n = 80) PVL correction. Propensity matching and Cox proportional hazards regression models were used to assess the effect of either intervention on long-term rates of all-cause death or hospitalization for heart failure. Survival after TR and SC were further compared with the survival in a matched general population and to matched patients undergoing their first surgical valve replacement. Over a median follow-up of 3.5 years, SC was associated with an important reduction in all-cause death or hospitalization for heart failure compared with TR (hazard ratio: 0.28; 95% confidence interval: 0.18 to 0.44; p < 0.001). There was a trend towards reduced all-cause death following SC versus TR (hazard ratio: 0.61; 95% confidence interval: 0.37 to 1.02; p = 0.06). Neither intervention normalized survival when compared with a general population or patients undergoing their first surgical valve replacement. In patients with significant prosthetic PVL, surgery is associated with better long-term outcomes compared with transcatheter intervention, but results in important perioperative mortality and morbidity. Future studies are needed in the face of increasing implementation of transcatheter PVL interventions across the world. Copyright © 2017 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Ethical aspects of care in the newborn surgical patient.

PubMed

Hazebroek, Frans W J; Tibboel, Dick; Wijnen, Rene M H

2014-10-01

This article places focus on three main subjects that are all related to the ethical aspects of care of newborns undergoing major surgical interventions. The first concerns the communication between the surgeon, as a representative of the treatment team, and the parents. The second is the way to handle new developments in neonatal surgery. The third issue covers several aspects of the ethical decision-making process with regard to forgoing life support in surgical neonates. These issues will be discussed on the basis of two clinical case reports. Copyright © 2014 Elsevier Inc. All rights reserved.

Effect of pre-operative octenidine nasal ointment and showering on surgical site infections in patients undergoing cardiac surgery.

PubMed

Reiser, M; Scherag, A; Forstner, C; Brunkhorst, F M; Harbarth, S; Doenst, T; Pletz, M W; Hagel, S

2017-02-01

To evaluate the effect of pre-operative octenidine (OCT) decolonization on surgical site infection (SSI) rates. Before-and-after cohort study. Patients undergoing an elective isolated coronary artery bypass graft (CABG) procedure: control group (1 st January to 31 st December 2013), N=475; intervention group (1 st January to 31 st December 2014), N=428. The intervention consisted of nasal application of OCT ointment three times daily, beginning on the day before surgery, and showering the night before and on the day of surgery with OCT soap. A median sternotomy was performed in 805 (89.1%) patients and a minimally invasive direct coronary artery bypass procedure was performed in 98 (10.9%) patients. Overall, there was no difference in SSI rates between the control and intervention groups (15.4% vs 13.3%, P=0.39). The rate of harvest site SSIs was significantly lower in patients in the intervention group (2.5% vs 0.5%, P=0.01). Patients who had undergone a median sternotomy in the intervention group had a significantly lower rate of organ/space sternal SSIs (1.9% vs 0.3%, P=0.04). However, there was a trend towards an increased rate of deep incisional sternal SSIs (1.2% vs 2.9%, P=0.08). Multi-variate analysis did not identify a significant protective effect of the intervention (odds ratio 0.79, 95% confidence interval 0.53-1.15, P=0.27). Pre-operative decolonization with OCT did not reduce overall SSI rates in patients undergoing an elective isolated CABG procedure, but significantly decreased harvest site and organ/space sternal SSIs. Randomized controlled trials, including controlled patient adherence to the intervention, are required to confirm these observations and to determine the clinical utility of OCT in pre-operative decolonization. Copyright © 2016 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.

A review of the surgical management of right-sided aortic arch aneurysms

PubMed Central

Barr, James G.; Sepehripour, Amir H.; Jarral, Omar A.; Tsipas, Pantelis; Kokotsakis, John; Kourliouros, Antonios; Athanasiou, Thanos

2016-01-01

Aneurysms and dissections of the right-sided aortic arch are rare and published data are limited to a few case reports and small series. The optimal treatment strategy of this entity and the challenges associated with their management are not yet fully investigated and conclusive. We performed a systematic review of the literature to identify all patients who underwent surgical or endovascular intervention for right aortic arch aneurysms or dissections. The search was limited to the articles published only in English. We focused on presentation and critically assessed different management strategies and outcomes. We identified 74 studies that reported 99 patients undergoing surgical or endovascular intervention for a right aortic arch aneurysm or dissection. The median age was 61 years. The commonest presenting symptoms were chest or back pain and dysphagia. Eighty-eight patients had an aberrant left subclavian artery with only 11 patients having the mirror image variant of a right aortic arch. The commonest pathology was aneurysm arising from a Kommerell's diverticulum occurring in over 50% of the patients. Twenty-eight patients had dissections, 19 of these were Type B and 9 were Type A. Eighty-one patients had elective operations while 18 had emergency procedures. Sixty-seven patients underwent surgical treatment, 20 patients had hybrid surgical and endovascular procedures and 12 had totally endovascular procedure. There were 5 deaths, 4 of which were in patients undergoing emergency surgery and none in the endovascular repair group. Aneurysms and dissections of a right-sided aortic arch are rare. Advances in endovascular treatment and hybrid surgical and endovascular management are making this rare pathology amenable to these approaches and may confer improved outcomes compared with conventional extensive repair techniques. PMID:27001673

Surgical management of chronic pancreatitis: current utilization in the United States.

PubMed

Bliss, Lindsay A; Yang, Catherine J; Eskander, Mariam F; de Geus, Susanna W L; Callery, Mark P; Kent, Tara S; Moser, A James; Freedman, Steven D; Tseng, Jennifer F

2015-09-01

Surgical intervention is uncommon in chronic pancreatitis. Literature largely describes single institution or international experiences. This study describes US-based chronic pancreatitis surgical management. Retrospective analysis of chronic pancreatitis patients in the Healthcare Cost and Utilization Project Florida State Inpatient Database 2007-2011. Patients with malignancy or congenital abnormalities were excluded. Univariate analysis using the chi-square test. The number of readmissions, inpatient length of stay and cost using Wilcoxon's signed-rank test. Multivariate analysis of surgery by logistic regression. Twenty-one thousand four hundred and forty-five patients with chronic pancreatitis. 10.8% (2 307) underwent surgery including 1652 cholecystectomies, 564 drainage procedures and 498 pancreatectomies. Procedures decreased from 12.1% to 8.3% over time (P < 0.001), but intervention within 3 months increased (7.2% to 8.4%; P = 0.017). 15.3% (3 278) had pancreatic cysts/pseudocysts and 43.4% (9 312) had diabetes. The median numbers of admissions were 2 [interquartile range (IQR) 1,5] and 3 (IQR 2,7) among non-surgical and surgical patients, respectively (P < 0.001). Predictors of surgery were fewer co-morbidities, private insurance, and either diabetes mellitus or pancreatic cyst/pseudocyst. Chronic pancreatitis leads to numerous inpatient readmissions, but surgical intervention only occurs in a minority of cases. Complicated patients are more likely to undergo surgery. The complexities of chronic pancreatitis management warrant early multidisciplinary evaluation and ongoing consideration of surgical and non-surgical options. © 2015 International Hepato-Pancreato-Biliary Association.

Outcomes of complete vs targeted approaches to endoscopic sinus surgery.

PubMed

DeConde, Adam S; Suh, Jeffrey D; Mace, Jess C; Alt, Jeremiah A; Smith, Timothy L

2015-08-01

Functional endoscopic sinus surgery (FESS) was historically predicated on targeted widening of narrow anatomic structures that caused postobstructive persistent sinus inflammation. It is now clear that chronic rhinosinusitis (CRS) is a multifactorial disease with subsets of patients which may require a more extensive surgical approach. This study compares quality-of-life (QOL) and disease severity outcomes after FESS based on the extent of surgical intervention. Participants with CRS were prospectively enrolled into an ongoing, multi-institutional, observational, cohort study. Surgical extent was determined by physician discretion. Participants undergoing bilateral frontal sinusotomy, ethmoidectomy, maxillary antrostomy, and sphenoidotomy were considered to have undergone "complete" surgery, whereas all other participants were categorized as receiving "targeted" surgery. Improvement was evaluated between surgical subgroups with at least 6-month follow-up using the 22-item Sino-Nasal Outcome Test (SNOT-22) and the Brief Smell Inventory Test (B-SIT). A total of 311 participants met inclusion criteria with 147 subjects undergoing complete surgery and 164 targeted surgery. A higher prevalence of asthma, acetylsalicylic acid (ASA) sensitivity, nasal polyposis, and a history of prior sinus surgery (p ≤ 0.002) was present in participants undergoing complete surgery. Mean improvement in SNOT-22 (28.1 ± 21.9 vs 21.9 ± 20.6; p = 0.011) and B-SIT (0.8 ± 3.1 vs 0.2 ± 2.4; p = 0.005) was greater in subjects undergoing complete surgery. Regression models demonstrated a 5.9 ± 2.5 greater relative mean improvement on SNOT-22 total scores with complete surgery over targeted approaches (p = 0.016). Complete surgery was an independent predictor of greater postoperative SNOT-22 score improvement, yet did not achieve clinical significance. Further study is needed to determine the optimal surgical extent. © 2015 ARS-AAOA, LLC.

Emergency strategies and trends in the management of liver trauma.

PubMed

Jiang, Hongchi; Wang, Jizhou

2012-09-01

The liver is the most frequently injured organ during abdominal trauma. The management of hepatic trauma has undergone a paradigm shift over the past several decades, with mandatory operation giving way to nonoperative treatment. Better understanding of the mechanisms and grade of liver injury aids in the initial assessment and establishment of a management strategy. Hemodynamically unstable patients should undergo focused abdominal sonography for trauma, whereas stable patients may undergo computed tomography, the standard examination protocol. The grade of liver injury alone does not accurately predict the need for operation, and nonoperative management is rapidly becoming popular for high-grade injuries. Hemodynamic instability with positive focused abdominal sonography for trauma and peritonitis is an indicator of the need for emergent operative intervention. The damage control concept is appropriate for the treatment of major liver injuries and is associated with significant survival advantages compared with traditional prolonged surgical techniques. Although surgical intervention for hepatic trauma is not as common now as it was in the past, current trauma surgeons should be familiar with the emergency surgical skills necessary to manage complex hepatic injuries, such as packing, Pringle maneuver, selective vessel ligation, resectional debridement, and parenchymal sutures. The present review presents emergency strategies and trends in the management of liver trauma.

The Effects of Perioperative Music Interventions in Pediatric Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

PubMed

van der Heijden, Marianne J E; Oliai Araghi, Sadaf; van Dijk, Monique; Jeekel, Johannes; Hunink, M G Myriam

2015-01-01

Music interventions are widely used, but have not yet gained a place in guidelines for pediatric surgery or pediatric anesthesia. In this systematic review and meta-analysis we examined the effects of music interventions on pain, anxiety and distress in children undergoing invasive surgery. We searched 25 electronic databases from their first available date until October 2014. Included were all randomized controlled trials with a parallel group, crossover or cluster design that included pediatric patients from 1 month to 18 years old undergoing minimally invasive or invasive surgical procedures, and receiving either live music therapy or recorded music. 4846 records were retrieved from the searches, 26 full text reports were evaluated and data was extracted by two independent investigators. Pain was measured with the Visual Analogue Scale, the Coloured Analogue Scale and the Facial Pain Scale. Anxiety and distress were measured with an emotional index scale (not validated), the Spielberger short State Trait Anxiety Inventory and a Facial Affective Scale. Three RCTs were eligible for inclusion encompassing 196 orthopedic, cardiac and day surgery patients (age of 1 day to 18 years) receiving either live music therapy or recorded music. Overall a statistically significant positive effect was demonstrated on postoperative pain (SMD -1.07; 95%CI-2.08; -0.07) and on anxiety and distress (SMD -0.34 95% CI -0.66; -0.01 and SMD -0.50; 95% CI -0.84; - 0.16. This systematic review and meta-analysis indicates that music interventions may have a statistically significant effect in reducing post-operative pain, anxiety and distress in children undergoing a surgical procedure. Evidence from this review and other reviews suggests music therapy may be considered for clinical use.

Functional Decline in Children Undergoing Selective Dorsal Rhizotomy after Age 10

ERIC Educational Resources Information Center

MacWilliams, Bruce A.; Johnson, Barbara A.; Shuckra, Amy L.; D'Astous, Jacques L.

2011-01-01

Aim: To compare function and gait in a group of children older than most children who received selective dorsal rhizotomy (SDR) with age- and function-matched peers who received either orthopedic surgery or no surgical intervention. Method: A retrospective study examined ambulatory children with diplegic cerebral palsy, aged between 10 years and…

Impact of an Infection Control and Antimicrobial Stewardship Program on Solid Organ Transplantation and Hepatobiliary Surgical Site Infections.

PubMed

Frenette, Charles; Sperlea, David; Leharova, Yveta; Thirion, Daniel J G

2016-12-01

OBJECTIVE The goal of this long-term quasi-experimental retrospective study was to assess the impact of a 5-year serial infection control and antimicrobial stewardship intervention on surgical site infections (SSIs). METHODS This study was conducted in a tertiary-care public teaching institution over a 5-year period from January 2010 to December 2014. All patients undergoing hepatobiliary surgery and liver, kidney, pancreas, and simultaneous pancreas-kidney transplantation were included. Outcomes were compared between a preintervention group (2010-2011) and a postintervention group (2012-2014). RESULTS A total of 1,424 procedures averaged an overall SSI rate of 11.2%. After implementation of the interventions, a decrease of 52.8% in SSI rates from 17.4% to 8.2% was observed (P50% (relative rate; P<.001) was observed in superficial incisional and organ-space infections between pre- and postintervention groups. In addition, a 54.9% decrease from 19.7% to 8.9% (P<.001; OR, 2.2; 95% CI, 1.4-3.5) and a 51.6% decrease from 15.5% to 7.5% (P=.001; OR, 2.2; 95% CI, 1.4-3.5) were observed for SSI rates in hepatobiliary surgery and solid organ transplantation, respectively. The antimicrobial stewardship intervention increased overall conformity to the internal surgical prophylaxis protocol by 15.2% (absolute rate) from 45.1% to 60.3% (P<.003; 95% CI, 5.4-24.9). CONCLUSIONS A long-term serial infection control and antimicrobial stewardship intervention decreased SSIs among patients undergoing hepatobiliary surgery and liver, kidney, pancreas, and simultaneous pancreas-kidney transplantation. Infect Control Hosp Epidemiol 2016;1468-1474.

Treatment for preventing bleeding in people with haemophilia or other congenital bleeding disorders undergoing surgery.

PubMed

Coppola, Antonio; Windyga, Jerzy; Tufano, Antonella; Yeung, Cindy; Di Minno, Matteo Nicola Dario

2015-02-09

In people with haemophilia or other congenital bleeding disorders undergoing surgical interventions, haemostatic treatment is needed in order to correct the underlying coagulation abnormalities and minimise the bleeding risk. This treatment varies according to the specific haemostatic defect, its severity and the type of surgical procedure. The aim of treatment is to ensure adequate haemostatic coverage for as long as the bleeding risk persists and until wound healing is complete. To assess the effectiveness and safety of different haemostatic regimens (type, dose and duration, modality of administration and target haemostatic levels) administered in people with haemophilia or other congenital bleeding disorders for preventing bleeding complications during and after surgical procedures. We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles and reviews.Date of the last search: 20 November 2014. Randomised and quasi-randomised controlled trials comparing any hemostatic treatment regimen to no treatment or to another active regimen in children and adults with haemophilia or other congenital bleeding disorders undergoing any surgical intervention. Two authors independently assessed trials (eligibility and risks of bias) and extracted data. Meta-analyses were performed on available and relevant data. Of the 16 identified trials, four (112 participants) were eligible for inclusion.Two trials evaluated 59 people with haemophilia A and B undergoing 63 dental extractions. Trials compared the use of a different type (tranexamic acid or epsilon-aminocaproic acid) and regimen of antifibrinolytic agents as haemostatic support to the initial replacement treatment. Neither trial specifically addressed mortality (one of this review's primary outcomes); however, in the frame of safety assessments, no fatal adverse events were reported. The second primary outcome of blood loss was assessed after surgery and these trials showed the reduction of blood loss and requirement of post-operative replacement treatment in people receiving antifibrinolytic agents compared with placebo. The remaining primary outcome of need for re-intervention was not reported by either trial.Two trials reported on 53 people with haemophilia A and B with inhibitors treated with different regimens of recombinant activated factor VII (rFVIIa) for haemostatic coverage of 33 major and 20 minor surgical interventions. Neither of the included trials specifically addressed any of the review's primary outcomes (mortality, blood loss and need for re-intervention). In one trial a high-dose rFVIIa regimen (90 μg/kg) was compared with a low-dose regimen (35 μg/kg); the higher dose showed increased haemostatic efficacy, in particular in major surgery, with shorter duration of treatment, similar total dose of rFVIIa administered and similar safety levels. In the second trial, bolus infusion and continuous infusion of rFVIIa were compared, showing similar haemostatic efficacy, duration of treatment and safety. There is insufficient evidence from randomised controlled trials to assess the most effective and safe haemostatic treatment to prevent bleeding in people with haemophilia or other congenital bleeding disorders undergoing surgical procedures. Ideally large, adequately powered, and well-designed randomised controlled trials would be needed, in particular to address the cost-effectiveness of such demanding treatments in the light of the increasing present economic constraints, and to explore the new challenge of ageing patients with haemophilia or other congenital bleeding disorders. However, performing such trials is always a complex task in this setting and presently does not appear to be a clinical and research priority. Indeed, major and minor surgeries are effectively and safely performed in these individuals in clinical practice, with the numerous national and international recommendations and guidelines providing regimens for treatment in this setting mainly based on data from observational, uncontrolled studies.

A pragmatic multi-centre randomised controlled trial of fluid loading in high-risk surgical patients undergoing major elective surgery--the FOCCUS study.

PubMed

Cuthbertson, Brian H; Campbell, Marion K; Stott, Stephen A; Elders, Andrew; Hernández, Rodolfo; Boyers, Dwayne; Norrie, John; Kinsella, John; Brittenden, Julie; Cook, Jonathan; Rae, Daniela; Cotton, Seonaidh C; Alcorn, David; Addison, Jennifer; Grant, Adrian

2011-01-01

Fluid strategies may impact on patient outcomes in major elective surgery. We aimed to study the effectiveness and cost-effectiveness of pre-operative fluid loading in high-risk surgical patients undergoing major elective surgery. This was a pragmatic, non-blinded, multi-centre, randomised, controlled trial. We sought to recruit 128 consecutive high-risk surgical patients undergoing major abdominal surgery. The patients underwent pre-operative fluid loading with 25 ml/kg of Ringer's solution in the six hours before surgery. The control group had no pre-operative fluid loading. The primary outcome was the number of hospital days after surgery with cost-effectiveness as a secondary outcome. A total of 111 patients were recruited within the study time frame in agreement with the funder. The median pre-operative fluid loading volume was 1,875 ml (IQR 1,375 to 2,025) in the fluid group compared to 0 (IQR 0 to 0) in controls with days in hospital after surgery 12.2 (SD 11.5) days compared to 17.4 (SD 20.0) and an adjusted mean difference of 5.5 days (median 2.2 days; 95% CI -0.44 to 11.44; P = 0.07). There was a reduction in adverse events in the fluid intervention group (P = 0.048) and no increase in fluid based complications. The intervention was less costly and more effective (adjusted average cost saving: £2,047; adjusted average gain in benefit: 0.0431 quality adjusted life year (QALY)) and has a high probability of being cost-effective. Pre-operative intravenous fluid loading leads to a non-significant reduction in hospital length of stay after high-risk major surgery and is likely to be cost-effective. Confirmatory work is required to determine whether these effects are reproducible, and to confirm whether this simple intervention could allow more cost-effective delivery of care. Prospective Clinical Trials, ISRCTN32188676.

A pragmatic multi-centre randomised controlled trial of fluid loading in high-risk surgical patients undergoing major elective surgery - the FOCCUS study

PubMed Central

2011-01-01

Introduction Fluid strategies may impact on patient outcomes in major elective surgery. We aimed to study the effectiveness and cost-effectiveness of pre-operative fluid loading in high-risk surgical patients undergoing major elective surgery. Methods This was a pragmatic, non-blinded, multi-centre, randomised, controlled trial. We sought to recruit 128 consecutive high-risk surgical patients undergoing major abdominal surgery. The patients underwent pre-operative fluid loading with 25 ml/kg of Ringer's solution in the six hours before surgery. The control group had no pre-operative fluid loading. The primary outcome was the number of hospital days after surgery with cost-effectiveness as a secondary outcome. Results A total of 111 patients were recruited within the study time frame in agreement with the funder. The median pre-operative fluid loading volume was 1,875 ml (IQR 1,375 to 2,025) in the fluid group compared to 0 (IQR 0 to 0) in controls with days in hospital after surgery 12.2 (SD 11.5) days compared to 17.4 (SD 20.0) and an adjusted mean difference of 5.5 days (median 2.2 days; 95% CI -0.44 to 11.44; P = 0.07). There was a reduction in adverse events in the fluid intervention group (P = 0.048) and no increase in fluid based complications. The intervention was less costly and more effective (adjusted average cost saving: £2,047; adjusted average gain in benefit: 0.0431 quality adjusted life year (QALY)) and has a high probability of being cost-effective. Conclusions Pre-operative intravenous fluid loading leads to a non-significant reduction in hospital length of stay after high-risk major surgery and is likely to be cost-effective. Confirmatory work is required to determine whether these effects are reproducible, and to confirm whether this simple intervention could allow more cost-effective delivery of care. Trial registration Prospective Clinical Trials, ISRCTN32188676 PMID:22177541

Improving the ward-based care of patients post-thyroidectomy.

PubMed

Mahalingam, Sridhayan; Singhal, Rachit; Mugilan, Sridhayani; Choudhury, Natasha

2016-11-02

Nursing staff play a crucial role in managing surgical patients in the postoperative period. However, with an increasing risk of subspecialty wards facing closure as a result of financial pressures within the NHS, the knowledge base and expertise of ward-based nursing staff of surgical subspecialties is becoming increasingly limited. Using patients undergoing thyroidectomy as an example, a quality improvement multidisciplinary audit is presented, which shows how simple targeted interventions through a multidisciplinary approach can help maintain high standards of patient care in a secondary care setting.

Perioperative antimicrobial therapy in preventing infectious complications following pancreatoduodenectomy

PubMed Central

Barreto, Savio George; Singh, Amanjeet; Perwaiz, Azhar; Singh, Tanveer; Singh, Manish Kumar; Sharma, Sunil; Chaudhary, Adarsh

2017-01-01

Background & objectives: Infectious complications have been reported to occur in up to 45 per cent of patients, following pancreatoduodenectomy (PD). The incidence of perioperative infectious and overall complications is higher in patients undergoing preoperative invasive endoscopic procedures. The aim of the study was to compare the role of a carbapenem administered as three-once daily perioperative doses on infectious complications in patients at high risk for these complications versus those at low risk. Methods: A retrospective study with some secondary data collected from records was carried out on the data from a prospectively maintained surgical database of patients undergoing PD for pancreatic and periampullary lesions at a tertiary referral care centre, between June 2011 and May 2013. Patients were divided into two groups for comparison based on whether they underwent at least one preoperative endoscopic interventional procedure before PD (high-risk - intervention and low-risk - no intervention). All patients were administered three-once daily doses of ertapenem (1 g). Results: A total of 135 patients in two groups were comparable in terms of demographic and nutritional, surgical and histopathological factors. No significant difference between the two groups in terms of the overall morbidity (38.7 vs 35.7%), infectious complications (9.7 vs 4.8%), mortality (2.2 vs 2.4%) and mean post-operative hospital stay (9.2 vs 8.9 days) was observed. Interpretation & conclusions: Perioperative three-day course of once-daily administered ertapenem resulted in a non-significant difference in infectious and overall complications in high-risk patients undergoing PD as compared to the low-risk group. PMID:29434066

[Experience with fenspiride in a rhinosurgeon's practice].

PubMed

Baryshevskaia, L A; Velikanov, A K; Sedykh, M I

2009-01-01

The postoperative use of fenspiride in patients undergoing various surgical interventions into the nasal cavity is shown to substantially change the course of posttraumatic rhinitis. With this therapy, fibrinous fur disappeared 2 days earlier than when conventional treatment was performed, and mucosal moisture restored 2.3 times more rapidly than that in those treated without using fenspiride.

Peri-operative interventions producing better functional outcomes and enhanced recovery following total hip and knee arthroplasty: an evidence-based review

PubMed Central

2013-01-01

The increasing numbers of patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA), combined with the rapidly growing repertoire of surgical techniques and interventions available have put considerable pressure on surgeons and other healthcare professionals to produce excellent results with early functional recovery and short hospital stays. The current economic climate and the restricted healthcare budgets further necessitate brief hospitalization while minimizing costs. Clinical pathways and protocols introduced to achieve these goals include a variety of peri-operative interventions to fulfill patient expectations and achieve the desired outcomes. In this review, we present an evidence-based summary of common interventions available to achieve enhanced recovery, reduce hospital stay, and improve functional outcomes following THA and TKA. It covers pre-operative patient education and nutrition, pre-emptive analgesia, neuromuscular electrical stimulation, pulsed electromagnetic fields, peri-operative rehabilitation, modern wound dressings, standard surgical techniques, minimally invasive surgery, and fast-track arthroplasty units. PMID:23406499

Surgical site infections in an abdominal surgical ward at Kosovo Teaching Hospital.

PubMed

Raka, Lul; Krasniqi, Avdyl; Hoxha, Faton; Musa, Ruustem; Mulliqi, Gjyle; Krasniqi, Selvete; Kurti, Arsim; Dervishaj, Antigona; Nuhiu, Beqir; Kelmendi, Baton; Limani, Dalip; Tolaj, Ilir

2007-12-01

Abdominal surgical site infections (SSI) cause substantial morbidity and mortality for patients undergoing operative procedures. We determined the incidence of and risk factors for SSI after abdominal surgery in the Department of Abdominal Surgery at the University Clinical Centre of Kosovo (UCCK). Prospective surveillance of patients undergoing abdominal surgery was performed between December 2005 and June 2006. CDC definitions were followed to detect SSI and study forms were based on Europe Link for Infection Control through Surveillance (HELICS) protocol. A total of 253 surgical interventions in 225 patients were evaluated. The median age of patients was 42 years and 55.1% of them were male. The overall incidence rate of SSI was 12%. Follow-up was achieved for 84.1% of the procedures. For patients with an SSI, the median duration of hospitalization was 9 days compared with 4 days for those without an SSI (p2, use of antibiotic prophylaxis and NNIS class of >2 were all significant at p < .001. The SSI rates for the NNIS System risk classes 0, 1 and 2-3 were 4.2%, 46.7% and 100%, respectively. SSI caused considerable morbidity among surgical patients in UCCK. Appropriate active surveillance and infection control measures should be introduced during preoperative, intra-operative, and postoperative care to reduce infection rates.

Effects of live music therapy sessions on quality of life indicators, medications administered and hospital length of stay for patients undergoing elective surgical procedures for brain.

PubMed

Walworth, Darcy; Rumana, Christopher S; Nguyen, Judy; Jarred, Jennifer

2008-01-01

The physiological and psychological stress that brain tumor patients undergo during the entire surgical experience can considerably affect several aspects of their hospitalization. The purpose of this study was to examine the effects of live music therapy on quality of life indicators, amount of medications administered and length of stay for persons receiving elective surgical procedures of the brain. Subjects (N = 27) were patients admitted for some type of surgical procedure of the brain. Subjects were randomly assigned to either the control group receiving no music intervention (n = 13) or the experimental group receiving pre and postoperative live music therapy sessions (n = 14). Anxiety, mood, pain, perception of hospitalization or procedure, relaxation, and stress were measured using a self-report Visual Analog Scale (VAS) for each of the variables. The documented administration of postoperative pain medications; the frequency, dosage, type, and how it was given was also compared between groups. Experimental subjects live and interactive music therapy sessions, including a pre-operative session and continuing with daily sessions until the patient was discharged home. Control subjects received routine hospital care without any music therapy intervention. Differences in experimental pretest and posttest scores were analyzed using a Wilcoxon Matched-Pairs Signed-Rank test. Results indicated statistically significant differences for 4 of the 6 quality of life measures: anxiety (p = .03), perception of hospitalization (p = .03), relaxation (p = .001), and stress (p = .001). No statistically significant differences were found for mood (p > .05) or pain (p > .05) levels. Administration amounts of nausea and pain medications were compared with a Two-Way ANOVA with One Repeated Measure resulting in no significant differences between groups and medications, F(1, 51) = 0.03; p > .05. Results indicate no significant differences between groups for length of stay (t = .97, df = 25, p > .05). This research study indicates that live music therapy using patient-preferred music can be beneficial in improving quality of life indicators such as anxiety, perception of the hospitalization or procedure, relaxation, and stress in patients undergoing surgical procedures of the brain.

Rabbit analgesia.

PubMed

Barter, Linda S

2011-01-01

With the increasing popularity of rabbits as household pets, the complexity of diagnostic and surgical procedures performed on rabbits is increasing, along with the frequency of routine surgical procedures. More practitioners are faced with the need to provide adequate analgesia for this species. Preemptive analgesia prior to planned surgical interventions may reduce nervous system changes in response to noxious input, as well as reduce postoperative pain levels and analgesic drug requirements. Concurrent administration of analgesic drugs to anesthetized rabbits undergoing painful procedures is warranted both pre- and intraoperatively as well as postoperatively. This article discusses the neuropharmacologic and pharmacologic aspects of pain in rabbits, and reviews current protocols for the use of analgesic drugs. Published by Elsevier Inc.

Patient expectations for surgery: are they being met?

PubMed

Jones, K R; Burney, R E; Christy, B

2000-06-01

The purpose of the study was to determine patient expectations for the outcomes of three elective surgical procedures, the extent to which patient expectations for surgery were met, the reasons for unmet expectations, and the factors that might predict unmet expectations. Better understanding of these questions might help identify targeted interventions to better prepare patients for specific health care experiences. In a longitudinal, prospective design, a convenience sample of 445 patients (age range, 18 to 86 years) at a general surgery clinic at a major academic medical center was included--177 patients undergoing inguinal hernia repair, 146 undergoing parathyroidectomy, and 122 undergoing cholecystectomy. Patients completed both standardized and newly developed condition-specific health survey instruments. Preoperative interviews were administered, followed by mailed surveys 2 months after surgery. Between 9% and 27% of the respondents reported unmet expectations, with significant variation by condition; reasons included perceived lack of symptom relief, surgical complications, and process of care issues. Patients undergoing parathyroidectomy had a greater probability of unmet expectations. Both feeling prepared for surgery and improved postoperative symptom relief and role functioning reduced the probability of unmet expectations. To reduce the level of unmet expectations, patients need to be prepared both for the surgical experience and for what to expect in the recovery phase. This is especially true for complex illnesses such as primary hyperparathyroidism. Innovative educational strategies to ensure adequate preparation for surgery will be needed, and attention will need to be paid to latent, unstated process measures, if unmet expectations are to be reduced.

Treatment tailoring for factor V deficient patients and perioperative management using global hemostatic coagulation assays.

PubMed

Levy-Mendelovich, Sarina; Barg, Assaf Arie; Rosenberg, Nurit; Avishai, Einat; Luboshitz, Jacob; Misgav, Mudi; Kenet, Gili; Livnat, Tami

2018-07-01

Congenital factor V deficiency (FVD) is a rare bleeding disorder with an estimated incidence of 1 in 1000,000 in the general population. Since the common coagulation tests do not correlate with the bleeding tendency there is an unmet need to predict FVD patients' bleeding hazard prior to surgical interventions. To optimize treatment prior to surgical interventions, using global coagulation assays, thrombin generation (TG) and rotating thromboelastogram (ROTEM). Our cohort included 5 patients with FVD, 4 severe and one mild. Two of them underwent TG and ROTEM prior to surgical interventions, including ex vivo spiking assays using bypass agents and platelets spiking. All five patients exhibited prolonged PT and PTT, non-dependent on their bleeding tendency. Patient 1, who demonstrated severe bleeding phenotype, underwent surgery treated by combination of APCC (FEIBA) and platelet transfusion. Therapy was guided by global tests (TG as well as ROTEM) results. During the pre and post-operative period neither excessive bleeding nor any thrombosis was noted. In contrast, TG and ROTEM analysis of patient 4 has lead us to perform the surgery without any blood products' support. Indeed, the patient did not encounter any bleeding. Global coagulation assays may be useful ancillary tools guiding treatment decisions in FVD patients undergoing surgical procedures. Copyright © 2018 Elsevier Inc. All rights reserved.

Effect of massage therapy on pain, anxiety, and tension in cardiac surgical patients: a pilot study.

PubMed

Cutshall, Susanne M; Wentworth, Laura J; Engen, Deborah; Sundt, Thoralf M; Kelly, Ryan F; Bauer, Brent A

2010-05-01

To assess the role of massage therapy in the cardiac surgery postoperative period. Specific aims included determining the difference in pain, anxiety, tension, and satisfaction scores of patients before and after massage compared with patients who received standard care. A randomized controlled trial comparing outcomes before and after intervention in and across groups. Saint Marys Hospital, Mayo Clinic, Rochester, Minnesota. Patients undergoing cardiovascular surgical procedures (coronary artery bypass grafting and/or valvular repair or replacement) (N=58). Patients in the intervention group received a 20-minute session of massage therapy intervention between postoperative days 2 and 5. Patients in the control group received standard care and a 20-minute quiet time between postoperative days 2 and 5. Linear Analogue Self-assessment scores for pain, anxiety, tension, and satisfaction. Statistically and clinically significant decreases in pain, anxiety, and tension scores were observed for patients who received a 20-minute massage compared with those who received standard care. Patient feedback was markedly positive. This pilot study showed that massage can be successfully incorporated into a busy cardiac surgical practice. These results suggest that massage may be an important therapy to consider for inclusion in the management of postoperative recovery of cardiovascular surgical patients. Copyright 2009 Elsevier Ltd. All rights reserved.

Current Surgical Options for Patients with Epilepsy.

PubMed

Rasul, Fahid T; Bal, Jarnail; Pereira, Erlick A; Tisdall, Martin; Themistocleous, Marios; Haliasos, Nikolaos

2017-01-01

Surgery for epilepsy dates back to 1886 and has undergone significant developments. Today it is considered a key treatment modality in patients who are resistant to pharmacological intervention. It improves seizure control, cognition and quality of life. New technologies, advances in surgical technique and progress in scientific research underlie the expansion of surgery in epilepsy treatment. Effectiveness of surgical treatment depends on several factors including the type of epilepsy, the underlying pathology and the localisation of the epileptogenic zone. Timely referral to an experienced epilepsy surgery centre is important to allow the greatest chance of seizure control and to minimise associated morbidity and mortality. Following referral, patients undergo thorough presurgical investigation to evaluate their suitability for surgery. The commonest form of epilepsy treated by surgery is mesial temporal lobe sclerosis and there is Class I evidence for the medium-term efficacy of temporal lobe resection from two randomised control trials. Various other forms of epilepsy are now considered for resective and neuromodulatory surgical intervention due to favourable results. In this article, the authors review the current status of surgical treatment for epilepsy including the presurgical evaluation of patients, surgical techniques and the future directions in epilepsy surgery. Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.org.

An Evaluation of Parastomal Hernia Repair Using the Americas Hernia Society Quality Collaborative.

PubMed

Fox, Sarah S; Janczyk, Randy; Warren, Jeremy A; Carbonell, Alfredo M; Poulose, Benjamin K; Rosen, Michael J; Hope, William W

2017-08-01

The purpose of this review was to evaluate outcomes relating to parastomal hernia repair. Data from the Americas Hernia Society Quality Collaborative were used to identify patients undergoing parastomal hernia repair from 2013 to 2016. Parastomal hernia repairs were compared with other repairs using Pearson's test and Wilcoxon test with a P value <0.05 considered significant. Parastomal hernia repairs were performed in 311 patients. Techniques of repair include open in 85 per cent and laparoscopic in 15 per cent. Mesh was used in 92 per cent with keyhole in 34 per cent, flat mesh in 33 per cent, and Sugarbaker in 25 per cent. Mesh types were permanent synthetic in 79 per cent, biologic in 13 per cent, absorbable synthetic in 6 per cent, and hybrid synthetic/biologic in 2 per cent. Most common location for mesh was sublay in 84 per cent followed by onlay in 14 per cent and inlay in 2 per cent with 59 per cent of patients undergoing a myofascial release. Ostomy disposition included ostomy left in situ (47%), moved to a new site (18%), taken down (22%), and rematured in same location in (13%). Outcomes related to parastomal hernia repair included 10 per cent surgical site infection, 24 per cent surgical site occurrence, and 12 per cent surgical site occurrences requiring procedural interventions with a 13 per cent readmission rate and 6 per cent reoperation rate. When comparing parastomal hernias with other ventral hernia repairs, parastomal hernias had a significantly higher surgical site infection, surgical site occurrence, surgical site occurrences requiring procedural intervention, readmission, reoperation rate, and length of stay, and were less commonly performed laparoscopically (P < 0.05). Most parastomal hernias are being repaired open with synthetic mesh in the sublay position. Less favorable outcomes of parastomal hernia repair when compared with other ventral hernia repairs are likely related to the complexity of parastomal hernia repair.

Introduction of an enhanced recovery protocol to reduce short-term complications following radical cystectomy and intestinal urinary diversion with vescica ileale Padovana neobladder.

PubMed

Cerruto, Maria Angela; De Marco, Vincenzo; D'Elia, Carolina; Bizzotto, Leonardo; Curti, Pierpaolo; Baldassarre, Roberto; Artibani, Walter

2014-01-01

To reduce short-term complications of radical cystectomy (RC) and intestinal urinary diversion with vescica ileale Padovana (VIP) neobladder, we described and assessed an enhanced recovery protocol (ERP) in a series of consecutive patients. An ERP was introduced focusing on reduced bowel preparation, standardized feeding and analgesic regimens. We analyzed the outcomes with all patients consecutively undergoing RC and VIP neobladder who met the following inclusion criteria: American Society of Anesthesiologists score <3; absence of malnutrition according to the Mini Nutritional Assessment-Short Form criteria; absence of inflammatory bowel diseases. Thirty-one consecutive patients were recruited to undergo our ERP. Mean age of patients was 62.16 years. No patients died due to surgical complications. Nine of 31 patients experienced complications (29.03%), none requiring surgical intervention. According to Clavien grading, all complications were grade <2. The application of our ERP to our patients undergoing RC and VIP neobladder contributed to reduce postoperative morbidity. Copyright © 2013 S. Karger AG, Basel.

Transcatheter Therapies for Treating Tricuspid Regurgitation.

PubMed

Rodés-Cabau, Josep; Hahn, Rebecca T; Latib, Azeem; Laule, Michael; Lauten, Alexander; Maisano, Francesco; Schofer, Joachim; Campelo-Parada, Francisco; Puri, Rishi; Vahanian, Alec

2016-04-19

Tricuspid valve (TV) disease has been relatively neglected, despite the known association between severe tricuspid regurgitation (TR) and mortality. Few patients undergo isolated tricuspid surgery, which remains associated with high in-hospital mortality rates, particularly in patients with prior left-sided valve surgery. Patients with severe TR are often managed medically for years before TV repair or replacement. Current guidelines recommend TV repair in the presence of a dilated tricuspid annulus at the time of a left-sided valve surgical intervention, even if regurgitation is mild. This proposed algorithm aims to prevent the inevitable progression to severe TR and the need for a second surgical intervention. Recently, novel transcatheter treatment options were developed for treating patients with severe TR and right heart failure with prohibitive surgical risk. Here we describe currently available transcatheter treatment options for severe TR implanted at different levels: the junction between vena cavae and right atrium; the tricuspid annulus; or between TV leaflets, improving coaptation. Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Surgical and medical management of extracranial carotid artery aneurysms.

PubMed

Fankhauser, Grant T; Stone, William M; Fowl, Richard J; O'Donnell, Mark E; Bower, Thomas C; Meyer, Fredric B; Money, Samuel R

2015-02-01

Extracranial carotid artery aneurysms (ECCAs) are extremely rare with limited information about management options. Our purpose was to review our institution's experience with ECCAs during 15 years and to discuss the presentation and treatment of these aneurysms. A retrospective review of patients diagnosed with ECCAs from 1998 to 2012 was performed. Symptoms, risk factors, etiology, diagnostic methods, treatments, and outcomes were reviewed. During the study period, 141 aneurysms were diagnosed in 132 patients (mean age, 61 years; 69 men). There were 116 (82%) pseudoaneurysms and 25 (18%) true aneurysms; 69 (49%) aneurysms were asymptomatic, whereas 72 (52%) had symptoms (28 painless masses; 10 transient ischemic attacks; 10 vision symptoms; 9 ruptures; 8 strokes; 4 painful mass; 1 dysphagia; 1 tongue weakness; 1 bruit). Causes of true aneurysms included fibromuscular dysplasia in 15 patients, Ehlers-Danlos syndrome in three, Marfan syndrome in one, and uncharacterized connective tissue diseases in two. Of 25 true aneurysms, 11 (44%) were symptomatic; 15 (60%) true aneurysms underwent open surgical treatment, whereas 10 (40%) were managed nonoperatively. Postoperative complications included one stroke during a mean follow-up of 31 months (range, 0-166 months). No aneurysms managed nonoperatively required intervention during a mean follow-up of 77 months (range, 1-115 months). Of 116 pseudoaneurysms, 60 (52%) were symptomatic; 33 (29%) pseudoaneurysms underwent open surgery, 18 (15%) underwent endovascular intervention, and 65 (56%) were managed medically. Pseudoaneurysm after endarterectomy (28 patients; 24%) presented at a mean of 82 months from the surgical procedure. Mean follow-up for all aneurysms was 33.9 months. One (0.7%) aneurysm-related death occurred (rupture treated palliatively). No patient undergoing nonoperative management suffered death or major morbidity related to the aneurysm. Nonoperative management was more common in asymptomatic patients (71%) than in symptomatic patients (31%). ECCAs are uncommon and may be manifested with varying symptoms. All segments of the carotid artery are susceptible, although the internal is most commonly affected. Open surgical intervention was more common in patients with symptoms and with true aneurysms. Patients with pseudoaneurysms were more likely to undergo endovascular intervention. Nonoperative treatment is safe in selected patients. Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

[Vaginism - a surgical or consultative problem? (author's transl)].

PubMed

Wenderlein, J M

1982-04-01

For the last one hundred years or so doctors have been confronted with the phenomenon of vaginism as a functional sexual disturbance. 70 years ago the psychogenetic nature of this disturbance was recognized, and yet gynaecologists and surgeons are still suggesting and practising surgical and mechanical interventions at the vaginal orifice. This is indeed regrettable - and not only because such attempts remain unsuccessful: in this manner doctors are fixed on the idea of an organic cause of the disturbance instead of motivating the patients to undergo consultative treatment. Vaginism may even entail psychosocial advantages for the women in some cases.

Different perception of surgical risks between physicians and patients undergoing laparoscopic cholecystectomy.

PubMed

Tuveri, Massimiliano; Caocci, Giovanni; Efficace, Fabio; Medas, Fabio; Collins, Gary S; Pisu, Salvatore

2009-08-01

Data on the quality of communication during informed consent for surgery is sparse; we investigated this issue in a cohort of patients undergoing laparoscopic cholecystectomy (LC). Two hundred and seven consecutive patients with benign biliary disease who had undergone LC completed 2 questionnaires. We investigated the patient choice to undergo the surgical procedure along with perceptions of risk complications presented by the surgeon. Nineteen attending surgeons also completed a questionnaire giving information on their recall perception on the information they provided. Multiple logistic regression analyses determined the predictors of perceived communication factors during the informed consent process. One hundred eighty-one patients (87.4%) returned questionnaires. Younger patients (<50 y) with lower education perceived higher level of risk complications compared with older and higher educated patients (P=0.04 and P<0.001). Younger patients felt psychologic support was necessary (P<0.001) and that quality of life issues related to the interventions were under addressed (P=0.018). Differences were observed between patients' recalled risk of complications and the risk to convert LC to open laparotomy and physicians' perception of information provided to patients regarding these aspects (P<0.01). Although informed consent for surgical procedures requires that the procedures are explained and that the patient understands the procedures and risks, our data suggest different perceptions of the quality of information provided during this process between patients and physicians. Physicians should be aware that surgical risks might be perceived differently by patients and this perception might be influenced, for example, by patients' age and education. Major efforts should be directed to improve communications skills in surgical laparoscopy.

Management of Iatrogenic Pseudoaneurysms in Patients Undergoing Coronary Artery Bypass Grafting.

PubMed

Stone, Patrick A; Thompson, Stephanie N; Hanson, Brent; Masinter, David

2016-05-01

A plethora of papers have been written regarding postcatheterization femoral pseudoaneurysms. However, literature is lacking on pseudoaneurysmal management in patients undergoing coronary artery bypass grafting (CABG). Thus, we examined if pseudoaneurysms with subsequent CABG can be managed with the same strategies as those not exposed to the intense anticoagulation accompanying CABGs. During a 14-year study period, we retrospectively examined femoral iatrogenic pseudoaneurysms (IPSAs) diagnosed postheart catheterization in patients having a subsequent CABG. Patient information was obtained from electronic medical records and included pseudoaneurysm characteristics, treatment, and resolution. Outcomes of interest included the occurrence of IPSA treatment failures and complications. In the 66 patients (mean age, 66 ± 11 years, 46% male) meeting inclusion criteria, mean dose of heparin received during the CABG procedure was 34 000 ± 23 000 units. The IPSA size distribution was the following: 17% of IPSAs measured <1 cm, 55% between 1 and 3 cm, and 21% measured >3 cm. Pseudoaneurysms were managed with compression, duplex-guided thrombin injection, and surgical repair (1%, 27%, and 26% of cases, respectively). Thrombin injection and surgical repair were 100% effective at treating pseudoaneurysms, with 1 patient experiencing a surgical site infection postsurgical repair. Observation-only management was employed in 30 (45%) patients. Nine of 30 patients with no intervention beyond observation had duplex documented resolution/thrombosis during follow-up. One patient initially managed by observation required readmission and surgical repair of an enlarging pseudoaneurysm (6 cm growth) following CABG. Management of pseudoaneurysms in patients prior to CABG should be similar to those patients not undergoing intense anticoagulation. In appropriate cases, small aneurysms can be safely observed, while thrombin injections are effective and safe as well. Thus, routine open surgical repair is not routinely required in patients with femoral pseudoaneurysms at time of CABG. © The Author(s) 2016.

Evaluation and establishment of a ward-based geriatric liaison service for older urological surgical patients: Proactive care of Older People undergoing Surgery (POPS)-Urology.

PubMed

Braude, Philip; Goodman, Anna; Elias, Tania; Babic-Illman, Gordana; Challacombe, Ben; Harari, Danielle; Dhesi, Jugdeep K

2017-07-01

To assess the impact of introducing and embedding a structured geriatric liaison service, Proactive care of Older People undergoing Surgery (POPS)-Urology, using comprehensive geriatric assessment methodology, on an inpatient urology ward. A phased quality improvement project was undertaken using stepwise interventions. Phase 1 was a before-and-after study with initiation of a daily board round, weekly multidisciplinary meeting, and targeted geriatrician-led ward rounds for elective and emergency urology patients aged ≥65 years admitted over two 1-month periods. Outcomes were recorded from medical records and discharge documentation, including length of inpatient stay, medical and surgical complications, and 30-day readmission and mortality rates. Phase 2 was a quality improvement project involving Plan-Do-Study-Act cycles and qualitative staff surveys in order to create a Geriatric Surgical Checklist (GSCL) to standardize the intervention in Phase 1, improve equity of care by extending it to all ages, improve team-working and streamline handovers for multidisciplinary staff. Phase 1 included 112 patients in the control month and 130 in the intervention month. The length of inpatient stay was reduced by 19% (mean 4.9 vs 4.0 days; P = 0.01), total postoperative complications were lower (risk ratio 0.24 [95% confidence interval 0.10, 0.54]; P = 0.001). A non-significant trend was seen towards fewer cancellations of surgery (10 vs 5%; P = 0.12) and 30-day readmissions (8 vs 3%; P = 0.07). In Phase 2, the GSCL was created and incrementally improved. Questionnaires repeated at intervals showed that the GSCL helped staff to understand their role better in multidisciplinary meetings, improved their confidence to raise issues, reduced duplication of handovers and standardized identification of geriatric issues. Equity of care was improved by providing the intervention to patients of all ages, despite which the time taken for the daily board round did not lengthen. This is the first known paper describing the benefits of daily proactive geriatric intervention in elective and emergency urological surgery. The results suggest that using a multidisciplinary team board round helps to facilitate collaborative working between surgical and geriatric medicine teams. The GSCL enables systematic identification of patients who require a focused comprehensive geriatric assessment. There is potential to transfer the GSCL package to other surgical specialties and hospitals to improve postoperative outcomes. © 2016 The Authors BJU International © 2016 BJU International Published by John Wiley & Sons Ltd.

The Effects of Perioperative Music Interventions in Pediatric Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

PubMed Central

van der Heijden, Marianne J. E.; Oliai Araghi, Sadaf; van Dijk, Monique; Jeekel, Johannes; Hunink, M. G. Myriam

2015-01-01

Objective Music interventions are widely used, but have not yet gained a place in guidelines for pediatric surgery or pediatric anesthesia. In this systematic review and meta-analysis we examined the effects of music interventions on pain, anxiety and distress in children undergoing invasive surgery. Data Sources We searched 25 electronic databases from their first available date until October 2014. Study Selection Included were all randomized controlled trials with a parallel group, crossover or cluster design that included pediatric patients from 1 month to 18 years old undergoing minimally invasive or invasive surgical procedures, and receiving either live music therapy or recorded music. Data Extraction and Synthesis 4846 records were retrieved from the searches, 26 full text reports were evaluated and data was extracted by two independent investigators. Main Outcome Measures Pain was measured with the Visual Analogue Scale, the Coloured Analogue Scale and the Facial Pain Scale. Anxiety and distress were measured with an emotional index scale (not validated), the Spielberger short State Trait Anxiety Inventory and a Facial Affective Scale. Results Three RCTs were eligible for inclusion encompassing 196 orthopedic, cardiac and day surgery patients (age of 1 day to 18 years) receiving either live music therapy or recorded music. Overall a statistically significant positive effect was demonstrated on postoperative pain (SMD -1.07; 95%CI-2.08; -0.07) and on anxiety and distress (SMD -0.34 95% CI -0.66; -0.01 and SMD -0.50; 95% CI -0.84; - 0.16. Conclusions and Relevance This systematic review and meta-analysis indicates that music interventions may have a statistically significant effect in reducing post-operative pain, anxiety and distress in children undergoing a surgical procedure. Evidence from this review and other reviews suggests music therapy may be considered for clinical use. PMID:26247769

Suboptimal identification of patient-specific risk factors for poor wound healing can be improved by simple interventions.

PubMed

Harris, Lauren S; Luck, Joshua E; Atherton, Rachel R

2017-02-01

Poor wound healing is an important surgical complication. At-risk wounds must be identified early and monitored appropriately. Wound surveillance is frequently inadequate, leading to increased rates of surgical site infections (SSIs). Although the literature demonstrates that risk factor identification reduces SSI rates, no studies have focused on wound management at a junior level. Our study assesses documentation rates of patient-specific risk factors for poor wound healing at a large district general hospital in the UK. It critically evaluates the efficacy of interventions designed to promote surveillance of high-risk wounds. We conducted a full-cycle clinical audit examining medical records of patients undergoing elective surgery over 5 days. Interventions included education of the multidisciplinary team and addition of a Wound Healing Risk Assessment (WHRA) checklist to surgical admissions booklets. This checklist provided a simple stratification tool for at-risk wounds and recommendations for escalation. Prior to interventions, the documentation of patient-specific risk factors ranged from 0·0% to 91·7% (mean 42·6%). Following interventions, this increased to 86·4-95·5% (mean 92·5%), a statistically significant increase of 117·1% (P < 0·01). This study demonstrates that documentation of patient-specific risk factors for poor wound healing is inadequate. We have shown the benefit of introducing interventions to increase risk factor awareness. © 2016 Medicalhelplines.com Inc and John Wiley & Sons Ltd.

Surgical treatment of childhood recurrent pancreatitis.

PubMed

Clifton, Matthew S; Pelayo, Juan C; Cortes, Raul A; Grethel, Erich J; Wagner, Amy J; Lee, Hanmin; Harrison, Michael R; Farmer, Diana L; Nobuhara, Kerilyn K

2007-07-01

Surgical intervention that improves pancreatic ductal drainage is a reasonable treatment strategy for recurrent pancreatitis in children. This study was approved by the Committee on Human Research (San Francisco, CA). A retrospective chart review was performed on children aged 0 to 17 years given the International Classification of Diseases, Ninth Revision coding diagnosis of chronic pancreatitis who underwent surgical intervention from 1981 to 2005. From 1981 to 2005, 32 children were treated for the diagnosis of chronic pancreatitis. The etiologies were obstructive (n = 13), idiopathic (n = 10), hereditary (n = 6), medications (n = 2), and infection (n = 1). Fifteen patients underwent 17 operations for chronic pancreatitis, including Puestow (n = 9), cystenterostomy (n = 2), Whipple (n = 1), distal pancreatectomy (n = 1), Frey (n = 1), DuVal (n = 1), excision of enteric duplication cyst (n = 1), and pancreatic ductal dilation (n = 1). The mean age at presentation of patients undergoing surgery was 6.0 +/- 4.1 years (mean +/- SD). The mean time from presentation to operation was 3.3 +/- 3.3 years. There were no deaths after surgical intervention. Of 15 patients, 2 (13%) required rehospitalization within 90 days of surgery, one for bowel obstruction, the other for splenic infarction. The median length of stay postoperatively was 8 days (range, 5-66 days). Chronic pancreatitis in children differs markedly in etiology when compared with adults. In most cases seen in our institution, chronic pancreatitis resulted from ineffective ductal drainage. These disorders are amenable to surgical decompression, which, ultimately, can prevent disease recurrence.

Obstructive Sleep Apnea and Surgery: Quality Improvement Imperatives and Opportunities

PubMed Central

Goldman, Julie L.

2014-01-01

Obstructive sleep apnea (OSA) is more common in surgical candidates than in the general population and may increase susceptibility to perioperative complications that range from transient desaturation to catastrophic injuries. Understanding the potential impact of OSA on patients’ surgical risk profile is of particular interest to otolaryngologists, who routinely perform airway procedures—including surgical procedures for treatment of OSA. Whereas the effects of OSA on long-term health outcomes are well documented, the relationship between OSA and surgical risk is not collinear, and clear consensus on the nature of the association is lacking. Better guidelines for optimization of pain control, perioperative monitoring, and surgical decision making are potential areas for quality improvement efforts. Many interventions have been suggested to mitigate the risk of adverse events in surgical patients with OSA, but wide variations in clinical practice remain. We review the current literature, emphasizing recent progress in understanding the complex pathophysiologic interactions noted in OSA patients undergoing surgery and outlining potential strategies to decrease perioperative risks. PMID:25013745

Systemic Inflammatory and Th17 Immune Activation among Patients Treated for Lumbar Radiculopathy Exceeds that of Patients Treated for Persistent Postoperative Neuropathic Pain.

PubMed

Shamji, Mohammed F; Guha, Daipayan; Paul, Darcia; Shcharinsky, Alina

2017-09-01

The pathophysiology of lumbar radiculopathy includes both mechanical compression and biochemical irritation of apposed neural elements. Inflammatory and immune cytokines have been implicated, induced by systemic exposure of immune-privileged intervertebral disc tissue. Surgical intervention provides improved symptoms and quality of life, but persistent postoperative neuropathic pain (PPNP) afflicts a significant fraction of patients. To compare the inflammatory and immune phenotypes among patients undergoing structural surgery for lumbar radiculopathy and spinal cord stimulation for neuropathic pain. Consecutive patients undergoing surgical intervention for lumbar radiculopathy or neuropathic pain were studied. Demographic data included age, gender, and VAS and neuropathic pain scores. Serum was evaluated for cytokine levels (IL-6, Il-17, TNF-α) and cellular content [white blood cell (WBC)/differential, lymphocyte subtypes]. The primary analysis differentiated molecular and cellular profiles between radiculopathy and neuropathic pain patients. Subgroup analysis within the surgical radiculopathy population compared those patients achieving relief of symptoms and those with PPNP. Heightened IL-6, Il-17, and TNF-α levels were observed for the lumbar radiculopathy group compared with the neuropathic pain group. This was complemented by higher WBC count and a greater fraction of Th17 lymphocytes among radiculopathy patients. In the lumbar discectomy subgroup, pain relief was seen among patients with preoperatively elevated IL-17 levels. Those patients with PPNP refractory to surgical discectomy exhibited normal cytokine levels. Differences in Th17 immune activation are seen among radiculopathy and neuropathic pain patients. These cellular and molecular profiles may be translated into biomarkers to improve patient selection for structural spine surgery. Copyright © 2017 by the Congress of Neurological Surgeons

Mixed Reality in Visceral Surgery: Development of a Suitable Workflow and Evaluation of Intraoperative Use-cases.

PubMed

Sauer, Igor M; Queisner, Moritz; Tang, Peter; Moosburner, Simon; Hoepfner, Ole; Horner, Rosa; Lohmann, Rudiger; Pratschke, Johann

2017-11-01

The paper evaluates the application of a mixed reality (MR) headmounted display (HMD) for the visualization of anatomical structures in complex visceral-surgical interventions. A workflow was developed and technical feasibility was evaluated. Medical images are still not seamlessly integrated into surgical interventions and, thus, remain separated from the surgical procedure.Surgeons need to cognitively relate 2-dimensional sectional images to the 3-dimensional (3D) during the actual intervention. MR applications simulate 3D images and reduce the offset between working space and visualization allowing for improved spatial-visual approximation of patient and image. The surgeon's field of vision was superimposed with a 3D-model of the patient's relevant liver structures displayed on a MR-HMD. This set-up was evaluated during open hepatic surgery. A suitable workflow for segmenting image masks and texture mapping of tumors, hepatic artery, portal vein, and the hepatic veins was developed. The 3D model was positioned above the surgical site. Anatomical reassurance was possible simply by looking up. Positioning in the room was stable without drift and minimal jittering. Users reported satisfactory comfort wearing the device without significant impairment of movement. MR technology has a high potential to improve the surgeon's action and perception in open visceral surgery by displaying 3D anatomical models close to the surgical site. Superimposing anatomical structures directly onto the organs within the surgical site remains challenging, as the abdominal organs undergo major deformations due to manipulation, respiratory motion, and the interaction with the surgical instruments during the intervention. A further application scenario would be intraoperative ultrasound examination displaying the image directly next to the transducer. Displays and sensor-technologies as well as biomechanical modeling and object-recognition algorithms will facilitate the application of MR-HMD in surgery in the near future.

Optic neuropathy in thyroid eye disease: results of the balanced decompression technique.

PubMed

Baril, Catherine; Pouliot, Denis; Molgat, Yvonne

2014-04-01

To determine the efficacy of combined endoscopic medial and external lateral orbital decompression for the treatment of compressive optic neuropathy (CON) in thyroid eye disease (TED). A retrospective review of all patients undergoing combined surgical orbital decompression for CON between 2000 and 2010 was conducted. Fifty-nine eyes of 34 patients undergoing combined surgical orbital decompression for CON. Clinical outcome measures included visual acuity, Hardy-Rand-Rittler (HRR) colour plate testing, relative afferent pupillary defect, intraocular pressure measurement, and Hertel exophthalmometry. A CON score was calculated preoperatively and postoperatively based on the visual acuity and the missed HRR plates. A higher CON score correlates with more severe visual dysfunction. All patients had improvement of their optic neuropathy after surgical decompression. CON score was calculated for 54 eyes and decreased significantly from a mean of 13.2 ± 10.35 preoperatively to a mean of 8.51 ± 10.24 postoperatively (p < 0.0001). Optic neuropathy was completely resolved in 93.22% (55/59 eyes). Eighteen of 34 patients (52.94%) experienced development of new-onset postoperative strabismus that required subsequent surgical intervention. Endoscopic medial combined with external lateral orbital decompression is an effective technique for the treatment of TED-associated CON. © 2013 Canadian Ophthalmological Society Published by Canadian Ophthalmological Society All rights reserved.

GEDOS-SECOT consensus on the care process of patients with knee osteoarthritis and arthoplasty.

PubMed

Ruiz Iban, M A; Tejedor, A; Gil Garay, E; Revenga, C; Hermosa, J C; Montfort, J; Peña, M J; López Millán, J M; Montero Matamala, A; Capa Grasa, A; Navarro, M J; Gobbo, M; Loza, E

To develop recommendations on the evaluation and management procedure in patients undergoing total knee replacement based on best evidence and the experience of a panel of experts. A multidisciplinary group of 12 experts was selected that defined the scope, users and the document parts. Three systematic reviews were performed in patients undergoing knee replacement: (i)efficacy and safety of fast-tracks; (ii)efficacy and safety of cognitive interventions in patients with catastrophic pain, and (iii) efficacy and safety of acute post-surgical pain management on post-surgical outcomes. A narrative review was conducted on the evaluation and management of pain sensitization, and about the efficacy and safety of pre-surgical physiotherapy. The experts generated the recommendations and explicative text. The level of agreement was evaluated in a multidisciplinary group of 85 experts with the Delphi technique. The level of evidence was established as well for each recommendation. A total of 20 recommendations were produced. An agreement higher than 80% was reached in all of them. We found the highest agreement on the need for a full discharge report, on providing proper information about the process and on following available guidelines. There is consensus among professionals involved in the management of patients undergoing total knee replacement, in that it is important to protocolize the replacement process, performing a proper, integrated and coordinated patient evaluation and follow-up, paying special attention to the surgical procedure and postoperative period. Copyright © 2017 SECOT. Publicado por Elsevier España, S.L.U. All rights reserved.

Risk factors for indications of intraoperative blood transfusion among patients undergoing surgical treatment for colorectal adenocarcinoma.

PubMed

Gonçalves, Iara; Linhares, Marcelo; Bordin, Jose; Matos, Delcio

2009-01-01

Identification of risk factors for requiring transfusions during surgery for colorectal cancer may lead to preventive actions or alternative measures, towards decreasing the use of blood components in these procedures, and also rationalization of resources use in hemotherapy services. This was a retrospective case-control study using data from 383 patients who were treated surgically for colorectal adenocarcinoma at 'Fundação Pio XII', in Barretos-SP, Brazil, between 1999 and 2003. To recognize significant risk factors for requiring intraoperative blood transfusion in colorectal cancer surgical procedures. Univariate analyses were performed using Fisher's exact test or the chi-squared test for dichotomous variables and Student's t test for continuous variables, followed by multivariate analysis using multiple logistic regression. In the univariate analyses, height (P = 0.06), glycemia (P = 0.05), previous abdominal or pelvic surgery (P = 0.031), abdominoperineal surgery (P<0.001), extended surgery (P<0.001) and intervention with radical intent (P<0.001) were considered significant. In the multivariate analysis using logistic regression, intervention with radical intent (OR = 10.249, P<0.001, 95% CI = 3.071-34.212) and abdominoperineal amputation (OR = 3.096, P = 0.04, 95% CI = 1.445-6.623) were considered to be independently significant. This investigation allows the conclusion that radical intervention and the abdominoperineal procedure in the surgical treatment of colorectal adenocarcinoma are risk factors for requiring intraoperative blood transfusion.

Spontaneous resolution of hemorrhagic polyps of the true vocal fold.

PubMed

Klein, Adam M; Lehmann, Marcus; Hapner, Edie R; Johns, Michael M

2009-01-01

Hemorrhagic polyps are the most common benign lesions surgically removed from the vocal folds. Although this modality does offer satisfactory results in most of the cases, there is a subset of polyps that seems to resolve with conservative therapy. This study was performed to examine this subset of polyps. Thirty-four consecutive subjects diagnosed with hemorrhagic polyps of the true vocal fold were retrospectively reviewed to determine the incidence of spontaneous resolution of the lesions with nonsurgical therapy. Sixteen subjects began conservative therapy, consisting of voice therapy and proper vocal hygiene, often while awaiting an optimal personal time for surgical intervention. Of these subjects, nine (56.3%) experienced a resolution of their lesion and symptoms without undergoing surgical therapy. Surgical removal of hemorrhagic polyps is often considered the standard of treatment for these benign lesions. However, these observations support a regimen of voice therapy and observation in select cases.

Surgically Induced Scleral Necrosis in a Patient With Rheumatoid Arthritis After AGV Implantation.

PubMed

Kumar, Suresh; Ichhpujani, Parul; Thakur, Sahil

2018-03-01

Surgically induced scleral necrosis (SINS) is a rare entity that has till date not been reported in a patient of glaucoma undergoing Ahmed glaucoma valve (AGV) implantation. We present a case of primary open-angle glaucoma who underwent AGV implantation followed by development of scleral necrosis, involving both the scleral patch graft and host sclera. After failure of surgical and medical management, AGV had to be explanted. The patient was diagnosed with rheumatoid arthritis and had to be treated with steroids and azathioprine for the same. SINS is a potentially disastrous complication of ocular surgery that can occur in patients with systemic diseases like rheumatoid arthritis and requires aggressive management to salvage the eye. SINS can occur with AGV implantation. Treatment may require aggressive medical and surgical intervention. It is imperative to evaluate patients for systemic illness before planning an AGV implant.

Fetal Heart Rate Monitoring During Surgical Correction of Spontaneous Pneumothorax During Pregnancy: Lessons in In Utero Resuscitation.

PubMed

Wilson, Bailey; Burt, Bryan; Baker, Byron; Clark, Steven L; Belfort, Michael; Gandhi, Manisha

2016-01-01

Spontaneous pneumothorax during pregnancy has potentially serious implications for the mother and fetus. When surgical correction is required, complex maternal physiologic alterations may significantly affect fetal well-being. A woman underwent thoracoscopic lung resection and pleurodesis at 29 weeks of gestation. At various points during the procedure, maternal hemodynamic and respiratory consequences of anesthetic and surgical management resulted in severe fetal heart rate (FHR) decelerations and bradycardia. In each instance, physiologic manipulations based on an understanding of the likely cause of fetal hypoxia allowed correction of the FHR abnormalities without delivery. Nonsurgical perinatal intervention based on FHR monitoring and analysis of the likely pathophysiologic abnormalities underlying fetal decelerations may allow the gravid woman to undergo complex procedures and continue the pregnancy.

Outcomes of gynecologic oncology patients undergoing gastrografin small bowel follow-through studies.

PubMed

Walters, Christen L; Sutton, Amelia L M; Huddleston-Colburn, Mary Kathryn; Whitworth, Jenny M; Schneider, Kellie E; Straughn, J Michael

2014-01-01

To characterize the outcomes of gynecologic oncology patients undergoing small bowel follow-throughs (SBFTs) with Gastrografin at our institution. We identified all gynecologic oncology patients undergoing an SBFT from January 2004 to December 2009. We characterized the SBFT as normal, delayed transit, partial obstruction, or complete obstruction. Patient outcomes were correlated with the SBFT results. Seventy patients underwent 79 SBFT examinations with Gastrografin to evaluate their bowel dysfunction. The overall rate of operative intervention was 23%. A total of 69% of patients with a complete obstruction underwent surgery as compared to 21% of patients with a partial obstruction (p = 0.002). Return of bowel function was significantly longer in patients with complete obstructions as compared to patients with partial obstructions (48 vs. 8 hours, p = 0.006). Length of stay was longest in patients with complete obstructions. The majority of patients with a complete obstruction on SBFT will require surgical intervention and have a protracted hospital stay. Patients with delayed transit or a partial obstruction on SBFT usually will have resolution of their bowel dysfunction with conservative management.

Continuous spinal anaesthesia with minimally invasive haemodynamic monitoring for surgical hip repair in two patients with severe aortic stenosis.

PubMed

López, María Mercedes; Guasch, Emilia; Schiraldi, Renato; Maggi, Genaro; Alonso, Eduardo; Gilsanz, Fernando

2016-01-01

Aortic stenosis increases perioperative morbidity and mortality, perioperative invasive monitoring is advised for patients with an aortic valve area <1.0 cm(2) or a mean aortic valve gradient >30 mmHg and it is important to avoid hypotension and arrhythmias. We report the anaesthetic management with continuous spinal anaesthesia and minimally invasive haemodynamic monitoring of two patients with severe aortic stenosis undergoing surgical hip repair. Two women with severe aortic stenosis were scheduled for hip fracture repair. Continuous spinal anaesthesia with minimally invasive haemodynamic monitoring was used for anaesthetic management of both. Surgery was performed successfully after two consecutive doses of 2mg of isobaric bupivacaine 0.5% in one of them and four consecutive doses in the other. Haemodynamic conditions remained stable throughout the intervention. Vital signs and haemodynamic parameters remained stable throughout the two interventions. Our report illustrates the use of continuous spinal anaesthesia with minimally invasive haemodynamic monitoring as a valid alternative to general or epidural anaesthesia in two patients with severe aortic stenosis who are undergoing lower limb surgery. However, controlled clinical trials would be required to establish that this technique is safe and effective in these type or patients. Copyright © 2013 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. All rights reserved.

Antibiotic prophylaxis for surgical site infection in people undergoing liver transplantation.

PubMed

Almeida, Ricardo A M B; Hasimoto, Claudia N; Kim, Anna; Hasimoto, Erica N; El Dib, Regina

2015-12-05

Surgical site infection is more frequent in liver transplantation than in other types of solid organ transplantation with different antibiotics. Studies have shown that the rate of surgical site infection varies from 8.8% to 37.5% after liver transplantation. Therefore, antimicrobial prophylaxis is likely an essential tool for reducing these infections. However, the literature lacks evidence indicating the best prophylactic antibiotic regimen that can be used for liver transplantation. To assess the benefits and harms of antibiotic prophylactic regimens for surgical site infection in people undergoing liver transplantation. We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Science Citation Index Expanded and Latin American Caribbean Health Sciences Literature (LILACS). The most recent search was performed on 11 September 2015. All eligible randomised clinical trials comparing any antibiotic regimen versus placebo, versus no intervention or versus another antibiotic regimen for surgical site infection in liver transplant recipients, regardless of age, sex and reason for transplantation. Quasi-randomised studies and other observational studies were considered for data on harm if retrieved with search results for randomised clinical trials. Two review authors selected relevant trials, assessed risk of bias of studies and extracted data. The electronic search identified 786 publications after removal of duplicates. From this search, only one seemingly randomised clinical trial, published in abstract form, fulfilled the inclusion criteria of this review. This trial was conducted at Shiraz Transplant Centre, Shiraz, Iran, where investigators randomly assigned a total of 180 consecutive liver transplant recipients. We judged the overall risk of bias of the trial published in abstract form as high. Researchers reported no numerical data but mentioned that 163 participants met the inclusion criteria after randomisation, and hence were included in the analyses. Most probably, the 17 excluded participants were high-risk liver transplant recipients. Trial authors concluded that they could find no differences between the two antibiotic regimens - ceftriaxone plus metronidazole versus ampicillin-sulbactam plus ceftizoxime - when given to liver transplant recipients. Review authors could not reconfirm the analyses because, as it has been mentioned, trial authors provided no trial data for analyses. Benefits and harms of antibiotic prophylactic regimens for surgical site infection in liver transplantation remain unclear. Additional well-conducted randomised clinical trials adhering to SPIRIT (Spirit Protocol Items: Recommendations for Interventional Trials) and CONSORT (Consolidated Standards of Reporting Trials) guidelines are needed to determine the exact role of antibiotic prophylactic regimens in patients undergoing liver transplantation.

Surgical Management of Encapsulating Peritoneal Sclerosis: A Case Report in Kidney Transplant Patient

PubMed Central

Talanian, M.; Azari, F.; Agarwal, A.

2018-01-01

Introduction Encapsulating peritoneal sclerosis (EPS) is a clinical syndrome of progressive fibrotic change in response to prolonged, repetitive, and typically severe insult to the peritoneal mesothelium, often occurring in the setting of peritoneal dialysis (PD). Clear guidelines for successful management remain elusive. We describe the successful surgical management of EPS in a 28-year-old male s/p deceased donor kidney transplant for end-stage renal disease (ESRD) secondary to focal segmental glomerulosclerosis (FSGS). This patient received PD for 7 years but changed to hemodialysis (HD) in the year of transplant due to consistent signs and symptoms of underdialysis. EPS was visualized at the time of transplant. Despite successful renal transplantation, EPS progressed to cause small bowel obstruction (SBO) requiring PEG-J placement for enteral nutrition and gastric decompression. The patient subsequently developed a chronic gastrocutaneous fistula necessitating chronic TPN and multiple admissions for pain crises and bowel obstruction. He was elected to undergo surgical intervention due to deteriorating quality of life and failure to thrive. Surgical management included an exploratory laparotomy with extensive lysis of adhesions (LOA), repair of gastrocutaneous fistula, and end ileostomy with Hartmann's pouch. Postoperative imaging confirmed resolution of the SBO, and the patient was transitioned to NGT feeds and eventually only PO intake. He is continuing with PO nutrition, gaining weight, and free from dialysis. Conclusion Surgical intervention with LOA and release of small intestine can be successful for definitive management of EPS in the proper setting. In cases such as this, where management with enteral nutrition fails secondary to ongoing obstructive episodes, surgical intervention can be pursued in the interest of preserving quality of life. PMID:29682387

Surgical Management of Encapsulating Peritoneal Sclerosis: A Case Report in Kidney Transplant Patient.

PubMed

Shahbazov, R; Talanian, M; Alejo, J L; Azari, F; Agarwal, A; Brayman, K L

2018-01-01

Encapsulating peritoneal sclerosis (EPS) is a clinical syndrome of progressive fibrotic change in response to prolonged, repetitive, and typically severe insult to the peritoneal mesothelium, often occurring in the setting of peritoneal dialysis (PD). Clear guidelines for successful management remain elusive. We describe the successful surgical management of EPS in a 28-year-old male s/p deceased donor kidney transplant for end-stage renal disease (ESRD) secondary to focal segmental glomerulosclerosis (FSGS). This patient received PD for 7 years but changed to hemodialysis (HD) in the year of transplant due to consistent signs and symptoms of underdialysis. EPS was visualized at the time of transplant. Despite successful renal transplantation, EPS progressed to cause small bowel obstruction (SBO) requiring PEG-J placement for enteral nutrition and gastric decompression. The patient subsequently developed a chronic gastrocutaneous fistula necessitating chronic TPN and multiple admissions for pain crises and bowel obstruction. He was elected to undergo surgical intervention due to deteriorating quality of life and failure to thrive. Surgical management included an exploratory laparotomy with extensive lysis of adhesions (LOA), repair of gastrocutaneous fistula, and end ileostomy with Hartmann's pouch. Postoperative imaging confirmed resolution of the SBO, and the patient was transitioned to NGT feeds and eventually only PO intake. He is continuing with PO nutrition, gaining weight, and free from dialysis. Surgical intervention with LOA and release of small intestine can be successful for definitive management of EPS in the proper setting. In cases such as this, where management with enteral nutrition fails secondary to ongoing obstructive episodes, surgical intervention can be pursued in the interest of preserving quality of life.

Correlation of technical surgical goals to the GDI and investigation of post-operative GDI change in children with cerebral palsy.

PubMed

Bickley, Christina; Linton, Judi; Scarborough, Nancy; Sullivan, Elroy; Mitchell, Katy; Barnes, Douglas

2017-06-01

The purpose of this study was to introduce a standardized set of surgical technical achievement goals (TAGs) as part of a comprehensive outcome assessment model for children with spastic cerebral palsy (CP) undergoing orthopaedic surgical intervention to improve gait. Examination of relationships of these surgical goals to the Gait Deviation Index (GDI) and use of two assessments in tandem provided a thorough picture of technical surgical outcomes. This study also investigated changes in GDI in children with spastic CP after surgery. Data from 269 participants with spastic CP, aged 4 to 19 years with Gross Motor Function Classification System (GMFCS) levels I, II, and III who underwent lower extremity orthopaedic surgical intervention to improve gait were retrospectively analyzed. Data were examined as one heterogeneous group and sub-grouped based on pattern of involvement and GMFCS level to determine change in GDI and relationships between GDI and TAGs. Differences in TAG achievement and GDI change by GMFCS level suggest a pairing of GDI with another technical measure to be beneficial. Analysis of the outcome tools individually revealed a significant difference between the pre-operative GDI and post-operative GDI mean for the entire group, as well as each of the subgroups. A significant difference in TAG achievement by GMFCS level was also noted. This paper provides evidence that lower extremity orthopedic intervention for the ambulatory child with spastic diplegic or hemiplegic CP improves gait and that a pairing of the GDI and TAGs system is beneficial to capture an accurate technical outcome assessment in both higher and lower functioning patients. Copyright © 2017 Elsevier B.V. All rights reserved.

Type 2 diabetes mellitus and microvascular complications 1 year after Roux-en-Y gastric bypass: a case-control study.

PubMed

Miras, Alexander D; Chuah, Ling Ling; Khalil, Nofal; Nicotra, Alessia; Vusirikala, Amoolya; Baqai, Najah; Graham, Christopher; Ravindra, Saranya; Lascaratos, Gerassimos; Oliver, Nick; le Roux, Carel W

2015-07-01

We aimed to examine the effects of bariatric surgery on microvascular complications in patients with type 2 diabetes using objective measures. Prospective case-control study of 70 obese surgical patients with type 2 diabetes undergoing gastric bypass surgery matched for age, sex and duration of diabetes to 25 medical patients treated using international guidelines. Microvascular complications were assessed before and 12-18 months after intervention using urine albumin creatinine ratio (ACR) measurements, two-field digital retinal images and peripheral nerve conduction studies (in the surgical group only). Urine ACR decreased significantly in the surgical group but increased in the medical group. There were no significant differences between the surgical and medical groups in the changes in retinopathy. There were no changes in the nerve conduction variables in the surgical group. In the short term, bariatric surgery may be superior to medical care in the treatment of diabetic nephropathy, but not retinopathy or neuropathy.

Surgical Interventions for Pediatric Unilateral Vocal Cord Paralysis: A Systematic Review.

PubMed

Butskiy, Oleksandr; Mistry, Bhavik; Chadha, Neil K

2015-07-01

The most widely used surgical interventions for pediatric unilateral vocal cord paralysis include injection laryngoplasty, thyroplasty, and laryngeal reinnervation. Despite increasing interest in surgical interventions for unilateral vocal cord paralysis in children, the surgical outcomes data in children are scarce. To appraise and summarize the available evidence for pediatric unilateral vocal cord paralysis surgical strategies. MEDLINE (1946-2014) and EMBASE (1980-2014) were searched for publications that described the results of laryngoplasty, thyroplasty, or laryngeal reinnervation for pediatric unilateral vocal cord paralysis. Further studies were identified from bibliographies of relevant studies, gray literature, and annual scientific assemblies. Two reviewers independently appraised the selected studies for quality, level of evidence, and risk of bias as well as extracted data, including unilateral vocal cord paralysis origin, voice outcomes, swallowing outcomes, and adverse events. Of 366 identified studies, the inclusion criteria were met by 15 studies: 6 observational studies, 6 case series, and 3 case reports. All 36 children undergoing laryngeal reinnervation (8 studies) had improvement or resolution of dysphonia. Of 31 children receiving injection laryngoplasty (6 studies), most experienced improvement in voice quality, speech, swallowing, aspiration, and glottic closure. Of 12 children treated by thyroplasty (5 studies), 2 experienced resolution of dysphonia, 4 had some improvement, and 4 had no improvement (2 patients had undocumented outcomes). Thyroplasty resolved or improved aspiration in 7 of 8 patients. Published studies suggest that reinnervation may be the most effective surgical intervention for children with dysphonia; however, long-term follow-up data are lacking. With the exception of polytetrafluoroethylene injections, injection laryngoplasty was reported to be a relatively safe, nonpermanent, and effective option for most children with dysphonia. Thyroplasty appears to have fallen out favor in recent years because of difficulty in performing this procedure in children under local anesthesia, but it continues to be a viable option for children with aspiration.

Perioperative management of adult patients with a history of stroke or transient ischaemic attack undergoing elective non-cardiac surgery.

PubMed

Mehdi, Zehra; Birns, Jonathan; Partridge, Judith; Bhalla, Ajay; Dhesi, Jugdeep

2016-12-01

It is increasingly common for physicians and anaesthetists to be asked for advice in the medical management of surgical patients who have an incidental history of stroke or transient ischaemic attack (TIA). Advising clinicians requires an understanding of the common predictors, outcomes and management of perioperative stroke. The most important predictor of perioperative stroke is a previous history of stroke, and outcomes associated with such an event are extremely poor. The perioperative management of this patient group needs careful consideration to minimise the thrombotic risk and a comprehensive, individualised approach is crucial. Although there is literature supporting the management of such patients undergoing cardiac surgery, evidence is lacking in the setting of non-cardiac surgical intervention. This article reviews the current evidence and provides a pragmatic interpretation to inform the perioperative management of patients with a history of stroke and/or TIA presenting for elective non-cardiac surgery. © Royal College of Physicians 2016. All rights reserved.

[Paradigm shift in the management of metastatic epidural spinal cord compression: the importance of preserving ambulation].

PubMed

Itshayek, Eyal

2013-12-01

In 2005, a Landmark study showed that direct decompressive surgery, followed by postoperative external beam radiotherapy (EBRT) is superior to EBRT alone in patients with metastatic epidural spinal cord compression (MESCC). Patients undergoing both surgery and EBRT had similar median survival but experienced longer ambulation than with EBRT alone. Additional studies have shown improvements in quality-of-life, higher cost-effectiveness, improved pain control, and higher functional status with surgery plus EBRT. Improved neurological outcome also improved the patients' ability to undergo postoperative adjuvant therapy. According to our experience, even patients over 65 or patients with aggressive primary tumors and additional metastases have benefited from surgical intervention, living longer than expected with preservation of ambulation and sphincter control until death or shortly before. Preserving ambulation is critical. With current surgical devices and techniques, patients with MESCC who present with a single area of cord compression, back pain, neurological deficit, or progressive deformity, may benefit from surgery prior to adjuvant radiation-based treatment or chemotherapy.

Comparison of Outcomes of Pericardiocentesis Versus Surgical Pericardial Window in Patients Requiring Drainage of Pericardial Effusions.

PubMed

Horr, Samuel E; Mentias, Amgad; Houghtaling, Penny L; Toth, Andrew J; Blackstone, Eugene H; Johnston, Douglas R; Klein, Allan L

2017-09-01

Comparative outcomes of patients undergoing pericardiocentesis or pericardial window are limited. Development of pericardial effusion after cardiac surgery is common but no data exist to guide best management. Procedural billing codes and Cleveland Clinic surgical registries were used to identify 1,281 patients who underwent either pericardiocentesis or surgical pericardial window between January 2000 and December 2012. The 656 patients undergoing an intervention for a pericardial effusion secondary to cardiac surgery were also compared. Propensity scoring was used to identify well-matched patients in each group. In the overall cohort, in-hospital mortality was similar between the group undergoing pericardiocentesis and surgical drainage (5.3% vs 4.4%, p = 0.49). Similar outcomes were found in the propensity-matched group (4.9% vs 6.1%, p = 0.55). Re-accumulation was more common after pericardiocentesis (24% vs 10%, p <0.0001) and remained in the matched cohorts (23% vs 9%, p <0.0001). The secondary outcome of hemodynamic instability after the procedure was more common in the pericardial window group in both the unmatched (5.2% vs 2.9%, p = 0.036) and matched cohorts (6.1% vs 2.0%, p = 0.022). In the subgroup of patients with a pericardial effusion secondary to cardiac surgery, there was a lower mortality after pericardiocentesis in the unmatched group (1.5% vs 4.6%, p = 0.024); however, after adjustment, this difference in mortality was no longer present (2.6% vs 4.5%, p = 0.36). In conclusion, both pericardiocentesis and surgical pericardial window are safe and effective treatment strategies for the patient with a pericardial effusion. In our study there were no significant differences in mortality in patients undergoing either procedure. Observed differences in outcomes with regard to recurrence rates, hemodynamic instability, and in those with postcardiac surgery effusions may help to guide the clinician in management of the patient requiring therapeutic or diagnostic drainage of a pericardial effusion. Copyright © 2017 Elsevier Inc. All rights reserved.

Effectiveness of a bundled intervention of decolonization and prophylaxis to decrease Gram positive surgical site infections after cardiac or orthopedic surgery: systematic review and meta-analysis.

PubMed

Schweizer, Marin; Perencevich, Eli; McDanel, Jennifer; Carson, Jennifer; Formanek, Michelle; Hafner, Joanne; Braun, Barbara; Herwaldt, Loreen

2013-06-13

To evaluate studies assessing the effectiveness of a bundle of nasal decolonization and glycopeptide prophylaxis for preventing surgical site infections caused by Gram positive bacteria among patients undergoing cardiac operations or total joint replacement procedures. Systematic review and meta-analysis. PubMed (1995 to 2011), the Cochrane database of systematic reviews, CINAHL, Embase, and clinicaltrials.gov were searched to identify relevant studies. Pertinent journals and conference abstracts were hand searched. Study authors were contacted if more data were needed. Randomized controlled trials, quasi-experimental studies, and cohort studies that assessed nasal decolonization or glycopeptide prophylaxis, or both, for preventing Gram positive surgical site infections compared with standard care. Patients undergoing cardiac operations or total joint replacement procedures. DATA EXTRACTION AND STUDY APPRAISAL: Two authors independently extracted data from each paper and a random effects model was used to obtain summary estimates. Risk of bias was assessed using the Downs and Black or the Cochrane scales. Heterogeneity was assessed using the Cochran Q and I(2) statistics. 39 studies were included. Pooled effects of 17 studies showed that nasal decolonization had a significantly protective effect against surgical site infections associated with Staphylococcus aureus (pooled relative risk 0.39, 95% confidence interval 0.31 to 0.50) when all patients underwent decolonization (0.40, 0.29 to 0.55) and when only S aureus carriers underwent decolonization (0.36, 0.22 to 0.57). Pooled effects of 15 prophylaxis studies showed that glycopeptide prophylaxis was significantly protective against surgical site infections related to methicillin (meticillin) resistant S aureus (MRSA) compared with prophylaxis using β lactam antibiotics (0.40, 0.20 to 0.80), and a non-significant risk factor for methicillin susceptible S aureus infections (1.47, 0.91 to 2.38). Seven studies assessed a bundle including decolonization and glycopeptide prophylaxis for only patients colonized with MRSA and found a significantly protective effect against surgical site infections with Gram positive bacteria (0.41, 0.30 to 0.56). Surgical programs that implement a bundled intervention including both nasal decolonization and glycopeptide prophylaxis for MRSA carriers may decrease rates of surgical site infections caused by S aureus or other Gram positive bacteria.

Surgical site infections in an abdominal surgical ward at Kosovo Teaching Hospital.

PubMed

Raka, Lul; Krasniqi, Avdyl; Hoxha, Faton; Musa, Ruustem; Mulliqi, Gjyle; Krasniqi, Selvete; Kurti, Arsim; Dervishaj, Antigona; Nuhiu, Beqir; Kelmendi, Baton; Limani, Dalip; Tolaj, Ilir

2008-01-01

Abdominal surgical site infections (SSI) cause substantial morbidity and mortality for patients undergoing operative procedures. We determined the incidence of and risk factors for SSI after abdominal surgery in the Department of Abdominal Surgery at the University Clinical Centre of Kosovo (UCCK). Prospective surveillance of patients undergoing abdominal surgery was performed between December 2005 and June 2006. CDC definitions were followed to detect SSI and study forms were based on Europe Link for Infection Control through Surveillance (HELICS) protocol. A total of 253 surgical interventions in 225 patients were evaluated. The median age of patients was 42 years and 55.1% of them were male. The overall incidence rate of SSI was 12%. Follow-up was achieved for 84.1% of the procedures. For patients with an SSI, the median duration of hospitalization was 9 days compared with 4 days for those without an SSI (p < 0.001). Surgical procedures were classified as emergent in 53.3% of cases. Superficial incisional SSI was most common (55%). Clinical infections were culture positive in 40.7% of cases. Duration of operation, duration of preoperative stay, wound class, ASA score > 2, use of antibiotic prophylaxis and NNIS class of > 2 were all significant at p < .001. The SSI rates for the NNIS System risk classes 0, 1 and 2-3 were 4.2%, 46.7% and 100%, respectively. SSI caused considerable morbidity among surgical patients in UCCK. Appropriate active surveillance and infection control measures should be introduced during preoperative, intra-operative, and postoperative care to reduce infection rates.

Does preoperative oral carbohydrate treatment reduce the postoperative surgical stress response in lumbar disc surgery?

PubMed

Dilmen, Ozlem Korkmaz; Yentur, Ercument; Tunali, Yusuf; Balci, Huriye; Bahar, Mois

2017-02-01

Surgical trauma produces metabolic and hormonal responses, which are characterized by insulin resistance. Due to extension of the preoperative fasting period, which increases the magnitude of postoperative insulin resistance, preoperative oral carbohydrates (POC) have been developed. This prospective, randomized, controlled study was performed on 43 ASA I-II patients undergoing elective microsurgical lumbar discectomy. The intervention group received oral carbohydrate solution 800mL the night before and 400mL 2h prior to operation. The other group fasted for 8h prior to operation. Blood samples were obtained the day before the operation, before induction of anesthesia, after skin incision, 1h, 2h, 6h and 24h following skin incision. Blood glucose, plasma insulin, cortisol and interleukin-6 (IL-6) levels were determined. The primary endpoint was to assess the effect of POC treatment on insulin resistance and surgical stress response following lumbar disc surgery. The secondary endpoint was to assess POC's effects on postoperative nausea and vomiting. The serum insulin levels were higher before induction of anesthesia in the study group and returned to fasted group levels by 2h after skin incision. The plasma IL-6 levels were higher in the intervention group at 6h after the skin incision. There were no differences between the two groups with respect to blood glucose, plasma cortisol levels and the incidence of nausea and vomiting. This study suggests that use of POC treatment does not attenuate development of insulin resistance in patients undergoing lumbar disc surgery. Copyright © 2016. Published by Elsevier B.V.

The Effect of Music on Anxiety and Cardiovascular Indices in Patients Undergoing Coronary Artery Bypass Graft: A Randomized Controlled Trial.

PubMed

Heidari, Saeide; Babaii, Atye; Abbasinia, Mohammad; Shamali, Mahdi; Abbasi, Mohammad; Rezaei, Mahboobe

2015-12-01

The instability of cardiovascular indices and anxiety disorders are common among patients undergoing coronary artery bypass graft (CABG) and could interfere with their recovery. Therefore, improving the cardiovascular indices and anxiety is essential. This study aimed to investigate the effect of music therapy on anxiety and cardiovascular indices in patients undergoing CABG. In this randomized controlled trial, 60 patients hospitalized in the cardiovascular surgical intensive care unit of Shahid Beheshti Hospital in Qom city, Iran, in 2013 were selected using a consecutive sampling method and randomly allocated into the experimental and control groups. In the experimental group, patients received 30 minutes of light music, whereas in the control group, patients had 30 minutes of rest in bed. The cardiovascular indices and anxiety were measured immediately before, immediately after and half an hour after the study. Data were analyzed using the chi-square test and repeated measures analysis of variance. Compared to the immediately before intervention, the mean anxiety scores immediately after and 30 minutes after the intervention were significantly lower in the experimental group (P < 0.037) while it did not significantly change in the control group. However, there were no significant differences regarding the cardiovascular indices in the three consecutive measurements (P > 0.05). Music therapy is effective in decreasing anxiety among patients undergoing CABG. However, the intervention was not effective on cardiovascular indices. Music can effectively be used as a non-pharmacological method to manage anxiety after CABG.

A non-interventional comparative study of the 20:1 combination of cafedrine/theodrenaline versus ephedrine for the treatment of intra-operative arterial hypotension: the 'HYPOTENS' study design and rationale.

PubMed

Eberhart, Leopold; Geldner, Götz; Huljic, Susanne; Marggraf, Kerstin; Keller, Thomas; Koch, Tilo; Kranke, Peter

2018-06-01

To compare the effectiveness of 20:1 cafedrine/theodrenaline approved for use in Germany to ephedrine in the restoration of arterial blood pressure and on post-operative outcomes in patients with intra-operative arterial hypotension of any origin under standard clinical practice conditions. 'HYPOTENS' is a national, multi-center, prospective, open-label, two-armed, non-interventional study. Effectiveness and post-operative outcome following cafedrine/theodrenaline or ephedrine therapy will be evaluated in two cohorts of hypotensive patients. Cohort A includes patients aged ≥50 years with ASA-classification 2-4 undergoing non-emergency surgical procedures under general anesthesia. Cohort B comprises patients undergoing Cesarean section under spinal anesthesia. Participating surgical departments will be assigned to a treatment arm by routinely used anti-hypotensive agent. To minimize bias, matched department pairs will be compared in a stratified selection process. The composite primary end-point is the lower absolute deviation from individually determined target blood pressure (IDTBP) and the incidence of heart rate ≥100 beats/min in the first 15 min. Secondary end-points include incidence and degree of early post-operative delirium (cohort A), severity of fetal acidosis in the newborn (cohort B), upper absolute deviation from IDTBP, percentage increase in systolic blood pressure, and time to IDTBP. This open-label, non-interventional study design mirrors daily practice in the treatment of patients with intra-operative hypotension and ensures full treatment decision autonomy with respect to each patient's individual condition. Selection of participating sites by a randomization process addresses bias without interfering with the non-interventional nature of the study. First results are expected in 2018. ClinicalTrials.gov identifier: NCT02893241; DRKS identifier: DRKS00010740.

A contemporary, single-institutional experience of surgical versus expectant management of congenital heart disease in trisomy 13 and 18 patients.

PubMed

Costello, John P; Weiderhold, Allison; Louis, Clauden; Shaughnessy, Conner; Peer, Syed M; Zurakowski, David; Jonas, Richard A; Nath, Dilip S

2015-06-01

The objective of this study was to examine a large institutional experience of patients with trisomy 13 and trisomy 18 in the setting of comorbid congenital heart disease and present the outcomes of surgical versus expectant management. It is a retrospective single-institution cohort study. Institutional review board approved this study. Thirteen consecutive trisomy 18 patients and three consecutive trisomy 13 patients (sixteen patients in total) with comorbid congenital heart disease who were evaluated by our institution's Division of Cardiovascular Surgery between January 2008 and December 2013 were included in the study. The primary outcome measures evaluated were operative mortality (for patients who received surgical management), overall mortality (for patients who received expectant management), and total length of survival during follow-up. Of the thirteen trisomy 18 patients, seven underwent surgical management and six received expectant management. With surgical management, operative mortality was 29 %, and 80 % of patients were alive after a median follow-up of 116 days. With expectant management, 50 % of patients died before hospital discharge. Of the three patients with trisomy 13, one patient underwent surgical management and two received expectant management. The patient who received surgical management with complete repair was alive at last follow-up over 2 years after surgery; both patients managed expectantly died before hospital discharge. Trisomy 13 and trisomy 18 patients with comorbid congenital heart disease can undergo successful cardiac surgical intervention. In this population, we advocate that nearly all patients with cardiovascular indications for operative congenital heart disease intervention should be offered complete surgical repair over palliative approaches for moderately complex congenital cardiac anomalies.

Advanced Stent Graft Treatment of Venous Stenosis Affecting Hemodialysis Vascular Access: Case Illustrations

PubMed Central

Patel, Darshan; Ray, Charles E.; Lokken, R. Peter; Bui, James T.; Lipnik, Andrew J.; Gaba, Ron C.

2016-01-01

Surgically placed dialysis access is an important component of dialysis replacement therapy. The vast majority of patients undergoing dialysis will have surgically placed accesses at some point in the course of their disease, and for many patients these accesses may represent their definitive renal replacement option. Most, if not all, arteriovenous fistulae and grafts will require interventions at some point in time. Percutaneous angioplasty is the typical first treatment performed for venous stenoses, with stents and stent grafts being reserved for patients in whom angioplasty and surgical options are exhausted. In some salvage situations, stent graft placement may be the only or best option for patients. This article describes, using case illustrations, placement of stent grafts in such patients; a focus will also be made on the techniques utilized in such salvage situations. PMID:27011426

Society of Family Planning clinical guidelines pain control in surgical abortion part 1 - local anesthesia and minimal sedation.

PubMed

Allen, Rebecca H; Singh, Rameet

2018-06-01

Satisfactory pain control for women undergoing surgical abortion is important for patient comfort and satisfaction. Clinicians ought to be aware of the safety and efficacy of different pain control regimens. This document will focus on nonpharmacologic modalities to reduce pain and pharmacologic interventions up to the level of minimal sedation. For surgical abortion without intravenous medications, a multimodal approach to pain control may combine a dedicated emotional-support person, visual or auditory distraction, administration of local anesthesia to the cervix with buffered lidocaine and a preoperative nonsteroidal anti-inflammatory drug. Oral opioids do not decrease procedural pain. Oral anxiolytics decrease anxiety but not the experience of pain. Further research is needed on alternative options to control pain short of moderate or deep sedation. Copyright © 2018 Elsevier Inc. All rights reserved.

Metabolic Bone Diseases and Total Hip Arthroplasty: Preventing Complications.

PubMed

Moya-Angeler, Joaquin; Lane, Joseph M; Rodriguez, Jose A

2017-11-01

Metabolic bone diseases are a diverse group of conditions characterized by abnormalities in calcium metabolism and/or bone cell physiology. These unbalanced processes can eventually lead to bony deformities and altered joint biomechanics, resulting in degenerative joint disease. Not infrequently, patients with metabolic bone diseases have restricting hip joint pain that ultimately necessitates hip arthroplasty. To minimize complications, the surgeon must consider the particular characteristics of these patients. The surgical and medical management of patients with metabolic bone diseases undergoing hip arthroplasty requires appropriate preoperative diagnosis, careful attention to the technical challenges of surgery, and strategies to maximize the long-term results of the surgical intervention, such as the use of bone anabolic and anticatabolic agents.

Use of Electrocautery for Coagulation and Wound Complications in Caesarean Sections

PubMed Central

Moreira, Cristiane M.; Amaral, Eliana

2014-01-01

Objective. To evaluate the safety of electrocautery for coagulation during Caesarean sections. Study Design. A randomized, controlled, clinical pilot study was performed at a university maternity hospital. After admission for delivery and decision to perform a C-section, volunteers were randomized to either the intervention group (use of electrocautery for coagulation) or nonintervention group. The women were examined at the time of postpartum discharge (day 3), at days 7 to 10, and again at days 30 to 40 for signs of infection, hematoma, seroma, or dehiscence. Data were analyzed using an intention-to-treat analysis, and risk ratios were calculated. Results. No significant differences were found between the two groups. Only 2.8% of patients in the intervention group developed surgical wound complications during hospitalization. However, 7 to 10 days following discharge, these rates reached 23.0% and 15.4% in the intervention and nonintervention groups, respectively (RR = 1.50, 95% CI = 0.84–2.60). Conclusion. Further studies should confirm whether the use of electrocautery for coagulation does not increase the risk of surgical wound complications in patients undergoing Caesarean sections. PMID:25143985

Use of electrocautery for coagulation and wound complications in Caesarean sections.

PubMed

Moreira, Cristiane M; Amaral, Eliana

2014-01-01

To evaluate the safety of electrocautery for coagulation during Caesarean sections. A randomized, controlled, clinical pilot study was performed at a university maternity hospital. After admission for delivery and decision to perform a C-section, volunteers were randomized to either the intervention group (use of electrocautery for coagulation) or nonintervention group. The women were examined at the time of postpartum discharge (day 3), at days 7 to 10, and again at days 30 to 40 for signs of infection, hematoma, seroma, or dehiscence. Data were analyzed using an intention-to-treat analysis, and risk ratios were calculated. No significant differences were found between the two groups. Only 2.8% of patients in the intervention group developed surgical wound complications during hospitalization. However, 7 to 10 days following discharge, these rates reached 23.0% and 15.4% in the intervention and nonintervention groups, respectively (RR = 1.50, 95% CI = 0.84-2.60). Further studies should confirm whether the use of electrocautery for coagulation does not increase the risk of surgical wound complications in patients undergoing Caesarean sections.

What's new in perioperative nutritional support?

PubMed

Awad, Sherif; Lobo, Dileep N

2011-06-01

To highlight recent developments in the field of perioperative nutritional support by reviewing clinically pertinent English language articles from October 2008 to December 2010, that examined the effects of malnutrition on surgical outcomes, optimizing metabolic function and nutritional status preoperatively and postoperatively. Recognition of patients with or at risk of malnutrition remains poor despite the availability of numerous clinical aids and clear evidence of the adverse effects of poor nutritional status on postoperative clinical outcomes. Unfortunately, poor design and significant heterogeneity remain amongst many studies of nutritional interventions in surgical patients. Patients undergoing elective surgery should be managed within a multimodal pathway that includes evidence-based interventions to optimize nutritional status perioperatively. The aforementioned should include screening patients to identify those at high nutritional risk, perioperative immuno-nutrition, minimizing 'metabolic stress' and insulin resistance by preoperative conditioning with carbohydrate-based drinks, glutamine supplementation, minimal access surgery and enhanced recovery protocols. Finally gut-specific nutrients and prokinetics should be utilized to improve enteral feed tolerance thereby permitting early enteral feeding. An evidence-based multimodal pathway that includes interventions to optimize nutritional status may improve outcomes following elective surgery.

Pediatric cataract: challenges and future directions

PubMed Central

Medsinge, Anagha; Nischal, Ken K

2015-01-01

Cataract is a significant cause of visual disability in the pediatric population worldwide and can significantly impact the neurobiological development of a child. Early diagnosis and prompt surgical intervention is critical to prevent irreversible amblyopia. Thorough ocular evaluation, including the onset, duration, and morphology of a cataract, is essential to determine the timing for surgical intervention. Detailed assessment of the general health of the child, preferably in conjunction with a pediatrician, is helpful to rule out any associated systemic condition. Although pediatric cataracts have a diverse etiology, with the majority being idiopathic, genetic counseling and molecular testing should be undertaken with the help of a genetic counselor and/or geneticist in cases of hereditary cataracts. Advancement in surgical techniques and methods of optical rehabilitation has substantially improved the functional and anatomic outcomes of pediatric cataract surgeries in recent years. However, the phenomenon of refractive growth and the process of emmetropization have continued to puzzle pediatric ophthalmologists and highlight the need for future prospective studies. Posterior capsule opacification and secondary glaucoma are still the major postoperative complications necessitating long-term surveillance in children undergoing cataract surgery early in life. Successful management of pediatric cataracts depends on individualized care and experienced teamwork. We reviewed the etiology, preoperative evaluation including biometry, choice of intraocular lens, surgical techniques, and recent developments in the field of childhood cataract. PMID:25609909

Incidence of Diabetes Insipidus in Postoperative Period among the Patients Undergoing Pituitary Tumour Surgery.

PubMed

Kadir, M L; Islam, M T; Hossain, M M; Sultana, S; Nasrin, R; Hossain, M M

2017-07-01

Post operative complications after pituitary tumour surgery vary according to procedure. There are several surgical procedures being done such as transcranial, transsphenoidal microsurgical and transsphenoidal endoscopic approaches. One of the commonest complications is diabetes insipidus (DI). Our main objective was to find out the incidence of diabetes insipidus in post operative period among patients undergoing surgical intervention for pituitary tumour in our institute. The presence of diabetes insipidus in the postoperative period was established by measuring serum Na+ concentration, hourly urine output and urinary specific gravity to find out the incidence of diabetes insipidus in postoperative period in relation to age, gender, tumour diameter, function of tumour (i.e., either hormone secreting or not) and operative procedure used for surgical resection of pituitary tumor. As it is the most common postoperative complication so, in this study we tried to find out how many of the patients develop diabetes insipidus in postoperative period following surgical resection of pituitary tumour. This cross sectional type of observational study was carried out in the department of Neurosurgery, BSMMU from May 2014 to October 2015 on 33 consecutive patients who underwent surgical intervention for pituitary tumour for the first time. Data was collected by using a data collection sheet. The incidence of diabetes insipidus was found 23.1% of patients in <30 year age group, 38.5% of patients in 31-40 year age group and 38.5% of patients in ≥40 year age group (p=0.764). In case of distribution of patients according to gender 38.5% of male and 61.5% of female developed diabetes insipidus (p=0.073). Regarding tumour size 30.8% and 69.2% of patients developed diabetes insipidus having tumour diameter <30mm and ≥30mm respectively (p=0.590). In case of operative procedure 69.2% of patients developed diabetes insipidus who was operated by transsphenoidal endoscopic approach, 23.1% and 7.7% of patients developed diabetes insipidus who underwent pituitary tumour resection through transsphenoidal microscopic approach and transcranial microscopic approach respectively (p=0.432). 17.6% of patients develop DI having functioning pituitary macroadenoma and 62.5% of patients develop DI having nonfunctioning pituitary macroadenoma. This observational study has been performed to find out the incidence of diabetes insipidus. Incidence of postoperative DI is more at or around the age of 40 years. It is slightly predominant in female. Most of the patients manifest DI in the first 24 hours of surgical intervention. Incidence of DI is low among patients having functioning pituitary macroadenoma.

Elective Stoma Reversal Has a Higher Incidence of Postoperative Clostridium Difficile Infection Compared With Elective Colectomy: An Analysis Using the American College of Surgeons National Surgical Quality Improvement Program and Targeted Colectomy Databases.

PubMed

Skancke, Matthew; Vaziri, Khashayar; Umapathi, Bindu; Amdur, Richard; Radomski, Michal; Obias, Vincent

2018-05-01

Clostridium difficile infection is caused by the proliferation of a gram-positive anaerobic bacteria after medical or surgical intervention and can result in toxic complications, emergent surgery, and death. This analysis evaluates the incidence of C difficile infection in elective restoration of intestinal continuity compared with elective colon resection. This was a retrospective database review of the 2015 American College of Surgeons National Surgical Quality Improvement Project and targeted colectomy database. The intervention cohort was defined as the primary Current Procedural Terminology codes for ileostomy/colostomy reversal (44227, 44620, 44625, and 44626) and International Classification of Diseases codes for ileostomy/colostomy status (VV44.2, VV44.3, VV55.2, VV55.3, Z93.2, Z93.3, Z43.3, and Z43.2). A total of 2235 patients underwent elective stoma reversal compared with 10403 patients who underwent elective colon resection. Multivariate regression modeling of the impact of stoma reversal on postoperative C difficile infection risk was used as the study intervention. The incidence of C difficile infection in the 30 days after surgery was measured. The incidence of C difficile infection in the 30-day postoperative period was significantly higher (3.04% vs 1.25%; p < 0.001) in patients undergoing stoma reversal. After controlling for differences in cohorts, regression analysis suggested that stoma reversal (OR = 2.701 (95% CI, 1.966-3.711); p < 0.001), smoking (OR = 1.520 (95% CI, 1.063-2.174); p = 0.022), steroids (OR = 1.677 (95% CI, 1.005-2.779); p = 0.048), and disseminated cancer (OR = 2.312 (95% CI, 1.437-3.719); p = 0.001) were associated with C difficile infection incidence in the 30-day postoperative period. The study was limited because it was a retrospective database review with observational bias. Patients who undergo elective stoma reversal have a higher incidence of postoperative C difficile infection compared with patients who undergo an elective colectomy. Given the impact of postoperative C difficile infection, a heightened sense of suspicion should be given to symptomatic patients after stoma reversal. See at Video Abstract at http://links.lww.com/DCR/A553.

Patients With Failed Prior Two-Stage Exchange Have Poor Outcomes After Further Surgical Intervention.

PubMed

Kheir, Michael M; Tan, Timothy L; Gomez, Miguel M; Chen, Antonia F; Parvizi, Javad

2017-04-01

Failure of 2-stage exchange arthroplasty for the management of periprosthetic joint infection (PJI) poses a major clinical challenge. There is a paucity of information regarding the outcomes of further surgical intervention in these patients. Thus, we aim to report the clinical outcomes of subsequent surgery for a failed prior 2-stage exchange arthroplasty. Our institutional database was used to identify 60 patients (42 knees and 18 hips), with a failed prior 2-stage exchange, who underwent further surgical intervention between 1998 and 2012, and had a minimum 2-year follow-up. A retrospective review was performed to extract relevant clinical information, including mortality, microbiology, and subsequent surgeries. Musculoskeletal Infection Society criteria were used to define PJI, and treatment success was defined using Delphi criteria. Irrigation and debridement (I&D) was performed after a failed 2-stage exchange in 61.7% of patients; 56.8% subsequently failed. Forty patients underwent an intended second 2-stage exchange; 6 cases required a spacer exchange. Reimplantation occurred only in 65% of cases, and 61.6% had infection controlled. The 14 cases that were not reimplanted resulted in 6 retained spacers, 5 amputations, 2 PJI-related mortalities, and 1 arthrodesis. Further surgical intervention after a failed prior 2-stage exchange arthroplasty has poor outcomes. Although I&D has a high failure rate, many patients who are deemed candidates for a second 2-stage exchange either do not undergo reimplantation or fail after reimplantation. The management of PJI clearly remains imperfect, and there is a dire need for further innovations that may improve the care of these patients. Copyright © 2016 Elsevier Inc. All rights reserved.

Predictors of short term treatment outcome in patients with achalasia following endoscopic or surgical therapy.

PubMed

Gheorghe, Cristian; Bancila, Ion; Tutuian, Radu; Iacob, Razvan; Tomulescu, Victor

2012-01-01

Pneumatic balloon dilation and surgical myotomy are the most effective treatments for achalasia. While there is controversy which method is best, the aim of the current study was to identify predictors of symptom recurrence after endoscopic or surgical therapy. Patients undergoing pneumatic balloon dilatation (30mm) or laparoscopic Heller myotomy with Dor fundoplication were included in the study. Analyzed parameters include total symptom score (sum of 0-5 point intensity for dysphagia, regurgitation and chest pain), width and height of esophageal column at 2 and 5 minutes after oral barium ingestion, lower esophageal sphincter (LES) length, resting (LESP) and residual pressure (LESRP) before and 3 months after intervention. Patients with symptoms score <3 at the 3-month follow-up visit were considered asymptomatic. Twenty-one patients underwent pneumatic dilation (14) or laparoscopic myotomy (7). Total symptom score improved (p<0.01) from pre- (7.2±2.7) to post-intervention (1.7±2.6). Eleven (85.8%) patients in the endoscopic group vs. 7 (100%) patients in the surgical group were symptom-free 3 months after intervention. Therapies improved LESP (24.4±8.2mmHg pre- vs. 15.4±10.3mmHg post-therapy; p=0.003) and mean LESRP (7.9±4.3mmHg pre- vs. 5.3±6.7mmHg post-therapy; p=0.03). Univariate linear regression analysis identified barium contrast column width >5cm at 2 minutes (p=0.04), LES length <2cm (p=0.003) and LESRP >10mmHg (p=0.02) as predictors for persistent symptoms. While >85% of achalasia patients responded well to 30mm pneumatic balloon dilation, patients with elevated LES pressure, short LES and wide esophagus should be considered as primary surgical candidates.

Readmissions, unplanned emergency room visits, and surgical retreatment rates after anti-reflux procedures.

PubMed

Wang, Hsin-Hsiao S; Tejwani, Rohit; Wolf, Steven; Wiener, John S; Routh, Jonathan C

2017-10-01

The choice between endoscopic injection (EI) and ureteroneocystotomy (UNC) for surgical correction of vesicoureteral reflux (VUR) is controversial. To compare postoperative outcomes of EI vs UNC. This study reviewed linked inpatient (SID), ambulatory surgery (SASD), and emergency department (SEDD) data from five states in the United States (2007-10) to identify pediatric patients with primary VUR undergoing EI or UNC as an initial surgical intervention. Unplanned readmissions, additional procedures, and emergency room (ER) visits were extracted. Statistical analysis was performed using multivariate logistic regression using generalized estimating equation (GEE) to adjust for hospital-level clustering. The study identified 2556 UNC and 1997 EI procedures. Compared with patients undergoing EI, those who underwent UNC were more likely to be younger (4.6 vs 6.0 years, P < 0.001), male (30 vs 20%, P < 0.001), and publicly insured (34 vs 29%, P < 0.001). As shown in Summary Figure, compared with EI, UNC patients had lower rates of additional anti-reflux procedures within 12 months (25 (1.0) vs 121 (6.1%), P < 0.001), but a higher rate of 30-day and 90-day readmissions and ER visits. On multivariate analysis, patients treated by UNC remained at higher odds of being readmitted (OR = 4.45; 2.69 in 30 days; 90 days, P < 0.001) and to have postoperative ER visits (OR = 3.33; 2.26 in 30 days; 90 days, P < 0.001); however, EI had significantly higher odds of repeat anti-reflux procedures in the subsequent year (OR = 7.12, P < 0.001). Endoscopic injection constituted nearly half of initial anti-reflux procedures in children. However, patients treated with UNC had significantly lower odds of requiring re-treatment in the first year relative to those treated with EI. By contrast, patients treated with UNC had more than twice the odds of being readmitted or visiting an ER postoperatively. Although the available data were amongst the largest and most well validated, the major limitation was the retrospective nature of the administrative database. The practice setting may not be generalizable to states not included in the analysis. Postoperative readmissions and ER visits were uncommon after any surgical intervention for VUR, but were more common among children undergoing UNC. The EI patients had a more than seven-fold increased risk of surgical re-treatment within 1 year. Copyright © 2017 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.

Graft and mesh use in vaginal surgery.

PubMed

Rizvi, Raheela Mohsin; Chughtai, Novera Ghayoor

2017-12-01

Pelvic organ prolapse and urinary incontinence are among the most common chronic disorders in women. These are common problems whose pathogenesis remains unclear. As life expectancy increases, significantly greater number of women now present with pelvic organ prolapse and urinary incontinence requiring surgical intervention. Currently, the lifetime risk of undergoing prolapse or continence surgery is one in 11, and up to 30% of patients will require repeat reconstructive surgery and repeat surgery for incontinence in 10%. In an attempt to improve surgical outcomes and to preserve vaginal capacity and coital function, a number of synthetic and biological prostheses have been developed. This review aims to look at the role of graft and mesh in vaginal surgery. We conducted a search for English-language articles published during 1997 to 2016, using MEDLINE, PubMed and United States' National Library of Medicine databases. We reviewed around 50 papers but referenced only 30 for this article. The literature review provided us a new insight regarding safety of mesh. Polypropylene mesh is safe for vaginal surgery if used by experienced surgeons. The safety of mesh becomes compromised in the hands of commercial surgical kit providers. All the new mesh tailored kits should undergo evidence-based trials and then can be safely used worldwide.

Comparing Active and Passive Distraction-Based Music Therapy Interventions on Preoperative Anxiety in Pediatric Patients and Their Caregivers.

PubMed

Millett, Christopher R; Gooding, Lori F

2018-01-13

Young children who experience high levels of preoperative anxiety often exhibit distress behaviors, experience more surgical complications, and are at a higher risk for developing a variety of negative postoperative consequences. A significant factor in pediatric preoperative anxiety is the level of anxiety present in their caregivers. Active and passive music therapy interventions addressing anxiety prior to invasive procedures have been met with success. The purpose of this study was to investigate the comparative effectiveness of two distraction-based music therapy interventions on reducing preoperative anxiety in young pediatric surgical patients and their caregivers. A total of 40 pediatric patient and caregiver dyads undergoing ambulatory surgery were included in this study. Pediatric preoperative anxiety was measured pre- and post-intervention using the modified Yale Pediatric Anxiety Scale, while caregiver anxiety was measured through self-report using the short-form Strait-Trait Anxiety Inventory-Y6. Participants were randomized to either an active or passive intervention group for a preoperative music therapy session. Results indicated a significant reduction in preoperative anxiety for both patients and their caregivers regardless of intervention type. Neither active nor passive music therapy interventions were significantly more effective than the other. For future studies, the researchers recommend an increased sample size, controlling for various factors such as sedative premedication use, and testing interventions with patients in various stages of development. © the American Music Therapy Association 2017. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

Basic science and surgical treatment options for articular cartilage injuries of the knee.

PubMed

Tetteh, Elizabeth S; Bajaj, Sarvottam; Ghodadra, Neil S

2012-03-01

The complex structure of articular cartilage allows for diverse knee function throughout range of motion and weight bearing. However, disruption to the structural integrity of the articular surface can cause significant morbidity. Due to an inherently poor regenerative capacity, articular cartilage defects present a treatment challenge for physicians and therapists. For many patients, a trial of nonsurgical treatment options is paramount prior to surgical intervention. In instances of failed conservative treatment, patients can undergo an array of palliative, restorative, or reparative surgical procedures to treat these lesions. Palliative methods include debridement and lavage, while restorative techniques include marrow stimulation. For larger lesions involving subchondral bone, reparative procedures such as osteochondral grafting or autologous chondrocyte implantation are considered. Clinical success not only depends on the surgical techniques but also requires strict adherence to rehabilitation guidelines. The purpose of this article is to review the basic science of articular cartilage and to provide an overview of the procedures currently performed at our institution for patients presenting with symptomatic cartilage lesions.

Early Surgery for Endocarditis Complicated by Preoperative Cerebral Emboli Is Not Associated With Worsened Outcomes

PubMed Central

Sorabella, Robert A.; Han, Sang Myung; Grbic, Mark; Wu, Yeu Sanz; Takyama, Hiroo; Kurlansky, Paul; Borger, Michal A.; Argenziano, Michael; Gordon, Rachel; George, Isaac

2015-01-01

Background Valve surgery for patients presenting with infective endocarditis (IE) complicated by stroke is thought to carry elevated risk of postoperative complications. Our aim is to compare outcomes of IE patients who undergo surgery early after diagnosis of septic cerebral emboli with patients without preoperative emboli. Methods All patients undergoing surgery for left-sided IE between 1996–2013 at our institution were reviewed. Patients undergoing surgery > 14 days after embolic stroke diagnosis (n=11) and those with purely hemorrhagic lesions were excluded from analysis (n=7). In total, 308 were included in the study and stratified according to the presence (STR, n=54) or absence of a preoperative septic cerebral embolus (NoSTR, n=254). Primary outcomes of interest were development of new postoperative stroke and 30-day mortality. Results Mean time to surgical intervention from stroke onset was 6.0 ± 4.1 days. S. aureus (39% STR vs. 21% NoSTR, p = 0.004) and annular abscess at surgery (52% STR vs. 27% NoSTR, p < 0.001) were more prevalent in STR patients. There was no significant difference in 30-day mortality (9.3% STR vs. 7.1% NoSTR, p = 0.57) or rate of new postoperative stroke [5 (9.4%) STR vs. 12 (4.7%) NoSTR, p = 0.19] between groups. Additionally, there was no difference in 10-year survival between groups (log rank p = 0.74). Conclusions Early surgical intervention in patients with IE complicated by preoperative septic cerebral emboli does not lead to significantly worse postoperative outcomes. Early surgery for IE following embolic stroke warrants consideration, particularly in patients with high-risk features such as S. aureus and/or annular abscess. PMID:26116483

The Effect of Music on Anxiety and Cardiovascular Indices in Patients Undergoing Coronary Artery Bypass Graft: A Randomized Controlled Trial

PubMed Central

Heidari, Saeide; Babaii, Atye; Abbasinia, Mohammad; Shamali, Mahdi; Abbasi, Mohammad; Rezaei, Mahboobe

2015-01-01

Background: The instability of cardiovascular indices and anxiety disorders are common among patients undergoing coronary artery bypass graft (CABG) and could interfere with their recovery. Therefore, improving the cardiovascular indices and anxiety is essential. Objectives: This study aimed to investigate the effect of music therapy on anxiety and cardiovascular indices in patients undergoing CABG. Patients and Methods: In this randomized controlled trial, 60 patients hospitalized in the cardiovascular surgical intensive care unit of Shahid Beheshti Hospital in Qom city, Iran, in 2013 were selected using a consecutive sampling method and randomly allocated into the experimental and control groups. In the experimental group, patients received 30 minutes of light music, whereas in the control group, patients had 30 minutes of rest in bed. The cardiovascular indices and anxiety were measured immediately before, immediately after and half an hour after the study. Data were analyzed using the chi-square test and repeated measures analysis of variance. Results: Compared to the immediately before intervention, the mean anxiety scores immediately after and 30 minutes after the intervention were significantly lower in the experimental group (P < 0.037) while it did not significantly change in the control group. However, there were no significant differences regarding the cardiovascular indices in the three consecutive measurements (P > 0.05). Conclusions: Music therapy is effective in decreasing anxiety among patients undergoing CABG. However, the intervention was not effective on cardiovascular indices. Music can effectively be used as a non-pharmacological method to manage anxiety after CABG. PMID:26835471

Thrombolytic therapy for mitral valve thrombosis.

PubMed

Lin, T K; Tsai, L M; Chen, J H; Yang, Y J

1997-05-01

A 44-year-old man with a St. Jude mitral valve was admitted because of progressive pulmonary edema. He was diagnosed with prosthetic heart valve thrombosis (PHVT) based on the findings of "muffled" prosthetic valve clicks. Doppler echocardiographic evidence of severe mitral stenosis and transesophageal echocardiographic evidence of limited mitral valve motility. Because the patient hesitated to undergo our recommended surgical treatment, he was immediately treated with intravenous recombinant tissue plasminogen activator (100 mg over 3 h) followed by heparinization. Two hours after the thrombolytic therapy, the prosthetic valve clicks became clearly audible and his congestive symptoms were dramatically improved. Follow-up echocardiography no longer-showed significant mitral valve obstruction. A transient cerebral ischemic attack occurred at the end of thrombolytic therapy but there were no neurologic sequalae. The patient, on warfarin therapy, was well at follow-up 8 months after discharge. Surgical intervention has long been the standard therapy for patients with PHVT. Our case experience suggests that thrombolytic therapy may be considered as an effective alternative to surgical intervention for selected patients with PHVT. In this report, we also review the current literature regarding the indications, effectiveness and safety of thrombolytic therapy in PHVT.

Analysis of complications from abdominoplasty: a review of 206 cases at a university hospital.

PubMed

Neaman, Keith C; Hansen, Juliana E

2007-03-01

The number of abdominoplasties performed in the United States has been steadily increasing over the past decade. A large proportion of these patients are bariatric patients who remain obese despite prior weight-reduction surgery. This study was done to review the experience of patients undergoing abdominoplasty at a university hospital. A retrospective chart review of 206 consecutive patients was performed. The overall complication rate was 37.4%. Major complications [hematoma requiring surgical intervention, seroma requiring aspiration or surgical drainage, cellulitis or abscess requiring hospitalization and intravenous (IV) antibiotics, deep vein thrombosis (DVT), and pulmonary embolism (PE)] occurred in 16% of patients. The rate of minor complications (hematoma or seroma requiring no intervention, epidermolysis, small-wound dehiscence, neuropathic pain, and minor cellulitis) was 26.7%. Obese patients had a significantly increased risk of developing major complications as compared with nonobese patients (53.4% versus 28.8%, P = 0.001). An in-depth analysis of all complications and risk factors was done.

Music as an auxiliary analgesic during first trimester surgical abortion: a randomized controlled trial.

PubMed

Guerrero, Jacqueline M; Castaño, Paula M; Schmidt, Elizabeth O; Rosario, Linette; Westhoff, Carolyn L

2012-08-01

Music has served as an auxiliary analgesic in perioperative settings. This study evaluates the impact of intraoperative music added to routine pain control measures during first trimester surgical abortion. We analyzed data from 101 women randomized to undergo abortion with routine pain control measures only (ibuprofen and paracervical block) or with the addition of intraoperative music via headphones. The primary outcome was the change in preoperative and postoperative pain scores on a 100-mm visual analog scale. Secondary outcomes included change in anxiety and vital signs, and satisfaction. Baseline characteristics were similar between groups. The magnitude of increase in pain scores was greater in the intervention than in the control group (+51.0 mm versus +39.3 mm, p=.045). Overall pain control was rated as good or very good by 70% of the intervention and 75% of the control group (p=.65). Intraoperative music added to routine pain control measures increases pain reported during abortion. Copyright © 2012 Elsevier Inc. All rights reserved.

State-of-the-Art Review of Echocardiographic Imaging in the Evaluation and Treatment of Functional Tricuspid Regurgitation.

PubMed

Hahn, Rebecca T

2016-12-01

Functional or secondary tricuspid regurgitation (TR) is the most common cause of severe TR in the Western world. The presence of functional TR, either isolated or in combination with left heart disease, is associated with unfavorable natural history. Surgical mortality for isolated tricuspid valve interventions remains higher than for any other single valve surgery, and surgical options for repair do not have consistent long-term durability. In addition, as more patients undergo transcatheter left valve interventions, developing transcatheter solutions for functional TR has gained greater momentum. Numerous transcatheter devices are currently in early clinical trials. All patients require an assessment of valve morphology and function, and transcatheter devices typically require intraprocedural guidance by echocardiography. The following review will describe tricuspid anatomy, define echocardiographic views for evaluating tricuspid valve morphology and function, and discuss imaging requirements for the current transcatheter devices under development for the treatment of functional TR. © 2016 American Heart Association, Inc.

Preoperative Use of Clopidogrel Does Not Affect Outcomes for Femoral Neck Fractures Treated With Hemiarthroplasty.

PubMed

Ghanem, Elie S; Richard, Raveesh D; Wingert, Nathaniel C H; Gotoff, James R; Graham, Jove H; Bowen, Thomas R

2017-07-01

The antiplatelet effect of clopidogrel on blood loss and perioperative complications after surgical intervention remains ambiguous. The purpose of this study was to determine if patients on clopidogrel before hemiarthroplasty for femoral neck fracture are predisposed to greater surgical bleeding and perioperative complications compared with those not taking clopidogrel before surgery. We conducted a review of our electronic medical record from 2006-2013 and identified 602 patients who underwent 623 hemiarthroplasty procedures for displaced femoral neck fracture, of which 54 cases (9%) were taking clopidogrel before hospital admission. Patient demographics and comorbidities, operative and surgical variables, and perioperative complications at 90 days were compared between the clopidogrel and nonclopidogrel user groups. The 2 groups of patients had similar baseline characteristics, but patients taking clopidogrel preoperatively were sicker with higher American Society of Anesthesiologists scores (P = .049) and age-adjusted Charlson index (P = .001). They also had a greater incidence of cerebrovascular disease (P = .01), chronic obstructive pulmonary disease (P = .03), diabetes (0.03), and malignancy (P < .001). There was no significant difference between the 2 patient groups with respect to 90-day postoperative medical readmissions (P = .85), surgical readmissions (P = .26), infection (P = .99), and mortality (P = .89). Patients taking clopidogrel who present with a displaced femoral neck fracture can safely undergo a hemiarthroplasty while actively on clopidogrel without an increase in medical or surgical complications and mortality. We do not recommend delaying surgical intervention until the antiplatelet effects of clopidogrel subside. Copyright © 2017 Elsevier Inc. All rights reserved.

Ultrasound diagnosis of postoperative complications of nerve repair.

PubMed

Fantoni, Caterina; Erra, Carmen; Fernandez Marquez, Eduardo Marcos; Ortensi, Andrea; Faiola, Andrea; Coraci, Daniele; Piccinini, Giulia; Padua, Luca

2018-05-03

Peripheral nerve injuries often undergo surgical repair, but poor postoperative functional recovery is frequently observed. We describe four cases of traumatic nerve lesions in whom postoperative recovery was prevented by complications such as detachment of nerve sutures or neuroma growth. To the best of our knowledge no similar cases have been reported in literature so far. It is important an early diagnosis of such condition because it prevents recovery and delays re-intervention, which should be performed before complete muscle denervation and atrophy. Nerve ultrasound is a valuable tool in traumatic nerve injury and has proven to be useful in postoperative follow-up, especially in diagnosing surgical complications such as detachment of nerve direct sutures. Copyright © 2018 Elsevier Inc. All rights reserved.

Effects of Guided Imagery on Postoperative Outcomes in Patients Undergoing Same-Day Surgical Procedures: A Randomized, Single-Blind Study

DTIC Science & Technology

2010-06-01

2O0O;9Ot3):706-712. 20. Bertrand P, Maye J. A description of the indices of heart rate variabil- ity in orofacial pain paticnis. Bcihcsda, MD: National...neck proce- dures were randomly assigned into 2 groups for this single-blind investigation. Anxiety and baseline pain levels were documented...control group patients received no intervention. Data were collected on pain and nar- cotic consumption at 7- and 2-hour postoperative inter- vals. In

Using an Educational Multimedia Application to Prepare Children for Outpatient Surgeries.

PubMed

Fernandes, Sara; Arriaga, Patrícia; Esteves, Francisco

2015-01-01

Surgery is a highly stressful event for children and caregivers. Extensive effort has been made to improve preoperative care in order to alleviate worry about the surgical procedure itself. This study tested the impact of an educational multimedia intervention on the cognitive, emotional, and physiological responses of children undergoing surgery, as well as on parental state anxiety. Children (n = 90) were assigned to three different groups: an educational multimedia intervention (experimental group), an entertainment video game intervention (comparison group), and a control group (no intervention). Children who received the educational multimedia intervention reported lower level of worries about hospitalization, medical procedures, illness, and negative consequences than those in the control and in the comparison groups. Parental state anxiety was also lower in the both the educational and the entertainment video game interventions compared to the control group. These findings suggest that providing information to children regarding medical procedures and hospital rules and routines is important to reduce their preoperative worries, and also relevant for parental anxiety.

Impact of Injury Mechanisms on Patterns and Management of Facial Fractures.

PubMed

Greathouse, S Travis; Adkinson, Joshua M; Garza, Ramon; Gilstrap, Jarom; Miller, Nathan F; Eid, Sherrine M; Murphy, Robert X

2015-07-01

Mechanisms causing facial fractures have evolved over time and may be predictive of the types of injuries sustained. The objective of this study is to examine the impact of mechanisms of injury on the type and management of facial fractures at our Level 1 Trauma Center. The authors performed an Institutional Review Board-approved review of our network's trauma registry from 2006 to 2010, documenting age, sex, mechanism, Injury Severity Score, Glasgow Coma Scale, facial fracture patterns (nasal, maxillary/malar, orbital, mandible), and reconstructions. Mechanism rates were compared using a Pearson χ2 test. The database identified 23,318 patients, including 1686 patients with facial fractures and a subset of 1505 patients sustaining 2094 fractures by motor vehicle collision (MVC), fall, or assault. Nasal fractures were the most common injuries sustained by all mechanisms. MVCs were most likely to cause nasal and malar/maxillary fractures (P < 0.01). Falls were the least likely and assaults the most likely to cause mandible fractures (P < 0.001), the most common injury leading to surgical intervention (P < 0.001). Although not statistically significant, fractures sustained in MVCs were the most likely overall to undergo surgical intervention. Age, number of fractures, and alcohol level were statistically significant variables associated with operative management. Age and number of fractures sustained were associated with operative intervention. Although there is a statistically significant correlation between mechanism of injury and type of facial fracture sustained, none of the mechanisms evaluated herein are statistically associated with surgical intervention. Clinical Question/Level of Evidence: Therapeutic, III.

Vocal fold pseudocyst: results of 46 cases undergoing a uniform treatment algorithm.

PubMed

Estes, Christine; Sulica, Lucian

2014-05-01

To describe treatment results and identify predictors of the need for surgical intervention in patients with vocal fold pseudocyst. Retrospective cohort study with longitudinal followup via survey. Clinical records were reviewed for demographic information, VHI-10 score, and degree of severity of dysphonia. Videostroboscopic examinations were evaluated for presence of vocal fold pseudocyst, along with additional clinical variables, including laterality, reactive lesion, paresis, varix, and hemorrhage. Follow-up surveys were sent to all participants to evaluate current VHI-10 score and degree of vocal limitation. Results were analyzed to determine predictors of surgery and recurrence of pathology. Forty-six patients (41F:5M) with pseudocyst (40 unilateral: 6 bilateral) were reviewed. Twenty-three (50%) had reactive lesions, nineteen (41%) had paresis by clinical criteria, 10 (22%) had varices, and 6 (13%) had hemorrhage on examination. All underwent initial behavioral management (2-12 sessions of voice therapy; mean of 8 sessions). Seventeen (37%) eventually required surgical intervention. No demographic or clinical variables proved predictive of surgical intervention. Follow-up surveys were completed by 63% of patients, and 79% agreed with the statement that they were not professionally limited by their voices. This experience supports behavioral management as an initial intervention in patients with pseudocyst, sufficient by itself to restore vocal function in approximately two out of three patients. Neither initial severity nor any of the studied clinical findings predicted the need for surgery. The large majority of patients with pseudocyst are able to be treated effectively without impact in their professional function. © 2013 The American Laryngological, Rhinological and Otological Society, Inc.

[Governance of innovative cardiovascular devices: when evidence is not enough].

PubMed

Addis, Antonio; Davoli, Marina

2016-01-01

Aortic stenosis is the most common valve disease and transcatheter aortic valve implantation (TAVI) is considered as an alternative to surgical valve replacement or to medical treatment in inoperable or high-risk patients. Although physicians have learned how to care for critically ill old patients and enable many to survive, major surgical procedures, operating on patients at very high risk, are often not suitable. Studies showed that selected cohorts of patients undergoing TAVI might have better outcomes in terms of survival and quality of life. However, mortality and safety data associated with the less invasive intervention do not always justify such new technologies for all patients with severe aortic stenosis, taking into account also the high cost associated. A systematic review of the available scientific literature has been performed. In this context, a DECIDE framework has been used providing a systematic and transparent approach for going from evidence to healthcare decisions. Before suggesting final recommendations, historical data of interventions done at regional level and regulatory decisions adopted in other countries following health technology assessment analysis, have been analyzed. All final recommendations based on this document have been discussed and reviewed with a working group done by the health operators directly involved in this technology within the regional health service context. Recommendations for the identification of patients suitable for TAVI are given together with a list of characteristics that should be required to all centers eligible for the performance of TAVI and with a procedure able to allow better quality assurance and prospective monitoring process of all new cases enrolled for such intervention. Impact of these recommendations will be measured using a regional registry collecting data on new patients undergoing TAVI.

Early recovery following lower limb arthroplasty: Qualitative interviews with patients undergoing elective hip and knee replacement surgery. Initial phase in the development of a patient-reported outcome measure.

PubMed

Strickland, Louise H; Kelly, Laura; Hamilton, Thomas W; Murray, David W; Pandit, Hemant G; Jenkinson, Crispin

2017-09-27

To explore the patients' perspective of surgery and early recovery when undergoing lower limb (hip or knee) arthroplasty. Lower limb arthroplasty is a commonly performed procedure for symptomatic arthritis, which has not responded to conservative medical treatment. Each patient's perspective of the surgical process and early recovery period impacts on their quality of life. Open, semistructured qualitative interviews were used to allow for a deeper understanding of the patient perspective when undergoing a hip or knee arthroplasty. Following ethical approval, 30 patients were interviewed between August and November 2016 during the perioperative period while undergoing an elective hip or knee arthroplasty (n = 30). The interviews were performed between the day of surgery and a nine-week postoperative clinic appointment. Data were analysed using an in-depth narrative thematic analysis method. NVivo qualitative data analysis software was used. Seven main themes evolved from the interviews: "improving function and mobility", "pain", "experiences of health care", "support from others", "involvement and understanding of care decisions", "behaviour and coping" and "fatigue and sleeping". The early postoperative recovery period is of vital importance to all surgical patients. This is no different for the orthopaedic patient. However, identifying key self-reported areas of importance from patients can guide clinical focus for healthcare professionals. To have specific patient-reported information regarding key areas of importance during the perioperative phase is invaluable when caring for the orthopaedic surgical patient. It gives insight and understanding in to this increasing population group. This study has also served as a starting point in the development of a questionnaire which could be used to assess interventions in the lower limb arthroplasty population. These results will influence both items and content of the questionnaire. © 2017 John Wiley & Sons Ltd.

Laparoscopic Roux-en-Y gastric bypass in adolescents with severe obesity (AMOS): a prospective, 5-year, Swedish nationwide study.

PubMed

Olbers, Torsten; Beamish, Andrew J; Gronowitz, Eva; Flodmark, Carl-Erik; Dahlgren, Jovanna; Bruze, Gustaf; Ekbom, Kerstin; Friberg, Peter; Göthberg, Gunnar; Järvholm, Kajsa; Karlsson, Jan; Mårild, Staffan; Neovius, Martin; Peltonen, Markku; Marcus, Claude

2017-03-01

Severe obesity in adolescence is associated with reduced life expectancy and impaired quality of life. Long-term benefits of conservative treatments in adolescents are known to be modest, whereas short-term outcomes of adolescent bariatric surgery are promising. We aimed to compare 5-year outcomes of adolescent surgical patients after Roux-en-Y gastric bypass with those of conservatively treated adolescents and of adults undergoing Roux-en-Y gastric bypass, in the Adolescent Morbid Obesity Surgery (AMOS) study. We did a nationwide, prospective, non-randomised controlled study of adolescents (aged 13-18 years) with severe obesity undergoing Roux-en-Y gastric bypass at three specialised paediatric obesity treatment centres in Sweden. We compared clinical outcomes in adolescent surgical patients with those of matched adolescent controls undergoing conservative treatment and of adult controls undergoing Roux-en-Y gastric bypass. The primary outcome measure was change in BMI over 5 years. We used multilevel mixed-effect regression models to assess longitudinal changes. This trial is registered with ClinicalTrials.gov, number NCT00289705. Between April, 2006, and May, 2009, 100 adolescents were recruited to the study, of whom 81 underwent Roux-en-Y gastric bypass (mean age 16·5 years [SD 1·2], bodyweight 132·8 kg [22·1], and BMI 45·5 kg/m 2 [SD 6·1]). 80 matched adolescent controls and 81 matched adult controls were enrolled for comparison of outcomes. The change in bodyweight in adolescent surgical patients over 5 years was -36·8 kg (95% CI -40·9 to -32·8), resulting in a reduction in BMI of -13·1 kg/m 2 (95% CI -14·5 to -11·8), although weight loss less than 10% occurred in nine (11%). Mean BMI rose in adolescent controls (3·3 kg/m 2 , 95% CI 1·1-4·8) over the 5-year study period, whereas the BMI change in adult controls was similar to that in adolescent surgical patients (mean change -12·3 kg/m 2 , 95% CI -13·7 to -10·9). Comorbidities and cardiovascular risk factors in adolescent surgical patients showed improvement over 5 years and compared favourably with those in adolescent controls. 20 (25%) of 81 adolescent surgical patients underwent additional abdominal surgery for complications of surgery or rapid weight loss and 58 (72%) showed some type of nutritional deficiency; health-care consumption (hospital attendances and admissions) was higher in adolescent surgical patients compared with adolescent controls. 20 (25%) of 81 adolescent controls underwent bariatric surgery during the 5-year follow-up. Adolescents with severe obesity undergoing Roux-en-Y gastric bypass had substantial weight loss over 5 years, alongside improvements in comorbidities and risk factors. However, gastric bypass was associated with additional surgical interventions and nutritional deficiencies. Conventional non-surgical treatment was associated with weight gain and a quarter of patients had bariatric surgery within 5 years. Swedish Research Council; Swedish Governmental Agency for Innovation Systems; National Board of Health and Welfare; Swedish Heart and Lung Foundation; Swedish Childhood Diabetes Foundation; Swedish Order of Freemasons Children's Foundation; Stockholm County Council; Västra Götaland Region; Mrs Mary von Sydow Foundation; Stiftelsen Göteborgs Barnhus; Stiftelsen Allmänna Barnhuset; and the US National Institute of Diabetes, Digestive, and Kidney Diseases (National Institutes of Health). Copyright © 2017 Elsevier Ltd. All rights reserved.

Operative hysteroscopy versus vacuum aspiration for incomplete spontaneous abortion (HY-PER): study protocol for a randomized controlled trial.

PubMed

Huchon, Cyrille; Koskas, Martin; Agostini, Aubert; Akladios, Cherif; Alouini, Souhail; Bauville, Estelle; Bourdel, Nicolas; Fernandez, Hervé; Fritel, Xavier; Graesslin, Olivier; Legendre, Guillaume; Lucot, Jean-Philippe; Matheron, Isabelle; Panel, Pierre; Raiffort, Cyril; Fauconnier, Arnaud

2015-08-19

Incomplete spontaneous abortions are defined by the intrauterine retention of the products of conception after their incomplete or partial expulsion. This condition may be managed by expectant care, medical treatment or surgery. Vacuum aspiration is currently the standard surgical treatment in most centers. However, operative hysteroscopy has the advantage over vacuum aspiration of allowing the direct visualization of the retained conception product, facilitating its elective removal while limiting surgical complications. Inadequately powered retrospective studies reported subsequent fertility to be higher in patients treated by operative hysteroscopy than in those treated by vacuum aspiration. These data require confirmation in a randomized controlled trial comparing fertility rates between women undergoing hysteroscopy and those undergoing vacuum aspiration for incomplete spontaneous abortion. After providing written informed consent, 572 women with incomplete spontaneous abortion recruited from 15 centers across France will undergo randomization by a centralized computer system for treatment by either vacuum aspiration or operative hysteroscopy. Patients will not be informed of the type of treatment that they receive and will be cared for during their hospital stay in accordance with standard practices at each center. The patients will be monitored for pregnancy or adverse effects by a telephone conversation or questionnaire sent by e-mail or post over a period of two years. In cases of complications, failure of the intervention or diagnosis of uterine cavity disease, patient care will be left to the discretion of the medical center team. If our hypothesis is confirmed, this study will provide evidence that the use of operative hysteroscopy can increase the number of pregnancies continuing beyond 22 weeks of gestation in the two-year period following incomplete spontaneous abortion without increasing the incidence of morbidity and peri- and postoperative complications. The standard surgical treatment of this condition would thus be modified. This study would therefore have a large effect on the surgical management of incomplete spontaneous abortion. ClinicalTrials.gov Identifier: NCT02201732 ; registered on 17 July 2014.

The influence of sarcopenia on survival and surgical complications in ovarian cancer patients undergoing primary debulking surgery.

PubMed

Rutten, I J G; Ubachs, J; Kruitwagen, R F P M; van Dijk, D P J; Beets-Tan, R G H; Massuger, L F A G; Olde Damink, S W M; Van Gorp, T

2017-04-01

Sarcopenia, severe skeletal muscle loss, has been identified as a prognostic factor in various malignancies. This study aims to investigate whether sarcopenia is associated with overall survival (OS) and surgical complications in patients with advanced ovarian cancer undergoing primary debulking surgery (PDS). Ovarian cancer patients (n = 216) treated with PDS were enrolled retrospectively. Total skeletal muscle surface area was measured on axial computed tomography at the level of the third lumbar vertebra. Optimum stratification was used to find the optimal skeletal muscle index cut-off to define sarcopenia (≤38.73 cm 2 /m 2 ). Cox-regression and Kaplan-Meier analysis were used to analyse the relationship between sarcopenia and OS. The effect of sarcopenia on the development of major surgical complications was studied with logistic regression. Kaplan-Meier analysis showed a significant survival disadvantage for patients with sarcopenia compared to patients without sarcopenia (p = 0.010). Sarcopenia univariably predicted OS (HR 1.536 (95% CI 1.105-2.134), p = 0.011) but was not significant in multivariable Cox-regression analysis (HR 1.362 (95% CI 0.968-1.916), p = 0.076). Significant predictors for OS in multivariable Cox-regression analysis were complete PDS, treatment in a specialised centre and the development of major complications. Sarcopenia was not predictive of major complications. Sarcopenia was not predictive of OS or major complications in ovarian cancer patients undergoing primary debulking surgery. However a strong trend towards a survival disadvantage for patients with sarcopenia was seen. Future prospective studies should focus on interventions to prevent or reverse sarcopenia and possibly increase ovarian cancer survival. Complete cytoreduction remains the strongest predictor of ovarian cancer survival. Copyright © 2017 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.

Patient selection and perioperative outcomes of bypass and endovascular intervention as first revascularization strategy for infrainguinal arterial disease.

PubMed

Bodewes, Thomas C F; Darling, Jeremy D; Deery, Sarah E; O'Donnell, Thomas F X; Pothof, Alexander B; Shean, Katie E; Moll, Frans L; Schermerhorn, Marc L

2018-01-01

The optimal initial revascularization strategy remains uncertain for patients with peripheral arterial disease. The purpose of this study was to evaluate current nationwide selection and perioperative outcomes of patients undergoing bypass or endovascular intervention for infrainguinal disease in those with no prior ipsilateral revascularization. Patients undergoing nonemergent first-time infrainguinal revascularization were identified in the Targeted Vascular module of the National Surgical Quality Improvement Program (NSQIP) for 2011 to 2014 and stratified by symptom status (chronic limb-threatening ischemia [CLTI] or claudication). Patients treated with endovascular intervention were compared with those who underwent bypass. Multivariable logistic regression was used to evaluate current selection of patients and to establish independent associations between first-time procedures and postoperative outcomes. Of 5998 first-time infrainguinal revascularizations performed, 3193 were bypass procedures (63% for CLTI) and 2805 were endovascular interventions (64% for CLTI). Current patient characteristics associated with an endovascular-first approach as opposed to bypass-first in CLTI patients were age ≥80 years, tissue loss, nonsmoking, functional dependence, diabetes, dialysis, and tibial lesions, whereas age ≥80 years, nonwhite race, nonsmoking, diabetes, and tibial lesions were associated with an endovascular approach for claudication. In comparing first-time endovascular intervention with bypass, there was no difference in 30-day mortality in CLTI patients (univariate: 2.1% vs 2.2%; adjusted: odds ratio [OR], 0.7; 95% confidence interval [CI], 0.4-1.1) or claudication patients (0.3% vs 0.6%). Among CLTI patients, endovascular-first intervention was associated with lower rates of major adverse cardiovascular event (3.6% vs 4.7%; OR, 0.6; 95% CI, 0.4-0.9), surgical site infection (0.9% vs 7.7%; OR, 0.1; 95% CI, 0.1-0.2), bleeding (8.5% vs 17%; OR, 0.4; 95% CI, 0.3-0.5), unplanned reoperation (13% vs 17%; OR, 0.7; 95% CI, 0.5-0.8), and unplanned readmission (17% vs 18%; OR, 0.8; 95% CI, 0.7-0.9). Patients with claudication undergoing endovascular-first intervention also had lower rates of major adverse cardiovascular event (0.8% vs 1.6%; OR, 0.4; 95% CI, 0.2-0.95), surgical site infection (0.7% vs 6.6%; OR, 0.1; 95% CI, 0.04-0.2), bleeding (2.3% vs 6.0%; OR, 0.3; 95% CI, 0.2-0.5), unplanned reoperation (4.3% vs 6.6%; OR, 0.6; 95% CI, 0.4-0.9), and unplanned readmission (5.9% vs 9.0%; OR, 0.6; 95% CI, 0.4-0.8). Conversely, endovascular-first intervention was associated with a higher rate of secondary revascularizations within 30 days for CLTI (4.3% vs 3.1%; OR, 1.6; 95% CI, 1.04-2.3) but not for claudication (2.6% vs 1.9%; OR, 1.7; 95% CI, 0.9-3.4). An endovascular-first approach as a revascularization strategy for infrainguinal disease was associated with substantially lower early morbidity but not mortality, at the cost of higher rates of postoperative secondary revascularizations. As a national representation of first-time revascularizations, this study highlights the early endovascular perioperative benefit, although more robust long-term data are needed to adopt either one strategy or the other in select patients with peripheral arterial disease. Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Pleurectomy versus pleural abrasion for primary spontaneous pneumothorax in children.

PubMed

Joharifard, Shahrzad; Coakley, Brian A; Butterworth, Sonia A

2017-05-01

Primary spontaneous pneumothorax (PSP) represents a common indication for urgent surgical intervention in children. First episodes are often managed with thoracostomy tube, whereas recurrent episodes typically prompt surgery involving apical bleb resection and pleurodesis, either via pleurectomy or pleural abrasion. The purpose of this study was to assess whether pleurectomy or pleural abrasion was associated with lower postoperative recurrence. The records of patients undergoing surgery for PSP between February 2005 and December 2015 were retrospectively reviewed. Recurrence was defined as an ipsilateral pneumothorax requiring surgical intervention. Bivariate logistic regressions were used to identify factors associated with recurrence. Fifty-two patients underwent 64 index operations for PSP (12 patients had surgery for contralateral pneumothorax, and each instance was analyzed separately). The mean age was 15.7±1.2years, and 79.7% (n=51) of patients were male. In addition to apical wedge resection, 53.1% (n=34) of patients underwent pleurectomy, 39.1% (n=25) underwent pleural abrasion, and 7.8% (n=5) had no pleural treatment. The overall recurrence rate was 23.4% (n=15). Recurrence was significantly lower in patients who underwent pleurectomy rather than pleural abrasion (8.8% vs. 40%, p<0.01). In patients who underwent pleural abrasion without pleurectomy, the relative risk of recurrence was 2.36 [1.41-3.92, p<0.01]. Recurrence of PSP is significantly reduced in patients undergoing pleurectomy compared to pleural abrasion. Level III, retrospective comparative therapeutic study. Copyright © 2017 Elsevier Inc. All rights reserved.

Preoperative clinical and diagnostic characteristics of patients who require delayed IPP after primary Peyronies repair.

PubMed

Alphs, Hannah H; Navai, Neema; Köhler, Tobias S; McVary, Kevin T

2010-03-01

Penile vascular abnormalities occur in a high proportion of patients with Peyronie's disease (PD). Penile duplex ultrasonography (PDU) and dynamic infusion cavernosometry and cavernosography (DICC) are tools that can be used to help tailor individualized treatment for patients undergoing surgical intervention for their PD. However, precisely which parameters can be used to predict those patients with PD at risk for developing erectile dysfunction (ED) after intervention without inflatable penile prosthesis (IPP) has not been previously elucidated. To evaluate preoperative vascular parameters that predispose PD patients for developing ED after intervention without IPP. Twenty-six patients receiving surgical intervention for their PD at a single center were retrospectively identified. Of these, 11 (42.3%) opted for primary repair without placement of an IPP. Three (27.2%) of these 11 patients went on to develop ED postoperatively. We compared various demographic, PDU, and DICC parameters between patients who did and did not fail primary repair of their PD. Mean age and follow-up of patients who went on to develop ED after repair of PD without IPP were not significantly different (P < 0.05). Resistive index (RI) and end diastolic volume were significantly different between these two groups (P < 0.05), while peak systolic volume, flow to maintain, and pressure decay were not significantly different. An RI cutoff of <0.80 was found to identify all patients who would later develop ED and fail primary repair without IPP. Penile vascular assessment can aid in counseling patients about their risk of developing delayed ED after primary repair of PD. In our cohort of patients, PDU provided preoperative risk stratification for postoperative erectile dysfunction in men undergoing Peyronie's repair without IPP. We propose the prospective study of an RI cutoff to identify patients at risk of failing primary PD repair without IPP.

Structured recording of intraoperative surgical workflows

NASA Astrophysics Data System (ADS)

Neumuth, T.; Durstewitz, N.; Fischer, M.; Strauss, G.; Dietz, A.; Meixensberger, J.; Jannin, P.; Cleary, K.; Lemke, H. U.; Burgert, O.

2006-03-01

Surgical Workflows are used for the methodical and scientific analysis of surgical interventions. The approach described here is a step towards developing surgical assist systems based on Surgical Workflows and integrated control systems for the operating room of the future. This paper describes concepts and technologies for the acquisition of Surgical Workflows by monitoring surgical interventions and their presentation. Establishing systems which support the Surgical Workflow in operating rooms requires a multi-staged development process beginning with the description of these workflows. A formalized description of surgical interventions is needed to create a Surgical Workflow. This description can be used to analyze and evaluate surgical interventions in detail. We discuss the subdivision of surgical interventions into work steps regarding different levels of granularity and propose a recording scheme for the acquisition of manual surgical work steps from running interventions. To support the recording process during the intervention, we introduce a new software architecture. Core of the architecture is our Surgical Workflow editor that is intended to deal with the manifold, complex and concurrent relations during an intervention. Furthermore, a method for an automatic generation of graphs is shown which is able to display the recorded surgical work steps of the interventions. Finally we conclude with considerations about extensions of our recording scheme to close the gap to S-PACS systems. The approach was used to record 83 surgical interventions from 6 intervention types from 3 different surgical disciplines: ENT surgery, neurosurgery and interventional radiology. The interventions were recorded at the University Hospital Leipzig, Germany and at the Georgetown University Hospital, Washington, D.C., USA.

Enhanced Recovery After Surgery Program Implementation in 2 Surgical Populations in an Integrated Health Care Delivery System.

PubMed

Liu, Vincent X; Rosas, Efren; Hwang, Judith; Cain, Eric; Foss-Durant, Anne; Clopp, Molly; Huang, Mengfei; Lee, Derrick C; Mustille, Alex; Kipnis, Patricia; Parodi, Stephen

2017-07-19

Novel approaches to perioperative surgical care focus on optimizing nutrition, mobility, and pain management to minimize adverse events after surgical procedures. To evaluate the outcomes of an enhanced recovery after surgery (ERAS) program among 2 target populations: patients undergoing elective colorectal resection and patients undergoing emergency hip fracture repair. A pre-post difference-in-differences study before and after ERAS implementation in the target populations compared with contemporaneous surgical comparator groups (patients undergoing elective gastrointestinal surgery and emergency orthopedic surgery). Implementation began in February and March 2014 and concluded by the end of 2014 at 20 medical centers within the Kaiser Permanente Northern California integrated health care delivery system. A multifaceted ERAS program designed with a particular focus on perioperative pain management, mobility, nutrition, and patient engagement. The primary outcome was hospital length of stay. Secondary outcomes included hospital mortality, home discharge, 30-day readmission rates, and complication rates. The study included a total of 3768 patients undergoing elective colorectal resection (mean [SD] age, 62.7 [14.1] years; 1812 [48.1%] male) and 5002 patients undergoing emergency hip fracture repair (mean [SD] age, 79.5 [11.8] years; 1586 [31.7%] male). Comparator surgical patients included 5556 patients undergoing elective gastrointestinal surgery and 1523 patients undergoing emergency orthopedic surgery. Most process metrics had significantly greater changes in the ERAS target populations after implementation compared with comparator surgical populations, including those for ambulation, nutrition, and opioid use. Hospital length of stay and postoperative complication rates were also significantly lower among ERAS target populations after implementation. The rate ratios for postoperative complications were 0.68 (95% CI, 0.46-0.99; P = .04) for patients undergoing colorectal resection and 0.67 (95% CI, 0.45-0.99, P = .05) for patients with hip fracture. Among patients undergoing colorectal resection, ERAS implementation was associated with decreased rates of hospital mortality (0.17; 95% CI, 0.03-0.86; P = .03), whereas among patients with hip fracture, implementation was associated with increased rates of home discharge (1.24; 95% CI, 1.06-1.44; P = .007). Multicenter implementation of an ERAS program among patients undergoing elective colorectal resection and patients undergoing emergency hip fracture repair successfully altered processes of care and was associated with significant absolute and relative decreases in hospital length of stay and postoperative complication rates. Rapid, large-scale implementation of a multidisciplinary ERAS program is feasible and effective in improving surgical outcomes.

Interventions to Promote Follow-up After Trabeculectomy Surgery in Rural Southern China: A Randomized Clinical Trial.

PubMed

Yang, Ke; Jin, Ling; Li, Li; Zeng, Siming; Wei, Ruqian; Li, Guirong; Man, Pingyi; Congdon, Nathan

2016-10-01

Follow-up after trabeculectomy surgery is important to surgical success, but little is known about the effect of interventions on improving follow-up in low-resource areas. To examine whether text message reminders and free eye medications improve follow-up after trabeculectomy in rural southern China. This randomized clinical trial studied 222 consecutive patients undergoing trabeculectomy from October 1, 2014, through November 31, 2015, at 4 rural hospitals in Guangdong and Guangxi Provinces, China. Data from the intention-to-treat population were analyzed. Patients undergoing trabeculectomy were randomized (1:1) to receive text message reminders 3 days before appointments at 1 and 2 weeks and 1 month after surgery and free topical corticosteroid medication (US$5.30) at each visit or to standard follow-up without reminders or free medication. Follow-up at 1 month postoperatively. Among 222 eligible patients, 13 (5.9%) refused and 209 (94.1%) were enrolled, with 106 (50.7%) randomized to the intervention group (mean [SD] age, 64.4 [12.7] years; 56 women [52.8%]) and 103 (49.3%) to the control group (mean [SD] age, 63.0 [12.7] years; 53 women [51.5%]). A total of 6 patients (2.9%) were unavailable for follow-up. Attendance at 1 month for the intervention group (59 of 102 [57.8%]) was significantly higher than for the control group (34 of 101 [33.7%]) (unadjusted relative risk [RR], 1.72; 95% CI, 1.13-2.63; P = .01). Factors associated with 1-month attendance in multiple regression models included intervention group membership (RR, 1.65; 95% CI, 1.08-2.53; P = .02) and being told to return for suture removal (RR, 1.80; 95% CI, 1.06-3.06; P = .03). One-month attendance among controls not told about suture removal was 3 of 31 (9.7%), whereas it was 44 of 68 (64.7%) among the intervention group with suture removal (unadjusted RR, 6.69; 95% CI, 2.08-21.6; P = .001). In this setting, low-cost interventions may significantly improve postoperative follow-up after glaucoma surgery, a potential opportunity for interventions known to improve surgical success. clinicaltrials.gov Identifier: NCT02328456.

Frequency of Dehiscence in Hand-Sutured and Stapled Intestinal Anastomoses in Dogs.

PubMed

Duell, Jason R; Thieman Mankin, Kelley M; Rochat, Mark C; Regier, Penny J; Singh, Ameet; Luther, Jill K; Mison, Michael B; Leeman, Jessica J; Budke, Christine M

2016-01-01

To determine the frequency of dehiscence of hand-sutured and stapled intestinal anastomoses in the dog and compare the surgery duration for the methods of anastomosis. Historical cohort study. Two hundred fourteen client-owned dogs undergoing hand-sutured (n = 142) or stapled (n = 72) intestinal anastomoses. Medical records from 5 referral institutions were searched for dogs undergoing intestinal resection and anastomosis between March 2006 and February 2014. Demographic data, presence of septic peritonitis before surgery, surgical technique (hand-sutured or stapled), surgery duration, surgeon (resident versus faculty member), indication for surgical intervention, anatomic location of resection and anastomosis, and if dehiscence was noted postoperatively were retrieved. Estimated frequencies were summarized and presented as proportions and 95% confidence intervals (CI) and continuous outcomes as mean (95% CI). Comparisons were made across methods of anastomosis. Overall, 29/205 dogs (0.14, 95% CI 0.10-00.19) had dehiscence, including 21/134 dogs (0.16, 0.11-0.23) undergoing hand-sutured anastomosis and 8/71 dogs (0.11, 0.06-0.21) undergoing stapled anastomosis. There was no significant difference in the frequency of dehiscence across anastomosis methods (χ(2), P = .389). The mean (95% CI) surgery duration of 140 minutes (132-147) for hand- sutured anastomoses and 108 minutes (99-119) for stapled anastomoses was significantly different (t-test, P < .001). No significant difference in frequency of dehiscence was noted between hand- sutured and stapled anastomoses in dogs but surgery duration is significantly reduced by the use of staples for intestinal closure. © Copyright 2015 by The American College of Veterinary Surgeons.

Music as therapy.

PubMed

Kemper, Kathi J; Danhauer, Suzanne C

2005-03-01

Music is widely used to enhance well-being, reduce stress, and distract patients from unpleasant symptoms. Although there are wide variations in individual preferences, music appears to exert direct physiologic effects through the autonomic nervous system. It also has indirect effects by modifying caregiver behavior. Music effectively reduces anxiety and improves mood for medical and surgical patients, for patients in intensive care units and patients undergoing procedures, and for children as well as adults. Music is a low-cost intervention that often reduces surgical, procedural, acute, and chronic pain. Music also improves the quality of life for patients receiving palliative care, enhancing a sense of comfort and relaxation. Providing music to caregivers may be a cost-effective and enjoyable strategy to improve empathy, compassion, and relationship-centered care while not increasing errors or interfering with technical aspects of care.

Management of the patient with a total joint replacement: the primary care practitioner's role.

PubMed

Palmer, L M

1999-01-01

The primary care practitioner assumes chief responsibility for patients with arthritis. More than 40 million Americans experience some form of arthritis. Management of the patient with arthritis may include a referral to an orthopedic surgeon for surgical intervention. As estimated, up to 500,000 total joint replacement procedures are performed by orthopedic surgeons each year in the United States. Presurgical evaluation for a total joint replacement is imperative to ensure that the patient can safely undergo this surgical procedure. Postsurgical care of a patient with total joint replacement involves coordinating care with the physical therapist and orthopedic surgeon to ensure adequate follow-through with the recommended rehabilitation program, prophylactic antibiotic coverage, and observation for any complications including infection, deep-vein thrombosis, or loosening of the total-joint prosthesis.

Time courses and value of circulating microparticles in patients with operable stage non-small cell lung cancer undergoing surgical intervention.

PubMed

Tseng, Chia-Cheng; Wang, Chin-Chou; Hsiao, Chang-Chun; Lu, Hung-I; Leu, Steve; Chang, Huang-Chih; Huang, Kuo-Tung; Fang, Wen-Feng; Chen, Yu-Mu; Liu, Shih-Feng; Yang, Cheng-Ta; Lin, Meng-Chih; Yip, Hon-Kan

2016-09-01

Microparticles (MPs) are substantially increased in patients with operable stage non-small cell lung cancer (NSCLC) prior to lung resection surgery. This study tested the hypothesis that there is a decrease in MPs after surgical intervention. Between March 2012 and January 2015, 33 patients who had operable stage NSCLC were consecutively and prospectively enrolled into the study. Additionally, 31 healthy subjects who were consecutively enrolled in the study period served as age- and gender-matched controls. Circulating MPs (EDAc-MPs, EDAp-MPs, PDAc-MPs, PDAp-MPs) were measured by flow cytometry once in control subjects and twice (i.e., prior to and three months later after surgical intervention) in NSCLC patients. Compared with control subjects, these four types of circulating MPs were significantly higher in NSCLC patients prior to operation (all P < 0.005), but did not differ among the controls and NSCLC patients at 3 months after surgery (all P > 0.2). Additionally, a receiver operating characteristic curve (ROC) showed that these four types of MPs were significantly valuable predictors for detecting early stage NSCLC (all P < 0.004). Circulating MPs which were remarkably increased in the operable stage of NSCLC prior to surgery were substantially decreased 3 months later after surgery. These findings show that circulating MPs might be an accessory biomarker for monitoring those of NSCLC after receiving lung resection surgery.

Conservative treatment of torn medial meniscus via mechanical force, manually assisted short lever chiropractic adjusting procedures.

PubMed

Polkinghorn, B S

1994-09-01

To present the first reported case of successful chiropractic intervention in treatment of a torn medial meniscus of the knee, the meniscal tear being documented by magnetic resonance imaging (MRI). A 54-yr-old woman complaining of right knee pain of several months' duration with accompanying marked functional impairment was diagnosed as having a tear in the posterior horn of the ipsilateral medial meniscus, verified by MRI studies of the same. Independent consultation with three medical specialists resulted in the unanimous decision that surgical intervention for the purpose of meniscectomy provided the only therapeutic approach indicated for the problem. However, the patient was reticent to undergo said surgical procedure and chose, instead, to utilize chiropractic care and conservative management in an effort to resolve her condition without having to resort to surgery. The patient received chiropractic treatment to the knee via mechanical force, manually assisted short lever chiropractic adjusting procedures (MFMA) utilizing an Activator Adjusting Instrument. Auxiliary treatment included the use of homeopathic therapy as an adjunct to chiropractic care. Said treatment resulted in a complete resolution of the patient's disability, the patient recovering full function of the knee joint and achieving an asymptomatic status without having to submit to surgical intervention and its possible adverse sequelae. Conservative management of meniscal tears via chiropractic treatment may provide a therapeutically effective and financially cost containing alternative to routine meniscectomy in certain cases involving torn medial menisci of the knee.

Contemporary results of surgical repair of recurrent aortic arch obstruction.

PubMed

Mery, Carlos M; Khan, Muhammad S; Guzmán-Pruneda, Francisco A; Verm, Raymond; Umakanthan, Ramanan; Watrin, Carmen H; Adachi, Iki; Heinle, Jeffrey S; McKenzie, E Dean; Fraser, Charles D

2014-07-01

There is a paucity of data on the current outcomes of surgical intervention for recurrent aortic arch obstruction (RAAO) after initial aortic arch repair in children. The goal of this study is to report the long-term results in these patients. All patients undergoing surgical intervention for RAAO at Texas Children's Hospital from 1995 to 2012 were included. The cohort was divided into four groups based on initial procedure: (1) simple coarctation repair, (2) Norwood procedure, (3) complex congenital heart disease, and (4) interrupted aortic arch. A total of 48 patients age 9 months (range, 22 days to 36 years) underwent 49 procedures for RAAO. All patients had an anatomic repair consisting of either patch aortoplasty (n=27, 55%), aortic arch advancement (n=8, 16%), sliding arch aortoplasty (n=6, 12%), placement of an interposition graft (n=2, 17%), reconstruction with donor allograft (n=4, 8%), extended end-to-end anastomosis (n=1, 2%), or redo Norwood-type reconstruction (n=1, 2%). Most procedures (n=46, 94%) were performed through a median sternotomy using cardiopulmonary bypass. At a median follow-up of 6.1 years (range, 9 days to 17 years), only 2 patients required surgical or catheter-based intervention for RAAO. Hypertension was present in 10% of patients at last follow-up. There were no neurologic or renal complications. There was 1 perioperative death after an aortic arch advancement in group 1. Four other patients have died during follow-up, none of the deaths related to RAAO. Anatomic repair of RAAO is a safe procedure associated with low morbidity and mortality, and low long-term reintervention rates. Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Necrotizing enterocolitis, a rare but severe condition with insidious postoperative complications.

PubMed

Bălălău, C; Motofei, I; Voiculescu, S; Popa, F; Scăunaşu, R V

2013-01-01

Necrotizing enterocolitis (NEC) is one of the most frequent causes of gastrointestinal perforation in premature neonates, only few case series and reports being described in adult patients. Early in the course of the disease, superficial mucosal ulceration, sub mucosal edema and hemorrhage occur. Further progression leads to transmural necrosis leading sometimes to bowel perforation. Six cases encountered in our clinic in recent years led us to resume discussions on necrotizing enteritis, not because it is a rare disease, but due to the severe postoperative complications. Our lot consisted of four stage 1 patients and two with Bell stage III NEC and severe intestinal injury, necrosis, and perforation. All of the patients were diagnosed preoperatory with other surgical conditions, like appendicitis with peritonitis, perforated duodenal ulcer or acute cholecystitis. We present to review two cases. For patients undergoing laparotomy, resection of the involved intestine mandates either enterostomy formation or primary anastomosis. An intermediate option is laparotomy with intestinal resection and delayed anastomosis 48 to 72 hours later. Because of the small number of patients in our lot, we cannot advise a certain surgical treatment, but a strategy involving bienterostomyper primam should be further analyzed. The choice of operative intervention reflects multiple variables, including age, physiologic status, institutional resources and surgeon preference based on experience. Primary peritoneal drainage for perforated NEC may help to resuscitate and treat a critically ill patient initially, and in some instances, may be definitive operative intervention. Relatively rare disease, of unknown etiology and elusive pathogenesis, NEC has initial non-specific symptoms and clinical features that mimic more common surgical diseases. There is considerable controversy regarding which procedure is preferable. Currently, in the absence of rigorous evidence supporting the superiority of one approach over the other, surgical intervention depends mostly on the treating institution or the individual surgeon.

Management of Mycobacterium abscessus Infection After Medical Tourism in Cosmetic Surgery and a Review of Literature.

PubMed

Cai, Stephen S; Chopra, Karan; Lifchez, Scott D

2016-12-01

Despite news reports, Food and Drug Administration disclaimers, and warnings from US plastic surgeons against the perils of cosmetic tourism, patients continue to seek care abroad and often present with infectious complications. Recent reports of Mycobacterium abscessus surgical site infection (SSI) is of particularly concern and its management, particularly surgical intervention, has been poorly documented. A retrospective review of 2 sisters who presented with M. abscessus SSI after cosmetic surgery in the Dominican Republic was performed. A comprehensive review of the literature was conducted to unveil similar cases after cosmetic tourism. Both patients presented four months after index operation after definitive diagnoses have been reached. They were counselled to undergo immediate, aggressive debridement and antibiotic therapy. Although 1 patient agreed, the other patient opted for local wound care and oral antibiotics in hopes to avoid reoperation. When unsuccessful, she agreed to the initial plan which led to rapid convalescence of her infection. However, aesthetic result was far inferior to the first patient. Review of literature revealed 14 women with an average age of 40 years (range, 19-60 years). Most frequent cosmetic operations that resulted in M. abscessus SSI were abdominoplasty (41%), liposuction (27%), breast augmentation (14%), breast reduction (9%), and rejuvenation surgery (9%). Surgical interventions were performed in all cases except one. Antibiotic therapies focused on macrolides, particularly clarithromycin or azithromycin, with average time to complete recovery of 8 months (range, 2-22 months). The 2 cases highlighted the importance of multidisciplinary approach of early aggressive surgical intervention and long-term intravenous antibiotics in treating M. abscessus SSI that is highly prevalent among those returning from medical tourism in cosmetic surgery.

Importance of perioperative glycemic control in general surgery: a report from the Surgical Care and Outcomes Assessment Program.

PubMed

Kwon, Steve; Thompson, Rachel; Dellinger, Patchen; Yanez, David; Farrohki, Ellen; Flum, David

2013-01-01

To determine the relationship of perioperative hyperglycemia and insulin administration on outcomes in elective colon/rectal and bariatric operations. There is limited evidence to characterize the impact of perioperative hyperglycemia and insulin on adverse outcomes in patients, with and without diabetes, undergoing general surgical procedures. The Surgical Care and Outcomes Assessment Program is a Washington State quality improvement benchmarking-based initiative. We evaluated the relationship of perioperative hyperglycemia (>180 mg/dL) and insulin administration on mortality, reoperative interventions, and infections for patients undergoing elective colorectal and bariatric surgery at 47 participating hospitals between fourth quarter of 2005 and fourth quarter of 2010. Of the 11,633 patients (55.4 ± 15.3 years; 65.7% women) with a serum glucose determination on the day of surgery, postoperative day 1, or postoperative day 2, 29.1% of patients were hyperglycemic. After controlling for clinical factors, those with hyperglycemia had a significantly increased risk of infection [odds ratio (OR) 2.0; 95% confidence interval (CI), 1.63-2.44], reoperative interventions (OR, 1.8; 95% CI, 1.41-2.3), and death (OR, 2.71; 95% CI, 1.72-4.28). Increased risk of poor outcomes was observed both for patients with and without diabetes. Those with hyperglycemia on the day of surgery who received insulin had no significant increase in infections (OR, 1.01; 95% CI, 0.72-1.42), reoperative interventions (OR, 1.29; 95% CI, 0.89-1.89), or deaths (OR, 1.21; 95% CI, 0.61-2.42). A dose-effect relationship was found between the effectiveness of insulin-related glucose control (worst 180-250 mg/dL, best <130 mg/dL) and adverse outcomes. Perioperative hyperglycemia was associated with adverse outcomes in general surgery patients with and without diabetes. However, patients with hyperglycemia who received insulin were at no greater risk than those with normal blood glucoses. Perioperative glucose evaluation and insulin administration in patients with hyperglycemia are important quality targets.

The effectiveness of systematic perioperative oral hygiene in reduction of postoperative respiratory tract infections after elective thoracic surgery in adults: a systematic review.

PubMed

Pedersen, Preben U; Larsen, Palle; Håkonsen, Sasja Jul

2016-01-01

Nosocomial infections are a significant contributor to patient morbidity and mortality. Nosocomial infections significantly increase hospital length of stay and total hospital costs. Thoracic surgery, mechanical ventilation and/or admission to an intensive care unit are known to increase patients' risk for nosocomial respiratory tract infection. To identify, appraise and synthesize the best available evidence on the effectiveness of systematic perioperative oral hygiene in the reduction of postoperative respiratory airway infections in adult patients undergoing elective thoracic surgery. Patients over the age of 18 years who had been admitted for elective thoracic surgery, regardless of gender, ethnicity, diagnosis severity, co-morbidity or previous treatment.Perioperative systematic oral hygiene (such as mechanical removal of dental biofilm or plaques and/or systematic use of mouth rinse) performed by patients themselves or by healthcare staff (such as nurses).Randomized controlled trials and quasi-experimental studies.Nosocomial infections, specifically respiratory tracts infections, and surgical site infections Multiple databases (PubMed, CINAHL, Embase, Scopus, Swemed+, Health Technology Assessment Database and Turning Research Into Practice [TRIP] database) were searched from 1980 to December 2014. Studies published in English, German, Danish, Swedish and Norwegian were considered for inclusion in this review. Two independent reviewers used the standard critical appraisal tool from the Joanna Briggs Institute to assess the methodological quality of studies. The process of data extraction was undertaken independently by two reviewers using tools from the Joanna Briggs Institute. Quantitative results were synthesized in meta-analysis. This review includes six studies: three randomized controlled trials and three quasi-experimental studies.The absolute magnitude of the summary effect sizes were: for nosocomial infections relative risk (RR) 0.65 (95% confidence interval [CI] 0.55-0.78) for respiratory tract infections RR 0.48 (95%CI: 0.36-0.65) and for deep surgical site infections RR 0.48 (95%CI 0.27-0.84). Systematic perioperative oral hygiene reduces postoperative nosocomial, lower respiratory tract infections and surgical site infections but not urinary tract infections. The effect is statistically, clinically and practically significant.Perioperative decontamination of the nasopharynx and/or oropharynx is a strategy worth pursuing. The intervention is cheap and can easily be carried out by the patients themselves. (Grade A)Studies testing decontamination of the nasopharynx and/or oropharynx have until now only included patients undergoing thoracic surgical procedures. As the interventions are cheap, easy to carry out and have a great impact on the patients' outcome, it is recommendable to carry out more studies involving other type of patients undergoing major surgery with a high prevalence of nosocomial infections, respiratory tract infections and surgical site infections.

Barriers to surgical care in Nepal.

PubMed

van Loenhout, Joris Adriaan Frank; Delbiso, Tefera Darge; Gupta, Shailvi; Amatya, Kapendra; Kushner, Adam L; Gil Cuesta, Julita; Guha-Sapir, Debarati

2017-01-23

Various barriers exist that preclude individuals from undergoing surgical care in low-income countries. Our study assessed the main barriers in Nepal, and identified individuals most at risk for not receiving required surgical care. A countrywide survey, using the Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey tool, was carried out in 2014, surveying 2,695 individuals with a response rate of 97%. Our study used data from a subset, namely individuals who required surgical care in the last twelve months. Data were collected on individual characteristics, transport characteristics, and reasons why individuals did not undergo surgical care. Of the 2,695 individuals surveyed, 207 individuals needed surgical care at least once in the previous 12 months. The main reasons for not undergoing surgery were affordability (n = 42), accessibility (n = 42) and fear/no trust (n = 34). A factor significantly associated with affordability was having a low education (OR = 5.77 of having no education vs. having secondary education). Living in a rural area (OR = 2.59) and a long travel time to a secondary and tertiary health facility (OR = 1.17 and 1.09, respectively) were some of the factors significantly associated with accessibility. Being a woman was significantly associated with fear/no trust (OR = 3.54). More than half of the individuals who needed surgical care did not undergo surgery due to affordability, accessibility, or fear/no trust. Providing subsidised transport, introducing mobile surgical clinics or organising awareness raising campaigns are measures that could be implemented to overcome these barriers to surgical care.

Body mass index and cholesterol level predict surgical outcome in patients with hepatocellular carcinoma in Taiwan - a cohort study.

PubMed

Lee, Ya-Ling; Li, Wan-Chun; Tsai, Tung-Hu; Chiang, Hsin-Yu; Ting, Chin-Tsung

2016-04-19

Curative surgical resection (CSR) remains the most effective therapeutic intervention for patients with hepatocellular carcinoma (HCC); however, frequent post-surgical recurrence leads to high cancer related mortality. This study aimed to clarify the role of body mass index (BMI) and serum cholesterol level in predicting post-surgical outcomes in HCC patients after CSR. A total of 484 HCC patients including 213 BMIhigh and 271 BMIlow patients were included. Overall survival (OS) and recurrence-free survival (RFS) rates were examined in patients with differential BMI and serum cholesterol level. The analysis showed that significant different 1-, 3- and 5-year cumulative OS rates (P-value=0.015) and RFS rate (P-value=0.010) between BMIlow and BMIhigh patients. Further analysis in groups with differential serum cholesterol levels among BMIlow and BMIhigh patients indicated that the BMIlow/Chollow patients exhibited the significant lower cumulative OS and RFS rates in comparison with the remaining subjects (P-value=0.007 and 0.039 for OS and RFS rates, respectively). In conclusion, the coexistence of low BMI and low serum cholesterol level could serve as prognostic factors to predict post-operative outcomes in HCC patients undergoing surgical hepatectomy.

Outcomes after medical and surgical interventions in horses with temporohyoid osteoarthropathy.

PubMed

Espinosa, P; Nieto, J E; Estell, K E; Kass, P H; Aleman, M

2017-11-01

Temporohyoid osteoarthropathy (THO) is a cause of neurological disease in horses that is characterised by facial and vestibulocochlear nerve deficits. Studies reporting and comparing survival following medical or surgical treatment of THO are lacking. To compare survival and prognosis in horses with THO treated medically or surgically, and to report surgical complications. Retrospective study. The medical records of horses diagnosed with THO were retrieved, and data on signalment, clinical signs and duration, corneal ulceration and bilateral occurrence were recorded. Neurological severity was graded according to clinical signs. Preoperative radiographic and endoscopic images were graded according to the severity of changes. Factors potentially affecting survival and treatment were compared using Cox proportional hazards regression. A total of 77 horses were identified as having THO during the period 1990-2014. Of these, 25 horses underwent ceratohyoid ostectomy (CHO) and eight underwent partial stylohyoid ostectomy (PSHO). Thirteen of 20, one of 25 and one of eight horses treated by medical therapy, CHO and PSHO, respectively, died or were subjected to euthanasia as a consequence of THO. Compared with CHO, medical therapy was significantly associated with nonsurvival, but there were no significant differences in survival between horses undergoing PSHO and medical therapy. The duration of clinical signs, and neurological, radiographic and endoscopic grades were not associated with survival of THO. However, the age of the horse was significantly associated with poorer survival. Survival time was significantly shorter in the medical therapy group compared with the two surgical groups combined, but did not differ significantly between the two surgical groups. No significant difference between groups was seen in the incidence of surgical complications (33.3% in the PSHO and 22.2% in the CHO group). This was a nonrandomised study of treatment effects on survival and included a low number of cases. The survival prognosis in horses with THO is good to excellent in those submitted to surgical intervention, and fair in those treated with medical therapy alone. © 2017 EVJ Ltd.

Laparoscopic surgery for trauma: the realm of therapeutic management.

PubMed

Zafar, Syed N; Onwugbufor, Michael T; Hughes, Kakra; Greene, Wendy R; Cornwell, Edward E; Fullum, Terrence M; Tran, Daniel D

2015-04-01

The use of laparoscopy in trauma is, in general, limited for diagnostic purposes. We aim to evaluate the therapeutic role of laparoscopic surgery in trauma patients. We analyzed the National Trauma Data Bank (2007 to 2010) for all patients undergoing diagnostic laparoscopy. Patients undergoing a therapeutic laparoscopic surgical procedure were identified and tabulated. Mortality and hospital length of stay for patients with isolated abdominal injuries were compared between the open and laparoscopic groups. Of a total of 2,539,818 trauma visits in the National Trauma Data Bank, 4,755 patients underwent a diagnostic laparoscopy at 467 trauma centers. Of these, 916 (19.3%) patients underwent a therapeutic laparoscopic intervention. Common laparoscopic operations included diaphragm repair, bowel repair or resection, and splenectomy. Patients undergoing laparoscopic surgery had a significantly shorter length of stay than the open group (5 vs 6 days; P < .001). Therapeutic laparoscopic surgery for trauma is feasible and may provide better outcomes. Copyright © 2015 Elsevier Inc. All rights reserved.

Pediatric Tonsillectomy and Ketorolac.

PubMed

Phillips-Reed, Lesley D; Austin, Paul N; Rodriguez, Ricardo E

2016-12-01

The use of ketorolac in children undergoing tonsillectomy remains limited because of the concern about postoperative bleeding. A search was performed addressing the question: For patients undergoing a surgical tonsillectomy, does a weight-appropriate single dose of intravenous ketorolac affect the incidence of postoperative hemorrhage? Five systematic reviews met the inclusion criteria. A Cochrane Review included 15 studies with 1,101 pediatric subjects and focused on perioperative bleeding requiring intervention. Many of the systematic reviews appraised the same studies. Subgroup analysis often allowed assessment of the effects of ketorolac administration. There was no consensus on the increased risk of bleeding when nonsteriodal anti-inflammatory drugs such as ketorolac are given to pediatric patients undergoing tonsillectomy. The conclusions varied from ketorolac should not be used to it is safe to use with these patients. The perianesthesia team must carefully weigh the risks and benefits before deciding to use ketorolac with this subset of patients. Copyright © 2016 American Society of PeriAnesthesia Nurses. Published by Elsevier Inc. All rights reserved.

Hospitalization, frequency of interventions, and quality of life after endoscopic, surgical, or conservative treatment in patients with chronic pancreatitis.

PubMed

Rutter, Karoline; Ferlitsch, A; Sautner, T; Püspök, A; Götzinger, P; Gangl, A; Schindl, M

2010-11-01

Patients with chronic pancreatitis usually have a long and debilitating history of disease with frequent hospital admissions, episodes of intractable pain and multiple interventions. The sequences of treatment at initial presentation, endoscopy, surgery, or conservative treatment may affect the time course and admissions needed for disease control, thereby determining quality of life and overall outcome. A total of 292 patients with initial endoscopic, surgical, or conservative pharmacological treatment were retrospectively analyzed regarding frequency of interventions, days in hospital, symptom-free intervals, morbidity, and mortality. Quality of life (QoL) at the latest follow-up was measured by two standardized quality of life questionnaires (EORTC C30 and PAN26). Endoscopic treatment was initially performed in 150 (51.4%) patients, whereas 99 (33.9%) underwent surgery and 43 (14.7%) patients were treated conservatively at their initial presentation. Patients who underwent surgery had a significantly shorter time in the hospital (25.3 ± 24.6, 34.4 ± 35.1, 61.1 ± 37.9; P < 0.001), fewer subsequent therapies (0.43 ± 1.0, 2.1 ± 2.4, 3.1 ± 3.0; P ≤ 0.001), and a longer relapse-free interval (P = 0.004) compared with endoscopically treated patients. The overall complication rate was 32% both after surgery and endoscopy. Infectious-related complications occurred more often after surgical treatment (P ≤ 0.001), whereas patients after endoscopic intervention developed acute or chronic pancreatitis or pseudocyst formation (P = 0.023). Patients who undergo surgery as their initial treatment for chronic pancreatitis require less consecutive interventions, a shorter hospital stay, and have a better quality of life compared with any other treatment. Surgery should therefore be considered early for the treatment of chronic pancreatitis, when endoscopic or conservative treatment fails and patients require further intervention.

Spinal epidural abscess: Report on 27 cases

PubMed Central

Khursheed, Nayil; Dar, Sultan; Ramzan, Altaf; Fomda, Bashir; Humam, Nisar; Abrar, Wani; Singh, Sarbjit; Sajad, Arif; Mahek, Masood; Yawar, Shoaib

2017-01-01

Background: Spinal epidural abscess, although an uncommon disease, often correlates with a high morbidity owing to significant delay in diagnosis. Methods: In a prospective 5-year study, the clinical and magnetic resonance (MR) findings, treatment protocols, microbiology, and neurological outcomes were analyzed for 27 patients with spinal epidural abscess. Results: Patients were typically middle-aged with underlying diabetes and presented with lumbar abscesses. Those undergoing surgical intervention >36 h after the onset of symptoms had poor neurological outcomes. Conclusion: Early recognition and timely evacuation of spinal abscesses minimized neurological morbidity and potential mortality. PMID:29026676

Spinal epidural abscess: Report on 27 cases.

PubMed

Khursheed, Nayil; Dar, Sultan; Ramzan, Altaf; Fomda, Bashir; Humam, Nisar; Abrar, Wani; Singh, Sarbjit; Sajad, Arif; Mahek, Masood; Yawar, Shoaib

2017-01-01

Spinal epidural abscess, although an uncommon disease, often correlates with a high morbidity owing to significant delay in diagnosis. In a prospective 5-year study, the clinical and magnetic resonance (MR) findings, treatment protocols, microbiology, and neurological outcomes were analyzed for 27 patients with spinal epidural abscess. Patients were typically middle-aged with underlying diabetes and presented with lumbar abscesses. Those undergoing surgical intervention >36 h after the onset of symptoms had poor neurological outcomes. Early recognition and timely evacuation of spinal abscesses minimized neurological morbidity and potential mortality.

Flat epithelial atypia of the breast on core needle biopsy: an indication for surgical excision.

PubMed

Sohn, Vance; Porta, Rees; Brown, Tommy

2011-11-01

Flat epithelial atypia (FEA) is an increasingly diagnosed breast lesion yet there remains a paucity of data regarding these findings and their clinical significance. By determining the pathologic concordance rate, we sought to evaluate the indications for surgical intervention for FEAs diagnosed on core needle biopsy (CNB). Using a retrospective review of an international pathology referral center database, we included all breast CNB specimens with FEA as the most advanced diagnosis that underwent surgical excision. Patient demographics, caliber of biopsy needle, and pathology results were then analyzed. Between 2000 and 2009, 463 FEAs were diagnosed among 15,000 specimens referred for expert opinion. Twenty-four lesions (5%) met inclusion criteria. Sampling ranged from 8- to 18-guage needles. Two lesions (8.4%) were upgraded after surgical excision; one patient was found to have infiltrating ductal carcinoma and another with tubular carcinoma. Twelve patients who were diagnosed with FEA did not undergo surgical excision but had no immediate evidence of malignancy. Based on the 8.4% upgrade rate, FEA diagnosed on CNB requires follow-up surgical excision. Regardless of CNB caliber, the risk of sampling error precludes nonoperative management and FEA should be considered an at-risk lesion until more studies and pooled analysis prove otherwise.

Correction of contracture and recurrence rates of Dupuytren contracture following invasive treatment: the importance of clear definitions.

PubMed

Werker, Paul M N; Pess, Gary M; van Rijssen, Annet L; Denkler, Keith

2012-10-01

To call attention to the wide variety of definitions for recurrence that have been employed in studies of different invasive procedures for the treatment of Dupuytren contracture and how this important limitation has contributed to the wide range of reported results. This study reviewed definitions and rates of contracture correction and recurrence in patients undergoing invasive treatment of Dupuytren contracture. A literature search was carried out in January 2011 using the terms "Dupuytren" AND ("fasciectomy" OR "fasciotomy" OR "dermofasciectomy" OR "aponeurotomy" OR "aponeurectomy") and limited to studies in English. The search returned 218 studies, of which 21 had definitions, quantitative results for contracture correction and recurrence, and a sample size of at least 20 patients. Definitions for correction of contracture and recurrence varied greatly among articles and were almost always qualitative. Percentages of patients who achieved correction of contracture (ie, responder rate) when evaluated at various times after completion of surgery ranged from 15% to 96% for fasciectomy/aponeurectomy. Responder rates were not reported for fasciotomy/aponeurotomy. Recurrence rates ranged from 12% to 73% for patients treated with fasciectomy/aponeurectomy and from 33% to 100% for fasciotomy/aponeurotomy. Review of these reports underscored the difficulty involved in comparing correction of contracture and recurrence rates for different surgical interventions because of differences in definition and duration of follow-up. Clearly defined objective definitions for correction of contracture and for recurrence are needed for more meaningful comparisons of results achieved with different surgical interventions. Recurrence after surgical intervention for Dupuytren contracture is common. This study, which evaluated reported rates of recurrence following surgical treatment of Dupuytren contracture, provides clinicians with practical information regarding expected long-term outcomes of surgical treatment choices. Economic and decision analysis III. Copyright © 2012 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

Surgical management of pancreatic necrosis: A practice management guideline from the Eastern Association for the Surgery of Trauma.

PubMed

Mowery, Nathan T; Bruns, Brandon R; MacNew, Heather G; Agarwal, Suresh; Enniss, Toby M; Khan, Mansoor; Guo, Weidun Alan; Cannon, Jeremy W; Lissauer, Matthew E; Duane, Therese M; Hildreth, Amy N; Pappas, Peter A; Gries, Lynn M; Kaiser, Meghann; Robinson, Bryce R H

2017-08-01

Pancreatic or peripancreatic tissue necrosis confers substantial morbidity and mortality. New modalities have created a wide variation in approaches and timing of interventions for necrotizing pancreatitis. As acute care surgery evolves, its practitioners are increasingly being called upon to manage these complex patients. A systematic review of the MEDLINE database using PubMed was performed. English language articles regarding pancreatic necrosis from 1980 to 2014 were included. Letters to the editor, case reports, book chapters, and review articles were excluded. Topics of investigation included operative timing, the use of adjuvant therapy and the type of operative repair. Grading of Recommendations, Assessment, Development and Evaluations methodology was applied to question development, outcome prioritization, evidence quality assessments, and recommendation creation. Eighty-eight studies were included and underwent full review. Increasing the time to surgical intervention had an improved outcome in each of the periods evaluated (72 hours, 12-14 days, 30 days) with a significant improvement in outcomes if surgery was delayed 30 days. The use of percutaneous and endoscopic procedures was shown to postpone surgery and potentially be definitive. The use of minimally invasive surgery for debridement and drainage has been shown to be safe and associated with reduced morbidity and mortality. Acute Care Surgeons are uniquely trained to care for those with pancreatic necrosis due their training in critical care and complex surgery with ongoing shock. In adult patients with pancreatic necrosis, we recommend that pancreatic necrosectomy be delayed until at least day 12. During the first 30 days of symptoms with infected necrotic collections, we conditionally recommend surgical debridement only if the patients fail to improve after radiologic or endoscopic drainage. Finally, even with documented infected necrosis, we recommend that patients undergo a step-up approach to surgical intervention as the preferred surgical approach. Systematic review/guideline, level III.

Acute peri-operative beta blockade in intermediate-risk patients.

PubMed

Biccard, B M; Sear, J W; Foëx, P

2006-10-01

Peri-operative beta-blockade has been shown to reduce the incidence of postoperative cardio- vascular complications including cardiac death in high-risk non-cardiac surgical patients. However, the recent analysis by Lindenauer et al. suggests that it is inappropriate to administer beta-blockers blindly to all surgical patients. In an attempt to determine the appropriateness of peri-operative beta-blocker administration across patients with a spectrum of cardiovascular risks, we have examined studies of intermediate-risk patient groups (that is those undergoing intermediate risk surgery or those with a Lee Revised Cardiac Risk Score of < or =2). We analysed data from randomised prospective studies of the effects of acute peri-operative beta-blockade on the incidence of peri-operative myocardial ischaemia. By examining the demographics and surgical interventions in these patients, we have compared these studies with other studies of peri-operative silent myocardial ischaemia representing patients of similar risk. We thus estimated the expected long-term postoperative cardiovascular complication rate associated with myocardial ischaemia in these patients in terms of number needed to treat for ischaemia prevention and for prevention of major cardiovascular complications. Prevention of peri-operative myocardial ischaemia with acute beta-blockade in non-cardiac surgical patients with 1-2 RCRI clinical risk factors can be achieved with a number needed to treat of 10. It is not associated with a significant increase in drug associated side-effects. However, acute beta-blockade shows no real benefit in the prevention of major cardiovascular complications in intermediate risk non-vascular surgical patients with a number-needed-to-treat of 833. Vascular surgical patients undergoing intermediate-risk surgery may benefit from the protective effects of acute peri-operative beta-blockade, however, with a number-needed-to-treat of 68 it would require a randomised clinical trial of over 24,000 patients to prove their efficacy.

The Nature and Extent of Body Image Concerns Among Surgically Treated Patients with Head and Neck Cancer

PubMed Central

Fingeret, Michelle Cororve; Yuan, Ying; Urbauer, Diana; Weston, June; Nipomnick, Summer; Weber, Randal

2016-01-01

Objective The purpose of this study was to describe body image concerns for surgically treated patients with head and neck cancer and evaluate the relationship between body image concerns and quality of life outcomes. Methods Data were obtained from 280 patients undergoing surgical treatment for head and neck cancer. We used a cross-sectional design and obtained data from individuals at different time points relative to initiation of surgical treatment. Participants completed the Body Image Scale, the Functional Assessment of Cancer Therapy scale – Head and Neck version, and a survey designed for this study to evaluate disease-specific body image issues, satisfaction with care regarding body image issues, and interest in psychosocial intervention. Results Body image concerns were prevalent in the majority of participants with 75% acknowledging concerns or embarrassment about one or more types of bodily changes at some point during treatment. Significant associations were found between body image concerns and all major domains of quality of life. Age, gender, cancer type, time since surgery, and body image variables were significantly associated with psychosocial outcomes. A clear subset of participants expressed dissatisfaction with care received about body image issues and/or indicated they would have liked additional resources to help them cope with body image changes. Conclusions These data provide useful information to document wide-ranging body image difficulties for this population and provide important targets for the development of relevant psychosocial interventions. PMID:21706673

Surgical management of sand colic impactions in horses: a retrospective study of 41 cases.

PubMed

Granot, N; Milgram, J; Bdolah-Abram, T; Shemesh, I; Steinman, A

2008-10-01

A retrospective review of the medical records of 41 horses requiring abdominal surgery for sand colic. The diagnosis of sand colic was made when sand was found to be the cause of impaction of the gastrointestinal tract during surgical exploration. The most common clinical signs at presentation were abdominal pain, abdominal distension and diarrhoea. A statistically significant association was found between the respiratory rate on arrival and short-term survival. Sand impaction at multiple locations was detected in one-third of the horses. Concurrent pathology was detected in half of the horses. Four horses were euthanased during surgery; of those that recovered from surgery, 35/37 (95%) were discharged from hospital. Short- and long-term complications were similar to those previously reported. Long-term (1 year) survival of the horses discharged was 100%. The good prognosis for horses undergoing surgery for the treatment of sand impaction supports early surgical intervention in cases where large amounts of sand are suspected.

Management of cataract in uveitis patients.

PubMed

Conway, Mandi D; Stern, Ethan; Enfield, David B; Peyman, Gholam A

2018-01-01

This review is timely because the outcomes of surgical invention in uveitic eyes with cataract can be optimized with adherence to strict anti-inflammatory principles. All eyes should be free of any cell/ flare for a minimum of 3 months preoperatively. Another helpful maneuver is to place dexamethasone in the infusion fluid or triamcinolone intracamerally at the end of surgery. Recent reports about the choice of intraocular lens material or lens design are germane to the best surgical outcome. Integrating these findings will promote better visual outcomes and allow advancement in research to further refine these surgical interventions in high-risk uveitic eyes. Control of inflammation has been shown to greatly improve postoperative outcomes in patients with uveitis. Despite better outcomes, more scientific research needs to be done regarding lens placement and materials and further research needs to adhere to the standardized reporting of uveitis nomenclature. Future studies should improve postoperative outcomes in eyes with uveitis so that they approach those of eyes undergoing routine cataract procedures.

Reintervention Rate Following Emergency Surgery for Crohn Disease.

PubMed

Slavu, Iulian; Alecu, Lucian; Tulin, Adrian; Mihaila, Daniela; Braga, Vlad; Voiosu, Theodor; Tomescu, Luminiţa; Constantinoiu, Silviu

2018-01-01

Backround/Objective: To assess the impact of emergency surgery and postoperative recurrence in Crohn's disease (CD) and to evaluate the disease course while observing different factors that may influence it. Methods: Information on 37 consecutive patients which were diagnosed and operated in emergency for CD complications and the the relapse rate (regarded as a second surgery) were retrospectively evaluated. Results: The risk of relapse and second surgery was increased in males under 50 years and in those who benefited from an anastomosis during the first invervention while stomy seemed to reduce the rate of surgical relapse. The median duration until relapse was 2,3 years while a percentage of 33% required reintervention. Conclusions: The majority of patients with CD will undergo at least one surgical intervention during their lifetime and one third of them will relapse requiring a second intervention. Although medical treatment has seen great advancements, surgery requirements have remained unchanged as the mainstay treatment in emergent complications of CD. The age of the patients, smoking status and the postoperative medication influence the rate of postoperative recurrence. Celsius.

Prevention and treatment of the chronic thromboembolic pulmonary hypertension.

PubMed

Pesavento, Raffaele; Prandoni, Paolo

2018-04-01

Chronic thromboembolic pulmonary hypertension (CTEPH) is an uncommon and late complication of pulmonary embolism resulting from misguided remodelling of residual pulmonary thromboembolic material and small-vessel arteriopathy. CTEPH is the only form of pulmonary hypertension (PH) potentially curable by pulmonary endarterectomy (PEA). Unfortunately, several patients have either an unacceptable risk-benefit ratio for undergoing the surgical intervention or develop persistent PH after PEA. Novel medical and endovascular therapies can be considered for them. The soluble guanylate cyclase stimulator riociguat is recommended for the treatment of patients with inoperable disease or with recurrent/persistent PH after PEA. Other drugs developed for the treatment of other forms of PH, as prostanoids, phosphodiesterase-5 inhibitors and endothelin receptor antagonists have been used in the treatment of CTEPH, with limited benefit. Balloon pulmonary angioplasty is a novel and promising technique and is progressively emerging from the pioneering phase. Highly specialized training level and complex protocols of postoperative care are mandatory to consolidate the technical success of the surgical and endovascular intervention. Copyright © 2018 Elsevier Ltd. All rights reserved.

Effectiveness of the Nursing Methodology in Pain Management after Major Ambulatory Surgery.

PubMed

Porras-González, María Helena; Barón-López, Francisco Javier; García-Luque, María José; Morales-Gil, Isabel María

2015-08-01

Patients undergoing a surgical intervention for the first time are unfamiliar with the perioperative context, and they usually have no knowledge of postoperative pain management. In the preoperative circuit, there is no time to educate the patient in these terms. The professional profile of nurses allows this need to be addressed, and provides a regulated language to evaluate their effectiveness. This study evaluates the effectiveness of nursing counseling during a preoperative consultation for the management of postoperative pain and its effects on patient satisfaction at hospital discharge. This quasi-experimental study assesses the efficacy of preoperative nursing intervention in two groups, control (n = 185) and intervention (n = 195). Those in the intervention group attended a preoperative session during which they received information from nursing staff and took part in activities to learn about postoperative pain management and the perioperative circuit. Control group patients underwent the standard preoperative protocol. Data were compiled from January to December 2009. Statistically significant differences existed between the two groups regarding postoperative pain (visual analogue scale >3, 20.5% versus 11.5%; p = .023), patient satisfaction (87.1% versus 78.7%; p = .041), and surgical wound complications (13.9% versus 5.5%; p = .010). The results confirm the benefits of applying the nursing methodology in preoperative clinics. Copyright © 2015 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.

Protocol for a multi-centre randomised controlled trial comparing arthroscopic hip surgery to physiotherapy-led care for femoroacetabular impingement (FAI): the Australian FASHIoN trial.

PubMed

Murphy, Nicholas J; Eyles, Jillian; Bennell, Kim L; Bohensky, Megan; Burns, Alexander; Callaghan, Fraser M; Dickenson, Edward; Fary, Camdon; Grieve, Stuart M; Griffin, Damian R; Hall, Michelle; Hobson, Rachel; Kim, Young Jo; Linklater, James M; Lloyd, David G; Molnar, Robert; O'Connell, Rachel L; O'Donnell, John; O'Sullivan, Michael; Randhawa, Sunny; Reichenbach, Stephan; Saxby, David J; Singh, Parminder; Spiers, Libby; Tran, Phong; Wrigley, Tim V; Hunter, David J

2017-09-26

Femoroacetabular impingement syndrome (FAI), a hip disorder affecting active young adults, is believed to be a leading cause of hip osteoarthritis (OA). Current management approaches for FAI include arthroscopic hip surgery and physiotherapy-led non-surgical care; however, there is a paucity of clinical trial evidence comparing these approaches. In particular, it is unknown whether these management approaches modify the future risk of developing hip OA. The primary objective of this randomised controlled trial is to determine if participants with FAI who undergo hip arthroscopy have greater improvements in hip cartilage health, as demonstrated by changes in delayed gadolinium-enhanced magnetic resonance imaging (MRI) of cartilage (dGEMRIC) index between baseline and 12 months, compared to those who undergo physiotherapy-led non-surgical management. This is a pragmatic, multi-centre, two-arm superiority randomised controlled trial comparing hip arthroscopy to physiotherapy-led management for FAI. A total of 140 participants with FAI will be recruited from the clinics of participating orthopaedic surgeons, and randomly allocated to receive either surgery or physiotherapy-led non-surgical care. The surgical intervention involves arthroscopic FAI surgery from one of eight orthopaedic surgeons specialising in this field, located in three different Australian cities. The physiotherapy-led non-surgical management is an individualised physiotherapy program, named Personalised Hip Therapy (PHT), developed by a panel to represent the best non-operative care for FAI. It entails at least six individual physiotherapy sessions over 12 weeks, and up to ten sessions over six months, provided by experienced musculoskeletal physiotherapists trained to deliver the PHT program. The primary outcome measure is the change in dGEMRIC score of a ROI containing both acetabular and femoral head cartilages at the chondrolabral transitional zone of the mid-sagittal plane between baseline and 12 months. Secondary outcomes include patient-reported outcomes and several structural and biomechanical measures relevant to the pathogenesis of FAI and development of hip OA. Interventions will be compared by intention-to-treat analysis. The findings will help determine whether hip arthroscopy or an individualised physiotherapy program is superior for the management of FAI, including for the prevention of hip OA. Australia New Zealand Clinical Trials Registry reference: ACTRN12615001177549 . Trial registered 2/11/2015 (retrospectively registered).

Transdermal rotigotine for the perioperative management of restless legs syndrome

PubMed Central

2012-01-01

Background Immobilisation, blood loss, sleep deficiency, and (concomitant) medications during perioperative periods might lead to acute exacerbation of symptoms in patients with the restless legs syndrome (RLS). Continuous transdermal delivery of the dopamine agonist rotigotine provides stable plasma levels over 24 h and may provide RLS patients with a feasible treatment option for perioperative situations. To assess the feasibility of use of rotigotine transdermal patch for the perioperative management of moderate to severe RLS, long-term data of an open-label extension of a rotigotine dose-finding study were retrospectively reviewed. Methods The data of all 295 patients who had entered the 5-year study were screened independently by two reviewers for the occurrence of surgical interventions during the study period. The following data were included in this post-hoc analysis: patient age, sex, surgical intervention and outcome, duration of hospital stay, rotigotine maintenance dose at the time of surgery, rotigotine dose adjustment, and continuation/discontinuation of rotigotine treatment. All parameters were analysed descriptively. No pre-specified efficacy assessments (e.g. IRLS scores) were available for the perioperative period. Results During the study period, 61 surgical interventions were reported for 52 patients (median age, 63 years; 67% female); the majority of patients (85%) had one surgical intervention. The mean rotigotine maintenance dose at time of surgery was 3.1 ± 1.1 mg/24 h. For most interventions (95%), rotigotine dosing regimens were maintained during the perioperative period. Administration was temporarily suspended in one patient and permanently discontinued in another two. The majority (96%) of the patients undergoing surgery remained in the study following the perioperative period and 30 of these patients (61%) completed the 5-year study. Conclusions Although the data were obtained from a study which was not designed to assess rotigotine use in the perioperative setting, this post-hoc analysis suggests that treatment with rotigotine transdermal patch can be maintained during the perioperative period in the majority of patients and may allow for uninterrupted alleviation of RLS symptoms. Trial Registration The 5-year rotigotine extension study is registered with ClinicalTrials.gov, identifier NCT00498186. PMID:23009552

Transdermal rotigotine for the perioperative management of restless legs syndrome.

PubMed

Högl, Birgit; Oertel, Wolfgang H; Schollmayer, Erwin; Bauer, Lars

2012-09-25

Immobilisation, blood loss, sleep deficiency, and (concomitant) medications during perioperative periods might lead to acute exacerbation of symptoms in patients with the restless legs syndrome (RLS). Continuous transdermal delivery of the dopamine agonist rotigotine provides stable plasma levels over 24 h and may provide RLS patients with a feasible treatment option for perioperative situations. To assess the feasibility of use of rotigotine transdermal patch for the perioperative management of moderate to severe RLS, long-term data of an open-label extension of a rotigotine dose-finding study were retrospectively reviewed. The data of all 295 patients who had entered the 5-year study were screened independently by two reviewers for the occurrence of surgical interventions during the study period. The following data were included in this post-hoc analysis: patient age, sex, surgical intervention and outcome, duration of hospital stay, rotigotine maintenance dose at the time of surgery, rotigotine dose adjustment, and continuation/discontinuation of rotigotine treatment. All parameters were analysed descriptively. No pre-specified efficacy assessments (e.g. IRLS scores) were available for the perioperative period. During the study period, 61 surgical interventions were reported for 52 patients (median age, 63 years; 67% female); the majority of patients (85%) had one surgical intervention. The mean rotigotine maintenance dose at time of surgery was 3.1 ± 1.1 mg/24 h. For most interventions (95%), rotigotine dosing regimens were maintained during the perioperative period. Administration was temporarily suspended in one patient and permanently discontinued in another two. The majority (96%) of the patients undergoing surgery remained in the study following the perioperative period and 30 of these patients (61%) completed the 5-year study. Although the data were obtained from a study which was not designed to assess rotigotine use in the perioperative setting, this post-hoc analysis suggests that treatment with rotigotine transdermal patch can be maintained during the perioperative period in the majority of patients and may allow for uninterrupted alleviation of RLS symptoms. The 5-year rotigotine extension study is registered with ClinicalTrials.gov, identifier NCT00498186.

Effects of music therapy under general anesthesia in patients undergoing abdominal surgery.

PubMed

Kahloul, Mohamed; Mhamdi, Salah; Nakhli, Mohamed Said; Sfeyhi, Ahmed Nadhir; Azzaza, Mohamed; Chaouch, Ajmi; Naija, Walid

2017-12-01

Music therapy, an innovative approach that has proven effectiveness in many medical conditions, seems beneficial also in managing surgical patients. The aim of this study is to evaluate its effects, under general anesthesia, on perioperative patient satisfaction, stress, pain, and awareness. This is a prospective, randomized, double-blind study conducted in the operating theatre of visceral surgery at Sahloul Teaching Hospital over a period of 4 months. Patients aged more than 18 undergoing a scheduled surgery under general anesthesia were included. Patients undergoing urgent surgery or presenting hearing or cognitive disorders were excluded. Before induction, patients wore headphones linked to an MP3 player. They were randomly allocated into 2 groups: Group M (with music during surgery) and group C (without music). Hemodynamic parameters, quality of arousal, pain experienced, patient's satisfaction, and awareness incidence during anesthesia were recorded. One hundred and forty patients were included and allocated into 2 groups that were comparable in demographic characteristics, surgical intervention type and anesthesia duration. Comparison of these two groups regarding the hemodynamic profile found more stability in group M for systolic arterial blood pressure. A calm recovery was more often noted in group M (77.1% versus 44%, p < 10 -3 ). The average Visual Analog Scale (VAS) score was lower in the intervention group (33.8 ± 13.63 versus 45.1 ± 16.2; p < 10 -3 ). The satisfaction rate was significantly higher among the experimental group (81.4% versus 51.4%; p < 10 -3 ). The incidence of intraoperative awareness was higher in group C (8 cases versus 3 cases) but the difference was not statistically significant. Music therapy is a non-pharmacological, inexpensive, and non-invasive technique that can significantly enhance patient satisfaction and decrease patients' embarrassing experiences related to perioperative stress, pain, and awareness.

Minimally Invasive Surgical Staging for Ovarian Carcinoma: A Propensity-Matched Comparison With Traditional Open Surgery.

PubMed

Ditto, Antonino; Bogani, Giorgio; Martinelli, Fabio; Signorelli, Mauro; Chiappa, Valentina; Scaffa, Cono; Indini, Alice; Leone Roberti Maggiore, Umberto; Lorusso, Domenica; Raspagliesi, Francesco

2017-01-01

Growing evidence supports the safety of a laparoscopic approach for patients affected by apparent early-stage ovarian cancer. However, no well-designed studies comparing laparoscopic and open surgical staging are available. In the present investigation we aimed to provide a balanced long-term comparison between these 2 approaches. Retrospective study (Canadian Task Force classification II-2). Tertiary center. Data of consecutive patients affected by early-stage ovarian cancer who had laparoscopic staging were matched 1:1 with a cohort of patients undergoing open surgical staging. The matching was conducted by a propensity-score comparison. Laparoscopic and open surgical staging. Fifty patient pairs (100 patients: 50 undergoing laparoscopic staging vs 50 undergoing open surgical staging) were included. Demographic and baseline oncologic characteristics were balanced between groups (p > .2). We observed that patients undergoing laparoscopic staging experienced longer operative time (207.2 [71.6] minutes vs 180.7 [47.0] minutes; p = .04), lower blood loss (150 [52.7] mL vs 339.8 [225.9] mL; p < .001), and shorter length of hospital stay (4.0 [2.6] days vs 6.1 [1.6] days; p < .001) compared with patients undergoing open surgical staging. No conversion to open surgery occurred. Complication rate was similar between groups. No difference in survival outcomes were observed, after a mean (SD) follow-up of 49.5 (64) and 52.6 (31.7) months after laparoscopic and open surgical staging, respectively. Our findings suggest that the implementation of minimally invasive staging does not influence survival outcomes of patients affected by early-stage ovarian cancer. Laparoscopic staging improved patient outcomes, reducing length of hospital stay. Further large prospective studies are warranted. Copyright © 2016 AAGL. Published by Elsevier Inc. All rights reserved.

Current therapies for Morquio A syndrome and their clinical outcomes

PubMed Central

Sawamoto, Kazuki; Suzuki, Yasuyuki; Mackenzie, William G.; Theroux, Mary C.; Pizarro, Christian; Yabe, Hiromasa; Orii, Kenji E.; Mason, Robert W.; Orii, Tadao; Tomatsu, Shunji

2016-01-01

Introduction Morquio A syndrome is characterized by a unique skeletal dysplasia, leading to short neck and trunk, pectus carinatum, laxity of joints, kyphoscoliosis, and tracheal obstruction. Cervical spinal cord compression/inability, a restrictive and obstructive airway, and/or bone deformity and imbalance of growth, are life-threatening to Morquio A patients, leading to a high morbidity and mortality. It is critical to review the current therapeutic approaches with respect to their efficacy and limitations. Areas covered Patients with progressive skeletal dysplasia often need to undergo orthopedic surgical interventions in the first two decades of life. Recently, we have treated four patients with a new surgery to correct progressive tracheal obstruction. Enzyme replacement therapy (ERT) has been approved clinically. Cell-based therapies such as hematopoietic stem cell therapy (HSCT) and gene therapy are typically one-time, permanent treatments for enzyme deficiencies. We report here on four Morquio A patients treated with HSCT approved in Japan and followed for at least ten years after treatment. Gene therapy is under investigation on mouse models but not yet available as a therapeutic option. Expert opinion ERT and HSCT in combination with surgical intervention(s) are a therapeutic option for Morquio A; however, the approach for bone and cartilage lesion remains an unmet challenge. PMID:28217429

Cognitive Outcomes of Cardiovascular Surgical Procedures in the Old: An Important but Neglected Area.

PubMed

Keage, Hannah A D; Smith, Ashleigh; Loetscher, Tobias; Psaltis, Peter

2016-12-01

Older individuals can now undergo invasive cardiovascular procedures without serious concern about mortality, and the numbers and proportions of the over 65s and 85s doing so in Australia has been increasing over the last 20 years. There is overwhelming evidence linking cardiovascular conditions to late-life (65 years and over) cognitive impairment and dementia including Alzheimer's Disease, primarily due to impaired cerebrovascularisation and cascading neuropathological processes. Somewhat paradoxically, these cardiovascular interventions, carried out with the primary aim of revascularisation, are not usually associated with short- or long-term improvements in cognitive function in older adults. We discuss factors associated with cognitive outcomes post-cardiovascular surgeries in patients over 65 years of age. There are many opportunities for future research: we know almost nothing about cognitive outcomes following invasive cardiac procedures in the oldest old (85 years and over) nor how to predict the cognitive/delirium outcome using pre-surgical data, and lastly, intervention opportunities exist both pre and postoperatively that have not been tested. As our population ages with increased cardiovascular burden and rates of cardiovascular interventions and surgeries, it is critical that we understand the cognitive consequences of these procedures, who is at greatest risk, and ways to optimise cognition. Copyright © 2016. Published by Elsevier B.V.

Spinal cord injury following operative shoulder intervention: A case report.

PubMed

Cleveland, Christine; Walker, Heather

2015-07-01

Cervical myelopathy is a spinal cord dysfunction that results from extrinsic compression of the spinal cord, its blood supply, or both. It is the most common cause of spinal cord dysfunction in patients greater than 55 years of age. A 57-year-old male with right shoulder septic arthritis underwent surgical debridement of his right shoulder and sustained a spinal cord injury intraoperatively. The most likely etiology is damage to the cervical spinal cord during difficult intubation requiring multiple attempts in this patient with underlying asymptomatic severe cervical stenosis. Although it is not feasible to perform imaging studies on all patients undergoing intubation for surgery, this patient's outcome would suggest consideration of inclusion of additional pre-surgical screening examination techniques, such as testing for a positive Hoffman's reflex, is appropriate to detect asymptomatic patients who may have underlying cervical stenosis.

Mitral valve replacement complicated by iatrogenic left ventricular outflow obstruction and paravalvular leak: case report and review of literature.

PubMed

Lee, Justin Z; Tey, Kai R; Mizyed, Ahmad; Hennemeyer, Charles T; Janardhanan, Rajesh; Lotun, Kapildeo

2015-10-09

Left ventricular outflow tract (LVOT) obstruction and paravalvular leak (PVL) are relatively uncommon, but are serious complications of prosthetic valve replacement. We present a case that displays the unique therapeutic challenges of treating a patient who developed both LVOT obstruction and mitral PVL after undergoing surgical aortic and mitral valve replacement (MVR). We also describe the use of alcohol septal ablation and albumin-glutaraldehyde (BioGlue) for septal ablation to percutaneously treat the patient's LVOT obstruction, followed by use of an Amplatzer vascular plug for percutaneous closure of an antero-medial mitral PVL associated with severe regurgitation. Percutaneous interventional management of these entities may be considered as an initial therapeutic option, especially in high-risk patients with significant morbidity and mortality of repeat surgical operations.

Clinical manifestations of optic pit maculopathy as demonstrated by spectral domain optical coherence tomography.

PubMed

Tzu, Jonathan H; Flynn, Harry W; Berrocal, Audina M; Smiddy, William E; Murray, Timothy G; Fisher, Yale L

2013-01-01

The purpose of this retrospective study was to evaluate the characteristic features, including spectral-domain optical coherence tomography (SD-OCT), clinical course, and outcome of treatment if given for patients with optic disc pit maculopathy. We investigated a consecutive series of patients with a diagnosis of optic pit maculopathy treated between 2001 and 2012 at the Bascom Palmer Eye Institute. Patients were divided into two main groups, ie, patients who were observed without surgery and patients who received surgical intervention. The main outcome measures were presenting and final visual acuity, and changes in SD-OCT imaging were recorded. Other data including age, gender, eye, age of onset, length of follow-up, location of optic pit, and location of fluid by OCT were also recorded. On OCT, 67% (12/18) of the eyes showed schisis-like cavities, 22% (4/18) had only subretinal fluid, and 17% (3/18) had only a schisis-like cavity without subretinal fluid. In the patients managed by observation, visual acuity was ≥20/200 in 6/8 eyes initially and 6/8 eyes at last follow-up. Ten of 18 patients received either focal laser, surgery or both. Six of 10 eyes undergoing surgery had initial visual acuity ≥ 20/200, and 8 of 10 eyes undergoing surgery had a visual acuity of ≥20/200 at last follow-up. In this study, many eyes were observed and remained stable during follow-up. In eyes with reduced vision, surgical intervention produced variable outcomes, and persistent intraretinal/subretinal fluid was a common occurrence.

An updated meta-analysis on the effectiveness of preoperative prophylactic antibiotics in patients undergoing breast surgical procedures.

PubMed

Sajid, Muhammad S; Hutson, Kristian; Akhter, Naved; Kalra, Lorain; Rapisarda, Ignacio F; Bonomi, Ricardo

2012-01-01

To systematically analyze published randomized trials on the effectiveness of preoperative prophylactic antibiotics in patients undergoing breast surgical procedures. Trials on the effectiveness of preoperative prophylactic antibiotics in patients undergoing breast surgery were selected and analyzed to generate summated data (expressed as risk ratio [RR]) by using RevMan 5.0. Nine randomized controlled trials encompassing 3720 patients undergoing breast surgery were retrieved from the electronic databases. The antibiotics group comprised a total of 1857 patients and non-antibiotics group, 1863 patients. There was no heterogeneity [χ(2) = 7.61, d.f. = 7, p < 0.37; I(2) = 8%] amongst trials. Therefore, in the fixed-effects model (RR, 0.64; 95% CI, 0.50-0.83; z = 3.48; p < 0.0005), the use of preoperative prophylactic antibiotics in patients undergoing breast surgical procedures was statistically significant in reducing the incidence of surgical site infection (SSI). Furthermore, in the fixed-effects model (RR, 1.30; 95% CI, 0.89-1.90; z = 1.37; p < 0.17), adverse reactions secondary to the use of prophylactic antibiotics was not statistically significant between the two groups. Preoperative prophylactic antibiotics significantly reduce the risk of SSI after breast surgical procedures. The risk of adverse reactions from prophylactic antibiotic administration is not significant in these patients. Therefore, preoperative prophylactic antibiotics in breast surgery patients may be routinely administered. Further research is required, however, on risk stratification for SSI, timing and duration of prophylaxis, and the need for prophylaxis in patients undergoing breast reconstruction versus no reconstruction. © 2012 Wiley Periodicals, Inc.

Pre-operative assessment of patients undergoing endoscopic, transnasal, transsphenoidal pituitary surgery.

PubMed

Lubbe, D; Semple, P

2008-06-01

To demonstrate the importance of pre-operative ear, nose and throat assessment in patients undergoing endoscopic, transsphenoidal surgery for pituitary tumours. Literature pertaining to the pre-operative otorhinolaryngological assessment and management of patients undergoing endoscopic anterior skull base surgery is sparse. We describe two cases from our series of 59 patients undergoing endoscopic pituitary surgery. The first case involved a young male patient with a large pituitary macroadenoma. His main complaint was visual impairment. He had no previous history of sinonasal pathology and did not complain of any nasal symptoms during the pre-operative neurosurgical assessment. At the time of surgery, a purulent nasal discharge was seen emanating from both middle meati. Surgery was abandoned due to the risk of post-operative meningitis, and postponed until the patient's chronic rhinosinusitis was optimally managed. The second patient was a 47-year-old woman with a large pituitary macroadenoma, who presented to the neurosurgical department with a main complaint of diplopia. She too gave no history of previous nasal problems, and she underwent uneventful surgery using the endoscopic, transnasal approach. Two weeks after surgery, she presented to the emergency unit with severe epistaxis. A previous diagnosis of hereditary haemorrhagic telangiectasia was discovered, and further surgical and medical intervention was required before the epistaxis was finally controlled. Pre-operative otorhinolaryngological assessment is essential prior to endoscopic pituitary or anterior skull base surgery. A thorough otorhinolaryngological history will determine whether any co-morbid diseases exist which could affect the surgical field. Nasal anatomy can be assessed via nasal endoscopy and sinusitis excluded. Computed tomography imaging is a valuable aid to decisions regarding additional procedures needed to optimise access to the pituitary fossa.

Long-Term Pain and Recovery After Major Pediatric Surgery: A Qualitative Study With Teens, Parents, and Perioperative Care Providers.

PubMed

Rabbitts, Jennifer A; Aaron, Rachel V; Fisher, Emma; Lang, Emily A; Bridgwater, Caroline; Tai, Gabrielle Ghafari; Palermo, Tonya M

2017-07-01

Research developing targeted treatment focused on coping with children's long-term pain after surgery is needed because of the high prevalence of chronic pain after surgery. This qualitative study aimed to: 1) understand the child's and family's experiences of pain over the course of their surgical experience, and 2) gather stakeholder input regarding potential barriers and facilitators of perioperative intervention delivery. Fifteen children ages 10 to 18 years who underwent recent major surgery, their primary caregivers, and 17 perioperative health care providers were interviewed. Interviews were coded using semantic thematic analysis. The perioperative period presented emotional challenges for families. Families felt unprepared for surgery and pain. Recovery and regaining physical functioning at home was challenging. Families struggled to return to valued activities. Families reported interest in a perioperative psychosocial intervention. Providers endorsed that families would benefit from enhanced coping skills. They emphasized that families would benefit from more detailed preparatory information. Providers suggested that flexible intervention delivery at home would be ideal. Research developing interventions addressing pain and anxiety in children undergoing major surgery is critically needed. The findings of the present study can inform intervention development with the aim of improving short- as well as long-term recovery in children undergoing major surgery. This qualitative study examined children and their parents' experience of long-term pain and recovery after major surgery, identifying barriers and facilitators of perioperative intervention delivery. Families experienced surgery as stressful, and felt underprepared for pain and recovery. Families and health care providers expressed interest in a preoperative intervention teaching coping skills. Copyright © 2017 American Pain Society. Published by Elsevier Inc. All rights reserved.

Racial/Ethnic Disparities in Perioperative Outcomes of Major Procedures: Results From the National Surgical Quality Improvement Program.

PubMed

Ravi, Praful; Sood, Akshay; Schmid, Marianne; Abdollah, Firas; Sammon, Jesse D; Sun, Maxine; Klett, Dane E; Varda, Briony; Peabody, James O; Menon, Mani; Kibel, Adam S; Nguyen, Paul L; Trinh, Quoc-Dien

2015-12-01

To determine the association between race/ethnicity and perioperative outcomes in individuals undergoing major oncologic and nononcologic surgical procedures in the United States. Prior work has shown that there are significant racial/ethnic disparities in perioperative outcomes after several types of major cardiac, general, vascular, orthopedic, and cancer surgical procedures. However, recent evidence suggests attenuation of these racial/ethnic differences, particularly at academic institutions. We utilized the American College of Surgeons National Surgical Quality Improvement Program database to identify 142,344 patients undergoing one of the 16 major cancer and noncancer surgical procedures between 2005 and 2011. Eighty-five percent of the cohort was white, with black and Hispanic individuals comprising 8% and 4%, respectively. In multivariable analyses, black patients had greater odds of experiencing prolonged length of stay after 10 of the 16 procedures studied (all P < 0.05), though there was no disparity in odds of 30-day mortality after any surgery. Hispanics were more likely to experience prolonged length of stay after 5 surgical procedures (all P < 0.04), and were at greater odds of dying within 30 days after colectomy, heart valve repair/replacement, or abdominal aortic aneurysm repair (all P < 0.03). Fewer disparities were observed for Hispanics, than for black patients, and also for cancer, than for noncancer surgical procedures. Important racial/ethnic disparities in perioperative outcomes were observed among patients undergoing major cancer and noncancer surgical procedures at American College of Surgeons National Surgical Quality Improvement Program institutions. There were fewer disparities among individuals undergoing cancer surgery, though black patients, in particular, were more likely to experience prolonged length of stay.

Perioperative Ruminal pH Changes in Domestic Sheep (Ovis aries) Housed in a Biomedical Research Setting

PubMed Central

Jasmin, Bambi H; Boston, Ray C; Modesto, Rolf B; Schaer, Thomas P

2011-01-01

Little information is available on normal ruminal pH values for domestic sheep (Ovis aries) housed in a research setting and fed a complete pelleted ration. Sheep maintained on pelleted diets undergoing surgical procedures often present with postoperative anorexia and rumen atony. To determine the relationship between diet and postoperative rumen acidosis and associated atony, we studied dietary effects on ruminal pH in an ovine surgical model. Sheep undergoing orthopedic surgical procedures were randomized into 2 diet groups. Group 1 (n = 6) was fed complete pelleted diet during the pre- and postoperative period, and group 2 (n = 6) was fed timothy grass hay exclusively throughout the study. Measures included ruminal pH, ruminal motility, and rate of feed refusal, which was monitored throughout the pre- and postoperative periods. The 2 groups did not differ significantly before surgery, and the ruminal parameters remained largely within normal limits. However, a downward trend in the strength and frequency of rumen contractions was observed in pellet-fed sheep. After surgery, the pellet-fed group showed clinical signs consistent with ruminal acidosis, supported by decreased ruminal motility, anorexia, putrid-smelling ruminal material, and death of ruminal protozoa. Intervention by transfaunation in clinically affected sheep resulted in resolution of signs. Our findings suggest that sheep fed grass hay appear to have a more stable ruminal pH, are less likely to experience anorexia and rumen atony, and thereby exhibit fewer postoperative gastrointestinal complications than do sheep on a pellet diet. PMID:21333159

Perioperative ruminal pH changes in domestic sheep (Ovis aries) housed in a biomedical research setting.

PubMed

Jasmin, Bambi H; Boston, Ray C; Modesto, Rolf B; Schaer, Thomas P

2011-01-01

Little information is available on normal ruminal pH values for domestic sheep (Ovis aries) housed in a research setting and fed a complete pelleted ration. Sheep maintained on pelleted diets undergoing surgical procedures often present with postoperative anorexia and rumen atony. To determine the relationship between diet and postoperative rumen acidosis and associated atony, we studied dietary effects on ruminal pH in an ovine surgical model. Sheep undergoing orthopedic surgical procedures were randomized into 2 diet groups. Group 1 (n = 6) was fed complete pelleted diet during the pre- and postoperative period, and group 2 (n = 6) was fed timothy grass hay exclusively throughout the study. Measures included ruminal pH, ruminal motility, and rate of feed refusal, which was monitored throughout the pre- and postoperative periods. The 2 groups did not differ significantly before surgery, and the ruminal parameters remained largely within normal limits. However, a downward trend in the strength and frequency of rumen contractions was observed in pellet-fed sheep. After surgery, the pellet-fed group showed clinical signs consistent with ruminal acidosis, supported by decreased ruminal motility, anorexia, putrid-smelling ruminal material, and death of ruminal protozoa. Intervention by transfaunation in clinically affected sheep resulted in resolution of signs. Our findings suggest that sheep fed grass hay appear to have a more stable ruminal pH, are less likely to experience anorexia and rumen atony, and thereby exhibit fewer postoperative gastrointestinal complications than do sheep on a pellet diet.

Surgical Management of Infective Endocarditis Complicated by Embolic Stroke: Practical Recommendations for Clinicians.

PubMed

Yanagawa, Bobby; Pettersson, Gosta B; Habib, Gilbert; Ruel, Marc; Saposnik, Gustavo; Latter, David A; Verma, Subodh

2016-10-25

There has been an overall improvement in surgical mortality for patients with infective endocarditis (IE), presumably because of improved diagnosis and management, centered around a more aggressive early surgical approach. Surgery is currently performed in approximately half of all cases of IE. Improved survival in surgery-treated patients is correlated with a reduction in heart failure and the prevention of embolic sequelae. It is reported that between 20% and 40% of patients with IE present with stroke or other neurological conditions. It is for these IE patients that the timing of surgical intervention remains a point of considerable discussion and debate. Despite evidence of improved survival in IE patients with earlier surgical treatment, a significant proportion of patients with IE and preexisting neurological complications either undergo delayed surgery or do not have surgery at all, even when surgery is indicated and guideline endorsed. Physicians and surgeons are caught in a common conundrum where the urgency of the heart operation must be balanced against the real or perceived risks of neurological exacerbation. Recent data suggest that the risk of neurological exacerbation may be lower than previously believed. Current guidelines reflect a shift toward early surgery for such patients, but there continue to be important areas of clinical equipoise. Individualized clinical assessment is of major importance for decision making, and, as such, we emphasize the need for the functioning of an endocarditis team, including cardiac surgeons, cardiologists, infectious diseases specialists, neurologists, neurosurgeons, and interventional neuroradiologists. Here, we present 2 illustrative cases, critically review contemporary data, and offer conceptual and practical suggestions for clinicians to address this important, common, and often fatal cardiac condition. © 2016 American Heart Association, Inc.

Patient selection for day case-eligible surgery: identifying those at high risk for major complications.

PubMed

Mathis, Michael R; Naughton, Norah N; Shanks, Amy M; Freundlich, Robert E; Pannucci, Christopher J; Chu, Yijia; Haus, Jason; Morris, Michelle; Kheterpal, Sachin

2013-12-01

Due to economic pressures and improvements in perioperative care, outpatient surgical procedures have become commonplace. However, risk factors for outpatient surgical morbidity and mortality remain unclear. There are no multicenter clinical data guiding patient selection for outpatient surgery. The authors hypothesize that specific risk factors increase the likelihood of day case-eligible surgical morbidity or mortality. The authors analyzed adults undergoing common day case-eligible surgical procedures by using the American College of Surgeons' National Surgical Quality Improvement Program database from 2005 to 2010. Common day case-eligible surgical procedures were identified as the most common outpatient surgical Current Procedural Terminology codes provided by Blue Cross Blue Shield of Michigan and Medicare publications. Study variables included anthropometric data and relevant medical comorbidities. The primary outcome was morbidity or mortality within 72 h. Intraoperative complications included adverse cardiovascular events; postoperative complications included surgical, anesthetic, and medical adverse events. Of 244,397 surgeries studied, 232 (0.1%) experienced early perioperative morbidity or mortality. Seven independent risk factors were identified while controlling for surgical complexity: overweight body mass index, obese body mass index, chronic obstructive pulmonary disease, history of transient ischemic attack/stroke, hypertension, previous cardiac surgical intervention, and prolonged operative time. The demonstrated low rate of perioperative morbidity and mortality confirms the safety of current day case-eligible surgeries. The authors obtained the first prospectively collected data identifying risk factors for morbidity and mortality with day case-eligible surgery. The results of the study provide new data to advance patient-selection processes for outpatient surgery.

Forced-Air Warmers and Surgical Site Infections in Patients Undergoing Knee or Hip Arthroplasty.

PubMed

Austin, Paul N

2017-01-01

The majority of the evidence indicates preventing inadvertent perioperative hypothermia reduces the incidence of many perioperative complications. Among the results of inadvertent perioperative hypothermia are increased bleeding, myocardial events, impaired wound healing, and diminished renal function. Most researchers agree there is an increased incidence of surgical site infections in patients who experience inadvertent perioperative hypothermia. Forced-air warming is effective in preventing inadvertent perioperative hypothermia. Paradoxically, forced-air warmers have been implicated in causing surgical site infections in patients undergoing total knee or hip arthroplasty. The results of investigations suggest these devices harbor pathogens and cause unwanted airflow disturbances. However, no significant increases in bacterial counts were found when forced-air warmers were used according to the manufacturer's directions. The results of one study suggested the incidence of surgical site infections in patients undergoing total joint arthroplasty was increased when using a forced-air warmer. However these researchers did not control for other factors affecting the incidence of surgical site infections in these patients. Current evidence does not support forced-air warmers causing surgical site infections in patients undergoing total knee or hip arthroplasty. Clinicians must use and maintain these devices as per the manufacturer's directions. They may consider using alternative warming methods. Well-conducted studies are needed to help determine the role of forced-air warmers in causing infections in these patients.

Endometriosis: an overview of Cochrane Reviews.

PubMed

Brown, Julie; Farquhar, Cindy

2014-03-10

This overview reports on interventions for pain relief and for subfertility in pre-menopausal women with clinically diagnosed endometriosis. The objective of this overview was to summarise the evidence from Cochrane systematic reviews on treatment options for women with pain or subfertility associated with endometriosis. Published Cochrane systematic reviews reporting pain or fertility outcomes in women with clinically diagnosed endometriosis were eligible for inclusion in the overview. We also identified Cochrane reviews in preparation (protocols and titles) for future inclusion. The reviews, protocols and titles were identified by searching the Cochrane Database of Systematic Reviews and Archie (the Cochrane information management system) in March 2014.Pain-related outcomes of the overview were pain relief, clinical improvement or resolution and pain recurrence. Fertility-related outcomes were live birth, clinical pregnancy, ongoing pregnancy, miscarriage and adverse events.Selection of systematic reviews, data extraction and quality assessment were undertaken in duplicate. Review quality was assessed using the AMSTAR tool. The quality of the evidence for each outcome was assessed using GRADE methods. Review findings were summarised in the text and the data for each outcome were reported in 'Additional tables'. Seventeen systematic reviews published in The Cochrane Library were included. All the reviews were high quality. The quality of the evidence for specific comparisons ranged from very low to moderate. Limitations in the evidence included risk of bias in the primary studies, inconsistency between the studies, and imprecision in effect estimates. Pain relief (14 reviews) Gonadotrophin-releasing hormone (GnRH) analogues One systematic review reported low quality evidence of an overall benefit for GnRH analogues compared with placebo or no treatment. Ovulation suppression Five systematic reviews reported on medical treatment using ovulation suppression. There was moderate quality evidence that the levonorgestrel-releasing intrauterine system (LNG-IUD) was more effective than expectant management, and very low quality evidence that danazol was more effective than placebo. There was no consistent evidence of a difference in effectiveness between oral contraceptives and goserelin, estrogen plus progestogen and placebo, or progestogens and placebo, though in all cases the relevant evidence was of low or very low quality. Non-steroidal anti-inflammatory drugs (NSAIDS)A review of NSAIDs reported inconclusive evidence of a benefit in symptom relief compared with placebo. Surgical interventions There were two reviews of surgical interventions. One reported moderate quality evidence of a benefit in pain relief following laparoscopic surgery compared to diagnostic laparoscopy only. The other reported very low quality evidence that recurrence rates of endometriomata were lower after excisional surgery than after ablative surgery. Post-surgical medical interventions Two reviews reported on post-surgical medical interventions. Neither found evidence of an effect on pain outcomes, though in both cases the evidence was of low or very low quality. Alternative medicine There were two systematic reviews of alternative medicine. One reported evidence of a benefit from auricular acupuncture compared to Chinese herbal medicine, and the other reported no evidence of a difference between Chinese herbal medicine and danazol. In both cases the evidence was of low or very low quality. Anti-TNF-α drugs One review found no evidence of a difference in effectiveness between anti-TNF-α drugs and placebo. However, the evidence was of low quality. Reviews reporting fertility outcomes (8 reviews) Medical interventions Four reviews reported on medical interventions for improving fertility in women with endometriosis. One compared three months of GnRH agonists with a control in women undergoing assisted reproduction and found very low quality evidence of an increase in clinical pregnancies in the treatment group. There was no evidence of a difference in effectiveness between the interventions in the other three reviews, which compared GnRH agonists versus antagonists, ovulation suppression versus placebo or no treatment, and pre-surgical medical therapy versus surgery alone. In all cases the evidence was of low or very low quality. Surgical interventions Three reviews reported on surgical interventions. There was moderate quality evidence that both live births or ongoing pregnancy rates and clinical pregnancy rates were higher after laparoscopic surgery than after diagnostic laparoscopy alone. There was low quality evidence of no difference in effectiveness between surgery and expectant management for endometrioma. One review found low quality evidence that excisional surgery resulted in higher clinical pregnancy rates than drainage or ablation of endometriomata. Post-surgical interventions Two reviews reported on post-surgical medical interventions. They found no evidence of an effect on clinical pregnancy rates. The evidence was of low or very low quality. Alternative medicine A review of Chinese herbal medicine in comparison with gestrinone found no evidence of a difference between the groups in clinical pregnancy rates. However, the evidence was of low quality. Adverse events Reviews of GnRH analogues and of danazol reported that the interventions were associated with higher rates of adverse effects than placebo; and depot progestagens were associated with higher rates of adverse events than other treatments. Chinese herbal medicine was associated with fewer side effects than gestrinone or danazol.Three reviews reported miscarriage as an outcome. No difference was found between surgical and diagnostic laparoscopy, between GnRH agonists and antagonists, or between aspiration of endometrioma and expectant management. However, in all cases the quality of the evidence was of low quality. For women with pain and endometriosis, suppression of menstrual cycles with gonadotrophin-releasing hormone (GnRH) analogues, the levonorgestrel-releasing intrauterine system (LNG-IUD) and danazol were beneficial interventions. Laparoscopic treatment of endometriosis and excision of endometriomata were also associated with improvements in pain. The evidence on NSAIDs was inconclusive. There was no evidence of benefit with post-surgical medical treatment.In women with endometriosis undergoing assisted reproduction, three months of treatment with GnRH agonist improved pregnancy rates. Excisional surgery improved spontaneous pregnancy rates in the nine to 12 months after surgery compared to ablative surgery. Laparoscopic surgery improved live birth and pregnancy rates compared to diagnostic laparoscopy alone. There was no evidence that medical treatment improved clinical pregnancy rates.Evidence on harms was scanty, but GnRH analogues, danazol and depot progestagens were associated with higher rates than other interventions.

Nationally representative household survey of surgery and mortality in Sierra Leone.

PubMed

Kwon, Steve; Groen, Reinou S; Kamara, Thaim B; Cassidy, Laura D; Samai, Mohamed; Yambasu, Sahr E; Kushner, Adam L

2013-08-01

There is limited evidence to characterize the burden of unmet need of surgical diseases in low- and middle-income countries. The purpose of this study was to determine rate of deaths attributable to a surgical condition and reasons for not seeking surgical care in Sierra Leone. The Surgeons OverSeas Assessment of Surgical Need (SOSAS) is a survey tool developed collaboratively to be used for cross-sectional data collection of the prevalence of surgical conditions in any country. A population-weighted cluster-sample household survey was conducted throughout Sierra Leone in 2012 using the SOSAS survey tool. Total of 1,840 households (11,870 individuals) were sampled, yielding a 98.3 % response rate. Overall, there were 709 total deaths reported (6.0 %). The mean age at death was 36.4 ± 30.1 years: 330 (46.6 %) were female. Most deaths occurred at home (58.1 % vs. 34.1 % in hospitals). Of the 709 deaths, 237 (33.4 %) were associated with conditions included in our predefined surgical disease category. Abdominal distension/pain was the most commonly associated surgical condition (13.9 %) followed by perinatal bleeding/illness (6.0 %). Among the 237 with surgical conditions, 51 (21.9 %) did not seek medical care, most commonly because of a lack of money (35.3 %) or inability to provide timely care (37.3 %). A large proportion of deaths in Sierra Leone was associated with surgical conditions, the majority of which did not undergo surgical intervention. Our results indicate that to remove barriers to effective surgical care in Sierra Leone policymakers should first focus on relieving financial burdens and increasing access to timely surgical care.

Primary Hyperparathyroidism in Older People: Surgical Treatment with Minimally Invasive Approaches and Outcome

PubMed Central

Dobrinja, Chiara; Silvestri, Marta; de Manzini, Nicolò

2012-01-01

Introduction. Elderly patients with primary hyperparathyroidism (pHPT) are often not referred to surgery because of their associated comorbidities that may increase surgical risk. The aim of the study was to review indications and results of minimally invasive approach parathyroidectomy in elderly patients to evaluate its impact on outcome. Materials and Methods. All patients of 70 years of age or older undergoing minimally approach parathyroidectomy at our Department from May 2005 to May 2011 were reviewed. Data collected included patients demographic information, biochemical pathology, time elapsed from pHPT diagnosis to surgical intervention, operative findings, complications, and results of postoperative biochemical studies. Results and Discussion. 37 patients were analysed. The average length of stay was 2.8 days. 11 patients were discharged within 24 hours after their operation. Morbidity included 6 transient symptomatic postoperative hypocalcemias while one patient developed a transient laryngeal nerve palsy. Time elapsed from pHPT diagnosis to first surgical visit evidences that the elderly patients were referred after their disease had progressed. Conclusions. Our data show that minimally invasive approach to parathyroid surgery seems to be safe and curative also in elderly patients with few associated risks because of combination of modern preoperative imaging, advances in surgical technique, and advances in anesthesia care. PMID:22737167

Unusual Complication of Surgical Abortion with Pelvic Extrusion of Fetal Head: A Case Report.

PubMed

Begum, Jasmina; Samal, Sunita; Ghose, Seetesh

2015-11-01

Unsafe abortion is one of the causes of maternal mortality and morbidity in developing countries. The complications mostly results following unsafe abortion procedure done by unskilled provider with or without minimal medical knowledge in rural part of developing countries. These complications can endanger the life of mother if proper medical or surgical interventions are not offered in time. A majority of these complications remains confidential. The uterine perforation is one of the serious but preventable complications of surgical abortion. A 21-year-old woman G4P2L2A1, presented in the emergency ward with complaints of lower abdominal pain for four days after attempting twice surgical termination of pregnancy at 19 weeks of gestation for an unwanted pregnancy. Transabdominal sonography and MRI revealed uterine rent with pelvic extrusion of fetal head. Emergency laparotomy with removal of fetal head and uterine rent repair was done. This case illustrates the importance of maintaining a high index of suspicion by the gynaecologist for uterine perforation in patient presenting with abdominal pain a few days after undergoing surgical abortion, also shows the complementary role of sonography and MRI in evaluation of the similar patient and this case also highlights the rampant illegal unsafe abortion procedure in rural India despite of legalization of abortion act.

Hypotheses, rationale, design, and methods for prognostic evaluation of cardiac biomarker elevation after percutaneous and surgical revascularization in the absence of manifest myocardial infarction. A comparative analysis of biomarkers and cardiac magnetic resonance. The MASS-V Trial.

PubMed

Hueb, Whady; Gersh, Bernard J; Rezende, Paulo Cury; Garzillo, Cibele Larrosa; Lima, Eduardo Gomes; Vieira, Ricardo D'Oliveira; Garcia, Rosa Maria Rahmi; Favarato, Desiderio; Segre, Carlos Alexandre W; Pereira, Alexandre Costa; Soares, Paulo Rogério; Ribeiro, Expedito; Lemos, Pedro; Perin, Marco A; Strunz, Célia Cassaro; Dallan, Luis A O; Jatene, Fabio B; Stolf, Noedir A G; Hueb, Alexandre Ciappina; Dias, Ricardo; Gaiotto, Fabio A; da Costa, Leandro Menezes Alves; Oikawa, Fernando Teiichi Costa; de Melo, Rodrigo Morel Vieira; Serrano, Carlos Vicente; de Ávila, Luiz Francisco Rodrigues; Villa, Alexandre Volney; Filho, José Rodrigues Parga; Nomura, César; Ramires, José A F; Kalil Filho, Roberto

2012-08-16

Although the release of cardiac biomarkers after percutaneous (PCI) or surgical revascularization (CABG) is common, its prognostic significance is not known. Questions remain about the mechanisms and degree of correlation between the release, the volume of myocardial tissue loss, and the long-term significance. Delayed-enhancement of cardiac magnetic resonance (CMR) consistently quantifies areas of irreversible myocardial injury. To investigate the quantitative relationship between irreversible injury and cardiac biomarkers, we will evaluate the extent of irreversible injury in patients undergoing PCI and CABG and relate it to postprocedural modifications in cardiac biomarkers and long-term prognosis. The study will include 150 patients with multivessel coronary artery disease (CAD) with left ventricle ejection fraction (LVEF) and a formal indication for CABG; 50 patients will undergo CABG with cardiopulmonary bypass (CPB); 50 patients with the same arterial and ventricular condition indicated for myocardial revascularization will undergo CABG without CPB; and another 50 patients with CAD and preserved ventricular function will undergo PCI using stents. All patients will undergo CMR before and after surgery or PCI. We will also evaluate the release of cardiac markers of necrosis immediately before and after each procedure. Primary outcome considered is overall death in a 5-year follow-up. Secondary outcomes are levels of CK-MB isoenzyme and I-Troponin in association with presence of myocardial fibrosis and systolic left ventricle dysfunction assessed by CMR. The MASS-V Trial aims to establish reliable values for parameters of enzyme markers of myocardial necrosis in the absence of manifest myocardial infarction after mechanical interventions. The establishments of these indices have diagnostic value and clinical prognosis and therefore require relevant and different therapeutic measures. In daily practice, the inappropriate use of these necrosis markers has led to misdiagnosis and therefore wrong treatment. The appearance of a more sensitive tool such as CMR provides an unprecedented diagnostic accuracy of myocardial damage when correlated with necrosis enzyme markers. We aim to correlate laboratory data with imaging, thereby establishing more refined data on the presence or absence of irreversible myocardial injury after the procedure, either percutaneous or surgical, and this, with or without the use of cardiopulmonary bypass.

[Surgical therapy of life-threatening tachycardic cardiac arrhythmias in children].

PubMed

Frank, G; Schmid, C; Baumgart, D; Lowes, D; Klein, H; Kallfelz, H C

1989-05-01

Surgical techniques for tachyarrhythmias refractory to medical treatment are used with increasing frequency. Among 211 patients undergoing antiarrhythmic surgery 10 children (2 to 14 years old) were operated by electrophysiologically directed procedures. 7 patients suffered from WPW syndrome, 2 from focal atrial tachycardias and 1 from recurrent ventricular tachycardia following the repair of Fallot's tetralogy. In all cases preoperative electrophysiologic study and intraoperative mapping preceded operative ablation. Surgical treatment consisted of interruption of the bundle of Kent (3 right-sided, 2 left-sided, 3 septal), ablation of the atrial focus (1 right-sided, 1 left-sided) and right ventricular outflow tract incision. In 7 operations cryo-techniques were added. 2 children with WPW syndrome had two interventions because of tachycardia recurrences due to multiple accessory pathways. In 1 case a VVI-pacemaker was implanted postoperatively due to complete atrioventricular block. Another 2 children with prolonged postoperative bradycardia received a pacemaker prophylactically. Only the child with previous tetralogy of Fallot is still under antiarrhythmic medication while all other children are free of tachycardiac episodes. Our data confirm the efficacy of surgical treatment of tachyarrhythmias in children thereby abolishing the need for life-long antiarrhythmic medication.

Does Psychological Profile Influence Third Molar Extraction and Postoperative Pain?

PubMed

González-Martínez, Raquel; Jovani-Sancho, María Del Mar; Cortell-Ballester, Isidoro

2017-03-01

Our purposes were to determine the influence of psychological profile on hemodynamic changes in patients who undergo surgical removal of the third molars under intravenous sedation and to evaluate the effect on patients' anxiety and postoperative recovery. We performed a prospective study of 100 patients (American Society of Anesthesiologists classes I and II; aged ≥18 years) seen in the CIMIVClinic (Department of Oral Surgery, Casa de Salud University Hospital, Valencia, Spain) who underwent extractions of all third molars under intravenous sedation. All patients were administered the Symptom Checklist 90 Revised (SCL-90-R). The following parameters were monitored at different times during the surgical interventions: systolic blood pressure, diastolic blood pressure, oxygen saturation, and heart rate. Position and depth of impaction of the tooth (Pell and Gregory classification and Winter classification), surgery duration, and surgical technique also were recorded. Finally, the degree of pain experienced the week after the surgical intervention was measured using a visual analog scale. Patients' anxiety levels preoperatively were significantly higher in patients with psychological distress (P = .023). Postoperative pain significantly decreased from the first day to the seventh day in healthy patients but not in patients with altered psychological conditions (P < .05). Nevertheless, the hemodynamic changes were not correlated with the psychological impairment. Intravenous sedation enables the control of hemodynamic changes in all patients independently of their psychological profile. Patients with psychological distress present with higher levels of dental anxiety and postoperative pain. Future studies are needed to further clarify this interaction. Copyright © 2016 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.

Referral Patterns of Emergent Pediatric Hand Injury Transfers to a Tertiary Care Center.

PubMed

Gornitzky, Alex L; Milby, Andrew H; Gunderson, Melissa A; Chang, Benjamin; Carrigan, Robert B

2016-01-01

Several studies have identified the inappropriate use of emergent interfacility transfer as an opportunity to improve health care use. The authors sought to identify common characteristics among children who were transferred from a community hospital to a pediatric tertiary care center for definitive treatment of hand/wrist injuries. All patients undergoing emergent transfer to a pediatric Level I trauma center and academic tertiary referral center for evaluation and management of injuries to the hand/wrist during the 2-year study period were retrospectively identified. Demographic and transfer data were abstracted from the medical record. Referring hospitals were subcategorized by the presence or absence of hand surgical emergency department coverage and the capability to admit/operate on children. Overall, 169 patients were identified who transferred to the authors' institution for hand injuries. There were no differences in the day or time of transfer. Of those transferred, 59 (35%) were admitted for definitive care, of whom 51 (86%) required a surgical intervention within 24 hours. Of the remaining 110 (65%) patients discharged from the emergency department, 27 (25%) underwent elective surgical intervention within 2 weeks. There were a greater number of transfers from institutions without the ability to admit children, regardless of hand surgical emergency department coverage status. Understanding pediatric referral patterns may improve use of emergency department facilities because most patients who were transferred were discharged the same day. Educational outreach and improved interfacility communication may result in enhanced resource use for evaluation and management of pediatric hand injuries. Copyright 2016, SLACK Incorporated.

Herbal medications for surgical patients: a systematic review protocol.

PubMed

Arruda, Ana Paula Nappi; Ayala, Ana Patricia; Lopes, Luciane C; Bergamaschi, Cristiane C; Guimarães, Caio; Grossi, Mariana Del; Righesso, Leonardo A R; Agarwal, Arnav; El Dib, Regina

2017-07-26

Postoperative nausea and vomiting (PONV) affect approximately 80% of surgical patients and is associated with increased length of hospital stay and systemic costs. Preoperative and postoperative pain, anxiety and depression are also commonly reported. Recent evidence regarding their safety and effectiveness has not been synthesised. The aim of this systematic review is to evaluate the efficacy and safety of herbal medications for the treatment and prevention of anxiety, depression, pain and PONV in patients undergoing laparoscopic, obstetrical/gynaecological and cardiovascular surgical procedures. The following electronic databases will be searched up to 1 October 2016 without language or publication status restrictions: CENTRAL, MEDLINE, EMBASE, CINAHL, Web of Science and LILACS. Randomised clinical trials enrolling adult surgical patients undergoing laparoscopic, obstetrical/gynaecological and cardiovascular surgeries and managed with herbal medication versus a control group (placebo, no intervention or active control) prophylactically or therapeutically will be considered eligible. Outcomes of interest will include the following: anxiety, depression, pain, nausea and vomiting. A team of reviewers will complete title and abstract screening and full-text screening for identified hits independently and in duplicate. Data extraction, risk of bias assessments and evaluation of the overall quality of evidence for each relevant outcome reported will be conducted independently and in duplicate using the Grading of Recommendations Assessment Development and Evaluation classification system. Dichotomous data will be summarised as risk ratios; continuous data will be summarised as standard average differences with 95% CIs. This is one of the first efforts to systematically summarise existing evidence evaluating the use of herbal medications in laparoscopic, obstetrical/gynaecological and cardiovascular surgical patients. The findings of this review will be disseminated through peer-reviewed publications and conference presentations. PROSPERO CRD42016042838. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Optimizing Blood Transfusion Practices Through Bundled Intervention Implementation in Patients With Gynecologic Cancer Undergoing Laparotomy.

PubMed

Wallace, Sumer K; Halverson, Jessica W; Jankowski, Christopher J; DeJong, Stephanie R; Weaver, Amy L; Weinhold, Megan R; Borah, Bijan J; Moriarty, James P; Cliby, William A; Kor, Daryl J; Higgins, Andrew A; Otto, Hilary A; Dowdy, Sean C; Bakkum-Gamez, Jamie N

2018-05-01

To examine blood transfusion practices and develop a standardized bundle of interventions to address the high rate of perioperative red blood cell transfusion among patients with ovarian and endometrial cancer. This was a retrospective cohort study. Our primary aim was to determine whether an implemented bundled intervention was associated with a reduction in perioperative red blood cell transfusions among cases of laparotomy for cancer. Secondary aims included comparing perioperative demographic, surgical, complication, and cost data. Interventions included blood transfusion practice standardization using American Society of Anesthesiologists guidelines, an intraoperative hemostasis checklist, standardized intraoperative fluid status communication, and evidence-based use of tranexamic acid. Prospective data from women undergoing laparotomy for ovarian or endometrial cancer from September 28, 2015, to May 31, 2016, defined the study cohort and were compared with historical controls (September 1, 2014, to September 25, 2015). Outcomes were compared in the full unadjusted cohorts and in propensity-matched cohorts. In the intervention and historical cohorts, respectively, 89 and 184 women underwent laparotomy for ovarian cancer (n=74 and 152) or advanced endometrial cancer (n=15 and 32). Tranexamic acid was administered in 54 (60.7%) patients. The perioperative transfusion rate was lower for the intervention group compared with historical controls (18.0% [16/89] vs 41.3% [76/184], P<.001), a 56.4% reduction. This improvement in the intervention group remained significant after propensity matching (16.2% [13/80] vs 36.2% [29/80], P=.004). The hospital readmission rate was also lower for the intervention group compared with historical controls (1.1% [1/89] vs 12.5% [23/184], P=.002); however, this improvement did not attain statistical significance after propensity matching (1.2% [1/80] vs 7.5% [6/80], P=.12). Cost analysis demonstrated that this intervention was cost-neutral during index hospitalization plus 30-day follow-up. Application of a standardized bundle of evidence-based interventions was associated with reduced blood use in our gynecologic oncology practice.

Requirements for emergent neurosurgical procedures among patients undergoing neuroendovascular procedures in contemporary practice.

PubMed

Khatri, R; Ansar, M; Sultan, F; Chaudhry, S A; Khan, A A; Rodriguez, G J; Tummala, R P; Qureshi, A I

2012-03-01

Provisions for an emergent neurosurgical procedure have been a mandatory component of centers that perform neuroendovascular procedures. We sought to determine the need for emergent neurosurgical procedures following neuroendovascular interventions in 2 comprehensive stroke centers in settings with such provisions. Analysis of retrospectively collected data from procedure logs and patient charts was performed to identify patients who required immediate (before the termination of the intervention) or adjunctive (within 24 hours of the intervention) neurosurgical procedures related to a neuroendovascular intervention complication. The types of neurosurgical procedures and in-hospital outcomes of identified patients are reported as an aggregate and per endovascular procedure-type analyses. We reviewed a total of 933 neuroendovascular procedures performed during 3.5 years (2006-2010). A total of 759 intracranial procedures were performed. There was a need for emergent neurosurgical procedures in 8 patients (0.85% cumulative incidence and 1.05% for major intracranial procedures) (mean age, 46 years; 7 were women); the procedures were categorized as 3 immediate and 5 adjunctive procedures. There were 5 in-hospital deaths (62.5%) among these 8 patients. Neurosurgical procedures performed were external ventricular drainage placement in 6 (6 of 8, 75%) patients, decompressive craniectomy in 1 (12.5%) patient, and both surgical procedures in 1 (12.5%) patient. The need for emergent neurosurgical procedures is very low among patients undergoing intracranial neuroendovascular procedures. Survival in such patients despite emergent neurosurgical procedures is quite low.

Should high risk patients with concomitant severe aortic stenosis and mitral valve disease undergo double valve surgery in the TAVR era?

PubMed

Yu, Pey-Jen; Mattia, Allan; Cassiere, Hugh A; Esposito, Rick; Manetta, Frank; Kohn, Nina; Hartman, Alan R

2017-12-29

Significant mitral regurgitation in patients undergoing transcatheter aortic valve replacement (TAVR) is associated with increased mortality. The aim of this study is to determine if surgical correction of both aortic and mitral valves in high risk patients with concomitant valvular disease would offer patients better outcomes than TAVR alone. A retrospective analysis of 43 high-risk patients who underwent concomitant surgical aortic valve replacement and mitral valve surgery from 2008 to 2012 was performed. Immediate and long term survival were assessed. There were 43 high-risk patients with severe aortic stenosis undergoing concomitant surgical aortic valve replacement and mitral valve surgery. The average age was 80 ± 6 years old. Nineteen (44%) patients had prior cardiac surgery, 15 (34.9%) patients had chronic obstructive lung disease, and 39 (91%) patients were in congestive heart failure. The mean Society of Thoracic Surgeons Predicted Risk of Mortality for isolated surgical aortic valve replacement for the cohort was 10.1% ± 6.4%. Five patients (11.6%) died during the index admission and/or within thirty days of surgery. Mortality rate was 25% at six months, 35% at 1 year and 45% at 2 years. There was no correlation between individual preoperative risk factors and mortality. High-risk patients with severe aortic stenosis and mitral valve disease undergoing concomitant surgical aortic valve replacement and mitral valve surgery may have similar long term survival as that described for such patients undergoing TAVR. Surgical correction of double valvular disease in this patient population may not confer mortality benefit compared to TAVR alone.

Surgical Closure of Patent Ductus Arteriosus in Premature Neonates Weighing Less Than 1,000 grams: Contemporary Outcomes.

PubMed

Lehenbauer, David G; Fraser, Charles D; Crawford, Todd C; Hibino, Naru; Aucott, Susan; Grimm, Joshua C; Patel, Nishant; Magruder, J Trent; Cameron, Duke E; Vricella, Luca

2018-07-01

The safety of surgical closure of patent ductus arteriosus (PDA) in very low birth weight premature neonates has been questioned because of associated morbidities. However, these studies are vulnerable to significant bias as surgical ligation has historically been utilized as "rescue" therapy. The objective of this study was to review our institutions' outcomes of surgical PDA ligation. All neonates with operative weight of ≤1.00 kg undergoing surgical PDA ligation from 2003 to 2015 were analyzed. Records were queried to identify surgical complications, perioperative morbidity, and mortality. Outcomes included pre- and postoperative ventilator requirements, pre- and postoperative inotropic support, acute kidney injury, surgical complications, and 30-day mortality. One hundred sixty-six preterm neonates underwent surgical ligation. One hundred twenty-one (70.3%) had failed indomethacin closure. One hundred sixty-four (98.8%) patients required mechanical ventilation prior to surgery. At 17 postoperative days, freedom from the ventilator reached 50%. Of 109 (66.4%) patients requiring prolonged preoperative inotropic support, 59 (54.1%) were liberated from inotropes by postoperative day 1. Surgical morbidity was encountered in four neonates (2.4%): two (1.2%) patients had a postoperative pneumothorax requiring tube thoracostomy, one (0.6%) patient had a recurrent laryngeal nerve injury, and one (0.6%) patient had significant intraoperative bleeding. The 30-day all-cause mortality was 1.8% (n = 3); no deaths occurred intraoperatively. In this retrospective investigation, surgical PDA closure was associated with low 30-day mortality and minimal morbidity and resulted in rapid discontinuation of inotropic support and weaning from mechanical ventilation. Given the safety of this intervention, surgical PDA ligation merits consideration in the management strategy of the preterm neonate with a PDA.

Pre-consultation educational group intervention to improve shared decision-making for postmastectomy breast reconstruction: a pilot randomized controlled trial.

PubMed

Causarano, Natalie; Platt, Jennica; Baxter, Nancy N; Bagher, Shaghayegh; Jones, Jennifer M; Metcalfe, Kelly A; Hofer, Stefan O P; O'Neill, Anne C; Cheng, Terry; Starenkyj, Elizabeth; Zhong, Toni

2015-05-01

Breast cancer survivors who make preference-sensitive decisions about postmastectomy breast reconstruction often have large gaps in knowledge and undergo procedures that are misaligned with their treatment goals. We evaluated the feasibility and effect of a pre-consultation educational group intervention on the decision-making process for breast reconstruction. We conducted a pilot randomized controlled trial (RCT) where participants were randomly assigned to the intervention with routine education or routine education alone. The outcomes evaluated were decisional conflict, decision self-efficacy, satisfaction with information, perceived involvement in care, and uptake of reconstruction following surgical consultation. Trial feasibility and acceptability were evaluated, and effect sizes were calculated to determine the primary outcome for the full-scale RCT. Of the 41 patients enrolled, recruitment rate was 72 %, treatment fidelity was 98 %, and retention rate was 95 %. The Cohen's d effect size in reduction of decisional conflict was moderate to high for the intervention group compared to routine education (0.69, 95 % CI = 0.02-1.42), while the effect sizes of increase in decision self-efficacy (0.05, 95 % CI = -0.60-0.71) and satisfaction with information (0.11, 95 % CI = -0.53-0.76) were small. A higher proportion of patients receiving routine education signed informed consent to undergo breast reconstruction (14/20 or 70 %) compared to the intervention group (8/21 or 38 %) P = 0.06. A pre-consultation educational group intervention improves patients' shared decision-making quality compared to routine preoperative patient education. A full-scale definitive RCT is warranted based on high feasibility outcomes, and the primary outcome for the main trial will be decisional conflict.

Minimising preoperative anxiety with music for day surgery patients - a randomised clinical trial.

PubMed

Ni, Cheng-Hua; Tsai, Wei-Her; Lee, Liang-Ming; Kao, Ching-Chiu; Chen, Yi-Chung

2012-03-01

The objective of this study was to evaluate the effects of musical intervention on preoperative anxiety and vital signs in patients undergoing day surgery. Studies and systematic meta-analyses have shown inconclusive results of the efficacy of music in reducing preoperative anxiety. We designed a study to provide additional evidence for its use in preoperative nursing care. Randomised, controlled study. Patients (n = 183) aged 18-65 admitted to our outpatient surgery department were randomly assigned to either the experimental group (music delivered by earphones) or control group (no music) for 20 minutes before surgery. Anxiety, measured by the State-Trait Anxiety Inventory, and vital signs were measured before and after the experimental protocol. A total of 172 patients (60 men and 112 women) with a mean age of 40·90 (SD 11·80) completed the study. The largest number (35·7%) was undergoing elective plastic surgery and 76·7% of the total reported previous experience with surgery. Even though there was only a low-moderate level of anxiety at the beginning of the study, both groups showed reduced anxiety and improved vital signs compared with baseline values; however, the intervention group reported significantly lower anxiety [mean change: -5·83 (SD 0·75) vs. -1·72 (SD 0·65), p < 0·001] on the State-Trait Anxiety Inventory compared with the control group. Patients undergoing day surgery may benefit significantly from musical intervention to reduce preoperative anxiety and improve physiological parameters. Finding multimodal approaches to ease discomfort and anxiety from unfamiliar unit surroundings and perceived risks of morbidity (e.g. disfigurement and long-term sequelae) is necessary to reduce preoperative anxiety and subsequent physiological complications. This is especially true in the day surgery setting, where surgical admission times are often subject to change and patients may have to accommodate on short notice or too long a wait that may provoke anxiety. Our results provide additional evidence that musical intervention may be incorporated into routine nursing care for patients undergoing minor surgery. © 2011 Blackwell Publishing Ltd.

Glaucoma and Corneal Transplant Procedures

PubMed Central

Al-Mahmood, Ammar M.; Al-Swailem, Samar A.; Edward, Deepak P.

2012-01-01

Glaucoma after corneal transplantation is a leading cause of ocular morbidity after penetrating keratoplasty. The incidence reported is highly variable and a number of etiologic factors have been identified. A number of treatment options are available; surgical intervention for IOP control is associated with a high incidence of graft failure. IOP elevation is less frequently seen following deep anterior lamellar keratoplasty. Descemet's striping-automated endothelial keratoplasty is also associated with postprocedure intraocular pressure elevation and secondary glaucoma and presents unique surgical challenges in patients with preexisting glaucoma surgeries. Glaucoma exists in up to three-quarters of patients who undergo keratoprosthesis surgery and the management if often challenging. The aim of this paper is to highlight the incidence, etiology, and management of glaucoma following different corneal transplant procedures. It also focuses on the challenges in the diagnosis of glaucoma and intraocular pressure monitoring in this group of patients. PMID:22315661

Endovascular Versus Open Surgical Intervention in Patients with Takayasu's Arteritis: A Meta-analysis.

PubMed

Jung, Jae Hyun; Lee, Young Ho; Song, Gwan Gyu; Jeong, Han Saem; Kim, Jae-Hoon; Choi, Sung Jae

2018-06-01

Although medical treatment has advanced, surgical treatment is needed to control symptoms of Takayasu's arteritis (TA), such as angina, stroke, hypertension, or claudication. Endovascular or open surgical intervention is performed; however, there are few comparative studies on these methods. This meta-analysis and systematic review aimed to examine the outcome of surgical treatment of TA. A meta-analysis comparing outcomes of endovascular and open surgical intervention was performed using MEDLINE and Embase. This meta-analysis included only observational studies, and the evidence level was low to moderate. Data were pooled and analysed using a fixed or random effects model with the I 2 statistic. The included studies involved a total of 770 patients and 1363 lesions, with 389 patients treated endovascularly and 420 treated by surgical revascularization. Restenosis was more common with endovascular than open surgical intervention (odds ratio [OR] 5.18, 95% confidence interval [CI] 2.78-9.62; p < .001). In subgroup analysis according to the involved lesions, endovascular intervention patients showed more restenosis than open surgical intervention patients in the coronary artery, supra-aortic branches, and renal artery. In both the active and inactive stages, restenosis was more common in those treated endovascularly than in those treated by open surgery. However, stroke occurred less often with endovascular intervention than with open surgical intervention (OR 0.33, 95% CI 0.12-0.90; p = .003). Mortality and complications other than stroke and mortality did not differ between endovascular and open surgical intervention. This meta-analysis has shown a lower risk of restenosis with open surgical intervention than with endovascular intervention. Stroke was generally more common with open surgical intervention than with endovascular intervention. However, there were differences according to the location of the lesion, and the risk of stroke in open surgery is higher when the supra-aortic branches are involved rather than the renal arteries. Copyright © 2018 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.

Revascularization of smokers with claudication is not predicted to limit quality of life despite a higher risk of late failure.

PubMed

Mixson, Joshua D; Brothers, Thomas E

2017-01-01

Tobacco smoking after lower extremity revascularization for claudication has repeatedly been shown to increase the risk of adverse events, such that many vascular specialists consider that refusal to abstain from smoking constitutes a major contraindication to open surgical bypass or endovascular intervention. A Markov decision analysis (DA) model was used to compare the options of direct revascularization vs medical therapy only in smokers with claudication. The primary outcome was calculated quality of life (cQoL), determined for each patient at follow-up based on the outcomes of the treatment received. Markov DA software was used to predict the QoL for each treatment option preoperatively based on smoking status. Among patients referred during a recent 64-month period with vasculogenic claudication, 94 were actively smoking compared with 217 who were not. The DA model predicted that if the patients who smoked were to discontinue smoking, the best therapy would be bypass surgery for 77% and endovascular intervention for 17%. However, despite at least doubling the risks with intervention in the patients who continue to smoke, the DA model still predicted that 78% and 9% would fare better with open surgical or endovascular intervention, respectively. Among actively smoking patients, open surgical (3%) or endovascular (4%) therapies were initially performed in few patients, whereas 93% were offered only medical therapy. Among initial nonsmokers, revascularization was performed by open (27%) or endovascular (42%) means. At 3 years, the median (interquartile range [IQR]) cQoL was lower in initial smokers than in nonsmokers (0.73 [IQR, 0.73-0.77] vs 0.82 [IQR, 0.75-0.86]; P < .0001), primarily because of a lack of revascularization for smokers. Among initial smokers who did undergo revascularization initially, because of progression of symptoms, or after smoking cessation, cQoL was similar to initial nonsmokers (0.77 [IQR, 0.73-0.84] vs 0.73 [IQR, 0.73-0.73]; P = .37). Although 26% of initial smokers had stopped by the time of their last follow-up, 10% of initially nonsmoking patients were smoking at follow-up. However, among all patients undergoing intervention, the cQoL of patients smoking at the time of last their follow-up was similar to nonsmokers (0.82 [IQR, 0.82-0.86] vs 0.83 [IQR, 0.73-0.86]; P = .99). Patients with claudication who smoke may be denied the symptom improvement associated with revascularization, yet recidivism for smoking also occurs among patients who have stopped smoking in order to receive revascularization. The strategy not to directly revascularize patients with claudication who continue to smoke does not appear to maximize patient midterm QoL. Published by Elsevier Inc.

Isolated tricuspid regurgitation: outcomes and therapeutic interventions

PubMed Central

Zack, Chad J; Nishimura, Rick A

2018-01-01

Isolated tricuspid regurgitation (TR) can be caused by primary valvular abnormalities such as flail leaflet or secondary annular dilation as is seen in atrial fibrillation, pulmonary hypertension and left heart disease. There is an increasing recognition of a subgroup of patients with isolated TR in the absence of other associated cardiac abnormalities. Left untreated isolated TR significantly worsens survival. Stand-alone surgery for isolated TR is rarely performed due to an average operative mortality of 8%–10% and a paucity of data demonstrating improved survival. When surgery is performed, valve repair may be preferred over replacement; however, there is a risk of significant recurrent regurgitation after repair. Existing society guidelines do not fully address the management of isolated TR. We propose that patients at low operative risk with symptomatic severe isolated TR and no reversible cause undergo surgery prior to the onset of right ventricular dysfunction and end-organ damage. For patients at increased surgical risk novel percutaneous interventions may offer an alternative treatment but further research is needed. Significant knowledge gaps remain and future research is needed to define operative outcomes and provide comparative data for medical and surgical therapy. PMID:29229649

Impact of Mitral Regurgitation on Clinical Outcomes After Transcatheter Aortic Valve Implantation

PubMed Central

Tüller, David; Zbinden, Rainer; Eberli, Franz R

2016-01-01

Severe aortic stenosis (AS) and mitral regurgitation (MR) are the two most common valvular lesions referred for surgical intervention in Europe and frequently co-exist. In patients with both severe AS and significant MR referred for surgical aortic valve replacement (SAVR), a concomitant mitral valve intervention is typically performed if the MR is severe, despite the higher associated perioperative risk. The management of moderate MR among SAVR patients is controversial and depends on a number of factors including MR aetiology (i.e., organic versus functional MR), feasibility of repair and patient risk profile. Moderate or severe MR is present in up to one-third of patients undergoing transcatheter aortic valve implantation (TAVI), is mainly of functional aetiology and is typically left untreated. Although data are conflicting, a growing body of evidence suggests that significant MR exerts an adverse effect on both short- and long-term clinical outcomes after TAVI. Moderate or severe MR improves in just over half of patients following TAVI and recent data suggest MR is more likely to improve among patients receiving a balloon-expandable as compared with a self-expandable transcatheter heart valve. PMID:29588707

Three good reasons for heart surgeons to understand cardiac metabolism.

PubMed

Doenst, Torsten; Bugger, Heiko; Schwarzer, Michael; Faerber, Gloria; Borger, Michael A; Mohr, Friedrich W

2008-05-01

It is the principal goal of cardiac surgeons to improve or reinstate contractile function with, through or after a surgical procedure on the heart. Uninterrupted contractile function of the heart is irrevocably linked to the uninterrupted supply of energy in the form of ATP. Thus, it would appear natural that clinicians interested in myocardial contractile function are interested in the way the heart generates ATP, i.e. the processes generally referred to as energy metabolism. Yet, it may appear that the relevance of energy metabolism in cardiac surgery is limited to the area of cardioplegia, which is a declining research interest. It is the goal of this review to change this trend and to illustrate the role and the therapeutic potential of metabolism and metabolic interventions for management. We present three compelling reasons why cardiac metabolism is of direct, practical interest to the cardiac surgeon and why a better understanding of energy metabolism might indeed result in improved surgical outcomes: (1) To understand cardioplegic arrest, ischemia and reperfusion, one needs a working knowledge of metabolism; (2) hyperglycemia is an underestimated and modifiable risk factor; (3) acute metabolic interventions can be effective in patients undergoing cardiac surgery.

The effect of autologous adipose derived mesenchymal stem cell therapy in the treatment of a large osteochondral defect of the knee following unsuccessful surgical intervention of osteochondritis dissecans - a case study.

PubMed

Freitag, Julien; Shah, Kiran; Wickham, James; Boyd, Richard; Tenen, Abi

2017-07-14

A prospective analysis of the effect of autologous adipose derived mesenchymal stem cell (MSC) therapy in the treatment of an osteochondral defect of the knee with early progressive osteoarthritis following unsuccessful surgical intervention of osteochondritis dissecans (OCD). After failed conventional management of OCD a patient undergoes intra-articular MSC therapy. Patient outcome measures included the Numeric Pain Rating Scale (NPRS), the Western Ontario and McMaster Universities Arthritis Index (WOMAC) and the Knee Injury and Osteoarthritis Outcome Score (KOOS). Structural outcome was assessed using MRI with the novel technique of T2 mapping used to indicate cartilage quality. Following MSC therapy the patient reported improvement in pain and function as measured by NPRS, WOMAC and KOOS. Repeat MRI analysis showed regeneration of cartilage. MRI T2 mapping indicated hyaline like cartilage regrowth. In this report, the use of MSCs, after unsuccessful conventional OCD management, resulted in structural, functional and pain improvement. These results highlight the need to further study the regenerative potential of MSC therapy. Australian and New Zealand Clinical Trial Registry Number - ACTRN12615000258550 (Date registered 19/03/2015 - retrospectively registered).

Vision and Task Assistance using Modular Wireless In Vivo Surgical Robots

PubMed Central

Platt, Stephen R.; Hawks, Jeff A.; Rentschler, Mark E.

2009-01-01

Minimally invasive abdominal surgery (laparoscopy) results in superior patient outcomes compared to conventional open surgery. However, the difficulty of manipulating traditional laparoscopic tools from outside the body of the patient generally limits these benefits to patients undergoing relatively low complexity procedures. The use of tools that fit entirely inside the peritoneal cavity represents a novel approach to laparoscopic surgery. Our previous work demonstrated that miniature mobile and fixed-based in vivo robots using tethers for power and data transmission can successfully operate within the abdominal cavity. This paper describes the development of a modular wireless mobile platform for in vivo sensing and manipulation applications. Design details and results of ex vivo and in vivo tests of robots with biopsy grasper, staple/clamp, video, and physiological sensor payloads are presented. These types of self-contained surgical devices are significantly more transportable and lower in cost than current robotic surgical assistants. They could ultimately be carried and deployed by non-medical personnel at the site of an injury to allow a remotely located surgeon to provide critical first response medical intervention irrespective of the location of the patient. PMID:19237337

Musical intervention reduces patients' anxiety in surgical extraction of an impacted mandibular third molar.

PubMed

Kim, Yu-Kyoung; Kim, Soung-Min; Myoung, Hoon

2011-04-01

Patients undergoing impacted mandibular third molar (IMTM) extraction often have severe perioperative anxiety, which may lead to increased perceptions of pain and vital sign instability throughout surgery. Intraoperational musical interventions have been used during operations to decrease patient anxiety levels. We investigated the anxiolytic effects of musical intervention during surgical extraction of an IMTM. We tested the hypothesis that musical intervention would have positive effects on patients' vital signs, anxiety levels, and perceptions of pain. We recruited 219 patients with IMTM surgery to participate in this study. Participants were randomly assigned to a music-treated group (106 subjects) or a control group (113 subjects). In a preoperative meeting, patient demographic data were collected, and the patients' favorite songs were selected. For the music-treated group, their selected music was played from the time of arrival to the operating room until the end of the operation. Perioperative anxiety and perceptions of pain were assessed using the Dental Anxiety Scale and the Visual Analog Scale, respectively. Patients' vital signs (blood pressure, heart rate, and respiratory rate) were monitored throughout the surgery. One-way analysis of covariance using perioperative anxiety as a covariant was performed to compare intraoperative anxiety levels and perioperative perceptions of pain between the 2 groups. Repeated measures analysis of variance was used to compare changes in vital signs across surgical stages between the 2 groups. Vital signs changed significantly throughout surgery according to the stage of the procedure. For both groups, vital signs increased from baseline and reached peak values at the time of the initial incision and then decreased quickly and plateaued within normal limits. There were no significant differences between groups in blood pressure; however, the music-treated group showed a significantly smaller change in heart rate than the control group. The music-treated group reported significantly less intraoperative anxiety than the nonmusic-treated control group when controlling for preoperative anxiety levels (F = 4.226, P < .05). These results support the hypothesis that the use of patient-chosen music during surgical extraction of an IMTM significantly lowers patient intraoperative anxiety levels. Copyright © 2011 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.

An empowerment health education program for children undergoing surgery for congenital heart diseases.

PubMed

Ni, Zhihong; Chao, Yannfen; Xue, Xiaoling

2016-09-01

Since the surgery for congenital heart disease (CHD) is considered highly risky, appropriate postoperative care is crucial. After the surgery, children are often discharged with unhealed wounds, incomplete recovery, and continuing pain. Health education programs based on empowerment education model can assist clients to develop skills in self-management. This study aimed to evaluate the effectiveness of an empowerment health education program for improving caregiving knowledge, caring behaviors, and self-efficacy of parents caring for children after corrective surgery for CHD. This prospective clinical trial enrolled pediatric patients undergoing surgical correction for CHD. Patients were divided into two groups: the control group (n = 42), which received the standard education program, and the intervention group (n = 44), which participated in the empowerment theory-based education program. We collected data on left ventricular ejection fraction (LVEF); peripheral oxygen saturation (SpO2); New York Heart Association classification of the patients; and the parents' caregiving knowledge, caring behaviors, and self-efficacy before surgery and one month and three months after surgery. At one month and three months after surgery, the intervention group scored higher than the control group in caregiving knowledge, caring behavior, and self-efficacy. By the third month after surgery, the intervention group had significantly higher values of LVEF and SpO2 than the control group. © The Author(s) 2015.

Rise and fall of NT-proBNP in aortic valve intervention.

PubMed

Hultkvist, Henrik; Holm, Jonas; Svedjeholm, Rolf; Vánky, Farkas

2018-01-01

To describe the dynamics of N-terminal pro-B-type natriuretic peptide (NT-proBNP) from preoperative evaluation to 6-month follow-up in patients undergoing aortic valve intervention, and to evaluate NT-proBNP with regard to 1-year mortality. At preoperative evaluation, we prospectively included 462 patients accepted for aortic valve intervention. The median time to surgical aortic valve replacement (SAVR; n=336) or transcatheter aortic valve implantation (TAVI; n=126) was 4 months. NT-proBNP was measured at enrolment for preoperative evaluation, on the day of surgery, postoperatively on day 1, day 3 and at the 6-month follow-up. Subgroups of patients undergoing SAVR with aortic regurgitation and aortic stenosis with and without coronary artery bypass were also analysed. NT-proBNP remained stable in all subgroups during the preoperative waiting period, but displayed a substantial transient early postoperative increase with a peak on day 3 except in the TAVI group, which peaked on day 1. At the 6-month follow-up, NT-proBNP had decreased to or below the preoperative level in all groups. In the SAVR group, NT-proBNP preoperatively and on postoperative days 1 and 3 revealed significant discriminatory power with regard to 1-year mortality (area under the curve (AUC)=0.79, P=0.0001; AUC=0.71, P=0.03; and AUC=0.79, P=0.002, respectively). This was not found in the TAVI group, which had higher levels of NT-proBNP both preoperatively and at the 6-month follow-up compared with the SAVR group. The dynamic profile of NT-proBNP differed between patients undergoing TAVI and SAVR. NT-proBNP in the perioperative course was associated with increased risk of 1-year mortality in SAVR but not in TAVI.

Effect of a preoperative decontamination protocol on surgical site infections in patients undergoing elective orthopedic surgery with hardware implantation.

PubMed

Bebko, Serge P; Green, David M; Awad, Samir S

2015-05-01

Surgical site infections (SSIs), commonly caused by methicillin-resistant Staphylococcus aureus (MRSA), are associated with significant morbidity and mortality, specifically when hardware is implanted in the patient. Previously, we have demonstrated that a preoperative decontamination protocol using chlorhexidine gluconate washcloths and intranasal antiseptic ointment is effective in eradicating MRSA in the nose and on the skin of patients. To examine the effect of a decontamination protocol on SSIs in patients undergoing elective orthopedic surgery with hardware implantation. A prospective database of patients undergoing elective orthopedic surgery with hardware implantation at the Michael E. DeBakey Veterans Affairs Medical Center in Houston, Texas, was analyzed from October 1, 2012, to December 31, 2013. Cohort groups before and after the intervention were compared. Starting in May 2013, during their preoperative visit, all of the patients watched an educational video about MRSA decontamination and were given chlorhexidine washcloths and oral rinse and nasal povidone-iodine solution to be used the night before and the morning of scheduled surgery. Thirty-day SSI rates were collected according to the definitions of the Centers for Disease Control and Prevention National Nosocomial Infections Surveillance. Data on demographics, comorbidities such as chronic obstructive pulmonary disease and coronary artery disease, tobacco use, alcohol use, and body mass index were also collected. Univariate analysis was performed between the 2 groups of patients. Multivariate analysis was used to identify independent predictors of SSI. A total of 709 patients were analyzed (344 controls and 365 patients who were decolonized). Both groups were well matched with no significant differences in age, body mass index, sex, or comorbidities. All of the patients (100%) completed the MRSA decontamination protocol. The SSI rate in the intervention group was significantly lower (1.1%; 4 of 365 patients developed an SSI) than the SSI rate in the control group (3.8%; 13 of 344 patients developed an SSI) (P = .02). Multivariate logistic regression identified MRSA decontamination as an independent predictor of not developing an SSI (adjusted odds ratio, 0.24 [95% CI, 0.08-0.77]; P = .02). Our study demonstrates that preoperative MRSA decontamination with chlorhexidine washcloths and oral rinse and intranasal povidone-iodine decreased the SSI rate by more than 50% among patients undergoing elective orthopedic surgery with hardware implantation. Universal decontamination using this low-cost protocol may be considered as an additional prevention strategy for SSIs in patients undergoing orthopedic surgery with hardware implantation and warrants further study.

Comparative effectiveness of peripheral vascular intervention versus surgical bypass for critical limb ischemia in the Vascular Study Group of Greater New York.

PubMed

Meltzer, Andrew J; Sedrakyan, Art; Isaacs, Abby; Connolly, Peter H; Schneider, Darren B

2016-11-01

In this study, the effectiveness of peripheral vascular intervention (PVI) was compared with surgical bypass grafting (BPG) for critical limb ischemia (CLI) in the Vascular Study Group of Greater New York (VSGGNY). Patients undergoing BPG or PVI for CLI at VSGGNY centers (2011-2013) were included. The Society for Vascular Surgery objective performance goals for CLI were used to directly compare the safety and effectiveness of PVI and BPG. Propensity score matching was used for risk-adjusted comparisons of PVI with BPG. A total of 414 patients (268 PVI, 146 BPG) were treated for tissue loss (69%) or rest pain (31%). Patients undergoing PVI were more likely to have tissue loss (74.6% vs 57.5%; P < .001) and comorbidities such as diabetes (69.3% vs 57.5%; P = .02), heart failure (22% vs 13.7%; P = .04), and severe renal disease (13.1% vs 4.1%; P = .004). No significant differences were found between the groups across a panel of safety objective performance goals. In unadjusted analyses at 1 year, BPG was associated with higher rates of freedom from reintervention, amputation, or restenosis (90.4% vs 81.7%; P = .02) and freedom from reintervention or amputation (92.5% vs 85.8%, P = .045). After propensity score matching, PVI was associated with improved freedom from major adverse limb events and postoperative death at 1 year (95.6% vs 88.5%; P < .05). By unadjusted comparison, early reintervention and restenosis are more prevalent with PVI. However, risk-adjusted comparison underscores the safety and effectiveness of PVI in the treatment of CLI. Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Surgical Management of Pediatric Epilepsy: Decision-Making and Outcomes.

PubMed

Kellermann, Tanja S; Wagner, Janelle L; Smith, Gigi; Karia, Samir; Eskandari, Ramin

2016-11-01

First-line treatment for epilepsy is antiepileptic drug and requires an interdisciplinary approach and enduring commitment and adherence from the patient and family for successful outcome. Despite adherence to antiepileptic drugs, refractory epilepsy occurs in approximately 30% of children with epilepsy, and surgical treatment is an important intervention to consider. Surgical management of pediatric epilepsy is highly effective in selected patients with refractory epilepsy; however, an evidence-based protocol, including best methods of presurgical imaging assessments, and neurodevelopmental and/or behavioral health assessments, is not currently available for clinicians. Surgical treatment of epilepsy can be critical to avoid negative outcomes in functional, cognitive, and behavioral health status. Furthermore, it is often the only method to achieve seizure freedom in refractory epilepsy. Although a large literature base can be found for adults with refractory epilepsy undergoing surgical treatment, less is known about how surgical management affects outcomes in children with epilepsy. The purpose of the review was fourfold: (1) to evaluate the available literature regarding presurgical assessment and postsurgical outcomes in children with medically refractory epilepsy, (2) to identify gaps in our knowledge of surgical treatment and its outcomes in children with epilepsy, (3) to pose questions for further research, and (4) to advocate for a more unified presurgical evaluation protocol including earlier referral for surgical candidacy of pediatric patients with refractory epilepsy. Despite its effectiveness, epilepsy surgery remains an underutilized but evidence-based approach that could lead to positive short- and long-term outcomes for children with refractory epilepsy. Copyright © 2016 Elsevier Inc. All rights reserved.

Predicted versus observed 30-day perioperative outcomes using the ACS NSQIP surgical risk calculator in patients undergoing partial nephrectomy for renal cell carcinoma.

PubMed

Blair, Brian M; Lehman, Erik B; Jafri, Syed M; Kaag, Matthew G; Raman, Jay D

2018-06-04

The purpose of the study was to evaluate the accuracy of the American College of Surgeons NSQIP Surgical Risk Calculator for predicting risk-adjusted 30-day outcomes for patients undergoing partial nephrectomy (PN) for renal cell carcinoma (RCC). A single institution, multi-surgeon, prospectively maintained database was queried for patients undergoing PN for RCC from 1998 to 2015. 21 preoperative factors were analyzed for each patient with predicted risk for 30-day complications, mortality, and length of stay (LOS) calculated. Differences between the mean predicted risk and observed rate of surgical outcomes were determined using two-sided one-sample t test with significance at p < 0.05. Subgroup analyses of outcomes stratified by surgical approach were also performed. 470 patients undergoing PN for RCC were analyzed. Comparing NSQIP predicted to observed outcomes, clinically significant underestimations occurred with rates of overall complications (9.16 vs. 16.81%, p < 0.001), surgical site infections [SSI] (1.65 vs. 2.77%, p < 0.001), urinary tract infection [UTI] (1.41 vs. 3.40%, p < 0.001), and LOS (3.25 vs. 3.73 days, p < 0.001). On subgroup analysis, 209 open PN and 261 minimally invasive PN (MIPN) were performed. The NSQIP calculator consistently underestimated overall complications, SSI, UTI, and LOS (p < 0.001) among both surgical approaches, while overestimating MIPN severe complications (p < 0.001). Clinically important differences persisted when stratifying the MIPN group by laparoscopic (N = 111) and robotic (N = 150) approaches. The ACS NSQIP Surgical Risk Calculator had significant discrepancies among observed and predicted outcomes. Additional analyses confirmed these differences remained significant irrespective of surgical approach. These findings emphasize the need for urologic oncology-specific calculators to better predict surgical outcomes in this complex patient population.

Vedolizumab as a rescue therapy for patients with medically refractory Crohn's disease.

PubMed

Crowell, K T; Tinsley, A; Williams, E D; Coates, M D; Bobb, A; Koltun, W A; Messaris, E

2018-04-19

Vedolizumab, a monoclonal antibody resulting in gut-selective anti-inflammatory activity, was approved by the US Food and Drug Administration in 2014 for use in patients with Crohn's disease (CD). The aim of this study was to investigate the efficacy of vedolizumab as a rescue therapy when other medical therapies have failed. A retrospective review was performed on consecutive patients with CD receiving vedolizumab at the Penn State Hershey IBD Center between May 2014 and March 2016. These patients were unresponsive or intolerant to tumour necrosis factor (TNF) antagonist therapy, and previously would have been candidates for surgery. Outcomes included surgical intervention, clinical response and endoscopic improvement. A total of 48 patients with medically refractory CD receiving vedolizumab were included. The median length of follow-up was 69 weeks (range 15-113 weeks). A majority (81%) of patients previously failed at least two TNF antagonists, and 77% had prior surgery for CD. Surgical intervention was required in 21 (44%) patients and 13 (27%) patients required intra-abdominal operations. At the conclusion of the study, 23 (48%) patients reported continued improvement of symptoms, and 22 of 37 (59%) patients undergoing endoscopy showed improvement. Patients with the inflammatory CD phenotype were more likely to improve clinically and avoid surgery. Vedolizumab alone or in combination with immunomodulators or steroids may be used as a rescue therapy in patients with medically refractory CD and may decrease the rate of surgical intervention. Patients with the inflammatory CD phenotype had the best clinical response and decreased need for surgery, suggesting that vedolizumab is most effective in the inflammatory phenotype. Colorectal Disease © 2018 The Association of Coloproctology of Great Britain and Ireland.

Active surveillance is suitable for intermediate term follow-up of renal oncocytoma diagnosed by percutaneous core biopsy.

PubMed

Liu, Shuo; Lee, Stephen; Rashid, Prem; Bangash, Haider; Hamid, Akhlil; Lau, Jason; Cohen, Ronald

2016-10-01

To evaluate the intermediate outcome of conservative management in patients with biopsy-proven oncocytoma. Patients with oncocytoma diagnosed on percutaneous core biopsy between January 2000 to December 2014 were identified from the renal biopsy database of a large specialist urologic pathology laboratory. After review of patient clinical records, the study cohort comprised only of patients enrolled in active surveillance. Clinicopathological and follow-up details were reviewed for each case, in particular: type and interval of surveillance imaging, tumour growth, definitive intervention and reason for intervention. Where possible, correlation was made between the final surgical and the initial biopsy specimens. Fifty three patients diagnosed with oncocytoma on core biopsy were initially placed on active surveillance with median follow-up of 34 months (range 6-109). The median age at diagnosis was 65 years (range 20-85) and median tumour size was 30 mm (range 13-87). Mean average tumour growth was 1.4 mm per annum (median 0 mm/year) with the majority (36 of 53, 68%) exhibiting minimal growth (less than 2 mm per annum) or partial regression. Forty seven of the 53 patients remained on active surveillance with no significant progression. Six patients elected to undergo definitive intervention (five surgical excision, one ablation). Renal oncocytoma was confirmed in all five patients who underwent surgical excision of their lesions. The majority of oncocytomas in this study showed minimal growth rate or regression. Patients with biopsy proven oncocytoma can be conservatively managed with active surveillance. © 2016 The Authors BJU International © 2016 BJU International Published by John Wiley & Sons Ltd.

Pathological findings of thyroid nodules after percutaneous laser ablation : a series of 22 cases with cyto-histological correlation.

PubMed

Piana, Simonetta; Riganti, Fabrizio; Froio, Elisabetta; Andrioli, Massimiliano; Pacella, Claudio M; Valcavi, Roberto

2012-06-01

Ultrasound (US)-guided percutaneous laser ablation (LA) of benign thyroid nodules may be a potential alternative to surgery in patients with compressive symptoms, at high surgical risk, or in patients who refuse to undergo surgery. We evaluated the morphological effects of LA procedure on 22 patients and compared the cytological findings before and after LA with the histological features on surgical specimens. Twenty-two (4.9%; 19 women, three men, mean age 53.2 years) out of 452 patients treated with LA for benign thyroid nodules in our Hospital underwent surgery after LA procedure, either because nodule regrowth (treatment failure, n = 17) or indeterminate cytology (Thy3) after LA (n = 5). Morphological findings varied according to the time between LA and surgical intervention. Within 2 months, the area was occasionally cavitated and filled in with dark amorphous material. The inflammatory response was abundant and composed of neutrophils, lymphocytes, and macrophages. After 18 months or more since LA, the expected laser-induced histologic changes in thyroid morphology consisted of a well-defined area surrounded by a fibrous capsule and filled in by amorphous material. No significant pathologic features were found in the thyroid tissue adjacent to the treated area. Histological evaluation of thyroid tissues after LA shows that thermal damage is restricted to the ablated area, with no involvement of the nearby parenchyma. Our long-term histopathological findings indicate that LA treatment of benign thyroid nodules is safe, and patients undergoing LA may also be followed up by fine needle aspiration.

The effects of whole-vault cranioplasty versus strip craniectomy on long-term neuropsychological outcomes in sagittal craniosynostosis.

PubMed

Hashim, Peter W; Patel, Anup; Yang, Jenny F; Travieso, Roberto; Terner, Jordan; Losee, Joseph E; Pollack, Ian; Jane, John; Jane, John; Kanev, Paul; Mayes, Linda; Duncan, Charles; Bridgett, David J; Persing, John A

2014-09-01

The optimal type of surgical management for isolated sagittal synostosis remains a source of significant debate. There is a paucity of data regarding possible differences in long-term neuropsychological outcomes following treatment with whole-vault cranioplasty or endoscopic strip craniectomy. This study provides the first comparative analysis examining the effects of the two techniques related to long-term intellectual functioning. A total of 70 patients were enrolled in this multicenter study, 29 of whom had previously undergone endoscopic strip craniectomy and 41 of whom had previously undergone whole-vault cranioplasty. All patients completed a battery of neurodevelopmental tests (Beery-Buktenica Developmental Test of Visual-Motor Integration, Wechsler Abbreviated Scale of Intelligence, and Wechsler Fundamentals) to evaluate various domains of neuropsychological function. In a group comparison of those treated before 6 months of age, whole-vault patients obtained higher scores relative to endoscopic strip craniectomy patients on visuomotor integration, full-scale intelligence quotient, verbal intelligence quotient, word reading, and reading comprehension (p < 0.05 for all). When compared against strip craniectomy performed before 3 months of age, the whole-vault group still showed significantly higher scores in verbal intelligence quotient, reading comprehension, and word reading (p < 0.05 for all). The type of surgical intervention for isolated sagittal synostosis impacts long-term neuropsychological outcomes. Patients undergoing early whole-vault cranioplasty attained higher intelligence quotient and achievement scores relative to those undergoing strip craniectomy. Surgical management with whole-vault cranioplasty performed before 6 months of age provides the most favorable long-term intellectual outcomes in patients with isolated sagittal synostosis. Therapeutic, II.

Intraoperative interventions for preventing surgical site infection: an overview of Cochrane Reviews.

PubMed

Liu, Zhenmi; Dumville, Jo C; Norman, Gill; Westby, Maggie J; Blazeby, Jane; McFarlane, Emma; Welton, Nicky J; O'Connor, Louise; Cawthorne, Julie; George, Ryan P; Crosbie, Emma J; Rithalia, Amber D; Cheng, Hung-Yuan

2018-02-06

Surgical site infection (SSI) rates vary from 1% to 5% in the month following surgery. Due to the large number of surgical procedures conducted annually, the costs of these SSIs can be considerable in financial and social terms. Many interventions are used with the aim of reducing the risk of SSI in people undergoing surgery. These interventions can be broadly delivered at three stages: preoperatively, intraoperatively and postoperatively. The intraoperative interventions are largely focused on decontamination of skin using soap and antiseptics; the use of barriers to prevent movement of micro-organisms into incisions; and optimising the patient's own bodily functions to promote best recovery. Both decontamination and barrier methods can be aimed at people undergoing surgery and operating staff. Other interventions focused on SSI prevention may be aimed at the surgical environment and include methods of theatre cleansing and approaches to managing theatre traffic. To present an overview of Cochrane Reviews of the effectiveness and safety of interventions, delivered during the intraoperative period, aimed at preventing SSIs in all populations undergoing surgery in an operating theatre. Published Cochrane systematic reviews reporting the effectiveness of interventions delivered during the intraoperative period in terms of SSI prevention were eligible for inclusion in this overview. We also identified Cochrane protocols and title registrations for future inclusion into the overview. We searched the Cochrane Library on 01 July 2017. Two review authors independently screened search results and undertook data extraction and 'Risk of bias' and certainty assessment. We used the ROBIS (risk of bias in systematic reviews) tool to assess the quality of included reviews, and we used GRADE methods to assess the certainty of the evidence for each outcome. We summarised the characteristics of included reviews in the text and in additional tables. We included 32 Cochrane Reviews in this overview: we judged 30 reviews as being at low risk of bias and two at unclear risk of bias. Thirteen reviews had not been updated in the past three years. Two reviews had no relevant data to extract. We extracted data from 30 reviews with 349 included trials, totaling 73,053 participants. Interventions assessed included gloving, use of disposable face masks, patient oxygenation protocols, use of skin antiseptics for hand washing and patient skin preparation, vaginal preparation, microbial sealants, methods of surgical incision, antibiotic prophylaxis and methods of skin closure. Overall, the GRADE certainty of evidence for outcomes was low or very low. Of the 77 comparisons providing evidence for the outcome of SSI, seven provided high- or moderate-certainty evidence, 39 provided low-certainty evidence and 31 very low-certainty evidence. Of the nine comparisons that provided evidence for the outcome of mortality, five provided low-certainty evidence and four very low-certainty evidence.There is high- or moderate-certainty evidence for the following outcomes for these intraoperative interventions. (1) Prophylactic intravenous antibiotics administered before caesarean incision reduce SSI risk compared with administration after cord clamping (10 trials, 5041 participants; risk ratio (RR) 0.59, 95% confidence interval (CI) 0.44 to 0.81; high-certainty evidence - assessed by review authors). (2) Preoperative antibiotics reduce SSI risk compared with placebo after breast cancer surgery (6 trials, 1708 participants; RR 0.74, 95% CI 0.56 to 0.98; high-certainty evidence - assessed by overview authors). (3) Antibiotic prophylaxis probably reduce SSI risk in caesarean sections compared with no antibiotics (82 relevant trials, 14,407 participants; RR 0.40, 95% CI 0.35 to 0.46; moderate-certainty evidence; downgraded once for risk of bias - assessed by review authors). (4) Antibiotic prophylaxis probably reduces SSI risk for hernia repair compared with placebo or no treatment (17 trials, 7843 participants; RR 0.67, 95% CI 0.54 to 0.84; moderate-certainty evidence; downgraded once for risk of bias - assessed by overview authors); (5) There is currently no clear difference in the risk of SSI between iodine-impregnated adhesive drapes compared with no adhesive drapes (2 trials, 1113 participants; RR 1.03, 95% CI 0.66 to 1.60; moderate-certainty evidence; downgraded once for imprecision - assessed by review authors); (6) There is currently no clear difference in SSI risk between short-term compared with long-term duration antibiotics in colorectal surgery (7 trials; 1484 participants; RR 1.05 95% CI 0.78 to 1.40; moderate-certainty evidence; downgraded once for imprecision - assessed by overview authors). There was only one comparison showing negative effects associated with the intervention: adhesive drapes increase the risk of SSI compared with no drapes (5 trials; 3082 participants; RR 1.23, 95% CI 1.02 to 1.48; high-certainty evidence - rated by review authors). This overview provides the most up-to-date evidence on use of intraoperative treatments for the prevention of SSIs from all currently published Cochrane Reviews. There is evidence that some interventions are useful in reducing SSI risk for people undergoing surgery, such as antibiotic prophylaxis for caesarean section and hernia repair, and also the timing of prophylactic intravenous antibiotics administered before caesarean incision. Also, there is evidence that adhesive drapes increase SSI risk. Evidence for the many other treatment choices is largely of low or very low certainty and no quality-of-life or cost-effectiveness data were reported. Future trials should elucidate the relative effects of some treatments. These studies should focus on increasing participant numbers, using robust methodology and being of sufficient duration to adequately assess SSI. Assessment of other outcomes such as mortality might also be investigated as part of non-experimental prospective follow-up of people with SSI of different severity, so the risk of death for different subgroups can be better understood.

Interventions in randomised controlled trials in surgery: issues to consider during trial design.

PubMed

Blencowe, Natalie S; Brown, Julia M; Cook, Jonathan A; Metcalfe, Chris; Morton, Dion G; Nicholl, Jon; Sharples, Linda D; Treweek, Shaun; Blazeby, Jane M

2015-09-04

Until recently, insufficient attention has been paid to the fact that surgical interventions are complex. This complexity has several implications, including the way in which surgical interventions are described and delivered in trials. In order for surgeons to adopt trial findings, interventions need to be described in sufficient detail to enable accurate replication; however, it may be permissible to allow some aspects to be delivered according to local practice. Accumulating work in this area has identified the need for general guidance on the design of surgical interventions in trial protocols and reports. Key issues to consider when designing surgical interventions include the identification of each surgical intervention and their components, who will deliver the interventions, and where and how the interventions will be standardised and monitored during the trial. The trial design (pragmatic and explanatory), comparator and stage of innovation may also influence the extent of detail required. Thoughtful consideration of surgical interventions in this way may help with the interpretation of trial results and the adoption of successful interventions into clinical practice.

Validation of COLA score for predicting wound infection in patients undergoing surgery for rectal cancer.

PubMed

Saylam, Baris; Tez, Mesut; Comcali, Bulent; Vural, Veli; Duzgun, Arife Polat; Ozer, Mehmet Vasfi; Coskun, Faruk

2017-01-01

The purpose of our study was to estimate the incidence of SSI (Surgical site infection) and the effect of COLA (contamination, obesity, laparotomy and ASA grade) score on SSI in patients undergoing rectal surgical procedures for rectal cancer. A total of 92 patients who underwent operation for rectum cancer were enrolled in this study. Wound surveillance was performed in all patients by a staff surgeon identified infected wounds during the hospital stay, and collected information for up to 30 days after operation. The overall rate of incisional SSI and organ/space SSI was 22.8% and 7.6% respectively. Surgical site infection rates were 14.2%, 20.58%, 40.7%, 57.1% for COLA 1,2,3 and 4 scores respectively. The area under the receiver/ operator characteristic curve for the score was 0,660. COLA scoring systems predict, with reasonable accuracy, the risk of SSI in rectal cancer patients undergoing elective rectal surgery. COLA score Rectal surgery, Surgical site infection, Risk prediction, Wound infection.

Opportunities for system level improvement in antibiotic use across the surgical pathway.

PubMed

Charani, E; Ahmad, R; Tarrant, C; Birgand, G; Leather, A; Mendelson, M; Moonesinghe, S R; Sevdalis, N; Singh, S; Holmes, A

2017-07-01

Optimizing antibiotic prescribing across the surgical pathway (before, during, and after surgery) is a key aspect of tackling important drivers of antimicrobial resistance and simultaneously decreasing the burden of infection at the global level. In the UK alone, 10 million patients undergo surgery every year, which is equivalent to 60% of the annual hospital admissions having a surgical intervention. The overwhelming majority of surgical procedures require effectively limited delivery of antibiotic prophylaxis to prevent infections. Evidence from around the world indicates that antibiotics for surgical prophylaxis are administered ineffectively, or are extended for an inappropriate duration of time postoperatively. Ineffective antibiotic prophylaxis can contribute to the development of surgical site infections (SSIs), which represent a significant global burden of disease. The World Health Organization estimates SSI rates of up to 50% in postoperative surgical patients (depending on the type of surgery), with a particular problem in low- and middle-income countries, where SSIs are the most frequently reported healthcare-associated infections. Across European hospitals, SSIs alone comprise 19.6% of all healthcare-acquired infections. Much of the scientific research in infection management in surgery is related to infection prevention and control in the operating room, surgical prophylaxis, and the management of SSIs, with many studies focusing on infection within the 30-day postoperative period. However it is important to note that SSIs represent only one of the many types of infection that can occur postoperatively. This article provides an overview of the surgical pathway and considers infection management and antibiotic prescribing at each step of the pathway. The aim was to identify the implications for research and opportunities for system improvement. Copyright © 2017 The Author(s). Published by Elsevier Ltd.. All rights reserved.

Actigraphy for Measurement of Sleep and Sleep-Wake Rhythms in Relation to Surgery

PubMed Central

Madsen, Michael T.; Rosenberg, Jacob; Gögenur, Ismail

2013-01-01

Study Objectives: Patients undergoing surgery have severe sleep and sleep-wake rhythm disturbances resulting in increased morbidity. Actigraphy is a tool that can be used to quantify these disturbances. The aim of this manuscript was to present the literature where actigraphy has been used to measure sleep and sleep-wake rhythms in relation to surgery. Methods: A systematic review was performed in 3 databases (Medline, Embase, and Psycinfo), including all literature until July 2012. Results: Thirty-two studies were included in the review. Actigraphy could demonstrate that total sleep time and sleep efficiency was reduced after surgery and number of awakenings was increased in patients undergoing major surgery. Disturbances were less severe in patients undergoing minor surgery. Actigraphy could be used to differentiate between delirious and non-delirious patients after major surgery. Actigraphy measurements could determine a differential effect of surgery based on the patient's age. The effect of pharmacological interventions (chronobiotics and hypnotics) in surgical patients could also be demonstrated by actigraphy. Conclusion: Actigraphy can be used to measure sleep and sleep-wake rhythms in patients undergoing surgery. Citation: Madsen MT; Rosenberg J; Gögenur I. Actigraphy for measurement of sleep and sleep-wake rhythms in relation to surgery. J Clin Sleep Med 2013;9(4):387-394. PMID:23585756

A dietary intervention to elicit rapid and complex dietary changes for studies investigating the effects of diet on tissues collected during invasive surgical procedures.

PubMed

Schenk, Jeannette M; Neuhouser, Marian L; Lin, Daniel W; Kristal, Alan R

2009-03-01

Nutrition intervention trials in patients undergoing surgical treatment for cancer offer a unique opportunity to study the mechanisms and pathways that underlie diet and cancer associations in target tissues. However, due to the short time period between diagnosis and treatment, traditional dietary intervention methods are not feasible. This report describes a novel dietary intervention program designed to elicit rapid and complex dietary change during a condensed study period. The intervention, based on Consumer Information Processing, used standardized menus and exchange lists to guide food choices, and was delivered using a single, in-person session followed by telephone-based counseling. This intervention program was used in a small pilot study evaluating the short-term effects of dietary change in men with newly diagnosed prostate cancer. Eight men were randomly assigned to either a low-fat/low-glycemic load or standard American diet during the 4 weeks preceding prostate surgery. Participants completed 24-hour dietary recalls each week, and were weighed at baseline and at surgery. Compared to men in the standard American arm (n=4), men in the low-fat/low-glycemic arm (n=4) reported consuming less total fat (51.0+/-36.0 vs 93.5+/-8.4 g/day, P=0.06), and had a lower glycemic load (134.8+/-6.0 vs 266.3+/-36.8 units/day, P<0.001). Men in the low-fat/low-glycemic arm lost a mean of 5.3+/-1.7 kg and men in the standard American arm gained 0.8+/-4.5 kg (P=0.04). Results of this small pilot study suggest that a relatively simple and minimally burdensome dietary intervention can elicit rapid and complex dietary changes that are maintained over a 4-week study period. Further studies in larger and more diverse populations are needed to fully understand the potential of this novel intervention approach.

Mediators of a brief hypnosis intervention to control side effects in breast surgery patients: Response expectancies and emotional distress

PubMed Central

Montgomery, Guy H.; Hallquist, Michael N.; Schnur, Julie B.; David, Daniel; Silverstein, Jeffrey H.; Bovbjerg, Dana H.

2010-01-01

Hypnosis is widely recognized as an empirically supported intervention to improve postsurgical outcomes. However, to date, no research has examined mediators of hypnotic benefit among surgery patients. The present study was designed to test the hypotheses that response expectancies and emotional distress would mediate the effects of an empirically validated presurgical hypnosis intervention on postsurgical side effects (i.e., pain, nausea, and fatigue). In a sample of 200 women undergoing breast conserving surgery (mean age = 48.50 years), structural equation modeling revealed the following: 1) hypnotic effects on postsurgical pain were partially mediated by pain expectancy (p< .0001), but not by distress (p=.12); 2) hypnotic effects on postsurgical nausea were partially mediated by presurgical distress (p=.02), but not by nausea expectancy (p=.10); 3) hypnotic effects on postsurgical fatigue were partially mediated by both fatigue expectancy (p=.0001) and presurgical distress (p=.02). These results improve understanding of the underlying mechanisms responsible for hypnotic phenomena in the surgical setting, and suggest that future hypnotic interventions target patient expectancies and distress to improve postsurgical recovery. PMID:20099953

Smoking Habits of Patients Undergoing Treatment for Intermittent Claudication in the Vascular Quality Initiative.

PubMed

Gabel, Joshua; Jabo, Brice; Patel, Sheela; Kiang, Sharon; Bianchi, Christian; Chiriano, Jason; Teruya, Theodore; Abou-Zamzam, Ahmed M

2017-10-01

Society for Vascular Surgery practice guidelines for the medical treatment of intermittent claudication give a GRADE 1A recommendation for smoking cessation. Active smoking is therefore expected to be low in patients suffering from intermittent claudication selected for vascular surgical intervention. The aim of this study is to evaluate the prevalence of smoking in patients undergoing intervention for intermittent claudication at the national level and to determine the relationship between smoking status and intervention. The Vascular Quality Initiative (VQI) registries for infra-inguinal bypass, supra-inguinal bypass, and peripheral vascular intervention (PVI) were queried to identify patients who underwent invasive treatment for intermittent claudication. Patient factors, procedure type (bypass versus PVI), and level of disease (supra-inguinal versus infra-inguinal) were evaluated for associations with smoking status (active smoking or nonsmoking) by univariate and covariate analysis. Between 2010 and 2015, 101,055 procedures were entered in the 3 registries, with 40,269 (40%) performed for intermittent claudication. Complete data for analysis were present in 37,632 cases. At the time of intervention, 44% of patients were active smokers, with wide variation by regional quality group (16-53%). In covariate analysis, active smoking at treatment was associated with age <70 years (prevalence ratio [PR] 2.42), male gender (PR 1.03), chronic obstructive pulmonary disease (PR 1.35), absence of prior cardiovascular procedures (PR 1.15), poor medication usage (PR 1.10), preoperative ankle-brachial index (ABI) <0.9 (PR 1.19), and supra-inguinal disease (PR 1.14). Invasiveness of treatment (PVI versus bypass procedures) was not significantly associated with smoking status. During follow-up, 36% of patients had quit smoking. Predictors of smoking cessation included age ≥70 years (RR 1.45), ABI ≥0.9 (RR 1.12), and bypass procedures (RR 1.22). At the time of treatment, 44% of patients undergoing intervention for intermittent claudication in the VQI were active smokers and there was a wide regional variation. Prevalence of active smoking was greater in the presence of younger age, fewer comorbidities, lower ABI, and supra-inguinal disease. Type of procedure performed, and in turn level of invasiveness required, did not appear to be influenced by smoking status. Elderly patients and those undergoing open procedures were more likely to quit smoking during follow up. These findings suggest opportunities for greater smoking cessation efforts before invasive therapies for intermittent claudication. Copyright © 2017 Elsevier Inc. All rights reserved.

Real time cancer prediction based on objective tissue compliance measurement in endoscopic surgery.

PubMed

Fakhry, Morkos; Bello, Fernando; Hanna, George B

2014-02-01

To investigate the feasibility of real time cancer tissue diagnosis intraoperatively based on in vivo tissue compliance measurements obtained by a recently developed laparoscopic smart device. Cancer tissue is stiffer than its normal counterpart. Modern forms of remote surgery such as laparoscopic and robotic surgical techniques diminish direct assessment of this important tissue property. In vivo human tissue compliance of the normal and cancer gastrointestinal tissue is unknown. A Clinical Real Time Tissue Compliance Mapping System (CRTCMS) with a predictive power comparable to the human hand and useable in routine surgical practice has been recently developed. The CRTCMS is employed in the operating theater to collect data from 50 patients undergoing intra-abdominal surgical interventions [40 men, 10 women, aged between 32 and 89 (mean = 66.4, range = 57)]. This includes 10 esophageal and 27 gastric cancer patients. A total of 1212 compliance measurements of normal and cancerous in vivo gastrointestinal tissues were taken. The data were used to calibrate the CRTCMS to predict cancerous tissue in a further 12 patients (3 cancer esophagus and 9 cancer stomach) involving 175 measurements. The system demonstrated a high prediction power to diagnose cancer tissue in real time during routine surgical procedures (sensitivity = 98.7%, specificity = 99%). An in vivo human tissue compliance data bank of the gastrointestinal tract was produced. Real time cancer diagnosis based on in vivo tissue compliance measurements is feasible. The reported data open new avenues in cancer diagnostics, surgical robotics, and development of more realistic surgical simulators.

Outcomes of nonemergent percutaneous coronary intervention with and without on-site surgical backup: a meta-analysis.

PubMed

Singh, Param Puneet; Singh, Mukesh; Bedi, Updesh Singh; Adigopula, Sasikanth; Singh, Sarabjeet; Kodumuri, Vamsi; Molnar, Janos; Ahmed, Aziz; Arora, Rohit; Khosla, Sandeep

2011-01-01

Despite major advances in percutaneous coronary intervention (PCI) techniques, the current guidelines recommend against elective PCI at hospitals without on-site cardiac surgery backup. Nonetheless, an increasing number of hospitals without on-site cardiac surgery in the United States have developed programs for elective PCI. Studies evaluating outcome in this setting have yielded mixed results, leaving the question unanswered. Hence, a meta-analysis comparing outcomes of nonemergent PCI in hospitals with and without on-site surgical backup was performed. A systematic review of literature identified four studies involving 6817 patients. Three clinical end points were extracted from each study and included in-hospital death, myocardial infarction, and the need for emergency coronary artery bypass grafting. The studies were homogenous for each outcome studied. Therefore, the combined relative risks (RRs) across all the studies and the 95% confidence intervals (CIs) were computed using the Mantel-Haenszel fixed-effect model. A two-sided alpha error less than 0.05 was considered to be statistically significant. Compared with facilities with on-site surgical backup, the risk of in-hospital death (RR, 2.7; CI, 0.6-12.9; P = 0.18), nonfatal myocardial infarction (RR, 1.3; CI, 0.7- 2.2; P = 0.29), and need of emergent coronary artery bypass grafting (RR, 0.46; CI, 0.06- 3.1; P = 0.43) was similar in those lacking on-site surgical backup. The present meta-analysis suggests that there is no difference in the outcome with regard to risk of nonfatal myocardial infarction, need for emergency coronary artery bypass grafting, and the risk of death in patients undergoing elective PCI in hospitals with and without on-site cardiac surgery backup.

[Circumscribed and diffuse peritonitis: severe complications in bariatric and metabolic surgery; specifics related to their diagnosis and therapy].

PubMed

Špička, P; Vaverka, P; Gryga, A; Malý, T

Cases of localized and diffuse peritonitis are severe surgical conditions. Despite expanding possibilities for the diagnosis and therapy, patients with peritonitis, its diffuse form in particular, still suffer from high morbidity and mortality. The management of this condition, both in the healthy and especially seriously ill population, is not satisfactory. Recently, we have witnessed an increase in bariatric and metabolic surgery in response to an ever rising number of extremely obese patients worldwide. Bariatric patients belong to a group of seriously ill patients with a significant risk of post-operative complications due to an infection. Although their treatment is identical to that of the normal population, a great emphasis is put on early recognition of complications, and the decision on any potential surgical revision should be actively approached, often necessitating the absence of frequently lengthy paraclinical assessments. We conducted a retrospective analysis of 346 obese bariatric patients undergoing surgical treatment for morbid obesity between August 2011 and August 2015. A total of 6 patients experienced severe complications including two cases of diffuse peritonitis, two cases of localized peritonitis and two cases of intraperitoneal bleeding. One patient died after her discharge from hospital due to toxic shock caused by stomach perforation. We describe two case reports in greater detail to highlight the importance of early detection of complications and a timely surgical intervention. In principle, bariatric patients are a severely ill population where standard diagnostic procedures for post-operative complications often fail. Clinical findings and the surgeons experience are commonly the only diagnostic signs that trigger a surgical revision. In contrast, surgical treatment of post-operative complications in obese patients with peritonitis is virtually identical to that in patients with normal or slightly increased BMI. It involves thorough toilette of the abdominal cavity, lavage and drainage. Due to high morbidity and large peritoneal surface, obese patients may deteriorate rapidly. Timely surgical intervention is thus the only proper therapeutic approach, even without any, often lengthy paraclinical assessments. peritonitis - bariatric surgery - complications in bariatric surgery.

Does Strict Adherence to the Ponseti Method Improve Isolated Clubfoot Treatment Outcomes? A Two-institution Review.

PubMed

Miller, Nancy H; Carry, Patrick M; Mark, Bryan J; Engelman, Glenn H; Georgopoulos, Gaia; Graham, Sue; Dobbs, Matthew B

2016-01-01

Despite being recognized as the gold standard in isolated clubfoot treatment, the Ponseti casting method has yielded variable results. Few studies have directly compared common predictors of treatment failure between institutions with high versus low failure rates. We asked: (1) is the provider's rigid adherence to the Ponseti method associated with a lower likelihood of unplanned clubfoot surgery, and (2) at the institution that did not adhere rigidly to Ponseti's principles, are any demographic or treatment-related factors associated with increased likelihood of unplanned clubfoot surgery? After institutional review board approval, a consecutive series of patients with a diagnosis of isolated clubfoot who underwent treatment between January 2003 and December 2007 were identified. At Institution 1, 91 of 133 patients met the eligibility criteria and were followed for a minimum of 2 years compared with 58 of 58 patients at Institution 2. At Institution 1, 16 providers managed care using a conservative casting approach based on the Ponseti method. However, treatment was adapted by the provider(s). At Institution 2, one orthopaedic surgeon managed care with strict adherence to the Ponseti method. Surgical indications at both institutions included the presence of a persistent equinovarus foot position while standing. A chart review was used to collect data related to proportion of patients undergoing unplanned additional treatment for deformity recurrences after Ponseti casting, demographics, and treatment patterns. The proportion of subjects who underwent unplanned major surgical intervention was greater (odds ratio [OR], 51.1; 95% CI, 6.8-384.0; p < 0.001) at Institution 1 (60 of 131, 47%) compared with Institution 2 (two of 91, 2%). There was no difference (p = 0.200) in the proportion of patients who underwent additional casting, repeat tendo Achilles lengthening, and/or anterior tibialis tendon transfer only (minor recurrence) at Institution 1 (nine of 131, 7%) compared with Institution 2 (11 of 91, 13%). At Institution 1, an increase in the number of revision casts (multiple vs no casts, hazard ratio [HR] = 3.9; 95% CI, 2.0-7.6; p < 0.001) and an increase in the number of cast-related complications (multiple vs no complications, HR = 2.8; 95% CI, 1.2-6.7; p = 0.019) were associated with increased risk of major surgery in the multivariate analysis. Rigid commitment to the Ponseti method in the conservative treatment of patients with isolated clubfoot was associated with a lower risk of subsequent unplanned surgical intervention. In addition, clubfoot treatment programs that use a care model that prioritizes continuity in care and dedication to the Ponseti method may decrease the proportion of patients who undergo unplanned surgical intervention. Level III, therapeutic study.

Prospective Analysis of Surgical Bone Margins After Partial Foot Amputation in Diabetic Patients Admitted With Moderate to Severe Foot Infections.

PubMed

Schmidt, Brian M; McHugh, Jonathan B; Patel, Rajiv M; Wrobel, James S

2018-04-01

Osteomyelitis is common in diabetic foot infections and medical management can lead to poor outcomes. Surgical management involves sending histopathologic and microbiologic specimens which guides future intervention. We examined the effect of obtainment of surgical margins in patients undergoing forefoot amputations to identify patient characteristics associated with outcomes. Secondary aims included evaluating interobserver reliability of histopathologic data at both the distal-to and proximal-to surgical bone margin. Data were prospectively collected on 72 individuals and was pooled for analysis. Standardized method to retrieve intraoperative bone margins was established. A univariate analysis was performed. Negative outcomes, including major lower extremity amputation, wound dehiscence, reulceration, reamputation, or death were recorded. Viable proximal margins were obtained in 63 out of 72 cases (87.5%). Strong interobserver reliability of histopathology was recorded. Univariate analysis demonstrated preoperative platelets, albumin, probe-to-bone testing, absolute toe pressures, smaller wound surface area were associated with obtaining viable margins. Residual osteomyelitis resulted in readmission 2.6 times more often and more postoperative complications. Certain patients were significantly different in the viable margin group versus dirty margin group. High interobserver reliability was demonstrated. Obtainment of viable margins resulted in reduced rates of readmission and negative outcomes. Prognostic, Level I: Prospective.

Retroperitoneal schwannomas: dilemmas in diagnostic approach and therapeutic management.

PubMed

Mastoraki, Aikaterini; Toska, Felicia; Tsiverdis, Ioannis; Kyriazi, Maria; Tsagkas, Athanasios; Danias, Nikolaos; Smyrniotis, Vasilios; Arkadopoulos, Nikolaos

2013-12-01

Schwannomas are rare tumors arising from Schwan cells of the peripheral nerve sheath. The majority of the cases are sporadic and familial clustering is often observed in association with von Rechlinghausen's disease. Cases of intrasacral (osseous) and spinal tumors have also been described. Histologically, schwannomas are distinguished by the presence of areas of high and low cellularity called Antoni A and B tissue, respectively. Clinical features are highly non-specific and depend on the location and size of the lesion, with abdominal pain and neurological deficit being the most common abnormalities. Radiological studies are fundamental in the diagnostic evaluation of RSs. Despite recent research on the therapeutic strategies against RS, surgical resection appears the only potentially curative approach. Unfortunately, a mere minority of patients is eligible to undergo surgical intervention. In addition, surgical removal of RS does not necessarily guarantee patient's long-term survival. Laparoscopic approach and enucleation of the tumor have been suggested as well. Alternative therapies, such as radio- and chemotherapy often proved insufficient. The aim of this review was to evaluate the results of surgical treatment for RS with special reference to the extent of its histological spread and to analyze the recent literature in order to provide an update on the current concepts of therapeutic management of this entity.

Frey procedure for surgical management of chronic pancreatitis in children.

PubMed

Rollins, Michael D; Meyers, Rebecka L

2004-06-01

The authors adopted the Frey procedure for the surgical management of chronic pancreatitis after one of their patients had recurrent disease in the head of the gland after a longitudinal pancreaticojejunostomy (LPJ or modified Puestow procedure). This is the first description of its use in children. A retrospective chart review was performed of all children undergoing a drainage or resection procedure for chronic pancreatitis from 1995 to 2002. Eleven children (6 boys, 5 girls, ages 8 to 18 years) underwent either the LPJ (3) or Frey (8) procedure. Etiologies included: idiopathic (5), familial (2), congenital anomaly of the major papilla (1), pancreatic head mass (1), short bowel syndrome (1), and pancreatic divisum (1). Before surgical therapy, patients had been symptomatic 2.3 years (range, 1 month to 6 years) and had been hospitalized for pancreatitis 4 times (range, 1 to 10). Four patients did not respond to endoscopic stenting, and 5 had a pancreatic pseudocyst. Patients were followed up in clinic an average of 2.5 years, with total time elapsed since surgery averaging 4.6 years. Eight of 11 patients experienced excellent or good results subsequent to surgical intervention. The Frey procedure is effective for children who have not responded to conservative management of chronic pancreatitis and may prevent recurrent disease in the head of the gland.

Impact of a theory-based video on initiation of long-acting reversible contraception after abortion.

PubMed

Davidson, AuTumn S; Whitaker, Amy K; Martins, Summer L; Hill, Brandon; Kuhn, Caroline; Hagbom-Ma, Catherine; Gilliam, Melissa

2015-03-01

Adoption of long-acting reversible contraception (LARC) (ie, the intrauterine device or the contraceptive implant) immediately after abortion is associated with high contraceptive satisfaction and reduced rates of repeat abortion. Theory-based counseling interventions have been demonstrated to improve a variety of health behaviors; data on theory-based counseling interventions for postabortion contraception are lacking. Informed by the transtheoretical model of behavioral change, a video intervention was developed to increase awareness of, and dispel misconceptions about, LARC methods. The intervention was evaluated in a randomized controlled trial among women aged 18-29 years undergoing surgical abortion at a clinic in Chicago, IL. Participants were randomized 1:1 to watch the intervention video or to watch a stress management video (control), both 7 minutes in duration. Contraceptive methods were supplied to all participants free of charge. Rates of LARC initiation immediately after abortion were compared. Rates of LARC initiation immediately after abortion were not significantly different between the 2 study arms; 59.6% in the intervention and 51.6% in the control arm chose a LARC method (P = .27). This study resulted in an unexpectedly high rate of LARC initiation immediately after abortion. High rates of LARC initiation could not be attributed to a theory-based counseling intervention. Copyright © 2015 Elsevier Inc. All rights reserved.

Young investigator challenge: Atypia of undetermined significance in thyroid FNA: Standardized terminology without standardized management--a closer look at repeat FNA and quality measures.

PubMed

Brandler, Tamar C; Aziz, Mohamed S; Coutsouvelis, Constantinos; Rosen, Lisa; Rafael, Oana C; Souza, Fabiola; Jelloul, Fatima-Zahra; Klein, Melissa A

2016-01-01

The Bethesda system (TBS) for the reporting of thyroid cytopathology established the category of atypia of undetermined significance (AUS) with a 7% target rate and a 5% to 15% implied malignancy risk. Recent literature has reported a broad range of AUS rates, subsequent malignancy rates, and discrepant results from repeat fine-needle aspiration (FNA) versus surgical follow-up. Therefore, this study examined AUS data from the Hofstra North Shore-LIJ School of Medicine to determine the best clinical follow-up. Thyroid aspirates interpreted as AUS in 2012-2014 at the Hofstra North Shore-LIJ School of Medicine were collected. Repeat FNA and surgical follow-up data were tabulated to establish AUS, secondary AUS (diagnosed upon repeat FNA follow-up of a primary FNA AUS diagnosis), atypia of undetermined significance/malignancy (AUS:M) ratios (according to the TBS categories), and malignancy rates for AUS. The AUS rate was 8.5% (976/11,481), and there was follow-up data for 545 cases. The AUS:M ratio was 2.0. Repeat FNA was performed for 281 cases; 57 proceeded to surgical intervention. Repeat FNA reclassified 71.17% of the cases. The malignancy rates for AUS cases proceeding directly to surgery and for those receiving a surgical intervention after a repeat AUS diagnosis were 33.33% and 43.75%, respectively. Repeat FNA resulted in definitive diagnostic reclassification for 67.61% of primary AUS cases and reduced the number of patients triaged to surgery, with 56.58% of the cases recategorized as benign. Cases undergoing surgery after repeat AUS had a higher malignancy rate than those going straight to surgery, and this emphasizes the value of repeat FNA in selecting surgical candidates. In addition, this study highlights the utility of AUS rate monitoring as a quality measure that has contributed to the ability of the Hofstra North Shore-LIJ School of Medicine to adhere closely to TBS recommendations. © 2016 American Cancer Society.

Clinical outcome of surgical treatment of the symptomatic accessory navicular.

PubMed

Kopp, Franz J; Marcus, Randall E

2004-01-01

When conservative treatment fails to provide relief for a symptomatic accessory navicular, surgical intervention may be necessary. Numerous studies have been published, reporting the results of the traditional Kidner procedure and alternative surgical techniques, all of which produce mostly satisfactory clinical outcomes. The purpose of this study was to report the clinical results, utilizing the American Orthopaedic Foot and Ankle Society (AOFAS) Midfoot Scale, of surgical management for symptomatic accessory navicular with simple excision and anatomic repair of the tibialis posterior tendon. The authors retrospectively reviewed the results of 13 consecutive patients (14 feet) who underwent surgical treatment for symptomatic accessory navicular. The patients ranged in age from 16 to 64 years (average, 34.1 years; mean, 28.2 years) at the time of surgery. All patients had a type II accessory navicular. The average follow-up of the patients involved in the study was 103.4 months (range, 45-194 months). The AOFAS Midfoot Scale was utilized to determine both preoperative and postoperative clinical status of the 14 feet included in the study. The average preoperative AOFAS score was 48.2 (range, 20-75; mean, 38.8). The average postoperative AOFAS score was 94.5 (range, 83-100; mean, 94.3). At last follow-up, 13 of 14 feet were without any pain, no patients had activity limitations, and only two of 14 feet required shoe insert modification. Postoperatively, no patients had a clinically notable change in their preoperative midfoot longitudinal arch alignment. All of the patients in the study were satisfied with the outcome of their surgery and would undergo the same operation again under similar circumstances. When conservative measures fail to relieve the symptoms of a painful accessory navicular, simple excision of the accessory navicular and anatomic repair of the posterior tibialis tendon is a successful intervention. Overall, the procedure provides reliable pain relief and patient satisfaction. In the current study, the clinical status of each patient improved significantly postoperatively, quantified utilizing the AOFAS Midfoot Scale.

Incidence and outcome of surgical procedures after coronary artery bypass grafting compared with those after percutaneous coronary intervention: a report from the Coronary Revascularization Demonstrating Outcome Study in Kyoto PCI/CABG Registry Cohort-2.

PubMed

Tokushige, Akihiro; Shiomi, Hiroki; Morimoto, Takeshi; Ono, Koh; Furukawa, Yutaka; Nakagawa, Yoshihisa; Kadota, Kazushige; Ando, Kenji; Shizuta, Satoshi; Tada, Tomohisa; Tazaki, Junichi; Kato, Yoshihiro; Hayano, Mamoru; Abe, Mitsuru; Hamasaki, Shuichi; Ohishi, Mitsuru; Nakashima, Hitoshi; Mitsudo, Kazuaki; Nobuyoshi, Masakiyo; Kita, Toru; Imoto, Yutaka; Sakata, Ryuzo; Okabayashi, Hitoshi; Hanyu, Michiya; Shimamoto, Mitsuomi; Nishiwaki, Noboru; Komiya, Tatsuhiko; Kimura, Takeshi

2014-08-01

Noncardiac surgery after percutaneous coronary intervention (PCI) has been reported to be carrying high risk for both ischemic and bleeding complications. However, there has been no report comparing the incidence and outcomes of surgical procedures after coronary artery bypass grafting (CABG) with those after PCI. Among 14 383 patients undergoing first coronary revascularization (PCI, n=12 207; CABG, n=2176) enrolled in the Coronary Revascularization Demonstrating Outcome Study in Kyoto (CREDO-Kyoto) PCI/CABG Registry Cohort-2, surgical procedures were performed more frequently after CABG (n=560) than after PCI (n=2398; cumulative 3-year incidence: 27% versus 22%; unadjusted P<0.0001), particularly <6 months of coronary revascularization. The risk for the primary ischemic outcome measure (death/myocardial infarction) at 30-day postsurgical procedures was not significantly different between the CABG and PCI groups (cumulative incidence: 3.1% versus 3.2%; unadjusted P=0.9; adjusted hazard ratio, 0.97; 95% confidence interval, 0.47-1.89; P=0.9). The risk for the primary bleeding outcome measure (moderate or severe bleeding by Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries classification) was lower in the CABG groups than in the PCI group (cumulative incidence: 1.3% versus 2.6%; unadjusted P=0.07; adjusted hazard ratio, 0.36; 95% confidence interval, 0.12-0.87; P=0.02). There were no interactions between the timing of surgery and the types of coronary revascularization (CABG/PCI) for both ischemic and bleeding outcomes. Surgical procedures were performed significantly more frequently after CABG than after PCI, particularly <6 months after coronary revascularization. Surgical procedures after CABG as compared with those after PCI were associated with similar risk for ischemic events and lower risk for bleeding events, regardless of the timing after coronary revascularization. © 2014 American Heart Association, Inc.

Does Receiving a Blood Transfusion Predict for Length of Stay in Children Undergoing Cranial Vault Remodeling for Craniosynostosis? Outcomes Using the Pediatric National Surgical Quality Improvement Program Dataset.

PubMed

Markiewicz, Michael R; Alden, Tord; Momin, Mohmed Vasim; Olsson, Alexis B; Jurado, Ray J; Abdullah, Fizan; Miloro, Michael

2017-08-01

Recent interventions have aimed at reducing the need for blood transfusions in the perioperative period in patients with craniosynostosis undergoing cranial vault remodeling. However, little is known regarding whether the receipt of a blood transfusion influences the length of hospital stay. The purpose of this study was to assess whether the receipt of a blood transfusion in patients undergoing cranial vault remodeling is associated with an increased length of stay. To address the research purposes, we designed a retrospective cohort study using the 2014 Pediatric National Surgical Quality Improvement Program (NSQIP Peds) dataset. The primary predictor variable was whether patients received a blood transfusion during cranial vault remodeling. The primary outcome variable was length of hospital stay after the operation. The association between the receipt of blood transfusions and length of stay was assessed using the Student t test. The association between other covariates and the outcome variable was assessed using linear regression, analysis of variance, and the Tukey test for post hoc pair-wise comparisons. The sample was composed of 756 patients who underwent cranial vault remodeling: 503 who received blood transfusions and 253 who did not. The primary predictor variable of blood transfusion was associated with an increased length of stay (4.1 days vs 3.0 days, P = .03). Other covariates associated with an increased length of stay included race, American Society of Anesthesiologists status, premature birth, presence of a congenital malformation, and number of sutures involved in craniosynostosis. The receipt of a blood transfusion in the perioperative period in patients with craniosynostosis undergoing cranial vault remodeling was associated with an increased length of stay. Copyright © 2017 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.

A meta-analysis of cortisol concentration, vocalization, and average daily gain associated with castration in beef cattle.

PubMed

Canozzi, Maria Eugênia Andrighetto; Mederos, America; Manteca, Xavier; Turner, Simon; McManus, Concepta; Zago, Daniele; Barcellos, Júlio Otávio Jardim

2017-10-01

A systematic review and meta-analysis (MA) were performed to summarize all scientific evidence for the effects of castration in male beef cattle on welfare indicators based on cortisol concentration, average daily gain (ADG), and vocalization. We searched five electronic databases, conference proceedings, and experts were contacted electronically. The main inclusion criteria involved completed studies using beef cattle up to one year of age undergoing surgical and non-surgical castration that presented cortisol concentration, ADG, or vocalization as an outcome. A random effect MA was conducted for each indicator separately with the mean of the control and treated groups. A total of 20 publications reporting 26 studies and 162 trials were included in the MA involving 1814 cattle. Between study heterogeneity was observed when analysing cortisol (I 2 =56.7%) and ADG (I 2 =79.6%). Surgical and non-surgical castration without drug administration compared to uncastrated animals showed no change (P≥0.05) in cortisol level. Multimodal therapy for pain did not decrease (P≥0.05) cortisol concentration after 30min when non-surgical castration was performed. Comparison between surgical castration, with and without anaesthesia, showed a tendency (P=0.077) to decrease cortisol levels after 120min of intervention. Non-surgical and surgical castration, performed with no pain mitigation, increased and tended to increase the ADG by 0.814g/d (P=0.001) and by 0.140g/d (P=0.091), respectively, when compared to a non-castrated group. Our MA study demonstrates an inconclusive result to draw recommendations on preferred castration practices to minimize pain in beef cattle. Copyright © 2017 Elsevier Ltd. All rights reserved.

Prophylactic antibiotics to prevent surgical site infection after breast cancer surgery.

PubMed

Cunningham, M; Bunn, F; Handscomb, K

2006-04-19

Surgery has been used as part of breast cancer treatment for centuries; however any surgical procedure has the potential risk of infection. Infection rates for surgical treatment of breast cancer are documented at between three and 15%, higher than average for a clean surgical procedure. Pre and peri-operative antibiotics have been found to be useful in lowering infection rates in other surgical groups, yet there is no current consensus on prophylactic antibiotic use in breast cancer surgery. To determine the effects of prophylactic antibiotics on the incidence of surgical site infection after breast cancer surgery. We searched the Cochrane Wounds and Breast Cancer Groups Specialised Registers, the Cochrane Central Register of Controlled Trials (CENTRAL) issue 1 2006. MEDLINE 2002-2005, EMBASE 1980-2005, NRR issue 1 2005, CINAHL 1982-2004 and SIGLE 1976-2004. Companies and experts in the field were contacted and reference lists were checked. No language restrictions were applied. Randomised controlled trials of pre and peri-operative antibiotics for patients undergoing surgery for breast cancer were included. Primary outcomes were, incidence of breast wound infection and adverse reactions to treatment. Two authors independently examined the title and abstracts of all studies identified by the search strategy, then assessed study quality and extracted data from those that met the inclusion criteria. Six studies met the inclusion criteria. All six evaluated pre-operative antibiotic compared with no antibiotic or placebo. Pooling of the results demonstrated that prophylactic antibiotics significantly reduce the incidence of surgical site infection for patients undergoing breast cancer surgery without reconstruction (pooled RR 0.66, 95% CI, 0.48 to 0.89). No studies presented separate data for patients who underwent reconstructive surgery at the time of removal of the breast tumour. Prophylactic antibiotics reduce the risk of surgical site infection in patients undergoing surgery for breast cancer. The potential morbidity caused by infection, such as delays in wound healing or adjuvant cancer treatments must be balanced against the cost of treatment and potential adverse effects such as drug reactions or increased bacterial resistance. Further studies of patients undergoing immediate breast reconstruction would be useful as studies have identified this group as being at higher risk of infection than those who do not undergo immediate breast reconstruction.

The effect of on-demand vs deep neuromuscular relaxation on rating of surgical and anaesthesiologic conditions in patients undergoing thoracolaparoscopic esophagectomy (DEPTH trial): study protocol for a randomized controlled trial.

PubMed

Veelo, Denise P; Gisbertz, Suzanne S; Hannivoort, Rebekka A; van Dieren, Susan; Geerts, Bart F; van Berge Henegouwen, Mark I; Hollmann, Markus W

2015-08-05

Deep muscle relaxation has been shown to facilitate operating conditions during laparoscopic surgery. Minimally invasive esophageal surgery is a high-risk procedure in which the use of deep neuromuscular block (NMB) may improve conditions in the thoracic phase as well. Neuromuscular antagonists can be given on demand or by continuous infusion (deep NMB). However, the positioning of the patient often hampers train-of-four (TOF) monitoring. A continuous infusion thus may result in a deep NMB at the end of surgery. The use of neostigmine not only is insufficient for reversing deep NMB but also may be contraindicated for this procedure because of its cholinergic effects. Sugammadex is an effective alternative but is rather expensive. This study aims to evaluate the use of deep versus on-demand NMB on operating, anaesthesiologic conditions, and costs in patients undergoing a two- or three-phase thoracolaparoscopic esophageal resection. We will conduct a single-center randomized controlled double-blinded intervention study. Sixty-six patients undergoing a thoracolaparoscopic esophageal resection will be included. Patients will receive either continuous infusion of rocuronium 0.6 mg/kg per hour (group 1) or continuous infusion of NaCl 0.9 % 0.06 ml/kg per hour (group 2). In both groups, on-demand boluses of rocuronium can be given (open-label design). The primary aim of this study is to compare the surgical rating scale (SRS) during the abdominal phase. Main secondary aims are to evaluate SRS during the thoracic phase, to evaluate anesthesiologic conditions, and to compare costs (in euros) associated with use of rocuronium, sugammadex, and duration of surgery. This study is the first to evaluate the benefits of deep neuromuscular relaxation on surgical and anaesthesiologic conditions during thoracolaparoscopic esophageal surgery. This surgical procedure is unique because it consists of both an abdominal phase and a thoracic phase taking place in different order depending on the subtype of surgery (a two- or three-stage transthoracic esophagectomy). In addition, possible benefits associated with deep NMB, such as decrease in operating time, will be weighed against costs. European Clinical Trials Database (EudraCT) number: 2014-002147-18 (obtained 19 May 2014) ClinicalTrials.gov: NCT02320734 (obtained 18 Dec. 2014).

[Evaluation of upper urinary tract function in patients undergoing autoplastic surgery for hydronphrosis of the intrarenal pelvis].

PubMed

Kurbanaliev, R M; Usupbaev, A Ch; Kolesnichenko, I V; Sadyrbekov, N Zh; Sultanov, B M

2018-05-01

To investigate the functional state of the upper urinary tract in patients undergoing autoplastic surgery for a hydronophrosis of the intrarenal pelvis. The study comprised 78 patients with the intrarenal pelvis and impaired urinary outflow due to stricture of the ureteropelvic junction and vascular conflict (interatrial and arteriovenous narrowing), who underwent pyeloplasty using autologous tunica vaginalis. All patients underwent an incision of ureteropelvic stricture and resection of the parietal layer of the tunica vaginalis which was used to repair the obstruction site and internal stenting of the upper urinary tract. The patients were examined at baseline and during follow-up ranging from 3 months to 3 years. At three months after surgery, there was a decrease in the size of the renal pelvis and calyces with an improvement of all parameters of uro- and hemodynamics. At three years after surgery, the structural and functional parameters of the upper urinary tract were completely restored. Obstructive uropathy, resulting from the intrarenal pelvis, leads to persistently impaired urinary outflow from the upper urinary tract. Surgical intervention is the only curative treatment able to restore the urinary flow. In men with the intrarenal pelvis, the autoplastic surgery of the ureteropelvic junction obstruction using a parietal layer of the tunica vaginalis is an effective surgical modality improving renal pelvis capacity and contributing to the recovery of urinary outflow from the upper urinary tract.

Airway management after maxillectomy with free flap reconstruction.

PubMed

Brickman, Daniel S; Reh, Douglas D; Schneider, Daniel S; Bush, Ben; Rosenthal, Eben L; Wax, Mark K

2013-08-01

Maxillectomy defects require complex 3-dimensional reconstructions often best suited to microvascular free tissue transfer. Postoperative airway management during this procedure has little discussion in the literature and is often dictated by surgical dogma. The purpose of this article was to review our experience in order to evaluate the effect of airway management on perioperative outcomes in patients undergoing maxillectomy with free flap reconstruction. A retrospective chart review was performed on patients receiving maxillectomy with microvascular reconstruction at 2 institutions between 1999 and 2011. Patient's airways were managed with or without elective tracheotomy at the surgical team's discretion and different perioperative outcomes were measured. The primary outcome was incidence of airway complication including pneumonia and need for further airway intervention. Secondary outcome was measured as factors leading to perioperative performance of the tracheotomy. Seventy-nine of 143 patients received elective tracheotomy perioperatively. The incidence of airway complication was equivalent between groups (10.1% vs 9.4%; p = .89). Patients with cardiopulmonary comorbidities were more likely to receive perioperative tracheotomy (74.1% vs 50.9%; p = .03) without a difference in airway complications. Other patient cofactors did not have an impact on perioperative tracheotomy or airway complication rate. Elective tracheotomy may safely be avoided in a subset of patients undergoing maxillectomy with microvascular reconstruction. Elective tracheotomy should be considered in patients with cardiopulmonary risk factors. Copyright © 2012 Wiley Periodicals, Inc.

Early and mid-term outcomes of endovascular and open surgical repair of non-dissected aortic arch aneurysm†.

PubMed

Hori, Daijiro; Okamura, Homare; Yamamoto, Takahiro; Nishi, Satoshi; Yuri, Koichi; Kimura, Naoyuki; Yamaguchi, Atsushi; Adachi, Hideo

2017-06-01

With the introduction of endovascular stent graft technology, a variety of surgical options are available for patients with aortic aneurysms. We sought to evaluate early-term and mid-term outcomes of patients undergoing endovascular and open surgical repair for non-dissected aortic arch aneurysm. Overall, 200 patients underwent treatment for isolated non-dissected aortic arch aneurysm between January 2008 and February 2016: 133 patients had open surgery and 67, endovascular repair. Early-term and mid-term outcomes were compared. Seventy percent ( n  = 47) needing endovascular repair underwent fenestrated stent graft and 30% ( n  = 20) underwent the debranched technique. Patients in the open surgery group were younger (71 vs 75 years, P  < 0.001) and had a lower prevalence of ischaemic heart disease (11% vs 35%, P  < 0.001). Intensive care unit stay (1 vs 3 days, P  < 0.001), hospital stay (11 vs 17 days, P  < 0.001) and surgical time (208 vs 390 min, P  < 0.001) were lower in the endovascular repair group than in the open surgery group. There were 3 in-hospital deaths each in the open surgery and endovascular groups (2% vs 5%, respectively, P  = 0.40). Mid-term survival ( P  < 0.001) and freedom from reintervention ( P  = 0.009) were better in the open surgery than in the endovascular repair group. No aneurysm-related deaths were observed. The propensity-matched comparison ( n  = 58) demonstrated that survival was better in the open surgery group ( P  = 0.011); no significant difference was seen in the reintervention rate ( P  = 0.28). Close follow-up for re-intervention may reduce the risk for aneurysm-related deaths and provide acceptable outcomes in patients undergoing endovascular repair. © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Defining quality for distal pancreatectomy: does the laparoscopic approach protect patients from poor quality outcomes?

PubMed

Baker, Marshall S; Sherman, Karen L; Stocker, Susan; Hayman, Amanda V; Bentrem, David J; Prinz, Richard A; Talamonti, Mark S

2013-02-01

Established systems for grading postoperative complications do not change the assigned grade when multiple interventions or readmissions are required to manage a complication. Studies using these systems may misrepresent outcomes for the surgical procedures being evaluated. We define a quality outcome for distal pancreatectomy (DP) and use this metric to compare laparoscopic distal pancreatectomy (LDP) to open distal pancreatectomy (ODP). Records for patients undergoing DP between January 2006 and December 2009 were reviewed. Clavien-Dindo grade IIIb, IV, and V complications were classified as severe adverse--poor quality--postoperative outcomes (SAPOs). II and IIIa complications requiring either significantly prolonged overall lengths of stay including readmissions within 90 days or more than one invasive intervention were also classified as SAPOs. By Clavien-Dindo system alone, 91 % of DP patients had either no complication or a low/moderate grade (I, II, IIIa) complication. Using our reclassification, however, 25 % had a SAPO. Patients undergoing LDP demonstrated a Clavien-Dindo complication profile identical to that for SDP but demonstrated significantly shorter overall lengths of stay, were less likely to require perioperative transfusion, and less likely to have a SAPO. Established systems undergrade the severity of some complications following DP. Using a procedure-specific metric for quality, we demonstrate that LDP affords a higher quality postoperative outcome than ODP.

Managing direct oral anticoagulants in patients undergoing dentoalveolar surgery.

PubMed

Patel, J P; Woolcombe, S A; Patel, R K; Obisesan, O; Roberts, L N; Bryant, C; Arya, R

2017-02-24

Our objective was to describe our experience of managing a cohort of adult patients prescribed direct oral anticoagulants (DOACs) undergoing dentoalveolar procedures between November 2012 and May 2016. Prior to conducting a procedure a formal assessment was made of each patient's anticoagulation treatment. A specific plan was then formulated, balancing the risk of bleeding with the risk of thrombosis. Patients received a telephone consultation one week following treatment to assess any post-operative bleeding. Eighty-two patients underwent 111 oral surgical procedures, the majority of which were dental extractions. In the case of 35 (32%) procedures, advice was given to omit the DOAC, either before or after treatment. There was no bleeding following the majority of procedures. Persistent bleeding followed 15 (13.5%) procedures, of which 7 (6.3%) procedures required specific intervention. The majority of patients prescribed DOACs can undergo dentoalveolar procedures safely. Important considerations when planning treatment are: (i) when the patient usually takes their dose of DOAC, (ii) the time the procedure is performed and, (iii) when the DOAC is taken post-procedure. In our experience, if these factors are considered carefully, omission of DOAC doses is unlikely to be required for most patients.

Decreased circulating T regulatory lymphocytes in obese patients undergoing bariatric surgery.

PubMed

Agabiti-Rosei, Claudia; Trapletti, Valentina; Piantoni, Silvia; Airò, Paolo; Tincani, Angela; De Ciuceis, Carolina; Rossini, Claudia; Mittempergher, Francesco; Titi, Amin; Portolani, Nazario; Caletti, Stefano; Coschignano, Maria Antonietta; Porteri, Enzo; Tiberio, Guido A M; Pileri, Paola; Solaini, Leonardo; Kumar, Rajesh; Ministrini, Silvia; Agabiti Rosei, Enrico; Rizzoni, Damiano

2018-01-01

It has been previously demonstrated that T lymphocytes may be involved in the development of hypertension and microvascular remodeling, and that circulating T effector lymphocytes may be increased in hypertension. In particular, Th1 and Th 17 lymphocytes may contribute to the progression of hypertension and microvascular damage while T-regulatory (Treg) lymphocytes seem to be protective in this regard. However, no data is available about patients with severe obesity, in which pronounced microvascular alterations were observed. We have investigated 32 severely obese patients undergoing bariatric surgery, as well as 24 normotensive lean subjects and 12 hypertensive lean subjects undergoing an elective surgical intervention. A peripheral blood sample was obtained before surgery for assessment of CD4+ T lymphocyte subpopulations. Lymphocyte phenotype was evaluated by flow cytometry in order to assess T-effector and Treg lymphocytes. A marked reduction of several Treg subpopulations was observed in obese patients compared with controls, together with an increased in CD4+ effector memory T-effector cells. In severely obese patients, Treg lymphocytes are clearly reduced and CD4+ effector memory cells are increased. It may be hypothesized that they might contribute to the development of marked microvascular alterations previously observed in these patients.

Robotic Versus Open Renal Transplantation in Obese Patients: Protocol for a Cost-Benefit Markov Model Analysis

PubMed Central

Puttarajappa, Chethan; Wijkstrom, Martin; Ganoza, Armando; Lopez, Roberto; Tevar, Amit

2018-01-01

Background Recent studies have reported a significant decrease in wound problems and hospital stay in obese patients undergoing renal transplantation by robotic-assisted minimally invasive techniques with no difference in graft function. Objective Due to the lack of cost-benefit studies on the use of robotic-assisted renal transplantation versus open surgical procedure, the primary aim of our study is to develop a Markov model to analyze the cost-benefit of robotic surgery versus open traditional surgery in obese patients in need of a renal transplant. Methods Electronic searches will be conducted to identify studies comparing open renal transplantation versus robotic-assisted renal transplantation. Costs associated with the two surgical techniques will incorporate the expenses of the resources used for the operations. A decision analysis model will be developed to simulate a randomized controlled trial comparing three interventional arms: (1) continuation of renal replacement therapy for patients who are considered non-suitable candidates for renal transplantation due to obesity, (2) transplant recipients undergoing open transplant surgery, and (3) transplant patients undergoing robotic-assisted renal transplantation. TreeAge Pro 2017 R1 TreeAge Software, Williamstown, MA, USA) will be used to create a Markov model and microsimulation will be used to compare costs and benefits for the two competing surgical interventions. Results The model will simulate a randomized controlled trial of adult obese patients affected by end-stage renal disease undergoing renal transplantation. The absorbing state of the model will be patients' death from any cause. By choosing death as the absorbing state, we will be able simulate the population of renal transplant recipients from the day of their randomization to transplant surgery or continuation on renal replacement therapy to their death and perform sensitivity analysis around patients' age at the time of randomization to determine if age is a critical variable for cost-benefit analysis or cost-effectiveness analysis comparing renal replacement therapy, robotic-assisted surgery or open renal transplant surgery. After running the model, one of the three competing strategies will result as the most cost-beneficial or cost-effective under common circumstances. To assess the robustness of the results of the model, a multivariable probabilistic sensitivity analysis will be performed by modifying the mean values and confidence intervals of key parameters with the main intent of assessing if the winning strategy is sensitive to rigorous and plausible variations of those values. Conclusions After running the model, one of the three competing strategies will result as the most cost-beneficial or cost-effective under common circumstances. To assess the robustness of the results of the model, a multivariable probabilistic sensitivity analysis will be performed by modifying the mean values and confidence intervals of key parameters with the main intent of assessing if the winning strategy is sensitive to rigorous and plausible variations of those values. PMID:29519780

The Effect of an Orthopaedic Surgical Procedure in the National Basketball Association.

PubMed

Minhas, Shobhit V; Kester, Benjamin S; Larkin, Kevin E; Hsu, Wellington K

2016-04-01

Professional basketball players have a high incidence of injuries requiring surgical intervention. However, no studies in the current literature have compared postoperative performance outcomes among common injuries to determine high- and low-risk procedures to these athletes' careers. To compare return-to-play (RTP) rates and performance-based outcomes after different orthopaedic procedures in National Basketball Association (NBA) players and to determine which surgeries are associated with the worst postoperative change in performance. Cohort study; Level of evidence, 3. Athletes in the NBA undergoing anterior cruciate ligament reconstruction, Achilles tendon repair, lumbar discectomy, microfracture, meniscus surgery, hand/wrist or foot fracture fixation, and shoulder stabilization were identified through team injury reports and archives on public record. The RTP rate, games played per season, and player efficiency rating (PER) were determined before and after surgery. Statistical analysis was used to compare the change between pre- and postsurgical performance among the different injuries. A total of 348 players were included. The RTP rates were highest in patients with hand/wrist fractures (98.1%; mean age, 27.0 years) and lowest for those with Achilles tears (70.8%; mean age, 28.4 years) (P = .005). Age ≥30 years (odds ratio [OR], 3.85; 95% CI, 1.24-11.91) and body mass index ≥27 kg/m(2) (OR, 3.46; 95% CI, 1.05-11.40) were predictors of not returning to play. Players undergoing Achilles tendon repair and arthroscopic knee surgery had a significantly greater decline in postoperative performance outcomes at the 1- and 3-year time points and had shorter career lengths compared with the other procedures. NBA players undergoing Achilles tendon rupture repair or arthroscopic knee surgery had significantly worse performance postoperatively compared with other orthopaedic procedures. © 2016 The Author(s).

Long-term surgical outcomes of retinal detachment in patients with Stickler syndrome

PubMed Central

Reddy, Devasis N; Yonekawa, Yoshihiro; Thomas, Benjamin J; Nudleman, Eric D; Williams, George A

2016-01-01

Purpose The aim of the study was to present the long-term anatomical and visual outcomes of retinal detachment repair in patients with Stickler syndrome. Patients and methods This study is a retrospective, interventional, consecutive case series of patients with Stickler syndrome undergoing retinal reattachment surgery from 2009 to 2014 at the Associated Retinal Consultants, William Beaumont Hospital. Results Sixteen eyes from 13 patients were identified. Patients underwent a mean of 3.1 surgical interventions (range: 1–13) with a mean postoperative follow-up of 94 months (range: 5–313 months). Twelve eyes (75%) developed proliferative vitreoretinopathy. Retinal reattachment was achieved in 100% of eyes, with ten eyes (63%) requiring silicone oil tamponade at final follow-up. Mean preoperative visual acuity (VA) was 20/914, which improved to 20/796 at final follow-up (P=0.81). There was a significant correlation between presenting and final VA (P<0.001), and patients with poorer presenting VA were more likely to require silicone oil tamponade at final follow-up (P=0.04). Conclusion Repair of retinal detachment in patients with Stickler syndrome often requires multiple surgeries, and visual outcomes are variable. Presenting VA is significantly predictive of long-term VA outcomes. PMID:27574392

Role of preoperative 3-dimensional computed tomography reconstruction in depressed skull fractures treated with craniectomy: a case report of forensic interest.

PubMed

Viel, Guido; Cecchetto, Giovanni; Manara, Renzo; Cecchetto, Attilio; Montisci, Massimo

2011-06-01

Patients affected by cranial trauma with depressed skull fractures and increased intracranial pressure generally undergo neurosurgical intervention. Because craniotomy and craniectomy remove skull fragments and generate new fracture lines, they complicate forensic examination and sometimes prevent a clear identification of skull fracture etiology. A 3-dimensional reconstruction based on preoperative computed tomography (CT) scans, giving a picture of the injuries before surgical intervention, can help the forensic examiner in identifying skull fracture origin and the means of production.We report the case of a 41-year-old-man presenting at the emergency department with a depressed skull fracture at the vertex and bilateral subdural hemorrhage. The patient underwent 2 neurosurgical interventions (craniotomy and craniectomy) but died after 40 days of hospitalization in an intensive care unit. At autopsy, the absence of various bone fragments did not allow us to establish if the skull had been stricken by a blunt object or had hit the ground with high kinetic energy. To analyze bone injuries before craniectomy, a 3-dimensional CT reconstruction based on preoperative scans was performed. A comparative analysis between autoptic and radiological data allowed us to differentiate surgical from traumatic injuries. Moreover, based on the shape and size of the depressed skull fracture (measured from the CT reformations), we inferred that the man had been stricken by a cylindric blunt object with a diameter of about 3 cm.

Newer regional analgesia interventions (fascial plane blocks) for breast surgeries: Review of literature.

PubMed

Garg, Rakesh; Bhan, Swati; Vig, Saurabh

2018-04-01

Surgical resection of the primary tumour with axillary dissection is one of the main modalities of breast cancer treatment. Regional blocks have been considered as one of the modalities for effective perioperative pain control. With the advent of ultrasound, newer interventions such as fascial plane blocks have been reported for perioperative analgesia in breast surgeries. Our aim is to review the literature for fascial plane blocks for analgesia in breast surgeries. The research question for initiating the review was 'What are the reported newer regional anaesthesia techniques (fascial plane blocks) for female patients undergoing breast surgery and their analgesic efficacy?.' The participants, intervention, comparisons, outcomes and study design were followed. Due to the paucity of similar studies and heterogeneity, the assessment of bias, systematic review or pooled analysis/meta-analysis was not feasible. Of the 989 manuscripts, the present review included 28 manuscripts inclusive of all types of published manuscripts. 15 manuscripts directly related to the administration of fascial plane blocks for breast surgery across all type of study designs and cases were reviewed for the utility of fascial plane blocks in breast surgeries. Interfascial blocks score over regional anaesthetic techniques such as paravertebral block as they have no risk of sympathetic blockade, intrathecal or epidural spread which may lead to haemodynamic instability and prolonged hospital stay. This review observed that no block effectively covers the whole of breast and axilla, thus a combination of blocks should be used depending on the site of incision and extent of surgical resection.

Comparison of Open and Closed Hand Fractures and the Effect of Urgent Operative Intervention.

PubMed

Minhas, Shobhit V; Catalano, Louis W

2018-06-13

To establish and compare the incidence of 30-day postoperative infection in surgically managed open and closed metacarpal and phalangeal fractures, and to determine whether open fractures treated urgently had a lower incidence of postoperative infection. We conducted a retrospective analysis of patient demographics, comorbidities, and 30-day infection rates of patients undergoing operative fixation of metacarpal, proximal, or middle phalanx fractures from 2008 to 2015 using the American College of Surgeons' National Surgical Quality Improvement Program database. A total of 3,506 patients were identified and patient variables and infection incidence were compared between open and closed injuries, as well as open injuries managed within 1 day of admission and those treated on an elective basis or treated more than 1 day after admission. Bivariate analysis was used to determine independent risk factors for postoperative infection. Although 34.2% of open hand fractures were taken urgently to the operating room, the diagnosis of open fractures along with nonurgent surgical treatment for open fractures was associated with a low incidence of postoperative infection. In addition, smoking was a risk factor for postoperative infection although anatomic location (phalanx vs metacarpal) was not. Patients undergoing surgery for metacarpal or proximal/middle phalangeal fractures are not at greater risk for infection based on the diagnosis of open fracture alone. In addition, patients with open fractures who are taken to the operating room more than 1 day from presentation did not have a higher incidence of infection. Smoking is associated with increased 30-day infection rates after surgery, and surgeons should identify these patients for preoperative risk stratification, counseling, and postoperative wound monitoring. Prognostic II. Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

Laparoscopic gastric bypass in patients on thyroid replacement therapy for subnormal thyroid function - prevalence and short-term outcome.

PubMed

Szomstein, Samuel; Avital, Shmuel; Brasesco, Oscar; Mehran, Amir; Cabral, Jose M; Rosenthal, Raul

2004-01-01

Hypothyroidism is associated with increased body weight. Weight gain may occur despite normal levels of serum thyroid stimulating hormone (TSH) and thyroxine (T4) achieved by replacement therapy. We evaluated the prevalence of patients on thyroid replacement for subnormal thyroid function who were operated on for morbid obesity and monitored their postoperative weight loss pattern. Data was identified from a prospectively accrued database of patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGBP) or laparoscopic adjustable gastric banding (LAGB) for morbid obesity from February 2000 to November 2001. All patients with subnormal thyroid function, diagnosed by past thyroid function tests and treated by an endocrinologist, who were on thyroid replacement therapy, were identified; 5 of these were matched for age, gender, preoperative body mass index (BMI) and surgical procedure (LRYGBP) to 5 non-hypothyroid patients. Weight loss at 3 and 9 months after surgery was compared between the 2 groups. 192 patients underwent LRYGBP (n=155) or LAGB (n=37). Of the 21 patients (10.9%) on thyroid replacement identified, 14 were primary, 4 were postablative, and 3 were post-surgical; 17 underwent LRYGBP. All patients had normal preoperative serum levels of TSH and T4. Comparison of the 2 matched groups of patients revealed no difference in weight loss at 3 and 9 months after surgery (P=1.0). The prevalence of euthyroid patients on thyroid replacement for subnormal thyroid function who undergo surgical intervention for morbid obesity is high. Short-term weight loss in these patients is comparable to normal thyroid patients. Longer follow-up may be necessary to demonstrate the weight loss pattern in this group.

Salvage C2 ganglionectomy after C2 nerve root decompression provides similar pain relief as a single surgical procedure for intractable occipital neuralgia.

PubMed

Pisapia, Jared M; Bhowmick, Deb A; Farber, Roger E; Zager, Eric L

2012-02-01

To determine the effectiveness of C2 nerve root decompression and C2 dorsal root ganglionectomy for intractable occipital neuralgia (ON) and C2 ganglionectomy after pain recurrence following initial decompression. A retrospective review was performed of the medical records of patients undergoing surgery for ON. Pain relief at the time of the most recent follow-up was rated as excellent (headache relieved), good (headache improved), or poor (headache unchanged or worse). Telephone contact supplemented chart review, and patients rated their preoperative and postoperative pain on a 10-point numeric scale. Patient satisfaction and disability were also examined. Of 43 patients, 29 were available for follow-up after C2 nerve root decompression (n = 11), C2 dorsal root ganglionectomy (n = 10), or decompression followed by ganglionectomy (n = 8). Overall, 19 of 29 patients (66%) experienced a good or excellent outcome at most recent follow-up. Among the 19 patients who completed the telephone questionnaire (mean follow-up 5.6 years), patients undergoing decompression, ganglionectomy, or decompression followed by ganglionectomy experienced similar outcomes, with mean pain reduction ratings of 5 ± 4.0, 4.5 ± 4.1, and 5.7 ± 3.5. Of 19 telephone responders, 13 (68%) rated overall operative results as very good or satisfactory. In the third largest series of surgical intervention for ON, most patients experienced favorable postoperative pain relief. For patients with pain recurrence after C2 decompression, salvage C2 ganglionectomy is a viable surgical option and should be offered with the potential for complete pain relief and improved quality of life (QOL). Copyright © 2012. Published by Elsevier Inc.

A primary tumor of mixed histological type is a novel poor prognostic factor for patients undergoing resection of liver metastasis from gastric cancer.

PubMed

Ikari, Naoki; Taniguchi, Kiyoaki; Serizawa, Akiko; Yamada, Takuji; Yamamoto, Masakazu; Furukawa, Toru

2017-05-01

Surgical resection can be an option for the treatment of metastatic liver tumors originating from gastric cancer; however, its prognostic impact is controversial. The aim of this study was to identify prognostic factors in patients with surgical resection of liver metastasis from gastric cancer. We retrospectively analyzed the clinicopathological features of 38 consecutive patients undergoing hepatectomy for metastatic tumors from gastric cancer in our institution between 1990 and 2014. The median overall survival of the patients was 28 months. The 5-year survival rate was 33.9%. Primary tumors of a mixed histological type, and residual tumors during the course of treatment were identified as significant independent poor prognostic factors. Histological evaluation of primary tumors may aid to identify patients suitable for undergoing surgical resection of liver metastasis from gastric cancer. © 2017 Japanese Society of Hepato-Biliary-Pancreatic Surgery.

Cognitive outcome of surgery.

PubMed

Gallagher, Anne; Jambaqué, Isabelle; Lassonde, Maryse

2013-01-01

Epilepsy surgery is now widely accepted as an effective therapeutic option for carefully selected children with medically refractory epilepsy. The surgical procedure may cause cognitive deficits or exacerbate existing impairments, but it may also improve cognitive abilities by the restoration of functions located in adjacent or contralateral areas that had been secondarily affected by the epilepsy or the underlying pathology. Compared to adults, better cognitive outcome has been reported in children, a finding probably due to the developing state of the brain, which possesses considerable structural and functional plasticity. More extensive and effective surgery such as hemispherectomy is more commonly used in the pediatric population, and this must also influence surgical outcome. However, studies related to cognitive outcome of epilepsy surgery in children are limited, and controversial results are often reported. In this chapter, we provide a current overview of the literature on cognitive outcomes in children who undergo different types of epilepsy surgery, including focal resections as well as corpus callosotomy and hemispherectomy. Early surgical intervention appears to be a rational option for the treatment of childhood epilepsy since many cognitive deficits are linked to the epileptic process and may disappear when seizures are controlled. Copyright © 2013 Elsevier B.V. All rights reserved.

Concurrent risk-reduction surgery in patients with increased lifetime risk for breast and ovarian cancer: an analysis of the National Surgical Quality Improvement Program (NSQIP) database.

PubMed

Elmi, Maryam; Azin, Arash; Elnahas, Ahmad; McCready, David R; Cil, Tulin D

2018-05-14

Patients with genetic susceptibility to breast and ovarian cancer are eligible for risk-reduction surgery. Surgical morbidity of risk-reduction mastectomy (RRM) with concurrent bilateral salpingo-oophorectomy (BSO) is unknown. Outcomes in these patients were compared to patients undergoing RRM without BSO using a large multi-institutional database. A retrospective cohort analysis was conducted using the American College of Surgeon's National Surgical Quality Improvement Program (NSQIP) 2007-2016 datasets, comparing postoperative morbidity between patients undergoing RRM with patients undergoing RRM with concurrent BSO. Patients with genetic susceptibility to breast/ovarian cancer undergoing risk-reduction surgery were identified. The primary outcome was 30-day postoperative major morbidity. Secondary outcomes included surgical site infections, reoperations, readmissions, length of stay, and venous thromboembolic events. A multivariate analysis was performed to determine predictors of postoperative morbidity and the adjusted effect of concurrent BSO on morbidity. Of the 5470 patients undergoing RRM, 149 (2.7%) underwent concurrent BSO. The overall rate of major morbidity and postoperative infections was 4.5% and 4.6%, respectively. There was no significant difference in the rate of postoperative major morbidity (4.5% vs 4.7%, p = 0.91) or any of the secondary outcomes between patients undergoing RRM without BSO vs. those undergoing RRM with concurrent BSO. Multivariable analysis showed Body Mass Index (OR 1.05; p < 0.001) and smoking (OR 1.78; p = 0.003) to be the only predictors associated with major morbidity. Neither immediate breast reconstruction (OR 1.02; p = 0.93) nor concurrent BSO (OR 0.94; p = 0.89) were associated with increased postoperative major morbidity. This study demonstrated that RRM with concurrent BSO was not associated with significant additional morbidity when compared to RRM without BSO. Therefore, this joint approach may be considered for select patients at risk for both breast and ovarian cancer.

Effectiveness of ketamine as an adjuvant to opioid-based therapy in decreasing pain associated with opioid tolerance in adults undergoing orthopedic surgery: a systematic review protocol.

PubMed

Bennett, Marsha; Bonanno, Laura; Kuhn, William

2016-10-01

The objective of this systematic review is to examine the best available evidence on the clinical effectiveness of ketamine as an adjuvant to opioid-based therapy versus opioid-based therapy alone in decreasing perioperative pain associated with opioid tolerance in adult patients, aged 18-70 years, undergoing orthopedic surgical procedures.The following question guides the systematic review: does the administration of ketamine as an adjuvant to opioid-based therapy, compared to opioid-based therapy alone, improve perioperative pain relief in opioid-tolerant adult patients undergoing orthopedic surgical procedures?

Primary Squamous Cell Carcinoma of the Thyroid Gland

PubMed Central

Ibrahim, Mohd-Irman-Shah; Jusoh, Yusri-Rahimi; Adam, Nurul-Nadhihah; Mohamad, Irfan

2018-01-01

Introduction: Primary squamous cell carcinoma (SCC) of the thyroid gland is one of the rarest types of all reported thyroid malignancies worldwide. It is very aggressive in nature and carries a poor prognosis. The surgical resection with adjuvant radiotherapy and chemotherapy is the most recommended treatment despite its poor reported outcome. Case Report: A 74-year-old woman presented with a rapidly progressive neck swelling, with hoarseness and compressive symptoms. Physical examination revealed a multilobulated firm thyroid mass with unilateral vocal cord palsy. Histopathological findings confirmed the diagnosis of SCC while radiological investigations and panendoscopy findings ruled out the possibility of other primary tumors. A surgical intervention was performed; however, the patient eventually succumbed to death prior to undergoing an oncological treatment. Conclusion: With no standard consensus to guide the management plan, SCC of the thyroid gland presents a great challenge for the managing team to come up with the best treatment option, due to its unfavorable rate of survival. PMID:29387667

Strategies for net cost reductions with the expanded role and expertise of anesthesiologists in the perioperative surgical home.

PubMed

Dexter, Franklin; Wachtel, Ruth E

2014-05-01

The Perioperative Surgical Home is a model adopted by the American Society of Anesthesiologists to increase quality and patient safety and to decrease costs. This Special Article is about the latter topic. Using narrative review, we show that there are two principal opportunities for net cost reduction. One opportunity is to reduce unnecessary interventions that do not have potential to benefit patients (e.g., preoperative laboratory studies in healthy patients undergoing low-risk surgery and use of substantial fresh gas flows with volatile anesthetics). The other opportunity is to optimize staff scheduling, case scheduling, and staff assignment. These two are the same as the principal ways that a positive return on investment can be achieved from use of an anesthesia information management system. Three other opportunities are much less likely to achieve as large (if any) net cost reduction among all patients but may at some hospitals. These are to reduce cancellations, operating room times, and/or hospital postoperative lengths of stay.

[Clinical experience on the use of total parenteral nutrition in patients subjected to radical cystectomy intervention for infiltrating neoplasms of the bladder].

PubMed

Del Boca, C; Furiosi, D; Bolis, C; Ferrari, C

1989-03-01

The Authors report their 7 year follow-up on the use of T.P.N. in 28 patients treated surgically for infiltrating cancer of the bladder. They consider the pathogenetic mechanisms that influence the organism's adaptation to surgical stress with particular reference to the multiple neuroendocrinal and biochemical interconnections. The procedures to define the nutritional/metabolic levels, of the patients undergoing operation are exposed. The T.P.N. is given according to the personal requirements of each patient and is a function of the "performance status", caloric need and to the presence of sepsis. Problems concerning the radical cistectomy such as: time of surgery, extention of exeresis, uroentheroanastomosis, metabolic variations, sepsis, etc., are evaluated. Considering the positive results obtained with this nutritional procedure, the Authors underline the importance of a systematic use of T.P.N. wich should be included, in their opinion, in a multidisciplinar treatment of advanced bladder neoplasms.

The mechanics of decompressive craniectomy: Bulging in idealized geometries

NASA Astrophysics Data System (ADS)

Weickenmeier, Johannes; Kuhl, Ellen; Goriely, Alain

2016-11-01

In extreme cases of traumatic brain injury or a stroke, the resulting uncontrollable swelling of the brain may lead to a harmful increase of the intracranial pressure. As a common measure for immediate release of pressure on the brain, part of the skull is surgically removed allowing for the brain to bulge outwards, a procedure known as a decompressive craniectomy. During this excessive brain swelling, the affected tissue typically undergoes large deformations resulting in a complex three-dimensional mechanical loading state with several important implications on optimal treatment strategies and outcome. Here, as a first step towards a better understanding of the mechanics of a decompressive craniectomy, we consider simple models for the bulging of elastic solids under geometric constraints representative of the surgical intervention. In small deformations and simple geometries, the exact solution of this problem is derived from the theory of contact mechanics. The analysis of these solutions reveals a number of interesting generic features relevant for the mechanics of craniectomy.

A novel index for quantifying the risk of early complications for patients undergoing cervical spine surgeries.

PubMed

Passias, Peter G; Diebo, Bassel G; Marascalchi, Bryan J; Jalai, Cyrus M; Horn, Samantha R; Zhou, Peter L; Paltoo, Karen; Bono, Olivia J; Worley, Nancy; Poorman, Gregory W; Challier, Vincent; Dixit, Anant; Paulino, Carl; Lafage, Virginie

2017-11-01

OBJECTIVE It is becoming increasingly necessary for surgeons to provide evidence supporting cost-effectiveness of surgical treatment for cervical spine pathology. Anticipating surgical risk is critical in accurately evaluating the risk/benefit balance of such treatment. Determining the risk and cost-effectiveness of surgery, complications, revision procedures, and mortality rates are the most significant limitations. The purpose of this study was to determine independent risk factors for medical complications (MCs), surgical complications (SCs), revisions, and mortality rates following surgery for patients with cervical spine pathology. The most relevant risk factors were used to structure an index that will help quantify risk and anticipate failure for such procedures. METHODS The authors of this study performed a retrospective review of the National Inpatient Sample (NIS) database for patients treated surgically for cervical spine pathology between 2001 and 2010. Multivariate models were performed to calculate the odds ratio (OR) of the independent risk factors that led to MCs and repeated for SCs, revisions, and mortality. The models controlled for age (< and > 65 years old), sex, race, revision status (except for revision analysis), surgical approach, number of levels fused/re-fused (2-3, 4-8, ≥ 9), and osteotomy utilization. ORs were weighted based on their predictive category: 2 times for revision surgery predictors and 4 times for mortality predictors. Fifty points were distributed among the predictors based on their cumulative OR to establish a risk index. RESULTS Discharges for 362,989 patients with cervical spine pathology were identified. The mean age was 52.65 years, and 49.47% of patients were women. Independent risk factors included medical comorbidities, surgical parameters, and demographic factors. Medical comorbidities included the following: pulmonary circulation disorder, coagulopathy, metastatic cancer, renal failure, congestive heart failure, alcohol abuse, neurological disorder, nonmetastatic cancer, liver disease, rheumatoid arthritis/collagen vascular diseases, and chronic blood loss/anemia. Surgical parameters included posterior approach to fusion/re-fusion, ≥ 9 levels fused/re-fused, corpectomy, 4-8 levels fused/re-fused, and osteotomy; demographic variables included age ≥ 65 years. These factors increased the risk of at least 1 of MC, SC, revision, or mortality (risk of death). A total of 50 points were distributed among the factors based on the cumulative risk ratio of every factor in proportion to the total risk ratios. CONCLUSIONS This study proposed an index to quantify the potential risk of morbidity and mortality prior to surgical intervention for patients with cervical spine pathology. This index may be useful for surgeons in patient counseling efforts as well as for health insurance companies and future socioeconomics studies in assessing surgical risks and benefits for patients undergoing surgical treatment of the cervical spine.

Primary and secondary arterial fistulas during chronic Q fever.

PubMed

Karhof, Steffi; van Roeden, Sonja E; Oosterheert, Jan J; Bleeker-Rovers, Chantal P; Renders, Nicole H M; de Borst, Gert J; Kampschreur, Linda M; Hoepelman, Andy I M; Koning, Olivier H J; Wever, Peter C

2018-04-20

After primary infection with Coxiella burnetii, patients may develop acute Q fever, which is a relatively mild disease. A small proportion of patients (1%-5%) develop chronic Q fever, which is accompanied by high mortality and can be manifested as infected arterial or aortic aneurysms or infected vascular prostheses. The disease can be complicated by arterial fistulas, which are often fatal if they are left untreated. We aimed to assess the cumulative incidence of arterial fistulas and mortality in patients with proven chronic Q fever. In a retrospective, observational study, the cumulative incidence of arterial fistulas (aortoenteric, aortobronchial, aortovenous, or arteriocutaneous) in patients with proven chronic Q fever (according to the Dutch Chronic Q Fever Consensus Group criteria) was assessed. Proven chronic Q fever with a vascular focus of infection was defined as a confirmed mycotic aneurysm or infected prosthesis on imaging studies or positive result of serum polymerase chain reaction for C. burnetii in the presence of an arterial aneurysm or vascular prosthesis. Of 253 patients with proven chronic Q fever, 169 patients (67%) were diagnosed with a vascular focus of infection (42 of whom had a combined vascular focus and endocarditis). In total, 26 arterial fistulas were diagnosed in 25 patients (15% of patients with a vascular focus): aortoenteric (15), aortobronchial (2), aortocaval (4), and arteriocutaneous (5) fistulas (1 patient presented with both an aortocaval and an arteriocutaneous fistula). Chronic Q fever-related mortality was 60% for patients with and 21% for patients without arterial fistula (P < .0001). Primary fistulas accounted for 42% and secondary fistulas for 58%. Of patients who underwent surgical intervention for chronic Q fever-related fistula (n = 17), nine died of chronic Q fever-related causes (53%). Of patients who did not undergo any surgical intervention (n = 8), six died of chronic Q fever-related causes (75%). The proportion of patients with proven chronic Q fever developing primary or secondary arterial fistulas is high; 15% of patients with a vascular focus of infection develop an arterial fistula. This observation suggests that C. burnetii, the causative agent of Q fever, plays a role in the development of fistulas in these patients. Chronic Q fever-related mortality in patients with arterial fistula is very high, in both patients who undergo surgical intervention and patients who do not. Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Importance of Perioperative Glycemic Control in General Surgery

PubMed Central

Kwon, Steve; Thompson, Rachel; Dellinger, Patchen; Yanez, David; Farrohki, Ellen; Flum, David

2014-01-01

Objective To determine the relationship of perioperative hyperglycemia and insulin administration on outcomes in elective colon/rectal and bariatric operations. Background There is limited evidence to characterize the impact of perioperative hyperglycemia and insulin on adverse outcomes in patients, with and without diabetes, undergoing general surgical procedures. Methods The Surgical Care and Outcomes Assessment Program is a Washington State quality improvement benchmarking-based initiative. We evaluated the relationship of perioperative hyperglycemia (>180 mg/dL) and insulin administration on mortality, reoperative interventions, and infections for patients undergoing elective colorectal and bariatric surgery at 47 participating hospitals between fourth quarter of 2005 and fourth quarter of 2010. Results Of the 11,633 patients (55.4 ± 15.3 years; 65.7% women) with a serum glucose determination on the day of surgery, postoperative day 1, or postoperative day 2, 29.1% of patients were hyperglycemic. After controlling for clinical factors, those with hyperglycemia had a significantly increased risk of infection [odds ratio (OR) 2.0; 95% confidence interval (CI), 1.63–2.44], reoperative interventions (OR, 1.8; 95% CI, 1.41–2.3), and death (OR, 2.71; 95% CI, 1.72–4.28). Increased risk of poor outcomes was observed both for patients with and without diabetes. Those with hyperglycemia on the day of surgery who received insulin had no significant increase in infections (OR, 1.01; 95% CI, 0.72–1.42), reoperative interventions (OR, 1.29; 95% CI, 0.89–1.89), or deaths (OR, 1.21; 95% CI, 0.61–2.42). A dose-effect relationship was found between the effectiveness of insulin-related glucose control (worst 180–250 mg/dL, best <130 mg/dL) and adverse outcomes. Conclusions Perioperative hyperglycemia was associated with adverse outcomes in general surgery patients with and without diabetes. However, patients with hyperglycemia who received insulin were at no greater risk than those with normal blood glucoses. Perioperative glucose evaluation and insulin administration in patients with hyperglycemia are important quality targets. PMID:23235393

Clinical outcomes and hospital length of stay in 2,756 elderly patients with hip fractures: a comparison of surgical and non-surgical management.

PubMed

Tan, Stephen Thong Soon; Tan, Wei Ping Marcus; Jaipaul, Josephine; Chan, Siew Pang; Sathappan, Sathappan S

2017-05-01

The purpose of this study was to compare the clinical outcomes of elderly hip fracture patients who received surgical treatment with those who received non-surgical treatment. This retrospective study involved 2,756 elderly patients with hip fractures who were admitted over a six-year period. The patients' biodata, complications, ambulatory status at discharge and length of hospital stay were obtained from the institution's hip fracture registry. Among the 2,756 hip fracture patients, 2,029 (73.6%) underwent surgical intervention, while 727 (26.4%) opted for non-surgical intervention. The complication rate among the patients who underwent surgical intervention was 6.6%, while that among the patients who underwent non-surgical intervention was 12.5% (p < 0.01). The mean length of hospital stay for the surgical and non-surgical hip fracture patients was 15.7 days and 22.4 days, respectively (p < 0.01). Surgical management of hip fractures among the elderly is associated with a lower complication rate, as well as a reduced length of hospital stay. Copyright: © Singapore Medical Association

Costs of care at the end of life among elderly patients with chronic kidney disease: patterns and predictors in a nationwide cohort study.

PubMed

Chen, Bradley; Fan, Victoria Y; Chou, Yiing-Jenq; Kuo, Chin-Chi

2017-01-26

Despite the urgent need for evidence to guide the end-of-life (EOL) care for patients with chronic kidney disease (CKD), we have limited knowledge of the costs and intensity of EOL care in this population. The present study examined patterns and predictors for EOL care intensity among elderly patients with CKD. We conducted a retrospective nationwide cohort study utilizing the Taiwan National Health Insurance (NHI) Research Database. A total of 65,124 CKD patients aged ≥ 60 years, who died in hospitals or shortly after discharge between 2002 and 2012 were analyzed. The primary outcomes were inpatient expenses and use of surgical interventions in the last 30 days of life. Utilization of intensive care unit (ICU), mechanical ventilation, resuscitation, and dialysis was also examined in a sub-sample of 2072 patients with detailed prescription data. Multivariate log-linear and logistic regression analyses were performed to assess patient-, physician-, and facility-specific predictors and the potential impact of a 2009 payment policy to reimburse hospice care for non-cancer patients. During the last 30 days of life, average inpatients costs for elderly CKD patients were approximately US$10,260, with 40.9% receiving surgical interventions, 40.2% experiencing ICU admission, 45.3% undergoing mechanical ventilation, 14.7% receiving resuscitation and 42.0% receiving dialysis. Significant variability was observed in the inpatient costs and use of intensive services. Costs were lower among individuals with the following characteristics: advanced age; high income; high Charlson Comorbidity Index scores; treatment by older physicians, nephrologists, and family medicine physicians; and treatment at local hospitals. Similar findings were obtained for the use of surgical interventions and other intensive services. A declining trend was detected in the costs of EOL care, use of surgical interventions and resuscitation between 2009 and 2012, which is consistent with the impact of a 2009 NHI payment policy to reimburse non-cancer hospice care. Overall EOL costs and rates of intensive service use among older patients with CKD were high, with significant variability across various patient and provider characteristics. Several opportunities exist for providers and policy makers to reduce costs and enhance the value of EOL care for this population.

Inferior sinus venosus defect: echocardiographic diagnosis and surgical approach.

PubMed

Crystal, Matthew A; Al Najashi, Khaled; Williams, William G; Redington, Andrew N; Anderson, Robert H

2009-06-01

We sought to define the inferior sinus venosus defect anatomically and document successful surgical approaches. We identified all patients previously given a diagnosis of an inferior sinus venosus defect at the Hospital for Sick Children, Toronto, Canada, between 1982 and 2005 by interrogating the cardiology and cardiac surgery databases. We included those having interatrial communications in which 1 or more of the right pulmonary veins drained to the inferior caval vein but retained connection with the left atrium, the rims of the oval fossa, and the walls of the coronary sinus, both being intact. We identified 11 children who had an interatrial communication meeting the criteria for and undergoing surgical repair of an inferior sinus venosus defect. Median age was 1.2 years; 6 (55%) subjects were male, and none were cyanotic. Transthoracic echocardiographic analysis was performed preoperatively in all children, revealing right ventricular dilation in all. Surgical repair was accomplished with a pericardial patch. A complex baffle was needed in 3 children to maintain unobstructed inferior caval and pulmonary venous return. The echocardiographic diagnosis was complete in only 5 patients, but all diagnoses were correct since the year 2000. In all children the observations at surgical intervention showed that the defect was a venoatrial communication involving drainage of the right pulmonary veins to the inferior caval vein while retaining connection to the left atrium. Transthoracic echocardiographic analysis should remain the modality of choice for diagnosis of the inferior sinus venosus defect. We report excellent surgical results with a patch or baffle, correctly redirecting the anomalous venoatrial connections.

The Importance of Perioperative Prophylaxis with Cefuroxime or Ceftriaxone in the Surgical Site Infections Prevention after Cranial and Spinal Neurosurgical Procedures.

PubMed

Dimovska-Gavrilovska, Aleksandra; Chaparoski, Aleksandar; Gavrilovski, Andreja; Milenkovikj, Zvonko

2017-09-01

Introduction Surgical site infections pose a significant problem in the treatment of neurosurgical procedures, regardless of the application of perioperative prophylaxis with systemic antibiotics. The infection rate in these procedures ranges from less than 1% to above 15%. Different antibiotics and administration regimes have been used in the perioperative prophylaxis so far, and there are numerous comparative studies regarding their efficiency, however, it is generally indicated that the choice thereof should be based on information and local specifics connected to the most probable bacterial causers, which would possibly contaminate the surgical site and cause infection, and moreover, the mandatory compliance with the principles of providing adequate concentration of the drug at the time of the anticipated contamination. Objective Comparing the protective effect of two perioperative prophylactic antibiotic regimes using cefuroxime (second generation cephalosporin) and ceftriaxone (third generation cephalosporin) in the prevention of postoperative surgical site infections after elective and urgent cranial and spinal neurosurgical procedures at the University Clinic for Neurosurgery in Skopje in the period of the first three months of 2016. Design of the study Prospective randomized comparative study. Outcome measures Establishing the clinical outcome represented as prevalence of superficial and deep incision and organ/space postoperative surgical site infections. Material and method We analyzed prospectively 40 patients who received parenteral antibiotic prophylaxis with two antibiotic regimes one hour before the routine neurosurgical cranial and spinal surgical procedures; the patients were randomized in two groups, according to the order of admission and participation in the study, alternately, non-selectively, those persons who fulfilled inclusion criteria were placed in one of the two programmed regimes with cefuroxime in the first, and cefotaxime in the second compared group. All relevant demographic and perioperative patient data were analyzed for both comparative groups, especially the factors known to cause disposition (predisposition) to infections. The prevalence of postoperative infections was evaluated as the primary outcome in both comparative groups, while the secondary outcome was the postoperative infection rate after cranial and spinal neurosurgical procedures at the Neurosurgical clinic in Skopje (having in consideration that so far no data have been published in this context), as well as the prevalence of the risk factors for occurrence of postoperative infections, pre-surgically in patients undergoing neurosurgical interventions locally in the Republic of Macedonia. Results A total of three cases of postoperative infections were registered, two of which classified as superficial incisional, while one case organ/space infection - meningitis (elective intervention) without etiological confirmation. Both comparative groups were statistically similar, without any statistically significant differences in the basic demographic and perioperative characteristics, especially in relation to the incidence of the factors, which, regardless of the antibiotic prophylaxis, show predisposition to postoperative infections. All three cases with infections were registered in the group of persons who received prophylaxis with ceftriaxone preoperatively, with isolated etiological S. aureus agent (elective intervention) in one of them, and methicillin resistant staphylococcus aureus (MRSA) in another (urgent intervention) with superficial incisional SSI. There was no case of SSI in the group of patients who received cefuroxime before surgery. Conclusion Administration of parenteral antibiotics before surgery reduces the incidence of postoperative infections after neurosurgical procedures, especially in cases with increased risk factors for SSI, such as ACA score of ≥ 2/3, the duration of the surgical intervention ≥ 4 hours, contaminated wound and comorbidities. Perioperative antibiotic prophylaxis should be directed to better coverage of the S.aureus arrays.

Poster — Thur Eve — 41: Considerations for Patients with Permanently Implant Radioactive Sources Requiring Unrelated Surgery

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

Basran, P. S; Beckham, WA; Baxter, P

Permanent implant of sealed radioactive sources is an effective technique for treating cancer. Typically, the radioactive sources are implanted in and near the disease, depositing dose locally over several months. There may be instances where these patients must undergo unrelated surgical procedures when the radioactive material remains active enough to pose risks. This work explores these risks, discusses strategies to mitigate those risks, and describes a case study for a permanent I-125 prostate brachytherapy implant patient who developed colo-rectal cancer and required surgery 6 months after brachytherapy. The first consideration is identifying the risk from unwarranted radiation to the patientmore » and staff before, during, and after the surgical procedure. The second is identifying the risk the surgical procedure may have on the efficacy of the brachytherapy implant. Finally, there are considerations for controlling for radioactive substances from a regulatory perspective. After these risks are defined, strategies to mitigate those risks are considered. These strategies may include applying the concepts of ALARA, the use of protective equipment and developing a best practice strategy with the operating room team. We summarize this experience with some guidelines: If the surgical procedure is near (ex: 5 cm) of the implant; and, the surgical intervention may dislodge radioisotopes enough to compromise treatment or introduces radiation safety risks; and, the radioisotope has not sufficiently decayed to background levels; and, the surgery cannot be postponed, then a detailed analysis of risk is advised.« less

Surgical Consultation as Social Process: Implications for Shared Decision Making.

PubMed

Clapp, Justin T; Arriaga, Alexander F; Murthy, Sushila; Raper, Steven E; Schwartz, J Sanford; Barg, Frances K; Fleisher, Lee A

2017-12-12

This qualitative study examines surgical consultation as a social process and assesses its alignment with assumptions of the shared decision-making (SDM) model. SDM stresses the importance of patient preferences and rigorous discussion of therapeutic risks/benefits based on these preferences. However, empirical studies have highlighted discrepancies between SDM and realities of surgical decision making. Qualitative research can inform understanding of the decision-making process and allow for granular assessment of the nature and causes of these discrepancies. We observed consultations between 3 general surgeons and 45 patients considering undergoing 1 of 2 preference-sensitive elective operations: (1) hernia repair, or (2) cholecystectomy. These patients and surgeons also participated in semi-structured interviews. By the time of the consultation, patients and surgeons were predisposed toward certain decisions by preceding events occurring elsewhere. During the visit, surgeons had differential ability to arbitrate surgical intervention and construct the severity of patients' conditions. These upstream dynamics frequently displaced the centrality of the risk/benefit-based consent discussion. The influence of events preceding consultation suggests that decision-making models should account for broader spatiotemporal spans. Given surgeons' authority to define patients' conditions and control service provision, SDM may be premised on an overestimation of patients' power to alter the course of decision making once in a specialist's office. Considering the subordinate role of the risk/benefit discussion in many surgical decisions, it will be important to study if and how the social process of decision making is altered by SDM-oriented decision aids that foreground this discussion.

Interventions to improve cardiopulmonary hemodynamics during laparoscopy in a porcine sepsis model.

PubMed

Grief, W M; Forse, R A

1999-11-01

Laparoscopy is increasingly used in severely ill and acutely septic patients. In animals undergoing laparoscopy, the hemodynamic response to sepsis is blunted. Specific interventions to augment the hemodynamic potential may make laparoscopic intervention a safer alternative in septic patients. We compared different interventions to improve hemodynamic performance during exploratory laparoscopy in a porcine endotoxic shock model. Domestic pigs (n = 12) received intravenous lipopolysaccharide injection and underwent surgical abdominal exploration using either laparoscopy or conventional laparotomy. For comparison, pigs exposed to endotoxin underwent laparoscopy with these interventions: intravenous infusions of prostacyclin (n = 5) or indomethacin (n = 4), intravenous crystalloid resuscitation (n = 5), pulmonary hyperventilation (n = 4), or abdominal insufflation with air (n = 5). Hemodynamic measurements and blood gas analyses were obtained using Swan-Ganz and arterial catheters. Septic animals treated with prostacyclin undergoing laparoscopy had a higher cardiac index (CI, p < 0.01), stroke volume (SV; p < 0.001) and oxygen delivery (p < 0.05) than the untreated group. Likewise, treatment with indomethacin was associated with a higher CI (p < 0.001), SV (p < 0.005), and oxygen delivery (p < 0.005) compared with the untreated group. These effects may be secondary to a decreased pulmonary vascular resistance, demonstrated in the animals that received either prostacyclin (p < 0.05) or indomethacin (p < 0.05). In addition, animals given aggressive fluid resuscitation had a significantly higher CI (p < 0.05) and SV (p < 0.001) than those with normal fluid resuscitation during laparoscopy. Manipulation of arterial pH by insufflation of the abdomen with air to create the pneumoperitoneum, or by aggressively hyperventilating the animals, did not improve CI. Adverse effects of laparoscopy on cardiovascular hemodynamics in the septic state may be mediated by increased pulmonary vascular resistance, diminished venous return, or both. Specific interventions to reverse these variables may ameliorate hemodynamic changes seen.

Variance in elective surgery for chronic pancreatitis.

PubMed

Shah, Nehal S; Siriwardena, Ajith K

2009-01-08

Evidence to guide selection of optimal surgical treatment for patients with painful chronic pancreatitis is limited. Baseline assessment data are limited and thus patients in different centres may be presenting at different stages of their illness. This study undertakes a systematic overview of reports of elective surgical intervention in chronic pancreatitis with particular reference to reporting of quality of life and baseline assessment and relation between disease and type of procedure. A computerised search of the PubMed, Embase and Cochrane databases was undertaken for the period January 1997 to March 2007 yielding 46 manuscripts providing data on 4,626 patients undergoing elective surgery for chronic pancreatitis. The median number of patients per study was 71 (range: 4-484). The median period for recruitment of patients was 10 years (range: 2-36 years). An externally validated quality of life questionnaire is reported in 8 (17.4%) of 46 manuscripts covering 441 (9.5%) of 4,626 patients. Formal comparison of pre-operative and post-operative pain scores was provided in 15 (32.6%) of manuscripts. Only seven (15.2%) reports provide a formal rationale or indication for selection of the type of elective surgical procedure for a stated disease variant and these papers cover 481 (10.4%) patients. In conclusion, this study demonstrates that there is a lack of standardization between units of the criteria for operative intervention in painful chronic pancreatitis. At a minimum, formal quality of life testing using a validated system should be undertaken in all patients prior to elective surgery for painful chronic pancreatitis.

Typhlitis: selective surgical management.

PubMed

Moir, C R; Scudamore, C H; Benny, W B

1986-05-01

Typhlitis is a neutropenic enterocolitis of varying severity. Its incidence is increasing, particularly in patients with acute myelogenous leukemia undergoing high dose cytosine arabinoside chemotherapy. The onset is heralded by prodromal fever, watery or bloody diarrhea, abdominal distension, and nausea during the phase of severe neutropenia. The symptoms may then localize to the right lower quadrant with an associated increase in systemic toxicity. The diagnosis can be confirmed in these and other less specific cases by serial reexamination and abdominal radiographs, ultrasonography, computerized tomograms, or radionucleotide scans. The mainstay of management is complete bowel rest with nasogastric suction and total parenteral nutrition. Broad-spectrum combination antibiotics are essential, as is the avoidance of laxatives or antidiarrheal agents. Granulocyte support may be helpful. Patients with a history of nonspecific gastrointestinal complaints or of true typhlitis, successfully managed nonoperatively, should have prophylactic bowel rest and total parenteral nutrition instituted at the beginning of further chemotherapy. Patients with ongoing severe systemic sepsis who do not respond to chemotherapy and those with overt perforation, obstruction, massive hemorrhage, or abscess formation require surgical intervention. All necrotic material must be resected, usually by a right hemicolectomy, ileostomy, and mucous fistula. Divided ileostomy for less severe cases may be useful. Failure to remove the necrotic focus in these severely immunocompromised patients is fatal. With adequate recognition of typhlitis and its precipitating factors, the incidence of complications can be reduced through prevention and timely surgical intervention. Although typhlitis developed in a quarter of our acute myeloblastic leukemia patients, use of this combined approach was successful in all cases.

Randomized Controlled Trial to Reduce Bacterial Colonization of Surgical Drains After Breast and Axillary Operations

PubMed Central

Degnim, Amy C.; Scow, Jeffrey S.; Hoskin, Tanya L.; Miller, Joyce P.; Loprinzi, Margie; Boughey, Judy C.; Jakub, James W.; Throckmorton, Alyssa; Patel, Robin; Baddour, Larry M.

2014-01-01

Objective To determine if bacterial colonization of drains can be reduced by local antiseptic interventions. Summary Background Drains are a potential source of bacterial entry into surgical wounds and may contribute to surgical site infection (SSI) after breast surgery. Methods Following IRB approval, patients undergoing total mastectomy and/or axillary lymph node dissection were randomized to standard drain care (control) or drain antisepsis (treated). Standard drain care comprised twice daily cleansing with alcohol swabs. Antisepsis drain care included 1) a chlorhexidine disc at the drain exit site and 2) irrigation of the drain bulb twice daily with dilute sodium hypochlorite (Dakin’s) solution. Cultures results of drain fluid and tubing were compared between control and antisepsis groups. Results Overall, 100 patients with 125 drains completed the study with 48 patients (58 drains) in the control group and 52 patients (67 drains) in the antisepsis group. Cultures of drain bulb fluid at one week were positive (1+ or greater growth) in 66% (38/58) of control drains compared to 21% of antisepsis drains (14/67), (p=0.0001). Drain tubing cultures demonstrated >50 CFU in 19% (8/43) of control drains versus 0% (0/53) of treated drains (p=0.004). SSI was diagnosed in 6 patients (6%) - 5 patients in the control group and 1 patient in the antisepsis group (p=0.06). Conclusions Simple and inexpensive local antiseptic interventions with a chlorhexidine disc and hypochlorite solution reduce bacterial colonization of drains. Based on these data, further study of drain antisepsis and its potential impact on SSI rate is warranted. PMID:23518704

Web-based audiovisual patient information system--a study of preoperative patient information in a neurosurgical department.

PubMed

Gautschi, Oliver P; Stienen, Martin N; Hermann, Christel; Cadosch, Dieter; Fournier, Jean-Yves; Hildebrandt, Gerhard

2010-08-01

In the current climate of increasing awareness, patients are demanding more knowledge about forthcoming operations. The patient information accounts for a considerable part of the physician's daily clinical routine. Unfortunately, only a small percentage of the information is understood by the patient after solely verbal elucidation. To optimise information delivery, different auxiliary materials are used. In a prospective study, 52 consecutive stationary patients, scheduled for an elective lumbar disc operation were asked to use a web-based audiovisual patient information system. A combination of pictures, text, tone and video about the planned surgical intervention is installed on a tablet personal computer presented the day before surgery. All patients were asked to complete a questionnaire. Eighty-four percent of all participants found that the audiovisual patient information system lead to a better understanding of the forthcoming operation. Eighty-two percent found that the information system was a very helpful preparation before the pre-surgical interview with the surgeon. Ninety percent of all participants considered it meaningful to provide this kind of preoperative education also to patients planned to undergo other surgical interventions. Eighty-four percent were altogether "very content" with the audiovisual patient information system and 86% would recommend the system to others. This new approach of patient information had a positive impact on patient education as is evident from high satisfaction scores. Because patient satisfaction with the informed consent process and understanding of the presented information improved substantially, the audiovisual patient information system clearly benefits both surgeons and patients.

Necrotizing fasciitis associated with primary cutaneous B-cell lymphoma. A case report.

PubMed

Spiridakis, K G; Intzepogazoglou, D S; Flamourakis, M E; Sfakianakis, E E; Daskalaki, A V; Vakonaki, E K; Rahmanis, E; Kostakis, G E; Christodoulakis, M S

2017-01-01

Necrotizing fasciitis is a rapidly progressive and life-threatening infection of the deeper skin layers and subcutaneous tissues that moves along the facial planes. We present the rare case of a patient with necrotizing fasciitis associated with high malignancy b-cell lymphoma. Our purpose is to investigate the probable connection between the two pathologies and evaluate the importance of early surgical intervention. 51-year old Caucasian woman presented at the E.R. with history of a painful left thigh over a week and fever up to 38,4°C over the last three days. Necrosis of the soft tissues and fascial planes were observed clinically. After the initial treatment and due to the patient's multiple organ dysfunction (septic shock), she was transferred to the ICU were she was intubated resuscitated with IV fluids and given IV antibiotics. 24 hours after the admission it was decided that the patient should undergo surgery and an extensive debridement of the necrotic area was performed. The antibiogram of the blood culture revealed streptococcus pyogenes and she was administered penicillin while intubated and monitored in the ICU until the seventh postoperative day. On the eighth post-day she was transferred back to the surgical department, hemodynamically normal and stable. She was discharged one month later and she was referred to a plastic surgery center for the final reconstruction surgery. This case highlights that the high index of suspicion and the early aggressive surgical intervention seems to be very critical to improve survival of the patients with necrotizing fasciitis.

Relevance of surgery in patients with non-variceal upper gastrointestinal bleeding.

PubMed

Dango, S; Beißbarth, T; Weiss, E; Seif Amir Hosseini, A; Raddatz, D; Ellenrieder, V; Lotz, J; Ghadimi, B M; Beham, A

2017-05-01

Upper GI bleeding remains one of the most common emergencies with a substantial overall mortality rate of up to 30%. In severe ill patients, death does not occur due to failure of hemostasis, either medical or surgical, but mainly from comorbidities, treatment complications, and decreased tolerated blood loss. Management strategies have changed dramatically over the last two decades and include primarily endoscopic intervention in combination with acid-suppressive therapy and decrease in surgical intervention. Herein, we present one of the largest patient-based analysis assessing clinical parameters and outcome in patients undergoing endoscopy with an upper GI bleeding. Data were further analyzed to identify potential new risk factors and to investigate the role of surgery. In this retrospective study, we aimed to analyze outcome of patients with an UGIB and data were analyzed to identify potential new risk factors and the role of surgery. Data collection included demographic data, laboratory results, endoscopy reports, and details of management including blood administration, and surgery was carried out. Patient events were grouped and defined as "overall" events and "operated," "non-operated," and "operated and death" as well as "non-operated and death" where appropriate. Blatchford, clinical as well as complete Rockall-score analysis, risk stratification, and disease-related mortality rate were calculated for each group for comparison. Overall, 253 patients were eligible for analysis: endoscopy was carried out in 96% of all patients, 17% needed surgical intervention after endoscopic failure of bleeding control due to persistent bleeding, and the remaining 4% of patients were subjected directly to surgery. The median length of stay to discharge was 26 days. Overall mortality was 22%; out of them, almost 5% were operated and died. Anticoagulation was associated with a high in-hospital mortality risk (23%) and was increased once patients were taken to surgery (43%). Patients taking steroids presented with a risk of death of 26%, once taken to surgery the risk increased to 80%. Patients with liver cirrhosis had a risk of death of 42%; we observed a better outcome for these patients once taken to theater. Clinically, once scored with Blatchford score, statistical correlation was found for initial need for blood transfusion and surgical intervention. Clinical as well as complete Rockall score revealed a correlation between need for blood transfusion as well as surgical intervention in addition with a decreased outcome with increasing Rockall scores. Risk factor analysis including comorbidity, drug administration, and anticoagulation therapy introduced the combination of tumor and non-steroidal antirheumatic medication as independent risk factors for increased disease-related mortality. UGIB remains challenging and endoscopy is the first choice of intervention. Care must be taken once a patient is taking antirheumatic non-steroidal pain medication and suffers from cancer. In patients with presence of liver cirrhosis, an earlier surgical intervention may be considered, in particular for patients with recurrent bleeding. Embolization is not widely available and carries the risk of necrosis of the affected organ and should be restricted to a subgroup of patients not primarily eligible for surgery once endoscopy has failed. Taken together, an interdisciplinary approach including gastroenterologists as well as surgeons should be used once the patient is admitted to the hospital to define the best treatment option.

Association of Hospitalization for Neurosurgical Operations in Magnet Hospitals With Mortality and Length of Stay.

PubMed

Missios, Symeon; Bekelis, Kimon

2018-03-01

The association of Magnet hospital status with improved surgical outcomes remains an issue of debate. To investigate whether hospitalization in a Magnet hospital is associated with improved outcomes for patients undergoing neurosurgical operations. A cohort study was executed using all patients undergoing neurosurgical operations in New York registered in the Statewide Planning and Research Cooperative System database from 2009 to 2013. We examined the association of Magnet status hospitalization after neurosurgical operations with inpatient case fatality and length of stay (LOS). We employed an instrumental variable analysis to simulate a randomized trial. Overall, 190 787 patients underwent neurosurgical operations. Of these, 68 046 (35.7%) were hospitalized in Magnet hospitals, and 122 741 (64.3%) in non-Magnet institutions. Instrumental variable analysis demonstrated that hospitalization in Magnet hospitals was associated with decreased case fatality (adjusted difference, -0.8%; -95% confidence interval, -0.7% to -0.6%), and LOS (adjusted difference, -1.9; 95% confidence interval, -2.2 to -1.5) in comparison to non-Magnet hospitals. These associations were also observed in propensity score adjusted mixed effects models. These associations persisted in prespecified subgroups of patients undergoing spine surgery, craniotomy for tumor resection, or neurovascular interventions. We identified an association of Magnet hospitals with lower case fatality, and shorter LOS in a comprehensive New York State patient cohort undergoing neurosurgical procedures. Copyright © 2017 by the Congress of Neurological Surgeons

Use of Sugammadex in a Patient with Amyotrophic Lateral Sclerosis

PubMed Central

Kelsaka, Ebru; Karakaya, Deniz; Zengin, Eyüp Cağatayn

2013-01-01

Objective To report on general anesthesia management in amyotrophic lateral sclerosis. Case Presentation and Intervention A 47-year-old man presented with fracture of the humerus. The patient was diagnosed with amyotrophic lateral sclerosis. General anesthesia was induced with propofol, rocuronium and remifentanil. After uneventful surgical repair, TOF (train-of-four) ratio reached >0.90 at the end of operation. However, muscle strength and tidal volume were inadequate. After sugammadex 2 mg kg−1 i.v. was given, the patient was extubated 120 s later. Conclusion This case highlights that rocuronium and sugammadex can be used safely in patients with amyotrophic lateral sclerosis undergoing surgery with general anesthesia. PMID:23075763

Simple mastectomy under hypnosis: A case study approach.

PubMed

Fiddaman, Joe

2016-10-01

There is a clear inverse relationship between preoperative anxiety and effective anaesthesia and recovery. Studies have shown that perioperative anxiety can be detrimental to the efficacy of recovery. In order to mitigate the perioperative anaesthetic risk to the patient, perioperative care must be inclusive of psychological as well as physiological elements. Therefore, when planning and implementing care for the surgical patient alternative interventions, such as hypnosis, should be considered when presented with difficult patient factors, such as crippling anxiety. This article takes on a case study approach to critically analyse and appraise the holistic care of a patient undergoing a simple mastectomy with hypnosis as the primary anaesthesia. Copyright the Association for Perioperative Practice.

Variability in Non-Cardiac Surgical Procedures in Children with Congenital Heart Disease

PubMed Central

Sulkowski, Jason P.; Cooper, Jennifer N.; McConnell, Patrick I.; Pasquali, Sara K.; Shah, Samir S.; Minneci, Peter C.; Deans, Katherine J.

2014-01-01

Background The purpose of this study was to examine the volume and variability of non-cardiac surgeries performed in children with congenital heart disease (CHD) requiring cardiac surgery in the first year of life. Methods Patients who underwent cardiac surgery by 1 year of age and had a minimum 5-year follow-up at 22 of the hospitals contributing to the Pediatric Health Information System database between 2004–2012 were included. Frequencies of non-cardiac surgical procedures by age 5 years were determined and categorized by subspecialty. Patients were stratified according to their maximum RACHS-1 (Risk Adjustment in Congenital Heart Surgery) category. The proportions of patients across hospitals who had a non-cardiac surgical procedure for each subspecialty were compared using logistic mixed effects models. Results 8,857 patients underwent congenital heart surgery during the first year of life, 3,621 (41%) of whom had 13,894 non-cardiac surgical procedures by 5 years. Over half of all procedures were in general surgery (4,432; 31.9%) or otolaryngology (4,002; 28.8%). There was significant variation among hospitals in the proportion of CHD patients having non-cardiac surgical procedures. Compared to children in the low risk group (RACHS-1 categories 1–3), children in the high-risk group (categories 4–6) were more likely to have general, dental, orthopedic, and thoracic procedures. Conclusions Children with CHD requiring cardiac surgery frequently also undergo non-cardiac surgical procedures; however, considerable variability in the frequency of these procedures exists across hospitals. This suggests a lack of uniformity in indications used for surgical intervention. Further research should aim to better standardize care for this complex patient population. PMID:25475794

Surgical Outcomes After Open, Laparoscopic, and Robotic Gastrectomy for Gastric Cancer.

PubMed

Yang, Seung Yoon; Roh, Kun Ho; Kim, You-Na; Cho, Minah; Lim, Seung Hyun; Son, Taeil; Hyung, Woo Jin; Kim, Hyoung-Il

2017-07-01

In contrast to the significant advantages of laparoscopic versus open gastrectomy, robotic gastrectomy has shown little benefit over laparoscopic gastrectomy. This study aimed to compare multi-dimensional aspects of surgical outcomes after open, laparoscopic, and robotic gastrectomy. Data from 915 gastric cancer patients who underwent gastrectomy by one surgeon between March 2009 and May 2015 were retrospectively reviewed. Perioperative parameters were analyzed for short-term outcomes. Surgical success was defined as the absence of conversion to open surgery, major complications, readmission, positive resection margin, or fewer than 16 retrieved lymph nodes. This study investigated 241 patients undergoing open gastrectomy, 511 patients undergoing laparoscopic gastrectomy, and 173 patients undergoing robotic gastrectomy. For each approach, the respective incidences were as follows: conversion to open surgery (not applicable, 0.4%, and 0%; p = 0.444), in-hospital major complications (5.8, 2.7, and 1.2%; p = 0.020), delayed complications requiring readmission (2.9, 2.0, and 1.2%; p = 0.453), positive resection margin (1.7, 0, and 0%; p = 0.003), and inadequate number of retrieved lymph nodes (0.4, 4.1, and 1.7%; p = 0.010). Compared with open and laparoscopic surgery, robotic gastrectomy had the highest surgical success rate (90, 90.8, and 96.0%). Learning-curve analysis of success using cumulative sum plots showed success with the robotic approach from the start. Multivariate analyses identified age, sex, and gastrectomy extent as significant independent parameters affecting surgical success. Surgical approach was not a contributing factor. Open, laparoscopic, and robotic gastrectomy exhibited different incidences and causes of surgical failure. Robotic gastrectomy produced the best surgical outcomes, although the approach method itself was not an independent factor for success.

Epidemiology of Vocal Fold Paralyses After Total Thyroidectomy for Well-Differentiated Thyroid Cancer in Medicare Population

PubMed Central

Francis, David O.; Pearce, Elizabeth C.; Ni, Shenghua; Garrett, C. Gaelyn; Penson, David F.

2014-01-01

Objectives Population-level incidence of vocal fold paralysis after thyroidectomy for well-differentiated thyroid carcinoma (WDTC) is not known. This study aimed to measure longitudinal incidence of post-operative vocal fold paralyses and need for directed interventions in the Medicare population undergoing total thyroidectomy for WDTC. Study Design Retrospective Cohort Study Setting United States Population Subjects Medicare Beneficiaries Methods SEER-Medicare data (1991 – 2009) were used to identify beneficiaries who underwent total thyroidectomy for WDTC. Incident vocal fold paralyses and directed interventions were identified. Multivariate analyses were used to determine factors associated with odds of developing these surgical complications. Results Of 5,670 total thyroidectomies for WDTC, 9.5% were complicated by vocal fold paralysis [8.2% unilateral vocal fold paralysis (UVFP); 1.3% bilateral vocal fold paralysis (BVFP)]. Rate of paralyses decreased 5% annually from 1991 to 2009 (OR 0.95, 95% CI 0.93 – 0.97; p<0.001). Overall, 22% of patients with vocal fold paralysis required surgical intervention (UVFP 21%, BVFP 28%). Multivariate logistic regression revealed odds of post-thyroidectomy paralysis increased with each additional year of age, with non-Caucasian race, particular histologic types, advanced stage, and in particular registry regions. Conclusions Annual rates of post-thyroidectomy vocal fold paralyses are decreasing among Medicare beneficiaries with WDTC. High incidence in this aged population is likely due to a preponderance of temporary paralyses, which is supported by the need for directed intervention in less than a quarter of affected patients. Further population-based studies are needed to refine the population incidence and risk factors for paralyses in the aging population. PMID:24482349

Internet based patient education improves informed consent for elective orthopaedic surgery: a randomized controlled trial.

PubMed

Fraval, Andrew; Chandrananth, Janan; Chong, Yew M; Coventry, Lillian S; Tran, Phong

2015-02-07

Obtaining informed consent is an essential step in the surgical pathway. Providing adequate patient education to enable informed decision making is a continued challenge of contemporary surgical practice. This study investigates whether the use of a patient information website, to augment patient education and informed consent for elective orthopaedic procedures is an effective measure. A randomised controlled trial was conducted comparing the quality of informed consent provided by a standard discussion with the treating surgeon compared to augmentation of this discussion with an online education resource (www.orthoanswer.org). Participants were recruited from orthopaedic outpatient clinics. Patients undergoing five common orthopaedic procedures were eligible to participate in the trial. The primary outcome measure was knowledge about their operation. Satisfaction with their informed consent and anxiety relating to their operation were the secondary outcome measures. There was a statistically significant increase in patient knowledge for the intervention arm as compared to the control arm (p < 0.01). Patients in the intervention arm, had an average score of 69.25% (SD 14.91) correct answers as compared to 47.38% (SD 17.77) in the control arm. Satisfaction was also improved in the intervention arm (p = 0.043). There was no statistically significant difference between the control and intervention arm relating to their anxiety scores (p = 0.195). The use of a patient education website as an augment to informed consent improves patient knowledge about their planned operation as well as satisfaction with the consent process whilst not increasing their anxiety levels. We recommend that all patients be directed to web based education tools to augment their consent. Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12614001058662 .

Cost effectiveness and cost utility of preventing trachomatous visual impairment: lessons from 30 years of trachoma control in Burma.

PubMed Central

Evans, T G; Ranson, M K; Kyaw, T A; Ko, C K

1996-01-01

AIMS/BACKGROUND: This paper reports on the findings of a cost and effectiveness study of the trachoma control programme (TCP) in Burma. The TCP began in 1964 employing non-surgical interventions (community education and mass treatment with topical antibiotics) and surgical correction of trichiasis. METHODS: Fixed and variable costs of the TCP are assessed over 30 years (1964-93) and apportioned to either surgical or non-surgical interventions. The change in the prevalence of trachoma blindness during this period is used to calculate cases of visual impairment prevented by the TCP. The years of life saved because of premature mortality averted and from living in a handicapped state are added to yield a single measure of utility called handicap adjusted life years (HALYs). RESULTS: The cost effectiveness of the TCP is $54 per case of visual impairment prevented: $193 and $47 for surgical and non-surgical interventions respectively. The cost utility of the TCP is $4 per HALY averted: $10 and $3 for surgical and non-surgical interventions respectively. Results are highly sensitive to the 1965 prevalence of blindness, the choice of discount rate, and the effectiveness of both interventions. CONCLUSIONS: Thirty years of trachoma control in Burma are associated with a remarkable decline in trachomatous blindness. Both surgical and non-surgical interventions are cost effective means of preventing trachomatous visual impairment. Discussion focuses on methodological limitations and implications for research and policy. PMID:8976698

Prophylactic antibiotics to prevent surgical site infection after breast cancer surgery.

PubMed

Jones, Daniel J; Bunn, Frances; Bell-Syer, Sophie V

2014-03-09

Surgery has been used as part of breast cancer treatment for centuries; however any surgical procedure has the potential risk of infection. Infection rates for surgical treatment of breast cancer are documented at between 3% and 15%, higher than average for a clean surgical procedure. Pre- and perioperative antibiotics have been found to be useful in lowering infection rates in other surgical groups, yet there is no consensus on the use of prophylactic antibiotics for breast cancer surgery. To determine the effects of prophylactic (pre- or perioperative) antibiotics on the incidence of surgical site infection (SSI) after breast cancer surgery. For this third update we searched the Cochrane Wounds Group Specialised Register (5 December 2013); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); the Database of Abstracts of Reviews of Effects (DARE) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL. We applied no language or date restrictions. Randomised controlled trials of pre- and perioperative antibiotics for patients undergoing surgery for breast cancer were included. Primary outcomes were rates of surgical site infection (SSI) and adverse reactions. Two review authors independently examined the title and abstracts of all studies identified by the search strategy, then assessed study quality and extracted data from those that met the inclusion criteria. A total of eleven studies (2867 participants) were included in the review. Ten studies evaluated preoperative antibiotic compared with no antibiotic or placebo. One study evaluated perioperative antibiotic compared with no antibiotic. Pooling of the results demonstrated that prophylactic antibiotics administered preoperatively significantly reduce the incidence of SSI for patients undergoing breast cancer surgery without reconstruction (pooled risk ratio (RR) 0.67, 95% confidence interval (CI) 0.53 to 0.85). Analysis of the single study comparing perioperative antibiotic with no antibiotic found no statistically significant effect of antibiotics on the incidence of SSI (RR 0.11, 95% CI 0.01 to 1.95). No studies presented separate data for patients who underwent reconstructive surgery at the time of removal of the breast tumour. Prophylactic antibiotics administered preoperatively reduce the risk of SSI in patients undergoing surgery for breast cancer. Further studies involving patients undergoing immediate breast reconstruction are needed as studies have identified this group as being at higher risk of infection than those who do not undergo immediate breast reconstruction.

Comparison of left ventricular diastolic function in obstructive hypertrophic cardiomyopathy in patients undergoing percutaneous septal alcohol ablation versus surgical myotomy/myectomy

NASA Technical Reports Server (NTRS)

Sitges, Marta; Shiota, Takahiro; Lever, Harry M.; Qin, Jian Xin; Bauer, Fabrice; Drinko, Jeannie K.; Agler, Deborah A.; Martin, Maureen G.; Greenberg, Neil L.; Smedira, Nicholas G.;

Airborne particle dispersion to an operating room environment during sliding and hinged door opening.

PubMed

Sadrizadeh, Sasan; Pantelic, Jovan; Sherman, Max; Clark, Jordan; Abouali, Omid

2018-03-08

Operating rooms (ORs) are usually over-pressurized in order to prevent the penetration of contaminated air and the consequent risk of surgical site infection. However, a door-opening can result in the rapid disappearance of pressure and contaminants can then easily penetrate into the surgical zone. Therefore, a broad knowledge and understanding of OR ventilation systems and their protective potential is essential for optimizing the surgical environment. This study investigated the air quality and level of airborne particles during a single and multiple door-opening cycles in an operating room supplied by a turbulent-mixing ventilation system. The exploration was carried out numerically using computational fluid dynamics. Model validation was performed to ensure the validity of the achieved results. The OR was initially over-pressurized by approximately 15Pa, relative to the adjacent corridors. Both sliding and hinged doors were simulated and compared. Penetration of bacteria carrying particles from the corridors to the OR can be successfully restricted by using a positive-pressure system. However, the results clearly indicate that frequent door opening can interfere with airflow ventilation systems, alter the pressure gradient, and increase the infection risk for the patient undergoing surgical intervention. Door-opening disturbs the airflow field and could result in containment failure. Copyright © 2018 The Authors. Published by Elsevier Ltd.. All rights reserved.

Safety of contemporary percutaneous peripheral arterial interventions in the elderly insights from the BMC2 PVI (Blue Cross Blue Shield of Michigan Cardiovascular Consortium Peripheral Vascular Intervention) registry.

PubMed

Plaisance, Benjamin R; Munir, Khan; Share, David A; Mansour, M Ashraf; Fox, James M; Bove, Paul G; Riba, Arthur L; Chetcuti, Stanley J; Gurm, Hitinder S; Grossman, P Michael

2011-06-01

This study sought to evaluate the effect of age on procedure type, periprocedural management, and in-hospital outcomes of patients undergoing lower-extremity (LE) peripheral vascular intervention (PVI). Surgical therapy of peripheral arterial disease is associated with significant morbidity and mortality in the elderly. There are limited data related to the influence of advanced age on the outcome of patients undergoing percutaneous LE PVI. Clinical presentation, comorbidities, and in-hospital outcomes of patients undergoing LE PVI in a multicenter, multidisciplinary registry were compared between 3 age groups: < 70 years, between 70 and 80 years, and ≥ 80 years (elderly group). In our cohort, 7,769 patients underwent LE PVI. The elderly patients were more likely to be female and to have a greater burden of comorbidities. Procedural success was lower in the elderly group (74.2% for age ≥ 80 years vs. 78% for age 70 to < 80 years and 81.4% in patients age < 70 years, respectively; p < 0.0001). Unadjusted rates of procedure-related vascular access complications, post-procedure transfusion, contrast-induced nephropathy, amputation, and major adverse cardiac events were higher in elderly patients. After adjustment for baseline covariates, the elderly patients were more likely to experience vascular access complications; however, advanced age was not found to be associated with major adverse cardiac events, transfusion, contrast-induced nephropathy, or amputation. Contemporary PVI can be performed in elderly patients with high procedural and technical success with low rates of periprocedural complications including mortality. These findings may support the notion of using PVI as a preferred revascularization strategy in the treatment of severe peripheral arterial disease in the elderly population. Copyright © 2011 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Early Lessons on Bundled Payment at an Academic Medical Center.

PubMed

Jubelt, Lindsay E; Goldfeld, Keith S; Blecker, Saul B; Chung, Wei-Yi; Bendo, John A; Bosco, Joseph A; Errico, Thomas J; Frempong-Boadu, Anthony K; Iorio, Richard; Slover, James D; Horwitz, Leora I

2017-09-01

Orthopaedic care is shifting to alternative payment models. We examined whether New York University Langone Medical Center achieved savings under the Centers for Medicare and Medicaid Services Bundled Payments for Care Improvement initiative. This study was a difference-in-differences study of Medicare fee-for-service patients hospitalized from April 2011 to June 2012 and October 2013 to December 2014 for lower extremity joint arthroplasty, cardiac valve procedures, or spine surgery (intervention groups), or for congestive heart failure, major bowel procedures, medical peripheral vascular disorders, medical noninfectious orthopaedic care, or stroke (control group). We examined total episode costs and costs by service category. We included 2,940 intervention episodes and 1,474 control episodes. Relative to the trend in the control group, lower extremity joint arthroplasty episodes achieved the greatest savings: adjusted average episode cost during the intervention period decreased by $3,017 (95% confidence interval [CI], -$6,066 to $31). For cardiac procedures, the adjusted average episode cost decreased by $2,999 (95% CI, -$8,103 to $2,105), and for spinal fusion, it increased by $8,291 (95% CI, $2,879 to $13,703). Savings were driven predominantly by shifting postdischarge care from inpatient rehabilitation facilities to home. Spinal fusion index admission costs increased because of changes in surgical technique. Under bundled payment, New York University Langone Medical Center decreased total episode costs in patients undergoing lower extremity joint arthroplasty. For patients undergoing cardiac valve procedures, evidence of savings was not as strong, and for patients undergoing spinal fusion, total episode costs increased. For all three conditions, the proportion of patients referred to inpatient rehabilitation facilities upon discharge decreased. These changes were not associated with an increase in index hospital length of stay or readmission rate. Opportunities for savings under bundled payment may be greater for lower extremity joint arthroplasty than for other conditions.

Beyond usual care: the economic consequences of expanding treatment options in early pregnancy loss.

PubMed

Dalton, Vanessa K; Liang, Angela; Hutton, David W; Zochowski, Melissa K; Fendrick, A Mark

2015-02-01

The objective of this study was to estimate the economic consequences of expanding options for early pregnancy loss (EPL) treatment beyond expectant management and operating room surgical evacuation (usual care). We constructed a decision model using a hypothetical cohort of women undergoing EPL management within a 30 day horizon. Treatment options under the usual care arm include expectant management and surgical uterine evacuation in an operating room (OR). Treatment options under the expanded care arm included all evidence-based safe and effective treatment options for EPL: expectant management, misoprostol treatment, surgical uterine evacuation in an office setting, and surgical uterine evacuation in an OR. Probabilities of entering various treatment pathways were based on previously published observational studies. The cost per case was US $241.29 lower for women undergoing treatment in the expanded care model as compared with the usual care model (US $1033.29 per case vs US $1274.58 per case, expanded care and usual care, respectively). The model was the most sensitive to the failure rate of the expectant management arm, the cost of the OR surgical procedure, the proportion of women undergoing an OR surgical procedure under usual care, and the additional cost per patient associated with implementing and using the expanded care model. This study demonstrates that expanding women's treatment options for EPL beyond what is typically available can result in lower direct medical expenditures. Copyright © 2015 Elsevier Inc. All rights reserved.

Impact of a Multi-disciplinary C. difficile Action Team

PubMed Central

Heil, Emily; Sivasailam, Bharathi; Park, SoEun; Diaz, Jose; Von Rosenvinge, Erik; Claeys, Kimberly; Hopkins, Teri; Leekha, Surbhi

2017-01-01

Abstract Background Clostridium difficile infection (CDI) is associated with increased length of hospital stay, morbidity, mortality, and cost of hospitalization. Early intervention by experts from multiple areas of practice such as gastroenterology (GI), infectious diseases (ID) and surgery can be essential to optimize care and increase utilization of novel treatment modalities such as fecal microbiota transplant (FMT) and minimally invasive, colon-preserving surgical management. Methods A multi-disciplinary C. difficile action team (MD-CAT) was implemented at University of Maryland Medical Center (UMMC) in March 2016 to engage appropriate specialty consultants in the care of CDI patients. The MD-CAT reviews positive C. difficile tests at UMMC and provides guidance and suggestions to the primary team including optimal antibiotic treatment (for CDI and any concomitant infection), and consultant involvement including ID, surgery, and GI, when appropriate. Using retrospective chart review, CDI patient management and outcomes were compared before and after implementation of the MD-CAT. Differences in the time to consults and frequency of interventional treatment was compared using Chi-square or Wilcoxon Rank-sum test. Results We compared 48 patients with CDI in the pre-intervention with 89 patients in the post-intervention period. Demographic and clinical characteristics of the groups were similar. MD-CAT intervention was associated with frequent (73%) modification or discontinuation of concomitant antibiotics. Median time to GI and ID consults was significantly shorter in the post group (P = 0.007 and P = 0.004, respectively). Five of 89 (5.6%) of patients received FMT or colon-preserving surgical intervention in the post-intervention group compared with no patients in the pre-intervention group. There was no difference in 30-day all-cause mortality or CDI recurrence between groups. Conclusion Early, multi-disciplinary action on patients with CDI increased the proportion of patients undergoing active specialty consultation and improved use of concomitant antibiotics. A larger sample size is needed to determine the effects of such a team on other clinical outcomes. Figure 1 Time to GI Consult Figure 2 Time to ID Consult Disclosures All authors: No reported disclosures.

Anterior Cervical Discectomy and Fusion for Adjacent Segment Disease: Clinical Outcomes and Cost Utility of Surgical Intervention.

PubMed

O'Neill, Kevin R; Wilson, Robert J; Burns, Katharine M; Mioton, Lauren M; Wright, Brian T; Adogwa, Owoicho; McGirt, Matthew J; Devin, Clinton J

2016-07-01

Retrospective review. Determine clinical outcomes and cost utility of anterior cervical discectomy and fusion (ACDF) for the treatment of adjacent segment disease (ASD). The incidence of symptomatic ASD after ACDF has been estimated to occur in up to 26% of patients. Commonly, these patients will undergo an additional ACDF procedure. However, there are currently no studies available that adequately describe the clinical outcomes or cost utility of performing ACDF for ASD. A retrospective review of 40 patients undergoing ACDF for ASD was performed. Baseline and 2-year neck and arm pain (NRS-NP, NRS-AP), neck disability index (NDI), physical and mental quality of life (SF-12 PCS & MCS), and Zung depression score (ZDS) were assessed. Two-year total neck-related medical resource utilization, amount of missed work, and health-state values were determined. Quality-adjusted life years (QALYs) were calculated from EQ-5D assessments with US valuation. Comprehensive costs (indirect, direct, and total cost) and the value (cost-per-QALY gained) of performing ACDF for ASD were assessed. Performing ACDF to treat ASD resulted in significant improvements (P<0.05) in NRS-NP, NRS-AP, NDI, SF-12 PCS, and ZDS outcome measures. Patient-reported health states also significantly improved, with a mean cumulative 2-year gain of 0.54 QALYs. The mean 2-year cost of surgery was $32,616 (direct cost: $25,391; indirect cost: $7225). ACDF for the treatment of ASD was associated with a mean 2-year cost per QALY gained of $60,526. Performing ACDF for ASD resulted in significant improvements in patient pain, disability, and quality of life. Further, the mean 2-year cost-per-QALY was determined to be $60,526, which suggests surgical intervention to be cost effective. This study is the first to provide evidence that performing an ACDF for ASD is both clinically and cost effective.

Utilising advance care planning videos to empower perioperative cancer patients and families: a study protocol of a randomised controlled trial.

PubMed

Aslakson, Rebecca A; Isenberg, Sarina R; Crossnohere, Norah L; Conca-Cheng, Alison M; Yang, Ting; Weiss, Matthew; Volandes, Angelo E; Bridges, John F P; Roter, Debra L

2017-06-06

Despite positive health outcomes associated with advance care planning (ACP), little research has investigated the impact of ACP in surgical populations. Our goal is to evaluate how an ACP intervention video impacts the patient centredness and ACP of the patient-surgeon conversation during the presurgical consent visit. We hypothesise that patients who view the intervention will engage in a more patient-centred communication with their surgeons compared with patients who view a control video. Randomised controlled superiority trial of an ACP video with two study arms (intervention ACP video and control video) and four visits (baseline, presurgical consent, postoperative 1 week and postoperative 1 month). Surgeons, patients, principal investigator and analysts are blinded to the randomisation assignment. Single, academic, inner city and tertiary care hospital. Data collection began July 16, 2015 and continues to March 2017. Patients recruited from nine surgical oncology clinics who are undergoing major cancer surgery. In the intervention arm, patients view a patient preparedness video developed through extensive engagement with patients, surgeons and other stakeholders. Patients randomised to the control arm viewed an informational video about the hospital surgical programme. Primary Outcome: Patient centredness and ACP of patient-surgeon conversations during the presurgical consent visit as measured through the Roter Interaction Analysis System. patient Hospital Anxiety and Depression Scale score; patient goals of care; patient, companion and surgeon satisfaction; video helpfulness; medical decision maker designation; and the frequency patients watch the video. Intent-to-treat analysis will be used to assess the impact of video assignment on outcomes. Sensitivity analyses will assess whether there are differential effects contingent on patient or surgeon characteristics. This study has been approved by the Johns Hopkins School of Medicine institutional review board and is registered on clinicaltrials.gov (NCT02489799, First received: July 1, 2015). clinicaltrials.gov, NCT02489799. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Surgical and clinical efficacy of sacroiliac joint fusion: a systematic review of the literature.

PubMed

Zaidi, Hasan A; Montoure, Andrew J; Dickman, Curtis A

2015-07-01

The sacroiliac joint (SIJ) and surgical intervention for treating SIJ pain or dysfunction has been a topic of much debate in recent years. There has been a resurgence in the implication of this joint as the pain generator for many patients experiencing low-back pain, and new surgical methods are gaining popularity within both the orthopedic and neurosurgical fields. There is no universally accepted gold standard for diagnosing or surgically treating SIJ pain. The authors systematically reviewed studies on SIJ fusion in the neurosurgical and orthopedic literature to investigate whether sufficient evidence exists to support its use. A literature search was performed using MEDLINE, Google Scholar, and OvidSP-Wolters Kluwer Health for all articles regarding SIJ fusion published from 2000 to 2014. Original, peer-reviewed, prospective or retrospective scientific papers with at least 2 patients were included in the study. Exclusion criteria included follow-up shorter than 1-year, nonsurgical treatment, inadequate clinical data as determined by 2 independent reviewers, non-English manuscripts, and nonhuman subjects. A total of 16 peer-reviewed journal articles met the inclusion criteria: 5 consecutive case series, 8 retrospective studies, and 3 prospective cohort studies. A total of 430 patients were included, of whom 131 underwent open surgery and 299 underwent minimally invasive surgery (MIS) for SIJ fusion. The mean duration of follow-up was 60 months for open surgery and 21 months for MIS. SIJ degeneration/arthrosis was the most common pathology among patients undergoing surgical intervention (present in 257 patients [59.8%]), followed by SIJ dysfunction (79 [18.4%]), postpartum instability (31 [7.2%]), posttraumatic (28 [6.5%]), idiopathic (25 [5.8%]), pathological fractures (6 [1.4%]), and HLA-B27+/rheumatoid arthritis (4 [0.9%]). Radiographically confirmed fusion rates were 20%-90% for open surgery and 13%-100% for MIS. Rates of excellent satisfaction, determined by pain reduction, function, and quality of life, ranged from 18% to 100% with a mean of 54% in open surgical cases. For MIS patients, excellent outcome, judged by patients' stated satisfaction with the surgery, ranged from 56% to 100% (mean 84%). The reoperation rate after open surgery ranged from 0% to 65% (mean 15%). Reoperation rate after MIS ranged from 0% to 17% (mean 6%). Major complication rates ranged from 5% to 20%, with 1 study that addressed safety reporting a 56% adverse event rate. Surgical intervention for SIJ pain is beneficial in a subset of patients. However, with the difficulty in accurate diagnosis and evidence for the efficacy of SIJ fusion itself lacking, serious consideration of the cause of pain and alternative treatments should be given before performing the operation.

Support surfaces for intraoperative prevention of pressure ulcers in patients undergoing surgery: a cost-effectiveness analysis.

PubMed

Pham, Ba'; Teague, Laura; Mahoney, James; Goodman, Laurie; Paulden, Mike; Poss, Jeff; Li, Jianli; Sikich, Nancy Joan; Lourenco, Rosemarie; Ieraci, Luciano; Carcone, Steven; Krahn, Murray

2011-07-01

Patients who undergo prolonged surgical procedures are at risk of developing pressure ulcers. Recent systematic reviews suggest that pressure redistribution overlays on operating tables significantly decrease the associated risk. Little is known about the cost effectiveness of using these overlays in a prevention program for surgical patients. Using a Markov cohort model, we evaluated the cost effectiveness of an intraoperative prevention strategy with operating table overlays made of dry, viscoelastic polymer from the perspective of a health care payer over a 1-year period. We simulated patients undergoing scheduled surgical procedures lasting ≥90 min in the supine or lithotomy position. Compared with the current practice of using standard mattresses on operating tables, the intraoperative prevention strategy decreased the estimated intraoperative incidence of pressure ulcers by 0.51%, corresponding to a number-needed-to-treat of 196 patients. The average cost of using the operating table overlay was $1.66 per patient. Compared with current practice, this intraoperative prevention strategy would increase slightly the quality-adjusted life days of patients and by decreasing the incidence of pressure ulcers, this strategy would decrease both hospital and home care costs for treating fewer pressure ulcers originated intraoperatively. The cost savings was $46 per patient, which ranged from $13 to $116 by different surgical populations. Intraoperative prevention was 99% likely to be more cost effective than the current practice. In patients who undergo scheduled surgical procedures lasting ≥90 min, this intraoperative prevention strategy could improve patients' health and save hospital costs. The clinical and economic evidence support the implementation of this prevention strategy in settings where it has yet to become current practice. Copyright © 2011 Mosby, Inc. All rights reserved.

Hospital costs associated with smoking in veterans undergoing general surgery.

PubMed

Kamath, Aparna S; Vaughan Sarrazin, Mary; Vander Weg, Mark W; Cai, Xueya; Cullen, Joseph; Katz, David A

2012-06-01

Approximately 30% of patients undergoing elective general surgery smoke cigarettes. The association between smoking status and hospital costs in general surgery patients is unknown. The objectives of this study were to compare total inpatient costs in current smokers, former smokers, and never smokers undergoing general surgical procedures in Veterans Affairs (VA) hospitals; and to determine whether the relationship between smoking and cost is mediated by postoperative complications. Patients undergoing general surgery during the period of October 1, 2005 to September 30, 2006 were identified in the VA Surgical Quality Improvement Program (VASQIP) data set. Inpatient costs were extracted from the VA Decision Support System (DSS). Relative surgical costs (incurred during index hospitalization and within 30 days of operation) for current and former smokers relative to never smokers, and possible mediators of the association between smoking status and cost were estimated using generalized linear regression models. Models were adjusted for preoperative and operative variables, accounting for clustering of costs at the hospital level. Of the 14,853 general surgical patients, 34% were current smokers, 39% were former smokers, and 27% were never smokers. After controlling for patient covariates, current smokers had significantly higher costs compared with never smokers: relative cost was 1.04 (95% Cl 1.00 to 1.07; p = 0.04); relative costs for former smokers did not differ significantly from those of never smokers: 1.02 (95% Cl 0.99 to 1.06; p = 0.14). The relationship between smoking and hospital costs for current smokers was partially mediated by postoperative respiratory complications. These findings complement emerging evidence recommending effective smoking cessation programs in general surgical patients and provide an estimate of the potential savings that could be accrued during the preoperative period. Published by Elsevier Inc.

Better Object Recognition and Naming Outcome With MRI-Guided Stereotactic Laser Amygdalohippocampotomy for Temporal Lobe Epilepsy

PubMed Central

Drane, Daniel L.; Loring, David W.; Voets, Natalie L.; Price, Michele; Ojemann, Jeffrey G.; Willie, Jon T.; Saindane, Amit M.; Phatak, Vaishali; Ivanisevic, Mirjana; Millis, Scott; Helmers, Sandra L.; Miller, John W.; Meador, Kimford J.; Gross, Robert E.

2015-01-01

SUMMARY OBJECTIVES Temporal lobe epilepsy (TLE) patients experience significant deficits in category-related object recognition and naming following standard surgical approaches. These deficits may result from a decoupling of core processing modules (e.g., language, visual processing, semantic memory), due to “collateral damage” to temporal regions outside the hippocampus following open surgical approaches. We predicted stereotactic laser amygdalohippocampotomy (SLAH) would minimize such deficits because it preserves white matter pathways and neocortical regions critical for these cognitive processes. METHODS Tests of naming and recognition of common nouns (Boston Naming Test) and famous persons were compared with nonparametric analyses using exact tests between a group of nineteen patients with medically-intractable mesial TLE undergoing SLAH (10 dominant, 9 nondominant), and a comparable series of TLE patients undergoing standard surgical approaches (n=39) using a prospective, non-randomized, non-blinded, parallel group design. RESULTS Performance declines were significantly greater for the dominant TLE patients undergoing open resection versus SLAH for naming famous faces and common nouns (F=24.3, p<.0001, η2=.57, & F=11.2, p<.001, η2=.39, respectively), and for the nondominant TLE patients undergoing open resection versus SLAH for recognizing famous faces (F=3.9, p<.02, η2=.19). When examined on an individual subject basis, no SLAH patients experienced any performance declines on these measures. In contrast, 32 of the 39 undergoing standard surgical approaches declined on one or more measures for both object types (p<.001, Fisher’s exact test). Twenty-one of 22 left (dominant) TLE patients declined on one or both naming tasks after open resection, while 11 of 17 right (non-dominant) TLE patients declined on face recognition. SIGNIFICANCE Preliminary results suggest 1) naming and recognition functions can be spared in TLE patients undergoing SLAH, and 2) the hippocampus does not appear to be an essential component of neural networks underlying name retrieval or recognition of common objects or famous faces. PMID:25489630

Preoperative oral antibiotics and intravenous antimicrobial prophylaxis reduce the incidence of surgical site infections in patients with ulcerative colitis undergoing IPAA.

PubMed

Oshima, Tsutomu; Takesue, Yoshio; Ikeuchi, Hiroki; Matsuoka, Hiroki; Nakajima, Kazuhiko; Uchino, Motoi; Tomita, Naohiro; Sasako, Mitsuru

2013-10-01

The usefulness of preoperative oral antibiotics for the prevention of surgical site infection in elective colorectal surgery remains controversial. This study aimed to investigate the effects of oral antimicrobial prophylaxis in addition to intravenous antimicrobial prophylaxis on patients with ulcerative colitis undergoing restorative proctocolectomy. This study was a randomized, nonblinded, single-center clinical trial. This study was conducted between July 1, 2006, and April 30, 2009, at Hyogo College of Medicine. Two hundred patients with ulcerative colitis scheduled to undergo restorative proctocolectomy with IPAA with an open approach were randomly assigned to either group A or B (n = 100). Combined use of preoperative oral antibiotics and intravenous antimicrobial prophylaxis were given to group A, and intravenous antimicrobial prophylaxis alone was given to group B. Patients in group A received oral antibiotics the day before surgery (500 mg of kanamycin and 500 mg of metronidazole at 2:00 P.M., 3:00 P.M., and 9:00 P.M.), whereas those in group B did not. All patients underwent preoperative mechanical bowel preparation, and intravenous antimicrobial prophylaxis with second-generation cephalosporin was given for 24 hours. The primary end point of this study was the incidence of overall surgical site infection according to intention-to-treat analysis. The incidence of overall surgical site infection was significantly lower in group A (6/97 patients, 6.1%) than in group B (22/98 patients, 22.4%) (p = 0.0024). In multivariate analysis, the administration of oral antibiotics (OR, 0.178; 95% CI, 0.057-0.552; p = 0.003) and ASA score ≥3 (OR, 5.343; 95% CI, 1.595-17.891; p = 0.007) were independent risk factors for surgical site infection. This study is limited because of its open-label nature. Combined oral and intravenous antimicrobial prophylaxis in patients with ulcerative colitis undergoing restorative proctocolectomy with IPAA contributed to the prevention of surgical site infection.

Perioperative cardiopulmonary exercise testing (CPET): consensus clinical guidelines on indications, organization, conduct, and physiological interpretation.

PubMed

Levett, D Z H; Jack, S; Swart, M; Carlisle, J; Wilson, J; Snowden, C; Riley, M; Danjoux, G; Ward, S A; Older, P; Grocott, M P W

2018-03-01

The use of perioperative cardiopulmonary exercise testing (CPET) to evaluate the risk of adverse perioperative events and inform the perioperative management of patients undergoing surgery has increased over the last decade. CPET provides an objective assessment of exercise capacity preoperatively and identifies the causes of exercise limitation. This information may be used to assist clinicians and patients in decisions about the most appropriate surgical and non-surgical management during the perioperative period. Information gained from CPET can be used to estimate the likelihood of perioperative morbidity and mortality, to inform the processes of multidisciplinary collaborative decision making and consent, to triage patients for perioperative care (ward vs critical care), to direct preoperative interventions and optimization, to identify new comorbidities, to evaluate the effects of neoadjuvant cancer therapies, to guide prehabilitation and rehabilitation, and to guide intraoperative anaesthetic practice. With the rapid uptake of CPET, standardization is key to ensure valid, reproducible results that can inform clinical decision making. Recently, an international Perioperative Exercise Testing and Training Society has been established (POETTS www.poetts.co.uk) promoting the highest standards of care for patients undergoing exercise testing, training, or both in the perioperative setting. These clinical cardiopulmonary exercise testing guidelines have been developed by consensus by the Perioperative Exercise Testing and Training Society after systematic literature review. The guidelines have been endorsed by the Association of Respiratory Technology and Physiology (ARTP). Copyright © 2017. Published by Elsevier Ltd.

Orthopedic surgery in rheumatoid arthritis in the era of biologic therapy.

PubMed

Leon, Leticia; Abasolo, Lydia; Carmona, Loreto; Rodriguez-Rodriguez, Luis; Lamas, Jose Ramon; Hernandez-Garcia, Cesar; Jover, Juan Angel

2013-11-01

To analyze sociodemographic and clinic-related factors associated with the use of orthopedic surgical procedures in rheumatoid arthritis (RA), focusing on the potential role of new biologic therapies. A retrospective medical record review was performed in a probability sample of 1272 patients with RA from 47 units distributed in 19 Spanish regions. Sociodemographic and clinical features, use of drugs, and arthritis-related joint surgeries were recorded following a standardized protocol. A total of 94 patients (7.4%) underwent any orthopedic surgery during their disease course, with a total of 114 surgeries; 47 (41.2%) of these surgeries were total joint replacement (TJR). The median time to first orthopedic procedure was 7.9 years from the onset of RA symptoms, and the rate of orthopedic surgery (excluding TJR) was 4.5 procedures per 100 person-years from the beginning of RA, while the rate of TJR was 2.25 interventions per 100 person-years. A higher risk of undergoing an orthopedic surgical procedure was associated with taking nonsteroidal antiinflammatory drugs (NSAID) in the previous 2 years, female sex, longterm disease, and the presence of extraarticular complications. The risk factors for undergoing a TJR were being old, having a longterm disease, and taking biologic therapies. In the era of biologics, our national audit found a low percentage of patients who underwent orthopedic surgery, probably reflecting a thorough management of the RA. Sociodemographic factors, longterm RA, extraarticular complications, and NSAID were associated with orthopedic surgery.

The epidemiology of upper airway injury in patients undergoing major surgical procedures.

PubMed

Hua, May; Brady, Joanne; Li, Guohua

2012-01-01

Airway injury is a potentially serious and costly adverse event of anesthesia care. The epidemiologic characteristics of airway injury have not been well documented. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) is a multicenter, prospective, outcome-oriented database for patients undergoing major surgical procedures. Using the NSQIP data for the years 2005 to 2008, we examined the incidence of, and risk factors for, airway injury. Of the 563,190 patients studied, 1202 (0.2%) sustained airway injury. The most common airway injury was lip laceration/hematoma (61.4%), followed by tooth injury (26.1%), tongue laceration (5.7%), pharyngeal laceration (4.7%), and laryngeal laceration (2.1%). Multivariable logistic modeling revealed an increased risk of airway injury in patients with Mallampati class III (adjusted odds ratio [OR], 1.69; 99% confidence interval [CI], 1.36-2.11, relative to patients with Mallampati classes I and II) or class IV (adjusted OR, 2.6; 99% CI, 1.52-4.02), and in patients aged 80 years or older (adjusted OR, 1.50; 99% CI, 1.02-2.19, relative to patients aged 40 to 49 years). The risk of airway injury for patients undergoing major surgical procedures is approximately 1 in 500. Patients with difficult airways as indicated by Mallampati classes III and IV are at significantly increased risk of sustaining airway injury during anesthesia for major surgical procedures.

[Hereditary heterozygous factor VII deficiency in patients undergoing surgery : Clinical relevance].

PubMed

Woehrle, D; Martinez, M; Bolliger, D

2016-10-01

A hereditary deficiency in coagulation factor VII (FVII) may affect the international normalized ratio (INR) value. However, FVII deficiency is occasionally associated with a tendency to bleed spontaneously. We hypothesized that perioperative substitution with coagulation factor concentrates might not be indicated in most patients. In this retrospective data analysis, we included all patients with hereditary heterozygous FVII deficiency who underwent surgical procedures at the University Hospital Basel between December 2010 and November 2015. In addition, by searching the literature, we identified publications reporting patients with FVII deficiency undergoing surgical procedures without perioperative substitution. We identified 22 patients undergoing 46 surgical procedures, resulting in a prevalence of 1:1500-2000. Coagulation factor concentrates were administered during the perioperative period in 15 procedures (33 %), whereas in the other 31 procedures (66 %), FVII deficiency was not substituted. No postoperative bleeding or thromboembolic events were reported. In addition, we found no differences in pre- and postoperative hemoglobin and coagulation parameters, with the exception of an improved postoperative INR value in the substituted group. In the literature review, we identified five publications, including 125 patients with FVII deficiency, undergoing 213 surgical procedures with no perioperative substitution. Preoperative substitution using coagulation factor concentrates does not seem to be mandatory in patients with an FVII level ≥15 %. For decision-making on preoperative substitution, patient history of an increased tendency to bleed may be more important than the FVII level or increased INR value.

Obesity paradox in patients undergoing coronary intervention: A review

PubMed Central

Patel, Nirav; Elsaid, Ossama; Shenoy, Abhishek; Sharma, Abhishek; McFarlane, Samy I

2017-01-01

There is strong relationship exist between obesity and cardiovascular disease including coronary artery disease (CAD). However, better outcomes noted in obese patients undergoing percutaneous cardiovascular interventions for CAD, a phenomenon known as the obesity paradox. In this review, we performed extensive search for obesity paradox in obese patients undergoing percutaneous coronary intervention and discussed possible mechanism and disparities in different race and sex. PMID:29081905

Endoscopic or surgical intervention for painful obstructive chronic pancreatitis.

PubMed

Ahmed Ali, Usama; Pahlplatz, Johanna M; Nealon, Wiliam H; van Goor, Harry; Gooszen, Hein G; Boermeester, Marja A

2015-03-19

Endoscopy and surgery are the treatment modalities of choice for patients with chronic pancreatitis and dilated pancreatic duct (obstructive chronic pancreatitis). Physicians face, without clear consensus, the choice between endoscopy or surgery for this group of patients. To assess and compare the effects and complications of surgical and endoscopic interventions in the management of pain for obstructive chronic pancreatitis. We searched the following databases in The Cochrane Library: CENTRAL (2014, Issue 2), the Cochrane Database of Systematic Reviews (2014, Issue 2), and DARE (2014, Issue 2). We also searched the following databases up to 25 March 2014: MEDLINE (from 1950), Embase (from 1980), and the Conference Proceedings Citation Index - Science (CPCI-S) (from 1990). We performed a cross-reference search. Two review authors independently performed the selection of trials. All randomised controlled trials (RCTs) of endoscopic or surgical interventions in obstructive chronic pancreatitis. We included trials comparing endoscopic versus surgical interventions as well as trials comparing either endoscopic or surgical interventions to conservative treatment (i.e. non-invasive treatment modalities). We included relevant trials irrespective of blinding, the number of participants randomised, and the language of the article. We used standard methodological procedures expected by The Cochrane Collaboration. Two authors independently extracted data from the articles. We evaluated the methodological quality of the included trials and requested additional information from study authors in the case of missing data. We identified three eligible trials. Two trials compared endoscopic intervention with surgical intervention and included a total of 111 participants: 55 in the endoscopic group and 56 in the surgical group. Compared with the endoscopic group, the surgical group had a higher proportion of participants with pain relief, both at middle/long-term follow-up (two to five years: risk ratio (RR) 1.62, 95% confidence interval (CI) 1.22 to 2.15) and long-term follow-up (≥ five years, RR 1.56, 95% CI 1.18 to 2.05). Surgical intervention resulted in improved quality of life and improved preservation of exocrine pancreatic function at middle/long-term follow-up (two to five years), but not at long-term follow-up (≥ 5 years). No differences were found in terms of major post-interventional complications or mortality, although the number of participants did not allow for this to be reliably evaluated. One trial, including 32 participants, compared surgical intervention with conservative treatment: 17 in the surgical group and 15 in the conservative group. The trial showed that surgical intervention resulted in a higher percentage of participants with pain relief and better preservation of pancreatic function. The trial had methodological limitations, and the number of participants was relatively small. For patients with obstructive chronic pancreatitis and dilated pancreatic duct, this review shows that surgery is superior to endoscopy in terms of pain relief. Morbidity and mortality seem not to differ between the two intervention modalities, but the small trials identified do not provide sufficient power to detect the small differences expected in this outcome.Regarding the comparison of surgical intervention versus conservative treatment, this review has shown that surgical intervention in an early stage of chronic pancreatitis is a promising approach in terms of pain relief and pancreatic function. Other trials need to confirm these results because of the methodological limitations and limited number of participants assessed in the present evidence.

Implementation of an enhanced recovery protocol in pediatric colorectal surgery.

PubMed

Short, Heather L; Heiss, Kurt F; Burch, Katelyn; Travers, Curtis; Edney, John; Venable, Claudia; Raval, Mehul V

2018-04-01

Enhanced recovery protocols (ERPs) have been shown to improve outcomes in adult surgical populations. Our purpose was to compare outcomes before and after implementation of an ERP in children undergoing elective colorectal surgery. A pediatric-specific colorectal ERP was developed and implemented at a single center starting in January 2015. A retrospective review was performed including 43 patients in the pre-ERP period (2012-2014) and 36 patients in the post-ERP period (2015-2016). Outcomes of interest included number of ERP interventions received, length of stay (LOS), complications, and readmissions. The median number of ERP interventions received per patient increased from 5 to 11 from 2012 to 2016. The median LOS decreased from 5days to 3days in the post-ERP period (p=0.01). We observed a simultaneous decrease in median time to regular diet, mean dose of narcotics, and mean volume of intraoperative fluids (p<0.001). The complication rate (21% vs. 17%, p=0.85) and 30-day readmission rate (23% vs. 11%, p=0.63) were not significantly different in the pre- and post-ERP periods. Implementation of a pediatric-specific ERP in children undergoing colorectal surgery is feasible, safe and may lead to improved outcomes. Further experience may highlight other opportunities for increased compliance and improved care. Treatment Study. Level III. Copyright © 2017 Elsevier Inc. All rights reserved.

Pre-operative Predictive Factors of Post-operative Pain in Patients With Hip or Knee Arthroplasty: A Systematic Review.

PubMed

Hernández, Clara; Díaz-Heredia, Jorge; Berraquero, María Luisa; Crespo, Pablo; Loza, Estíbaliz; Ruiz Ibán, Miguel Ángel

2015-01-01

To analyze pre-surgical predictive factors of post-surgical pain in patients undergoing hip or knee arthoplasty. A systematic literature review was performed. We defined a sensitive strategy on Medline, Embase and Cochrane Library up to May 2013. The inclusion criteria were: patients undertaking knee and/or hip arthroplasty, adults with moderate or severe pain (≥4 on a Visual Analog Scale) in whom predictive factors of post-surgical pain were evaluated before surgery. Systematic reviews, meta-analyses, controlled trials and observational studies were selected. We excluded animals and basic science articles, reviews of prosthesis, prosthesis due to fractures, patients with rheumatic diseases or studies with mixed population in which disaggregated data was not possible to obtain. A total 37 articles of moderate quality were selected. The articles included representative patients undergoing a knee or hip arthroplasty in our country; most of them were aged 60 years or above, with osteoarthritis, and with a high rate of obesity and comorbidities. We found great variability regarding the type of studies and predictive factors. There was a strong association between post-surgical pain and the following pre-surgical factors: female gender, low socio-economic status, higher pain, comorbidities, low back pain, poor functional status, and psychological factors (depression, anxiety or catastrophic pain). There are pre-surgical factors that might influence post-surgical pain in patients undergoing a knee or hip arthroplasty. Therefore, they should be taken into account when considering an arthroplasty. Copyright © 2014 Elsevier España, S.L.U. y Sociedad Española de Reumatología y Colegio Mexicano de Reumatología. All rights reserved.

The effects of nitrous oxide on vascular endothelial growth factor (VEGF) and its soluble receptor 1 (VEGFR1) in patient undergoing urological surgery

PubMed Central

Hakimoglu, Yasemin; Can, Murat; Hakimoglu, Sedat; Gorkem Mungan, Ayca; Acikgoz, Sereften; Cikcikoglu Yildirim, Nuran; Aydin Mungan, Necmettin; Ozkocak Turan, Isil

2014-01-01

Objective: Anesthesia and surgical intervention, leads to the development of systemic inflammatory response. The severity of the inflammatory response depends on the pharmacological effects of anesthetic agents and duration of anesthesia. Objective of the study was to investigate the effect of nitrous oxide on VEGF and VEGFR1 levels in patients undergoing surgery. Methods: Forty-four patients undergoing elective urological surgery were included in the study. Anesthesia maintenance was provided with 1-2 MAC sevoflurane, O2 50%, N2O 50% in 4L/m transporter gase for group 1 (n=22) and 1-2 MAC sevoflurane, O2 50%, air 50% in 4L/m transporter gase for group 2 (n=22) Venous blood samples for the measurement of VEGF and VEGFR1 were taken before the induction of anaesthesia, 60 minutes of anesthesia induction, at the end of anaesthesia and 24 hours after operation. In statistical analysis Bonferroni test and analysis of variance at the repeated measures were used Results: In the postoperative period serum VEGF levels had decreased significantly in both group whereas VEGFR1 did not show a significant change. Conclusions: Nitrous oxide showed significant effect on angiogenic parameters. Further detailed studies are required to evaluate the effect of nitrous oxide. PMID:24639829

The effects of nitrous oxide on vascular endothelial growth factor (VEGF) and its soluble receptor 1 (VEGFR1) in patient undergoing urological surgery.

PubMed

Hakimoglu, Yasemin; Can, Murat; Hakimoglu, Sedat; Gorkem Mungan, Ayca; Acikgoz, Sereften; Cikcikoglu Yildirim, Nuran; Aydin Mungan, Necmettin; Ozkocak Turan, Isil

2014-01-01

Anesthesia and surgical intervention, leads to the development of systemic inflammatory response. The severity of the inflammatory response depends on the pharmacological effects of anesthetic agents and duration of anesthesia. OBJECTIVE of the study was to investigate the effect of nitrous oxide on VEGF and VEGFR1 levels in patients undergoing surgery. Forty-four patients undergoing elective urological surgery were included in the study. Anesthesia maintenance was provided with 1-2 MAC sevoflurane, O2 50%, N2O 50% in 4L/m transporter gase for group 1 (n=22) and 1-2 MAC sevoflurane, O2 50%, air 50% in 4L/m transporter gase for group 2 (n=22) Venous blood samples for the measurement of VEGF and VEGFR1 were taken before the induction of anaesthesia, 60 minutes of anesthesia induction, at the end of anaesthesia and 24 hours after operation. In statistical analysis Bonferroni test and analysis of variance at the repeated measures were used Results: In the postoperative period serum VEGF levels had decreased significantly in both group whereas VEGFR1 did not show a significant change. Nitrous oxide showed significant effect on angiogenic parameters. Further detailed studies are required to evaluate the effect of nitrous oxide.

Effectiveness of standardized approach versus usual care on physiotherapy treatment for patients submitted to alveolar bone graft: a pilot study.

PubMed

Vidotto, Laís Silva; Bigliassi, Marcelo; Alencar, Tatiane Romanini Rodrigues; Silva, Thaísa Maria Santos; Probst, Vanessa Suziane

2015-07-01

To compare the acute effects of a standardized physiotherapy protocol versus a typical non-standardized physiotherapy protocol on pain and performance of patients undergoing alveolar bone graft (ABG). Sixteen patients (9 males; 12 [11-13] years) with cleft lip and palate undergoing ABG were allocated into two groups: (1) experimental group--EG (standardized physiotherapy protocol); and (2) control group--CG (typical, non-standardized physiotherapy treatment). Range of motion, muscle strength, gait speed, and pain level were assessed prior to surgical intervention (PRE), as well as on the first, second, and third post-operative days (1st, 2nd, and 3rd PO, respectively). Recovery with respect to range of motion of hip flexion was more pronounced in the EG (64.6 ± 11.0°) in comparison to the CG (48.5 ± 17.7° on the 3rd PO; p < 0.05). In addition, less pain was observed in the EG (0 [0-0.2] versus 2 [0.7-3] in the CG on the 3rd PO; p < 0.05). A standardized physiotherapy protocol appears to be better than a non-standardized physiotherapy protocol for acute improvement of range of motion of hip flexion and for reducing pain in patients undergoing ABG.

Immediate postpartum ultrasound evaluation for suspected retained placental tissue in patients undergoing manual removal of placenta.

PubMed

Weissbach, T; Haikin-Herzberger, E; Bacci-Hugger, K; Shechter-Maor, G; Fejgin, M; Biron-Shental, T

2015-09-01

Approximately 1% of term deliveries are complicated by retained products of conception. Untreated, this condition may cause bleeding, infection and intrauterine adhesions. This study assessed whether performing routine bedside uterine ultrasound immediately after manual removal of the placenta reduced the occurrence of undiagnosed, retained products of conception and its associated complications. A retrospective study was conducted using the records of patients who delivered and underwent manual removal of placenta at a single obstetrics center over a 6-year period. The outcomes of patients who were assessed using immediate bedside ultrasound were compared to a similar group who were treated based on clinical evaluation alone. All patients underwent ultrasound examination prior to discharge. Outcome variables included the rate of additional interventions (medical or surgical), abnormal pre-discharge uterine ultrasound findings, postpartum hemorrhage rate, puerperal fever and length of hospital stay. A total of 399 charts were reviewed. Immediate post-procedural ultrasound was performed in 235 patients. The remaining 164 women did not undergo immediate post-procedural ultrasound. All patients underwent an ultrasound examination prior to discharge. Among the patients who had an immediate post-procedural ultrasound, 12 (5.1%) received immediate re-intervention (2 methergine, 6 curettage and 4 manual uterine revision) vs. no intervention in the second group (p<0.001). No statistically significant difference was found between the group of patients who had immediate post-procedural ultrasound and those who did not, in the rates of postpartum hemorrhage (3.1% vs. 0.7%, p=0.13), abnormal ultrasound findings prior to discharge (14.9% vs. 14.8%, p=0.96) or additional late intervention (7.2% vs. 7.9%, p=0.79), respectively. Our findings suggest that immediate, bedside uterine ultrasound examination after manual removal of placenta might not change patient outcomes. Furthermore, it might increase unnecessary interventions. Further studies are needed to prospectively assess the benefit of routine uterine ultrasound examination after manual removal of placenta. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Incidence of intraoperative seizures during motor evoked potential monitoring in a large cohort of patients undergoing different surgical procedures.

PubMed

Ulkatan, Sedat; Jaramillo, Ana Maria; Téllez, Maria J; Kim, Jinu; Deletis, Vedran; Seidel, Kathleen

2017-04-01

OBJECTIVE The purpose of this study was to investigate the incidence of seizures during the intraoperative monitoring of motor evoked potentials (MEPs) elicited by electrical brain stimulation in a wide spectrum of surgeries such as those of the orthopedic spine, spinal cord, and peripheral nerves, interventional radiology procedures, and craniotomies for supra- and infratentorial tumors and vascular lesions. METHODS The authors retrospectively analyzed data from 4179 consecutive patients who underwent surgery or an interventional radiology procedure with MEP monitoring. RESULTS Of 4179 patients, only 32 (0.8%) had 1 or more intraoperative seizures. The incidence of seizures in cranial procedures, including craniotomies and interventional neuroradiology, was 1.8%. In craniotomies in which transcranial electrical stimulation (TES) was applied to elicit MEPs, the incidence of seizures was 0.7% (6/850). When direct cortical stimulation was additionally applied, the incidence of seizures increased to 5.4% (23/422). Patients undergoing craniotomies for the excision of extraaxial brain tumors, particularly meningiomas (15 patients), exhibited the highest risk of developing an intraoperative seizure (16 patients). The incidence of seizures in orthopedic spine surgeries was 0.2% (3/1664). None of the patients who underwent surgery for conditions of the spinal cord, neck, or peripheral nerves or who underwent cranial or noncranial interventional radiology procedures had intraoperative seizures elicited by TES during MEP monitoring. CONCLUSIONS In this largest such study to date, the authors report the incidence of intraoperative seizures in patients who underwent MEP monitoring during a wide spectrum of surgeries such as those of the orthopedic spine, spinal cord, and peripheral nerves, interventional radiology procedures, and craniotomies for supra- and infratentorial tumors and vascular lesions. The low incidence of seizures induced by electrical brain stimulation, particularly short-train TES, demonstrates that MEP monitoring is a safe technique that should not be avoided due to the risk of inducing seizures.

Minimally invasive image-guided interventional management of hepatic artery pseudoaneurysms.

PubMed

Vyas, Sameer; Khandelwal, Niranjan; Gupta, Vivek; Kamal Ahuja, Chirag; Kumar, Ajay; Kalra, Naveen; Kang, Mandeep; Prakash, Mahesh

2014-01-01

Hepatic artery pseudoaneurysms (HAPs) are uncommon entities. With the development of interventional techniques, their management has evolved from conventional (surgical) to non-surgical minimally invasive image-guided interventional techniques. Fifteen cases of HAPs who had undergone non-surgical interventional management in our department were reviewed. All patients were comprehensively evaluated for demographic information, morphology of pseudoaneurysm, indication for intervention and means of intervention, approach (endovascular or percutaneous), follow up and complications. Trauma and iatrogenic injury were most common causes of HAPs. Most of the HAPs (9 out of 10 in whom long follow up was available) managed with image-guided interventional techniques had favorable outcome. Minimally invasive image-guided interventional management is the preferred modality for HAPs.

Comparison of surgical conditions following premedication with oral clonidine versus oral diazepam for endoscopic sinus surgery: A randomized, double-blinded study

PubMed Central

Bhat Pai, Rohini V; Badiger, Santhoshi; Sachidananda, Roopa; Basappaji, Santhosh Mysore Chandramouli; Shanbhag, Raghunath; Rao, Raghavendra

2016-01-01

Background and Aims: Endoscopic sinus surgery (ESS) provides a challenge and an opportunity to the anesthesiologists to prove their mettle and give the surgeons a surgical field which can make their delicate surgery safer,more precise and faster. The aim of the study was to evaluate the surgical field and the rate of blood loss in patients premedicated with oral clonidine versus oral diazepam for endoscopic sinus surgery. Material and Methods: ASA I or II patients who were scheduled to undergo ESS were randomly allocated to group D (n = 30) or group C (n = 30). The patients' vital parameters, propofol infusion rate, and rate of blood loss were observed and calculated. The surgeon, who was blinded, rated the visibility of the surgical field from grade 0-5. Results: In the clonidine group, the rate of blood loss, the surgical time, propofol infusion rate was found to be statistically lower as compared to the diazepam group. Also a higher number of patients in the clonidine group had a better surgical score (better surgical field) than the diazepam group and vice versa. Conclusions: Premedication with clonidine as compared to diazepam, provides a better surgical field with less blood loss in patients undergoing ESS. PMID:27275059

The Role of BMI in Hip Fracture Surgery.

PubMed

Akinleye, Sheriff D; Garofolo, Garret; Culbertson, Maya Deza; Homel, Peter; Erez, Orry

2018-01-01

Obesity is an oft-cited cause of surgical morbidity and many institutions require extensive supplementary screening for obese patients prior to surgical intervention. However, in the elderly patients, obesity has been described as a protective factor. This article set out to examine the effect of body mass index (BMI) on outcomes and morbidity after hip fracture surgery. The National Surgical Quality Improvement Program database was queried for all patients undergoing 1 of 4 surgical procedures to manage hip fracture between 2008 and 2012. Patient demographics, BMI, and known factors that lead to poor surgical outcomes were included as putative predictors for complications that included infectious, cardiac, pulmonary, renal, and neurovascular events. Using χ 2 tests, 30-day postoperative complication rates were compared between 4 patient groups stratified by BMI as low weight (BMI < 20), normal (BMI = 20-30), obese (BMI = 30-40), and morbidly obese (BMI > 40). A total of 15 108 patients underwent surgery for hip fracture over the examined 5-year period. Of these, 18% were low weight (BMI < 20), 67% were normal weight (BMI = 20-30), 13% were obese (BMI = 30-40), and 2% were morbidly obese (BMI > 40). The low-weight and morbidly obese patients had both the highest mortality rates and the lowest superficial infection rates. There was a significant increase in blood transfusion rates that decreased linearly with increasing BMI. Deep surgical site infection and renal failure increased linearly with increasing BMI, however, these outcomes were confounded by comorbidities. This study demonstrates that patients at either extreme of the BMI spectrum, rather than solely the obese, are at greatest risk of major adverse events following hip fracture surgery. This runs contrary to the notion that obese hip fracture patients automatically require additional preoperative screening and perioperative services, as currently implemented in many institutions.

Therapeutic Decision-Making for Elderly Patients With Symptomatic Severe Valvular Heart Diseases.

PubMed

Hu, Kui; Wan, Yun; Hong, Tao; Lu, Shu Yang; Guo, Chang Fa; Li, Jun; Wang, Chun Sheng

2016-07-27

The aim of this study was to determine how older age and co-morbidities affect the treatment decision-making and long-term survival in elderly patients with symptomatic severe valvular heart diseases.A total of 181 elderly patients (mean age, 78.4 ± 3.4 years) hospitalized between January 2003 and June 2012 with symptomatic severe valvular heart diseases were enrolled. Cardiac and geriatric factors associated with treatment decision-making were analyzed. Survival outcomes were investigated.Surgical treatment was performed in 116 (64%) patients (surgical group) and 65 patients (36%) were treated conservatively (conservative group). The most common [62% (40/65)] reason for refusing surgical treatment was high operative risk as assessed by the physicians who initially cared for the patients. Multivariate logistic regression analysis identified female gender, chronic renal insufficiency, older age, pneumonia, and emergent status as independent predictors of the conservative treatment. Patients with isolated aortic valve disease tended to undergo an operation. Overall 5-year survival in the surgical group was 76.8% versus 42.9% in the conservative group (P < 0.0001). After matching using the propensity score, the surgical group still had a better long-term survival than the conservative group (P = 0.001). Cox regression analysis revealed conservative treatment as the single risk factor associated with poor long-term survival in all series.Approximately 40% of the elderly patients with symptomatic severe heart valve disease were treated conservatively despite a definite indication for surgical intervention. Cardiac and geriatric co-morbidities profoundly affect the treatment decision-making. Interdisciplinary discussion should be encouraged to optimize therapeutic options for elderly patients with valvular heart disease.

Therapeutic options in locally advanced thyroid carcinoma. Our experience.

PubMed

Avenia, Nicola; Monacelli, Massimo; Sanguinetti, Alessandro; Santoprete, Stefano; Pecoriello, Roberta; Ragusa, Mark; Puma, Francesco

2012-01-01

Thyroid cancer is the most common endocrine malignancy with an incidence equal to 1% of all malignant tumors. Prognostic factors affecting survival are manifold, including in several classifications (AMES, AGES, CORN and TNM). In this sense, the invasion of adjacent structures is one of the most important variables. The authors describe the experience of a single center in surgical treatment of advanced thyroid cancer. Between 1986 and 2010 , 1565 patients were undergoing surgery with thyroid cancer. In particular, 1403 interventions were made for differentiated cancer, 97 for medullary carcinoma, 25 for insular carcinoma, 29 for anaplastic carcinoma, 2 for plasmacytoma, and 7 for lymphoma and 2 for angiosarcoma. Among these 896 showed invasion of adjacent structures and / or distant metastases. There were no perioperative deaths or major complications. Surgical procedures consisted of: 13 loboistmectomy, 519 total thyroidectomy (TT), 325 TT with lymphadenectomy of the central compartment, 7 TT with radical lymphectomy, 621 TT with functional lymphectomy, 6 TT with breast lumpectomy, 5 TT with with video-assisted lung metastasectomy, 16-TT with resection and tracheal anastomosis, 6 TT with laryngotracheal resection, 3 TT with laryngectomy, 4 TT with trachetomy, 28 TT with respiratory stent placement, 12 tracheotomy. At present, 1328 patients were free of disease, while 104 showed recurrence. Total of 133 deaths were recorded, all linked to disease relapse. The role of surgery in the treatment of advanced thyroid cancer is still undeniable. In the presence of extracapsular trespassing, in fact, the adoption of interventions demolition permits long-term survival, given the lack of aggressiveness of the tumor differentiated representing the majority of cases. The aim of surgical radicalization addition, even in the presence of distant metastases, it is justified by the possibilities offered by the therapeutic radioiodine treatment, which is not feasible in the presence of significant amounts of thyroid tissue which picks. In the presence of undifferentiated tumors, finally, endoscopic or surgical treatment may be indicated by simple purpose of palliation of respiratory symptoms.

Video-assisted thoracoscopic lobectomy after percutaneous coronary intervention in lung cancer patients with concomitant coronary heart disease.

PubMed

Li, Xin; Fu, YiLi; Miao, JinBai; Li, Hui; Hu, Bin

2017-09-01

In recent years, based on clinical observations, the number of lung cancer patients with concomitant coronary heart disease (CHD) has gradually increased. However, because of the requirement of long-term anticoagulant therapy after percutaneous coronary intervention (PCI), some of these patients lose the opportunity for surgical treatment, resulting in tumor progression. The objective of this study was to determine the appropriate timing of video-assisted thoracic surgery (VATS) lobectomy after PCI without increasing perioperative cardiovascular risk. This study retrospectively analyzed clinical data of patients with a combination of NSCLC and CHD who underwent selective pulmonary lobectomy by VATS in the early postoperative PCI period between 2010 and 2015 at Beijing Chaoyang Hospital, China. Fourteen patients received VATS lobectomy after PCI. The disease had progressed to T stage in two patients after PCI. No perioperative death occurred. Two patients suffered postoperative atrial fibrillation: one had a pulmonary infection, and the other had acute coronary syndrome. All patients recovered and were discharged. For NSCLC patients with severe CHD, the use of VATS lobectomy in the early postoperative PCI period could not only advance the timing of surgery, but may also control perioperative hemorrhage and CHD event risks within acceptable ranges, which could provide more patients with an opportunity to undergo surgical treatment. © 2017 The Authors. Thoracic Cancer published by China Lung Oncology Group and John Wiley & Sons Australia, Ltd.

Perioperative supplementation with bifidobacteria improves postoperative nutritional recovery, inflammatory response, and fecal microbiota in patients undergoing colorectal surgery: a prospective, randomized clinical trial

PubMed Central

MIZUTA, Minoru; ENDO, Izuru; YAMAMOTO, Sumiharu; INOKAWA, Hidetoshi; KUBO, Masatoshi; UDAKA, Tetsunobu; SOGABE, Osanori; MAEDA, Hiroya; SHIRAKAWA, Kazutoyo; OKAZAKI, Eriko; ODAMAKI, Toshitaka; ABE, Fumiaki; XIAO, Jin-zhong

2015-01-01

The use of probiotics has been widely documented to benefit human health, but their clinical value in surgical patients remains unclear. The present study investigated the effect of perioperative oral administration of probiotic bifidobacteria to patients undergoing colorectal surgery. Sixty patients undergoing colorectal resection were randomized to two groups prior to resection. One group (n=31) received a probiotic supplement, Bifidobacterium longum BB536, preoperatively for 7–14 days and postoperatively for 14 days, while the other group (n=29) received no intervention as a control. The occurrences of postoperative infectious complications were recorded. Blood and fecal samples were collected before and after surgery. No significant difference was found in the incidence of postoperative infectious complications and duration of hospital stay between the two groups. In comparison to the control group, the probiotic group tended to have higher postoperative levels of erythrocytes, hemoglobin, lymphocytes, total protein, and albumin and lower levels of high sensitive C-reactive proteins. Postoperatively, the proportions of fecal bacteria changed significantly; Actinobacteria increased in the probiotic group, Bacteroidetes and Proteobacteria increased in the control group, and Firmicutes decreased in both groups. Significant correlations were found between the proportions of fecal bacteria and blood parameters; Actinobacteria correlated negatively with blood inflammatory parameters, while Bacteroidetes and Proteobacteria correlated positively with blood inflammatory parameters. In the subgroup of patients who received preoperative chemoradiotherapy treatment, the duration of hospital stay was significantly shortened upon probiotic intervention. These results suggest that perioperative oral administration of bifidobacteria may contribute to a balanced intestinal microbiota and attenuated postoperative inflammatory responses, which may subsequently promote a healthy recovery after colorectal resection. PMID:27200261

Predisposing cardiac conditions, interventional procedures, and antibiotic prophylaxis among patients with infective endocarditis.

PubMed

Chirillo, Fabio; Faggiano, Pompilio; Cecconi, Moreno; Moreo, Antonella; Squeri, Angelo; Gaddi, Oscar; Cecchi, Enrico

2016-09-01

Efficacy and safety of antibiotic prophylaxis (AP) for prevention of infective endocarditis (IE) in patients with predisposing cardiac condition (PCC) undergoing invasive procedures is still debated. We sought to assess the prevalence of PCC, the type of interventional procedures preceding the onset of symptoms, and the usefulness of AP in a large cohort of consecutive patients with definite IE. We examined 677 (median age 65.34 years; male 492 [73%]) consecutive patients with IE enrolled from July 2007 through 2010 into the Italian Registry of Infective Endocarditis. Predisposing cardiac condition was present in 341 patients (50%).Thirty-two patients (4.7%) underwent dental procedures. Of 20 patients with PCC undergoing dental procedure, 13 had assumed AP. Viridans group streptococci were isolated from blood cultures in 8 of 20 patients with PCC and prior dental procedure. Nondental procedures preceded IE in 139 patients (21%). They were significantly older and had more comordibities compared with patients undergoing dental procedures. Predisposing cardiac condition was identified in 91 patients. Perioperative antimicrobial prophylaxis was administered to 67 patients. Staphylococcus aureus was the most frequent causative agent. Cardiac surgery was necessary in 85 patients (20 with prior dental and 65 with nondental procedure). Surgical mortality (12% vs 0%, P = .03) and hospital mortality (23% vs 3%, P = .001) were significantly larger among patients with nondental procedures. In a large unselected cohort of patients with IE, the incidence of preceding dental procedures was minimal. The number of cases potentially preventable by means of AP was negligible. Nondental procedures were more frequent than dental procedures and were correlated with poorer prognosis. Copyright © 2016 Elsevier Inc. All rights reserved.

Incidence and management of inadvertent puncture and sheath placement in the aorta during attempted transseptal puncture.

PubMed

Wasmer, Kristina; Zellerhoff, Stephan; Köbe, Julia; Mönnig, Gerold; Pott, Christian; Dechering, Dirk G; Lange, Philipp S; Frommeyer, Gerrit; Eckardt, Lars

2017-03-01

Transseptal punctures (TSP) are routinely performed in cardiac interventions requiring access to the left heart. While pericardial effusion/tamponade are well-recognized complications, few data exist on accidental puncture of the aorta and its management and outcome. We therefore analysed our single centre database for this complication. We assessed frequency and outcome of inadvertent aortic puncture during TSP in consecutive patients undergoing ablation procedures between January 2005 and December 2014. During the 10-year period, two inadvertent aortic punctures occurred among 2936 consecutive patients undergoing 4305 TSP (0.07% of patients, 0.05% of TSP) and in one Mustard patient during attempted baffle puncture. The first two patients required left ventricular access for catheter ablation of ventricular tachycardia. In both cases, an 11.5F steerable sheath (inner diameter 8.5F) was accidentally placed in the ascending aorta just above the aortic valve. In the presence of surgical standby, the sheaths were pulled back with a wire left in the aorta. Under careful haemodynamic and echocardiographic observation, this wire was also pulled back 30 min later. None of the patients required a closing device or open heart surgery. None of the patients suffered complications from the accidental aortic puncture and sheath placement. Inadvertent aortic puncture and sheath placement are rare complications in patients undergoing TSP for interventional procedures. Leaving a guidewire in place during the observation period may allow introduction of sheaths or other tools in order to control haemodynamic deterioration. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2016. For permissions please email: journals.permissions@oup.com.

Endoscopic or surgical intervention for painful obstructive chronic pancreatitis.

PubMed

Ahmed Ali, Usama; Pahlplatz, Johanna M; Nealon, Wiliam H; van Goor, Harry; Gooszen, Hein G; Boermeester, Marja A

2012-01-18

Endoscopy and surgery are the treatment modalities of choice in patients with obstructive chronic pancreatitis. Physicians face the decision between endoscopy and surgery for this group of patients, without clear consensus. To assess and compare the effectiveness and complications of surgical and endoscopic interventions in the management of pain for obstructive chronic pancreatitis. We searched The Cochrane Library, MEDLINE, EMBASE and the Conference Proceedings Citation Index; and performed a cross-reference search. Two review authors performed the selection of trials independently. All randomised controlled trials (RCTs) investigating endoscopic or surgical interventions for obstructive chronic pancreatitis. All trials were included irrespective of blinding, number of patients randomised and language of the article. Two authors independently extracted data from the articles. The methodological quality of included trials was evaluated. Authors were requested additional information in the case of missing data. We screened 2082 publications and identified three eligible trials. Two trials compared endoscopic intervention to surgical intervention. These included a total of 111 patients, 55 in the endoscopic group and 56 in the surgical group. A higher proportion of patients with pain relief was found in the surgical group compared to the endoscopic group (partial or complete pain relief: RR 1.62, 95% confidence interval (CI) 1.11 to 2.37; complete pain relief: RR 2.45, 95% CI 1.18 to 5.09). Surgical intervention resulted in improved quality of life and improved preservation of exocrine pancreatic function in one trial. The number of patients did not allow for a reliable evaluation of morbidity and mortality between the two treatment modalities. One trial compared surgical intervention to conservative treatment. It included 32 patients: 17 in the surgical group and 15 in the conservative group. The trial showed that surgical intervention resulted in a higher percentage of patients with pain relief and better preservation of pancreatic function. The trial had methodological limitations and the number of patients was relatively small. For patients with obstructive chronic pancreatitis and dilated pancreatic duct, this review showed that surgery is superior to endoscopy in terms of pain control. Morbidity and mortality seemed not to differ between the two intervention modalities, but the small trials identified do not provide sufficient power to detect the small differences expected in this outcome.Regarding the comparison of surgical intervention versus conservative treatment, this review has shown that surgical intervention in an early stage of chronic pancreatitis seems to be a promising approach in terms of pain control and pancreatic function. Confirmation of these results is needed in other trials due to the methodological limitations and limited number of patients of the present evidence.

Pre-operative training induces changes in the histomorphometry and muscle function of the pelvic floor in patients with indication of radical prostatectomy.

PubMed

Ocampo-Trujillo, A; Carbonell-González, J; Martínez-Blanco, A; Díaz-Hung, A; Muñoz, C A; Ramírez-Vélez, R

2014-01-01

To evaluate the efficacy of preoperative pelvic floor muscle training (PFMT) on histomorphometry, muscle function, urinary continence and quality of life of patients undergoing radical prostatectomy (RP). A prospective intervention clinical study was designed in 16 patients with indication of RP who were randomized into two groups. The Control Group received routine pre-surgical education (hygienic-dietary measures). The intervention group received a training session with supervised PFMT, three times a day, for four weeks, 30 days before the PR. Muscle function of the external urethral sphincter, contraction pressure of the levator ani, urinary continence and quality of life related to health (HRQoL) were evaluated before and after the intervention. At the end of the intervention and day of the surgery, samples of residual muscle tissue were obtained from the external sphincter muscle of the urethra for histomorphometric analysis. After the intervention, those participants who carried out PFMT showed an increase in the cross-sectional area of the muscle fibers of the external urethral sphincter (1,313 ± 1,075 μm(2)vs. 1,056 ± 844 μm(2), P=.03) and higher pressure contraction of the levator ani (F=9.188; P=.010). After catheter removal, 62% of patients in the experimental group and 37% in the control group showed no incontinence. After removal of the catheter, 75% of the experimental group did not require any pad compared to 25% in the control group (p=NS). There were no significant differences between the two groups in any of the HRQoL domains studied. Pre-surgical PFMT in patients with RP indication induces changes in the histology and function of the pelvic floor muscles, without changes in urogenital function and HRQoL. These results provide new evidence regarding the benefit of PFMT in preventing RP associated complications. Copyright © 2013 AEU. Published by Elsevier Espana. All rights reserved.

Implementing a pain management nursing protocol for orthopaedic surgical patients: Results from a PAIN OUT project.

PubMed

Cui, Cui; Wang, Ling-Xiao; Li, Qi; Zaslansky, Ruth; Li, Li

2018-04-01

To investigate the effect of introducing a standardised pain management nursing protocol in orthopaedic patients undergoing surgery. Postoperative pain is a common phenomenon but is still undertreated in hospitalised patients. Nurses' lack of sufficient knowledge and skills about pain management may be a contributing factor to poor outcomes. An interventional, separate sample pre- and post-test. A pain management nursing protocol was introduced and a handbook and training sessions regarding management of postsurgical pain were provided to the nurses on a Joint Orthopaedic ward at a university-affiliated general hospital in Guangzhou, China. Before and after the intervention, nurses' knowledge about pain management and attitudes were assessed, and perioperative management practices and pain-related patient-reported outcomes were evaluated. Sixteen and 15 registered nurses, and 77 and 71 patients participated in the study before and after the intervention, respectively. Nurses' scores related to knowledge and skills increased significantly after the protocol was introduced but were still insufficient with regard to pharmacological-related items. The proportion of patients receiving a combined opioid and nonopioid increased after the intervention. Clinically significant changes were observed in some patient-reported outcomes, such as worst pain since surgery, percentage of time experiencing severe pain, and pain interference with activities out of bed. There were significant changes in nonpharmacological methods administered by nurses to patients or used by patients to relieve pain. Implementation of a pain management nursing protocol combined with education in one surgical ward was associated with nurses' increased knowledge and attitudes regarding pain, a change in some management practices, and improvement in a number of pain-related patient-reported outcomes. It was feasible to develop and implement a standardised pain management nursing protocol and use it in the clinical routine. The intervention had an effect on changing some features of care, with an improvement in patient-reported outcomes. Support by leaders and medical team facilitated the process of the implementation. © 2017 John Wiley & Sons Ltd.

Multicenter evaluation of an interdisciplinary 52-week weight loss program for obesity with regard to body weight, comorbidities and quality of life--a prospective study.

PubMed

Bischoff, S C; Damms-Machado, A; Betz, C; Herpertz, S; Legenbauer, T; Löw, T; Wechsler, J G; Bischoff, G; Austel, A; Ellrott, T

2012-04-01

To determine the effectiveness of a structured multidisciplinary non-surgical obesity therapy program on the basis of a temporary low-calorie-diet for 12 weeks, and additional intervention modules to enhance nutritional education, to increase physical activity and to modify eating behavior. Prospective multicenter observational study in obese individuals undergoing a medically supervised outpatient-based 52-week treatment in 37 centers in Germany. A total of 8296 participants with a body mass index (BMI) of >30 kg m(-2) included within 8.5 years. Main outcome measures were body weight loss, waist circumference (WC), blood pressure, quality of life and adverse events. In females, initial body weight was reduced after the 1-year-intervention by 19.6 kg (95% confidence intervals 19.2-19.9 kg) and in males by 26.0 kg (25.2-26.8) according to per protocol analysis of 4850 individuals. Intention-to-treat (ITT) analysis revealed a weight reduction of 15.2 kg (14.9-15.6) in females and 19.4 kg (18.7-20.1) in males. Overall, the intervention resulted in mean reduction in WC of 11 cm; it reduced the prevalence of the metabolic syndrome by 50% and the frequency of hypertension from 47 to 29% of all participants (ITT, all P<0.001). The beneficial effects could be documented for up to 3 years and comprised significant improvement of health-related quality of life. The incidence of adverse effects was low; the only event repeatedly observed and possibly related to either the intervention or the underlying disease was biliary disorders. The present non-surgical intervention program is a highly effective treatment of obesity grades I-III and obesity-related diseases, and therefore, could be a valuable basis for future weight maintenance strategies required for sustained success.

Multicenter evaluation of an interdisciplinary 52-week weight loss program for obesity with regard to body weight, comorbidities and quality of life—a prospective study

PubMed Central

Bischoff, S C; Damms-Machado, A; Betz, C; Herpertz, S; Legenbauer, T; Löw, T; Wechsler, J G; Bischoff, G; Austel, A; Ellrott, T

2012-01-01

Objectives: To determine the effectiveness of a structured multidisciplinary non-surgical obesity therapy program on the basis of a temporary low-calorie-diet for 12 weeks, and additional intervention modules to enhance nutritional education, to increase physical activity and to modify eating behavior. Design: Prospective multicenter observational study in obese individuals undergoing a medically supervised outpatient-based 52-week treatment in 37 centers in Germany. Subjects: A total of 8296 participants with a body mass index (BMI) of >30 kg m−2 included within 8.5 years. Measurements: Main outcome measures were body weight loss, waist circumference (WC), blood pressure, quality of life and adverse events. Results: In females, initial body weight was reduced after the 1-year-intervention by 19.6 kg (95% confidence intervals 19.2–19.9 kg) and in males by 26.0 kg (25.2–26.8) according to per protocol analysis of 4850 individuals. Intention-to-treat (ITT) analysis revealed a weight reduction of 15.2 kg (14.9–15.6) in females and 19.4 kg (18.7–20.1) in males. Overall, the intervention resulted in mean reduction in WC of 11 cm; it reduced the prevalence of the metabolic syndrome by 50% and the frequency of hypertension from 47 to 29% of all participants (ITT, all P<0.001). The beneficial effects could be documented for up to 3 years and comprised significant improvement of health-related quality of life. The incidence of adverse effects was low; the only event repeatedly observed and possibly related to either the intervention or the underlying disease was biliary disorders. Conclusion: The present non-surgical intervention program is a highly effective treatment of obesity grades I–III and obesity-related diseases, and therefore, could be a valuable basis for future weight maintenance strategies required for sustained success. PMID:21673653

Technology-Enabled Remote Monitoring and Self-Management - Vision for Patient Empowerment Following Cardiac and Vascular Surgery: User Testing and Randomized Controlled Trial Protocol.

PubMed

McGillion, Michael; Yost, Jennifer; Turner, Andrew; Bender, Duane; Scott, Ted; Carroll, Sandra; Ritvo, Paul; Peter, Elizabeth; Lamy, Andre; Furze, Gill; Krull, Kirsten; Dunlop, Valerie; Good, Amber; Dvirnik, Nazari; Bedini, Debbie; Naus, Frank; Pettit, Shirley; Henry, Shaunattonie; Probst, Christine; Mills, Joseph; Gossage, Elaine; Travale, Irene; Duquette, Janine; Taberner, Christy; Bhavnani, Sanjeev; Khan, James S; Cowan, David; Romeril, Eric; Lee, John; Colella, Tracey; Choinière, Manon; Busse, Jason; Katz, Joel; Victor, J Charles; Hoch, Jeffrey; Isaranuwatchai, Wanrudee; Kaasalainen, Sharon; Ladak, Salima; O'Keefe-McCarthy, Sheila; Parry, Monica; Sessler, Daniel I; Stacey, Michael; Stevens, Bonnie; Stremler, Robyn; Thabane, Lehana; Watt-Watson, Judy; Whitlock, Richard; MacDermid, Joy C; Leegaard, Marit; McKelvie, Robert; Hillmer, Michael; Cooper, Lynn; Arthur, Gavin; Sider, Krista; Oliver, Susan; Boyajian, Karen; Farrow, Mark; Lawton, Chris; Gamble, Darryl; Walsh, Jake; Field, Mark; LeFort, Sandra; Clyne, Wendy; Ricupero, Maria; Poole, Laurie; Russell-Wood, Karsten; Weber, Michael; McNeil, Jolene; Alpert, Robyn; Sharpe, Sarah; Bhella, Sue; Mohajer, David; Ponnambalam, Sem; Lakhani, Naeem; Khan, Rabia; Liu, Peter; Devereaux, P J

2016-08-01

Tens of thousands of cardiac and vascular surgeries (CaVS) are performed on seniors in Canada and the United Kingdom each year to improve survival, relieve disease symptoms, and improve health-related quality of life (HRQL). However, chronic postsurgical pain (CPSP), undetected or delayed detection of hemodynamic compromise, complications, and related poor functional status are major problems for substantial numbers of patients during the recovery process. To tackle this problem, we aim to refine and test the effectiveness of an eHealth-enabled service delivery intervention, TecHnology-Enabled remote monitoring and Self-MAnagemenT-VIsion for patient EmpoWerment following Cardiac and VasculaR surgery (THE SMArTVIEW, CoVeRed), which combines remote monitoring, education, and self-management training to optimize recovery outcomes and experience of seniors undergoing CaVS in Canada and the United Kingdom. Our objectives are to (1) refine SMArTVIEW via high-fidelity user testing and (2) examine the effectiveness of SMArTVIEW via a randomized controlled trial (RCT). CaVS patients and clinicians will engage in two cycles of focus groups and usability testing at each site; feedback will be elicited about expectations and experience of SMArTVIEW, in context. The data will be used to refine the SMArTVIEW eHealth delivery program. Upon transfer to the surgical ward (ie, post-intensive care unit [ICU]), 256 CaVS patients will be reassessed postoperatively and randomly allocated via an interactive Web randomization system to the intervention group or usual care. The SMArTVIEW intervention will run from surgical ward day 2 until 8 weeks following surgery. Outcome assessments will occur on postoperative day 30; at week 8; and at 3, 6, 9, and 12 months. The primary outcome is worst postop pain intensity upon movement in the previous 24 hours (Brief Pain Inventory-Short Form), averaged across the previous 14 days. Secondary outcomes include a composite of postoperative complications related to hemodynamic compromise-death, myocardial infarction, and nonfatal stroke- all-cause mortality and surgical site infections, functional status (Medical Outcomes Study Short Form-12), depressive symptoms (Geriatric Depression Scale), health service utilization-related costs (health service utilization data from the Institute for Clinical Evaluative Sciences data repository), and patient-level cost of recovery (Ambulatory Home Care Record). A linear mixed model will be used to assess the effects of the intervention on the primary outcome, with an a priori contrast of weekly average worst pain intensity upon movement to evaluate the primary endpoint of pain at 8 weeks postoperation. We will also examine the incremental cost of the intervention compared to usual care using a regression model to estimate the difference in expected health care costs between groups. Study start-up is underway and usability testing is scheduled to begin in the fall of 2016. Given our experience, dedicated industry partners, and related RCT infrastructure, we are confident we can make a lasting contribution to improving the care of seniors who undergo CaVS.

Technology-Enabled Remote Monitoring and Self-Management — Vision for Patient Empowerment Following Cardiac and Vascular Surgery: User Testing and Randomized Controlled Trial Protocol

PubMed Central

Yost, Jennifer; Turner, Andrew; Bender, Duane; Scott, Ted; Carroll, Sandra; Ritvo, Paul; Peter, Elizabeth; Lamy, Andre; Furze, Gill; Krull, Kirsten; Dunlop, Valerie; Good, Amber; Dvirnik, Nazari; Bedini, Debbie; Naus, Frank; Pettit, Shirley; Henry, Shaunattonie; Probst, Christine; Mills, Joseph; Gossage, Elaine; Travale, Irene; Duquette, Janine; Taberner, Christy; Bhavnani, Sanjeev; Khan, James S; Cowan, David; Romeril, Eric; Lee, John; Colella, Tracey; Choinière, Manon; Busse, Jason; Katz, Joel; Victor, J Charles; Hoch, Jeffrey; Isaranuwatchai, Wanrudee; Kaasalainen, Sharon; Ladak, Salima; O'Keefe-McCarthy, Sheila; Parry, Monica; Sessler, Daniel I; Stacey, Michael; Stevens, Bonnie; Stremler, Robyn; Thabane, Lehana; Watt-Watson, Judy; Whitlock, Richard; MacDermid, Joy C; Leegaard, Marit; McKelvie, Robert; Hillmer, Michael; Cooper, Lynn; Arthur, Gavin; Sider, Krista; Oliver, Susan; Boyajian, Karen; Farrow, Mark; Lawton, Chris; Gamble, Darryl; Walsh, Jake; Field, Mark; LeFort, Sandra; Clyne, Wendy; Ricupero, Maria; Poole, Laurie; Russell-Wood, Karsten; Weber, Michael; McNeil, Jolene; Alpert, Robyn; Sharpe, Sarah; Bhella, Sue; Mohajer, David; Ponnambalam, Sem; Lakhani, Naeem; Khan, Rabia; Liu, Peter

2016-01-01

Background Tens of thousands of cardiac and vascular surgeries (CaVS) are performed on seniors in Canada and the United Kingdom each year to improve survival, relieve disease symptoms, and improve health-related quality of life (HRQL). However, chronic postsurgical pain (CPSP), undetected or delayed detection of hemodynamic compromise, complications, and related poor functional status are major problems for substantial numbers of patients during the recovery process. To tackle this problem, we aim to refine and test the effectiveness of an eHealth-enabled service delivery intervention, TecHnology-Enabled remote monitoring and Self-MAnagemenT—VIsion for patient EmpoWerment following Cardiac and VasculaR surgery (THE SMArTVIEW, CoVeRed), which combines remote monitoring, education, and self-management training to optimize recovery outcomes and experience of seniors undergoing CaVS in Canada and the United Kingdom. Objective Our objectives are to (1) refine SMArTVIEW via high-fidelity user testing and (2) examine the effectiveness of SMArTVIEW via a randomized controlled trial (RCT). Methods CaVS patients and clinicians will engage in two cycles of focus groups and usability testing at each site; feedback will be elicited about expectations and experience of SMArTVIEW, in context. The data will be used to refine the SMArTVIEW eHealth delivery program. Upon transfer to the surgical ward (ie, post-intensive care unit [ICU]), 256 CaVS patients will be reassessed postoperatively and randomly allocated via an interactive Web randomization system to the intervention group or usual care. The SMArTVIEW intervention will run from surgical ward day 2 until 8 weeks following surgery. Outcome assessments will occur on postoperative day 30; at week 8; and at 3, 6, 9, and 12 months. The primary outcome is worst postop pain intensity upon movement in the previous 24 hours (Brief Pain Inventory-Short Form), averaged across the previous 14 days. Secondary outcomes include a composite of postoperative complications related to hemodynamic compromise—death, myocardial infarction, and nonfatal stroke— all-cause mortality and surgical site infections, functional status (Medical Outcomes Study Short Form-12), depressive symptoms (Geriatric Depression Scale), health service utilization-related costs (health service utilization data from the Institute for Clinical Evaluative Sciences data repository), and patient-level cost of recovery (Ambulatory Home Care Record). A linear mixed model will be used to assess the effects of the intervention on the primary outcome, with an a priori contrast of weekly average worst pain intensity upon movement to evaluate the primary endpoint of pain at 8 weeks postoperation. We will also examine the incremental cost of the intervention compared to usual care using a regression model to estimate the difference in expected health care costs between groups. Results Study start-up is underway and usability testing is scheduled to begin in the fall of 2016. Conclusions Given our experience, dedicated industry partners, and related RCT infrastructure, we are confident we can make a lasting contribution to improving the care of seniors who undergo CaVS. PMID:27480247

Decreased Surgical Site Infection Rate in Hysterectomy: Effect of a Gynecology-Specific Bundle.

PubMed

Andiman, Sarah E; Xu, Xiao; Boyce, John M; Ludwig, Elizabeth M; Rillstone, Heidi R W; Desai, Vrunda B; Fan, Linda L

2018-06-01

We implemented a hysterectomy-specific surgical site infection prevention bundle after a higher-than-expected surgical site infection rate was identified at our institution. We evaluate how this bundle affected the surgical site infection rate, length of hospital stay, and 30-day postoperative readmission rate. This is a quality improvement study featuring retrospective analysis of a prospectively implemented, multidisciplinary team-designed surgical site infection prevention bundle that consisted of chlorhexidine-impregnated preoperative wipes, standardized aseptic surgical preparation, standardized antibiotic dosing, perioperative normothermia, surgical dressing maintenance, and direct feedback to clinicians when the protocol was breached. There were 2,099 hysterectomies completed during the 33-month study period. There were 61 surgical site infections (4.51%) in the pre-full bundle implementation period and 14 (1.87%) in the post-full bundle implementation period; we found a sustained reduction in the proportion of patients experiencing surgical site infection during the last 8 months of the study period. After adjusting for clinical characteristics, patients who underwent surgery after full implementation were less likely to develop a surgical site infection (adjusted odds ratio [OR] 0.46, P=.01) than those undergoing surgery before full implementation. Multivariable regression analysis showed no statistically significant difference in postoperative days of hospital stay (adjusted mean ratio 0.95, P=.09) or rate of readmission for surgical site infection-specific indication (adjusted OR 2.65, P=.08) between the before and after full-bundle implementation periods. The multidisciplinary implementation of a gynecologic perioperative surgical site infection prevention bundle was associated with a significant reduction in surgical site infection rate in patients undergoing hysterectomy.

Do patients fear undergoing general anesthesia for oral surgery?

PubMed

Elmore, Jasmine R; Priest, James H; Laskin, Daniel M

2014-01-01

Many patients undergoing major surgery have more fear of the general anesthesia than the procedure. This appears to be reversed with oral surgery. Therefore, patients need to be as well informed about this aspect as the surgical operation.

Is triple contrast computed tomographic scanning useful in the selective management of stab wounds to the back?

PubMed

McAllister, E; Perez, M; Albrink, M H; Olsen, S M; Rosemurgy, A S

1994-09-01

We devised a protocol to prospectively manage stab wounds to the back with the hypothesis that the triple contrast computed tomographic (CT) scan is an effective means of detecting occult injury in these patients. All wounds to the back in hemodynamically stable adults were locally explored. All patients with muscular fascial penetration underwent triple contrast CT scanning utilizing oral, rectal, and IV contrast. Patients did not undergo surgical exploration if their CT scan was interpreted as negative or if the CT scan demonstrated injuries not requiring surgical intervention. Fifty-three patients were entered into the protocol. The time to complete the triple contrast CT scan ranged from 3 to 6 hours at a cost of $1050 for each scan. In 51 patients (96%), the CT scan either had negative findings (n = 31) or showed injuries not requiring exploration (n = 20). These patients did well with nonsurgical management. Two CT scans documented significant injury and led to surgical exploration and therapeutic celiotomies. Although triple contrast CT scanning was able to detect occult injury in patients with stab wounds to the back it did so at considerable cost and the results rarely altered clinical care. Therefore, its routine use in these patients is not recommended.

Surgery for Patients With Recalcitrant Plantar Fasciitis

PubMed Central

Wheeler, Patrick; Boyd, Kevin; Shipton, Mary

2014-01-01

Background: Plantar fasciitis is a common cause of foot pain, and although many episodes are self-limiting with short duration, 10% leave chronic symptoms. Recalcitrant cases can be managed surgically, with studies demonstrating good results in the short term but uncertainties over longer term outcomes. Purpose: To assess the outcome following surgical intervention for patients with plantar fasciitis. Study Design: Case series; Level of evidence, 4. Methods: Seventy-nine patients were identified from operative diaries undergoing plantar fasciotomy surgery between 1993 and 2009. They were contacted to investigate long-term results using self-reported outcome measures. Results: Sixty-eight responses were received (86% response rate), with an average of 7 years (range, 1-15 years) of follow-up. Patients reported an average reduction in pain by visual analog scale of 79%, and 84% of patients were happy with the surgical results. Greater success was achieved in patients with shorter duration of symptoms preoperatively. No deterioration in success was seen over time. Conclusion: Plantar fasciotomy surgery for plantar fasciitis remains controversial, with biomechanical arguments against surgery; however, this article reports good success following surgery over a long follow-up period. The results of current operative techniques need to be fully investigated for longer term success, as do the outcomes of newer nonoperative management strategies. PMID:26535314

Treatment of oropharyngeal dysphagia secondary to idiopathic cricopharyngeal bar: Surgical cricopharyngeal muscle myotomy versus dilation.

PubMed

Marston, Alexander P; Maldonado, Francisco J; Ravi, Karthik; Kasperbauer, Jan L; Ekbom, Dale C

To compare swallowing outcomes following cricopharyngeal (CP) dilation versus surgical myotomy in patients with dysphagia secondary to idiopathic CP bar. All patients had an idiopathic CP bar without a history of Zenker's diverticulum, head and neck cancer, or systemic neurologic disease treated between 2000 and 2013. The Functional Outcome Swallowing Scale (FOSS) was utilized to assess dysphagia symptoms. Twenty-three patients underwent 46 dilations and 20 patients had a myotomy. Nineteen of 23 (83%) patients in the dilation group and all patients in the myotomy group reported improved swallow function. The median difference in pre- versus post-intervention FOSS scores was not statistically significant (p=0.07) between the dilation and myotomy groups with mean reductions of 1.3 and 1.8, respectively. Seventeen of 23 (74%) dilation patients had persistent or recurrent dysphagia with 13 (57%) requiring repeat dilation and 4 (17%) undergoing CP myotomy. The median time to first reintervention in the dilation group was 13.6months. Nineteen of 20 (95%) surgical myotomy patients did not experience recurrent dysphagia. Both endoscopic CP dilation and myotomy led to similar initial improvement in swallow function for patients with primary idiopathic CP bar; however, dilation is more likely to provide temporary benefit. Copyright © 2016 Elsevier Inc. All rights reserved.

Substitution of Usual Perioperative Care by eHealth to Enhance Postoperative Recovery in Patients Undergoing General Surgical or Gynecological Procedures: Study Protocol of a Randomized Controlled Trial

PubMed Central

Huirne, Judith AF; Bouwsma, Esther VA; van Dongen, Johanna M; Terwee, Caroline B; van de Ven, Peter M; den Bakker, Chantal M; van der Meij, Suzan; van Baal, W Marchien; Leclercq, Wouter KG; Geomini, Peggy MAJ; Consten, Esther CJ; Schraffordt Koops, Steven E; van Kesteren, Paul JM; Stockmann, Hein BAC; ten Cate, A Dorien; Davids, Paul HP; Scholten, Petrus C; van den Heuvel, Baukje; Schaafsma, Frederieke G; Meijerink, Wilhelmus JHJ; Bonjer, H Jaap; Anema, Johannes R

2016-01-01

Background Due to the strong reduction in the length of hospital stays in the last decade, the period of in-hospital postoperative care is limited. After discharge from the hospital, guidance and monitoring on recovery and resumption of (work) activities are usually not provided. As a consequence, return to normal activities and work after surgery is hampered, leading to a lower quality of life and higher costs due to productivity loss and increased health care consumption. Objective With this study we aim to evaluate whether an eHealth care program can improve perioperative health care in patients undergoing commonly applied abdominal surgical procedures, leading to accelerated recovery and to a reduction in costs in comparison to usual care. Methods This is a multicenter randomized, single-blinded, controlled trial. At least 308 patients between 18 and 75 years old who are on the waiting list for a laparoscopic cholecystectomy, inguinal hernia surgery, or laparoscopic adnexal surgery for a benign indication will be included. Patients will be randomized to an intervention or control group. The intervention group will have access to an innovative, perioperative eHealth care program. This intervention program consists of a website, mobile phone app, and activity tracker. It aims to improve patient self-management and empowerment by providing guidance to patients in the weeks before and after surgery. The control group will receive usual care and will have access to a nonintervention (standard) website consisting of the digital information brochure about the surgical procedure being performed. Patients are asked to complete questionnaires at 5 moments during the first 6 months after surgery. The primary outcome measure is time to return to normal activities based on a patient-specific set of 8 activities selected from the Patient-Reported Outcomes Measurement Information System (PROMIS) physical functioning item bank version 1.2. Secondary outcomes include social participation, self-rated health, duration of return to work, physical activity, length of recovery, pain intensity, and patient satisfaction. In addition, an economic evaluation alongside this randomized controlled trial will be performed from the societal and health care perspective. All statistical analyses will be conducted according to the intention-to-treat principle. Results The enrollment of patients started in September 2015. The follow-up period will be completed in February 2017. Data cleaning and analyses have not begun as of the time this article was submitted. Conclusions We hypothesize that patients receiving the intervention program will resume their normal activities sooner than patients in the control group and costs will be lower. ClinicalTrial Netherlands Trial Registry NTC4699; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4699 (Archived by WebCite at http://www.webcitation.org/6mcCBZmwy) PMID:28003177

Factors That Influence Surgical Margin State in Patients Undergoing Cold Knife Conization - A Single Center Experience.

PubMed

Aluloski, Igor; Tanturovski, Mile; Petrusevska, Gordana; Jovanovic, Rubens; Kostadinova-Kunovska, Slavica

2017-12-01

To evaluate the factors that influence the surgical margin state in patients undergoing cold knife conization at the University Clinic of Gynecology and Obstetrics in Skopje, Republic of Macedonia Materials and methods: We have retrospectively analyzed the medical records of all patients that underwent a cold knife conization at our Clinic in 2015. We cross-referenced the surgical margin state with the histopathological diagnosis (LSIL, HSIL or micro-invasive/invasive cancer), menopausal status of the patients, number of pregnancies, surgeon experience, operating time and cone depth. The data was analyzed with the Chi square test, Fisher's exact test for categorical data and Student's T test for continuous data and univariate and multivariate logistical regressions were performed. A total of 246 medical records have neen analyzed, out of which 29 (11.79%) patients had LSIL, 194 (78.86%) had HSIL and 23 (9.34%) patients suffered micro-invasive/invasive cervical cancer. The surgical margins were positive in 78 (31.7%) of the patients. The average age of the patients was 41.13 and 35 (14.23%) of the patients were menopausal. The multivariate logistic regression identified preoperative forceps biopsy of micro-invasive SCC, HSIL or higher cone specimen histology and shorter cone depth as independent predictors of surgical margin involvement in patients undergoing cold knife conization. In the current study, we have found no association between the inherent characteristics of the patient and the surgeon and the surgical margin state after a CKC. The most important predictors for positive margins were the severity of the lesion and the cone depth.

Laparoscopic myotomy: technique and efficacy in treating achalasia.

PubMed

Ali, A; Pellegrini, C A

2001-04-01

Esophageal Heller myotomy and a partial antireflux procedure for achalasia are the ideal procedures to benefit from the advances in minimally invasive surgery. The magnified view of the operative field provided by the laparoscope allows precise division of the esophageal muscle fibers with excellent results. Laparoscopic Heller myotomy results in reduced postoperative pain, less morbidity, shorter hospitalization, better resolution of dysphagia, and less postoperative heartburn when compared with the open abdominal and even the thoracoscopic approach. A longer myotomy especially at the distal end, and a loose, well-formed partial fundoplication are the keys to a successful outcome. Superior long-term results after surgical myotomy when compared with nonsurgical interventions argue strongly in favor of surgery in any patient who is fit enough to undergo general anesthesia.

Inflammatory response and extracorporeal circulation.

PubMed

Kraft, Florian; Schmidt, Christoph; Van Aken, Hugo; Zarbock, Alexander

2015-06-01

Patients undergoing cardiac surgery with extracorporeal circulation (EC) frequently develop a systemic inflammatory response syndrome. Surgical trauma, ischaemia-reperfusion injury, endotoxaemia and blood contact to nonendothelial circuit compounds promote the activation of coagulation pathways, complement factors and a cellular immune response. This review discusses the multiple pathways leading to endothelial cell activation, neutrophil recruitment and production of reactive oxygen species and nitric oxide. All these factors may induce cellular damage and subsequent organ injury. Multiple organ dysfunction after cardiac surgery with EC is associated with an increased morbidity and mortality. In addition to the pathogenesis of organ dysfunction after EC, this review deals with different therapeutic interventions aiming to alleviate the inflammatory response and consequently multiple organ dysfunction after cardiac surgery. Copyright © 2015 Elsevier Ltd. All rights reserved.

[Indications and surgical approach for lamellar macular holes and pseudoholes].

PubMed

Haritoglou, C; Schumann, R G

2017-12-01

This article presents a discussion on the indications for surgical interventions of lamellar macular holes and pseudoholes. What are the criteria for deciding on the surgical intervention for lamellar macular holes and pseudoholes? The article is based on a literature search in PubMed RESULTS: Lamellar macular holes and pseudoholes are subdivided into degenerative and tractive alterations. Both entities are associated with relatively specific morphological and functional criteria, which correlate with the expected functional and morphological results of the surgical intervention. Patients with pseudoholes therefore profit more from a surgical intervention because alterations to the outer retina are less pronounced in these cases. The indications for surgery of lamellar macular holes and pseudoholes are established by the type of lamellar defect and the morphological and functional alterations associated with this condition.

Better evidence for earlier assessment and surgical intervention for refractory epilepsy (The BEST study): a mixed methods study protocol.

PubMed

Rapport, Frances; Shih, Patti; Mitchell, Rebecca; Nikpour, Armin; Bleasel, Andrew; Herkes, Geoffrey; Vagholkar, Sanjyot; Mumford, Virginia

2017-08-21

One-third of patients with refractory epilepsy may be candidates for resective surgery, which can lead to positive clinical outcomes if efficiently managed. In Australia, there is currently between a 6-month and 2-year delay for patients who are candidates for respective epilepsy surgery from the point of referral for surgical assessment to the eventual surgical intervention. This is a major challenge for implementation of effective treatment for individuals who could potentially benefit from surgery. This study examines implications of delays following the point of eligibility for surgery, in the assessment and treatment of patients, and the factors causing treatment delays. Mixed methods design: Observations of qualitative consultations, patient and healthcare professional interviews, and health-related quality of life assessments for a group of 10 patients and six healthcare professionals (group 1); quantitative retrospective medical records' reviews examining longitudinal outcomes for 50 patients assessed for, or undergoing, resective surgery between 2014 and 2016 (group 2); retrospective epidemiological study of all individuals hospitalised with a diagnosis of epilepsy in New South Wales (NSW) in the last 5 years (2012-2016; approximately 11 000 hospitalisations per year, total 55 000), examining health services' use and treatment for individuals with epilepsy, including refractory surgery outcomes (group 3). Ethical approval has been granted by the North Sydney Local Health District Human Research Ethics Committee (HREC/17/HAWKE/22) and the NSW Population & Health Services Research Ethics Committee (HREC/16/CIPHS/1). Results will be disseminated through publications, reports and conference presentations to patients and families, health professionals and researchers. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Factors in Surgical Decision Making for Thoracolumbar/Lumbar AIS: It's About More Than Just the Curve Magnitude.

PubMed

Souder, Christopher; Newton, Peter O; Shah, Suken A; Lonner, Baron S; Bastrom, Tracey P; Yaszay, Burt

2017-12-01

A retrospective review of prospective data OBJECTIVE:: The purpose of this study was to compare operative and nonoperative patients with similar curve magnitudes to determine motivating factors associated with surgical correction in "smaller" curves. Despite traditional treatment recommendations on major curve angle measurements, many patients with thoracolumbar/lumbar (TH/L) curves of smaller magnitudes are unhappy and desire correction. A prospectively enrolled multicenter adolescent idiopathic scoliosis database was queried. Patients with major TH/L curves <50 degrees and low risk of progression (Risser 3, 4, and 5) were identified and grouped based on their treatment (operative vs. nonoperative). Preoperative demographic, radiographic, Scoliosis Research Society (SRS) outcome scores, and trunk shape values were compared. A total of 126 patients undergoing surgical intervention and 17 patients pursuing nonoperative treatment were analyzed. The average lumbar curve of the operative group was 43 degrees (range, 35 to 49 degrees) and for the nonoperative group was 39 degrees (range, 26 to 49 degrees). The operative group was significantly younger, had larger lumbar major curve angles, lower thoracic to lumbar curve ratio, increased TH/L apical translation, and greater trunk shift (P<0.05). Only lumbar curve (P=0.018, OR=1.19) and trunk shift (P=0.01, OR=3.22) remained significant predictors of surgery in a multivariate regression analysis. SRS scores were significantly lower in the operative group for pain, self-image, function, mental health, and total (P<0.05). When SRS total score was entered into the regression, it was the only significant predictor of surgical intervention (P=0.004, OR=0.03). Many patients with smaller lumbar curves have clinical deformities that are more consistent with larger curves. These smaller curves can produce similar coronal imbalance and trunk shift, with lower SRS domains that may drive patients to seek surgical treatment. What is unclear is the reason for this greater degree of imbalance in this select group of patients and whether the natural history is different for a more balanced TH/L curve. Level II-Prognostic.

Operative management of chronic pancreatitis: A review.

PubMed

Tillou, John D; Tatum, Jacob A; Jolissaint, Joshua S; Strand, Daniel S; Wang, Andrew Y; Zaydfudim, Victor; Adams, Reid B; Brayman, Kenneth L

2017-08-01

Pain secondary to chronic pancreatitis is a difficult clinical problem to manage. Many patients are treated medically or undergo endoscopic therapy and surgical intervention is often reserved for those who have failed to gain adequate pain relief from a more conservative approach. There have been a number of advances in the operative management of chronic pancreatitis over the last few decades and current therapies include drainage procedures (pancreaticojejunostomy, etc.), resection (pancreticoduodenectomy, etc.) and combined drainage/resection procedures (Frey procedure, etc.). Additionally, many centers currently perform total pancreatectomy with islet autotransplantation, in addition to minimally invasive options that are intended to tailor therapy to individual patients. Operative management of chronic pancreatitis often improves quality of life, and is associated with low rates of morbidity and mortality. The decision as to which procedure is optimal for each patient should be based on a combination of pathologic changes, prior interventions, and individual surgeon and center experience. Copyright © 2017 Elsevier Inc. All rights reserved.

Iliopsoas abscess as a complication of tunneled jugular vein catheterization in a hemodialysis patient.

PubMed

Hsiao, Po-Jen; Tsai, Ming-Hsien; Leu, Jyh-Gang; Fang, Yu-Wei

2015-04-01

Iliopsoas abscess is a rare complication in hemodialysis patients that is mainly due to adjacent catheterization, local acupuncture, discitis, and bacteremia. Herein, we report a 47-year-old woman undergoing regular hemodialysis via a catheter in the internal jugular vein who presented with low back pain and dyspnea. A heart murmur suggested the presence of catheter-related endocarditis, and this was confirmed by an echocardiogram and a blood culture of methicillin-resistant Staphylococcus aureus. A computed tomography indicated a pulmonary embolism and an incidental finding of iliopsoas abscess. Following surgical intervention and intravenous daptomycin, the patient experienced full recovery and a return to usual activities. This case indicates that an iliopsoas abscess can be related to a jugular vein catheter, which is apparently facilitated by infective endocarditis. The possibility of iliopsoas abscess should be considered when a hemodialysis patient presents with severe low back pain, even when there is no history of adjacent mechanical intervention. © 2014 International Society for Hemodialysis.

Wrong-Site Surgery, Retained Surgical Items, and Surgical Fires : A Systematic Review of Surgical Never Events.

PubMed

Hempel, Susanne; Maggard-Gibbons, Melinda; Nguyen, David K; Dawes, Aaron J; Miake-Lye, Isomi; Beroes, Jessica M; Booth, Marika J; Miles, Jeremy N V; Shanman, Roberta; Shekelle, Paul G

2015-08-01

Serious, preventable surgical events, termed never events, continue to occur despite considerable patient safety efforts. To examine the incidence and root causes of and interventions to prevent wrong-site surgery, retained surgical items, and surgical fires in the era after the implementation of the Universal Protocol in 2004. We searched 9 electronic databases for entries from 2004 through June 30, 2014, screened references, and consulted experts. Two independent reviewers identified relevant publications in June 2014. One reviewer used a standardized form to extract data and a second reviewer checked the data. Strength of evidence was established by the review team. Data extraction was completed in January 2015. Incidence of wrong-site surgery, retained surgical items, and surgical fires. We found 138 empirical studies that met our inclusion criteria. Incidence estimates for wrong-site surgery in US settings varied by data source and procedure (median estimate, 0.09 events per 10,000 surgical procedures). The median estimate for retained surgical items was 1.32 events per 10,000 procedures, but estimates varied by item and procedure. The per-procedure surgical fire incidence is unknown. A frequently reported root cause was inadequate communication. Methodologic challenges associated with investigating changes in rare events limit the conclusions of 78 intervention evaluations. Limited evidence supported the Universal Protocol (5 studies), education (4 studies), and team training (4 studies) interventions to prevent wrong-site surgery. Limited evidence exists to prevent retained surgical items by using data-matrix-coded sponge-counting systems (5 pertinent studies). Evidence for preventing surgical fires was insufficient, and intervention effects were not estimable. Current estimates for wrong-site surgery and retained surgical items are 1 event per 100,000 and 1 event per 10,000 procedures, respectively, but the precision is uncertain, and the per-procedure prevalence of surgical fires is not known. Root-cause analyses suggest the need for improved communication. Despite promising approaches and global Universal Protocol evaluations, empirical evidence for interventions is limited.

Prophylactic antibiotics to prevent surgical site infection after breast cancer surgery.

PubMed

Bunn, Frances; Jones, Daniel J; Bell-Syer, Sophie

2012-01-18

Surgery has been used as part of breast cancer treatment for centuries; however any surgical procedure has the potential risk of infection. Infection rates for surgical treatment of breast cancer are documented at between 3% and 15%, higher than average for a clean surgical procedure. Pre- and perioperative antibiotics have been found to be useful in lowering infection rates in other surgical groups, yet there is no consensus on the use of prophylactic antibiotics for breast cancer surgery. To determine the effects of prophylactic (pre- or perioperative) antibiotics on the incidence of surgical site infection (SSI) after breast cancer surgery. For this second update we searched the Cochrane Wounds Group Specialised Register (searched 31 August 2011); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 3); Ovid MEDLINE (2008 to August Week 3 2011); Ovid MEDLINE (In-Process & Other Non-Indexed Citations 30 August 2011); Ovid EMBASE (1980 to 2011 Week 34); and EBSCO CINAHL (2008 to 25 August 2011). We applied no language or date restrictions. Randomised controlled trials of pre- and perioperative antibiotics for patients undergoing surgery for breast cancer were included. Primary outcomes were rates of surgical site infection (SSI) and adverse reactions. Two review authors independently examined the title and abstracts of all studies identified by the search strategy, then assessed study quality and extracted data from those that met the inclusion criteria. A total of nine studies (2260 participants) is included in the review. Eight studies evaluated preoperative antibiotic compared with no antibiotic or placebo. One study evaluated perioperative antibiotic compared with no antibiotic. Pooling of the results demonstrated that prophylactic antibiotics administered preoperatively significantly reduce the incidence of SSI for patients undergoing breast cancer surgery without reconstruction (pooled risk ratio (RR) 0.71, 95% confidence interval (CI) 0.53 to 0.94). Analysis of the single study comparing perioperative antibiotic with no antibiotic found no statistically significant effect of antibiotics on the incidence of SSI (RR 0.11, 95% CI 0.01 to 1.95). No studies presented separate data for patients who underwent reconstructive surgery at the time of removal of the breast tumour. Prophylactic antibiotics administered preoperatively reduce the risk of SSI in patients undergoing surgery for breast cancer. Further studies involving patients undergoing immediate breast reconstruction are needed as studies have identified this group as being at higher risk of infection than those who do not undergo immediate breast reconstruction.

Association of hospitalization for neurosurgical operations in Magnet hospitals with mortality and length-of-stay

PubMed Central

Missios, Symeon; Bekelis, Kimon

2017-01-01

Background The association of Magnet hospital status with improved surgical outcomes remains an issue of debate. Objective To investigate whether hospitalization in a Magnet hospital is associated with improved outcomes for patients undergoing neurosurgical operations. Methods A cohort study was executed using all patients undergoing neurosurgical operations in New York registered in the Statewide Planning and Research Cooperative System (SPARCS) database from 2009–2013. We examined the association of Magnet status hospitalization after neurosurgical operations with inpatient case-fatality, and length of stay (LOS). We employed an instrumental variable analysis to simulate a randomized trial. Results Overall, 190,787 patients underwent neurosurgical operations. Of these, 68,046 (35.7%) were hospitalized in Magnet hospitals, and 122,741 (64.3%) in non-Magnet institutions. Instrumental variable analysis demonstrated that hospitalization in Magnet hospitals was associated with decreased case-fatality (Adjusted difference, −0.8%; −95% CI, −0.7% to −0.6%), and LOS (Adjusted difference, −1.9; 95% CI, −2.2 to −1.5) in comparison to non-Magnet hospitals. These associations were also observed in propensity score adjusted mixed effects models. These associations persisted in pre-specified subgroups of patients undergoing spine surgery, craniotomy for tumor resection, or neurovascular interventions. Conclusions We identified an association of Magnet hospitals with lower case-fatality, and shorter LOS in a comprehensive New York State patient cohort undergoing neurosurgical procedures. PMID:28472336

Periprocedural considerations of transcatheter aortic valve implantation for anesthesiologists

PubMed Central

Afshar, Ata Hassani; Pourafkari, Leili; Nader, Nader D

2016-01-01

Transcatheter aortic valve replacement (TAVR) is rapidly gaining popularity as a viable option in the management of patients with symptomatic aortic stenosis (AS) and high risk for open surgical intervention. TAVR soon expanding its indications from "high-risk" group of patients to those with "intermediate-risk". As an anesthesiologist; understanding the procedure and the challenges inherent to it is of utmost importance, in order to implement optimal care for this generally frail population undergoing a rather novel procedure. Cardiac anesthesiologists generally play a pivotal role in the perioperative care of the patients, and therefore they should be fully familiar with the circumstances occurring surrounding the procedure. Along with increasing experience and technical developments for TAVR, the procedure time becomes shorter. Due to this improvement in the procedure time, more and more anesthesiologists feel comfortable in using monitored anesthesia care with moderate sedation for patients undergoing TAVR. A number of complications could arise during the procedure needing rapid diagnoses and occasionally conversion to general anesthesia. This review focuses on the periprocedural anesthetic considerations for TAVR. PMID:27489596

Bronchial asthma.

PubMed

Liccardi, Gennaro; Salzillo, Antonello; Sofia, Matteo; D'Amato, Maria; D'Amato, Gennaro

2012-02-01

The aim of this review is to underline the need for an adequate clinical and functional evaluation of respiratory function and asthma control in patients undergoing surgical procedures requiring general anesthesia to obtain useful information for an adequate preoperative pharmacological approach. It has been shown that baseline uncontrolled clinical/functional conditions of airways represent the most important risk factors for perioperative bronchospasm. In nonemergency conditions, asthma patients should undergo clinical/functional assessment at least 1 week before the surgery intervention to obtain, the better feasible control of asthma symptoms in the single patient. Some simple preoperative information given by the patient in preoperative consultation may be sufficient to identify individuals with uncontrolled or poor controlled asthmatic conditions. Spirometric evaluation is essential in individuals with poor control of symptoms, as well as in those patients with uncertain anamnestic data or limited perception of respiratory symptoms, and in those requiring lung resection. A better control of asthma must be considered the 'gold standard' for a patient at 'a reasonable low risk' to develop perioperative/postoperative bronchospasm. International consensus promoted by pulmonologists, anesthesiologists, and allergists might be useful to define a better diagnostic and therapeutic approach.

Intestinal stoma in patients with colorectal cancer from the perspective of 20-year period of clinical observation.

PubMed

Banaszkiewicz, Zbigniew; Woda, Łukasz P; Zwoliński, Tomasz; Tojek, Krzysztof; Jarmocik, Paweł; Jawień, Arkadiusz

2015-01-01

Intestinal stoma is a procedure most often performed in patients with colorectal cancer. To identify the percentage of patients with colorectal cancer in which the intestinal stoma was performed. We retrospectively analysed 443 patients treated during a 20-year period (1994-2013) due to colorectal cancer, in which the intestinal stoma was made during the first surgical intervention. In the second analysed decade, a significant decrease in the percentage of created stomas, definitive stomas in particular, was observed. Stomas were made significantly more often in patients with a tumour located in the rectum, the left half of the colon, and in patients undergoing urgent surgeries. An increased incidence of intestinal stomas was associated with a higher severity of illness and higher proportion of unresectable and non-radical procedures. The definitive stomas were significantly more often made in men and in patients with tumours located in the rectum, whereas temporary stomas were created significantly more often in patients undergoing urgent operations. In the last decade (2004-2013) the number of intestinal stomas in patients operated due to colorectal cancer was significantly reduced.

Reproductive Microbiomes: Using the microbiome as a novel diagnostic tool for endometriosis

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

Cregger, Melissa; Lenz, Katherine; Leary, Elizabeth

Endometriosis is a chronic inflammatory disease which results in significant pain and long term reproductive consequences for up to 50% of infertile women. This study was focused to understand how endometriosis altered the uterine and cervical bacterial community. Urogenital swabs and uterine washes were collected from 19 pre-menopausal women undergoing laparoscopic surgery for pelvic pain, suspected endometriosis (experimental n = 10), and women undergoing laparoscopic surgery for benign ovarian/uterine conditions (control n = 9). Patients were followed for the next year and repeat cervical swabs were obtained. Bacterial community composition was assessed from these samples using Illumina next generation 16Smore » rRNA amplicon sequencing. Bacterial communities were significantly different between sample sites, the uterus and cervix, and stage III endometriosis resulted in significant alterations in the cervical bacterial community. Both bacterial richness and phylogenetic diversity increased in association with stage III endometriosis. Surgical intervention resulted in a stabilized cervical bacterial community for a short period of time. Lastly, bacterial community profiling may provide a useful diagnostic tool for identifying endometriosis in asymptomatic, infertile women in a clinical setting.« less

Reproductive Microbiomes: Using the microbiome as a novel diagnostic tool for endometriosis

DOE PAGES

Cregger, Melissa; Lenz, Katherine; Leary, Elizabeth; ...

2017-09-25

Endometriosis is a chronic inflammatory disease which results in significant pain and long term reproductive consequences for up to 50% of infertile women. This study was focused to understand how endometriosis altered the uterine and cervical bacterial community. Urogenital swabs and uterine washes were collected from 19 pre-menopausal women undergoing laparoscopic surgery for pelvic pain, suspected endometriosis (experimental n = 10), and women undergoing laparoscopic surgery for benign ovarian/uterine conditions (control n = 9). Patients were followed for the next year and repeat cervical swabs were obtained. Bacterial community composition was assessed from these samples using Illumina next generation 16Smore » rRNA amplicon sequencing. Bacterial communities were significantly different between sample sites, the uterus and cervix, and stage III endometriosis resulted in significant alterations in the cervical bacterial community. Both bacterial richness and phylogenetic diversity increased in association with stage III endometriosis. Surgical intervention resulted in a stabilized cervical bacterial community for a short period of time. Lastly, bacterial community profiling may provide a useful diagnostic tool for identifying endometriosis in asymptomatic, infertile women in a clinical setting.« less

Topical versus peribulbar anaesthesia for cataract surgery.

PubMed

Sauder, Gangolf; Jonas, Jost B

2003-12-01

To assess and compare the efficacy and safety of topical versus peribulbar anaesthesia in patients undergoing routine cataract surgery. The unicentre, prospective, randomized, clinical interventional trial included 140 consecutive patients undergoing routine cataract surgery performed by one of two surgeons. The patients were randomly distributed to either peribulbar anaesthesia or topical anaesthesia. To assess intraoperative pain, each patient was asked immediately after surgery to quantitate his/her pain using a 10-point pain rating scale. The study groups did not differ significantly in pain score (p=0.54), duration of surgery (p=0.52), anaesthesia-related intraoperative difficulties (p=0.17), postoperative visual acuity (p=0.94), overall intraoperative surgical complication rate, blood pressure rise (p=0.16) or blood oxygen saturation (p=0.74) Patient comfort and surgery-related complications did not differ between topical anaesthesia and peribulbar anaesthesia. As there are no significant differences between the two techniques in terms of subjective pain experienced by patients, intraoperative complications and postoperative visual outcome, and in view of the minimally invasive character of topical anaesthesia compared to peribulbar anaesthesia, the present study suggests the use of topical anaesthesia for routine cataract surgery.

Implementation of a Surgeon-Level Comparative Quality Performance Review to Improve Positive Surgical Margin Rates during Radical Prostatectomy.

PubMed

Matulewicz, Richard S; Tosoian, Jeffrey J; Stimson, C J; Ross, Ashley E; Chappidi, Meera; Lotan, Tamara L; Humphreys, Elizabeth; Partin, Alan W; Schaeffer, Edward M

2017-05-01

Success in the era of value-based payment will depend on the capacity of health systems to improve quality while controlling costs. Comparative quality performance review can be used to drive improvements in surgical outcomes and thereby reduce costs. We sought to determine the efficacy of a comparative quality performance review to improve a surgeon-level measure of surgical oncologic quality, that is the positive surgical margin rate at the time of radical prostatectomy. Eight surgeons who performed consecutive radical prostatectomies at a single high volume institution between January 1, 2015 and December 31, 2015 were included in analysis. Individual surgeons were provided with confidential report cards every 6 months detailing their case mix, case volume and pT2 radical prostatectomy positive surgical margin rate relative to 1) their own self-matched data, 2) the de-identified data of their colleagues and 3) institutional aggregate data during the study period. Positive surgical margin rates were compared before and after intervention. Hierarchal logistic regression analysis was used to examine the association of study period on the odds of positive surgical margins, adjusted for prostate specific antigen level and National Comprehensive Cancer Network® risk group. Overall, 1,822 (1,392 before and 430 after intervention) radical prostatectomies were performed that met study inclusion criteria. The aggregate departmental unadjusted positive surgical margin rates were 10.6% and 7.4% in the pre-intervention and post-intervention groups, respectively. After adjusting for higher risk cancer in the post-intervention group, there was a significant protective association of post-intervention status on positive margins (OR 0.64, 95% CI 0.43-0.97, p = 0.03). All 5 surgeons with positive surgical margin rates higher than the aggregate department rate in the pre-intervention period showed improvement after intervention. Comparative quality performance review can be implemented at the surgeon level and can promote improvement in an objective measure of surgical oncology quality. Copyright © 2017 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

Hybrid minimally invasive esophagectomy for cancer: impact on postoperative inflammatory and nutritional status.

PubMed

Scarpa, M; Cavallin, F; Saadeh, L M; Pinto, E; Alfieri, R; Cagol, M; Da Roit, A; Pizzolato, E; Noaro, G; Pozza, G; Castoro, C

2016-11-01

The purpose of this case-control study was to evaluate the impact of hybrid minimally invasive esophagectomy for cancer on surgical stress response and nutritional status. All 34 consecutive patients undergoing hybrid minimally invasive esophagectomy for cancer at our surgical unit between 2008 and 2013 were retrospectively compared with 34 patients undergoing esophagectomy with open gastric tubulization (open), matched for neoadjuvant therapy, pathological stage, gender and age. Demographic data, tumor features and postoperative course (including quality of life and systemic inflammatory and nutritional status) were compared. Postoperative course was similar in terms of complication rate. Length of stay in intensive care unit was shorter in patients undergoing hybrid minimally invasive esophagectomy (P = 0.002). In the first postoperative day, patients undergoing hybrid minimally invasive esophagectomy had lower C-reactive protein levels (P = 0.001) and white cell blood count (P = 0.05), and higher albumin serum level (P = 0.001). In this group, albumin remained higher also at third (P = 0.06) and seventh (P = 0.008) postoperative day, and C-reactive protein resulted lower at third post day (P = 0.04). Hybrid minimally invasive esophagectomy significantly improved the systemic inflammatory and catabolic response to surgical trauma, contributing to a shorter length of stay in intensive care unit. © 2015 International Society for Diseases of the Esophagus.

Left atrial concomitant surgical ablation for treatment of atrial fibrillation in cardiac surgery: A meta-analysis of randomized controlled trials

PubMed Central

Wang, Chunguo; Ye, Minhua; Lin, Jiang; Jin, Jiang; Hu, Quanteng; Zhu, Chengchu; Chen, Baofu

2018-01-01

Introduction Surgical ablation is a generally established treatment for patients with atrial fibrillation undergoing concomitant cardiac surgery. Left atrial (LA) lesion set for ablation is a simplified procedure suggested to reduce the surgery time and morbidity after procedure. The present meta-analysis aims to explore the outcomes of left atrial lesion set versus no ablative treatment in patients with AF undergoing cardiac surgery. Methods A literature research was performed in six database from their inception to July 2017, identifying all relevant randomized controlled trials (RCTs) comparing left atrial lesion set versus no ablative treatment in AF patient undergoing cardiac surgery. Data were extracted and analyzed according to predefined clinical endpoints. Results Eleven relevant RCTs were included for analysis in the present study. The prevalence of sinus rhythm in ablation group was significantly higher at discharge, 6-month and 1-year follow-up period. The morbidity including 30 day mortality, late all-cause mortality, reoperation for bleeding, permanent pacemaker implantation and neurological events were of no significant difference between two groups. Conclusions The result of our meta-analysis demonstrates that left atrial lesion set is an effective and safe surgical ablation strategy for AF patients undergoing concomitant cardiac surgery. PMID:29360851

Impact of perioperative hypoglycaemia in subjects with diabetes undergoing colorectal surgery.

PubMed

Goh, Si Ning Serene; Yeoh, Ester; Tan, Kok Yang

2017-02-01

This study explores the association between perioperative hypoglycaemia and surgical outcomes in subjects with diabetes, undergoing colorectal surgery. A retrospective review of 149 subjects with Type 2 Diabetes Mellitus (DM) who underwent colorectal surgery between 2010 and 2015 was performed. Perioperative glucose levels, glycated haemoglobin (HbA1c) measurements within 3 months of surgery and surgical complications based on Clavien-Dindo classification were analysed. The mean age was 67 years (67 ± 11.2). Perioperative hypoglycaemia was found in 7.4% of subjects. The mean HbA1c of subjects with Clavien 2 and above surgical complications were higher than patients with Clavien 1 or no complications, Hba1c 7.6% (7.6 ± 2.5%) and 7.0% (7.0 ± 1.1%, p = 0.008), respectively. Similar findings in subjects with Clavien 3 and above complications, HbA1c of 8.2% (8.2 ± 3.9%) as compared to those with Clavien 2 and below complications, 7.2% (7.2 ± 1.5%, p = 0.001). Adjusted multivariate analysis showed that hypoglycaemia was significantly associated with Clavien 2 and above surgical complications, OR of 19.0 (CI 2.23-162, p = 0.007). Preoperative hypoglycaemia was associated with Clavien 2 and above surgical complications, OR 10.7 (CI 1.22-94.1, p = 0.032). Suboptimal glycaemic control (Hba1c >8.0%) was significantly associated with Clavien 2 and above complications, OR 2.48 (CI 1.04-5.91, p = 0.04), but not with Clavien 3 and above complications, OR 1.50 (CI 0.450-4.98, p = 0.511). Perioperative hypoglycaemia is associated with adverse surgical outcomes in diabetic patients undergoing colorectal surgery. Prevention of hypoglycaemia may improve surgical outcomes. HbA1c is an independent predictor for adverse surgical outcomes.

Management of antithrombotic therapy in patients with coronary artery disease or atrial fibrillation who underwent abdominal surgical operations.

PubMed

Schizas, Dimitrios; Kariori, Maria; Boudoulas, Konstantinos Dean; Siasos, Gerasimos; Patelis, Nikolaos; Kalantzis, Charalampos; Carmen-Maria, Moldovan; Vavuranakis, Manolis

2018-04-02

Patients treated with antithrombotic therapy that require abdominal surgical procedures has progressively increased overtime. The management of antithrombotics during both the peri- and post- operative period is of crucial importance. The goal of this review is to present current data concerning the management of antiplatelets in patients with coronary artery disease and of anticoagulants in patients with atrial fibrillation who had to undergo abdominal surgical operations. For this purpose, incidence of major adverse cardiovascular events (MACE) and risk of antithrombotic use during surgical procedures, as well as the recommendations based on recent guidelines were reported. A thorough search of PubMed, Scopus and the Cochrane Databases was conducted to identify randomized controlled trials, observational studies, novel current reviews, and ESC and ACC/AHA guidelines on the subject. Antithrombotic use in daily clinical practice results to two different pathways: reduction of thromboembolic risk, but a simultaneous increase of bleeding risk. This may cause a therapeutic dilemma during the perioperative period. Nevertheless, careless cessation of antithrombotics can increase MACE and thromboembolic events, however, maintenance of antithrombotic therapy may increase bleeding complications. Studies and current guidelines can assist clinicians in making decisions for the treatment of patients that undergo abdominal surgical operations while on antithrombotic therapy. Aspirin should not be stopped perioperatively in the majority of surgical operations. Determining whether to discontinue the use of anticoagulants before surgery depends on the surgical procedure. In surgical operations with a low risk for bleeding, oral anticoagulants should not be discontinued. Bridging therapy should only be considered in patients with a high risk of thromboembolism. Finally, patients with an intermediate risk for thromboembolism, management should be individualized according to patient's thrombotic and bleeding risk. Management of antithrombotics therapy during the perioperative period in patients undergoing abdominal surgery should follow a patient-centered approach according to a patient's medical history and thrombotic risk weighted for bleeding risk. Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.org.

AORTIC COARCTATION: RECENT DEVELOPMENTS IN EXPERIMENTAL AND COMPUTATIONAL METHODS TO ASSESS TREATMENTS FOR THIS SIMPLE CONDITION

PubMed Central

LaDisa, John F.; Taylor, Charles A.; Feinstein, Jeffrey A.

2010-01-01

Coarctation of the aorta (CoA) is often considered a relatively simple disease, but long-term outcomes suggest otherwise as life expectancies are decades less than in the average population and substantial morbidity often exists. What follows is an expanded version of collective work conducted by the authors’ and numerous collaborators that was presented at the 1st International Conference on Computational Simulation in Congenital Heart Disease pertaining to recent advances for CoA. The work begins by focusing on what is known about blood flow, pressure and indices of wall shear stress (WSS) in patients with normal vascular anatomy from both clinical imaging and the use of computational fluid dynamics (CFD) techniques. Hemodynamic alterations observed in CFD studies from untreated CoA patients and those undergoing surgical or interventional treatment are subsequently discussed. The impact of surgical approach, stent design and valve morphology are also presented for these patient populations. Finally, recent work from a representative experimental animal model of CoA that may offer insight into proposed mechanisms of long-term morbidity in CoA is presented. PMID:21152106

Brazilian guidelines for the diagnosis and treatment of hereditary angioedema.

PubMed

Giavina-Bianchi, Pedro; França, Alfeu T; Grumach, Anete S; Motta, Abílio A; Fernandes, Fátima R; Campos, Regis A; Valle, Solange O; Rosário, Nelson A; Sole, Dirceu

2011-01-01

Hereditary angioedema is an autosomal dominant disease characterized by edema attacks with multiple organ involvement. It is caused by a quantitative or functional deficiency of the C1 inhibitor, which is a member of the serine protease inhibitor family. Hereditary angioedema is unknown to many health professionals and is therefore an underdiagnosed disease. The causes of death from hereditary angioedema include laryngeal edema with asphyxia. The estimated mortality rate in patients in whom the disease goes undetected and who are therefore incorrectly treated is 25-40%. In addition to edema of the glottis, hereditary angioedema often results in edema of the gastrointestinal tract, which can be incapacitating. Patients with hereditary angioedema may undergo unnecessary surgical interventions because the digestive tract can be the primary or only organ system involved, thus mimicking acute surgical abdomen. It is estimated that patients with hereditary angioedema experience some degree of disability 20-100 days per year. The Experts in Clinical Immunology and Allergy of the "Associação Brasileira de Alergia e Imunopatologia -ASBAI" developed these guidelines for the diagnosis, therapy, and management of hereditary angioedema.

Outcomes and Safety of the Combined Abdominoplasty-Hysterectomy: A Preliminary Study.

PubMed

Massenburg, Benjamin B; Sanati-Mehrizy, Paymon; Ingargiola, Michael J; Rosa, Jonatan Hernandez; Taub, Peter J

2015-10-01

Abdominoplasty (ABP) at the time of hysterectomy (HYS) has been described in the literature since 1986 and is being increasingly requested by patients. However, outcomes of the combined procedure have not been thoroughly explored. The authors reviewed the American College of Surgeons National Surgical Quality Improvement Program database and identified each ABP, HYS, and combined ABP-HYS performed between 2005 and 2012. The incidence of complications in each of the three procedures was calculated, and a multiplicative-risk model was used to calculate the probability of a complication for a patient undergoing distinct HYS and ABP on different dates. One-sample binomial hypothesis tests were performed to determine statistical significance. There were 1325 ABP cases, 12,173 HYS cases, and 143 ABP-HYS cases identified. Surgical complications occurred in 7.7 % of patients undergoing an ABP-HYS, while the calculated risk of a surgical complication was 12.5 % (p = 0.0407) for patients undergoing separate ABP and HYS procedures. The mean operative time was significantly lower for an ABP-HYS at 238 vs. 270 min for separate ABP and HYS procedures (p < 0.0001), and the mean time under anesthesia was significantly lower at 295 vs. 364 min (p < 0.0001). A combined ABP-HYS has a lower incidence of surgical complications than separate ABP and HYS procedures performed on different dates. These data should not encourage all patients to elect a combined ABP-HYS, if only undergoing a HYS, as the combined procedure is associated with increased risks when compared to either isolated individual procedure. However, in patients who are planning on undergoing both procedures on separate dates, a combined ABP-HYS is a safe option that will result in fewer surgical complications, less operative time, less time under anesthesia, and a trend towards fewer days in the hospital. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Characteristics of the patients undergoing surgical treatment for pneumothorax: A descriptive study.

PubMed

Cakmak, Muharrem; Yuksel, Melih; Kandemir, Mehmet Nail

2016-05-01

To identify the characteristic features of pneumothorax patients treated surgically. The retrospective study was conducted at Gazi Yasargil Education and Research Hospital Thoracic Surgery Clinic, Diyarbakir, Turkey and comprised records of pneumothorax patients from January 2004 to December 2014. They were divided into two groups as spontaneous and traumatic. Patients who had not undergone any surgical intervention were excluded. Mean age, gender distribution, location of the disease, type of pneumothorax, and treatment method were noted. Among patients with spontaneous pneumothorax, age and months distribution, smoking habits, pneumothorax size, and treatment method were assessed. The effect of gender, location, comorbid disease, smoking, subgroup of disease, and pneumothorax size on surgical procedures were also investigated. The mean age of the 672 patients in the study was 34.5±6.17 years. There were 611(91%) men and 61(9%) women. Disease was on the right side in 360(53.6%) patients, on the left side in 308(45.8%), and bilateral in 4(0.59%). Besides, 523(77.8%) patients had spontaneous, and 149(22.7%) had traumatic pneumothorax. Overall, 561(83.5%) patients had been treated with tube thoracostomy, whereas 111(16.5%) were treated with thoracotomy/thoracoscopic surgery. The presence of comorbid diseases, being primary, and being total or subtotal according to partial were found to create predisposition to thoracotomy/ thoracoscopic surgery (p<0.05 each). In the case of pneumothorax being total, the presence of comorbid diseases, and the increase in pneumothorax size, thoracotomy or thoracoscopic surgery is preferred.

Aortic valve replacement with or without coronary artery bypass graft surgery: the risk of surgery in patients > or =80 years old.

PubMed

Maslow, Andrew; Casey, Paula; Poppas, Athena; Schwartz, Carl; Singh, Arun

2010-02-01

The purpose of this study was to evaluate the outcomes for elderly (> or =80 years) patients undergoing aortic valve replacement (AVR) with or without coronary artery bypass graft surgery (AVR/CABG). The authors hypothesized that the mortalities of AVR and AVR/CABG are lower than that predicted by published risk scores. A retrospective analysis of data from a single-hospital database. Single tertiary care, private practice. Consecutive patients undergoing AVR or AVR/CABG. Two hundred sixty-one elderly (> or =80 years) patients undergoing isolated AVR (145) or AVR/CABG (116) were evaluated. The majority (94.6%) underwent AVR for aortic valve stenosis. Outcomes were recorded and compared between the 2 surgical procedures with predicted mortalities based on published risk assessment scoring systems. The overall short-term mortality for the elderly group was 6.1% (AVR 5.5% and AVR/CABG 6.9%). The median long-term survival was 6.8 years. There were no significant differences in either morbidity or mortality between the AVR and AVR/CABG groups. Although predicted mortalities were similar for each surgical procedure, they overestimated observed outcome by up to 4-fold. Short- and long-term mortality was low for this group of elderly patients undergoing AVR or AVR/CABG and not significantly different between the 2 surgical groups. Predicted outcomes were worse than that observed, consistent with the hypothesis, and supportive of a more aggressive surgical treatment for aortic valve disease in the elderly patient. Copyright 2010 Elsevier Inc. All rights reserved.

Cervical spine injury from gunshot wounds.

PubMed

Beaty, Narlin; Slavin, Justin; Diaz, Cara; Zeleznick, Kyle; Ibrahimi, David; Sansur, Charles A

2014-09-01

Gunshot wounds (GSWs) to the cervical spine have been examined in a limited number of case series, and operative management of this traumatic disease has been sparsely discussed. The current literature supports and the authors hypothesize that patients without neurological deficit need neither surgical fusion nor decompression. Patients with GSWs and neurological deficits, however, pose a greater management challenge. The authors have compiled the experience of the R Adams Cowley Shock Trauma Center in Baltimore, Maryland, over the past 12 years, creating the largest series of such injuries, with a total number of 40 civilian patients needing neurosurgical evaluation. The current analysis examines presenting bone injury, surgical indication, presenting neurological examination, and neurological outcome. In this study, the authors characterize the incidence, severity, and recovery potential of cervical GSWs. The rate of unstable fractures requiring surgical intervention is documented. A detailed discussion of surgical indications with a treatment algorithm for cervical instability is offered. A total of 144 cervical GSWs were retrospectively reviewed. Of these injuries, 40 had documented neurological deficits. No neurosurgical consultation was requested for patients without deficit. Epidemiological and clinical information was collected on patients with neurological deficit, including age, sex, timing, indication, type of surgery, initial examination after resuscitation, follow-up examination, and imaging data. Twenty-eight patients (70%) presented with complete neurological deficits and 12 patients (30%) presented with incomplete injuries. Fourteen (35%) of the 40 patients underwent neurosurgical intervention. Twelve patients (30%) required intervention for cervical instability. Seven patients required internal fixation involving 4 anterior fusions, 2 posterior fusions, and 1 combined approach. Five patients were managed with halo immobilization. Two patients underwent decompression alone for neurological deterioration and persistent compressive injury, both of whom experienced marked neurological recovery. Follow-up was obtained in 92% of cases. Three patients undergoing stabilization converted at least 1 American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade and the remaining operative cases experienced small ASIA motor score improvement. Eighteen patients underwent inpatient MRI. No patient suffered complications or neurological deterioration related to retained metal. Three of 28 patients presenting with AIS Grade A improved to Grade B. For those 12 patients with incomplete injury, 1 improved from AIS Grade C to D, and 3 improved from Grade D to E. Spinal cord injury from GSWs often results in severe neurological deficits. In this series, 30% of these patients with deficits required intervention for instability. This is the first series that thoroughly documents AIS improvement in this patient population. Adherence to the proposed treatment algorithm may optimize neurological outcome and spine stability.

The development of search filters for adverse effects of surgical interventions in medline and Embase.

PubMed

Golder, Su; Wright, Kath; Loke, Yoon Kong

2018-06-01

Search filter development for adverse effects has tended to focus on retrieving studies of drug interventions. However, a different approach is required for surgical interventions. To develop and validate search filters for medline and Embase for the adverse effects of surgical interventions. Systematic reviews of surgical interventions where the primary focus was to evaluate adverse effect(s) were sought. The included studies within these reviews were divided randomly into a development set, evaluation set and validation set. Using word frequency analysis we constructed a sensitivity maximising search strategy and this was tested in the evaluation and validation set. Three hundred and fifty eight papers were included from 19 surgical intervention reviews. Three hundred and fifty two papers were available on medline and 348 were available on Embase. Generic adverse effects search strategies in medline and Embase could achieve approximately 90% relative recall. Recall could be further improved with the addition of specific adverse effects terms to the search strategies. We have derived and validated a novel search filter that has reasonable performance for identifying adverse effects of surgical interventions in medline and Embase. However, we appreciate the limitations of our methods, and recommend further research on larger sample sizes and prospective systematic reviews. © 2018 The Authors Health Information and Libraries Journal published by John Wiley & Sons Ltd on behalf of Health Libraries Group.

The use of clopidogrel (Plavix) in patients undergoing nonelective orthopaedic surgery.

PubMed

Nydick, Jason A; Farrell, Eric D; Marcantonio, Andrew J; Hume, Eric L; Marburger, Robert; Ostrum, Robert F

2010-06-01

To assess the effects of Plavix on patients requiring nonelective orthopaedic surgery. Retrospective cohort study. University-affiliated teaching institutions. The orthopaedic trauma registry was used to retrospectively identify all patients taking clopidogrel (Plavix; Bristol-Myers Squibb/Sanofi Pharmaceuticals, Bridgewater, NJ) who required nonelective orthopaedic surgery from 2004 to 2008. Twenty-nine patients were identified on Plavix (PG) and 32 matched patients in the control group not taking Plavix (NPG). The Plavix group was separated into those with a surgical delay less than 5 days of the last dose (PG < 5) (n = 28) and a delay greater than 5 days (PG > 5) (n = 1). A randomized age- and injury-matched control group not on Plavix was separated with surgical delay less than 5 days (NPG < 5) (n = 29) and delay greater than 5 days (NPG > 5) (n = 3). A retrospective review was performed comparing pre- and postoperative hemoglobin, blood transfusion requirements, surgical delay, 30-day mortality, and postoperative complications. Statistical analyses were performed using the Student t test and chi square test to identify differences between the groups. : The mean preoperative hemoglobin of the PG and the NPG was 11.2 g/dL and 12.3 g/dL (P = 0.03). Transfusion rates were similar with 18 of 28 in the PG compared with 13 of 29 in the NPG (P = 0.22). The mean surgical delay between the PG and NPG was 1.88 and 1.68 days (P = 0.64). Overall complications between the PG and NPG was nine of 28 and nine of 29 (P = 0.92). In both groups, two patients had postoperative wound drainage, which resolved without intervention. One patient in each group required revision surgery for nonunion. The 30-day mortality in the Plavix group was zero of 28 (0%) compared with one of 29 (3%) in the control group (cardiac arrest) (P = 0.32). In this study, there were no serious complications or increased transfusion requirements in the Plavix group. Avoiding surgical delay for patients on Plavix requiring nonelective orthopaedic surgery appears to be safe. The goal should be early operative intervention to decrease the morbidity and mortality of surgical delay. This is especially true for patients with hip fractures, which was the most common nonelective orthopaedic surgery required of patients on Plavix in this study.

Caesarean section surgical techniques (CORONIS): a fractional, factorial, unmasked, randomised controlled trial.

PubMed

Abalos, E; Addo, V; Brocklehurst, P; El Sheikh, M; Farrell, B; Gray, S; Hardy, P; Juszczak, E; Mathews, J E; Masood, S Naz; Oyarzun, E; Oyieke, J; Sharma, J B; Spark, P

2013-07-20

Variations exist in the surgical techniques used for caesarean section and many have not been rigorously assessed in randomised controlled trials. We aimed to assess whether any surgical techniques were associated with improved outcomes for women and babies. CORONIS was a pragmatic international 2×2×2×2×2 non-regular fractional, factorial, unmasked, randomised controlled trial that examined five elements of the caesarean section technique in intervention pairs. CORONIS was undertaken at 19 sites in Argentina, Chile, Ghana, India, Kenya, Pakistan, and Sudan. Each site was assigned to three of the five intervention pairs: blunt versus sharp abdominal entry; exteriorisation of the uterus for repair versus intra-abdominal repair; single-layer versus double-layer closure of the uterus; closure versus non-closure of the peritoneum (pelvic and parietal); and chromic catgut versus polyglactin-910 for uterine repair. Pregnant women were eligible if they were to undergo their first or second caesarean section through a planned transverse abdominal incision. Women were randomly assigned by a secure web-based number allocation system to one intervention from each of the three assigned pairs. All investigators, surgeons, and participants were unmasked to treatment allocation. The primary outcome was the composite of death, maternal infectious morbidity, further operative procedures, or blood transfusion (>1 unit) up to the 6-week follow-up visit. Women were analysed in the groups into which they were allocated. The CORONIS Trial is registered with Current Controlled Trials: ISRCTN31089967. Between May 20, 2007, and Dec 31, 2010, 15 935 women were recruited. There were no statistically significant differences within any of the intervention pairs for the primary outcome: blunt versus sharp entry risk ratio 1·03 (95% CI 0·91-1·17), exterior versus intra-abdominal repair 0·96 (0·84-1·08), single-layer versus double-layer closure 0·96 (0·85-1·08), closure versus non-closure 1·06 (0·94-1·20), and chromic catgut versus polyglactin-910 0·90 (0·78-1·04). 144 serious adverse events were reported, of which 26 were possibly related to the intervention. Most of the reported serious adverse events were known complications of surgery or complications of the reasons for the caesarean section. These findings suggest that any of these surgical techniques is acceptable. However, longer-term follow-up is needed to assess whether the absence of evidence of short-term effects will translate into an absence of long-term effects. UK Medical Research Council and WHO. Copyright © 2013 Elsevier Ltd. All rights reserved.

[Management of patients with bronchial asthma received general anesthesia and surgical intervention].

PubMed

To, Masako; Tajima, Makoto; Ogawa, Cyuhei; Otomo, Mamoru; Suzuki, Naohito; Sano, Yasuyuki

2002-01-01

Stimulation to bronchial mucosa is one of the major risk factor of asthma attack. When patients receive surgical intervention and general anesthesia, they are always exposed to stimulation to bronchial mucosa. Prevention method of bronchial asthma attack during surgical intervention is not established yet. We investigated that clinical course of patients with bronchial asthma who received general anesthesia and surgical intervention. Seventy-six patients with bronchial asthma were received general anesthesia and surgical intervention from 1993 to 1998. Twenty-four patients were mild asthmatic patients, 39 were moderate asthmatic patients and 13 were severe asthmatic patients. Preoperative treatment for preventing asthma attack was as follows; Eight patients were given intravenous infusion of aminophylline before operation. Fifty-two patients were given intravenous infusion of aminophylline and hydrocortisone before operation. Three patients were given intravenous infusion of hydrocortisone for consecutive 3 days before operation. Thirteen patients were given no treatment for preventing asthma attack. One patient was suffered from asthma attack during operation. She was given no preventing treatment for asthma attack before operation. Three patients were suffered from asthma attack after operation. No wound dehiscence was observed in all patients. To prevent asthma attack during operation, intravenous infusion of steroid before operation is recommended, when patients with asthma receive general anesthesia and surgical intervention.

[Improving the provision of major obstetric interventions by task delegation in Africa: An example from the Bogodogo health district hospital in Ouagadougou, Burkina Faso].

PubMed

Ouédraogo, C M; Ouattara, A; Ouédraogo, A; Bikienga, M; Lankoandé, J

2015-01-01

To describe the role of task delegation in the practice of major obstetric procedures in the Bogodogo health district hospital. This descriptive and analytic prospective study took place in the hospital's department of obstetrics and gynecology from February through October 2013. It included all women undergoing a major obstetric surgical intervention, performed by either by a gynecologist-obstetrician or by a nurse specializing in surgery. Data were collected from individual records and analyzed by SPSS and Epidata software. There were 601 major obstetric interventions during the study period. The women's mean age was 26.7 years. Cesarean deliveries accounted for 90% of these procedures, followed by laparotomy (7.7%). The Misgav-Ladach technique was used for cesareans by 86.5% of the obstetricians and 95.3% of the nurses specialized in surgery. The primary complications were anemia and postpartum hemorrhage. Maternal mortality did not differ significantly between the groups of operators, nor did maternal, fetal, and neonatal outcomes. Task delegation in obstetric surgery at the Bogodogo district hospital is effective. Its extension to the national level would make it possible to overcome the lack of highly qualified human resources to enable adequate availability of major obstetric interventions in rural hospitals.

[Benefit assessment of operative interventions from the perspective of surgical research].

PubMed

Hüttner, F J; Ulrich, A; Mihaljevic, A L; Probst, P; Rossion, I; Diener, Markus K

2015-03-01

The benefit assessment of surgical procedures serves as the basis for the concept of evidence-based surgery. However, especially in the field of surgery, many interventions are lacking assessment in high-quality clinical trials. Therefore, a well-structured benefit assessment of surgical interventions in the future is imperative. Considering the different perspectives, e.g. of the patients, surgeons, industry or health care investors, the implications of the benefits and risks of a procedure can differ significantly. Researchers have to abide by different regulations, depending on the type of intervention being evaluated in a surgical trial. Furthermore, the benefit assessment of surgical procedures poses specific challenges, from the choice of a relevant endpoint to issues concerning the standardization of the interventions and the impact of learning curves. The IDEAL concept, which was established by a group of international experts in 2009, serves as a framework for the future development and assessment of innovations in the field of surgery. For example, the SDGC (Study Center of the German Society of Surgery) and CHIR-Net (Surgical Studies Network) indicate that such collaborations of clinicians and methodologists can lead to the creation of a qualified structure for the effective benefit assessment of surgical procedures. In the future, the aforementioned evidence gaps must be eliminated and innovations evaluated efficiently by the work of such networks.

Novel ways to explore surgical interventions in randomised controlled trials: applying case study methodology in the operating theatre.

PubMed

Blencowe, Natalie S; Blazeby, Jane M; Donovan, Jenny L; Mills, Nicola

2015-12-28

Multi-centre randomised controlled trials (RCTs) in surgery are challenging. It is particularly difficult to establish standards of surgery and ensure that interventions are delivered as intended. This study developed and tested methods for identifying the key components of surgical interventions and standardising interventions within RCTs. Qualitative case studies of surgical interventions were undertaken within the internal pilot phase of a surgical RCT for obesity (the By-Band study). Each case study involved video data capture and non-participant observation of gastric bypass surgery in the operating theatre and interviews with surgeons. Methods were developed to transcribe and synchronise data from video recordings with observational data to identify key intervention components, which were then explored in the interviews with surgeons. Eight qualitative case studies were undertaken. A novel combination of video data capture, observation and interview data identified variations in intervention delivery between surgeons and centres. Although surgeons agreed that the most critical intervention component was the size and shape of the gastric pouch, there was no consensus regarding other aspects of the procedure. They conceded that evidence about the 'best way' to perform bypass was lacking and, combined with the pragmatic nature of the By-Band study, agreed that strict standardisation of bypass might not be required. This study has developed and tested methods for understanding how surgical interventions are designed and delivered delivered in RCTs. Applying these methods more widely may help identify key components of interventions to be delivered by surgeons in trials, enabling monitoring of key components and adherence to the protocol. These methods are now being tested in the context of other surgical RCTs. Current Controlled Trials ISRCTN00786323 , 05/09/2011.

Challenges in evaluating surgical innovation.

PubMed

Ergina, Patrick L; Cook, Jonathan A; Blazeby, Jane M; Boutron, Isabelle; Clavien, Pierre-Alain; Reeves, Barnaby C; Seiler, Christoph M; Altman, Douglas G; Aronson, Jeffrey K; Barkun, Jeffrey S; Campbell, W Bruce; Cook, Jonathan A; Feldman, Liane S; Flum, David R; Glasziou, Paul; Maddern, Guy J; Marshall, John C; McCulloch, Peter; Nicholl, Jon; Strasberg, Steven M; Meakins, Jonathan L; Ashby, Deborah; Black, Nick; Bunker, John; Burton, Martin; Campbell, Marion; Chalkidou, Kalipso; Chalmers, Iain; de Leval, Marc; Deeks, Jon; Grant, Adrian; Gray, Muir; Greenhalgh, Roger; Jenicek, Milos; Kehoe, Sean; Lilford, Richard; Littlejohns, Peter; Loke, Yoon; Madhock, Rajan; McPherson, Kim; Rothwell, Peter; Summerskill, Bill; Taggart, David; Tekkis, Parris; Thompson, Matthew; Treasure, Tom; Trohler, Ulrich; Vandenbroucke, Jan

2009-09-26

Research on surgical interventions is associated with several methodological and practical challenges of which few, if any, apply only to surgery. However, surgical evaluation is especially demanding because many of these challenges coincide. In this report, the second of three on surgical innovation and evaluation, we discuss obstacles related to the study design of randomised controlled trials and non-randomised studies assessing surgical interventions. We also describe the issues related to the nature of surgical procedures-for example, their complexity, surgeon-related factors, and the range of outcomes. Although difficult, surgical evaluation is achievable and necessary. Solutions tailored to surgical research and a framework for generating evidence on which to base surgical practice are essential.

Surgical management of tumors invading the aorta and major arterial structures.

PubMed

Carpenter, Susanne G; Stone, William M; Bower, Thomas C; Fowl, Richard J; Money, Samuel R

2011-11-01

This study investigates surgical management of tumors arising from or involving the aorta and major arterial structures. A retrospective single institutional review was conducted of patients undergoing arterial resection for tumors involving the aorta or major arterial structures between January 1992 and May 2009 at a tertiary care center. Patients with tumors abutting arteries without necessitating resection and those involving only venous structures were excluded. Patients were analyzed in groups by vessel involvement: aorta, carotid, external/common iliac, internal iliac, superficial femoral, and miscellaneous. Sixty patients were identified and included for review. The iliac arteries were most often resected, and sarcomatous pathology was most common (37 patients, 62%). Twelve patients underwent aortic resection, with eight (67%) of these undergoing graft reconstruction, one (8%) graft patch, and two (17%) primary repair. None of the 17 patients undergoing internal iliac resection underwent reconstruction, whereas the majority of patients in all other groups underwent reconstruction. Thirty-day mortality (TDM) was 0% in all groups, except the aortic (2/12, 17% TDM), and internal iliac arteries (1/17, 6% TDM). Estimated blood loss varied widely and was not significantly different between vessel groups (p = 0.280). Overall, 44 of 60 (73%) patients had negative margins. Fourteen patients (23%) returned to the operating room, most for wound infection or dehiscence. Mean follow-up was 20.25 months (range: 0.5-122.0 months, SD: 23 months). Forty patients were followed up for more than 1 year. Thus, with an overall median follow-up of 12.25 months, overall survival was 60% with disease-free survival of 40%. Resection of tumors involving the aorta and major arterial structures provides a reasonable option for treatment, but with significant perioperative morbidity. In selected patients, this aggressive intervention should be considered. Copyright © 2011 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.

Surgical care for the direct and indirect victims of violence in the eastern Democratic Republic of Congo.

PubMed

Chu, Kathryn; Havet, Philippe; Ford, Nathan; Trelles, Miguel

2010-04-14

The provision of surgical assistance in conflict is often associated with care for victims of violence. However, there is an increasing appreciation that surgical care is needed for non-traumatic morbidities. In this paper we report on surgical interventions carried out by Médecins sans Frontières in Masisi, North Kivu, Democratic Republic of Congo to contribute to the scarce evidence base on surgical needs in conflict. We analysed data on all surgical interventions done at Masisi district hospital between September 2007 and December 2009. Types of interventions are described, and logistic regression used to model associations with violence-related injury. 2869 operations were performed on 2441 patients. Obstetric emergencies accounted for over half (675, 57%) of all surgical pathology and infections for another quarter (160, 14%). Trauma-related injuries accounted for only one quarter (681, 24%) of all interventions; among these, 363 (13%) were violence-related. Male gender (adjusted odds ratio (AOR) = 20.0, p < 0.001), military status (AOR = 4.1, p < 0.001), and age less than 20 years (AOR = 2.1, p < 0.001) were associated with violence-related injury. Immediate peri-operative mortality was 0.2%. In this study, most surgical interventions were unrelated to violent trauma and rather reflected the general surgical needs of a low-income tropical country. Programs in conflict zones in low-income countries need to be prepared to treat both the war-wounded and non-trauma related life-threatening surgical needs of the general population. Given the limited surgical workforce in these areas, training of local staff and task shifting is recommended to support broad availability of essential surgical care. Further studies into the surgical needs of the population are warranted, including population-based surveys, to improve program planning and resource allocation and the effectiveness of the humanitarian response.

CArbon dioxide surgical field flooding and aortic NO-touch off-pump coronary artery bypass grafting to reduce Neurological injuries after surgical coronary revascularisation (CANON): protocol for a randomised, controlled, investigator and patient blinded single-centre superiority trial with three parallel arms.

PubMed

Krzysztof, Szwed; Wojciech, Pawliszak; Zbigniew, Serafin; Mariusz, Kowalewski; Remigiusz, Tomczyk; Damian, Perlinski; Magdalena, Szwed; Marta, Tomaszewska; Lech, Anisimowicz; Alina, Borkowska

2017-07-10

Neurological injuries remain a major concern following coronary artery bypass grafting (CABG) that offsets survival benefit of CABG over percutaneous coronary interventions. Among numerous efforts to combat this issue is the development of off-pump CABG (OPCABG) that obviates the need for extracorporeal circulation and is associated with improved neurological outcomes. The objective of this study is to examine whether the neuroprotective effect of OPCABG can be further pronounced by the use of two state-of-the-art operating techniques. In this randomised, controlled, investigator and patient blinded single-centre superiority trial with three parallel arms, a total of 360 patients will be recruited. They will be allocated in a 1:1:1 ratio to two treatment arms and one control arm. Treatment arms undergoing either aortic no-touch OPCABG or OPCABG with partial clamp applying carbon dioxide surgical field flooding will be compared against control arm undergoing OPCABG with partial clamp. The primary endpoint will be the appearance of new lesions on control brain MRI 3 days after surgery. Secondary endpoints will include the prevalence of new focal neurological deficits in the first 7 days after surgery, the occurrence of postoperative cognitive dysfunction at either 1 week or 3 months after surgery and the incidence of delirium in the first 7 days after surgery. Data will be analysed on intention-to-treat principles and a per protocol basis. Ethical approval has been granted for this study. Results will be disseminated through peer-reviewed media. NCT03074604; Pre-results. 10-Mar-2017 Original. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

The Effect of Body Mass Index on Perioperative Outcomes After Major Surgery: Results from the National Surgical Quality Improvement Program (ACS-NSQIP) 2005-2011.

PubMed

Sood, Akshay; Abdollah, Firas; Sammon, Jesse D; Majumder, Kaustav; Schmid, Marianne; Peabody, James O; Preston, Mark A; Kibel, Adam S; Menon, Mani; Trinh, Quoc-Dien

2015-10-01

Obesity is associated with poor surgical outcomes and disparity in access-to-care. There is a lack of quality data on the effect of body mass index (BMI) on perioperative outcomes. Accordingly, we sought to determine the procedure specific, independent-effect of BMI on 30-day perioperative outcomes in patients undergoing major surgery. Participants included individuals undergoing one of 16 major surgery (cardiovascular, orthopedic, oncologic; n = 141,802) recorded in the ACS-NSQIP (2005-2011). Outcomes evaluated included complications, blood transfusion, length-of-stay (LOS), re-intervention, readmission, and perioperative mortality. Multivariable-regression models assessed the independent-effect of BMI on outcomes. Nearly, 74 % of patients had a BMI disturbance; the majority being overweight (35.3 %) or obese (29.8 %). Morbidly obese patients constituted a small but significant proportion of the patients (5.7 %; n = 8067). In adjusted-analyses, morbidly obese patients had significantly increased odds of wound complications in 15 of the examined procedures, of renal complications after 6-procedures, of thromboembolism after 5-procedures, of pulmonary, septic and UTI complications after 2-procedures, and of cardiovascular complications after CABG. Conversely, obese/overweight patients, except for increased odds of wound complications after select procedures, had significantly decreased odds of perioperative mortality, prolonged-LOS and blood transfusion relative to normal BMI patients after 4, 8, and 9 of the examined procedures. The prevalence of BMI derangements in surgical patients is high. The effect of BMI on outcomes is procedure specific. Patients with BMI between 18.5 and 40-kg/m(2) at time of surgery fare equally well with regard to complications and mortality. However, morbidly obese patients are at-risk for postsurgical complications and targeted preoperative-optimization may improve outcomes and attenuate disparity in access-to-care.

An Intensive Lifestyle Intervention Is an Effective Treatment of Morbid Obesity: The TRAMOMTANA Study—A Two-Year Randomized Controlled Clinical Trial

PubMed Central

Burguera, Bartolomé; Jesús Tur, Juan; Escudero, Antonio Jorge; Alos, María; Pagán, Alberto; Cortés, Baltasar; González, Xavier Francesc; Soriano, Joan B.

2015-01-01

Bariatric surgery is currently the most effective therapy to induce weight loss in morbidly obese patients. Objective. This controlled, clinical trial with a two-year intervention was aimed at comparing the efficacy of two nonsurgical approaches versus bariatric surgery, on body weight changes and metabolic parameters in morbidly obese patients. Methods. Patients were randomized to an Intensive Lifestyle Intervention (ILI) (n = 60) or Conventional Obesity Therapy (COT) (n = 46). The ILI group received behavioral therapy and nutritional counseling. The COT group received standard medical treatment. They were compared with a third group, Surgical Obesity Group (SOG) (n = 37). Results. Patients who received ILI had a greater percentage of weight loss than patients receiving COT (−11.3% versus −1.6%; p < 0.0044). Interestingly 31.4% of patients included in the ILI group were no longer morbidly obese after just six months of intervention, increasing to 44.4% after 24 months of intervention. The percentage weight loss in SOG was −29.6% after that same period of time. Conclusions. ILI was associated with significant weight loss when compared to COT, in a group of patients with obesity. An ILI approach could be an alternative therapy to patients with obesity, who are not candidates to undergo bariatric surgery. This trial is registered with EudraCT 2009-013737-24. PMID:26257780

An Intensive Lifestyle Intervention Is an Effective Treatment of Morbid Obesity: The TRAMOMTANA Study-A Two-Year Randomized Controlled Clinical Trial.

PubMed

Burguera, Bartolomé; Jesús Tur, Juan; Escudero, Antonio Jorge; Alos, María; Pagán, Alberto; Cortés, Baltasar; González, Xavier Francesc; Soriano, Joan B

2015-01-01

Bariatric surgery is currently the most effective therapy to induce weight loss in morbidly obese patients. Objective. This controlled, clinical trial with a two-year intervention was aimed at comparing the efficacy of two nonsurgical approaches versus bariatric surgery, on body weight changes and metabolic parameters in morbidly obese patients. Methods. Patients were randomized to an Intensive Lifestyle Intervention (ILI) (n = 60) or Conventional Obesity Therapy (COT) (n = 46). The ILI group received behavioral therapy and nutritional counseling. The COT group received standard medical treatment. They were compared with a third group, Surgical Obesity Group (SOG) (n = 37). Results. Patients who received ILI had a greater percentage of weight loss than patients receiving COT (-11.3% versus -1.6%; p < 0.0044). Interestingly 31.4% of patients included in the ILI group were no longer morbidly obese after just six months of intervention, increasing to 44.4% after 24 months of intervention. The percentage weight loss in SOG was -29.6% after that same period of time. Conclusions. ILI was associated with significant weight loss when compared to COT, in a group of patients with obesity. An ILI approach could be an alternative therapy to patients with obesity, who are not candidates to undergo bariatric surgery. This trial is registered with EudraCT 2009-013737-24.

Better object recognition and naming outcome with MRI-guided stereotactic laser amygdalohippocampotomy for temporal lobe epilepsy.

PubMed

Drane, Daniel L; Loring, David W; Voets, Natalie L; Price, Michele; Ojemann, Jeffrey G; Willie, Jon T; Saindane, Amit M; Phatak, Vaishali; Ivanisevic, Mirjana; Millis, Scott; Helmers, Sandra L; Miller, John W; Meador, Kimford J; Gross, Robert E

2015-01-01

Patients with temporal lobe epilepsy (TLE) experience significant deficits in category-related object recognition and naming following standard surgical approaches. These deficits may result from a decoupling of core processing modules (e.g., language, visual processing, and semantic memory), due to "collateral damage" to temporal regions outside the hippocampus following open surgical approaches. We predicted that stereotactic laser amygdalohippocampotomy (SLAH) would minimize such deficits because it preserves white matter pathways and neocortical regions that are critical for these cognitive processes. Tests of naming and recognition of common nouns (Boston Naming Test) and famous persons were compared with nonparametric analyses using exact tests between a group of 19 patients with medically intractable mesial TLE undergoing SLAH (10 dominant, 9 nondominant), and a comparable series of TLE patients undergoing standard surgical approaches (n=39) using a prospective, nonrandomized, nonblinded, parallel-group design. Performance declines were significantly greater for the patients with dominant TLE who were undergoing open resection versus SLAH for naming famous faces and common nouns (F=24.3, p<0.0001, η2=0.57, and F=11.2, p<0.001, η2=0.39, respectively), and for the patients with nondominant TLE undergoing open resection versus SLAH for recognizing famous faces (F=3.9, p<0.02, η2=0.19). When examined on an individual subject basis, no SLAH patients experienced any performance declines on these measures. In contrast, 32 of the 39 patients undergoing standard surgical approaches declined on one or more measures for both object types (p<0.001, Fisher's exact test). Twenty-one of 22 left (dominant) TLE patients declined on one or both naming tasks after open resection, while 11 of 17 right (nondominant) TLE patients declined on face recognition. Preliminary results suggest (1) naming and recognition functions can be spared in TLE patients undergoing SLAH, and (2) the hippocampus does not appear to be an essential component of neural networks underlying name retrieval or recognition of common objects or famous faces. Wiley Periodicals, Inc. © 2014 International League Against Epilepsy.

Socioeconomic status and impact of treatment on families of children with congenital heart disease.

PubMed

Mughal, Abdul Razzaq; Sadiq, Masood; Hyder, Syed Najam; Qureshi, Ahmad Usaid; A Shah, S Salman; Khan, Mohammad Asim; Nasir, Jamal Abdul

2011-07-01

To assess the socioeconomic status, treatment being offered and the impact of congenital heart disease treatment on families. Observational study. The Children's Hospital / Institute of Child Health, Lahore, from 1st March to 31st August 2010. All patients undergoing a cardiac surgical or angiographic intervention were enrolled. Socioeconomic status was assessed by Kuppuswamy socioeconomic status scale with income group modification. The impact was measured by the source of financing, effect on family financing source and schooling and health of siblings. Of 211 patients undergoing treatment in the study period, surgery was the definitive treatment in 164 (77.7%) and angiographic intervention in 47 (22.3%) patients. Male to female ratio was 1.5:1. The mean age of the patient was 39.1 + 3.2 months (range 01 day to 15 years). Majority of families belonged to middle (66.4%, n=140) and lower (27%, n=57) socioeconomic class. The mean cost of medicines and disposables was PKR 78378.2 ± 8845.9 (US$ 933.1 ± 105.3) in open heart surgery, PKR 12581 ± 7010.8 (US$ 149.8 ± 83.5) in closed heart surgery and PKR 69091 + 60906 in angiographic interventions. In 63.1% patients, families contributed towards these costs either completely (12.3%) or partly (50.8%) with significant contribution from the hospital. Adverse effect on families ranged from leave without pay to losing jobs or business (46%), and selling their assets (11.3%). It also affected schooling and health of siblings (22.7% and 26.1% respectively). Majority of children with congenital heart disease belonged to middle and lower socioeconomic status in this study. Main definitive treatment was surgery. The cost of health care facilities posed a marked socioeconomic burden on those families.

The treatment of female pattern hair loss and other applications of surgical hair restoration in women.

PubMed

Epstein, Jeffrey S

2004-05-01

In the specialty of surgical hair restoration, men comprise more than 90% of the patients treated; however, in the last few years the number of women undergoing the procedure has increased significantly. The reasons for this growth are many and include the increase in public awareness of the efficacy of hair transplantation from such sources as the media,the Internet, advertising and word of mouth. More importantly, advances in technique have significantly improved results, increasing the confidence level in women to undergo the procedure and in hair transplant specialists to offer it.

Efficacy of a dual-ring wound protector for prevention of incisional surgical site infection after Whipple's procedure (pancreaticoduodenectomy) with preoperatively-placed intrabiliary stents: protocol for a randomised controlled trial.

PubMed

Bressan, Alexsander K; Roberts, Derek J; Edwards, Janet P; Bhatti, Sana U; Dixon, Elijah; Sutherland, Francis R; Bathe, Oliver; Ball, Chad G

2014-08-21

Among surgical oncology patients, incisional surgical site infection is associated with substantially increased morbidity, mortality and healthcare costs. Moreover, while adults undergoing pancreaticoduodenectomy with preoperative placement of an intrabiliary stent have a high risk of this type of infection, and wound protectors may significantly reduce its risk, no relevant studies of wound protectors yet exist involving this patient population. This study will evaluate the efficacy of a dual-ring wound protector for prevention of incisional surgical site infection among adults undergoing pancreaticoduodenectomy with preoperatively-placed intrabiliary stents. This study will be a parallel, dual-arm, randomised controlled trial that will utilise a more explanatory than pragmatic attitude. All adults (≥18 years) undergoing a pancreaticoduodenectomy at the Foothills Medical Centre in Calgary, Alberta, Canada with preoperative placement of an intrabiliary stent will be considered eligible. Exclusion criteria will include patient age <18 years and those receiving long-term glucocorticoids. The trial will employ block randomisation to allocate patients to a commercial dual-ring wound protector (the Alexis Wound Protector) or no wound protector and the current standard of care. The main outcome measure will be the rate of surgical site infection as defined by the Centers for Disease Control and Prevention criteria within 30 days of the index operation date as determined by a research assistant blinded to treatment allocation. Outcomes will be analysed by a statistician blinded to allocation status by calculating risk ratios and 95% CIs and compared using Fisher's exact test. This will be the first randomised trial to evaluate the efficacy of a dual-ring wound protector for prevention of incisional surgical site infection among patients undergoing pancreaticoduodenectomy. Results of this study are expected to be available in 2016/2017 and will be disseminated using an integrated and end-of-grant knowledge translation strategy. ClinicalTrials.gov identifier NCT01836237. 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.

A Population-Based Study of 30-day Incidence of Ischemic Stroke Following Surgical Neck Dissection

PubMed Central

MacNeil, S. Danielle; Liu, Kuan; Garg, Amit X.; Tam, Samantha; Palma, David; Thind, Amardeep; Winquist, Eric; Yoo, John; Nichols, Anthony; Fung, Kevin; Hall, Stephen; Shariff, Salimah Z.

2015-01-01

Abstract The objective of this study was to determine the 30-day incidence of ischemic stroke following neck dissection compared to matched patients undergoing non-head and neck surgeries. A surgical dissection of the neck is a common procedure performed for many types of cancer. Whether such dissections increase the risk of ischemic stroke is uncertain. A retrospective cohort study using data from linked administrative and registry databases (1995–2012) in the province of Ontario, Canada was performed. Patients were matched 1-to-1 on age, sex, date of surgery, and comorbidities to patients undergoing non-head and neck surgeries. The primary outcome was ischemic stroke assessed in hospitalized patients using validated database codes. A total of 14,837 patients underwent surgical neck dissection. The 30-day incidence of ischemic stroke following the dissection was 0.7%. This incidence decreased in recent years (1.1% in 1995 to 2000; 0.8% in 2001 to 2006; 0.3% in 2007 to 2012; P for trend <0.0001). The 30-day incidence of ischemic stroke in patients undergoing neck dissection is similar to matched patients undergoing thoracic surgery (0.5%, P = 0.26) and colectomy (0.5%, P = 0.1). Factors independently associated with a higher risk of stroke in 30 days following neck dissection surgery were of age ≥75 years (odds ratio (OR) 1.63, 95% confidence interval (CI) 1.05–2.53), and a history of diabetes (OR 1.60, 95% CI 1.02–2.49), hypertension (OR 2.64, 95% CI 1.64–4.25), or prior stroke (OR 4.06, 95% CI 2.29–7.18). Less than 1% of patients undergoing surgical neck dissection will experience an ischemic stroke in the following 30 days. This incidence of stroke is similar to thoracic surgery and colectomy. PMID:26287406

Identification of potential surgical site infections leveraging an enterprise clinical information warehouse.

PubMed

Santangelo, Jennifer; Erdal, Selnur; Wellington, Linda; Mekhjian, Hagop; Kamal, Jyoti

2008-11-06

At The Ohio State University Medical Center (OSUMC), infection control practitioners (ICPs) need an accurate list of patients undergoing defined operative procedures to track surgical site infections. Using data from the OSUMC Information Warehouse (IW), we have created an automated report detailing required data. This report also displays associated surgical and pathology text or dictated reports providing additional information to the ICPs.

Risk factors associated with surgical site infection and the development of short-term complications in macaques undergoing indwelling vascular access port placement.

PubMed

Graham, M L; Rieke, E F; Wijkstrom, M; Dunning, M; Aasheim, T C; Graczyk, M J; Pilon, K J; Hering, B J

2008-08-01

Risk factors associated with surgical site infection (SSI) and the development of short-term complications in macaques undergoing vascular access port (VAP) placement are evaluated in this study. Records from 80 macaques with VAPs were retrospectively reviewed. Logistic regression was used to identify factors associated with short-term post-operative complications. The primary outcome was SSI, which occurred in 21.6% (52.6% in the first 12 months vs. 13% thereafter) of procedures. SSI was associated with major secondary complications including VAP removal (11.4%), wound dehiscence (5.7%), and mechanical catheter occlusion (5.7%). In multivariate modeling, only surgical program progress was a statistically significant predictor of SSI, while animal compliance had a slightly protective effect. Vascular access ports have a moderate risk of complications, provided the surgical program optimizes best practices. Under complex experimental conditions, VAPs represent an important refinement, both improving animals' overall well-being and environment and reducing stress.

Patent ductus arteriosus ligation in premature infants in the United States.

PubMed

Tashiro, Jun; Wang, Bo; Sola, Juan E; Hogan, Anthony R; Neville, Holly L; Perez, Eduardo A

2014-08-01

Patent ductus arteriosus (PDA) is a condition that commonly affects premature and low birth weight (BW) infants at times necessitating surgical intervention. We examined outcomes after surgical ligation (SL). We analyzed the Kids' Inpatient Database for premature infants diagnosed with PDA, admitted at <8 d of age. Patient demographics, disposition, morbidity, and mortality were analyzed. All cases were weighted appropriately to project nationally representative estimates. A total of 63,208 patients were identified with diagnosis of PDA. Of these, 6766 (10.7%) underwent SL. Lower gestational age (GA) and BW patients had higher incidence of PDA and rates of SL. Overall survival was 90.8% for the cohort. Survival for the SL group was 88.0% and 91.2% for the non-SL group; however, infants undergoing SL had higher survival rates up to 28 wk and 1250 g for GA and BW, respectively. GA did not affect post-SL survival adversely. Rather, lower BW was associated with extremely high mortality rates. Black infants and boys had lower survival compared with other races and girls, respectively. Larger hospitals had higher survival rates, but hospital location, teaching status, and type did not affect survival. Payer status and income quartile did not affect survival. PDA and SL are more common in lower BW and GA groups. Higher survival rates are found for infants with SL versus non-SL in the lowest BW and GA groups. Morbidity and mortality are not affected by SL timing. BW, rather than GA, determines survival of infants undergoing SL. Copyright © 2014 Elsevier Inc. All rights reserved.

A 20-year study on treating childhood infective endocarditis with valve replacement in a single cardiac center in China.

PubMed

Xiao, Jian; Yin, Liang; Lin, Yiyun; Zhang, Yufeng; Wu, Lihui; Wang, Zhinong

2016-07-01

Children with infective endocarditis (IE) have to undergo valve replacement instead of valve repair in China due to severe valve damage. The present study is to review our experience on surgical treatment of children with IE in reference to the incidence, pathologic status, diagnosis, surgical strategies and outcomes. We reviewed 35 patients with a mean age of 13.7±2.2 years who were underwent valve replacement surgery for IE during the period from January 1993 to December 2013. Preoperative transthoracic echocardiographic (TTE) evaluation and transesophageal echocardiography during operation were performed in all patients. All the children underwent chart review and retrospective risk-hazard analysis. Among the patients surveyed congenital cardiac lesions were present in 15 (42.8%), rheumatic heart valve disease in 2 (5.7%) and previous heart surgery in 2 (5.7%). The median stay of intensive care unit was 6 days. Intraoperative findings showed that the endocarditis involved mostly the mitral and aortic valves (88.5%). Triple or quadruple valve involvement was found in one patient each. Ten-year freedom from IE-related death and re-intervention was 94.2% and 91.6%, respectively. Children undergoing surgery for IE frequently have advanced disease with embolic complications. Although valve replacement is not the primary option for pediatric IE, the rate of 5-year survival and freedom from re-operation was optimal prognostically. Pediatric physicians should pay attention to the common clinical features of IE so that the native valve is preserved well.

Organization of Hospital Nursing and 30-Day Readmissions in Medicare Patients Undergoing Surgery.

PubMed

Ma, Chenjuan; McHugh, Matthew D; Aiken, Linda H

2015-01-01

Growing scrutiny of readmissions has placed hospitals at the center of readmission prevention. Little is known, however, about hospital nursing—a critical organizational component of hospital service system—in relation to readmissions. To determine the relationships between hospital nursing factors—nurse work environment, nurse staffing, and nurse education—and 30-day readmissions among Medicare patients undergoing general, orthopedic, and vascular surgery. We linked Medicare patient discharge data, multistate nurse survey data, and American Hospital Association Annual Survey data. Our sample included 220,914 Medicare surgical patients and 25,082 nurses from 528 hospitals in 4 states (California, Florida, New Jersey, and Pennsylvania). Risk-adjusted robust logistic regressions were used for analyses. The average 30-day readmission rate was 10% in our sample (general surgery: 11%; orthopedic surgery: 8%; vascular surgery: 12%). Readmission rates varied widely across surgical procedures and could be as high as 26% (upper limb and toe amputation for circulatory system disorders). Each additional patient per nurse increased the odds of readmission by 3% (OR=1.03; 95% CI, 1.00-1.05). Patients cared in hospitals with better nurse work environments had lower odds of readmission (OR=0.97; 95% CI, 0.95-0.99). Administrative support to nursing practice (OR=0.96; 95% CI, 0.94-0.99) and nurse-physician relations (OR=0.97; 95% CI, 0.95-0.99) were 2 main attributes of the work environment that were associated with readmissions. Better nurse staffing and work environment were significantly associated with 30-day readmission, and can be considered as system-level interventions to reduce readmissions and associated financial penalties.

Surgical Care of Pediatric Patients in the Humanitarian Setting: The Médecins Sans Frontières Experience, 2012-2013.

PubMed

Trudeau, Maeve O'Neill; Baron, Emmanuel; Hérard, Patrick; Labar, Amy S; Lassalle, Xavier; Teicher, Carrie Lee; Rothstein, David H

2015-11-01

Little is known about the scope of practice and outcomes in pediatric surgery performed by humanitarian organizations in resource-poor settings and conflict zones. This study provides the largest report to date detailing such data for a major nongovernmental organization providing humanitarian surgical relief support in these settings. To characterize pediatric surgical care provision by a major nongovernmental organization in specialized humanitarian settings and conflict zones. A retrospective cohort study was conducted from August 15, 2014, to March 9, 2015, of 59,928 surgical interventions carried out from January 1, 2012, to December 31, 2013, by the Médecins Sans Frontières Operational Centre Paris (MSF-OCP) program in 20 locations, including South Sudan, Yemen, Syria, Gaza, Pakistan, Nigeria, Central African Republic, Democratic Republic of Congo, and the Philippines. Surgical interventions were primarily for general surgical, traumatic, and obstetric emergencies and were categorized by mechanism, type of intervention, American Society of Anesthesia risk classification, and urgency of intervention. Operative indications, type of intervention, and operative case mortality. Among all age groups, 59,928 surgical interventions were performed in dedicated trauma, obstetric, and reconstructive centers for 2 years. Nearly one-third of interventions (18,040 [30.1%]) involved preteen patients (aged <13 years) and 4571 (7.6%) involved teenaged patients (aged 13-17 years). The proportion of violence-related injuries in the preteen group was significantly lower than in the teenage group (4.8% vs 17.5%; P < .001). Burns (50.1%), other accidental injuries (16.4%), and infections (23.4%) composed the bulk of indications in the preteen group. Interventions in the teenage group were principally caused by trauma-related injuries (burns, 22.9%; traffic accidents, 10.1%; gunshot wounds, 8.0%). Crude perioperative case mortality rates were 0.07% in the preteen group, 0.15% in the teenage group, and 0.22% in the adult group (>17 years) (P = .001). One-third of the cases (33.4%) were deemed urgent, while most of the remaining cases (57.7%) were deemed semielective (surgical intervention to be performed within 48 hours). When examining surgical interventions in a population of pediatric patients cared for in the specialized setting of humanitarian aid and conflict zones, burns, other accidental injuries, and infection composed the bulk of indications in the preteen group; interventions in the teenage group were principally caused by trauma-related injuries. Crude perioperative case mortality rates in the preteen group were significantly lower than in the adult group. Further work is needed to examine long-term outcomes of pediatric operations in these settings and to guide context-specific surgical program development.

Risk factors and outcomes of in-hospital cardiac arrest following pediatric heart operations of varying complexity.

PubMed

Gupta, Punkaj; Rettiganti, Mallikarjuna; Jeffries, Howard E; Scanlon, Matthew C; Ghanayem, Nancy S; Daufeldt, Jennifer; Rice, Tom B; Wetzel, Randall C

2016-08-01

Multi center data regarding cardiac arrest in children undergoing heart operations of varying complexity are limited. Children <18 years undergoing heart surgery (with or without cardiopulmonary bypass) in the Virtual Pediatric Systems (VPS, LLC) Database (2009-2014) were included. Multivariable mixed logistic regression models were adjusted for patient's characteristics, surgical risk category (STS-EACTS Categories 1, 2, and 3 classified as "low" complexity and Categories 4 and 5 classified as "high" complexity), and hospital characteristics. Overall, 26,909 patients (62 centers) were included. Of these, 2.7% had cardiac arrest after cardiac surgery with an associated mortality of 31%. The prevalence of cardiac arrest was lower among patients undergoing low complexity operations (low complexity vs. high complexity: 1.7% vs. 5.9%). Unadjusted outcomes after cardiac arrest were significantly better among patients undergoing low complexity operations (mortality: 21.6% vs. 39.1%, good neurological outcomes: 78.7% vs. 71.6%). In adjusted models, odds of cardiac arrest were significantly lower among patients undergoing low complexity operations (OR: 0.55, 95% CI: 0.46-0.66). Adjusted models, however, showed no difference in mortality or neurological outcomes after cardiac arrest regardless of surgical complexity. Further, our results suggest that incidence of cardiac arrest and mortality after cardiac arrest are a function of patient characteristics, surgical risk category, and hospital characteristics. Presence of around the clock in-house attending level pediatric intensivist coverage was associated with lower incidence of post-operative cardiac arrest, and presence of a dedicated cardiac ICU was associated with lower mortality after cardiac arrest. This study suggests that the patients undergoing high complexity operations are a higher risk group with increased prevalence of post-operative cardiac arrest. These data further suggest that patients undergoing high complexity operations can be rescued after cardiac arrest with a high survival rate. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Overall outcomes following early interventions for intracranial arteriovenous malformations with hematomas.

PubMed

Bir, Shyamal C; Maiti, Tanmoy Kumar; Konar, Subhas; Nanda, Anil

2016-01-01

We evaluated the timing and predictors of surgical intervention for intracranial arteriovenous malformations (AVM) with hematoma. A ruptured intracranial AVM with hematoma is an emergency condition, and the optimal timing for surgical intervention is not well understood. In addition, the outcome predictors of surgical intervention have rarely been reported. We identified and analyzed 78 patients treated with microsurgical resection for pathologically proven AVM at Louisiana State University Health in Shreveport from February 1992 to December 2004. All 78 patients were diagnosed with ruptured AVM before surgery. The independent variables, including patient demographics, timing of surgery, location of the AVM and comorbidities were analyzed to assess outcome. The results of this series revealed that surgical intervention after 48hours resulted in poor outcomes for patients with hematoma, following a ruptured AVM. Several other prognostic factors, including younger age (11-40years), Spetzler-Martin Grade I and II, and AVM in a supratentorial location, had significant positive effects on outcomes. However, hypertension, smoking, and a prior embolization showed significant negative effects on outcomes after surgery. The multiple logistic regression analyses also revealed that the timing of surgical intervention had a significant effect on outcomes in patients with hematoma following ruptured AVM. Early intervention is the key to success in these patients. Published by Elsevier Ltd.

Very Large Metastases to the Brain: Retrospective Study on Outcomes of Surgical Management.

PubMed

Gattozzi, Domenico A; Alvarado, Anthony; Kitzerow, Collin; Funkhouser, Alexander; Bimali, Milan; Moqbel, Murad; Chamoun, Roukoz B

2018-05-25

The incidence of brain metastases is rising. No published study focuses exclusively on brain metastases larger than 4 cm. We present our surgical outcomes for patients with brain metastases larger than 4 cm. This is a retrospective chart review of inpatient data at our institution from January 2006 to September 2015. Primary endpoints included overall survival, progression-free survival, and local recurrence rate. Sixty-one patients had a total of 67 brain metastases larger than 4 cm: 52 supratentorial and 15 infratentorial. Forty-three patients underwent surgical resection. Average duration of disease freedom after resection was 4.79 months (range 0-30). Excluding patients with residual on immediate post-operative MRI, average rate of local recurrence was 7 months (range 1-14). Overall survival after surgery excluding patients who chose palliation in the immediate postoperative period averaged 8.76 months (range 1-37). Thirty-five (81.4%) of 43 patients had stable or improved neurological exams post-operatively. Six (13.95%) patients developed surgical complications. There were 3 (6.98%) major complications: 2 pseudomeningoceles requiring intervention, and 1 post-operative hematoma requiring external ventricular drain placement. There were 3 (6.98%) minor complications: 1 self-limited pseudomeningocele, 1 subgaleal fluid collection, and 1 post-operative seizure. Surgery resulted in stable or improved neurological exam in 81.4% of cases. On statistical analysis, significantly increased overall survival was noted in patients undergoing surgical resection, as well as those with higher KPS and lower number of brain metastases at presentation. There is need for further studies to evaluate management of brain metastases larger than 4 cm. Copyright © 2018 Elsevier Inc. All rights reserved.

Management and Outcomes Following Surgery for Gastrointestinal Typhoid: An International, Prospective, Multicentre Cohort Study.

PubMed

2018-05-03

Gastrointestinal perforation is the most serious complication of typhoid fever, with a high disease burden in low-income countries. Reliable, prospective, contemporary surgical outcome data are scarce in these settings. This study aimed to investigate surgical outcomes following surgery for intestinal typhoid. Two multicentre, international prospective cohort studies of consecutive patients undergoing surgery for gastrointestinal typhoid perforation were conducted. Outcomes were measured at 30 days and included mortality, surgical site infection, organ space infection and reintervention rate. Multilevel logistic regression models were used to adjust for clinically plausible explanatory variables. Effect estimates are expressed as odds ratios (ORs) alongside their corresponding 95% confidence intervals. A total of 88 patients across the GlobalSurg 1 and GlobalSurg 2 studies were included, from 11 countries. Children comprised 38.6% (34/88) of included patients. Most patients (87/88) had intestinal perforation. The 30-day mortality rate was 9.1% (8/88), which was higher in children (14.7 vs. 5.6%). Surgical site infection was common, at 67.0% (59/88). Organ site infection was common, with 10.2% of patients affected. An ASA grade of III and above was a strong predictor of 30-day post-operative mortality, at the univariable level and following adjustment for explanatory variables (OR 15.82, 95% CI 1.53-163.57, p = 0.021). With high mortality and complication rates, outcomes from surgery for intestinal typhoid remain poor. Future studies in this area should focus on sustainable interventions which can reduce perioperative morbidity. At a policy level, improving these outcomes will require both surgical and public health system advances.

Evidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery: Focus on Anesthesiology for Total Knee Arthroplasty.

PubMed

Soffin, Ellen M; Gibbons, Melinda M; Ko, Clifford Y; Kates, Stephen L; Wick, Elizabeth; Cannesson, Maxime; Scott, Michael J; Wu, Christopher L

2018-06-08

Enhanced recovery after surgery (ERAS) has rapidly gained popularity in a variety of surgical subspecialities. A large body of literature suggests that ERAS leads to superior outcomes, improved patient satisfaction, reduced length of hospital stay, and cost benefits, without affecting rates of readmission after surgery. These patterns have been described for patients undergoing elective total knee arthroplasty (TKA); however, adoption of ERAS to orthopedic surgery has lagged behind other surgical disciplines. The Agency for Healthcare Research and Quality, in partnership with the American College of Surgeons and the Johns Hopkins Medicine Armstrong Institute (AI) for Patient Safety and Quality, has developed the Safety Program for Improving Surgical Care and Recovery. The program comprises a national effort to incorporate best practice in perioperative care and improve patient safety, for over 750 hospitals and multiple procedures over the next 5 years, including orthopedic surgery. We have conducted a full evidence review of anesthetic interventions to derive anesthesiology-related components of an evidence-based ERAS pathway for TKA. A PubMed search was performed for each protocol component, focusing on the highest levels of evidence in the literature. Search findings are summarized in narrative format. Anesthesiology components of care were identified and evaluated across the pre-, intra-, and postoperative phases. A summary of the best available evidence, together with recommendations for inclusion in ERAS protocols for TKA, is provided. There is extensive evidence in the literature, and from society guidelines to support the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery goals for TKA.

Effects of non-surgical periodontal therapy on serum lipids and C-reactive protein among hyperlipidemic patients with chronic periodontitis.

PubMed

Tawfig, Ahmed

2015-05-01

To evaluate the effect of non-surgical periodontal therapy on plasma lipid levels in hyperlipidemic patients with chronic periodontitis. After considering the inclusion and exclusion criteria, 30 hyperlipidemic patients with chronic periodontitis in the age group of 30-70 years, undergoing treatment in Ahmed Gasim Cardiac and Renal transplant Centre in north Sudan were recruited for the study. Patients were randomly assigned to the study and control groups. The study group received non-surgical periodontal therapy - oral hygiene instructions, scaling and root planing. The control group participants received only oral hygiene instructions. Lipid profile [total cholesterol (TC), low density lipoprotein (LDL), high density lipoprotein (HDL), triglycerides (TG)], C-reactive protein (CRP), and periodontal parameters [Plaque index (PI), Gingival index (GI), probing pocket depth (PD), and attachment loss (ATL)] were measured and compared at baseline and after 3 months of the respective intervention. Between-groups analysis was done using independent "t" test and within-group analysis was done using dependent "t" test. At baseline, groups were comparable based on lipid profile and periodontal parameters. After 3 months, the control group showed significant decrease in the PI and GI scores while there was no significant change in the other parameters. However, the study group showed significant decrease in the LDL and CRP levels along with a significant decrease in PD, ATL, PI, and GI scores, compared to the baseline values. Local non-surgical periodontal therapy resulted in improved periodontal health, with significant decrease in the LDL and CRP levels in hyperlipidemic patients with chronic periodontitis. Hence, local non-surgical periodontal therapy may be considered as an adjunct in the control of hyperlipidemia, along with standard care.

Physical activity and frailty as indicators of cardiorespiratory reserve and predictors of surgical prognosis: General and digestive surgery population characterization.

PubMed

Dana, F; Capitán, D; Ubré, M; Hervás, A; Risco, R; Martínez-Pallí, G

2018-01-01

Frailty and low physical activity and cardiorespiratory reserve are related to higher perioperative morbimortality. The crucial step in improving the prognosis is to implement specific measures to optimize these aspects. It is critical to know the magnitude of the problem in order to implement preoperative optimization programmes. To characterize surgical population in a university hospital. All patients undergoing preoperative evaluation for abdominal surgery with admission were prospectively included during a 3-month period. Level of physical activity, functional capacity, frailty and emotional state were assessed using score tests. Additionally, physical condition was evaluated using 5 Times Sit-to-Stand Test. Demographic, clinical and surgical data were collected. One hundred and forty patients were included (60±15yr-old, 56% male, 25% ASA III or IV). Forty-nine percent of patients were proposed for oncologic surgery and 13% of which had received neoadjuvant treatment. Seventy percent of patients presented a low functional capacity and were sedentary. Eighteen percent of patients were considered frail and more than 50% completed the 5 Times Sit-to-Stand Test at a higher time than the reference values adjusted to age and sex. Advanced age, ASA III/IV, sedentarism, frailty and a high level of anxiety and depression were related to a lower functional capacity. The surgical population of our area has a low functional reserve and a high index of sedentary lifestyle and frailty, predictors of postoperative morbidity. It is mandatory to implement preoperative measures to identify population at risk and prehabilitation programmes, considered highly promising preventive interventions towards improving surgical outcome. Copyright © 2017 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.

Interventional Cardiology for Congenital Heart Disease

PubMed Central

2018-01-01

Congenital heart interventions are now replacing surgical palliation and correction in an evolving number of congenital heart defects. Right ventricular outflow tract and ductus arteriosus stenting have demonstrated favorable outcomes compared to surgical systemic to pulmonary artery shunting, and it is likely surgical pulmonary valve replacement will become an uncommon procedure within the next decade, mirroring current practices in the treatment of atrial septal defects. Challenges remain, including the lack of device design focused on smaller infants and the inevitable consequences of somatic growth. Increasing parental and physician expectancy has inevitably lead to higher risk interventions on smaller infants and appreciation of the consequences of these interventions on departmental outcome data needs to be considered. Registry data evaluating congenital heart interventions remain less robust than surgical registries, leading to a lack of insight into the longer-term consequences of our interventions. Increasing collaboration with surgical colleagues has not been met with necessary development of dedicated equipment for hybrid interventions aimed at minimizing the longer-term consequences of scar to the heart. Therefore, great challenges remain to ensure children and adults with congenital heart disease continue to benefit from an exponential growth in minimally invasive interventions and technology. This can only be achieved through a concerted collaborative approach from physicians, industry, academia and regulatory bodies supporting great innovators to continue the philosophy of thinking beyond the limits that has been the foundation of our specialty for the past 50 years. PMID:29671282

Surgical Versus Conservative Intervention for Acute Achilles Tendon Rupture: A PRISMA-Compliant Systematic Review of Overlapping Meta-Analyses.

PubMed

Zhang, Hao; Tang, Hao; He, Qianyun; Wei, Qiang; Tong, Dake; Wang, Chuangfeng; Wu, Dajiang; Wang, Guangchao; Zhang, Xin; Ding, Wenbin; Li, Di; Ding, Chen; Liu, Kang; Ji, Fang

2015-11-01

Although many meta-analyses comparing surgical intervention with conservative treatment have been conducted for acute Achilles tendon rupture, discordant conclusions are shown. This study systematically reviewed the overlapping meta-analyses relating to surgical versus conservative intervention of acute Achilles tendon rupture to assist decision makers select among conflicting meta-analyses, and to offer intervention recommendations based on the currently best evidence.Multiple databases were comprehensively searched for meta-analyses comparing surgical with conservative treatment of acute Achilles tendon rupture. Meta-analyses only comprising randomized controlled trials (RCTs) were included. Two authors independently evaluated the meta-analysis quality and extracted data. The Jadad decision algorithm was applied to ascertain which meta-analysis offered the best evidence.A total of 9 meta-analyses were included. Only RCTs were determined as Level-II evidence. The scores of Assessment of Multiple Systematic Reviews (AMSTAR) ranged from 5 to 10 (median 7). A high-quality meta-analysis with more RCTs was selected according to the Jadad decision algorithm. This study found that when functional rehabilitation was used, conservative intervention was equal to surgical treatment regarding the incidence of rerupture, range of motion, calf circumference, and functional outcomes, while reducing the incidence of other complications. Where functional rehabilitation was not performed, conservative intervention could significantly increase rerupture rate.Conservative intervention may be preferred for acute Achilles tendon rupture at centers offering functional rehabilitation, because it shows a similar rerupture rate with a lower risk of other complications when compared with surgical treatment. However, surgical treatment should be considered at centers without functional rehabilitation as this can reduce the incidence of rerupture.

The Effect of Music Therapy Entrainment on Physiologic Measures of Infants in the Cardiac Intensive Care Unit: Single Case Withdrawal Pilot Study.

PubMed

Yurkovich, Jennifer; Burns, Debra S; Harrison, Tondi

2018-03-09

Although evidence suggests music therapy lowers the heart rate of ill adults undergoing painful procedures and premature infants in the NICU, the effect of music therapy interventions on physiologic response in infants with congenital heart disease (CHD) being cared for in the cardiac intensive care unit (CICU) has not been explored. The purpose of this study was to explore the effect of the music therapy entrainment on physiologic responses of infants with CHD in the CICU. Five infants in the CICU received music therapy entrainment 3-5 times per week for up to 3 weeks. Sessions took place both prior to and after the infant's surgical cardiac repair. Heart rate, respiratory rate, blood pressure, and oxygen saturations were recorded every 15 seconds for 20 minutes prior to the intervention (baseline), during the 20-minute music therapy entrainment (intervention), and for 20 minutes after the intervention (return to baseline). Comparisons of baseline to intervention measures were based on means, standard deviations, and derivatives of the signal. Four of 5 infants experienced a decrease in average heart and respiratory rates as well as improvement in the derivative of the heart rate signal. Greater improvements were found when infants were located in the open bay and were receiving sedatives or narcotics. Our findings provide initial evidence that music therapy entrainment may be a valuable intervention to support improved physiologic stability in infants with CHD.

Wound Concerns and Healthcare Consumption of Resources after Colorectal Surgery: An Opportunity for Innovation?

PubMed

Shah, Puja M; Evans, Heather L; Harrigan, Amy; Sawyer, Robert G; Friel, Charles M; Hedrick, Traci L

2017-07-01

Significant portions of patients undergoing colorectal surgical procedures have minor incision disturbances, yet very few meet definitions for surgical site infection (SSI). We sought to investigate the natural history of incision disturbances with a focus on the patient experience and resource utilization. We hypothesize that patients who have an incision disturbance consume frequent healthcare resources in the post-operative period despite the fact that most never receive a diagnosis of SSI. A 24-month prospective observational study was undertaken at an academic institution. Patients undergoing elective colorectal operation by two board-certified colorectal surgeons were followed prospectively for 90 days. Incisions were photographed serially and clinically characterized beginning as early as post-operative day two and at follow-up visits. The primary outcome was patient concern for an incision disturbance. Three surgeons reviewed clinical data and photographs to determine the presence of an incisional surgical infection, and diagnosis required agreement from two of three surgeons. There were 171 patients included; 31 (15%) sought evaluation from a healthcare provider for concerns related to their incision including 46 telephone calls, six emergency department visits, seven primary care visits, 10 home health and 40 surgical clinic visits. Incision erythema and drainage were the most common sources of patient concern. Mean body mass index was higher in patients with concern for incision disturbances (34 vs. 28 kg/m 2 , p < 0.0001). Ultimately, 8% (14/171) received a diagnosis of SSI by study criteria while only 2% (4/171) were captured as having an SSI by the institutional National Surgical Quality Improvement Program database (p < 0.0001). Patients undergoing colorectal surgical procedures commonly are concerned with post-operative incision disturbance, yet few are associated with a diagnosis of SSI, and in-person evaluation yields frequent utilization of healthcare resources. This presents an opportunity for secure electronic communication with the surgical team and the patient to potentially reduce consumption of healthcare resources.

Patients with single ventricle physiology undergoing noncardiac surgery are at high risk for adverse events.

PubMed

Brown, Morgan L; DiNardo, James A; Odegard, Kirsten C

2015-08-01

Patients with single ventricle physiology are at increased anesthetic risk when undergoing noncardiac surgery. To review the outcomes of anesthetics for patients with single ventricle physiology undergoing noncardiac surgery. This study is a retrospective chart review of all patients who underwent a palliative procedure for single ventricle physiology between January 1, 2007 and January 31, 2014. Anesthetic and surgical records were reviewed for noncardiac operations that required sedation or general anesthesia. Any noncardiac operation occurring prior to completion of a bidirectional Glenn procedure was included. Diagnostic procedures, including cardiac catheterization, insertion of permanent pacemaker, and procedures performed in the ICU, were excluded. During the review period, 417 patients with single ventricle physiology had initial palliation. Of these, 70 patients (16.7%) underwent 102 anesthetics for 121 noncardiac procedures. The noncardiac procedures included line insertion (n = 23); minor surgical procedures such as percutaneous endoscopic gastrostomy or airway surgery (n = 38); or major surgical procedures including intra-abdominal and thoracic operations (n = 41). These interventions occurred on median day 60 of life (1-233 days). The procedures occurred most commonly in the operating room (n = 79, 77.5%). Patients' median weight was 3.4 kg (2.4-15 kg) at time of noncardiac intervention. In 102 anesthetics, 26 patients had an endotracheal tube or tracheostomy in situ, 57 patients underwent endotracheal intubation, and 19 patients had a natural or mask airway. An intravenous induction was performed in 77 anesthetics, an inhalational induction in 17, and a combination technique in 8. The median total anesthetic time was 126 min (14-594 min). In 22 anesthetics (21.6%), patients were on inotropic support upon arrival; an additional 24 patients required inotropic support (23.5%), of which dopamine was the most common medication. There were 10 intraoperative adverse events (9.8%) including: arrhythmias requiring treatment (n = 4), conversion from sedation to a general anesthetic (n = 2), difficult airway (n = 1), inadvertent extubation with desaturation and bradycardia (n = 1), hypotension and desaturation (n = 1), and cardiac arrest (n = 1). Postoperative events (<48 h) included ST segment changes requiring cardiac catheterization (n = 1), and cardiorespiratory arrest (n = 1). Age, size, gender, type of cardiac palliation, patient location, procedure location, and type of procedure were not associated with adverse outcome. After 62 anesthetics (60.8%), patients went postoperatively to the cardiac ICU. There were no deaths at 48 h. We observed no mortality during or after noncardiac surgery in a high-risk subgroup of palliated cardiac patients with single ventricle physiology. However, 11.8% of patients had an adverse event associated with their anesthetic. © 2015 John Wiley & Sons Ltd.

Lactobacillus as a rare cause of an infected total knee replacement: a case report

PubMed Central

2009-01-01

Introduction We report a rare case of an infected revision total knee replacement as a result of a Lactobacillus species infection. Lactobacillus infections have been associated with prolonged broad-spectrum antibiotic use. This can have implications in revision surgery, especially when patients have been on previous long-term suppressive antibiotic therapy. Case presentation An 81-year-old British man with a previous history of complex revision knee arthroplasty for infection presented with a hot, swollen knee joint. He had previously been on long-term suppressive antibiotic therapy. Aspiration of the knee joint yielded a culture of Lactobacillus species. Conclusion In patients undergoing revision joint arthroplasty, especially for previous infection, the presence of common and uncommon bacterial species must be excluded and eradicated before further surgical intervention. PMID:19830207

Central venous access: techniques and indications in oncology.

PubMed

Marcy, Pierre-Yves

2008-10-01

Long lines can be inserted centrally or peripherally through patent veins into the central venous system down to the atrial caval junction. Traditionally surgeons, anesthetists, cardiologists and more recently interventional radiologists have been placing them using vein cutdown or percutaneous needle puncture techniques. Typical candidates for implanted venous catheters are cancer patients undergoing long-term chemotherapy. The most important issues, in addition to the patency of central veins and the history of previous indwelling catheters, pacewires or venous thrombosis, are the patient's performance status, body mass index, medical history and respiratory status, and the relevant technique. The present article will give an overview of the radiological and surgical implantation techniques and will highlight the impact of imaging means on the technical feasibility, assessment and treatment of device-related complications.

Outcomes of cardiac surgery in the elderly.

PubMed

Drury, Nigel E; Nashef, Samer A M

2006-07-01

The elderly represent a rapidly growing and substantially under-treated sector in industrialized countries, with coronary artery disease and degenerative aortic stenosis rampant. The proportion of elderly patients undergoing cardiac surgery is rising steadily and outcomes continue to improve with the refinement of operative techniques and perioperative care. Advanced risk stratification models, such as the logistic European System for Cardiac Operative Risk Evaluation now offer validated prediction of operative mortality in these high-risk patients. Current trends towards off-pump coronary artery surgery, hybrid revascularization and mitral repair may have advantages in the elderly, who often have more diffuse cardiovascular disease and a lower tolerance to intervention. Recent advances may also provide surgical options for the emerging epidemics of cardiovascular disease affecting the elderly, atrial fibrillation and heart failure.

A pragmatic multi-centre randomised controlled trial of fluid loading and level of dependency in high-risk surgical patients undergoing major elective surgery: trial protocol

PubMed Central

2010-01-01

Background Patients undergoing major elective or urgent surgery are at high risk of death or significant morbidity. Measures to reduce this morbidity and mortality include pre-operative optimisation and use of higher levels of dependency care after surgery. We propose a pragmatic multi-centre randomised controlled trial of level of dependency and pre-operative fluid therapy in high-risk surgical patients undergoing major elective surgery. Methods/Design A multi-centre randomised controlled trial with a 2 * 2 factorial design. The first randomisation is to pre-operative fluid therapy or standard regimen and the second randomisation is to routine intensive care versus high dependency care during the early post-operative period. We intend to recruit 204 patients undergoing major elective and urgent abdominal and thoraco-abdominal surgery who fulfil high-risk surgical criteria. The primary outcome for the comparison of level of care is cost-effectiveness at six months and for the comparison of fluid optimisation is the number of hospital days after surgery. Discussion We believe that the results of this study will be invaluable in determining the future care and clinical resource utilisation for this group of patients and thus will have a major impact on clinical practice. Trial Registration Trial registration number - ISRCTN32188676 PMID:20398378

Surgical interventions for gastric cancer: a review of systematic reviews.

PubMed

He, Weiling; Tu, Jian; Huo, Zijun; Li, Yuhuang; Peng, Jintao; Qiu, Zhenwen; Luo, Dandong; Ke, Zunfu; Chen, Xinlin

2015-01-01

To evaluate methodological quality and the extent of concordance among meta-analysis and/or systematic reviews on surgical interventions for gastric cancer (GC). A comprehensive search of PubMed, Medline, EMBASE, the Cochrane library and the DARE database was conducted to identify the reviews comparing different surgical interventions for GC prior to April 2014. After applying included criteria, available data were summarized and appraised by the Oxman and Guyatt scale. Fifty six reviews were included. Forty five reviews (80.4%) were well conducted, with scores of adapted Oxman and Guyatt scale ≥ 14. The reviews differed in criteria for avoiding bias and assessing the validity of the primary studies. Many primary studies displayed major methodological flaws, such as randomization, allocation concealment, and dropouts and withdrawals. According to the concordance assessment, laparoscopy-assisted gastrectomy (LAG) was superior to open gastrectomy, and laparoscopy-assisted distal gastrectomy was superior to open distal gastrectomy in short-term outcomes. However, the concordance regarding other surgical interventions, such as D1 vs. D2 lymphadenectomy, and robotic gastrectomy vs. LAG were absent. Systematic reviews on surgical interventions for GC displayed relatively high methodological quality. The improvement of methodological quality and reporting was necessary for primary studies. The superiority of laparoscopic over open surgery was demonstrated. But concordance on other surgical interventions was rare, which needed more well-designed RCTs and systematic reviews.

Increased Resistance of Skin Flora to Antimicrobial Prophylaxis in Patients Undergoing Hip Revision Arthroplasty.

PubMed

Mühlhofer, Heinrich M L; Deiss, Lukas; Mayer-Kuckuk, Philipp; Pohlig, Florian; Harrasser, Norbert; Lenze, Ulrich; Gollwitzer, Hans; Suren, Christian; Prodinger, Peter; VON Eisenhart-Rothe, Rüdiger; Schauwecker, Johannes

2017-01-01

Prosthetic joint infection (PJI) remains a major complication after total joint replacement and is the primary indication for revision arthroplasty. Specifically, coagulase-negative Staphylococci (CNS) can cause low-grade infections. Despite the use of cephalosporin-based antimicrobial prophylaxis (AMP) and antiseptic treatment at the surgical site, evidence suggests that a significant number of cases of dermal CNS results in low-grade PJI. Thus, this study examined the bacterial colonization and resistance patterns at the surgical site. We hypothesized that the bacteria developed resistance to antibiotics that are frequently used in primary and revision total hip arthroplasty (THA) procedures. Ninety patients, including 63 primary and 27 revision THA patients, were enrolled in this study. For each patient, a single swab of the skin at the surgical site was subjected to clinical microbiology to assess bacterial colonization. Furthermore, resistance to a sentinel panel of antibiotics (benzylpenicillin, erythromycin, tetracycline, oxacillin, fusidic acid, clindamycin, gentamicin, levofloxacin/moxifloxacin, rifampicin, linezolid and vancomycin) was tested. In 96.7% of the patients, at least one bacterial strain was identified at the surgical site, with CNS strains comprising 93.1% of the total. The sentinel panel showed that 30.7% of the CNS strains exhibited maximal resistance to oxacillin, a commonly used cephalosporin. Additionally, oxacillin resistance increased 1.9-fold (p=0.042) between primary and revision THA. Notably, 8.1% of the CNS stains found on patients undergoing primary THA were resistant to gentamicin, an aminoglycoside, and this rate increased 4.7-fold (p=0.001) for patients undergoing revision THA. CNS strains have significant resistance to standard AMP, particularly in individuals undergoing revision THA. Copyright© 2017, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.

Evaluation of the AJCC 8th Edition Staging System for Pathologically Versus Clinically Staged Intrahepatic Cholangiocarcinoma (iCCA): a Time to Revisit a Dogma? A Surveillance, Epidemiology, and End Results (SEER) Analysis.

PubMed

Kamarajah, Sivesh K

2018-03-07

Recently, the AJCC has released its 8th edition changes to the staging system for intrahepatic cholangiocarcinoma (iCCA). This study sought to validate the proposed changes to the 8th edition of AJCC system for T and N classification of iCCA using a population-based data set. Using the Surveillance, Epidemiology, and End Results (SEER) database (1998-2013), patients undergoing resection or non-surgical management for non-metastatic iCCA were identified. Overall survival was estimated using the Kaplan-Meier method and compared using log-rank tests. Concordance indices (c-indices) calculated from Cox proportional hazards models were calculated to evaluate discriminatory power. The study included 2630 patients resected (37%) or non-surgically managed (63%) for iCCA. Nodal staging was performed in 56%, of whom 31% had positive nodes. For all patients with iCCA, the median 5-year survival by AJCC T classification for T1a, T1b, T2, T3, and T4 was 32, 21, 14, 10, and 10 months, respectively (p < 0.001). The concordance index for the staging system was 0.57 for all patients, 0.62 for those who underwent resection, and 0.54 for patients who did not undergo resection. In summary, the new AJCC 8th edition staging system is comparable to the 7th edition and valid in stratifying patients with iCCA. However, the performance of the staging system is better in patients undergoing surgical resection than those undergoing non-surgical management. These findings further highlight the need for improved accuracy of radiological imaging in clinically staging patients to guide prognosis.

Postoperative infections after major heart surgery and prevention of ventilator-associated pneumonia: a one-day European prevalence study (ESGNI-008).

PubMed

Bouza, E; Hortal, J; Muñoz, P; Pascau, J; Pérez, M J; Hiesmayr, M

2006-11-01

Few data have been published on the prevalence of postoperative infection in patients undergoing major heart surgery (MHS). The degree of compliance with standard measures used to prevent them is unknown. This study assessed the prevalence of infections, particularly ventilator-associated pneumonia (VAP), in patients undergoing MHS in 42 institutions from 13 European countries. On the study day, there were 321 postoperative MHS patients, of whom 164 (51%) were mechanically ventilated. The overall prevalence of infection was 26.8%. Lower respiratory tract infections represented 57% of all the infections present on the study day. Other infections included intravenous-catheter-related bloodstream infections (2.8%), surgical site infections (2.2%), urinary tract infections (0.9%) and postoperative mediastinitis (0.9%). Of the mechanically ventilated patients, 55 (33.5%) were not being nursed in a semi-recumbent position, 36 (22%) had heat-moisture exchangers with no antibacterial filters, and intracuff pressure was not monitored in 78 patients (47.6%). Only 13 patients (8%) were given continuous subglottic suctioning, 64 patients (39%) did not receive postural oscillation, and gastric overdistension was not actively prevented in 23 patients (14%). In conclusion, these data from intensive care units across Europe provide information on postoperative infections in an important subset of the patient population, and stress the need for active interventions to prevent VAP in patients undergoing MHS.

Early Primary Care Provider Follow-up and Readmission After High-Risk Surgery

PubMed Central

Brooke, Benjamin S.; Stone, David H.; Cronenwett, Jack L.; Nolan, Brian; DeMartino, Randall R.; MacKenzie, Todd A.; Goodman, David C.; Goodney, Philip P.

2014-01-01

IMPORTANCE Follow-up with a primary care provider (PCP) in addition to the surgical team is routinely recommended to patients discharged after major surgery despite no clear evidence that it improves outcomes. OBJECTIVE To test whether PCP follow-up is associated with lower 30-day readmission rates after open thoracic aortic aneurysm (TAA) repair and ventral hernia repair (VHR), surgical procedures known to have a high and low risk of readmission, respectively. DESIGN, SETTING, AND PARTICIPANTS In a cohort of Medicare beneficiaries discharged to home after open TAA repair (n = 12 679) and VHR (n = 52 807) between 2003 to 2010, we compared 30-day readmission rates between patients seen and not seen by a PCP within 30 days of discharge and across tertiles of regional primary care use. We stratified our analysis by the presence of complications during the surgical (index) admission. MAIN OUTCOMES AND MEASURES Thirty-day readmission rate. RESULTS Overall, 2619 patients (20.6%) undergoing open TAA repair and 4927 patients (9.3%) undergoing VHR were readmitted within 30 days after surgery. Complications occurred in 4649 patients (36.6%) undergoing open TAA repair and 4528 patients (8.6%) undergoing VHR during their surgical admission. Early follow-up with a PCP significantly reduced the risk of readmission among open TAA patients who experienced perioperative complications, from 35.0% (without follow-up) to 20.4% (with follow-up) (P < .001). However, PCP follow-up made no significant difference in patients whose hospital course was uncomplicated (19.4% with follow-up vs 21.9% without follow-up; P = .31). In comparison, early follow-up with a PCP after VHR did not reduce the risk of readmission, regardless of complications. In adjusted regional analyses, undergoing open TAA repair in regions with high compared with low primary care use was associated with an 18% lower likelihood of 30-day readmission (odds ratio, 0.82; 95% CI, 0.71–0.96; P = .02), whereas no significant difference was found among patients after VHR. CONCLUSIONS AND RELEVANCE Follow-up with a PCP after high-risk surgery (eg, open TAA repair), especially among patients with complications, is associated with a lower risk of hospital readmission. Patients undergoing lower-risk surgery (eg, VHR) do not receive the same benefit from early PCP follow-up. Identifying high-risk surgical patients who will benefit from PCP integration during care transitions may offer a low-cost solution toward limiting readmissions. PMID:25074237

Anesthetic exposure in the treatment of symptomatic urinary calculi in pregnant women.

PubMed

Rivera, Marcelino E; McAlvany, Kelly L; Brinton, Thomas S; Gettman, Matthew T; Krambeck, Amy E

2014-12-01

To assess the duration and total number of anesthetic exposures required for the treatment of urolithiasis during pregnancy, specifically comparing temporizing measures with active treatment because urolithiasis and its management may pose potential theoretical risks for the mother and fetus. We retrospectively reviewed patients with a confirmed diagnosis of urolithiasis during pregnancy who underwent surgical intervention from 1997 to 2012 at our institution. The number and duration of anesthetic exposures were assessed. We identified 26 women with urolithiasis during pregnancy, of which 15 (58%) were treated with temporizing stents and 11 (42%) with ureteroscopic stone extraction. In the ureteroscopy group, the median number of anesthetic exposures was 1.18 (interquartile range [IQR], 1-2), and the median total anesthetic time was 80 minutes (IQR, 37-126 minutes). In the stent group, 6 (40%) required multiple stent exchanges for a median of 1.47 (IQR, 1-3) anesthetic events and a median total anesthetic time of 70 minutes (IQR, 29-208 minutes). In the ureteral stent group, 7 women (47%) were induced before spontaneous labor due to inability to tolerate the stent. There was no difference in the number of anesthetic events (P = .208) or anesthesia time (P = .503) between stenting and ureteroscopy. Women undergoing ureteroscopic surgical intervention during pregnancy were at no greater risk in the number or cumulative duration of anesthesia exposure than women managed with temporizing ureteral stent placement and subsequent exchanges. Copyright © 2014 Elsevier Inc. All rights reserved.

Revascularization Trends in Patients With Diabetes Mellitus and Multivessel Coronary Artery Disease Presenting With Non-ST Elevation Myocardial Infarction: Insights From the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry-Get with the Guidelines (NCDR ACTION Registry-GWTG).

PubMed

Pandey, Ambarish; McGuire, Darren K; de Lemos, James A; Das, Sandeep R; Berry, Jarett D; Brilakis, Emmanouil S; Banerjee, Subhash; Marso, Steven P; Barsness, Gregory W; Simon, DaJuanicia N; Roe, Matthew; Goyal, Abhinav; Kosiborod, Mikhail; Amsterdam, Ezra A; Kumbhani, Dharam J

2016-05-01

Current guidelines recommend surgical revascularization (coronary artery bypass graft [CABG]) over percutaneous coronary intervention (PCI) in patients with diabetes mellitus and multivessel coronary artery disease. Few data are available describing revascularization patterns among these patients in the setting of non-ST-segment-elevation myocardial infarction. Using Acute Coronary Treatment and Intervention Outcomes Network Registry-Get with the Guidelines (ACTION Registry-GWTG), we compared the in-hospital use of different revascularization strategies (PCI versus CABG versus no revascularization) in diabetes mellitus patients with non-ST-segment-elevation myocardial infarction who had angiography, demonstrating multivessel coronary artery disease between July 2008 and December 2014. Factors associated with use of CABG versus PCI were identified using logistic multivariable regression analyses. A total of 29 769 patients from 539 hospitals were included in the study, of which 10 852 (36.4%) were treated with CABG, 13 760 (46.2%) were treated with PCI, and 5157 (17.3%) were treated without revascularization. The overall use of revascularization increased over the study period with an increase in the proportion undergoing PCI (45% to 48.9%; Ptrend=0.0002) and no change in the proportion undergoing CABG (36.1% to 34.7%; ptrend=0.88). There was significant variability between participating hospitals in the use of PCI and CABG (range: 22%-100%; 0%-78%, respectively; P value <0.0001 for both). Patient-level, but not hospital-level, characteristics were statistically associated with the use of PCI versus CABG, including anatomic severity of the disease, early treatment of adenosine diphosphate receptor antagonists at presentation, older age, female sex, and history of heart failure. Among patients with diabetes mellitus and multivessel coronary artery disease presenting with non-ST-segment-elevation myocardial infarction, only one third undergo CABG during the index admission. Furthermore, the use of PCI, but not CABG, increased modestly over the past 6 years. © 2016 American Heart Association, Inc.

Prospective, Randomized Study on the Use of a Prosthetic Mesh for Prevention of Parastomal Hernia of Permanent Colostomy.

PubMed

Vierimaa, Mika; Klintrup, Kai; Biancari, Fausto; Victorzon, Mikael; Carpelan-Holmström, Monika; Kössi, Jyrki; Kellokumpu, Ilmo; Rauvala, Erkki; Ohtonen, Pasi; Mäkelä, Jyrki; Rautio, Tero

2015-10-01

Prophylactic placement of a mesh has been suggested to prevent parastomal hernia, but evidence to support this approach is scarce. The aim of this study was to evaluate whether laparoscopic placement of a prophylactic, dual-component, intraperitoneal onlay mesh around a colostomy is safe and prevents parastomal hernia formation after laparoscopic abdominoperineal resection. This is a prospective, multicenter, randomized controlled clinical trial. This study was conducted at 2 university and 3 central Finnish hospitals. From 2010 to 2013, 83 patients undergoing laparoscopic abdominoperineal resection for rectal cancer were recruited. After withdrawals and exclusions, the outcome of 70 patients, 35 patients in each study group, could be examined. In the intervention group, an end colostomy was created with placement of a intraperitoneal, dual-component onlay mesh and compared with a group with a traditional stoma. The main outcome measures were the incidence of clinically and radiologically detected parastomal hernias and their extent 12 months after surgery. Stoma-related morbidity and the need for surgical repair of parastomal hernia were secondary outcome measures. Parastomal hernia was observed by clinical inspection in 5 intervention patients (14.3%) and in 12 control patients (32.3%; p = 0.049). Surgical repair of parastomal hernia was performed in 1 control patient (3.2%) and in none of the patients in the intervention group. CT detected parastomal hernia in 18 intervention patients (51.4%) and in 17 control patients (53.1%; p = 1.00). The extent of hernias was similar according to European Hernia Society classification (p = 0.41). Colostomy-related morbidity (32.3% vs 14.3%; p = 0.140) did not differ between the study groups. The study was limited by its small size and short follow-up time. Prophylactic laparoscopic placement of intraperitoneal onlay mesh does not significantly reduce the overall risk of radiologically detected parastomal hernia after laparoscopic abdominoperineal resection. However, prophylactic mesh repair was associated with significantly lower risk of clinically detected parastomal hernia.

Interventions for treating chronic ankle instability.

PubMed

de Vries, J S; Krips, R; Sierevelt, I N; Blankevoort, L

2006-10-18

Chronic lateral ankle instability occurs in 10% to 20% of people after an acute ankle sprain. The initial form of treatment is conservative but if this fails and ligament laxity is present, surgical intervention is considered. To compare different treatments, both conservative and surgical, for chronic lateral ankle instability. We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialized Register (to July 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2005, Issue 3), and MEDLINE (1966 to April 2006), EMBASE (1980 to April 2006), CINAHL (1982 to April 2006) and reference lists of articles. All randomised and quasi-randomised controlled trials of interventions for chronic lateral ankle instability were included. Two review authors independently assessed methodological quality and extracted data. Where appropriate, results of comparable studies were pooled. Seven randomised trials were included and divided into three groups: surgical interventions; rehabilitation programs after surgical interventions; and conservative interventions. None of the studies were methodologically flawless. Only one study described an adequate randomisation procedure. Only two studies, both about rehabilitation programs after surgery, had a moderate risk of bias; all other studies had a high risk of bias. Due to clinical and methodological diversity, extensive pooling of the data was not possible. Surgical interventions (four studies): one study showed more complications after the Chrisman-Snook procedure compared to an anatomical reconstruction, whereas another study showed greater mean talar tilt after an anatomical reconstruction. Subjective instability and hindfoot inversion was greater after a dynamic than after a static tenodesis in a third study. The fourth study showed that the operating time for anatomical reconstructions was shorter for the reinsertion technique than for the imbrication method. Rehabilitation after surgical interventions (two studies): both studies provided evidence that early functional mobilization leads to an earlier return to work and sports than immobilisation. Conservative interventions: the only study in this group showed better proprioception and functional outcome with the bi-directional than with the uni-directional pedal technique on a cyclo-ergometer. In view of the low quality methodology of almost all the studies, this review does not provide sufficient evidence to support any specific surgical or conservative intervention for chronic ankle instability. However, after surgical reconstruction, early functional rehabilitation was shown to be superior to six weeks immobilisation regarding time to return to work and sports.

Surgical RF ablation of atrial fibrillation in patients undergoing mitral valve repair for Barlow disease.

PubMed

Rostagno, Carlo; Droandi, G; Gelsomino, S; Carone, E; Gensini, G F; Stefàno, P L

2013-01-01

At present, limited experience exists on the treatment of atrial fibrillation (AF) in patients undergoing mitral valve repair (MVR) for Barlow disease. The aim of this investigation was to prospectively evaluate the radiofrequency ablation of AF in patients undergoing MVR for severe regurgitation due to Barlow disease. From January 1, 2007 to December 31, 2010, out of 85 consecutive patients with Barlow disease, 27 with AF underwent RF ablation associated with MVR. They were examined every 4 months in the first year after surgery and thereafter twice yearly. At follow-up, AF was observed in 4/25 (16.0%). NYHA (New York Heart Association) functional class improved significantly, with no patients in class III or IV (before surgery, 81.5% had been). Otherwise, among 58 patients in sinus rhythm, 6 (11%) developed AF during follow-up. No clinical or echocardiographic predictive factor was found in this subgroup. Results from our investigation suggest that radiofrequency ablation of AF in patients with Barlow disease undergoing MVR for severe regurgitation is effective and should be considered in every patient with Barlow disease and AF undergoing valve surgical repair. Copyright © 2013 S. Karger AG, Basel.

The relationship between cervical lordosis and Nurick scores in patients undergoing circumferential vs. posterior alone cervical decompression, instrumentation and fusion for treatment of cervical spondylotic myelopathy.

PubMed

Patel, Shalin; Glivar, Phillip; Asgarzadie, Farbod; Cheng, David Juma Wayne; Danisa, Olumide

2017-11-01

The loss of regional cervical sagittal alignment and the progressive development of cervical kyphosis is a factor in the advancement of myelopathy. Adequate decompression of the spinal canal along with reestablishment of cervical lordosis are desired objective with regard to the surgical treatment of patients with cervical spondylotic myelopathy. A retrospective chart review was conducted in which patients who underwent either a combined anterior/posterior instrumentation and decompression or a posterior alone instrumentation and decompression for the treatment of CSM at our institution were identified. Any patient undergoing operative intervention for trauma, infection or tumors were excluded. Similarly, patients undergoing posterior instrumentation with constructs extending beyond the level of C2-C7 were similarly excluded from this study. A total of 67 patients met the inclusion criteria for this study. A total of 32 patients underwent posterior alone surgery and the remaining 35 underwent combined anterior/posterior procedure. Radiographic evaluation of patient's preoperative and postoperative cervical lordosis as measured by the C2-C7 Cobb angle was performed. Each patient's preoperative and postoperative functional disability as enumerated by the Nurick score was also recorded. Statistical analysis was conducted to determine if there was a significant relationship between improvement in cervical lordosis and improvement in patient's clinical outcomes as enumerated by the Nurick Score in patients undergoing posterior alone versus combined anterior/posterior decompression, instrumentation and fusion of the cervical spine. Copyright © 2017 Elsevier Ltd. All rights reserved.

Meralgia Paresthetica

MedlinePlus

... in which pain is persistent or severe, surgical intervention may be indicated. × Treatment Treatment for meralgia paresthetica ... in which pain is persistent or severe, surgical intervention may be indicated. View Full Treatment Information Definition ...

Management of acute perianal sepsis in neutropenic patients with hematological malignancy.

PubMed

Baker, B; Al-Salman, M; Daoud, F

2014-04-01

In neutropenic patients with acute perianal sepsis in the setting of hematological malignancy, the classical clinical features of abscess formation are lacking. Additionally, the role of surgical intervention is not well established. In this review, we discuss the challenges and controversy regarding diagnosis and optimal management when clear surgical guidelines are absent. In the literature, there is great diversity in the surgical approach to these patients, which leads to a high percentage of diagnostic errors, risks of complications, and unnecessary interventions. We review the literature and assess whether surgical intervention produces better outcomes than a non-surgical approach. Studies published on perianal sepsis in neutropenic cancer patients were identified by searching PubMed using the following key words: "perianal sepsis/abscesses, anorectal sepsis/abscess, neutropenia, hematological malignancy, cancer". No randomized or prospective studies on the management of acute perianal sepsis in hematological malignancies were found. The largest retrospective study and most comprehensive clinical data demonstrated that 42% of patients were treated successfully without surgical intervention and without morbidity or mortality related to treatment chosen. Small retrospective studies advocated surgical intervention, while the majority of successes were in a non-operative treatment. It is difficult to formulate a conclusion given the small retrospective series on management of neutropenic patients with hematological malignancies. While there is no evidence mandating a routine surgical approach in this category of patients, non-surgical management including careful follow-up to determine whether the patient's condition is deteriorating or treatment has failed is an acceptable approach in selected patients without pathognomonic features of abscess. Comprehensive and well-designed prospective studies are needed to firmly establish the guidelines of treatment protocols.

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.

Blunt hepatic trauma: comparison between surgical and nonoperative treatment.

PubMed

Zago, Thiago Messias; Pereira, Bruno Monteiro; Calderan, Thiago Rodrigues Araujo; Hirano, Elcio Shiyoiti; Rizoli, Sandro; Fraga, Gustavo Pereira

2012-01-01

To examine the outcomes of blunt hepatic trauma, and compare surgical and non-surgical treatment in patients admitted with hemodynamic stability and with no obvious indications of laparotomy. This is a retrospective study of cases admitted to a university teaching hospital between the years 2000 and 2010. Patients undergoing surgical treatment were divided into two groups: (a) all patients undergoing surgical treatment, and (b) patients with obvious need for surgery. In this period, 120 patients were admitted with blunt hepatic trauma. Sixty five patients (54.1%) were treated non-operatively and fifty five patients were operated upon. Patients treated non-operatively had better physiologic conditions on admission, demonstrated less severe injuries (except the grade of hepatic injury), received less blood components and had lower morbidity and mortality than the patients operated upon. Patients who underwent non-operative treatment had a lower need for blood transfusion but higher rates of complications and mortality than the patients operated upon. Patients who were operated upon, with no obvious indications for surgery, had higher rates of complication and mortality than patients not operated upon. A non-operative approach resulted in lower complications, a lower need for blood transfusions and lower mortality.

The business case for the reduction of surgical complications in VA hospitals.

PubMed

Vaughan-Sarrazin, Mary; Bayman, Levent; Rosenthal, Gary; Henderson, William; Hendricks, Ann; Cullen, Joseph J

2011-04-01

Surgical complications contribute substantially to costs. Most important, surgical complications contribute to morbidity and mortality, and some may be preventable. This study estimates costs of specific surgical complications for patients undergoing general surgery in VA hospitals using merged data from the VA Surgical Quality Improvement Program and VA Decision Support System. Costs associated with 19 potentially preventable complications within 6 broader categories were estimated using generalized, linear mixed regression models to control for patient-level determinants of costs (eg, type of operation, demographics, comorbidity, severity) and hospital-level variation in costs. Costs included costs of the index hospitalization and subsequent 30-day readmissions. In 14,639 patients undergoing general surgical procedures from 10/2005 through 9/2006, 20% of patients developed postoperative surgical complications. The presence of any complication significantly increased unadjusted costs nearly 3-fold ($61,083 vs $22,000), with the largest cost differential attributed to respiratory complications. Patients who developed complications had several markers for greater preoperative severity, including increased age and a lesser presurgery functional health status. After controlling for differences in patient severity, costs for patients with any complication were 1.89 times greater compared to costs for patients with no complications (P < .0001). Within major complication categories, adjusted costs were significantly greater for patients with respiratory, cardiac, central nervous system, urinary, wound, or other complications. Surgical complications contribute markedly to costs of inpatient operations. Investment in quality improvement that decreases the incidence of surgical complications could decrease costs. Copyright © 2011 Mosby, Inc. All rights reserved.

An access to care study for the pre-surgical nasoalveolar molding and other treatments for cleft lip and palate.

PubMed

Blume, Carlen P; Henson, Timothy B

2011-07-01

This study is designed to ascertain whether a regional bias exists, as well as provide a reference to those seeking the various modalities used in pre-surgical intervention for cleft lip and palate either for their own patients or educational purposes. A survey was constructed using Survey Monkey and distributed via e-mail to American Academy of Pediatric Dentistry members. Approximately 3689 surveys were delivered consisting of 12 questions asking whether they provide pre-surgical intervention to cleft lip and palate patients, and what type of interventions they use. A total of 572 members responded. Of the respondents, 480 reported they treat children affected by cleft lip and/or cleft palate. Of these, only 102 reported that they provide pre-surgical treatment. Pre-surgical nasoalveolar molding (PNAM) represented 29.2 percent of the interventions used and was most heavily concentrated in Texas. Other modalities used included the Latham appliance, lip adhesion/tacking, the passive appliance, and a category 'other' was included. Those checking 'other' most often described alveolar grafting prior to later surgical procedures than were of interest in this study. The University of Texas Health Science Center San Antonio had the largest number of respondents using the PNAM. A very small proportion of pediatric dentists are providing pre-surgical intervention of any kind to patients with cleft lip and palate. However, those that are providing the service are spread around the country enough to consider PNAM as the standard of care for pre-surgical infant cleft treatment.

Myocardial infarction and subsequent death in a patient undergoing robotic prostatectomy.

PubMed

Thompson, Judy

2009-10-01

A 52-year-old patient, ASA physical status IV, undergoing a radical prostatectomy for cancer with a robotic system had a cardiac arrest 3 hours into the case. All attempts to resuscitate were unsuccessful, and several hours later he was pronounced dead. Underlying patient comorbidity and procedural issues contributed to the patient's death. The patient had a history of coronary artery disease that required the placement of drug-eluting stents 2 years before this surgical procedure. The preoperative cardiac evaluation and pharmacological management of patients with drug-eluting coronary stents are reviewed. There are a number of positional and technical considerations for patients undergoing robotic surgical procedures, especially in relation to the requirement of low-lithotomy and steep Trendelenburg positions. The cardiac and respiratory systems are especially vulnerable to the extreme and lengthy head-down position. The needed positioning, combined with the problems associated with insufflation, presents a unique challenge in anesthetic management. This course reviews the current literature on the surgical implications for patients with drug-eluting stents and the physiologic factors related to position and pneumoperitoneum and their associated stressors. By using a review of the contemporary literature, a best-evidence approach to anesthetic management is reviewed.

New and emerging treatments for the prevention of recurrent diverticulitis

PubMed Central

Martin, Sean T; Stocchi, Luca

2011-01-01

Sigmoid diverticulitis is a common benign condition which carries significant morbidity and socioeconomic burden. This article describes the management of sigmoid diverticulitis with a focus on indications for surgical intervention. The mainstay of management of uncomplicated diverticulitis is broad-spectrum antibiotic therapy. The old surgical dictum that two episodes of sigmoid diverticulitis warranted surgical intervention has been challenged by recently published data. Surgery for diverticulitis thus needs to be tailored to suit individual presentation; patients presenting with recurrent diverticulitis, severe symptoms or debilitating disease impacting patient’s quality of life mandate surgical intervention. Complicated diverticular disease typically prompts intervention to resect a diseased, strictured sigmoid colon, fistulizing disease, or a life-threatening colonic perforation. Laterally, minimally invasive surgery has been utilized in the management of this disease and recent data suggests that localized colonic perforation may be managed by laparoscopic peritoneal lavage, without resection. This review focuses discussion on available evidence for contemporary surgical and nonoperative management of diverticulitis. PMID:22016581

Characterization of Complications Associated with Open and Endoscopic Craniosynostosis Surgery at a Single Institution

PubMed Central

Han, Rowland H.; Nguyen, Dennis C.; Bruck, Brent S.; Skolnick, Gary B.; Yarbrough, Chester K.; Naidoo, Sybill D.; Patel, Kamlesh B.; Kane, Alex A.; Woo, Albert S.; Smyth, Matthew D.

2016-01-01

Object We present a retrospective cohort study examining complications in patients undergoing surgery for craniosynostosis using both minimally invasive endoscopic and open approaches. Methods Over the past ten years, 295 non-syndromic patients (140 endoscopic, 155 open) and 33 syndromic patients (10 endoscopic, 23 open) met our criteria. Variables analyzed included: age at surgery, presence of pre-existing CSF shunt, skin incision method, estimated blood loss (EBL), transfusions of packed red blood cells (PRBC), use of intravenous (IV) steroids or tranexamic acid (TXA), intraoperative durotomies, procedure length, and length of hospital stay. Complications were classified as either surgically or medically related. Results In the non-syndromic endoscopic group, we experienced 3 (2.1%) surgical and 5 (3.6%) medical complications. In the non-syndromic open group, there were 2 (1.3%) surgical and 7 (4.5%) medical complications. Intraoperative durotomies occurred in 5 (3.6%) endoscopic and 12 (7.8%) open cases, were repaired primarily, and did not result in reoperations for CSF leakage. Syndromic cases resulted in similar complication rates. No mortality or permanent morbidity occurred. Additionally, endoscopic procedures were associated with significantly decreased EBL, transfusions, procedure lengths, and lengths of hospital stay compared to open procedures. Conclusions Rates of intraoperative durotomies, surgical and medical complications were comparable between endoscopic and open techniques. This is the largest direct comparison to date between endoscopic and open interventions for synostosis, and the results are in agreement with previous series that endoscopic surgery confers distinct advantages over open in appropriate patient populations. PMID:26588461

The role of surgery in the therapeutic approach of gastric cancer liver metastases.

PubMed

Mastoraki, Aikaterini; Benetou, Christina; Mastoraki, Sotiria; Papanikolaou, Ioannis S; Danias, Nikolaos; Smyrniotis, Vassilios; Arkadopoulos, Nikolaos

2016-09-01

Gastric cancer (GC) currently prevails as the second cause of death by malignancy worldwide. Estimations suggest that 35 % of affected patients appear with synchronous distant metastases. The vast majority of patients present with hepatic metastatic disease, sometimes accompanied by synchronous peritoneal and lung dissemination. The disease mostly remains asymptomatic at an early stage, with few reported cases of incidental abdominal discomfort. As the cancer advances, symptoms such as nausea or vomiting arise, along with indigestion and dysphagia, blood loss in the form of melena or hematemesis, as well as anorexia and weight loss. Having spread to the liver, it also causes jaundice due to hepatomegaly and general inanition. Despite recent research on the therapeutic strategies against GC metastatic disease, surgical resection appears the only potentially curative approach. Unfortunately, the majority of patients are not eligible to undergo surgical intervention. With regard to treatment modalities of the advanced stage disease, the role of metastasectomy is still debatable and quite unclear, while prolonged survival was succeeded only under certain specific circumstances. Systemic chemotherapy remains however another option, as well as local management in the form of cryotherapy, radiofrequency ablation, or transcatheter arterial chemoembolization. The aims of this review were to evaluate the results of surgical treatment for metastatic GC with special reference to the extent of its histological spread and to present the recent literature in order to provide an update on the current concepts of advanced surgical management of this entity. Relevant publications in the last two decades are briefly reviewed.

Surgical Elimination of the Gastric Digestion by Roux-en-Y Gastric Bypass Impacts on Food Sensitisation-a Pilot Study.

PubMed

Shakeri-Leidenmühler, Soheila; Lukschal, Anna; Schultz, Cornelia; Bohdjalian, Arthur; Langer, Felix; Birsan, Tudor; Diesner, Susanne C; Greisenegger, Elli K; Scheiner, Otto; Kopp, Tamara; Jensen-Jarolim, Erika; Prager, Gerhard; Untersmayr, Eva

2015-12-01

Impairment of gastric digestion due to pH elevation increases the risk for food allergy induction. As patients after Roux-en-Y gastric bypass (RYGB) surgery have lower gastric acidity and less gastric gland secretion, we aimed to analyse in a prospective study the effect of limiting gastric digestion capacity by surgical intervention on the immune response towards allergens. Nine patients undergoing RYGB surgery for morbid obesity and one control patient having undergone surgery for treatment of an incisional hernia were enrolled in the study. Before and 1, 3, 6, 9 and 12 months after surgery, blood was collected for analysis of specific IgE antibodies, and patients were subjected to skin prick testing with 16 food and 18 aeroallergens. Skin prick test results revealed an increase of positive reactions indicating sensitisations towards the tested food and aeroallergens in 77.8 and 88.9 % of the patients, respectively, after surgical elimination of gastric digestion. These results were in line with elevated titers of food- and aeroallergen-specific IgE antibodies in 7 out of 9 (7/9) and 5/9 patients, respectively, after RYGB surgery. Serum cytokine levels revealed a mixed response for IFN-γ and were mostly beneath detection limit for IL-4. A change of IgE reactivity pattern occurred after impairment of gastric digestion due to surgical elimination underlining the important gastric gatekeeping function during oral sensitisation. Even though this study indicates an increased allergy risk for gastric bypass patients, further studies are needed to investigate in-depth the immunological changes associated with RYGB surgery.

Repair or Replacement for Isolated Tricuspid Valve Pathology? Insights from a Surgical Analysis on Long-Term Survival

PubMed Central

Farag, Mina; Arif, Rawa; Sabashnikov, Anton; Zeriouh, Mohamed; Popov, Aron-Frederik; Ruhparwar, Arjang; Schmack, Bastian; Dohmen, Pascal M.; Szabó, Gábor; Karck, Matthias; Weymann, Alexander

2017-01-01

Background Long-term follow-up data concerning isolated tricuspid valve pathology after replacement or reconstruction is limited. Current American Heart Association guidelines equally recommend repair and replacement when surgical intervention is indicated. Our aim was to investigate and compare operative mortality and long-term survival in patients undergoing isolated tricuspid valve repair surgery versus replacement. Material/Methods Between 1995 and 2011, 109 consecutive patients underwent surgical correction of tricuspid valve pathology at our institution for varying structural pathologies. A total of 41 (37.6%) patients underwent tricuspid annuloplasty/repair (TAP) with or without ring implantation, while 68 (62.3%) patients received tricuspid valve replacement (TVR) of whom 36 (53%) were mechanical and 32 (47%) were biological prostheses. Results Early survival at 30 days after surgery was 97.6% in the TAP group and 91.1% in the TVR group. After 6 months, 89.1% in the TAP group and 87.8% in the TVR group were alive. In terms of long-term survival, there was no further mortality observed after one year post surgery in both groups (Log Rank p=0.919, Breslow p=0.834, Tarone-Ware p=0.880) in the Kaplan-Meier Survival analysis. The 1-, 5-, and 8-year survival rates were 85.8% for TAP and 87.8% for TVR group. Conclusions Surgical repair of the tricuspid valve does not show survival benefit when compared to replacement. Hence valve replacement should be considered generously in patients with reasonable suspicion that regurgitation after repair will reoccur. PMID:28236633

Interventional Cardiology for Congenital Heart Disease.

PubMed

Kenny, Damien

2018-05-01

Congenital heart interventions are now replacing surgical palliation and correction in an evolving number of congenital heart defects. Right ventricular outflow tract and ductus arteriosus stenting have demonstrated favorable outcomes compared to surgical systemic to pulmonary artery shunting, and it is likely surgical pulmonary valve replacement will become an uncommon procedure within the next decade, mirroring current practices in the treatment of atrial septal defects. Challenges remain, including the lack of device design focused on smaller infants and the inevitable consequences of somatic growth. Increasing parental and physician expectancy has inevitably lead to higher risk interventions on smaller infants and appreciation of the consequences of these interventions on departmental outcome data needs to be considered. Registry data evaluating congenital heart interventions remain less robust than surgical registries, leading to a lack of insight into the longer-term consequences of our interventions. Increasing collaboration with surgical colleagues has not been met with necessary development of dedicated equipment for hybrid interventions aimed at minimizing the longer-term consequences of scar to the heart. Therefore, great challenges remain to ensure children and adults with congenital heart disease continue to benefit from an exponential growth in minimally invasive interventions and technology. This can only be achieved through a concerted collaborative approach from physicians, industry, academia and regulatory bodies supporting great innovators to continue the philosophy of thinking beyond the limits that has been the foundation of our specialty for the past 50 years. Copyright © 2018. The Korean Society of Cardiology.

Initial experience of US Marine Corps forward resuscitative surgical system during Operation Iraqi Freedom.

PubMed

Chambers, Lowell W; Rhee, Peter; Baker, Bruce C; Perciballi, John; Cubano, Miguel; Compeggie, Michael; Nace, Michael; Bohman, Harold R

2005-01-01

Modern US Marine Corps (USMC) combat tactics are dynamic and nonlinear. While effective strategically, this can prolong the time it takes to transport the wounded to surgical capability, potentially worsening outcomes. To offset this, the USMC developed the Forward Resuscitative Surgical System (FRSS). By operating in close proximity to active combat units, these small, rapidly mobile trauma surgical teams can decrease the interval between wounding and arrival at surgical intervention with resultant improvement in outcomes. Case series. Echelon 2 surgical units during the invasion phase of Operation Iraqi Freedom. Ninety combat casualties, consisting of 30 USMC and 60 Iraqi patients, were treated in the FRSS between March 21 and April 22, 2003. Tactical surgical intervention consisting of selectively applied damage control or definitive trauma surgical procedures. Time to surgical intervention and outcome following treatment in the FRSS. Ninety combat casualties with 170 injuries required 149 procedures by 6 FRSS teams. The USMC patients were received within a median of 1 hour of wounding with the critically injured being received within a median of 30 minutes. Fifty-three USMC personnel were killed in action and 3 died of wounds for a killed in action rate of 13.5% and a died of wounds rate of 0.8% during the invasion phase of Operation Iraqi Freedom. All Marines treated in the FRSS survived. The use of the FRSS in close proximity to the point of engagement during the initial, dynamic combat phase of Operation Iraqi Freedom prevented delays in surgical intervention of USMC combat casualties with resultant beneficial effects on patient outcomes.

Feasibility study to assess the delivery of a lifestyle intervention (TreatWELL) for patients with colorectal cancer undergoing potentially curative treatment.

PubMed

Macleod, Maureen; Steele, Robert J C; O'Carroll, Ronan E; Wells, Mary; Campbell, Anna; Sugden, Jacqui A; Rodger, Jackie; Stead, Martine; McKell, Jennifer; Anderson, Annie S

2018-06-06

To assess the feasibility of delivering and evaluating a lifestyle programme for patients with colorectal cancer undergoing potentially curative treatments. Non-randomised feasibility trial. National Health Service (NHS) Tayside. Adults with stage I-III colorectal cancer. The programme targeted smoking, alcohol, physical activity, diet and weight management. It was delivered in three face-to-face counselling sessions (plus nine phone calls) by lifestyle coaches over three phases (1: presurgery, 2: surgical recovery and 3: post-treatment recovery). Feasibility measures (recruitment, retention, programme implementation, achieved measures, fidelity, factors affecting protocol adherence and acceptability). Measured changes in body weight, waist circumference, walking and self-reported physical activity, diet, smoking, alcohol intake, fatigue, bowel function and quality of life. Of 84 patients diagnosed, 22 (26%) were recruited and 15 (18%) completed the study. Median time for intervention delivery was 5.5 hours. Coaches reported covering most (>70%) of the intervention components but had difficulties during phase 2. Evaluation measures (except walk test) were achieved by all participants at baseline, and most (<90%) at end of phase 2 and phase 3, but <20% at end of phase 1. Protocol challenges included limited time between diagnosis and surgery and the presence of comorbidities. The intervention was rated highly by participants but limited support from NHS staff was noted. The majority of participants (77%) had a body mass index>25 kg/m 2 and none was underweight. Physical activity data showed a positive trend towards increased activity overall, but no other changes in secondary outcomes were detected. To make this intervention feasible for testing as a full trial, further research is required on (a) recruitment optimisation, (b) appropriate assessment tools, (c) protocols for phase 2 and 3, which can build in flexibility and (d) ways for NHS staff to facilitate the programme. ISRCTN52345929; Post-results. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Management of sickle cell disease in patients undergoing cardiac surgery.

PubMed

Crawford, Todd C; Carter, Michael V; Patel, Rina K; Suarez-Pierre, Alejandro; Lin, Sophie Z; Magruder, Jonathan Trent; Grimm, Joshua C; Cameron, Duke E; Baumgartner, William A; Mandal, Kaushik

2017-02-01

Sickle cell disease is a life-limiting inherited hemoglobinopathy that poses inherent risk for surgical complications following cardiac operations. In this review, we discuss preoperative considerations, intraoperative decision-making, and postoperative strategies to optimize the care of a patient with sickle cell disease undergoing cardiac surgery. © 2017 Wiley Periodicals, Inc.

Intractable duodenal ulcer caused by transmural migration of gossypiboma into the duodenum--a case report and literature review.

PubMed

Lv, Yun-Xiao; Yu, Cheng-Chan; Tung, Chun-Fang; Wu, Cheng-Chung

2014-06-10

Gossypiboma is a term used to describe a mass that forms around a cotton sponge or abdominal compress accidentally left in a patient during surgery. Transmural migration of an intra-abdominal gossypiboma has been reported to occur in the digestive tract, bladder, vagina and diaphragm. Open surgery is the most common approach in the treatment of gossypiboma. However, gossypibomas can be extracted by endoscopy while migrating into the digestive tract. We report a case of intractable duodenal ulcer caused by transmural migration of gossypiboma successfully treated by duodenorrhaphy. A systemic literature review is provided and a scheme of the therapeutic approach is proposed. A 61-year-old Han Chinese man presented with intermittent epigastric pain for the last 10 months. He had undergone laparoscopic cholecystectomy conversion to open cholecystectomy for acute gangrenous cholecystitis 10 months ago at another hospital. Transmural migration of gossypiboma into the duodenum was found. Endoscopic intervention failed to remove the entire gauze, and duodenal ulcer caused by the gauze persisted. Surgical intervention was performed and the gauze was removed successfully. The penetrated ulcer was repaired with duodenorrhaphy. The postoperative period was uneventful.We systematically reviewed the literature on transmural migration of gossypiboma into duodenum and present an overview of published cases. Our PubMed search yielded seven reports of transmural migration of retained surgical sponge into the duodenum. Surgical interventions were necessary in two patients. Transmural migration of gossypiboma into the duodenum is a rare surgical complication. The treatment strategies include endoscopic extraction and surgical intervention. Prompt surgical intervention should be considered for emergent conditions such as active bleeding, gastrointestinal obstruction, or intra-abdominal sepsis. For non-emergent conditions, surgical intervention could be considered for intractable cases in which endoscopic extraction failed.

Use of endobronchial valve insertion to treat relapsing pneumothorax: a case report and literature review.

PubMed

Qi, Fei; Tian, Qing; Chen, Liang'an; Li, Chunyan; Zhang, Shu; Liu, Xingchen; Xiao, Binbin

2017-07-01

Backgorund and Aims: Unidirectional endobronchial valves have recently been shown to be beneficial as treatment for persistent air leaks. This report presents a first case of endobronchial valve implantation to treat relapsing pneumothorax in a Chinese patient, and also presents a review of the literature on the use of one-way valve insertion for the treatment of persistent air leaks. The patient did undergo a recent but failed chest tube intervention. By bronchoscopy and using Chartis® system measurements, the upper left lobe (including the left apical bronchus) was closed using a catheter. After the expected decrease in airflow following bronchial occlusion, increased air pressure and decreased spilled air were noted; it was concluded that the pneumothorax was located in the left upper lobe. A Zephyr ® endobronchial valve was placed in the left upper apical bronchus. The health benefits of the procedure were noticed in the following days. Our review suggests that the use of endobronchial valves could be used as an effective, minimally invasive, low-risk intervention for patients with pneumothorax that cannot be treated surgically. © 2015 John Wiley & Sons Ltd.

[Foot drop: an iatrogenic complication of spinal anesthesia].

PubMed

Goyal, Vipin Kumar; Mathur, Vijay

2018-01-16

Foot drop in postoperative period is very rare after spinal anesthesia. Early clinical assessment and diagnostic interventions is of prime importance to establish the etiology and to start appropriate management. Close follow-up is warranted in early postoperative period in cases when patient complain paresthesia or pain during needle insertion or drug injection. A 22-year-old male was undergone lower limb orthopedic surgery in spinal anesthesia. During shifting from postoperative ward footdrop was suspected during routine assessment of regression of spinal level. Immediately the patient was referred to a neurologist and magnetic resonance imaging was done, which was inconclusive. Conservative management was started and nerve conduction study was done on the 4th postoperative day that confirmed pure motor neuropathy of right peroneal nerve. Patient was discharged with ankle splint and physiotherapy after slight improvement in motor power (2/5). Foot drop is very rare after spinal anesthesia. Any suspected patient must undergo emergent neurological consultation and magnetic resonance imaging to exclude major finding and need for early surgical intervention. Copyright © 2017 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.

A program for sustained improvement in preventing ventilator associated pneumonia in an intensive care setting

PubMed Central

2012-01-01

Background Ventilator-associated pneumonia (VAP) is a common infection in the intensive care unit (ICU) and associated with a high mortality. Methods A quasi-experimental study was conducted in a medical-surgical ICU. Multiple interventions to optimize VAP prevention were performed from October 2008 to December 2010. All of these processes, including the Institute for Healthcare Improvement’s (IHI) ventilator bundle plus oral decontamination with chlorhexidine and continuous aspiration of subglottic secretions (CASS), were adopted for patients undergoing mechanical ventilation. Results We evaluated a total of 21,984 patient-days, and a total of 6,052 ventilator-days (ventilator utilization rate of 0.27). We found VAP rates of 1.3 and 2.0 per 1,000 ventilator days respectively in 2009 and 2010, achieving zero incidence of VAP several times during 12 months, whenever VAP bundle compliance was over 90%. Conclusion These results suggest that it is possible to reduce VAP rates to near zero and sustain these rates, but it requires a complex process involving multiple performance measures and interventions that must be permanently monitored. PMID:23020101

A program for sustained improvement in preventing ventilator associated pneumonia in an intensive care setting.

PubMed

Caserta, Raquel A; Marra, Alexandre R; Durão, Marcelino S; Silva, Cláudia Vallone; Pavao dos Santos, Oscar Fernando; Neves, Henrique Sutton de Sousa; Edmond, Michael B; Timenetsky, Karina Tavares

2012-09-29

Ventilator-associated pneumonia (VAP) is a common infection in the intensive care unit (ICU) and associated with a high mortality. A quasi-experimental study was conducted in a medical-surgical ICU. Multiple interventions to optimize VAP prevention were performed from October 2008 to December 2010. All of these processes, including the Institute for Healthcare Improvement's (IHI) ventilator bundle plus oral decontamination with chlorhexidine and continuous aspiration of subglottic secretions (CASS), were adopted for patients undergoing mechanical ventilation. We evaluated a total of 21,984 patient-days, and a total of 6,052 ventilator-days (ventilator utilization rate of 0.27). We found VAP rates of 1.3 and 2.0 per 1,000 ventilator days respectively in 2009 and 2010, achieving zero incidence of VAP several times during 12 months, whenever VAP bundle compliance was over 90%. These results suggest that it is possible to reduce VAP rates to near zero and sustain these rates, but it requires a complex process involving multiple performance measures and interventions that must be permanently monitored.

The Influence of Surgical Stabilization on Glenohumeral Abduction Using 3-Dimensional Computed Tomography in Patients With Shoulder Instability.

PubMed

Bakshi, Neil K; Jameel, Omar F; Merrill, Zachary F; Debski, Richard E; Sekiya, Jon K

2016-08-01

This study compared the amount of glenohumeral abduction during arm abduction in the affected and unaffected shoulders of 3 groups of patients with shoulder instability: failed surgical stabilization, successful surgical stabilization, and unstable shoulder with no prior surgical intervention. All patients underwent bilateral shoulder computed tomography scans in 3 positions: 0° of abduction and 0° of external rotation (0-0 position), 30° of abduction and 30° of external rotation (30-30 position), and arms maximally abducted (overhead position). Three-dimensional computed tomography reconstruction was performed for both shoulders in all 3 positions. A specialized coordinate system marked specific points and directions on the humerus and glenoid of each model. These coordinates were used to calculate the glenohumeral abduction for the normal and affected sides in the 0-0, 30-30, and overhead positions. Thirty-nine patients with shoulder instability were included, of whom 14 had failed surgical repairs, 10 had successful surgical repairs, and 15 had unstable shoulders with no prior surgical intervention. In the overhead position, patients with failed surgical intervention had significantly less glenohumeral abduction in the failed shoulder (95.6° ± 12.7°) compared with the normal shoulder (101.5° ± 12.4°, P = .02). Patients with successfully stabilized shoulders had significantly less glenohumeral abduction in the successfully stabilized shoulder (93.6° ± 10.8°) compared with the normal shoulder (102.1° ± 12.5°, P = .03). Unstable shoulders with no prior surgical intervention (102.1° ± 10.3°) did not differ when compared with the normal shoulders (101.9° ± 10.9°, P = .95). Surgical intervention, regardless of its success, limits the amount of abduction at the glenohumeral joint. Level III, retrospective comparative study. Copyright © 2016 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.

Intestinal stoma in patients with colorectal cancer from the perspective of 20-year period of clinical observation

PubMed Central

Banaszkiewicz, Zbigniew; Woda, Łukasz P.; Tojek, Krzysztof; Jarmocik, Paweł; Jawień, Arkadiusz

2015-01-01

Introduction Intestinal stoma is a procedure most often performed in patients with colorectal cancer. Aim To identify the percentage of patients with colorectal cancer in which the intestinal stoma was performed. Material and methods We retrospectively analysed 443 patients treated during a 20-year period (1994–2013) due to colorectal cancer, in which the intestinal stoma was made during the first surgical intervention. Results In the second analysed decade, a significant decrease in the percentage of created stomas, definitive stomas in particular, was observed. Stomas were made significantly more often in patients with a tumour located in the rectum, the left half of the colon, and in patients undergoing urgent surgeries. An increased incidence of intestinal stomas was associated with a higher severity of illness and higher proportion of unresectable and non-radical procedures. The definitive stomas were significantly more often made in men and in patients with tumours located in the rectum, whereas temporary stomas were created significantly more often in patients undergoing urgent operations. Conclusions In the last decade (2004–2013) the number of intestinal stomas in patients operated due to colorectal cancer was significantly reduced. PMID:25960811

Manipulating parallel circuits: the perioperative management of patients with complex congenital cardiac disease.

PubMed

Lawrenson, John; Eyskens, Benedicte; Vlasselaers, Dirk; Gewillig, Marc

2003-08-01

In all patients undergoing cardiac surgery, the effective delivery of oxygen to the tissues is of paramount importance. In the patient with relatively normal cardiac structures, the pulmonary and systemic circulations are relatively independent of each other. In the patient with a functional single ventricle, the pulmonary and systemic circulations are dependent on the same pump. As a consequence of this interdependency, the haemodynamic changes following complex palliative procedures, such as the Norwood operation, can be difficult to understand. Comparison of the newly created surgical connections to a simple set of direct current electrical circuits may help the practitioner to successfully care for the patient. In patients undergoing complex palliations, the pulmonary and systemic circulations can be compared to two circuits in parallel. Manipulations of variables, such as resistance or flow, in one circuit, can profoundly affect the performance of the other circuit. A large pulmonary flow might result in a large increase in the saturation of haemoglobin with oxygen returning to the heart via the pulmonary veins at the expense of a decreased systemic flow. Accurate balancing of these parallel circulations requires an appreciation of all interventions that can affect individual components of both circulations.

Assessment of routine elimination of postoperative nasogastric decompression after Roux-en-Y gastric bypass.

PubMed

Huerta, Sergio; Arteaga, James R; Sawicki, Mark P; Liu, Carson D; Livingston, Edward H

2002-11-01

Anastomotic disruption after surgical intervention is an infrequent complication, but may lead to severe morbidity and mortality when it occurs. Of the various gastric procedures, the Roux-en-Y gastric bypass (RYGB) has one of the highest risks for anastomotic leakage. Consequently, a nasogastric tube (NGT) is frequently placed when these operations are performed. Most studies examining the outcomes for patients without postoperative NGTs have been relatively small with groups of patients undergoing a variety of operations. Assessing the incidence of anastomotic leaks by routine elimination of postoperative NGTs requires a large number of patients. In this study, we assessed the safety and efficacy of routine elimination of NGTs in a large cohort of patients undergoing a single operation. We reviewed our experience with 1067 patients who underwent RYGB at the UCLA medical center. Fifty-six patients had NGTs routinely placed before the implementation of a standard protocol, which eliminated postoperative NGT decompression. The complication rate for the RYGB patient cohort with and without postoperative NGT was compared. We found no difference in the complication rates between the 2 groups (Fisher exact test; P =.21). Our findings suggest that routine placement of an NGT after RYGB is unnecessary.

Utility and Clinical Profile of Dexmedetomidine in Pediatric Cardiac Catheterization Procedures: A Matched Controlled Analysis.

PubMed

Riveros, Ricardo; Makarova, Natalya; Riveros-Perez, Efrain; Chodavarapu, Praneeta; Saasouh, Wael; Yılmaz, Hüseyin Oğuz; Cuko, Evis; Babazade, Rovnat; Kimatian, Stephen; Turan, Alparslan

2017-12-01

Dexmedetomidine is increasingly used in children undergoing cardiac catheterization procedures. We compared the percentage of surgical time with hemodynamic instability and the incidence of postoperative agitation between pediatric cardiac catheterization patients who received dexmedetomidine infusion and those who did not and the incidence of postoperative agitation. We matched 653 pediatric patients scheduled for cardiac catheterization. Two separate multivariable linear mixed models were used to assess the association between dexmedetomidine use and intraoperative blood pressure and heart rate instability. A multivariate logistic regression was used for relationship between dexmedetomidine and postoperative agitation. No difference between the study groups was found in the duration of MAP ( P = .867) or heart rate (HR) instabilities ( P = .224). The relationship between dexmedetomidine use and the duration of negative hemodynamic effects does not depend on any of the considered CHD types (all P > .001) or intervention ( P = .453 for MAP and P = .023 for HR). No difference in postoperative agitation was found between the study groups ( P = .590). Our study demonstrated no benefit in using dexmedetomidine infusion compared with other general anesthesia techniques to maintain hemodynamic stability or decrease agitation in pediatric patients undergoing cardiac catheterization procedures.

[NIC as a tool for assessing competences of nursing students in clinical placement at surgical units].

PubMed

Celma Vicente, Matilde; Ajuria-Imaz, Eloisa; Lopez-Morales, Manuel; Fernandez-Marín, Pilar; Menor-Castro, Alicia; Cano-Caballero Galvez, Maria Dolores

2015-01-01

This paper shows the utility of a NIC standardized language to assess the extent of nursing student skills at Practicum in surgical units To identify the nursing interventions classification (NIC) that students can learn to perform in surgical units. To determine the level of difficulty in learning interventions, depending on which week of rotation in clinical placement the student is. Qualitative study using Delphi consensus technique, involving nurses with teaching experience who work in hospital surgical units, where students undertake the Practicum. The results were triangulated through a questionnaire to tutors about the degree of conformity. A consensus was reached about the interventions that students can achieve in surgical units and the frequency in which they can be performed. The level of difficulty of each intervention, and the amount of weeks of practice that students need to reach the expected level of competence was also determined. The results should enable us to design better rotations matched to student needs. Knowing the frequency of each intervention that is performed in each unit determines the chances of learning it, as well as the indicators for its assessment. Copyright © 2015 Elsevier España, S.L.U. All rights reserved.

Factors Associated with Knee Stiffness following Surgical Management of Multiligament Knee Injuries.

PubMed

Hanley, Jessica; Westermann, Robert; Cook, Shane; Glass, Natalie; Amendola, Ned; Wolf, Brian R; Bollier, Matthew

2017-07-01

Postoperative knee stiffness can influence outcomes following operative treatment of multiligament knee injuries (MLKIs). The purpose of this study was to evaluate patient and surgical factors that may potentially contribute to stiffness following surgery for MLKIs. All surgically managed MLKIs involving two or more ligaments over a 10-year period at a single level one trauma center were included in this study. A retrospective review was performed to gather objective data related to the development of knee stiffness after surgery. Patients were classified as "stiff" postoperatively if they (1) had a flexion contracture greater than 10 degrees, (2) failed to reach 120 degrees of flexion at final follow-up, or (3) underwent a manipulation under anesthesia with or without arthroscopic lysis of adhesions to improve range of motion. Patient and surgical factors were evaluated systematically to determine factors associated with stiffness. The mean age of the cohort was 27.6 years at the time of surgery and mean follow-up was 50 weeks. Overall, 26/121 (21.5%) knees were diagnosed with postoperative stiffness. In the acute postoperative phase, 17 patients underwent manipulation under anesthesia. There were no significant differences in age, body mass index, associated injuries, mechanism, external fixation use or surgical timing (acute vs. chronic) between stiff and normal knees. Factors associated with the development of postoperative stiffness included knee dislocation ( p  = 0.04) and surgical intervention on three or more ligaments ( p  = 0.04). Careful attention to postoperative rehabilitation regimens should be given to patients with knee dislocations and/or those undergoing reconstruction or repair of three or more injured ligaments. Surgeons may utilize spanning external fixation if necessary without increasing the rate of long-term stiffness. Further, acute surgery does not appear to influence rates of postoperative stiffness or the need for manipulation. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Intermuscular pterygoid-temporal abscess following inferior alveolar nerve block anesthesia–A computer tomography based navigated surgical intervention: Case report and review

PubMed Central

Wallner, Jürgen; Reinbacher, Knut Ernst; Pau, Mauro; Feichtinger, Matthias

2014-01-01

Inferior alveolar nerve block (IANB) anesthesia is a common local anesthetic procedure. Although IANB anesthesia is known for its safety, complications can still occur. Today immediately or delayed occurring disorders following IANB anesthesia and their treatment are well-recognized. We present a case of a patient who developed a symptomatic abscess in the pterygoid region as a result of several inferior alveolar nerve injections. Clinical symptoms included diffuse pain, reduced mouth opening and jaw's hypomobility and were persistent under a first step conservative treatment. Since image-based navigated interventions have gained in importance and are used for various procedures a navigated surgical intervention was initiated as a second step therapy. Thus precise, atraumatic surgical intervention was performed by an optical tracking system in a difficult anatomical region. A symptomatic abscess was treated by a computed tomography-based navigated surgical intervention at our department. Advantages and disadvantages of this treatment strategy are evaluated. PMID:24987612

Intermuscular pterygoid-temporal abscess following inferior alveolar nerve block anesthesia-A computer tomography based navigated surgical intervention: Case report and review.

PubMed

Wallner, Jürgen; Reinbacher, Knut Ernst; Pau, Mauro; Feichtinger, Matthias

2014-01-01

Inferior alveolar nerve block (IANB) anesthesia is a common local anesthetic procedure. Although IANB anesthesia is known for its safety, complications can still occur. Today immediately or delayed occurring disorders following IANB anesthesia and their treatment are well-recognized. We present a case of a patient who developed a symptomatic abscess in the pterygoid region as a result of several inferior alveolar nerve injections. Clinical symptoms included diffuse pain, reduced mouth opening and jaw's hypomobility and were persistent under a first step conservative treatment. Since image-based navigated interventions have gained in importance and are used for various procedures a navigated surgical intervention was initiated as a second step therapy. Thus precise, atraumatic surgical intervention was performed by an optical tracking system in a difficult anatomical region. A symptomatic abscess was treated by a computed tomography-based navigated surgical intervention at our department. Advantages and disadvantages of this treatment strategy are evaluated.

Updated clinical indications for transcatheter aortic valve implantation in patients with severe aortic stenosis: expert opinion of the Italian Society of Cardiology and GISE.

PubMed

Indolfi, Ciro; Bartorelli, Antonio L; Berti, Sergio; Golino, Paolo; Esposito, Giovanni; Musumeci, Giuseppe; Petronio, Sonia; Tamburino, Corrado; Tarantini, Giuseppe; Ussia, Gianpaolo; Vassanelli, Corrado; Spaccarotella, Carmen; Violini, Roberto; Mercuro, Giuseppe; Romeo, Francesco

2018-05-01

: The introduction of percutaneous treatment of severe aortic stenosis with transcatheter aortic valve implantation (TAVI) remains one of the greatest achievements of interventional cardiology. In fact, TAVI emerged as a better option than either medical therapy or balloon aortic valvuloplasty for patients who cannot undergo surgical aortic valve replacement (SAVR) or are at high surgical risk. Recently, increased operator experience and improved device systems have led to a worldwide trend toward the extension of TAVI to low-risk or intermediate-risk patients. In this expert opinion paper, we first discuss the basic pathophysiology of aortic stenosis in different settings then the key results of recent clinical investigations on TAVI in intermediate-risk aortic stenosis patients are summarized. Particular emphasis is placed on the results of the nordic aortic valve intervention, placement of aortic transcatheter valves (PARTNER) 2 and Surgical Replacement and Transcatheter Aortic Valve Implantation Randomized trials. The PARTNER 2 was the first large randomized trial that evaluated the outcome of TAVI in patients at intermediate risk. The PARTNER 2 data demonstrated that TAVI is a feasible and reasonable alternative to surgery in intermediate-risk patients (Society of Thoracic Surgeons 4-8%), especially if they are elderly or frail. There was a significant interaction between TAVI approach and mortality, with transfemoral TAVI showing superiority over SAVR. Moreover, we examine the complementary results of the recently concluded Surgical Replacement and Transcatheter Aortic Valve Implantation trial. This prospective randomized trial demonstrated that TAVI is comparable with surgery (primary end point 12.6% in the TAVI group vs. 14.0% in the SAVR group) in severe aortic stenosis patients deemed to be at intermediate risk. We review the most relevant clinical evidence deriving from nonrandomized studies and meta-analyses. Altogether, clinical outcome available data suggest that TAVI with a newer generation device might be the preferred treatment option in this patient subgroup. Finally, the differences between the latest European and American Guidelines on TAVI were reported and discussed. The conclusion of this expert opinion article is that TAVI, if feasible, is the treatment of choice in patients with prohibitive or high surgical risk and may lead to similar or lower early and midterm mortality rates compared with SAVR in intermediate-risk patients with severe aortic stenosis.

Perioperative Care and the Importance of Continuous Quality Improvement—A Controlled Intervention Study in Three Tanzanian Hospitals

PubMed Central

Mtatifikolo, Ferdinand; Ngoli, Baltazar; Neuner, Bruno; Wernecke, Klaus–Dieter; Spies, Claudia

2015-01-01

Introduction Surgical services are increasingly seen to reduce death and disability in Sub-Saharan Africa, where hospital-based mortality remains alarmingly high. This study explores two implementation approaches to improve the quality of perioperative care in a Tanzanian hospital. Effects were compared to a control group of two other hospitals in the region without intervention. Methods All hospitals conducted quality assessments with a Hospital Performance Assessment Tool. Changes in immediate outcome indicators after one and two years were compared to final outcome indicators such as Anaesthetic Complication Rate and Surgical Case Fatality Rate. Results Immediate outcome indicators for Preoperative Care in the intervention hospital improved (52.5% in 2009; 84.2% in 2011, p<0.001). Postoperative Inpatient Care initially improved to then decline again (63.3% in 2009; 70% in 2010; 58.6% in 2011). In the control group, preoperative care declined from 50.8% (2009) to 32.8% (2011, p <0.001), while postoperative care did not significantly change. Anaesthetic Complication Rate in the intervention hospital declined (1.89% before intervention; 0.96% after intervention, p = 0.006). Surgical Case Fatality Rate in the intervention hospital declined from 5.67% before intervention to 2.93% after intervention (p<0.0010). Surgical Case Fatality Rate in the control group was 4% before intervention and 3.8% after intervention (p = 0.411). Anaesthetic Complication Rate in the control group was not available. Discussion Immediate outcome indicators initially improved, while at the same time final outcome declined (Surgical Case Fatality, Anaesthetic Complication Rate). Compared to the control group, final outcome improved more in the intervention hospital, although the effect was not significant over the whole study period. Documentation of final outcome indicators seemed inconsistent. Immediate outcome indicators seem more helpful to steer the Continuous Quality Improvement program. Conclusion Specific interventions as part of Continuous Quality Improvement might lead to sustainable improvement of the quality of care, if embedded in a multi-faceted approach. PMID:26327392

Perioperative Care and the Importance of Continuous Quality Improvement--A Controlled Intervention Study in Three Tanzanian Hospitals.

PubMed

Bosse, Goetz; Abels, Wiltrud; Mtatifikolo, Ferdinand; Ngoli, Baltazar; Neuner, Bruno; Wernecke, Klaus-Dieter; Spies, Claudia

2015-01-01

Surgical services are increasingly seen to reduce death and disability in Sub-Saharan Africa, where hospital-based mortality remains alarmingly high. This study explores two implementation approaches to improve the quality of perioperative care in a Tanzanian hospital. Effects were compared to a control group of two other hospitals in the region without intervention. All hospitals conducted quality assessments with a Hospital Performance Assessment Tool. Changes in immediate outcome indicators after one and two years were compared to final outcome indicators such as Anaesthetic Complication Rate and Surgical Case Fatality Rate. Immediate outcome indicators for Preoperative Care in the intervention hospital improved (52.5% in 2009; 84.2% in 2011, p<0.001). Postoperative Inpatient Care initially improved to then decline again (63.3% in 2009; 70% in 2010; 58.6% in 2011). In the control group, preoperative care declined from 50.8% (2009) to 32.8% (2011, p <0.001), while postoperative care did not significantly change. Anaesthetic Complication Rate in the intervention hospital declined (1.89% before intervention; 0.96% after intervention, p = 0.006). Surgical Case Fatality Rate in the intervention hospital declined from 5.67% before intervention to 2.93% after intervention (p<0.0010). Surgical Case Fatality Rate in the control group was 4% before intervention and 3.8% after intervention (p = 0.411). Anaesthetic Complication Rate in the control group was not available. Immediate outcome indicators initially improved, while at the same time final outcome declined (Surgical Case Fatality, Anaesthetic Complication Rate). Compared to the control group, final outcome improved more in the intervention hospital, although the effect was not significant over the whole study period. Documentation of final outcome indicators seemed inconsistent. Immediate outcome indicators seem more helpful to steer the Continuous Quality Improvement program. Specific interventions as part of Continuous Quality Improvement might lead to sustainable improvement of the quality of care, if embedded in a multi-faceted approach.

Dentoalveolar oral surgery in children and adolescents: organization and surgical treatment in a large, Danish municipal dental service.

PubMed

Grønbæk, Anni Birgitte; Petersen, Flemming; Haubek, Dorte; Poulsen, Sven

2017-11-01

To describe a population-based organization of dentoalveolar surgical service for 0 to 18-year old subjects in a Danish municipal dental service, and analyze the type of dentoalveolar surgical interventions needed. The study was conducted in the Municipality of Aarhus, Denmark during five consecutive school-years. An internal referral system was established within the municipality where patients could be referred to colleagues with a higher level of competencies and more experiences with paediatric dentoalveolar surgery. The analysis includes a total of 1812 children and a total of 2854 surgical interventions. Almost 80% of the patients, representing more than 80% of the dentoalveolar surgical interventions needed, were referred internally. Denudations were the most frequent treatment type (40.3%) carried out, followed by removal of third molars (18.0%). Furthermore, 22 odontomas and 100 supernumerary teeth were removed. The need of dentoalveolar surgery in children and adolescents is relatively low, but includes a wide range of interventions. An organizational system, where dentists can refer to colleagues who have developed special competencies in this field, results in most of these surgical patients being referred and treated internally.

Investigating the effect of Eye Movement Desensitization and Reprocessing (EMDR) on postoperative pain intensity in adolescents undergoing surgery: a randomized controlled trial.

PubMed

Maroufi, Mohsen; Zamani, Shahla; Izadikhah, Zahra; Marofi, Maryam; O'Connor, Peter

2016-09-01

To investigate the efficacy of Eye Movement Desensitization and Reprocessing for postoperative pain management in adolescents. Eye Movement Desensitization and Reprocessing is an inexpensive, non-pharmacological intervention that has successfully been used to treat chronic pain. It holds promise in the treatment of acute, postsurgical pain based on its purported effects on the brain and nervous system. A randomized controlled trial was used. Fifty-six adolescent surgical patients aged between 12-18 years were allocated to gender-balanced Eye Movement Desensitization and Reprocessing (treatment) or non-Eye Movement Desensitization and Reprocessing (control) groups. Pain was measured using the Wong-Baker FACES(®) Pain Rating Scale (WBFS) before and after the intervention (or non-intervention for the control group). A Wilcoxon signed-rank test demonstrated that the Eye Movement Desensitization and Reprocessing group experienced a significant reduction in pain intensity after treatment intervention, whereas the control group did not. Additionally, a Mann-Whitney U-test showed that, while there was no significant difference between the two groups at time 1, there was a significant difference in pain intensity between the two groups at time 2, with the Eye Movement Desensitization and Reprocessing group experiencing lower levels of pain. These results suggest that Eye Movement Desensitization and Reprocessing may be an effective treatment modality for postoperative pain. © 2016 John Wiley & Sons Ltd.

Risk of Liver Abscess Formation in Patients with Prior Biliary Intervention Following Yttrium-90 Radioembolization

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

Cholapranee, Aurada; Houten, Diana van; Deitrick, Ginna

PurposePatients without a competent sphincter of Oddi due to prior surgical or endoscopic therapy are at high risk for liver abscess following chemoembolization despite aggressive antimicrobial prophylaxis. We examined a cohort of such patients undergoing Y-90 resin radioembolization and compared them to a cohort of chemoembolized patients.MethodsReview of our quality-assurance database identified 24 radioembolizations performed in 16 patients with prior biliary intervention. An aggressive prophylactic regimen of oral levofloxacin and metronidazole 2 days pre-procedure continuing for 14 days after, oral neomycin/erythromycin bowel prep the day before, and IV levofloxacin/metronidazole the day of treatment was prescribed. Patients underwent resin microsphere radioembolization dosed accordingmore » to the BSA method. Patients had clinical, imaging, and laboratory assessment 1 month after each treatment, and then every 3 months. The chemoembolization cohort consisted of 13 patients with prior biliary intervention who had undergone 24 chemoembolization procedures.ResultsNo radioembolization patient developed an abscess. In the cohort of chemoembolized patients who received the same prophylaxis, liver abscess occurred following 3 of 24 (12.5 %) procedures in 3 of 13 (23 %) patients, one fatal.ConclusionsThis preliminary experience suggests that the risk of liver abscess among patients with prior biliary intervention may be lower following radioembolization than chemoembolization, which could potentially expand treatment options in this high-risk population.« less

Aortic occlusion balloon catheter technique is useful for uncontrollable massive intraabdominal bleeding after hepato-pancreato-biliary surgery.

PubMed

Miura, Fumihiko; Takada, Tadahiro; Ochiai, Takenori; Asano, Takehide; Kenmochi, Takashi; Amano, Hodaka; Yoshida, Masahiro

2006-04-01

Massive intraabdominal hemorrhage sometimes requires urgent hemostatic surgical intervention. In such cases, its rapid stabilization is crucial to reestablish a general hemodynamic status. We used an aortic occlusion balloon catheter in patients with massive intraabdominal hemorrhage occurring after hepato-pancreato-biliary surgery. An 8-French balloon catheter was percutaneously inserted into the aorta from the femoral artery, and the balloon was placed just above the celiac artery. Fifteen minutes inflation and 5 minutes deflation were alternated during surgery until the bleeding was surgically controlled. An aortic occlusion balloon catheter was inserted on 13 occasions in 10 patients undergoing laparotomy for hemostasis of massive hemorrhage. The aorta was successfully occluded on 12 occasions in nine patients. Both systolic pressure and heart rate were normalized during aortic occlusion, and the operative field became clearly visible after adequate suction of leaked blood. Bleeding sites were then easily found and controlled. Hemorrhage was successfully controlled in 7 of 10 patients (70%), and they were discharged in good condition. The aortic occlusion balloon catheter technique was effective for easily controlling massive intraabdominal bleeding by hemostatic procedure after hepato-pancreato-biliary surgery.

Endovascular approach to treat ascending aortic pseudoaneurysm in a patient with previous CABG and very high surgical risk.

PubMed

Zago, Alexandre C; Saadi, Eduardo K; Zago, Alcides J

2011-10-01

Pseudoaneurysm of the ascending aorta is an uncommon pathology and a challenge in high-risk patients who undergo conventional surgery because of high operative morbidity and mortality. Endovascular exclusion of an aortic pseudoaneurysm using an endoprosthesis is a less invasive approach, but few such cases have been reported. Moreover, the use of this approach poses unique therapeutic challenges because there is no specific endoprosthesis for ascending aortic repair, particularly to treat patients with previous coronary artery bypass graft (CABG). We describe the case of a 74-year-old patient who had undergone CABG and later presented with an iatrogenic ascending aortic pseudoaneurysm that occurred during an angiography. This patient was at very high risk for surgical treatment and, therefore, an endovascular approach was adopted: percutaneous coronary intervention for the left main coronary artery, left anterior descending and left circumflex native coronary arteries followed by endovascular endoprosthesis deployment in the ascending aorta to exclude the pseudoaneurysm. Both procedures were successfully performed, and the patient was discharged without complications 4 days later. At 5 months' clinical follow-up, his clinical condition was good and he had no complications. Copyright © 2011 Wiley-Liss, Inc.

Systemic Inflammation after Third Molar Removal: A Case-Control Study.

PubMed

Graziani, F; D'Aiuto, F; Gennai, S; Petrini, M; Nisi, M; Cirigliano, N; Landini, L; Bruno, R M; Taddei, S; Ghiadoni, L

2017-12-01

Third molar extraction is one of the most frequent interventions in dentistry. Nevertheless, there is scarce evidence on the host response of individuals with impacted or semi-impacted third molars and the possible effects of surgical removal. A case-control study of 40 patients was designed to evaluate 1) the differences in biomarkers of systemic inflammation, vascular function, and metabolism (high-sensitive C-reactive protein, lipids, fibrinogen, oxidative stress, and endothelial function analysis) and 2) the acute and short-term effects of surgical removal in patients with bilateral impacted or semi-impacted third molars compared to controls with no third molars. Patients undergoing third molar extraction exhibited greater levels of systemic inflammation, oxidative stress, and triglycerides than controls. Raised white blood cell counts as well as peaks of serum levels of C-reactive protein and fibrinogen were noticed in the first postoperative week. Three months after the extraction, all markers returned to baseline values. Malondialdehyde, an indicator of oxidative stress indicator, was significantly reduced after third molar removal. Semi-impacted or impacted third molars are associated with higher systemic inflammation, and their removal may represent a useful human model to study acute inflammation and determine beneficial systemic effects ( ClinicalTrials.gov NCT03048175).

Current challenges in the recognition, prevention and treatment of perioperative pulmonary atelectasis.

PubMed

Restrepo, Ruben D; Braverman, Jane

2015-02-01

Innovations in surgery have significantly increased the number of procedures performed every year. While more individuals benefit from better surgical techniques and technology, a larger group of patients previously deemed ineligible for surgery now undergo high-complexity surgical procedures. Despite continuous improvements in the operating room and post-operative care, post-operative pulmonary complications (PPCs) continue to pose a serious threat to successful outcomes. PPCs are common, serious and costly. Growing awareness of the impact of PPCs has led to intensified efforts to understand the underlying causes. Current evidence demonstrates that a high proportion of PPCs are directly traceable to the pre-operative risk for and perioperative development of atelectasis. The substantial costs and losses associated with PPCs demand strategies to reduce their prevalence and impact. Effective interventions will almost certainly produce cost savings that significantly offset current economic and human resource expenditures. The purpose of this review is to describe the most common challenges encountered in the recognition, prevention and management of perioperative atelectasis. Expanding awareness and understanding of the role of atelectasis as a cause of PPCs can reduce their prevalence, impact important clinical outcomes and reduce the financial burden associated with treating these complications.

Nonoperative treatment of patients with presumed penile fracture.

PubMed

Mydlo, J H; Gershbein, A B; Macchia, R J

2001-02-01

Immediate surgical intervention is the basis for treatment of penile fractures due to the high risk of complications associated with conservative management. Unfortunately, patient refusal to undergo surgery has led to conservative treatment of a small group of patients with presumed penile fractures at our institution. We followed these patients in regard to clinical outcome. Between 1992 and 1999, 5 patients were evaluated after blunt trauma to an erect penis. Patient age at presentation ranged from 19 to 31 years (mean 25). The interval from time of injury to presentation was 24 to 72 hours. Of these patients 4 had been injured during sexual intercourse, while 1 had been injured during masturbation. All 5 patients refused immediate surgical exploration for presumed penile fracture. No patient had any immediate complications. At 6 and 12-month followup all patients reported erections adequate for intercourse without associated pain. One patient reported only mild curvature for which he did not seek treatment. We report on a subset of young males with presumed penile fracture who refused diagnostic evaluation and therapy, and were able to maintain normal erectile and voiding function. However, longer followup and radiographic evidence will be necessary to corroborate or refute these initial observations.

Practical anesthetic considerations in patients undergoing tracheobronchial surgeries: a clinical review of current literature

PubMed Central

Ahuja, Sanchit; Cohen, Barak; Hinkelbein, Jochen; Diemunsch, Pierre

2016-01-01

Tracheobronchial surgeries require close cooperation and extensive communication between the anesthesia providers and the surgeons. Anesthetic management of tracheal and bronchial pathologies differ basically from regular upper airways management, due access to the patients airway is limited, mostly even practically impossible for the anesthesia providers. As a consequence, the surgeon overtakes responsibility for the airway access from the anesthesia provider in the variety of the cases. Preoperative recognition of a difficult airway, detailed planning and being aware of plan B and plan C are the elementary keys to success. Providers have to be aware, that preoperative airway assessment does not always correlate with the ease of oxygenation and ventilation. Therefore, various methods have been described in the literature and several authors have adopted unique ways to manage the airways in a successful manner. With the advancement of surgical techniques over the years, anesthetic management has also evolved tremendously to match the needs. The commonly encountered conditions requiring surgical interventions include post-intubation stenosis and foreign body aspiration. In this review we will discuss the most common pathologies of tracheobronchial lesions and specific anesthetic management considerations related to them. PMID:28066624

Preoperative selection of patients with colorectal cancer liver metastasis for hepatic resection

PubMed Central

Mattar, Rafif E; Al-alem, Faisal; Simoneau, Eve; Hassanain, Mazen

2016-01-01

Surgical resection of colorectal liver metastases (CRLM) has a well-documented improvement in survival. To benefit from this intervention, proper selection of patients who would be adequate surgical candidates becomes vital. A combination of imaging techniques may be utilized in the detection of the lesions. The criteria for resection are continuously evolving; currently, the requirements that need be met to undergo resection of CRLM are: the anticipation of attaining a negative margin (R0 resection), whilst maintaining an adequate functioning future liver remnant. The timing of hepatectomy in regards to resection of the primary remains controversial; before, after, or simultaneously. This depends mainly on the tumor burden and symptoms from the primary tumor. The role of chemotherapy differs according to the resectability of the liver lesion(s); no evidence of improved survival was shown in patients with resectable disease who received preoperative chemotherapy. Presence of extrahepatic disease in itself is no longer considered a reason to preclude patients from resection of their CRLM, providing limited extra-hepatic disease, although this currently is an area of active investigations. In conclusion, we review the indications, the adequate selection of patients and perioperative factors to be considered for resection of colorectal liver metastasis. PMID:26811608

A comparison of trends in operative approach and postoperative outcomes for colorectal cancer surgery.

PubMed

Addae, Jamin K; Gani, Faiz; Fang, Sandy Y; Wick, Elizabeth C; Althumairi, Azah A; Efron, Jonathan E; Canner, Joseph K; Euhus, David M; Schneider, Eric B

2017-02-01

Data-assessing trends and perioperative outcomes relative to surgical approach for colorectal cancer (CRC) surgery are lacking. We report national trends of CRC surgery and compare postoperative outcomes by surgical approach. A total of 261,886 patients undergoing surgery for CRC were identified using the Nationwide Inpatient Sample from 2009 to 2012. Trends in surgical approach were assessed using the Cochrane-Armitage test of trends. Multivariable logistic and linear regression analyses were performed to compare length of stay (LOS), postoperative complications, and cost by surgical approach. At the time of surgery, 57.5% underwent an open procedure, whereas 42.4% underwent either a laparoscopic (39.9%) or robotic (2.5%) colorectal surgery. The use of minimally invasive surgery increased over time (2009 versus 2012: 37.3% versus 46.8%; P < 0.001). Postoperative morbidity was 15.9% and was higher after open surgery (open versus laparoscopic versus robotic: 18.4% versus 12.4% versus 13.3%; P < 0.001). Patients who underwent a minimally invasive surgery had shorter LOS (laparoscopic: OR, 0.55, 95% CI, 0.52-0.58; robotic: OR, 0.58; 95% CI, 0.49-0.69; both P < 0.001). Robotic surgery was consistently associated with the highest mean costs followed by laparoscopic and open surgery (P < 0.001). Patients undergoing minimally invasive colorectal surgery had a lower postoperative morbidity and shorter LOS compared with patients undergoing open colorectal surgery. Copyright © 2016 Elsevier Inc. All rights reserved.

[Minimal access surgery: A survey among surgeons in Central Germany].

PubMed

Weigt, A; Rauchfuss, F; Dittmar, Y; Settmacher, U; Scheuerlein, H

2015-06-01

A survey about perceptions concerning natural orifice transluminal endoscopic surgery (NOTES) and single port operations (SPO) was conducted among medical professionals at hospitals in Central Germany. The identity of the participants remained anonymous. The focus was on the subjective perception of medical colleagues and included a statement of preferred methods if the medical professional would need to undergo surgery. Within a radius of 120 km of the city of Erfurt, all 150 surgical departments were approached and asked to complete a series of questionnaires containing general and personal questions. The analysis was performed according to the professional rank, age and sex of the participants. The questionnaires contained questions on patient preferences, cosmetic aspects and other factors, such as marketing, industry-driven, playful approach of the surgeon and appeal of a new procedure. In total 83 surgical departments participated in the survey resulting in 432 eligible questionnaires. Of the participants 29 % were female, the average age was 44 years, 20 % were heads of departments, 37 % senior surgeons, 20 % specialist surgeons and 23 % residents. The proportion of conventional minimally invasive surgical procedures was on average 30 % of all surgical interventions. Two hospitals offered transvaginal hybrid NOTES (cholecystectomy), 45 % performed SPOs, 36 % of the participants agreed strongly or moderately with the concept of SPO and 34 % rejected NOTES. The factors industry-driven, promotion/marketing and appeal of a new procedure were evaluated as very important or relatively important by the majority of the participants (> 70 %). When evaluating the factor playful approach of the surgeon, the proportion was 55 %. The factor patient preferences was evaluated as very high or high by 25% of the participants while it had no impact on 8 % or only a minor impact on 36 %. In case of undergoing surgery themselves, conventional laparoscopy would be preferred and NOTES was rated last among all options. The soft factors that were analyzed (i.e. marketing, industry-driven, playful approach of the surgeon and appeal of something new) were evaluated as much more important in the surgeons' opinion compared to patient criteria (i.e. patient preferences and cosmetic results). The soft factors are, however, not to be judged as generally negative as they are to a certain extent necessary (marketing), useful (impulses from industry) or are part of the surgical creativity (playfulness). The discrepancies in the medical professional evaluation of the different factors shows that the reasoning and the motivation of the actions are not necessarily identical.

A qualitative study exploring the views, attitudes and beliefs of patients and health professionals towards exercise intervention for people who are surgically treated for lung cancer.

PubMed

Crandall, K; Maguire, R; Campbell, A; Kearney, N

2018-03-01

Surgical removal remains the best curative option for patients diagnosed with early-stage lung cancer. However, it is also associated with significant morbidity and reduced quality of life. Interventions to improve patient outcomes are required. This study aimed to explore the views, attitudes and beliefs of key stakeholders on exercise intervention for people who are surgically treated for lung cancer to inform the development of future interventions. Focus groups and individual interviews were carried out at two Scottish sites. The study was guided by the Health Action Process Approach behaviour change model. A total of 23 (12 patients and 11 health professionals) participated in the study. The data analysis resulted in three main themes: attitudes and beliefs, external factors and intervention design. The results highlighted certain key elements that should be included in an exercise intervention, such as the need for supervised sessions, an element of individualisation and the perceived social benefits of exercising with others. This study emphasises the importance of including key stakeholders in the development of complex interventions such as exercise and provides important information for the development of future exercise intervention trials for people who are surgically treated for lung cancer. © 2018 John Wiley & Sons Ltd.

Modeling the effect of surgical sterilization on owned dog population size in Villa de Tezontepec, Hidalgo, Mexico, using an individual-based computer simulation model

PubMed Central

Kisiel, Luz Maria; Jones-Bitton, Andria; Sargeant, Jan M.; Coe, Jason B.; Flockhart, D. T. Tyler; Canales Vargas, Erick J.

2018-01-01

Surgical sterilization programs for dogs have been proposed as interventions to control dog population size. Models can be used to help identify the long-term impact of reproduction control interventions for dogs. The objective of this study was to determine the projected impact of surgical sterilization interventions on the owned dog population size in Villa de Tezontepec, Hidalgo, Mexico. A stochastic, individual-based simulation model was constructed and parameterized using a combination of empirical data collected on the demographics of owned dogs in Villa de Tezontepec and data available from the peer-reviewed literature. Model outcomes were assessed using a 20-year time horizon. The model was used to examine: the effect of surgical sterilization strategies focused on: 1) dogs of any age and sex, 2) female dogs of any age, 3) young dogs (i.e., not yet reached sexual maturity) of any sex, and 4) young, female dogs. Model outcomes suggested that as surgical capacity increases from 21 to 84 surgeries/month, (8.6% to 34.5% annual sterilization) for dogs of any age, the mean dog population size after 20 years was reduced between 14% and 79% compared to the base case scenario (i.e. in the absence of intervention). Surgical sterilization interventions focused only on young dogs of any sex yielded greater reductions (81% - 90%) in the mean population size, depending on the level of surgical capacity. More focused sterilization targeted at female dogs of any age, resulted in reductions that were similar to focusing on mixed sex sterilization of only young dogs (82% - 92%). The greatest mean reduction in population size (90% - 91%) was associated with sterilization of only young, female dogs. Our model suggests that targeting sterilization to young females could enhance the efficacy of existing surgical dog population control interventions in this location, without investing extra resources. PMID:29856830

What Evidence Underlies Clinical Practice in Paediatric Surgery? A Systematic Review Assessing Choice of Study Design.

PubMed

Allin, Benjamin; Aveyard, Nicholas; Campion-Smith, Timothy; Floyd, Eleanor; Kimpton, James; Swarbrick, Kate; Williams, Emma; Knight, Marian

2016-01-01

Identify every paediatric surgical article published in 1998 and every paediatric surgical article published in 2013, and determine which study designs were used and whether they were appropriate for robustly assessing interventions in surgical conditions. A systematic review was conducted according to a pre-specified protocol (CRD42014007629), using EMBASE and Medline. Non-English language studies were excluded. Studies were included if meeting population criteria and either condition or intervention criteria. Children under the age of 18, or adults who underwent intervention for a condition managed by paediatric surgeons when they were under 18 years of age. One managed by general paediatric surgeons. Used for treatment of a condition managed by general paediatric surgeons. Studies were classified according to whether the IDEAL collaboration recommended their design for assessing surgical interventions or not. Change in proportions between 1998 and 2013 was calculated. 1581 paediatric surgical articles were published in 1998, and 3453 in 2013. The most commonly used design, accounting for 45% of studies in 1998 and 46.8% in 2013, was the retrospective case series. Only 1.8% of studies were RCTs in 1998, and 1.9% in 2013. Overall, in 1998, 9.8% of studies used a recommended design. In 2013, 11.9% used a recommended design (proportion increase 2.3%, 95% confidence interval 0.5% increase to 4% increase, p = 0.017). A low proportion of published paediatric surgical manuscripts utilise a design that is recommended for assessing surgical interventions. RCTs represent fewer than 1 in 50 studies. In 2013, 88.1% of studies used a less robust design, suggesting the need for a new way of approaching paediatric surgical research.

Cohort study examining long-term respiratory health, career duration and racing performance in racehorses that undergo left-sided prosthetic laryngoplasty and ventriculocordectomy surgery for treatment of left-sided laryngeal hemiplegia.

PubMed

Mason, B J; Riggs, C M; Cogger, N

2013-03-01

The risk of respiratory conditions, such as inflammatory airway disease (IAD) and exercise-induced pulmonary haemorrhage (EIPH), are thought to be higher in racehorses that undergo prosthetic laryngoplasty with ventriculocordectomy (PLVC) surgery to treat left-sided laryngeal hemiplegia (LLH) than in racehorses with normal laryngeal function. However, this has not been investigated formally owing to the difficulty of obtaining reliable follow-up data. To determine the incidence of respiratory conditions (IAD and EIPH), duration of racing career, number of starts and number of starts for which stakes money was earned in racehorses that had undergone PLVC surgery to treat LLH, compared with racehorses that did not have LLH or undergo any laryngeal surgery. A retrospective cohort study design was used, with surgical, clinical and race data of Thoroughbred racehorses obtained from the time of importation until retirement. The surgical cohort consisted of racehorses that had undergone PLVC for LLH and met specific inclusion criteria. Every surgical case was matched, according to trainer, year of import into Hong Kong and pre-import international handicap rating, to 2 unexposed racehorses. Respiratory conditions, such as excessive tracheal mucus and epistaxis due to severe EIPH, were significantly increased in the surgical cohort, compared with the matched unexposed cohort (P values <0.001 and <0.004, respectively). Racing career duration in the surgical cohort was significantly shorter than in the unexposed cohort, which was primarily due to retirement because of epistaxis. The number of race starts was fewer in the surgical than in the unexposed cohort after surgery/matching, but the number of starts for which stakes money was earned was not significantly different. Owners and trainers should be advised that racehorses with LLH that undergo PLVC surgery are at an increased risk of respiratory conditions (IAD and severe EIPH), which is likely to shorten their racing career compared to racehorses with normal laryngeal function. Racing performance in terms of race starts was significantly less in racehorses that had undergone PLVC surgery; however, the number of starts for which stakes money was earned was similar to those racehorses that were unexposed. © 2012 EVJ Ltd.

Cervical degenerative disease: systematic review of economic analyses.

PubMed

Alvin, Matthew D; Qureshi, Sheeraz; Klineberg, Eric; Riew, K Daniel; Fischer, Dena J; Norvell, Daniel C; Mroz, Thomas E

2014-10-15

Systematic review. To perform an evidence-based synthesis of the literature assessing the cost-effectiveness of surgery for patients with symptomatic cervical degenerative disc disease (DDD). Cervical DDD is a common cause of clinical syndromes such as neck pain, cervical radiculopathy, and myelopathy. The appropriate surgical intervention(s) for a given problem is controversial, especially with regard to quality-of-life outcomes, complications, and costs. Although there have been many studies comparing outcomes and complications, relatively few have compared costs and, more importantly, cost-effectiveness of the interventions. We conducted a systematic search in PubMed/MEDLINE, EMBASE, the Cochrane Collaboration Library, the Cost-Effectiveness Analysis registry database, and the National Health Service Economic Evaluation Database for full economic evaluations published through January 16, 2014. Identification of full economic evaluations that were explicitly designed to evaluate and synthesize the costs and consequences of surgical procedures or surgical intervention with nonsurgical management in patients with cervical DDD were considered for inclusion, based on 4 key questions. Five studies were included, each specific to 1 or more of our focus questions. Two studies suggested that cervical disc replacement may be more cost-effective compared with anterior cervical discectomy and fusion. Two studies comparing anterior with posterior surgical procedures for cervical spondylotic myelopathy suggested that anterior surgery was more cost-effective than posterior surgery. One study suggested that posterior cervical foraminotomy had a greater net economic benefit than anterior cervical discectomy and fusion in a military population with unilateral cervical radiculopathy. No studies assessed the cost-effectiveness of surgical intervention compared with nonoperative treatment of cervical myelopathy or radiculopathy, although it is acknowledged that existing studies demonstrate the cost-effectiveness of surgical intervention for these 2 clinical entities. A paucity of high-quality economic literature exists regarding cost-effectiveness of surgical intervention for cervical DDD. Future research is necessary to validate the findings of the few studies that do exist to guide decisions for surgery by the physician and patient with respect to cost-effectiveness. 2.

Incorporating spirituality in psychosocial group intervention for women undergoing in vitro fertilization: a prospective randomized controlled study.

PubMed

Chan, Celia H Y; Chan, Cecilia L W; Ng, Ernest H Y; Ho, P C; Chan, Timothy H Y; Lee, G L; Hui, W H C

2012-12-01

This study examined the efficacy of a group intervention, the Integrative Body-Mind-Spirit (I-BMS) intervention, which aims at improving the psychosocial and spiritual well-being of Chinese women undergoing their first IVF treatment cycle. The I-BMS intervention facilitates the search of meaning of life in the context of family and childbearing, as well as the letting go of high IVF expectations. A randomized controlled study of 339 women undergoing first IVF treatment cycle in a local Hong Kong hospital was conducted (intervention: n= 172; no-intervention control: n= 167). Assessments of anxiety, perceived importance of childbearing, and spiritual well-being were made at randomization (T(0) ), on the day starting ovarian stimulations (T(1)), and on the day undertaking embryo transfer (T(2)). Comparing T(0) and T(2), interaction analyses showed women who had received the intervention reported lower levels of physical distress, anxiety, and disorientation. They reported being more tranquil and satisfied with their marriage, and saw childbearing as less important compared to women in the control group. These findings suggest that I-BMS intervention was successful at improving the psychosocial and spiritual well-being of women undergoing their first IVF treatment cycle. This study highlights the importance of providing integrative fertility treatment that incorporates psychosocial and spiritual dimensions. ©2011 The British Psychological Society.

Repeated Surgical or Endoscopic Myotomy for Recurrent Dysphagia in Patients After Previous Myotomy for Achalasia.

PubMed

Fumagalli, Uberto; Rosati, Riccardo; De Pascale, Stefano; Porta, Matteo; Carlani, Elisa; Pestalozza, Alessandra; Repici, Alessandro

2016-03-01

Surgical myotomy of the lower esophageal sphincter has a 5-year success rate of approximately 91 %. Peroral endoscopic myotomy can provide similar results for controlling dysphagia. Some patients experience either persistent or recurrent dysphagia after myotomy. We present here a retrospective analysis of our experience with redo myotomy for recurrent dysphagia in patients with achalasia. From March 1996 to February 2015, 234 myotomies for primary or recurrent achalasia were performed in our center. Fifteen patients (6.4 %) had had a previous myotomy and were undergoing surgical redo myotomy (n = 9) or endoscopic redo myotomy (n = 6) for recurrent symptoms. Patients presented at a median of 10.4 months after previous myotomy. Median preoperative Eckardt score was 6. Among the nine patients undergoing surgical myotomy, three esophageal perforations occurred intraoperatively (all repaired immediately). Surgery lasted 111 and 62 min on average (median) in the surgical and peroral endoscopic myotomy (POEM) groups, respectively. No postoperative complications occurred in either group. Median postoperative stay was 3 and 2.5 days in the surgical and POEM groups, respectively. In the surgical group, Eckardt score was <3 for seven out of nine patients after a mean follow-up of 19 months; it was <3 for all six patients in the POEM group after a mean follow-up of 5 months. A redo myotomy should be considered in patients who underwent myotomy for achalasia and presenting with recurrent dysphagia. Preliminary results using POEM indicate that the technique can be safely used in patients who have undergone previous surgical myotomy.

Surgical versus conservative management of Type III acromioclavicular dislocation: a systematic review.

PubMed

Longo, Umile Giuseppe; Ciuffreda, Mauro; Rizzello, Giacomo; Mannering, Nicholas; Maffulli, Nicola; Denaro, Vincenzo

2017-06-01

The management of Type III acromioclavicular (AC) dislocations is still controversial. We wished to compare the rate of recurrence and outcome scores of operative versus non-operative treatment of patients with Type III AC dislocations. A systematic review of the literature was performed by applying the PRISMA guidelines according to the PRISMA checklist and algorithm. A search in Medline, PubMed, Cochrane and CINAHL was performed using combinations of the following keywords: 'dislocation', 'Rockwood', 'type three', 'treatment', 'acromioclavicular' and 'joint'. Fourteen studies were included, evaluating 646 shoulders. The rate of recurrence in the surgical group was 14%. No statistical significant differences were found between conservative and surgical approaches in terms of postoperative osteoarthritis and persistence of pain, although persistence of pain seemed to occur less frequently in patients undergoing a surgical treatment. Persistence of pain seemed to occur less frequently in patients undergoing surgery. Persistence of pain seems to occur less frequently in patients treated surgically for a Type III AC dislocation. There is insufficient evidence to establish the effects of surgical versus conservative treatment on functional outcome of patients with AC dislocation. High-quality randomized controlled clinical trials are needed to establish whether there is a difference in functional outcome. © The Author 2017. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

Temporal lobe surgery in childhood and neuroanatomical predictors of long-term declarative memory outcome

PubMed Central

Skirrow, Caroline; Cross, J. Helen; Harrison, Sue; Cormack, Francesca; Harkness, William; Coleman, Rosie; Meierotto, Ellen; Gaiottino, Johanna; Vargha-Khadem, Faraneh

2015-01-01

The temporal lobes play a prominent role in declarative memory function, including episodic memory (memory for events) and semantic memory (memory for facts and concepts). Surgical resection for medication-resistant and well-localized temporal lobe epilepsy has good prognosis for seizure freedom, but is linked to memory difficulties in adults, especially when the removal is on the left side. Children may benefit most from surgery, because brain plasticity may facilitate post-surgical reorganization, and seizure cessation may promote cognitive development. However, the long-term impact of this intervention in children is not known. We examined memory function in 53 children (25 males, 28 females) who were evaluated for epilepsy surgery: 42 underwent unilateral temporal lobe resections (25 left, 17 right, mean age at surgery 13.8 years), 11 were treated only pharmacologically. Average follow-up was 9 years (range 5–15). Post-surgical change in visual and verbal episodic memory, and semantic memory at follow-up were examined. Pre- and post-surgical T1-weighted MRI brain scans were analysed to extract hippocampal and resection volumes, and evaluate post-surgical temporal lobe integrity. Language lateralization indices were derived from functional magnetic resonance imaging. There were no significant pre- to postoperative decrements in memory associated with surgery. In contrast, gains in verbal episodic memory were seen after right temporal lobe surgery, and visual episodic memory improved after left temporal lobe surgery, indicating a functional release in the unoperated temporal lobe after seizure reduction or cessation. Pre- to post-surgical change in memory function was not associated with any indices of brain structure derived from MRI. However, better verbal memory at follow-up was linked to greater post-surgical residual hippocampal volumes, most robustly in left surgical participants. Better semantic memory at follow-up was associated with smaller resection volumes and greater temporal pole integrity after left temporal surgery. Results were independent of post-surgical intellectual function and language lateralization. Our findings indicate post-surgical, hemisphere-dependent material-specific improvement in memory functions in the intact temporal lobe. However, outcome was linked to the anatomical integrity of the temporal lobe memory system, indicating that compensatory mechanisms are constrained by the amount of tissue which remains in the operated temporal lobe. Careful tailoring of resections for children undergoing epilepsy surgery may enhance long-term memory outcome. PMID:25392199

Emergency management in patients with late hemorrhage after pancreatoduodenectomy for a periampullary tumor.

PubMed

Jilesen, Anneke P J; Tol, Johanna A M G; Busch, Olivier R C; van Delden, Otto M; van Gulik, Thomas M; Nieveen van Dijkum, Els J M; Gouma, Dirk J

2014-09-01

The mortality rate due to late hemorrhage after surgery for periampullary tumors is high, especially in patients with anastomotic leakage. Patients usually require emergency intervention for late hemorrhage. In this study patients with late hemorrhage and their outcomes were analyzed. Furthermore, independent predictors for late hemorrhage, the need for emergency intervention, and type of intervention are reported. From a prospective database that includes 1,035 patients who underwent pancreatoduodenectomy for periampullary tumors between 1992 and 2012, patients with late hemorrhage (>24 h after index operation) were identified. Patient, disease-specific, and operation characteristics, type of intervention, and outcomes were analyzed. Emergency intervention was defined as surgical or radiological intervention in hemodynamically unstable patients. Of the 47 patients (4.5 %) with late hemorrhage, pancreatic fistula was an independent predictor for developing late hemorrhage (OR 10.2). The mortality rate in patients with late hemorrhage was 13 % compared with 1.5 % in all patients without late hemorrhage. Twenty patients required emergency intervention; 80 % underwent primary radiological intervention and 20 % primary surgical intervention. Extraluminal location of the bleeding (OR 5.6) and occurrence of a sentinel bleed (OR 6.6) are indications for emergency intervention. The type of emergency intervention needed for late hemorrhage is unpredictable. Radiological intervention is preferred, but if it fails, immediate change to surgical treatment is mandatory. This can be difficult to manage but possible when both radiological and surgical interventions are in close proximity such as in a hybrid operating room and should be considered in the emergency management of patients with late hemorrhage.

The American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator Does Not Accurately Predict Risk of 30-Day Complications Among Patients Undergoing Microvascular Head and Neck Reconstruction.

PubMed

Arce, Kevin; Moore, Eric J; Lohse, Christine M; Reiland, Matthew D; Yetzer, Jacob G; Ettinger, Kyle S

2016-09-01

The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Surgical Risk Calculator (SRC) is a novel universal risk calculator designed to aid in risk stratification of patients undergoing various types of major surgery. The purpose of this study was to assess the validity of the ACS NSQIP SRC in predicting postoperative complications in patients undergoing microvascular head and neck reconstruction. A retrospective cohort study of patients undergoing head and neck microvascular reconstruction with fibular free flaps at a single institution was completed. The NSQIP SRC was used to compute complication risk estimates and length of stay (LOS) estimates for all patients under study. Associations between complication risk estimates generated by the SRC and actual rates of observed complications were evaluated using logistic regression models. Logistic regression models also were used to evaluate the SRC estimates for LOS duration compared with the actual observed LOS after surgery. Of 153 patients under study, 46 (30%) developed a postoperative complication corresponding to those defined by NSQIP SRC. Thirty-eight patients (25%) developed a postoperative complication categorized as severe in the parameters of the NSQIP SRC. None of the SRC complication estimates showed a statistically relevant association with the corresponding observed rates of complications. The mean LOS predicted by the SRC was 8.0 days (median, 7.5 days; interquartile range [IQR], 6.5 to 9; range, 5.0 to 18.5 days). The mean observed LOS for the study group was 9.6 days (median, 7.0 days; IQR, 6 to 9; range, 5 to 67 days). Lin's (Biometrics 45:255, 1989) concordance correlation coefficient to measure agreement between observed and predicted LOS was 0.10, indicating only slight agreement between the 2 values. The ACS NSQIP SRC is not a useful risk-stratifying metric for patients undergoing major head and neck reconstruction with microvascular fibular free flaps. The SRC also does not accurately predict hospital LOS for this same patient cohort. Copyright © 2016 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.

Effects of a minor surgery on health related quality of life in children from different perspectives

PubMed

Brazo-Sayavera, Javier; Parejo-Cabezas, Inés M; Gusi, Narcís; Olivares, Pedro R

2018-01-01

To compare the health related quality of life (HRQoL) perceptions in parents and physician regarding the patient undergoing ambulatory surgery, and to analyse the evolution of HRQoL before and after the ambulatory surgery. 36 patients underwent ambulatory surgical interventions taken part in this study. The questionnaires EQ-5D-Y were administered to the patients and questionnaires EQ-5D-Y proxy to parents and physicians. Variable TTO was used. Statistical differences were found at baseline between answers of patients and physicians (p < 0.05). However, after surgery, answers of patients and proxies were similar. Paediatric patients undergone to a minor surgery improve HRQoL after the operation and this improvement goes on a month after the surgery. Copyright: © 2018 SecretarÍa de Salud

Effect of amiodarone-induced hyperthyroidism on left ventricular outflow obstruction after septal myectomy for hypertrophic cardiomyopathy.

PubMed

Pokorney, Sean D; Stone, Neil J; Passman, Rod; Oyer, David; Rigolin, Vera H; Bonow, Robert O

2010-12-01

Patients with obstructive hypertrophic cardiomyopathy who undergo septal myectomy are at risk for developing postoperative atrial fibrillation. Amiodarone is effective in treating this arrhythmia but is associated with multiple adverse effects, often with delayed onset. A novel case is described of a patient who developed type 2 amiodarone-induced hyperthyroidism that presented as recurrence of outflow obstruction after septal myectomy. The patient's symptoms and echocardiographic findings of outflow obstruction resolved substantially with the treatment of the amiodarone-induced hyperthyroidism. Amiodarone-induced hyperthyroidism of delayed onset can be a subtle diagnosis, requiring a high index of suspicion. In conclusion, recognition of this diagnosis in patients with recurrence of outflow obstruction by symptoms and cardiac imaging after septal myectomy may avoid unnecessary repeat surgical intervention. Copyright © 2010 Elsevier Inc. All rights reserved.

Dental Management of a Pediatric Patient with Moyamoya Syndrome: A Rare Clinical Entity.

PubMed

Ko, Brittany L; Unkel, John H

2018-01-01

Moyamoya disease (MMD) is a rare cerebrovascular disorder involving progressive constriction of the internal carotid artery and its branches. The disease has a particularly aggressive course in very young patients, and early surgical intervention is often necessary to prevent permanent neurological damage. MMD patients have an increased risk of stroke development, which may be provoked by pain or anxiety. Currently, no reports of pediatric patients with MMD exist in the dental literature. The purpose of this paper was to discuss the dental management of a two-year-old with moyamoya disease who presented with early childhood caries and dental fear, offering recommendations for dental providers with emphasis on stroke prevention, collaboration with the medical team, anesthesia considerations for patients with increased stroke risk, and the challenges to maintain the oral health of a patient undergoing complex medical treatment.

Postoperative Complications of Total Joint Arthroplasty in Obese Patients Stratified by BMI.

PubMed

Zusmanovich, Mikhail; Kester, Benjamin S; Schwarzkopf, Ran

2018-03-01

High body mass index (BMI) is associated with significant complications in patients undergoing total joint arthroplasty. Many studies have evaluated this trend, but few have looked at the rates of complications based on BMI as a continuous variable. The purpose of this study was to stratify obese patients into 3 BMI categories and evaluate their rates of complications and gauge whether transitioning from higher to lower BMI category lowers complication. Patients undergoing primary total joint arthroplasty were selected from the National Surgical Quality Improvement Program database from 2008-2015 and arranged into 3 groups based on BMI: O1 (BMI 30-34.9 kg/m 2 ), O2 (BMI 35-39.9 kg/m 2 ), and O3 (BMI >40 kg/m 2 ). Thirty-day complications were recorded and evaluated utilizing univariate and multivariate analyses stratified by BMI. A total of 268,663 patients were identified. Patients with a BMI >30 kg/m 2 had more infectious and medical complications compared with nonobese patients. Furthermore, there were increased complications as the BMI categories increased. Patients with a BMI >40 kg/m 2 (O3) had longer operating times, length of stay, higher rates of readmissions, reoperations, deep venous thrombosis, renal insufficiency, superficial infections, deep infections, and wound dehiscence. These trends were present when comparing the O2 with O1 category as well. We have demonstrated increased rates of medical and surgical complications in obese patients. Furthermore, we demonstrated a stepwise increase in complication rates when transitioning to higher BMI groups. Based on our data, we believe that preoperative counseling and interventions to decrease BMI should be explored before offering elective surgery to obese patients. Copyright © 2017 Elsevier Inc. All rights reserved.

Cost-effectiveness of preoperative nasal mupirocin treatment in preventing surgical site infection in patients undergoing total hip and knee arthroplasty: a cost-effectiveness analysis.

PubMed

Courville, Xan F; Tomek, Ivan M; Kirkland, Kathryn B; Birhle, Marian; Kantor, Stephen R; Finlayson, Samuel R G

2012-02-01

To perform a cost-effectiveness analysis to evaluate preoperative use of mupirocin in patients with total joint arthroplasty (TJA). Simple decision tree model. Outpatient TJA clinical setting. Hypothetical cohort of patients with TJA. A simple decision tree model compared 3 strategies in a hypothetical cohort of patients with TJA: (1) obtaining preoperative screening cultures for all patients, followed by administration of mupirocin to patients with cultures positive for Staphylococcus aureus; (2) providing empirical preoperative treatment with mupirocin for all patients without screening; and (3) providing no preoperative treatment or screening. We assessed the costs and benefits over a 1-year period. Data inputs were obtained from a literature review and from our institution's internal data. Utilities were measured in quality-adjusted life-years, and costs were measured in 2005 US dollars. Incremental cost-effectiveness ratio. The treat-all and screen-and-treat strategies both had lower costs and greater benefits, compared with the no-treatment strategy. Sensitivity analysis revealed that this result is stable even if the cost of mupirocin was over $100 and the cost of SSI ranged between $26,000 and $250,000. Treating all patients remains the best strategy when the prevalence of S. aureus carriers and surgical site infection is varied across plausible values as well as when the prevalence of mupirocin-resistant strains is high. Empirical treatment with mupirocin ointment or use of a screen-and-treat strategy before TJA is performed is a simple, safe, and cost-effective intervention that can reduce the risk of SSI. S. aureus decolonization with nasal mupirocin for patients undergoing TJA should be considered. Level II, economic and decision analysis.

Incidence and risk factors for preoperative deep venous thrombosis in 314 consecutive patients undergoing surgery for spinal metastasis.

PubMed

Zacharia, Brad E; Kahn, Sweena; Bander, Evan D; Cederquist, Gustav Y; Cope, William P; McLaughlin, Lily; Hijazi, Alexa; Reiner, Anne S; Laufer, Ilya; Bilsky, Mark

2017-08-01

OBJECTIVE The authors of this study aimed to identify the incidence of and risk factors for preoperative deep venous thrombosis (DVT) in patients undergoing surgical treatment for spinal metastases. METHODS Univariate analysis of patient age, sex, ethnicity, laboratory values, comorbidities, preoperative ambulatory status, histopathological classification, spinal level, and surgical details was performed. Factors significantly associated with DVT univariately were entered into a multivariate logistic regression model. RESULTS The authors identified 314 patients, of whom 232 (73.9%) were screened preoperatively for a DVT. Of those screened, 22 (9.48%) were diagnosed with a DVT. The screened patients were older (median 62 vs 55 years, p = 0.0008), but otherwise similar in baseline characteristics. Nonambulatory status, previous history of DVT, lower partial thromboplastin time, and lower hemoglobin level were statistically significant and independent factors associated with positive results of screening for a DVT. Results of screening were positive in only 6.4% of ambulatory patients in contrast to 24.4% of nonambulatory patients, yielding an odds ratio of 4.73 (95% CI 1.88-11.90). All of the patients who had positive screening results underwent preoperative placement of an inferior vena cava filter. CONCLUSIONS Patients requiring surgery for spinal metastases represent a population with unique risks for venous thromboembolism. This study showed a 9.48% incidence of DVT in patients screened preoperatively. The highest rates of preoperative DVT were identified in nonambulatory patients, who were found to have a 4-fold increase in the likelihood of harboring a DVT. Understanding the preoperative thrombotic status may provide an opportunity for early intervention and risk stratification in this critically ill population.

Outcome of patients undergoing open heart surgery at the Uganda heart institute, Mulago hospital complex.

PubMed

Aliku, Twalib O; Lubega, Sulaiman; Lwabi, Peter; Oketcho, Michael; Omagino, John O; Mwambu, Tom

2014-12-01

Heart disease is a disabling condition and necessary surgical intervention is often lacking in many developing countries. Training of the superspecialties abroad is largely limited to observation with little or no opportunity for hands on experience. An approach in which open heart surgeries are conducted locally by visiting teams enabling skills transfer to the local team and helps build to build capacity has been adopted at the Uganda Heart Institute (UHI). We reviewed the progress of open heart surgery at the UHI and evaluated the postoperative outcomes and challenges faced in conducting open heart surgery in a developing country. Medical records of patients undergoing open heart surgery at the UHI from October 2007 to June 2012 were reviewed. A total of 124 patients underwent open heart surgery during the study period. The commonest conditions were: venticular septal defects (VSDs) 34.7% (43/124), Atrial septal defects (ASDs) 34.7% (43/124) and tetralogy of fallot (TOF) in 10.5% (13/124). Non governmental organizations (NGOs) funded 96.8% (120/124) of the operations, and in only 4 patients (3.2%) families paid for the surgeries. There was increasing complexity in cases operated upon from predominantly ASDs and VSDs at the beginning to more complex cases like TOFs and TAPVR. The local team independently operated 19 patients (15.3%). Postoperative morbidity was low with arrhythmias, left ventricular dysfunction and re-operations being the commonest seen. Post operative sepsis occurred in only 2 cases (1.6%). The overall mortality rate was 3.2. Open heart surgery though expensive is feasible in a developing country. With increased direct funding from governments and local charities to support open heart surgeries, more cardiac patients access surgical treatment locally.

Perforated peptic ulcer in South India: an institutional perspective.

PubMed

Arveen, Sankar; Jagdish, Sadasivan; Kadambari, Dharanipragada

2009-08-01

Perforated peptic ulcer is one of the most common surgical emergencies in South India. The advent of medical therapy for peptic ulcer has remarkably decreased the number of elective surgical procedures. The incidence of perforated peptic ulcer on the contrary, is increasing. The high incidence of complications necessitates the identification of factors associated with the morbidity and mortality of patients undergoing surgery for perforated peptic ulcer. Three hundred twenty-eight consecutive patients (299 men and 29 women) who underwent surgery for perforated peptic ulcer in our institute between November 2006 and June 2008 were studied prospectively. The mean age was 43.4 +/- 14.4 years. The mean hospital stay was 10.9 +/- 6.8 days. Of the 328 patients, 58 presented with shock, 159 presented with delay more than 24 h, and 24 had co-morbid illness. Wound infection and intra-abdominal abscess were encountered in 12.5% and 13.4% of the patients, respectively. Altogether, 85 patients had postoperative complications. Twenty-eight (8.5%) patients died. The mortality rate among men and women was 7.9% and 20.7%, respectively. Age > or = 60 years, lag period longer than 24 h, presence of co-morbid illness, and shock at presentation were identified as independent predictors of postoperative complications. Shock at presentation, presence of co-morbid illness, American Society of Anesthesiologists (ASA) grade III or more, and renal failure were identified as independent predictors of mortality. Decreasing the delay in intervention and improving access to medical care may improve the outcome of patients undergoing surgery for perforated peptic ulcer. High-risk patients are those who present with shock and co-morbid illness.

What are estimated reimbursements for lower extremity prostheses capable of surgical and nonsurgical lengthening?

PubMed

Henderson, Eric R; Pepper, Andrew M; Letson, G Douglas

2012-04-01

Growing prostheses accommodate skeletally immature patients with bone tumors undergoing limb-preserving surgery. Early devices required surgical procedures for lengthening; recent devices lengthen without surgery. Expenses for newer expandable devices that lengthen without surgery are more than for their predecessors but overall reimbursement amounts are not known. We sought to determine reimbursement amounts associated with lengthening of growing prostheses requiring surgical and nonsurgical lengthening. We retrospectively reviewed 17 patients with growing prostheses requiring surgical expansion and eight patients with prostheses capable of nonsurgical expansion. Insurance documents were reviewed to determine the reimbursement for implantation, lengthening, and complications. Growth data were obtained from the literature. Mean reimbursement amounts of surgical and nonsurgical lengthenings were $9950 and $272, respectively. Estimated reimbursements associated with implantation of a growing prosthesis varied depending on age, sex, and location. The largest difference was found for 4-year-old boys with distal femoral replacement where reimbursement for expansion to maturity for surgical and nonsurgical lengthening prostheses would be $379,000 and $208,000, respectively. For children requiring more than one surgical expansion, net reimbursements were lower when a noninvasive lengthening device was used. Annual per-prosthesis maintenance reimbursements to address complications for surgical and nonsurgical lengthening prostheses were $3386 and $1856, respectively. This study showed that reimbursements for lengthening of growing endoprostheses capable of nonsurgical expansion may be less expensive in younger patients, particularly male patients undergoing distal femur replacement, than endoprostheses requiring surgical lengthening. Longer outcomes studies are required to see if reimbursements for complications differ between devices. Level III, economic and decision analysis. See the Guidelines for Authors for a complete description of levels of evidence.

ANALYSIS OF SURGICAL SITE INFECTIONS IN PEDIATRIC PATIENTS AFTER ORTHOPEDIC SURGERY: A CASE-CONTROL STUDY

PubMed Central

Chagas, Mariana de Queiroz Leite; Costa, Ana Maria Magalhães; Mendes, Pedro Henrique Barros; Gomes, Saint Clair

2017-01-01

ABSTRACT Objectives: To describe the rate of surgical site infections in children undergoing orthopedic surgery in centers of excellence and analyze the patients’ profiles. Methods: Medical records of pediatric patients undergoing orthopedic surgery in the Jamil Haddad National Institute of Traumatology and Orthopedics from January 2012 to December 2013 were analyzed and monitored for one year. Patients diagnosed with surgical site infection were matched with patients without infection by age, date of admission, field of orthopedic surgery and type of surgical procedure. Patient, surgical and follow-up variables were examined. Descriptive, bivariate and correspondence analyses were performed to evaluate the patients’ profiles. Results: 347 surgeries and 10 surgical site infections (2.88%) were identified. There was association of infections with age - odds ratio (OR) 11.5 (confidence interval - 95%CI 1.41-94.9) -, implant - OR 7.3 (95%CI 1.46-36.3) -, preoperative period - OR 9.8 (95%CI 1.83-53.0), and length of hospitalization - OR 20.6 (95%CI 3.7-114.2). The correspondence analysis correlated the infection and preoperative period, weight, weight Z-score, age, implant, type of surgical procedure, and length of hospitalization. Average time to diagnosis of infection occurred 26.5±111.46 days after surgery. Conclusions: The rate of surgical site infection was 2.88%, while higher in children over 24 months of age who underwent surgical implant procedures and had longer preoperative periods and lengths of hospitalization. This study identified variables for the epidemiological surveillance of these events in children. Available databases and appropriate analysis methods are essential to monitor and improve the quality of care offered to the pediatric population. PMID:28977312

Delaying Surgical Treatment of Penile Fracture Results in Poor Functional Outcomes: Results from a Large Retrospective Multicenter European Study.

PubMed

Bozzini, Giorgio; Albersen, Maarten; Otero, Javier Romero; Margreiter, Markus; Cruz, Eduard Garcia; Mueller, Alexander; Gratzke, Christian; Serefoglu, Ege Can; Salamanca, Juan Ignacio Martinez; Verze, Paolo

2018-01-01

Penile fracture is a rare clinical entity that represents a urologic emergency. It involves traumatic rupture of the tunica albuginea of the corpora cavernosa due to twisting or bending of the penile shaft during erection. To determine the differences in preoperative diagnostic evaluation patterns and outcomes of penile fracture patients to investigate the impact of surgical delay on functional outcomes. A retrospective analysis was performed using data obtained from 137 patients presenting with penile fracture at seven different European academic medical centers between 1996 and 2013. Age, imaging modalities used, timing of surgical intervention, length of tunica albuginea defect, and surgical technique were recorded. Postoperative erectile function outcomes were assessed with the International Index of Erectile Function (IIEF-5), and the presence of postoperative penile curvature was noted. The association between timing of surgical intervention and postoperative IIEF-5 results was evaluated with discriminant function analysis. The median age of the patients was 34.50 yr (interquartile range [IQR]: 28.0-46.5 yr). Of the 137 patients, 82 (59.85%) underwent penile Doppler ultrasound, and 5 patients (3.64%) were evaluated with magnetic resonance imaging. All patients were treated surgically, and the duration between emergency room admission and surgical intervention was 5.0h (IQR: 3.6-8.0h). The median length of tunica albuginea defect was 10mm (IQR: 8-20mm). Postoperative IIEF-5 scores were 21 (IQR: 12-23) and 23 (IQR: 15-24) at the first and third postoperative months, respectively. Discriminant function analysis revealed that if the surgical intervention was performed >8.23hours after emergency room admission, postoperative erectile function was significantly worse (p=0.0051 at first month and p=0.0057 at third month postoperatively). Our multicenter study showed that delaying surgical intervention results in significantly impaired erectile function. Surgical treatment must be planned as soon as possible to avoid postoperative erectile dysfunction. We looked at sexual outcomes following the repair of penile fracture in a large European population. We found that outcomes worsened if surgical repair was delayed. Copyright © 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Randomized Controlled Trial of a Special Acupuncture Technique for Pain after Thoracotomy

PubMed Central

Deng, Gary; Rusch, Valerie; Vickers, Andrew; Malhortra, Vivek; Ginex, Pamela; Downey, Robert; Bains, Manjit; Park, Bernard; Rizk, Nabil; Flores, Raja; Yeung, Simon; Cassileth, Barrie

2009-01-01

Objective To determine whether an acupuncture technique specially developed for a surgical oncology population (intervention) reduces pain or analgesic use after thoracotomy compared to a sham acupuncture technique (control). Methods One hundred and sixty two cancer patients undergoing thoracotomy were randomized to group A) preoperative implantation of small intradermal needles which were retained for 4 weeks or B) preoperative placement of sham needles at the same schedule. Numerical Rating Scale (NRS) of pain and total opioid use we evaluated during the in-patient stay; Brief Pain Inventory (BPI) and Medication Quantification Scale (MQS) were evaluated after discharge up to 3 months after the surgery. Results The principal analysis, a comparison of BPI pain intensity scores at the 30 day follow-up, showed no significant difference between the intervention and control group. Pain scores were marginally higher in the intervention group 0.05 (95% C.I.: 0.74, -0.64; p=0.9). There were also no statistically significant differences between groups for secondary endpoints, including chronic pain assessments at 60 and 90 days, in-patient pain, and medication use in hospital and after discharge. Conclusion A special acupuncture technique as provided in this study did not reduce pain or use of pain medication after thoracotomy more than a sham technique. PMID:19114190

Equipment for surgical interventions and childbirth in weightlessness

NASA Astrophysics Data System (ADS)

Mutke, H. G.

A transparent plastic sack has been devised for surgical interventions in space. Fixed airtight on the patient, containing sterilized medical equipment and comprising long sleeves for the operations, it retains all its contents for the rest of the flight.

How to write a surgical clinical research protocol: literature review and practical guide.

PubMed

Rosenthal, Rachel; Schäfer, Juliane; Briel, Matthias; Bucher, Heiner C; Oertli, Daniel; Dell-Kuster, Salome

2014-02-01

The study protocol is the core document of every clinical research project. Clinical research in studies involving surgical interventions presents some specific challenges, which need to be accounted for and described in the study protocol. The aim of this review is to provide a practical guide for developing a clinical study protocol for surgical interventions with a focus on methodologic issues. On the basis of an in-depth literature search of methodologic literature and on some cardinal published surgical trials and observational studies, the authors provides a 10-step guide for developing a clinical study protocol in surgery. This practical guide outlines key methodologic issues important when planning an ethically and scientifically sound research project involving surgical interventions, with the ultimate goal of providing high-level evidence relevant for health care decision making in surgery. Copyright © 2014 Elsevier Inc. All rights reserved.

Etiology of Readmissions Following Orthopaedic Procedures and Medical Admissions. A Comparative Analysis.

PubMed

Maslow, Jed; Hutzler, Lorraine; Slover, James; Bosco, Joseph

2015-12-01

The Federal Government, the largest payer of health care, considers readmission within 30 days of discharge an indicator of quality of care. Many studies have focused on causes for and strategies to reduce readmissions following medical admissions. However, few studies have focused on the differences between them. We believe that the causes for readmission following orthopaedic surgery are markedly different than those following medical admissions, and therefore, the strategies developed to reduce medical readmissions will not be as effective in reducing readmissions after elective orthopaedic surgery. All unplanned 30-day readmissions following an index hospitalization for an elective orthopaedic procedure (primary and revision total joint arthroplasty and spine procedure) or for one of the three publicly reported medical conditions (AMI, HF, and pneumonia, which accounted for 11% of readmissions) were identified at our institution from 2010 through 2012. A total of 268 patients and 390 medical patients were identified as having an unplanned 30-day readmission. We reviewed a prospectively collected data base to determine the reason for readmission in each encounter. A total of 233 (86.9%) orthopaedic patients were readmitted for surgical complications, most commonly for a wound infection (56.0%) or wound complication (11.6%). Following an index admission of HF or AMI, the primary reason for readmission was a disease of the circulatory system (55.9% and 57.4%, respectively). Following an index admission for pneumonia, the primary reason for readmission was a disease of the respiratory system (34.5%). The causes of readmissions following orthopaedic surgery and medical admissions are different. Patients undergoing orthopaedic procedures are readmitted for surgical complications, frequently unrelated to aftercare, and medicine patients are readmitted for reasons related to the index diagnosis. Interventions designed to reduce orthopaedic readmissions must focus on reducing surgical complications, differing from interventions designed to reduce readmissions following medical admissions, which focus on medical diagnoses.

The Surgical Treatments Outcomes Project for Dysfunctional Uterine Bleeding: summary of an Agency for Health Research and Quality-sponsored randomized trial of endometrial ablation versus hysterectomy for women with heavy menstrual bleeding.

PubMed

Munro, Malcolm G; Dickersin, Kay; Clark, Melissa A; Langenberg, Patricia; Scherer, Roberta W; Frick, Kevin D

2011-04-01

Surgical Treatments Outcomes Project for Dysfunctional Uterine Bleeding is an agency for the Healthcare Research and Quality project built around a multicenter randomized clinical trial comparing hysterectomy and endometrial ablation (EA) for the treatment of heavy menstrual bleeding unrelated to structural causes. For inclusion, women self-defined their complaint, and the endometrial cavity was evaluated to exclude structural lesions. The primary outcomes were bleeding and major problem "solved" at 24 months, with length of institutional stay, surgical complications, quality of life, and reoperation included as secondary outcomes. Also measured was the baseline economic impact of heavy menstrual bleeding. The randomized controlled trial enrolled 237 women. Institutional stay was longer, and perioperative adverse events were more common and severe for those randomized to hysterectomy. At 24 months, 94.4% and 84.9% of women randomized to hysterectomy and EA, respectively, considered their major problem to be solved; at 48 months, the numbers were similar at 98.0% and 85.1%. Postprocedure quality-of-life measures (SF-36, EuroQOL) improved similarly in both groups, but reoperation was more common for women undergoing EA (34, or 30.9%, at 60 mo), with most (32 of 34) selecting hysterectomy.At baseline, women reported missed work as well as activity and leisure limitations. Excess monetary costs were $306 per patient-year (95% CI, $30-$1,872). Excess work and home management loss costs were $2,152 (95% CI, $1,862-$2,479). It was estimated that successful treatment, regardless of the type of intervention, could result in a gain of 1.8 quality-adjusted life years. Future studies will examine and compare the impact of the study interventions on economic outcomes. © 2011 by The North American Menopause Society

[Hysterectomies at the Conakry university hospitals: social, demographic, and clinical characteristics, types, indications, surgical approaches, and prognosis].

PubMed

Baldé, I S; Sy, T; Diallo, B S; Diallo, Y; Mamy, M N; Diallo, M H; Bah, E M; Diallo, T S; Keita, N

2014-01-01

The objectives of this study were to calculate the frequency of hysterectomies at the Conakry university hospitals (Donka Hospital and Ignace Deen Hospital), describe the women's social, demographic, and clinical characteristics, and identify the key indications, the surgical techniques used, and the prognosis. This was a 2-year descriptive study, retrospective for the first year (May 2011-April 2012) and prospective for the second (May 2012-April 2013), of 333 consecutive hysterectomies performed in the obstetrics and gynecology departments of these two hospitals. Hysterectomy is one of the surgical procedures most commonly performed in these departments (following cesarean deliveries), with frequency of 4.4% interventions. The profile of the women undergoing this surgery was that of a woman aged younger than 49 years (61%), married (75.7%), multiparous (33%), of childbearing age (61%), and with no history of abdominal or pelvic surgery (79.6%). Nearly all hysterectomies were total (95%, compared with 5% subtotal; the approach was abdominal in 82.25% of procedures and vaginal in 17.75%. The most common indication for surgery was uterine fibroids (39.6%), followed by genital prolapse (22.2%), and obstetric emergencies (17.8%). The average duration of surgery was 96 minutes for abdominal and 55 minutes for vaginal hysterectomies. The principal intraoperative complication was hemorrhage (12.31%), and the main postoperative complication parietal suppuration (21.02%). The average length of hospital stay was 10.3 days for abdominal hysterectomies and 7.15 days for vaginal procedures. We recorded 14 deaths for a lethality rate of 4.2%; most of these deaths were associated with hemorrhagic shock during or after an obstetric hysterectomy (93%). Hysterectomy remains a common intervention in developing countries. Its indications are common during the pregnancy and postpartum period, with high morbidity and mortality rates. Improving obstetric coverage could reduce its indications.

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.

Using the Consolidated Framework for Implementation Research to implement and evaluate national surgical planning

PubMed Central

Saluja, Saurabh; Silverstein, Allison; Mukhopadhyay, Swagoto; Lin, Yihan; Raykar, Nakul; Keshavjee, Salmaan; Samad, Lubna; Meara, John G

2017-01-01

The Lancet Commission on Global Surgery defined six surgical indicators and a framework for a national surgical plan that aimed to incorporate surgical care as a part of global public health. Multiple countries have since begun national surgical planning; each faces unique challenges in doing so. Implementation science can be used to more systematically explain this heterogeneous process, guide implementation efforts and ultimately evaluate progress. We describe our intervention using the Consolidated Framework for Implementation Research. This framework requires identifying characteristics of the intervention, the individuals involved, the inner and outer setting of the intervention, and finally describing implementation processes. By hosting a consultative symposium with clinicians and policy makers from around the world, we are able to specify key aspects of each element of this framework. We define our intervention as the incorporation of surgical care into public health planning, identify local champions as the key individuals involved, and describe elements of the inner and outer settings. Ultimately we describe top-down and bottom-up models that are distinct implementation processes. With the Consolidated Framework for Implementation Research, we are able to identify specific strategic models that can be used by implementers in various settings. While the integration of surgical care into public health throughout the world may seem like an insurmountable challenge, this work adds to a growing effort that seeks to find a way forward. PMID:29225930

Reasons for and Experiences With Surgical Interventions for Female Genital Mutilation/Cutting (FGM/C): A Systematic Review.

PubMed

Berg, Rigmor C; Taraldsen, Sølvi; Said, Maryan A; Sørbye, Ingvil Krarup; Vangen, Siri

2017-08-01

Because female genital mutilation/cutting (FGM/C) leads to changes in normal genital anatomy and functionality, women are increasingly seeking surgical interventions for their FGM/C-related concerns. To conduct a systematic review of empirical quantitative and qualitative research on interventions for women with FGM/C-related complications. We conducted systematic searches up to May 2016 in 16 databases to obtain references from different disciplines. We accepted all study designs consisting of girls and women who had been subjected to FGM/C and that examined a reparative intervention for a FGM/C-related concern. We screened the titles, abstracts, and full texts of retrieved records for relevance. Then, we assessed the methodologic quality of the included studies and extracted and synthesized the study data. All outcomes were included. Of 3,726 retrieved references, 71 studies including 7,291 women were eligible for inclusion. We identified three different types of surgical intervention: defibulation or surgical separation of fused labia, excision of a cyst with or without some form of reconstruction, and clitoral or clitoral-labial reconstruction. Reasons for seeking surgical interventions consisted of functional complaints, sexual aspirations, esthetic aspirations, and identity recovery. The most common reasons for defibulation were a desire for improved sexual pleasure, vaginal appearance, and functioning. For cyst excision, cystic swelling was the main reason for seeking excision; for reconstruction, the main reason was to recover identity. Data on women's experiences with a surgical intervention are sparse, but we found that women reported easier births after defibulation. Our findings also suggested that most women were satisfied with defibulation (overall satisfaction = 50-100%), typically because of improvements in their sexual lives. Conversely, the results suggested that defibulation had low social acceptance and that the procedure created distress in some women who disliked the new appearance of their genitalia. Most women were satisfied with clitoral reconstruction, but approximately one third were dissatisfied with or perceived a worsening in the esthetic look. The information health care professionals give to women who seek surgical interventions for FGM/C should detail the intervention options available and what women can realistically expect from such interventions. The systematic review was conducted in accordance with guidelines, but there is a slight possibility that studies were missed. There are some data on women's motivations for surgery for FGM/C-related concerns, but little is known about whether women are satisfied with the surgery, and experiences appear mixed. Berg RC, Taraldsen S, Said MA, et al. Reasons for and Experiences With Surgical Interventions for Female Genital Mutilation/Cutting (FGM/C): A Systematic Review. J Sex Med 2017;14:977-990. Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.

Cost effective management of duodenal ulcers in Uganda: interventions based on a series of seven cases.

PubMed

Nzarubara, Gabriel R

2005-03-01

Our understanding of the cause and treatment of peptic ulcer disease has changed dramatically over the last couple of decades. It was quite common some years ago to treat chronic ulcers surgically. These days, the operative treatment is restricted to the small proportion of ulcer patients who have complications such as perforation. The author reports seven cases of perforated duodenal ulcers seen in a surgical clinic between 1995 and 2001. Recommendations on the criteria for selecting the appropriate surgical intervention for patients with perforated duodenal ulcer are given. To decide on the appropriate surgical interventions for patients with perforated duodenal ulcer. These are case series of 7 patients who presented with perforated duodenal ulcers without a history of peptic ulcer disease. Seven patients presented with perforated duodenal ulcer 72 hours after perforation in a specialist surgical clinic in Kampala were analyzed. Appropriate management based on these patients is suggested. These patients were initially treated in upcountry clinics for acute gastritis from either alcohol consumption or suspected food poisoning. There was no duodenal ulcer history. As a result, they came to specialist surgical clinic more than 72 hours after perforation. Diagnosis of perforated duodenal ulcer was made and they were operated using the appropriate surgical intervention. Diagnosis of hangovers and acute gastritis from alcoholic consumption or suspected food poisoning should be treated with suspicion because the symptoms and signs may mimic perforated peptic ulcer in "silent" chronic ulcers. The final decision on the appropriate surgical intervention for patients with perforated duodenal ulcer stratifies them into two groups: The previously fit patients who have relatively mild physiological compromise imposed on previously healthy organ system by the perforation can withstand the operative stress of definitive procedure. The Second category includes patients who are critically ill, who poorly tolerate any operation and hence poor surgical risks. These require urgent, adequate resuscitation and simple suture with omental patch.

Institutional prescreening for detection and eradication of methicillin-resistant Staphylococcus aureus in patients undergoing elective orthopaedic surgery.

PubMed

Kim, David H; Spencer, Maureen; Davidson, Susan M; Li, Ling; Shaw, Jeremy D; Gulczynski, Diane; Hunter, David J; Martha, Juli F; Miley, Gerald B; Parazin, Stephen J; Dejoie, Pamela; Richmond, John C

2010-08-04

Surgical site infection has been identified as one of the most important preventable sources of morbidity and mortality associated with medical treatment. The purpose of the present study was to evaluate the feasibility and efficacy of an institutional prescreening program for the preoperative detection and eradication of both methicillin-resistant and methicillin-sensitive Staphylococcus aureus in patients undergoing elective orthopaedic surgery. Data were collected prospectively during a single-center study. A universal prescreening program, employing rapid polymerase chain reaction analysis of nasal swabs followed by an eradication protocol of intranasal mupirocin and chlorhexidine showers for identified carriers, was implemented. Surgical site infection rates were calculated and compared with a historical control period immediately preceding the start of the screening program. During the study period, 7019 of 7338 patients underwent preoperative screening before elective surgery, for a successful screening rate of 95.7%. One thousand five hundred and eighty-eight (22.6%) of the patients were identified as Staphylococcus aureus carriers, and 309 (4.4%) were identified as methicillin-resistant Staphylococcus aureus carriers. A significantly higher rate of surgical site infection was observed among methicillin-resistant Staphylococcus aureus carriers (0.97%; three of 309) compared with noncarriers (0.14%; seven of 5122) (p = 0.0162). Although a higher rate of surgical site infection was also observed among methicillin-sensitive Staphylococcus aureus carriers (0.19%; three of 1588) compared with noncarriers, this difference did not achieve significance (p = 0.709). Overall, thirteen cases of surgical site infection were identified during the study period, for an institutional infection rate of 0.19%. This rate was significantly lower than that observed during the control period (0.45%; twenty-four cases of surgical site infection among 5293 patients) (p = 0.0093). Implementation of an institution-wide prescreening program for the identification and eradication of methicillin-resistant and methicillin-sensitive Staphylococcus aureus carrier status among patients undergoing elective orthopaedic surgery is feasible and can lead to significant reductions in postoperative rates of surgical site infection. Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

Daily Physical Activity in Total Hip Arthroplasty Patients Undergoing Different Surgical Approaches: A Cohort Study.

PubMed

Engdal, Monika; Foss, Olav A; Taraldsen, Kristin; Husby, Vigdis S; Winther, Siri B

2017-07-01

Muscle weakness due to trauma from the surgical approach is anticipated to affect the ability of the patient to undertake daily physical activity early after total hip arthroplasty (THA). The objective of this study was to compare daily physical activity on days 1 to 4 after discharge, in patients following THA performed by 1 of 3 surgical approaches. A cohort study included 60 hip osteoarthritis patients, scheduled for THA, allocated to direct lateral approach, posterior approach, or anterior approach. Daily physical activity was measured by an accelerometer, with upright time per 24 hours as primary outcome and walking time, number of steps, and number of upright events per 24 hours as secondary outcomes. There were no statistically significant group differences in any of the measures of daily physical activity (P > 0.290) or between days of follow-up (P > 0.155). Overall, the median participant had 3.50 hours (interquartile range, 2.85-4.81 hours) of upright time, and participants showed wide variation in all outcomes of daily physical activity. There were no differences in daily physical activity between THA patients undergoing different surgical approaches. The surgical approach may not be a limiting factor for daily physical activity early after surgery in a fast-track treatment course.

The impact of obesity on 30-day complications in pediatric surgery.

PubMed

Train, A T; Cairo, S B; Meyers, H A; Harmon, C M; Rothstein, D H

2017-11-01

To examine the effects of obesity on specialty-specific surgical outcomes in children. Retrospective cohort study using the National Surgical Quality Improvement Program, Pediatric, 2012-2014. Patients included those aged 2-17 years who underwent a surgical procedure in one of six specialties. Obesity was the primary patient variable of interest. Outcomes of interest were postoperative complications and operative times. Odds ratios for development of postoperative complications were calculated using stepwise multivariate regression analysis. Obesity was associated with a significantly greater risk of wound complications (OR 1.24, 95% CI 1.13-1.36), but decreased risk of non-wound complications (OR 0.68, 95% CI 0.63-0.73) and morbidity (OR 0.79, 95% CI 0.75-0.84). Obesity was not a significant factor in predicting postoperative complications in patients undergoing otolaryngology or plastic surgery procedures. Anesthesia times and operative times were significantly longer for obese patients undergoing most types of pediatric surgical procedures. Obesity confers an increased risk of wound complications in some pediatric surgical specialties and is associated with overall decreased non-wound complications and morbidity. These findings suggest that the relationship between obesity and postoperative complications is complex and may be more dependent on underlying procedure- or specialty-related factors than previously suspected.

A comparison of piezosurgery and conventional surgery by heat shock protein 70 expression.

PubMed

Gülnahar, Y; Hüseyin Köşger, H; Tutar, Y

2013-04-01

The effects of mechanical instruments on the viability of cells are essential in terms of regeneration. There is considerable interest in cell repair following damage mediated by dental surgical procedures. Cells can tolerate stress by expressing heat shock protein 70 (Hsp70). During and after surgical tooth removal, oxidative stress can activate Hsp70 expression proportional to the intensity of the stress signal stimulus to cope with stress. This study examined the expression of Hsp70 as a potential biomarker of immediate postoperative stress in patients undergoing two different surgical procedures of different severity. Expression of Hsp70 both at mRNA and at protein level in the conventional group was two-fold higher than that of the piezo group. This suggests that tooth movement by the piezo method causes relatively lower stress in the alveolar bone. Piezosurgery provides relatively low stress to the patients and this may help cell repair after the surgical procedure. Patients undergoing more aggressive surgery using conventional methods showed a significant increase in Hsp70 in the immediate postoperative period. Therefore, Hsp70 induction can be a potential tool as a prognostic surgical marker. Copyright © 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

AN AUDIT OF THE CURRENT PRACTICES OF AIRWAY MANAGEMENT IN PATIENTS UNDERGOING SURGERY FOR ATLANTO-AXIAL DISLOCATION IN A SINGLE INSTITUTION.

PubMed

Redhu, Shruti; Radhakrishnan, M; Rao, G S Umamaheswara

2015-06-01

Patients with atlanto axial dislocation (AAD) undergo stabilisation procedures under general anesthesia. Airway management in these patients is difficult as cervical spine movements during laryngoscopy can worsen spinal cord damage. Though multiple airway devices are used to intubate the trachea of these patients, there is no evidence of superiority of one technique over another. This retrospective study was designed to audit the practice of airway management during surgery for AAD over a 5 year period, starting from 2006 till 2011. Patients' demographics, airway intervention techniques, types of surgical procedures, postoperative neurological and respiratory deterioration were recorded from the case files. Association between the types of airway interventions and the postoperative neurological and respiratory deterioration were analysed. One hundred and six patients underwent surgery for AAD during the study period. Sixty one percent of the patients were intubated with the help of a fiberoptic bronchoscope (FOB) and among them 15% received general anesthesia to facilitate FOB. Eighteen patients developed neurological deterioration and 15 patients developed respiratory weakness requiring ventilation postoperatively. Congenital AAD patients had higher chances for extubation at the end of surgery when intubated using FOB (p = 0.007). Among the AAD patients, female gender had significantly higher incidence of neurological deterioration compared to males. In the current audit, there was no correlation between the perioperative variables and postoperative respiratory and neurological deterioration. Most of the respiratory problems occurred between 2-5 postoperative days stressing the need for extended intensive postoperative monitoring of these patients.

Psychological and Social Factors in Undergoing Reconstructive Surgery Among Individuals With Craniofacial Conditions: An Exploratory Study

PubMed Central

Bemmels, Heather; Biesecker, Barbara; Schmidt, Johanna L.; Krokosky, Alyson; Guidotti, Rick; Sutton, Erica J.

2012-01-01

Objective Reconstructive surgery to improve psychological well-being is commonly offered to children with craniofacial conditions. Few studies have explored the challenges of reconstructive surgery beyond the physical risks: poor treatment outcomes, infection, brain damage, and death. This qualitative study aims to understand the psychological and social implications such interventions can have for individuals with craniofacial conditions. Design A total of 38 individuals between the ages of 12 and 61 with such craniofacial conditions as Sturge-Weber syndrome, Treacher Collins syndrome, Möbius syndrome, cleft lip and palate, Noonan syndrome, Crouzon syndrome, and amniotic band syndrome participated in semistructured video-recorded interviews. Participants were recruited at conferences, through study flyers, and by word of mouth. Descriptive, thematic analysis was used to identify themes related to reconstructive surgery. Results Dominant themes included undergoing surgery to reduce stigmatization, the psychological and social implications of the interventions, outcome satisfaction, parental involvement in decision making about surgery, and recommendations for parents considering surgery for their children with craniofacial conditions. Experiences with reconstructive surgery varied, with some participants expressing surgical benefits and others, disillusionment. Conclusions The range of participant attitudes and experiences reflect the complexity of reconstructive surgery. Pediatric health care teams involved in the care of children with craniofacial conditions play an important role in advising patients (and their parents) about existing treatment options. The psychological and social implications of reconstructive surgery should be relayed to help families weigh the risks and benefits of surgery in an informed and meaningful way. PMID:22315960

Development of a blunt chest injury care bundle: An integrative review.

PubMed

Kourouche, Sarah; Buckley, Thomas; Munroe, Belinda; Curtis, Kate

2018-06-01

Blunt chest injuries (BCI) are associated with high rates of morbidity and mortality. There are many interventions for BCI which may be able to be combined as a care bundle for improved and more consistent outcomes. To review and integrate the BCI management interventions to inform the development of a BCI care bundle. A structured search of the literature was conducted to identify studies evaluating interventions for patients with BCI. Databases MEDLINE, CINAHL, PubMed and Scopus were searched from 1990-April 2017. A two-step data extraction process was conducted using pre-defined data fields, including research quality indicators. Each study was appraised using a quality assessment tool, scored for level of evidence, then data collated into categories. Interventions were also assessed using the APEASE criteria then integrated to develop a BCI care bundle. Eighty-one articles were included in the final analysis. Interventions that improved BCI outcomes were grouped into three categories; respiratory intervention, analgesia and surgical intervention. Respiratory interventions included continuous positive airway pressure and high flow nasal oxygen. Analgesia interventions included regular multi-modal analgesia and paravertebral or epidural analgesia. Surgical fixation was supported for use in moderate to severe rib fractures/BCI. Interventions supported by evidence and that met APEASE criteria were combined into a BCI care bundle with four components: respiratory adjuncts, analgesia, complication prevention, and surgical fixation. The key components of a BCI care bundle are respiratory support, analgesia, complication prevention including chest physiotherapy and surgical fixation. Copyright © 2018 Elsevier Ltd. All rights reserved.

The Effectiveness of Group Spiritual Intervention on Self-esteem and Happiness among Men Undergoing Methadone Maintenance Treatment.

PubMed

Jalali, Amir; Behrouzi, Mahvash Kashkouli; Salari, Nader; Bazrafshan, Mohammad-Rafi; Rahmati, Mahmoud

2018-05-10

Drug dependence or substance use disorder not only affects a person's life but also brings a lot of challenges for families and communities and imposes heavy burdens on them. There are various therapies in the domain of addiction whose main purposes are to reduce or to cut down substance abuse. This study aimed to determine the effectiveness of group spiritual intervention on self-esteem and happiness among male clients undergoing methadone maintenance treatment. This study was an intervention study in which 60 clients affected with substance abuse and undergoing methadone maintenance treatment were recruited. The study samples were selected through convenience sampling method and then divided randomly into two groups of 30 individuals: intervention and control. The intervention group attended group spiritual interventions for 10 sessions. Self-esteem and happiness among the study participants were also measured through Coopersmith Self-Esteem Inventory and Oxford Happiness Questionnaire before and after the intervention. The results showed a significant difference between both intervention and control groups in terms of self-esteem and happiness (P˂0.05); so that the participants in the intervention group demonstrated a significant improvement in their self-esteem and happiness. It was concluded that group spiritual intervention as a useful method could be effective in enhancing self-esteem and happiness among addicted individuals undergoing methadone maintenance treatment. The given treatment could be also used as a complementary therapy beside methadone maintenance treatment to reduce the likelihood of people returning to substance abuse. Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.org.

General surgical complications associated with the use of long-term mechanical circulatory support devices: are we 'under-reporting' problems?

PubMed

Tchantchaleishvili, Vakhtang; Umakanthan, Ramanan; Karp, Seth; Stulak, John M; Keebler, Mary E; Maltais, Simon

2013-05-01

Multiple complications are associated with use of ventricular assist devices (VADs). Cardiac-related complications and infections are most frequently reported. VADs, however, can also lead to a number of general surgical complications equally significant in terms of morbidity and mortality. The authors performed a systematic literature search to review current data that specifically relate general surgical complications to patients who undergo left VAD implantation. The review provides a relatively clear understanding of the spectrum of general surgical complications and shows that they contribute significantly to morbidity and mortality in these patients.

Surgical smoke.

PubMed

Fan, Joe King-Man; Chan, Fion Siu-Yin; Chu, Kent-Man

2009-10-01

Surgical smoke is the gaseous by-product formed during surgical procedures. Most surgeons, operating theatre staff and administrators are unaware of its potential health risks. Surgical smoke is produced by various surgical instruments including those used in electrocautery, lasers, ultrasonic scalpels, high speed drills, burrs and saws. The potential risks include carbon monoxide toxicity to the patient undergoing a laparoscopic operation, pulmonary fibrosis induced by non-viable particles, and transmission of infectious diseases like human papilloma virus. Cytotoxicity and mutagenicity are other concerns. Minimisation of the production of surgical smoke and modification of any evacuation systems are possible solutions. In general, a surgical mask can provide more than 90% protection to exposure to surgical smoke; however, in most circumstances it cannot provide air-tight protection to the user. An at least N95 grade or equivalent respirator offers the best protection against surgical smoke, but whether such protection is necessary is currently unknown.

Using the Safer Clinical Systems approach and Model for Improvement methodology to decrease Venous Thrombo-Embolism in Elective Surgical Patients.

PubMed

Humphries, Angela; Peden, Carol; Jordan, Lesley; Crowe, Josephine; Peden, Carol

2016-01-01

A significant incidence of post-procedural deep vein thrombosis (DVT) and pulmonary embolus (PE) was identified in patients undergoing surgery at our hospital. Investigation showed an unreliable peri-operative process leading to patients receiving incorrect or missed venous thromboembolism (VTE) prophylaxis. The Trust had previously participated in a project funded by the Health Foundation using the "Safer Clinical Systems" methodology to assess, diagnose, appraise options, and implement interventions to improve a high risk medication pathway. We applied the methodology from that study to this cohort of patients demonstrating that the same approach could be applied in a different context. Interventions were linked to the greatest hazards and risks identified during the diagnostic phase. This showed that many surgical elective patients had no VTE risk assessment completed pre-operatively, leading to missed or delayed doses of VTE prophylaxis post-operatively. Collaborative work with stakeholders led to the development of a new process to ensure completion of the VTE risk assessment prior to surgery, which was implemented using the Model for Improvement methodology. The process was supported by the inclusion of a VTE check in the Sign Out element of the WHO Surgical Safety Checklist at the end of surgery, which also ensured that appropriate prophylaxis was prescribed. A standardised operation note including the post-operative VTE plan will be implemented in the near future. At the end of the project VTE risk assessments were completed for 100% of elective surgical patients on admission, compared with 40% in the baseline data. Baseline data also revealed that processes for chemical and mechanical prophylaxis were not reliable. Hospital wide interventions included standardisation of mechanical prophylaxis devices and anti-thromboembolic stockings (resulting in a cost saving of £52,000), and a Trust wide awareness and education programme. The education included increased emphasis on use of mechanical prophylaxis when chemical prophylaxis was contraindicated. VTE guidelines were also included in the existing junior Doctor guideline App. and a "CLOTS" anticoagulation webpage was developed and published on the hospital intranet. The improvement in VTE processes resulted in an 80% reduction in hospital associated thrombosis following surgery from 0.2% in January 2014 to 0.04% in December 2015 and a reduction in the number of all hospital associated VTE from a baseline median of 9 per month as of January 2014 to a median of 1 per month by December 2015.

The Effect of Live Classical Piano Music on the Vital Signs of Patients Undergoing Ophthalmic Surgery

PubMed Central

Camara, Jorge G.; Ruszkowski, Joseph M.; Worak, Sandra R.

2008-01-01

Context Music and surgery. Objective To determine the effect of live classical piano music on vital signs of patients undergoing ophthalmic surgery. Design Retrospective case series. Setting and Patients 203 patients who underwent various ophthalmologic procedures in a period during which a piano was present in the operating room of St. Francis Medical Center. [Note: St. Francis Medical Center has recently been renamed Hawaii Medical Center East.] Intervention Demographic data, surgical procedures, and the vital signs of 203 patients who underwent ophthalmic procedures were obtained from patient records. Blood pressure, heart rate, and respiratory rate measured in the preoperative holding area were compared with the same parameters taken in the operating room, with and without exposure to live piano music. A paired t-test was used for statistical analysis. Main outcome measure Mean arterial pressure, heart rate, and respiratory rate. Results 115 patients who were exposed to live piano music showed a statistically significant decrease in mean arterial blood pressure, heart rate, and respiratory rate in the operating room compared with their vital signs measured in the preoperative holding area (P < .0001). The control group of 88 patients not exposed to live piano music showed a statistically significant increase in mean arterial blood pressure (P < .0002) and heart rate and respiratory rate (P < .0001). Conclusion Live classical piano music lowered the blood pressure, heart rate, and respiratory rate in patients undergoing ophthalmic surgery. PMID:18679538

An environmental scan of advance care planning decision AIDS for patients undergoing major surgery: a study protocol.

PubMed

Aslakson, Rebecca A; Schuster, Anne L R; Miller, Judith; Weiss, Matthew; Volandes, Angelo E; Bridges, John F P

2014-01-01

Patients who undergo major surgery are at risk for perioperative morbidity and mortality. It would be appropriate to initiate advance care planning with patients prior to surgery, but surgeons may experience difficulty initiating such conversations. Rather than focus on changing clinician behavior, advance care planning decision aids can be an innovative vehicle to motivate advance care planning among surgical patients and their families. The purpose of this paper is to describe a study protocol for conducting an environmental scan concerning advance care planning decision aids that may be relevant to patients undergoing high-risk surgery. This study will gather information from written or verbal data sources that incorporate professional and lay perspectives: a systematic review, a grey literature review, key informant interviews, and patient and family engagement. It is envisioned that this study will generate three outcomes: a synthesis of current evidence, a summary of gaps in knowledge, and a taxonomy of existing advance care planning decision aids. This environmental scan will demonstrate principles of patient-centered outcomes research, and it will exemplify a pioneering approach for reviewing complex interventions. Anticipated limitations are that information will be gathered from a small sample of patients and families, and that potentially relevant information could also be missing from the environmental scan due to the inclusion/exclusion criteria. Outcomes from the environmental scan will inform future patient-centered research to develop and evaluate a new decision aid.

Short-Term Outcomes of Minimally Invasive Esophagectomy for Carcinoma In Patients with Liver Cirrhosis.

PubMed

Sozzi, Marco; Siboni, Stefano; Asti, Emanuele; Bonitta, Gianluca; Bonavina, Luigi

2017-06-01

Open esophagectomy is a high-risk procedure in patients with liver cirrhosis. With the advent of minimally invasive surgical techniques, the overall morbidity and mortality rates of esophagectomy have decreased. The aim of this study was to describe short-term outcomes of minimally invasive esophagectomy in patients with proven liver cirrhosis. Retrospective observational cohort study. Demographics, preoperative clinical characteristics, and outcomes of patients undergoing minimally invasive esophagectomy for carcinoma were analyzed. Patients with concomitant liver cirrhosis were compared to patients without liver cirrhosis undergoing similar surgical procedures. In addition, variables possibly associated with postoperative morbidity and mortality in patients with cirrhosis were investigated. Out of 443 patients undergoing minimally invasive esophagectomy, 18 (4.1%) had concomitant liver cirrhosis. Demographics and preoperative clinical variables were similar in the 2 patient groups. While the overall morbidity rate was similar, the 90-day mortality rate was significantly higher in patients with liver cirrhosis (P = .023). There was a significantly higher rate of sepsis and anastomotic, respiratory, and hemorrhagic complications in patients with liver cirrhosis who died in the postoperative period. Minimally invasive esophagectomy is feasible in patients with liver cirrhosis. Future strategies should focus on total minimally invasive procedures and early recognition of surgical complications.

Non-cardiac surgery in patients with prosthetic heart valves: a 12 years experience.

PubMed

Akhtar, Raja Parvez; Abid, Abdul Rehman; Zafar, Hasnain; Gardezi, Syed Javed Raza; Waheed, Abdul; Khan, Jawad Sajid

2007-10-01

To study patients with mechanical heart valves undergoing non-cardiac surgery and their anticoagulation management during these procedures. It was a cohort study. The study was conducted at the Department of Cardiac Surgery, Punjab Institute of Cardiology, Lahore and Department of Surgery, Services Institute of Medical Sciences, Lahore, from September 1994 to June 2006. Patients with mechanical heart valves undergoing non-cardiac surgical operation during this period, were included. Their anticoagulation was monitored and anticoagulation related complications were recorded. In this study, 507 consecutive patients with a mechanical heart valve replacement were followed-up. Forty two (8.28%) patients underwent non-cardiac surgical operations of which 24 (57.1%) were for abdominal and non-abdominal surgeries, 5 (20.8%) were emergency and 19 (79.2%) were planned. There were 18 (42.9%) caesarean sections for pregnancies. Among the 24 procedures, there were 7(29.1%) laparotomies, 7(29.1%) hernia repairs, 2 (8.3%) cholecystectomies, 2 (8.3%) hysterectomies, 1(4.1%) craniotomy, 1(4.1%) spinal surgery for neuroblastoma, 1(4.1%) ankle fracture and 1(4.1%) carbuncle. No untoward valve or anticoagulation related complication was seen during this period. Patients with mechanical valve prosthesis on life-long anticoagulation, if managed properly, can undergo any type of non-cardiac surgical operation with minimal risk.

[Post-surgical morbidity in paediatric patients undergoing surgery for congenital heart disease in the UMAE of Yucatan, Mexico].

PubMed

Castillo-Espínola, Addy; Velázquez-Ibarra, Ana; Zetina-Solórzano, Aurea; Bolado-García, Patricia; Gamboa-López, Gonzalo

To describe the clinical course of paediatric patients undergoing surgery for congenital heart disease in UMAE of Yucatan. Descriptive review was performed on the records of paediatric patients undergoing surgery for congenital heart disease from 1 November 2011 to 30 November 2013. The most frequent heart diseases were persistent ductus arteriosus (37.6%) and transposition of the great vessels. The median intensive care stay was 3 days. Mortality was 11.76%, with septic shock (44.4%) in most cases. The most frequent complications were sepsis (5.9%), low cardiac output syndrome (4.7%), cardiac arrest, and AV block and ventricular tachycardia (2.4% each). There was a moderate positive correlation between surgical complications and survival or death. The number of surgical patients is lower compared to reference centres for cardiovascular surgery. There is a marked tendency to perform corrective and palliative surgeries in specific disease in patients with added risk or 'bad' cardiac anatomy that prevent full correction at the first attempt. Prospective epidemiological and clinical studies should be conducted to understand the behaviour of congenital heart diseases treated in the region. Copyright © 2016 Instituto Nacional de Cardiología Ignacio Chávez. Publicado por Masson Doyma México S.A. All rights reserved.

Integrating surgery and genetic testing for the modern surgeon.

PubMed

Caso, Raul; Beamer, Matthew; Lofthus, Alexander D; Sosin, Michael

2017-10-01

The field of cancer genetics is rapidly evolving and several genetic mutations have been identified in hereditary cancer syndromes. These mutations can be diagnosed via routine genetic testing allowing prompt intervention. This is especially true for certain variants of colorectal, breast, and thyroid cancers where genetic testing may guide surgical therapy. Ultimately, surgical intervention may drastically diminish disease manifestation or progression in individuals deemed as high-risk based on their genetic makeup. Understanding the concepts of gene-based testing and integrating into current surgical practice is crucial. This review addresses common genetic syndromes, tests, and interventions salient to the current surgeon.

Prospective data collection of a new procedure by a specialty society: the FIBROID registry.

PubMed

Myers, Evan R; Goodwin, Scott; Landow, Wendy; Mauro, Matthew; Peterson, Eric; Pron, Gaylene; Spies, James B; Worthington-Kirsch, Robert

2005-07-01

To describe registry methods and baseline patient demographics from a national sample of women undergoing uterine artery embolization for uterine leiomyomata. Interventional radiology practices were recruited to submit data by a secure Web site on women undergoing uterine artery embolization for symptomatic leiomyomata. Baseline data included patient demographics, prior medical, surgical, and obstetrical history, uterine anatomy, and quality-of-life measures. Subsequent data collected included details of the uterine artery embolization procedure and hospital stay and outcomes at 30 days; patients were also offered the opportunity to participate in longer-term follow-up. Characteristics of white and African-American women were compared using t tests, chi(2), or Wilcoxon rank-sum tests as appropriate. As of December 31, 2002, 3,319 uterine artery embolization cases had been entered into the registry by 72 sites; number of patients entered by individual sites ranged from 1 to 514. Of these patients, 95.4% consented to participation in the short-term outcomes registry. Forty-eight percent of patients were African American, and 44.4% were white and non-Hispanic. Heavy menstrual bleeding was the single most bothersome symptom in 64.3% of patients. Compared with white non-Hispanic women, African-American women were significantly younger, more likely to be obese, had larger uteri and more numerous leiomyomata, more severe symptoms, and poorer quality-of-life scores before treatment. It is feasible to collect prospective data on new technologies. The FIBROID Registry prospectively collected data on more than 3,000 women undergoing uterine artery embolization for symptomatic leiomyomata. Baseline patient characteristics of this patient population seem to be similar to those of women undergoing other procedures for leiomyomata. III.

Diagnosis and expedited surgical intervention of a complete hamstring avulsion in a military combatives athlete: a case report.

PubMed

O'Laughlin, Shaun J; Flynn, Timothy W; Westrick, Richard B; Ross, Michael D

2014-05-01

Hamstring injuries are frequent injuries in athletes, with the most common being strains at the musculotendinous junction or within the muscle belly. Conversely, hamstring avulsions are rare and often misdiagnosed leading to delay in appropriate surgical interventions. The purpose of this case report is to describe the history and physical examination findings that led to appropriate diagnostic imaging and the subsequent diagnosis and expedited surgical intervention of a complete avulsion of the hamstring muscle group from the ischium in a military combatives athlete. The patient was a 25 year-old male who sustained a hyperflexion injury to his right hip with knee extension while participating in military combatives, presenting with acute posterior thigh and buttock pain. History and physical examination findings from a physical therapy evaluation prompted an urgent magnetic resonance imaging (MRI) study, which led to the diagnosis of a complete avulsion of the hamstring muscle group off the ischium. Expedited surgical intervention occurred within 13 days of the injury potentially limiting comorbidities associated with delayed diagnosis. Recognition of the avulsion led to prompt surgical evaluation and intervention. Literature has shown that diagnosis of hamstring avulsions are frequently missed or delayed, which results in a myriad of complications. Level 4.

3D Printed Cardiac Phantom for Procedural Planning of a Transcatheter Native Mitral Valve Replacement.

PubMed

Izzo, Richard L; O'Hara, Ryan P; Iyer, Vijay; Hansen, Rose; Meess, Karen M; Nagesh, S V Setlur; Rudin, Stephen; Siddiqui, Adnan H; Springer, Michael; Ionita, Ciprian N

2016-02-27

3D printing an anatomically accurate, functional flow loop phantom of a patient's cardiac vasculature was used to assist in the surgical planning of one of the first native transcatheter mitral valve replacement (TMVR) procedures. CTA scans were acquired from a patient about to undergo the first minimally-invasive native TMVR procedure at the Gates Vascular Institute in Buffalo, NY. A python scripting library, the Vascular Modeling Toolkit (VMTK), was used to segment the 3D geometry of the patient's cardiac chambers and mitral valve with severe stenosis, calcific in nature. A stereolithographic (STL) mesh was generated and AutoDesk Meshmixer was used to transform the vascular surface into a functioning closed flow loop. A Stratasys Objet 500 Connex3 multi-material printer was used to fabricate the phantom with distinguishable material features of the vasculature and calcified valve. The interventional team performed a mock procedure on the phantom, embedding valve cages in the model and imaging the phantom with a Toshiba Infinix INFX-8000V 5-axis C-arm bi-Plane angiography system. After performing the mock-procedure on the cardiac phantom, the cardiologists optimized their transapical surgical approach. The mitral valve stenosis and calcification were clearly visible. The phantom was used to inform the sizing of the valve to be implanted. With advances in image processing and 3D printing technology, it is possible to create realistic patient-specific phantoms which can act as a guide for the interventional team. Using 3D printed phantoms as a valve sizing method shows potential as a more informative technique than typical CTA reconstruction alone.