Patient Satisfaction after Thoracoscopic Sympathectomy for Palmar Hyperhidrosis: Do Method and Level Matter?

PubMed Central

Cheng, Amy; Johnsen, Hege; Chang, Michael Y

2015-01-01

Context: Although surgery is widely recognized as the best treatment for palmar hyperhidrosis (PH), the decision to perform a sympathicotomy, sympathectomy, or clipping of the thoracic sympathetic chain is based on surgeon preference. Objective: We investigated the outcomes of patients who underwent surgical intervention for PH with regard to method used and level of sympathetic chain interrupted. Design: This was a retrospective medical chart review. Patients who underwent thoracoscopic intervention for PH were mailed questionnaires regarding their presenting and postoperative symptoms and satisfaction 6 months to 15 years after their procedure. Analyses were performed to investigate whether the surgical method applied affected these outcomes. Results: A total of 635 patients underwent bilateral thoracoscopic procedures for PH between April 1995 and February 2010, and 210 (33%) responded to the questionnaires. Sixteen surgeons performed 108 sympathicotomies, 83 sympathectomies, and 19 ligations with titanium clips for PH. Mean follow-up was 5.5 years. Overall palmar success was 85.4% and was not affected by the surgical method. The rate of compensatory hyperhidrosis was significantly lower if the operative level did not include the R2 ganglion (66.7% vs 80.6%, p = 0.028). Nevertheless, 76.2% of patients were satisfied with the results, and 85.7% would repeat the procedure if given the option to do it again. Conclusion: Most patients reported relief of their PH and were satisfied with surgical intervention, regardless of method used. Although postoperative compensatory hyperhidrosis was common, this did not appear to affect overall patient satisfaction. The inclusion of rib level 2 ganglion resulted in a significantly increased incidence of compensatory hyperhidrosis. PMID:26517433

On clipping of anterior communicating artery aneurysm via eyebrow-lateral keyhole approach

PubMed Central

Wang, Hui; Chen, Chuan; Ye, Zhuo-Peng; Luo, Lun; Li, Wen-Sheng; Guo, Ying

2015-01-01

Objective: To evaluate the application of eyebrow-lateral keyhole approach in clipping of anterior communicating artery aneurysm (ACAA) through observing the therapeutic effect of eyebrow-lateral keyhole approach on ACAA. Methods: In 37 patients with ACAA, cisterns were exposed via the eyebrow-lateral keyhole approach to reveal ACAA complex followed by clipping of ACAA. Of the 37 patients, external ventricular drainage was performed on 5 patients before microsurgery. All patients underwent head CT angiography on the second day after operation. Results: Clipping of ACAA was successful in all patients at the first time. In 3 patients, ruptured aneurysm occurred during operation. Three patients underwent ventriculoperitoneal shunt because of postoperative hydrocephalus. Two patients had one-sided anterior cerebral artery infarction after operation. No patient died during operation. Follow-up after the operation indicated that 26 patients returned to normal life and work, 6 patients were able to look after themselves, 4 patients required care in their daily life and one patient died. Conclusion: The eyebrow-lateral keyhole approach is a preferred choice for surgical treatment of ACAA because it can cope with brain swelling and intraoperative ruptured aneurysm. However, it has a certain range of application, so we must strictly follow its indications. PMID:26885043

Unruptured cerebral aneurysm clipping: the association of combined open and endovascular expertise with outcomes

PubMed Central

Bekelis, Kimon; Gottlieb, Dan; Bovis, George; Su, Yin; Tjoumakaris, Stavropoula; Jabbour, Pascal; MacKenzie, Todd A.

2017-01-01

Background It is often questioned if one physician can conduct both open and endovascular techniques successfully and safely. We investigated the association of combined open and endovascular expertise with the outcomes of unruptured cerebral aneurysm clipping. Methods We performed a cohort study of 100% of Medicare fee-for-service claims data for elderly patients who underwent surgical clipping for unruptured cerebral aneurysms from 2007 to 2012. In order to control for confounding we used propensity score conditioning, and controlled for clustering at the physician level. Results During the study period, there were 3,247 patients, who underwent clipping for unruptured cerebral aneurysms, and met the inclusion criteria. Of these, 766 (23.6%) underwent treatment by hybrid neurosurgeons, and 2,481 (76.4%) by proceduralists who performed only clipping. Multivariable regression analysis with propensity score adjustment demonstrated lack of association of combined practice with 1-year postoperative mortality (OR, 0.81; 95% CI, 0.51–1.28), discharge to rehabilitation (OR, 0.95; 95% CI, 0.72–1.25), LOS (adjusted difference 0.85 days; 95% CI, −0.31 to 2.00), or 30-day readmission rate (OR, 1.05; 95% CI, 0.80–1.39). Higher procedural volume was independently associated with improved outcomes. Conclusions In a cohort of Medicare patients with unruptured aneurysms, we did not demonstrate a difference in mortality, discharge to rehabilitation, or readmission rate between hybrid neurosurgeons and surgeons only performing clipping. Funding Supported by grants from the National Institute on Aging (PO1- AG19783), and the National Institutes of Health (NIH) Common Fund (U01-AG046830) and the National Center for Advancing Translational Sciences (NCATS) of the NIH (Dartmouth Clinical and Translational Science Institute-UL1TR001086). The funders had no role in the design or execution of the study. PMID:26385788

Recurrence of ICA-PCoA aneurysms after neck clipping.

PubMed

Sakaki, T; Takeshima, T; Tominaga, M; Hashimoto, H; Kawaguchi, S

1994-01-01

Between 1975 and 1992, 2211 patients underwent aneurysmal neck clipping at the Nara Medical University clinic and associated hospitals. The aneurysm in 931 of these patients was situated at the junction of the internal carotid artery (ICA) and posterior communicating artery (PCoA). Seven patients were readmitted 4 to 17 years after the first surgery because of regrowth and rupture of an ICA-PCoA aneurysmal sac that had arisen from the residual neck. On angiograms obtained following aneurysmal neck clipping, a large primitive type of PCoA was demonstrated in six patients and a small PCoA in one. A small residual aneurysm was confirmed in only two patients and angiographically complete neck clipping in five. Recurrent ICA-PCoA aneurysms were separated into two types based on the position of the old clip in relation to the new growth. Type 1 aneurysms regrow from the entire neck and balloon eccentrically. In this type, it is possible to apply the clip at the neck as in conventional clipping for a ruptured aneurysm. Type 2 includes aneurysms in which the proximal portion of a previous clip is situated at the corner of the ICA and aneurysmal neck and the distal portion on the enlarged dome of the aneurysm, because the sac is regrowing from a portion of the residual neck. In this type of aneurysm, a Sugita fenestrated clip can occlude the residual neck, overriding the old clip. Classifying these aneurysms into two groups is very useful from a surgical point of view because it is possible to apply a new clip without removing the old clip, which was found to be adherent to surrounding tissue.

Comparison of clipping and coiling in elderly patients with unruptured cerebral aneurysms

PubMed Central

Bekelis, Kimon; Gottlieb, Daniel J.; Su, Yin; O’Malley, A. James; Labropoulos, Nicos; Goodney, Philip; Lawton, Michael T.; MacKenzie, Todd A.

2016-01-01

OBJECTIVE The comparative effectiveness of the 2 treatment options—surgical clipping and endovascular coiling—for unruptured cerebral aneurysms remains an issue of debate and has not been studied in clinical trials. The authors investigated the association between treatment method for unruptured cerebral aneurysms and outcomes in elderly patients. METHODS The authors performed a cohort study of 100% of Medicare fee-for-service claims data for elderly patients who had treatment for unruptured cerebral aneurysms between 2007 and 2012. To control for measured confounding, the authors used propensity score conditioning and inverse probability weighting with mixed effects to account for clustering at the level of the hospital referral region (HRR). An instrumental variable (regional rates of coiling) analysis was used to control for unmeasured confounding and to create pseudo-randomization on the treatment method. RESULTS During the study period, 8705 patients underwent treatment for unruptured cerebral aneurysms and met the study inclusion criteria. Of these patients, 2585 (29.7%) had surgical clipping and 6120 (70.3%) had endovascular coiling. Instrumental variable analysis demonstrated no difference between coiling and clipping in 1-year postoperative mortality (OR 1.25, 95% CI 0.68–2.31) or 90-day readmission rate (OR 1.04, 95% CI 0.66–1.62). However, clipping was associated with a greater likelihood of discharge to rehabilitation (OR 6.39, 95% CI 3.85–10.59) and 3.6 days longer length of stay (LOS; 95% CI 2.90–4.71). The same associations were present in propensity score–adjusted and inverse probability– weighted models. CONCLUSIONS In a cohort of Medicare patients, there was no difference in mortality and the readmission rate between clipping and coiling of unruptured cerebral aneurysms. Clipping was associated with a higher rate of discharge to a rehabilitation facility and a longer LOS. PMID:27203150

Surgical management of giant posterior communicating artery aneurysms.

PubMed

Velat, Gregory J; Zabramski, Joseph M; Nakaji, Peter; Spetzler, Robert F

2012-09-01

Giant posterior communicating artery (PCoA) aneurysms (> 25 mm) are rare lesions associated with a poor prognosis and high rates of morbidity and mortality. To review the clinical results of giant PCoA aneurysms surgically treated at our institution, focusing on operative nuances. All cases of giant PCoA aneurysms treated surgically at our institution were identified from a prospectively maintained patient database. Patient demographic factors, medical comorbidities, rupture status, neurological presentation, clinical outcomes, and surgical records were critically reviewed. From 1989 to 2010, 11 patients (10 women) underwent surgical clipping of giant PCoA aneurysms. Presenting signs and symptoms included cranial nerve palsies, diminished mental status, headache, visual changes, and seizures. Five aneurysms were ruptured on admission. All aneurysms were clipped primarily except 1, which was treated by parent artery sacrifice and extracranial-to-intracranial bypass after intraoperative aneurysm rupture. Perioperative morbidity and mortality rates were 36% (4 of 11) and 18.3% (2 of 11), respectively. Excellent or good clinical outcomes, defined as modified Rankin Scale scores ≤ 2, were achieved in 86% (5 of 6) of patients available for long-term clinical follow-up (mean, 12.5 ± 13.6 months). Giant PCoA aneurysms are rare vascular lesions that may present with a variety of neurological signs and symptoms. These lesions can be successfully managed surgically with satisfactory morbidity and mortality rates. To the best of our knowledge, this is the largest surgical series of giant PCoA aneurysms published to date.

Three-Dimensional Printing of Surgical Clips: An In Vitro Pilot Study and Trial of Efficacy.

PubMed

Canvasser, Noah E; De, Shuvro; Koseoglu, Ersin; Lay, Aaron H; Sorokin, Igor; Fernandez, Raul; Cadeddu, Jeffrey A

2017-09-01

Three-dimensional (3D) printing applications have increased over the past decade. Our objective was to test rapid prototyping of a 3D printed surgical clip for intraoperative use. Our prototype was modeled after the 10 mm Weck ® Hem-o-lok ® polymer clip (Teleflex, Inc., Wayne, PA). A 3D computer-aided design model of the Hem-o-lok clip was reverse engineered using commercial microscopy and printing was done using an Objet Connex500 multijetting system (Stratasys, Eden Prairie, MN). The initial polymer was Objet VeroWhitePlus RGD835; the addition of Objet TangoBlackPlus FLX980 during the design process improved hinge flexibility. The 3D printed clips were then pressure tested on rubber Penrose tubing and compared in vitro versus commercial Hem-o-lok clips. Initial 3D printed clips were not functional as they split at the hinge upon closure of the clip jaws. Design changes were made to add Objet TangoBlackPlus FLX980 at the hinge to improve flexibility. Additional modifications were made to allow for clips to be compatible with the Hem-o-lok endoscopic clip applier. A total of 50 clips were tested. Fracture rate for the printed clips using a clip applier was 54% (n = 27), whereas none of the commercial Hem-o-lok clips broke upon closure. Of the 23 printed clips that closed, mean leak was at 20.7 κPa (range 4.8-42.7). In contrast, none of the commercial clips leaked, and fill continued until Penrose rupture at mean 46.2 κPa (44.8-47.6). This pilot study demonstrates feasibility of 3D printing functional surgical clips. However, the performance of our first generation clips is poor compared with commercial grade product. Refinement in printers and materials available may allow for customization of such printed surgical instruments that could be economically competitive to purchasing and stocking product.

Virtual Cerebral Aneurysm Clipping with Real-Time Haptic Force Feedback in Neurosurgical Education.

PubMed

Gmeiner, Matthias; Dirnberger, Johannes; Fenz, Wolfgang; Gollwitzer, Maria; Wurm, Gabriele; Trenkler, Johannes; Gruber, Andreas

2018-04-01

Realistic, safe, and efficient modalities for simulation-based training are highly warranted to enhance the quality of surgical education, and they should be incorporated in resident training. The aim of this study was to develop a patient-specific virtual cerebral aneurysm-clipping simulator with haptic force feedback and real-time deformation of the aneurysm and vessels. A prototype simulator was developed from 2012 to 2016. Evaluation of virtual clipping by blood flow simulation was integrated in this software, and the prototype was evaluated by 18 neurosurgeons. In 4 patients with different medial cerebral artery aneurysms, virtual clipping was performed after real-life surgery, and surgical results were compared regarding clip application, surgical trajectory, and blood flow. After head positioning and craniotomy, bimanual virtual aneurysm clipping with an original forceps was performed. Blood flow simulation demonstrated residual aneurysm filling or branch stenosis. The simulator improved anatomic understanding for 89% of neurosurgeons. Simulation of head positioning and craniotomy was considered realistic by 89% and 94% of users, respectively. Most participants agreed that this simulator should be integrated into neurosurgical education (94%). Our illustrative cases demonstrated that virtual aneurysm surgery was possible using the same trajectory as in real-life cases. Both virtual clipping and blood flow simulation were realistic in broad-based but not calcified aneurysms. Virtual clipping of a calcified aneurysm could be performed using the same surgical trajectory, but not the same clip type. We have successfully developed a virtual aneurysm-clipping simulator. Next, we will prospectively evaluate this device for surgical procedure planning and education. Copyright © 2018 Elsevier Inc. All rights reserved.

Use of a surgical rehearsal platform and improvement in aneurysm clipping measures: results of a prospective, randomized trial.

PubMed

Chugh, A Jessey; Pace, Jonathan R; Singer, Justin; Tatsuoka, Curtis; Hoffer, Alan; Selman, Warren R; Bambakidis, Nicholas C

2017-03-01

OBJECTIVE The field of neurosurgery is constantly undergoing improvements and advances, both in technique and technology. Cerebrovascular neurosurgery is no exception, with endovascular treatments changing the treatment paradigm. Clipping of aneurysms is still necessary, however, and advances are still being made to improve patient outcomes within the microsurgical treatment of aneurysms. Surgical rehearsal platforms are surgical simulators that offer the opportunity to rehearse a procedure prior to entering the operative suite. This study is designed to determine whether use of a surgical rehearsal platform in aneurysm surgery is helpful in decreasing aneurysm dissection time and clip manipulation of the aneurysm. METHODS The authors conducted a blinded, prospective, randomized study comparing key effort and time variables in aneurysm clip ligation surgery with and without preoperative use of the SuRgical Planner (SRP) surgical rehearsal platform. Initially, 40 patients were randomly assigned to either of two groups: one in which surgery was performed after use of the SRP (SRP group) and one in which surgery was performed without use of the SRP (control group). All operations were videotaped. After exclusion of 6 patients from the SRP group and 9 from the control group, a total of 25 surgical cases were analyzed by a reviewer blinded to group assignment. The videos were analyzed for total microsurgical time, number of clips used, and number of clip placement attempts. Means and standard deviations (SDs) were calculated and compared between groups. RESULTS The mean (± SD) amount of operative time per clip used was 920 ± 770 seconds in the SRP group and 1294 ± 678 seconds in the control group (p = 0.05). In addition, the mean values for the number of clip attempts, total operative time, ratio of clip attempts to clips used, and time per clip attempt were all lower in the SRP group, although the between-group differences were not statistically significant. CONCLUSIONS Preoperative rehearsal with SRP increased efficiency and safety in aneurysm microsurgery as demonstrated by the statistically significant improvement in time per clip used. Although the rest of the outcomes did not demonstrate statistically significant between-group differences, the fact that the SRP group showed improvement in mean values for all measures studied suggests that preoperative rehearsal may increase the efficiency and safety of aneurysm microsurgery. Future studies aimed at improving patient outcome and safety during surgical clipping of aneurysms will be needed to keep pace with the quickly advancing endovascular field.

Preoperative computed tomography-guided percutaneous hookwire localization of metallic marker clips in the breast with a radial approach: initial experience.

PubMed

Uematsu, T; Kasami, M; Uchida, Y; Sanuki, J; Kimura, K; Tanaka, K; Takahashi, K

2007-06-01

Hookwire localization is the current standard technique for radiological marking of nonpalpable breast lesions. Stereotactic directional vacuum-assisted breast biopsy (SVAB) is of sufficient sensitivity and specificity to replace surgical biopsy. Wire localization for metallic marker clips placed after SVAB is needed. To describe a method for performing computed tomography (CT)-guided hookwire localization using a radial approach for metallic marker clips placed percutaneously after SVAB. Nineteen women scheduled for SVAB with marker-clip placement, CT-guided wire localization of marker clips, and, eventually, surgical excision were prospectively entered into the study. CT-guided wire localization was performed with a radial approach, followed by placement of a localizing marker-clip surgical excision. Feasibility and reliability of the procedure and the incidence of complications were examined. CT-guided wire localization surgical excision was successfully performed in all 19 women without any complications. The mean total procedure time was 15 min. The median distance on CT image from marker clip to hookwire was 2 mm (range 0-3 mm). CT-guided preoperative hookwire localization with a radial approach for marker clips after SVAB is technically feasible.

Ocular Biocompatibility of Nitinol Intraocular Clips

PubMed Central

Velez-Montoya, Raul; Erlanger, Michael

2012-01-01

Purpose. To evaluate the tolerance and biocompatibility of a preformed nitinol intraocular clip in an animal model after anterior segment surgery. Methods. Yucatan mini-pigs were used. A 30-gauge prototype injector was used to attach a shape memory nitinol clip to the iris of five pigs. Another five eyes received conventional polypropylene suture with a modified Seipser slip knot. The authors compared the surgical time of each technique. All eyes underwent standard full-field electroretinogram at baseline and 8 weeks after surgery. The animals were euthanized and eyes collected for histologic analysis after 70 days (10 weeks) postsurgery. The corneal thickness, corneal endothelial cell counts, specular microscopy parameters, retina cell counts, and electroretinogram parameters were compared between the groups. A two sample t-test for means and a P value of 0.05 were use for assessing statistical differences between measurements. Results. The injection of the nitinol clip was 15 times faster than conventional suturing. There were no statistical differences between the groups for corneal thickness, endothelial cell counts, specular microscopy parameters, retina cell counts, and electroretinogram measurements. Conclusions. The nitinol clip prototype is well tolerated and showed no evidence of toxicity in the short-term. The injectable delivery system was faster and technically less challenging than conventional suture techniques. PMID:22064995

Influence of percutaneous mitral valve repair using the MitraClip® system on renal function in patients with severe mitral regurgitation.

PubMed

Rassaf, Tienush; Balzer, Jan; Rammos, Christos; Zeus, Tobias; Hellhammer, Katharina; v Hall, Silke; Wagstaff, Rabea; Kelm, Malte

2015-04-01

In patients with mitral regurgitation (MR), changes in cardiac stroke volume, and thus renal preload and afterload may affect kidney function. Percutaneous mitral valve repair (PMVR) with the MitraClip® system can be a therapeutic alternative to surgical valve repair. The influence of MitraClip® therapy on renal function and clinical outcome parameters is unknown. Sixty patients with severe MR underwent PMVR using the MitraClip® system in an open-label observational study. Patients were stratified according to their renal function. All clips have been implanted successfully. Effective reduction of MR by 2-3 grades acutely improved KDOQI class. Lesser MR reduction (MR reduction of 0-1 grades) led to worsening of renal function in patients with pre-existing normal or mild (KDOQI 1-2) compared to severe (KDOQI 3-4) renal dysfunction. Reduction of MR was associated with improvement in Minnesota Living with Heart Failure Questionnaire (MLHFQ), NYHA-stadium, and 6-minute walk test. Successful PMVR was associated with an improvement in renal function. The improvement in renal function was associated with the extent of MR reduction and pre-existing kidney dysfunction. Our data emphasize the relevance of PVMR to stabilize the cardiorenal axis in patients with severe MR. © 2014 Wiley Periodicals, Inc.

Ischemic mass effect from biliary surgical clips.

PubMed

Mateo, Rod; Tsai, Steven; Stapfer, Maria V; Sher, Linda S; Selby, Rick; Genyk, Yuri S

2008-02-01

Migrating surgical clips in the hepatic hilum are known causes of biliary stricture or obstruction, most often due to direct intraluminal obstruction or secondary stone formation. Two cases are reported on patients with previous cholecystectomies presenting with delayed symptoms of biliary tract stricture. Both patients were successfully treated with a resection of the strictured area and a Roux-en-Y hepatico-jejunostomy. Resected specimens grossly demonstrated surgical clips adjacent to the stricture, but not directly within the lumen, suggestive of an ischemic mass effect, which was supported by histology. In addition to the direct intraluminal obstruction and lithogenic effects of migratory surgical clips, "clipomas" due to an ischemic mass effect can also lead to biliary tract strictures.

Surgical treatment for a ruptured true posterior communicating artery aneurysm arising on the fetal-type posterior communicating artery--two case reports and review of the literature.

PubMed

Nakano, Yoshiteru; Saito, Takeshi; Yamamoto, Junkoh; Takahashi, Mayu; Akiba, Daisuke; Kitagawa, Takehiro; Miyaoka, Ryo; Ueta, Kunihiro; Kurokawa, Toru; Nishizawa, Shigeru

2011-12-01

Only a small number of aneurysms arising on the posterior communicating artery itself (true Pcom aneurysm) have been reported. We report two cases of ruptured true Pcom aneurysms with some characteristic features of true Pcom aneurysm. A 43 year old man suffering from subarachnoid hemorrhage (SAH) had an aneurysm arising on the fetal-type Pcom artery itself, and underwent surgery for clipping. Most of the aneurysm was buried in the temporal lobe, so retraction of the temporal lobe was mandatory. During the retraction, premature rupture was encountered. After tentative dome clipping and the control of bleeding, complete clipping was achieved. Another patient, a 71 year old woman presenting with consciousness disturbance due to SAH, had an aneurysm on the fetal-type Pcom artery itself, and underwent surgery for clipping. It has been generally considered that hemodynamic factor plays an important role in the formation, the growth, and the rupture of the cerebral aneurysm. This factor is especially significant in true Pcom aneurysm formation and rupture. According to the literature, a combination of fetal type Pcom and formation of the true Pcom aneurysm has been reported in most cases (81.8%). Most of the aneurysm can be buried in the temporal lobe, and the retraction of the temporal lobe during the dissection of the neck would be necessary, which causes premature rupture of the true Pcom aneurysm. In the surgery for a true Pcom aneurysm, we should be aware of possible premature rupture when temporal lobe retraction is necessary.

High-flow bypass and wrap-clipping for ruptured blood blister-like aneurysm of the internal carotid artery using intraoperative monitoring of cerebral hemodynamics

PubMed Central

Kubo, Yoshitaka; Koji, Takahiro; Yoshida, Kenji; Saito, Hideo; Ogawa, Akira; Ogasawara, Kuniaki

2015-01-01

Aneurysms at non-branching sites in the supraclinoid internal carotid artery (ICA) can be classified as “blood blister-like aneurysms” (BBAs), which have blood blister-like configurations and fragile walls. While surgical treatment for the BBA in the acute stage is recommended, the optimal surgical procedure remains controversial. In the study reported here, we describe the case of a 37-year-old woman with a ruptured BBA in the ophthalmic segment of the right ICA who underwent wrap-clipping with external carotid artery–internal carotid artery bypass by intraoperative estimation of the measurement of cortical cerebral blood flow (CoBF) using a thermal diffusion flow probe. Trapping of the ICA in the acute stage of subarachnoid hemorrhage may result in ischemic complications secondary to hemodynamic hypoperfusion or occlusion of the perforating artery, and/or delayed vasospasm, even with concomitant bypass surgery. We believe that it is important to perform scheduled external carotid artery–internal carotid artery bypass before trapping of the ICA in patients with a ruptured BBA in the acute stage of subarachnoid hemorrhage and to perform wrap-clipping rather than trapping. This would provide much more CoBF if a reduction of CoBF occurs after trapping occlusion of the ICA including a ruptured BBA according to intraoperative CoBF monitoring. As far as we are aware, the case reported here is the first report on high-flow bypass and wrap-clipping for a ruptured BBA of the ICA using intraoperative monitoring of cerebral hemodynamics. PMID:26082641

Intraoperative loss of core biopsy clips: clinical implications.

PubMed

Calhoun, Kristine; Giuliano, Armando; Brenner, R James

2008-03-01

The purpose of this study was to report the occurrence of intraoperative loss of metallic marking clips placed during image-guided biopsy and to hypothesize the likely mechanism of this clinical problem. From January 2003 through December 2004, patients presenting for preoperative mammographic localization and operative excision of biopsy site marking clips were identified. Age, method of image-guided biopsy, number of excised specimens, and tissue diagnosis were determined. Specimen radiographs were used to identify cases of suspected intraoperative clip loss. Clips absent on specimen radiographs and postoperative mammograms were defined as lost intraoperatively. Biopsy site marking clips, surgical clips, and suction device apertures were measured. In 78 surgical procedures performed during the study period, three (3.8%) of the patients experienced clip loss. Specimen radiographs confirmed the absence of clips in all submitted tissues. A median of four (range, three to five) separate biopsy specimens were excised among these three cases. A healing biopsy site from the stereotactic biopsy preceding the clip placement procedure was confirmed in all cases. Absence of the metallic clip was confirmed on postoperative mammograms. The apertures of two types of suction device were four and two times those of the biopsy clips. Intraoperative loss of metallic clips placed at the conclusion of image-guided breast biopsy is unusual but can occur during subsequent surgical excision. Repeated inability to locate the clip on specimen radiographs after accurate preoperative localization should raise the suspicion that the target clip has been lost, not missed, during surgery, likely because of inadvertent removal of the clip with the suction device.

Flexible Ultrathin Endoscope Integrated with Irrigation Suction Apparatus for Assisting Microneurosurgery.

PubMed

Otani, Naoki; Morimoto, Yuji; Fujii, Kazuya; Toyooka, Terushige; Wada, Kojiro; Mori, Kentaro

2017-12-01

Endoscopy can observe the anatomical components in a deeply located and/or hidden area during neurosurgical procedures under the operating microscope. We have newly developed a flexible ultrathin endoscope integrated with irrigation suction apparatus (FUEISA) to visualize deeply located and/or hidden areas for assisting microneurosurgery. The present study investigated the usefulness of the FUEISA system for direct clipping surgery of cerebral aneurysms. Twenty-one patients underwent microneurosurgery assisted with the FUEISA system for direct clipping of cerebral aneurysms. The flexible ultrathin endoscope (outer diameter 0.75mm) consists of an image guide (6000 dpi) and a light guide, integrated with the irrigation suction apparatus. This endoscopic system was inserted before and after clipping to observe the anatomical conditions surrounding the lesions. In all cases, handling and operation of the FUEISA was technically successful during the surgical procedure. The ultrathin endoscope was adequately integrated with the irrigation suction apparatus in all cases. General anatomy visualization including the lenticulostriate arteries, medial striate arteries, and/or internal carotid artery perforators was possible, and the correct clip positioning and vessel conditions were easily checked. The endoscope revealed that the clip had been positioned incorrectly in one case. No complications associated with the endoscopic system occurred. The FUEISA system can be applied with safe manipulation, which was remarkably useful for confirmation of the presence of perforators and cranial nerves behind the lesions, particularly anatomical components located in deep and/or hidden areas during clipping of cerebral aneurysms. Copyright © 2017 Elsevier Inc. All rights reserved.

Reoperation and readmission after clipping of an unruptured intracranial aneurysm: a National Surgical Quality Improvement Program analysis.

PubMed

Dasenbrock, Hormuzdiyar H; Smith, Timothy R; Rudy, Robert F; Gormley, William B; Aziz-Sultan, M Ali; Du, Rose

2018-03-01

OBJECTIVE Although reoperation and readmission have been used as quality metrics, there are limited data evaluating the rate of, reasons for, and predictors of reoperation and readmission after microsurgical clipping of unruptured aneurysms. METHODS Adult patients who underwent craniotomy for clipping of an unruptured aneurysm electively were extracted from the prospective National Surgical Quality Improvement Program registry (2011-2014). Multivariable logistic regression and recursive partitioning analysis evaluated the independent predictors of nonroutine hospital discharge, unplanned 30-day reoperation, and readmission. Predictors screened included patient age, sex, comorbidities, American Society of Anesthesiologists (ASA) classification, functional status, aneurysm location, preoperative laboratory values, operative time, and postoperative complications. RESULTS Among the 460 patients evaluated, 4.2% underwent any reoperation at a median of 7 days (interquartile range [IQR] 2-17 days) postoperatively, and 1.1% required a cranial reoperation. The most common reoperation was ventricular shunt placement (23.5%); other reoperations were tracheostomy, craniotomy for hematoma evacuation, and decompressive hemicraniectomy. Independent predictors of any unplanned reoperation were age greater than 51 years and longer operative time (p ≤ 0.04). Readmission occurred in 6.3% of patients at a median of 6 days (IQR 5-13 days) after discharge from the surgical hospitalization; 59.1% of patients were readmitted within 1 week and 86.4% within 2 weeks of discharge. The most common reason for readmission was seizure (26.7%); other causes of readmission included hydrocephalus, cerebrovascular accidents, and headache. Unplanned readmission was independently associated with age greater than 65 years, Class II or III obesity (body mass index > 35 kg/m 2 ), preoperative hyponatremia, and preoperative anemia (p ≤ 0.04). Readmission was not associated with operative time, complications during the surgical hospitalization, length of stay, or discharge disposition. Recursive partitioning analysis identified the same 4 variables, as well as ASA classification, as associated with unplanned readmission. The most potent predictors of nonroutine hospital discharge (16.7%) were postoperative neurological and cardiopulmonary complications; other predictors were age greater than 51 years, preoperative hyponatremia, African American and Asian race, and a complex vertebrobasilar circulation aneurysm. CONCLUSIONS In this national analysis, patient age greater than 65 years, Class II or III obesity, preoperative hyponatremia, and anemia were associated with adverse events, highlighting patients who may be at risk for complications after clipping of unruptured cerebral aneurysms. The preponderance of early readmissions highlights the importance of early surveillance and follow-up after discharge; the frequency of readmission for seizure emphasizes the need for additional data evaluating the utility and duration of postcraniotomy seizure prophylaxis. Moreover, readmission was primarily associated with preoperative characteristics rather than metrics of perioperative care, suggesting that readmission may be a suboptimal indicator of the quality of care received during the surgical hospitalization in this patient population.

Practical Use of the Extended No Action Level (eNAL) Correction Protocol for Breast Cancer Patients With Implanted Surgical Clips

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

Penninkhof, Joan, E-mail: j.penninkhof@erasmusmc.nl; Quint, Sandra; Baaijens, Margreet

Purpose: To describe the practical use of the extended No Action Level (eNAL) setup correction protocol for breast cancer patients with surgical clips and evaluate its impact on the setup accuracy of both tumor bed and whole breast during simultaneously integrated boost treatments. Methods and Materials: For 80 patients, two orthogonal planar kilovoltage images and one megavoltage image (for the mediolateral beam) were acquired per fraction throughout the radiotherapy course. For setup correction, the eNAL protocol was applied, based on registration of surgical clips in the lumpectomy cavity. Differences with respect to application of a No Action Level (NAL) protocolmore » or no protocol were quantified for tumor bed and whole breast. The correlation between clip migration during the fractionated treatment and either the method of surgery or the time elapsed from last surgery was investigated. Results: The distance of the clips to their center of mass (COM), averaged over all clips and patients, was reduced by 0.9 {+-} 1.2 mm (mean {+-} 1 SD). Clip migration was similar between the group of patients starting treatment within 100 days after surgery (median, 53 days) and the group starting afterward (median, 163 days) (p = 0.20). Clip migration after conventional breast surgery (closing the breast superficially) or after lumpectomy with partial breast reconstructive techniques (sutured cavity). was not significantly different either (p = 0.22). Application of eNAL on clips resulted in residual systematic errors for the clips' COM of less than 1 mm in each direction, whereas the setup of the breast was within about 2 mm of accuracy. Conclusions: Surgical clips can be safely used for high-accuracy position verification and correction. Given compensation for time trends in the clips' COM throughout the treatment course, eNAL resulted in better setup accuracies for both tumor bed and whole breast than NAL.« less

Iatrogenic Subtotal Stenosis of the Right Subclavian Artery Treated With Percutaneous Transluminal Angioplasty

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

Smeenk, Robert M., E-mail: r.m.smeenk@asz.nl; Kock, Mark C. J. M.; Elgersma, Otto E. H.

2011-02-15

This report describes a rare vascular complication of surgical placement of a marking clip and a possible approach to problem solving. A 55-year-old patient presented with loss of sensation in the fingers and loss of peripheral pulsations in the right arm 4 days after right upper lobectomy for a pT2N1 moderately differentiated adenocarcinoma of the lung. Duplex examination and computed tomography were performed the same day and showed a subtotal stenosis of the right subclavian artery, which was caused by the surgical placement of a metal clip to mark the surgical boundary. Selective angiography was subsequently performed. Percutaneous transluminal angioplastymore » (PTA) successfully dilated the stenosis and pushed the clip off. Flow in the right subclavian artery (RSA) was completely restored as were neurology and peripheral pulses. In conclusion, arterial stenosis by a surgical (marking) clip may be feasibly treated with PTA.« less

Cerebral Protection During MitraClip Implantation: Initial Experience at 2 Centers.

PubMed

Frerker, Christian; Schlüter, Michael; Sanchez, Oscar D; Reith, Sebastian; Romero, Maria E; Ladich, Elena; Schröder, Jörg; Schmidt, Tobias; Kreidel, Felix; Joner, Michael; Virmani, Renu; Kuck, Karl-Heinz

2016-01-25

This study sought to assess the feasibility and safety of using a filter-based cerebral protection system (CPS) during MitraClip implantation and to report on the histopathologic analysis of the captured debris. Stroke is one of the serious adverse events associated with MitraClip therapy. Between July 2014 and March 2015, 14 surgical high-risk patients (age 75 ± 7 years; 7 men; median logistic EuroSCORE 21%) underwent MitraClip implantation employing cerebral protection with a dual embolic filter system. All patients had severe mitral regurgitation of predominantly functional origin. All procedures were successfully completed for both CPS deployment/retrieval and MitraClip implantation. A total of 28 filters (2 from each patient) were analyzed. Microscopically, debris was identified in all 14 patients. The most common tissue types were acute thrombus and small fragments of foreign material, which were found in 12 patients (85.7%) each. Organizing thrombus was present in 4 patients (28.6%), valve tissue and/or superficial atrial wall tissue in 9 patients (64.3%), and fragments of myocardium in 2 patients (14.3%). No transient ischemic attacks, strokes, or deaths occurred peri-procedurally or during a median follow-up interval of 8.4 months. In this small study of patients undergoing MitraClip treatment with cerebral protection, embolic debris potentially conducive to cerebrovascular events was found in all patients. Debris was composed most often of acute thrombus, foreign material likely originating from the hydrophilic device coating, and valve/atrial wall tissue. Further studies are warranted to assess the impact of cerebral protection on the incidence of cerebrovascular events after MitraClip therapy. Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Development of mitral stenosis after single MitraClip insertion for severe mitral regurgitation.

PubMed

Cockburn, James; Fragkou, Paraskevi; Hildick-Smith, David

2014-02-01

We report the first case of mitral stenosis following Mitra-Clip insertion in a patient with symptomatic NYHA IV heart failure, secondary to severe mitral regurgitation (MR). A 79-year-old female with a history of prior aortic valve replacement underwent percutaneous mitral valve (MV) repair. A single clip was advanced coaxially down onto the MV under TOE guidance, with the anterior and posterior leaflets clipped together between A2 and P2. TOE confirmed a significant reduction in MR (grade 4 to grade 1). Despite initial symptomatic relief, she represented 3 months later with similar symptoms. Repeat TOE confirmed a well positioned Mitra-Clip with mild residual MR. However, the possibility of significant mitral stenosis was raised due to the presence of significant turbulence through the bi-orifice valve, with a peak gradient of 25 mm Hg. In addition there was evidence of severe functional tricuspid valve (TV) regurgitation with elevated pulmonary artery pressures (PAP 90 mm Hg), confirmed on subsequent right heart catheterization. After repeated heart team discussions and a failure of optimal medical therapy, and despite a logistic EuroScore of 35.5, minimally invasive surgical replacement of the MV and simultaneous TV repair was undertaken via a right thoracotomy. Despite procedural success and initial good postoperative response, the patient died subsequently from a combination of hospital-acquired pneumonia and significant gastrointestinal bleeding (post operative day 35). Mitra-Clip is a promising novel approach to MV repair. The establishment of further clinical and echocardiographic based selection criteria will help identify the correct patients for this treatment. Copyright © 2013 Wiley Periodicals, Inc.

21 CFR 878.4320 - Removable skin clip.

Code of Federal Regulations, 2010 CFR

2010-04-01

... 21 Food and Drugs 8 2010-04-01 2010-04-01 false Removable skin clip. 878.4320 Section 878.4320...) MEDICAL DEVICES GENERAL AND PLASTIC SURGERY DEVICES Surgical Devices § 878.4320 Removable skin clip. (a) Identification. A removable skin clip is a clip-like device intended to connect skin tissues temporarily to aid...

Migrated Hem-o-Lok clips in the ureter: a rare cause of recurrent urinary tract infection.

PubMed

Shrivastava, Prashant; Nayak, Brusabhanu; Singh, Prabhjot

2017-02-15

Erosion of surgical materials into the adjacent organs following surgical procedures is a rare complication. Migrations of these surgical materials into the urinary tract like pelvicalyceal system, ureter and bladder have been reported following various urological procedures. We present a case of migrated Hem-o-Lok clips into the ureter following a laparoscopic partial nephrectomy for angiomyolipoma of the left kidney presented with recurrent urinary tract infection. The case was managed with ureteroscopic removal of clips. The patient is asymptomatic on last follow-up. 2017 BMJ Publishing Group Ltd.

Endoscopic treatment and risk factors of postoperative anastomotic bleeding after gastrectomy for gastric cancer.

PubMed

Kim, Ki-Han; Kim, Min-Chan; Jung, Ghap-Joong; Jang, Jin-Seok; Choi, Seok-Ryeol

2012-01-01

Anastomotic leakage, bleeding, and stricture are major complications after gastrectomy. Of these complications, postoperative anastomotic bleeding is relatively rare, but lethal if not treated immediately. Of 2031 patients with gastric cancer who underwent radical gastrectomy (R0 resection) between January 2002 and December 2010, postoperative anastomotic bleeding was observed in 7 patients. The clinicopathological features, postoperative outcomes such as surgical procedures, bleeding sites and, methods used to achieve hemostasis, and the risk factors of anastomotic bleeding of these 7 patients were analyzed. Of the 2031 patients, 1613 and 418 underwent distal and total gastrectomy, respectively. The bleeding sites were as follows: Billroth-I anastomosis using a circular stapler (n = 1), Billroth-II anastomosis by manual suture (n = 5), and esophagojejunostomy using a circular stapler (n = 1). All patients were treated with endoscopic clipping or epinephrine injection. There was no further endoscopic intervention or reoperation for anastomotic bleeding. Postoperative anastomotic bleeding is an infrequent but potentially life-threatening complication. Scrupulous surgical procedures are essential for the prevention of postoperative bleeding, and endoscopy was useful for both the confirmation of bleeding and therapeutic intervention. Copyright © 2012 Surgical Associates Ltd. All rights reserved.

21 CFR 882.4215 - Clip rack.

Code of Federal Regulations, 2011 CFR

2011-04-01

... 21 Food and Drugs 8 2011-04-01 2011-04-01 false Clip rack. 882.4215 Section 882.4215 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL DEVICES NEUROLOGICAL DEVICES Neurological Surgical Devices § 882.4215 Clip rack. (a) Identification. A clip rack is a...

21 CFR 882.4150 - Scalp clip.

Code of Federal Regulations, 2010 CFR

2010-04-01

... 21 Food and Drugs 8 2010-04-01 2010-04-01 false Scalp clip. 882.4150 Section 882.4150 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL DEVICES NEUROLOGICAL DEVICES Neurological Surgical Devices § 882.4150 Scalp clip. (a) Identification. A scalp clip is a...

21 CFR 882.4150 - Scalp clip.

Code of Federal Regulations, 2011 CFR

2011-04-01

... 21 Food and Drugs 8 2011-04-01 2011-04-01 false Scalp clip. 882.4150 Section 882.4150 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL DEVICES NEUROLOGICAL DEVICES Neurological Surgical Devices § 882.4150 Scalp clip. (a) Identification. A scalp clip is a...

21 CFR 882.4215 - Clip rack.

Code of Federal Regulations, 2010 CFR

2010-04-01

... 21 Food and Drugs 8 2010-04-01 2010-04-01 false Clip rack. 882.4215 Section 882.4215 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL DEVICES NEUROLOGICAL DEVICES Neurological Surgical Devices § 882.4215 Clip rack. (a) Identification. A clip rack is a...

21 CFR 882.4175 - Aneurysm clip applier.

Code of Federal Regulations, 2014 CFR

2014-04-01

... 21 Food and Drugs 8 2014-04-01 2014-04-01 false Aneurysm clip applier. 882.4175 Section 882.4175...) MEDICAL DEVICES NEUROLOGICAL DEVICES Neurological Surgical Devices § 882.4175 Aneurysm clip applier. (a) Identification. An aneurysm clip applier is a device used by the surgeon for holding and applying intracranial...

21 CFR 882.4175 - Aneurysm clip applier.

Code of Federal Regulations, 2013 CFR

2013-04-01

... 21 Food and Drugs 8 2013-04-01 2013-04-01 false Aneurysm clip applier. 882.4175 Section 882.4175...) MEDICAL DEVICES NEUROLOGICAL DEVICES Neurological Surgical Devices § 882.4175 Aneurysm clip applier. (a) Identification. An aneurysm clip applier is a device used by the surgeon for holding and applying intracranial...

21 CFR 882.4175 - Aneurysm clip applier.

Code of Federal Regulations, 2012 CFR

2012-04-01

... 21 Food and Drugs 8 2012-04-01 2012-04-01 false Aneurysm clip applier. 882.4175 Section 882.4175...) MEDICAL DEVICES NEUROLOGICAL DEVICES Neurological Surgical Devices § 882.4175 Aneurysm clip applier. (a) Identification. An aneurysm clip applier is a device used by the surgeon for holding and applying intracranial...

Angiographic and epidemiological characteristics associated with aneurysm remnants after microsurgical clipping

PubMed Central

Dellaretti, Marcos; da Silva Martins, Warley Carvalho; Dourado, Jules Carlos; Faglioni, Wilson; Quadros, Ricardo Souza; de Souza Moraes, Vítor Vieira; de Souza Filho, Carlos Batista Alves

2017-01-01

Background: Despite new techniques for the treatment of cerebral aneurysms, the percentage of aneurysm remnants after surgical intervention seems to be relatively constant. The objective of this study was to assess angiographic and epidemiological features associated with aneurysm remnants after microsurgical clipping. Methods: This study was conducted from February 2009 to August 2012 on a series of 90 patients with 105 aneurysms referred to the Santa Casa of Belo Horizonte who were surgically treated and angiographically controlled. Results: Surgical clipping was considered incomplete in 13.3% of the aneurysms. The mean age of cases with an aneurysm remnant was 57.5 years, whereas the mean age without aneurysm remnant was 49.7 years (P = 0.02). Aneurysm remnants were detected more frequently on the internal carotid artery, nevertheless, no statistically significant differences were verified when comparing the locations. Aneurysm size in the preoperative angiography verified that the mean size of aneurysms operated was 6.56 mm, such that in cases showing a postoperative remnant, the mean size was 9.7 mm and in cases with complete clipping it was 6.08 mm (P = 0.02). Postoperative angiography showed that, in cases with residual aneurysm, the number of clips used was higher – a mean of 1.8 for complete clipping and 3.1 for incomplete clipping (P < 0.001). Conclusions: Aneurysm size and patient age showed significant correlations with residual intracranial aneurysm. The mean number of clips used was higher in cases with incomplete occlusion. PMID:28904825

Advances in open microsurgery for cerebral aneurysms.

PubMed

Davies, Jason M; Lawton, Michael T

2014-02-01

Endovascular techniques introduced strong extrinsic forces that provoked reactive changes in aneurysm surgery. Microsurgery has become less invasive, more appealing to patients, lower risk, and efficacious for complex aneurysms, particularly those unfavorable for or failing endovascular therapy. To review specific advances in open microsurgery for aneurysms. A university-based, single-surgeon practice was examined for the use of minimally invasive craniotomies, surgical management of recurrence after coiling, the use of intracranial-intracranial bypass techniques, and cerebrovascular volume-outcome relationships. The mini-pterional, lateral supraorbital, and orbital-pterional craniotomies are minimally invasive alternatives to standard craniotomies. Mini-pterional and lateral supraorbital craniotomies were used in one-fourth of unruptured patients, increasing from 22% to 28%, whereas 15% of patients underwent orbital-pterional craniotomies and trended upward from 11% to 20%. Seventy-four patients were treated for coil recurrences (2.3% of all aneurysms) with direct clip occlusion (77%), clip occlusion after coil extraction (7%), or parent artery occlusion with bypass (16%). Intracranial-intracranial bypass (in situ bypass, reimplantation, reanastomosis, and intracranial grafts) transformed the management of giant aneurysms and made the surgical treatment of posterior inferior cerebellar artery aneurysms competitive with endovascular therapy. Centralization maximized the volume-outcome relationships observed with clipping. Aneurysm microsurgery has embraced minimalism, tailoring the exposure to the patient's anatomy with the smallest possible craniotomy that provides adequate exposure. The development of intracranial-intracranial bypasses is an important advancement that makes microsurgery a competitive option for complex and recurrent aneurysms. Trends toward centralizing aneurysm surgery in tertiary centers optimize results achievable with open microsurgery.

Protocol design and current status of CLIVIT: a randomized controlled multicenter relevance trial comparing clips versus ligatures in thyroid surgery

PubMed Central

Seiler, CM; Fröhlich, BE; Veit, JA; Gazyakan, E; Wente, MN; Wollermann, C; Deckert, A; Witte, S; Victor, N; Buchler, MW; Knaebel, HP

2006-01-01

Background Annually, more than 90000 surgical procedures of the thyroid gland are performed in Germany. Strategies aimed at reducing the duration of the surgical procedure are relevant to patients and the health care system especially in the context of reducing costs. However, new techniques for quick and safe hemostasis have to be tested in clinically relevance randomized controlled trials before a general recommendation can be given. The current standard for occlusion of blood vessels in thyroid surgery is ligatures. Vascular clips may be a safe alternative but have not been investigated in a large RCT. Methods/design CLIVIT (Clips versus Ligatures in Thyroid Surgery) is an investigator initiated, multicenter, patient-blinded, two-group parallel relevance randomized controlled trial designed by the Study Center of the German Surgical Society. Patients scheduled for elective resection of at least two third of the gland for benign thyroid disease are eligible for participation. After surgical exploration patients are randomized intraoperatively into either the conventional ligature group, or into the clip group. The primary objective is to test for a relevant reduction in operating time (at least 15 min) when using the clip technique. Since April 2004, 121 of the totally required 420 patients were randomized in five centers. Discussion As in all trials the different forms of bias have to be considered, and as in this case, a surgical trial, the role of surgical expertise plays a key role, and will be documented and analyzed separately. This is the first randomized controlled multicenter relevance trial to compare different vessel occlusion techniques in thyroid surgery with adequate power and other detailed information about the design as well as framework. If significant, the results might be generalized and may change the current surgical practice. PMID:16948853

Intraoperative Matas test using microscope-integrated intraoperative indocyanine green videoangiography with temporary unilateral occlusion of the A1 segment of the anterior cerebral artery.

PubMed

Murai, Yasuo; Adachi, Koji; Takagi, Ryo; Koketsu, Kenta; Matano, Fumihiro; Teramoto, Akira

2011-11-01

The aim of the present study was to assess a new technique of surgical microscope-based indocyanine green (ICG) videoangiography (VAG) to confirm the patency of the anterior communicating artery (AcomA) after clipping AcomA aneurysms. Aneurysmal clipping of five cases of unruptured, broad-neck AcomA aneurysm was performed using the Carl Zeiss Surgical Microscope OPMI Pentero INFRARED 800. In all five patients, after clipping AcomA aneurysms, the patency of AcomA was confirmed using ICGVAG findings and temporary unilateral occlusion of the A1 segment of the anterior cerebral artery using temporary clips. Images were excellent and enabled a real-time surgical assessment because the structures of interest, including vessels, perforating arteries, or residual aneurysm neck, were visible to the surgeon's eye under the microscope in all five patients. ICGVAG and temporary unilateral occlusion with clips provides a simple, reliable, real-time, and rapid intraoperative assessment of the patency of AcomA. This technique may help to improve the quality of neurosurgical procedures. Copyright © 2011 Elsevier Inc. All rights reserved.

Significantly Elevated C-Reactive Protein Levels After Epicardial Clipping of the Left Atrial Appendage.

PubMed

Verberkmoes, Niels J; Akca, Ferdi; Vandevenne, Ann-Sofie; Jacobs, Luuk; Soliman Hamad, Mohamed A; van Straten, Albert H M

Besides mechanical and anatomical changes of the left atrium, epicardial closure of the left atrial appendage has also possible homeostatic effects. The aim of this study was to assess whether epicardial clipping of the left atrial appendage has different biochemical effects compared with complete removal of the left atrial appendage. Eighty-two patients were included and underwent a totally thoracoscopic AF ablation procedure. As part of the procedure, the left atrial appendage was excluded with an epicardial clip (n = 57) or the left atrial appendage was fully amputated with an endoscopic vascular stapler (n = 25). From all patients' preprocedural and postprocedural blood pressure, electrolytes and inflammatory parameters were collected. The mean age and left atrial volume index were comparable between the epicardial clip and stapler group (64 ± 8 years vs. 60 ± 9 years, P = non-significant; 44 ± 15 mL/m vs. 40 ± 13 mL/m, P = non-significant). Patients receiving left atrial appendage clipping had significantly elevated C-reactive protein levels compared with patients who had left atrial appendage stapling at the second, third, and fourth postoperative day (225 ± 84 mg/L vs. 149 ± 76 mg/L, P = 0.002, 244 ± 78 vs. 167 ± 76, P = 0.004, 190 ± 74 vs. 105 ± 48, P < 0.001, respectively). Patients had a significant decrease in sodium levels, systolic, and diastolic blood pressure at 24 and 72 hours after left atrial appendage closure. However, this was comparable for both the left atrial appendage clipping and stapling group. Increased activation of the inflammatory response was observed after left atrial appendage clipping compared with left atrial appendage stapling. Furthermore, a significant decrease in blood pressure was observed after surgical removal of the left atrial appendage. Whether the inflammatory response affects the outcome of arrhythmia surgery needs to be further evaluated.

Surgical decision making in a teaching hospital: a linguistic analysis.

PubMed

Bezemer, Jeff; Murtagh, Ged; Cope, Alexandra; Kneebone, Roger

2016-10-01

The aim of the study was to gain insight in the involvement of non-operating surgeons in intraoperative surgical decision making at a teaching hospital. The decision to proceed to clip and cut the cystic duct during laparoscopic cholecystectomy was investigated through direct observation of team work. Eleven laparoscopic cholecystectomies performed by consultant surgeons and specialty trainees at a London teaching hospital were audio and video recorded. Talk among the surgical team was transcribed and subjected to linguistic analysis, in conjunction with observational analysis of the video material, sequentially marking the unfolding operation. Two components of decision making were identified, participation and rationalization. Participation refers to the degree to which agreement was sought within the surgical team prior to clipping the cystic duct. Rationalization refers to the degree to which the evidential grounds for clipping and cutting were verbalized. The decision to clip and cut the cystic duct was jointly made by members of the surgical team, rather than a solitary surgeon in the majority of cases, involving verbal explication of clinical reasoning and verbal agreement. The extent of joint decision making appears to have been mitigated by two factors: trainee's level of training and duration of the case. © 2014 Royal Australasian College of Surgeons.

21 CFR 882.4200 - Clip removal instrument.

Code of Federal Regulations, 2011 CFR

2011-04-01

... 21 Food and Drugs 8 2011-04-01 2011-04-01 false Clip removal instrument. 882.4200 Section 882.4200 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL DEVICES NEUROLOGICAL DEVICES Neurological Surgical Devices § 882.4200 Clip removal instrument. (a...

21 CFR 882.4175 - Aneurysm clip applier.

Code of Federal Regulations, 2011 CFR

2011-04-01

... 21 Food and Drugs 8 2011-04-01 2011-04-01 false Aneurysm clip applier. 882.4175 Section 882.4175 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL DEVICES NEUROLOGICAL DEVICES Neurological Surgical Devices § 882.4175 Aneurysm clip applier. (a...

21 CFR 882.4190 - Clip forming/cutting instrument.

Code of Federal Regulations, 2011 CFR

2011-04-01

... 21 Food and Drugs 8 2011-04-01 2011-04-01 false Clip forming/cutting instrument. 882.4190 Section 882.4190 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL DEVICES NEUROLOGICAL DEVICES Neurological Surgical Devices § 882.4190 Clip forming...

21 CFR 882.4175 - Aneurysm clip applier.

Code of Federal Regulations, 2010 CFR

2010-04-01

... 21 Food and Drugs 8 2010-04-01 2010-04-01 false Aneurysm clip applier. 882.4175 Section 882.4175 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL DEVICES NEUROLOGICAL DEVICES Neurological Surgical Devices § 882.4175 Aneurysm clip applier. (a...

21 CFR 882.4200 - Clip removal instrument.

Code of Federal Regulations, 2010 CFR

2010-04-01

... 21 Food and Drugs 8 2010-04-01 2010-04-01 false Clip removal instrument. 882.4200 Section 882.4200 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL DEVICES NEUROLOGICAL DEVICES Neurological Surgical Devices § 882.4200 Clip removal instrument. (a...

21 CFR 878.4300 - Implantable clip.

Code of Federal Regulations, 2014 CFR

2014-04-01

... 21 Food and Drugs 8 2014-04-01 2014-04-01 false Implantable clip. 878.4300 Section 878.4300 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL DEVICES GENERAL AND PLASTIC SURGERY DEVICES Surgical Devices § 878.4300 Implantable clip. (a...

21 CFR 878.4300 - Implantable clip.

Code of Federal Regulations, 2011 CFR

2011-04-01

... 21 Food and Drugs 8 2011-04-01 2011-04-01 false Implantable clip. 878.4300 Section 878.4300 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL DEVICES GENERAL AND PLASTIC SURGERY DEVICES Surgical Devices § 878.4300 Implantable clip. (a...

21 CFR 878.4300 - Implantable clip.

Code of Federal Regulations, 2012 CFR

2012-04-01

... 21 Food and Drugs 8 2012-04-01 2012-04-01 false Implantable clip. 878.4300 Section 878.4300 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL DEVICES GENERAL AND PLASTIC SURGERY DEVICES Surgical Devices § 878.4300 Implantable clip. (a...

21 CFR 878.4300 - Implantable clip.

Code of Federal Regulations, 2013 CFR

2013-04-01

... 21 Food and Drugs 8 2013-04-01 2013-04-01 false Implantable clip. 878.4300 Section 878.4300 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL DEVICES GENERAL AND PLASTIC SURGERY DEVICES Surgical Devices § 878.4300 Implantable clip. (a...

21 CFR 878.4300 - Implantable clip.

Code of Federal Regulations, 2010 CFR

2010-04-01

... 21 Food and Drugs 8 2010-04-01 2010-04-01 false Implantable clip. 878.4300 Section 878.4300 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL DEVICES GENERAL AND PLASTIC SURGERY DEVICES Surgical Devices § 878.4300 Implantable clip. (a...

21 CFR 878.4320 - Removable skin clip.

Code of Federal Regulations, 2013 CFR

2013-04-01

... 21 Food and Drugs 8 2013-04-01 2013-04-01 false Removable skin clip. 878.4320 Section 878.4320 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL DEVICES GENERAL AND PLASTIC SURGERY DEVICES Surgical Devices § 878.4320 Removable skin clip. (a...

21 CFR 878.4320 - Removable skin clip.

Code of Federal Regulations, 2011 CFR

2011-04-01

... 21 Food and Drugs 8 2011-04-01 2011-04-01 false Removable skin clip. 878.4320 Section 878.4320 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL DEVICES GENERAL AND PLASTIC SURGERY DEVICES Surgical Devices § 878.4320 Removable skin clip. (a...

21 CFR 878.4320 - Removable skin clip.

Code of Federal Regulations, 2012 CFR

2012-04-01

... 21 Food and Drugs 8 2012-04-01 2012-04-01 false Removable skin clip. 878.4320 Section 878.4320 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL DEVICES GENERAL AND PLASTIC SURGERY DEVICES Surgical Devices § 878.4320 Removable skin clip. (a...

21 CFR 878.4320 - Removable skin clip.

Code of Federal Regulations, 2014 CFR

2014-04-01

... 21 Food and Drugs 8 2014-04-01 2014-04-01 false Removable skin clip. 878.4320 Section 878.4320 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL DEVICES GENERAL AND PLASTIC SURGERY DEVICES Surgical Devices § 878.4320 Removable skin clip. (a...

[Hurt eczematiforme column (chronicle) of the breast after implementation of a surgical clip].

PubMed

Motton, S; Gardinal, I; Soulé-Tholy, M; Viraben, R; Hoff, J; Leguevaque, P

2011-04-01

We report a case of atopic dermatitis in relation with a surgical titanium clip. Such a complication has only been reported once in the literature. We advocate to ask the patients about query atopic manifestations especially contact dermatitis to metal before any procedure involving metallic implants. Copyright © 2010 Elsevier Masson SAS. All rights reserved.

Oculomotor nerve palsy by posterior communicating artery aneurysms: influence of surgical strategy on recovery.

PubMed

Güresir, Erdem; Schuss, Patrick; Seifert, Volker; Vatter, Hartmut

2012-11-01

Resolution of oculomotor nerve palsy (ONP) after clipping of posterior communicating artery (PCoA) aneurysms has been well documented. However, whether additional decompression of the oculomotor nerve via aneurysm sac dissection or resection is superior to pure aneurysm clipping is the subject of much debate. Therefore, the objective in the present investigation was to analyze the influence of surgical strategy--specifically, clipping with or without aneurysm dissection--on ONP resolution. Between June 1999 and December 2010, 18 consecutive patients with ruptured and unruptured PCoA aneurysms causing ONP were treated at the authors' institution. Oculomotor nerve palsy was evaluated on admission and at follow-up. The electronic database MEDLINE was searched for additional data in published studies of PCoA aneurysms causing ONP. Two reviewers independently extracted data. Overall, 8 studies from the literature review and 6 patients in the current series (121 PCoA aneurysms) met the study inclusion criteria. Ninety-four aneurysms were treated with simple aneurysm neck clipping and 27 with clipping plus aneurysm sac decompression. The surgical strategy, simple aneurysm neck clipping versus clipping plus oculomotor nerve decompression, had no effect on full ONP resolution on univariate (p = 0.5) and multivariate analyses. On multivariate analysis, patients with incomplete ONP at admission were more likely to have full resolution of the palsy than were those with complete ONP at admission (p = 0.03, OR = 4.2, 95% CI 1.1-16). Data in the present study indicated that ONP caused by PCoA aneurysms improves after clipping without and with oculomotor nerve decompression. The resolution of ONP is inversely associated with the initial severity of ONP.

Epicardial clip occlusion of the left atrial appendage during cardiac surgery provides optimal surgical results and long-term stability.

PubMed

Kurfirst, Vojtech; Mokrácek, Aleš; Canádyová, Júlia; Frána, Radim; Zeman, Petr

2017-07-01

Occlusion of the left atrial appendage (LAA) has become an integral and important part of the surgical treatment of atrial fibrillation. Different methods of surgical occlusion of the LAA have been associated with varying levels of short- and long-term success for closure. The purpose of this study was to evaluate long-term results of epicardial placement and endocardial occlusion in patients undergoing cardiac operative procedures. A total of 101 patients (average age 65.7 years) undergoing cardiac operative procedures with the epicardial AtriClip Exclusion System of the LAA were enrolled in the study. The AtriClip was placed via a sternotomy or a thoracotomy or from a thoracoscopic approach. Postoperative variables, such as thromboembolic events, clip stability and endocardial leakage around the device, were examined by transoesophageal echocardiography (TEE) and/or computed tomography. Perioperative clip implantation was achieved in 98% of patients. TEE and/or computed tomography conducted during the follow-up period, comprising 1873 patient-months with a mean duration of 18 ± 11 months, revealed no clip migration, no leakage around the device and no clot formation near the remnant cul-de-sac. During the follow-up period, 4 of the cardiac patients experienced transitory ischaemic attacks, whereas no patient experienced a cerebrovascular attack. The Epicardial AtriClip Exclusion System of the LAA appears to be a feasable and safe operative method with a high success rate. Long-term follow-up confirmed clip stability, complete occlussion of the LAA and absence of any atrial fibrilation-related thromboembolic events. These results need to be confirmed by a larger, multicentre study. © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Catheter Entrapment During Posterior Mitral Leaflet Pushing Maneuver for MitraClip Implantation.

PubMed

Castrodeza, Javier; Amat-Santos, Ignacio J; Tobar, Javier; Varela-Falcón, Luis H

2016-06-01

MitraClip (Abbott Vascular) therapy has been reported to be an effective procedure for mitral regurgitation, especially in high-risk patients. Recently, the novel pushing maneuver technique has been described for approaching restricted and short posterior leaflets with a pigtail catheter in order to facilitate grasping of the clip. However, complications or unexpected situations may occur. We report the case of an 84-year-old patient who underwent MitraClip implantation wherein the pushing maneuver was complicated by the clip accidentally gripping the pigtail catheter along with the two leaflets.

Surgical gesture classification from video and kinematic data.

PubMed

Zappella, Luca; Béjar, Benjamín; Hager, Gregory; Vidal, René

2013-10-01

Much of the existing work on automatic classification of gestures and skill in robotic surgery is based on dynamic cues (e.g., time to completion, speed, forces, torque) or kinematic data (e.g., robot trajectories and velocities). While videos could be equally or more discriminative (e.g., videos contain semantic information not present in kinematic data), they are typically not used because of the difficulties associated with automatic video interpretation. In this paper, we propose several methods for automatic surgical gesture classification from video data. We assume that the video of a surgical task (e.g., suturing) has been segmented into video clips corresponding to a single gesture (e.g., grabbing the needle, passing the needle) and propose three methods to classify the gesture of each video clip. In the first one, we model each video clip as the output of a linear dynamical system (LDS) and use metrics in the space of LDSs to classify new video clips. In the second one, we use spatio-temporal features extracted from each video clip to learn a dictionary of spatio-temporal words, and use a bag-of-features (BoF) approach to classify new video clips. In the third one, we use multiple kernel learning (MKL) to combine the LDS and BoF approaches. Since the LDS approach is also applicable to kinematic data, we also use MKL to combine both types of data in order to exploit their complementarity. Our experiments on a typical surgical training setup show that methods based on video data perform equally well, if not better, than state-of-the-art approaches based on kinematic data. In turn, the combination of both kinematic and video data outperforms any other algorithm based on one type of data alone. Copyright © 2013 Elsevier B.V. All rights reserved.

SU-E-J-64: Feasibility Study of Surgical Clips for Fiducial Tracking in CyberKnife System

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

Lee, H; Yoon, J; Lee, E

Purpose: To investigate the ability of CyberKnife to track surgical clips used as fiducial markers. Methods: The Octavius 1000SRS detector and solid water (RW3) slab phantom were used with motion platform to evaluate the study. The RW3 slab phantom was set up to measure the dose distribution from coronal plane. It consists of 9 plates and the thickness of each plate is 10mm. Among them, one plate was attached with 3 surgical clips, which are orthogonally positioned on outer region of array. The length of attached clip was represented as 1cm on planning CT. The clip plate was placed onmore » the 1000SRS detector and 3 slabs were stacked up on the plate to build the measuring depth. Below the detector, 5 slabs were set. The two-axis motion platform was programmed with 1D sinusoidal movement (20mm peak-to-peak, 3s period) toward superior/inferior and left/right directions to simulate target motion. During delivery, two clips were extracted by two X-ray imagers, which led to translational error correction only. Synchrony was also used for dynamic tracking. After the irradiation, the measured dose distribution of coronal plane was compared with the planar dose distribution calculated by the CyberKnife treatment planning system (Multiplan) for cross verification. The results were assessed by comparing the absolute Gamma (γ) index. Results: The dose distributions measured by the 1000SRS detector were in good agreements with those calculated by Multiplan. In the dosimetric comparison using γ-function criteria based on the distance-to-agreement of 3mm and the local dose difference of 3%, the passing rate with γ- parameter ≤1 was 91% in coronal plane. Conclusion: The surgical clips can be considered as new fiducials for robotic radiosurgery delivery by considering the target margin with less than 5mm.« less

Virtual reality cerebral aneurysm clipping simulation with real-time haptic feedback.

PubMed

Alaraj, Ali; Luciano, Cristian J; Bailey, Daniel P; Elsenousi, Abdussalam; Roitberg, Ben Z; Bernardo, Antonio; Banerjee, P Pat; Charbel, Fady T

2015-03-01

With the decrease in the number of cerebral aneurysms treated surgically and the increase of complexity of those treated surgically, there is a need for simulation-based tools to teach future neurosurgeons the operative techniques of aneurysm clipping. To develop and evaluate the usefulness of a new haptic-based virtual reality simulator in the training of neurosurgical residents. A real-time sensory haptic feedback virtual reality aneurysm clipping simulator was developed using the ImmersiveTouch platform. A prototype middle cerebral artery aneurysm simulation was created from a computed tomographic angiogram. Aneurysm and vessel volume deformation and haptic feedback are provided in a 3-dimensional immersive virtual reality environment. Intraoperative aneurysm rupture was also simulated. Seventeen neurosurgery residents from 3 residency programs tested the simulator and provided feedback on its usefulness and resemblance to real aneurysm clipping surgery. Residents thought that the simulation would be useful in preparing for real-life surgery. About two-thirds of the residents thought that the 3-dimensional immersive anatomic details provided a close resemblance to real operative anatomy and accurate guidance for deciding surgical approaches. They thought the simulation was useful for preoperative surgical rehearsal and neurosurgical training. A third of the residents thought that the technology in its current form provided realistic haptic feedback for aneurysm surgery. Neurosurgical residents thought that the novel immersive VR simulator is helpful in their training, especially because they do not get a chance to perform aneurysm clippings until late in their residency programs.

Optic neuropathy after anterior communicating artery aneurysm clipping: 3 cases and techniques to address a correctable pitfall.

PubMed

Linzey, Joseph R; Chen, Kevin S; Savastano, Luis; Thompson, B Gregory; Pandey, Aditya S

2018-06-01

Brain shifts following microsurgical clip ligation of anterior communicating artery (ACoA) aneurysms can lead to mechanical compression of the optic nerve by the clip. Recognition of this condition and early repositioning of clips can lead to reversal of vision loss. The authors identified 3 patients with an afferent pupillary defect following microsurgical clipping of ACoA aneurysms. Different treatment options were used for each patient. All patients underwent reexploration, and the aneurysm clips were repositioned to prevent clip-related compression of the optic nerve. Near-complete restoration of vision was achieved at the last clinic follow-up visit in all 3 patients. Clip ligation of ACoA aneurysms has the potential to cause clip-related compression of the optic nerve. Postoperative visual examination is of utmost importance, and if any changes are discovered, reexploration should be considered as repositioning of the clips may lead to resolution of visual deterioration.

An Efficient Method for Hair Containment During Head and Neck Surgery.

PubMed

Zingaretti, Nicola; De Biasio, Fabrizio; Riccio, Michele; Marchesi, Andrea; Parodi, Pier Camillo

2017-11-01

The authors present a simple technique for operations around hair-bearing areas such as during a rhytidectomy. Hair surrounding the surgical field is twisted into bundles and clipped with duckbill clips. The authors repeat the procedure for each strand of hair. Between 5 and 7 duckbill clips may be required per surgery.The clippers are faster, easily applicable, and well performing. They can be used with different hair lengths, and they do not require any additional trimming or shaving; clips also keep the hair firmly in place, and they do not loosen up in the process.This technical note explains a very simple, economical, and less time-consuming method to control hair located around the surgical site. It may be applied to all procedures within the field of the hair-bearing scalp, including craniofacial and maxillofacial surgery.

Real-time surgery simulation of intracranial aneurysm clipping with patient-specific geometries and haptic feedback

NASA Astrophysics Data System (ADS)

Fenz, Wolfgang; Dirnberger, Johannes

2015-03-01

Providing suitable training for aspiring neurosurgeons is becoming more and more problematic. The increasing popularity of the endovascular treatment of intracranial aneurysms leads to a lack of simple surgical situations for clipping operations, leaving mainly the complex cases, which present even experienced surgeons with a challenge. To alleviate this situation, we have developed a training simulator with haptic interaction allowing trainees to practice virtual clipping surgeries on real patient-specific vessel geometries. By using specialized finite element (FEM) algorithms (fast finite element method, matrix condensation) combined with GPU acceleration, we can achieve the necessary frame rate for smooth real-time interaction with the detailed models needed for a realistic simulation of the vessel wall deformation caused by the clamping with surgical clips. Vessel wall geometries for typical training scenarios were obtained from 3D-reconstructed medical image data, while for the instruments (clipping forceps, various types of clips, suction tubes) we use models provided by manufacturer Aesculap AG. Collisions between vessel and instruments have to be continuously detected and transformed into corresponding boundary conditions and feedback forces, calculated using a contact plane method. After a training, the achieved result can be assessed based on various criteria, including a simulation of the residual blood flow into the aneurysm. Rigid models of the surgical access and surrounding brain tissue, plus coupling a real forceps to the haptic input device further increase the realism of the simulation.

Transcatheter Treatment of Tricuspid Regurgitation Using Edge-to-Edge Repair: Procedural Results, Clinical Implications and Predictors for Success.

PubMed

Lurz, Philipp; Besler, Christian; Noack, Thilo; Forner, Anna Flo; Bevilacqua, Carmine; Seeburger, Joerg; Rommel, Karl-Philipp; Blazek, Stephan; Hartung, Philipp; Zimmer, Marion; Mohr, Friedrich; Schuler, Gerhard; Linke, Axel; Ender, Joerg; Thiele, Holger

2018-04-10

To analyze the feasibility, safety and effectiveness of Tricuspid valve (TV) repair using the MitraClip system in patients at high surgical risk. Forty-two elderly high-risk patients (76.8±7.3 years, EuroScore II 8.1±5.7) with isolated TR or combined TR and mitral regurgitation (MR) underwent edge-to-edge repair of the TV (n=11) or combined edge-to-edge repair of the TV and mitral valve (n=31). Procedural details, success rate, impact on TR severity and predictors for success at 30 day follow-up were analyzed. Successful edge-to-edge repair of TR was achieved in 35/42 patients (83%, 68 clips in total, 94% in the anteroseptal commissure, 6% in the posteroseptal commissure). In 5 patients, grasping of the leaflets was impossible and two patients had no decrease in TR after clipping. In those with procedural success, clipping of the TV led to a reduction in effective regurgitant orifice area by -62,5 % (from 0.8±0.4 to 0.3±0.2 cm2; p<0.0001). In both, patients with isolated TV and combined procedures, 6 minute walking distance improved (from 285±118 to 344±81 and 225±113 to 261±130 m, p=0.02 and 0.03, respectively). Predominant anteroseptal or central TR was identified as predictor of procedural success (p=0.025). Edge-to-edge repair of the TV is feasible with promising reduction in TR, which could result in clinical improvement.

Audiological comparison between two different clips prostheses in stapes surgery.

PubMed

Potena, M; Portmann, D; Guindi, S

2015-01-01

To compare audiometric results and complications of stapes surgery with two different types of piston prosthesis, the Portmann Clip Piston (Medtronic) (PCP) and the Soft Clip Piston (Kurz) (SCP). Study conducted on 64 patients who underwent primary stapedotomy from 2008 to 2011. We matched for each case of stapedotomy with the PCP (Medtronic Xomed Inc. Portmann Clip Piston Stainless Steel/Fluoroplastic) a case with the SCP (Heinz Kurz GmbH Medizintechnik Soft Piston Clip Titanium). Each group consisted of 32 patients, and patients in both groups were matched with respect to gender, age, bilateral or unilateral otosclerosis, otological symptoms (tinnitus, vertigo or dizziness), family history, operated side and the Portmann grading for otosclerosis. The length of the prosthesis used was reported. Post-operative complications such as tinnitus, vertigo, hearing loss and altered taste were documented. Each patient was subjected to a preoperative and postoperative audiogram (follow-up at the second month after the surgery). We used the Student test for statistical analysis. Statistical significance was set at < 0.01. None of the patients experienced a post-operative hearing loss and none required a later revision surgery. No statistically significant difference was found between the two populations regarding demographic data (age, sex, side, bilaterality, family history, stage and lenght of piston) and hearing level (> 0.01) in the air, bone conduction and air-bone gap (ABG). Postoperative complications did not result to be significantly different between the two groups. Also, both groups showed a significant improvement (< 0.01) in the post-operative air, bone conduction and air-bone gap. There was no statistically significant difference (> 0.01) between the post-operative hearing results (bone conduction, air conduction, air-bone gap) using the two pistons. The mean ABG improvement was respectively 16.63 dB in the SCP group and 20.59 dB in the PCP group. The titanium Soft clip piston (SCP) is a good alternative to the Portmann clip piston (PCP). Nevertheless there are some differences in the surgical fixing of these two pistons in the correct position.

Coil Embolization for Intracranial Aneurysms

PubMed Central

2006-01-01

Executive Summary Objective To determine the effectiveness and cost-effectiveness of coil embolization compared with surgical clipping to treat intracranial aneurysms. The Technology Endovascular coil embolization is a percutaneous approach to treat an intracranial aneurysm from within the blood vessel without the need of a craniotomy. In this procedure, a microcatheter is inserted into the femoral artery near the groin and navigated to the site of the aneurysm. Small helical platinum coils are deployed through the microcatheter to fill the aneurysm, and prevent it from further expansion and rupture. Health Canada has approved numerous types of coils and coil delivery systems to treat intracranial aneurysms. The most favoured are controlled detachable coils. Coil embolization may be used with other adjunct endovascular devices such as stents and balloons. Background Intracranial Aneurysms Intracranial aneurysms are the dilation or ballooning of part of a blood vessel in the brain. Intracranial aneurysms range in size from small (<12 mm in diameter) to large (12–25 mm), and to giant (>25 mm). There are 3 main types of aneurysms. Fusiform aneurysms involve the entire circumference of the artery; saccular aneurysms have outpouchings; and dissecting aneurysms have tears in the arterial wall. Berry aneurysms are saccular aneurysms with well-defined necks. Intracranial aneurysms may occur in any blood vessel of the brain; however, they are most commonly found at the branch points of large arteries that form the circle of Willis at the base of the brain. In 85% to 95% of patients, they are found in the anterior circulation. Aneurysms in the posterior circulation are less frequent, and are more difficult to treat surgically due to inaccessibility. Most intracranial aneurysms are small and asymptomatic. Large aneurysms may have a mass effect, causing compression on the brain and cranial nerves and neurological deficits. When an intracranial aneurysm ruptures and bleeds, resulting in a subarachnoid hemorrhage (SAH), the mortality rate can be 40% to 50%, with severe morbidity of 10% to 20%. The reported overall risk of rupture is 1.9% per year and is higher for women, cigarette smokers, and cocaine users, and in aneurysms that are symptomatic, greater than 10 mm in diameter, or located in the posterior circulation. If left untreated, there is a considerable risk of repeat hemorrhage in a ruptured aneurysm that results in increased mortality. In Ontario, intracranial aneurysms occur in about 1% to 4% of the population, and the annual incidence of SAH is about 10 cases per 100,000 people. In 2004-2005, about 660 intracranial aneurysm repairs were performed in Ontario. Treatment of Intracranial Aneurysms Treatment of an unruptured aneurysm attempts to prevent the aneurysm from rupturing. The treatment of a ruptured intracranial aneurysm aims to prevent further hemorrhage. There are 3 approaches to treating an intracranial aneurysm. Small, asymptomatic aneurysms less than 10 mm in diameter may be monitored without any intervention other than treatment for underlying risk factors such as hypertension. Open surgical clipping, involves craniotomy, brain retraction, and placement of a silver clip across the neck of the aneurysm while a patient is under general anesthesia. This procedure is associated with surgical risks and neurological deficits. Endovascular coil embolization, introduced in the 1990s, is the health technology under review. Literature Review Methods The Medical Advisory Secretariat searched the International Health Technology Assessment (INAHTA) Database and the Cochrane Database of Systematic Reviews to identify relevant systematic reviews. OVID Medline, Medline In-Process and Other Non-Indexed Citations, and Embase were searched for English-language journal articles that reported primary data on the effectiveness or cost-effectiveness of treatments for intracranial aneurysms, obtained in a clinical setting or analyses of primary data maintained in registers or institutional databases. Internet searches of Medscape and manufacturers’ databases were conducted to identify product information and recent reports on trials that were unpublished but that were presented at international conferences. Four systematic reviews, 3 reports on 2 randomized controlled trials comparing coil embolization with surgical clipping of ruptured aneurysms, 30 observational studies, and 3 economic analysis reports were included in this review. Results Safety and Effectiveness Coil embolization appears to be a safe procedure. Complications associated with coil embolization ranged from 8.6% to 18.6% with a median of about 10.6%. Observational studies showed that coil embolization is associated with lower complication rates than surgical clipping (permanent complication 3-7% versus 10.9%; overall 23% versus 46% respectively, p=0.009). Common complications of coil embolization are thrombo-embolic events (2.5%–14.5%), perforation of aneurysm (2.3%–4.7%), parent artery obstruction (2%–3%), collapsed coils (8%), coil malposition (14.6%), and coil migration (0.5%–3%). Randomized controlled trials showed that for ruptured intracranial aneurysms with SAH, suitable for both coil embolization and surgical clipping (mostly saccular aneurysms <10 mm in diameter located in the anterior circulation) in people with good clinical condition:Coil embolization resulted in a statistically significant 23.9% relative risk reduction and 7% absolute risk reduction in the composite rate of death and dependency compared to surgical clipping (modified Rankin score 3–6) at 1-year. The advantage of coil embolization over surgical clipping varies widely with aneurysm location, but endovascular treatment seems beneficial for all sites. There were less deaths in the first 7 years following coil embolization compared to surgical clipping (10.8% vs 13.7%). This survival benefit seemed to be consistent over time, and was statistically significant (log-rank p= 0.03). Coil embolization is associated with less frequent MRI-detected superficial brain deficits and ischemic lesions at 1-year. The 1- year rebleeding rate was 2.4% after coil embolization and 1% for surgical clipping. Confirmed rebleeding from the repaired aneurysm after the first year and up to year eight was low and not significantly different between coil embolization and surgical clipping (7 patients for coil embolization vs 2 patients for surgical clipping, log-rank p=0.22). Observational studies showed that patients with SAH and good clinical grade had better 6-month outcomes and lower risk of symptomatic cerebral vasospasm after coil embolization compared to surgical clipping. For unruptured intracranial aneurysms, there were no randomized controlled trials that compared coil embolization to surgical clipping. Large observational studies showed that: The risk of rupture in unruptured aneurysms less than 10 mm in diameter is about 0.05% per year for patients with no pervious history of SAH from another aneurysm. The risk of rupture increases with history of SAH and as the diameter of the aneurysm reaches 10 mm or more. Coil embolization reduced the composite rate of in hospital deaths and discharge to long-term or short-term care facilities compared to surgical clipping (Odds Ratio 2.2, 95% CI 1.6–3.1, p<0.001). The improvement in discharge disposition was highest in people older than 65 years. In-hospital mortality rate following treatment of intracranial aneurysm ranged from 0.5% to 1.7% for coil embolization and from 2.1% to 3.5% for surgical clipping. The overall 1-year mortality rate was 3.1% for coil embolization and 2.3% for surgical clipping. One-year morbidity rate was 6.4% for coil embolization and 9.8% for surgical clipping. It is not clear whether these differences were statistically significant. Coil embolization is associated with shorter hospital stay compared to surgical clipping. For both ruptured and unruptured aneurysms, the outcome of coil embolization does not appear to be dependent on age, whereas surgical clipping has been shown to yield worse outcome for patients older than 64 years. Angiographic Efficiency and Recurrences The main drawback of coil embolization is its low angiographic efficiency. The percentage of complete aneurysm occlusion after coil embolization (27%–79%, median 55%) remains lower than that achieved with surgical clipping (82%–100%). However, about 90% of coiled aneurysms achieve near total occlusion or better. Incompletely coiled aneurysms have been shown to have higher aneurysm recurrence rates ranging from 7% to 39% for coil embolization compared to 2.9% for surgical clipping. Recurrence is defined as refilling of the neck, sac, or dome of a successfully treated aneurysm as shown on an angiogram. The long-term clinical significance of incomplete occlusion following coil embolization is unknown, but in one case series, 20% of patients had major recurrences, and 50% of these required further treatment. Long-Term Outcomes A large international randomized trial reported that the survival benefit from coil embolization was sustained for at least 7 years. The rebleeding rate between year 2 and year 8 following coil embolization was low and not significantly different from that of surgical clipping. However, high quality long-term angiographic evidence is lacking. Accordingly, there is uncertainty about long-term occlusion status, coil durability, and recurrence rates. While surgical clipping is associated with higher immediate procedural risks, its long-term effectiveness has been established. Indications and Contraindications Coil embolization offers treatment for people at increased risk for craniotomy, such as those over 65 years of age, with poor clinical status, or with comorbid conditions. The technology also makes it possible to treat surgical high-risk aneurysms. Not all aneurysms are suitable for coil embolization. Suitability depends on the size, anatomy, and location of the aneurysm. Aneurysms more than 10 mm in diameter or with an aneurysm neck greater than or equal to 4 mm are less likely to achieve total occlusion. They are also more prone to aneurysm recurrences and to complications such as coil compaction or parent vessel occlusion. Aneurysms with a dome to neck ratio of less than 1 have been shown to have lower obliteration rates and poorer outcome following coil embolization. Furthermore, aneurysms in the middle cerebral artery bifurcation are less suitable for coil embolization. For some aneurysms, treatment may require the use of both coil embolization and surgical clipping or adjunctive technologies, such as stents and balloons, to obtain optimal results. Diffusion Information from 3 countries indicates that coil embolization is a rapidly diffusing technology. For example, it accounted for about 40% of aneurysm treatments in the United Kingdom. In Ontario, coil embolization is an insured health service, with the same fee code and fee schedule as open surgical repair requiring craniotomy. Other costs associated with coil embolization are covered under hospitals’ global budgets. Utilization data showed that in 2004-2005, coil embolization accounted for about 38% (251 cases) of all intracranial aneurysm repairs in the province. With the 2005 publication of the positive long-term survival data from the International Subarachnoid Aneursym Trial, the pressure for diffusion will likely increase. Economic Analysis Recent economic studies show that treatment of unruptured intracranial aneurysms smaller than 10 mm in diameter in people with no previous history of SAH, either by coil embolization or surgical clipping, would not be effective or cost-effective. However, in patients with aneurysms that are greater than or equal to 10 mm or symptomatic, or in patients with a history of SAH, treatment appears to be cost-effective. In Ontario, the average device cost of coil embolization per case was estimated to be about $7,500 higher than surgical clipping. Assuming that the total number of intracranial aneurysm repairs in Ontario increases to 750 in the fiscal year of 2007, and assuming that up to 60% (450 cases) of these will be repaired by coil embolization, the difference in device costs for the 450 cases (including a 15% recurrence rate) would be approximately $3.8 million. This figure does not include capital costs (e.g. $3 million for an angiosuite), additional human resources required, or costs of follow-up. The increase in expenditures associated with coil embolization may be offset partially, by shorter operating room times and hospitalization stays for endovascular repair of unruptured aneurysms; however, the impact of these cost savings is probably not likely to be greater than 25% of the total outlay since the majority of cases involve ruptured aneurysms. Furthermore, the recent growth in aneurysm repair has predominantly been in the area of coil embolization presumably for patients for whom surgical clipping would not be advised; therefore, no offset of surgical clipping costs could be applied in such cases. For ruptured aneurysms, downstream cost savings from endovascular repair are likely to be minimal even though the savings for individual cases may be substantial due to lower perioperative complications for endovascular aneurysm repair. Guidelines The two Guidance documents issued by the National Institute of Clinical Excellence (UK) in 2005 support the use of coil embolization for both unruptured and ruptured (SAH) intracranial aneurysms, provided that procedures are in place for informed consent, audit, and clinical governance, and that the procedure is performed in specialist units with expertise in the endovascular treatment of intracranial aneurysms. Conclusion For people in good clinical condition following subarachnoid hemorrhage from an acute ruptured intracranial aneurysm suitable for either surgical clipping or endovascular repair, coil embolization results in improved independent survival in the first year and improved survival for up to seven years compared to surgical clipping. The rebleeding rate is low and not significantly different between the two procedures after the first year. However, there is uncertainty regarding the long-term occlusion status, durability of the stent graft, and long-term complications. For people with unruptured aneurysms, level 4 evidence suggests that coil embolization may be associated with comparable or less mortality and morbidity, shorter hospital stay, and less need for discharge to short-term rehabilitation facilities. The greatest benefit was observed in people over 65 years of age. In these patients, the decision regarding treatment needs to be based on the assessment of the risk of rupture against the risk of the procedure, as well as the morphology of the aneurysm. In people who require treatment for intracranial aneurysm, but for whom surgical clipping is too risky or not feasible, coil embolization provides survival benefits over surgical clipping, even though the outcomes may not be as favourable as in people in good clinical condition and with small aneurysms. The procedure may be considered under the following circumstances provided that the aneurysm is suitable for coil embolization: Patients in poor/unstable clinical or neurological state Patients at high risk for surgical repair (e.g. people>age 65 or with comorbidity), or Aneurysm(s) with poor accessibility or visibility for surgical treatment due to their location (e.g. ophthalmic or basilar tip aneurysms) Compared to small aneurysms with a narrow neck in the anterior circulation, large aneurysms (> 10 mm in diameter), aneurysms with a wide neck (>4mm in diameter), and aneurysms in the posterior circulation have lower occlusion rates and higher rate of hemorrhage when treated with coil embolization. The extent of aneurysm obliteration after coil embolization remains lower than that achieved with surgical clipping. Aneurysm recurrences after successful coiling may require repeat treatment with endovascular or surgical procedures. Experts caution that long-term angiographic outcomes of coil embolization are unknown at this time. Informed consent for and long-term follow-up after coil embolization are recommended. The decision to treat an intracranial aneurysm with surgical clipping or coil embolization needs to be made jointly by the neurosurgeon and neuro-intervention specialist, based on the clinical status of the patient, the size and morphology of the aneurysm, and the preference of the patient. The performance of endovascular coil embolization should take place in centres with expertise in both neurosurgery and endovascular neuro-interventions, with adequate treatment volumes to maintain good outcomes. Distribution of the technology should also take into account that patients with SAH should be treated as soon as possible with minimal disruption. PMID:23074479

Efficacy and safety of the remOVE System for OTSC® and FTRD® clip removal: data from a PMCF analysis.

PubMed

Caputo, Antonio; Schmidt, Arthur; Caca, Karel; Bauerfeind, Peter; Schostek, Sebastian; Ho, Chi-Nghia; Gottwald, Thomas; Schurr, Marc O

2018-06-01

The remOVE System (Ovesco Endoscopy AG, Tuebingen, Germany) is a medical device for the endoscopic removal of OTSC or FTRD clips (Ovesco Endoscopy AG, Tuebingen, Germany). The aim of this paper is to assess the efficacy and safety of this system. A total of 74 patients underwent clip extraction. The standard removal procedure comprises fragmenting the clip by applying an electrical direct current pulse at two opposing sides of the clip. Clip fragmentation was successful in 72 of 74 patients (97.3%). In two cases (2.7%) clip fragmentation was not possible. In nine cases (12.2%) a clip fragment could not be removed and was left in place. Complications occurred in three cases (4.1%): two minor bleedings near the clip removal site (2.7%), and one superficial mucosal tear resulting from clip fragment extraction (1.4%). Based on this study, the use of the remOVE System for OTSC or FTRD clip removal can be considered safe and effective.

Virtual Reality Cerebral Aneurysm Clipping Simulation With Real-time Haptic Feedback

PubMed Central

Alaraj, Ali; Luciano, Cristian J.; Bailey, Daniel P.; Elsenousi, Abdussalam; Roitberg, Ben Z.; Bernardo, Antonio; Banerjee, P. Pat; Charbel, Fady T.

2014-01-01

Background With the decrease in the number of cerebral aneurysms treated surgically and the increase of complexity of those treated surgically, there is a need for simulation-based tools to teach future neurosurgeons the operative techniques of aneurysm clipping. Objective To develop and evaluate the usefulness of a new haptic-based virtual reality (VR) simulator in the training of neurosurgical residents. Methods A real-time sensory haptic feedback virtual reality aneurysm clipping simulator was developed using the Immersive Touch platform. A prototype middle cerebral artery aneurysm simulation was created from a computed tomography angiogram. Aneurysm and vessel volume deformation and haptic feedback are provided in a 3-D immersive VR environment. Intraoperative aneurysm rupture was also simulated. Seventeen neurosurgery residents from three residency programs tested the simulator and provided feedback on its usefulness and resemblance to real aneurysm clipping surgery. Results Residents felt that the simulation would be useful in preparing for real-life surgery. About two thirds of the residents felt that the 3-D immersive anatomical details provided a very close resemblance to real operative anatomy and accurate guidance for deciding surgical approaches. They believed the simulation is useful for preoperative surgical rehearsal and neurosurgical training. One third of the residents felt that the technology in its current form provided very realistic haptic feedback for aneurysm surgery. Conclusion Neurosurgical residents felt that the novel immersive VR simulator is helpful in their training especially since they do not get a chance to perform aneurysm clippings until very late in their residency programs. PMID:25599200

Evaluation of Sentinel Lymph Node Dose Distribution in 3D Conformal Radiotherapy Techniques in 67 pN0 Breast Cancer Patients.

PubMed

Witucki, Gerlo; Degregorio, Nikolaus; Rempen, Andreas; Schwentner, Lukas; Bottke, Dirk; Janni, Wolfgang; Ebner, Florian

2015-01-01

Introduction. The anatomic position of the sentinel lymph node is variable. The purpose of the following study was to assess the dose distribution delivered to the surgically marked sentinel lymph node site by 3D conformal radio therapy technique. Material and Method. We retrospectively analysed 70 radiotherapy (RT) treatment plans of consecutive primary breast cancer patients with a successful, disease-free, sentinel lymph node resection. Results. In our case series the SN clip volume received a mean dose of 40.7 Gy (min 28.8 Gy/max 47.6 Gy). Conclusion. By using surgical clip markers in combination with 3D CT images our data supports the pathway of tumouricidal doses in the SN bed. The target volume should be defined by surgical clip markers and 3D CT images to give accurate dose estimations.

Tricuspid Clip: Step-by-Step and Clinical Data.

PubMed

Tang, Gilbert H L

2018-01-01

Symptomatic severe tricuspid regurgitation (TR), if untreated, carries a dismal prognosis. These patients are at very high risk for surgical repair or replacement and transcatheter options to treat TR are emerging. More than 300 transcatheter tricuspid repairs with the MitraClip system have been performed worldwide with promising results. The TriClip system, with the MitraClip NT delivered via a dedicated tricuspid steerable guide catheter, is currently under investigation. This article describes the step-by-step technique on using the MitraClip system to perform transcatheter tricuspid repair using echocardiographic and fluoroscopic guidance. The latest data on worldwide experience with tricuspid clipping are also discussed. Copyright © 2017 Elsevier Inc. All rights reserved.

Definition and visualisation of regions of interest in post-prostatectomy image-guided intensity modulated radiotherapy

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

Bell, Linda J, E-mail: linda.bell1@health.nsw.gov.au; Cox, Jennifer; Faculty of Health Sciences, University of Sydney, Lidcombe, New South Wales

2014-09-15

Standard post-prostatectomy radiotherapy (PPRT) image verification uses bony anatomy alignment. However, the prostate bed (PB) moves independently of bony anatomy. Cone beam computed tomography (CBCT) can be used to soft tissue match, so radiation therapists (RTs) must understand pelvic anatomy and PPRT clinical target volumes (CTV). The aims of this study are to define regions of interest (ROI) to be used in soft tissue matching image guidance and determine their visibility on planning CT (PCT) and CBCT. Published CTV guidelines were used to select ROIs. The PCT scans (n = 23) and CBCT scans (n = 105) of 23 post-prostatectomymore » patients were reviewed. Details on ROI identification were recorded. Eighteen patients had surgical clips. All ROIs were identified on PCTs at least 90% of the time apart from mesorectal fascia (MF) (87%) due to superior image quality. When surgical clips are present, the seminal vesicle bed (SVB) was only seen in 2.3% of CBCTs and MF was unidentifiable. Most other structures were well identified on CBCT. The anterior rectal wall (ARW) was identified in 81.4% of images and penile bulb (PB) in 68.6%. In the absence of surgical clips, the MF and SVB were always identified; the ARW was identified in 89.5% of CBCTs and PB in 73.7%. Surgical clips should be used as ROIs when present to define SVB and MF. In the absence of clips, SVB, MF and ARW can be used. RTs must have a strong knowledge of soft tissue anatomy and PPRT CTV to ensure coverage and enable soft tissue matching.« less

A new method for digital video documentation in surgical procedures and minimally invasive surgery.

PubMed

Wurnig, P N; Hollaus, P H; Wurnig, C H; Wolf, R K; Ohtsuka, T; Pridun, N S

2003-02-01

Documentation of surgical procedures is limited to the accuracy of description, which depends on the vocabulary and the descriptive prowess of the surgeon. Even analog video recording could not solve the problem of documentation satisfactorily due to the abundance of recorded material. By capturing the video digitally, most problems are solved in the circumstances described in this article. We developed a cheap and useful digital video capturing system that consists of conventional computer components. Video images and clips can be captured intraoperatively and are immediately available. The system is a commercial personal computer specially configured for digital video capturing and is connected by wire to the video tower. Filming was done with a conventional endoscopic video camera. A total of 65 open and endoscopic procedures were documented in an orthopedic and a thoracic surgery unit. The median number of clips per surgical procedure was 6 (range, 1-17), and the median storage volume was 49 MB (range, 3-360 MB) in compressed form. The median duration of a video clip was 4 min 25 s (range, 45 s to 21 min). Median time for editing a video clip was 12 min for an advanced user (including cutting, title for the movie, and compression). The quality of the clips renders them suitable for presentations. This digital video documentation system allows easy capturing of intraoperative video sequences in high quality. All possibilities of documentation can be performed. With the use of an endoscopic video camera, no compromises with respect to sterility and surgical elbowroom are necessary. The cost is much lower than commercially available systems, and setting changes can be performed easily without trained specialists.

Intraoperative monitoring for spinal radiculomedullary artery aneurysm occlusion treatment: What, when, and how long?

PubMed

Landriel, Federico; Baccanelli, Matteo; Hem, Santiago; Vecchi, Eduardo; Bendersky, Mariana; Yampolsky, Claudio

2017-01-01

Spinal radiculomedullary artery aneurysms are extremely rare. Treatment should be tailored to clinical presentation, distal aneurysm flow, and lesion anatomical features. When a surgical occlusion is planned, it is necessary to evaluate whether intraoperative monitoring (IOM) should be considered as an indispensable tool to prevent potential spinal cord ischemia. We present a patient with symptoms and signs of spinal subarachnoid hemorrhage resulting from the rupture of a T4 anterior radiculomedullary aneurysm who underwent open surgical treatment under motor evoked potential (MEP) monitoring. Due to the aneurysmal fusiform shape and preserved distal flow, the afferent left anterior radiculomedullary artery was temporarily clipped; 2 minutes after the clamping, the threshold stimulation level rose higher than 100 V, and at minute 3, MEPs amplitude became attenuated over 50%. This was considered as a warning criteria to leave the vessel occlusion. The radiculomedullary aneurysm walls were reinforced and wrapped with muscle and fibrin glue to prevent re-bleeding. The patient awoke from general anesthesia without focal neurologic deficit and made an uneventful recovery with complete resolution of her symptoms and signs. This paper attempts to build awareness of the possibility to cause or worsen a neurological deficit if a radiculomedullary aneurysm with preserved distal flow is clipped or embolized without an optimal IOM control. We report in detail MEP monitoring during the occlusion of a unilateral T4 segmental artery that supplies an anterior radiculomedullary artery aneurysm.

[Thoracoscopic, epicardial ablation of atrial fibrillation using the COBRA Fusion system as the first part of hybrid ablation].

PubMed

Budera, P; Osmančík, P; Talavera, D; Fojt, R; Kraupnerová, A; Žďárská, J; Vaněk, T; Straka, Z

2017-01-01

Treatment of persistent and long-standing persistent atrial fibrillation is not successfully managed by methods of catheter ablation or pharmacotherapy. Hybrid ablation (i.e. combination of minimally invasive surgical ablation, followed by electrophysiological assessment and subsequent endocardial catheter ablation to complete the entire intended procedure) presents an ever more used and very promising treatment method. Patients underwent thoracoscopic ablation of pulmonary veins and posterior wall of the left atrium (the box-lesion) with use of the COBRA Fusion catheter; thoracoscopic occlusion of the left atrial appendage using the AtriClip system was also done in later patients. After 23 months, electrophysiological assessment and catheter ablation followed. In this article we summarize a strategy of the surgical part of the hybrid procedure performed in our centre. We describe the surgery itself (including possible periprocedural complications) and we also present our short-term results, especially with respect to subsequent electrophysiological findings. Data of the first 51 patients were analyzed. The first 25 patients underwent unilateral ablation; the mean time of surgery was 102 min. Subsequent 26 patients underwent the bilateral procedure with the mean surgery time of 160 min. Serious complications included 1 stroke, 1 phrenic nerve palsy and 2 surgical re-explorations for bleeding. After 1 month, 65% of patients showed sinus rhythm. The box-lesion was found complete during electrophysiological assessment in 38% of patients and after catheter ablation, 96% of patients were discharged in sinus rhythm. The surgical part of the hybrid procedure with use of the minimally invasive approach and the COBRA Fusion catheter is a well-feasible method with a low number of periprocedural complications. For electrophysiologists, it provides a very good basis for successful completion of the hybrid ablation.Key words: atrial fibrillation hybrid ablation - thoracoscopy catheter ablation electrophysiology assessment.

Short-term outcomes of laparoscopic D2 lymphadenectomy with complete mesogastrium excision for advanced gastric cancer.

PubMed

Xie, Daxing; Yu, Chaoran; Liu, Liang; Osaiweran, Hasan; Gao, Chun; Hu, Junbo; Gong, Jianping

2016-11-01

D2 lymphadenectomy has been widely accepted as a standard procedure of surgical treatment for local advanced gastric cancer [1, 2]. However, neither the dissection boundary nor the extent of the excision for perigastric soft tissues has been described [3-7]. Our previous researches demonstrate the existence of disseminated cancer cells in the mesogastrium [8, 9] and present an understandable mesogastrium model for gastrectomy [10]. Hence, the D2 lymphadenectomy plus complete mesogastrium excision (D2 + CME) is firstly proposed in this study, aiming to assess the safety, feasibility and corresponding short-term surgical outcomes. All of these patients underwent laparoscopy assisted D2 + CME radical gastrectomy with a curative R0 resection, and all the operations were performed by Prof. Jianping Gong, chief of GI surgery of Tongji Hospital, Huazhong University of Science and Technology. All participants provided informed written consent to participate in the study. This study was approved by the Tongji Hospital Ethics Committee. The standard surgical procedures in the video are described as follows. Dissect along the gastrocolic ligament and then toward the left colic flexture with special made gauze. Bluntly separate the adipose tissues to find fascia plane. Expose along the plane toward the splenic inferior polar area. Precede to the origins of left gastroepiploic vessels (LGEVs), clip and cut. All the mobilized adipose tissues in this area are defined as left gastroepiploic mesentery (LGEM) [10]. Next, turn to infra-pyloric area. Dissect the fascia plane between right gastroepiploic mesentery (RGEM) and transverse mesocolon. Turn to the pancreas head, remove the covering adipose tissues, identify the superior mesentery vein and expose the origins of right gastroepiploic vessels (RGEVs). Clip and cut. All the surrounding mobilized adipose tissues are defined as RGEM [10]. Move to the superior boarder of pancreas with the stomach reflected cephalad, incise the serosa and bluntly mobilize through the plane with gauze. Turn to the common hepatic artery (CHA), remove the adherent adipose tissue. Expose the root of left gastric vein, clip and cut. Dissect the thick sheath of left gastric artery, expose at the root, trip clip and cut. All mobilized lateral adipose tissues and dorsal parts are defined as left gastric mesentery (LGM) [10]. Toward right, dissect follow the CHA and hepatic portal vein (HPV). Next, move toward the left side of LGM and dissect along the splenic artery until reaching the posterior gastric wall. Move to the anterior area of stomach and divide the lesser omentum. Clean up the adipose tissue and nerves along the lesser curvature up to the gastroesophageal junction. Expose and cut the right gastric vessels (RGVs) where the mobilized adipose tissues are defined as right gastric mesentery (RGM) [10]. Reconstruction of the alimentary tract was done by extracorporeal anastomosis. Standard recovery protocols were followed in postoperative treatments. Fifty-four patients between September 2014 and March 2015 have been recruited with informed consent and underwent laparoscopic D2 + CME by a single surgeon. The mean number of retrieved regional lymph nodes was 35.04 ± 10.70 (range 14-55). The mean volume of blood loss was 12.44 ± 22.89 ml (range 5-100). The mean laparoscopic surgery time was 127.82 ± 17.63 min (range 110-165). The mean hospitalization time was 11.09 ± 4.28 days (range 8-28). No operative complication was observed during the hospitalization. The anatomical boundary of mesogastrium is well described and dissected within D2 + CME surgical process. It proves to be safely feasible and repeatable with less blood lost, qualified lymph nodes retrieval results and other improved short-term surgical outcomes in advanced gastric cancer. Meanwhile, potential disseminated cancer cells fall into the mesogastrium can be eradicated by D2 + CME.

[The comparison of efficacy of female sterilization by modified Uchida technique and silver clips in China].

PubMed

Qiu, Hong-yan; Zou, Yan; Li, Li; Liang, Hong; Zhang, Hong-yan; Wu, Shang-chun

2011-02-01

To compare efficacy of female sterilization by modified Uchida technique and silver clips and to evaluate the influence on operation procedure and clinical effect with or without surgery training of service providers. A comparative, multicenter clinical trial was performed in 18 county and township-level service centers. Totally 2198 women underwent sterilization from these 18 study center were divided into 1116 women sterilized by modified Uchida technique and 1082 women by silver clips. Those 18 centers were classified into 9 training groups which provide surgical skills of sterilization and other contents and 9 non training groups. Clinical documents of sterilization were recorded. All women were follow-up at 3, 6 and 12 months after surgery. There were no complications during surgery by both sterilization. The failure rate was 2.03% (22/1082) in silver clip method and the mean operative time were (12.4 ± 6.4) minutes in training group and (14.4 ± 8.1) minutes in non training group. In modified Uchida method, the failure rate was 0.18% (2/1116) and the mean operative time were (16.2 ± 4.9) minutes in training group and (19.0 ± 8.6) minutes in non training group. The mean operative time between two groups reached statistical difference (all P < 0.05). Total ended rate in modified Uchida technique were 2.2/hundred women year in training group and 2.5/hundred women year in non training group, and the rate of silver slips were 3.9/hundred women year and 4.8/hundred women year, which did not show significant difference (all P > 0.05). There was no significant difference in acceptability and side effects of all women between two methods (P > 0.05). The training of service providers could influence acceptability of women (P < 0.05). Clinical efficacy was not influenced by those two methods. The operative time and acceptability were improved by training surgeons in silver clips method.

Impact of Right-Sided Aneurysm, Rupture Status, and Size of Aneurysm on Perforator Infarction Following Microsurgical Clipping of Posterior Communicating Artery Aneurysms with a Distal Transsylvian Approach.

PubMed

Tanabe, Jun; Ishikawa, Tatsuya; Moroi, Junta; Sakata, Yoshinori; Hadeishi, Hiromu

2018-03-01

Posterior communicating artery (PCoA) aneurysms are among the most common aneurysms. Because blockage of the PCoA and perforators can cause adverse outcomes, occlusion of these arteries by surgical clipping should be avoided. The impact of factors on PCoA perforator infarction when using a distal transsylvian approach for PCoA aneurysms was examined. A total of 183 patients underwent PCoA aneurysm clipping, excluding application of fenestrated clips. Patients were divided into 2 groups: patients with PCoA perforator infarction (infarction group) and patients without infarction (noninfarction group). Multiple factors were analyzed in the 2 groups. Twenty-two of the 183 patients (12.0%) showed perforator infarction, mainly on magnetic resonance imaging evaluation, resulting in permanent deficits in 2 patients (1.1%). The proportion of right-sided operations (86.4% vs. 53.4%; P = 0.005) and surgery for rupture (90.9% vs. 55.9%; P = 0.002) were significantly higher in the infarction group than in the noninfarction group. Aneurysms were significantly larger in the infarction group (8.4 ± 3.8 mm) than in the noninfarction group (6.3 ± 3.0 mm; P = 0.02). Ruptured status (odds ratio [OR], 7.35; P = 0.01), right side (OR, 5.19; P = 0.01), and aneurysm size (OR, 1.18; P = 0.02) remained independent predictors of perforator infarction on multivariate logistic regression analysis. Ruptured status, right side, and large PCoA aneurysm were independent predictors of PCoA perforator infarction. Symptoms due to PCoA perforating infarction were mostly transient and rarely affected outcomes. Copyright © 2018 Elsevier Inc. All rights reserved.

Initial experience of percutaneous treatment of mitral regurgitation with MitraClip® therapy in Spain.

PubMed

Carrasco-Chinchilla, Fernando; Arzamendi, Dabit; Romero, Miguel; Gimeno de Carlos, Federico; Alonso-Briales, Juan Horacio; Li, Chi-Hion; Mesa, Maria Dolores; Arnold, Roman; Serrador Frutos, Ana María; Pan, Manuel; Roig, Eulalia; Rodríguez-Bailón, Isabel; de la Fuente Galán, Luis; Hernández, José María; Serra, Antonio; Suárez de Lezo, José

2014-12-01

Symptomatic mitral regurgitation has an unfavorable prognosis unless treated by surgery. However, the European registry of valvular heart disease reports that 49% of patients with this condition do not undergo surgery. Percutaneous treatment of mitral regurgitation with MitraClip® has been proved a safe, efficient adjunct to medical treatment in patients with this profile. The objective of the present study is to describe initial experience of MitraClip® therapy in Spain. Retrospective observational study including all patients treated between November 2011 and July 2013 at the 4 Spanish hospitals recording the highest numbers of implantations. A total of 62 patients (77.4% men) were treated, mainly for restrictive functional mitral regurgitation (85.4%) of grade III (37%) or grade IV (63%), mean (standard deviation) ejection fraction 36% (14%), and New York Heart Association functional class III (37%) or IV (63%). Device implantation was successful in 98% of the patients. At 1 year, 81.2% had mitral regurgitation ≤ 2 and 90.9% were in New York Heart Association functional class ≤ II. One periprocedural death occurred (sepsis at 20 days post-implantation) and another 3 patients died during follow-up (mean, 9.1 months). Two patients needed a second implantation due to partial dehiscence of the first device and 2 others underwent heart transplantation. In Spain, MitraClip® therapy has principally been aimed at patients with functional mitral regurgitation, significant systolic ventricular dysfunction, and high surgical risk. It is considered a safe alternative treatment, which can reduce mitral regurgitation and improve functional capacity. Copyright © 2014 Sociedad Española de Cardiología. Published by Elsevier Espana. All rights reserved.

Outcome of Limited Video-Assisted Lumbar Sympathetic Block for Plantar Hyperhidrosis Using Clipping Method.

PubMed

Yun, Seok Won; Kim, Yun Seok; Lee, Yongjik; Lim, Han Jung; Park, Soon Ik; Jung, Jong Pil; Park, Chang Ryul

2017-01-01

There are many ways to treat focal hyperhidrosis, including surgeries for palmar and axillary hyperhidrosis. However, doctors and patients tend to be reluctant to perform surgery for plantar hyperhidrosis due to misconceptions and prejudices about surgical treatment. In addition, few studies have reported the outcome of surgeries for plantar hyperhidrosis. Therefore, the objective of this study was to determine the outcome (early and late postoperative satisfaction, complication, compensatory hyperhidrosis, recurrence rate, and efficiency) of surgical treatment for plantar hyperhidrosis. From August 2014 to October 2015, lumbar sympathetic block (LSB) was performed in 82 patients with plantar hyperhidrosis using clipping method. Limited video-assisted LSB was performed using 5 mm ligamax-clip or 3 mm horizontal-clip after identifying L3-4 sympathetic ganglion through finger-touch and endoscopic vision. Of the 82 patients, 45 were male and 37 were female. Their mean age was 26.38 years (range, 14-51 years). Mean follow-up time was 6.60 ± 3.56 months. Mean early postoperative satisfaction score was 9.6 on the 10th day postoperative evaluation. At more than 1 month later, the mean late postoperative satisfaction score was 9.2. There was no significant difference in early postoperative satisfaction score between clipping level L3 and L4/5. However, late postoperative satisfaction score was significantly better in the L3 group than that in the L4/5 group. Patient's age and body mass index did not affect the satisfaction score. However, male patients and patients who had history of hyperhidrosis operation showed higher satisfaction score than others. Limited video-assisted LSB using clip provided good results with minimal complications and low compensatory hidrosis, contrary to the prejudice toward it. Therefore, surgical treatment is recommended for plantar hyperhidrosis.

Intraoperative validation of CT-based lymph nodal levels, sublevels IIa and IIb: Is it of clinical relevance in selective radiation therapy?

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

Levendag, Peter; Gregoire, Vincent; Hamoir, Marc

2005-07-01

Purpose: The objectives of this study are to discuss the intraoperative validation of CT-based boundaries of lymph nodal levels in the neck, and in particular the clinical relevance of the delineation of sublevels IIa and IIb in case of selective radiation therapy (RT). Methods and Materials: To validate the radiologically defined level contours, clips were positioned intraoperatively at the level boundaries defined by surgical anatomy. In 10 consecutive patients, clips were placed, at the time of a neck dissection being performed, at the most cranial border of the neck. Anterior-posterior and lateral X-ray films were obtained intraoperatively. Next, in 3more » patients, neck levels were contoured on preoperative contrast-enhanced CT scans according to the international consensus guidelines. From each of these 3 patients, an intraoperative CT scan was also obtained, with clips placed at the surgical-anatomy-based level boundaries. The preoperative (CT-based) and intraoperative (surgery-defined) CT scans were matched. Results: Clips placed at the most cranial part of the neck lined up at the caudal part of the transverse process of the cervical vertebra C-I. The posterior border of surgical level IIa (spinal accessory nerve [SAN]) did not match with the posterior border of CT-based level IIa (internal jugular vein [IJV]). Other surgical boundaries and CT-based contours were in good agreement. Conclusions: The cranial border of the neck, i.e., the cranial border of level IIa/IIb, corresponds to the caudal edge of the lateral process of C-I. Except for the posterior border between level IIa and level IIb, a perfect match was observed between the other surgical-clip-identified levels II-V boundaries (surgical-anatomy) and the CT-based delineation contours. It is argued that (1) because of the parotid gland overlapping part of level II, and (2) the frequent infestation of occult metastatic cells in the lymph channels around the IJV, the division of level II into radiologic sublevels IIa and IIb may not be relevant. Sparing of, for example, the ipsilateral parotid gland in selective RT can even be a treacherous undertaking with respect to regional tumor control. In contrast, the surgeon's reasoning for preserving the surgical sublevel IIb is that the morbidity associated with dissection of the supraspinal accessory nerve compartment of level II is reduced, whereas there is evidence from the surgical literature that no extra risk for regional tumor control is observed. Therefore, in selective neck dissections, the division into surgical sublevels IIa/IIb makes sense.« less

Cerebral Aneurysm Clipping Surgery Simulation Using Patient-Specific 3D Printing and Silicone Casting.

PubMed

Ryan, Justin R; Almefty, Kaith K; Nakaji, Peter; Frakes, David H

2016-04-01

Neurosurgery simulator development is growing as practitioners recognize the need for improved instructional and rehearsal platforms to improve procedural skills and patient care. In addition, changes in practice patterns have decreased the volume of specific cases, such as aneurysm clippings, which reduces the opportunity for operating room experience. The authors developed a hands-on, dimensionally accurate model for aneurysm clipping using patient-derived anatomic data and three-dimensional (3D) printing. Design of the model focused on reproducibility as well as adaptability to new patient geometry. A modular, reproducible, and patient-derived medical simulacrum was developed for medical learners to practice aneurysmal clipping procedures. Various forms of 3D printing were used to develop a geometrically accurate cranium and vascular tree featuring 9 patient-derived aneurysms. 3D printing in conjunction with elastomeric casting was leveraged to achieve a patient-derived brain model with tactile properties not yet available from commercial 3D printing technology. An educational pilot study was performed to gauge simulation efficacy. Through the novel manufacturing process, a patient-derived simulacrum was developed for neurovascular surgical simulation. A follow-up qualitative study suggests potential to enhance current educational programs; assessments support the efficacy of the simulacrum. The proposed aneurysm clipping simulator has the potential to improve learning experiences in surgical environment. 3D printing and elastomeric casting can produce patient-derived models for a dynamic learning environment that add value to surgical training and preparation. Copyright © 2016 Elsevier Inc. All rights reserved.

Microsurgery Simulator of Cerebral Aneurysm Clipping with Interactive Cerebral Deformation Featuring a Virtual Arachnoid.

PubMed

Shono, Naoyuki; Kin, Taichi; Nomura, Seiji; Miyawaki, Satoru; Saito, Toki; Imai, Hideaki; Nakatomi, Hirofumi; Oyama, Hiroshi; Saito, Nobuhito

2018-05-01

A virtual reality simulator for aneurysmal clipping surgery is an attractive research target for neurosurgeons. Brain deformation is one of the most important functionalities necessary for an accurate clipping simulator and is vastly affected by the status of the supporting tissue, such as the arachnoid membrane. However, no virtual reality simulator implementing the supporting tissue of the brain has yet been developed. To develop a virtual reality clipping simulator possessing interactive brain deforming capability closely dependent on arachnoid dissection and apply it to clinical cases. Three-dimensional computer graphics models of cerebral tissue and surrounding structures were extracted from medical images. We developed a new method for modifiable cerebral tissue complex deformation by incorporating a nonmedical image-derived virtual arachnoid/trabecula in a process called multitissue integrated interactive deformation (MTIID). MTIID made it possible for cerebral tissue complexes to selectively deform at the site of dissection. Simulations for 8 cases of actual clipping surgery were performed before surgery and evaluated for their usefulness in surgical approach planning. Preoperatively, each operative field was precisely reproduced and visualized with the virtual brain retraction defined by users. The clear visualization of the optimal approach to treating the aneurysm via an appropriate arachnoid incision was possible with MTIID. A virtual clipping simulator mainly focusing on supporting tissues and less on physical properties seemed to be useful in the surgical simulation of cerebral aneurysm clipping. To our knowledge, this article is the first to report brain deformation based on supporting tissues.

Preoperative endoscopic titanium clip placement facilitates intraoperative localization of early-stage esophageal cancer or severe dysplasia.

PubMed

Tan, Lei; Feng, Juan; Zhao, Qin; Chen, Ping; Yang, Guotao

2017-08-02

Accurate intraoperative localization of esophageal lesions is essential for successful surgical resection. We tested whether preoperative endoscopic placement of titanium clips could facilitate intraoperative localization of early-stage esophageal cancer or severe dysplasia. A prospective randomized clinical trial was performed between May 2012 and July 2014. All enrolled patients received preoperative endoscopy and esophageal endoscopic ultrasound, as well as pathological study on the biopsy specimen, to confirm early stage esophageal cancer or severe dysplasia. One day before the surgical operation, patients in the experimental group received the preoperative endoscopic titanium labeling of esophageal lesions. Then, during the surgical operation, palpitation of titanium clips was used to localize the lesions in these patients. In patients in the control group, palpitation of nodules or esophageal wall mucosal thickening, together with the consideration of the results from preoperative endoscopic and ultrasound studies, was applied to estimate the location of the esophageal lesions. Study outcomes included the proportions of patients having successful intraoperative pre-resection lesion localization, post-esophagectomy lesion visualization, negative upper surgical margin, change of surgical approaches, and positive postoperative pathological diagnosis. A total of 27 patients were enrolled into the study, with 14 in the experimental group and 13 in the control group. Compared to the patients in the control group, a higher proportion of patients in the experimental group had statistically significant successful intraoperative esophageal lesion localization (100 versus 15.3% in the experimental versus control group). Preoperative endoscopic titanium clip placement could facilitate intraoperative localization of early-stage esophageal cancer or severe dysplasia. Current study was registered in Chinese Clinical Trial Registry and World Health Organization International Clinical Trials Registry Platform, ChiCTR-INR-17010949 . Registered 22 March 2017, retrospectively registered.

Plastic bag clip discovered in partial colectomy accompanying proposal for phylogenic plastic bag clip classification

PubMed Central

Lehmer, Larisa M; Ragsdale, Bruce D; Daniel, John; Hayashi, Edwin; Kvalstad, Robert

2011-01-01

A plastic bag clip was incidentally found anchored in the mucosa of a partial colectomy specimen 2.6 cm proximal to a ruptured diverticulum for which the patient, a mentally retarded, diabetic, 58-year-old man, underwent surgery. Over 20 cases of accidental ingestion of plastic bag clips have been published. Known complications include small bowel perforation, obstruction, dysphagia, gastrointestinal bleeding and colonic impaction. Preoperative diagnosis of plastic clips lodged in the gastrointestinal tract is frustrated due to radiographic translucency. This occult threat could likely be prevented by the design of gastrointestinally safe, plastic-bag-sealing devices. Presented here is a morphologically based classification of bag clips as a possible guide for determining the most hazardous varieties and to aid further discussions of their impact on health. PMID:22679182

The Factors Associated with Outcomes in Surgically Managed Ruptured Cerebral Aneurysm.

PubMed

Chee, Lai Chuang; Siregar, Johari Adnan; Ghani, Abdul Rahman Izani; Idris, Zamzuri; Rahman Mohd, Noor Azman A

2018-02-01

Ruptured cerebral aneurysm is a life-threatening condition that requires urgent medical attention. In Malaysia, a prospective study by the Umum Sarawak Hospital, Neurosurgical Center, in the year 2000-2002 revealed an average of two cases of intracranial aneurysms per month with an operative mortality of 20% and management mortality of 25%. Failure to diagnose, delay in admission to a neurosurgical centre, and lack of facilities could have led to the poor surgical outcome in these patients. The purpose of this study is to identify the factors that significantly predict the outcome of patients undergoing a surgical clipping of ruptured aneurysm in the local population. A single center retrospective study with a review of medical records was performed involving 105 patients, who were surgically treated for ruptured intracranial aneurysms in the Sultanah Aminah Hospital, in Johor Bahru, from July 2011 to January 2016. Information collected was the patient demographic data, Glasgow Coma Scale (GCS) prior to surgery, World Federation of Neurosurgical Societies Scale (WFNS), subarachnoid hemorrhage (SAH) grading system, and timing between SAH ictus and surgery. A good clinical grade was defined as WFNS grade I-III, whereas, WFNS grades IV and V were considered to be poor grades. The outcomes at discharge and six months post surgery were assessed using the modified Rankin's Scale (mRS). The mRS scores of 0 to 2 were grouped into the "favourable" category and mRS scores of 3 to 6 were grouped into the "unfavourable" category. Only cases of proven ruptured aneurysmal SAH involving anterior circulation that underwent surgical clipping were included in the study. The data collected was analysed using the Statistical Package for Social Sciences (SPSS). Univariate and multivariate analyses were performed and a P -value of < 0.05 was considered to be statistically significant. A total of 105 patients were included. The group was comprised of 42.9% male and 57.1% female patients. The mean GCS of the patients subjected to surgical clipping was 13, with the majority falling into the good clinical grade (78.1%). The mean timing of the surgery after SAH was 5.3 days and this was further categorised into early (day one to day three, 45.3%), intermediate (day four to day ten, 56.2%), and late (after day ten, 9.5%). The total favourable outcome achieved at discharge was 59.0% as compared to 41.0% of the unfavourable outcome, with an overall mortality rate of 10.5%. At the six-month post surgery review ( n = 94), the patients with a favourable outcome constituted 71.3% as compared to 28.7% with an unfavourable outcome. The mortality, six months post surgery was 3.2%. On a univariate analysis of early surgical clipping, patients with a better GCS and good clinical grade had a significantly better outcome at discharge. Based on the univariate study, six months post surgery, the timing of the surgery and the clinical grade remained significant predictors of the outcome. On the basis of the multivariate analysis, male patients of younger age, with a good clinical grade, were associated with favourable outcomes, both at discharge and six months post surgery. In this study, we concluded that younger male patients with a good clinical grade were associated with a favourable outcome both at discharge and six months post surgery. We did not find the timing of the surgery, size of the aneurysm or duration of surgery to be associated with a patient's surgical outcome. Increasing age was not associated with the surgical outcome in a longer term of patient's follow up.

Clipping Versus Coiling in the Management of Posterior Communicating Artery Aneurysms with Third Nerve Palsy: A Systematic Review and Meta-Analysis.

PubMed

Gaberel, Thomas; Borha, Alin; di Palma, Camille; Emery, Evelyne

2016-03-01

To compare surgical clipping with endovascular coiling in terms of recovery from oculomotor nerve palsy (ONP) in the management of posterior communicating artery (PCoA) aneurysms causing third nerve palsy. We conducted a systematic review of the literature and meta-analysis. The meta-analysis included 11 relevant studies involving 384 patients with third nerve palsy caused by PCoA aneurysms at baseline, of whom 257 (67.0%) were treated by clipping and 127 were treated by coiling (33.0%). Pooled odds ratios of the impact of clipping or coiling on complete ONP recovery, lack of ONP recovery, and procedure-related death were calculated. The overall complete ONP recovery rate was 42.5% in the coiling group compared with 83.6% in the clipping group. The increase in complete ONP recovery in the clipping group corresponds to an overall pooled Mantel-Haenszel odds ratio of 4.44 (95% confidence interval = 1.66-11.84). Subgroup analysis revealed a clear benefit of clipping over coiling in patients with ruptured aneurysms, but not in patients with unruptured aneurysms. No procedure-related deaths were reported by any of the 11 studies. Surgical clipping of PCoA aneurysms causing third nerve palsy achieves better ONP recovery than endovascular coiling; this could be particularly true in the case of ruptured aneurysms. In view of the purely observational data, statements about this effect should be made with great caution. A randomized trial would better address the therapeutic dilemma, but pending the results of such a trial, we recommend treating PCoA aneurysms causing ONP with surgery. Copyright © 2016 Elsevier Inc. All rights reserved.

Laparoscopic enucleation of liver tumors. Corkscrew technique revisited.

PubMed

Makdissi, Fabio F; Surjan, Rodrigo C T; Machado, Marcel Autran C

2009-03-01

Enucleation of small lesions located near the hepatic surface can be achieved with low morbidity and mortality. This article describes a simple laparoscopic technique for enucleation of liver tumors. After inspection and intraoperative ultrasonography, Glisson's capsule is marked with eletrocautery 2 cm away from the tumor margin. Ultrasonography is used to ascertain surgical margin right before liver transection. Hemihepatic ischemia is applied and marked area is anchored by stitches. The suture is held together by metallic clips and upward traction is performed, facilitating the transection of the parenchyma and correct identification of vascular and biliary structures. This technique has been successfully employed in six consecutive patients. There were four men and two women, mean age 50.3 years. Four patients underwent liver resection for malignant disease and two for benign liver neoplasm. Pathologic surgical margins were free in all cases and mean hospital stay was 2 days. No postoperative mortality was observed. This technique may facilitate laparoscopic nonanatomical liver resection and reduce risk of positive surgical margins. It is also useful in combination with anatomical laparoscopic liver resections such as right or left hemihepatectomies in patients with bilateral liver tumors as occurred in one of our patients.

Minimally Invasive Thumb-sized Pterional Craniotomy for Surgical Clip Ligation of Unruptured Anterior Circulation Aneurysms.

PubMed

Deshaies, Eric M; Villwock, Mark R; Singla, Amit; Toshkezi, Gentian; Padalino, David J

2015-08-11

Less invasive surgical approaches for intracranial aneurysm clipping may reduce length of hospital stay, surgical morbidity, treatment cost, and improve patient outcomes. We present our experience with a minimally invasive pterional approach for anterior circulation aneurysms performed in a major tertiary cerebrovascular center and compare the results with an aged matched dataset from the Nationwide Inpatient Sample (NIS). From August 2008 to December 2012, 22 elective aneurysm clippings on patients ≤55 years of age were performed by the same dual fellowship-trained cerebrovascular/endovascular neurosurgeon. One patient (4.5%) experienced transient post-operative complications. 18 of 22 patients returned for follow-up imaging and there were no recurrences through an average duration of 22 months. A search in the NIS database from 2008 to 2010, also for patients aged ≤55 years of age, yielded 1,341 hospitalizations for surgical clip ligation of unruptured cerebral aneurysms. Inpatient length of stay and hospital charges at our institution using the minimally invasive thumb-sized pterional technique were nearly half that of NIS (length of stay: 3.2 vs 5.7 days; hospital charges: $52,779 vs. $101,882). The minimally invasive thumb-sized pterional craniotomy allows good exposure of unruptured small and medium-sized supraclinoid anterior circulation aneurysms. Cerebrospinal fluid drainage from key subarachnoid cisterns and constant bimanual microsurgical techniques avoid the need for retractors which can cause contusions, localized venous infarctions, and post-operative cerebral edema at the retractor sites. Utilizing this set of techniques has afforded our patients with a shorter hospital stay at a lower cost compared to the national average.

Training in Cerebral Aneurysm Clipping Using Self-Made 3-Dimensional Models.

PubMed

Mashiko, Toshihiro; Kaneko, Naoki; Konno, Takehiko; Otani, Keisuke; Nagayama, Rie; Watanabe, Eiju

Recently, there have been increasingly fewer opportunities for junior surgeons to receive on-the-job training. Therefore, we created custom-built three-dimensional (3D) surgical simulators for training in connection with cerebral aneurysm clipping. Three patient-specific models were composed of a trimmed skull, retractable brain, and a hollow elastic aneurysm with its parent artery. The brain models were created using 3D printers via a casting technique. The artery models were made by 3D printing and a lost-wax technique. Four residents and 2 junior neurosurgeons attended the training courses. The trainees retracted the brain, observed the parent arteries and aneurysmal neck, selected the clip(s), and clipped the neck of an aneurysm. The duration of simulation was recorded. A senior neurosurgeon then assessed the trainee's technical skill and explained how to improve his/her performance for the procedure using a video of the actual surgery. Subsequently, the trainee attempted the clipping simulation again, using the same model. After the course, the senior neurosurgeon assessed each trainee's technical skill. The trainee critiqued the usefulness of the model and the effectiveness of the training course. Trainees succeeded in performing the simulation in line with an actual surgery. Their skills tended to improve upon completion of the training. These simulation models are easy to create, and we believe that they are very useful for training junior neurosurgeons in the surgical techniques needed for cerebral aneurysm clipping. Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

[Choledochal lithiasis and stenosis secondary to the migration of a surgical clip].

PubMed

Baldomà España, M; Pernas Canadell, J C; González Ceballos, S

2014-01-01

The migration of a clip to the common bile duct after cholecystectomy is an uncommon, usually late, complication that can lead to diverse complications like stone formation, stenosis, and obstruction in the bile duct. We present the case of a patient who presented with signs and symptoms of cholangitis due to clip migration one year after laparoscopic cholecystectomy; endoscopic retrograde cholangiopancreatography and biliary tract stent placement resolved the problem. Copyright © 2011 SERAM. Published by Elsevier Espana. All rights reserved.

Microsurgical clipping of ophthalmic artery aneurysms: surgical results and visual outcomes with 208 aneurysms.

PubMed

Kamide, Tomoya; Tabani, Halima; Safaee, Michael M; Burkhardt, Jan-Karl; Lawton, Michael T

2018-01-26

OBJECTIVE While most paraclinoid aneurysms can be clipped with excellent results, new postoperative visual deficits are a concern. New technology, including flow diverters, has increased the popularity of endovascular therapy. However, endovascular treatment of paraclinoid aneurysms is not without procedural risks, is associated with higher rates of incomplete aneurysm occlusion and recurrence, and may not address optic nerve compression symptoms that surgical debulking can. The increasing endovascular management of paraclinoid aneurysms should be justified by comparisons to surgical benchmarks. The authors, therefore, undertook this study to define patient, visual, and aneurysm outcomes in the most common type of paraclinoid aneurysm: ophthalmic artery (OphA) aneurysms. METHODS Results from microsurgical clipping of 208 OphA aneurysms in 198 patients were retrospectively reviewed. Patient demographics, aneurysm morphology (size, calcification, etc.), clinical characteristics, and patient outcomes were recorded and analyzed. RESULTS Despite 20% of these aneurysms being large or giant in size, complete aneurysm occlusion was accomplished in 91% of 208 cases, with OphA patency preserved in 99.5%. The aneurysm recurrence rate was 3.1% and the retreatment rate was 0%. Good outcomes (modified Rankin Scale score 0-2) were observed in 96.2% of patients overall and in all 156 patients with unruptured aneurysms. New visual field defects (hemianopsia or quadrantanopsia) were observed in 8 patients (3.8%), decreased visual acuity in 5 (2.4%), and monocular blindness in 9 (4.3%). Vision improved in 9 (52.9%) of the 17 patients with preoperative visual deficits. CONCLUSIONS The most important risk associated with clipping OphA aneurysms is a new visual deficit. Meticulous microsurgical technique is necessary during anterior clinoidectomy, aneurysm dissection, and clip application to optimize visual outcomes, and aggressive medical management postoperatively might potentially decrease the incidence of delayed visual deficits. As the results of endovascular therapy and specifically flow diverters become known, they warrant comparison with these surgical benchmarks to determine best practices.

Application of actuator-driven pulsed water jet in aneurysmal subarachnoid hemorrhage surgery: its effectiveness for dissection around ruptured aneurysmal walls and subarachnoid clot removal.

PubMed

Endo, Hidenori; Endo, Toshiki; Nakagawa, Atsuhiro; Fujimura, Miki; Tominaga, Teiji

2017-07-01

In clipping surgery for aneurysmal subarachnoid hemorrhage (aSAH), critical steps include clot removal and dissection of aneurysms without premature rupture or brain injuries. To pursue this goal, a piezo actuator-driven pulsed water jet (ADPJ) system was introduced in this study. This study included 42 patients, who suffered aSAH and underwent clipping surgery. Eleven patients underwent surgery with the assistance of the ADPJ system (ADPJ group). In the other 31 patients, surgery was performed without the ADPJ system (Control group). The ADPJ system was used for clot removal and aneurysmal dissection. The clinical impact of the ADPJ system was judged by comparing the rate of premature rupture, degree of clot removal, and clinical outcomes. Intraoperatively, a premature rupture was encountered in 18.2 and 25.8% of cases in the ADPJ and control groups, respectively. Although the differences were not statistically significant, intraoperative observation suggested that the ADPJ system was effective in clot removal and dissection of aneurysms in a safe manner. Computed tomography scans indicated the achievement of higher degrees of clot removal, especially when the ADPJ system was used for cases with preoperative clot volumes of more than 25 ml (p = 0.047, Mann-Whitney U test). Clinical outcomes, including incidence of postoperative brain injury or symptomatic vasospasm, were similar in both groups. We described our preliminary surgical results using the ADPJ system for aSAH. Although further study is needed, the ADPJ system was considered a safe and effective tool for clot removal and dissection of aneurysms.

PubMed Central

Labrecque, M.; Bédard, L.; Laperrière, L.

1998-01-01

OBJECTIVE: To compare the efficacy of, and complications associated with, vasectomies performed in two medical clinics. DESIGN: Retrospective cohort study. SETTING: A private medical clinic and a family planning clinic at a teaching hospital in the Quebec City region, where one doctor performs all surgery. PARTICIPANTS: The 1223 men who underwent a first vasectomy between January 1994 and February 1996. INTERVENTIONS: Isolations of the vas deferens through the scrotum was performed using the no-scalpel technique in both clinics. At the private clinic (n = 775), vasectomy was performed by ligature with tantalum clips. At the family planning clinic (n = 448), a combination of cauterisation of the abdominal end of the vas deferens, leaving the testicular end open, and fascial interposition with a clip was used. MAIN OUTCOME MEASURES: Rate of postoperative complications (painful granuloma; noninfectious inflammation of the vas deferens, epididymis, and testes; hematoma; infection; undiagnosed pain) and rate of recanalization (early and late). RESULTS: At the private clinic, 39 patients (5.0%) consulted for postoperative complications, compared with 55 patients (12.3%) at the family planning clinic (chi (2)1 = 21.0; P < 0.001). Of the patients who underwent semen analysis, 15 (2.8%) at the private clinic and 4 (1.2%) at the family planning clinic experienced early or late recanalization (chi (2)1 = 2.2; P < .14). CONCLUSION: The rate of consultation for postoperative complications was lower at the private clinic than at the family planning clinic, but the efficacy of the procedure appeared to be higher at the family planning clinic. The surgical techniques used at the two clinics might partially explain these differences. PMID:9789666

Quantitative study of the opticocarotid and carotid-oculomotor windows for the interpeduncular fossa, before and after internal carotid artery mobilization and posterior communicating division.

PubMed

Kim, Young-Don; Elhadi, Ali M; Mendes, George A C; Maramreddy, Naveen; Agrawal, Abhishek; Kalb, Samuel; Nakaji, Peter; Spetzler, Robert F; Preul, Mark C

2015-03-01

The management of basilar apex (BX) aneurysms remains problematic. We quantified the surgical exposure of the BX through the opticocarotid window (OCW) and the carotid-oculomotor window (COW), before and after mobilization of the internal carotid artery and division of the posterior communicating artery (PCoA). Eleven silicone-injected cadaveric heads were dissected bilaterally. The surgical dissection was divided into 4 major steps: (1) supraorbital modified orbitozygomatic craniotomy, (2) mobilization of the internal carotid artery after drilling out the anterior clinoid process intradurally and cutting the distal dural ring, (3) drilling out the posterior clinoid process and dorsum sellae, and (4) dividing the PCoA from the posterior third portion of the vessel. A frameless navigation system was used to quantify the surgical exposure area of the BX through the OCW and COW. The total surgical area increased significantly from steps 1 to 4 (P < .001) in both OCW and COW groups. Overall, there was a larger total surgical area obtained in the COW compared with the OCW (P = .010). ICA mobilization increased the surgical area for temporary (P < .001) and permanent (P < .003) clip application in both windows. The division of PCoA significantly increased the overall surgical area for permanent clip application (P < .003). Compared with the OCW, the COW had a significantly increased change in the area for permanent clip application in the low-lying group (P = .03). When approaching the BX via the pterion route, the appropriate surgical step and window should be selected according to characteristics of the PCoA and height of the BX.

Focused opening of the sylvian fissure for microsurgical management of MCA aneurysms.

PubMed

Elsharkawy, Ahmed; Niemelä, Mika; Lehečka, Martin; Lehto, Hanna; Jahromi, Behnam Rezai; Goehre, Felix; Kivisaari, Riku; Hernesniemi, Juha

2014-01-01

A wide sylvian opening, with either a proximal or distal start, has been standard for microsurgical management of middle cerebral artery (MCA) aneurysms. However, extensive sylvian dissection is potentially associated with increased incidence of iatrogenic injury to the brain and neurovascular structures. The aim of the present study was to describe the technique of focused opening of the sylvian fissure for microsurgical management of MCA aneurysms with additional tips on handling difficulties which may be encountered with this technique. A 3D image-based anatomic orientation, clipping field-focused surgical planning, slack brain, and high magnification are the basic requirements for this approach. A 10-15 mm sylvian opening is placed so that it allows safe access and a good surgical view of the MCA aneurysm clipping field. Under proximal control of the MCA, the aneurysm neck can be dissected and clipped effectively and safely, in this small surgical field. The presented technique has been developed and refined by the senior author during the surgery of 1,097 aneurysms over the last 13 years. It has proved to be safe, and effective for clipping of both ruptured and unruptured MCA aneurysms. Its greatest advantages are a shorter operative time and less brain and vessel manipulation compared to more extensive approaches. The focused sylvian opening is a less-invasive alternative to the classical wide sylvian opening for the microsurgical management of most MCA aneurysms.

Intracranial aneurysms: optimized diagnostic tools call for thorough interdisciplinary treatment strategies.

PubMed

Mueller, Oliver M; Schlamann, Marc; Mueller, Daniela; Sandalcioglu, I Erol; Forsting, Michael; Sure, Ulrich

2011-09-01

Intracranial aneurysms (IAs) require deliberately selected treatment strategies as they are incrementally found prior to rupture and deleterious subarachnoid haemorrhage (SAH). Multiple and recurrent aneurysms necessitate both neurointerventionalists and neurosurgeons to optimize aneurysmal occlusion in an interdisciplinary effort. The present study was conducted to condense essential strategies from a single neurovascular centre with regard to the lessons learned. Medical charts of 321 consecutive patients treated for IAs at our centre from September 2008 until December 2010 were retrospectively analysed for clinical presentation of the aneurysms, multiplicity and treatment pathways. In addition, a selective Medline search was performed. A total of 321 patients with 492 aneurysms underwent occlusion of their symptomatic aneurysm: 132 (41.1%) individuals were treated surgically, 189 (58.2%) interventionally; 138 patients presented with a SAH, of these 44.2% were clipped and 55.8% were coiled. Aneurysms of the middle cerebral artery were primarily occluded surgically (88), whereas most of the aneurysms of the internal carotid artery and anterior communicating artery (114) were treated endovascularly. Multiple aneurysms (range 2-5 aneurysms/individual) were diagnosed in 98 patients (30.2%). During the study period 12 patients with recurrent aneurysms were allocated to another treatment modality (previously clip to coil and vice versa). Our data show that successful interdisciplinary occlusion of IAs is based on both neurosurgical and neurointerventional therapy. In particular, multiple and recurrent aneurysms require tailored individual approaches to aneurysmal occlusion. This is achieved by a consequent interdisciplinary pondering of the optimal strategy to occlude IAs in order to prevent SAH.

Which Clip? A Prospective Comparative Study of Retention Rates of Endoscopic Clips on Normal Mucosa and Ulcers in a Porcine Model

PubMed Central

Saxena, Payal; Ji-Shin, Eun; Haito-Chavez, Yamile; Valeshabad, Ali K.; Akshintala, Venkata; Aguila, Gerard; Kumbhari, Vivek; Ruben, Dawn S.; Lennon, Anne-Marie; Singh, Vikesh; Canto, Marcia; Kalloo, Anthony; Khashab, Mouen A.

2014-01-01

Background/Aim: There are currently no data on the relative retention rates of the Instinct clip, Resolution clip, and QuickClip2Long. Also, it is unknown whether retention rate differs when clips are applied to ulcerated rather than normal mucosa. The aim of this study is to compare the retention rates of three commonly used endoscopic clips. Materials and Methods: Six pigs underwent upper endoscopy with placement of one of each of the three types of clips on normal mucosa in the gastric body. Three mucosal resections were also performed to create “ulcers”. Each ulcer was closed with placement of one of the three different clips. Repeat endoscopy was performed weekly for up to 4 weeks. Results: Only the Instinct and Resolution clips remained attached for the duration of the study (4 weeks). At each time point, a greater proportion of Instinct clips were retained on normal mucosa, followed by Resolution clips. QuickClip2Long had the lowest retention rate on normal mucosa. Similar retention rates of Instinct clips and Resolution clips were seen on simulated ulcers, although both were superior to QuickClip2Long. However, the difference did not reach statistical significance. All QuickClip2Long clips were dislodged at 4 weeks in both the groups. Conclusions: The Resolution and Instinct clips have comparable retention rates and both appeared to be better than the QuickClip2Long on normal mucosa-simulated ulcers; however this did not reach statistical significance. Both the Resolution clip and the Instinct clip may be preferred in clinical situations when long-term clip attachment is required, including marking of tumors for radiotherapy and anchoring feeding tubes or stents. Either of the currently available clips may be suitable for closure of iatrogenic mucosal defects without features of chronicity. PMID:25434317

Surgical margin-negative endoscopic mucosal resection with simple three-clipping technique: a randomized prospective study (with video).

PubMed

Mori, Hirohito; Kobara, Hideki; Nishiyama, Noriko; Fujihara, Shintaro; Kobayashi, Nobuya; Ayaki, Maki; Masaki, Tsutomu

2016-11-01

Although endoscopic mucosal resection is an established colorectal polyp treatment, local recurrence occurs in 13 % of cases due to inadequate snaring. We evaluated whether pre-clipping to the muscularis propria resulted in resected specimens with negative surgical margins without thermal denaturation. Of 245 polyps from 114 patients with colorectal polyps under 20 mm, we included 188 polyps from 81 patients. We randomly allocated polyps to the conventional injection group (CG) (97 polyps) or the pre-clipping injection group (PG) (91 polyps). The PG received three-point pre-clipping to ensure ample gripping to the muscle layer on the oral and both sides of the tumor with 4 mL local injection. Endoscopic ultrasonography was performed to measure the resulting bulge. Outcomes included the number of instances of thermal denaturation of the horizontal/vertical margin (HMX/VMX) or positive horizontal/vertical margins (HM+/VM+), the shortest distance from tumor margins to resected edges, and the maximum bulge distances from tumor surface to the muscularis propria. The numbers of HMX and HM+ in the CG and PG were 27 and 6, and 9 and 2 (P = 0.001), and VMX and VM+ were 8 and 5, and 0 and 0 (P = 0.057). The shortest distance from tumor margin to resected edge [median (range), mm] in polyps in the CG and PG was 0.6 (0-2.7) and 4.7 (2.1-8.9) (P = 0.018). The maximum bulge distances were 4.6 (3.0-8.0) and 11.0 (6.8-17.0) (P = 0.005). Pre-clipping enabled surgical margin-negative resection without thermal denaturation.

Neurosurgeon academic impact is associated with clinical outcomes after clipping of ruptured intracranial aneurysms

PubMed Central

Ibrahim, George M.; Wang, Justin; Guha, Daipayan; Mamdani, Muhammad; Schweizer, Tom A.; Macdonald, R. Loch

2017-01-01

Background Surgeon-dependent factors such as experience and volume are associated with patient outcomes. However, it is unknown whether a surgeon’s research productivity could be related to outcomes. The main aim of this study is to investigate the association between the surgeon’s academic productivity and clinical outcomes following neurosurgical clipping of ruptured aneurysms. Methods We performed a post-hoc analysis of 3567 patients who underwent clipping of ruptured intracranial aneurysms in the randomized trials of tirilazad mesylate from 1990 to 1997. These trials included 162 centers and 156 surgeons from 21 countries. Primary and secondary outcomes were: Glasgow outcome scale score and mortality, respectively. Total publications, H-index, and graduate degrees were used as academic indicators for each surgeon. The association between outcomes and academic factors were assessed using a hierarchical logistic regression analysis, adjusting for patient covariates. Results Academic profiles were available for 147 surgeons, treating a total of 3307 patients. Most surgeons were from the USA (62, 42%), Canada (18, 12%), and Germany (15, 10%). On univariate analysis, the H-index correlated with better functional outcomes and lower mortality rates. In the multivariate model, patients under the care of surgeons with higher H-indices demonstrated improved neurological outcomes (p = 0.01) compared to surgeons with lower H-indices, without any significant difference in mortality. None of the other academic indicators were significantly associated with outcomes. Conclusion Although prognostication following surgery for ruptured intracranial aneurysms primarily depends on clinical and radiological factors, the academic impact of the operating neurosurgeon may explain some heterogeneity in surgical outcomes. PMID:28727832

Neurosurgeon academic impact is associated with clinical outcomes after clipping of ruptured intracranial aneurysms.

PubMed

Alotaibi, Naif M; Ibrahim, George M; Wang, Justin; Guha, Daipayan; Mamdani, Muhammad; Schweizer, Tom A; Macdonald, R Loch

2017-01-01

Surgeon-dependent factors such as experience and volume are associated with patient outcomes. However, it is unknown whether a surgeon's research productivity could be related to outcomes. The main aim of this study is to investigate the association between the surgeon's academic productivity and clinical outcomes following neurosurgical clipping of ruptured aneurysms. We performed a post-hoc analysis of 3567 patients who underwent clipping of ruptured intracranial aneurysms in the randomized trials of tirilazad mesylate from 1990 to 1997. These trials included 162 centers and 156 surgeons from 21 countries. Primary and secondary outcomes were: Glasgow outcome scale score and mortality, respectively. Total publications, H-index, and graduate degrees were used as academic indicators for each surgeon. The association between outcomes and academic factors were assessed using a hierarchical logistic regression analysis, adjusting for patient covariates. Academic profiles were available for 147 surgeons, treating a total of 3307 patients. Most surgeons were from the USA (62, 42%), Canada (18, 12%), and Germany (15, 10%). On univariate analysis, the H-index correlated with better functional outcomes and lower mortality rates. In the multivariate model, patients under the care of surgeons with higher H-indices demonstrated improved neurological outcomes (p = 0.01) compared to surgeons with lower H-indices, without any significant difference in mortality. None of the other academic indicators were significantly associated with outcomes. Although prognostication following surgery for ruptured intracranial aneurysms primarily depends on clinical and radiological factors, the academic impact of the operating neurosurgeon may explain some heterogeneity in surgical outcomes.

A clip-based protocol for breast boost radiotherapy provides clear target visualisation and demonstrates significant volume reduction over time

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

Lewis, Lorraine; Cox, Jennifer; Faculty of Health Sciences, University of Sydney, Sydney, New South Wales

2015-09-15

The clinical target volume (CTV) for early stage breast cancer is difficult to clearly identify on planning computed tomography (CT) scans. Surgical clips inserted around the tumour bed should help to identify the CTV, particularly if the seroma has been reabsorbed, and enable tracking of CTV changes over time. A surgical clip-based CTV delineation protocol was introduced. CTV visibility and its post-operative shrinkage pattern were assessed. The subjects were 27 early stage breast cancer patients receiving post-operative radiotherapy alone and 15 receiving post-operative chemotherapy followed by radiotherapy. The radiotherapy alone (RT/alone) group received a CT scan at median 25 daysmore » post-operatively (CT1rt) and another at 40 Gy, median 68 days (CT2rt). The chemotherapy/RT group (chemo/RT) received a CT scan at median 18 days post-operatively (CT1ch), a planning CT scan at median 126 days (CT2ch), and another at 40 Gy (CT3ch). There was no significant difference (P = 0.08) between the initial mean CTV for each cohort. The RT/alone cohort showed significant CTV volume reduction of 38.4% (P = 0.01) at 40 Gy. The Chemo/RT cohort had significantly reduced volumes between CT1ch: median 54 cm{sup 3} (4–118) and CT2ch: median 16 cm{sup 3}, (2–99), (P = 0.01), but no significant volume reduction thereafter. Surgical clips enable localisation of the post-surgical seroma for radiotherapy targeting. Most seroma shrinkage occurs early, enabling CT treatment planning to take place at 7 weeks, which is within the 9 weeks recommended to limit disease recurrence.« less

Surgical Treatment of Large or Giant Fusiform Middle Cerebral Artery Aneurysms: A Case Series.

PubMed

Xu, Feng; Xu, Bin; Huang, Lei; Xiong, Ji; Gu, Yuxiang; Lawton, Michael T

2018-04-14

Management of large or giant fusiform middle cerebral artery (MCA) aneurysms represents a significant challenge. To describe the authors' experience in the treatment of large or giant fusiform MCA aneurysm by using various surgical techniques. We retrospectively reviewed a database of aneurysms treated at our division between 2015 and 2017. Overall, 20 patients (11 males, 9 females) were identified, with a mean age of 40.7 years (range, 13-65 years; median, 43 years). Six patients (30%) had ruptured aneurysms and 14 (70%) had unruptured aneurysms. The mean aneurysm size was 19 mm (range, 10-35 mm). The aneurysms involved the prebifurcation in 5 cases, bifurcation in 4 cases, and postbifurcation in 11 cases. The aneurysms were treated by clip reconstruction (n = 5), clip wrapping (n = 1), proximal occlusion or trapping (n = 4), and bypass revascularization (n = 10). Bypasses included 7 low-flow superficial temporal artery-MCA bypasses, 2 high-flow extracranial-intracranial bypasses, and 1 intracranial-intracranial bypass (reanastomosis). Bypass patency was 90%. Nineteen aneurysms (95%) were completely obliterated, and no rehemorrhage occurred during follow-up. There was no procedural-related mortality. Clinical outcomes were good (modified Rankin Scale score ≤2) in 18 of 20 patients (90%) at the last follow-up. Surgical treatment strategy for large or giant fusiform MCA aneurysms should be determined on an individual basis, based on aneurysm morphology, location, size, and clinical status. Favorable outcomes can be achieved by various surgical techniques, including clip reconstruction, wrap clipping, aneurysm trapping, aneurysm excision followed by reanastomosis, and partial trapping with bypass revascularization. Copyright © 2018 Elsevier Inc. All rights reserved.

Minimally Invasive Thumb-sized Pterional Craniotomy for Surgical Clip Ligation of Unruptured Anterior Circulation Aneurysms

PubMed Central

Deshaies, Eric M; Villwock, Mark R; Singla, Amit; Toshkezi, Gentian; Padalino, David J

2015-01-01

Less invasive surgical approaches for intracranial aneurysm clipping may reduce length of hospital stay, surgical morbidity, treatment cost, and improve patient outcomes. We present our experience with a minimally invasive pterional approach for anterior circulation aneurysms performed in a major tertiary cerebrovascular center and compare the results with an aged matched dataset from the Nationwide Inpatient Sample (NIS). From August 2008 to December 2012, 22 elective aneurysm clippings on patients ≤55 years of age were performed by the same dual fellowship-trained cerebrovascular/endovascular neurosurgeon. One patient (4.5%) experienced transient post-operative complications. 18 of 22 patients returned for follow-up imaging and there were no recurrences through an average duration of 22 months. A search in the NIS database from 2008 to 2010, also for patients aged ≤55 years of age, yielded 1,341 hospitalizations for surgical clip ligation of unruptured cerebral aneurysms. Inpatient length of stay and hospital charges at our institution using the minimally invasive thumb-sized pterional technique were nearly half that of NIS (length of stay: 3.2 vs 5.7 days; hospital charges: $52,779 vs. $101,882). The minimally invasive thumb-sized pterional craniotomy allows good exposure of unruptured small and medium-sized supraclinoid anterior circulation aneurysms. Cerebrospinal fluid drainage from key subarachnoid cisterns and constant bimanual microsurgical techniques avoid the need for retractors which can cause contusions, localized venous infarctions, and post-operative cerebral edema at the retractor sites. Utilizing this set of techniques has afforded our patients with a shorter hospital stay at a lower cost compared to the national average. PMID:26325337

Microsurgical Clipping of an Anterior Communicating Artery Aneurysm Using a Novel Robotic Visualization Tool in Lieu of the Binocular Operating Microscope: Operative Video.

PubMed

Klinger, Daniel R; Reinard, Kevin A; Ajayi, Olaide O; Delashaw, Johnny B

2018-01-01

The binocular operating microscope has been the visualization instrument of choice for microsurgical clipping of intracranial aneurysms for many decades. To discuss recent technological advances that have provided novel visualization tools, which may prove to be superior to the binocular operating microscope in many regards. We present an operative video and our operative experience with the BrightMatterTM Servo System (Synaptive Medical, Toronto, Ontario, Canada) during the microsurgical clipping of an anterior communicating artery aneurysm. To the best of our knowledge, the use of this device for the microsurgical clipping of an intracranial aneurysm has never been described in the literature. The BrightMatterTM Servo System (Synaptive Medical) is a surgical exoscope which avoids many of the ergonomic constraints of the binocular operating microscope, but is associated with a steep learning curve. The BrightMatterTM Servo System (Synaptive Medical) is a maneuverable surgical exoscope that is positioned with a directional aiming device and a surgeon-controlled foot pedal. While utilizing this device comes with a steep learning curve typical of any new technology, the BrightMatterTM Servo System (Synaptive Medical) has several advantages over the conventional surgical microscope, which include a relatively unobstructed surgical field, provision of high-definition images, and visualization of difficult angles/trajectories. This device can easily be utilized as a visualization tool for a variety of cranial and spinal procedures in lieu of the binocular operating microscope. We anticipate that this technology will soon become an integral part of the neurosurgeon's armamentarium. Copyright © 2017 by the Congress of Neurological Surgeons

Intracranial Aneurysms of Neuro-Ophthalmologic Relevance.

PubMed

Micieli, Jonathan A; Newman, Nancy J; Barrow, Daniel L; Biousse, Valérie

2017-12-01

Intracranial saccular aneurysms are acquired lesions that often present with neuro-ophthalmologic symptoms and signs. Recent advances in neurosurgical techniques, endovascular treatments, and neurocritical care have improved the optimal management of symptomatic unruptured aneurysms, but whether the chosen treatment has an impact on neuro-ophthalmologic outcomes remains debated. A review of the literature focused on neuro-ophthalmic manifestations and treatment of intracranial aneurysms with specific relevance to neuro-ophthalmologic outcomes was conducted using Ovid MEDLINE and EMBASE databases. Cavernous sinus aneurysms were not included in this review. Surgical clipping vs endovascular coiling for aneurysms causing third nerve palsies was compared in 13 retrospective studies representing 447 patients. Complete recovery was achieved in 78% of surgical patients compared with 44% of patients treated with endovascular coiling. However, the complication rate, hospital costs, and days spent in intensive care were reported as higher in surgically treated patients. Retrospective reviews of surgical clipping and endovascular coiling for all ocular motor nerve palsies (third, fourth, or sixth cranial nerves) revealed similar results of complete resolution in 76% and 49%, respectively. Improvement in visual deficits related to aneurysmal compression of the anterior visual pathways was also better among patients treated with clipping than with coiling. The time to treatment from onset of visual symptoms was a predictive factor of visual recovery in several studies. Few reports have specifically assessed the improvement of visual deficits after treatment with flow diverters. Decisions regarding the choice of therapy for intracranial aneurysms causing neuro-ophthalmologic signs ideally should be made at high-volume centers with access to both surgical and endovascular treatments. The status of the patient, location of the aneurysm, and experience of the treating physicians are important factors to consider. Although a higher rate of visual recovery was reported with neurosurgical clipping, this must be weighed against the potentially longer intensive care stays and increased early morbidity.

Image Guidance in External Beam Accelerated Partial Breast Irradiation: Comparison of Surrogates for the Lumpectomy Cavity

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

Hasan, Yasmin; Kim, Leonard; Martinez, Alvaro

Purpose: To compare localization of the lumpectomy cavity by using breast surface matching vs. clips for image-guided external beam accelerated partial breast irradiation. Methods and Materials: Twenty-seven patients with breast cancer with two computed tomography (CT) scans each had three CT registrations performed: (1) to bony anatomy, (2) to the center of mass (COM) of surgical clips, and (3) to the breast surface. The cavity COM was defined in both the initial and second CT scans after each type of registration, and distances between COMs ({delta}COM{sub Bone}, {delta}COM{sub Clips}, and {delta}COM{sub Surface}) were determined. Smaller {delta}COMs were interpreted as bettermore » localizations. Correlation coefficients were calculated for {delta}COM vs. several variables. Results: The {delta}COM{sub Bone} (mean, 7 {+-} 2 [SD] mm) increased with breast volume (r = 0.4; p = 0.02) and distance from the chest wall (r = 0.5; p = 0.003). Relative to bony registration, clip registration provided better localization ({delta}COM{sub Clips} < {delta}COM{sub Bone}) in 25 of 27 cases. Breast surface matching improved cavity localization ({delta}COM{sub Surface} < {delta}COM{sub Bone}) in 19 of 27 cases. Mean improvements ({delta}COM{sub Bone} - {delta}COM{sub ClipsorSurface}) were 4 {+-} 3 and 2 {+-} 4 mm, respectively. In terms of percentage of improvement ([{delta}COM{sub Bone} - {delta}COM{sub ClipsorSurface}]/{delta}COM{sub Bone}), only surface matching showed a correlation with breast volume. Clip localization outperformed surface registration for cavities located superior to the breast COM. Conclusions: Use of either breast surface or surgical clips as surrogates for the cavity results in improved localization in most patients compared with bony registration and may allow smaller planning target volume margins for external beam accelerated partial breast irradiation. Compared with surface registration, clip registration may be less sensitive to anatomic characteristics and therefore more broadly applicable.« less

Patient-specific cardiac phantom for clinical training and preprocedure surgical planning.

PubMed

Laing, Justin; Moore, John; Vassallo, Reid; Bainbridge, Daniel; Drangova, Maria; Peters, Terry

2018-04-01

Minimally invasive mitral valve repair procedures including MitraClip ® are becoming increasingly common. For cases of complex or diseased anatomy, clinicians may benefit from using a patient-specific cardiac phantom for training, surgical planning, and the validation of devices or techniques. An imaging compatible cardiac phantom was developed to simulate a MitraClip ® procedure. The phantom contained a patient-specific cardiac model manufactured using tissue mimicking materials. To evaluate accuracy, the patient-specific model was imaged using computed tomography (CT), segmented, and the resulting point cloud dataset was compared using absolute distance to the original patient data. The result, when comparing the molded model point cloud to the original dataset, resulted in a maximum Euclidean distance error of 7.7 mm, an average error of 0.98 mm, and a standard deviation of 0.91 mm. The phantom was validated using a MitraClip ® device to ensure anatomical features and tools are identifiable under image guidance. Patient-specific cardiac phantoms may allow for surgical complications to be accounted for preoperative planning. The information gained by clinicians involved in planning and performing the procedure should lead to shorter procedural times and better outcomes for patients.

Spontaneous spinal cerebrospinal fluid leak as a cause of coma after craniotomy for clipping of an unruptured intracranial aneurysm.

PubMed

Schievink, Wouter I; Palestrant, David; Maya, M Marcel; Rappard, George

2009-03-01

Spontaneous spinal CSF leaks are best known as a cause of orthostatic headache, but may also be the cause of coma. The authors encountered a unique case of a spontaneous spinal CSF leak causing coma 2 days after craniotomy for clipping of an unruptured aneurysm. This 44-year-old woman with autosomal dominant polycystic kidney disease underwent an uneventful craniotomy for an incidental anterior choroidal artery aneurysm. No intraoperative spinal CSF drainage was used. Two days after surgery the patient became comatose with a left oculomotor nerve palsy. Computed tomography scanning revealed a right extraceberal hematoma and loss of gray-white matter differentiation. The hematoma was evacuated and a diagnosis of hemodialysis disequilibrium syndrome was made. Continuous hemodialysis and hyperosmolar therapy were instituted without any improvement. The CT scans were then reinterpreted as showing sagging of the brain, and the patient was placed in the Trendelenburg position which resulted in prompt improvement in her level of consciousness. A CT myelogram demonstrated an upper thoracic CSF leak that eventually required surgical correction. The patient made a complete neurological recovery. Neurological deterioration after craniotomy may be caused by brain sagging caused by a spontaneous spinal CSF leak, similar to intracranial hypotension due to intraoperative lumbar CSF drainage.

Comparison of holding strength of suture anchors for hepatic and renal parenchyma.

PubMed

Ames, Caroline D; Perrone, Juan M; Frisella, Alison J; Morrissey, Kevin; Landman, Jaime

2005-12-01

Various laparoscopic devices have been described for suture anchoring during solidorgan parenchymal closure. Application of these devices expedites the closure of parenchymal defects and minimizes ischemia time. We compared different technologies as suture anchors for parenchymal closure. A tensometer was used to determine the amount of tension necessary to dislodge each of five different clips from Vicryl suture alone or against two different substrates (fresh pig kidney and liver) with and without an intervening pledget. The clips investigated were the Lapra-Ty (Ethicon), Endoclip II (US Surgical), small Horizon Ligating Clips (Weck), Hem-o-lok Medium Polymer Clips (Week), and a novel Suture-clip (Applied Medical). ANOVA and two-sided Fisher's exact test provided statistical analysis. The force required to dislodge the Lapra-Ty clip from bare suture for both 0 and 1 Vicryl (7.0 N) was approximately fourfold the force required to dislodge the Endoclips or the 5-mm or 10-mm Hem-o-lok clips (p<0.01). When clips were applied to suture running through renal or liver parenchyma, the novel Suture-clip required the greatest tension to dislodge (P<0.01), followed by the Horizon and Lapra-Ty clips. There were no statistically significant differences in the tension required to dislodge a given clip from the two parenchymal substrates or in the presence or absence of a pledget. In our experimental model, the Suture-clip, Lapra-Ty, and Horizon clips required significantly greater tension to dislodge than the Hem-o-lok and Endoclip clips. The addition of a pledget did not improve tension resistance.

Surgical revision after percutaneous mitral valve repair by edge-to-edge device: when the strategy fails in the highest risk surgical population.

PubMed

Alozie, Anthony; Westphal, Bernd; Kische, Stephan; Kaminski, Alexander; Paranskaya, Liliya; Bozdag-Turan, Ilkay; Ortak, Jasmin; Schubert, Jochen; Steinhoff, Gustav; Ince, Hüseyin

2014-07-01

Percutaneous edge-to-edge devices for non-surgical repair of mitral valve regurgitation are under clinical evaluation in high-risk patients deemed not suitable for conventional surgery. To address guidelines for initial therapy decision, we here report on 13 cases of surgery after failed percutaneous edge-to-edge mitral valve repair or attempted repair, and discuss methodology and prognostic factors for operative outcome in this high-risk situation. Thirteen patients referred to our cardiothoracic unit after failed percutaneous mitral valve repair or attempted repair using the edge-to-edge technique, were treated surgically for mitral valve failure between June 2010 and December 2012. Pathology of mitral valve before and after interventional mitral valve repair (especially prevalent mode of failure) was evaluated and classified for each individual patient by echocardiography and intraoperative direct visualization. Number of implanted edge-to-edge devices were identified. Preoperative risk scores were matched with intraoperative observations and histopathological findings of valve tissue. Postoperative morbidity and mortality were analysed with respect to mitral valve and patient-related data. Three of 10 patients were referred with severe mitral valve regurgitation/stenosis after initially successful percutaneous edge-to-edge therapy or attempted therapy. In 3 patients, ≥ 2 edge-to-edge devices were implanted leading to very tight edge-to-edge leaflet connection and fibrosis. All patients underwent successful surgical mitral valve replacement and concomitant complete cardiac surgery (CABG, aortic or tricuspid valve surgery, ASD closure and pulmonary vein isolation for atrial fibrillation). The likelihood of repair was reduced with respect to multiple edge-to-edge technology. One device could not be harvested surgically because of embolization. One patient died on the second postoperative day due to sepsis with multiple organ failure. The remaining 12 patients were discharged with excellent valve prosthesis function and followed up to 2 years post-surgery. The current long-term survival rate is 77%. Our series demonstrate that highest risk patients can survive mitral valve surgery after failed multiple edge-to-edge interventional mitral valve repair. As long-term results of the MitraClip therapy are pending, we recommend close meshed follow-up of patients treated with the MitraClip device, especially within the first year of the index procedure as delays in salvage management, interventional or surgical, when the index procedure fails may increase morbidity and mortality. © The Author 2013. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

From tricuspid to double orifice Morphology: Percutaneous tricuspid regurgitation repair with the MitraClip device in congenitally corrected-transposition of great arteries.

PubMed

Picard, Fabien; Tadros, Victor-Xavier; Asgar, Anita W

2017-09-01

Edge to edge transcatheter mitral valve repair with MitraClip (Abbott Vascular, Menlo Park, CA) is increasing for high-risk surgical patients with significant mitral regurgitation. Patients with congenitally corrected transposition of the great arteries (CCTGA) presenting with tricuspid valve regurgitation of a systemic right ventricle may represent particularly challenging candidates for MitraClip given their anatomy. We report the case of a 67-year-old gentleman with CCTGA and severe tricuspid regurgitation who was referred for MitraClip implantation after heart team consensus. Successful implantation of one clip was performed, achieving a significant reduction of the regurgitation. Similarly, favorable findings were confirmed at 6 months, 1 and 2 years follow-up and the patient had no recurrent heart failure admissions after 2-year follow-up. We describe the technical considerations and the importance of 3D-transoesophageal echocardiography for performing the MitraClip of a trileaflet systemic atrioventricular valve. © 2016 Wiley Periodicals, Inc. © 2016 Wiley Periodicals, Inc.

Use of pneumocystoplasty for overinflation of the swim bladder in a goldfish.

PubMed

Britt, Tara; Weisse, Chick; Weber, E Scott; Matzkin, Zach; Klide, Alan

2002-09-01

A Ryukin goldfish was evaluated because of a 6-month history of progressive abdominal distention and positive buoyancy. Overinflation of the swim bladder was diagnosed, and the fish was anesthetized with tricaine methanesulfonate. Archimedes' principle was used to determine the volume of swim bladder that was removed surgically. The caudal swim bladder was exteriorized through an abdominal incision and 2 surgical clips were placed across it to limit its size. After surgery, the fish remained in a state of negative buoyancy in sternal and lateral recumbency on the bottom of the tank. Sutures were removed 15 days after surgery, but the fish died 24 days after surgery. A full necropsy could not be performed because of autolysis of the tissues, but the surgical clips and the swim bladder appeared unremarkable. Pneumocystoplasty may be a viable treatment for this condition.

Laparoendoscopic single-site urologic surgery in children less than 5 years of age.

PubMed

Ganpule, Arvind; Sheladiya, Chetan; Mishra, Shashikant; Sabnis, Ravindra; Desai, Mahesh

2013-08-01

We report our experience with laparoendoscopic single-site (LESS) urological procedures in children less than 5 years of age. Ten patients (11 procedures) underwent LESS through the umbilicus. Seven patients underwent nephrectomy and three patients underwent pyeloplasty (one simultaneous bilateral). R-port port (Advanced Surgical Concepts, Ireland) was used in nine cases, in one case, the Gelpoint access port (Applied Medical, Rancho Santa Margarita, CA, USA) was used. The Olympus Endoeye camera with coaxial light cable was used. The hilum was secured in all cases with Hem-o-Lok clips (Teleflex Medical, Research Triangle Park, NC, USA) except in one case in which an Endo GIA stapler (Covidien Surgical, Norwalk, CT, USA) was used. All procedures were technically successful. Accessory port (3 mm) was used in 3 patients. Mean age in nephrectomized patients was 3.14±1.7 years, the mean operative room time (ORT) was 97.5±12.54 minutes. In the pyeloplasty group, mean ORT was 192±47.16 minutes and mean age was 2.43±2.3 years. Bilateral pyeloplasty was done in a 4-month-old infant. The ORT in this case was 180 minutes. A follow-up renogram done in the pyeloplasty patients (n=2) showed good drainage. Mean length of stay was 3.6 days (range, 3 to 6 days).The analgesic requirement was 23.86 mg (range, 12.5 to 50 mg) of diclofenac sodium. LESS is technically feasible in patients as young as 4 months of age. It has the potential to offer better cosmesis. This needs to be proved in further comparative studies. Development of miniature instruments will further the growth of LESS in this age group.

Dual-Channel Endoscopic Indocyanine Green Fluorescence Angiography for Clipping of Cerebral Aneurysms.

PubMed

Cho, Won-Sang; Kim, Jeong Eun; Kang, Hyun-Seung; Ha, Eun Jin; Jung, Minwoong; Lee, Choonghee; Shin, Il Hyung; Kang, Uk

2017-04-01

Neuroendoscopy is useful for assessing status of perforators, parent arteries, and aneurysms beyond the straight line of microscopic view during aneurysm clipping. We aimed to evaluate the clinical usefulness of our endoscopic indocyanine green angiography (ICGA) system, which can simultaneously display visible light and indocyanine green fluorescent images. Surgical clipping of 16 unruptured aneurysms in 10 patients was performed via the keyhole approach. Using our endoscopic ICGA and commercial microscopic ICGA systems, we prospectively compared 10 targeted cerebral aneurysms at the posterior communicating (n = 4) and anterior choroidal (n = 6) arteries. Microscopic ICGA and endoscopic ICGA were feasible during surgery. Microscopic ICGA displayed 50% of branch orifices, 100% of branch trunks, and 20% of exact clip positions, whereas endoscopic ICGA showed 100% of these. Based on endoscopic ICGA findings such as incomplete clipping and compromise of parent arteries or branches, clips were repositioned in 2 cases, and additional clips were applied in 2 cases. Complete occlusion and residual neck states were achieved in 6 and 4 aneurysms after surgery. There were no neurologic deficits within 3 months after surgery except for frontalis palsy and anosmia in each patient. The endoscopic ICGA system with dual imaging of visible light and indocyanine green fluorescence was very useful for assessing geometry of aneurysms and surrounding vessels before clipping and for evaluating completeness of clip position after clipping. Copyright © 2017 Elsevier Inc. All rights reserved.

Near-real-time transcutaneous vascular clipping guided by magnetic resonance angiography: a minimally invasive technique for vascular control

NASA Astrophysics Data System (ADS)

Ennevor, Sean J.; Castro, Dan J.; Girardi, Gino; Lufkin, Robert B.; Farahani, Keyvan; Cho, Richard C.; Soudant, Jacques

1993-07-01

Interstitial tumor therapy guided by imaging techniques is minimally invasive and a promising surgical approach which will become clinically practical only when effective, simple, and safe modalities for tumor excision and control of tumor vascular supply are available. In a novel experiment utilizing a 1.5 T magnetic resonance (MR) scanner, the carotid artery of a New Zealand white rabbit was identified and then clamped using the Premium Surgicliptm 9.0' disposable automatic clip applier. The magnetic resonance imager equipped with an angiography package was used to locate vasculature in the carotid triangle of the rabbit via fast scan techniques. The artery was then clamped with titanium clips, and repeat magnetic resonance angiography (MRA) clearly demonstrated the cessation of blood flow within the chosen vessel. The experimental results are promising, since the angiography package not only provided the visualization of the arterial vessel, but was also used to guide an MR compatible surgical instrument to the vessel, with no artifact seen.

Results of microsurgical treatment of large and giant ICA aneurysms using the retrograde suction decompression (RSD) technique: series of 92 patients.

PubMed

Eliava, Shalva S; Filatov, Yuri M; Yakovlev, Sergei B; Shekhtman, Oleg D; Kheireddin, Ali S; Sazonov, Ilya A; Sazonova, Olga B; Okishev, Dmitry N

2010-06-01

Microsurgical treatment of large and giant paraclinoid internal carotid artery (ICA) aneurysms often requires the use of the retrograde suction decompression (RSD) technique to facilitate clipping. Surgical results, functional outcomes at discharge, and technique limitations based on single institution series are presented. Between 1996 and 2009, eighty-three consecutive patients (19 to 68 years, mean 45.5 ± 9.9 years), predominantly women (69 women and 14 men) with large (23 patients, 27.7%) or giant (60 patients, 72.3%) paraclinoid aneurysms were surgically treated with the RSD technique performed by the neck route (62 patients, 74.4%) or later on, by endovascular means (21 patients, 25.3%). Patients were admitted after hemorrhage (48 patients, 57.9%), pseudotumor course (28 patients, 33.7%), mixed symptoms (5 patients, 6%), or asymptomatic (2 patients, 2.4%). In most RSD surgeries (90.4%) aneurysms were successfully excluded: neck was clipped in 57 patients (68.7%) or clipping with ICA reconstruction was achieved in 18 patients (21.7%). In six patients aneurysms were wrapped with glue (7.2%), trapped in one patient (1.2%), and in one patient, ICA balloon deconstruction was performed (1.2%). Good or excellent results (Glasgow Outcome Scale scores 4-5) at discharge were achieved in 69 patients (83.1%), 11 patients (13.3%) remained severely disabled (Glasgow Outcome Scale 3), and 3 patients died (3.6%). Surgical clipping with the RSD method remains a treatment of choice with acceptable outcomes for patients not amenable for endovascular treatment. Copyright © 2010 Elsevier Inc. All rights reserved.

Duodenal Ulcer Induced by Hem-o-Lok clip after Reduced Port Laparoscopic Cholecystectomy.

PubMed

Soga, Koichi; Kassai, Kyoichi; Itani, Kenji

2016-03-01

The patient was a 66-year-old woman who had undergone laparoscopic cholecystectomy (Lap-C) secondary to chronic cholecystitis status post endoscopic choledocholithotomy 13 months previously. During surgery, Hem-o-Lok clips were used to control the cystic duct and the cystic artery. Due to the presence of extensive adhesions of the cystic duct and surrounding tissue, the surgeons had difficulty in debriding the area. Thirteen months after Lap-C, the patient underwent a screening esophagogastroduodenoscopy (EGD), which demonstrated clip appearance at the inferior wall of the first part of the duodenum. In the EGD, duodenal erosions and edema were observed around the clip. We appreciated that endoscopic clip removal would be difficult because of the presence of severe adhesions and inflammation of the duodenal bulb. On clinical examination of the patient, no major abnormalities or physical findings were noted. Therefore, we decided not to attempt to remove the clip. The patient was treated with an oral proton pump inhibitor to prevent extensive duodenal mucosal injury. Two months later, we repeated the EGD, which revealed that the clip was no longer present, and the duodenum was covered with normal mucosa surrounding the scar.

Advanced technical skills are required for microsurgical clipping of posterior communicating artery aneurysms in the endovascular era.

PubMed

Sanai, Nader; Caldwell, Nolan; Englot, Dario J; Lawton, Michael T

2012-08-01

Many neurosurgeons feel competent clipping posterior communicating artery (PCoA) aneurysms and include this lesion in their practice. However, endovascular therapy removes simple aneurysms that would have been easiest to clip with the best results. What remains are aneurysms with complex anatomy and technical challenges that are not well described. A contemporary surgical series with PCoA aneurysms is reviewed to define the patients, microsurgical techniques, and outcomes in current practice. A total of 218 patients had 218 PCoA aneurysms that were treated microsurgically during an 11-year period. Complexities influencing aneurysm management included (1) large/giant size; (2) fetal posterior cerebral artery; (3) previous coiling; (4) anterior clinoidectomy; (5) adherence of the anterior choroidal artery (AChA); (6) intraoperative aneurysm rupture; (7) complex clipping; and (8) atherosclerotic calcification. Simple PCoA aneurysms were encountered in 113 patients (51.8%) and complex aneurysms in 105 (48.2%). Adherent AChA (13.8%) and intraoperative rupture (11.5%) were the most common complexities. Simple aneurysms had favorable outcomes in 86.6% of patients, whereas aneurysms with 1 or multiple complexities had favorable outcomes in 78.2% and 75.0%, respectively. Intraoperative rupture (P < .01), large/giant size (P = .04), and complex clipping (P = .05) were associated with increased neurological worsening. Because endovascular therapy alters the surgical population, neurosurgeons should recalibrate their expectations with this once straightforward aneurysm. The current mix of PCoA aneurysms requires advanced techniques including clinoidectomy, AChA microdissection, complex clipping, and facility with intraoperative rupture. Microsurgery is recommended for recurrent aneurysms after coiling, complex branches, aneurysms causing oculomotor nerve palsy, multiple aneurysms, and patients with hematomas.

Retrograde suction decompression of a large internal carotid aneurysm using a balloon guide catheter combined with a blood-returning circuit and STA-MCA bypass: a technical note.

PubMed

Matano, Fumihiro; Mizunari, Takayuki; Kominami, Shushi; Suzuki, Masanori; Fujiki, Yu; Kubota, Asami; Kobayashi, Shiro; Murai, Yasuo; Morita, Akio

2017-04-01

It is difficult to treat large internal carotid aneurysms with simple surgical clipping. Here, we present a retrograde suction decompression (RSD) procedure for large internal carotid aneurysms using a balloon guide catheter combined with a blood-returning circuit and a superficial temporal artery to middle cerebral artery (STA-MCA) bypass.All patients underwent an STA-MCA bypass before the temporary occlusion of the internal carotid artery (ICA). A 6-French sheath was inserted into the common carotid artery (CCA), and a 6-French Patrive balloon catheter was placed into the ICA 5 cm past the bifurcation. Aneurysm exposure was obtained; temporary clips were placed on the proximal M1, A1, and posterior communicating (Pcom) segments; and an extension tube was then connected to the balloon catheter. A three-way stopcock was placed, and aspiration was performed through the device to collapse the aneurysm. The aspirated blood was returned to a venous line with an added heparin to prevent anemia after aspiration. During the decompression, the blood flow to the cortical area was supplied through the STA-MCA bypass. After the aneurysm collapse, the surgeon carefully dissected the perforating artery from the aneurysm dome or neck, and permanent clips were then placed on the aneurysm neck. Our procedure has several advantages, such as STA-MCA bypass without external carotid artery occlusion for preventing ischemic complications of the cortical area, anemia may be avoided because of the return of the aspirated blood, and a hybrid operation room is not required to perform this method.

Endoscopic removal of over-the-scope clips using a novel cutting device: a retrospective case series.

PubMed

Schmidt, Arthur; Riecken, Bettina; Damm, Michael; Cahyadi, Oscar; Bauder, Markus; Caca, Karel

2014-09-01

Over-the-scope clips (OTSCs; Ovesco Endoscopy, Tübingen, Germany) are extensively used for treatment of gastrointestinal perforations, leakages, fistulas, and bleeding. In this report, a new method of removing OTSCs using a prototype bipolar cutting device is described. A total of 11 patients underwent endoscopic removal of an OTSC. The OTSC was cut at two opposing sites by a prototype device (DC ClipCutter; Ovesco Endoscopy). The remaining clip fragments were extracted using a standard forceps. Mean procedure time was 47 minutes (range 35 - 75 minutes). Cutting of the OTSC at two opposing sites was successful in all cases (100 %). Complete retrieval of all clip fragments was possible in 10 patients (91 %). The overall success rate for cutting and complete removal of the clip was 91 %. No major complications were observed. Removal of OTSCs with the prototype device was feasible and effective. The device may be valuable for OTSC removal in emergency as well as elective indications. © Georg Thieme Verlag KG Stuttgart · New York.

[Surgical fixation of rib fractures with clips and titanium bars (STRATOS System). Preliminary experience].

PubMed

Moreno De La Santa Barajas, Pablo; Polo Otero, María Dolores; Delgado Sánchez-Gracián, Carlos; Lozano Gómez, Manuel; Toscano Novella, Alberto; Calatayud Moscoso Del Prado, Julia; Leal Ruiloba, Sonsoles; Choren Durán, Maria L

2010-09-01

Rib fractures are very common in closed chest injuries. The majority of these patients suffer significant pain with movement and cough. The purpose of this study is to assess the usefulness of titanium rib bars and clips in stabilising rib fractures. Twenty-two patients with rib fractures were treated with open reduction and internal fixation between 2008 and 2009. Indications for treatment were defined as; 1) Patients with unstable chest (13 patients), 2) Patients with pain or instability due to rib fractures (6 patients), and 3) Significant traumatic deformities of the chest wall (3 patients). Age, traumatic mechanism, chest and associated injuries, surgical data, complications and follow-up were prospectively analysed. The surgical technique is described. The majority of patients were extubated immediately after surgery. All patients with pain or instability showed a subjective improvement or disappearance of pain after the surgery. Four patients had a wound infection which had to be drained. After 3 months, 55% of the patients had returned to work or normal life. The results in each group are described. Open reduction with internal fixation of rib fractures is a good alternative. The use of titanium rib bars and clips give good clinical results, are easy to apply and have few complications. Copyright © 2010 AEC. Published by Elsevier Espana. All rights reserved.

The efficiency of the new Yasargil titanium fenestrated mini-clips for ideal clipping of a cerebral aneurysm

PubMed Central

Ota, Nakao; Tanikawa, Rokuya; Noda, Kosumo; Tsuboi, Toshiyuki; Kamiyama, Hiroyasu; Tokuda, Sadahisa

2015-01-01

Background: The fenestrated clip is sometimes useful in limited approach angle and narrow working space. However, before the development of the new Yasargil titanium fenestrated mini-clip, the only variations of fenestrated clips were those of larger sizes. And those larger clips have a problem of the triangle-shaped gap at the proximal end of the blade. The authors describe the efficiency, limitations and surgical technique of using the Yasargil titanium fenestrated mini-clip. Methods: Fifty-nine cases of aneurysms were treated using these mini-clips. Aneurysm location, size and dome neck ratio, mean follow-up period, neck remnant, and recurrence rate were also analyzed. Among these cases, we present eight characteristic cases, including a case with aneurysm recurrence, and we review the problems associated with the triangle-shaped gap at the proximal end of the clip. Results: The average size of the aneurysms was 5.57 mm, and the dome neck ratio was >2.0 in 1.69%, >1.5 in 11.8%, >1.2 in 35.6%, and <1.2 in 50.8% of cases. The mean follow-up period for the 59 cases was 5.5 months (range, 0.5–16 months). Angiographic recurrence of the treated portion occurred in 1 case (1.7%), including an aneurysm in the basilar artery tip aneurysm. Conclusion: The availability of the Yasargil titanium fenestrated mini-clip increases the options for clipping to minimize the remnant of the clipped aneurysm. However, there is still concern over the triangular space at the base of the blade, especially when treating an aneurysm with a thin vessel wall. Therefore, modification of the clipping technique is sometimes needed. PMID:26664871

Long-Term Follow-Up for a Giant Basilar Trunk Aneurysm Surgically Treated by Proximal Occlusion and External Carotid Artery to Posterior Cerebral Artery Bypass Using a Saphenous Vein Graft.

PubMed

Yanagisawa, Toshiharu; Kinouchi, Hiroyuki; Sasajima, Toshio; Shimizu, Hiroaki

2016-11-01

The authors describe a case of a basilar trunk aneurysm with long-term follow-up after successful bypass and proximal occlusion. A 64-year-old woman had a giant aneurysm of the basilar trunk and underwent external carotid artery-to-posterior cerebral artery vein graft bypass surgery and proximal clipping of the basilar artery, which was followed by low-dose aspirin (100 mg/d) treatment. No ischemic symptoms and lesions developed and the thrombosed aneurysm was stable during 11 years of follow-up. An extracranial-intracranial high flow bypass combined with immediate proximal occlusion and aspirin administration may be an acceptable treatment option for patients with giant posterior circulation aneurysms. Copyright © 2016 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Fast MRI-guided vacuum-assisted breast biopsy: initial experience.

PubMed

Liberman, Laura; Morris, Elizabeth A; Dershaw, D David; Thornton, Cynthia M; Van Zee, Kimberly J; Tan, Lee K

2003-11-01

The purpose of this study was to evaluate a new method for performing MRI-guided vacuum-assisted breast biopsy in a study of lesions that had subsequent surgical excision. SUBJECTS AND METHODS. Twenty women scheduled for MRI-guided needle localization and surgical biopsy were prospectively entered in the study. MRI-guided biopsy was performed with a vacuum-assisted probe, followed by placement of a localizing clip, and then needle localization for surgical excision. Vacuum-assisted biopsy and surgical histology were correlated. Vacuum-assisted biopsy was successfully performed in 19 (95%) of the 20 women. The median size of 27 MRI-detected lesions that had biopsy was 1.0 cm (range, 0.4-6.4 cm). Cancer was present in eight (30%) of 27 lesions and in six (32%) of 19 women; among these eight cancers, five were infiltrating and three were ductal carcinoma in situ (DCIS). Among these 27 lesions, histology was benign at vacuum-assisted biopsy and at surgery in 19 (70%), cancer at vacuum-assisted biopsy in six (22%), atypical ductal hyperplasia at vacuum-assisted biopsy and DCIS at surgery in one (4%), and benign at vacuum-assisted biopsy with surgery showing microscopic DCIS that was occult at MRI in one (4%). The median time to perform vacuum-assisted biopsy of a single lesion was 35 min (mean, 35 min; range, 24-48 min). Placement of a localizing clip, attempted in 26 lesions, was successful in 25 (96%) of 26, and the clip was retrieved on specimen radiography in 22 (96%) of 23. One complication occurred: a hematoma that resolved with compression. MRI-guided vacuum-assisted biopsy is a fast, safe, and accurate alternative to surgical biopsy for breast lesions detected on MRI.

Suture retraction technique to prevent parent vessel obstruction following aneurysm tandem clipping.

PubMed

Rayan, Tarek; Amin-Hanjani, Sepideh

2015-08-01

With large or giant aneurysms, the use of multiple tandem clips can be essential for complete obliteration of the aneurysm. One potential disadvantage, however, is the considerable cumulative weight of these clips, which may lead to kinking of the underlying parent vessels and obstruction of flow. The authors describe a simple technique to address this problem, guided by intraoperative blood flow measurements, in a patient with a ruptured near-giant 2.2 × 1.7-cm middle cerebral artery bifurcation aneurysm that was treated with the tandem clipping technique. A total of 11 clips were applied in a vertical stacked fashion. The cumulative weight of the clips caused kinking of the temporal M2 branch of the bifurcation with reduction of flow. A 4-0 Nurolon suture tie was applied to the hub of one of the clips and was tethered to the dura of the sphenoid ridge by a small mini-clip and reinforced by application of tissue sealant. The patient underwent intraoperative indocyanine green videoangiography as well as catheter angiography, which demonstrated complete aneurysmal obliteration and preservation of vessel branches. Postoperative angiography confirmed patency of the bifurcation vessels with mild vasospasm. The patient had a full recovery with no postoperative complications and was neurologically intact at her 6-month follow-up. The suture retraction technique allows a simple solution to parent vessel obstruction following aneurysm tandem clipping, in conjunction with the essential guidance provided by intraoperative flow measurements.

Use of the 5-mm Endoscopic Stapler for Ligation of Fistula in Laparoscopic-Assisted Repair of Anorectal Malformation.

PubMed

Slater, Bethany J; Kay, Saundra; Rothenberg, Steven S

2018-02-15

Laparoscopic anorectoplasty (LARRP) for the treatment of select anorectal malformations has gained popularity due to enhanced visualization of the fistula and the ability to place the rectum within the sphincter complex while minimizing division of muscles and the perineal incision. However, given the technical challenges and reported complications of ligation, a number of techniques have been described, including using clips, suture ligation, endoloops, or division without closure. We aimed to evaluate fistula closure and division for high imperforate anus using a 5-mm stapler (JustRight Surgical, Boulder, CO). A retrospective chart review was performed on patients who underwent LAARP for imperforate anus between March 2015 and December 2016. Four patients underwent LAARP with division of the fistula using the 5-mm stapler. The average age was 3.2 months and average weight was 4.5 kg. The location of the fistula was rectoprostatic in 3 cases and rectobladder neck in 1 case. There were no complications. Division of a fistula at or above the level of the prostate can safely and effectively be performed with the 5-mm stapler. The stapler allows for division flush with the urethra or bladder ergonomically and quickly.

Sealing of the cystic and appendix arteries with monopolar electrocautery during laparoscopic combined cholecystectomy and appendectomy.

PubMed

Liu, Gui-Bao; Mao, Yuan-Yuan; Yang, Chang-Ping; Cao, Jin-Lin

2018-03-01

The best method to ligate the arteries during laparoscopic cholecystectomy or appendectomy remains controversy. The aim of this study is to introduce a new approach during laparoscopic combined cholecystectomy and appendectomy using a monopolar electrocautery to seal the cystic and appendix arteries. We retrospectively reviewed data from 57 patients who underwent laparoscopic combined cholecystectomy and appendectomy between December 2006 and June 2016. Each laparoscopic combined cholecystectomy and appendectomy was performed by coagulating and sealing the cystic and appendix arteries. Absorbable clip or coils were then used to ligate the proximal of cystic duct and the stump of appendix. The other side of the cystic duct and appendix which subsequently were to be removed from abdomen were used titanium clips or silk ligature. Of the 57 patients, 3 patients (5.3%) were converted to open surgery due to severe abdominal adhesions or gallbladder perforation. The mean operative time was 56 minutes (range, 40-80 minutes). Mean blood loss was 12 mL (range, 5-120 mL), and the mean postoperative hospital stay was 3.0 days (range, 2-5 days). No postoperative bleeding, biliary leakage, infection, or mortality occurred. Monopolar electrocautery to seal the cystic and appendix arteries is a safe, effective, and economical surgical procedure during laparoscopic combined cholecystectomy and appendectomy. Further randomized controlled clinical trials are required to validate our findings.

Sealing of the cystic and appendix arteries with monopolar electrocautery during laparoscopic combined cholecystectomy and appendectomy

PubMed Central

Liu, Gui-Bao; Mao, Yuan-Yuan; Yang, Chang-Ping; Cao, Jin-Lin

2018-01-01

Abstract The best method to ligate the arteries during laparoscopic cholecystectomy or appendectomy remains controversy. The aim of this study is to introduce a new approach during laparoscopic combined cholecystectomy and appendectomy using a monopolar electrocautery to seal the cystic and appendix arteries. We retrospectively reviewed data from 57 patients who underwent laparoscopic combined cholecystectomy and appendectomy between December 2006 and June 2016. Each laparoscopic combined cholecystectomy and appendectomy was performed by coagulating and sealing the cystic and appendix arteries. Absorbable clip or coils were then used to ligate the proximal of cystic duct and the stump of appendix. The other side of the cystic duct and appendix which subsequently were to be removed from abdomen were used titanium clips or silk ligature. Of the 57 patients, 3 patients (5.3%) were converted to open surgery due to severe abdominal adhesions or gallbladder perforation. The mean operative time was 56 minutes (range, 40–80 minutes). Mean blood loss was 12 mL (range, 5–120 mL), and the mean postoperative hospital stay was 3.0 days (range, 2–5 days). No postoperative bleeding, biliary leakage, infection, or mortality occurred. Monopolar electrocautery to seal the cystic and appendix arteries is a safe, effective, and economical surgical procedure during laparoscopic combined cholecystectomy and appendectomy. Further randomized controlled clinical trials are required to validate our findings. PMID:29595660

SU-E-J-201: Position Verification in Breast Cancer Radiotherapy Using Tantalum Clips in the Lumpectomy Cavity

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

Santvoort, J van; Van der Drift, M; Kuipers, J

2014-06-01

Purpose: To find out whether tantalum surgical clips can be used for online position verification in treatment of the lumpectomy cavity (LC) in breast cancer patients. Tantalum is a high density metal that could be visible on Electronic Portal Images (EPIs) and be an affordable alternative to gold markers. Clips are considered more representative for the LC position than nearby bony structures. Methods: In twelve patients the surgeon had placed 2 to 5 tantalum clips in the LC. The AP and lateral fields used for portal imaging, were adapted. In doing so, both bony structures and tantalum clips were visiblemore » on EPIs. The following analyses were performed:1. Image degradation, with respect to delineating the CTV, of the axial CT slices by artefacts because of the tantalum clips was evaluated by a radiation oncologist;2. The visibility of the tantalum clips on the EPIs was evaluated by four radiation therapists (RTTs);3. Bony anatomy and tantalum clip matches were performed on the same images independently by two observers. Results: 1. Delineation of the CTV by the radiation oncologist was not hampered by CT image artefacts because of the clips.2. The mean score for visibility of the clips on the EPIs, analysed by the four RTTs, was 5.6 on a scale of 10 (range 3.9 – 8.0).3. In total 12 patients with 16 fractions each were analysed. The differences between clip match and bone match are significant with a mean vector length of 5.2 mm (SD 1.9 mm) for the difference. Conclusion: Results of matches on tantalum clips as compared to matches on bony structures differ substantially. Therefore clip matches can result in smaller CTV to PTV margins than bone matches. Visibility of the clips on EPIs is sufficient, so they can be an alternative to gold markers.« less

The utility of dual-energy CT for metal artifact reduction from intracranial clipping and coiling.

PubMed

Mera Fernández, D; Santos Armentia, E; Bustos Fiore, A; Villanueva Campos, A M; Utrera Pérez, E; Souto Bayarri, M

2018-04-23

To assess the ability of dual-energy CT (DECT) to reduce metal-related artifacts in patients with clips and coils in head CT angiography, and to analyze the differences in this reduction between both type of devices. Thirteen patients (6 clips, 7 coils) were selected and retrospectively analized. Virtual monoenergetic images (MEI) with photon energies from 40 to 150 keV were obtained. Noise was measured at the area of maximum artifact. Subjective evaluation of streak artifact was performed by two radiologists independently. Differences between noise values in all groups were tested by using the ANOVA test. Mann-Whitney U test was used to compare the differences between clips and coils. Coheńs κ statistic was used to determine interobserver agreement. The lowest noise value was observed at high energy levels (p<0,05). Noise was higher in the coil group than in the clip group (p<0.001). Interobserver agreement was good (κ=0.72). TCED with MEI helps to minimize the artifact from clips ands coils in patients who undergo head CT angiography. The reduction of the artifact is greater in patients with surgical clipping than in patients with endovascular coiling. Copyright © 2018 SERAM. Publicado por Elsevier España, S.L.U. All rights reserved.

Comparative analysis of T2 selective division of rami-communicantes (ramicotomy) with T2 sympathetic clipping in the treatment of craniofacial hyperhidrosis.

PubMed

Kim, Do Hyung; Paik, Hyo Chae; Lee, Doo Yun

2004-08-01

The main cause of dissatisfaction after sympathetic trunk blocking surgery (T2 sympathectomy, sympathetic clipping) for craniofacial hyperhidrosis is compensatory sweating. Preserving sympathetic trunk may decrease the incidence of compensatory sweating, and we introduce T2 ramicotomy, which may better preserve the sympathetic nerve trunk in order to reduce compensatory sweating. From January 2000 to November 2002, video-assisted thoracoscopic (VAT) T2 sympathetic clipping and VAT ramicotomy were performed in 44 patients suffering from craniofacial hyperhidrosis. Twenty-two patients underwent T2 sympathetic clipping (group 1), and 22 underwent division of T2 rami-communicantes (group 2). We retrospectively analyzed the rate of satisfaction, dryness of face, and grade of compensatory sweating. Both groups were similar with respect to facial dryness (P = 0.099). Group 1: excessive dry 5 patients (22.7%), dry 17 patients (77.3%); group 2: excessive dry 3 patients (13.6%), dry 15 patients (68.1%), and persistent sweating 4 patients (18.3%). The rate of satisfaction was 77.3% in group 1, and 63.6% in group 2 with no significant difference (P > 0.05). The rate of compensatory sweating in group 2 (72.7%) was significantly lower than in group 1 (95.4%) (P < 0.039). The chance of embarrassing and disabling compensatory sweating was lower in group 2 than in group 1; 76.5% (embarrassing in 8 patients, disabling in 9) in group 1, and 36.4% (embarrassing in 7 patients, disabling in 1) in group 2 which was statistically significant (P < 0.006). T2 ramicotomy for craniofacial hyperhidrosis lowers the rate of compensatory sweating and excessive dryness of face compared to T2 clipping.

Analysis of saccular aneurysms in the Barrow Ruptured Aneurysm Trial.

PubMed

Spetzler, Robert F; Zabramski, Joseph M; McDougall, Cameron G; Albuquerque, Felipe C; Hills, Nancy K; Wallace, Robert C; Nakaji, Peter

2018-01-01

OBJECTIVE The Barrow Ruptured Aneurysm Trial (BRAT) is a prospective, randomized trial in which treatment with clipping was compared to treatment with coil embolization. Patients were randomized to treatment on presentation with any nontraumatic subarachnoid hemorrhage (SAH). Because all other randomized trials comparing these 2 types of treatments have been limited to saccular aneurysms, the authors analyzed the current BRAT data for this subgroup of lesions. METHODS The primary BRAT analysis included all sources of SAH: nonaneurysmal lesions; saccular, blister, fusiform, and dissecting aneurysms; and SAHs from an aneurysm associated with either an arteriovenous malformation or a fistula. In this post hoc review, the outcomes for the subgroup of patients with saccular aneurysms were further analyzed by type of treatment. The extent of aneurysm obliteration was adjudicated by an independent neuroradiologist not involved in treatment. RESULTS Of the 471 patients enrolled in the BRAT, 362 (77%) had an SAH from a saccular aneurysm. Patients with saccular aneurysms were assigned equally to the clipping and the coiling cohorts (181 each). In each cohort, 3 patients died before treatment and 178 were treated. Of the 178 clip-assigned patients with saccular aneurysms, 1 (1%) was crossed over to coiling, and 64 (36%) of the 178 coil-assigned patients were crossed over to clipping. There was no statistically significant difference in poor outcome (modified Rankin Scale score > 2) between these 2 treatment arms at any recorded time point during 6 years of follow-up. After the initial hospitalization, 1 of 241 (0.4%) clipped saccular aneurysms and 21 of 115 (18%) coiled saccular aneurysms required retreatment (p < 0.001). At the 6-year follow-up, 95% (95/100) of the clipped aneurysms were completely obliterated, compared with 40% (16/40) of the coiled aneurysms (p < 0.001). There was no difference in morbidity between the 2 treatment groups (p = 0.10). CONCLUSIONS In the subgroup of patients with saccular aneurysms enrolled in the BRAT, there was no significant difference between modified Rankin Scale outcomes at any follow-up time in patients with saccular aneurysms assigned to clipping compared with those assigned to coiling (intent-to-treat analysis). At the 6-year follow-up evaluation, rates of retreatment and complete aneurysm obliteration significantly favored patients who underwent clipping compared with those who underwent coiling. Clinical trial registration no.: NCT01593267 (clinicaltrials.gov).

[Ligation of the retrobulbar vascular-nervous bunch during performance of evisceration and enucleation using titanic clips in ophthalmic surgery].

PubMed

Rykov, S A; Torchinskaia, N V; Bakbardina, I I; Simchuk, I V

2011-10-01

The efficacy of hemostasis achievement during conduction of a retrobulbar vascular-nervous bunch ligation (RVNBL), using titanic clips while evisceroenucleation performance, was studied up. A comparative analysis of clinical and functional results of surgical treatment of 36 patients, suffering terminal dolorous glaucoma and disaster of a sympathetic ophthalmia complication after an eye penetrating wounding occurrence. In 16 patients (the first group) a standard method of a hemostasis achievement was used while doing evisceroenucleation - a deep orbital tamponade for 5 minutes. In 20 patients (the second group) a procedure of RVNBL was conducted, using titanic clips before the bunch transsection doing. There was established, that while doing a RVNPL using titanic clips, a hemorrhage never occurs, a retrobulbar hematoma do not formated, the soft tissues reaction in the early postoperative period is less pronounced, and the patients postoperative rehabilitation period shortens.

Development of three-dimensional hollow elastic model for cerebral aneurysm clipping simulation enabling rapid and low cost prototyping.

PubMed

Mashiko, Toshihiro; Otani, Keisuke; Kawano, Ryutaro; Konno, Takehiko; Kaneko, Naoki; Ito, Yumiko; Watanabe, Eiju

2015-03-01

We developed a method for fabricating a three-dimensional hollow and elastic aneurysm model useful for surgical simulation and surgical training. In this article, we explain the hollow elastic model prototyping method and report on the effects of applying it to presurgical simulation and surgical training. A three-dimensional printer using acrylonitrile-butadiene-styrene as a modeling material was used to produce a vessel model. The prototype was then coated with liquid silicone. After the silicone had hardened, the acrylonitrile-butadiene-styrene was melted with xylene and removed, leaving an outer layer as a hollow elastic model. Simulations using the hollow elastic model were performed in 12 patients. In all patients, the clipping proceeded as scheduled. The surgeon's postoperative assessment was favorable in all cases. This method enables easy fabrication at low cost. Simulation using the hollow elastic model is thought to be useful for understanding of three-dimensional aneurysm structure. Copyright © 2015 Elsevier Inc. All rights reserved.

Teflon Implants Versus Titanium Implants in Stapes Surgery.

PubMed

Bansal, Mohan

2016-03-01

Otosclerosis is the most common cause of bilateral gradually progressive conductive hearing loss with normal tympanic membrane and Eustachian tube. Otosclerosis surgical treatment is one of the most gratifying operations in Otorhinolaryngology. It is not only the surgical techniques but also the prosthesis which are evolving in the attempt of providing best hearing results. Teflon piston is the most commonly employed prosthesis in stapes surgery. Titanium pistons are relatively the new development in the evolution of stapes prosthesis. The aim of this review article is to know and compare the surgical technicalities and postoperative outcomes including hearing improvement after the use of Teflon and titanium stapes piston. The adverse reactions occurred during follow-up were taken into consideration. The data in this article are supported by a Medline search. The use of both the prosthesis gave good results in cases of otosclerosis. The placement of titanium soft clip design was found easier than the earlier àWengen design of clip piston.

Surgical Management of Ruptured Isolated Aneurysm of Artery of Adamkiewicz: Interesting Report and Overview of Literature.

PubMed

Aljuboori, Zaid; Sharma, Mayur; Simpson, Jessica; Altstadt, Thomas

2018-03-01

Spinal subarachnoid hemorrhage due to rupture of an isolated spinal aneurysm is extremely rare. Patients usually present with symptoms and signs resulting from spinal cord compression. No standard guidelines are available for the treatment of this condition. In this report we present the case of a 78-year-old Caucasian male who presented with sudden-onset back pain and bilateral lower extremity weakness. Spinal angiogram revealed an isolated aneurysm of the artery of Adamkiewicz. The aneurysm was successfully managed by surgical clipping, and the patient recovered well with rehabilitation. At 46 months' follow-up, the patient was able to ambulate and perform activities of daily living independently. Our case is the first description of surgical clipping of a ruptured isolated spinal aneurysm of the artery of Adamkiewicz with a long-term successful outcome and shows that it is a safe and feasible option in carefully selected patients. Copyright © 2017 Elsevier Inc. All rights reserved.

Gaze entropy reflects surgical task load.

PubMed

Di Stasi, Leandro L; Diaz-Piedra, Carolina; Rieiro, Héctor; Sánchez Carrión, José M; Martin Berrido, Mercedes; Olivares, Gonzalo; Catena, Andrés

2016-11-01

Task (over-)load imposed on surgeons is a main contributing factor to surgical errors. Recent research has shown that gaze metrics represent a valid and objective index to asses operator task load in non-surgical scenarios. Thus, gaze metrics have the potential to improve workplace safety by providing accurate measurements of task load variations. However, the direct relationship between gaze metrics and surgical task load has not been investigated yet. We studied the effects of surgical task complexity on the gaze metrics of surgical trainees. We recorded the eye movements of 18 surgical residents, using a mobile eye tracker system, during the performance of three high-fidelity virtual simulations of laparoscopic exercises of increasing complexity level: Clip Applying exercise, Cutting Big exercise, and Translocation of Objects exercise. We also measured performance accuracy and subjective rating of complexity. Gaze entropy and velocity linearly increased with increased task complexity: Visual exploration pattern became less stereotyped (i.e., more random) and faster during the more complex exercises. Residents performed better the Clip Applying exercise and the Cutting Big exercise than the Translocation of Objects exercise and their perceived task complexity differed accordingly. Our data show that gaze metrics are a valid and reliable surgical task load index. These findings have potential impacts to improve patient safety by providing accurate measurements of surgeon task (over-)load and might provide future indices to assess residents' learning curves, independently of expensive virtual simulators or time-consuming expert evaluation.

The outcome of a surgical protocol based on ischemia overprotection in large and giant aneurysms of the anterior cerebral circulation.

PubMed

Imai, Hideaki; Watanabe, Katsushige; Miyagishima, Takaaki; Yoshimoto, Yuhei; Kin, Taichi; Nakatomi, Hirofumi; Saito, Nobuhito

2016-07-01

Aiming to define the optimal treatment of large and giant aneurysms (LGAs) in the anterior circulation, we present our surgical protocol and patient outcome. A series of 42 patients with intracavernous LGAs (n = 16), paraclinoid (C2) LGAs (n = 17), and peripheral (middle cerebral artery-MCA or anterior cerebral artery-ACA) LGAs (n = 9) were treated after bypass under motor evoked potential (MEP) monitoring. Preoperatively, three categories of ischemic tolerance during internal carotid artery (ICA) occlusion were defined on conventional angiography: optimal, suboptimal, and insufficient collaterals. Accordingly, three types of bypass: low flow (LFB), middle flow (MFB) and high flow (HFB) were applied for the cases with optimal, suboptimal, and insufficient collaterals, respectively. Outcome was evaluated by the Glasgow Outcome Scale (GOS). All patients had excellent GOS score except one, who suffered a major ischemic stroke immediately after surgery for a paraclinoid lesion. Forty-one patients were followed up for 87.1 ± 40.1 months (range 13-144 months). Intracavernous LGAs were all treated by proximal occlusion with bypass surgery. Of paraclinoid LGA patients, 15 patients had direct clipping under suction decompression and other 2 patients with recurrent aneurysms had ICA (C2) proximal clipping with HFB. MEP monitoring guided for temporary clipping time and clip repositioning, observing significant MEP changes for up to 6 min duration. Of 9 peripheral LGAs patients 7 MCA LGAs had reconstructive clipping (n = 4) or trapping (n = 3) with bypass including LFB in 3 cases, MFB in 1 and HFB in 1. Two ACA LGAs had clipping (n = 1) or trapping (n = 1) with A3-A3 bypass. The applied protocol provided excellent results in intracavernous, paraclinoid, and peripheral thrombosed LGAs of the anterior circulation.

Assessment of incomplete clipping of aneurysms intraoperatively by a near-infrared indocyanine green-video angiography (Niicg-Va) integrated microscope.

PubMed

Imizu, S; Kato, Y; Sangli, A; Oguri, D; Sano, H

2008-08-01

The objective of this article was to assess the clinical use and the completeness of clipping with total occlusion of the aneurysmal lumen, real-time assessment of vascular patency in the parent, branching and perforating vessels, intraoperative assessment of blood flow, image quality, spatial resolution and clinical value in difficult aneurysms using near infrared indocyanine green video angiography integrated on to an operative Pentero neurosurgical microscope (Carl Zeiss, Oberkochen Germany). Thirteen patients with aneurysms were operated upon. An infrared camera with near infrared technology was adapted on to the OPMI Pentero microscope with a special filter and infrared excitation light to illuminate the operating field which was designed to allow passage of the near infrared light required for excitation of indocyanine green (ICG) which was used as the intravascular marker. The intravascular fluorescence was imaged with a video camera attached to the microscope. ICG fluorescence (700-850 nm) from a modified microscope light source on to the surgical field and passage of ICG fluorescence (780-950 nm) from the surgical field, back into the optical path of the microscope was used to detect the completeness of aneurysmal clipping Incomplete clipping in three patients (1 female and 2 males) with unruptured complicated aneurysms was detected using indocyanine green video angiography. There were no adverse effects after injection of indocyanine green. The completeness of clipping was inadequately detected by Doppler ultrasound miniprobe and rigid endoscopy and was thus complemented by indocyanine green video angiography. The operative microscope-integrated ICG video angiography as a new intraoperative method for detecting vascular flow, was found to be quick, reliable, cost-effective and possibly a substitute or adjunct for Doppler ultrasonography or intraoperative DSA, which is presently the gold standard. The simplicity of the method, the speed with which the investigation can be performed, the quality of the images, and the outcome of surgical procedures have all reduced the need for angiography. This technique may be useful during routine aneurysm surgery as an independent form of angiography and/or as an adjunct to intraoperative or postoperative DSA.

Neuropsychological function after endovascular and neurosurgical treatment of subarachnoid hemorrhage: a systematic review and meta-analysis.

PubMed

Egeto, Peter; Loch Macdonald, R; Ornstein, Tisha J; Schweizer, Tom A

2018-03-01

OBJECTIVE Subarachnoid hemorrhage (SAH) is treated with either surgical clipping or endovascular coiling, though the latter is the preferred treatment method given its more favorable functional outcomes. However, neuropsychological functioning after treatment is rarely taken into account. In this meta-analysis, the authors synthesized relevant data from the literature and compared neuropsychological functioning in patients after coiling and clipping of SAH. They hypothesized that the coiled patients would outperform the clipped patients; that group differences would be greater with higher posterior circulation rupture rates, in older patients, and in more recent publications; that group differences would be smaller with greater rates of middle cerebral artery (MCA) rupture; and that anterior communicating artery (ACoA) rupture rates would not influence effect sizes. METHODS The MEDLINE, Embase, and PsycINFO databases were searched for clinical studies that compared neuropsychological functioning after either endovascular coiling or surgical clipping for SAH. Hedge's g and 95% confidence intervals were calculated using random effects models. Patients who had undergone coiling or clipping were compared on test performance in 8 neuropsychological domains: executive functions, language, attention/processing speed, verbal memory, visual memory, spatial memory, visuospatial functions, and intelligence. Patients were also compared with healthy controls, and meta-regressions were used to explore the relation between effect sizes and publication year, delay between treatment and neuropsychological testing, mean patient age, and rates of posterior circulation, ACoA, and MCA ruptures. RESULTS Thirteen studies with 396 clipped cases, 314 coiled cases, and 169 healthy controls were included in the study. The coil-treated patients outperformed the clip-treated patients on executive function (g = 0.17, 95% CI 0.08-0.25) and language tests (g = 0.23, 95% CI 0.07-0.39), and all patients were impaired relative to healthy controls (g ranged from -0.93 to -0.29). Coiled patients outperformed clipped patients to a greater degree in more recent publications, over longer posttreatment testing delays, and among older patients. Higher rates of posterior circulation and MCA aneurysms were associated with smaller group differences, while ACoA rupture rates did not influence effect sizes. CONCLUSIONS Coiling of SAH may promote superior neuropsychological functioning under certain circumstances and could have applications for the specialized care of SAH patients.

Planning the Breast Boost: Comparison of Three Techniques and Evolution of Tumor Bed During Treatment

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

Hepel, Jaroslaw T.; Department of Radiation Oncology, Brown University, Rhode Island Hospital, Providence, RI; Evans, Suzanne B.

2009-06-01

Purpose: To evaluate the accuracy of two clinical techniques for electron boost planning compared with computed tomography (CT)-based planning. Additionally, we evaluated the tumor bed characteristics at whole breast planning and boost planning. Methods and Materials: A total of 30 women underwent tumor bed boost planning within 2 weeks of completing whole breast radiotherapy using three planning techniques: scar-based planning, palpation/clinical-based planning, and CT-based planning. The plans were analyzed for dosimetric coverage of the CT-delineated tumor bed. The cavity visualization score was used to define the CT-delineated tumor bed as well or poorly defined. Results: Scar-based planning resulted in inferiormore » tumor bed coverage compared with CT-based planning, with the minimal dose received by 90% of the target volume >90% in 53% and a geographic miss in 53%. The results of palpation/clinical-based planning were significantly better: 87% and 10% for the minimal dose received by 90% of the target volume >90% and geographic miss, respectively. Of the 30 tumor beds, 16 were poorly defined by the cavity visualization score. Of these 16, 8 were well demarcated by the surgical clips. The evaluation of the 22 well-defined tumor beds revealed similar results. A comparison of the tumor bed volume from the initial planning CT scan to the boost planning CT scan revealed a decrease in size in 77% of cases. The mean decrease in volume was 52%. Conclusion: The results of our study have shown that CT-based planning allows for optimal tumor bed coverage compared with clinical and scar-based approaches. However, in the setting of a poorly visualized cavity on CT without surgical clips, palpation/clinical-based planning can help delineate the appropriate target volumes and is superior to scar-based planning. CT simulation at boost planning could allow for a reduction in the boost volumes.« less

Efficacy of electrocoagulation in sealing the cystic artery and cystic duct occluded with only one absorbable clip during laparoscopic cholecystectomy.

PubMed

Yang, Chang-Ping; Cao, Jin-Lin; Yang, Ren-Rong; Guo, Hong-Rong; Li, Zhao-Hui; Guo, Hai-Ying; Shao, Yin-Can; Liu, Gui-Bao

2014-02-01

Even though laparoscopic cholecystectomy (LC) emerged over 20 years ago, controversies persist with regard to the best method to ligate the cystic duct and artery. We proposed to assess the effectiveness and safety of electrocoagulation to seal the cystic artery and cystic duct after their occlusion with only one absorbable clip. We retrospectively compared the clinical data for 635 patients undergoing LC using electrocoagulation to seal the cystic artery and cystic duct that were occluded with only one absorbable clip (Group 1) and 728 patients undergoing LC using titanium clips (Group 2). In parallel, 30 rabbits randomized into six groups underwent cholecystectomy. After cystic duct ligation with absorbable or titanium clips, the animals were sacrificed 1, 3, or 6 months later, and intraabdominal adhesions were assessed after celiotomy. The mean operative time was significantly shorter (41.6 versus 58.9 minutes, P<.01) in Group 1 than in Group 2. No cystic duct leaks occurred in any patients from Group 1, compared with seven leaks among the 728 (0.96%) patients from Group 2 (P<.05). The morbidity was significantly higher in Group 2 than in Group 1 (3.43% versus 1.58%). Mean intraoperative blood loss and hospitalization length were not significantly different between the two groups, and no deaths occurred in either group. In animal experiments, adhesion was tighter for absorbable than for titanium clips, but fibrous tissue encapsulation was thinner at the site of titanium clips. Electrocoagulation of the cystic artery and cystic duct that were occluded with only one absorbable clip is safe and effective during LC. This approach is associated with shortened operative times and reduced leakage, compared with the standard method using metal clips.

A comparative study of female sterilization via modified Uchida and silver clip techniques in rural China.

PubMed

Qiu, Hongyan; Li, Li; Wu, Shangchun; Liang, Hong; Yuan, Wei; He, Yingqin

2011-03-01

To compare the specific effects of 2 female sterilization methods: the modified Uchida technique and the application of silver clips. A total of 2198 women living in rural areas who were still of reproductive age but opting for sterilization were enrolled. The participants were randomly divided into 2 groups, and underwent sterilization by either modified Uchida technique or silver clips. Information on acceptability, operation conditions, effectiveness, adverse effects, and complaints was collected 3, 6, and 12 months after the procedure. No significant difference in effectiveness, adverse effects or chief complaints between the 2 procedures was found. Differences in operative outcome, bleeding volume during the procedure, and operation time were found. A shorter operation time and less bleeding for the silver clip method indicated that female sterilization by this technique was as safe as that by modified Uchida technique. Copyright © 2010 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Prophylactic clipping for the prevention of bleeding following wide-field endoscopic mucosal resection of laterally spreading colorectal lesions: an economic modeling study.

PubMed

Bahin, Farzan F; Rasouli, Khalid N; Williams, Stephen J; Lee, Eric Y T; Bourke, Michael J

2016-08-01

Clinically significant bleeding (CSPEB) is the most common adverse event following endoscopic mucosal resection (EMR) of large sessile and laterally spreading colorectal lesions (LSLs), and is associated with morbidity and resource utilization. CSPEB occurs more frequently with proximal LSLs. Prophylactic clipping of the post-EMR defect may be beneficial in CSPEB prevention. The aim of this study was to determine the cost-effectiveness of a prophylactic clipping strategy. We hypothesized that prophylactic clipping in the proximal colon was cost-effective. An economic model was applied to outcomes from the Australian Colonic Endoscopic Mucosal Resection (ACE) Study. Clip distances of 3, 5, 8, and 10 mm were analyzed. The cost of treating CSPEB was determined from an independent costing agency. The funds needed to spend (FNS) was the cost incurred in order to prevent one episode of CSPEB. A break-even analysis was performed to determine cost equivalence of the costs of clipping and CSPEB. Outcomes of 1717 LSLs (mean size 35.8 mm; 52.6 % proximal colon) that underwent EMR were analyzed. The overall rate of CSPEB was 6.4 % (proximal 8.9 %; distal 3.7 %). Endoscopic management was required in 45 % of CSPEB episodes. With a clip distance of 3 mm, the expected cost of prophylactic clipping was € 1106 per lesion compared with € 157 per lesion for the expected cost of CSPEB without clipping. At 100 % clipping efficacy, the FNS was € 14 826 (proximal and distal lesions € 9309 and € 29 540, respectively). A clip price of € 10.35 was required for the cost of clipping to offset the cost of CSPEB. A prophylactic clipping strategy is not cost-effective and at present cannot be justified for all lesions or selectively for lesions in the proximal colon. ClinicalTrials.gov (NCT01368289). © Georg Thieme Verlag KG Stuttgart · New York.

Hem-o-lok clip: a neglected cause of severe bladder neck contracture and consequent urinary incontinence after robot-assisted laparoscopic radical prostatectomy.

PubMed

Cormio, Luigi; Massenio, Paolo; Lucarelli, Giuseppe; Di Fino, Giuseppe; Selvaggio, Oscar; Micali, Salvatore; Carrieri, Giuseppe

2014-02-20

Hem-o-lok clips are widely used during robot-assisted and laparoscopic radical prostatectomy to control the lateral pedicles. There are a few reports of hem-o-lok clip migration into the bladder or vesico-urethral anastomosis and only four cases of hem-o-lok clip migration resulting into bladder neck contracture. Herein, we describe the first case, to our knowledge, of hem-o-lok clip migration leading to severe bladder neck contracture and subsequent stress urinary incontinence. A 62-year-old Caucasian man underwent robot-assisted laparoscopic radical prostatectomy for a T1c Gleason 8 prostate cancer. One month after surgery the patient was fully continent; however, three months later, he presented with acute urinary retention requiring suprapubic drainage. Urethroscopy showed a hem-o-lok clip strongly attached to the area between the vesico-urethral anastomosis and the urethral sphincter and a severe bladder neck contracture behind it. Following cold-knife urethral incision and clip removal, the bladder neck contracture was widely resected. At 3-month follow-up, the patient voided spontaneously with a peak flow rate of 9.5 ml/sec and absence of post-void residual urine, but leaked 240 ml urine at the 24-hour pad test. To date, at 1-year follow-up, his voiding situation remains unchanged. The present report provides further evidence for the risk of hem-o-lok clip migration causing bladder neck contracture, and is the first to demonstrate the potential of such complication to result into stress urinary incontinence.

Retreatment of Recurrent Internal Carotid-Posterior Communicating Artery Aneurysm after Coil Embolization

PubMed Central

TOYOTA, Shingo; TAKI, Takuyu; WAKAYAMA, Akatsuki; YOSHIMINE, Toshiki

2015-01-01

Internal carotid-posterior communicating artery (IC-PC) aneurysms account for more than 20% of all intracranial aneurysms. As a result of the increase in coiling, there has also been an increase in recurrent IC-PC aneurysms after coiling. We present our experience of 10 recurrent IC-PC aneurysms after coiling that were retreated using surgical or endovascular techniques in order to discuss the choice of treatment and the points of clipping without removal of coils. From 2007 to 2014, 10 recurrent IC-PC aneurysms after coiling were retreated. When the previous frames covered the aneurysms all around or almost around except a part of the neck, coiling was chosen. In other cases, clipping was chosen. Clipping was attempted without removal of coils when it was technically feasible. Among the 10 IC-PC aneurysms retreated, 3 were retreated with coiling and 7 were retreated with clipping. In all three cases retreated with coiling, almost complete occlusion was accomplished. In the seven cases retreated with clipping, coil extrusion was observed during surgery in six cases. In most of them, it was necessary to dissect strong adhesions around the coiled aneurysms and to utilize temporary occlusion of the internal carotid artery. In all seven cases, neck clipping was accomplished without the removal of coils. There were no neurological complications in any cases. The management of recurrent lesions of embolized IC-PC aneurysms requires appropriate choice of treatment using both coiling and clipping. Clipping, especially without the removal of coils, plays an important role in safe treatment. PMID:26437796

Retreatment of Recurrent Internal Carotid-Posterior Communicating Artery Aneurysm after Coil Embolization.

PubMed

Toyota, Shingo; Taki, Takuyu; Wakayama, Akatsuki; Yoshimine, Toshiki

2015-01-01

Internal carotid-posterior communicating artery (IC-PC) aneurysms account for more than 20% of all intracranial aneurysms. As a result of the increase in coiling, there has also been an increase in recurrent IC-PC aneurysms after coiling. We present our experience of 10 recurrent IC-PC aneurysms after coiling that were retreated using surgical or endovascular techniques in order to discuss the choice of treatment and the points of clipping without removal of coils. From 2007 to 2014, 10 recurrent IC-PC aneurysms after coiling were retreated. When the previous frames covered the aneurysms all around or almost around except a part of the neck, coiling was chosen. In other cases, clipping was chosen. Clipping was attempted without removal of coils when it was technically feasible. Among the 10 IC-PC aneurysms retreated, 3 were retreated with coiling and 7 were retreated with clipping. In all three cases retreated with coiling, almost complete occlusion was accomplished. In the seven cases retreated with clipping, coil extrusion was observed during surgery in six cases. In most of them, it was necessary to dissect strong adhesions around the coiled aneurysms and to utilize temporary occlusion of the internal carotid artery. In all seven cases, neck clipping was accomplished without the removal of coils. There were no neurological complications in any cases. The management of recurrent lesions of embolized IC-PC aneurysms requires appropriate choice of treatment using both coiling and clipping. Clipping, especially without the removal of coils, plays an important role in safe treatment.

Reduction of chronic post-herniotomy pain and recurrence rate. Use of the anatomical self-gripping ProGrip laparoscopic mesh in TAPP hernia repair. Preliminary results of a prospective study

PubMed Central

Hoskovec, David

2015-01-01

Introduction The role of fixation of the mesh is especially important in the endoscopic technique. The fixation of mesh through penetrating techniques using staples, clips or screws is associated with a significantly increased risk of developing a post-herniotomy pain syndrome. Aim To demonstrate the safety and efficacy of the self-fixating anatomical Parietex ProGrip laparoscopic mesh (Sofradim Production, Trévoux France) used with laparoscopic transabdominal preperitoneal hernia repair. The incidence of chronic post-herniotomy pain and recurrence rate in the follow-up after 12 months were evaluated. Material and methods Data analysis included all patients who underwent inguinal hernia surgery at our Surgical Department within the period from 1.05.2013 to 31.12.2014, who fulfilled the inclusion criteria. Standard surgical technique was used. Data were prospectively entered and subsequently analyzed on the Herniamed platform. Herniamed is an internet-based register in German and English language and includes all data of patients who underwent surgery for some types of hernia. Results There were 95 patients enrolled in the group and there were in total 156 inguinal hernias repaired. The mean follow-up was 15.52 months. At the assessment at 1 year mild discomfort in the groin was reported in 2 patients (3.51%) (1–3 VAS). No recurrence or chronic postoperative pain was reported. Conclusions Laparoscopic inguinal hernia repair using the transabdominal preperitoneal technique with implantation of the ProGrip laparoscopic mesh is a fast, effective and reliable method in experienced hands, which according to our results reduces the occurrence of chronic post-operative inguinal pain with simultaneously a low recurrence rate. PMID:26649083

Whole-brain haemodynamic after-effects of 1-Hz magnetic stimulation of the posterior superior temporal cortex during action observation.

PubMed

Arfeller, Carola; Schwarzbach, Jens; Ubaldi, Silvia; Ferrari, Paolo; Barchiesi, Guido; Cattaneo, Luigi

2013-04-01

The posterior superior temporal sulcus (pSTS) is active when observing biological motion. We investigated the functional connections of the pSTS node within the action observation network by measuring the after-effect of focal repetitive transcranial magnetic stimulation (rTMS) with whole-brain functional magnetic resonance imaging (fMRI). Participants received 1-Hz rTMS over the pSTS region for 10 min and underwent fMRI immediately after. While scanned, they were shown short video clips of a hand grasping an object (grasp clips) or moving next to it (control clips). rTMS-fMRI was repeated for four consecutive blocks. In two blocks we stimulated the left pSTS region and in the other two the right pSTS region. For each side TMS was applied with an effective intensity (95 % of motor threshold) or with ineffective intensity (50 % of motor threshold). Brain regions showing interactive effects of (clip type) × (TMS intensity) were identified in the lateral temporo-occipital cortex, in the anterior intraparietal region and in the ventral premotor cortex. Remote effects of rTMS were mostly limited to the stimulated hemisphere and consisted in an increase of blood oxygen level-dependent responses to grasp clips compared to control clips. We show that the pSTS occupies a pivotal relay position during observation of goal-directed actions.

[Neuroanesthetic management for surgical clipping of a ruptured cerebral aneurysm: clinical practice guidelines].

PubMed

Ingelmo Ingelmo, I; Carmona Aurioles, J; Rama-Maceiras, P; Fàbregas Julià, N; Hernández-Palazón, J

2010-12-01

Subarachnoid hemorrhage due to spontaneous rupture of a cerebral aneurysm is associated with high rates of morbidity and mortality and requires multidisciplinary treatment. The debate on surgical vs endovascular treatment continues, although short-term clinical outcomes and survival rates are better after endovascular treatment. In Spain, a strong trend toward reduced use of clipping has been noted, and neuroanesthetists are less often called on to provide anesthesia in this setting. Our intervention, however, can be decisive. The neuroscience working group of the Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor has developed guidelines for managing anesthesia in these procedures. Based on a national survey and a systematic review of the literature, the recommendations emphasize the importance of ensuring appropriate intracranial conditions, treating complications, and taking steps to protect against cerebral hemorrhage.

Three-port laparoscopic cholecystectomy by harmonic dissection without cystic duct and artery clipping.

PubMed

Tebala, Giovanni D

2006-05-01

The technique of laparoscopic cholecystectomy (LC) still has areas of refinements. To decrease the number of ports, a cannula may be replaced by a percutaneous suture suspension of the gallbladder. The risk of tissue injury caused by repeat blind extraction and insertion of various instruments in and out of the abdomen may be decreased by the use of the multipurpose harmonic dissector. One hundred consecutive patients with symptomatic cholelithiasis underwent 3-port LC entirely performed by harmonic dissector without cystic duct and artery clipping. In 8 cases, a fourth trocar was necessary. In 2 cases, the cystic duct was clipped after an unsafe ultrasound sealing. In 1 case, continuous bleeding from the liver required the use of diathermy. No common bile duct injury was registered. The 3-port harmonic LC is a feasible, effective, and safe technique.

Easy clip to treat anal fistula tracts: a word of caution.

PubMed

Gautier, M; Godeberge, P; Ganansia, R; Bozio, G; Godart, B; Bigard, M A; Barthet, M; Siproudhis, L

2015-05-01

Closing the internal opening by a clip ovesco has been recently proposed for healing the fistula tract, but, to date, data on benefit are poorly analyzed. The aim was to report a preliminary multicenter experience. Retrospective study was undertaken in six different French centers: surgical procedure, immediate complications, and follow-up have been collected. Nineteen clips were inserted in 17 patients (M/F, 4/13; median age, 42 years [29-54]) who had an anal fistula: 12 (71%) high fistulas (including 4 rectovaginal fistulas), 5 (29%) lower fistulas (with 3 rectovaginal fistulas), and 6 (35%) Crohn's fistulas. Out of 17 patients, 15 had a seton drainage beforehand. The procedure was easy in 8 (47%) patients and the median operative time was 27.5 min (20-36.5). Postoperative period was painful for 11 (65%) patients. A clip migration was noted in 11 patients (65%) after a median follow-up of 10 days (5.5-49.8). Eleven patients (65%) who failed had reoperation including 10 new drainages within the first month (0.5-5). After a mean follow-up of 4 months (2-7),, closing the tract was observed in 2 patients (12%) following the first insertion of the clip and in another one after a second insertion. Treatment of anal fistula by placing a clip on the internal opening is disappointing and deleterious for some patients. A better assessment before dissemination is recommended.

Teaching Surgical Procedures with Movies: Tips for High-quality Video Clips.

PubMed

Jacquemart, Mathieu; Bouletreau, Pierre; Breton, Pierre; Mojallal, Ali; Sigaux, Nicolas

2016-09-01

Video must now be considered as a precious tool for learning surgery. However, the medium does present production challenges, and currently, quality movies are not always accessible. We developed a series of 7 surgical videos and made them available on a publicly accessible internet website. Our videos have been viewed by thousands of people worldwide. High-quality educational movies must respect strategic and technical points to be reliable.

Supraorbital Keyhole Craniotomy for Basilar Artery Aneurysms: Accounting for the "Cliff" Effect.

PubMed

Stamates, Melissa M; Wong, Andrew K; Bhansali, Anita; Wong, Ricky H

2017-04-01

Treatment of basilar artery aneurysms is challenging. While endovascular techniques have dominated, there still remain circumstances where open surgical clipping is required or preferred. Minimally invasive "keyhole" approaches are being used more frequently to provide the durability of surgical clipping with a lower morbidity profile; however, careful patient selection is required. The supraorbital "keyhole" approach has been described for the treatment of basilar artery aneurysms, but careful assessment of the basilar exposure is necessary to ensure proper visualization of the aneurysm and ability to obtain proximal vascular control. Various methods of estimating the basilar artery exposure in this approach have been described, including the anterior skull base line and the posterior clinoid line, but both are unreliable and inaccurate. To propose a new method, the orbital roof-dorsum line, to simply and accurately predict the basilar artery exposure. CT angiograms for 20 consecutive unique patients were analyzed to obtain the anterior skull base line, posterior clinoid line, and the orbital roof-dorsum line. CT angiograms were then loaded onto a Stealth neuronavigation system (Medtronic, Minneapolis, Minnesota) to obtain "true" visualization lengths. A case illustration is presented. Pairwise comparison tests demonstrated that both the anterior skull base and the posterior clinoid estimation lines differed significantly from the "true"  value ( P < .0001). Our orbital roof-dorsum estimation provided results that accurately predicted the "true" value ( P = .71). The orbital roof-dorsum line provides a simple and reliable method of estimating basilar artery exposure and should be used whenever considering patients for surgical clipping by this approach. Copyright © 2017 by the Congress of Neurological Surgeons

Endoscopic closure of duodenal perforations by using an over-the-scope clip: a randomized, controlled porcine study.

PubMed

von Renteln, Daniel; Rudolph, Hans-Ulrich; Schmidt, Arthur; Vassiliou, Melina C; Caca, Karel

2010-01-01

Duodenal perforations during diagnostic upper endoscopy are rare; however, when therapeutic techniques are performed, the reported incidence is as great as 2.8%. Surgical repair is usually mandated, but it is associated with significant morbidity and mortality. To compare closure of duodenal perforations by using an over-the-scope clip (OTSC) with a surgical closure. Randomized, controlled animal study. Animal facility laboratory. Domestic pigs (24 females). Large (10-mm) duodenal perforations were created by using an endoscopic needle-knife. The animals were randomly assigned to either open surgical repair (n=12) or endoscopic closure by using the OTSC system (n=12). Pressurized leak tests were performed during necropsy. One major bleed occurred because of a liver injury during creation of the duodenotomy. Mean time for endoscopic closure was 5 minutes (range, 3-8 min; SD +/- 2). No complications occurred during any of the closure procedures. At necropsy, all OTSC and surgical closures demonstrated complete sealing of duodenotomy sites. Pressurized leak tests demonstrated a mean burst pressure of 166 mm Hg (range, 80-260; SD +/- 65) for OTSC closures and 143 mm Hg (range, 30-300, SD +/- 83) for surgical sutures. Ex vivo intact duodenal specimens exhibited a mean burst pressure of 247 mm Hg (range, 200-300; SD +/- 35), which was significantly higher compared with in vivo OTSC and surgical closures (P < .01). There were no significant differences between burst pressures of OTSC and surgical closures (P = .461). Nonsurvival setting. Endoscopic closure of duodenal perforations by using the OTSC system is comparable with surgical closure in a nonsurvival porcine model. This technique is easy to perform and seems suitable for repairing duodenal perforations. 2010 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.

Surgical flow modification of the anterior cerebral artery-anterior communicating artery complex in the management of giant aneurysms of internal carotid artery bifurcation: An alternative for a difficult clip reconstruction

PubMed Central

Pahl, Felix Hendrik; de Oliveira, Matheus Fernandes; Beer-Furlan, André Luiz; Rotta, José Marcus

2016-01-01

Background: Internal carotid artery bifurcation (ICAb) aneurysms account for about 2–15% of all intracranial aneurysms. In giant and complex cases, treatment may be difficult and dangerous, once some aneurysms have wide neck and anterior cerebral artery (ACA) and middle cerebral artery (MCA) may arise from the aneurysm itself. Clip reconstruction may be difficult in such cases. Whenever possible, the occlusion of ACA transform the bifurcation in a single artery reconstruction (ICA to MCA), much easier than a bifurcation reconstruction. Methods: In patients with giant and complex ICAb aneurysms, we propose routine preoperative angiography with anatomical evaluation of anterior communicating artery (ACoA) patency during cervical common carotid compression with concomitant contralateral carotid artery injection. This allowed visualization of the expected reversal of flow in the A1 segment–ACoA complex. When test is positive, we can perform ipsilateral ACA (A1 segment) clip occlusion and flow modification of the ACA-ACoA complex transforming a three vessel (ICA, ACA, and MCA) reconstruction into a two vessel (ICA and MCA) reconstruction. Results: Two patients were treated, with 100% of occlusion and good outcome. Conclusions: Surgical treatment of giant and complex ICAb may be achieved with acceptable morbidity. PMID:27313968

Does Warm-Up Training in a Virtual Reality Simulator Improve Surgical Performance? A Prospective Randomized Analysis.

PubMed

da Cruz, José Arnaldo Shiomi; Dos Reis, Sabrina Thalita; Cunha Frati, Rodrigo Marcus; Duarte, Ricardo Jordão; Nguyen, Hiep; Srougi, Miguel; Passerotti, Carlo Camargo

Virtual reality surgical simulators (VRSS) have been showing themselves as a valuable tool in laparoscopy training and education. Taking in consideration the effectiveness of the VRSS, new uses for this tool have been purposed. In sports, warming up before exercise clearly shows benefit in performance. It is hypothesized that warming up in the VRSS before going to the operating room may show benefit in surgical performance. Verify whether there is benefit in surgical performance with preoperatory warm-up using a VRSS. A total of 20 medical students with basic knowledge in laparoscopy were divided in 2 groups (I and II). Group I performed a laparoscopic cholecystectomy in a porcine model. Group II performed preoperative warm-up in a VRSS and then performed a laparoscopic cholecystectomy in a porcine model. The performance between both groups was compared regarding quantitative parameters (time for dissection of the gallbladder pedicle, time for clipping the pedicle, time for cutting the pedicle, time for gallbladder removal, total operative time, and aspirated blood loss) and qualitative parameters (depth perception, bimanual dexterity, efficiency, tissue handling, and autonomy) based on a previously validated score system, in which the higher the score, the better the result. Data were analyzed with level of significance of 5%. The group that underwent preoperative warm-up (group II) showed significantly superior results as to the time for dissection of the gallbladder pedicle (11.91 ± 9.85 vs. 4.52 ± 2.89min, p = 0.012), time for clipping the pedicle (5.51 ± 2.36 vs. 2.89 ± 2.76min, p = 0.004), time for cutting the pedicle (1.84 ± 0.7 vs. 1.13 ± 0.51, p = 0.019), aspirated blood loss (171 ± 112 vs. 57 ± 27.8ml, p = 0.006), depth perception (4.5 ± 0.7 vs. 3.3 ± 0.67, p = 0.004), bianual dexterity (4.2 ± 0.78 vs. 3.3 ± 0.67, p = 0.004), tissue handling (4.2 ± 0.91 vs. 3.6 ± 0.66, p = 0.012), and autonomy (4.9 ± 0.31 vs. 3.6 ± 0.96, p = 0.028). There was no difference in time for gallbladder removal (11.58 ± 4.31 vs. 15.08 ± 4.51min, p = 0.096), total operative time (30.8 ± 11.07 vs. 25.60 ± 5.10min, p = 0.188), and efficiency (4 ± 0.66 vs. 3.6 ± 0.69, p = 0.320). The practice of preoperative warm-up training seems to benefit surgical performance even in subject with mild laparoscopic experience. Copyright © 2016 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Ovarian cryopreservation after laparoscopic ovariectomy using the Endo-GIA stapling device and LAPRO-clip absorbable ligating clip in a woman: a case report

PubMed Central

2011-01-01

Introduction Several options are available for preserving fertility before cytotoxic treatment, including ovarian tissue cryopreservation. Most reported surgical techniques include electrocoagulation. Our hypothesis is that avoidance of electrocoagulation may decrease ovarian cortex injury during cryopreservation procedures. Case presentation We report a laparoscopic technique of whole-ovary removal without coagulation using Endo-GIA forceps and clips. Laparoscopic ovariectomy was performed for cryopreservation in a 37-year-old Caucasian woman with breast cancer and for whom chemotherapy was planned. The procedure was completed quickly and without complication. This Endo-GIA procedure was of short duration with a short period of ischemia before freezing. Conclusion Laparoscopic ovariectomy using the Endo-GIA stapling device procedure without coagulation may diminish ovary injury before ovarian cryopreservation. PMID:21291518

Safety and efficacy of endoscopic submucosal dissection using IT knife nano with clip traction method for early esophageal squamous cell carcinoma.

PubMed

Kitagawa, Yoshiyasu; Suzuki, Takuto; Hara, Taro; Yamaguchi, Taketo

2018-01-01

Although endoscopic submucosal dissection (ESD) is an accepted and established treatment for early esophageal squamous cell carcinoma (EESCC), it is technically difficult, time consuming, and less safe than endoscopic mucosal resection. To perform ESD safely and more efficiently, we proposed a new technique of esophageal ESD using an IT knife nano with the clip traction method. This study aimed to evaluate the efficacy and safety of ESD using this new technique. We retrospectively reviewed all consecutive cases of esophageal ESD performed using an IT knife nano with the clip traction method at our hospital between March 2013 and January 2017. Therapeutic efficacy and safety were also assessed. A total of 103 patients underwent esophageal ESD using the IT knife nano with the clip traction method. In all cases, we performed en bloc resection. Complete resection was achieved in 100 cases (97.1%). The median operating time was 40 (range 13-230) min. No cases of perforation or delayed bleeding occurred. Although two cases (2.0%) of mediastinal emphysema occurred without visible perforation at endoscopy, all were successfully managed conservatively. The new technique of esophageal ESD using the IT knife nano with the clip traction method appears to be feasible, effective, and safe for EESCC treatment.

Role of over the scope clips in the management of iatrogenic gastrointestinal perforations

PubMed Central

Changela, Kinesh; Virk, Muhhamad A; Patel, Niravkumar; Duddempudi, Sushil; Krishnaiah, Mahesh; Anand, Sury

2014-01-01

Advances in endoscopic and surgical techniques have increased the frequency and complexity of these procedures and associated complications such as gastrointestinal perforation. With the advancements in the field of gastroenterology, the promising use of an over the scope clips (OTSC) has fulfilled the unmet need for a reliable endoscopic devise in approximation of gastrointestinal perforation. This novel approach has raised the level of confidence in endoscopist in dealing with this serious complication during endoscopy. Here we have shared our experience with OTSC to evaluate its efficacy and safety in managing iatrogenic gastrointestinal perforations during endoscopy. PMID:25170237

Role of over the scope clips in the management of iatrogenic gastrointestinal perforations.

PubMed

Changela, Kinesh; Virk, Muhhamad A; Patel, Niravkumar; Duddempudi, Sushil; Krishnaiah, Mahesh; Anand, Sury

2014-08-28

Advances in endoscopic and surgical techniques have increased the frequency and complexity of these procedures and associated complications such as gastrointestinal perforation. With the advancements in the field of gastroenterology, the promising use of an over the scope clips (OTSC) has fulfilled the unmet need for a reliable endoscopic devise in approximation of gastrointestinal perforation. This novel approach has raised the level of confidence in endoscopist in dealing with this serious complication during endoscopy. Here we have shared our experience with OTSC to evaluate its efficacy and safety in managing iatrogenic gastrointestinal perforations during endoscopy.

Interhemispheric Information Transfer: A New Diagnostic Method for Mild Traumatic Brain Injury

DTIC Science & Technology

2011-10-01

brain tumors, meningitis, cerebral palsy, encephalitis, brain abscesses , vascular malformations, cerebrovascular disease, Alzheimer’s disease...disease including head trauma with loss of consciousness 2) Having a contraindication to MRI such as pregnancy, breast feeding, surgical clips

Teaching Surgical Procedures with Movies: Tips for High-quality Video Clips

PubMed Central

Jacquemart, Mathieu; Bouletreau, Pierre; Breton, Pierre; Mojallal, Ali

2016-01-01

Summary: Video must now be considered as a precious tool for learning surgery. However, the medium does present production challenges, and currently, quality movies are not always accessible. We developed a series of 7 surgical videos and made them available on a publicly accessible internet website. Our videos have been viewed by thousands of people worldwide. High-quality educational movies must respect strategic and technical points to be reliable. PMID:27757342

Mesh Displacement After Bilateral Inguinal Hernia Repair With No Fixation

PubMed Central

Rocha, Gabriela Moreira; Campos, Antonio Carlos Ligocki; Paulin, João Augusto Nocera; Coelho, Julio Cesar Uili

2017-01-01

Background and Objectives: About 20% of patients with inguinal hernia present bilateral hernias in the diagnosis. In these cases, laparoscopic procedure is considered gold standard approach. Mesh fixation is considered important step toward avoiding recurrence. However, because of cost and risk of pain, real need for mesh fixation has been debated. For bilateral inguinal hernias, there are few specific data about non fixation and mesh displacement. We assessed mesh movement in patients who had undergone laparoscopic bilateral inguinal hernia repair without mesh fixation and compared the results with those obtained in patients with unilateral hernia. Methods: From January 2012 through May 2014, 20 consecutive patients with bilateral inguinal hernia underwent TEP repair with no mesh fixation. Results were compared with 50 consecutive patients with unilateral inguinal hernia surgically repaired with similar technique. Mesh was marked with 3 clips. Mesh movements were measured by comparing initial radiography performed at the end of surgery, with a second radiographic scan performed 30 days later. Results: Mean movements of all 3 clips in bilateral nonfixation (NF) group were 0.15–0.4 cm compared with 0.1–0.3 cm in unilateral NF group. Overall displacement of bilateral and unilateral NF groups did not show significant difference. Mean overall displacement was 1.9 cm versus 1.8 cm in the bilateral and unilateral NF groups, respectively (P = .78). Conclusions: TEP with no mesh fixation is safe in bilateral inguinal repairs. Early mesh displacement is minimal. This technique can be safely used in most patients with inguinal hernia. PMID:28904521

Proton beam irradiation: a safe procedure in post-equatorial extraocular extension from uveal melanoma.

PubMed

Seibel, Ira; Riechardt, Aline I; Erb-Eigner, Katharina; Böker, Alexander; Cordini, Dino; Heufelder, Jens; Joussen, Antonia M

2018-04-12

This study was performed to show long-term outcomes concerning metastasis rates and local recurrence rates after primary proton beam therapy in uveal melanoma with posterior extraocular extension (EOE) with the main focus on optic nerve invasion. Retrospective case series METHODS: All patients treated with primary proton beam therapy for choroidal or ciliary body melanoma with posterior EOE between July 1998 and August 2010 were included. EOE was either detected upon sonography at primary examination or during the surgical application of tantalum clips onto the sclera. Ultrasound was performed in each patient before surgery, and if EOE was detected, a magnetic resonance imaging (MRI) scan was performed to confirm EOE. All patients with tumors exceeding 6 mm in thickness or abutting the optic disc received a 1.5 Tesla MRI scan after clip surgery. To asses EOE during follow-up, either ultrasound examinations or-if initially detected only by MRI-MRI scans were performed during follow-up. A total of 27 patients underwent primary proton beam therapy. The EOE was separated into 3 growth types: Optic nerve infiltration in 10 patients, vortex vein infiltration in 9 patients, and transscleral growth post-equatorially in 8 patients. No local recurrences were found during the overall median follow-up of 80 months (11-168 months). Metastasis rates correlated with AJCC stages but not EOE volume. This study shows that posterior EOE can safely be treated by proton beam therapy, even if the optic nerve is infiltrated. MRI enables safe detection of optic nerve invasion. Copyright © 2018 Elsevier Inc. All rights reserved.

Macrovascular Decompression of the Brainstem and Cranial Nerves: Evolution of an Anteromedial Vertebrobasilar Artery Transposition Technique.

PubMed

Choudhri, Omar; Connolly, Ian D; Lawton, Michael T

2017-08-01

Tortuous and dolichoectatic vertebrobasilar arteries can impinge on the brainstem and cranial nerves to cause compression syndromes. Transposition techniques are often required to decompress the brainstem with dolichoectatic pathology. We describe our evolution of an anteromedial transposition technique and its efficacy in decompressing the brainstem and relieving symptoms. To present the anteromedial vertebrobasilar artery transposition technique for macrovascular decompression of the brainstem and cranial nerves. All patients who underwent vertebrobasilar artery transposition were identified from the prospectively maintained database of the Vascular Neurosurgery service, and their medical records were reviewed retrospectively. The extent of arterial displacement was measured pre- and postoperatively on imaging. Vertebrobasilar arterial transposition and macrovascular decompression was performed in 12 patients. Evolution in technique was characterized by gradual preference for the far-lateral approach, use of a sling technique with muslin wrap, and an anteromedial direction of pull on the vertebrobasilar artery with clip-assisted tethering to the clival dura. With this technique, mean lateral displacement decreased from 6.6 mm in the first half of the series to 3.8 mm in the last half of the series, and mean anterior displacement increased from 0.8 to 2.5 mm, with corresponding increases in satisfaction and relief of symptoms. Compressive dolichoectatic pathology directed laterally into cranial nerves and posteriorly into the brainstem can be corrected with anteromedial transposition towards the clivus. Our technique accomplishes this anteromedial transposition from an inferolateral surgical approach through the vagoaccessory triangle, with sling fixation to clival dura using aneurysm clips. Copyright © 2017 by the Congress of Neurological Surgeons

Surgical transposition of the ovaries: imaging findings in 14 patients.

PubMed

Kier, R; Chambers, S K

1989-11-01

Pelvic radiation therapy for cervical or vaginal cancer often leads to ovarian failure. To remove the ovaries from the radiation portal and preserve their function, they can be transposed to the lateral abdomen. Serial imaging studies in 14 patients who had undergone ovarian transposition (five bilateral, nine unilateral) were reviewed. Images obtained included 32 CT scans, 20 sonograms, and one MR image. Most transposed ovaries were located along the paracolic gutters near the iliac crests, creating an extrinsic mass effect on adjacent bowel. Detection of surgical clips on the ovary on CT scans allowed confident recognition of all 19 transposed ovaries. Cysts in the transposed ovaries, noted on most imaging studies, did not correlate with complications of pain or hormonal dysfunction. In one case, a large physiologic cyst in a transposed ovary distorted the cecum and was mistaken for a mucocele of the appendix. In another case, a large ovarian cyst was thought to be tumor recurrence or a lymphocele. These findings indicate that although the transposed ovaries can be recognized on CT scans by the surgical clips attached to the ovaries, the appearance of the ovary does not predict reliably the development of complications.

Diagnosis and Treatment of Traumatic Cerebrovascular Injury: Pitfalls in the Management of Neurotrauma.

PubMed

Kobata, Hitoshi

2017-08-15

Traumatic cerebrovascular injury (TCVI) is an uncommon clinical entity in traumatic brain injury (TBI), yet it may cause devastating brain injury with high morbidity and mortality. Early recognition and prioritized strategic treatment are of paramount importance. A total of 1966 TBI patients admitted between 1999 and 2015 in our tertiary critical care center were reviewed. Screening of TCVI was based on the Guidelines for the Management of Severe Head Injury in Japan. TCVI was confirmed in 33 (1.7%) patients; 29 blunt and 4 penetrating injuries. The primary location of the injury included 16 cervical, 6 craniofacial, and 11 intracranial lesions. On arrival, 15 patients presented with hemorrhage, 5 of these arrived in shock status with massive hemorrhage. Ten presented with ischemic symptoms. Sixteen patients underwent surgical or endovascular intervention, 13 of whom required immediate treatment upon arrival. Surgical procedures included clipping or trapping for traumatic aneurysms, superficial temporal artery - middle cerebral artery bypass, carotid endarterectomy, and direct suture of the injured vessels. Endovascular intervention was undertaken in 7 patients; embolization with Gelfoam (Pharmacia and Upjohn Company, Kalamazoo, MI, USA) or coil for 6 hemorrhagic lesions and stent placement for 1 lesion causing ischemia. Patients' outcome assessed by the Glasgow Outcome Scale at 3 months were good recovery in 8, moderate disability in 3, severe disability in 9, persistent vegetative state in 1, and death in 12, respectively. In order to rescue potentially salvageable TCVI patients, neurosurgeons in charge should be aware of TCVI and master basic skills of cerebrovascular surgical and endovascular procedures to utilize in an emergency setting.

No association between intraoperative hypothermia or supplemental protective drug and neurologic outcomes in patients undergoing temporary clipping during cerebral aneurysm surgery: findings from the Intraoperative Hypothermia for Aneurysm Surgery Trial.

PubMed

Hindman, Bradley J; Bayman, Emine O; Pfisterer, Wolfgang K; Torner, James C; Todd, Michael M

2010-01-01

Although hypothermia and barbiturates improve neurologic outcomes in animal temporary focal ischemia models, the clinical efficacy of these interventions during temporary occlusion of the cerebral vasculature during intracranial aneurysm surgery (temporary clipping) is not established. A post hoc analysis of patients from the Intraoperative Hypothermia for Aneurysm Surgery Trial who underwent temporary clipping was performed. Univariate and multivariate logistic regression methods were used to test for associations between hypothermia, supplemental protective drug, and short- (24-h) and long-term (3-month) neurologic outcomes. An odds ratio more than 1 denotes better outcome. Patients undergoing temporary clipping (n = 441) were assigned to intraoperative hypothermia (33.3 degrees +/- 0.8 degrees C, n = 208) or normothermia (36.7 degrees +/- 0.5 degrees C, n = 233), with 178 patients also receiving supplemental protective drug (thiopental or etomidate) during temporary clipping. Three months after surgery, 278 patients (63%) had good outcome (Glasgow Outcome Score = 1). Neither hypothermia (P = 0.847; odds ratio = 1.043, 95% CI = 0.678-1.606) nor supplemental protective drug (P = 0.835; odds ratio = 1.048, 95% CI = 0.674-1.631) were associated with 3-month Glasgow Outcome Score. The effect of supplemental protective drug did not significantly vary with temperature. The effects of hypothermia and protective drug did not significantly vary with temporary clip duration. Similar findings were made for 24-h neurologic status and 3-month Neuropsychological Composite Score. In the Intraoperative Hypothermia for Aneurysm Surgery Trial, neither systemic hypothermia nor supplemental protective drug affected short- or long-term neurologic outcomes of patients undergoing temporary clipping.

Endovascular Broad-Neck Aneurysm Creation in a Porcine Model Using a Vascular Plug

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

Muehlenbruch, Georg, E-mail: gmuehlenbruch@ukaachen.de; Nikoubashman, Omid; Steffen, Bjoern

2013-02-15

Ruptured cerebral arterial aneurysms require prompt treatment by either surgical clipping or endovascular coiling. Training for these sophisticated endovascular procedures is essential and ideally performed in animals before their use in humans. Simulators and established animal models have shown drawbacks with respect to degree of reality, size of the animal model and aneurysm, or time and effort needed for aneurysm creation. We therefore aimed to establish a realistic and readily available aneurysm model. Five anticoagulated domestic pigs underwent endovascular intervention through right femoral access. A total of 12 broad-neck aneurysms were created in the carotid, subclavian, and renal arteries usingmore » the Amplatzer vascular plug. With dedicated vessel selection, cubic, tubular, and side-branch aneurysms could be created. Three of the 12 implanted occluders, two of them implanted over a side branch of the main vessel, did not induce complete vessel occlusion. However, all aneurysms remained free of intraluminal thrombus formation and were available for embolization training during a surveillance period of 6 h. Two aneurysms underwent successful exemplary treatment: one was stent-assisted, and one was performed with conventional endovascular coil embolization. The new porcine aneurysm model proved to be a straightforward approach that offers a wide range of training and scientific applications that might help further improve endovascular coil embolization therapy in patients with cerebral aneurysms.« less

Sympathetic block by metal clips may be a reversible operation.

PubMed

Thomsen, Lars L; Mikkelsen, Rasmus T; Derejko, Miroslawa; Schrøder, Henrik D; Licht, Peter B

2014-12-01

Thoracoscopic sympathectomy is now used routinely to treat patients with disabling primary hyperhidrosis or facial blushing. Published results are excellent, but side effects, such as compensatory sweating, are also very frequent. The surgical techniques used and the levels of targeting the sympathetic chain vary tremendously. Most surgeons transect or resect the sympathetic chain, but application of a metal clip that blocks transmission of nerve impulses in the sympathetic chain is used increasingly worldwide. This approach offers potential reversibility if patients regret surgery, but the question of reversibility remains controversial. Two recent experimental studies found severe histological signs of nerve damage 4-6 weeks after clip removal, but they only used conventional histopathological staining methods. Thoracoscopic clipping of the sympathetic trunk was performed in adult sheep, and the clip was removed thoracoscopically after 7 days. Following another 4 weeks (n = 6) or 12 weeks (n = 3), the sympathetic trunks were harvested and analysed by conventional and specific nerve tissue immunohistochemical stains (S100, neurofilament protein and synaptophysin). The contralateral sympathetic chains were used as controls. Conventional and immunohistochemical stains demonstrated severe signs of neural damage on the operated side 4 weeks after clip removal. After 12 weeks, these changes had decreased markedly and conventional histology had almost normalized. Conventional and immunohistochemical stains confirmed that application of metal clips to the sympathetic chain caused severe histological damage in the sympathetic trunk that remained visible 4 weeks after clip removal. However, after 12 weeks, these signs of damage had clearly decreased, which suggests in theory that application of metal clips to the sympathetic chain is a reversible procedure if only the observation period is prolonged. Further studies with longer periods between application and removal as well as investigations of nerve conduction should be encouraged, because we do not know whether histological reversibility at cellular level translates into physiological reversibility and possible correlation of nerve trauma with the duration of the applied clip. © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Minimizing hair dispersal: Is this an opportunity for improvement in health care-acquired infection prevention?

PubMed

Mantyh, Christopher R; Xi, Hugo; Pearson, Lena; Perl, Trish M

2017-03-01

We performed a study to understand common practices in surgical site hair removal and barriers to guideline compliance in surgical site hair removal. We found most health care providers in the United States do not remove hair outside of the operating room. Our findings reveal minimizing hair dispersal in the operating room, including improved and innovative ways for collecting clipped loose hair, is a significant area for improvement in surgical quality and health care-acquired infection prevention. Copyright © 2017 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

Evaluation of stereoscopic medical video content on an autostereoscopic display for undergraduate medical education

NASA Astrophysics Data System (ADS)

Ilgner, Justus F. R.; Kawai, Takashi; Shibata, Takashi; Yamazoe, Takashi; Westhofen, Martin

2006-02-01

Introduction: An increasing number of surgical procedures are performed in a microsurgical and minimally-invasive fashion. However, the performance of surgery, its possibilities and limitations become difficult to teach. Stereoscopic video has evolved from a complex production process and expensive hardware towards rapid editing of video streams with standard and HDTV resolution which can be displayed on portable equipment. This study evaluates the usefulness of stereoscopic video in teaching undergraduate medical students. Material and methods: From an earlier study we chose two clips each of three different microsurgical operations (tympanoplasty type III of the ear, endonasal operation of the paranasal sinuses and laser chordectomy for carcinoma of the larynx). This material was added by 23 clips of a cochlear implantation, which was specifically edited for a portable computer with an autostereoscopic display (PC-RD1-3D, SHARP Corp., Japan). The recording and synchronization of left and right image was performed at the University Hospital Aachen. The footage was edited stereoscopically at the Waseda University by means of our original software for non-linear editing of stereoscopic 3-D movies. Then the material was converted into the streaming 3-D video format. The purpose of the conversion was to present the video clips by a file type that does not depend on a television signal such as PAL or NTSC. 25 4th year medical students who participated in the general ENT course at Aachen University Hospital were asked to estimate depth clues within the six video clips plus cochlear implantation clips. Another 25 4th year students who were shown the material monoscopically on a conventional laptop served as control. Results: All participants noted that the additional depth information helped with understanding the relation of anatomical structures, even though none had hands-on experience with Ear, Nose and Throat operations before or during the course. The monoscopic group generally estimated resection depth to much lesser values than in reality. Although this was the case with some participants in the stereoscopic group, too, the estimation of depth features reflected the enhanced depth impression provided by stereoscopy. Conclusion: Following first implementation of stereoscopic video teaching, medical students who are inexperienced with ENT surgical procedures are able to reproduce depth information and therefore anatomically complex structures to a greater extent following stereoscopic video teaching. Besides extending video teaching to junior doctors, the next evaluation step will address its effect on the learning curve during the surgical training program.

Clips versus suture technique: is there a difference?

PubMed

Chughtai, T; Chen, L Q; Salasidis, G; Nguyen, D; Tchervenkov, C; Morin, J F

2000-11-01

Coronary artery bypass grafting (CABG) is one of the most common procedures performed today, and wound complications are a major source of morbidity and cost. To determine whether there is any difference in wound outcome (including cost in a Canadian context) between a subcuticular suture technique and skin stapling technique for closure of sternal and leg incisions in CABG patients. One hundred and sixty-two patients undergoing CABG were prospectively, randomly placed to have their sternal and leg incisions closed with either a subcuticular suture technique or with a skin clip. Data were obtained through chart review, in-hospital assessments and follow-up visits. Nonblinded assessments were made regarding wound leakage, inflammation, infection, necrosis, swelling, dehiscence and cosmesis. Each of the parameters was graded on a scale from 1 to 4. The cost was evaluated in Canadian dollars. There were trends toward increased rates of in-hospital sternal (P=0.09) and leg (P=0.17) incision inflammation when the wounds were closed with skin clips. There was a significantly greater (P=0.05) rate of sternal wound infection with clips, as well as a tendency (P=0.15) toward a greater rate of mediastinitis at follow-up assessment. Cosmetic outcome was similar for both groups. The cost incurred was significantly greater when skin clips were used for closure. There was a greater than threefold difference, which translates to a greater than $10,000 difference over one year. Closure with a subcuticular technique achieves better outcomes than the use of skin clips. When factoring in the increased cost incurred by using clips, as well as other intangible factors such as surgical skill acquisition, subcuticular suture closure appears to be a favourable method of wound closure in CABG patients compared with the use of skin stapling techniques.

Dosimetric impact of tumor bed delineation variability based on 4DCT scan for external-beam partial breast irradiation.

PubMed

Guo, Bing; Li, Jianbin; Wang, Wei; Li, Fengxiang; Guo, Yanluan; Li, Yankang; Liu, Tonghai

2015-01-01

This study sought to evaluate the dosimetric impact of tumor bed delineation variability (based on clips, seroma or both clips and seroma) during external-beam partial breast irradiation (EB-PBI) planned utilizing four-dimensional computed tomography (4DCT) scans. 4DCT scans of 20 patients with a seroma clarity score (SCS) 3~5 and ≥5 surgical clips were included in this study. The combined volume of the tumor bed formed using clips, seroma, or both clips and seroma on the 10 phases of 4DCT was defined as the internal gross target volume (termed IGTVC, IGTVS and IGTVC+S, respectively). A 1.5-cm margin was added by defining the planning target volume (termed PTVC, PTVS and PTVC+S, respectively). Three treatment plans were established using the 4DCT images (termed EB-PBIC, EB-PBIS, EB-PBIC+S, respectively). The results showed that the volume of IGTVC+S was significantly larger than that of IGTVCand IGTVS. Similarly, the volume of PTVC+S was markedly larger than that of PTVC and PTVS. However, the PTV coverage for EB-PBIC+S was similar to that of EB-PBIC and EB-PBIS, and there were no significant differences in the homogeneity index or conformity index between the three treatment plans (P=0.878, 0.086). The EB-PBIS plan resulted in the lowest ipsilateral normal breast and ipsilateral lung doses compared with the EB-PBIC and EB-PBIC+S plans. To conclude, the volume variability delineated based on clips, seroma or both clips and seroma resulted in dosimetric variability for organs at risk, but did not show a marked influence on the dosimetric distribution.

Dosimetric impact of tumor bed delineation variability based on 4DCT scan for external-beam partial breast irradiation

PubMed Central

Guo, Bing; Li, Jianbin; Wang, Wei; Li, Fengxiang; Guo, Yanluan; Li, Yankang; Liu, Tonghai

2015-01-01

This study sought to evaluate the dosimetric impact of tumor bed delineation variability (based on clips, seroma or both clips and seroma) during external-beam partial breast irradiation (EB-PBI) planned utilizing four-dimensional computed tomography (4DCT) scans. 4DCT scans of 20 patients with a seroma clarity score (SCS) 3~5 and ≥5 surgical clips were included in this study. The combined volume of the tumor bed formed using clips, seroma, or both clips and seroma on the 10 phases of 4DCT was defined as the internal gross target volume (termed IGTVC, IGTVS and IGTVC+S, respectively). A 1.5-cm margin was added by defining the planning target volume (termed PTVC, PTVS and PTVC+S, respectively). Three treatment plans were established using the 4DCT images (termed EB-PBIC, EB-PBIS, EB-PBIC+S, respectively). The results showed that the volume of IGTVC+S was significantly larger than that of IGTVCand IGTVS. Similarly, the volume of PTVC+S was markedly larger than that of PTVC and PTVS. However, the PTV coverage for EB-PBIC+S was similar to that of EB-PBIC and EB-PBIS, and there were no significant differences in the homogeneity index or conformity index between the three treatment plans (P=0.878, 0.086). The EB-PBIS plan resulted in the lowest ipsilateral normal breast and ipsilateral lung doses compared with the EB-PBIC and EB-PBIC+S plans. To conclude, the volume variability delineated based on clips, seroma or both clips and seroma resulted in dosimetric variability for organs at risk, but did not show a marked influence on the dosimetric distribution. PMID:26885108

Delayed recovery of adipsic diabetes insipidus (ADI) caused by elective clipping of anterior communicating artery and left middle cerebral artery aneurysms.

PubMed

Tan, Jeffrey; Ndoro, Samuel; Okafo, Uchenna; Garrahy, Aoife; Agha, Amar; Rawluk, Danny

2016-12-16

Adipsic diabetes insipidus (ADI) is an extremely rare complication following microsurgical clipping of anterior communicating artery aneurysm (ACoA) and left middle cerebral artery (MCA) aneurysm. It poses a significant challenge to manage due to an absent thirst response and the co-existence of cognitive impairment in our patient. Recovery from adipsic DI has hitherto been reported only once. A 52-year-old man with previous history of clipping of left posterior communicating artery aneurysm 20 years prior underwent microsurgical clipping of ACoA and left MCA aneurysms without any intraoperative complications. Shortly after surgery, he developed clear features of ADI with adipsic severe hypernatraemia and hypotonic polyuria, which was associated with cognitive impairment that was confirmed with biochemical investigations and cognitive assessments. He was treated with DDAVP along with a strict intake of oral fluids at scheduled times to maintain eunatremia. Repeat assessment at six months showed recovery of thirst and a normal water deprivation test. Management of ADI with cognitive impairment is complex and requires a multidisciplinary approach. Recovery from ADI is very rare, and this is only the second report of recovery in this particular clinical setting.

Complete closure of artificial gastric ulcer after endoscopic submucosal dissection by combined use of a single over-the-scope clip and through-the-scope clips (with videos).

PubMed

Maekawa, Satoshi; Nomura, Ryosuke; Murase, Takayuki; Ann, Yasuyoshi; Harada, Masaru

2015-02-01

A 5-7 day hospital stay is usually needed after endoscopic submucosal dissection (ESD) of gastric tumor because of the possibility of delayed perforation or bleeding. The aim of this study was to evaluate the efficacy of combined use of a single over-the-scope clip (OTSC) and through-the-scope clips (TTSCs) to achieve complete closure of artificial gastric ulcer after ESD. We prospectively studied 12 patients with early gastric cancer or gastric adenoma. We performed complete closure of post-ESD artificial gastric ulcer using a combination of a single OTSC and TTSCs. Mean size of post-ESD artificial ulcer was 54.6 mm. The mean operating time for the closure procedure was 15.2 min., and the success rate was 91.7 % (11/12). Patients who underwent complete closure of post-ESD artificial gastric ulcer could be discharged the day after ESD and the closing procedure. Complete closure of post-ESD artificial gastric ulcer using a combination of a single OTSC and TTSCs is useful for shortening the period of hospitalization and reducing treatment cost.

Hemodynamic response during aneurysm clipping surgery among experienced neurosurgeons.

PubMed

Bunevicius, Adomas; Bilskiene, Diana; Macas, Andrius; Tamasauskas, Arimantas

2016-02-01

Neurosurgery is a challenging field associated with high levels of mental stress. The goal of this study was to investigate the hemodynamic response of experienced neurosurgeons during aneurysm clipping surgery and to evaluate whether neurosurgeons' hemodynamic responses are associated with patients' clinical statuses. Four vascular neurosurgeons (all male; mean age 51 ± 10 years; post-residency experience ≥7 years) were studied during 42 aneurysm clipping procedures. Blood pressure (BP) and heart rate (HR) were assessed at rest and during seven phases of surgery: before the skin incision, after craniotomy, after dural opening, after aneurysm neck dissection, after aneurysm clipping, after dural closure and after skin closure. HR and BP were significantly greater during surgery relative to the rest situation (p ≤ 0.03). There was a statistically significant increase in neurosurgeons' HR (F [6, 41] = 10.88, p < 0.001), systolic BP (F [6, 41] = 2.97, p = 0.01), diastolic BP (F [6, 41] = 2.49, p = 0.02) and mean BP (F [6, 41] = 3.36, p = 0.003) during surgery. The greatest mean HR was after aneurysm clipping, and the greatest BP was after aneurysm neck dissection. Systolic, diastolic and mean BPs were significantly greater during surgical clipping for unruptured aneurysms compared to ruptured aneurysms across all stages of surgery (p ≤ 0.002); however, after adjusting for neurosurgeon experience, the difference in BP as a function of aneurysm rupture was not significant (p > 0.08). Aneurysm location, intraoperative aneurysm rupture, admission WFNS score, admission Glasgow Coma Scale scores and Fisher grade were not associated with neurosurgeons' intraoperative HR and BP (all p > 0.07). Aneurysm clipping surgery is associated with significant hemodynamic system activation among experienced neurosurgeons. The greatest HR and BP were after aneurysm neck dissection and clipping. Aneurysm location and patient clinical status were not associated with intraoperative changes of neurosurgeons' HR and BP.

Unilateral vocal fold paralysis in premature infants after ligation of patent ductus arteriosus: vascular clip versus suture ligature.

PubMed

Spanos, William C; Brookes, James T; Smith, Mark C; Burkhart, Harold M; Bell, Edward F; Smith, Richard J H

2009-10-01

We investigated risk factors associated with unilateral iatrogenic vocal fold paralysis (IVFP) in the context of ligation of patent ductus arteriosus (PDA) and compared the rates of paralysis between vascular clip and suture ligation procedures. We performed a prospective examination of infants with isolated PDA treated surgically during 1995 to 2005. Statistical significance was determined with a 2-tailed t-test. Of 68 PDA ligations, 13 cases of left-sided IVFP were diagnosed, for an overall incidence of 19%. All cases of IVFP occurred in 55 infants who weighed less than 1 kg at birth. Suture ligature was used in 60% of all PDA ligation patients, and vascular clips in 40%. The incidence of IVFP in patients with vascular clips (19%) was similar to the incidence in those with suture ligature (20%). Hoarseness or stridor was present in 69% of patients with IVFP, compared to 17% of normal controls (p <0.001). The rate of aspiration was not increased in the IVFP group; however, 15% of the patients with IVFP had episodes of decreased oxygen saturation, versus 7% of infants with normal vocal fold mobility. A hoarse infant with a birth weight of less than 1 kg who has undergone PDA ligation should be examined for unilateral IVFP. Vascular clips and suture ligature are associated with similar rates of IVFP.

Delayed Visual Loss and Its Surgical Rescue Following Extracranial-Intracranial Arterial Bypass and Native Internal Carotid Artery Sacrifice.

PubMed

Li, Lai-Fung; Leung, Gilberto Ka-Kit; Lui, Wai-Man

2017-02-01

High-flow extracranial-intracranial (EC-IC) bypass followed by sacrifice of the native internal carotid artery (ICA) is a recognized treatment option for giant ICA aneurysm and skull base tumor involving the ICA. Distal clipping at the supraclinoid portion of the ICA is technically straightforward, but it can potentially compromise ophthalmic artery (OA) perfusion. Because of the extensive EC-IC anastomoses with the OA, visual symptoms are fortunately uncommon. We report a patient who developed complete blindness after distal trapping of the supraclinoid ICA; it was reversed after emergency clip removal. Our patient is a 47-year-old man with recurrent nasopharyngeal carcinoma in close proximity to the left petrosal ICA. The first stage of the procedure involved an EC-IC bypass using radial artery graft, followed by a second stage with combined craniofacial excision. Trapping of the native ICA was achieved using a permanent aneurysm clip placed at the supraclinoid ICA distal to the origin of the OA. He complained of a new onset of complete left eye visual loss approximately 6 hours after the distal aneurysm clip was applied. He was immediately sent to the operating theatre for the removal of the supraclinoid aneurysm clip. On the next day, his vision improved and left pupil became reactive again. OA flow following ICA trapping is complicated and precarious. Delayed onset of visual loss is possible. Prompt action by direct exploration and clip removal is needed and can be effective in reversing blindness. Copyright © 2016 Elsevier Inc. All rights reserved.

Impact of dexamethasone in patients with aneurysmal subarachnoid haemorrhage.

PubMed

Czorlich, P; Sauvigny, T; Ricklefs, F; Abboud, T; Nierhaus, A; Vettorazzi, E; Reuter, D A; Regelsberger, J; Westphal, M; Schmidt, N O

2017-04-01

The role of corticosteroids in the treatment of patients with aneurysmal subarachnoid haemorrhage (SAH) has remained controversial for decades. Recent studies have suggested that the administration of corticosteroids in SAH patients is associated with favourable outcomes. Given their significant adverse effects, it is essential to identify those patients who will benefit from treatment with corticosteroids. A retrospective analysis of a prospectively collected cohort (n = 306) with SAH who were treated by microsurgical clipping or endovascular intervention was performed. The role of dexamethasone administration was analysed with regard to clinical conditions and SAH-related complications. Outcome was assessed at discharge and during follow-up using the Glasgow Outcome Scale (GOS). Patients treated with dexamethasone presented with more episodes of hyperglycaemia (P < 0.001), more overall infections (P < 0.001) and more ventriculostomy-related infections (P = 0.004). Multivariate analysis demonstrated that treatment with dexamethasone was associated with an unfavourable outcome at discharge (GOS 1-3) [odds ratio (OR) 2.814, 95% confidence interval (CI) 1.440-5.497, P = 0.002]. In the subgroup of microsurgically treated patients, dexamethasone administration was associated with a favourable outcome at follow-up (OR 0.193, 95% CI 0.06-0.621, P = 0.006). A higher risk for unfavourable outcome (OR 3.382, 95% CI 1.67-6.849, P = 0.001) at discharge was observed in endovascularly treated patients who received dexamethasone but this had no impact on the outcome at follow-up. Treatment with dexamethasone seems to be associated with a risk reduction for an unfavourable outcome in those patients who underwent microsurgical clipping. Despite an increased frequency of adverse effects, glucocorticoids may have a potential benefit in this specific surgical subgroup compared to endovascularly treated SAH patients. © 2017 EAN.

Over the scope clip: technique and expanding clinical applications.

PubMed

Singhal, Shashideep; Changela, Kinesh; Papafragkakis, Haris; Anand, Sury; Krishnaiah, Mahesh; Duddempudi, Sushil

2013-10-01

Advances in endoscopic and surgical techniques have increased the frequency and complexity of these procedures, and thus, the incidence of associated complications. To describe the use and clinical applications of the Over the Scope Clip (OTSC) system. An English language literature search was conducted using the key words "endoscopy" and "over the scope clip" in order to identify human studies evaluating the application of OTSC from January 2001 to August 2012. The indication, efficacy, complications, and limitations were recorded. Overall success rates of OTSC based on current literature range are in the range of 75% to 100% for closure of iatrogenic gastrointestinal perforations, 38% to 100% for closure of gastrointestinal fistulas, 50% to 100% for anastomotic leaks, and 71% to 100% for bleeding lesions. OTSCs have shown 100% success rates in managing postbariatric surgery weight gain secondary to dilation of the gastrojejunal pouch. OTSC is easy to use with good results, thus decreasing the morbidity and mortality associated with the complications secondary to both diagnostic and therapeutic endoscopy and avoiding surgery in many situations.

[MitraClip® for treatment of tricuspid valve insufficiency].

PubMed

Pfister, R; Baldus, S

2017-11-01

Tricuspid valve regurgitation is frequently found as a result of right ventricular remodeling due to advanced left heart diseases. Drug treatment is limited to diuretics and the cardiac or pulmonary comorbidities. Due to the high risk only a small percentage of patients are amenable to surgical treatment of tricuspid regurgitation in those who undergo left-sided surgery for other reasons. Catheter-based procedures are an attractive treatment alternative, particularly since the strong prognostic impact of tricuspid regurgitation suggests an unmet need of treatment, independent of the underlying heart disease. A vast amount of clinical experience exists for the MitraClip system for treatment of mitral regurgitation. A first case series shows that the application for treatment of tricuspid regurgitation is technically feasible, seems to be safe and the degree of valve regurgitation can be reduced. In this review the background of tricuspid regurgitation treatment is summarized and first experiences and perspectives with the MitraClip system are assessed.

A Comparison of Over-the-Counter Mechanical Nasal Dilators: A Systematic Review.

PubMed

Kiyohara, Nicole; Badger, Christopher; Tjoa, Tjoson; Wong, Brian

2016-09-01

The internal nasal valve is the narrowest part of the nasal airway and a common site of inspiratory collapse and obstruction of nasal airflow. Over-the-counter mechanical nasal dilators are an alternative to surgical intervention that attempts to improve airflow through the internal nasal valve. To determine the efficacy of over-the-counter mechanical nasal dilators and classify these products by mechanism. A database of 33 available over-the-counter mechanical nasal dilators was generated via a PubMed search as well as an internet search via Amazon.com and Google, conducted from April 1, 2013, through December 31, 2015. Products determined to be unavailable or discontinued were excluded from the database. Of the devices examined in published literature, efficacy was based on objective measures, such as measured airflow, the cross-sectional area of the nasal valve, and changes in resistance. Measures of reported sleep quality or patient perception were excluded. An analysis of each product's mechanism revealed 4 broad classes: external nasal dilator strips, nasal stents, nasal clips, and septal stimulators. A review demonstrated 5 studies supporting the use of external nasal dilator strips, 4 studies supporting the use of nasal clips, 1 study supporting the use of nasal stents, and no studies supporting the use of septal stimulators. Our findings suggest that external nasal dilator strips and nasal clips effectively relieve obstruction of the internal nasal valve and may be an alternative to surgical intervention in some patients.

Inflammation scores predict survival for hepatitis B virus-related hepatocellular carcinoma patients after transarterial chemoembolization

PubMed Central

Zhou, Dong-Sheng; Xu, Li; Luo, Yao-Ling; He, Feng-Ying; Huang, Jun-Ting; Zhang, Yao-Jun; Chen, Min-Shan

2015-01-01

AIM: To compare the prognostic ability of inflammation scores for patients with hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC) undergoing transarterial chemoembolization (TACE). METHODS: Data of 224 consecutive patients who underwent TACE for unresectable HBV-related HCC from September 2009 to November 2011 were retrieved from a prospective database. The association of inflammation scores with clinicopathologic variables and overall survival (OS) were analyzed, and receiver operating characteristic curves were generated, and the area under the curve (AUC) was calculated to evaluate the discriminatory ability of each inflammation score and staging system, including tumor-node-metastasis, Barcelona Clinic Liver Cancer, and Cancer of the Liver Italian Program (CLIP) scores. RESULTS: The median follow-up period was 390 d, the one-, two-, and three-year OS were 38.4%, 18.3%, and 11.1%, respectively, and the median OS was 390 d. The Glasgow Prognostic Score (GPS), modifed GPS, neutrophil-lymphocyte ratio, and Prognostic Index were associated with OS. The GPS consistently had a higher AUC value at 6 mo (0.702), 12 mo (0.676), and 24 mo (0.687) in comparison with other inflammation scores. CLIP consistently had a higher AUC value at 6 mo (0.656), 12 mo (0.711), and 24 mo (0.721) in comparison with tumor-node-metastasis and Barcelona Clinic Liver Cancer staging systems. Multivariate analysis revealed that alanine aminotransferase, GPS, and CLIP were independent prognostic factors for OS. The combination of GPS and CLIP (AUC = 0.777) was superior to CLIP or GPS alone in prognostic ability for OS. CONCLUSION: The prognostic ability of GPS is superior to other inflammation scores for HCC patients undergoing TACE. Combining GPS and CLIP improved the prognostic power for OS. PMID:25987783

Microneurosurgical Management of Posterior Communicating Artery Aneurysm: A Contemporary Series from Helsinki.

PubMed

Thiarawat, Peeraphong; Jahromi, Behnam Rezai; Kozyrev, Danil A; Intarakhao, Patcharin; Teo, Mario K; Choque-Velasquez, Joham; Hernesniemi, Juha

2017-05-01

The objectives of this study were to analyze microsurgical techniques and to determine correlations between microsurgical techniques and the radiographic findings in the microneurosurgical treatment of posterior communicating artery aneurysms (PCoAAs). We retrospectively analyzed radiographic findings and videos of surgeries in 64 patients with PCoAAs who underwent microsurgical clipping by the senior author from August 2010 to 2014. From 64 aneurysms, 30 (47%) had acute subarachnoid hemorrhage (SAH) that necessitated lamina terminalis fenestration (odds ratio [OR], 67.67; P < 0.001) and Liliequist membrane fenestration (OR, 19.62; P < 0.001). The low-lying aneurysms significantly necessitated the coagulation of the dura covering the anterior clinoid process (ACP) (OR, 7.43; P = 0.003) or anterior clinoidectomy (OR, 91.0; P < 0.001). We preferred straight clips in 45 (83%) of 54 posterolateral projecting aneurysms (OR, 45.0; P < 0.001), but preferred curved clips for posteromedial projecting aneurysms (OR, 6.39; P = 0.008). The mean operative time from the brain retraction to the final clipping was 17 minutes and 43 seconds. Postoperative computed tomography angiography revealed complete occlusion of 60 (94%) aneurysms. Three (4.6%) patients with acute SAH suffered postoperative lacunar infarction. For ruptured aneurysms, lamina terminalis and Liliequist membrane fenestration are useful for additional cerebrospinal fluid drainage. For low-lying aneurysms, coagulation of the dura covering the ACP or tailored anterior clinoidectomy might be necessary for exposing the proximal aneurysm neck. Type of clips depends on the direction of projection. The microsurgical clipping of the PCoAAs can achieve good immediate complete occlusion rate with low postoperative stroke rate. Copyright © 2017 Elsevier Inc. All rights reserved.

Mature Follow-Up for High-Risk Stage I Non-Small-Cell Lung Carcinoma Treated With Sublobar Resection and Intraoperative Iodine-125 Brachytherapy

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

Colonias, Athanasios, E-mail: acolonia@wpahs.or; Drexel University College of Medicine, Allegheny Campus, Pittsburgh, PA; Betler, James

2011-01-01

Purpose: To update the Allegheny General Hospital experience of high-risk Stage I non-small-cell lung cancer patients treated with sublobar resection and intraoperative {sup 125}I Vicryl mesh brachytherapy. Methods and Materials: Between January 5, 1996 and February 19, 2008, 145 patients with Stage I non-small-cell lung cancer who were not lobectomy candidates because of cardiopulmonary compromise underwent sublobar resection and placement of {sup 125}I seeds along the resection line. The {sup 125}I seeds embedded in Vicryl suture were attached with surgical clips to a sheet of Vicryl mesh, inserted over the target area, and prescribed to a 0.5-cm planar margin. Results:more » The mean target area, total activity, number of seeds implanted, and prescribed total dose was 33.3 cm{sup 2} (range, 18.0-100.8), 20.2 mCi (range, 11.1-29.7), 46 (range, 30-100), and 117 Gy (range, 80-180), respectively. The median length of the surgical stay was 6 days (range, 1-111), with a perioperative mortality rate of 3.4%. At a median follow-up of 38.3 months (range, 1-133), 6 patients had developed local recurrence (4.1%), 9 had developed regional failure (6.2%), and 25 had distant failure (17.2%). On multivariate analysis, no patient- or tumor-specific factors or surgical or dosimetric factors were predictive of local recurrence. The overall median survival was 30.5 months with a 3- and 5-year overall survival rate of 65% and 35%, respectively. Conclusion: {sup 125}I brachytherapy for high-risk, Stage I non-small-cell lung cancer after sublobar resection is well tolerated and associated with a low local failure rate.« less

Energy sources for laparoscopic colectomy: a prospective randomized comparison of conventional electrosurgery, bipolar computer-controlled electrosurgery and ultrasonic dissection. Operative outcome and costs analysis.

PubMed

Targarona, Eduardo Ma; Balague, Carmen; Marin, Juan; Neto, Rene Berindoague; Martinez, Carmen; Garriga, Jordi; Trias, Manuel

2005-12-01

The development of operative laparoscopic surgery is linked to advances in ancillary surgical instrumentation. Ultrasonic energy devices avoid the use of electricity and provide effective control of small- to medium-sized vessels. Bipolar computer-controlled electrosurgical technology eliminates the disadvantages of electrical energy, and a mechanical blade adds a cutting action. This instrument can provide effective hemostasis of large vessels up to 7 mm. Such devices significantly increase the cost of laparoscopic procedures, however, and the amount of evidence-based information on this topic is surprisingly scarce. This study compared the effectiveness of three different energy sources on the laparoscopic performance of a left colectomy. The trial included 38 nonselected patients with a disease of the colon requiring an elective segmental left-sided colon resection. Patients were preoperatively randomized into three groups. Group I had electrosurgery; vascular dissection was performed entirely with an electrosurgery generator, and vessels were controlled with clips. Group II underwent computer-controlled bipolar electrosurgery; vascular and mesocolon section was completed by using the 10-mm Ligasure device alone. In group III, 5-mm ultrasonic shears (Harmonic Scalpel) were used for bowel dissection, vascular pedicle dissection, and mesocolon transection. The mesenteric vessel pedicle was controlled with an endostapler. Demographics (age, sex, body mass index, comorbidity, previous surgery and diagnoses requiring surgery) were recorded, as were surgical details (operative time, conversion, blood loss), additional disposable instruments (number of trocars, EndoGIA charges, and clip appliers), and clinical outcome. Intraoperative economic costs were also evaluated. End points of the trial were operative time and intraoperative blood loss, and an intention-to-treat principle was followed. The three groups were well matched for demographic and pathologic features. Surgical time was significantly longer in patients operated on with conventional electrosurgery vs the Harmonic Scalpel or computed-based bipolar energy devices. This finding correlated with a significant reduction in intraoperative blood loss. Conversion to other endoscopic techniques was more frequent in Group I; however, conversion to open surgery was similar in all three groups. No intraoperative accident related to the use of the specific device was observed in any group. Immediate outcome was similar in the three groups, without differences in morbidity, mortality, or hospital stay. Analysis of operative costs showed no significant differences between the three groups. High-energy power sources specifically adapted for endoscopic surgery reduce operative time and blood loss and may be considered cost-effective when left colectomy is used as a model.

The second-generation eCLIPs Endovascular Clip System: initial experience.

PubMed

Chiu, Albert H; De Vries, Joost; O'Kelly, Cian J; Riina, Howard; McDougall, Ian; Tippett, Jonathan; Wan, Martina; de Oliveira Manoel, Airton Leonardo; Marotta, Thomas R

2018-02-01

OBJECTIVE Treatment of wide-necked intracranial aneurysms is associated with higher recanalization and complication rates; however, the most commonly used methods are not specifically designed to work in bifurcation lesions. To address these issues, the authors describe the evolution in the design and use of the eCLIPs (Endovascular Clip System) device, a novel hybrid stent-like assist device with flow diverter properties that was first described in 2008. METHODS A registry was established covering 13 international centers at which patients were treated with the second-generation eCLIPs device. Aneurysm morphology and rupture status, device neck coverage, coil retention, and procedural and late morbidity and mortality were recorded. For those patients who had undergone successful implantation more than 6 months earlier, the final imaging and clinical follow-up results and need for re-treatment were recorded. RESULTS Thirty-three patients were treated between June 2013 and September 2015. Twenty-five (76%) patients had successful placement of an eCLIPs device; 23 (92%) of these 25 patients had complete data. Eight cases of nondeployment occurred during the 1st year of use, consistent with a learning curve; no failures of deployment occurred thereafter. Two periprocedural transient ischemic attacks and 2 asymptomatic thrombotic events occurred. Twenty-one (91%) of 23 patients underwent follow-up at an average of 8 months (range 3-18 months); 9 (42.9%) of these 21 patients demonstrated an improvement in Raymond grade at follow-up; no cases of worsening Raymond grade were recorded, and 17 (81.0%) patients sustained a modified Raymond-Roy Classification class of I or II angiographic result at follow-up. Two delayed ruptures were recorded, both in previously coiled, symptomatic giant aneurysms where the device was used as a part of a salvage strategy. CONCLUSIONS The second-generation eCLIPs device is a viable treatment option for bifurcation aneurysms. The aneurysm occlusion rates in this initial clinical series are comparable to the initial experience with other bifurcation support devices.

[Rapid 3-Dimensional Models of Cerebral Aneurysm for Emergency Surgical Clipping].

PubMed

Konno, Takehiko; Mashiko, Toshihiro; Oguma, Hirofumi; Kaneko, Naoki; Otani, Keisuke; Watanabe, Eiju

2016-08-01

We developed a method for manufacturing solid models of cerebral aneurysms, with a shorter printing time than that involved in conventional methods, using a compact 3D printer with acrylonitrile-butadiene-styrene(ABS)resin. We further investigated the application and utility of this printing system in emergency clipping surgery. A total of 16 patients diagnosed with acute subarachnoid hemorrhage resulting from cerebral aneurysm rupture were enrolled in the present study. Emergency clipping was performed on the day of hospitalization. Digital Imaging and Communication in Medicine(DICOM)data obtained from computed tomography angiography(CTA)scans were edited and converted to stereolithography(STL)file formats, followed by the production of 3D models of the cerebral aneurysm by using the 3D printer. The mean time from hospitalization to the commencement of surgery was 242 min, whereas the mean time required for manufacturing the 3D model was 67 min. The average cost of each 3D model was 194 Japanese Yen. The time required for manufacturing the 3D models shortened to approximately 1 hour with increasing experience of producing 3D models. Favorable impressions for the use of the 3D models in clipping were reported by almost all neurosurgeons included in this study. Although 3D printing is often considered to involve huge costs and long manufacturing time, the method used in the present study requires shorter time and lower costs than conventional methods for manufacturing 3D cerebral aneurysm models, thus making it suitable for use in emergency clipping.

E-learning teaches attendings "how to" objectively assess pediatric urology trainees' surgery skills for orchiopexy.

PubMed

Fernandez, Nicolas; Maizels, Max; Farhat, Walid; Smith, Edwin; Liu, Dennis; Chua, Michael; Bhanji, Yasin

2018-04-01

Established methods to train pediatric urology surgery by residency training programs require updating in response to administrative changes such as new, reduced trainee duty hours. Therefore, new objective methods must be developed to teach trainees. We approached this need by creating e-learning to teach attendings objective assessment of trainee skills using the Zwisch scale, an established assessment tool. The aim of this study was to identify whether or not e-learning is an appropriate platform for effective teaching of this assessment tool, by assessing inter-rater correlation of assessments made by the attendings after participation in the e-learning. Pediatric orchiopexy was used as the index case. An e-learning tool was created to teach attending surgeons objective assessment of trainees' surgical skills. First, e-learning content was created which showed the assessment method videotape of resident surgery done in the operating room. Next, attendings were enrolled to e-learn this method. Finally, the ability of enrollees to assess resident surgery skill performance was tested. Namely, test video was made showing a trainee performing inguinal orchiopexy. All enrollees viewed the same online videos. Assessments of surgical skills (Zwisch scale) were entered into an online survey. Data were analyzed by intercorrelation coefficient kappa analysis (strong correlation was ICC ≥ 0.7). A total of 11 attendings were enrolled. All accessed the online learning and then made assessments of surgical skills trainees showed on videotapes. The e-learning comprised three modules: 1. "Core concepts," in which users learned the assessment tool methods; 2. "Learn to assess," in which users learned how to assess by watching video clips, explaining the assessment method; and 3. "Test," in which users tested their skill at making assessments by watching video clips and then actively inputting their ratings of surgical and global skills as viewed in the video clips (Figure). A total of 89 surgical skill ratings were performed with 56 (65%) exact matches between raters and 89 (100%) matched within one rank. Interclass correlation coefficient (ANOVA) showed statistically significant correlation. (r = 0.725, 95% CI 0.571-0.837, F = 3.976, p ≤ 0.00001). Kappa analysis of inter-rater reliability showed strong consensus between attendings for average measures with ICC = 0.71, 95% CI 0.46-0.95 (p = 0.03). We launched e-learning to teach pediatric urology attendings "how to" assess trainee surgical skills objectively (Zwisch scale). After e-learning, there was strong inter-rater correlation in assessments made. We plan to extend such e-learning to pediatric urology surgical training programs. Copyright © 2017 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.

Multivariable and Bayesian Network Analysis of Outcome Predictors in Acute Aneurysmal Subarachnoid Hemorrhage: Review of a Pure Surgical Series in the Post-International Subarachnoid Aneurysm Trial Era.

PubMed

Zador, Zsolt; Huang, Wendy; Sperrin, Matthew; Lawton, Michael T

2018-06-01

Following the International Subarachnoid Aneurysm Trial (ISAT), evolving treatment modalities for acute aneurysmal subarachnoid hemorrhage (aSAH) has changed the case mix of patients undergoing urgent surgical clipping. To update our knowledge on outcome predictors by analyzing admission parameters in a pure surgical series using variable importance ranking and machine learning. We reviewed a single surgeon's case series of 226 patients suffering from aSAH treated with urgent surgical clipping. Predictions were made using logistic regression models, and predictive performance was assessed using areas under the receiver operating curve (AUC). We established variable importance ranking using partial Nagelkerke R2 scores. Probabilistic associations between variables were depicted using Bayesian networks, a method of machine learning. Importance ranking showed that World Federation of Neurosurgical Societies (WFNS) grade and age were the most influential outcome prognosticators. Inclusion of only these 2 predictors was sufficient to maintain model performance compared to when all variables were considered (AUC = 0.8222, 95% confidence interval (CI): 0.7646-0.88 vs 0.8218, 95% CI: 0.7616-0.8821, respectively, DeLong's P = .992). Bayesian networks showed that age and WFNS grade were associated with several variables such as laboratory results and cardiorespiratory parameters. Our study is the first to report early outcomes and formal predictor importance ranking following aSAH in a post-ISAT surgical case series. Models showed good predictive power with fewer relevant predictors than in similar size series. Bayesian networks proved to be a powerful tool in visualizing the widespread association of the 2 key predictors with admission variables, explaining their importance and demonstrating the potential for hypothesis generation.

Left Atrial Appendage Closure for Stroke Prevention: Devices, Techniques, and Efficacy.

PubMed

Iskandar, Sandia; Vacek, James; Lavu, Madhav; Lakkireddy, Dhanunjaya

2016-05-01

Left atrial appendage closure can be performed either surgically or percutaneously. Surgical approaches include direct suture, excision and suture, stapling, and clipping. Percutaneous approaches include endocardial, epicardial, and hybrid endocardial-epicardial techniques. Left atrial appendage anatomy is highly variable and complex; therefore, preprocedural imaging is crucial to determine device selection and sizing, which contribute to procedural success and reduction of complications. Currently, the WATCHMAN is the only device that is approved for left atrial appendage closure in the United States. Copyright © 2016 Elsevier Inc. All rights reserved.

Hazard perception test for pedestrians.

PubMed

Rosenbloom, Tova; Mandel, Roi; Rosner, Yotam; Eldror, Ehud

2015-06-01

This research was aimed to construct and develop a unique system for training of pedestrians - children, adults and older persons - to cross streets safely and especially to detect successfully on-road hazards as pedestrians. For this purpose, an interactive computerized program has been inspired by the format of the popular HPT (hazard perception test) for drivers. The HPTP (hazard perception test for pedestrians) includes 10 pairs of video clips that were filmed in various locations but had a similar hazardous element. The clips presented potentially dangerous crossing scenarios such as a vehicle merging from the right side of the road from the perspective of the pedestrian who is trying to cross the street. The participants were asked to press the spacebar key every time they identified an approaching hazard. The participants were instructed to use the arrow keys for moving the viewing panel to the left or to the right in order to enlarge the field of view accordingly. Totally, 359 participants took part. Adults, children, and elders were assigned to two practice groups and three control groups in a 3 (age groups)×5 (experimental groups) design. One practice group underwent pretest, practice, discussion and posttest, the second experimental group through pretest, practice and posttest, one control group that underwent posttest only, the second control group underwent pretest, discussion and posttest and the third control group underwent both pretest and posttest. The most important finding was that children and adults who underwent practice received higher scores in the posttest compared to the pretest. Also, children who underwent practice increased their use of the arrow keys in the posttest compared to the pretest. Across conditions men scored higher than women on the HPTP, and used the keys more often. Age differences were found, with adults scoring being the highest, followed by children and the older persons. Copyright © 2015 Elsevier Ltd. All rights reserved.

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

Do You See What I See? How We Use Video as an Adjunct to General Surgery Resident Education.

PubMed

Abdelsattar, Jad M; Pandian, T K; Finnesgard, Eric J; El Khatib, Moustafa M; Rowse, Phillip G; Buckarma, EeeL N H; Gas, Becca L; Heller, Stephanie F; Farley, David R

2015-01-01

Preparation of learners for surgical operations varies by institution, surgeon staff, and the trainees themselves. Often the operative environment is overwhelming for surgical trainees and the educational experience is substandard due to inadequate preparation. We sought to develop a simple, quick, and interactive tool that might assess each individual trainee's knowledge baseline before participating in minimally invasive surgery (MIS). A 4-minute video with 5 separate muted clips from laparoscopic procedures (splenectomy, gastric band removal, cholecystectomy, adrenalectomy, and inguinal hernia repair) was created and shown to medical students (MS), general surgery residents, and staff surgeons. Participants were asked to watch the video and commentate (provide facts) on the operation, body region, instruments, anatomy, pathology, and surgical technique. Comments were scored using a 100-point grading scale (100 facts agreed upon by 8 surgical staff and trainees) with points deducted for incorrect answers. All participants were video recorded. Performance was scored by 2 separate raters. An academic medical center. MS = 10, interns (n = 8), postgraduate year 2 residents (PGY)2s (n = 11), PGY3s (n = 10), PGY4s (n = 9), PGY5s (n = 7), and general surgery staff surgeons (n = 5). Scores ranged from -5 to 76 total facts offered during the 4-minute video examination. MS scored the lowest (mean, range; 5, -5 to 8); interns were better (17, 4-29), followed by PGY2s (31, 21-34), PGY3s (33, 10-44), PGY4s (44, 19-47), PGY5s (48, 28-49), and staff (48, 17-76), p < 0.001. Rater concordance was 0.98-measured using a concordance correlation coefficient (95% CI: 0.96-0.99). Only 2 of 8 interns acknowledged the critical view during the laparoscopic cholecystectomy video clip vs 10 of 11 PGY2 residents (p < 0.003). Of 8 interns, 7 misperceived the spleen as the liver in the splenectomy clip vs 2 of 7 chief residents (p = 0.02). Not surprisingly, more experienced surgeons were able to relay a larger number of laparoscopic facts during a 4-minute video clip of 5 MIS operations than inexperienced trainees. However, even tenured staff surgeons relayed very few facts on procedures they were unfamiliar with. The potential differentiating capabilities of such a quick and inexpensive effort has pushed us to generate better online learning tools (operative modules) and hands-on simulation resources for our learners. We aim to repeat this and other studies to see if our learners are better prepared for video assessment and ultimately, MIS operations. Copyright © 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Robot-assisted radical prostatectomy: Multiparametric MR imaging-directed intraoperative frozen-section analysis to reduce the rate of positive surgical margins.

PubMed

Petralia, Giuseppe; Musi, Gennaro; Padhani, Anwar R; Summers, Paul; Renne, Giuseppe; Alessi, Sarah; Raimondi, Sara; Matei, Deliu V; Renne, Salvatore L; Jereczek-Fossa, Barbara A; De Cobelli, Ottavio; Bellomi, Massimo

2015-02-01

To investigate whether use of multiparametric magnetic resonance (MR) imaging-directed intraoperative frozen-section (IFS) analysis during nerve-sparing robot-assisted radical prostatectomy reduces the rate of positive surgical margins. This retrospective analysis of prospectively acquired data was approved by an institutional ethics committee, and the requirement for informed consent was waived. Data were reviewed for 134 patients who underwent preoperative multiparametric MR imaging (T2 weighted, diffusion weighted, and dynamic contrast-material enhanced) and nerve-sparing robot-assisted radical prostatectomy, during which IFS analysis was used, and secondary resections were performed when IFS results were positive for cancer. Control patients (n = 134) matched for age, prostate-specific antigen level, and stage were selected from a pool of 322 patients who underwent nerve-sparing robot-assisted radical prostatectomy without multiparametric MR imaging and IFS analysis. Rates of positive surgical margins were compared by means of the McNemar test, and a multivariate conditional logistic regression model was used to estimate the odds ratio of positive surgical margins for patients who underwent MR imaging and IFS analysis compared with control subjects. Eighteen patients who underwent MR imaging and IFS analysis underwent secondary resections, and 13 of these patients were found to have negative surgical margins at final pathologic examination. Positive surgical margins were found less frequently in the patients who underwent MR imaging and IFS analysis than in control patients (7.5% vs 18.7%, P = .01). When the differences in risk factors are taken into account, patients who underwent MR imaging and IFS had one-seventh the risk of having positive surgical margins relative to control patients (adjusted odds ratio: 0.15; 95% confidence interval: 0.04, 0.61). The significantly lower rate of positive surgical margins compared with that in control patients provides preliminary evidence of the positive clinical effect of multiparametric MR imaging-directed IFS analysis for patients who undergo prostatectomy. © RSNA, 2014.

Recovery of Third Nerve Palsy after Endovascular Packing of Internal Carotid-Posterior Communicating Artery Aneurysms

PubMed Central

Mavilio, N.; Pisani, R.; Rivano, C.; Testa, V.; Spaziante, R.; Rosa, M.

2000-01-01

Summary Endovascular packing of intracranial aneurysm with preservation of the parent vessel has become in many cases a valid alternative to surgical clipping. Regression of oculomotor disorders after clipping of internal carotid-posterior communicating artery (ICA-PCoA) aneurysms has been well assessed. This report focuses on the reversal of third nerve palsy after endovascular packing of ICA-PCoA aneurysms. To this end, clinical appearances, neuroradiological features, and endovascular interventional procedures of six treated patient are reported and discussed in the light of the very few previous case observations found in the literature. Results indicate that endovascular packing of ICA-PCoA aneurysms may produce effective recovery of correlated third nerve dysfunction. PMID:20667199

Comparison of Fluoroplastic Causse Loop Piston and Titanium Soft-Clip in Stapedotomy

PubMed Central

Faramarzi, Mohammad; Gilanifar, Nafiseh; Roosta, Sareh

2017-01-01

Introduction: Different types of prosthesis are available for stapes replacement. Because there has been no published report on the efficacy of the titanium soft-clip vs the fluoroplastic Causse loop Teflon piston, we compared short-term hearing results of both types of prosthesis in patients who underwent stapedotomy due to otosclerosis. Materials and Methods: A total of 57 ears were included in the soft-clip group and 63 ears were included in the Teflon-piston group. Pre-operative and post-operative air conduction, bone conduction, air-bone gaps, speech discrimination score, and speech reception thresholds were analyzed. Results: Post-operative speech reception threshold gains did not differ significantly between the two groups (P=0.919). However, better post-operative air-bone gap improvement at low frequencies was observed in the Teflon-piston group over the short-term follow-up (at frequencies of 0.25 and 0.50 kHz; P=0.007 and P=0.001, respectively). Conclusion: Similar post-operative hearing results were observed in the two groups in the short-term. PMID:28229059

Natural orifice transluminal endoscopic surgery gastrotomy closure with an over-the-endoscope clip: a randomized, controlled porcine study (with videos).

PubMed

von Renteln, Daniel; Schmidt, Arthur; Vassiliou, Melina C; Gieselmann, Maria; Caca, Karel

2009-10-01

Secure endoscopic closure of transgastric natural orifice transluminal endoscopic surgery (NOTES) access is of paramount importance. The over-the-scope clip (OTSC) system has previously been shown to be effective for NOTES gastrotomy closure. To compare OTSC gastrotomy closure with surgical closure. Randomized, controlled animal study. Animal facility laboratory. Thirty-six female domestic pigs. Gastrotomies were created by using a needle-knife and an 18-mm balloon. The animals were subsequently randomized to either open surgical repair with interrupted sutures or endoscopic repair with 12-mm OTSCs. In addition, pressurized leak tests were performed in ex vivo specimens of 18-mm scalpel incisions closed with suture (n = 14) and of intact stomachs (n = 10). The mean time for endoscopic closure was 9.8 minutes (range 3-22, SD 5.5). No complications occurred during either type of gastrotomy closure. At necropsy, examination of all OTSC and surgical closures demonstrated complete sealing of gastrotomy sites without evidence of injury to adjacent organs. Pressurized leak tests showed a mean burst pressure of 83 mm Hg (range 30-140, SD 27) for OTSC closures and 67 mm Hg (range 30-130, SD 27.7) for surgical sutures. Ex vivo hand-sewn sutures of 18-mm gastrotomies (n = 14) exhibited a mean burst pressure of 65 mm Hg (range 20-140, SD 31) and intact ex vivo stomachs (n = 10) had a mean burst pressure of 126 mm Hg (range 90-170, SD 28). The burst pressure of ex vivo intact stomachs was significantly higher compared with OTSC closures (P < .01), in vivo surgical closures (P < .01), and ex vivo hand-sewn closures (P < .01). There was a trend toward higher burst pressures in the OTSC closures compared with surgical closures (P = .063) and ex vivo hand-sewn closures (P = .094). In vivo surgical closures demonstrated similar burst pressures compared with ex vivo hand-sewn closures (P = .848). Nonsurvival setting. Endoscopic closure by using the OTSC system is comparable to surgical closure in a nonsurvival porcine model. This technique is easy to perform and is suitable for NOTES gastrotomy closure.

Sutureless Fixation of Amniotic Membrane for Therapy of Ocular Surface Disorders

PubMed Central

Kotomin, Ilya; Valtink, Monika; Hofmann, Kai; Frenzel, Annika; Morawietz, Henning; Werner, Carsten; Funk, Richard H. W.; Engelmann, Katrin

2015-01-01

Amniotic membrane is applied to the diseased ocular surface to stimulate wound healing and tissue repair, because it releases supportive growth factors and cytokines. These effects fade within about a week after application, necessitating repeated application. Generally, amniotic membrane is fixed with sutures to the ocular surface, but surgical intervention at the inflamed or diseased site can be detrimental. Therefore, we have developed a system for the mounting of amniotic membrane between two rings for application to a diseased ocular surface without surgical intervention (sutureless amniotic membrane transplantation). With this system, AmnioClip, amniotic membrane can be applied like a large contact lens. First prototypes were tested in an experiment on oneself for wearing comfort. The final system was tested on 7 patients in a pilot study. A possible influence of the ring system on the biological effects of amniotic membrane was analyzed by histochemistry and by analyzing the expression of vascular endothelial growth factor-A (VEGF-A), hepatocyte growth factor (HGF), fibroblast growth factor 2 (FGF 2) and pigment epithelium-derived factor (PEDF) from amniotic membranes before and after therapeutic application. The final product, AmnioClip, showed good tolerance and did not impair the biological effects of amniotic membrane. VEGF-A and PEDF mRNA was expressed in amniotic membrane after storage and mounting before transplantation, but was undetectable after a 7-day application period. Consequently, transplantation of amniotic membranes with AmnioClip provides a sutureless and hence improved therapeutic strategy for corneal surface disorders. Trial Registration ClinicalTrials.gov NCT02168790 PMID:25955359

A cadaveric study of the endoscopic endonasal transclival approach to the basilar artery.

PubMed

Lai, Leon T; Morgan, Michael K; Chin, David C W; Snidvongs, Kornkiat; Huang, June X Z; Malek, Joanne; Lam, Matthew; McLachlan, Rohan; Harvey, Richard J

2013-04-01

The anterior transclival route to basilar artery aneurysms is not widely performed. The objective of this study was to carry out a feasibility assessment of the transclival approach to basilar aneurysms with advanced endonasal techniques on 11 cadaver heads. Clival dura was exposed from the sella to the foramen magnum between the paraclival segments of the internal carotid arteries (ICA) laterally. An inverted dural "U" flap was reflected inferiorly to expose the basilar artery. The maximal dimensions from operative measurements were recorded. Surgical manoeuvrability of multiple instruments and the proficiency to place proximal and distal vascular clips were evaluated. The mean operative depth (± standard deviation), measured from the anterior choanae to the basilar artery, was 110±6mm. The lateral corridors were limited distally by the medial pterygoids (mean width 21±2mm) and paraclival ICA (mean width 20±2mm). The mean transclival craniectomy dimensions were 19±2mm (width) and 23±4mm (height). Exposure of the basilar-anterior inferior cerebellar artery junction, superior cerebellar artery, and the basilar caput were possible in 100%, 91%, and 64% of instances, respectively. Placements of proximal and distal aneurysm clips were achieved in all instances. Based on our findings, the transclival endoscopic endonasal surgery approach provides excellent visualisation of the basilar artery. Clip application and manoeuvrability of instruments was considered adequate for basilar aneurysm surgery. Surgical skills and instrumentation to control significant haemorrhage can potentially limit the clinical applicability of this technique. Crown Copyright © 2012. Published by Elsevier Ltd. All rights reserved.

Indocyanine Green Videoangiography Transoptic Visualization and Clipping Confirmation of an Optic Splitting Ophthalmic Artery Aneurysm.

PubMed

Rustemi, Oriela; Cester, Giacomo; Causin, Francesco; Scienza, Renato; Della Puppa, Alessandro

2016-06-01

Ophthalmic artery aneurysms with medial and superior projection in exceptionally rare cases can split the optic nerve. Treatment of these aneurysms is challenging, because the aneurysm dome is hidden from the optic nerve, rendering its visualization and clipping confirmation difficult. In addition, optic nerve function should be preserved during surgical maneuvers. Preoperative detection of this growing feature is usually missing. We illustrate the first case of indocyanine green videoangiography (ICG-VA) application in an optic penetrating ophthalmic artery aneurysm treatment. A 57-year-old woman presented with temporal hemianopsia, slight right visual acuity deficit, and new onset of headache. The cerebral angiography detected a right ophthalmic artery aneurysm medially and superiorly projecting. The A1 tract of the ipsilateral anterior cerebral artery was elevated and curved, being suspicious for an under optic aneurysm growth. Surgery was performed. Initially the aneurysm was not visible. ICG-VA permitted the transoptic aneurysm visualization. After optic canal opening, the aneurysm was clipped and transoptic ICG-VA confirmed the aneurysm occlusion. ICG-VA showed also the slight improvement of the optic nerve pial vascularization. Postoperatively, the visual acuity was 10/10 and the hemianopsia did not worsen. The elevation and curve of the A1 tract in medially and superiorly projecting ophthalmic aneurysms may be an indirect sign of under optic growth, or optic splitting aneurysms. ICG-VA transoptic aneurysm detection and occlusion confirmation reduces the surgical maneuvers on the optic nerve, contributing to function preservation. Copyright © 2016 Elsevier Inc. All rights reserved.

Predictors of 30-day perioperative morbidity and mortality of unruptured intracranial aneurysm surgery.

PubMed

Kerezoudis, Panagiotis; McCutcheon, Brandon A; Murphy, Meghan; Rayan, Tarek; Gilder, Hannah; Rinaldo, Lorenzo; Shepherd, Daniel; Maloney, Patrick R; Hirshman, Brian R; Carter, Bob S; Bydon, Mohamad; Meyer, Fredric; Lanzino, Giuseppe

2016-10-01

Large-scale studies examining the incidence and predictors of perioperative complications after surgical clipping of unruptured intracranial aneurysms (UIA) using nationally representative prospectively collected data are lacking in the literature. Using the American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) dataset, we conducted a retrospective analysis of the complications experienced by patients that underwent surgical management of a UIA between the years of 2007 and 2013. The primary outcomes of interest were mortality within the 30-day perioperative period and adverse discharge disposition to a location other than home. Predictors of morbidity and mortality were elucidated using multivariable logistic regression analyses controlling for available patient demographic, comorbidity, and operative characteristics. 662 patients were identified in the ACS-NSQIP dataset for operative management of an unruptured aneurysm. The observed rates of 30-day mortality and adverse discharge disposition were 2.27% and 19.47%, respectively. A hundred and eight (16.31%) patients developed at least one major complication. On multivariable analysis, death within 30days was significantly associated with increased operative time (OR 1.005 per minute, 95% CI 1.002-1.008) and chronic preoperative corticosteroid use (OR 28.4, 95% CI 1.68-480.42), whereas major complication development was associated with increased operative time (OR 1.004 per minute, 95% CI 1.002-1.006), age (OR 1.017 per year, 95% CI 1-1.034), preoperative dependency (OR 3.3, 95% CI 1.16-9.40) and diabetes mellitus (OR 2.89, 95% CI 1.45-5.75). Lastly, increasing age (OR 1.017 per year, 95% CI 1-1.034) as well as ASA Class 3 (OR 1.73, 95% CI 1.08-2.77) and 4 (OR 2.28, 95% CI 1.1-4.72) were independent predictors of discharge to a location other than home. Our study yields morbidity and mortality benchmarks for UIA surgery in a representative, national surgical registry. It will hopefully aid in recognizing those patients at greater risk for postoperative complications following surgical management, leading to appropriate changes in treatment strategies for this selected group of patients. Copyright © 2016 Elsevier B.V. All rights reserved.

Pain management in the neonatal piglet during routine management procedures. Part 1: a systematic review of randomized and non-randomized intervention studies.

PubMed

Dzikamunhenga, R S; Anthony, R; Coetzee, J; Gould, S; Johnson, A; Karriker, L; McKean, J; Millman, S T; Niekamp, S R; O'Connor, A M

2014-06-01

Routine procedures carried out on piglets (i.e. castration, tail docking, teeth clipping, and ear notching) are considered painful. Unfortunately the efficacy of current pain mitigation modalities is poorly understood. The aim of this systematic review was to synthesize the existing primary scientific literature regarding the effectiveness of pain management interventions used for routine procedures on piglets. The review question was, 'In piglets under twenty-eight days old, undergoing castration, tail docking, teeth clipping, and/or methods of identification that involve cutting of the ear tissue, what is the effect of pain mitigation compared with no pain mitigation on behavioral and non-behavioral outcomes that indicate procedural pain and post-procedural pain?' A review protocol was designed a priori. Data sources used were Agricola (EBSCO), CAB Abstracts (Thomson Reuters), PubMed, Web of Science (Thomson Reuters), BIOSIS Previews (Thomson Reuters), and ProQuest Dissertations & Theses Full Text. No restrictions on year of publication or language were placed on the search. Eligible studies assessed an intervention designed to mitigate the pain of the procedures of interest and included a comparison group that did not receive an intervention. Eligible non-English studies were translated using a translation service. Two reviewers independently screened titles and abstracts for relevance using pre-defined questions. Data were extracted from relevant articles onto pre-defined forms. From the 2203 retrieved citations forty publications, containing 52 studies met the eligibility criteria. In 40 studies, piglets underwent castration only. In seven studies, piglets underwent tail docking only. In one study, piglets underwent teeth clipping only, and in one study piglets underwent ear notching only. Three studies used multiple procedures. Thirty-two trial arms assessed general anesthesia protocols, 30 trial arms assessed local anesthetic protocols, and 28 trial arms assessed non-steroidal anti-inflammatory drugs (NSAIDs) protocols. Forty-one trial arms were controls where piglets received either placebo or no treatment. Forty-five outcomes were extracted from the studies, however only the results from studies that assessed cortisol (six studies), β-endorphins (one study), vocalisations (nine studies), and pain-related behaviors (nine studies) are reported. Other outcomes were reported in only one or two studies. Confident decision making will likely be difficult based on this body of work because lack of comprehensive reporting precludes calculation of the magnitude of pain mitigation for most outcomes.

Preoperative Prediction of the Necessity for Anterior Clinoidectomy During Microsurgical Clipping of Ruptured Posterior Communicating Artery Aneurysms.

PubMed

Kamide, Tomoya; Burkhardt, Jan-Karl; Tabani, Halima; Safaee, Michael M; Lawton, Michael T

2018-01-01

Although most posterior communicating artery (PCoA) aneurysms can be clipped easily with excellent results, some require anterior clinoidectomy for safe and complete clipping. To review our microsurgical series of ruptured PCoA aneurysms and identify the preoperative predictors for anterior clinoidectomy during microsurgical clipping for PCoA aneurysms. Results from microsurgical clipping of 104 patients with ruptured PCoA aneurysms were reviewed retrospectively. Distances and angles were obtained from computed tomographic angiography and compared between the anterior and nonanterior clinoidectomy groups. Anterior clinoidectomy was required in 19 of the 104 cases (18%). None developed surgical complications due to anterior clinoid process (ACP) resection, including postoperative visual deficit. Univariate and multivariate analyses revealed that the distances from the ACP tip to the aneurysmal proximal neck and from the ACP line to the aneurysmal proximal neck were statistically significant predictive factors for the need of anterior clinoidectomy. Based on a receiver operating characteristic analysis, the distances from the ACP tip to the aneurysmal proximal neck <4.0 mm and from the ACP line to the aneurysmal proximal neck ≤2.0 mm were selected as optimal cutoff values for predicting the necessity of anterior clinoidectomy, and the area under the receiver operating characteristic curve values were 0.991 and 0.955, respectively. In case of ruptured PCoA aneurysm surgery, the distances from the ACP tip to the aneurysmal proximal neck and from the ACP line to the aneurysmal proximal neck were both found to be useful predictors of whether anterior clinoidectomy was required. Copyright © 2017 Elsevier Inc. All rights reserved.

Large Bariatric-Specific Stents and Over-the-Scope Clips in the Management of Post-Bariatric Surgery Leaks.

PubMed

Shehab, Hany; Abdallah, Emad; Gawdat, Khaled; Elattar, Inas

2018-01-01

Endoscopic stents are successful in the management of surgical leaks; however, stent migration remains a significant problem. In this study, we present our approach depending on a large bariatrics-specific stent (Mega stent) and over-the-scope clips in the management of post-bariatric surgery leaks. A retrospective analysis of all patients with post-bariatric surgery leaks treated at our institution using an approach reliant on Mega stents and over-the-scope clips was conducted. Potential factors associated with procedure success and occurrence of complications were also evaluated. A total of 81 stents were inserted in 62 patients with post-bariatric surgery leaks, 46 sleeve gastrectomies (73%) and 16 Roux-en-Y gastric bypass (27%). Over-the-scope clips were applied in 29 patients (46%). Leak closure was achieved in 51 patients (82%). Median number of procedures per patient was 3 (range 2-8). Complications included the following: stent migration (11/62, 18%), intolerance necessitating premature removal (7/62, 11%), esophageal stricture (8/62, 13%), bleeding (4/62, 6%), perforation (4/62, 6%). One stent-induced mortality was encountered (bleeding). The presence of open surgery (vs laparoscopic) was significantly associated with the occurrence of stent-induced complications (p 0.002). The approach combining Mega stents and over-the-scope clips is highly effective in the management of post-bariatric surgery leaks and is associated with a low rate of stent migration and a low number of procedures and stents per patient. Mega stents, however, should be used with great caution due to the significant morbidity associated with their use.

Lateral supraorbital approach to ipsilateral PCA-P1 and ICA-PCoA aneurysms.

PubMed

Goehre, Felix; Jahromi, Behnam Rezai; Elsharkawy, Ahmed; Lehto, Hanna; Shekhtman, Oleg; Andrade-Barazarte, Hugo; Munoz, Francisco; Hijazy, Ferzat; Makhkamov, Makhkam; Hernesniemi, Juha

2015-01-01

Aneurysms of the posterior cerebral artery (PCA) are rare and often associated with anterior circulation aneurysms. The lateral supraorbital approach allows for a very fast and safe approach to the ipsilateral lesions Circle of Willis. A technical note on the successful clip occlusion of two aneurysms in the anterior and posterior Circle of Willis via this less invasive approach has not been published before. The objective of this technical note is to describe the simultaneous microsurgical clip occlusion of an ipsilateral PCA-P1 and an internal carotid artery - posterior communicating artery (ICA-PCoA) aneurysm via the lateral supraorbital approach. The authors present a technical report of successful clip occlusions of ipsilateral located PCA-P1 and ICA-PCoA aneurysms. A 59-year-old female patient was diagnosed with a PCA-P1 and an ipsilateral ICA-PCoA aneurysm by computed tomography angiography (CTA) after an ischemic stroke secondary to a contralateral ICA dissection. The patient underwent microsurgical clipping after a lateral supraorbital craniotomy. The intraoperative indocyanine green (ICG) videoangiography and the postoperative CTA showed a complete occlusion of both aneurysms; the parent vessels (ICA and PCA) were patent. The patient presents postoperative no new neurologic deficit. The lateral supraorbital approach is suitable for the simultaneous microsurgical treatment of proximal anterior circulation and ipsilateral proximal PCA aneurysms. Compared to endovascular treatment, direct visual control of brainstem perforators is possible.

Left atrial remodeling in patients undergoing percutaneous mitral valve repair with the MitraClip system: an advanced echocardiography study.

PubMed

Toprak, Cuneyt; Kahveci, Gokhan; Kilicgedik, Alev; Pala, Selcuk; Kirma, Cevat; Tabakci, Mehmet Mustafa; Inanir, Mehmet; Esen, Ali Metin

2016-10-01

The goal of this study was to determine changes in left atrial (LA) function with two-dimensional speckle tracking echocardiography (2DSTE) and real-time full-volume three-dimensional echocardiography (RT3DE) after percutaneous mitral valve repair with the MitraClip system. Furthermore, we investigated whether baseline and/or changes in LA function after MitraClip repair had any impact on prognosis. A total of 25 consecutive patients (age: 57±12 years, 76% male) with moderate-to-severe or severe mitral regurgitation (MR) were included. Patients underwent 2DSTE and RT3DE before the clip implantation and after the 12-month follow-up. Prognostic data were also recorded via the use of telephone calls and follow-up visits for 12 months after the procedure. Compared with the baseline, the LA reservoir strain (LA-Res) (7.66±4.3% vs 11.15±7.5%, P<.001) and LA contraction strain (LA-Pump) (4.64±4.3% vs 7.63±5.8%, P=.001) improved significantly after MitraClip repair; significant improvements were also seen in three-dimensional (3D) minimum LA volume index (LAV min) and maximum LA volume index (LAV max). On the other hand, conventional LA indices did not change. In total, eleven major adverse cardiac events (MACE) were observed at the 1-year follow-up. In univariate analyses, the preprocedural echocardiographic parameters that were associated with the MACE within 1 year after MitraClip repair were 3D-LAV min and LA-Res. Furthermore, these indices significantly correlated with improved functional parameters and MR reduction. In conclusion, a successful MitraClip procedure can reverse the process of LA remodeling within 12 months, and this can be detected by 2DSTE and RT3DE. Also, patients with preprocedural lower LA-Res and higher 3D-LAV min had the worst prognoses at the 1-year follow-up. © 2016, Wiley Periodicals, Inc.

Median Supraorbital Keyhole Approach for Clipping Ruptured Distal Anterior Cerebral Artery Aneurysm: Technical Report with Review of Literature.

PubMed

Dhandapani, Sivashanmugam; Sahoo, Sushant Kumar

2018-04-01

The minimally invasive approach to distal anterior cerebral artery (DACA) aneurysms has not gained much acceptance due to difficulties associated with the conventional frontal paramedian approach. The more proximal basal interhemispheric approach, however, necessitates extensive dissection of soft tissues. We describe a novel minimally invasive median supraorbital keyhole craniotomy with a basal interhemispheric approach for clipping a ruptured DACA aneurysm. A 62-year-old patient presented with subarachnoid hemorrhage. Computed tomography angiography revealed a DACA aneurysm. The surgical technique involved a keyhole craniotomy made via an eyebrow incision extending between the supraorbital notches, and flush with the anterior cranial fossa. The dura was opened at the anterior part, the falx was cut, an interhemispheric dissection was carried out, adequate proximal control was obtained, and the aneurysm neck was dissected and clipped. A relevant review of the literature was carried out. The patient recovered well, with no residual aneurysm or forehead numbness, with good cosmesis. Compared with the previously described "keyhole unilateral interhemispheric" approaches, our technique has less likelihood of encountering bridging veins; easier cisternal cerebrospinal fluid release, making it feasible even in swollen brain; better proximal vascular control; and trajectory toward the neck rather than dome. The median supraorbital keyhole approach is a minimally invasive technique sufficient for clipping most DACA aneurysms, with easier access, better proximal control, and good cosmesis. Copyright © 2018 Elsevier Inc. All rights reserved.

Stability of the prosthetic screws of three types of craniofacial prostheses retention systems

PubMed Central

2016-01-01

Objectives This study aimed to evaluate the stability of prosthetic screws from three types of craniofacial prostheses retention systems (bar-clip, ball/O-ring, and magnet) when submitted to mechanical cycling. Materials and Methods Twelve models of acrylic resin were used with implants placed 20 mm from each other and separated into three groups: (1) bar-clip (Sistema INP, São Paulo, Brazil), (2) ball/O-ring (Sistema INP), and (3) magnet (Metalmag, São Paulo, Brazil), with four samples in each group. Each sample underwent a mechanical cycling removal and insertion test (f=0.5 Hz) to determine the torque and the detorque values of the retention screws. A servo-hydraulic MTS machine (810-Flextest 40; MTS Systems, Eden Prairie, MN, USA) was used to perform the cycling with 2.5 mm and a displacement of 10 mm/s. The screws of the retention systems received an initial torque of 30 Ncm and the torque values required for loosening the screw values were obtained in three cycles (1,080, 2,160, and 3,240). The screws were retorqued to 30 Ncm before each new cycle. Results The sample was composed of 24 screws grouped as follows: bar-clip (n=8), ball/O-ring (n=8), and magnet (n=8). There were significant differences between the groups, with greater detorque values observed in the ball/O-ring group when compared to the bar-clip and magnet groups for the first cycle. However, the detorque value was greater in the bar-clip group for the second cycle. Conclusion The results of this study indicate that all prosthetic screws will loosen slightly after an initial tightening torque, also the bar-clip retention system demonstrated greater loosening of the screws when compared with ball/O-ring and magnet retention systems. PMID:28053905

Extended use of percutaneous edge-to-edge mitral valve repair beyond EVEREST (Endovascular Valve Edge-to-Edge Repair) criteria: 30-day and 12-month clinical and echocardiographic outcomes from the GRASP (Getting Reduction of Mitral Insufficiency by Percutaneous Clip Implantation) registry.

PubMed

Attizzani, Guilherme F; Ohno, Yohei; Capodanno, Davide; Cannata, Stefano; Dipasqua, Fabio; Immé, Sebastiano; Mangiafico, Sarah; Barbanti, Marco; Ministeri, Margherita; Cageggi, Anna; Pistritto, Anna Maria; Giaquinta, Sandra; Farruggio, Silvia; Chiarandà, Marta; Ronsivalle, Giuseppe; Schnell, Audrey; Scandura, Salvatore; Tamburino, Corrado; Capranzano, Piera; Grasso, Carmelo

2015-01-01

This study sought to compare, in high-risk patients with 3+ to 4+ mitral regurgitation (MR) dichotomized by baseline echocardiographic features, acute, 30-day, and 12-month outcomes following percutaneous mitral valve repair using the MitraClip. The feasibility and mid-term outcomes after MitraClip implantation in patients with echocardiographic features different from the EVEREST (Endovascular Valve Edge-to-Edge Repair) I and II trials have been scarcely studied. Clinical and echocardiographic outcomes through 12-month follow-up of consecutive patients who underwent MitraClip implantation were obtained from an ongoing prospective registry. Two different groups, divided according to baseline echocardiographic criteria (investigational group [EVERESTOFF] and control group [EVERESTON]), were compared. Seventy-eight patients were included in EVERESTOFF and 93 patients in EVERESTON groups. Important and comparable acute reductions in MR and no clip-related complications were revealed. The primary safety endpoint at 30 days was comparable between groups (2.6% vs. 6.5%, respectively, p = 0.204); in addition, MR reduction was mostly sustained, whereas equivalent improvement in New York Heart Association functional class were demonstrated. Kaplan-Meier freedom from death, surgery for mitral valve dysfunction, or grade ≥3+ MR at 12 months was demonstrated in 71.4% and 76.2%, respectively, in the EVERESTOFF and EVERESTON groups (log rank p = 0.378). Significant improvements in ejection fraction and reduction in left ventricle volumes were demonstrated in both groups over time, but the baseline between-group differences were sustained. MitraClip implantation in patients with expanded baseline echocardiographic features, compared with the control group, was associated with similar rates of safety and efficacy through 12-month follow-up. Further validation of our findings is warranted. Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Dual-Image Videoangiography During Intracranial Microvascular Surgery.

PubMed

Feletti, Alberto; Wang, Xiangdong; Tanaka, Riki; Yamada, Yasuhiro; Suyama, Daisuke; Kawase, Tsukasa; Sano, Hirotoshi; Kato, Yoko

2017-03-01

Indocyanine green videoangiography (ICG-VA) is a valuable tool to assess vessel and aneurysm patency during neurovascular surgical procedures. However, ICG-VA highlights vascular structures, which appear white over a black background. Anatomic relationships are sometimes difficult to understand at first glance. Dual-image videoangiography (DIVA) enables simultaneous visualization of light and near-infrared fluorescence images of ICG-VA. The DIVA system was mounted on an OPMI Pentero Flow 800 intraoperative microscope. DIVA was used during microsurgical procedures on 5 patients who were operated for aneurysm clipping and superficial temporal artery-middle cerebral artery bypass. DIVA provides real-time simultaneous visualization of aneurysm and vessels and surrounding structures including brain, nerves, and surgical clips. Although visual contrast between vessels and background is higher with standard black-and-white imaging, DIVA makes it easier to understand anatomic relationships between intracranial structures. DIVA also provides better vision of the depth of field. DIVA has the potential to become a widely used intraoperative tool to check patency of intracranial vessels. It should be considered as an adjunct to standard ICG-VA for better understanding of vascular anatomy in relation to surrounding structures and can have an impact on decision making during surgery. Copyright © 2016 Elsevier Inc. All rights reserved.

Robotic digital subtraction angiography systems within the hybrid operating room.

PubMed

Murayama, Yuichi; Irie, Koreaki; Saguchi, Takayuki; Ishibashi, Toshihiro; Ebara, Masaki; Nagashima, Hiroyasu; Isoshima, Akira; Arakawa, Hideki; Takao, Hiroyuki; Ohashi, Hiroki; Joki, Tatsuhiro; Kato, Masataka; Tani, Satoshi; Ikeuchi, Satoshi; Abe, Toshiaki

2011-05-01

Fully equipped high-end digital subtraction angiography (DSA) within the operating room (OR) environment has emerged as a new trend in the fields of neurosurgery and vascular surgery. To describe initial clinical experience with a robotic DSA system in the hybrid OR. A newly designed robotic DSA system (Artis zeego; Siemens AG, Forchheim, Germany) was installed in the hybrid OR. The system consists of a multiaxis robotic C arm and surgical OR table. In addition to conventional neuroendovascular procedures, the system was used as an intraoperative imaging tool for various neurosurgical procedures such as aneurysm clipping and spine instrumentation. Five hundred one neurosurgical procedures were successfully conducted in the hybrid OR with the robotic DSA. During surgical procedures such as aneurysm clipping and arteriovenous fistula treatment, intraoperative 2-/3-dimensional angiography and C-arm-based computed tomographic images (DynaCT) were easily performed without moving the OR table. Newly developed virtual navigation software (syngo iGuide; Siemens AG) can be used in frameless navigation and in access to deep-seated intracranial lesions or needle placement. This newly developed robotic DSA system provides safe and precise treatment in the fields of endovascular treatment and neurosurgery.

Augmented reality in the surgery of cerebral aneurysms: a technical report.

PubMed

Cabrilo, Ivan; Bijlenga, Philippe; Schaller, Karl

2014-06-01

Augmented reality is the overlay of computer-generated images on real-world structures. It has previously been used for image guidance during surgical procedures, but it has never been used in the surgery of cerebral aneurysms. To report our experience of cerebral aneurysm surgery aided by augmented reality. Twenty-eight patients with 39 unruptured aneurysms were operated on in a prospective manner with augmented reality. Preoperative 3-dimensional image data sets (angio-magnetic resonance imaging, angio-computed tomography, and 3-dimensional digital subtraction angiography) were used to create virtual segmentations of patients' vessels, aneurysms, aneurysm necks, skulls, and heads. These images were injected intraoperatively into the eyepiece of the operating microscope. An example case of an unruptured posterior communicating artery aneurysm clipping is illustrated in a video. The described operating procedure allowed continuous monitoring of the accuracy of patient registration with neuronavigation data and assisted in the performance of tailored surgical approaches and optimal clipping with minimized exposition. Augmented reality may add to the performance of a minimally invasive approach, although further studies need to be performed to evaluate whether certain groups of aneurysms are more likely to benefit from it. Further technological development is required to improve its user friendliness.

Gemstone spectral imaging reduced artefacts from metal coils or clips after treatment of cerebral aneurysms: a retrospective study of 35 patients.

PubMed

Jia, Yulin; Zhang, Jinling; Fan, Jinyu; Li, Chao; Sun, Yuanyuan; Li, Di; Xiao, Xigang

2015-01-01

This study aimed to evaluate the effect of gemstone spectral imaging (GSI) for metal artefact reduction in cerebral artery CT angiography (CTA) after metal coils or clips treatment. 35 patients with cerebral aneurysms were treated with metal coils or clips and underwent CTA using gemstone spectral CT between February and December 2013. The data were reconstructed into three image groups including Group A (quality check images with 140 kVp), Group B (monochromatic image sets in the range of 40-140 keV) and Group C [monochromatic image sets with metal artefacts reduction software (MARS GE Medical Systems, Waukesha, WI)]. CT attenuation value of cerebral artery, contrast-to-noise ratio (CNR), signal-to-noise ratio (SNR) and the subjective score of all images were measured and compared statistically. CT attenuation value of cerebral artery decreased in Groups B and C as the photon energy increased. The average energy levels of 60.05 ± 5.37 and 59.93 ± 5.57 keV presented the best CNR in Groups B and C, respectively. CNR values, SNR values and the subjective scores of the image quality of the two sets were higher than those of Group A. GSI reduced metal artefact and improved the image quality of CTA after metal coils or clips treatment in patients with cerebral aneurysm. The monochromatic images at the average energy level of 60.05 ± 5.37 keV with MARS and 59.93 ± 5.57 keV without MARS were suggested to be the optimal parameters. GSI could reduce metal artefact after metal coils or clips treatment in patients with cerebral aneurysm.

A Critical Analysis of the Utility of Intraoperative Angiography.

PubMed

Ares, William J; Kenmuir, Cynthia L; Panczykowski, David M; Weiner, Gregory M; Jadhav, Ashu P; Jovin, Tudor G; Gross, Bradley A; Jankowitz, Brian T

2018-02-01

Intraoperative digital subtraction angiography (ioDSA) is touted as the gold standard imaging evaluation for aneurysm clip constructs. Candid evaluations of its limitations are sparse. A prospectively collected hospital billing database was queried to identify craniotomies for aneurysm clipping from January 2010 to December 2013. We evaluated the rate of occult residual and parent vessel stenosis determined on follow-up angiography for patients undergoing ioDSA and those not undergoing ioDSA. Comparisons were performed via Fisher exact test, with P < 0.05 considered statistically significant. From our database search, we found 187 patients who underwent ioDSA after aneurysm clipping and an additional 91 patients who did not. Results from ioDSA influenced operative management in 17% of cases. Sixty-four patients with 70 treated aneurysms undergoing ioDSA had postoperative angiography; 7 occult residuals were discovered, yielding a 10% false-negative rate, with 10% of aneurysms showing residual. Occult residuals at the middle cerebral artery bifurcation represented most discovered residuals (6/7). Thirty-two patients with 37 treated aneurysms did not undergo ioDSA and had angiographic follow-up; 24% of patients were found to have residual aneurysms (P = 0.08 compared with patients undergoing ioDSA). Residuals at the anterior communicating artery (ACoA) represented 56% of all residuals, whereas the ACoA represented only 18% of aneurysms clipped. The rate of residuals was significantly higher than that for patients with clipped ACoA aneurysms undergoing ioDSA (P = 0.008). ioDSA influenced management in nearly one fifth of cases. It can be particularly beneficial in detecting residuals for ACoA aneurysms; its benefit was less apparent for middle cerebral artery aneurysms. Copyright © 2017 Elsevier Inc. All rights reserved.

Late diagnosis and surgical treatment of patients diagnosed with unilateral congenital cataract at Fundación Visión, in Asuncion, Paraguay.

PubMed

Zegarra, Manuel; Burga, Gisella Harumi; Lansingh, Van; Samudio, Margarita; Duarte, Edgar; Ferreira, Rocio; Dorantes, Yesenia; Ginés, Juan Carlos; Zepeda, Luz

2014-10-01

Purpose: Providing data on the late diagnosis and surgical treatment of patients who underwent surgery for total unilateral congenital cataract. Methods: Systematic retrospective review of the medical record of all patients between 0 and 16 years old with total unilateral congenital cataract who underwent surgery at Fundación Vision between January 2010 and July 2012. Results: Medical records of 37 patients (51 % females) were studied, age was 7.4 (± 4.9) years (average ± SD) and 62% lived on Departamento Central (the most populated region from Paraguay). A total of 97.3% patients underwent late surgical treatment and 86.5% received a late diagnosis. The average time elapsed between the diagnosis and the surgical treatment was one month, and 62.2% of the patients underwent surgery within six months from the diagnosis. Conclusion: This study evidences that most of the patients in our series had a late treatment as a result of a late diagnosis. Based on these results we recommend establishing strategies to improve the early detection and surgical treatment of the newborns.

Surgical management of esophageal achalasia: Evolution of an institutional approach to minimally invasive repair.

PubMed

Petrosyan, Mikael; Khalafallah, Adham M; Guzzetta, Phillip C; Sandler, Anthony D; Darbari, Anil; Kane, Timothy D

2016-10-01

Surgical management of esophageal achalasia (EA) in children has transitioned over the past 2 decades to predominantly involve laparoscopic Heller myotomy (LHM) or minimally invasive surgery (MIS). More recently, peroral endoscopic myotomy (POEM) has been utilized to treat achalasia in children. Since the overall experience with surgical management of EA is contingent upon disease incidence and surgeon experience, the aim of this study is to report a single institutional contemporary experience for outcomes of surgical treatment of EA by LHM and POEM, with regards to other comparable series in children. An IRB approved retrospective review of all patients with EA who underwent treatment by a surgical approach at a tertiary US children's hospital from 2006 to 2015. Data including demographics, operative approach, Eckardt scores pre- and postoperatively, complications, outcomes, and follow-up were analyzed. A total of 33 patients underwent 35 operative procedures to treat achalasia. Of these operations; 25 patients underwent laparoscopic Heller myotomy (LHM) with Dor fundoplication; 4 patients underwent LHM alone; 2 patients underwent LHM with Thal fundoplication; 2 patients underwent primary POEM; 2 patients who had had LHM with Dor fundoplication underwent redo LHM with takedown of Dor fundoplication. Intraoperative complications included 2 mucosal perforations (6%), 1 aspiration, 1 pneumothorax (1 POEM patient). Follow ranged from 8months to 7years (8-84months). There were no deaths and no conversions to open operations. Five patients required intervention after surgical treatment of achalasia for recurrent dysphagia including 3 who underwent between 1 and 3 pneumatic dilations; and 2 who had redo LHM with takedown of Dor fundoplication with all patients achieving complete resolution of symptoms. Esophageal achalasia in children occurs at a much lower incidence than in adults as documented by published series describing the surgical treatment in children. We believe the MIS surgical approach remains the standard of care for this condition in children and describe the surgical outcomes and complications for LHM, as well as, the introduction of the POEM technique in our center for treating achalasia. Our institutional experience described herein represents the largest in the "MIS era" with excellent results. We will refer to alterations in our practice that have included the use of flexible endoscopy in 100% of LHM cases and use of the endoscopic functional lumen imaging probe (EndoFLIP) in both LHM and POEM cases which we believe enables adequate Heller myotomy. Copyright © 2016 Elsevier Inc. All rights reserved.

Duodenal endoscopic full-thickness resection (with video).

PubMed

Schmidt, Arthur; Meier, Benjamin; Cahyadi, Oscar; Caca, Karel

2015-10-01

Endoscopic resection of duodenal non-lifting adenomas and subepithelial tumors is challenging and harbors a significant risk of adverse events. We report on a novel technique for duodenal endoscopic full-thickness resection (EFTR) by using an over-the-scope device. Data of 4 consecutive patients who underwent duodenal EFTR were analyzed retrospectively. Main outcome measures were technical success, R0 resection, histologic confirmation of full-thickness resection, and adverse events. Resections were done with a novel, over-the-scope device (full-thickness resection device, FTRD). Four patients (median age 60 years) with non-lifting adenomas (2 patients) or subepithelial tumors (2 patients) underwent EFTR in the duodenum. All lesions could be resected successfully. Mean procedure time was 67.5 minutes (range 50-85 minutes). Minor bleeding was observed in 2 cases; blood transfusions were not required. There was no immediate or delayed perforation. Mean diameter of the resection specimen was 28.3 mm (range 22-40 mm). Histology confirmed complete (R0) full-thickness resection in 3 of 4 cases. To date, 2-month endoscopic follow-up has been obtained in 3 patients. In all cases, the over-the-scope clip was still in place and could be removed without adverse events; recurrences were not observed. EFTR in the duodenum with the FTRD is a promising technique that has the potential to spare surgical resections. Modifications of the device should be made to facilitate introduction by mouth. Prospective studies are needed to further evaluate efficacy and safety for duodenal resections. Copyright © 2015 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.

The influence of the different forms of appendix base closure on patient outcome in laparoscopic appendectomy: a randomized trial.

PubMed

Delibegović, Samir; Mehmedovic, Zlatan

2018-05-01

During laparoscopic appendectomy, the base of the appendix is usually secured by loop ligature or stapling device. Hem-o-lok and DS clips have been shown as alternative techniques. The aim of this study was to compare the clinical outcomes of various forms of securing the base of the appendix, in order to find the most suitable method. The study included 120 patients with acute appendicitis randomly divided into four groups with 30 patients in each. In the first group, the base of the appendix was secured using an Endoloop, in the second group using a stapling device, in the third group using Hem-o-lok, and in the fourth group using a DS clip. The primary outcome was overall morbidity following securing the base of the appendix. Secondary outcomes were time of application and operative procedure, total length of stay, and surgical outcome. No morbidity was recorded in any group. The time of application was significantly longer in the Endoloop group than in the Stapler (P < 0.0001), Hem-o-lok (P < 0.0001), and DS clips (P < 0.0001) groups. The time of application in the Stapler group was significantly shorter than in the Hem-o-lok (P < 0.0001) and the DS clips (P < 0.0001) groups. The time of the operative procedure was significantly longer in the Endoloop than in the Stapler group (P < 0.0001). The time of the operative procedure in the Stapler group was significantly shorter than in the DS clips group (P < 0.0001) but did not differ significantly from the Hem-o-lok group (P = 0.199). The time of the operative procedure in the Hem-o-lok group was significantly shorter than in the DS clips group (P = 0.044). All forms of closure of the appendix base are acceptable, but Hem-o-lok and DS clips have the best potential for further development, and will probably become the method of choice in securing the base of the appendix.

Mitral Valve Clip for Treatment of Mitral Regurgitation: An Evidence-Based Analysis

PubMed Central

Ansari, Mohammed T.; Ahmadzai, Nadera; Coyle, Kathryn; Coyle, Doug; Moher, David

2015-01-01

Background Many of the 500,000 North American patients with chronic mitral regurgitation may be poor candidates for mitral valve surgery. Objective The objective of this study was to investigate the comparative effectiveness, harms, and cost-effectiveness of percutaneous mitral valve repair using mitral valve clips in candidates at prohibitive risk for surgery. Data Sources We searched articles in MEDLINE, Embase, and the Cochrane Library published from 1994 to February 2014 for evidence of effectiveness and harms; for economic literature we also searched NHS EED and Tufts CEA registry. Grey literature was also searched. Review Methods Primary studies were sought from existing systematic reviews that had employed reliable search and screening methods. Newer studies were sought by searching the period subsequent to the last search date of the review. Two reviewers screened records and assessed study validity. We used the Cochrane risk of bias tool for randomized, generic assessment for non-randomized studies, and the Phillips checklist for economic studies. Results Ten studies including 1 randomized trial were included. The majority of the direct comparative evidence compared the mitral valve clip repair with surgery in patients not particularly at prohibitive surgical risk. Irrespective of degenerative or functional chronic mitral regurgitation etiology, evidence of effectiveness and harms is inconclusive and of very low quality. Very-low-quality evidence indicates that percutaneous mitral valve clip repair may provide a survival advantage, at least during the first 1 to 2 years, particularly in medically managed chronic functional mitral regurgitation. Because of limitations in the design of studies, the cost-effectiveness of mitral valve clips in patients at prohibitive risk for surgery also could not be established. Limitations Because of serious concerns of risk of bias, indirectness, and imprecision, evidence is of very low quality. Conclusions No meaningful conclusions can be drawn about the comparative effectiveness, harms, and cost-effectiveness of mitral valve clips in the population with chronic mitral regurgitation who are at prohibitive risk for surgery. PMID:26379810

High-intensity focused ultrasound (HIFU)-assisted hepatic resection in an animal model.

PubMed

Gandini, Alessandro; Melodelima, David; Schenone, Francesco; N'Djin, Apoutou William; Chapelon, Jean Yves; Rivoire, Michel

2012-07-01

Bleeding is the main cause of postoperative complications of hepatic surgery. To minimize intraoperative bleeding during hepatectomy, resections are generally carried out under hepatic vascular control despite the risk of liver dysfunction in patients with chronic liver disease. This study evaluates the feasibility and safety of high-intensity focused ultrasound (HIFU)-assisted hepatic resection during an open procedure in an animal model. Three groups of 12-14-week-old Landrace pigs (n = 7/group) were used to evaluate HIFU-assisted liver resection (group A) vs liver resection with or without portal triad clamping (groups B and C). In each pig, liver resection was performed on the right and left paramedian lobes. The following were evaluated and compared in the 3 groups: total blood loss, blood loss/cm(2) of resection area, clip density, procedure duration, morbidity, and mortality. Median blood loss was significantly lower in group A than in group B (P = .02), and group C (P = .007). Median blood loss/cm(2) of resection area was 4.77 mL/cm² in group A, 11.35 mL/cm² in group B, 12.22 mL/cm² in Group C. Precoagulation resulted in sealing blood vessels <5 mm; therefore, median clip density during liver transection was 0.78 clip/cm² in group A, 1.61 clip/cm(2) in group B, and 1.57 clip/cm(2) in group C. Median duration of the surgical procedure was 12 min in group A, 21 min in group B, and 19 min in group C. HIFU-assisted hepatic resection during an open procedure in an animal model is safe, reduces bleeding, and allows real-time ultrasound guidance.

Surgical treatment of liver metastasis of gastric cancer: a retrospective multicenter cohort study (KSCC1302).

PubMed

Oki, Eiji; Tokunaga, Shoji; Emi, Yasunori; Kusumoto, Tetsuya; Yamamoto, Manabu; Fukuzawa, Kengo; Takahashi, Ikuo; Ishigami, Sumiya; Tsuji, Akihito; Higashi, Hidefumi; Nakamura, Toshihiko; Saeki, Hiroshi; Shirabe, Ken; Kakeji, Yoshihiro; Sakai, Kenji; Baba, Hideo; Nishimaki, Tadashi; Natsugoe, Shoji; Maehara, Yoshihiko

2016-07-01

The necessity of surgical treatment of liver metastases of gastric cancer is still controversial. We conducted a multicenter retrospective cohort study of liver-limited metastasis of gastric cancer treated surgically between 2000 and 2010. In this study, 103 patients were registered, with nine patients excluded from the analysis as they did not meet the eligibility criteria. Of the 94 patients, 69 underwent surgical resection, 11 underwent surgical resection combined with radiofrequency ablation or microwave coagulation therapy for small or deep tumors, and 14 underwent radiofrequency ablation or microwave coagulation therapy only. Synchronous and metachronous metastases were found in 37 and 57 patients, respectively. The 3- and 5-year overall survival rates of all the patients were 51.4 and 42.3 %, respectively. The 3- and 5-year relapse-free survival rates were 29.2 and 27.7 %, respectively. No significant difference in prognosis was observed between the patients who underwent surgical resection and those who underwent ablation therapy. The patients with hepatic solitary lesions and low-grade lymph node metastases of primary gastric cancer had significantly better overall survival and relapse-free survival. To our knowledge, this study is the largest series and first multicenter cohort study of liver-limited metastasis of gastric cancer. The study indicated that patients with a single liver metastasis with a grade lower than N2 lymph node metastasis of the primary lesion are the best candidates for liver resection.

[Virtual surgical education: experience with medicine and surgery students].

PubMed

Bonavina, Luigi; Mozzi, Enrico; Peracchia, Alberto

2003-01-01

The use of virtual reality simulation is currently being proposed within programs of postgraduate surgical education. The simple tasks that make up an operative procedure can be repeatedly performed until satisfactory execution is achieved, and the errors can be corrected by means of objective assessment. The aim of this study was to evaluate the applicability and the results of structured practice with the LapSim laparoscopic simulator used by undergraduate medical students. A significant reduction in operative time and errors was noted in several tasks (navigation, clipping, etc.). Although the transfer of technical skills to the operating room environment remains to be demonstrated, our research shows that this type of teaching is applicable to undergraduate medical students and in future may become a useful tool for selecting individuals for surgical residency programs.

Lateral supraorbital approach to ipsilateral PCA-P1 and ICA-PCoA aneurysms

PubMed Central

Goehre, Felix; Jahromi, Behnam Rezai; Elsharkawy, Ahmed; Lehto, Hanna; Shekhtman, Oleg; Andrade-Barazarte, Hugo; Munoz, Francisco; Hijazy, Ferzat; Makhkamov, Makhkam; Hernesniemi, Juha

2015-01-01

Background: Aneurysms of the posterior cerebral artery (PCA) are rare and often associated with anterior circulation aneurysms. The lateral supraorbital approach allows for a very fast and safe approach to the ipsilateral lesions Circle of Willis. A technical note on the successful clip occlusion of two aneurysms in the anterior and posterior Circle of Willis via this less invasive approach has not been published before. The objective of this technical note is to describe the simultaneous microsurgical clip occlusion of an ipsilateral PCA-P1 and an internal carotid artery - posterior communicating artery (ICA-PCoA) aneurysm via the lateral supraorbital approach. Case Description: The authors present a technical report of successful clip occlusions of ipsilateral located PCA-P1 and ICA-PCoA aneurysms. A 59-year-old female patient was diagnosed with a PCA-P1 and an ipsilateral ICA-PCoA aneurysm by computed tomography angiography (CTA) after an ischemic stroke secondary to a contralateral ICA dissection. The patient underwent microsurgical clipping after a lateral supraorbital craniotomy. The intraoperative indocyanine green (ICG) videoangiography and the postoperative CTA showed a complete occlusion of both aneurysms; the parent vessels (ICA and PCA) were patent. The patient presents postoperative no new neurologic deficit. Conclusion: The lateral supraorbital approach is suitable for the simultaneous microsurgical treatment of proximal anterior circulation and ipsilateral proximal PCA aneurysms. Compared to endovascular treatment, direct visual control of brainstem perforators is possible. PMID:26060600

Parent artery occlusion for ruptured “true” posterior communicating artery aneurysm

PubMed Central

Takeda, Nobuaki; Oishi, Hidenori; Arai, Hajime

2015-01-01

A case of a patient with a ruptured true posterior communicating artery (PCoA) aneurysm is reported, who had been managed by early endovascular parent artery occlusion with coils. The small blister aneurysm was located at the proximal PCoA itself and directed superiorly. Postoperative course was uneventful. During 1-month follow-up, the patient recovered well and could care for herself. Aneurysms of the PCoA itself are very rare. As reported to date, surgical procedures would favor microsurgical clipping over endovascular coil embolization. Endovascular treatment may be a good alternative to surgical trapping for true PCoA blister aneurysm. PMID:25953771

Impact of routine cerebral CT angiography on treatment decisions in infective endocarditis.

PubMed

Meshaal, Marwa Sayed; Kassem, Hussein Heshmat; Samir, Ahmad; Zakaria, Ayman; Baghdady, Yasser; Rizk, Hussein Hassan

2015-01-01

Infective endocarditis (IE) is commonly complicated by cerebral embolization and hemorrhage secondary to intracranial mycotic aneurysms (ICMAs). These complications are associated with poor outcome and may require diagnostic and therapeutic plans to be modified. However, routine screening by brain CT and CT angiography (CTA) is not standard practice. We aimed to study the impact of routine cerebral CTA on treatment decisions for patients with IE. From July 2007 to December 2012, we prospectively recruited 81 consecutive patients with definite left-sided IE according to modified Duke's criteria. All patients had routine brain CTA conducted within one week of admission. All patients with ICMA underwent four-vessel conventional angiography. Invasive treatment was performed for ruptured aneurysms, aneurysms ≥ 5 mm, and persistent aneurysms despite appropriate therapy. Surgical clipping was performed for leaking aneurysms if not amenable to intervention. The mean age was 30.43 ± 8.8 years and 60.5% were males. Staph aureus was the most common organism (32.3%). Among the patients, 37% had underlying rheumatic heart disease, 26% had prosthetic valves, 23.5% developed IE on top of a structurally normal heart and 8.6% had underlying congenital heart disease. Brain CT/CTA revealed that 51 patients had evidence of cerebral embolization, of them 17 were clinically silent. Twenty-six patients (32%) had ICMA, of whom 15 were clinically silent. Among the patients with ICMAs, 11 underwent endovascular treatment and 2 underwent neurovascular surgery. The brain CTA findings prompted different treatment choices in 21 patients (25.6%). The choices were aneurysm treatment before cardiac surgery rather than at follow-up, valve replacement by biological valve instead of mechanical valve, and withholding anticoagulation in patients with prosthetic valve endocarditis for fear of aneurysm rupture. Routine brain CT/CTA resulted in changes in the treatment plan in a significant proportion of patients with IE, even those without clinically evident neurological disease. Routine brain CT/CTA may be indicated in all hospitalized patients with IE.

Awake craniotomy for microsurgical obliteration of mycotic aneurysms: technical report of three cases.

PubMed

Lüders, Jürgen C; Steinmetz, Michael P; Mayberg, Marc R

2005-01-01

Infectious (mycotic) aneurysms that do not resolve with medical treatment require surgical obliteration, usually requiring sacrifice of the parent artery. In addition, patients with mycotic aneurysms frequently need subsequent cardiac valve repair, which often necessitates anticoagulation. Three cases of awake craniotomy for microsurgical clipping of mycotic aneurysms are presented. Awake minimally invasive craniotomy using frameless stereotactic guidance on the basis of computed tomographic angiography enables temporary occlusion of the parent artery with neurological assessment before obliteration of the aneurysm. A 56-year-old woman presented with progressively worsening mitral valve disease and a history of subacute bacterial endocarditis and subarachnoid hemorrhage 30 years previously. A cerebral angiogram revealed a 4-mm left middle cerebral artery (MCA) angular branch aneurysm, which required obliteration before mitral valve replacement. The second patient, a 64-year-old woman with a history of rheumatic fever, had an 8-mm right distal MCA aneurysm diagnosed in the setting of pulmonary abscess and worsening cardiac function as a result of mitral valve disease. The third patient, a 57-year-old man with a history of fevers, night sweats, and progressive mitral valve disease, had an enlarging left MCA angular branch aneurysm despite the administration of antibiotics. Because of their location on distal MCA branches, none of the aneurysms were amenable to preoperative test balloon occlusion. After undergoing stereotactic computed tomographic angiography with fiducial markers, the patients underwent a minimally invasive awake craniotomy with frameless stereotactic navigation. In all cases, the results of the neurological examination were unchanged during temporary parent artery occlusion and the aneurysms were successfully obliterated. Awake minimally invasive craniotomy for an infectious aneurysm located in eloquent brain enables awake testing before permanent clipping or vessel sacrifice. Combining frameless stereotactic navigation with computed tomographic angiography allowed us to perform the operation quickly through a small craniotomy with minimal exploration.

Laparoscopy vs robotics in surgical management of endometrial cancer: comparison of intraoperative and postoperative complications.

PubMed

Seror, Julien; Bats, Anne-Sophie; Huchon, Cyrille; Bensaïd, Chérazade; Douay-Hauser, Nathalie; Lécuru, Fabrice

2014-01-01

To compare the rates of intraoperative and postoperative complications of robotic surgery and laparoscopy in the surgical treatment of endometrial cancer. Unicentric retrospective study (Canadian Task Force classification II-2). Tertiary teaching hospital. The study was performed from January 2002 to December 2011 and included patients with endometrial cancer who underwent laparoscopic or robotically assisted laparoscopic surgical treatment. Data collected included preoperative data, tumor characteristics, intraoperative data (route of surgery, surgical procedures, and complications), and postoperative data (early and late complications according to the Clavien-Dindo classification, and length of hospital stay). Morbidity was compared between the 2 groups. The study included 146 patients, of whom 106 underwent laparoscopy and 40 underwent robotically assisted surgery. The 2 groups were comparable in terms of demographic and preoperative data. Intraoperative complications occurred in 9.4% of patients who underwent laparoscopy and in none who underwent robotically assisted surgery (p = .06). There was no difference between the 2 groups in terms of postoperative events. Robotically assisted surgery is not associated with a significant difference in intraoperative and postoperative complications, even when there were no intraoperative complications of robotically assisted surgery. Copyright © 2014 AAGL. Published by Elsevier Inc. All rights reserved.

Evaluation of Breast Sentinel Lymph Node Coverage by Standard Radiation Therapy Fields

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

Rabinovitch, Rachel; Ballonoff, Ari; Newman, Francis M.S.

2008-04-01

Background: Biopsy of the breast sentinel lymph node (SLN) is now a standard staging procedure for early-stage invasive breast cancer. The anatomic location of the breast SLN and its relationship to standard radiation fields has not been described. Methods and Materials: A retrospective review of radiotherapy treatment planning data sets was performed in patients with breast cancer who had undergone SLN biopsy, and those with a surgical clip at the SLN biopsy site were identified. The location of the clip was evaluated relative to vertebral body level on an anterior-posterior digitally reconstructed radiograph, treated whole-breast tangential radiation fields, and standardmore » axillary fields in 106 data sets meeting these criteria. Results: The breast SLN varied in vertebral body level position, ranging from T2 to T7 but most commonly opposite T4. The SLN clip was located below the base of the clavicle in 90%, and hence would be excluded from standard axillary radiotherapy fields where the inferior border is placed at this level. The clip was within the irradiated whole-breast tangent fields in 78%, beneath the superior-posterior corner multileaf collimators in 12%, and outside the tangent field borders in 10%. Conclusions: Standard axillary fields do not encompass the lymph nodes at highest risk of containing tumor in breast cancer patients. Elimination of the superior-posterior corner MLCs from the tangent field design would result in inclusion of the breast SLN in 90% of patients treated with standard whole-breast irradiation.« less

Acute outcomes after MitraClip therapy in highly aged patients: results from the German TRAnscatheter Mitral valve Interventions (TRAMI) Registry.

PubMed

Schillinger, Wolfgang; Hünlich, Mark; Baldus, Stephan; Ouarrak, Taoufik; Boekstegers, Peter; Hink, Ulrich; Butter, Christian; Bekeredjian, Raffi; Plicht, Björn; Sievert, Horst; Schofer, Joachim; Senges, Jochen; Meinertz, Thomas; Hasenfuß, Gerd

2013-05-20

The influence of age on baseline demographics and outcomes of patients selected for MitraClip has not been previously investigated. Baseline demographics and acute outcomes in 1,064 patients from the German TRAMI registry were stratified by age (525 patients ≥76 years and 539 patients <76 years). In elderly patients, logistic EuroSCORE was higher (25[15-40]% vs. 18[10-31]%, p<0.0001) and the proportion of women was greater (47.2% vs. 29.3%, p<0.0001). Elderly patients were more likely to have preserved left ventricular ejection fraction >50% (40.1% vs. 21.8%, p<0.0001) and degenerative mitral regurgitation (DMR, 35.3% vs. 25.6%, p<0.01). Age was the most frequent reason for non-surgical treatment in the elderly (69.4% vs. 36.1%, p<0.0001). The intrahospital MACCE (death, myocardial infarction, stroke) was low in both groups (3.5% vs. 3.4%, p=0.93) and the proportion of non-severe mitral regurgitation at discharge was similar (95.8% vs. 96.4%, p=0.73). A logistic regression model did not reveal any significant impact of age on acute efficacy and safety of MitraClip therapy. In both groups, the majority of patients were discharged home (81.8% vs. 86.2%, p=0.06). Elderly and younger patients have similar benefits from MitraClip therapy. Age was the most frequent cause for denying surgery in elderly patients.

Antibiotic stewardship in the newborn surgical patient: A quality improvement project in the neonatal intensive care unit.

PubMed

Walker, Sarah; Datta, Ankur; Massoumi, Roxanne L; Gross, Erica R; Uhing, Michael; Arca, Marjorie J

2017-12-01

There is significant diversity in the utilization of antibiotics for neonates undergoing surgical procedures. Our institution standardized antibiotic administration for surgical neonates, in which no empiric antibiotics were given to infants with surgical conditions postnatally, and antibiotics are given no more than 72 hours perioperatively. We compared the time periods before and after implementation of antibiotic protocol in an institution review board-approved, retrospective review of neonates with congenital surgical conditions who underwent surgical correction within 30 days after birth. Surgical site infection at 30 days was the primary outcome, and development of hospital-acquired infections or multidrug-resistant organism were secondary outcomes. One hundred forty-eight infants underwent surgical procedures pre-protocol, and 127 underwent procedures post-protocol implementation. Surgical site infection rates were similar pre- and post-protocol, 14% and 9% respectively, (P = .21.) The incidence of hospital-acquired infections (13.7% vs 8.7%, P = .205) and multidrug-resistant organism (4.7% vs 1.6%, P = .143) was similar between the 2 periods. Elimination of empiric postnatal antibiotics did not statistically change rates of surgical site infection, hospital-acquired infections, or multidrug-resistant organisms. Limiting the duration of perioperative antibiotic prophylaxis to no more than 72 hours after surgery did not increase the rate of surgical site infection, hospital-acquired infections, or multidrug-resistant organism. Median antibiotic days were decreased with antibiotic standardization for surgical neonates. Copyright © 2017 Elsevier Inc. All rights reserved.

Rehabilitation after Clipping of Cerebral Aneurysms without Acute Subarachnoid Hemorrhage: Outcome Analysis of 100 Consecutive Cases.

PubMed

Jödicke, Andreas; Bauer, Karsten; Hajdukova, Andrea

2018-06-11

 Discharge to rehabilitation is reported in large studies as one important outcome parameter based on hospital codes. Because neurologic outcome scores (e.g., the modified Rankin Scale [mRS]) are missing in International Classification of Diseases (ICD) databases, rehabilitation indirectly serves as a kind of surrogate parameter for overall outcome. Reported fractions of patients with rehabilitation, however, largely differ between studies and seem high for patients with aneurysm clipping. Variances in rehabilitation fractions seem to largely differ between treatments (clipping versus coiling) for unruptured intracranial aneurysms, so we analyzed our patients for percentage of and potential factors predicting rehabilitation.  From July 2007 to September 2013, 100 consecutive patients with at least one cerebral aneurysm underwent aneurysm clipping. Aneurysms were classified as incidental, associated, pretreated (coil compaction after subarachnoid hemorrhage), and symptomatic (oculomotor nerve compression, microemboli), and they were assigned to their anatomical location. Complications (infection, hemorrhage, cerebrospinal fluid fistula, transient and permanent neurologic deficit, reoperation) and outcome (mRS at 6 months; clip occlusion rate by postoperative digital subtraction angiography) as well as frequency and type of rehabilitation were analyzed and correlated retrospectively. Multiple aneurysms clipped in one procedure were not counted separately regarding complications or outcome (i.e., one patient, one outcome).  The overall complication rate was 17% including 10% early and 3% permanent neurologic deficits and 7% reoperations. There were no deaths. Overall, 98% of patients had a good outcome (mRS 0-2). Clip occlusion rate was 97.9%. Multivariate logistic regression analysis identified aneurysm location as the only significant independent factor for risk of complication ( p  < 0.001) and complication as the only significant independent risk factor for rehabilitation ( p  = 0.003). Rehabilitation was indicated or requested by the patient as early neurologic rehabilitation (5%), inpatient follow-up (15%), and outpatient follow-up (15%). The long-term care rate was 2%.  Microsurgery of unruptured and not acutely ruptured aneurysms (including post-coil and associated aneurysms) has a low rate of rehabilitation with a low risk of a permanent neurologic deficit, long-term care, or early neurologic rehabilitation. The rate of rehabilitation is well below reported risks from studies based on ICD-based health care analysis. Rehabilitation per se is not a good indicator for outcome. Georg Thieme Verlag KG Stuttgart · New York.

Indocyanine Green Videoangiography for Surgery of a Ruptured Dissecting Aneurysm in the Precommunicating Anterior Cerebral Artery: A Technical Case Report.

PubMed

Nagai, Yasunori; Goto, Masanori; Toda, Hiroki; Nishida, Namiko; Yoshimoto, Naoya; Iwasaki, Koichi

2017-08-01

Indocyanine green videoangiography (ICG-VA) is an important intraoperative adjunct for saccular aneurysm surgery, but its efficacy in surgery for dissecting aneurysms has rarely been reported. The authors describe the usefulness of preclipping ICG-VA in a rare case of a ruptured dissecting aneurysm located at the precommunicating (A1) segment of the anterior cerebral artery. A 52-year-old woman, with no history of connective tissue diseases or vascular disorders, presented with sudden headache and convulsion. The CT scan showed that the patient had subarachnoid hemorrhage. Angiography showed a dissecting aneurysm in the left A1 segment of the anterior cerebral artery. Thus, the patient underwent trapping of the dissecting aneurysm. ICG-VA was used as an intraoperative adjunct before and after clipping. The preclipping ICG-VA showed the heterogeneously bright dissecting aneurysm and branching arteries even in the presence of hematoma. Preclipping ICG-VA may enhance the advantage of direct surgery for dissecting aneurysm by allowing visualization of the extent of the dissected vascular wall and the related branching arteries. ICG-VA can be an indispensable adjunct to minimize the compromise from the surgical treatment for intracranial dissecting aneurysms. Copyright © 2017 by the Congress of Neurological Surgeons

[Anesthetic management for cerebral aneurysm surgery in a patient with aortitis syndrome accompanied by lung edema].

PubMed

Maeda, Ryoko; Kohno, Yumiko; Hoshino, Hajime; Suzuki, Hideo; Hirabayashi, Yoshiyuki; Seo, Norimasa

2003-08-01

A 48-year-old woman with aortitis syndrome underwent clipping of dissecting aneurysm of the left posterior inferior cerebellar artery following subarachnoid hemorrhage. Preoperative echocardiography demonstrated moderate aortic regurgitation and pulmonary hypertension. Intravenous infusion (1900 ml.day-1) was performed to avoid cerebral vasospasm, but the patient developed lung edema. She received delayed surgical treatment after the improvement of lung symptoms. Anesthesia was induced with fentanyl (0.1 mg), propofol (90 mg) and vecuronium (6 mg). Radial arterial flow was judged to be insufficient for cannulation, and a cannulation was therefore performed on the dorsal pedis artery. During induction of anesthesia, there was a significant decrease in the arterial pressure, that required a total of 32 mg of intravenous ephedrine. Following tracheal intubation, a central venous catheter was inserted and dopamine was continuously administered. The patient was positioned in the park bench position. We thought that the placement of the introducer for Swan-Ganz catheter was difficult under the position and Swan-Ganz catheter was not inserted. Anesthesia was maintained with sevoflurane, air, and oxygen. We continuously monitored the central venous pressure as an indicator of fluid balance. In this case, we monitored dorsal pedis arterial pressure directly, which might not be sufficiently reliable to predict the decrease in cerebral blood flow.

The role of laryngoscopy in the diagnosis of spasmodic dysphonia.

PubMed

Daraei, Pedram; Villari, Craig R; Rubin, Adam D; Hillel, Alexander T; Hapner, Edie R; Klein, Adam M; Johns, Michael M

2014-03-01

Spasmodic dysphonia (SD) can be difficult to diagnose, and patients often see multiple physicians for many years before diagnosis. Improving the speed of diagnosis for individuals with SD may decrease the time to treatment and improve patient quality of life more quickly. To assess whether the diagnosis of SD can be accurately predicted through auditory cues alone without the assistance of visual cues offered by laryngoscopic examination. Single-masked, case-control study at a specialized referral center that included patients who underwent laryngoscopic examination as part of a multidisciplinary workup for dysphonia. Twenty-two patients were selected in total: 10 with SD, 5 with vocal tremor, and 7 controls without SD or vocal tremor. The laryngoscopic examination was recorded, deidentified, and edited to make 3 media clips for each patient: video alone, audio alone, and combined video and audio. These clips were randomized and presented to 3 fellowship-trained laryngologist raters (A.D.R., A.T.H., and A.M.K.), who established the most probable diagnosis for each clip. Intrarater and interrater reliability were evaluated using repeat clips incorporated in the presentations. We measured diagnostic accuracy for video-only, audio-only, and combined multimedia clips. These measures were established before data collection. Data analysis was accomplished with analysis of variance and Tukey honestly significant differences. Of patients with SD, diagnostic accuracy was 10%, 73%, and 73% for video-only, audio-only, and combined, respectively (P < .001, df = 2). Of patients with vocal tremor, diagnostic accuracy was 93%, 73%, and 100% for video-only, audio-only, and combined, respectively (P = .05, df = 2). Of the controls, diagnostic accuracy was 81%, 19%, and 62% for video-only, audio-only, and combined, respectively (P < .001, df = 2). The diagnosis of SD during examination is based primarily on auditory cues. Viewing combined audio and video clips afforded no change in diagnostic accuracy compared with audio alone. Laryngoscopy serves an important role in the diagnosis of SD by excluding other pathologic causes and identifying vocal tremor.

Successful Treatment of Residual Curvature in Peyronie Disease in Men Previously Treated With Intralesional Collagenase Clostridium Histolyticum.

PubMed

DeLay, Kenneth; Diao, Linley; Nguyen, Hoang Minh Tue; Zurawin, Jonathan; Libby, Russell; Yafi, Faysal; Hellstrom, Wayne J G

2017-12-01

To determine the success and feasibility of surgically correcting residual curvature after intralesional collagenase clostridium histolyticum (CCH) for the treatment of Peyronie disease (PD). We performed a retrospective analysis of patients who had intralesional CCH treatment for PD and who subsequently underwent penile plication (PP), plaque incision and grafting (PIG), or inflatable penile prosthesis (IPP) placement. Ten men who underwent PP, PIG, or IPP for the treatment of residual curvature after intralesional CCH were identified. Six patients underwent PP; 1 patient underwent PIG; and 3 patients underwent IPP with ancillary straightening maneuvers. The mean time from the last CCH injection to surgical correction was 150.9 days, or 5 months. The mean pre-CCH curvature was 67 degrees and the mean post-CCH curvature was 51 degrees. Eight of 10 patients had no residual curvature after surgical treatment. The mean postprocedure curvature was 4.5 degrees. The mean operative time was 72.1 minutes. The mean estimated blood loss was 20 mL. Increased fibrosis with increased surgical difficulty was noted in 3 (all <6 months post CCH treatment) of 10 patients. No postoperative complications were noted. The surgical treatment of PD after intralesional CCH is safe and effective. If surgery is considered, this should be performed at least 6 months after the last CCH injection, given the potential for an increased inflammatory reaction in this area. Copyright © 2017 Elsevier Inc. All rights reserved.

Contribution of whole platelet aggregometry to the endovascular management of unruptured aneurysms: an institutional experience.

PubMed

Aoun, S G; Welch, B G; Pride, L G; White, J; Novakovic, R; Hoes, K; Sarode, R

2017-10-01

Stent-assisted coiling of intracranial aneurysms is an efficient alternative treatment to surgical clipping but requires prolonged antiplatelet therapy. Some patients are non-responsive to aspirin and/or clopidogrel. To analyze the implications of this assessment using the 'whole blood aggregometry (WBA) by impedance' technique. The Southwestern Tertiary Aneurysm Registry was reviewed between 2002 and 2012 for patients with unruptured aneurysms treated with stent-assisted coiling. The study population was divided into patients who were tested preoperatively for platelet responsiveness to aspirin and clopidogrel ('tested' patients) and those who were not ('non-tested'). Where necessary, tested patients received additional doses of antiplatelet drugs to achieve adequate platelet inhibition. Endpoints included the incidence of non-responsiveness, the rates of thrombotic and hemorrhagic complications, and the rates of permanent morbidity and mortality. A total of 266 patients fulfilled our selection criteria: 114 non-tested patients who underwent 121 procedures, and 152 tested patients who underwent 171 procedures. The two groups did not vary significantly in patient age, gender, and aneurysms location. Aspirin non-responsiveness was detected in 3 patients (1.75%) and clopidogrel non-responsiveness in 21 patients (12.3%). Non-tested patients had an 11.6% rate of thrombotic complications with a 4.1% permanent morbidity or mortality rate versus 2.3% and 0.6% in tested patients (p=0.0013). The incidence of hemorrhagic complications was similar between the two groups. Preoperative platelet inhibition testing using WBA can be useful to assess and correct antiaggregant non-responsiveness, and may reduce postoperative mortality and permanent morbidity. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Effect of scalp blocks with levobupivacaine on recovery profiles after craniotomy for aneurysm clipping: a randomized, double-blind, and controlled study.

PubMed

Hwang, Jin-Young; Bang, Jae-Seung; Oh, Chang-Wan; Joo, Jin-Deok; Park, Seong-Joo; Do, Sang-Hwan; Yoo, Yong-Jae; Ryu, Jung-Hee

2015-01-01

This study was conducted to evaluate the effect of scalp blocks using levobupivacaine on recovery profiles including postoperative pain, patient-controlled analgesia (PCA) consumption, postoperative nausea and vomiting (PONV), and other adverse events in patients undergoing frontoparietal craniotomy for aneurysm clipping. Fifty-two patients scheduled for elective frontoparietal craniotomy for unruptured aneurysm clipping were enrolled. After surgery, scalp blocks were performed using normal saline (group C, n = 26) or 0.75% levobupivacaine (group L, n = 26). Postoperative pain scores and PCA consumption were recorded for 72 hours after recovery of consciousness. The time from patient recovery to the first use of PCA drug and rescue analgesics, the requirement for vasoactive agents, and adverse effects related to PCA and local anesthetics also were recorded. Postoperative pain scores and PCA consumption in group L were lower than in group C (P < .05). The time intervals from patient recovery to the first use of PCA drug (P < .001) and rescue analgesics (P = .038) was longer in group L than in group C. Additionally, less antihypertensive agent was required (P = .017), and PONV occurred less frequently (P = .039) in group L than in group C. Scalp blocks with 0.75% levobupivacaine improved recovery profiles in that it effectively lowered postoperative pain and PCA consumption without severe adverse events and also reduced the requirement for a postoperative antihypertensive agent and the incidence of PONV in patients who underwent frontoparietal craniotomy for aneurysm clipping. Copyright © 2015 Elsevier Inc. All rights reserved.

Parent artery occlusion for ruptured "true" posterior communicating artery aneurysm.

PubMed

Mitsuhashi, Takashi; Takeda, Nobuaki; Oishi, Hidenori; Arai, Hajime

2015-04-01

A case of a patient with a ruptured true posterior communicating artery (PCoA) aneurysm is reported, who had been managed by early endovascular parent artery occlusion with coils. The small blister aneurysm was located at the proximal PCoA itself and directed superiorly. Postoperative course was uneventful. During 1-month follow-up, the patient recovered well and could care for herself. Aneurysms of the PCoA itself are very rare. As reported to date, surgical procedures would favor microsurgical clipping over endovascular coil embolization. Endovascular treatment may be a good alternative to surgical trapping for true PCoA blister aneurysm. © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.

Update of transcatheter valve treatment

PubMed Central

Liu, Xian-bao; Wang, Jian-an

2013-01-01

Transcatheter valve implantation or repair has been a very promising approach for the treatment of valvular heart diseases since transcatheter aortic valve implantation (TAVI) was successfully performed in 2002. Great achievements have been made in this field (especially TAVI and transcatheter mitral valve repair—MitraClip system) in recent years. Evidence from clinical trials or registry studies has proved that transcatheter valve treatment for valvular heart diseases is safe and effective in surgical high-risk or inoperable patients. As the evidence accumulates, transcatheter valve treatment might be an alterative surgery for younger patients with surgically low or intermediate risk valvular heart diseases in the near future. In this paper, the updates on transcatheter valve treatment are reviewed. PMID:23897785

Catering to millennial learners: assessing and improving fine-needle aspiration performance.

PubMed

Rowse, Phillip G; Ruparel, Raaj K; AlJamal, Yazan N; Abdelsattar, Jad M; Heller, Stephanie F; Farley, David R

2014-01-01

Fine-needle aspiration (FNA) of a palpable cervical lymph node is a straightforward procedure that should be safely performed by educated general surgery (GS) trainees. Retention of technical skill is suspect, unless sequential learning experiences are provided. However, voluntary learning experiences are no guarantee that trainees will actually use the resource. A 3-minute objective structured assessment of technical skill-type station was created to assess GS trainee performance using FNA. Objective criteria were developed and a checklist was generated (perfect score = 24). Following abysmal performance of 11 postgraduate year (PGY)-4 trainees on the FNA station of our semiannual surgical skills assessment ("X-Games"), we provided all GS residents with electronic access to a 90-second YouTube video clip demonstrating proper FNA technique. PGY-2 (n = 11) and PGY-3 (n = 10) residents subsequently were tested on FNA technique 5 and 12 days later, respectively. All 32 trainees completed the station in less than 3 minutes. Overall scores ranged from 4 to 24 (mean = 14.9). PGY-4 residents assessed before the creation of the video clip scored lowest (range: 4-18, mean = 11.4). PGY-3 residents (range: 10-22, mean = 17.8) and PGY-2 residents (range: 10-24, mean = 15.8) subsequently scored higher (p < 0.05). Ten residents admitted watching the 90-second FNA video clip and scored higher (mean = 21.7) than the 11 residents that admitted they did not watch the clip (mean = 13.1, p < 0.001). Of the 11 trainees who did not watch the video, 6 claimed they did not have time, and 5 felt it would not be useful to them. Overall performance of FNA was poor in 32 midlevel GS residents. However, a 90-second video clip demonstrating proper FNA technique viewed less than 2 weeks before the examination significantly elevated scores. Half of trainees given the chance to learn online did not take the opportunity to view the video clip. Although preemptive learning is effective, future efforts should attempt to improve self-directed learning habits of trainees and evaluate actual long-term skill retention. Copyright © 2014. Published by Elsevier Inc.

Transapical implantation of a second-generation transcatheter heart valve in patients with noncalcified aortic regurgitation.

PubMed

Seiffert, Moritz; Diemert, Patrick; Koschyk, Dietmar; Schirmer, Johannes; Conradi, Lenard; Schnabel, Renate; Blankenberg, Stefan; Reichenspurner, Hermann; Baldus, Stephan; Treede, Hendrik

2013-06-01

This study sought to report on the feasibility and early results of transcatheter aortic valve implantation employing a second-generation device in a series of patients with pure aortic regurgitation. Efficacy and safety of transcatheter aortic valve implantation in patients with calcific aortic stenosis and high surgical risk has been demonstrated. However, experience with implantation for severe noncalcified aortic regurgitation has been limited due to increased risk for valve dislocation or annular rupture. Five patients (mean age: 66.6 ± 7 years) underwent transapical implantation of a JenaValve (JenaValve Technology GmbH, Munich, Germany) transcatheter heart valve for moderate to severe, noncalcified aortic regurgitation. All patients were considered high risk for surgical aortic valve replacement after evaluation by an interdisciplinary heart team (logistic EuroSCORE [European System for Cardiac Operative Risk Evaluation] range 3.1% to 38.9%). Procedural and acute clinical outcomes were analyzed. Implantation was successful in all cases without relevant remaining aortic regurgitation or signs of stenosis in any of the patients. No major device- or procedure-related adverse events occurred and all 5 patients were alive with improved exercise tolerance at 3-month follow-up. Noncalcified aortic regurgitation continues to be a challenging pathology for transcatheter aortic valve implantation due to the risk for insufficient anchoring of the valve stent within the aortic annulus. This report provides first evidence that the JenaValve prosthesis may be a reasonable option in these specific patients due to its unique stent design, clipping the native aortic valve leaflets, and offering promising early results. Copyright © 2013 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

A comparison of two endoscopic closures: over-the-scope clip (OTSC) versus KING closure (endoloop + clips) in a randomized long-term experimental study.

PubMed

Dolezel, R; Ryska, O; Kollar, M; Juhasova, J; Kalvach, J; Ryska, M; Martinek, J

2016-11-01

Both over-the-scope clip (OTSC) and KING (endoloop + clips) closures provide reliable and safe full-thickness endoscopic closure. Nevertheless, OTSC clip demonstrated significantly inferior histological healing in the short-term follow-up. To compare OTSC versus KING closure of a perforation with regard to long-term effectiveness and macroscopic and histological quality of healing. We performed a randomized experimental study with 16 mini-pigs (mean weight 43.2 ± 11.2 kg). A standardized perforation was performed on the anterior sigmoid wall. KING closure (n = 8) was attained by approximation of an endoloop fixed to the margins of a perforation with endoclips. OTSC closure (n = 8) was performed by deploying OTSC (OVESCO) over the defect. Pigs underwent a control sigmoidoscopy 8 months after the closure to assess the macroscopic quality of healing. Then, autopsy was performed and the rectosigmoid was sent for histopathological assessment. All closures were completed successfully without air leaks. The duration of closure was similar in both techniques (OTSC 17.8 ± 7.6 min vs. KING 19.6 ± 8.8 min). At autopsy, all KING closures (100 %) were healed with a flat scar without signs of leakage. Microscopically, no inflammatory changes were observed after KING closure. In the OTSC group, microscopic ulcers were present in two pigs (25 %), cryptal abscesses in three pigs (38 %) and significant neutrophil accumulation in all eight pigs (P < 0.01). Giant cell granulomas, dysplasia or abundant scarification was not observed in either group. Both OTSC and KING closures offer a long-term reliable seal of a gastrointestinal perforation without stenosis or fistulas. KING closure provides long-term histologically superior healing.

Percutaneous mitral valve repair with the MitraClip system according to the predicted risk by the logistic EuroSCORE: preliminary results from the German Transcatheter Mitral Valve Interventions (TRAMI) Registry.

PubMed

Wiebe, Jens; Franke, Jennifer; Lubos, Edith; Boekstegers, Peter; Schillinger, Wolfgang; Ouarrak, Taoufik; May, Andreas E; Eggebrecht, Holger; Kuck, Karl-Heinz; Baldus, Stephan; Senges, Jochen; Sievert, Horst

2014-10-01

To evaluate in-hospital and short-term outcomes of percutaneous mitral valve repair according to patients' logistic EuroSCORE (logEuroSCORE) in a multicenter registry The logEuroSCORE is an established tool to predict the risk of mortality during cardiac surgery. In high-risk patients percutaneous mitral valve repair with the MitraClip system represents a less-invasive alternative Data from 1002 patients, who underwent percutaneous mitral valve repair with the MitraClip system, were analyzed in the German Transcatheter Mitral Valve Interventions (TRAMI) Registry. A logEuroSCORE (mortality risk in %) ≥ 20 was considered high risk Of all patients, 557 (55.6%) had a logEuroSCORE ≥ 20. Implantation of the MitraClip was successful in 95.5 % (942/986) patients. Moderate residual mitral valve regurgitation was more often detected in patients with a logEuroSCORE ≥ 20 (23.8% vs. 17.1%, respectively, P < 0.05). In patients with a logEuroSCORE ≥ 20 the procedural complication rate was 8.9% (vs. 6.4, n.s.) and the in-hospital MACCE rate 4.9% (vs. 1.4% P < 0.01). The in-hospital mortality rate in patients with a logEuroSCORE ≥ 20 and logEuroSCORE < 20 was 4.3 and 1.1%, respectively (P ≤ 0.01) CONCLUSION: Percutaneous mitral valve repair with the MitraClip system is feasible in patients with a logEuroSCORE ≥ 20 with similar procedural results compared to patients with lower predicted risk. Although mortality was four times higher than in patients with logEuroSCORE < 20, mortality in high risk patients was lower than predicted. In those with a logEuroSCORE ≥ 20, moderate residual mitral valve regurgitation was more frequent. © 2014 Wiley Periodicals, Inc.

Aneurysm treatment practice patterns for newly appointed dual-trained cerebrovascular/endovascular neurosurgeons: Comparison of open surgical to neuroendovascular procedures in the first 2 years of academic practice.

PubMed

Jiang, Bowen; Bender, Matthew T; Hasjim, Bima; Hsu, Frank P K; Tamargo, Rafael J; Huang, Judy; Colby, Geoffrey P; Coon, Alexander L; Lin, Li-Mei

2017-01-01

The practice patterns of a hybrid open cerebrovascular/neuroendovascular (CVNV) neurosurgeon in early academic practice is unknown. We performed a multi-institutional retrospective cohort study of patients with cerebral aneurysms that were treated within the first 24 months of the neurosurgeon's practice. A total of 533 aneurysms were treated by the three senior authors within the first 24 months of their academic practice. Of these aneurysms, 172 were treated with microsurgical clipping, 191 with coiling, and 170 with flow diversion. Treatment in the setting of acute subarachnoid hemorrhage (SAH) occurred in 23% (122/533) of the aneurysms. Majority of the clipped aneurysms (70%, 121/172) were anterior cerebral artery (ACA), anterior communicating artery (ACOM), or middle cerebral artery (MCA) in location. In comparison, only 23% (82/361) of aneurysms treated with coiling or flow diversion therapy were ACA, ACOM, or MCA in location ( P < 0.05). Additionally, majority of the flow diverted aneurysm (65%, 111/170) were cavernous or ophthalmic/paraophthalmic in location. During the second year of practice, there appeared to be a trend towards more aneurysms treated with neuroendovascular techniques (22% increase), particularly in flow diversion. Although the CVNV neurosurgeon treats cerebral aneurysms more commonly with neuroendovascular techniques, a third of the cerebral aneurysms are still selected for microsurgical clipping. Aneurysms located along the ACA/ACOM or MCA are the most frequent aneurysms reserved for microsurgical clipping. The CVNV neurosurgeon must be prepared to manage a high percentage of ACA/ACOM or MCA aneurysms microsurgically.

Laser ablation of surgical margins after excisional partial vulvectomy for VIN: Effect on recurrence.

PubMed

Brown, John V; Goldstein, Bram H; Rettenmaier, Mark A; Aylward, Michelle M; Graham, Cheri L; Micha, John P

2005-05-01

To determine the recurrence rates in patients who underwent different surgical treatments for vulvar intraepithelial neoplasia (VIN) 2 and 3. Data on every patient who underwent surgical treatment for VIN 2 or 3 between January 1994 and December 2002 by a single gynecologic oncologist were retrospectively reviewed. The recurrence rates for 3 different surgical therapies were analyzed using Fischer's exact test. Thirty-three patients, who had a median age of 46 years (range, 31-80), were identified. The preoperative biopsy demonstrated VIN 2 or 3 in 9.1% and 90.9% of the patients, respectively. The following primary surgical procedures were employed: 16 patients (48.4%) underwent excisional partial vulvectomy with CO2 laser ablation of the margins, 10 patients (30.3%) had CO2 laser ablation alone, 6 patients (18.2%) had an excisional partial vulvectomy, and 1 patient (3.0%) was. treated with the ultrasonic surgical aspirator. No patient had invasive disease. Recurrent disease was seen in 7 patients (70.0%) treated by laser alone, 3 patients (50.0%) who had an excisional partial vulvectomy and 1 patient (6.25%) who underwent a combined laser and excisional partial vulvectomy (p = 0.0016). The results of this small study suggest that laser and excisional partial vulvectomy for the treatment of VIN 2 and 3 may be associated with a lower recurrence rate than either modality alone. A larger study will be needed to confirm these results.

Effect of Unshaven Hair with Absorbable Sutures and Early Postoperative Shampoo on Cranial Surgery Site Infection.

PubMed

Oh, Won-Oak; Yeom, Insun; Kim, Dong-Seok; Park, Eun-Kyung; Shim, Kyu-Won

2018-01-01

Cranial surgical site infection is a significant cause of morbidity and mortality in hospitals. Preoperative hair shaving for cranial neurosurgical procedures is performed traditionally in an attempt to protect patients against complications from infections at cranial surgical sites. However, preoperative shaving of surgical incision sites using traditional surgical blades without properly washing the head after surgery can cause infections at surgical sites. Therefore, a rapid protocol in which the scalp remains unshaven and absorbable sutures are used for scalp closure with early postoperative shampooing is examined in this study. A retrospective comparative study was conducted from January 2008 to December 2012. A total of 2,641 patients who underwent unshaven cranial surgery with absorbable sutures for scalp closure were enrolled in this study. Data of 1,882 patients who underwent surgery with the traditional protocol from January 2005 to December 2007 were also analyzed for comparison. Of 2,641 patients who underwent cranial surgery with the rapid protocol, all but 2 (0.07%) patients experienced satisfactory wound healing. Of 1,882 patients who underwent cranial surgery with the traditional protocol, 3 patients (0.15%) had infections. Each infection occurred at the superficial incisional surgical site. Unshaven cranial surgery using absorbable sutures for scalp closure with early postoperative shampooing is safe and effective in the cranial neurosurgery setting. This protocol has a positive psychological effect. It can help patients accept neurosurgical procedures and improve their self-image after the operation. © 2017 S. Karger AG, Basel.

The management of vertebral artery injury in anterior cervical spine operation: a systematic review of published cases.

PubMed

Park, Hyung-Ki; Jho, Hae-Dong

2012-12-01

Anterior cervical spine operations (ACSO) are generally considered to be safe and effective, but the vertebral artery (VA) is at risk during the procedure. Because the consequences of VA injury can be catastrophic, properly managing a VA injury is very important. However, due to the rarity of these injuries, there is no agreed upon treatment strategy. Studies were identified for inclusion in the review via sensitive searches of electronic databases through 31 December 2011. All cases included in the review were qualitatively analyzed to explore the relationship between type of VA injury management and neurological complications. Seventeen articles describing 39 cases of VA injury during ACSO were included in this study. Seven patients (17.9 %) had neurological complications followed by VA insufficiency. Two patients (5.1 %) had root damage due to ligation. One case (2.6 %) resulted in intraoperative death due to fatal bleeding. Delayed vascular complications were identified in nine (45.0 %) of the 20 patients that underwent only tamponade or hemostatic agent during the operation. Four patients underwent intraoperative endovascular treatment, and three of these patients had a cerebral infarction. All three patients who underwent clipping also had neurological complications. The five patients treated by direct repair did not have any complications. Our review suggests the management of VA injury should be considered in order listed: (1) performing tamponade with a hemostatic agent, (2) direct repair, (3) postoperative endovascular procedures to prevent delayed complications. If tamponade fails to achieve proper hemostasis, additional procedures as endovascular embolization, clipping and ligation should be considered but carry the risk of neurological complications. Because of the limitations of this review, further studies are recommended with larger sample sizes.

The importance of prostate bed tilt during postprostatectomy intensity-modulated radiotherapy

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

Bell, Linda J., E-mail: Linda.Bell1@health.nsw.gov.au; Faculty of Health Sciences, University of Sydney, Lidcombe, New South Wales; Cox, Jennifer

2014-10-01

Variations in rectal and bladder filling can create a tilt of the prostate bed, which generates the potential for a geographic miss during postprostatectomy radiotherapy. The aim of this study is to assess the effect that bladder and rectum filling has on planning target volume angle, to determine a method to assess prostate bed tilt leading to potential geographic miss, and to discuss possible implementation issues. The cone-beam computed tomography images (n = 377) of 40 patients who received postprostatectomy radiotherapy with intensity-modulated radiotherapy were reviewed. The amount of tilt in the prostate bed was defined as the angle changemore » between 2 surgical clips, one in the upper prostate bed and another in the lower. A potential geographic miss was defined as movement of any clip of more than 1 cm in any direction or 0.5 cm posteriorly when aligned to bone anatomy. Variations in bladder and rectum size were correlated with the degree of prostate bed tilt, and the rate of potential geographic miss was determined. A possible clinical use of prostate bed tilt was then assessed for different imaging techniques. A tilt of more than 10° was seen in 20.2% of images, which resulted in a 57.9% geographic miss rate of the superior clip. When tilt remained within 10°, there was only a 9% rate of geographic miss. Potential geographic miss of the inferior surgical clip was rare, occurring in only 1.9% of all images reviewed. The most common occurrence when the prostate bed tilt increased by more than 10° was a smaller bladder and larger rectum (6.4% of all images). The most common occurrence when the prostate bed tilt decreased by more than 10° was a larger bladder and smaller rectum (1.3% of all images). Significant prostate bed tilt (>± 10°) occurred in more than 20% of images, creating a 58% rate of geographic miss. Greatest prostate bed tilt occurred when the bladder size increased or reduced by more than 2 cm or the superior rectum size increased by more than 1.5 cm or reduced by more than 1 cm from the planned size. Using prostate bed tilt could be an effective measurement for assessing potential geographic miss on orthogonal images if volumetric imaging is unavailable.« less

Importance of Early Postoperative Body Temperature Management for Treatment of Subarachnoid Hemorrhage.

PubMed

Suehiro, Eiichi; Sadahiro, Hirokazu; Goto, Hisaharu; Oku, Takayuki; Oka, Fumiaki; Fujiyama, Yuichi; Shirao, Satoshi; Yoneda, Hiroshi; Koizumi, Hiroyasu; Ishihara, Hideyuki; Suzuki, Michiyasu

2016-06-01

The importance of acute-phase brain temperature management is widely accepted for prevention of exacerbation of brain damage by a high body temperature. In this study, we investigated the influence of body temperature in the early postoperative period on the outcomes of 62 patients with subarachnoid hemorrhage who were admitted to our department. Body temperature was measured from day 4 to day 14 after onset. The patients were divided into those treated with surgical clipping (clip group) and coil embolization (coil group), those graded I-III (mild) and IV-V (severe) based on the Hunt & Hess classification on admission, those with and without development of delayed cerebral ischemia (DCI), and those with favorable and poor outcomes. Body temperatures throughout the hospital stay were compared in each group. There was no significant difference in body temperature between the clip and coil groups or between the mild and severe groups, but body temperature was significantly higher in patients with DCI compared to those without DCI, and in patients with a poor outcome compared to those with a favorable outcome. Fever in the early postoperative period of subarachnoid hemorrhage is associated with development of DCI and a poor outcome. Copyright © 2016 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Transcatheter treatment of severe tricuspid regurgitation with the MitraClip system.

PubMed

Hammerstingl, Christoph; Schueler, Robert; Malasa, Margarita; Werner, Nikos; Nickenig, Georg

2016-03-07

The aim of this study was to show technical principles and feasibility of transcatheter tricuspid valve repair by use of the MitraClip system. Three consecutive patients were treated successfully for severe symptomatic Tricuspid regurgitation. Three-dimensional transoesophageal echocardiography confirmed reduction of measured effective regurgitant orifice in all patients [effective regurgitant orifice area-baseline/post-procedure (cm(2)): 0.7/0.3; 1.5/0.8; 0.4/0.1], which was accompanied by an increase in left ventricular stroke volumes [baseline/post-procedure (mL): 42.8/45.4; 38/45; 35.2/45], decrease of measured levels of N terminal pro brain natriuretic peptide (pg/mL: baseline/post-procedure: 548/440; 2526/1702; 1754/623), and significant relief of clinical symptoms for chronic right heart failure in all patients. Transcatheter tricuspid valve repair by use of interventional edge-to-edge repair with the MitraClip system was feasible, and safe in three consecutive patients. Reduction of tricuspid insufficiency associates with relief of clinical symptoms for right heart failure. This strategy seems a promising treatment option for patients at prohibitive surgical risk. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2016. For permissions please email: journals.permissions@oup.com.

Development of a novel marking system for laparoscopic gastrectomy using endoclips with radio frequency identification tags: feasibility study in a canine model.

PubMed

Kojima, Fumitsugu; Sato, Toshihiko; Tsunoda, Shigeru; Takahata, Hiromi; Hamaji, Masatsugu; Komatsu, Teruya; Okada, Minoru; Sugiura, Tadao; Oshiro, Osamu; Sakai, Yoshiharu; Date, Hiroshi; Nakamura, Tatsuo

2014-09-01

Intraoperative identification of early gastric cancer is difficult to conduct during laparoscopic procedures. In this study, we investigated the feasibility and accuracy of a newly developed marking system using endoclips with radio frequency identification (RFID) tags in a canine model. RFID is a wireless near field communication technology. Among the open frequency bands available for medical use, 13.56 MHz is suitable for a surgical marking system because of the similar and linear signal decay both in air and in biological tissues. The proposed system consists of four parts: (a) endoclips with RFID tags, (b) endo-clip applier equipment, (c) laparoscopic locating probe, and (d) signal processing units with audio interface. In the experimental setting using canine models, RFID-tagged endoclips were applied to the mucosa of each dog's stomach. During the subsequent operation, the clips with RFID tags placed in five dogs were located by the detection of the RFID signal from the tag (RFID group), and the conventional clips in the other six dogs were located by finger palpation (FP group). The detected sites were marked by ablation on the serosal surface. Distance between the clips and the metal pin needles indicating ablated sites were measured with X-ray radiographs of the resected specimen. All clips were successfully detected by the marking system in the RFID group (10/10) and by finger palpation in the FP group (17/17). The medians of detection times were 31.5 and 25.0 s, respectively; the distances were 5.63 and 7.62 mm, respectively. The differences were not statistically significant. No adverse event related to the procedures was observed. Endoclips with RFID tags were located by our novel marking system in an experimental laparoscopic setting using canine stomachs with substantial accuracy comparable to conventional endoclips located by finger palpation through an open approach.

Cost-minimization Analysis of the Management of Acute Achilles Tendon Rupture.

PubMed

Truntzer, Jeremy N; Triana, Brian; Harris, Alex H S; Baker, Laurence; Chou, Loretta; Kamal, Robin N

2017-06-01

Outcomes of nonsurgical management of acute Achilles tendon rupture have been demonstrated to be noninferior to those of surgical management. We performed a cost-minimization analysis of surgical and nonsurgical management of acute Achilles tendon rupture. We used a claims database to identify patients who underwent surgical (n = 1,979) and nonsurgical (n = 3,065) management of acute Achilles tendon rupture and compared overall costs of treatment (surgical procedure, follow-up care, physical therapy, and management of complications). Complication rates were also calculated. Patients were followed for 1 year after injury. Average treatment costs in the year after initial diagnosis were higher for patients who underwent initial surgical treatment than for patients who underwent nonsurgical treatment ($4,292 for surgical treatment versus $2,432 for nonsurgical treatment; P < 0.001). However, surgical treatment required fewer office visits (4.52 versus 10.98; P < 0.001) and less spending on physical therapy ($595 versus $928; P < 0.001). Rates of rerupture requiring subsequent treatment (2.1% versus 2.4%; P = 0.34) and additional costs ($2,950 versus $2,515; P = 0.34) were not significantly different regardless whether initial treatment was surgical or nonsurgical. In both cohorts, management of complications contributed to approximately 5% of the total cost. From the payer's perspective, the overall costs of nonsurgical management of acute Achilles tendon rupture were significantly lower than the overall costs of surgical management. III, Economic Decision Analysis.

Comparison of effectiveness and cost of patent ductus arteriosus device occlusion versus surgical ligation of patent ductus arteriosus.

PubMed

Zulqarnain, Arif; Younas, Muhammad; Waqar, Tariq; Beg, Ahsan; Asma, Touseef; Baig, Mirza Ahmad Raza

2016-01-01

Comparison of effectiveness and cost of transcatheter occlusion of patent ductus arteriosus (PDA) with surgical ligation of PDA. This retrospective comparative study was conducted in the pediatric cardiology department of Ch. Pervaiz Elahi Institute of Cardiology Multan, Pakistan. Data of 250 patients who underwent patent ductus arteriosus (PDA) closure either surgical or trans-catheter closure using SHSMA Occluder having weight >5 kg from April 2012 to October 2015 were included in this study. SPSS version 20 was used for data analysis. Quantitative variables were compared using independent sample t-test. Chi-square test and fishers exact was used for qualitative variables. P-value <0.05 was considered statistically significant. There were one hundred and twenty (120) patients who underwent transcatheter occlusion of PDA using SHSMA occluder (PDA Device Group) and one hundred and thirty (130) patients who underwent surgical ligation of PDA (Surgical Group). Incidence of residual shunting was two (1.5%) in surgical group and 0 (0.0%) in PDA Device group for one month follow up period. There were 4 (3.1%) major complications in surgical group. The rate of blood transfusions were high in surgical group (p-value 0.04). Hospital stay time was significantly less in PDA Device group (P-value <0.001). Total procedural cost was 110695+1054 Pakistani rupees in PDA Device group and 92414+3512 in surgical group (p-value <0.001). The cost of PDA device closure was 16.52% higher than the surgical ligation of PDA. There was no operative mortality. The transcatheter closure of PDA is an effective and less invasive method as compared to the surgical ligation. There is a lower rate of complications and the cost is not much high as compared to surgical PDA ligation.

Percutaneous edge-to-edge mitral valve repair in high-surgical-risk patients: do we hit the target?

PubMed

Van den Branden, Ben J L; Swaans, Martin J; Post, Martijn C; Rensing, Benno J W M; Eefting, Frank D; Jaarsma, Wybren; Van der Heyden, Jan A S

2012-01-01

This study sought to assess the feasibility and safety of percutaneous edge-to-edge mitral valve (MV) repair in patients with an unacceptably high operative risk. MV repair for mitral regurgitation (MR) can be accomplished by use of a clip that approximates the free edges of the mitral leaflets. All patients were declined for surgery because of a high logistic EuroSCORE (>20%) or the presence of other specific surgical risk factors. Transthoracic echocardiography was performed before and 6 months after the procedure. Differences in New York Heart Association (NYHA) functional class, quality of life (QoL) using the Minnesota questionnaire, and 6-min walk test (6-MWT) distances were reported. Fifty-five procedures were performed in 52 patients (69.2% male, age 73.2 ± 10.1 years, logistic EuroSCORE 27.1 ± 17.0%). In 3 patients, partial clip detachment occurred; a second clip was placed successfully. One patient experienced cardiac tamponade. Two patients developed inguinal bleeding, of whom 1 needed surgery. Six patients (11.5%) died during 6-month follow-up (5 patients as a result of progressive heart failure and 1 noncardiac death). The MR grade before repair was ≥3 in 100%; after 6 months, a reduction in MR grade to ≤2 was present in 79% of the patients. Left ventricular (LV) end-diastolic diameter, LV ejection fraction, and systolic pulmonary artery pressure improved significantly. Accompanied improvements in NYHA functional class, QoL index, 6-MWT distances, and log N-terminal pro-B-type natriuretic peptide were observed. In a high-risk population, MR reduction can be achieved by percutaneous edge-to-edge valve repair, resulting in LV remodeling with improvement of functional capacity after 6 months. Copyright © 2012 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Postoperative adjuvant OK-432 sclerotherapy for treatment of cervicofacial lymphatic malformations: an outcomes comparison.

PubMed

Kim, So Young; Lee, Sanghoon; Seo, Jeong-Meen; Lim, So Young

2015-04-01

Surgical treatment of extensive cervicofacial lymphatic malformations is often challenging due to a high rate of postoperative fluid re-accumulation and lesion recurrence resulting from incomplete resection. This study suggests a combined treatment of surgical resection and postoperative adjuvant OK-432 sclerotherapy via closed suction drainage. Using comparative analysis, this study aims to evaluate the efficacy of adjuvant sclerotherapy. A retrospective chart review was performed on patients who underwent surgical resection of cervicofacial lymphatic malformations between January 2009 and July 2013. Patients were divided into two groups based on whether or not adjuvant OK-432 sclerotherapy was administered via closed suction drainage after surgery. Both surgery-related and adjuvant sclerotherapy-related complications were assessed, and treatment effectiveness was measured based on the change in Cologne Disease Score (CDS) or the need for further treatment. A total of 17 patients underwent surgical resection. Nine of these patients underwent surgical resection only, while the other eight underwent surgical resection with adjuvant OK-432 sclerotherapy. The increase in total Cologne Disease Score (CDS) and change of progression parameters were significantly higher for the adjuvant sclerotherapy group compared to the surgery-only group. Additionally, there were no cases of postoperative lymphatic fluid retention among the adjuvant sclerotherapy group. The two groups exhibited similar complication rates with no statistically significant difference. Adjuvant OK-432 sclerotherapy via closed suction drainage is a safe and effective treatment modality. The combination of surgical resection and post-operative adjuvant sclerotherapy via closed suction drainage should be integrated into the treatment algorithm of extensive cervicofacial lymphatic malformation. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

The Impact of Laparoscopic Approaches on Short-term Outcomes in Patients Undergoing Liver Surgery for Metastatic Tumors.

PubMed

Karagkounis, Georgios; Seicean, Andreea; Berber, Eren

2015-06-01

To compare the perioperative outcomes associated with open and laparoscopic (LAP) surgical approaches for liver metastases. The American College of Surgeons National Surgical Quality Improvement Program database was used to identify all adult patients who underwent surgical therapy for metastatic liver tumors between 2006 and 2012 (N=7684). Patients who underwent >1 procedure were excluded. Logistic regression after matching on propensity scores was used to assess the association between surgical approaches and perioperative outcomes. A total of 4555 patients underwent open resection, 387 LAP resection, 297 open radiofrequency ablation (RFA), and 265 LAP RFA. In propensity-matched samples (over 95% of patients successfully matched), there was no significant difference between LAP resection and LAP RFA in perioperative complications and length of stay and both compared favorably with their open counterparts. Minimally invasive approaches for secondary hepatic malignancies were associated with improved postoperative morbidity and length of stay and should be preferred in appropriate patients.

Predicting device failure after percutaneous repair of functional mitral regurgitation in advanced heart failure: Implications for patient selection.

PubMed

Stolfo, Davide; De Luca, Antonio; Morea, Gaetano; Merlo, Marco; Vitrella, Giancarlo; Caiffa, Thomas; Barbati, Giulia; Rakar, Serena; Korcova, Renata; Perkan, Andrea; Pinamonti, Bruno; Pappalardo, Aniello; Berardini, Alessandra; Biagini, Elena; Saia, Francesco; Grigioni, Francesco; Rapezzi, Claudio; Sinagra, Gianfranco

2018-04-15

Patients with heart failure (HF) and severe symptomatic functional mitral regurgitation (FMR) may benefit from MitraClip implantation. With increasing numbers of patients being treated the success of procedure becomes a key issue. We sought to investigate the pre-procedural predictors of device failure in patients with advanced HF treated with MitraClip. From April 2012 to November 2016, 76 patients with poor functional class (NYHA class III-IV) and severe left ventricular (LV) remodeling underwent MitraClip implantation at University Hospitals of Trieste and Bologna (Italy). Device failure was assessed according to MVARC criteria. Patients were subsequently followed to additionally assess the patient success after 12months. Mean age was 67±12years, the mean Log-EuroSCORE was 23.4±16.5%, and the mean LV end-diastolic volume index and ejection fraction (EF) were 112±33ml/m 2 and 30.6±8.9%, respectively. At short-term evaluation, device failure was observed in 22 (29%) patients. Univariate predictors of device failure were LVEF, LV and left atrial volumes and anteroposterior mitral annulus diameter. Annulus dimension (OR 1.153, 95% CI 1.002-1.327, p=0.043) and LV end-diastolic volume (OR 1.024, 95% CI 1.000-1.049, p=0.049) were the only variables independently associated with the risk of device failure at the multivariate model. Pre-procedural anteroposterior mitral annulus diameter accurately predicted the risk of device failure after MitraClip in the setting of advanced HF. Its assessment might aid the selection of the best candidates to percutaneous correction of FMR. Copyright © 2018 Elsevier B.V. All rights reserved.

Post-operative outcomes of surgical and chemical castration with zinc gluconate in dogs presenting to veterinary field clinics.

PubMed

DiGangi, Brian A; Grijalva, Jaime; Jaramillo, Erika Pamela Puga; Dueñas, Ivette; Glenn, Christine; Cruz, María Emilia Calero; Pérez, Renán Patricio Mena

2017-11-01

The objective of this study was to characterize post-operative outcomes of chemical castration as compared to surgical castration performed by existing municipal field clinics. Fifty-four healthy adult male dogs underwent chemical castration with zinc gluconate solution and 55 healthy adult male dogs underwent surgical castration in veterinary field clinics. Dogs in each group were evaluated for swelling, inflammation, and ulceration (chemical castration) or dehiscence (surgical castration) at Days 3, 7, and 14 following castration. More surgically castrated dogs required medical intervention than chemically castrated dogs (P=0.0328); the number of dogs requiring surgical repair within each group did not differ (P=0.3421). Seven chemically castrated dogs and 22 surgically castrated dogs experienced swelling, inflammation, and/or ulceration; all were managed medically. Two chemically castrated dogs experienced scrotal ulceration requiring surgical castration at Days 3 and 7. One surgically castrated dog experienced partial incisional dehiscence requiring surgical repair at Day 3. Our results suggest that chemical castration of dogs in field clinics is a feasible alternative to surgical castration, but proper follow-up care should be ensured for at least 7days post-procedurally. Copyright © 2017 Elsevier Ltd. All rights reserved.

Microsurgical clipping for the true posterior communicating artery aneurysm in the distal portion of the posterior communicating artery

PubMed Central

Takeda, Masaru; Kashimura, Hiroshi; Chida, Kohei; Murakami, Toshiyuki

2015-01-01

Background: Aneurysms arising from the posterior communicating artery (PCoA) itself are rare in which aneurysms usually located in the proximal portion of the PCoA. The authors report a case of the true PCoA ruptured aneurysm in the distal portion of the PCoA. Case Description: The patient was an 83-year-old man who suffered subarachnoid hemorrhage. Cerebral angiography revealed a saccular aneurysm arising on the fetal type right PCoA itself in the distal portion of the PCoA. 2 days after the onset of symptoms, the patient underwent right interfascial pterional craniotomy, with anterior temporal approach. The aneurysm was successfully clipped with the preservation of both the PCoA and the thalamoperforating artery. Conclusion: We speculated that blood flow into the PCoA gradually increased after occlusion of the left vertebral artery, which induced tortuosity of the PCoA. As a result, hemodynamic stress might increase near the curvature and cause aneurysm formation. PMID:26110082

Microsurgical clipping for the true posterior communicating artery aneurysm in the distal portion of the posterior communicating artery.

PubMed

Takeda, Masaru; Kashimura, Hiroshi; Chida, Kohei; Murakami, Toshiyuki

2015-01-01

Aneurysms arising from the posterior communicating artery (PCoA) itself are rare in which aneurysms usually located in the proximal portion of the PCoA. The authors report a case of the true PCoA ruptured aneurysm in the distal portion of the PCoA. The patient was an 83-year-old man who suffered subarachnoid hemorrhage. Cerebral angiography revealed a saccular aneurysm arising on the fetal type right PCoA itself in the distal portion of the PCoA. 2 days after the onset of symptoms, the patient underwent right interfascial pterional craniotomy, with anterior temporal approach. The aneurysm was successfully clipped with the preservation of both the PCoA and the thalamoperforating artery. We speculated that blood flow into the PCoA gradually increased after occlusion of the left vertebral artery, which induced tortuosity of the PCoA. As a result, hemodynamic stress might increase near the curvature and cause aneurysm formation.

Rescue endoscopic bleeding control for nonvariceal upper gastrointestinal hemorrhage using clipping and detachable snaring.

PubMed

Lee, J H; Kim, B K; Seol, D C; Byun, S J; Park, K H; Sung, I K; Park, H S; Shim, C S

2013-06-01

Nonvariceal upper gastrointestinal (UGI) bleeding recurs after appropriate endoscopic therapy in 10 % - 15 % of cases. The mortality rate can be as high as 25 % when bleeding recurs, but there is no consensus about the best modality for endoscopic re-treatment. The aim of this study was to evaluate clipping and detachable snaring (CDS) for rescue endoscopic control of nonvariceal UGI hemorrhage. We report a case series of seven patients from a Korean tertiary center who underwent endoscopic hemostasis using the combined method of detachable snares with hemoclips. The success rate of endoscopic hemostasis with CDS was 86 %: six of the seven patients who had experienced primary endoscopic treatment failure or recurrent bleeding after endoscopic hemostasis were treated successfully. In conclusion, rescue endoscopic bleeding control by means of CDS is an option for controlling nonvariceal UGI bleeding when no other method of endoscopic treatment for recurrent bleeding and primary hemostatic failure is possible. © Georg Thieme Verlag KG Stuttgart · New York.

Management of necrotising appendicitis associated with widespread necrotising enterocolitis of the small and large bowel and perforated duodenal ulcer.

PubMed

Gupta, Vaibhav; Zani, Augusto; Jackson, Paul; Singh, Shailinder

2015-06-08

A 7-year-old boy presented in septic shock secondary to appendicitis with generalised peritonitis. Following crystalloid resuscitation, he underwent surgery. Faecopurulent contamination and free air were found. This was secondary to a perforated and gangrenous appendix, multiple large and small bowel segments with perforations, patches of necrosis, interspersed with healthy bowel and segments of questionable viability. There was also a perforated duodenal ulcer. Necrotic segments were resected using a 'clip-and-drop' technique to shorten operative duration and guide resection to preserve bowel length. After six laparotomies and multiple bowel resections, the child was discharged home with an ileostomy that was subsequently reversed. He is currently on a normal diet and pursuing all activities appropriate for his age. Perforated appendicitis can be associated with widespread bowel necrosis and multiple perforations. A conservative damage limitation approach using the 'clip-and-drop' technique and relook laparotomies is useful in the management of extensive bowel necrosis in children. 2015 BMJ Publishing Group Ltd.

Long-term survival and quality of life in dogs with clinical signs associated with a congenital portosystemic shunt after surgical or medical treatment.

PubMed

Greenhalgh, Stephen N; Reeve, Jenny A; Johnstone, Thurid; Goodfellow, Mark R; Dunning, Mark D; O'Neill, Emma J; Hall, Ed J; Watson, Penny J; Jeffery, Nick D

2014-09-01

To compare long-term survival and quality of life data in dogs with clinical signs associated with a congenital portosystemic shunt (CPSS) that underwent medical or surgical treatment. Prospective cohort study. 124 client-owned dogs with CPSS. Dogs received medical or surgical treatment without regard to signalment, clinical signs, or clinicopathologic results. Survival data were analyzed with a Cox regression model. Quality of life information, obtained from owner questionnaires, included frequency of CPSS-associated clinical signs (from which a clinical score was derived), whether owners considered their dog normal, and (for surgically treated dogs) any ongoing medical treatment for CPSS. A Mann-Whitney U test was used to compare mean clinical score data between surgically and medically managed dogs during predetermined follow-up intervals. 97 dogs underwent surgical treatment; 27 were managed medically. Median follow-up time for all dogs was 1,936 days. Forty-five dogs (24 medically managed and 21 surgically managed) died or were euthanized during the follow-up period. Survival rate was significantly improved in dogs that underwent surgical treatment (hazard ratio, 8.11; 95% CI, 4.20 to 15.66) than in those treated medically for CPSS. Neither age at diagnosis nor shunt type affected survival rate. Frequency of clinical signs was lower in surgically versus medically managed dogs for all follow-up intervals, with a significant difference between groups at 4 to 7 years after study entry. Surgical treatment of CPSS in dogs resulted in significantly improved survival rate and lower frequency of ongoing clinical signs, compared with medical management. Age at diagnosis did not affect survival rate and should not influence treatment choice.

Implant-specific follow-up imaging of treated intracranial aneurysms: TOF-MRA vs. metal artifact reduced intravenous flat panel computed tomography angiography (FPCTA).

PubMed

Hänsel, N H; Schubert, G A; Scholz, B; Nikoubashman, O; Othman, A E; Wiesmann, M; Pjontek, R; Brockmann, M A

2018-02-01

To compare the diagnostic quality of time-of-flight magnetic resonance angiography (TOF-MRA) and metal-artefact-reduction (MAR) flat-panel-detector computed tomography angiography (FPCTA) and to determine the imaging technique best suited for evaluation endovascular and surgically treated aneurysms. The image quality of TOF-MRA and MAR-FPCTA of 44 intracranial implants (coiling: n=20; clipping: n=15; coiling + stenting: n=9) in a patient cohort of 25 was evaluated by two independent readers. Images obtained using MAR-FPCTA (20 second scan time, 496 projections, intravenous contrast medium administration; Artis Zee, Siemens Healthcare, Forchheim) were compared with TOF-MRA-images (1.5 or 3 T). Nominal data were analysed using McNemar's chi-square test and ordinal variables using the Wilcoxon rank test. Compared to TOF-MRA, MAR-FPCTA was significantly better suited to detect aneurysm remnants and to evaluate parent vessels after clipping (p<0.01). For coil packages >160 mm 3 , TOF-MRA provided significantly better assessment than MAR-FPCTA (p<0.01). For small coil packages (<160 mm 3 ), no significant difference between TOF-MRA and MAR-FPCTA (p=0.232) was observed. For different clip sizes (cut-off 492 mm 3 ) likewise no significant differences were found. The interobserver comparison showed high interrater agreement. MAR-FPCTA is significantly better suited for follow-up examinations of clipped aneurysms, whereas for larger coil packages TOF-MRA is preferable. Smaller coil packages can be analysed using MAR-FPCTA or TOF-MRA. Copyright © 2017 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

Aneurysm treatment practice patterns for newly appointed dual-trained cerebrovascular/endovascular neurosurgeons: Comparison of open surgical to neuroendovascular procedures in the first 2 years of academic practice

PubMed Central

Jiang, Bowen; Bender, Matthew T.; Hasjim, Bima; Hsu, Frank P. K.; Tamargo, Rafael J.; Huang, Judy; Colby, Geoffrey P.; Coon, Alexander L.; Lin, Li-Mei

2017-01-01

Background: The practice patterns of a hybrid open cerebrovascular/neuroendovascular (CVNV) neurosurgeon in early academic practice is unknown. Methods: We performed a multi-institutional retrospective cohort study of patients with cerebral aneurysms that were treated within the first 24 months of the neurosurgeon’s practice. Results: A total of 533 aneurysms were treated by the three senior authors within the first 24 months of their academic practice. Of these aneurysms, 172 were treated with microsurgical clipping, 191 with coiling, and 170 with flow diversion. Treatment in the setting of acute subarachnoid hemorrhage (SAH) occurred in 23% (122/533) of the aneurysms. Majority of the clipped aneurysms (70%, 121/172) were anterior cerebral artery (ACA), anterior communicating artery (ACOM), or middle cerebral artery (MCA) in location. In comparison, only 23% (82/361) of aneurysms treated with coiling or flow diversion therapy were ACA, ACOM, or MCA in location (P < 0.05). Additionally, majority of the flow diverted aneurysm (65%, 111/170) were cavernous or ophthalmic/paraophthalmic in location. During the second year of practice, there appeared to be a trend towards more aneurysms treated with neuroendovascular techniques (22% increase), particularly in flow diversion. Conclusion: Although the CVNV neurosurgeon treats cerebral aneurysms more commonly with neuroendovascular techniques, a third of the cerebral aneurysms are still selected for microsurgical clipping. Aneurysms located along the ACA/ACOM or MCA are the most frequent aneurysms reserved for microsurgical clipping. The CVNV neurosurgeon must be prepared to manage a high percentage of ACA/ACOM or MCA aneurysms microsurgically. PMID:28808603

Microsurgical subtemporal approach to aneurysms on the P(2) segment of the posterior cerebral artery.

PubMed

Zhitao, Jing; Yibao, Wang; Anhua, Wu; Shaowu, Ou; Yunchao, Ban; Renyi, Zhou; Yunjie, Wang

2010-01-01

Aneurysms arising from the P(2) segment of the posterior cerebral artery (PCA) are rare, accounting for less than 1% of all intracranial aneurysms. To date, few studies concerning the management of P(2) segment aneurysms have been reported. To review the microsurgical techniques and clinical outcomes of microsurgical treatment by different approaches in patients with aneurysms on the P(2) segment of the PCA. Forty-two patients with P2 segment aneurysms had microsurgical treatment by subtemporal approach. All the patients had drainage of cerebrospinal fluid for decompression, and indocyanine green (ICG) angiography was used in 20 patients to assess the effect of clipping. Of the 42 patients, 16 were operated by combined pterional-subtemporal approach. In 40 patients aneurysms were successfully treated by clipping the P(2) aneurysmal neck while preserving the parent artery. Two patients with giant aneurysms were treated using surgical trapping. Postoperatively, 41 patients had a good recovery. One patient after aneurysm trapping had ischemic infarction in the PCA tertiary and presented with hemiparesis and homonymous hemianopia. However, this patient recovered after three weeks of treatment. Subtemporal approach is the most appropriate approach to clip the aneurysms of the P(2) segment. It allows the neurosurgeon to operate on the aneurysms while preserving the patency of the parent artery. Gaint P(2) segment aneurysms can safely be treated by rapping of the aneurysm by combined subtemporal or pterional-subtemporal approach in experienced hands. ICG angiography will be an important tool in monitoring for the presence of residual aneurysm or perforating artery occlusion during aneurysm clipping. Preoperative lumbar drainage of cerebrospinal fluid may help to avoid temporal lobe damage.

Outcome of urethral strictures treated by endoscopic urethrotomy and urethroplasty

PubMed Central

Tinaut-Ranera, Javier; Arrabal-Polo, Miguel Ángel; Merino-Salas, Sergio; Nogueras-Ocaña, Mercedes; López-León, Víctor Manuel; Palao-Yago, Francisco; Arrabal-Martín, Miguel; Lahoz-García, Clara; Alaminos, Miguel; Zuluaga-Gomez, Armando

2014-01-01

Introduction: We analyze the outcomes of patients with urethral stricture who underwent surgical treatment within the past 5 years. Methods: This is a retrospective study of male patients who underwent surgery for urethral stricture at our service from January 2008 to June 2012. We analyzed the comorbidities, type, length and location of the stricture and the surgical treatment outcome after endoscopic urethrotomy, urethroplasty or both. Results: In total, 45 patients with a mean age of 53.7 ± 16.7 years underwent surgical treatment for urethral stricture. Six months after surgery, 46.7% of the patients had a maximum urinary flow greater than 15 mL/s, whereas 87.3% of the patients exhibited no stricture by urethrography after the treatment. The success rate in the patients undergoing urethrotomy was 47.8% versus 86.4% in those undergoing urethroplasty (p = 0.01). Twenty percent of the patients in whom the initial urethrotomy had failed subsequently underwent urethroplasty, thereby increasing the treatment success. Conclusion: In most cases, the treatment of choice for urethral stricture should be urethroplasty. Previous treatment with urethrotomy does not appear to produce adverse effects that affect the outcome of a urethroplasty if urethrotomy failed, so urethrotomy may be indicated in patients with short strictures or in patients at high surgical risk. PMID:24454595

Outcome of urethral strictures treated by endoscopic urethrotomy and urethroplasty.

PubMed

Tinaut-Ranera, Javier; Arrabal-Polo, Miguel Ángel; Merino-Salas, Sergio; Nogueras-Ocaña, Mercedes; López-León, Víctor Manuel; Palao-Yago, Francisco; Arrabal-Martín, Miguel; Lahoz-García, Clara; Alaminos, Miguel; Zuluaga-Gomez, Armando

2014-01-01

We analyze the outcomes of patients with urethral stricture who underwent surgical treatment within the past 5 years. This is a retrospective study of male patients who underwent surgery for urethral stricture at our service from January 2008 to June 2012. We analyzed the comorbidities, type, length and location of the stricture and the surgical treatment outcome after endoscopic urethrotomy, urethroplasty or both. In total, 45 patients with a mean age of 53.7 ± 16.7 years underwent surgical treatment for urethral stricture. Six months after surgery, 46.7% of the patients had a maximum urinary flow greater than 15 mL/s, whereas 87.3% of the patients exhibited no stricture by urethrography after the treatment. The success rate in the patients undergoing urethrotomy was 47.8% versus 86.4% in those undergoing urethroplasty (p = 0.01). Twenty percent of the patients in whom the initial urethrotomy had failed subsequently underwent urethroplasty, thereby increasing the treatment success. In most cases, the treatment of choice for urethral stricture should be urethroplasty. Previous treatment with urethrotomy does not appear to produce adverse effects that affect the outcome of a urethroplasty if urethrotomy failed, so urethrotomy may be indicated in patients with short strictures or in patients at high surgical risk.

Economic burden of cancer among patients with surgical resections of the lung, rectum, liver and uterus: results from a US hospital database claims analysis.

PubMed

Kalsekar, Iftekhar; Hsiao, Chia-Wen; Cheng, Hang; Yadalam, Sashi; Chen, Brian Po-Han; Goldstein, Laura; Yoo, Andrew

2017-12-01

To determine hospital resource utilization, associated costs and the risk of complications during hospitalization for four types of surgical resections and to estimate the incremental burden among patients with cancer compared to those without cancer. Patients (≥18 years old) were identified from the Premier Research Database of US hospitals if they had any of the following types of elective surgical resections between 1/2008 and 12/2014: lung lobectomy, lower anterior resection of the rectum (LAR), liver wedge resection, or total hysterectomy. Cancer status was determined based on ICD-9-CM diagnosis codes. Operating room time (ORT), length of stay (LOS), and total hospital costs, as well as frequency of bleeding and infections during hospitalization were evaluated. The impact of cancer status on outcomes (from a hospital perspective) was evaluated using multivariable generalized estimating equation models; analyses were conducted separately for each resection type. Among the identified patients who underwent surgical resection, 23 858 (87.9% with cancer) underwent lung lobectomy, 13 522 (63.8% with cancer) underwent LAR, 2916 (30.0% with cancer) underwent liver wedge resection and 225 075 (11.3% with cancer) underwent total hysterectomy. After adjusting for patient, procedural, and hospital characteristics, mean ORT, LOS, and hospital cost were statistically higher by 3.2%, 8.2%, and 9.2%, respectively for patients with cancer vs. no cancer who underwent lung lobectomy; statistically higher by 6.9%, 9.4%, and 9.6%, respectively for patients with cancer vs. no cancer who underwent LAR; statistically higher by 4.9%, 14.8%, and 15.7%, respectively for patients with cancer vs. no cancer who underwent liver wedge resection; and statistically higher by 16.0%, 27.4%, and 31.3%, respectively for patients with cancer vs. no cancer who underwent total hysterectomy. Among patients who underwent each type of resection, risks for bleeding and infection were generally higher among patients with cancer as compared to those without cancer. In this analysis, we found that patients who underwent lung lobectomy, lower anterior resection of the rectum (LAR), liver wedge resection or total hysterectomy for a cancer indication have significantly increased hospital resource utilization compared to these same surgeries for benign indications.

Dosimetric Improvements with a Novel Breast Stereotactic Radiotherapy Device for Delivery of Preoperative Partial-Breast Irradiation.

PubMed

Snider, James W; Mutaf, Yildirim; Nichols, Elizabeth; Hall, Andrea; Vadnais, Patrick; Regine, William F; Feigenberg, Steven J

2017-01-01

Partial-breast irradiation (PBI) with external-beam radiotherapy has produced higher than expected rates of fair-to-poor cosmesis. Worsened outcomes have been correlated with larger volumes of breast tissue exposed to radiation. A novel breast-specific stereotactic radiotherapy (BSRT) device (BSRTD) has been developed at our institution and has shown promise in delivering highly conformal dose distributions. We compared normal tissue sparing with this device with that achieved with intensity-modulated radiation therapy (IMRT)-PBI. Fifteen women previously treated with breast conservation therapy were enrolled on an institutional review board-approved protocol. Each of them underwent CT simulation in the prone position using the BSRTD-specific immobilization system. Simulated postoperative and preoperative treatment volumes were generated based on surgical bed/clip position. Blinded planners generated IMRT-PBI plans and BSRT plans for each set of volumes. These plans were compared based on clinically validated markers for cosmetic outcome and toxicity using a Wilcoxon rank-sum test. The BSRT plans consistently reduced the volumes receiving each of several dose levels (Vx) to breast tissue, the chest wall, the lung, the heart, and the skin in both preoperative and postoperative settings (p < 0.05). Preoperative BSRT yielded particularly dramatic improvements. The novel BSRTD has demonstrated significant dosimetric benefits over IMRT-PBI. Further investigation is currently proceeding through initial clinical trials. © 2016 S. Karger AG, Basel.

Three-dimensional intrafractional internal target motions in accelerated partial breast irradiation using three-dimensional conformal external beam radiotherapy.

PubMed

Hirata, Kimiko; Yoshimura, Michio; Mukumoto, Nobutaka; Nakamura, Mitsuhiro; Inoue, Minoru; Sasaki, Makoto; Fujimoto, Takahiro; Yano, Shinsuke; Nakata, Manabu; Mizowaki, Takashi; Hiraoka, Masahiro

2017-07-01

We evaluated three-dimensional intrafractional target motion, divided into respiratory-induced motion and baseline drift, in accelerated partial breast irradiation (APBI). Paired fluoroscopic images were acquired simultaneously using orthogonal kV X-ray imaging systems at pre- and post-treatment for 23 patients who underwent APBI with external beam radiotherapy. The internal target motion was calculated from the surgical clips placed around the tumour cavity. The peak-to-peak respiratory-induced motions ranged from 0.6 to 1.5mm in all directions. A systematic baseline drift of 1.5mm towards the posterior direction and a random baseline drift of 0.3mm in the lateral-medial and cranial-caudal directions were observed. The baseline for an outer tumour cavity drifted towards the lateral and posterior directions, and that for an upper tumour cavity drifted towards the cranial direction. Moderate correlations were observed between the posterior baseline drift and the patients' physical characteristics. The posterior margin for intrafractional uncertainties was larger than 5mm in patients with greater fat thickness due to the baseline drift. The magnitude of the intrafractional motion was not uniform according to the direction, patients' physical characteristics, or tumour cavity location due to the baseline drift. Therefore, the intrafractional systematic movement should be properly managed. Copyright © 2017 Elsevier B.V. All rights reserved.

Comparison of effectiveness and cost of patent ductus arteriosus device occlusion versus surgical ligation of patent ductus arteriosus

PubMed Central

Zulqarnain, Arif; Younas, Muhammad; Waqar, Tariq; Beg, Ahsan; Asma, Touseef; Baig, Mirza Ahmad Raza

2016-01-01

Objectives: Comparison of effectiveness and cost of transcatheter occlusion of patent ductus arteriosus (PDA) with surgical ligation of PDA. Methods: This retrospective comparative study was conducted in the pediatric cardiology department of Ch. Pervaiz Elahi Institute of Cardiology Multan, Pakistan. Data of 250 patients who underwent patent ductus arteriosus (PDA) closure either surgical or trans-catheter closure using SHSMA Occluder having weight >5 kg from April 2012 to October 2015 were included in this study. SPSS version 20 was used for data analysis. Quantitative variables were compared using independent sample t-test. Chi-square test and fishers exact was used for qualitative variables. P-value <0.05 was considered statistically significant. Results: There were one hundred and twenty (120) patients who underwent transcatheter occlusion of PDA using SHSMA occluder (PDA Device Group) and one hundred and thirty (130) patients who underwent surgical ligation of PDA (Surgical Group). Incidence of residual shunting was two (1.5%) in surgical group and 0 (0.0%) in PDA Device group for one month follow up period. There were 4 (3.1%) major complications in surgical group. The rate of blood transfusions were high in surgical group (p-value 0.04). Hospital stay time was significantly less in PDA Device group (P-value <0.001). Total procedural cost was 110695+1054 Pakistani rupees in PDA Device group and 92414+3512 in surgical group (p-value <0.001). The cost of PDA device closure was 16.52% higher than the surgical ligation of PDA. There was no operative mortality. Conclusion: The transcatheter closure of PDA is an effective and less invasive method as compared to the surgical ligation. There is a lower rate of complications and the cost is not much high as compared to surgical PDA ligation. PMID:27648051

Reversible surgical model of biliary inflammation and obstructive jaundice in mice.

PubMed

Kirkland, Jacob G; Godfrey, Cody B; Garrett, Ryan; Kakar, Sanjay; Yeh, Benjamin M; Corvera, Carlos U

2010-12-01

Common bile duct (CBD) ligation is used in animal models to induce biliary inflammation, fibrosis, and cholestatic liver injury, but results in a high early postoperative mortality rate, probably from traumatic pancreatitis. We modified the CBD ligation model in mice by placing a small metal clip across the lower end of the CBD. To reverse biliary obstruction, a suture was incorporated within the clip during its placement. The suture and clip were removed on postoperative d 5 or 10 for biliary decompression. After 5 d of biliary obstruction, the gallbladder showed an 8-fold increase in wall thickness and a 17-fold increase in tissue myeloperoxidase activity. Markedly elevated serum levels of alkaline phosphatase and bilirubin indicated injury to the biliary epithelium and hepatocytes. Early postoperative (d 0-2) survival was 100% and later (d 3-5) survival was 85% (n=54 mice). We successfully reversed biliary obstruction in 20 mice (37%). Overall survival after reversal was 70%. In surviving mice, biliary decompression was complete, inflammation was reduced, and jaundice resolved. Histologic features confirmed reduced epithelial damage, edema, and neutrophil infiltration. Our technique minimized postoperative death, maintained an effective inflammatory response, and was easily reversible without requiring repeat laparotomy. This reversible model can be used to further define molecular mechanisms of biliary inflammation, fibrosis, and liver injury in genetically altered mice. Copyright © 2010. Published by Elsevier Inc.

Surgical procedures in liver transplant patients: A monocentric retrospective cohort study.

PubMed

Sommacale, Daniele; Nagarajan, Ganesh; Lhuaire, Martin; Dondero, Federica; Pessaux, Patrick; Piardi, Tullio; Sauvanet, Alain; Kianmanesh, Reza; Belghiti, Jacques

2017-05-01

Pre-existing chronic liver diseases and the complexity of the transplant surgery procedures lead to a greater risk of further surgery in transplanted patients compared to the general population. The aim of this monocentric retrospective cohort study was to assess the epidemiology of surgical complications in liver transplanted patients who require further surgical procedures and to characterize their post-operative risk of complications to enhance their medical care. From January 1997 to December 2011, 1211 patients underwent orthotropic liver transplantation in our center. A retrospective analysis of prospectively collected data was performed considering patients who underwent surgical procedures more than three months after transplantation. We recorded liver transplantation technique, type of surgery, post-operative complications, time since the liver transplant and immunosuppressive regimens. Among these, 161 patients (15%) underwent a further 183 surgical procedures for conditions both related and unrelated to the transplant. The most common surgical procedure was for an incisional hernia repair (n = 101), followed by bilioenteric anastomosis (n = 44), intestinal surgery (n = 23), liver surgery (n = 8) and other surgical procedures (n = 7). Emergency surgery was required in 19 procedures (10%), while 162 procedures (90%) were performed electively. Post-operative mortality and morbidity were 1% and 30%, respectively. According to the Dindo-Clavien classification, the most common grade of morbidity was grade III (46%), followed by grade II (40%). Surgical procedures on liver transplanted patients are associated with a significantly high risk of complications, irrespective of the time elapsed since transplantation. Copyright © 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.

Contralateral Supracerebellar-Infratentorial Approach for Resection of Thalamic Cavernous Malformations.

PubMed

Mascitelli, Justin; Burkhardt, Jan-Karl; Gandhi, Sirin; Lawton, Michael T

2018-02-26

Surgical resection of cavernous malformations (CM) in the posterior thalamus, pineal region, and midbrain tectum is technically challenging owing to the presence of adjacent eloquent cortex and critical neurovascular structures. Various supracerebellar infratentorial (SCIT) approaches have been used in the surgical armamentarium targeting lesions in this region, including the median, paramedian, and extreme lateral variants. Surgical view of a posterior thalamic CM from the traditional ipsilateral vantage point may be obscured by occipital lobe and tentorium. To describe a novel surgical approach via a contralateral SCIT (cSCIT) trajectory for resecting posterior thalamic CMs. From 1997 to 2017, 75 patients underwent the SCIT approach for cerebrovascular/oncologic pathology by the senior author. Of these, 30 patients underwent the SCIT approach for CM resection, and 3 patients underwent the cSCIT approach. Historical patient data, radiographic features, surgical technique, and postoperative neurological outcomes were evaluated in each patient. All 3 patients presented with symptomatic CMs within the right posterior thalamus with radiographic evidence of hemorrhage. All surgeries were performed in the sitting position. There were no intraoperative complications. Neuroimaging demonstrated complete CM resection in all cases. There were no new or worsening neurological deficits or evidence of rebleeding/recurrence noted postoperatively. This study establishes the surgical feasibility of a contralateral SCIT approach in resection of symptomatic thalamic CMs It demonstrates the application for this procedure in extending the surgical trajectory superiorly and laterally and maximizing safe resectability of these deep CMs with gravity-assisted brain retraction.

Plastic surgical operative workload in major trauma patients following establishment of the major trauma network in England: A retrospective cohort study.

PubMed

Hendrickson, S A; Khan, M A; Verjee, L S; Rahman, K M A; Simmons, J; Hettiaratchy, S P

2016-07-01

The introduction of major trauma centres (MTCs) in England has led to 63% reduction in trauma mortality.(1) The role of plastic surgeons supporting these centres has not been quantified previously. This study aimed to quantify plastic surgical workload at an urban MTC to determine the contribution of plastic surgeons to major trauma care. All Trauma Audit and Research Network (TARN)-recorded major trauma patients who presented to an urban MTC in 2013 and underwent an operation were identified retrospectively. Patients who underwent plastic surgery were identified and the type and date of procedure(s) were recorded. The trauma operative workload data of another tertiary surgical specialty and local historical plastics workload data from pre-MTC go-live were collected for comparison. Of the 416 major trauma patients who required surgical intervention, 29% (n = 122) underwent plastic surgery. Of these patients, 43% had open lower limb fractures, necessitating plastic surgical involvement according to British Orthopaedic Association Standards for Trauma (BOAST) 4 guidance. The overall plastic surgery operative workload increased sevenfold post-MTC go-live. A similar proportion of the same cohort required neurosurgery (n = 115; p = 0.589). This study quantifies plastic surgery involvement in major trauma and demonstrates that plastic surgical operative workload is at least on par with other tertiary surgical specialties. It also reports one centre's experience of a significant change in plastic surgery activity following designation of MTC status. The quantity of plastic surgical operative workload in major trauma must be considered when planning major trauma service design and workforce provision, and for plastic surgical postgraduate training. Copyright © 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Surgical Dislocation of the Hip for the Treatment of Pre-Arthritic Hip Disease.

PubMed

Beaulé, Paul E; Singh, Amardeep; Poitras, Stéphane; Parker, Gillian

2015-09-01

The purpose of this study was to report the clinical results of surgical dislocation of the hip in the treatment of pre-arthritic hip disease. Between 2005 and 2010, eighty-two patients (89 hips) underwent a surgical dislocation of the hip at a mean age of 30.5 years (range 14.8-51.7); 10 females and 72 males. At a mean follow-up of 7.1 years (range 5-9.6) clinical function improved significantly. 6 patients were converted to total hip arthroplasty and 3 patients underwent an arthroscopy and an additional three patients had >1mm of joint space narrowing at latest follow-up giving us a 9-year cumulative Kaplan-Meier survivorship of 86.4% (CI, 79% to 94%). Thirty-four patients underwent internal fixation removal at a mean of 12.0 months (range 0.3-40.8 months). Although effective in the treatment of early hip disease, the surgical dislocation approach carries a high re-operation rate for removal of internal fixation; consequently, less invasive approaches should be considered for less complex deformities. Copyright © 2015 Elsevier Inc. All rights reserved.

Impact of interventional edge-to-edge repair on mitral valve geometry.

PubMed

Schueler, Robert; Kaplan, Sarah; Melzer, Charlotte; Öztürk, Can; Weber, Marcel; Sinning, Jan-Malte; Welz, Armin; Werner, Nikos; Nickenig, Georg; Hammerstingl, Christoph

2017-03-01

The acute and long-term effects of interventional edge-to-edge repair on the mitral valve (MV) geometry are unclear. We sought to assess MV-annular geometry and the association of changes in MV-diameters with functional response one year after MitraClip implantation. Consecutive patients (n=84; age 81.2±8.3years, logistic EuroSCORE 21.7±17.9%) with symptomatic moderate-to-severe mitral regurgitation (MR) underwent MitraClip-procedure. MV-annular geometry was assessed with 3D TOE before, immediately and one year after clip implantation. 96.7% of secondary mitral regurgitation (SMR) patients presented with moderate-to-severe MR, 3.3% with severe SMR, respectively. 66.7% of primary MR (PMR) patients had moderate-to-severe MR, and 33.3% severe PMR respectively. When analyzing immediate effects of MitraClipC on mitral geometry, only patients with SMR (n=60, 71.4%) experienced significant reductions of the diastolic MV anterior-posterior diameters (AP: 3.9±0.5cm, 3.5±0.7cm; p<0.001), and annulus-areas (2D: 12.9±3.8cm2, 12.6±3.7cm2; p<0.001; 3D: 13.4±3.8, 13.1±3.2cm2; p<0.001). All measures on MV annular geometry were not significantly altered in patients with PMR (p>0.05). After one year of follow-up, MV annular parameters remained significantly reduced in SMR patients (p<0.05) and remained unchanged in subjects with PMR (p>0.05). Only SMR patients experienced significant increase in 6min walking distances (p=0.004), decrease in pulmonary pressures (p=0.007) and functional NYHA-class (p<0.001); in patients with PMR only NYHA class improved after one year (p<0.001). Edge-to-edge repair with the MitraClip-system impacts on MV-geometry in patients with SMR with stable results after 12months. Reduction of MV-annular dimensions was associated with higher rates of persisting MR reduction and better functional status in patients with SMR. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Obstructive Sleep Apnea Syndrome in Children with 22q11.2 Deletion Syndrome after Operative Intervention for Velopharyngeal Insufficiency

PubMed Central

Crockett, David Jeffrey; Goudy, Steven L.; Chinnadurai, Sivakumar; Wootten, Christopher Todd

2014-01-01

Introduction: Surgical treatment of velopharyngeal insufficiency (VPI) in 22q11.2 deletion syndrome is often warranted. In this patient population, VPI is characterized by poor palatal elevation and muscular hypotonia with an intact palate. We hypothesize that 22q11.2 deletion patients are at greater risk of obstructive sleep apnea (OSA) after surgical correction of VPI, due, in part, to their functional hypotonia, large velopharyngeal gap size, and the need to surgically obstruct the velopharynx. Methods: We performed a retrospective analysis of patients with 22q11.2 deletion syndrome treated at a tertiary pediatric hospital between the years of 2002 and 2012. The incidence of VPI, need for surgery, post-operative polysomnogram, post-operative VPI assessment, and OSA treatments were evaluated. Results: Forty-three patients (18 males, 25 females, ages 1–14 years) fitting the inclusion criteria were identified. Twenty-eight patients were evaluated by speech pathology due to hypernasality. Twenty-one patients had insufficient velopharyngeal function and required surgery. Fifteen underwent pharyngeal flap surgery, three underwent sphincter pharyngoplasty, two underwent Furlow palatoplasty, and one underwent combined sphincter pharyngoplasty with Furlow palatoplasty. Of these, eight had post-operative snoring. Six of these underwent polysomnography (five underwent pharyngeal flap surgeries and one underwent sphincter pharyngoplasty). Four patients were found to have OSA based on the results of the polysomnography (average apnea/hypopnea index of 4.9 events/h, median = 5.1, SD = 2.1). Two required continuous positive airway pressure (CPAP) due to moderate OSA. Conclusion: Surgery is often necessary to correct VPI in patients with 22q11.2 deletion syndrome. Monitoring for OSA should be considered after surgical correction of VPI due to a high occurrence in this population. Furthermore, families should be counseled of the risk of OSA after surgery and the potential need for treatment with CPAP. PMID:25157342

History, Evolution, and Continuing Innovations of Intracranial Aneurysm Surgery.

PubMed

Lai, Leon T; O'Neill, Anthea H

2017-06-01

Evolution in the surgical treatment of intracranial aneurysms is driven by the need to refine and innovate. From an early application of the Hunterian carotid ligation to modern-day sophisticated aneurysm clip designs, progress has been made through dedication and technical maturation of cerebrovascular neurosurgeons to overcome challenges in their practices. The global expansion of endovascular services has challenged the existence of aneurysm surgery, changing the complexity of the aneurysm case mix and volume that are referred for surgical repair. Concepts of how to best treat intracranial aneurysms have evolved over generations and will continue to do so with further technological innovations. As with the evolution of any type of surgery, innovations frequently arise from the criticism of current techniques. Copyright © 2017 Elsevier Inc. All rights reserved.

A failure to communicate: patients with cerebral aneurysms and vascular neurosurgeons

PubMed Central

King, J; Yonas, H; Horowitz, M; Kassam, A; Roberts, M

2005-01-01

Objective: To assess communication between vascular neurosurgeons and their patients with unruptured cerebral aneurysms about treatment options and expected outcomes. Methods: Vascular neurosurgeons and their patients with cerebral aneurysms were surveyed immediately following outpatient appointments in a neurosurgery clinic. Data collected included how well the patient understood their aneurysm treatment options, the risks of a poor outcome from various treatments, and the consensus "best" treatment. Patient and neurosurgeon responses were measured using Likert scales, multiple choice questions, and visual analogue scales. Agreement between patient and neurosurgeon was assessed with kappa scores. The Wilcoxon sign rank test was used to compare visual analogue scale responses. Results: Data for 44 patient–neurosurgeon pairs were collected. Only 61% of patient–neurosurgeon pairs agreed on the best treatment plan for the patient's aneurysm (κ = 0.51, moderate agreement). Among the neurosurgeons, agreement with their patients ranged from 82% (κ = 0.77, almost perfect agreement) to 52% (κ = 0.37, fair agreement). Patients estimated much higher risks of stroke or death from surgical clipping, endovascular embolisation, or no intervention compared with the estimates offered by their neurosurgeons (surgical clipping: patient 36% v neurosurgeon 13%, p<0.001; endovascular embolisation: patient 35% v neurosurgeon 19%, p = 0.040; and no intervention: patient 63% v neurosurgeon 25%, p<0.001). Conclusions: Following consultation with a vascular neurosurgeon, many patients with cerebral aneurysms have an inaccurate understanding of their aneurysm treatment plan and an exaggerated sense of the risks of aneurysmal disease and treatment. PMID:15774444

A failure to communicate: patients with cerebral aneurysms and vascular neurosurgeons.

PubMed

King, J T; Yonas, H; Horowitz, M B; Kassam, A B; Roberts, M S

2005-04-01

To assess communication between vascular neurosurgeons and their patients with unruptured cerebral aneurysms about treatment options and expected outcomes. Vascular neurosurgeons and their patients with cerebral aneurysms were surveyed immediately following outpatient appointments in a neurosurgery clinic. Data collected included how well the patient understood their aneurysm treatment options, the risks of a poor outcome from various treatments, and the consensus "best" treatment. Patient and neurosurgeon responses were measured using Likert scales, multiple choice questions, and visual analogue scales. Agreement between patient and neurosurgeon was assessed with kappa scores. The Wilcoxon sign rank test was used to compare visual analogue scale responses. Data for 44 patient-neurosurgeon pairs were collected. Only 61% of patient-neurosurgeon pairs agreed on the best treatment plan for the patient's aneurysm (kappa = 0.51, moderate agreement). Among the neurosurgeons, agreement with their patients ranged from 82% (kappa = 0.77, almost perfect agreement) to 52% (kappa = 0.37, fair agreement). Patients estimated much higher risks of stroke or death from surgical clipping, endovascular embolisation, or no intervention compared with the estimates offered by their neurosurgeons (surgical clipping: patient 36% v neurosurgeon 13%, p<0.001; endovascular embolisation: patient 35% v neurosurgeon 19%, p = 0.040; and no patient 63% v neurosurgeon 25%, p<0.001). Following consultation with a vascular neurosurgeon, many patients with cerebral aneurysms have an inaccurate understanding of their aneurysm treatment plan and an exaggerated sense of the risks of aneurysmal disease and treatment.

Surgical treatment of childhood hepatoblastoma in the Netherlands (1990-2013).

PubMed

Busweiler, Linde A D; Wijnen, Marc H W A; Wilde, Jim C H; Sieders, Egbert; Terwisscha van Scheltinga, Sheila E J; van Heurn, L W Ernest; Ziros, Joseph; Bakx, Roel; Heij, Hugo A

2017-01-01

Achievement of complete surgical resection plays a key role in the successful treatment of children with hepatoblastoma. The aim of this study is to assess the surgical outcomes after partial liver resections for hepatoblastoma, focusing on postoperative complications, resection margins, 30-day mortality, and long-term survival. Chart reviews were carried out on all patients treated for hepatoblastoma in the Netherlands between 1990 and 2013. A total of 103 patients were included, of whom 94 underwent surgery. Partial hepatectomy was performed in 76 patients and 18 patients received a liver transplant as a primary procedure. In 42 of 73 (58 %) patients, one or more complications were reported. In 3 patients, information regarding complications was not available. Hemorrhage necessitating blood transfusion occurred in 33 (45 %) patients and 9 (12 %) patients developed biliary complications, of whom 8 needed one or more additional surgical interventions. Overall, 5-year disease-specific survival was 82, 92 % in the group of patients who underwent partial hepatectomy, and 77 % in the group of patients who underwent liver transplantation. Partial hepatectomy after chemotherapy in children with hepatoblastoma offers good chances of survival. This type of major surgery is associated with a high rate of surgical complications (58 %), which is not detrimental to survival.

Biologic Collagen Cylinder with Skate Flap Technique for Nipple Reconstruction

PubMed Central

Tierney, Brian P.; Hodde, Jason P.; Changkuon, Daniela I.

2014-01-01

A surgical technique using local tissue skate flaps combined with cylinders made from a naturally derived biomaterial has been used effectively for nipple reconstruction. A retrospective review of patients who underwent nipple reconstruction using this technique was performed. Comorbidities and type of breast reconstruction were collected. Outcome evaluation included complications, surgical revisions, and nipple projection. There were 115 skate flap reconstructions performed in 83 patients between July 2009 and January 2013. Patients ranged from 32 to 73 years old. Average body mass index was 28.0. The most common comorbidities were hypertension (39.8%) and smoking (16.9%). After breast reconstruction, 68.7% of the patients underwent chemotherapy and 20.5% underwent radiation. Seventy-one patients had immediate breast reconstruction with expanders and 12 had delayed reconstruction. The only reported complications were extrusions (3.5%). Six nipples (5.2%) in 5 patients required surgical revision due to loss of projection; two patients had minor loss of projection but did not require surgical revision. Nipple projection at time of surgery ranged from 6 to 7 mm and average projection at 6 months was 3–5 mm. A surgical technique for nipple reconstruction using a skate flap with a graft material is described. Complications are infrequent and short-term projection measurements are encouraging. PMID:25114802

Biologic collagen cylinder with skate flap technique for nipple reconstruction.

PubMed

Tierney, Brian P; Hodde, Jason P; Changkuon, Daniela I

2014-01-01

A surgical technique using local tissue skate flaps combined with cylinders made from a naturally derived biomaterial has been used effectively for nipple reconstruction. A retrospective review of patients who underwent nipple reconstruction using this technique was performed. Comorbidities and type of breast reconstruction were collected. Outcome evaluation included complications, surgical revisions, and nipple projection. There were 115 skate flap reconstructions performed in 83 patients between July 2009 and January 2013. Patients ranged from 32 to 73 years old. Average body mass index was 28.0. The most common comorbidities were hypertension (39.8%) and smoking (16.9%). After breast reconstruction, 68.7% of the patients underwent chemotherapy and 20.5% underwent radiation. Seventy-one patients had immediate breast reconstruction with expanders and 12 had delayed reconstruction. The only reported complications were extrusions (3.5%). Six nipples (5.2%) in 5 patients required surgical revision due to loss of projection; two patients had minor loss of projection but did not require surgical revision. Nipple projection at time of surgery ranged from 6 to 7 mm and average projection at 6 months was 3-5 mm. A surgical technique for nipple reconstruction using a skate flap with a graft material is described. Complications are infrequent and short-term projection measurements are encouraging.

Crowd-sourced assessment of technical skills: an opportunity for improvement in the assessment of laparoscopic surgical skills.

PubMed

Deal, Shanley B; Lendvay, Thomas S; Haque, Mohamad I; Brand, Timothy; Comstock, Bryan; Warren, Justin; Alseidi, Adnan

2016-02-01

Objective, unbiased assessment of surgical skills remains a challenge in surgical education. We sought to evaluate the feasibility and reliability of Crowd-Sourced Assessment of Technical Skills. Seven volunteer general surgery interns were given time for training and then testing, on laparoscopic peg transfer, precision cutting, and intracorporeal knot-tying. Six faculty experts (FEs) and 203 Amazon.com Mechanical Turk crowd workers (CWs) evaluated 21 deidentified video clips using the Global Objective Assessment of Laparoscopic Skills validated rating instrument. Within 19 hours and 15 minutes we received 662 eligible ratings from 203 CWs and 126 ratings from 6 FEs over 10 days. FE video ratings were of borderline internal consistency (Krippendorff's alpha = .55). FE ratings were highly correlated with CW ratings (Pearson's correlation coefficient = .78, P < .001). We propose the use of Crowd-Sourced Assessment of Technical Skills as a reliable, basic tool to standardize the evaluation of technical skills in general surgery. Copyright © 2016 Elsevier Inc. All rights reserved.

Numerical simulations of post-surgical flow and thrombosis in basilar artery aneurysms

NASA Astrophysics Data System (ADS)

Seshadhri, Santhosh; Lawton, Michael; Boussel, Loic; Saloner, David; Rayz, Vitaliy

2015-11-01

Surgical treatment of basilar artery aneurysms presents a major challenge since it is crucial to preserve the flow to the vital brainstem perforators branching of the basilar artery. In some cases, basilar aneurysms can be treated by clipping vessels in order to induce flow reduction and aneurysm thrombosis. Patient-specific CFD models can provide guidance to clinicians by simulating postoperative flows resulting from alternative surgeries. Several surgical options were evaluated for four basilar aneurysm patients. Patient-specific models were generated from preoperative MR angiography and MR velocimetry data and modified to simulate different procedures. The Navier-Stokes equations were solved with a finite-volume solver Fluent. Virtual contrast injections were simulated by solving the advection-diffusion equation in order to estimate the flow residence time and determine thrombus-prone regions. The results indicated on procedures that reduce intra-aneurysmal velocities and flow regions which are likely to become thrombosed. Thus CFD modeling can help improve the outcome of surgeries altering the flow in basilar aneurysms.

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.

Three surgical planes identified in laparoscopic complete mesocolic excision for right-sided colon cancer.

PubMed

Zhu, Da-Jian; Chen, Xiao-Wu; OuYang, Man-Zhao; Lu, Yan

2016-01-12

Complete mesocolic excision provides a correct anatomical plane for colon cancer surgery. However, manifestation of the surgical plane during laparoscopic complete mesocolic excision versus in computed tomography images remains to be examined. Patients who underwent laparoscopic complete mesocolic excision for right-sided colon cancer underwent an abdominal computed tomography scan. The spatial relationship of the intraoperative surgical planes were examined, and then computed tomography reconstruction methods were applied. The resulting images were analyzed. In 44 right-sided colon cancer patients, the surgical plane for laparoscopic complete mesocolic excision was found to be composed of three surgical planes that were identified by computed tomography imaging with cross-sectional multiplanar reconstruction, maximum intensity projection, and volume reconstruction. For the operations performed, the mean bleeding volume was 73±32.3 ml and the mean number of harvested lymph nodes was 22±9.7. The follow-up period ranged from 6-40 months (mean 21.2), and only two patients had distant metastases. The laparoscopic complete mesocolic excision surgical plane for right-sided colon cancer is composed of three surgical planes. When these surgical planes were identified, laparoscopic complete mesocolic excision was a safe and effective procedure for the resection of colon cancer.

Posterior inferior cerebellar artery aneurysms: Anatomical variations and surgical strategies

PubMed Central

Singh, Rohit K.; Behari, Sanjay; Kumar, Vijendra; Jaiswal, Awadhesh K.; Jain, Vijendra K.

2012-01-01

Context: Posterior inferior cerebellar artery (PICA) aneurysms are associated with multiple anatomical variations of the parent vessel. Complexities in their surgical clipping relate to narrow corridors limited by brain-stem, petrous-occipital bones, and multiple neurovascular structures occupying the cerebellomedullary and cerebellopontine cisterns. Aims: The present study focuses on surgical considerations during clipping of saccular PICA aneurysms. Setting and Design: Tertiary care, retrospective study. Materials and Methods: In 20 patients with PICA aneurysms, CT angiogram/digital substraction angiogram was used to correlate the site and anatomical variations of aneurysms located on different segments of PICA with the approach selected, the difficulties encountered and the final outcome. Statistical Analysis: Comparison of means and percentages. Results: Aneurysms were located on PICA at: vertebral artery/basilar artery (VA/BA)-PICA (n=5); anterior medullary (n=4); lateral medullary (n=3); tonsillomedullary (n=4); and, telovelotonsillar (n=4) segments. The Hunt and Hess grade distribution was I in 15; II in 2; and, III in 3 patients (mean ictus-surgery interval: 23.5 days; range: 3-150 days). Eight patients had hydrocephalus. Anatomical variations included giant, thrombosed aneurysms; 2 PICA aneurysms proximal to an arteriovenous malformation; bilobed or multiple aneurysms; low PICA situated at the foramen magnum with a hypoplastic VA; and fenestrated PICA. The approaches included a retromastoid suboccipital craniectomy (n=9); midline suboccipital craniectomy (n=6); and far-lateral approach (n=5). At a follow-up (range 6 months-2.5 years), 13 patients had no deficits (modified Rankin score (mRS) 0); 2 were symptomatic with no significant disability (mRS1); 1 had mild disability (mRS2); 1 had moderately severe disability (mRS4); and 3 died (mRS6). Three mortalities were caused by vasospasm (2) and, rupture of unclipped second VA-BA junctional aneurysm (1). Conclusions: PICA aneurysms may present with only IVth ventricular blood without subarachnoid hemorrhage. PICA may have multiple anomalies and its aneurysms may be missed on CT angiograms. Surgical approach is influenced by VA-BA tortuosity and variations in anatomy, location of the VA-BA junction and the PICA aneurysm relative to the brain-stem, and the pattern of collateral supply. The special category of VA-PICA junctional aneurysms and its management; and, the multiple anatomical variations of PICA aneurysms, merit special surgical considerations and have been highlighted in this study. PMID:22639684

Early excision and grafting, an alternative approach to the surgical management of large body surface area levamisole-adulterated cocaine induced skin necrosis.

PubMed

Miner, Jason; Gruber, Paul; Perry, Travis L

2015-05-01

Levamisole-adulterated cocaine as a cause of retiform purpura progressing to full-thickness skin necrosis was first documented in 2003 and currently comprises over 200 reported cases. Whereas, its presentation, pathophysiology, and diagnostic workup have been reasonably well-defined, only one publication has significantly detailed its surgical management. For this reason there exists a relative absence of data in comparison to its reported incidence to suggest a preferred treatment strategy. In the case mentioned, treatment emphasized delayed surgical intervention while awaiting lesion demarcation and the monitoring of autoantibodies. At our institution we offer an alternative approach and present the case of a 34 year old female who presented with 49% TBSA, levamisole-induced skin necrosis managed with early surgical excision and skin grafting. The patient presented three days following cocaine exposure with painful, purpura involving the ears, nose, buttocks, and bilateral lower extremities which quickly progressed to areas of full-thickness necrosis. Lab analysis demonstrated elevated p-ANCA and c-ANCA, as well as leukopenia, decreased C4 complement, and urinalysis positive for levamisole, corroborating the diagnosis. Contrasting the most thoroughly documented case in which the patient underwent first surgical excision on hospital day 36 and underwent 18 total excisions, our patient underwent first excision on hospital day 10 and received only one primary excision prior to definitive autografting. To our knowledge, this is the largest surface area surgically treated that did not result in surgical amputation or autoamputation of limbs or appendages, respectively. We contend that early excision and grafting provides optimal surgical management of this syndrome while avoiding the morbidity seen with delayed intervention. Published by Elsevier Ltd.

Laparoscopic versus open inguinal hernia repair in patients with obesity: an American College of Surgeons NSQIP clinical outcomes analysis.

PubMed

Froylich, Dvir; Haskins, Ivy N; Aminian, Ali; O'Rourke, Colin P; Khorgami, Zhamak; Boules, Mena; Sharma, Gautam; Brethauer, Stacy A; Schauer, Phillip R; Rosen, Michael J

2017-03-01

The laparoscopic approach to inguinal hernia repair (IHR) has proven beneficial in reducing postoperative pain and facilitating earlier return to normal activity. Except for indications such as recurrent or bilateral inguinal hernias, there remains a paucity of data that specifically identities patient populations that would benefit most from the laparoscopic approach to IHR. Nevertheless, previous experience has shown that obese patients have increased wound morbidity following open surgical procedures. The aim of this study was to investigate the effect of a laparoscopic versus open surgical approach to IHR on early postoperative morbidity and mortality in the obese population using the National Surgical Quality Improvement Program (NSQIP) database. All IHRs were identified within the NSQIP database from 2005 to 2013. Obesity was defined as a body mass index ≥30 kg/m 2 . A propensity score matching technique between the laparoscopic and open approaches was used. Association of obesity with postoperative outcomes was investigated using an adjusted and unadjusted model based on clinically important preoperative variables identified by the propensity scoring system. A total of 7346 patients met inclusion criteria; 5573 patients underwent laparoscopic IHR, while 1773 patients underwent open IHR. On univariate analysis, obese patients who underwent laparoscopic IHR were less likely to experience a deep surgical site infection, wound dehiscence, or return to the operating room compared with those who underwent an open IHR. In both the adjusted and unadjusted propensity score models, there was no difference in outcomes between those who underwent laparoscopic versus open IHR. The laparoscopic approach to IHR in obese patients has similar outcomes as an open approach with regard to 30-day wound events. Preoperative risk stratification of obese patients is important to determining the appropriate surgical approach to IHR. Further studies are needed to investigate the long-term effects of the open and laparoscopic approaches to IHR in the obese population.

Accelerated partial breast irradiation using robotic radiotherapy: a dosimetric comparison with tomotherapy and three-dimensional conformal radiotherapy.

PubMed

Rault, Erwann; Lacornerie, Thomas; Dang, Hong-Phuong; Crop, Frederik; Lartigau, Eric; Reynaert, Nick; Pasquier, David

2016-02-27

Accelerated partial breast irradiation (APBI) is a new breast treatment modality aiming to reduce treatment time using hypo fractionation. Compared to conventional whole breast irradiation that takes 5 to 6 weeks, APBI is reported to induce worse cosmetic outcomes both when using three-dimensional conformal radiotherapy (3D-CRT) and intensity-modulated radiotherapy (IMRT). These late normal tissue effects may be attributed to the dose volume effect because a large portion of the non-target breast tissue volume (NTBTV) receives a high dose. In the context of APBI, non-coplanar beams could spare the NTBTV more efficiently. This study evaluates the dosimetric benefit of using the Cyberknife (CK) for APBI in comparison to IMRT (Tomotherapy) and three dimensional conformal radiotherapy (3D-CRT). The possibility of using surgical clips, implanted during surgery, to track target movements is investigated first. A phantom of a female thorax was designed in-house using the measurements of 20 patients. Surgical clips of different sizes were inserted inside the breast. A treatment plan was delivered to the mobile and immobile phantom. The motion compensation accuracy was evaluated using three radiochromic films inserted inside the breast. Three dimensional conformal radiotherapy (3D-CRT), Tomotherapy (TOMO) and CK treatment plans were calculated for 10 consecutive patients who received APBI in Lille. To ensure a fair comparison of the three techniques, margins applied to the CTV were set to 10 mm. However, a second CK plan was prepared using 3 mm margins to evaluate the benefits of motion compensation. Only the larger clips (VITALITEC Medium-Large) could be tracked inside the larger breast (all gamma indices below 1 for 1 % of the maximum dose and 1 mm). All techniques meet the guidelines defined in the NSABP/RTOG and SHARE protocols. As the applied dose volume constraints are very strong, insignificant dosimetric differences exist between techniques regarding the PTV coverage and the sparing of the lung and heart. However, the CK may be used to reduce high doses received by the NTBTV more efficiently. Robotic stereotactic radiotherapy may be used for APBI to more efficiently spare the NTBTV and improve cosmetic results of APBI.

SURGICAL TREATMENT OF DISTAL RADIUS FRACTURES WITH A VOLAR LOCKED PLATE: CORRELATION OF CLINICAL AND RADIOGRAPHIC RESULTS

PubMed Central

Xavier, Claudio Roberto Martins; Dal Molin, Danilo Canesin; dos Santos, Rafael Mota Marins; dos Santos, Roberto Della Torre; Neto, Julio Cezar Ferreira

2015-01-01

Objectives: To analyze and correlate the clinical and radiographic results from patients with distal radius fractures who underwent surgical treatment with a fixed-angle volar locked plate. Methods: Sixty-four patients with distal radius fractures were evaluated. They all underwent surgical treatment with a volar locked plate for the distal radius, with a minimum of six months of postoperative follow-up. They underwent a physical examination that measured range of motion and grip strength, answered the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and underwent radiographic examination. Results: In the physical examination on the patients, all the range-of-motion measurements were reduced. Grip strength measured in kgf was on average 85.8% of the strength on the unaffected side. The mean DASH score was 15.99. A significant relationship was found between lower DASH scores and losses of extension and grip strength. On the radiographs, the mean values in relation to the unfractured side were 84.0% for radial inclination, 85.4% for radial length and 86.8% for volar deviation of the radius. Loss of radial length was correlated with losses of extension and grip strength. PMID:27027046

dCLIP: a computational approach for comparative CLIP-seq analyses

PubMed Central

2014-01-01

Although comparison of RNA-protein interaction profiles across different conditions has become increasingly important to understanding the function of RNA-binding proteins (RBPs), few computational approaches have been developed for quantitative comparison of CLIP-seq datasets. Here, we present an easy-to-use command line tool, dCLIP, for quantitative CLIP-seq comparative analysis. The two-stage method implemented in dCLIP, including a modified MA normalization method and a hidden Markov model, is shown to be able to effectively identify differential binding regions of RBPs in four CLIP-seq datasets, generated by HITS-CLIP, iCLIP and PAR-CLIP protocols. dCLIP is freely available at http://qbrc.swmed.edu/software/. PMID:24398258

Surgical management of obstructive sleep apnea in children with cerebral palsy.

PubMed

Magardino, T M; Tom, L W

1999-10-01

To evaluate the surgical management of obstructive sleep apnea in children with cerebral palsy. Retrospective review of 27 children with cerebral palsy who underwent surgical treatment for obstructive sleep apnea. Charts were reviewed. Data gathered included primary complaint, coexisting illnesses, initial procedure performed, age at initial surgery, number of days the child was monitored postoperatively in the intensive care unit, notation of postoperative respiratory distress and management, and outcome. Nineteen children underwent adenotonsillectomy for initial treatment of obstructive sleep apnea. Three of these children also had a uvulectomy. Six children had an adenoidectomy alone as their initial procedure. Neither uvulopalatopharyngoplasty nor tracheostomy was performed as an initial procedure. Mean follow-up was 34 months. Seventy-six percent of these children have not required any further surgery. Of the six children who have undergone further surgery, one has required a revision adenoidectomy, and another underwent a tonsillectomy and uvulectomy 2 months after the initial adenoidectomy. Four children ultimately required a tracheotomy. Eighty-four percent of these children were successfully managed without a tracheotomy. We recommend tonsillectomy and/or adenoidectomy for initial surgical treatment of obstructive sleep apnea in children with cerebral palsy.

Over-the-scope clip placement for closure of gastrointestinal fistula, postoperative leaks and refractory gastrointestinal bleed.

PubMed

Nasa, Mukesh; Sharma, Zubin Dev; Choudhary, Narendra S; Patil, Gaurav; Puri, Rajesh; Sud, Randhir

2016-09-01

The over-the-scope clip (OTSC) has been successfully used in the closure of fistula, perforation, dehiscence, and endoscopic hemostasis. We describe our experience with the OTSC application. Between April 2014 and April 2015, seven patients underwent OTSC application. In four patients, OTSC was applied for the closure of esophageal fistula, one had OTSC closure of persistent gastrocutaneous fistula after percutaneous endoscopic gastrostomy removal, and OTSC was applied in duodenum in two patients, for duodenal Dieulafoy's lesion after failed conventional endotherapy and massive rebleed in one and duodenal perforation in another. All procedures had technical success with no immediate complication related to OTSC application. Patients were followed up for every month with mean duration of follow up 10.2 months. One patient with bronchoesophageal fistula had development of another fistulous opening above the site of OTSC placement, which was successfully closed with another OTSC. One patient had superficial esophageal wall ulcer opposite the OTSC but it healed spontaneously. OTSC provided safe and successful closure in a number of settings.

More patients should undergo surgery after sigmoid volvulus.

PubMed

Ifversen, Anne Kathrine Wewer; Kjaer, Daniel Willy

2014-12-28

To assess the outcome of patients treated conservatively vs surgically during their first admission for sigmoid volvulus. We conducted a retrospective study of 61 patients admitted to Aarhus University Hospital in Denmark between 1996 and 2011 for their first incidence of sigmoid volvulus. The condition was diagnosed by radiography, sigmoidoscopy or surgery. Patients treated with surgery underwent either a sigmoid resection or a percutaneous endoscopic colostomy (PEC). Conservatively treated patients were managed without surgery. Data was recorded into a Microsoft Access database and calculations were performed with Microsoft Excel. Kaplan-Meier plotting and Mantel-Cox (log-rank) testing were performed using GraphPad Prism software. Mortality was defined as death within 30 d after intervention or surgery. Among the total 61 patients, 4 underwent emergency surgery, 55 underwent endoscopy, 1 experienced resolution of the volvulus after contrast enema, and 1 died without treatment because of large bowel perforation. Following emergency treatment, 28 patients underwent sigmoid resection (semi-elective n = 18; elective n = 10). Two patients who were unfit for surgery underwent PEC and both died, 1 after 36 d and the other after 9 mo, respectively. The remaining 26 patients were managed conservatively without sigmoid resection. Patients treated conservatively on their first admission had a poorer survival rate than patients treated surgically on their first admission (95%CI: 3.67-14.37, P = 0.036). Sixty-three percent of the 26 conservatively treated patients had not experienced a recurrence 3 mo after treatment, but that number dropped to 24% 2 years after treatment. Eight of the 14 patients with recurrence after conservative treatment had surgery with no 30-d mortality. Surgically-treated sigmoid volvulus patients had a higher long-term survival rate than conservatively managed patients, indicating a benefit of surgical resection or PEC insertion if feasible.

More patients should undergo surgery after sigmoid volvulus

PubMed Central

Ifversen, Anne Kathrine Wewer; Kjaer, Daniel Willy

2014-01-01

AIM: To assess the outcome of patients treated conservatively vs surgically during their first admission for sigmoid volvulus. METHODS: We conducted a retrospective study of 61 patients admitted to Aarhus University Hospital in Denmark between 1996 and 2011 for their first incidence of sigmoid volvulus. The condition was diagnosed by radiography, sigmoidoscopy or surgery. Patients treated with surgery underwent either a sigmoid resection or a percutaneous endoscopic colostomy (PEC). Conservatively treated patients were managed without surgery. Data was recorded into a Microsoft Access database and calculations were performed with Microsoft Excel. Kaplan-Meier plotting and Mantel-Cox (log-rank) testing were performed using GraphPad Prism software. Mortality was defined as death within 30 d after intervention or surgery. RESULTS: Among the total 61 patients, 4 underwent emergency surgery, 55 underwent endoscopy, 1 experienced resolution of the volvulus after contrast enema, and 1 died without treatment because of large bowel perforation. Following emergency treatment, 28 patients underwent sigmoid resection (semi-elective n = 18; elective n = 10). Two patients who were unfit for surgery underwent PEC and both died, 1 after 36 d and the other after 9 mo, respectively. The remaining 26 patients were managed conservatively without sigmoid resection. Patients treated conservatively on their first admission had a poorer survival rate than patients treated surgically on their first admission (95%CI: 3.67-14.37, P = 0.036). Sixty-three percent of the 26 conservatively treated patients had not experienced a recurrence 3 mo after treatment, but that number dropped to 24% 2 years after treatment. Eight of the 14 patients with recurrence after conservative treatment had surgery with no 30-d mortality. CONCLUSION: Surgically-treated sigmoid volvulus patients had a higher long-term survival rate than conservatively managed patients, indicating a benefit of surgical resection or PEC insertion if feasible. PMID:25561806

Predicting symptomatic cerebral vasospasm after aneurysmal subarachnoid hemorrhage with an artificial neural network in a pediatric population.

PubMed

Skoch, Jesse; Tahir, Rizwan; Abruzzo, Todd; Taylor, John M; Zuccarello, Mario; Vadivelu, Sudhakar

2017-12-01

Artificial neural networks (ANN) are increasingly applied to complex medical problem solving algorithms because their outcome prediction performance is superior to existing multiple regression models. ANN can successfully identify symptomatic cerebral vasospasm (SCV) in adults presenting after aneurysmal subarachnoid hemorrhage (aSAH). Although SCV is unusual in children with aSAH, the clinical consequences are severe. Consequently, reliable tools to predict patients at greatest risk for SCV may have significant value. We applied ANN modeling to a consecutive cohort of pediatric aSAH cases to assess its ability to predict SCV. A retrospective chart review was conducted to identify patients < 21 years of age who presented with spontaneously ruptured, non-traumatic, non-mycotic, non-flow-related intracranial arterial aneurysms to our institution between January 2002 and January 2015. Demographics, clinical, radiographic, and outcome data were analyzed using an adapted ANN model using learned value nodes from the adult aneurysmal SAH dataset previously reported. The strength of the ANN prediction was measured between - 1 and 1 with - 1 representing no likelihood of SCV and 1 representing high likelihood of SCV. Sixteen patients met study inclusion criteria. The median age for aSAH patients was 15 years. Ten underwent surgical clipping and 6 underwent endovascular coiling for definitive treatment. One patient experienced SCV and 15 did not. The ANN applied here was able to accurately predict all 16 outcomes. The mean strength of prediction for those who did not exhibit SCV was - 0.86. The strength for the one patient who did exhibit SCV was 0.93. Adult-derived aneurysmal SAH value nodes can be applied to a simple AAN model to accurately predict SCV in children presenting with aSAH. Further work is needed to determine if ANN models can prospectively predict SCV in the pediatric aSAH population in toto; adapted to include mycotic, traumatic, and flow-related origins as well.

Thoracic duct lesions in thyroid surgery: An update on diagnosis, treatment and prevention based on a cohort study.

PubMed

Polistena, Andrea; Vannucci, Jacopo; Monacelli, Massimo; Lucchini, Roberta; Sanguinetti, Alessandro; Avenia, Stefano; Santoprete, Stefano; Triola, Roberta; Cirocchi, Roberto; Puma, Francesco; Avenia, Nicola

2016-04-01

Thoracic duct fistula at the cervical level is a severe but rare complication following thyroid surgery, particularly associated to lateral dissection of the neck and to mediastinal goiter. we retrospectively analyzed chylous fistulas observed in a cohort of 13.224 patients underwent surgery for thyroid disease since 1986 to 2014, in the Unit of Endocrine Surgery, S. Maria University Hospital, Terni, Italy. We observed 20 cases of chylous fistula. Thirteen patients underwent primary surgery in our institution while the remaining 7 cases had been referred to our Department from other hospitals for an already diagnosed lymphatic leak. Surgical procedures carried out included total thyroidectomy for mediastinal goiter in 4 patients, total thyroidectomy for cancer in 2 patients, unilateral functional lymphadenectomy in 11 patients and bilateral in 3. Intraoperative repair was carried out in 4 cases. Of the remaining 16 cases, 4 of the 6 fistulas with low flow leakage healed in about 30 days of conservative treatment, 2 cases instead required surgical repair. All 10 patients with "high-flow" fistula underwent surgery. Despite surgery was performed later, postoperative course in patients with late surgical repair is similar to what observed in those patients with early surgical repair. Both groups underwent cervical drainage removal in post-operative day 4. Healing of a cervical chylous fistula can be achieved by conservative medical therapy (nutritional and pharmacological) but in case of therapeutic failure with rapid decrease of general condition, the surgical approach is necessary. In our experience, duct ligation after unsuccessful conservative treatment, is the only resolutive treatment. Copyright © 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.

Clinical assessment of diode laser-assisted endoscopic intrasphenoidal vidian neurectomy in the treatment of refractory rhinitis.

PubMed

Lai, Wen-Sen; Cheng, Sheng-Yao; Lin, Yuan-Yung; Yang, Pei-Lin; Lin, Hung-Che; Cheng, Li-Hsiang; Yang, Jinn-Moon; Lee, Jih-Chin

2017-12-01

For chronic rhinitis that is refractory to medical therapy, surgical intervention such as endoscopic vidian neurectomy (VN) can be used to control the intractable symptoms. Lasers can contribute to minimizing the invasiveness of ENT surgery. The aim of this retrospective study is to compare in patients who underwent diode laser-assisted versus traditional VN in terms of operative time, surgical field, quality of life, and postoperative complications. All patients had refractory rhinitis with a poor treatment response to a 6-month trial of corticosteroid nasal sprays and underwent endoscopic VN between November 2006 and September 2015. They were non-randomly allocated into either a cold instrument group or a diode laser-assisted group. Vidian nerve was excised with a 940-nm continuous wave diode laser through a 600-μm silica optical fiber, utilizing a contact mode with the power set at 5 W. A visual analog scale (VAS) was used to grade the severity of the rhinitis symptoms for quality of life assessment before the surgery and 6 months after. Of the 118 patients enrolled in the study, 75 patients underwent cold instrument VN and 43 patients underwent diode laser-assisted VN. Patients in the laser-assisted group had a significantly lower surgical field score and a lower postoperative bleeding rate than those in the cold instrument group. Changes in the VAS were significant in preoperative and postoperative nasal symptoms in each group. The application of diode lasers for vidian nerve transection showed a better surgical field and a lower incidence of postoperative hemorrhage. Recent advancements in laser application and endoscopic technique has made VN safer and more effective. We recommend this surgical approach as a reliable and effective treatment for patients with refractory rhinitis.

Surgical outcomes of robot-assisted rectal cancer surgery using the da Vinci Surgical System: a multi-center pilot Phase II study.

PubMed

Tsukamoto, Shunsuke; Nishizawa, Yuji; Ochiai, Hiroki; Tsukada, Yuichiro; Sasaki, Takeshi; Shida, Dai; Ito, Masaaki; Kanemitsu, Yukihide

2017-12-01

We conducted a multi-center pilot Phase II study to examine the safety of robotic rectal cancer surgery performed using the da Vinci Surgical System during the introduction period of robotic rectal surgery at two institutes based on surgical outcomes. This study was conducted with a prospective, multi-center, single-arm, open-label design to assess the safety and feasibility of robotic surgery for rectal cancer (da Vinci Surgical System). The primary endpoint was the rate of adverse events during and after robotic surgery. The secondary endpoint was the completion rate of robotic surgery. Between April 2014 and July 2016, 50 patients were enrolled in this study. Of these, 10 (20%) had rectosigmoid cancer, 17 (34%) had upper rectal cancer, and 23 (46%) had lower rectal cancer; six underwent high anterior resection, 32 underwent low anterior resection, 11 underwent intersphincteric resection, and one underwent abdominoperineal resection. Pathological stages were Stage 0 in 1 patient, Stage I in 28 patients, Stage II in 7 patients and Stage III in 14 patients. Pathologically complete resection was achieved in all patients. There was no intraoperative organ damage or postoperative mortality. Eight (16%) patients developed complications of all grades, of which 2 (4%) were Grade 3 or higher, including anastomotic leakage (2%) and conversion to open surgery (2%). The present study demonstrates the feasibility and safety of robotic rectal cancer surgery, as reflected by low morbidity and low conversion rates, during the introduction period. © The Author 2017. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

[Percutaneously implantable aortic valve: the JenaValve concept evolution].

PubMed

Figulla, Hans R; Ferrari, Markus

2006-10-01

Due to the increasing incidence of severe aortic stenosis in old and multimorbid patients, the percutaneous implantation of aortic valve-carrying stents has become an alternative to the surgical replacement of aortic valves. Starting in 1995, the authors developed a self-expanding stent which transferred the necessary forces for anchoring up to the aorta ascendens-a conception taken over from CoreValve. The further improvement of this idea over the past 11 years has led to a self-expanding, relatively short stent-valve system that is reliably positioned in the cusps of the old aortic valve and holds the old valve like a paper clip, thus transferring the holding forces physiologically. As compared to conventional systems, the sophisticated insertion catheter requires further chronic animal tests so as to represent a true alternative to the conventional surgical procedure.

Metal artifact reduction for flat panel detector intravenous CT angiography in patients with intracranial metallic implants after endovascular and surgical treatment

PubMed Central

Pjontek, Rastislav; Önenköprülü, Belgin; Scholz, Bernhard; Kyriakou, Yiannis; Schubert, Gerrit A; Othman, Ahmed; Wiesmann, Martin; Brockmann, Marc A

2016-01-01

Background Flat panel detector CT angiography with intravenous contrast agent injection (IV CTA) allows high-resolution imaging of cerebrovascular structures. Artifacts caused by metallic implants like platinum coils or clips lead to degradation of image quality and are a significant problem. Objective To evaluate the influence of a prototype metal artifact reduction (MAR) algorithm on image quality in patients with intracranial metallic implants. Methods Flat panel detector CT after intravenous application of 80 mL contrast agent was performed with an angiography system (Artis zee; Siemens, Forchheim, Germany) using a 20 s rotation protocol (200° rotation angle, 20 s acquisition time, 496 projections). The data before and after MAR of 26 patients with a total of 34 implants (coils, clips, stents) were independently evaluated by two blinded neuroradiologists. Results MAR improved the assessability of the brain parenchyma and small vessels (diameter <1 mm) in the neighborhood of metallic implants and at a distance of 6 cm (p<0.001 each, Wilcoxon test). Furthermore, MAR significantly improved the assessability of parent vessel patency and potential aneurysm remnants (p<0.005 each, McNemar test). MAR, however, did not improve assessability of stented vessels. Conclusions When an intravenous contrast protocol is used, MAR significantly ameliorates the assessability of brain parenchyma, vessels, and treated aneurysms in patients with intracranial coils or clips. PMID:26346458

Evaluation of long-term results and quality of life in patients who underwent rib fixation with titanium devices after trauma.

PubMed

Billè, Andrea; Okiror, Lawrence; Campbell, Aideen; Simons, Jason; Routledge, Tom

2013-06-01

To describe the long-term results, quality of life and chronic pain after chest wall fixation for traumatic rib fracture using a quality of life (QOL) score and a numeric pain score. Retrospective analysis of 10 consecutive patients who underwent surgery for rib fractures after trauma and reconstruction between October 2010 and March 2012. Chest rib fractures were fixed with titanium clips and bars or titanium plates and screws through a posterolateral thoracotomy. Pain was assessed with a numeric pain scale 0-10 and quality of life (QOL) with the EORTC questionnaire QLQ-C30. There were 5 males and 5 females. The median age was 58 years (range 21-80). There were no postoperative deaths. The only postoperative complication observed was a contralateral pleural effusion requiring drainage. Median length of stay of the drain and median length of hospital stay were 2 days (range 0-8) and 4 days (range 1-42 days), respectively. The average follow-up period of operatively managed patients was 14 months (range 8-23.5 months). Seven patients scored the pain as 0, one as 1 (mild), one as 4 (moderate) and one as 8 (severe). Only two patients are taking occasionally pain killers. Only one patient presents severe limitation in his life scoring his QOL as poor. Titanium devices (clips and bars; screws and plates) are effective and safe for repair of rib fractures and showed good long-term results in terms of pain and quality of life after the operation.

Surgical prediction of skeletal and soft tissue changes in treatment of Class II.

PubMed

de Lira, Ana de Lourdes Sá; de Moura, Walter Leal; Artese, Flávia; Bittencourt, Marcos Alan Vieira; Nojima, Lincoln Issamu

2013-04-01

The purpose of this study was to study the treatment outcomes and the accuracy of digital prediction and the actual postoperative outcome with Dolphin program on subjects presenting Class II malocclusions. Forty patients underwent surgical mandibular advancement (Group 1) and 40 underwent combined surgery of mandibular advancement and maxillary impaction (Group 2). The available pre surgical (t₁) and a minimum of 12 months post surgical (t₂) cephalometric radiographs were digitized. Predictive cephalograms (t₃) for both groups were traced. At all times evaluated, Group 1 displayed a shorter mandibular length and Group 2 had a longer lower face. In both groups the surgical interventions (t₂) were greater than initially predicted. There was no significant difference between groups with regards to overjet, overbite and soft tissue measurements. In both groups surgeries were more extensive than planned. Facial convexity and the distance of the lips to cranial base presented similar values between t₂ (post surgical) and t₃ (predicted). Copyright © 2012 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

Surgical aspects of pulmonary histoplasmosis

PubMed Central

Sutaria, M. K.; Polk, J. W.; Reddy, P.; Mohanty, S. K.

1970-01-01

Histoplasmosis is of special interest to thoracic surgeons because it may appear in such a wide variety of clinical forms. Fourteen years' experience with 110 proved cases of surgically treated pulmonary histoplasmosis has been reviewed. Twenty-one of these patients manifested as `coinlesion' and underwent only wedge resection without amphotericin B therapy. A long-term follow-up of these patients indicates that these lesions are benign and need no additional therapy. Thirteen patients with pulmonary infiltration underwent surgery and three received post-operative amphotericin B therapy. Our largest group of surgically treated patients is of cavitary histoplasmosis. There were 76 patients in this group; 38 were managed with only surgical resection and the other 38 had surgical resection together with amphotericin B therapy. Operative indications, various forms of treatment, post-operative complications, and their results have been critically analysed. From this study we conclude that amphotericin B offers little protection against the immediate post-operative complications, but it reduces mortality and a recurrence of the disease, as judged from long-term follow-up. Images PMID:5418008

Sedation improves early outcome in severely septic Sprague Dawley rats

PubMed Central

2009-01-01

Introduction Sepsis, a systemic inflammatory response to infective etiologies, has a high mortality rate that is linked both to excess cytokine activity and apoptosis of critical immune cells. Dexmedetomidine has recently been shown to improve outcome in a septic cohort of patients when compared to patients randomized to a benzodiazepine-based sedative regimen. We sought to compare the effects of dexmedetomidine and midazolam, at equi-sedative doses, on inflammation and apoptosis in an animal model of severe sepsis. Methods After central venous access, Sprague Dawley rats underwent cecal ligation and intestinal puncture (CLIP) with an 18 G needle without antibiotic cover and received either saline, or an infusion of comparable volume of saline containing midazolam (0.6 mg.kg-1.h-1) or dexmedetomidine (5 ug.kg-1.h-1) for 8 hours. Following baseline measurements and CLIP, blood was sampled for cytokine measurement (tumour necrosis factor (TNF)-alpha and interleukin (IL)-6; n = 4-6 per group) at 2, 4 and 5 hours, and animal mortality rate (MR) was monitored (n = 10 per group) every 2 hours until 2 hours had elapsed. In addition, spleens were harvested and apoptosis was assessed by immunoblotting (n = 4 per group). Results The 24 hour MR in CLIP animals (90%) was significantly reduced by sedative doses of either dexmedetomidine (MR = 20%) or midazolam (MR = 30%). While both sedatives reduced systemic levels of the inflammatory cytokine TNF-alpha (P < 0.05); only dexmedetomidine reduced the IL-6 response to CLIP, though this narrowly missed achieving significance (P = 0.05). Dexmedetomidine reduced splenic caspase-3 expression (P < 0.05), a marker of apoptosis, when compared to either midazolam or saline. Conclusions Sedation with midazolam and dexmedetomidine both improve outcome in polymicrobial severely septic rats. Possible benefits conveyed by one sedative regimen over another may become evident over a more prolonged time-course as both IL-6 and apoptosis were reduced by dexmedetomidine but not midazolam. Further studies are required to evaluate this hypothesis. PMID:19691839

Survival Prediction in Patients Undergoing Open-Heart Mitral Valve Operation After Previous Failed MitraClip Procedures.

PubMed

Geidel, Stephan; Wohlmuth, Peter; Schmoeckel, Michael

2016-03-01

The objective of this study was to analyze the results of open heart mitral valve operations for survival prediction in patients with previously unsuccessful MitraClip procedures. Thirty-three consecutive patients who underwent mitral valve surgery in our institution were studied. At a median of 41 days, they had previously undergone one to five futile MitraClip implantations. At the time of their operations, patients were 72.6 ± 10.3 years old, and the calculated risk, using the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II, was a median of 26.5%. Individual outcomes were recorded, and all patients were monitored postoperatively. Thirty-day mortality was 9.1%, and the overall survival at 2.2 years was 60.6%. Seven cardiac-related and six noncardiac deaths occurred. Univariate survival regression models demonstrated a significant influence of the following variables on survival: EuroSCORE II (p = 0.0022), preoperative left ventricular end-diastolic dimension (p = 0.0052), left ventricular ejection fraction (p = 0.0249), coronary artery disease (p = 0.0385), and severe pulmonary hypertension (p = 0.0431). Survivors showed considerable improvements in their New York Heart Association class (p < 0.0001), left ventricular ejection fraction (p = 0.0080), grade of mitral regurgitation (p = 0.0350), and mitral valve area (p = 0.0486). Survival after mitral repair was not superior to survival after replacement. Indications for surgery after failed MitraClip procedures must be considered with the greatest of care. Variables predicting postoperative survival should be taken into account regarding the difficult decision as to whether to operate or not. Our data suggest that replacement of the pretreated mitral valve is probably the more reasonable concept rather than complex repairs. When the EuroSCORE II at the time of surgery exceeds 30%, conservative therapy is advisable. Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Impact of cardiac comorbidities on early and 1-year outcome after percutaneous mitral valve interventions: data from the German transcatheter mitral valve interventions (TRAMI) registry.

PubMed

Schwencke, Carsten; Bijuklic, Klaudija; Ouarrak, Taoufik; Lubos, Edith; Schillinger, Wolfgang; Plicht, Björn; Eggebrecht, Holger; Baldus, Stephan; Schymik, Gerhard; Boekstegers, Peter; Hoffmann, Rainer; Senges, Jochen; Schofer, Joachim

2017-04-01

The use of the MitraClip system has gained widespread acceptance for the treatment of patients with mitral regurgitation (MR) who are not suitable for the conventional surgery. This study sought to investigate the early and 1-year outcome after MitraClip therapy of patients with MR and cardiac comorbidities. Outcomes through 12-month follow-up of patients (n = 528) who underwent MitraClip implantation were obtained from the German transcatheter mitral valve interventions (TRAMI) registry. The majority of these patients (n = 409, 77.5 %) also suffered from coronary artery disease (CAD). Patients with a dilated cardiomyopathy (DCM, n = 65, 12.3 %) or concomitant valvular aortic disease (AV, n = 54, 10.2 %) were less frequent. Although the prevalent pathogenesis was functional MR, patients with DCM had significantly more frequent a functional MR (96.9 %) compared to patients with CAD (74.9 %) or AV (62.5 %, p < 0.001). Technical success was achieved in 97.5 % of patients. Procedural echocardiograms demonstrated in the vast majority of patients a reduction from severe MR III to mild MR I with no difference between the groups (p = 0.83). The peri-procedural complication rate was very low. At 30-day and 12-month follow-up, the majority of patients were in NYHA functional class II or lower. The rate of death, stroke, and myocardial infarction (MACCE) was comparable in the three patient groups during 12-month follow-up (DCM 26.9 %, CAD 30.3 % and AV 27.5 %, p = 0.85). The MitraClip implantation is feasible and safe even in high-risk patients with MR and cardiac comorbidities.

The effect of a performance-based intra-procedural checklist on a simulated emergency laparoscopic task in novice surgeons.

PubMed

El Boghdady, Michael; Tang, Benjie; Alijani, Afshin

2017-05-01

Surgical checklists are in use as means to reduce errors. Checklists are infrequently applied during emergency situations in surgery. We aimed to study the effect of a simple self-administered performance-based checklist on the laparoscopic task when applied during an emergency-simulated scenario. The aviation checklist for unexpected situations is commonly used for simulated training of pilots to handle emergency during flights. This checklist was adopted for use as a standardised-performance-based checklist during emergency surgical tasks. Thirty consented laparoscopic novices were exposed unexpectedly to a bleeding vessel in a laparoscopic virtual reality simulator as an emergency scenario. The task consisted of using laparoscopic clips to achieve haemostasis. Subjects were randomly allocated into two equal groups; those using the checklist that was applied once every 20 s (checklist group) and those without (control group). The checklist group performed significantly better in 5 out of 7 technical factors when compared to the control group: right instrument path length (m), median (IQR) 1.44 [1.22] versus 2.06 [1.70] (p = 0.029), right instrument angular path (degree) 312.10 (269.44 versus 541.80 [455.16] (p = 0.014), left instrument path length (m) 1.20 [0.60] versus 2.08 [2.02] (p = 0.004), and left instrument angular path (degree) 277.62 [132.11] versus 385.88 [428.42] (p = 0.017). The checklist group committed significantly fewer number of errors in the application of haemostatic clips, 3 versus 28 (p = 0.006). Although statistically not significant, total blood loss (lit) decreased in the checklist group from 0.83 [1.23] to 0.78 [0.28] (p = 0.724) and total time (sec) from 186.51 [145.69] to 125.14 [101.46] (p = 0.165). The performance-based intra-procedural checklist significantly enhanced the surgical task performance of novices in an emergency-simulated scenario.

Can Teamwork and High-Volume Experience Overcome Challenges of Lymphadenectomy in Morbidly Obese Patients (Body Mass Index of 40 kg/m2 or Greater) with Endometrial Cancer?: A Cohort Study of Robotics and Laparotomy and Review of Literature.

PubMed

Fornalik, Hubert; Zore, Temeka; Fornalik, Nicole; Foster, Todd; Katschke, Adrian; Wright, Gary

2018-06-01

This study aimed to compare surgical outcomes and the adequacy of surgical staging in morbidly obese women with a body mass index (BMI) of 40 kg/m or greater who underwent robotic surgery or laparotomy for the staging of endometrioid-type endometrial cancer. This is a retrospective cohort study of patients who underwent surgical staging between May 2011 and June 2014. Patients' demographics, surgical outcomes, intraoperative and postoperative complications, and pathological outcomes were compared. Seventy-six morbidly obese patients underwent robotic surgery, and 35 underwent laparotomy for surgical staging. Robotic surgery was associated with more lymph nodes collected with increasing BMI (P < 0.001) and decreased chances for postoperative respiratory failure and intensive care unit admissions (P = 0.03). Despite a desire to comprehensively stage all patients, we performed successful pelvic and paraaortic lymphadenectomy in 96% versus 89% (P = 0.2) and 75% versus 60% (P = 0.12) of robotic versus laparotomy patients, respectively. In the robotic group, with median BMI of 47 kg/m, no conversions to laparotomy occurred. The robotic group experienced less blood loss and a shorter length of hospital stay than the laparotomy group; however, the surgeries were longer. In a high-volume center, a high rate of comprehensive surgical staging can be achieved in patients with BMI of 40 kg/m or greater either by laparotomy or robotic approach. In our experience, robotic surgery in morbidly obese patients is associated with better quality staging of endometrial cancer. With a comprehensive approach, a professional bedside assistant, use of a monopolar cautery hook, and our protocol of treating morbidly obese patients, robotic surgeries can be safely performed in the vast majority of patients with a BMI of 40 kg/m or greater, with lymph node counts being similar to nonobese patients, and with conversions to laparotomy reduced to a minimum.

Can Teamwork and High-Volume Experience Overcome Challenges of Lymphadenectomy in Morbidly Obese Patients (Body Mass Index of 40 kg/m2 or Greater) with Endometrial Cancer?

PubMed Central

Fornalik, Hubert; Zore, Temeka; Fornalik, Nicole; Foster, Todd; Katschke, Adrian; Wright, Gary

2018-01-01

Objective This study aimed to compare surgical outcomes and the adequacy of surgical staging in morbidly obese women with a body mass index (BMI) of 40 kg/m2 or greater who underwent robotic surgery or laparotomy for the staging of endometrioid-type endometrial cancer. Methods This is a retrospective cohort study of patients who underwent surgical staging between May 2011 and June 2014. Patients' demographics, surgical outcomes, intraoperative and postoperative complications, and pathological outcomes were compared. Results Seventy-six morbidly obese patients underwent robotic surgery, and 35 underwent laparotomy for surgical staging. Robotic surgery was associated with more lymph nodes collected with increasing BMI (P < 0.001) and decreased chances for postoperative respiratory failure and intensive care unit admissions (P = 0.03). Despite a desire to comprehensively stage all patients, we performed successful pelvic and paraaortic lymphadenectomy in 96% versus 89% (P = 0.2) and 75% versus 60% (P = 0.12) of robotic versus laparotomy patients, respectively. In the robotic group, with median BMI of 47 kg/m2, no conversions to laparotomy occurred. The robotic group experienced less blood loss and a shorter length of hospital stay than the laparotomy group; however, the surgeries were longer. Conclusions In a high-volume center, a high rate of comprehensive surgical staging can be achieved in patients with BMI of 40 kg/m2 or greater either by laparotomy or robotic approach. In our experience, robotic surgery in morbidly obese patients is associated with better quality staging of endometrial cancer. With a comprehensive approach, a professional bedside assistant, use of a monopolar cautery hook, and our protocol of treating morbidly obese patients, robotic surgeries can be safely performed in the vast majority of patients with a BMI of 40 kg/m2 or greater, with lymph node counts being similar to nonobese patients, and with conversions to laparotomy reduced to a minimum. PMID:29621128

Mechanism of valve failure and efficacy of reintervention through catheterization in patients with bioprosthetic valves in the pulmonary position

PubMed Central

Callahan, Ryan; Bergersen, Lisa; Baird, Christopher W; Porras, Diego; Esch, Jesse J; Lock, James E; Marshall, Audrey C

2017-01-01

Background: Surgical and transcatheter bioprosthetic valves (BPVs) in the pulmonary position in patients with congenital heart disease may ultimately fail and undergo transcatheter reintervention. Angiographic assessment of the mechanism of BPV failure has not been previously described. Aims: The aim of this study was to determine the mode of BPV failure (stenosis/regurgitation) requiring transcatheter reintervention and to describe the angiographic characteristics of the failed BPVs and report the types and efficacy of reinterventions. Materials and Methods: This is a retrospective single-center review of consecutive patients who previously underwent pulmonary BPV placement (surgical or transcatheter) and subsequently underwent percutaneous reintervention from 2005 to 2014. Results: Fifty-five patients with surgical (41) and transcutaneous pulmonary valve (TPV) (14) implantation of BPVs underwent 66 catheter reinterventions. The surgically implanted valves underwent fifty reinterventions for indications including 16 for stenosis, seven for regurgitation, and 27 for both, predominantly associated with leaflet immobility, calcification, and thickening. Among TPVs, pulmonary stenosis (PS) was the exclusive failure mode, mainly due to loss of stent integrity (10) and endocarditis (4). Following reintervention, there was a reduction of right ventricular outflow tract gradient from 43 ± 16 mmHg to 16 ± 10 mmHg (P < 0.001) and RVp/AO ratio from 0.8 ± 0.2 to 0.5 ± 0.2 (P < 0.001). Reintervention with TPV placement was performed in 45 (82%) patients (34 surgical, 11 transcatheter) with no significant postintervention regurgitation or paravalvular leak. Conclusion: Failing surgically implanted BPVs demonstrate leaflet calcification, thickness, and immobility leading to PS and/or regurgitation while the mechanism of TPV failure in the short- to mid-term is stenosis, mainly from loss of stent integrity. This can be effectively treated with a catheter-based approach, predominantly with the valve-in-valve technique. PMID:28163423

Quality of Life of Patients with Spinal Metastasis from Cancer of Unknown Primary Origin: A Longitudinal Study of Surgical Management Combined with Postoperative Radiation Therapy.

PubMed

Ma, Yifei; He, Shaohui; Liu, Tielong; Yang, Xinghai; Zhao, Jian; Yu, Hongyu; Feng, Jiaojiao; Xu, Wei; Xiao, Jianru

2017-10-04

Patients with spinal metastasis from cancer of unknown primary origin have limited life expectancy and poor quality of life. Surgery and radiation therapy remain the main treatment options, but, to our knowledge, there are limited data concerning quality-of-life improvement after surgery and radiation therapy and even fewer data on whether surgical intervention would affect quality of life. Patients were enrolled between January 2009 and January 2014 at the Changzheng Hospital, Shanghai, People's Republic of China. The quality of life of 2 patient groups (one group that underwent surgery followed by postoperative radiation therapy and one group that underwent radiation therapy only) was assessed by the Functional Assessment of Cancer Therapy-General (FACT-G) questionnaire during a 6-month period. A subgroup analysis of quality of life was performed to compare different surgical strategies in the surgical group. A total of 287 patients, including 191 patients in the group that underwent surgery and 96 patients in the group that underwent radiation therapy only, were enrolled in the prospective study; 177 patients completed all 5 checkpoints and 110 patients had died by the final checkpoint. The surgery group had significantly higher adjusted quality-of-life scores than the radiation therapy group in each domain of the FACT-G questionnaire (all p < 0.05). Subgroup analysis showed that adjusted functional and physical well-being scores were higher in the circumferential surgical decompression group. Surgery followed by postoperative radiation therapy improved and maintained quality of life in patients with spinal metastasis from cancer of unknown primary origin in the 6-month assessment. In terms of surgical strategies, circumferential decompression seems better than laminectomy alone in quality-of-life improvement. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Results of surgical excision of urethral prolapse in symptomatic patients.

PubMed

Hall, Mary E; Oyesanya, Tola; Cameron, Anne P

2017-11-01

Here, we present the clinical presentation and surgical outcomes of women with symptomatic urethral prolapse presenting to our institution over 20 years, and seek to provide treatment recommendations for management of symptomatic urethral prolapse and caruncle. A retrospective review of medical records from female patients who underwent surgery for symptomatic urethral prolapse from June 1995 to August 2015 was performed. Surgical technique consisted of a four-quadrant excisional approach for repair of urethral prolapse. A total of 26 patients were identified with a mean age of 38.8 years (range 3-81). The most common presentations were vaginal bleeding, hematuria, pain, and dysuria. All patients underwent surgical excision of urethral prolapse via a standard approach. Follow-up data was available in 24 patients. Six patients experienced temporary postoperative bleeding, and one patient required placement of a Foley catheter for tamponade. One patient experienced temporary postoperative urinary retention requiring Foley catheter placement. Three patients had visible recurrence of urethral prolapse, for which one later underwent re-excision. Surgical excision of urethral prolapse is a reasonable treatment option in patients who have tried conservative management without relief, as well as in those who present with severe symptoms. Possible complications following excision include postoperative bleeding and recurrence, and patients must be counseled accordingly. In this work, we propose a treatment algorithm for symptomatic urethral prolapse. © 2017 Wiley Periodicals, Inc.

Strategy for laparoscopic cervical myomectomy.

PubMed

Matsuoka, Shozo; Kikuchi, Iwaho; Kitade, Mari; Kumakiri, Jun; Kuroda, Keiji; Tokita, Sachiko; Kuroda, Masako; Takeda, Satoru

2010-01-01

Myoma of the uterine cervix is rare, accounting for about 5% of all myomas. Compared with myomas that occur in the uterine corpus, cervical myomas are closer to other organs such as the bladder, ureter, and rectum, and the approach needs to be modified because the organs that have to be considered differ depending on the location of the myoma. We divided cervical myomas into 2 types according to location, comprising an intracervical type and extracervical types. A clear outline of surgical treatment for cervical myoma has not described in previous papers. We then investigated the surgical strategy for these types. Subjects comprised 16 patients who were diagnosed with cervical myoma in our hospital between January 2005 and April 2009, and who underwent laparoscopic myomectomy. Mean operative time was 105.8 + or - 43.2 (82.8-128.8) min, mean blood loss was 105 + or - 117 (42.6-167.4) ml, and mean specimen weight was 208.3 + or - 195.4 (99.3-306.2) g. Histopathological examination showed atypical myoma in 1 case and leiomyoma in others. 16 cases of cervical myomectomy were performed safely by developing a uniform strategy that uses a fixed operative procedure, even with laparotomy, if sufficient attention is paid to the following 6 points: 1) attempting to reduce the size of the myoma with the use of preoperative GnRH; 2) determining the positional relationship between the myoma and surrounding organs; 3) temporarily blocking uterine artery blood flow with the use of vessel clips; 4) suppressing bleeding during myomectomy with the use of vasopressin; 5) minimizing the risk of damaging surrounding organs by positioning the incision in the myometrium somewhat lateral to the uterine corpus; and 6) the bottom of the wound after enculation should be pulled up by the forceps for suturing to avoid making dead space. Copyright 2010 AAGL. Published by Elsevier Inc. All rights reserved.

Magnetic resonance imaging metallic artifact of commonly encountered surgical implants and foreign material.

PubMed

Sutherland-Smith, James; Tilley, Brenda

2012-01-01

Magnetic resonance imaging (MRI) artifacts secondary to metallic implants and foreign bodies are well described. Herein, we provide quantitative data from veterinary implants including total hip arthroplasty implants, cranial cruciate repair implants, surgical screws, a skin staple, ligation clips, an identification microchip, ameroid constrictor, and potential foreign bodies including air gun and BB projectiles and a sewing needle. The objects were scanned in a gelatin phantom with plastic grid using standardized T2-weighted turbo-spin echo (TSE), T1-weighted spin echo, and T2*-weighted gradient recalled echo (GRE) image acquisitions at 1.5 T. Maximum linear dimensions and areas of signal voiding and grid distortion were calculated using a DICOM workstation for each sequence and object. Artifact severity was similar between the T2-weighted TSE and T1-weighted images, while the T2*-weighted images were most susceptible to artifact. Metal type influenced artifact size with the largest artifacts arising from steel objects followed by surgical stainless steel, titanium, and lead. For animals with metallic surgical implants or foreign bodies, the quantification of the artifact size will help guide clinicians on the viability of MRI. © 2012 Veterinary Radiology & Ultrasound.

Surgical approach to giant aneurysms of the anterior circulation.

PubMed

Giombini, S; Solero, C L; Ferraresi, S; Melcarne, A; Broggi, G; Pluchino, F

1988-01-01

The surgical approach to cerebral giant aneurysms is still a source of great concern. We describe our experience with giant aneurysms of the anterior circulation and discuss the different surgical techniques adopted. During the period January 1972-December 1985, a total of 33 patients were operated upon at the Istituto Neurologico "C. Besta" of Milan for a giant aneurysm of the anterior circulation. Nineteen cases had suffered subarachnoid haemorrhage before admission; in 14 cases the hospitalization was due to evidence of mass effect on the surrounding neurovascular structures. All aneurysms were directly approached: in 24 cases the neck was occluded by a suitable clip, in 4 cases intramural thrombosis was attempted, in 3 cases the aneurysms were definitively trapped and in one case aneurysmorrhaphy was performed after resection of the sac. Operative mortality was 12%. Long-term follow-up shows good results whenever exclusion of the aneurysm from cerebral circulation had been achieved, either after removal of the sac or not; on the contrary, only fair or poor results were evident when other surgical techniques were adopted, either electively or out of necessity. The importance of intraoperative protection and monitoring of brain function is stressed.

Outcomes of atrioesophageal fistula following catheter ablation of atrial fibrillation treated with surgical repair versus esophageal stenting.

PubMed

Mohanty, Sanghamitra; Santangeli, Pasquale; Mohanty, Prasant; Di Biase, Luigi; Trivedi, Chintan; Bai, Rong; Horton, Rodney; Burkhardt, J David; Sanchez, Javier E; Zagrodzky, Jason; Bailey, Shane; Gallinghouse, Joseph G; Hranitzky, Patrick M; Sun, Albert Y; Hongo, Richard; Beheiry, Salwa; Natale, Andrea

2014-06-01

Atrioesophageal fistula (AEF) is a rare but devastating complication of radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF). Surgical repair and esophageal stents are available treatment options for AEF. We report outcomes of these 2 management strategies. Nine patients with AEF post-RFCA for AF were included in this study. AEF was diagnosed based on symptoms and chest CT imaging. Of the 9 patients, 5 received stents and 4 underwent surgical repair of fistula. AF ablation was performed under general anesthesia (n = 4) or conscious sedation (n = 5). During ablation, RF power was maintained between 25 and 35 Watts in areas close to the esophagus and energy delivery discontinued when esophageal temperature reached 38 °C. Seven patients underwent ablation with 3.5-mm open-irrigated catheter, 1 with 8-mm nonirrigated catheter, and 1 had surgical epicardial ablation. Seven patients received proton pump inhibitor and sucralfate before and after procedure. AEF symptoms developed within 2–6 weeks from ablation. Esophageal stenting was performed in 5 patients (median age 58 years, median time from RFCA 4 weeks) and 4 underwent surgical repair (median age 54 years, median time from RFCA 4 weeks) within 2–4 hours from diagnosis. All 5 patients receiving stents died within 1 week of the procedure due to cerebral embolism, septic shock, or respiratory failure. On the other hand, the 4 patients that received surgical repair were alive at median follow-up of 2.1 years (P = 0.005). Esophageal stenting should be discouraged and prompt surgical repair is crucial for survival in patients with atrioesophageal fistula.

Lessons learned from the American College of Surgeons National Surgical Quality Improvement Program Database: has centralized data collection improved immediate breast reconstruction outcomes and safety?

PubMed

Wang, Frederick; Koltz, Peter F; Sbitany, Hani

2014-11-01

The American College of Surgeons National Surgical Quality Improvement Program database was implemented to longitudinally track surgical 30-day surgical outcomes and complications. The authors analyze the program-reported outcomes for immediate breast reconstruction from 2007 to 2011, to assess whether longitudinal data collection has improved national outcomes and to highlight areas in need of continued improvement. The authors reviewed the database from 2007 to 2011 and identified encounters for immediate breast reconstruction using Current Procedural Terminology codes for prosthetic and autologous reconstruction. Demographics and comorbidities were tabulated for all patients. Postoperative complications analyzed included surgical-site infection, wound dehiscence, implant or flap loss, pulmonary embolism, and respiratory infections. A total of 15,978 patients underwent mastectomy and immediate reconstruction. Fewer smokers underwent immediate reconstruction over time (p=0.126), whereas more obese patients (p=0.001) and American Society of Anesthesiologists class 3 and 4 patients (p<0.001) underwent surgery. An overall increase in superficial surgical-site infection was noted, from 1.7 percent to 2.3 percent (p=0.214). Wound dehiscence (p=0.036) increased over time, whereas implant loss (p=0.015) and flap loss (p=0.012) decreased over time. Mean operative times increased over the analyzed years, as did all complications for prosthetic and autologous reconstruction. The American College of Surgeons National Surgical Quality Improvement Program data set has shown an increase in complications for immediate breast reconstruction over time, because of a longitudinally higher number of comorbid patients and longer operative times. This knowledge allows plastic surgeons the unique opportunity to improve patient selection criteria and efficiency. Therapeutic, III.

Long-Term Seizure, Quality of Life, Depression, and Verbal Memory Outcomes in a Controlled Mesial Temporal Lobe Epilepsy Surgical Series Using Portuguese-Validated Instruments.

PubMed

Dias, Luis Augusto; Angelis, Geisa de; Teixeira, Wagner Afonso; Casulari, Luiz Augusto

2017-08-01

We aimed to evaluate long-term surgical outcomes in patients treated for mesial temporal lobe epilepsy compared with a similar group of patients who underwent a preoperative evaluation. Patient interviews were conducted by an independent neuropsychologist and included a sociodemographic questionnaire and validated versions of the Beck Depression Inventory-II, Adverse Events Profile, Quality of Life in Epilepsy-31, and Rey Auditory Verbal Learning Test. Seventy-one patients who underwent surgery and 20 who underwent mesial temporal lobe epilepsy preoperative evaluations were interviewed. After an 81-month mean postoperative follow-up, 44% of the surgical patients achieved complete seizure relief according to the Engel classification and 68% according to the International League Against Epilepsy classification. The surgical group had a significantly lower prevalence of depression (P = 0.002) and drug-related adverse effects (P = 0.002). Improvement on unemployment (P = 0.02) was achieved but not on driving or education. Delayed verbal memory recall was impaired in 76% of the surgical and 65% of the control cases (P = 0.32). Regarding the Quality of Life in Epilepsy-31, the operated patients scored higher in their total score (mean, 75.44 vs. mean, 60.08; P < 0.001) and in all but the cognitive functioning domain irrespective of the follow-up length. Seizure control, Beck Depression Score, and Adverse Events Profile severity explained 73% of the variance in the surgical group quality of life. Our study found that, although surgical treatment was effective, its impact on social indicators was modest. Moreover, the self-reported quality of life relied not only on seizure control but also on depressive symptoms and antiepileptic drug burden. Copyright © 2017 The Author(s). Published by Elsevier Inc. All rights reserved.

Microsurgical training on an in vitro chicken wing infusion model.

PubMed

Olabe, Jon; Olabe, Javier

2009-12-01

Microneurovascular anastomosis and aneurysm clipping require extensive training before mastering the technique and are a surgical challenge. We developed the "infused chicken wing method" to provide a simple but realistic training method minimizing animal use and need for special facilities for animal care and anesthesia. Fresh chicken wings were used in this model. The main brachial artery was cannulated, and water was infused at 140 mm Hg followed by anatomical neurovascular dissection. Multiple microsurgical training exercises were performed under microscope vision including terminoterminal, lateroterminal, laterolateral vascular anastomosis, and nerve anastomosis. Different complexity aneurysms were created using venous patches, clipping, rupture, and vascular reconstruction techniques were performed. This novel training model is inexpensive, easily obtainable, and no live animals are required. The diameter and characteristics of arteries and veins used are similar to those of the human brain. Great microsurgical technique progress may be obtained. The infused chicken wing artery model presents a realistic microvascular training method. It is inexpensive and easy to set up. Such simplicity provides the adequate environment for developing microsurgical technique. Copyright 2009 Elsevier Inc. All rights reserved.

Surgical Treatment in Active Infective Endocarditis: Results of a Four-Year Experience

PubMed Central

Rostagno, Carlo; Carone, Enrico; Rossi, Alessandra; Gensini, Gian Franco; Stefano, Pier Luigi

2011-01-01

Background. Aim of present investigation was to analyze survival and recurrence rate in patients with active endocarditis referred to our centre for surgical treatment. Methods. 80 consecutive patients with active infective endocarditis (52 males, 28 females, mean age 59.2 years) were referred to our institution for surgical treatment. 78 patients underwent surgery, and 2 patients died before intervention. Results. Fifty patients had native valve endocarditis, 30 prosthetic valve involvement. Hospital mortality has been 10.2%. Three discharged patients (4.9%) died at an average 18-month followup. Endocarditis recurred in 4 (2 being S. aureus prosthetic tricuspid endocarditis in drug addicts). All patients who underwent valve repair or homograft implant were alive and free of recurrence. Conclusions. Our results suggest that with proper surgical treatment patients with active endocarditis discharged alive from hospital have a survival >90% at 18 months with a low recurrence rate. PMID:22347645

Isolated avulsion of the vastus lateralis tendon insertion in a weightlifter: a case report.

PubMed

Phadnis, Joideep; Trikha, Paul S; Wood, David G

2009-08-25

We report a case of isolated, unilateral avulsion of the vastus lateralis tendon from its insertion at the patella. This was diagnosed by magnetic resonance imaging, and underwent successful surgical repair. A healthy 32-year-old national level power lifter presented with an isolated avulsion of the vastus lateralis tendon. After a failed course of conservative therapy he underwent surgical repair and a graded physical therapy programme. One year later he returned to full training with no evidence of re-rupture. This is the first reported case of an isolated vastus lateralis avulsion. Our experience suggests that magnetic resonance imaging is invaluable in the diagnosis of this condition and that surgical repair provides a good outcome in high demand patients.

DAI-CLIPS: Distributed, Asynchronous, Interacting CLIPS

NASA Technical Reports Server (NTRS)

Gagne, Denis; Garant, Alain

1994-01-01

DAI-CLIPS is a distributed computational environment within which each CLIPS is an active independent computational entity with the ability to communicate freely with other CLIPS. Furthermore, new CLIPS can be created, others can be deleted or modify their expertise, all dynamically in an asynchronous and independent fashion during execution. The participating CLIPS are distributed over a network of heterogeneous processors taking full advantage of the available processing power. We present the general framework encompassing DAI-CLIPS and discuss some of its advantages and potential applications.

An Optimized Online Verification Imaging Procedure for External Beam Partial Breast Irradiation

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

Willis, David J., E-mail: David.Willis@petermac.or; Royal Melbourne Institute of Technology University, Melbourne, Victoria; Kron, Tomas

2011-07-01

The purpose of this study was to evaluate the capabilities of a kilovoltage (kV) on-board imager (OBI)-equipped linear accelerator in the setting of on-line verification imaging for external-beam partial breast irradiation. Available imaging techniques were optimized and assessed for image quality using a modified anthropomorphic phantom. Imaging dose was also assessed. Imaging techniques were assessed for physical clearance between patient and treatment machine using a volunteer. Nonorthogonal kV image pairs were identified as optimal in terms of image quality, clearance, and dose. After institutional review board approval, this approach was used for 17 patients receiving accelerated partial breast irradiation. Imagingmore » was performed before every fraction verification with online correction of setup deviations >5 mm (total image sessions = 170). Treatment staff rated risk of collision and visibility of tumor bed surgical clips where present. Image session duration and detected setup deviations were recorded. For all cases, both image projections (n = 34) had low collision risk. Surgical clips were rated as well as visualized in all cases where they were present (n = 5). The average imaging session time was 6 min, 16 sec, and a reduction in duration was observed as staff became familiar with the technique. Setup deviations of up to 1.3 cm were detected before treatment and subsequently confirmed offline. Nonorthogonal kV image pairs allowed effective and efficient online verification for partial breast irradiation. It has yet to be tested in a multicenter study to determine whether it is dependent on skilled treatment staff.« less

Clinicopathological Features of Cervical Esophageal Cancer: Retrospective Analysis of 63 Consecutive Patients Who Underwent Surgical Resection.

PubMed

Saeki, Hiroshi; Tsutsumi, Satoshi; Yukaya, Takafumi; Tajiri, Hirotada; Tsutsumi, Ryosuke; Nishimura, Sho; Nakaji, Yu; Kudou, Kensuke; Akiyama, Shingo; Kasagi, Yuta; Nakashima, Yuichiro; Sugiyama, Masahiko; Sonoda, Hideto; Ohgaki, Kippei; Oki, Eiji; Yasumatsu, Ryuji; Nakashima, Torahiko; Morita, Masaru; Maehara, Yoshihiko

2017-01-01

The objectives of this retrospective study were to elucidate the clinicopathological features and recent surgical results of cervical esophageal cancer. Cervical esophageal cancer has been reported to have a dismal prognosis. Accurate knowledge of the clinical characteristics of cervical esophageal cancer is warranted to establish appropriate therapeutic strategies. The clinicopathological features and treatment results of 63 consecutive patients with cervical esophageal cancer (Ce group) who underwent surgical resection from 1980 to 2013 were analyzed and compared with 977 patients with thoracic or abdominal esophageal cancer (T/A group) who underwent surgical resection during that time. Among the patients who received curative resection, the 5-year overall and disease-specific survival rates of the Ce patients were significantly better than those of the T/A patients (overall: 77.3% vs 46.5%, respectively, P = 0.0067; disease-specific: 81.9% vs 55.8%, respectively, P = 0.0135). Although total pharyngo-laryngo-esophagectomy procedures were less frequently performed in the recent period, the rate of curative surgical procedures was markedly higher in the recent period (2000-1013) than that in the early period (1980-1999) (44.4% vs 88.9%, P = 0.0001). The 5-year overall survival rate in the recent period (71.5%) was significantly better than that in the early period (40.7%, P = 0.0342). Curative resection for cervical esophageal cancer contributes to favorable outcomes compared with other esophageal cancers. Recent surgical results for cervical esophageal cancer have improved, and include an increased rate of curative resection and decreased rate of extensive surgery.

Beyond Volume: Hospital-Based Healthcare Technology for Better Outcomes in Cerebrovascular Surgical Patients Diagnosed With Ischemic Stroke: A Population-Based Nationwide Cohort Study From 2002 to 2013.

PubMed

Kim, Jae-Hyun; Park, Eun-Cheol; Lee, Sang Gyu; Lee, Tae-Hyun; Jang, Sung-In

2016-03-01

We examined whether the level of hospital-based healthcare technology was related to the 30-day postoperative mortality rates, after adjusting for hospital volume, of ischemic stroke patients who underwent a cerebrovascular surgical procedure. Using the National Health Insurance Service-Cohort Sample Database, we reviewed records from 2002 to 2013 for data on patients with ischemic stroke who underwent cerebrovascular surgical procedures. Statistical analysis was performed using Cox proportional hazard models to test our hypothesis. A total of 798 subjects were included in our study. After adjusting for hospital volume of cerebrovascular surgical procedures as well as all for other potential confounders, the hazard ratio (HR) of 30-day mortality in low healthcare technology hospitals as compared to high healthcare technology hospitals was 2.583 (P < 0.001). We also found that, although the HR of 30-day mortality in low healthcare technology hospitals with high volume as compared to high healthcare technology hospitals with high volume was the highest (10.014, P < 0.0001), cerebrovascular surgical procedure patients treated in low healthcare technology hospitals had the highest 30-day mortality rate, irrespective of hospital volume. Although results of our study provide scientific evidence for a hospital volume/30-day mortality rate relationship in ischemic stroke patients who underwent cerebrovascular surgical procedures, our results also suggest that the level of hospital-based healthcare technology is associated with mortality rates independent of hospital volume. Given these results, further research into what components of hospital-based healthcare technology significantly impact mortality is warranted.

Percutaneous Repair of Postoperative Mitral Regurgitation After Left Ventricular Assist Device Implant.

PubMed

Cork, David P; Adamson, Robert; Gollapudi, Raghava; Dembitsky, Walter; Jaski, Brian

2018-02-01

Mitral regurgitation commonly improves after implantation of a left ventricular assist device without concomitant valvular repair owing to the mechanical unloading of the left ventricle. However, the development (or persistence) of significant mitral regurgitation after implantation of a left ventricular assist device is associated with adverse clinical events. We present a case of a left ventricular assist device patient who successfully underwent a percutaneous MitraClip procedure for repair of persistent late postoperative mitral insufficiency with demonstrable clinical and hemodynamic improvement. Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Role of Surgical Versus Clinical Staging in Chemoradiated FIGO Stage IIB-IVA Cervical Cancer Patients-Acute Toxicity and Treatment Quality of the Uterus-11 Multicenter Phase III Intergroup Trial of the German Radiation Oncology Group and the Gynecologic Cancer Group.

PubMed

Marnitz, Simone; Martus, Peter; Köhler, Christhardt; Stromberger, Carmen; Asse, Elke; Mallmann, Peter; Schmidberger, Heinz; Affonso Júnior, Renato José; Nunes, João Soares; Sehouli, Jalid; Budach, Volker

2016-02-01

The Uterus-11 trial was designed to evaluate the role of surgical staging in patients with cervical cancer before primary chemoradiation therapy (CRT). The present report provides the toxicity data stratified by the treatment arm and technique. A total of 255 patients with carcinoma of the uterine cervix (International Federation of Gynecology and Obstetrics stage IIB-IVA) were randomized to either surgical staging followed by CRT (arm A) or clinical staging followed by CRT (arm B). Patients with para-aortic metastases underwent extended field radiation therapy (RT). Brachytherapy was mandatory. The present report presents the acute therapy-related toxicities stratified by treatment arm and radiation technique. A total of 240 patients were eligible (n=121 in arm A; n=119 in arm B). Of the 240 patients, 236 (98.3%) underwent external beam RT with a median total dose of 50.4 Gy. The mean treatment duration was 53 days. Of the patients, 60% underwent intensity modulated RT (IMRT). A total of 234 patients (97.5%) underwent chemotherapy, and 231 (96.3%) underwent brachytherapy, with a median single dose of 6 Gy covering the tumor to a median nominal total dose of 28 Gy. Treatment was well tolerated, with 0% grade ≥3 genitourinary and gastrointestinal toxicity, 6% grade 3 nausea, 3% grade 3 vomiting, and <2% grade 3 diarrhea. More patients after surgical staging experienced grade 2 anemia (54.3% in arm A vs 45.3% in arm B; P=.074) and grade 2 leukocytopenia (41.4% vs 31.6%; P=.56). Of the patients who received IMRT versus a 3-dimensional technique, 65.3% versus 33.7% presented with grade 2 anemia. Grade 3 gastrointestinal and grade 2 bladder toxicity were significantly reduced with the use of IMRT. The incidence and severity of acute therapy-related toxicity compared favorably with those from other randomized trials. Excellent adherence to treatment and treatment quality was achieved compared with patterns of care analyses. Surgical staging led to a doubled number of patients treated with extended field RT. The question of whether surgical staging is beneficial in the context of primary CRT requires further study. Copyright © 2016 Elsevier Inc. All rights reserved.

Does omphalocele major undergo spontaneous closure?

PubMed Central

Emordi, Victor C.; Osifo, David O.

2017-01-01

Abstract The early surgical management of omphalocele major in Africa predisposes neonates to surgical complications which are often worsened by the presence of associated anomalies. Conservative management using available escharotics results in early skin cover by secondary wound healing. This delays the need for fascial closure and avoids neonatal surgical risks thus improving survival. We present a case of omphalocele major that underwent spontaneous closure during conservative management with honey dressing without surgical intervention. PMID:28928917

Surgery for atrial fibrillation.

PubMed

Viganò, M; Graffigna, A; Ressia, L; Minzioni, G; Pagani, F; Aiello, M; Gazzoli, F

1996-01-01

The mechanisms of atrial fibrillation arc multiple reentry circuits spinning around the atrial surface, and these baffle any attempt to direct surgical interruption. The purpose of this article is to report the surgical experience in the treatment of isolated and concomitant atrial fibrillation at the Cardiac Surgical Institute of the University of Pavia. In cases of atrial fibrillation secondary to mitral/valve disease, surgical isolation of the left atrium at the time of mitral valve surgery can prevent atrial fibrillation from involving the right atrium, which can exert its diastolic pump function on the right ventricle. Left atrial isolation was performed on 205 patients at the time of mitral valve surgery. Atrial partitioning ("maze operation") creates straight and blind atrial alleys so that non-recentry circuits can take place. Five patients underwent this procedure. In eight-cases of atrial fibrillation secondary to atrial septal defect, the adult patients with atrial septal defect and chronic or paroxysmal atrial fibrillation underwent surgical isolation of the right atrium associated which surgical correction of the defect, in order to let sinus rhythm govern the left atrium and the ventricles. "Lone" atrial fibrillation occurs in hearts with no detectable organic disease. Bi-atrial isolation with creation of an atrial septal internodal "corridor" was performed on 14 patients. In cases of atrial fibrillation secondary to mitral valve disease, left atrial isolation was performed on 205 patients at the time of mitral valve surgery with an overall sinus rhythm recovery of 44%. In the same period, sinus rhythm was recovered and persisted in only 19% of 252 patients who underwent mitral valve replacement along (P < 0.001). Sinus rhythm was less likely to recover in patients with right atriomegaly requiring tricuspid valve annuloplasty: 59% vs 84% (P < 0.001). Restoration of the right atrial function raised the cardiac index from 2.25 +/- 0.55 1/min per m2 during atrial fibrillation to 2.54 +/- 0.58 1/min per m2, with a mean percentage increase in cardiac index of 13.5% (P < 0.00018). Atrial partitioning ("maze operation") was performed on five patients with an immediate sinus rhythm recovery of 100%, but with two patients requiring pacemaker implant. Seven out of eight patients (87.5%), with atrial fibrillation secondary to atrial septal defect, who underwent surgical isolation of the right atrium at the time of surgery were free from atrial fibrillation and without medications. 2-52 months after operation. Thirteen of 14 patients with "lone" atrial fibrillation who underwent corridor procedure remained in sinus rhythm with a sinus rhythm recovery rate of 92%. Different surgical options can be chosen for different cases of atrial fibrillation, according to the underlying cardiac disease.

[Functional proctology at the University of Pécs].

PubMed

Kalmár, Katalin; Baracs, József; Illés, Anita; Czimmer, József; Weninger, Csaba; Horváth, Ors Péter

2012-10-01

Functional proctological investigations have been introduced at Pécs University of Sciences 15 years ago. The Pelvic Floor Multidisciplinary Team has been re-launched after many years of pause in 2010. Experience of the team in the treatment of faecal incontinence and obstructed defecation syndrome is discussed. In the past 3 years 9 patients underwent sphincter reconstruction for faecal incontinence. The Pelvic Floor Team in the past 1.5 year consulted 31 patients with constipation, who were considered by the referee for surgical intervention. Following investigations 10 patients underwent surgery, the rest of them were treated conservatively. Seven patients underwent perineal reconstruction with mesh, three patients had ventral rectopexy with additional levatoro-pexy. 78% of patients operated on for faecal incontinence reported full continence, 88% improvement. We invented a new symptom score with a maximum of 20 points to evaluate results of treatment of patients with Obstructed Defecation Syndrome. Patients who underwent perineal repair were interviewed pre and postoperatively. They scored 14 ± 2.83 and 5.4 ± 4.62 points, respectively (p = 0.0075). Functional proctological patients require a specialist approach from history taking through investigation to treatment. Majority of patients benefit from conservative treatment. Adequate patient selection is essential for successful surgical treatment. Symptom scores applied pre and postoperatively facilitate proper patient selection for various surgical methods.

Outcomes of De Vega versus biodegradable ring annuloplasty in the surgical treatment of tricuspid regurgitation (mid-term results).

PubMed

Basel, Halil; Aydin, Unal; Kutlu, Hakan; Dostbil, Aysenur; Karadag, Melike; Odabasi, Dolunay; Aydin, Cemalettin

2010-08-01

The aim of this study was to compare De Vega semicircular annuloplasty and a new biodegradable ring annuloplasty technique in patients requiring surgical intervention for tricuspid valve disease with concomitant disease of the mitral valve. Between January 2004 and May 2008, 129 consecutive patients underwent annuloplasty procedures to correct tricuspid valve regurgitation during a concomitant mitral valve operation requiring replacement. Additionally, 24 patients underwent aortic valve replacement (AVR), 11 underwent coronary artery bypass grafting (CABG), 5 underwent AVR plus CABG, 3 underwent mitral valve replacement plus atrial septal defect (ASD) closure, and 2 underwent ASD closure. The patients in this study were assigned to 2 groups: Kalangos ring annuloplasty was performed in 67 patients (group 1), and De Vega semicircular annuloplasty was performed in the remaining 62 patients (group 2). Both tricuspid valve repair techniques produced a low rate of complications; however, the number of patients who developed residual tricuspid regurgitation was significantly lower in group 1. The biodegradable ring annuloplasty technique may be used easily and safely in moderate and severe cases of tricuspid regurgitation; however, larger clinical series are necessary to confirm our promising results.

The Role of Surgery in the Clinical Management of Primary Gastrointestinal Non-Hodgkin's Lymphoma.

PubMed

MacQueen, Ian T; Shannon, Evan M; Dawes, Aaron J; Ostrzega, Nora; Russell, Marcia M; Maggard-Gibbons, Melinda

2015-10-01

Primary gastrointestinal non-Hodgkin's lymphoma (PGINHL) is a heterogeneous family of tumors, with treatment modalities including chemotherapy, surgery, and radiotherapy. Because the role of surgery in PGINHL remains disputed, this study aims to assess the impact of operative resection on survival. We used a pathology database to identify all cases of PGINHL diagnosed at a single academic-affiliated medical center from 1988 to 2013. Demographic and clinical data were abstracted from the medical record. We summarized the clinical courses of patients with PGINHL and then performed a survival analysis to compare overall and disease-free survival, stratified by demographic and clinical variables. We identified 33 patients diagnosed with PGINHL during the study period. Of 29 who subsequently received treatment at the institution, 15 initially underwent chemotherapy, 10 underwent surgical resection, and 4 underwent surgery for other reasons such as diagnosis without resection or management of disease complications. Three patients suffered surgical complications and two of these patients died. We found no difference in overall survival between patients receiving surgical resection and patients managed initially with chemotherapy. This case series supports a continued role for surgical resection in the management of patients with PGINHL, though anticipated benefits should be weighed against the risk of complications.

Surgical outcomes of laparoscopic adrenalectomy for patients with Cushing's and subclinical Cushing's syndrome: a single center experience.

PubMed

Miyazato, Minoru; Ishidoya, Shigeto; Satoh, Fumitoshi; Morimoto, Ryo; Kaiho, Yasuhiro; Yamada, Shigeyuki; Ito, Akihiro; Nakagawa, Haruo; Ito, Sadayoshi; Arai, Yoichi

2011-12-01

We retrospectively examined the outcome of patients who underwent laparoscopic adrenalectomy for Cushing's/subclinical Cushing's syndrome in our single institute. Between 1994 and 2008, a total of 114 patients (29 males and 85 females, median age 54 years) with adrenal Cushing's/subclinical Cushing's syndrome were studied. We compared the outcome of patients who underwent laparoscopic adrenalectomy between intraperitoneal and retroperitoneal approaches. Surgical complications were graded according to the Clavien grading system. We also examined the long-term results of subclinical Cushing's syndrome after laparoscopic adrenalectomy. Laparoscopic surgical outcome did not differ significantly between patients with Cushing's syndrome and those with subclinical Cushing's syndrome. Patients who underwent laparoscopic intraperitoneal adrenalectomy had longer operative time than those who received retroperitoneal adrenalectomy (188.2 min vs. 160.9 min). However, operative blood loss and surgical complications were similar between both approaches. There were no complications of Clavien grade III or higher in either intraperitoneal or retroperitoneal approach. We confirmed the improvement of hypertension and glucose tolerance in patients with subclinical Cushing's syndrome after laparoscopic adrenalectomy. Laparoscopic adrenalectomy for adrenal Cushing's/subclinical Cushing's syndrome is safe and feasible in either intraperitoneal or retroperitoneal approach. The use of the Clavien grading system for reporting complications in the laparoscopic adrenalectomy is encouraged for a valuable quality assessment.

Outcomes of Complete Versus Partial Surgical Stabilization of Flail Chest.

PubMed

Nickerson, Terry P; Thiels, Cornelius A; Kim, Brian D; Zielinski, Martin D; Jenkins, Donald H; Schiller, Henry J

2016-01-01

Rib fractures are common after chest wall trauma. For patients with flail chest, surgical stabilization is a promising technique for reducing morbidity. Anatomical difficulties often lead to an inability to completely repair the flail chest; thus, the result is partial flail chest stabilization (PFS). We hypothesized that patients with PFS have outcomes similar to those undergoing complete flail chest stabilization (CFS). A prospectively collected database of all patients who underwent rib fracture stabilization procedures from August 2009 until February 2013 was reviewed. Abstracted data included procedural and complication data, extent of stabilization, and pulmonary function test results. Of 43 patients who underwent operative stabilization of flail chest, 23 (53%) had CFS and 20 (47%) underwent PFS. Anterior location of the fracture was the most common reason for PFS (45%). Age, sex, operative time, pneumonia, intensive care unit and hospital length of stay, and narcotic use were the same in both groups. Total lung capacity was significantly improved in the CFS group at 3 months. No chest wall deformity was appreciated on follow-up, and no patients underwent additional stabilization procedures following PFS. Despite advances in surgical technique, not all fractures are amenable to repair. There was no difference in chest wall deformity, narcotic use, or clinically significant impairment in pulmonary function tests among patients who underwent PFS compared with CFS. Our data suggest that PFS is an acceptable strategy and that extending or creating additional incisions for CFS is unnecessary.

Findings of the International Subarachnoid Aneurysm Trial and the National Study of Subarachnoid Haemorrhage in context.

PubMed

Reeves, B C; Langham, J; Lindsay, K W; Molyneux, A J; Browne, J P; Copley, L; Shaw, D; Gholkar, A; Kirkpatrick, P J

2007-08-01

Concern has been expressed about the applicability of the findings of the International Subarachnoid Aneurysm Trial (ISAT) with respect to the relative effects on outcome of coiling and clipping. It has been suggested that the findings of the National Study of Subarachnoid Haemorrhage may have greater relevance for neurosurgical practice. The objective of this paper was to interpret the findings of these two studies in the context of differences in their study populations, design, execution and analysis. Because of differences in design and analysis, the findings of the two studies are not directly comparable. The ISAT analysed all randomized patients by intention-to-treat, including some who did not undergo a repair, and obtained the primary outcome for 99% of participants. The National Study only analysed participants who underwent clipping or coiling, according to the method of repair, and obtained the primary outcome for 91% of participants. Time to repair was also considered differently in the two studies. The comparison between coiling and clipping was susceptible to confounding in the National Study, but not in the ISAT. The two study populations differed to some extent, but inspection of these differences does not support the view that coiling was applied inappropriately in the National Study. Therefore, there are many reasons why the two studies estimated different sizes of effect. The possibility that there were real, systematic differences in practice between the ISAT and the National Study cannot be ruled out, but such explanations must be seen in the context of other explanations relating to chance, differences in design or analysis, or confounding.

Advanced real-time multi-display educational system (ARMES): An innovative real-time audiovisual mentoring tool for complex robotic surgery.

PubMed

Lee, Joong Ho; Tanaka, Eiji; Woo, Yanghee; Ali, Güner; Son, Taeil; Kim, Hyoung-Il; Hyung, Woo Jin

2017-12-01

The recent scientific and technologic advances have profoundly affected the training of surgeons worldwide. We describe a novel intraoperative real-time training module, the Advanced Robotic Multi-display Educational System (ARMES). We created a real-time training module, which can provide a standardized step by step guidance to robotic distal subtotal gastrectomy with D2 lymphadenectomy procedures, ARMES. The short video clips of 20 key steps in the standardized procedure for robotic gastrectomy were created and integrated with TilePro™ software to delivery on da Vinci Surgical Systems (Intuitive Surgical, Sunnyvale, CA). We successfully performed the robotic distal subtotal gastrectomy with D2 lymphadenectomy for patient with gastric cancer employing this new teaching method without any transfer errors or system failures. Using this technique, the total operative time was 197 min and blood loss was 50 mL and there were no intra- or post-operative complications. Our innovative real-time mentoring module, ARMES, enables standardized, systematic guidance during surgical procedures. © 2017 Wiley Periodicals, Inc.

Introduction of a simulation model for choledocho- and pancreaticojejunostomy.

PubMed

Narumi, Shunji; Toyoki, Yoshikazu; Ishido, Keinosuke; Kudo, Daisuke; Umehara, Minoru; Kimura, Norihisa; Miura, Takuya; Muroya, Takahiro; Hakamada, Kenichi

2012-10-01

Pancreaticoduodenectomy includes choledochojejunostomy and pancreaticojejunostomy, which require hand-sewn anastomoses. Educational simulation models for choledochojejunostomy and pancreaticojejunostomy have not been designed. We introduce a simulation model for choledochojejunostomy and pancreaticojejunostomy created with a skin closure pad and a vascular model. A wound closure pad and a vein model (4 mm diameter) were used as a stump model of the pancreas. Pancreaticojejunostomy was simulated with a stump model of the pancreas and a double layer bowel model; these models were stabilized in an end-to-side fashion on a magnetic board using magnetic clips. In addition, vein (6 or 8 mm diameter) and bowel models were used to simulate choledochojejunostomy. Pancreatic and hepatobiliary surgery are relatively rare, particularly in a community hospital although surgical residents wish to practice these procedures. Our simulator enables surgeons and surgical residents to practice choledocho- and pancreaticojejunostomy through open or laparoscopic approaches.

Emerging Transcatheter Options for Tricuspid Regurgitation

PubMed Central

Kalra, Ankur; Uberoi, Angad S.; Latib, Azeem; Khera, Sahil; Little, Stephen H.; Bhatt, Deepak L.; Reardon, Michael J.; Kleiman, Neal S.; Barker, Colin M.

2017-01-01

Tricuspid regurgitation (TR) presents as either primary valve pathology or secondary to pulmonary or left-sided heart disease. Severe TR portends a worse prognosis independent of age, right ventricular size and function, severe left ventricular dysfunction, and increased pulmonary arterial pressures. Surgical treatment for TR has mostly been limited to patients undergoing mitral valve repair since those at high surgical risk are not candidates for traditional TR surgery. For these patients, minimally invasive techniques could be of great benefit, yet these techniques have been slow to develop because of the various anatomic and physiological aspects of the tricuspid valve apparatus. Several promising new techniques are currently undergoing clinical investigation, including caval valve implantation, percutaneous tricuspid annuloplasty techniques (Trialign, TriCinch, Cardioband), edge-to-edge repair with the MitraClip system, the FORMA device, and the GATE tricuspid Atrioventricular Valved Stent. Further evaluation of their safety and long-term efficacy is warranted prior to commercial approval and widespread adoption. PMID:29743996

Indocyanine green video-angiography as an aid to surgical treatment of spinal dural arteriovenous fistulae.

PubMed

Hettige, Samantha; Walsh, Daniel

2010-03-01

To illustrate the use of indocyanine green (ICG) video-angiography to confirm abolition of spinal dural arteriovenous fistula (SDAVF) and preserve the normal vascular anatomy intraoperatively. A 73-year-old woman presenting with progressive myelopathy was diagnosed with an SDAVF, where the origin of the fistula was in close proximity to the origin of the posterior spinal artery. ICG was injected intravenously. Using a filter on the microscope, dynamic filling of the abnormal vasculature was visualised. After applying a clip to the fistulous connection, we were able to see the successful interruption of the dural fistula, on-table in real time. ICG video angiography confirmed interruption of the fistula and preservation of the associated posterior spinal artery. We find the application of this relatively new technology has the potential to shorten operating times, gives additional reassurance of completeness of surgical treatment and preservation of normal spinal vasculature.

Comparison between transcatheter and surgical aortic valve replacement: a single-center experience.

PubMed

Silberman, Shuli; Abu Akr, Firas; Bitran, Daniel; Almagor, Yaron; Balkin, Jonathan; Tauber, Rachel; Merin, Ofer

2013-07-01

A comparison was made of the outcomes after transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (AVR) in high-risk patients. All patients aged > 75 years that underwent a procedure for severe aortic stenosis with or without coronary revascularization at the authors' institution were included in the study; thus, 64 patients underwent TAVI and 188 underwent AVR. Patients in the TAVI group were older (mean age 84 +/- 5 versus 80 +/- 4 years; p < 0.0001) and had a higher logistic EuroSCORE (p = 0.004). Six patients (9%) died during the procedure in the TAVI group, and 23 (12%) died in the AVR group (p = 0.5). Predictors for mortality were: age (p < 0.0001), female gender (p = 0.02), and surgical valve replacement (p = 0.01). Gradients across the implanted valves at one to three months postoperatively were lower in the TAVI group (p < 0.0001). Actuarial survival at one, two and three years was 78%, 64% and 64%, respectively, for TAVI, and 83%, 78% and 75%, respectively, for AVR (p = 0.4). Age was the only predictor for late mortality (p < 0.0001). TAVI patients were older and posed a higher predicted surgical risk. Procedural mortality was lower in the TAVI group, but mid-term survival was similar to that in patients undergoing surgical AVR. Age was the only predictor for late survival. These data support the referral of high-risk patients for TAVI.

Correction of clipped pixels in color images.

PubMed

Xu, Di; Doutre, Colin; Nasiopoulos, Panos

2011-03-01

Conventional images store a very limited dynamic range of brightness. The true luma in the bright area of such images is often lost due to clipping. When clipping changes the R, G, B color ratios of a pixel, color distortion also occurs. In this paper, we propose an algorithm to enhance both the luma and chroma of the clipped pixels. Our method is based on the strong chroma spatial correlation between clipped pixels and their surrounding unclipped area. After identifying the clipped areas in the image, we partition the clipped areas into regions with similar chroma, and estimate the chroma of each clipped region based on the chroma of its surrounding unclipped region. We correct the clipped R, G, or B color channels based on the estimated chroma and the unclipped color channel(s) of the current pixel. The last step involves smoothing of the boundaries between regions of different clipping scenarios. Both objective and subjective experimental results show that our algorithm is very effective in restoring the color of clipped pixels. © 2011 IEEE

Sellar door: Harvey Cushing's entry into the pituitary gland, the unabridged Johns Hopkins experience 1896-1912.

PubMed

Pendleton, Courtney; Adams, Hadie; Mathioudakis, Nestoras; Quiñones-Hinojosa, Alfredo

2013-02-01

To review the original surgical records from the Johns Hopkins Hospital, and analyze the records of patients Cushing treated for pituitary disorders from 1896 to 1912. Following IRB approval, and through the courtesy of the Alan Mason Chesney Archives, we reviewed the original surgical files from the Johns Hopkins Hospital. Patients presenting with pituitary-related symptoms, who underwent surgical treatment directed at the pituitary gland, were selected for further review. Thirty-seven patients who underwent surgical intervention for pituitary disorders were found. Of these patients, 12 were mentioned only briefly in Cushing's 1912 monograph, whereas 6 were not described at all. The remaining 19 were documented by Cushing in his 1912 monograph. Cushing used three main surgical approaches to the pituitary: transsphenoidal, transcranial, and the subfrontal "omega incision." There were 6 inpatient deaths. The mean time to last follow-up was 41.0 months. At follow-up, headache was the most common unresolved symptom. This review highlights Cushing's accomplishments in the surgical treatment of suspected pituitary pathology during his early career as a young attending at Johns Hopkins Hospital. It reveals new information about patients whom Cushing did not include in his publications detailing his surgical experience at the Johns Hopkins Hospital. Copyright © 2013 Elsevier Inc. All rights reserved.

Sellar Door: Harvey Cushing’s Entry into the Pituitary Gland, the Unabridged Johns Hopkins Experience 1896-1912

PubMed Central

Pendleton, Courtney; Adams, Hadie; Mathioudakis, Nestoras; Quiñones-Hinojosa, Alfredo

2014-01-01

OBJECTIVE To review the original surgical records from the Johns Hopkins Hospital, and analyze the records of patients Cushing treated for pituitary disorders from 1896 to 1912. METHODS Following IRB approval, and through the courtesy of the Alan Mason Chesney Archives, we reviewed the original surgical files from the Johns Hopkins Hospital. Patients presenting with pituitary-related symptoms, who underwent surgical treatment directed at the pituitary gland, were selected for further review. RESULTS Thirty-seven patients who underwent surgical intervention for pituitary disorders were found. Of these patients, 12 were mentioned only briefly in Cushing’s 1912 monograph, whereas 6 were not described at all. The remaining 19 were documented by Cushing in his 1912 monograph. Cushing used three main surgical approaches to the pituitary: transsphenoidal, transcranial, and the subfrontal “omega incision.” There were 6 inpatient deaths. The mean time to last follow-up was 41.0 months. At follow-up, headache was the most common unresolved symptom. CONCLUSION This review highlights Cushing’s accomplishments in the surgical treatment of suspected pituitary pathology during his early career as a young attending at Johns Hopkins Hospital. It reveals new information about patients whom Cushing did not include in his publications detailing his surgical experience at the Johns Hopkins Hospital. PMID:22079823

Effectiveness of bilateral tubotubal anastomosis in a large outpatient population

PubMed Central

Berger, Gary S.; Thorp, John M.; Weaver, Mark A.

2016-01-01

STUDY QUESTION Is bilateral tubotubal anastomosis a successful treatment in an outpatient patient population? SUMMARY ANSWER For women wanting children after tubal sterilization, bilateral tubotubal anastomosis is an effective outpatient treatment. WHAT IS KNOWN ALREADY With the current emphasis in reproductive medicine on high technology procedures, the effectiveness of female surgical sterilization reversal is often overlooked. Previous clinical studies of tubal sterilization reversal have been mostly retrospective analyses of small patient populations. STUDY DESIGN, SIZE, DURATION A cohort of women who underwent outpatient bilateral tubotubal anastomosis from January 2000 to June 2013 was followed prospectively until December 2014 to determine the proportions of women undergoing the procedure who became pregnant and who had live births. Data were collected at the time of pregnancy. Differences in pregnancy rates and live birth rates associated with age, race and sterilization method were evaluated. PARTICIPANTS/MATERIALS, SETTING, METHODS A total of 6692 women, aged 20–51 years, underwent outpatient bilateral tubotubal anastomosis. MAIN RESULTS AND THE ROLE OF CHANCE The crude overall pregnancy rate was 69%. The crude overall birth rate was 35%. Results varied according to age at sterilization reversal and the method of sterilization. Women under 30 years of age at reversal of ring/clip sterilizations had an 88% pregnancy rate and 62% birth rate. Pregnancy and birth rates declined as age increased at sterilization reversal. Coagulation sterilization reversals resulted in the lowest rates of pregnancies and births. Ligation/resection reversals had intermediate success rates. LIMITATIONS, REASONS FOR CAUTION Limitations of our study include probable underreporting of pregnancies based on patient-initiated reports; possible errors in the reporting of pregnancies or early miscarriages that may have been based solely on home pregnancy tests; and probable over-reporting of the diagnosis of ectopic pregnancies. We identified age and sterilization method as being associated with subsequent pregnancy, however, in order to be considered predictive, the associations would need to be validated in an independent second prospectively studied group of representative patients. Finally, we also included patients in the study population who had additional surgical procedures performed at the time of tubotubal anastomosis (e.g. uterine myomectomy, fimbrioplasty, ovarian cystectomy and adhesiolysis), factors that could result in differences in pregnancy statistics in our study versus other patient populations. WIDER IMPLICATIONS OF THE FINDINGS The results of this study can help inform patients and clinicians about this low technology alternative to IVF. STUDY FUNDING/COMPETING INTEREST(S) None. TRIAL REGISTRATION NUMBER N/A. PMID:26980770

Isolated avulsion of the vastus lateralis tendon insertion in a weightlifter: a case report

PubMed Central

Trikha, Paul S; Wood, David G

2009-01-01

Introduction We report a case of isolated, unilateral avulsion of the vastus lateralis tendon from its insertion at the patella. This was diagnosed by magnetic resonance imaging, and underwent successful surgical repair. Case presentation A healthy 32-year-old national level power lifter presented with an isolated avulsion of the vastus lateralis tendon. After a failed course of conservative therapy he underwent surgical repair and a graded physical therapy programme. One year later he returned to full training with no evidence of re-rupture. Conclusion This is the first reported case of an isolated vastus lateralis avulsion. Our experience suggests that magnetic resonance imaging is invaluable in the diagnosis of this condition and that surgical repair provides a good outcome in high demand patients. PMID:19918436

Modified CLIP with objective liver reserve assessment retains prognosis prediction for patients with advanced hepatocellular carcinoma.

PubMed

Shao, Yu-Yun; Liu, Tsung-Hao; Lee, Ying-Hui; Hsu, Chih-Hung; Cheng, Ann-Lii

2016-07-01

The Cancer of the Liver Italian Program (CLIP) score is a commonly used staging system for hepatocellular carcinoma (HCC) helpful with predicting prognosis of advanced HCC. CLIP uses the Child-Turcotte-Pugh (CTP) score to evaluate liver reserve. A new scoring system, the albumin-bilirubin (ALBI) grade, has been proposed as they objectively evaluate liver reserve. We examined whether the modification of CLIP with ALBI retained its prognosis prediction for patients with advanced HCC. We included patients who received first-line antiangiogenic therapy for advanced HCC. Liver reserve was assessed using CTP and ALBI scores, which were then incorporated into CLIP and ALBI-CLIP, respectively. To assess their efficacies of prognostic prediction, the Cox's proportional hazard model and concordance indexes were used. A total of 142 patients were included; 137 of them were classified CTP A and 5 patients CTP B. Patients could be divided into four or five groups with different prognosis according to CLIP and ALBI-CLIP, respectively. Higher R(2) (0.249 vs 0.216) and lower Akaike information criterion (995.0 vs 1001.1) were observed for ALBI-CLIP than for CLIP in the Cox's model predicting overall survival. ALBI-CLIP remained an independent predictor for overall survival when CLIP and ALBI-CLIP were simultaneously incorporated in Cox's models allowing variable selection with adjustment for hepatitis etiology, treatment, and performance status. The concordance index was also higher for ALBI-CLIP than for CLIP (0.724 vs 0.703). Modification of CLIP scoring with ALBI, which objectively assesses liver reserve, retains and might have improved prognosis prediction for advanced HCC. © 2016 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.

Rebleeding from clipped aneurysm after 35 years: Report of 2 cases

PubMed Central

Ishida, Atsushi; Matsuo, Seigo; Asakuno, Keizoh; Nemoto, Akio; Niimura, Kaku; Yoshimoto, Haruko; Shiramizu, Hideki; Yuzawa, Miki

2015-01-01

Background: A successfully applied clip for a ruptured aneurysm keeps the aneurysm's neck closed, preventing rerupture throughout the patient's life. Unfortunately, rebleeding from a clipped aneurysm does occur, but the likelihood declines with time. Since relatively old people suffer from subarachnoid hemorrhage, they die from diseases other than rebleeding, such as cancer. Therefore, rebleeding from a clipped aneurysm after two decades is quite rare. Case Description: Here, we report 2 cases of rerupture after an extremely long time since the initial clipping. In both cases, the old clip was removed, and the regrown gourd-shaped aneurysm was successfully obliterated. The clips in both cases were submitted to their manufacturers and inspected thoroughly. They were found to be second-generation, stainless steel clips, and were almost intact, even keeping their closing forces. In both cases, the clip existed on the surface of the newly made dome, and the previous dome completely disappeared. Conclusions: We experienced 2 cases of rebleeding from the clipped aneurysm after 35 years. In one of the cases, the clip was a Yasargil second generation stainless steel clip that retained its mechanical properties and surface elemental composition in vivo for a long time. These cases should be informative as they show extremely long-term course of a clip applied for a ruptured aneurysm. PMID:26322244

Reconstruction of total pelvic exenteration defects with rectus abdominus myocutaneous flaps versus primary closure.

PubMed

Chokshi, Ravi J; Kuhrt, Maureen P; Arrese, David; Martin, Edward W

2013-01-01

Total pelvic exenteration (TPE) is reserved for patients with locally invasive and recurrent pelvic malignancies. Complications such as wound infections, dehiscence, hernias, abscesses, and fistulas are common after this procedure. The purpose of this study was to determine whether tissue transfer to the pelvis after TPE decreases wound complications. Fifty-three patients who underwent TPE between 2004 and 2010 were reviewed. Two groups were identified, those who underwent pelvic reconstruction with a vertical rectus abdominus myocutaneous flap (n = 17) and those who underwent primary closure (n = 36). Demographics, clinicopathologic characteristics, and outcomes were compared. The 2 groups were similar in demographics and histopathologic characteristics. Preoperative and surgical factors including comorbidities, nutrition, radiation, surgical times, blood loss, length of stay, and complications were similar between the groups. Of the 17 patients undergoing vertical rectus abdominus myocutaneous flap placement, complications were seen in 11 patients (65%), with most of them stemming from flap dehiscence (n = 7). In our study, the transfer of tissue into the pelvis did not increase surgical times, blood loss, length of stay, or wound complications. Copyright © 2013 Elsevier Inc. All rights reserved.

Locoregional control of tongue base adenoid cystic carcinoma with primary resection and radial forearm free flap reconstruction.

PubMed

Yarlagadda, Bharat B; Meier, Josh C; Lin, Derrick T; Emerick, Kevin S; Deschler, Daniel G

2017-01-01

Adenoid cystic carcinoma of the minor salivary glands can be challenging and marked by high rates of local recurrence despite appropriate surgical resection. Management of this pathology in the base of the tongue is particularly difficult given the poor functional outcomes traditionally associated with an aggressive surgical approach. This article presents a case series of patients who underwent up-front surgical resection followed by free tissue transfer reconstruction. A retrospective analysis was performed of patients with adenoid cystic carcinoma of the base of the tongue who underwent composite resection and reconstruction with a radial forearm free flap. Three patients met inclusion criteria and underwent analysis. All patients achieved locoregional control after at least 4 years of surveillance. In addition, all patients were decannulated and were swallowing without the need for gastrostomy tube feeding. This series demonstrates that for select patients with adenoid cystic carcinoma of the base of the tongue, excellent locoregional control can be achieved with acceptable functional outcomes and prolonged survival when appropriate reconstructive measures are employed.

Surgical approach to posterior inferior cerebellar artery aneurysms.

PubMed

La Pira, Biagia; Sturiale, Carmelo Lucio; Della Pepa, Giuseppe Maria; Albanese, Alessio

2018-02-01

The far-lateral is a standardised approach to clip aneurysms of the posterior inferior cerebellar artery (PICA). Different variants can be adopted to manage aneurysms that differ in morphology, topography, ruptured status, cerebellar swelling and surgeon preference. We distinguished five paradigmatic approaches aimed to manage aneurysms that are: proximal unruptured; proximal ruptured requiring posterior fossa decompression (PFD); proximal ruptured not requiring PFD; distal unruptured; distal ruptured. Preoperative planning in the setting of PICA aneurysm surgery is of paramount importance to perform an effective and safe procedure, to ensure an adequate PFD and optimal proximal control before aneurysm manipulation.

[Zwipp Percutaneous Suture of the Achilles Tendon with the Dresden Instruments].

PubMed

Chmielnicki, M; Prokop, A

2016-06-01

Rupture of the Achilles tendon is the most common rupture of a tendon in man. Acute rupture of the Achilles tendon may be treated in a variety of manners, including conservative treatment, open suture and percutaneous suture. Surgical treatment of active patients is recommended, as the risk of re-rupture is greater after non-surgical treatment. The aim of surgery is adequate treatment of Achilles tendon rupture with a low rate of complications, high comfort for patients and fast social and occupational rehabilitation. The indication for surgical treatment of Achilles tendon rupture predominantly includes ruptures in active patients, with the goal of optimal functional rehabilitation. Furthermore, the percutaneous technique protects soft tissue, with a lower rate of wound healing disorders and infection than with open surgical treatment. In our clinic we perform the percutaneous suturing technique with the Dresden instruments. The surgical technique and functional aftercare are shown in a video clip. Between 2007 and 2013, we treated 212 patients with acute Achilles tendon rupture by surgery with the Dresden instruments. There were 7 re-ruptures (3.3 %) and one case of infection within one year of surgery. Percutaneous Achilles tendon suture technique with the Dresden instruments is a safe operation that protects soft tissue. Patient satisfaction is high and the rate of complications is low. This allows rapid social and occupational rehabilitation. Georg Thieme Verlag KG Stuttgart · New York.

Metal artifact reduction for flat panel detector intravenous CT angiography in patients with intracranial metallic implants after endovascular and surgical treatment.

PubMed

Pjontek, Rastislav; Önenköprülü, Belgin; Scholz, Bernhard; Kyriakou, Yiannis; Schubert, Gerrit A; Nikoubashman, Omid; Othman, Ahmed; Wiesmann, Martin; Brockmann, Marc A

2016-08-01

Flat panel detector CT angiography with intravenous contrast agent injection (IV CTA) allows high-resolution imaging of cerebrovascular structures. Artifacts caused by metallic implants like platinum coils or clips lead to degradation of image quality and are a significant problem. To evaluate the influence of a prototype metal artifact reduction (MAR) algorithm on image quality in patients with intracranial metallic implants. Flat panel detector CT after intravenous application of 80 mL contrast agent was performed with an angiography system (Artis zee; Siemens, Forchheim, Germany) using a 20 s rotation protocol (200° rotation angle, 20 s acquisition time, 496 projections). The data before and after MAR of 26 patients with a total of 34 implants (coils, clips, stents) were independently evaluated by two blinded neuroradiologists. MAR improved the assessability of the brain parenchyma and small vessels (diameter <1 mm) in the neighborhood of metallic implants and at a distance of 6 cm (p<0.001 each, Wilcoxon test). Furthermore, MAR significantly improved the assessability of parent vessel patency and potential aneurysm remnants (p<0.005 each, McNemar test). MAR, however, did not improve assessability of stented vessels. When an intravenous contrast protocol is used, MAR significantly ameliorates the assessability of brain parenchyma, vessels, and treated aneurysms in patients with intracranial coils or clips. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Images created in a model eye during simulated cataract surgery can be the basis for images perceived by patients during cataract surgery

PubMed Central

Inoue, M; Uchida, A; Shinoda, K; Taira, Y; Noda, T; Ohnuma, K; Bissen-Miyajima, H; Hirakata, A

2014-01-01

Purpose To evaluate the images created in a model eye during simulated cataract surgery. Patients and methods This study was conducted as a laboratory investigation and interventional case series. An artificial opaque lens, a clear intraocular lens (IOL), or an irrigation/aspiration (I/A) tip was inserted into the ‘anterior chamber' of a model eye with the frosted posterior surface corresponding to the retina. Video images were recorded of the posterior surface of the model eye from the rear during simulated cataract surgery. The video clips were shown to 20 patients before cataract surgery, and the similarity of their visual perceptions to these images was evaluated postoperatively. Results The images of the moving lens fragments and I/A tip and the insertion of the IOL were seen from the rear. The image through the opaque lens and the IOL without moving objects was the light of the surgical microscope from the rear. However, when the microscope light was turned off after IOL insertion, the images of the microscope and operating room were observed by the room illumination from the rear. Seventy percent of the patients answered that the visual perceptions of moving lens fragments were similar to the video clips and 55% reported similarity with the IOL insertion. Eighty percent of the patients recommended that patients watch the video clip before their scheduled cataract surgery. Conclusions The patients' visual perceptions during cataract surgery can be reproduced in the model eye. Watching the video images preoperatively may help relax the patients during surgery. PMID:24788007

Endoscopy versus radiology in post-procedural monitoring after peroral endoscopic myotomy (POEM).

PubMed

Nast, Jan Friso; Berliner, Christoph; Rösch, Thomas; von Renteln, Daniel; Noder, Tania; Schachschal, Guido; Groth, Stefan; Ittrich, Harald; Kersten, Jan F; Adam, Gerhard; Werner, Yuki B

2018-03-15

The newly developed technique of peroral endoscopic myotomy (POEM) has been shown to be effective in several short- and mid-term studies. Limited information is available about the adequacy of immediate post-POEM monitoring tests. POEM was performed under general anesthesia in 228 patients (59.6% male, mean age 45.6 ± 15.5 years). Post-procedural checks comprised clinical and laboratory examination, and, during post-procedure days 1-5, endoscopy and-in the first 114 cases-radiologic examination using water-soluble contrast (1st group); the remaining patients underwent post-procedure controls without radiology (2nd group). Main outcome was value of endoscopic compared to radiologic control for recognition of early adverse events. In the first group, routine fluoroscopic contrast swallow suggested minor leakages at the mucosal entry site in two cases which was confirmed endoscopically in only one. Endoscopy revealed two minor entry site leakages and, in six additional cases, dislocated clips without leakage (overall 5.3%). All eight patients underwent reclipping and healed without clinical sequelae. In the 2nd group, endoscopy showed 5 clip dislocations (all reclipped) and one ischemic cardiac perforation in a patient with clinical deterioration on post-POEM day 1 who had to undergo surgery after confirmation of leakage by CT. Radiologic monitoring (contrast swallow) after POEM is not useful and can be omitted. Even routine endoscopic monitoring for detection and closure of minor defects of the mucosal entry site yields limited information with regards to final outcome; major complications are very rare and probably associated with clinical deterioration. Clinical Trials Gov Registration number of the main study: NCT01405417.

Automated rule-base creation via CLIPS-Induce

NASA Technical Reports Server (NTRS)

Murphy, Patrick M.

1994-01-01

Many CLIPS rule-bases contain one or more rule groups that perform classification. In this paper we describe CLIPS-Induce, an automated system for the creation of a CLIPS classification rule-base from a set of test cases. CLIPS-Induce consists of two components, a decision tree induction component and a CLIPS production extraction component. ID3, a popular decision tree induction algorithm, is used to induce a decision tree from the test cases. CLIPS production extraction is accomplished through a top-down traversal of the decision tree. Nodes of the tree are used to construct query rules, and branches of the tree are used to construct classification rules. The learned CLIPS productions may easily be incorporated into a large CLIPS system that perform tasks such as accessing a database or displaying information.

Interhospital transfer delays emergency abdominal surgery and prolongs stay.

PubMed

Limmer, Alexandra M; Edye, Michael B

2017-11-01

Interhospital transfer of patients requiring emergency surgery is common practice. It has the potential to delay surgical intervention, increase rate of complications and thus length of hospital stay. A retrospective cohort study was conducted of adult patients who underwent emergency surgery for abdominal pain at a large metropolitan hospital in New South Wales (Hospital A) in 2013. The impact of interhospital transfer on time to surgical intervention, post-operative length of stay and overall length of stay was assessed. Of the 910 adult patients who underwent emergency surgery for abdominal pain at Hospital A in 2013, 31.9% (n = 290) were transferred by road ambulance from a local district hospital (Hospital B). The leading surgical procedures performed were appendicectomy (n = 299, 32.9%), cholecystectomy (n = 174, 19.1%), gastrointestinal endoscopy (n = 95, 10.4%), cystoscopy (n = 86, 9.5%), hernia repair (n = 45, 4.9%), salpingectomy (n = 19, 2.1%) and oversewing of perforated peptic ulcer (n = 13, 1.4%). Overall, interhospital transfer (n = 290, 31.9%) was associated with increases in mean time to surgical intervention (14.2 h, P < 0.001), post-operative length of stay (1.1 days, P = 0.001) and overall length of stay (1.6 days, P < 0.001). Delayed surgical intervention was observed across all procedure types except surgery for perforated peptic ulcer, where transferred patients underwent surgery within a comparable timeframe to direct admissions. Interhospital transfer delays surgical intervention and increases length of hospital stay. This mandates attention due to the implications for patient outcomes and added burden to the healthcare system. The system did, however, show capability to appropriately expedite surgery for acutely life-threatening cases. © 2016 Royal Australasian College of Surgeons.

Planum Sphenoidale and Tuberculum Sellae Meningiomas: Operative Nuances of a Modern Surgical Technique with Outcome and Proposal of a New Classification System.

PubMed

Mortazavi, Martin M; Brito da Silva, Harley; Ferreira, Manuel; Barber, Jason K; Pridgeon, James S; Sekhar, Laligam N

2016-02-01

The resection of planum sphenoidale and tuberculum sellae meningiomas is challenging. A universally accepted classification system predicting surgical risk and outcome is still lacking. We report a modern surgical technique specific for planum sphenoidale and tuberculum sellae meningiomas with associated outcome. A new classification system that can guide the surgical approach and may predict surgical risk is proposed. We conducted a retrospective review of the patients who between 2005 and March 2015 underwent a craniotomy or endoscopic surgery for the resection of meningiomas involving the suprasellar region. Operative nuances of a modified frontotemporal craniotomy and orbital osteotomy technique for meningioma removal and reconstruction are described. Twenty-seven patients were found to have tumors arising mainly from the planum sphenoidale or the tuberculum sellae; 25 underwent frontotemporal craniotomy and tumor removal with orbital osteotomy and bilateral optic canal decompression, and 2 patients underwent endonasal transphenoidal resection. The most common presenting symptom was visual disturbance (77%). Vision improved in 90% of those who presented with visual decline, and there was no permanent visual deterioration. Cerebrospinal fluid leak occurred in one of the 25 cranial cases (4%) and in 1 of 2 transphenoidal cases (50%), and in both cases it resolved with treatment. There was no surgical mortality. An orbitotomy and early decompression of the involved optic canal are important for achieving gross total resection, maximizing visual improvement, and avoiding recurrence. The visual outcomes were excellent. A new classification system that can allow the comparison of different series and approaches and indicate cases that are more suitable for an endoscopic transsphenoidal approach is presented. Copyright © 2016 Elsevier Inc. All rights reserved.

Single-layer continuous suture contributes to the reduction of surgical complications in digestive tract anastomosis involving special anatomical locations.

PubMed

Li, Guo-Cai; Zhang, Yu-Chun; Xu, Yong; Zhang, Fang-Cheng; Huang, Wei-Hua; Xu, Jian-Qing; Ma, Qing-Jiu

2014-01-01

The key point of digestive cancer surgery is reconstruction and anastomosis of the digestive tract. Traditional anastomoses involve double-layer interrupted suturing, manually or using a surgical stapler. In special anatomical locations, however, suturing may become increasingly difficult and the complication rate increases accordingly. In this study, we aimed to investigate the feasibility and safety of a new manual suturing method, the single-layer continuous suture in the posterior wall of the anastomosis. Between January, 2007 and August, 2012, 101 patients with digestive cancer underwent surgery in Xi'an Gaoxin Hospital. Of those patients, 27 underwent surgery with the new manual method and the remaining 74 underwent surgery using traditional methods of anastomosis of the digestive tract. Surgical time, intraoperative blood loss, drainage duration, complications, blood tests, postoperative quality of life (QOL) and overall expenditure were recorded and analyzed. No significant differences were observed in surgical time, intraoperative blood loss, temperature, blood tests and postoperative QOL between the two groups. However, compared with the control group, the new manual suture group exhibited a lower surgical complication rate (7.40 vs. 31.08%; P=0.018), lower blood transfusion volume (274.07±419.33 vs. 646.67±1,146.06 ml; P=0.053), shorter postoperative hospital stay (14.60±4.19 vs. 17.60±6.29 days; P=0.038) and lower overall expenditure (3,509.85±768.68 vs. 6,141.83±308.90 renminbi; P=0.001). Our results suggested that single-layer continuous suturing for the anastomosis of the digestive tract is feasible and safe and may contribute to the reduction of surgical complications and overall expenditure.

Single-layer continuous suture contributes to the reduction of surgical complications in digestive tract anastomosis involving special anatomical locations

PubMed Central

LI, GUO-CAI; ZHANG, YU-CHUN; XU, YONG; ZHANG, FANG-CHENG; HUANG, WEI-HUA; XU, JIAN-QING; MA, QING-JIU

2014-01-01

The key point of digestive cancer surgery is reconstruction and anastomosis of the digestive tract. Traditional anastomoses involve double-layer interrupted suturing, manually or using a surgical stapler. In special anatomical locations, however, suturing may become increasingly difficult and the complication rate increases accordingly. In this study, we aimed to investigate the feasibility and safety of a new manual suturing method, the single-layer continuous suture in the posterior wall of the anastomosis. Between January, 2007 and August, 2012, 101 patients with digestive cancer underwent surgery in Xi’an Gaoxin Hospital. Of those patients, 27 underwent surgery with the new manual method and the remaining 74 underwent surgery using traditional methods of anastomosis of the digestive tract. Surgical time, intraoperative blood loss, drainage duration, complications, blood tests, postoperative quality of life (QOL) and overall expenditure were recorded and analyzed. No significant differences were observed in surgical time, intraoperative blood loss, temperature, blood tests and postoperative QOL between the two groups. However, compared with the control group, the new manual suture group exhibited a lower surgical complication rate (7.40 vs. 31.08%; P=0.018), lower blood transfusion volume (274.07±419.33 vs. 646.67±1,146.06 ml; P=0.053), shorter postoperative hospital stay (14.60±4.19 vs. 17.60±6.29 days; P=0.038) and lower overall expenditure (3,509.85±768.68 vs. 6,141.83±308.90 renminbi; P=0.001). Our results suggested that single-layer continuous suturing for the anastomosis of the digestive tract is feasible and safe and may contribute to the reduction of surgical complications and overall expenditure. PMID:24649327

CLIPS++: Embedding CLIPS into C++

NASA Technical Reports Server (NTRS)

Obermeyer, Lance; Miranker, Daniel P.

1994-01-01

This paper describes a set of C++ extensions to the CLIPS language and their embodiment in CLIPS++. These extensions and the implementation approach of CLIPS++ provide a new level of embeddability with C and C++. These extensions are a C++ include statement and a defcontainer construct; (include (c++-header-file.h)) and (defcontainer (c++-type)). The include construct allows C++ functions to be embedded in both the LHS and RHS of CLIPS rules. The header file in an include construct is the same header file the programmer uses for his/her own C++ code, independent of CLIPS. The defcontainer construct allows the inference engine to treat C++ class instances as CLIPS deftemplate facts. Consequently existing C++ class libraries may be transparently imported into CLIPS. These C++ types may use advanced features like inheritance, virtual functions, and templates. The implementation has been tested with several class libraries, including Rogue Wave Software's Tools.h++, GNU's libg++, and USL's C++ Standard Components. The execution speed of CLIPS++ has been determined to be 5 to 700 times the execution speed of CLIPS 6.0 (10 to 20X typical).

Thinking it through: mental rehearsal and performance on 2 types of laparoscopic cholecystectomy simulators.

PubMed

Paige, John T; Yu, Qingzhao; Hunt, John P; Marr, Alan B; Stuke, Lance E

2015-01-01

Simulation-based training (SBT) in laparoscopic cholecystectomy (LCCY) provides an opportunity for junior residents to learn the procedure in a safe, nonthreatening environment. Mental rehearsal (MR) has the potential of augmenting skill acquisition. This project investigated the correlation between MR of LCCY with performance on 2 different types of simulators: a procedural task (PT) training model and virtual reality (VR) machine. Prospective, quasi-experimental design with purposeful sampling. Postgraduate years (PGYs) 1 through 3 general surgical residents underwent standardized, distributed SBT in LCCY on either a PT trainer or a VR machine with group-based MR undertaken before 2 SBT sessions. Participants completed a pre-MR and post-MR session mental imagery questionnaire (MIQ) containing 8-items using a 7-point Likert-type scale. Data related to VR objective measures and PT video-based performances were also collected. Total scale mean scores were calculated for the first MR session and the second MR session and were compared using the t test. Pearson correlation analysis of MIQ scores with performance scores was determined. Louisiana State University Health New Orleans Health Sciences Center in New Orleans, Louisiana. This health sciences center is a tertiary care, academic state institution located in the Southeastern United States. A total of 21 PGYs 1 through 3 general surgery residents participated. They were purposefully divided into the PT and VR training groups to allow for even PGY distribution. Of the 21 participants, 19 completed both training sessions (n = 10 for PT [PGY1 = 4, PGY2 = 4, PGY3 = 2] and n = 9 for VR [PGY1 = 4, PGY2 = 3, PGY3 = 2]). After the Bonferroni adjustment, significant gains in the MIQ items related to confidence, visual imagery, and knowledge of the procedure were found. VR performance data demonstrated some statistically significant improvements. A significant negative correlation was present between the two-handed clip-and-cut VR task and MIQ gains. Group MR in LCCY before SBT on a VR machine is related to improved performance time for the VR two-handed clip-and-cut task. MR may be a useful adjunct to SBT LCCY. Future work will look at the translation of these skills to clinical practice. Copyright © 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

[Surgical technique for the treatment of the serious acute necrotic pancreatitis in the National Hospital Edgardo Rebagliati Martins].

PubMed

Barreda Cevasco, Luis Alberto; Targarona Modena, Javier; Rodriguez Alegría, César

2002-01-01

A surgical technique for the treatment of severe acute pancreatitis with necrosis is presented as an alternative in the surgical treatment of this pathology; 60 patients underwent a surgery by the author et al. between October 1997 and January 2002, at the National Hospital Edgardo Rebagliati Martins, Lima, Peru. The mortality rate was 25%.

Prognostic significance of nuclear factor of activated T-cells 5 expression in non-small cell lung cancer patients who underwent surgical resection.

PubMed

Cho, Hyun Jin; Yun, Hwan-Jung; Yang, Hee Chul; Kim, Soo Jin; Kang, Shin Kwang; Che, Chengri; Lee, Sang Do; Kang, Min-Woong

2018-06-01

Nuclear factor of activated T-cells 5 (NFAT5) is known to be correlated with migration or invasion of tumor cells based on previous in vitro studies. The aim of this study was to analyze the relationship between NFAT5 expression and clinical prognosis in non-small cell lung cancer (NSCLC) patients who underwent surgical resection. A total of 92 NSCLC patients who underwent surgical resection were enrolled. The tissue microarray core was obtained from surgically resected tumor specimens. NFAT5 expression was evaluated by immunohistochemistry. Relationships of NFAT5 expression with disease recurrence, overall survival, and disease-free survival (DFS) were analyzed. The mean age of 92 patients was 63.7 y. The median follow-up duration was 63.3 mo. Fifty-one (55%) patients exhibited positive expression of NFAT5. Disease recurrence in the NFAT5-positive group was significantly (P = 0.022) higher than that in the NFAT5-negative group. NFAT5-positive expression (odds ratio: 2.632, 95% confidence interval: 1.071-6.465, P = 0.035) and pathologic N stage (N1-2 versus N0; odds ratio: 3.174, 95% confidence interval: 1.241-8.123, P = 0.016) were independent and significant risk factors for disease recurrence. DFS of the NFAT5-positive group was significantly worse than that of the NFAT5-negative group (89.7 versus 48.7 mo, P = 0.011). A multivariate analysis identified NFAT5 expression (P < 0.029) as a significant independent risk factor for DFS of patients with postoperative pathologic T and N stages (P < 0.001 and P = 0.017, respectively). NFAT5 expression is a useful prognostic biomarker for NSCLC patients who underwent surgical resection. Copyright © 2018 Elsevier Inc. All rights reserved.

The value of three-dimensional photogrammetry in isolated sagittal synostosis: Impact of age and surgical technique on intracranial volume and cephalic index─a retrospective cohort study.

PubMed

Mertens, Christian; Wessel, Eline; Berger, Moritz; Ristow, Oliver; Hoffmann, Jürgen; Kansy, Katinka; Freudlsperger, Christian; Bächli, Heidrun; Engel, Michael

2017-12-01

The aim of this study was to compare the outcome of intracranial volume (ICV) and cephalic index (CI) between two different techniques for surgical therapy of sagittal synostosis. Between 2011 and 2015, all patients scheduled for surgical therapy of sagittal synostosis were consecutively enrolled. All patients younger than 6 months underwent early extended strip craniectomy (ESC group), and patients older than 6 months underwent late modified pi-procedure (MPP group). To measure ICV and CI, data acquisition was performed via three-dimensional photogrammetry, 1 day before (T0) and between 10 and 12 weeks after surgery (T1). Results were compared with an age-matched reference group of healthy children. Perioperative parameters, as duration of surgery and the amount of blood loss of both surgical procedures were analyzed. A total of 85 patients were enrolled. Of the patients, 48 underwent an extended strip craniotomy with parietal osteotomies and biparietal widening and 37 patients underwent a late modified pi-procedure. There was no significant difference between the ESC group and the MPP group regarding the efficacy of improving CI (p > 0.05). Both techniques were able to normalize CI and to improve head shape. ICV was normal compared to age-matched norm-groups with both techniques, pre- and postoperatively. However, duration of the surgical procedure and calculated blood loss were significantly lower in the ESC group (p < 0.05). ESC and MPP were effective techniques to normalize cephalic index (CI) and improve head shape at their recommended time of surgery. Measurement of ICV and CI with 3D photogrammetry is a valid method to objectively evaluate patients before and after surgery without exposing pediatric patients to ionizing radiation. Copyright © 2017 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

Adhesions small bowel obstruction in emergency setting: conservative or operative treatment?

PubMed

Assenza, M; De Gruttola, I; Rossi, D; Castaldi, S; Falaschi, F; Giuliano, G

2016-01-01

Adhesions small bowel obstructions (aSBO) are among the leading causes of emergency operative intervention. About the 80% of aSBO cases resolve without a surgical treatment. It's important to identify which patients could undergo a conservative treatment to prevent an useless surgery The aim of this study is to determine findings that can indicate whether patients with aSBO should undergo a conservative or a surgical treatment. 313 patients with diagnosis of submission of aSBO were restudied. Patients were divided into two groups based on the different type of treatment received, 225 patients who underwent surgical treatment within 24 hours after admission, 88 patients which underwent conservative treatment successfully. For each patient, clinical, hematochemical and radiological findings have been analysed. The treatment of aSBO should be, at the beginning, conservative except that cases that presents clinical and/or CT-scan findings predictive for a surgical treatment (free peritoneal fluid, mesenterial edema, transitional point) or a peritonitis (pneumatosis intestinalis, pneumoperitoneum).

Surgery for vertigo: 10-year audit from a contemporary vertigo clinic.

PubMed

Patnaik, U; Srivastava, A; Sikka, K; Thakar, A

2015-12-01

To present the profile of patients undergoing surgical treatment for vertigo at a contemporary institutional vertigo clinic. A retrospective analysis of clinical charts. The charts of 1060 patients, referred to an institutional vertigo clinic from January 2003 to December 2012, were studied. The clinical profile and long-term outcomes of patients who underwent surgery were analysed. Of 1060 patients, 12 (1.13 per cent) were managed surgically. Of these, disease-modifying surgical procedures included perilymphatic fistula repair (n = 7) and microvascular decompression of the vestibular nerve (n = 1). Labyrinth destructive procedures included transmastoid labyrinthectomy (n = 2) and labyrinthectomy with vestibular nerve section (n = 1). One patient with vestibular schwannoma underwent both a disease-modifying and destructive procedure (translabyrinthine excision). All patients achieved excellent vertigo control, classified as per the American Academy of Otolaryngology - Head and Neck Surgery 1995 criteria. With the advent of intratympanic treatments, surgical treatments for vertigo have become further limited. However, surgery with directed intent, in select patients, can give excellent results.

Vascular closure staples-a new technique for biliary reconstruction: prospective randomized comparison with manual suture in an animal model.

PubMed

Birth, Matthias; Markert, Uwe; Strik, Martin; Wohlschläger, Charlotte; Brugmans, Frederik; Gerberding, Jürgen; Bruch, Hans P

2002-01-15

In orthotopic liver transplantation the incidence of biliary complications is up to 49%. In view of the relative frequency of such complications despite seemingly good preconditions, method-related disadvantages of conventional suture must also be considered as a possible cause. These include perforating needle injury of the choledochal wall with at least temporary exposure of suture material in the lumen, suboptimal approximation of the mucosa, and an additional decrease in blood flow in the choledochal stumps as a result of suture-related tissue strangulation. Hence the search for alternative anastomosis techniques. To evaluate the surgical suitability of extramucosal titanium clips (Vascular Closure Staples; VCS) in comparison with conventional manual suture, a study was performed in 36 pigs, which were randomly assigned to 4 groups, each containing 9 animals. Choledochal excision was performed in 18 pigs and transection in the other 18 pigs; end-to-end anastomosis was then carried out, using a VCS stapler in half of the animals in each of these two groups and conventional manual suture in the other half. Pre- and postanastomotic blood flow was measured during the surgery with the aid of a laser Doppler flow meter. The long-term behavior of the closure techniques was ascertained by regular laboratory checks over the ensuing 6-month observation period, after which the pigs were killed so that the specimens could be harvested. Using medium-sized VCS clips, we were able to create a tension-free, everted biliary anastomosis with exact mucosal approximation and no narrowing of the lumen, and without any technical problems during the performance of the procedure. Measurements with the laser Doppler flow meter showed well-preserved anastomotic blood flow after clip reconstruction, with significantly higher perfusion values than after manual suture. The postoperative courses of the investigated laboratory parameters did not reveal any significant differences between the two methods. In contrast, histomorphometric evaluation showed wall thickness and thus fibrosis in the anastomosis region to be less in the clip group than in the suture group (median: 510 microm versus 660 microm, P<0.001). In the pigs in which clip anastomosis was used, there were no detectable anastomotic stenoses; in the pigs in which conventional suture was used, however, ultrasonography revealed five anastomoses with varying degrees of narrowing. Extramucosal VCS clip anastomosis not only offers potential advantages with respect to nonpenetrating and optimal mucosal contact, investigations in animals also show it to be superior to conventional manual suture as regards anastomotic blood flow and medium-term fibrosis formation. We believe that our data and the available literature warrant a clinical evaluation of this technique in appropriate studies.

CLIPS: An expert system building tool

NASA Technical Reports Server (NTRS)

Riley, Gary

1991-01-01

The C Language Integrated Production System (CLIPS) is an expert system building tool, which provides a complete environment for the development and delivery of rule and/or object based expert systems. CLIPS was specifically designed to provide a low cost option for developing and deploying expert system applications across a wide range of hardware platforms. The commercial potential of CLIPS is vast. Currently, CLIPS is being used by over 3,300 individuals throughout the public and private sector. Because the CLIPS source code is readily available, numerous groups have used CLIPS as a basis for their own expert system tools. To date, three commercially available tools have been derived from CLIPS. In general, the development of CLIPS has helped to improve the ability to deliver expert system technology throughout the public and private sectors for a wide range of applications and diverse computing environments.

Surgical management of breast cancer in China: A 15-year single-center retrospective study of 18,502 patients.

PubMed

Huang, Nai-Si; Liu, Meng-Ying; Chen, Jia-Jian; Yang, Ben-Long; Xue, Jing-Yan; Quan, Chen-Lian; Mo, Miao; Liu, Guang-Yu; Shen, Zhen-Zhou; Shao, Zhi-Min; Wu, Jiong

2016-11-01

The aim of the study was to review the surgical trends in breast cancer treatment in China over the past 15 years and to explore the possible factors related to the choice of surgical modality.The medical records of 18,502 patients with unilateral early stage breast cancer who underwent surgery from January 1999 to December 2013 at our institute were retrospectively reviewed. The utilization of different surgical modalities and the associated clinicopathological factors were analyzed. Furthermore, the prognostic role of surgical modality was also evaluated.The median patient age was 50.0 years. According to the pTNM staging system, 12.5% of the patients were classified as stage 0; 30.2% as stage I; 40.0% as stage II; and 17.3% as stage III. In total, 9.3% of the patients could not be staged. Overall, 67.1% of the breast cancer cases were estrogen receptor (ER) positive. The pattern of breast cancer surgery has changed tremendously over the past 15 years (P < 0.001). The pattern of mastectomy has shifted from radical mastectomy to modified radical mastectomy and simple mastectomy + sentinel lymph node biopsy. A total of 81.7% of the patients underwent mastectomy without immediate reconstruction, 15.2% underwent breast-conserving surgery (BCS), and 3.7% received immediate breast reconstruction after mastectomy. Age, TNM staging, and pathological characteristics greatly affected the choice of surgical modality. The 5-year recurrence-free survival (RFS) rates for the mastectomy, BCS, and reconstruction groups were 87.6%, 93.2%, and 91.7%, respectively (P < 0.001); the RFS rate was likely affected by distant recurrence instead of loco-regional recurrence. We also identified improved RFS over time, stratified by surgical modality and tumor stage. Multivariate Cox-regression analysis revealed that time of treatment, tumor stage, tumor grade, LVI status, and ER status were independent prognostic factors for RFS in our cohort, whereas surgical modality was not.Mastectomy remains the most prevalent surgical modality used to manage early stage breast cancer in China, although the utilization of BCS has increased in the past decade. However, surgical management was not a prognostic factor for RFS. The selection of appropriate patients depended on the assessment of multiple clinicopathological factors, which is essential for making surgical decisions.

HyperCLIPS: A HyperCard interface to CLIPS

NASA Technical Reports Server (NTRS)

Pickering, Brad; Hill, Randall W., Jr.

1990-01-01

HyperCLIPS combines the intuitive, interactive user interface of the Apple Macintosh(TM) with the powerful symbolic computation of an expert system interpreter. HyperCard(TM) is an excellent environment for quickly developing the front end of an application with buttons, dialogs, and pictures, while the CLIPS interpreter provides a powerful inference engine for complex problem solving and analysis. By integrating HyperCard and CLIPS the advantages and uses of both packages are made available for a wide range of uses: rapid prototyping of knowledge-based expert systems, interactive simulations of physical systems, and intelligent control of hypertext processes, to name a few. Interfacing HyperCard and CLIPS is natural. HyperCard was designed to be extended through the use of external commands (XCMDs), and CLIPS was designed to be embedded through the use of the I/O router facilities and callable interface routines. With the exception of some technical difficulties which will be discussed later, HyperCLIPS implements this interface in a straight forward manner, using the facilities provided. An XCMD called 'ClipsX' was added to HyperCard to give access to the CLIPS routines: clear, load, reset, and run. And an I/O router was added to CLIPS to handle the communication of data between CLIPS and HyperCard.

[Preparation of simulate craniocerebral models via three dimensional printing technique].

PubMed

Lan, Q; Chen, A L; Zhang, T; Zhu, Q; Xu, T

2016-08-09

Three dimensional (3D) printing technique was used to prepare the simulate craniocerebral models, which were applied to preoperative planning and surgical simulation. The image data was collected from PACS system. Image data of skull bone, brain tissue and tumors, cerebral arteries and aneurysms, and functional regions and relative neural tracts of the brain were extracted from thin slice scan (slice thickness 0.5 mm) of computed tomography (CT), magnetic resonance imaging (MRI, slice thickness 1mm), computed tomography angiography (CTA), and functional magnetic resonance imaging (fMRI) data, respectively. MIMICS software was applied to reconstruct colored virtual models by identifying and differentiating tissues according to their gray scales. Then the colored virtual models were submitted to 3D printer which produced life-sized craniocerebral models for surgical planning and surgical simulation. 3D printing craniocerebral models allowed neurosurgeons to perform complex procedures in specific clinical cases though detailed surgical planning. It offered great convenience for evaluating the size of spatial fissure of sellar region before surgery, which helped to optimize surgical approach planning. These 3D models also provided detailed information about the location of aneurysms and their parent arteries, which helped surgeons to choose appropriate aneurismal clips, as well as perform surgical simulation. The models further gave clear indications of depth and extent of tumors and their relationship to eloquent cortical areas and adjacent neural tracts, which were able to avoid surgical damaging of important neural structures. As a novel and promising technique, the application of 3D printing craniocerebral models could improve the surgical planning by converting virtual visualization into real life-sized models.It also contributes to functional anatomy study.

Development of a new biodegradable operative clip made of a magnesium alloy: Evaluation of its safety and tolerability for canine cholecystectomy.

PubMed

Yoshida, Toshihiko; Fukumoto, Takumi; Urade, Takeshi; Kido, Masahiro; Toyama, Hirochika; Asari, Sadaki; Ajiki, Tetsuo; Ikeo, Naoko; Mukai, Toshiji; Ku, Yonson

2017-06-01

Operative clips used to ligate vessels in abdominal operation usually are made of titanium. They remain in the body permanently and form metallic artifacts in computed tomography images, which impair accurate diagnosis. Although biodegradable magnesium instruments have been developed in other fields, the physical properties necessary for operative clips differ from those of other instruments. We developed a biodegradable magnesium-zinc-calcium alloy clip with good biologic compatibility and enough clamping capability as an operative clip. In this study, we verified the safety and tolerability of this clip for use in canine cholecystectomy. Nine female beagles were used. We performed cholecystectomy and ligated the cystic duct by magnesium alloy or titanium clips. The chronologic change of clips and artifact formation were compared at 1, 4, 12, 18, and 24 weeks postoperative by computed tomography. The animals were killed at the end of the observation period, and the clips were removed to evaluate their biodegradability. We also evaluated their effect on the living body by blood biochemistry data. The magnesium alloy clip formed much fewer artifacts than the titanium clip, and it was almost absorbed at 6 months postoperative. There were no postoperative complications and no elevation of constituent elements such as magnesium, calcium, and zinc during the observation period in both groups. The novel magnesium alloy clip demonstrated sufficient sealing capability for the cystic duct and proper biodegradability in canine models. The magnesium alloy clip revealed much fewer metallic artifacts in CT than the conventional titanium clip. Copyright © 2016 Elsevier Inc. All rights reserved.

[Peroperative risks in cerebral aneurysm surgery].

PubMed

Mustaki, J P; Bissonnette, B; Archer, D; Boulard, G; Ravussin, P

1996-01-01

The perioperative complications associated with cerebral aneurysm surgery require a specific anaesthetic management. Four major perioperative accidents are discussed in this review. The anaesthetic and surgical management in case of rebleeding subsequent to the re-rupture of the aneurysm is mainly prophylactic. It includes haemodynamic stability assurance, maintenance of mean arterial pressure (MAP) between 80-90 mmHg during stimulation of the patient such as endotracheal intubation, application of the skull-pin head-holder, incision, and craniotomy. The aneurysmal transmural pressure should be adequately maintained by avoiding an aggressive decrease of intracranial pressure. Once the skull is open, the brain must be kept slack in order to decrease pressure under the retractors and avoid the risks of stretching and tearing of the adjacent vessels. If, despite these precautions, the aneurysm ruptures again. MAP should be decreased to 60 mmHg and the brain rendered more slack, in order to allow direct clipping of the aneurysm, or temporary clipping of the adjacent vessels. The optimal agents in this situation are isoflurane (which decreases CMRO2), intravenous anaesthetic agents (inspite their negative inotropic effect, they may potentially protect the brain) and sodium nitroprusside. Vasospasm occurs usually between the 3rd and the 7th day after subarachnoid haemorrhage. It may be seen peroperatively. The optimal treatment, as well as prophylaxis, is moderate controlled hypertension (MAP > 100 mmHg), associated with hypervolaemia and haemodilution, the so-called triple H therapy, with strict control of the filling pressures. Other beneficial therapies are calcium antagonists (nimodipine and nicardipine), the removal of the blood accumulated around the brain and in the cisternae, and possibly local administration of papaverine. Abrupt MAP increases are controlled in order to maintain adequate aneurysmal transmural pressure. Beta-blockers, local anaesthetics administered locally or intravenously, a carefully titrated level of anaesthesia, a maintained volaemia play a protective role. Cerebral oedema is sometimes already present at the opening of the skull or may arise later, due to a high pressure under the retractors, to the surgical manipulations of the brain or to brain ischaemia subsequent to temporary clipping. Its treatment is aggressive, with intravenous agents, mannitol, deep hypocapnia and/or lumbar drainage. Prophylaxis, according to the "brain homeostasis concept", is the preferred method to avoid these four peroperative accidents. It includes normal blood volume, normoglycaemia, moderate hypocapnia, normotension, soft manipulation of the brain and optimal brain relaxation.

Laparoscopy Improves Short-term Outcomes After Surgery for Diverticular Disease

PubMed Central

RUSS, ANDREW J.; OBMA, KARI L.; RAJAMANICKAM, VICTORIA; WAN, YIN; HEISE, CHARLES P.; FOLEY, EUGENE F.; HARMS, BRUCE; KENNEDY, GREGORY D.

2012-01-01

BACKGROUND & AIMS Observational studies and small randomized controlled trials have shown that the use of laparoscopy in colon resection for diverticular disease is feasible and results in fewer complications. We analyzed data from a large, prospectively maintained, multicenter database (National Surgical Quality Initiative Program) to determine whether the use of laparoscopy in the elective treatment of diverticular disease decreases rates of complications compared with open surgery, independent of preoperative comorbid factors. METHODS The analysis included data from 6970 patients who underwent elective surgeries for diverticular disease from 2005 to 2008. Patients with diverticular disease were identified by International Classification of Diseases, 9th revision codes and then categorized into open or laparoscopic groups based on Current Procedural Terminology codes. Preoperative, intraoperative, and postoperative data were analyzed to determine factors associated with increased risk for postoperative complications. RESULTS Data were analyzed from 3468 patients who underwent open surgery and 3502 patients who underwent laparoscopic procedures. After correcting for probability of morbidity, American Society of Anesthesiology class, and ostomy creation, overall complications (including superficial surgical site infections, deep incisional surgical site infections, sepsis, and septic shock) occurred with significantly lower incidence among patients who underwent laparoscopic procedures compared with those who received open operations. CONCLUSIONS The use of laparoscopy for treating diverticular disease, in the absence of absolute contraindications, results in fewer postoperative complications compared with open surgery. PMID:20193685

Content-based video retrieval by example video clip

NASA Astrophysics Data System (ADS)

Dimitrova, Nevenka; Abdel-Mottaleb, Mohamed

1997-01-01

This paper presents a novel approach for video retrieval from a large archive of MPEG or Motion JPEG compressed video clips. We introduce a retrieval algorithm that takes a video clip as a query and searches the database for clips with similar contents. Video clips are characterized by a sequence of representative frame signatures, which are constructed from DC coefficients and motion information (`DC+M' signatures). The similarity between two video clips is determined by using their respective signatures. This method facilitates retrieval of clips for the purpose of video editing, broadcast news retrieval, or copyright violation detection.

Assessment of construct validity of a virtual reality laparoscopy simulator.

PubMed

Rosenthal, Rachel; Gantert, Walter A; Hamel, Christian; Hahnloser, Dieter; Metzger, Juerg; Kocher, Thomas; Vogelbach, Peter; Scheidegger, Daniel; Oertli, Daniel; Clavien, Pierre-Alain

2007-08-01

The aim of this study was to assess whether virtual reality (VR) can discriminate between the skills of novices and intermediate-level laparoscopic surgical trainees (construct validity), and whether the simulator assessment correlates with an expert's evaluation of performance. Three hundred and seven (307) participants of the 19th-22nd Davos International Gastrointestinal Surgery Workshops performed the clip-and-cut task on the Xitact LS 500 VR simulator (Xitact S.A., Morges, Switzerland). According to their previous experience in laparoscopic surgery, participants were assigned to the basic course (BC) or the intermediate course (IC). Objective performance parameters recorded by the simulator were compared to the standardized assessment by the course instructors during laparoscopic pelvitrainer and conventional surgery exercises. IC participants performed significantly better on the VR simulator than BC participants for the task completion time as well as the economy of movement of the right instrument, not the left instrument. Participants with maximum scores in the pelvitrainer cholecystectomy task performed the VR trial significantly faster, compared to those who scored less. In the conventional surgery task, a significant difference between those who scored the maximum and those who scored less was found not only for task completion time, but also for economy of movement of the right instrument. VR simulation provides a valid assessment of psychomotor skills and some basic aspects of spatial skills in laparoscopic surgery. Furthermore, VR allows discrimination between trainees with different levels of experience in laparoscopic surgery establishing construct validity for the Xitact LS 500 clip-and-cut task. Virtual reality may become the gold standard to assess and monitor surgical skills in laparoscopic surgery.

Construct validity of individual and summary performance metrics associated with a computer-based laparoscopic simulator.

PubMed

Rivard, Justin D; Vergis, Ashley S; Unger, Bertram J; Hardy, Krista M; Andrew, Chris G; Gillman, Lawrence M; Park, Jason

2014-06-01

Computer-based surgical simulators capture a multitude of metrics based on different aspects of performance, such as speed, accuracy, and movement efficiency. However, without rigorous assessment, it may be unclear whether all, some, or none of these metrics actually reflect technical skill, which can compromise educational efforts on these simulators. We assessed the construct validity of individual performance metrics on the LapVR simulator (Immersion Medical, San Jose, CA, USA) and used these data to create task-specific summary metrics. Medical students with no prior laparoscopic experience (novices, N = 12), junior surgical residents with some laparoscopic experience (intermediates, N = 12), and experienced surgeons (experts, N = 11) all completed three repetitions of four LapVR simulator tasks. The tasks included three basic skills (peg transfer, cutting, clipping) and one procedural skill (adhesiolysis). We selected 36 individual metrics on the four tasks that assessed six different aspects of performance, including speed, motion path length, respect for tissue, accuracy, task-specific errors, and successful task completion. Four of seven individual metrics assessed for peg transfer, six of ten metrics for cutting, four of nine metrics for clipping, and three of ten metrics for adhesiolysis discriminated between experience levels. Time and motion path length were significant on all four tasks. We used the validated individual metrics to create summary equations for each task, which successfully distinguished between the different experience levels. Educators should maintain some skepticism when reviewing the plethora of metrics captured by computer-based simulators, as some but not all are valid. We showed the construct validity of a limited number of individual metrics and developed summary metrics for the LapVR. The summary metrics provide a succinct way of assessing skill with a single metric for each task, but require further validation.

SUPRAPUBIC LAPAROSCOPIC CHOLECYSTECTOMY: TECHNIQUE AND PRELIMINARY RESULTS

PubMed Central

SALES, Leonardo Adolpho S.; PINTO, João Odilo G.; QUEIROZ, Carlos Eduardo F.; CASTRO, Marcelo; DOURADO, Paulo Henrique F.; PINHEIRO, Fernando Antonio S.

2014-01-01

Background The minimally invasive abdominal surgery has evolved to reduce portals, culminating with a single incision and natural orifice operation. However, these methods are still expensive, difficult to implement and with questionable aesthetic results. Aim To present the standardization and preliminary results of a technique for performing laparoscopic suprapubic access by the principle which was called the Supra Pubic Endoscopic Surgery for cholecystectomy. Method The average body mass index of patients, the mean operative time, clinical data of the postoperative complications and quality of life were prospectively studied. The operation incisions consisted of: A) umbilical for instrumental dissection and clipping; B) in the right groin for handling and gallbladder gripping; C) suprapubic for the camera. With the patient in reverse Trendelenburg and left lateral decubitus, the operation flew by the camera trocar in C, proceeding with dissection and isolation of the biliary pedicle, identification of cystic duct and artery, with usual instrumentation. Transcystic intraoperative cholangiography was performed in all cases in which there were indications. The procedure was completed with clipping and sectioning of the cystic duct and artery, retrograde resection of the gallbladder and extracting it by the umbilical trocar incision under direct vision. Results Thirty patients undergone this surgical procedure between March and June 2012 and were evaluated. The mean age was 40.7 years and the indications were typical biliary colic in 18 cases (60 %), cholecystitis in five cases (16.6 %), biliary pancreatitis in one case (3.3%); polyp in three cases (10%) and obstructive jaundice at three cases (10%). The average body mass index was 27.8 (23.1-35.1) and surgical time ranged between 24 and 70 minutes. Conclusion The technique proved to be feasible and safe , with no significant complications, and satisfactory cosmetic results. PMID:24676293

Harmonic scalpel in multinodular goiter surgery: impact on surgery and cost analysis.

PubMed

Sebag, Frederic; Fortanier, Cécile; Ippolito, Guiseppe; Lagier, Aude; Auquier, Pascal; Henry, Jean-Francois

2009-04-01

The aim of this study was to evaluate the potential advantages and the general operative cost of the Harmonic Scalpel (HS) in surgery for multinodular goiter (MNG). Patients undergoing total thyroidectomy (TT) for MNG were prospectively allocated in a conventional tie-and-clip (TC) group (n = 50) and an HS group (n = 50). All pre- and postoperative data were recorded. The economic evaluation was based on a microcost measurement and aimed to consider all the resources consumed for each patient during the surgical procedure. To compare the results, we used the nonparametric unpaired two-tailed Mann-Whitney test. There were 81 women and 19 men (mean age, 55 +/- 15 years). Mean preoperative TSH level was 1.2 (SD, 1.1) (TC) and 1.3 (SD, 2) (HS) (P = NS). Mean body mass index was 24.72 (SD, 8) (TC) and 25.6 (SD, 8) (HS) (P = NS). Four patients experienced a transient hypocalcemia (2 in each group). One patient had a postoperative hematoma requiring surgical evacuation (HS). One patient experienced a transient recurrent nerve palsy (TC). Mean length of surgery was 104 (SD, 32) (TC) and 84 minutes (SD, 17) (HS) (P = .0001). Mean length of hospitalization was 2 days in both groups (SD, 1) (P = NS). Mean operative cost per patient was 990 euro (SD, 191) in the TC group and 1,024 euro (SD, 143) in the HS group (P = NS). Safety and efficiency of the HS is comparable to the tie-and-clip technique in thyroid surgery. The use of the HS in MNG surgery allows for a significant reduction in the length of the procedure with a comparable cost.

Non-contrast 3D time-of-flight magnetic resonance angiography for visualization of intracranial aneurysms in patients with absolute contraindications to CT or MRI contrast.

PubMed

Yanamadala, Vijay; Sheth, Sameer A; Walcott, Brian P; Buchbinder, Bradley R; Buckley, Deidre; Ogilvy, Christopher S

2013-08-01

The preoperative evaluation of patients with intracranial aneurysms typically includes a contrast-enhanced vascular study, such as computed tomography angiography (CTA), magnetic resonance angiography (MRA), or digital subtraction angiography. However, there are numerous absolute and relative contraindications to the administration of imaging contrast agents, including pregnancy, severe contrast allergy, and renal insufficiency. Evaluation of patients with contrast contraindications thus presents a unique challenge. We identified three patients with absolute contrast contraindications who presented with intracranial aneurysms. One patient was pregnant, while the other two had previous severe anaphylactic reactions to iodinated contrast. Because of these contraindications to intravenous contrast, we performed non-contrast time-of-flight MRA with 3D reconstruction (TOF MRA with 3DR) with maximum intensity projections and volume renderings as part of the preoperative evaluation prior to successful open surgical clipping of the aneurysms. In the case of one paraclinoid aneurysm, a high-resolution non-contrast CT scan was also performed to assess the relationship of the aneurysm to the anterior clinoid process. TOF MRA with 3DR successfully identified the intracranial aneurysms and adequately depicted the surrounding microanatomy. Intraoperative findings were as predicted by the preoperative imaging studies. The aneurysms were successfully clip-obliterated, and the patients had uneventful post-operative courses. These cases demonstrate that non-contrast imaging is a viable modality to assess intracranial aneurysms as part of the surgical planning process in patients with contrast contraindications. TOF MRA with 3DR, in conjunction with high-resolution non-contrast CT when indicated, provides adequate visualization of the microanatomy of the aneurysm and surrounding structures. Copyright © 2013 Elsevier Ltd. All rights reserved.

Blood blister-like aneurysms: single center experience and systematic literature review.

PubMed

Gonzalez, Ana Marcos; Narata, Ana Paula; Yilmaz, Hasan; Bijlenga, Philippe; Radovanovic, Ivan; Schaller, Karl; Lovblad, Karl-Olof; Pereira, Vitor Mendes

2014-01-01

Blood blister-like aneurysms (BBAs) are a controversial entity. They arise from non-branching sites on the supraclinoid internal carotid artery (ICA) and are suspected to originate from a dissection. Our aim is to describe the BBA cases seen in our center and to present a systematic review of the literature on BBAs. We analyzed the eleven cases of BBA admitted to our center from 2003 to 2012. We assessed the medical history, treatment modality (endovascular and/or surgery), complications and clinical outcome. The cohort included 8 women and 4 men with a mean age of 53.16 years. Treatment of the BBA consisted of stenting and coiling in 5 patients, stenting only in 4 patients, coiling and clipping in 1 patient, clipping only in 1 patient, and conservative treatment in 1 patient. A good outcome was found in 10 patients, as defined by a modified Rankin Scale (mRS) less than or equal to two at three months. A systematic review of the literature was performed, and 314 reported patients were found: 221 patients were treated with a primarily surgical approach, and 87 patients were treated with a primarily endovascular approach. A rescue or second treatment was required in 46 patients (21%). The overall estimated treatment morbidity rate was 17%, and the mortality rate was 15%. BBAs exhibit more aggressive behavior compared to saccular aneurysms, and more intra-operative complications occur with BBAs, independent of the treatment type offered. They are also significantly more likely to relapse and rebleed after treatment. Endovascular treatment offers a lower morbidity-mortality compared with surgical approaches. Multilayer flow-diverting stents appear to be a promising strategy. Copyright © 2013 The Authors. Published by Elsevier Ireland Ltd.. All rights reserved.

How can periorbital oedema and ecchymose be reduced in rhinoplasty?

PubMed

Caglar, Erdem; Celebi, Saban; Topak, Murat; Develioglu, Necati Omer; Yalcin, Enis; Kulekci, Mehmet

2016-09-01

Oedema and ecchymose are frequent morbidities of septorhinoplasty, a facial surgical procedure for reforming the shape and functions of the nose. Periorbital oedema (PO) and periorbital ecchymose (PE) are normal occurrences, but are undesirable for patients undergoing the procedure for aesthetic purposes. The present study examined 65 patients who underwent open technique septorhinoplasty for aesthetic and functional complaints. Patients were divided into two groups: Group 1 patients underwent lateral osteotomy following tip plasty, at the end of the surgical operation; Group 2 patients underwent lateral osteotomy before tip plasty, at the beginning of the surgical operation. Patients were followed on the postoperative first, third and seventh days. PO and PE values of patients were scored from 0 to 4. The plastering time (Pt) was significantly shorter for Group I than Group II (p < 0.05). The total surgical time (T) showed no significant difference (p > 0.05). The PO value at the first, third and seventh days was significantly smaller for Group I than Group II (p < 0.05). The PE value at the first, third and seventh days was also significantly smaller for Group I than Group II (p < 0.05). The obtained data indicate that performing a lateral osteotomy in the final stages of surgery, and subsequently applying a nasal plaster and splint as rapidly as possible, decreases PO and PE in the postoperative period.

Can a surgery-first orthognathic approach reduce the total treatment time?

PubMed

Jeong, Woo Shik; Choi, Jong Woo; Kim, Do Yeon; Lee, Jang Yeol; Kwon, Soon Man

2017-04-01

Although pre-surgical orthodontic treatment has been accepted as a necessary process for stable orthognathic correction in the traditional orthognathic approach, recent advances in the application of miniscrews and in the pre-surgical simulation of orthodontic management using dental models have shown that it is possible to perform a surgery-first orthognathic approach without pre-surgical orthodontic treatment. This prospective study investigated the surgical outcomes of patients with diagnosed skeletal class III dentofacial deformities who underwent orthognathic surgery between December 2007 and December 2014. Cephalometric landmark data for patients undergoing the surgery-first approach were analyzed in terms of postoperative changes in vertical and horizontal skeletal pattern, dental pattern, and soft tissue profile. Forty-five consecutive Asian patients with skeletal class III dentofacial deformities who underwent surgery-first orthognathic surgery and 52 patients who underwent conventional two-jaw orthognathic surgery were included. The analysis revealed that the total treatment period for the surgery-first approach averaged 14.6 months, compared with 22.0 months for the orthodontics-first approach. Comparisons between the immediate postoperative and preoperative and between the postoperative and immediate postoperative cephalometric data revealed factors that correlated with the total treatment duration. The surgery-first orthognathic approach can dramatically reduce the total treatment time, with no major complications. Copyright © 2016 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Prospective Observational Study on acute Appendicitis Worldwide (POSAW).

PubMed

Sartelli, Massimo; Baiocchi, Gian L; Di Saverio, Salomone; Ferrara, Francesco; Labricciosa, Francesco M; Ansaloni, Luca; Coccolini, Federico; Vijayan, Deepak; Abbas, Ashraf; Abongwa, Hariscine K; Agboola, John; Ahmed, Adamu; Akhmeteli, Lali; Akkapulu, Nezih; Akkucuk, Seckin; Altintoprak, Fatih; Andreiev, Aurelia L; Anyfantakis, Dimitrios; Atanasov, Boiko; Bala, Miklosh; Balalis, Dimitrios; Baraket, Oussama; Bellanova, Giovanni; Beltran, Marcelo; Melo, Renato Bessa; Bini, Roberto; Bouliaris, Konstantinos; Brunelli, Daniele; Castillo, Adrian; Catani, Marco; Che Jusoh, Asri; Chichom-Mefire, Alain; Cocorullo, Gianfranco; Coimbra, Raul; Colak, Elif; Costa, Silvia; Das, Koray; Delibegovic, Samir; Demetrashvili, Zaza; Di Carlo, Isidoro; Kiseleva, Nadezda; El Zalabany, Tamer; Faro, Mario; Ferreira, Margarida; Fraga, Gustavo P; Gachabayov, Mahir; Ghnnam, Wagih M; Giménez Maurel, Teresa; Gkiokas, Georgios; Gomes, Carlos A; Griffiths, Ewen; Guner, Ali; Gupta, Sanjay; Hecker, Andreas; Hirano, Elcio S; Hodonou, Adrien; Hutan, Martin; Ioannidis, Orestis; Isik, Arda; Ivakhov, Georgy; Jain, Sumita; Jokubauskas, Mantas; Karamarkovic, Aleksandar; Kauhanen, Saila; Kaushik, Robin; Kavalakat, Alfie; Kenig, Jakub; Khokha, Vladimir; Khor, Desmond; Kim, Dennis; Kim, Jae I; Kong, Victor; Lasithiotakis, Konstantinos; Leão, Pedro; Leon, Miguel; Litvin, Andrey; Lohsiriwat, Varut; López-Tomassetti Fernandez, Eudaldo; Lostoridis, Eftychios; Maciel, James; Major, Piotr; Dimova, Ana; Manatakis, Dimitrios; Marinis, Athanasio; Martinez-Perez, Aleix; Marwah, Sanjay; McFarlane, Michael; Mesina, Cristian; Pędziwiatr, Michał; Michalopoulos, Nickos; Misiakos, Evangelos; Mohamedahmed, Ali; Moldovanu, Radu; Montori, Giulia; Mysore Narayana, Raghuveer; Negoi, Ionut; Nikolopoulos, Ioannis; Novelli, Giuseppe; Novikovs, Viktors; Olaoye, Iyiade; Omari, Abdelkarim; Ordoñez, Carlos A; Ouadii, Mouaqit; Ozkan, Zeynep; Pal, Ajay; Palini, Gian M; Partecke, Lars I; Pata, Francesco; Pędziwiatr, Michał; Pereira Júnior, Gerson A; Pintar, Tadeja; Pisarska, Magdalena; Ploneda-Valencia, Cesar F; Pouggouras, Konstantinos; Prabhu, Vinod; Ramakrishnapillai, Padmakumar; Regimbeau, Jean-Marc; Reitz, Marianne; Rios-Cruz, Daniel; Saar, Sten; Sakakushev, Boris; Seretis, Charalampos; Sazhin, Alexander; Shelat, Vishal; Skrovina, Matej; Smirnov, Dmitry; Spyropoulos, Charalampos; Strzałka, Marcin; Talving, Peep; Teixeira Gonsaga, Ricardo A; Theobald, George; Tomadze, Gia; Torba, Myftar; Tranà, Cristian; Ulrych, Jan; Uzunoğlu, Mustafa Y; Vasilescu, Alin; Occhionorelli, Savino; Venara, Aurélien; Vereczkei, Andras; Vettoretto, Nereo; Vlad, Nutu; Walędziak, Maciej; Yilmaz, Tonguç U; Yuan, Kuo-Ching; Yunfeng, Cui; Zilinskas, Justas; Grelpois, Gérard; Catena, Fausto

2018-01-01

Acute appendicitis (AA) is the most common surgical disease, and appendectomy is the treatment of choice in the majority of cases. A correct diagnosis is key for decreasing the negative appendectomy rate. The management can become difficult in case of complicated appendicitis. The aim of this study is to describe the worldwide clinical and diagnostic work-up and management of AA in surgical departments. This prospective multicenter observational study was performed in 116 worldwide surgical departments from 44 countries over a 6-month period (April 1, 2016-September 30, 2016). All consecutive patients admitted to surgical departments with a clinical diagnosis of AA were included in the study. A total of 4282 patients were enrolled in the POSAW study, 1928 (45%) women and 2354 (55%) men, with a median age of 29 years. Nine hundred and seven (21.2%) patients underwent an abdominal CT scan, 1856 (43.3%) patients an US, and 285 (6.7%) patients both CT scan and US. A total of 4097 (95.7%) patients underwent surgery; 1809 (42.2%) underwent open appendectomy and 2215 (51.7%) had laparoscopic appendectomy. One hundred eighty-five (4.3%) patients were managed conservatively. Major complications occurred in 199 patients (4.6%). The overall mortality rate was 0.28%. The results of the present study confirm the clinical value of imaging techniques and prognostic scores. Appendectomy remains the most effective treatment of acute appendicitis. Mortality rate is low.

Surgical outcomes of lung cancer measuring less than 1 cm in diameter.

PubMed

Hamatake, Daisuke; Yoshida, Yasuhiro; Miyahara, So; Yamashita, Shin-ichi; Shiraishi, Takeshi; Iwasaki, Akinori

2012-11-01

The increased use of computed tomography has led to an increasing proportion of lung cancers that are identified when still less than 1 cm in diameter. However, there is no defined treatment strategy for such cases. The aim of this study was to investigate the surgical outcomes of small lung cancers. A total of 143 patients were retrospectively evaluated, who had undergone a complete surgical resection for lung cancer less than 1 cm in diameter between January 1995 and December 2011. The 143 study subjects included 62 male and 81 female patients. The mean age was 64.0 years (43-82 years). The mean tumour size was 0.8 cm (0.3-1.0 cm). Seventy-seven patients (53.8%) underwent lobectomy. Thirty-two patients (22.4%) underwent segmentectomy and 34 patients (23.8%) underwent wedge resection. The 3-, 5- and 10-year survival rates were 95.7, 92.2 and 85.7%, respectively, after resection for sub-centimetre lung cancer. There were no significant differences between sub-lobar resection and lobectomy. However, two patients (1.4%) had recurrent cancer and seven (4.9%) had lymph node metastasis. The selection of the surgical procedure is important and a long-term follow-up is mandatory, because lung cancer of only 1 cm or less can be associated with lymph node metastasis and distant metastatic recurrence.

Right and left partial iatrogenic injuries of the biliary tree. Therapeutic options.

PubMed

Mercado, Miguel Angel; Domínguez, Ismael; Arriola, Juan Carlos; Ramirez-Del Val, Fernando; Urencio, Miguel; Sánchez-Fernández, Norberto

2010-01-01

Bile duct injuries (BDI) have a wide array of presentation. Left partial injuries (Strasberg D) of the hepatic duct are the result of excessive traction, which dissects the hepatic hilum and provokes medial perforations without continuity loss. Right partial injuries (Strasberg A, B and C) are produced by direct damage to the hepatic duct or isolated injury to the right and accessory ducts. It is important to determine frequency, spectrum and treatment outcome of this BDI in the surgical scenario. Patients with BDI who underwent surgical treatment in our hospital were reviewed, right and left partial injuries were selected. Demographic, clinical and therapeutic data were analyzed. In a 16-year period, 405 patients underwent surgical treatment of BDI. 31 (8%) were classified as a left partial injury (Strasberg D): 23 injuries at the common hepatic duct treated with a Hepatojejunostomy (HJ); four at the confluence level which received a HJ with neoconfluence construction; two partial injuries in the left hepatic duct underwent a selective left HJ; and two complete occlusions of the left hepatic duct, one treated with a partial hepatectomy and the last case underwent a partial HJ. Right partial injuries (Strasberg A, B or C) were identified in 21 cases (5%), their treatment was tailored according to the type of BDI (conservative, selective HJ, or hepatectomy). In our series the frequency of left and right partial BDI injuries was 8% and 5%, respectively. The spectrum of analyzed injuries included four subtypes for the left partial and eight for the right partial lesions. Most BDI in the two analyzed groups presented concomitant devascularization of the extra-hepatic ducts, therefore receiving surgical treatment rather than endoscopic treatment was done.

Meningiomas involving the optic nerve: technical aspects and outcomes for a series of 50 patients.

PubMed

Margalit, Nevo S; Lesser, Jonathan B; Moche, Jason; Sen, Chandranath

2003-09-01

Surgical strategies and results for 50 patients with meningiomas involving the optic nerves are discussed and evaluated. Factors affecting the degree of resection and patient outcomes are presented. We emphasize our surgical techniques for resection of these tumors and we discuss the advantages of different approaches, depending on the relationship of the tumor to the optic nerves. Data for 50 patients with meningiomas involving the optic nerves who were surgically treated between 1991 and 2002 were reviewed, by using patient files, operative notes, and pre- and postoperative imaging and ophthalmological examination findings. Thirty-one female patients and 19 male patients, with a mean age of 53 years, were treated. Thirty-one patients (62%) underwent complete tumor removal (Simpson Grade 1 or 2), and 19 patients underwent subtotal removal (Grade 4). Factors affecting the grade of resection were tumor size (P = 0.01), location (P = 0.007), and internal carotid artery encasement (P = 0.019). Patients who underwent Grade 1 or 2 resection exhibited a mean tumor size of 3.0 cm, and patients who underwent Grade 4 resection exhibited a mean tumor size of 4.1 cm. Only three patients had residual tumor on the optic nerve; all others had tumor in the cavernous sinus or at the orbital apex or exhibited vascular involvement. Visual outcomes were influenced predominantly by tumor size, preoperative visual function, and optic nerve encasement. Meningiomas that involve the optic nerves require special considerations and surgical techniques. Early decompression of the optic nerve within the bony canal allows identification and separation of the tumor from the nerve, permitting removal of the tumor from this area with minimal manipulation of the optic nerve.

Management of pediatric second branchial fistulae: is tonsillectomy necessary?

PubMed

Cheng, Jeffrey; Elden, Lisa

2012-11-01

To describe the surgical management of second branchial fistulae that extend to the pharynx, specifically to determine whether tonsillectomy, along with surgical excision of the tract affects the rate of recurrence. Retrospective chart review of pediatric patients (age<18) who underwent surgical excision of second branchial anomalies at a tertiary-care children's hospital between January 1, 2006 and September 1, 2011. Sinus tracts that extended to the pharynx were considered to be fistulae. Seventy-four patients were identified who underwent surgical excision of 85 total second branchial anomalies - 20 cysts (23.5%), 29 sinuses (34.1%), and 36 fistulae (42.4%). The 36 fistulae were removed from 32 patients, 23 males and 9 females, with an average age of 43.3 months. There were 16 right, 11 left, and 5 bilateral lesions. In 14 (43.8%) of the fistulae cases, a tonsillectomy was performed. There was only one recurrence (2.8%), which occurred 41 months postoperatively. No statistically significant difference for recurrence (p=1.0) was found between the group of patients that underwent tonsillectomy and those that did not. Pediatric branchial anomalies can present as a cyst, sinus, or fistula. They are developmental failures in the involution of the branchial apparatus during the embryologic period. Management of second branchial anomalies is with surgical excision of the tract and ligation of the terminal attachment to the pharynx. Our results suggest that the recurrence rates are not affected by whether or not an ipsilateral tonsillectomy is performed. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Adoptive cell therapy with autologous tumor-infiltrating lymphocytes and high-dose interleukin-2 for metastatic melanoma: The surgeon’s perspective

PubMed Central

ZIPPEL, DOUGLAS B.; BESSER, MICHAL; SHAPIRA, RONI; BEN-NUN, ALON; GOITEIN, DAVID; DAVIDSON, TIMA; TREVES, ABRAHAM J.; MARKEL, GAL; SCHACHTER, JACOB; PAPA, MOSHE Z.

2012-01-01

Tumor-infiltrating lymphocytes (TILs) are produced by resecting tumor tissue and growing and expanding ex vivo large quantities of autologous T cells. Once the TILs are ready for infusion, the patient undergoes a non-myeloablative lympho-depleting course of chemotherapy and subsequent TIL infusion with high-dose bolus IL-2. This study reviews the surgical experience of the TIL program at the Chaim Sheba Cancer Research Center in Israel. Eligible patients underwent surgical consultation to determine what tumorectomy would be beneficial for harvesting appropriate tissue. Factors involved in the decision included tumor mass size, location and morbidity of the procedure. Between January 2006 and May 2010, 44 patients underwent 47 procedures of adoptive transfer of TILs. Three patients underwent the procedure twice for recurrence after initial good responses, including an additional surgical procedure to produce fresh tumor. Thirty-seven excisions were with general anesthesia and 10 were with local anesthesia. Of the 37 general anesthesia procedures, 27 were open procedures involving a thoracotomy, a laparotomy or dissection of a major lymph node basin. Ten used minimally invasive techniques such as thorascopy or laparoscopy. Tumorectomy sites included 18 lymph node metastasis, 13 subcutaneous nodules, 11 lung specimens and 5 abdominal visceral metastasis including 2 liver lesions. Surgical mortality and major morbidity was 0%. Minor morbidity included only wound complications. Maximal number of TILs were derived from lymph node specimens, while liver metastasis procured the fewest TILs. Adoptive cell transfer technology affords a maximal tumor response with minimal surgical morbidity in metastatic patients. PMID:22969990

Tongue base suspension in children with cerebral palsy and obstructive sleep apnea.

PubMed

Hartzell, Larry David; Guillory, Ryan M; Munson, Patrick David; Dunham, Andrew K; Bower, Charles Michael; Richter, Gresham Thomas

2013-04-01

Children with cerebral palsy (CP) are commonly affected by obstructive sleep apnea (OSA). This study examines the efficacy of combined surgical techniques for OSA including tongue base suspension (TBS), using perioperative polysomnograms (PSG) in pediatric patients with CP. Case series with outcome analysis. University based tertiary care children's hospital. A 7-year retrospective chart review of children with CP who underwent surgical management for OSA. Surgical procedures, postoperative complications, and perioperative PSG data were examined. Only patients with both preoperative and postoperative PSG results were included in the study. Based upon procedures performed patients fell into 2 equal groups for analysis. Fourteen children were identified. Seven patients (mean age = 6.0 years) underwent combined adenotonsillectomy (T&A), uvulopalatopharyngoplasty (UPPP), and tongue base suspension (TBS). Another 7 patients (mean age = 6.3 years) underwent T&A and UPPP alone. Those who received TBS had a mean preoperative AHI of 27.2 compared to 6.8 in the group that did not have TBS. The AHI decreased by a mean of 16.5 in the TBS group and 5.0 in the non-TBS group. The mean oxygen saturation nadir improved in both the TBS (74.0-84.0) and non-TBS (64.8-84.6) groups. The arousal index also improved in the TBS (33.1-20.7) and non-TBS (11.0-5.8) groups. No surgical complications occurred. This study suggests that concomitant surgical approaches for OSA in children with CP are effective. Moderate to severe OSA in this population may safely benefit from the added technique of tongue base suspension. Published by Elsevier Ireland Ltd.

Safety of concomitant cholecystectomy at the time of laparoscopic sleeve gastrectomy: analysis of the American College of Surgeons National Surgical Quality Improvement Program database.

PubMed

Dakour-Aridi, Hanaa N; El-Rayess, Hebah M; Abou-Abbass, Hussein; Abu-Gheida, Ibrahim; Habib, Robert H; Safadi, Bassem Y

2017-06-01

The indication and safety of concomitant cholecystectomy (CC) during bariatric surgical procedures are topics of controversy. Studies on the outcomes of CC with laparoscopic sleeve gastrectomy (LSG) are scarce. To assess the safety and 30-day surgical outcomes of CC with LSG. A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database 2010 to 2013. Univariate and multivariate analyses were used. Between 2010 and 2013, 21,137 patients underwent LSG; of those 422 (2.0%) underwent CC (LSG+CC), and the majority (20,715 [98%]) underwent LSG alone. Patients in both groups were similar in age, sex distribution, baseline weight, and body mass index. The average surgical time was significantly higher, by 33 minutes, in the LSG+CC cohort. No differences were noted between the groups with regard to overall 30-day mortality and length of hospital stay. CC increased the odds of any adverse event (5.7% versus 4.0%), but the difference did not reach statistical significance (odds ratio 1.49, P = .07). Two complications were noted to be significantly higher with LSG+CC, namely bleeding (P = .04) and pneumonia (P = .02). CC during LSG appears to be a safe procedure with slightly increased risk of bleeding and pneumonia compared with LSG alone. When factoring the potential risk and cost of further hospitalization for deferred cholecystectomy, these data support CC for established gallbladder disease. Copyright © 2017 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.

Role of Surgical Versus Clinical Staging in Chemoradiated FIGO Stage IIB-IVA Cervical Cancer Patients—Acute Toxicity and Treatment Quality of the Uterus-11 Multicenter Phase III Intergroup Trial of the German Radiation Oncology Group and the Gynecologic Cancer Group

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

Marnitz, Simone, E-mail: simone.marnitz-schulze@uk-koeln.de; Martus, Peter; Köhler, Christhardt

Purpose: The Uterus-11 trial was designed to evaluate the role of surgical staging in patients with cervical cancer before primary chemoradiation therapy (CRT). The present report provides the toxicity data stratified by the treatment arm and technique. Methods and Materials: A total of 255 patients with carcinoma of the uterine cervix (International Federation of Gynecology and Obstetrics stage IIB-IVA) were randomized to either surgical staging followed by CRT (arm A) or clinical staging followed by CRT (arm B). Patients with para-aortic metastases underwent extended field radiation therapy (RT). Brachytherapy was mandatory. The present report presents the acute therapy-related toxicities stratifiedmore » by treatment arm and radiation technique. Results: A total of 240 patients were eligible (n=121 in arm A; n=119 in arm B). Of the 240 patients, 236 (98.3%) underwent external beam RT with a median total dose of 50.4 Gy. The mean treatment duration was 53 days. Of the patients, 60% underwent intensity modulated RT (IMRT). A total of 234 patients (97.5%) underwent chemotherapy, and 231 (96.3%) underwent brachytherapy, with a median single dose of 6 Gy covering the tumor to a median nominal total dose of 28 Gy. Treatment was well tolerated, with 0% grade ≥3 genitourinary and gastrointestinal toxicity, 6% grade 3 nausea, 3% grade 3 vomiting, and <2% grade 3 diarrhea. More patients after surgical staging experienced grade 2 anemia (54.3% in arm A vs 45.3% in arm B; P=.074) and grade 2 leukocytopenia (41.4% vs 31.6%; P=.56). Of the patients who received IMRT versus a 3-dimensional technique, 65.3% versus 33.7% presented with grade 2 anemia. Grade 3 gastrointestinal and grade 2 bladder toxicity were significantly reduced with the use of IMRT. Conclusions: The incidence and severity of acute therapy-related toxicity compared favorably with those from other randomized trials. Excellent adherence to treatment and treatment quality was achieved compared with patterns of care analyses. Surgical staging led to a doubled number of patients treated with extended field RT. The question of whether surgical staging is beneficial in the context of primary CRT requires further study.« less

Radiologic advantages of potential use of polymer plastic clips in neurosurgery.

PubMed

Delibegović, Samir

2014-01-01

Plastic clips are made of diamagnetic material and may result in fewer computed tomography (CT) and magnetic resonance artifacts than titanium clips. Considering that polymer plastic clips are increasingly being used in endoscopic surgery, our study examined the CT and magnetic resonance imaging (MRI) characteristics of plastic clips after application in the neurocranium and compared them with titanium clips. Craniotomy was performed on the heads of domestic pigs (Sus scrofa domestica), and, at an angle of 90°, a permanent Yasargil FT 746 T clip was placed in a frontobasal, interhemispheric position. A plastic polymer medium-large Hem-o-lok clip was placed in the same position into another animal. After this procedure, CT of the brain was performed using Siemens 16 slice, followed by an MRI scan, on Philips MRI, 1.5 Tesla. The CT and magnetic resonance scans were analyzed. On axial CT sections through the site of placement of titanium clips, dotted hyperdensity with a high value of Hounsfield units (HUI) of about 2800-3000 could be clearly seen. At the site where the plastic polymer clips were placed, discrete hyperdensity was observed, measuring 130-140 HUI. MRI of the brain in which titanium clips were used revealed a hypointensive T1W signal in the interhemispheric fissure, with a hypointensive T2W signal. On the other hand, upon examination of the MRI of the brain in which plastic clips were used, the T1W signal described above did not occur, and there was also no T2W signal, and no artifacts observed. The plastic clips are made of a diamagnetic, nonconductive material that results in fewer CT and MRI artifacts than titanium clips. Copyright © 2014 Elsevier Inc. All rights reserved.

Single-incision laparoscopic cholecystectomy: a systematic review of methodology and outcomes.

PubMed

Yamazaki, Masato; Yasuda, Hideki; Koda, Keiji

2015-05-01

(1) To survey the dissemination of SILC; (2) to determine which SILC method has become mainstream; (3) to determine whether the characteristic complications vary according to the type of procedure. An electronic search of PubMed, Databases@Ovid, and SciVerse Scopus between 2003/01/01 and 2012/12/31 was performed. The peak number of annually published articles was 70 in 2011. The most common procedures were single skin incision, the use of a SILS Port(®), suture suspension and a 5-mm oblique scope. The intraoperative complications rate was 1.69 %. Postoperative complications occurred in 213/5283 cases. According to the surgical procedure, five factors (approach; P = 0.0017, gallbladder anchorage; P < 0.001, size; P = 0.049 and type; P < 0.001 of the scope, and size of the clip applier; P = 0.074) significantly affected the incidence of wound infection. The incidence of wound seroma/bleeding was significantly influenced by gallbladder anchorage (P = 0.009), the use of curved/articulated instruments (P = 0.048), and the diameter of the clip applier (P < 0.001). To determine the best operative procedure for SILC, an analysis of uniform operative procedures is needed.

In vivo measurement of hemodynamic information in stenosed rat blood vessels using X-ray PIV

NASA Astrophysics Data System (ADS)

Park, Hanwook; Park, Jun Hong; Lee, Sang Joon

2016-11-01

Measurements of the hemodynamic information of blood flows, especially wall shear stress (WSS), in animal models with circulatory vascular diseases (CVDs) are important to understand the pathological mechanism of CVDs. In this study, X-ray particle image velocimetry (PIV) with high spatial resolution was applied to obtain velocity field information in stenosed blood vessels with high WSS. 3D clips fabricated with a 3D printer were applied to the abdominal aorta of a rat cadaver to induce artificial stenosis in the real blood vessel of an animal model. The velocity and WSS information of blood flows in the stenosed vessel were obtained and compared at various stenosis severities. In vivo measurement was also conducted by fastening a stenotic clip on a live rat model through surgical intervention to reduce the flow rate to match the limited temporal resolution of the present X-ray PIV system. Further improvement of the temporal resolution of the system might be able to provide in vivo measurements of hemodynamic information from animal disease models under physiological conditions. The present results would be helpful for understanding the relation between hemodynamic characteristics and the pathological mechanism in animal CVD models.

[Cerebral aneurysms complicating bacterial endocarditis. Seven cases (author's transl)].

PubMed

Pecker, J; Vallée, B; Camuzet, J P; Faivre, J; Javalet, A

The authors report seven cases of cerebral aneurysms complicating bacterial endocarditis. The evolution was good in three cases, two of which without sequelae. The bacteries involved were staphylococcus, streptococcus, and enterobacter. The cardiopathy was mitral in four cases. Two patients presented an isolated focal neurological impairment, while the other five presented a severe coma either isolated (one case) or associated with focal neurological deficits (four cases). An intracerebral hematoma was diagnosed in five cases (four died). Only one patient was not operated. The surgical treatment was as follows: one carotid ligation (good result), two evacuations of intracerebral hematomas (both died), two evacuations of intracerebral hematomas with clipping of the aneurysms (one died, one had a fair result in despite of residual hemiplegia), one clipping of aneurysm (good result). Repeated cerebral angiographies should be systematically performed in cases of bacterial endocarditis in order to disclose and follow up cerebral aneurysms which may occur in this condition. Except in cases of emergency, surgery should be differed, in particular, in cases of proximal or multiple aneurysms. Aneurysms of the peripheral cortical arteries are more accessible to treatment and may be operated in the acute phase.

Surgical management and clinical prognosis of adrenocortical carcinoma.

PubMed

Dong, Dexin; Li, Hanzhong; Yan, Weigang; Ji, Zhigang; Mao, Quanzong

2012-01-01

To study the relationship between surgical management and prognosis of adrenocortical carcinoma (ACC) in order to guide the surgical management of ACC. Clinical data of 45 cases of ACC treated in our hospital were retrospectively analyzed. The 45 cases included 3 cases in stage I, 12 cases in stage II, 7 cases in stage III, and 23 cases in stage IV. 17 cases underwent complete excision, 14 cases underwent palliative excision, 8 cases had non-operative treatment and 6 cases gave up treatment. All patients were followed up from 2 to 141 months. The average survival time of 31 patients with surgery was 32.46 months, and the average survival time of 14 patients without surgery was 4.75 months. There were statistically significant differences between the two groups (p < 0.01). There were no statistically significant differences between the two groups in survival time in stage III and stage IV (p > 0.05). Surgery is considered to be the only method to cure ACC. For ACC in stage I and II, tumor resection is the most effective treatment, and second surgical operation is recommended for local recurrence. For ACC in stage III, extensive surgical operation is recommended, and for ACC in stage IV, surgical operation has no effect on the prognosis. Copyright © 2012 S. Karger AG, Basel.

Financial impact of surgical technique in the treatment of acute appendicitis in children.

PubMed

Litz, Cristen; Danielson, Paul D; Gould, Jay; Chandler, Nicole M

2013-09-01

Appendicitis is the most common emergent problem encountered by pediatric surgeons. Driven by improved cosmetic outcomes, many surgeons are offering pediatric patients single-incision laparoscopic appendectomy. We sought to investigate the financial impact of different surgical approaches to appendectomy. A retrospective study of patients with acute appendicitis undergoing appendectomy from February 2010 to September 2011 was conducted. Based on surgeon preference, patients underwent open appendectomy (OA), laparoscopic appendectomy (LA), or single-incision laparoscopic appendectomy (SILA). Demographic information, surgical outcomes, surgical supply costs, and total direct costs were recorded. A total of 465 patients underwent appendectomy during the study. The mean age of all patients was 11.2 years (range, 1 to 18 years). There were no conversions in the LA or SILA groups. There was a significant difference among surgical technique in regard to surgical supply costs (OA $159 vs. LA $650 vs. SILA $814, P < 0.01) and total direct costs (OA $2129 vs. LA $2624 vs. SILA $2991, P < 0.01). In our institution, both multiport laparoscopic and SILA carry higher costs when compared with OA, largely as a result of the cost of disposable instrumentation. Cost efficiency should be considered by surgeons when undertaking a minimally invasive approach to appendectomy.

Computer-designed surgical guide template compared with free-hand operation for mesiodens extraction in premaxilla using “trapdoor” method

PubMed Central

Hu, Ying Kai; Xie, Qian Yang; Yang, Chi; Xu, Guang Zhou

2017-01-01

Abstract The aim of this study was to introduce a novel method of mesiodens extraction using a vascularized pedicled bone flap by piezosurgery and to compare the differences between a computer-aided design surgical guide template and free-hand operation. A total of 8 patients with mesiodens, 4 with a surgical guide (group I), and 4 without it (group II) were included in the study. The surgical design was to construct a trapdoor pedicle on the superior mucoperiosteal attachment with application of piezosurgery. The bone lid was repositioned after mesiodens extraction. Group I patients underwent surgeries based on the preoperative planning with surgical guide templates, while group II patients underwent free-hand operation. The outcome variables were success rate, intraoperative time, anterior nasal spine (ANS) position, changes of nasolabial angle (NLA), and major complications. Data from the 2 groups were compared by SPSS 17.0, using Wilcoxon test. The operative time was significantly shorter in group I patients. All the mesiodentes were extracted successfully and no obvious differences of preoperative and postoperative ANS position and NLA value were found in both groups. The patients were all recovered uneventfully. Surgical guide templates can enhance clinical accuracy and reduce operative time by facilitating accurate osteotomies. PMID:28658139

Ratings for emotion film clips.

PubMed

Gabert-Quillen, Crystal A; Bartolini, Ellen E; Abravanel, Benjamin T; Sanislow, Charles A

2015-09-01

Film clips are widely utilized to elicit emotion in a variety of research studies. Normative ratings for scenes selected for these purposes support the idea that selected clips correspond to the intended target emotion, but studies reporting normative ratings are limited. Using an ethnically diverse sample of college undergraduates, selected clips were rated for intensity, discreteness, valence, and arousal. Variables hypothesized to affect the perception of stimuli (i.e., gender, race-ethnicity, and familiarity) were also examined. Our analyses generally indicated that males reacted strongly to positively valenced film clips, whereas females reacted more strongly to negatively valenced film clips. Caucasian participants tended to react more strongly to the film clips, and we found some variation by race-ethnicity across target emotions. Finally, familiarity with the films tended to produce higher ratings for positively valenced film clips, and lower ratings for negatively valenced film clips. These findings provide normative ratings for a useful set of film clips for the study of emotion, and they underscore factors to be considered in research that utilizes scenes from film for emotion elicitation.

Authoring Data-Driven Videos with DataClips.

PubMed

Amini, Fereshteh; Riche, Nathalie Henry; Lee, Bongshin; Monroy-Hernandez, Andres; Irani, Pourang

2017-01-01

Data videos, or short data-driven motion graphics, are an increasingly popular medium for storytelling. However, creating data videos is difficult as it involves pulling together a unique combination of skills. We introduce DataClips, an authoring tool aimed at lowering the barriers to crafting data videos. DataClips allows non-experts to assemble data-driven "clips" together to form longer sequences. We constructed the library of data clips by analyzing the composition of over 70 data videos produced by reputable sources such as The New York Times and The Guardian. We demonstrate that DataClips can reproduce over 90% of our data videos corpus. We also report on a qualitative study comparing the authoring process and outcome achieved by (1) non-experts using DataClips, and (2) experts using Adobe Illustrator and After Effects to create data-driven clips. Results indicated that non-experts are able to learn and use DataClips with a short training period. In the span of one hour, they were able to produce more videos than experts using a professional editing tool, and their clips were rated similarly by an independent audience.

Pancreatic duct stones in patients with chronic pancreatitis: surgical outcomes.

PubMed

Liu, Bo-Nan; Zhang, Tai-Ping; Zhao, Yu-Pei; Liao, Quan; Dai, Meng-Hua; Zhan, Han-Xiang

2010-08-01

Pancreatic duct stone (PDS) is a common complication of chronic pancreatitis. Surgery is a common therapeutic option for PDS. In this study we assessed the surgical procedures for PDS in patients with chronic pancreatitis at our hospital. Between January 2004 and September 2009, medical records from 35 patients diagnosed with PDS associated with chronic pancreatitis were retrospectively reviewed and the patients were followed up for up to 67 months. The 35 patients underwent ultrasonography, computed tomography, or both, with an overall accuracy rate of 85.7%. Of these patients, 31 underwent the modified Puestow procedure, 2 underwent the Whipple procedure, 1 underwent simple stone removal by duct incision, and 1 underwent pancreatic abscess drainage. Of the 35 patients, 28 were followed up for 4-67 months. There was no postoperative death before discharge or during follow-up. After the modified Puestow procedure, abdominal pain was reduced in patients with complete or incomplete stone clearance (P>0.05). Steatorrhea and diabetes mellitus developed in several patients during a long-term follow-up. Surgery, especially the modified Puestow procedure, is effective and safe for patients with PDS associated with chronic pancreatitis. Decompression of intraductal pressure rather than complete clearance of all stones predicts postoperative outcome.

Repeated transsphenoidal surgery for resection of pituitary adenoma.

PubMed

Wang, Shousen; Xiao, Deyong; Wang, Rumi; Wei, Liangfeng; Hong, Jingfang

2015-03-01

To investigate the surgical strategy of repeated microscopic transsphenoidal surgery (TSS) for treatment of pituitary adenoma, surgical techniques and treatment outcomes for 29 patients with pituitary adenoma were reviewed and analyzed. There were 17 patients who underwent TSS 18 times and 12 patients who underwent TSS 13 times. The interval between each TSS ranged from 3 months to 18 years, with a median time of 4 years. The tumor height was 15 to 45 mm on the last surgery. Among the 29 patients, 16 patients underwent total tumor resection, 11 patients underwent subtotal resection, and 2 patients underwent partial resection. Cerebrospinal fluid leak occurred in 10 patients. Among 24 patients who were followed up effectively, 1 patient developed abducens paralysis after surgery, 1 patient had chronic diabetes insipidus, and 1 patient received steroid-dependent alternative treatment. The repeated TSS may present satisfied outcomes in experienced hands. The upper edge of the posterior choanae should be identified to ensure the right orientation. The openings of the anterior wall of the sphenoid sinus and the sellar floor should be appropriately expanded to improve tumor exposure. The artificial materials should be identified and removed carefully. Intraoperative cerebrospinal fluid leakage should be managed well.

Is Surgical Navigation Useful During Closed Reduction of Nasal Bone Fractures?

PubMed

Kim, Seon Tae; Jung, Joo Hyun; Kang, Il Gyu

2017-05-01

To report the case of a 42-year-old woman with a nasal bone fracture that was easily treated using a surgical navigation system. In this clinical report, the authors suggest that intraoperative surgical navigation systems are useful diagnostically and for localizing sites of nasal bone fractures exactly. The patient underwent successful closed reduction of the nasal bone fracture. Surgical navigation is a useful tool for identifying nasal bone fracture locations and for guiding closed reduction. Surgical navigation is recommended when nasal bone fractures are complicated or not well reduced using the ordinary method.

Proposal for a CLIPS software library

NASA Technical Reports Server (NTRS)

Porter, Ken

1991-01-01

This paper is a proposal to create a software library for the C Language Integrated Production System (CLIPS) expert system shell developed by NASA. Many innovative ideas for extending CLIPS were presented at the First CLIPS Users Conference, including useful user and database interfaces. CLIPS developers would benefit from a software library of reusable code. The CLIPS Users Group should establish a software library-- a course of action to make that happen is proposed. Open discussion to revise this library concept is essential, since only a group effort is likely to succeed. A response form intended to solicit opinions and support from the CLIPS community is included.

Biocompatibility of Plastic Clip in Neurocranium - Experimental Study on Dogs.

PubMed

Delibegovic, Samir; Dizdarevic, Kemal; Cickusic, Elmir; Katica, Muhamed; Obhodjas, Muamer; Ocus, Muhamed

2016-01-01

A potential advantage of the use of the plastic clips in neurosurgery is their property of causing fewer artifacts than titanium clips as assessed by computed tomography and magnetic resonance scans. The biocompatibility of plastic clips was demonstrated in the peritoneal cavity, but their behavior in the neurocranium is not known. Twelve aggressive stray dogs designated for euthanasia were taken for this experimental study. The animals were divided into two groups. In all cases, after anesthesia, a craniotomy was performed, and after opening the dura, a proximal part titanium clip was placed on the isolated superficial Sylvian vein (a permanent Yasargil FT 746 T clip at a 90° angle, while a plastic Hem-o-lok clip ML was placed on another part of the vein). The first group of animals was sacrificed on the 7 < sup > th < /sup > postoperative day and the second group on the 60 < sup > th < /sup > postoperative day. Samples of tissue around the clips were taken for a histopathological evaluation. The plastic clip caused a more intensive tissue reaction than the titanium clip on the 7 < sup > th < /sup > postoperative day, but there was no statistical difference. Even on the 60 < sup > th < /sup > postoperative day there was no significant difference in tissue reaction between the titanium and plastic clips. These preliminary results confirm the possibility for the use of plastic clips in neurosurgery. Before their use in human neurosurgery, further studies are needed to investigate the long-term effects of the presence of plastic clips in the neurocranium, as well as studies of the aneurysmal model.

Fuzzy expert systems using CLIPS

NASA Technical Reports Server (NTRS)

Le, Thach C.

1994-01-01

This paper describes a CLIPS-based fuzzy expert system development environment called FCLIPS and illustrates its application to the simulated cart-pole balancing problem. FCLIPS is a straightforward extension of CLIPS without any alteration to the CLIPS internal structures. It makes use of the object-oriented and module features in CLIPS version 6.0 for the implementation of fuzzy logic concepts. Systems of varying degrees of mixed Boolean and fuzzy rules can be implemented in CLIPS. Design and implementation issues of FCLIPS will also be discussed.

One hundred and one over-the-scope-clip applications for severe gastrointestinal bleeding, leaks and fistulas.

PubMed

Wedi, Edris; Gonzalez, Susana; Menke, Detlev; Kruse, Elena; Matthes, Kai; Hochberger, Juergen

2016-02-07

To investigate the efficacy and clinical outcome of patients treated with an over-the-scope-clip (OTSC) system for severe gastrointestinal hemorrhage, perforations and fistulas. From 02-2009 to 10-2012, 84 patients were treated with 101 OTSC clips. 41 patients (48.8%) presented with severe upper-gastrointestinal (GI) bleeding, 3 (3.6%) patients with lower-GI bleeding, 7 patients (8.3%) underwent perforation closure, 18 patients (21.4%) had prevention of secondary perforation, 12 patients (14.3%) had control of secondary bleeding after endoscopic mucosal resection or endoscopic submucosal dissection (ESD) and 3 patients (3.6%) had an intervention on a chronic fistula. In 78/84 patients (92.8%), primary treatment with the OTSC was technically successful. Clinical primary success was achieved in 75/84 patients (89.28%). The overall mortality in the study patients was 11/84 (13.1%) and was seen in patients with life-threatening upper GI hemorrhage. There was no mortality in any other treatment group. In detail OTSC application lead to a clinical success in 35/41 (85.36%) patients with upper GI bleeding and in 3/3 patients with lower GI bleeding. Technical success of perforation closure was 100% while clinical success was seen in 4/7 cases (57.14%) due to attendant circumstances unrelated to the OTSC. Technical and clinic success was achieved in 18/18 (100%) patients for the prevention of bleeding or perforation after endoscopic mucosal resection and ESD and in 3/3 cases of fistula closure. Two application-related complications were seen (2%). This largest single center experience published so far confirms the value of the OTSC for GI emergencies and complications. Further clinical experience will help to identify optimal indications for its targeted and prophylactic use.

Restoration of clipped seismic waveforms using projection onto convex sets method

PubMed Central

Zhang, Jinhai; Hao, Jinlai; Zhao, Xu; Wang, Shuqin; Zhao, Lianfeng; Wang, Weimin; Yao, Zhenxing

2016-01-01

The seismic waveforms would be clipped when the amplitude exceeds the upper-limit dynamic range of seismometer. Clipped waveforms are typically assumed not useful and seldom used in waveform-based research. Here, we assume the clipped components of the waveform share the same frequency content with the un-clipped components. We leverage this similarity to convert clipped waveforms to true waveforms by iteratively reconstructing the frequency spectrum using the projection onto convex sets method. Using artificially clipped data we find that statistically the restoration error is ~1% and ~5% when clipped at 70% and 40% peak amplitude, respectively. We verify our method using real data recorded at co-located seismometers that have different gain controls, one set to record large amplitudes on scale and the other set to record low amplitudes on scale. Using our restoration method we recover 87 out of 93 clipped broadband records from the 2013 Mw6.6 Lushan earthquake. Estimating that we recover 20 clipped waveforms for each M5.0+ earthquake, so for the ~1,500 M5.0+ events that occur each year we could restore ~30,000 clipped waveforms each year, which would greatly enhance useable waveform data archives. These restored waveform data would also improve the azimuthal station coverage and spatial footprint. PMID:27966618

Rapid assessment of avoidable blindness in Bhutan.

PubMed

Lepcha, Nor Tshering; Chettri, Chandra Kumar; Getshen, Kunzang; Rai, Bhim Bahadur; Ramaswamy, Shamanna Bindiganavale; Saibaba, Saravanan; Nirmalan, Praveen Kumar; Demarchis, Emilia Hansson; Tabin, Geoffrey; Morley, Michael; Morley, Katharine

2013-08-01

To conduct a rapid assessment of avoidable blindness survey in Bhutan to obtain estimates of blindness, visual impairment, and cataract surgical coverage, outcomes and barriers among persons ≥50 years old. A total of 82 clusters of 50 people ≥50 years were selected using probability proportionate to size sampling. Eligible participants were selected from households using compact segment sampling, and underwent ophthalmic examination for visual acuity, followed by penlight and direct ophthalmoscopy. Participants with cataract were interviewed regarding surgical outcomes and barriers to surgery. Overall, 4046 of 4100 persons enumerated (98.7%) underwent ophthalmic examination. Adjusting for age and sex, the prevalence of bilaterally blind persons with available correction was 1.5% (95% confidence interval 1.09-1.89). Most blindness (67.1%) and severe visual impairment (74.1%) resulted from cataract, but 22.1% resulted from posterior segment pathology. Cataract surgical coverage for bilaterally blind persons was 72.7%. Almost 90% of patients reported moderate or good satisfaction, despite poor surgical outcomes in 23.6%. The prevalence of blindness in people aged ≥50 years in Bhutan was relatively low when compared with neighboring countries and World Health Organization sub-region estimates. Areas for improvement include community outreach, surgical outcomes, and posterior segment diseases.

Congenital megaprepuce: a 12-year experience (52 cases) of this specific form of buried penis.

PubMed

Rod, Julien; Desmonts, Alexis; Petit, Thierry; Ravasse, Philippe

2013-12-01

Congenital megaprepuce is a specific form of buried penis. Children affected by this malformation usually suffer from a subjective difficulty in voiding which is the main indication for early surgical correction. The aim of this study was to report a single center's 12-year experience in the treatment of megaprepuce in children, describing the surgical procedure we used to treat it and the results. We retrospectively reviewed the charts of all children who underwent congenital megaprepuce repair between January 1999 and August 2011 in our institution. Fifty-two children were operated during the study period. Our single surgical technique, not an original one, consists of fixing the penile shaft at the base of the penis, and widely reducing the inner prepuce. Four children (8%) underwent revision surgery but according to our criteria a very good result was observed in only 23 patients, and a less good but still acceptable result in 25 patients. Our 12-year experience in the surgical treatment of congenital megaprepuce demonstrated satisfying results from a safe and simple surgical technique, but to achieve the optimum result remains difficult. Copyright © 2012 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.

Surgical treatment outcomes of patients with bilateral warthin tumors in the parotid gland.

PubMed

Lee, Dong Hoon; Yoon, Tae Mi; Lee, Joon Kyoo; Lim, Sang Chul

2014-01-01

We describe the treatment outcomes of patients with bilateral Warthin tumors in the parotid gland according to surgical methods. The medical records of ten patients with bilateral Warthin tumors in the parotid gland who underwent surgery between 2004 and 2011 were retrospectively reviewed. Ten patients were included in the study and 13 parotidectomies were performed. Patients with bilateral Warthin tumors in the parotid gland were divided into three groups according to the surgical methods used to treat these individuals. In group 1, the patients were closely observed without undergoing contralateral parotidectomy after unilateral parotidectomy. In group 2, the patients underwent concurrent bilateral parotidectomies. In group 3, the patient underwent contralateral parotidectomy 2 months after unilateral parotidectomy was performed. The overall rate of transient facial nerve dysfunction was 31%. Our findings suggest that concurrent superficial parotidectomy may be an appropriate method for treating bilateral Warthin tumors in the parotid gland, at least for desired patients. The symptoms of this type of tumor and physical examination findings are frequently non-specific and present in the unilateral parotid gland. Therefore, a high degree of discernment is needed and imaging techniques are essential for the determining the correct pre-operative diagnosis.

Surgical Resection and Inferior Vena Cava Reconstruction for Treatment of the Malignant Tumor: Technical Success and Outcomes

PubMed Central

2014-01-01

Objective: The purpose of this study was to review patients who underwent inferior vena cava (IVC) resection with concomitant malignant tumor resection and to consider the operative procedures and the outcomes. Materials and Methods: Between 2000 and 2012, 41 patients underwent resection of malignant tumors concomitant with surgical resection of the IVC at our institute. The records of these patients were retrospectively reviewed. Results: Primary tumor resections included nephrectomy, hepatectomy, retroperitoneal tumor extirpation, lymph node dissection, and pancreaticoduodenectomy. The IVC interventions were partial resection in 23 patients and total resection in 18 patients. Four patients underwent IVC replacement. Operation-related complications included pulmonary embolism, acute myocardial infarction, deep vein thrombosis, leg edema and temporary hemodialysis. There were no operative deaths. The mean follow-up period was 24.9 months (range: 2–98 months). The prognosis depended on the type and stage of the tumor. Conclusion: Resection and reconstruction of the IVC can be performed safely if the preoperative evaluations and surgical procedures are performed properly. The IVC resection without reconstruction was permissive if the IVC was completely obstructed preoperatively, but it may also be considered in cases where the IVC is not completely obstructed. PMID:24995055

Surgical management of traumatic tricuspid insufficiency.

PubMed

Zhang, Zhiqi; Yin, Kanhua; Dong, Lili; Sun, Yongxin; Guo, Changfa; Lin, Yi; Wang, Chunsheng

2017-06-01

This study reviews our experience with traumatic tricuspid insufficiency (TTI) following blunt chest trauma. From January 2010 to June 2016, 10 patients (nine males, mean age 49.0 ± 12.4 years) underwent surgical treatment of TTI following blunt chest trauma. The mean intervals between trauma and diagnosis and between trauma and surgery were 74.1 and 81.8 months, respectively. Preoperatively, all patients exhibited severe tricuspid regurgitation. Five patients underwent tricuspid valve repair, and the remaining patients underwent valve replacement. The mean follow-up duration (with echocardiography) was 29.7 months. There was no early or late death. Seven patients had anterior chordal rupture, two patients had anterior papillary muscle rupture, and one patient had both anterior chordal and anterior leaflet rupture. The median postoperative intensive care unit and hospital stays were 1 and 6 days, respectively. There were no severe postoperative complications. During follow-up, four patients exhibited trivial to mild tricuspid regurgitation, and the remaining six patients exhibited no regurgitation. Surgical treatment of TTI via either valve repair or replacement can be performed with low perioperative morbidity and mortality. Early surgery is recommended for achieving a successful valve repair and preserving right ventricular function. © 2017 Wiley Periodicals, Inc.

A systematic review of discomfort due to toe or ear clipping in laboratory rodents

PubMed Central

Geessink, Florentine J.; Brouwer, Michelle A. E.; Tillema, Alice; Ritskes-Hoitinga, Merel

2017-01-01

Toe clipping and ear clipping (also ear notching or ear punching) are frequently used methods for individual identification of laboratory rodents. These procedures potentially cause severe discomfort, which can reduce animal welfare and distort experimental results. However, no systematic summary of the evidence on this topic currently exists. We conducted a systematic review of the evidence for discomfort due to toe or ear clipping in rodents. The review methodology was pre-specified in a registered review protocol. The population, intervention, control, outcome (PICO) question was: In rodents, what is the effect of toe clipping or ear clipping, compared with no clipping or sham clipping, on welfare-related outcomes? Through a systematic search in PubMed, Embase, Web of Science and grey literature, we identified seven studies on the effect of ear clipping on animal welfare, and five such studies on toe clipping. Studies were included in the review if they contained original data from an in vivo experiment in rodents, assessing the effect of toe clipping or ear clipping on a welfare-related outcome. Case studies and studies applying unsuitable co-interventions were excluded. Study quality was appraised using an extended version of SYstematic Review Centre for Laboratory animal Experimentation (SYRCLE)’s risk of bias tool for animal studies. Study characteristics and outcome measures were highly heterogeneous, and there was an unclear or high risk of bias in all studies. We therefore present a narrative synthesis of the evidence identified. None of the studies reported a sample size calculation. Out of over 60 different outcomes, we found evidence of discomfort due to ear clipping in the form of increased respiratory volume, vocalization and blood pressure. For toe clipping, increased vocalization and decreased motor activity in pups were found, as well as long-term effects in the form of reduced grip strength and swimming ability in adults. In conclusion, there is too little evidence to reliably assess discomfort due to toe or ear clipping, and the quality of the available evidence is uncertain. Adequately powered, high-quality studies reporting reliable, relevant outcome measures are needed to accurately assess the impact of these identification techniques. Until more reliable evidence is available, any effect of toe clipping or ear clipping on animal welfare and study results cannot be confirmed or excluded. PMID:28429644

Taxonomic and Functional Responses of Soil Microbial Communities to Annual Removal of Aboveground Plant Biomass

PubMed Central

Guo, Xue; Zhou, Xishu; Hale, Lauren; Yuan, Mengting; Feng, Jiajie; Ning, Daliang; Shi, Zhou; Qin, Yujia; Liu, Feifei; Wu, Liyou; He, Zhili; Van Nostrand, Joy D.; Liu, Xueduan; Luo, Yiqi; Tiedje, James M.; Zhou, Jizhong

2018-01-01

Clipping, removal of aboveground plant biomass, is an important issue in grassland ecology. However, few studies have focused on the effect of clipping on belowground microbial communities. Using integrated metagenomic technologies, we examined the taxonomic and functional responses of soil microbial communities to annual clipping (2010–2014) in a grassland ecosystem of the Great Plains of North America. Our results indicated that clipping significantly (P < 0.05) increased root and microbial respiration rates. Annual temporal variation within the microbial communities was much greater than the significant changes introduced by clipping, but cumulative effects of clipping were still observed in the long-term scale. The abundances of some bacterial and fungal lineages including Actinobacteria and Bacteroidetes were significantly (P < 0.05) changed by clipping. Clipping significantly (P < 0.05) increased the abundances of labile carbon (C) degrading genes. More importantly, the abundances of recalcitrant C degrading genes were consistently and significantly (P < 0.05) increased by clipping in the last 2 years, which could accelerate recalcitrant C degradation and weaken long-term soil carbon stability. Furthermore, genes involved in nutrient-cycling processes including nitrogen cycling and phosphorus utilization were also significantly increased by clipping. The shifts of microbial communities were significantly correlated with soil respiration and plant productivity. Intriguingly, clipping effects on microbial function may be highly regulated by precipitation at the interannual scale. Altogether, our results illustrated the potential of soil microbial communities for increased soil organic matter decomposition under clipping land-use practices. PMID:29904372

Thoracoscopy with Concurrent Esophagoscopy for Persistent Right Aortic Arch in 9 Dogs.

PubMed

Townsend, Sarah; Oblak, Michelle L; Singh, Ameet; Steffey, Michele A; Runge, Jeffrey J

2016-11-01

To report the diagnosis, treatment, and short-term outcome in dogs with suspected persistent right aortic arch (PRAA) undergoing thoracoscopy with concurrent esophagoscopy. Multi-institutional retrospective case series. Dogs with suspected PRAA (n=9). Medical records were reviewed from 2012 to 2016. Dogs undergoing thoracoscopy for PRAA at 3 referral hospitals were included. Signalment, clinical signs, diagnostic imaging, anesthesia protocol (including the use of one-lung ventilation), surgical approach, complications, and short-term outcome were recorded. Dogs underwent a left-sided intercostal thoracoscopic approach with concurrent intraoperative esophagoscopy. The ligamentum arteriosum (LA) and constricting fibers were divided using a vessel-sealing device using a 3 or 4 port thoracoscopy technique. Visualization and dissection of the LA was aided by transesophageal illumination by esophagoscopy. Thoracoscopy confirmed PRAA in 9 dogs, with an aberrant left subclavian artery (LS) identified in 5 dogs. Major complications occurred in 2 dogs: postoperative hemorrhage from the LS and esophageal perforation, which resulted in euthanasia. Median follow-up was 250 days (range, 56-1,595). Regurgitation resolved in 4 of 8 surviving dogs. One dog had recurrence of regurgitation 1,450 days postoperatively, esophageal compression by the LS was identified, and regurgitation resolved following LS transection. Esophagoscopy aided identification and dissection of the LA in all cases. Due to the potential for the LS to cause clinical esophageal constriction postoperatively, a recommendation for LS transection may be warranted. Vascular clips can also be considered as an alternative for vessel ligation to avoid complications associated with vessel-sealing device use. © Copyright 2016 by The American College of Veterinary Surgeons.

Covered Esophageal Stenting Is Effective for Symptomatic Gastric Lumen Narrowing and Related Complications Following Laparoscopic Sleeve Gastrectomy.

PubMed

Aburajab, Murad A; Max, Joshua B; Ona, Mel A; Gupta, Kapil; Burch, Miguel; Michael Feiz, F; Lo, Simon K; Jamil, Laith H

2017-11-01

Laparoscopic sleeve gastrectomy (LSG) is gaining popularity in treating morbid obesity. Prior studies showed a 3.5% risk of gastric sleeve stenosis (GSS). There is no consensus on how to treat these patients, and the role of endoscopic therapy has been addressed in only a few studies. We aim to assess the efficacy and safety of endoscopic stenting in the management of GSS following LSG. Retrospective data were reviewed from July 2009 to November 2013. Patients were referred for endoscopic therapy for symptoms or imaging findings suggestive of gastric leak or narrowing following LSG. Endoscopic therapy included the use of fully covered self-expanding esophageal metal stents (FCSEMS) in addition to over-the-scope clip system (OTSC) when necessary. All 27 patients were females with mean age of 40 years; six patients were excluded from the study. Major symptom was nausea and vomiting in 57% of the patients. Five of 21 patients had concomitant leaks. All 21 patients underwent FCSEMS placement, and four out of five patients (80%) with concomitant leak had OTSC. The success rate in both groups for resolution of stricture and leak was 100%, and no surgical intervention was required. There were no immediate or delayed complications of endoscopic therapy. Median follow-up of 6 months was available for 20/21 patients. Among patients with gastric leak, 80% had resolution of their symptoms compared with 93% of patients with GSS. Endoscopic therapy for LSG-related GSS or leaks with FCSEMS is highly effective and safe.

[A Distal Bile Duct Carcinoma Patient Who Underwent Surgical Resection for Liver Metastasis].

PubMed

Komiyama, Sosuke; Izumiya, Yasuhito; Kimura, Yu; Nakashima, Shingo; Kin, Syuichi; Kawakami, Sadao

2018-03-01

A 70-year-old man with distal bile duct carcinoma underwent a subtotal stomach-preserving pancreaticoduodenectomy without adjuvant chemotherapy. One and a half years after the surgery, elevated levels of serum SPan-1(38.1 U/mL)were observed and CT scans demonstrated a solitary metastasis, 25mm in size, in segment 8 of the liver. The patient received 2 courses of gemcitabine-cisplatin combination chemotherapy. No new lesions were detected after chemotherapy and the patient underwent a partial liver resection of segment 8. The pathological examination revealed a metachronous distant metastasis originating from the bile duct carcinoma. Subsequently, the patient received S-1 adjuvant chemotherapy for 6 months. Following completion of all therapies, the patient survived without tumor recurrence for 3 years and 10 months after the initial operation. Thus, surgical interventions might be effective in improving prognosis among selected patients with postoperative liver metastasis of bile duct carcinoma.

It is time for a better clip applier - 3 mm, percutaneous, non-crushing and locking.

PubMed

Yuval, Jonathan B; Weiss, Daniel J; Paz, Adrian; Bachar, Yehuda; Brodie, Ronit; Shapira, Yinon; Mintz, Yoav

2017-10-06

Since the advent of laparoscopy there have been attempts to minimize abdominal wall incisions. For this purpose smaller instruments have been produced. Our aim was to develop the first 3 mm percutaneous clip applier and to make it better than the standard clips of today. The ClipTip clip is made of Nitinol and has a crocodile shaped jaws, which when apposed effectively seal vessels. The shaft operates as a retractable needle permitting percutaneous insertion. Closing, reopening and reclosing is possible. The physical properties of the device were compared to three commercially available clip appliers. Surgeries were performed on porcine animals by experienced surgeons. In comparison to available clips, the superiority of the ClipTip is a combination of wide effective length alongside the ability to withstand strong forces. In live animal studies the Cliptip was inserted into the peritoneal cavity without any injuries. Vessels were ligated successfully and no clip dislodgement or leakage occurred. We developed the next generation clip applier with better properties. Advantages include its length, the needleoscopic caliber, non-crushing effect, locking mechanism and wide aperture. The device has performed safely and effectively in pre-clinical tests. Further studies are planned in humans.

Persistence in and Release of 2,4-D and Azoxystrobin from Turfgrass Clippings.

PubMed

Jeffries, Matthew D; Yelverton, Fred H; Ahmed, Khalied A; Gannon, Travis W

2016-11-01

Research has shown that pesticide residue in clippings from previously treated turfgrass may become bioavailable as grass decomposes, adversely affecting off-target organisms. We conducted a field study to quantify 2,4-D (2,4-dichlorophenoxyacetic acid) and azoxystrobin (methyl(E)-2-{2[6-(2-cyanophenoxy)pyrmidin-4-yloxy]phenyl}-3-methoxyacrylate) residues in turfgrass clippings collected from hybrid bermudagrass [ (L.) Pers. × Burtt-Davy], tall fescue [ (Schreb.) S.J. Darbyshire], and zoysiagrass ( Steud.). A subsequent greenhouse experiment was conducted to measure pesticide release from clippings into water. 2,4-D (1.6 kg a.i. ha) and azoxystrobin (0.6 kg a.i. ha) were applied to field plots at 32, 16, 8, 4, 2, 1, or 0 d before collection of the clippings. Clippings were collected from each experimental unit to quantify pesticide release from clippings into water. Both 2,4-D and azoxystrobin were detected when turfgrass was treated over the 32-d experimental period, suggesting that clipping management should be implemented for an extended period of time after application. Pesticide residue was detected in all water samples collected, confirming 2,4-D and azoxystrobin release from turfgrass clippings; however, pesticide release varied between compounds. Two days after clippings were incorporated in water, 39 and 10% of 2,4-D and azoxystrobin were released from clippings, respectively. Our research supports the currently recommended practice of returning clippings to the turfgrass stand when mowing because removal of 2,4-D and azoxystrobin in clippings may reduce pest control and cause adverse off-target impacts. Copyright © by the American Society of Agronomy, Crop Science Society of America, and Soil Science Society of America, Inc.

Aneurysmal subarachnoid hemorrhage with concomitant posterior communicating artery fenestration.

PubMed

Weiner, Gregory M; Grandhi, Ramesh; Zwagerman, Nathan T; Agarwal, Nitin; Friedlander, Robert M

2015-02-01

Fenestrations of the posterior communicating artery (PCoA) are extremely rare. Associated aneurysms have only been documented three times in the literature, and none associated with a subarachnoid hemorrhage. We describe a 52-year-old female who presented with a subarachnoid hemorrhage secondary to a ruptured saccular aneurysm at the proximal limb of a fenestrated right PCoA. The patient was also found to have bilateral middle cerebral artery (MCA) aneurysms. Surgical management included surmising the etiology of the subarachnoid hemorrhage with subsequent clipping of both the right PCoA and MCA aneurysm. The potential embryological mechanisms leading to a PCoA fenestration are discussed.

Intracranial aneurysm and arachnoid cyst: just a coincidence? A case report.

PubMed

Aguiar, Guilherme Brasileiro de; Santos, Rafael Gomes Dos; Paiva, Aline Lariessy Campos; Silva, João Miguel de Almeida; Silva, Rafael Carlos da; Veiga, José Carlos Esteves

2017-12-18

Presence of an arachnoid cyst and a non-ruptured intracystic brain aneurysm is extremely rare. The aim of this paper was to describe a case of a patient with an arachnoid cyst and a non-ruptured aneurysm inside it. Clinical, surgical and radiological data were analyzed and the literature was reviewed. A patient complained of chronic headache. She was diagnosed as having a temporal arachnoid cyst and a non-ruptured middle cerebral artery aneurysm inside it. Surgery was performed to clip the aneurysm and fenestrate the cyst. This report raises awareness about the importance of intracranial vascular investigation in patients with arachnoid cysts and brain hemorrhage.

Quantifying the real-world cost saving from using surgical adjuncts to prevent complications during cataract surgery.

PubMed

Jamison, Aaron; Benjamin, Larry; Lockington, David

2018-06-06

Surgical adjuncts in cataract surgery are often perceived as sometimes necessary, always expensive, particularly in the "lean" cost-saving era. However, prevention of a surgical complication, rather than subsequent management, should always be the preferred strategy. We wished to model real-world costs associated with surgical adjuncts use and test the maxim for cataract surgery-"if you think of it, use it". We compared UK list prices for equipment and related costs of preventing vitreous loss (VL) via use of surgical adjuncts vs its subsequent management in a hypothetical cataract surgery scenario of a white swollen cataract with a moderately dilated pupil. The original surgery costs for the "cautious with adjuncts, no complications" approach was £943.54, including adjuncts costing £137.47. In the "minimalist, no adjunct" scenario, management of VL using the Anterior Vitrectomy Kit cost £142.45, and additional management and follow-up costs resulted in total cost of £1178.20 (£234.66 (25%) more expensive). If left aphakic, an additional operation for secondary iris clip IOL insertion and further follow-up to address the impact of the complication ultimately cost £2124.67 overall. An additional initial spend on surgical adjuncts of £137.47 could potentially prevent £1293.60 (9× increase) in direct costs in this scenario. Through simple scenario modelling, we have demonstrated the cost benefits provided by the use of precautionary surgical adjuncts during cataract surgery. VL costs significantly more in terms of complication management and follow-up. This supports the cataract surgeon's maxim-"if you think of it, use it".

Dynamic article: surgical anatomical planes for complete mesocolic excision and applied vascular anatomy of the right colon.

PubMed

Açar, Halil İbrahim; Cömert, Ayhan; Avşar, Abdullah; Çelik, Safa; Kuzu, Mehmet Ayhan

2014-10-01

Lower local recurrence rates and better overall survival are associated with complete mesocolic excision with central vascular ligation for treatment of colon cancer. To accomplish this, surgeons need to pay special attention to the surgical anatomical planes and vascular anatomy of the colon. However, surgical education in this area has been neglected. The aim of this study is to define the correct surgical anatomical planes for complete mesocolic excision with central vascular ligation and to demonstrate the correct dissection technique for protecting anatomical structures. Macroscopic and microscopic surgical dissections were performed on 12 cadavers in the anatomy laboratory and on autopsy specimens. The dissections were recorded as video clips. Dissections were performed in accordance with the complete mesocolic excision technique on 10 male and 2 female cadavers. Vascular structures, autonomic nerves, and related fascias were shown. Within each step of the surgical procedure, important anatomical structures were displayed on still images captured from videos by animations. Three crucial steps for complete mesocolic excision with central vascular ligation are demonstrated on the cadavers: 1) full mobilization of the superior mesenteric root following the embryological planes between the visceral and the parietal fascias; 2) mobilization of the mesocolon from the duodenum and the pancreas and identification of vascular structures, especially the veins around the pancreas; and 3) central vascular ligation of the colonic vessels at their origin, taking into account the vascular variations within the mesocolonic vessels and the autonomic nerves around the superior mesenteric artery. The limitation of this study was the number of the cadavers used. Successful complete mesocolic excision with central vascular ligation depends on an accurate knowledge of the surgical anatomical planes and the vascular anatomy of the colon.

[Tissular expansion in giant congenital nevi treatment].

PubMed

Nguyen Van Nuoi, V; Francois-Fiquet, C; Diner, P; Sergent, B; Zazurca, F; Franchi, G; Buis, J; Vazquez, M-P; Picard, A; Kadlub, N

2014-08-01

Surgical management of giant melanotic naevi remains a surgical challenge. Tissue expansion provides tissue of the same quality for the repair of defects. The aim of this study is to review tissular expansion for giant melanotic naevi. We conducted a retrospective study from 2000 to 2012. All children patients who underwent a tissular expansion for giant congenital naevi had been included. Epidemiological data, surgical procedure, complication rate and results had been analysed. Thirty-tree patients had been included; they underwent 61 procedures with 79 tissular-expansion prosthesis. Previous surgery, mostly simple excision had been performed before tissular expansion. Complete naevus excision had been performed in 63.3% of the cases. Complications occurred in 45% of the cases, however in 50% of them were minor. Iterative surgery increased the complication rate. Tissular expansion is a valuable option for giant congenital naevus. However, complication rate remained high, especially when iterative surgery is needed. Copyright © 2013 Elsevier Masson SAS. All rights reserved.

Posterior Mandibular Ridge Resorption Associated with Different Retentive Systems for Overdentures: A 7-Year Retrospective Preliminary Study.

PubMed

Elsyad, Moustafa Abdou; Mohamed, Shahinaz Sayed; Shawky, Ahmad Fathalla

This retrospective study compared posterior mandibular residual ridge resorption with two different retentive mechanisms for overdentures after 7 years. A convenience sample of 18 edentulous men was assigned to one of two equal groups. Two implants were placed in the mandibular canine areas for each patient using the conventional two-stage surgical protocol, and the implants were splinted with a round bar 3 months later. New mandibular overdentures were then connected to the bars with clips (clip-retained overdentures, CR group) or resilient liners (resilient liner-retained overdentures, RR group). Posterior mandibular ridge resorption (PMRR) was recorded using proportional measurements and posterior area index (PAI) on panoramic radiographs taken immediately after overdenture insertion (T 0 ) and 7 years later (T 7 ). A linear regression model was used to verify the relationship between PAI and the following considerations: attachment type, age, initial mandibular ridge height, period of mandibular edentulism, number of previously worn dentures, and relining events. After 7 years, the RR group demonstrated a significantly (P = .014) higher change in PAI (0.11 ± 0.02) than the CR group (0.06 ± 0.04). The average PMRR for each mm of posterior mandibular ridge was 0.79 mm (0.11 mm/year) in the CR group and 1.4 mm (0.2 mm/year) in the RR group. Attachment type, initial mandibular ridge height, and relining times were significantly correlated with change in the PAI (P = .004, P = .035, and P = .045, respectively). Within the limitations of this preliminary study's design, it was observed that following a 7-year period of use, resilient liner attachments for bar/implant-retained overdentures appear to be associated with greater posterior mandibular ridge resorption when compared to clip attachments.

Obliteration of a giant fusiform carotid terminus-M1 aneurysm after distal clip application and extracranial-intracranial bypass. Case report.

PubMed

Ferroli, P; Ciceri, E; Parati, E; Minati, L; Broggi, G

2007-06-01

Giant intracranial aneurysms may not be amenable to direct surgical clipping or endovascular coiling because of three critical factors: 1) lack of clear aneurysmal neck; 2) giant size; 3) involvement with critical perforating or branch vessels. Techniques of flow redirection, however, may offer an alternative treatment strategy for these difficult lesions. In this paper, we report on the use of this alternative strategy in the successful treatment of a left giant fusiform carotid terminus-M1 aneurysm in a 16 year-old boy suffering from Ehler-Danlos disease. This patient was admitted to our Institution because his aneurysm was continuing to be increasing in size, despite a previous ligation of his left cervical ICA which was performed at another institution 2 years earlier after the patient had experienced a hemorrhagic stroke. Upon admission, a neurological examination revealed a slight motor aphasia with mild right hemiparesis, remnant of the ancient stroke. Because of its size and the involvement with M1 perforating arteries, a direct aneurysm attack was deemed inadvisable. After an initial ECA-ICA high flow bypass which spontaneously thrombosed, we performed a repeated high flow bypass with the application of a single clip on M1, right distal to the fusiform dilatation. After an uneventful postoperative course, we were unable to observe any new neurological deficits after surgery. A CT scan on postoperative day 1 revealed that the aneurysm had undergone a spontaneous thrombosis which was completely obliterated at the time of a 6-month follow-up angiogram. At that time, the ECA-ICA bypass was found to be patent. In conclusion the alternative of flow alteration strategies can be successfully used in the treatment of aneurysms that cannot be safely trapped or occluded by traditional neurosurgical methods.

Laparoscopic sterilization with the spring clip: instrumentation development and current clinical experience.

PubMed

Hulka, J F; Omran, K; Lieberman, B A; Gordon, A G

1979-12-15

Since the original spring clip sterilization studies were reported, a number of clinically important modifications to the spring clip and applicator have been developed. The spring-loaded clip, manufactured by Richard Wolf Medical Instruments Corporation of Chicago, Illinois, and Rocket of London, Inc., London, England, and New York, New York can be applied with either a one- or two-incision applicator and the clips and applicators currently available incorporate improvements to the original prototypes in design, manufacture, and quality control. The two-incision applicator is associated with significantly fewer misapplications and the high pregnancy rates reported with the original clip and applicator have not occurred with the current designs. Comparative studies between the clip and band have revealed less operative bleeding and pain associated with the clip. The method is appropriate to all women requesting sterilization but especially to those in the younger age group who may subsequently request reversal because of divorce and remarriage.

An object oriented extension to CLIPS

NASA Technical Reports Server (NTRS)

Sobkowicz, Clifford

1990-01-01

A presentation of software sub-system developed to augment C Language Production Systems (CLIPS) with facilities for object oriented Knowledge representation. Functions are provided to define classes, instantiate objects, access attributes, and assert object related facts. This extension is implemented via the CLIPS user function interface and does not require modification of any CLIPS code. It does rely on internal CLIPS functions for memory management and symbol representation.

[Surgical treatment of pulmonary metastases from colon and rectal cancer].

PubMed

Togashi, Ken-ichi; Aoki, K; Hirahara, H; Sugawara, M; Oguma, F

2004-09-01

We retrospectively studied the surgical treatment for pulmonary metastases from colon and rectal cancer. A total of 24 patients (9 males and 15 females; mean age 61 years) underwent 29 thoracotomies for metastatic colon carcinoma, while 22 patients (16 males and 6 females; mean age 63 years) underwent 29 thoracotomies for metastatic rectal cancer. The median interval between the primary procedure and lung resection for metastases was 26 months in the patients with colon carcinoma and 32 months in the patients with rectal cancer. In the patients with colon carcinoma, 16 underwent wedge resection or segmentectomy (including 4 video-assisted procedures) and 13 (54%) underwent lobectomy or pneumonectomy. In the patients with rectal cancer, 15 underwent wedge or segmentectomy (including 1 video-assisted procedure), 13 (59%) underwent lobectomy or pneumonectomy, and 1 underwent exploratory thoracotomy. All procedures except exploratory thoracotomy were curative operations. There was no mortality. Overall 5-year survival was 56% (n=46). Five-year survival was 65% for patients with colon metastases (n=24) and 45% for patients with rectal metastases (n=22), and there was no significant difference. Recurrent sites were 4 lungs (36%), 4 livers (36%), 1 bone, 1 uterus, and 1 peritoneum in patients with colon carcimoma, and 10 lungs (43%), 5 brains (22%), 3 livers (13%), 1 bone, and 1 vagina in patients with rectal cancer. Pulmonary resection for metastases from colon carcinoma may have better prognosis than that from rectal cancer. However, further investigation may be required to obtain convincing conclusions.

New concept of 3D printed bone clip (polylactic acid/hydroxyapatite/silk composite) for internal fixation of bone fractures.

PubMed

Yeon, Yeung Kyu; Park, Hae Sang; Lee, Jung Min; Lee, Ji Seung; Lee, Young Jin; Sultan, Md Tipu; Seo, Ye Bin; Lee, Ok Joo; Kim, Soon Hee; Park, Chan Hum

Open reduction with internal fixation is commonly used for the treatment of bone fractures. However, postoperative infection associated with internal fixation devices (intramedullary nails, plates, and screws) remains a significant complication, and it is technically difficult to fix multiple fragmented bony fractures using internal fixation devices. In addition, drilling in the bone to install devices can lead to secondary fracture, bone necrosis associated with postoperative infection. In this study, we developed bone clip type internal fixation device using three- dimensional (3D) printing technology. Standard 3D model of the bone clip was generated based on computed tomography (CT) scan of the femur in the rat. Polylacticacid (PLA), hydroxyapatite (HA), and silk were used for bone clip material. The purpose of this study was to characterize 3D printed PLA, PLA/HA, and PLA/HA/Silk composite bone clip and evaluate the feasibility of these bone clips as an internal fixation device. Based on the results, PLA/HA/Silk composite bone clip showed similar mechanical property, and superior biocompatibility compared to other types of the bone clip. PLA/HA/Silk composite bone clip demonstrated excellent alignment of the bony segments across the femur fracture site with well-positioned bone clip in an animal study. Our 3D printed bone clips have several advantages: (1) relatively noninvasive (drilling in the bone is not necessary), (2) patient-specific design (3) mechanically stable device, and (4) it provides high biocompatibility. Therefore, we suggest that our 3D printed PLA/HA/Silk composite bone clip is a possible internal fixation device.

Using CLIPS as the cornerstone of a graduate expert systems course

NASA Technical Reports Server (NTRS)

Yue, Kwok-Bun

1991-01-01

The effective use of the C Language Integrated Production System (CLIPS) as a cornerstone in a graduate expert systems course is described. The course include 8 or 9 hours of in-depth lecturing in CLIPS, as well as a broad coverage of major topics and techniques in expert systems. As part of the requirements of the course, students solved two small yet non-trival problems in CLIPS before going on to develop a toy expert system in CLIPS in an incremental manner as the term project. Furthermore, students were required to evaluate CLIPS programs written by their classmates. An anonymous questionnaire at the end of the semester revealed that the students responded very favorably to the course, especially their experience with CLIPS.

Third CLIPS Conference Proceedings, volume 2

NASA Technical Reports Server (NTRS)

Riley, Gary (Editor)

1994-01-01

Expert systems are computer programs which emulate human expertise in well defined problem domains. The C Language Integrated Production System (CLIPS) is an expert system building tool, developed at the Johnson Space Center, which provides a complete environment for the development and delivery of rule and/or object based expert systems. CLIPS was specifically designed to provide a low cost option for developing and deploying expert system applications across a wide range of hardware platforms. The development of CLIPS has helped to improve the ability to deliver expert system technology throughout the public and private sectors for a wide range of applications and diverse computing environments. The Third Conference on CLIPS provided a forum for CLIPS users to present and discuss papers relating to CLIPS applications, uses, and extensions.

[Surgical treatment of perinatal ovarian cysts].

PubMed

Armas Alvarez, A L; Taboada Santomil, P; Pradillos Serna, J M; Rivera Chavez, L L; Méndez Gallart, R; Estévez Martínez, E; Rodríguez Barca, P; Bautista Casasnovas, A; Varela Cives, R

2010-10-01

Actually, the perinatal ovarian cysts are increasingly being diagnosed by prenatal and neonatal ultrasound. We reported our experience in the surgical management of perinatal ovarian cysts. Patients and methods. We have reviewed the clinical charts of 10 female newborns diagnosed of ovarian cysts who underwent surgical management in our hospital from 1989 to 2009. The ovarian cysts were diagnosed antenatally in 8 cases and period neonatal in 2 cases. The clinical presentation was asymptomatic abdominal mass in 7 cases. Ultrasound confirmed the ovarian mass in 8 patients. CT scan and MRI were necessary for confirm suspected diagnosis in two patients. Ultrasonography showed 7 complex cysts and 3 simple cysts. Surgery of the complicated cysts revealed ovarian torsion in 5 cases and 1 hemorragic cyst. At surgery, 5 patients underwent salpingooophorectomy, 2 patients needed oophorectomy and in 3 cases only cystectomy were necessary. The ovarian torsion is the most common complication and the cause of loss of the ovary. The neonatal ovarian cysts greater than 5 centimetres, symptomatic cysts, complex cysts and cysts persisting for more than 6 months need surgical intervention.

Experience of treatment of patients with granulomatous lobular mastitis.

PubMed

Hur, Sung Mo; Cho, Dong Hui; Lee, Se Kyung; Choi, Min-Young; Bae, Soo Youn; Koo, Min Young; Kim, Sangmin; Choe, Jun-Ho; Kim, Jung-Han; Kim, Jee Soo; Nam, Seok-Jin; Yang, Jung-Hyun; Lee, Jeong Eon

2013-07-01

To present the author's experience with various treatment methods of granulomatous lobular mastitis (GLM) and to determine effective treatment methods of GLM. Fifty patients who were diagnosed with GLM were classified into five groups based on the initial treatment methods they underwent, which included observation (n = 8), antibiotics (n = 3), steroid (n = 13), drainage (n = 14), and surgical excision (n = 12). The treatment processes in each group were examined and their clinical characteristics, treatment processes, and results were analyzed respectively. Success rates with each initial treatment were observation, 87.5%; antibiotics, 33.3%; steroids, 30.8%; drainage, 28.6%; and surgical excision, 91.7%. In most cases of observation, the lesions were small and the symptoms were mild. A total of 23 patients underwent surgical excision during treatment. Surgical excision showed particularly fast recovery, high success rate (90.3%) and low recurrence rate (8.7%). The clinical course of GLM is complex and the outcome of each treatment type are variable. Surgery may play an important role when a lesion is determined to be mass-forming or appears localized as an abscess pocket during breast examination or imaging study.

MIRO: A debugging tool for CLIPS incorporating historical Rete networks

NASA Technical Reports Server (NTRS)

Tuttle, Sharon M.; Eick, Christoph F.

1994-01-01

At the last CLIPS conference, we discussed our ideas for adding a temporal dimension to the Rete network used to implement CLIPS. The resulting historical Rete network could then be used to store 'historical' information about a run of a CLIPS program, to aid in debugging. MIRO, a debugging tool for CLIPS built on top of CLIPS, incorporates such a historical Rete network and uses it to support its prototype question-answering capability. By enabling CLIPS users to directly ask debugging-related questions about the history of a program run, we hope to reduce the amount of single-stepping and program tracing required to debug a CLIPS program. In this paper, we briefly describe MIRO's architecture and implementation, and the current question-types that MIRO supports. These question-types are further illustrated using an example, and the benefits of the debugging tool are discussed. We also present empirical results that measure the run-time and partial storage overhead of MIRO, and discuss how MIRO may also be used to study various efficiency aspects of CLIPS programs.

Clinical Features and Surgical Results of Right Atrial Myxoma.

PubMed

Li, Han; Guo, Hongwei; Xiong, Hui; Xu, Jianping; Wang, Wei; Hu, Shengshou

2016-01-01

We retrospectively analyzed 367 patients receiving surgical resection of cardiac myxomas in our center over six years, and analyzed the incidence and surgical results of 28 cases of right atrial myxomas. We also compared the age, gender, and attached sites between left atrial myxoma and right atrial myxoma. Between January 2007 and December 2012, 28 patients with right atrial myxomas underwent surgical resection. There were 16 males and 12 females. The mean age was 47.77 ± 13.20 years (range: 8.00-79.00 years). Associated cardiac lesions included moderate and severe tricuspid regurgitation in four, coronary atherosclerotic heart disease in five, and pulmonary embolism in one. Twenty-seven patients (96.43%) were followed from 26 to 94 months (mean 55.78 ± 21.10 months). There was no early death after operation. The incidence of right atrial myxomas among sporadic cardiac myxomas was 7.89%. One patient died of lung cancer 34 months after myxoma resection. Two patients underwent coronary artery stent implantation due to coronary atherosclerotic heart disease during the follow-up period. One patient underwent myxoma resection due to recurrence in the left atrium four years after the first operation. There was no significant difference in the age between left atrial myxoma and right atrial myxoma (p > 0.05). There was a significant difference in the gender between left atrial myxomas and right atrial myxomas (p < 0.05). The most common attached sites of left atrial myxomas and right atrial myxomas are the atrial septum. Surgical resection of the right atrial myxoma results in good clinical outcomes and a decreased incidence of recurrence. © 2015 Wiley Periodicals, Inc.

Surgical advantages of reduced-port laparoscopic gastrectomy in gastric cancer.

PubMed

Kunisaki, Chikara; Makino, Hirochika; Yamaguchi, Naotaka; Izumisawa, Yusuke; Miyamato, Hiroshi; Sato, Kei; Hayashi, Tsutomu; Sugano, Nobuhiro; Suzuki, Yoshihiro; Ota, Mitsuyoshi; Tsuburaya, Akira; Kimura, Jun; Takagawa, Ryo; Kosaka, Takashi; Ono, Hidetaka Andrew; Akiyama, Hirotoshi; Endo, Itaru

2016-12-01

Although a few studies have reported the use of reduced-port laparoscopic gastrectomy (RPG) in gastric cancer patients, the feasibility of routinely using this technique remains unclear. It is therefore important to evaluate the surgical advantages of this technique in this patient group. Between August 2010 and July 2015, 165 patients underwent RPGs at our hospital, performed by a single surgeon. Of these patients, 88 underwent reduced-port laparoscopic distal gastrectomy (RPLDG) and 77 underwent reduced-port laparoscopic total gastrectomy (RPLTG). In addition to short-term surgical outcomes after RPG, survival times and the surgical learning curve were also evaluated. Blood losses during lymph node dissection in the RPLDG and RPLTG groups were not significantly different (p = 0.160). Conversion to open surgery was necessary in only two patients. Postoperative morbidities were observed in 14.8 % of the RPLDG group and 14.3 % of the RPLTG group, but there were no deaths. Most patients expressed high cosmetic satisfaction in both groups. In the RPLDG group, operation time during reconstruction decreased over the first 50 cases and then plateaued, as the surgeon's experience of the technique increased. In contrast, in the RPLTG group, operation times dropped with surgical experience for both lymph node dissection, plateauing after 40 cases, and for reconstruction, plateauing after 30 cases. Only three patients died of gastric cancer in the follow-up period and three patients died of other diseases. Five-year overall survival and 5-year disease-specific survival were 95.6 and 98.0 %, respectively. We have shown that reduced-port gastrectomy (RPG) could be an acceptable and satisfactory procedure for treating gastric cancer for an experienced laparoscopic gastric surgeon who has sufficient previous experience of conventional laparoscopic gastrectomies.

Overall Hospital Cost Estimates in Children with Congenital Heart Disease: Analysis of the 2012 Kid's Inpatient Database.

PubMed

Faraoni, David; Nasr, Viviane G; DiNardo, James A

2016-01-01

This study sought to determine overall hospital cost in children with congenital heart disease (CHD) and to compare cost associated with cardiac surgical procedures, cardiac catheterizations, non-cardiac surgical procedures, and medical admissions. The 2012 Healthcare Cost and Utilization Project Kid's Inpatient Database was used to evaluate hospital cost in neonates and children with CHD undergoing cardiac surgery, cardiac catheterization, non-cardiac surgical procedures, and medical treatments. Multivariable logistic regression was applied to determine independent predictors for increased hospital cost. In 2012, total hospital cost was 28,900 M$, while hospital cost in children with CHD represented 23% of this total and accounted for only 4.4% of hospital discharges. The median cost was $51,302 ($32,088-$100,058) in children who underwent cardiac surgery, $21,920 ($13,068-$51,609) in children who underwent cardiac catheterization, $4134 ($1771-$10,253) in children who underwent non-cardiac surgery, and $23,062 ($5529-$71,887) in children admitted for medical treatments. Independent predictors for increased cost were hospital bed size <400 beds (P < 0.001), more than four procedures performed during the same hospitalization (P = 0.001), use of ECMO (P < 0.001), length of hospital stay exceeding 14 days (P < 0.001), cardiac failure (P < 0.001), sepsis (P < 0.001), acute kidney injury (P < 0.001), and neurologic (P < 0.001) and thromboembolic complications (P < 0.001). Hospital cost in children with CHD represented 23% of global cost while accounting for only 4.4% of discharges. This study identified factors associated with increased cost of cardiac surgical procedures, cardiac catheterizations, non-cardiac surgical procedures, and medical management in children with CHD.

A prospective study comparing endoscopic subcutaneous mastectomy plus immediate reconstruction with implants and breast conserving surgery for breast cancer.

PubMed

Fan, Lin-Jun; Jiang, Jun; Yang, Xin-Hua; Zhang, Yi; Li, Xing-Gang; Chen, Xian-Chun; Zhong, Ling

2009-12-20

Breast conserving surgery (BCS) has been the standard surgical procedure for the treatment of early breast cancer. Endoscopic subcutaneous mastectomy (ESM) plus immediate reconstruction with implants is an emerging procedure. The objective of this prospective study was to evaluate the clinical outcomes of these two surgical procedures in our clinical setting. From March 2004 to October 2007, 43 patients with breast cancer underwent ESM plus axillary lymph node dissection and immediate reconstruction with implants, while 54 patients underwent BCS. The clinical and pathological characteristics, surgical safety, and therapeutic effects were compared between the two groups. There were no significant differences in the age, clinical stage, histopathologic type of tumor, operative blood loss, postoperative drainage time, and postoperative complications between the two groups (P > 0.05). The postoperative complications were partial necrosis of the nipple and superficial skin flap in the ESM patients, and hydrops in the axilla and residual cavity in the BCS patients. There was no significant difference in the rate of satisfactory postoperative cosmetic outcomes between the ESM (88.4%, 38/43) and BCS (92.6%, 50/54) patients (P > 0.05). During follow-up of 6 months to 4 years, all patients treated with ESM were disease-free, but 3 patients who underwent BCS had metastasis or recurrence -one of these patients died of multiple organ metastasis. After considering the wide indications for use, high surgical safety, and favorable cosmetic outcomes, we conclude that ESM plus axillary lymph node dissection and immediate reconstruction with implants - the new surgery of choice for breast cancer - warrants serious consideration as the prospective next standard surgical procedure.

Improved Early Cleft Lip and Palate Complications at a Surgery Specialty Center in the Developing World.

PubMed

Park, Eugene; Deshpande, Gaurav; Schonmeyr, Bjorn; Restrepo, Carolina; Campbell, Alex

2018-01-01

To evaluate complication rates following cleft lip and cleft palate repairs during the transition from mission-based care to center-based care in a developing region. We performed a retrospective review of 3419 patients who underwent cleft lip repair and 1728 patients who underwent cleft palate repair in Guwahati, India between December 2010 and February 2014. Of those who underwent cleft lip repair, 654 were treated during a surgical mission and 2765 were treated at a permanent center. Of those who underwent cleft palate repair, 236 were treated during a surgical mission and 1491 were treated at a permanent center. Two large surgical missions to Guwahati, India, and the Guwahati Comprehensive Cleft Care Center (GCCCC) in Assam, India. Overall complication rates following cleft lip and cleft palate repair. Overall complication rates following cleft lip repair were 13.2% for the first mission, 6.7% for the second mission, and 4.0% at GCCCC. Overall complication rates following cleft palate repair were 28.0% for the first mission, 30.0% for the second mission, and 15.8% at GCCCC. Complication rates following cleft palate repair by the subset of surgeons permanently based at GCCCC (7.2%) were lower than visiting surgeons ( P < .05). Our findings support the notion that transitioning from a mission-based model to a permanent facility-based model of cleft care delivery in the developing world can lead to decreased complication rates.

Variety of audiologic manifestations in patients with superior semicircular canal dehiscence.

PubMed

Chi, Fang-Lu; Ren, Dong-Dong; Dai, Chun-Fu

2010-01-01

To present diverse symptoms, signs, and findings on diagnostic tests of 11 patients with superior semicircular canal dehiscence (SSCD) syndrome and surgical treatments for dehiscence of 3 patients. Retrospective case review. Tertiary neurotologic and audiologic center. Patients with SSCD documented by history, physical examination, vestibular function testing, and high-resolution computed tomographic scans. Two patients underwent surgical procedures through middle fossa approach, and 1 patient underwent transmastoid repair. The rest underwent conservative treatments. Eleven patients were identified as SSCD. The variety of clinical manifestations, including 1) hearing presentations: mix hearing loss (4 of 11), conductive hearing loss (3 of 11), profound sensorineural hearing loss (2 of 11), and normal hearing (2 of 11); 2) vestibular manifestations: chronic disequilibrium (8 of 11), Tullio phenomenon (7 of 11), Hennebert sign (8 of 11), tinnitus (3 of 11), and autophony (3 of 11); and 3) accompanying disorders: encephalomeningocele (1 of 11). Abnormal nystagmus was identified in 3 patients. Dehiscence of bone overlying superior semicircular canal was confirmed by high-resolution computed tomographic scan in all cases. Three patients underwent operative management. (2 through the middle fossa approach and 1 through a transmastoid repair). Superior semicircular canal dehiscence demonstrates diverse and complex clinical features. Tegmental or petrosal bone rarefaction or mild dehiscences can be a harbinger or an aggressive cause of developing SSCD. No correlation was observed between the size of dehiscence and the severity of vestibular symptoms or the degree of hearing loss. Surgical repair of dehiscence can relieve symptoms with low morbidity.

Sutureless versus Conventional Aortic Valve Replacement: Outcomes in 70 High-Risk Patients Undergoing Concomitant Cardiac Procedures.

PubMed

Hanedan, Muhammet Onur; Yuruk, Mehmet Ali; Parlar, Ali Ihsan; Ziyrek, Ugur; Arslan, Ali Kemal; Sayar, Ufuk; Mataraci, Ilker

2018-02-01

In elderly, high-risk surgical patients, sutureless aortic valve replacement (AVR) can often be an alternative to conventional AVR; shorter aortic cross-clamp and cardiopulmonary bypass times are the chief advantages. We compared the outcomes of sutureless AVR with those of conventional AVR in 70 elderly patients who underwent concomitant cardiac surgical procedures. We retrospectively analyzed the cases of 42 men and 28 women (mean age, 70.4 ± 10.3 yr; range, 34-93 yr) who underwent cardiac operations plus AVR with either a sutureless valve (group 1, n=38) or a conventional bioprosthetic or mechanical valve (group 2, n=32). Baseline patient characteristics were similar except for worse New York Heart Association functional status and the prevalence of diabetes mellitus in group 1. In group 1, the operative, cross-clamp, and cardiopulmonary bypass times were shorter (all P =0.001), postoperative drainage amounts were lower ( P =0.009), hospital stays were shorter ( P =0.004), and less red blood cell transfusion was needed ( P =0.037). Echocardiograms before patients' discharge from the hospital showed lower peak and mean aortic gradients in group 1 (mean transvalvular gradient, 8.4 ± 2.8 vs 12.2 ± 5.2 mmHg; P =0.012). We found that elderly, high-risk patients who underwent multiple cardiac surgical procedures and sutureless AVR had better hemodynamic outcomes and shorter ischemic times than did patients who underwent conventional AVR.

The operative management of children with complex perianal Crohn's disease.

PubMed

Seemann, Natashia M; King, Sebastian K; Elkadri, Abdul; Walters, Thomas; Fish, Joel; Langer, Jacob C

2016-12-01

Perianal Crohn's disease (PCD) can affect both quality of life and psychological wellbeing. A subset of pediatric patients with complex PCD require surgical intervention, although appropriate timing and treatment regimens remain unclear. This study aimed to describe a large pediatric cohort in a tertiary center to determine the range of surgical management in children with complex PCD. A retrospective review of children requiring operative intervention for PCD over 13 years (2002-2014) was performed. PCD was divided into simple and complex based on the type of surgical procedure, and the two groups were compared. The 57 children were divided into two groups: the simple group (N=43) underwent abscess drainage ± seton insertion alone, and the complex group (N=14) underwent loop ileostomy ± more extensive surgery. In the complex group, females were more predominant (57% of complex vs 30% of simple), and the average age at diagnosis was lower. Anti-TNF therapy was utilized in 79.1% of simple and 100% of complex PCD. All 14 complex patients underwent a defunctioning ileostomy, with 7 requiring further operations (subtotal colectomy=4, proctocolectomy ± anal sparing=5, plastic surgery reconstruction with perineal flap/graft=4). Complex PCD represents a small but challenging subset of patients in which major surgical intervention may be necessary to alleviate the symptoms of this debilitating condition. retrospective case study with no control group - level IV. Copyright © 2016 Elsevier Inc. All rights reserved.

Ovarian masses in pediatric patients: a multicenter study of 98 surgical cases in Tunisia.

PubMed

Abid, I; Zouari, M; Jallouli, M; Sahli, S; Bouden, A; Ben Abdallah, R; Trabelsi, F; Jabloun, A; Charieg, A; Mrad, C; Marzouki, M; Mosbahi, S; Ezzi, A; Mootamri, R; Hamzaoui, M; Kaabar, N; Jlidi, S; Nouri, A; Mhiri, R

2018-03-01

Ovarian masses requiring surgical intervention are uncommon in the pediatric population. Our aim is to report results of a multicentric Tunisian study concerning the clinical practice and the management of pediatric ovarian masses and to identify the factors that are associated with ovarian preservation. Between January 2000 and December 2015, 98 pediatric patients (<14 years) were surgically treated for ovarian masses at the five pediatric surgery departments in Tunisia. Ninety-eight patients were included in this study. The mean age of the patients at time of surgery was 8.46 ± 4.87 years. Sixty-three ovarian masses (64.3%) were non-neoplastic lesions, 24 (24.5%) were benign tumors, and 11 (11.2%) were malignant neoplasms. Conservative surgery (ovarian-preserving surgery) was successfully performed in 72.4% of the benign lesions, whereas only three patients (27.3%) with malignant tumors underwent ovary-sparing tumor resection (p < .001). The mean diameter of the tumors in the patients who underwent oophorectomy was significantly larger than that in the patients who underwent conservative surgery (7.8 ± 3.9 cm vs. 5.7 ± 2.9 cm, respectively, p = .001). In our study, the risk factors for oophorectomy were a malignant pathology and large tumor size. In accordance with the Gynecologic Cancer Intergroup consensus, we recommend that surgical management of ovarian masses in children should be based on ovarian-preserving surgery.

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.

Prospective comparison of long-term pain relief rates after first-time microvascular decompression and stereotactic radiosurgery for trigeminal neuralgia.

PubMed

Wang, Doris D; Raygor, Kunal P; Cage, Tene A; Ward, Mariann M; Westcott, Sarah; Barbaro, Nicholas M; Chang, Edward F

2018-01-01

OBJECTIVE Common surgical treatments for trigeminal neuralgia (TN) include microvascular decompression (MVD), stereotactic radiosurgery (SRS), and radiofrequency ablation (RFA). Although the efficacy of each procedure has been described, few studies have directly compared these treatment modalities on pain control for TN. Using a large prospective longitudinal database, the authors aimed to 1) directly compare long-term pain control rates for first-time surgical treatments for idiopathic TN, and 2) identify predictors of pain control. METHODS The authors reviewed a prospectively collected database for all patients who underwent treatment for TN between 1997 and 2014 at the University of California, San Francisco. Standardized collection of data on preoperative clinical characteristics, surgical procedure, and postoperative outcomes was performed. Data analyses were limited to those patients who received a first-time procedure for treatment of idiopathic TN with > 1 year of follow-up. RESULTS Of 764 surgical procedures performed at the University of California, San Francisco, for TN (364 SRS, 316 MVD, and 84 RFA), 340 patients underwent first-time treatment for idiopathic TN (164 MVD, 168 SRS, and 8 RFA) and had > 1 year of follow-up. The analysis was restricted to patients who underwent MVD or SRS. Patients who received MVD were younger than those who underwent SRS (median age 63 vs 72 years, respectively; p < 0.001). The mean follow-up was 59 ± 35 months for MVD and 59 ± 45 months for SRS. Approximately 38% of patients who underwent MVD or SRS had > 5 years of follow-up (60 of 164 and 64 of 168 patients, respectively). Immediate or short-term (< 3 months) postoperative pain-free rates (Barrow Neurological Institute Pain Intensity score of I) were 96% for MVD and 75% for SRS. Percentages of patients with Barrow Neurological Institute Pain Intensity score of I at 1, 5, and 10 years after MVD were 83%, 61%, and 44%, and the corresponding percentages after SRS were 71%, 47%, and 27%, respectively. The median time to pain recurrence was 94 months (25th-75th quartiles: 57-131 months) for MVD and 53 months (25th-75th quartiles: 37-69 months) for SRS (p = 0.006). A subset of patients who had MVD also underwent partial sensory rhizotomy, usually in the setting of insignificant vascular compression. Compared with MVD alone, those who underwent MVD plus partial sensory rhizotomy had shorter pain-free intervals (median 45 months vs no median reached; p = 0.022). Multivariable regression demonstrated that shorter preoperative symptom duration (HR 1.005, 95% CI 1.001-1.008; p = 0.006) was associated with favorable outcome for MVD and that post-SRS sensory changes (HR 0.392, 95% CI 0.213-0.723; p = 0.003) were associated with favorable outcome for SRS. CONCLUSIONS In this longitudinal study, patients who received MVD had longer pain-free intervals compared with those who underwent SRS. For patients who received SRS, postoperative sensory change was predictive of favorable outcome. However, surgical decision making depends upon many factors. This information can help physicians counsel patients with idiopathic TN on treatment selection.

The disappearing clip: an unusual complication in MRI biopsy

PubMed Central

Bourke, Anita Geraldine; Peter, Prasant; Jose, Chaitra Lesli

2014-01-01

MRI-guided biopsies are being increasingly used for otherwise occult breast lesions. Clip migration has been reported however, to the best of our knowledge, there have been no documented cases of entire disappearance of a marker clip. Absence of the postbiopsy marker clip was noted when our patient returned for preoperative hook-wire localisation even though accurate clip placement had been confirmed on the post-MRI biopsy mammogram. PMID:25139917

Using film clips to enhance nursing education.

PubMed

Herrman, Judith W

2006-01-01

Film clips in nursing education provide a unique way to promote active learning. Several methods for using film clips and combining them with other teaching strategies are discussed. Suggestions for the use of popular clips, logistical aspects of showing clips in class, and legal issues associated with copyright are addressed. Faculty are encouraged to use this strategy to evoke emotional responses, generate discussion, enhance clinical decision making, and provide vicarious learning.

The impact of the alexander technique on improving posture and surgical ergonomics during minimally invasive surgery: pilot study.

PubMed

Reddy, Pramod P; Reddy, Trisha P; Roig-Francoli, Jennifer; Cone, Lois; Sivan, Bezalel; DeFoor, W Robert; Gaitonde, Krishnanath; Noh, Paul H

2011-10-01

One of the main ergonomic challenges during surgical procedures is surgeon posture. There have been reports of a high number of work related injuries in laparoscopic surgeons. The Alexander technique is a process of psychophysical reeducation of the body to improve postural balance and coordination, permitting movement with minimal strain and maximum ease. We evaluated the efficacy of the Alexander technique in improving posture and surgical ergonomics during minimally invasive surgery. We performed a prospective cohort study in which subjects served as their own controls. Informed consent was obtained. Before Alexander technique instruction/intervention subjects underwent assessment of postural coordination and basic laparoscopic skills. All subjects were educated about the Alexander technique and underwent post-instruction/intervention assessment of posture and laparoscopic skills. Subjective and objective data obtained before and after instruction/intervention were tabulated and analyzed for statistical significance. All 7 subjects completed the study. Subjects showed improved ergonomics and improved ability to complete FLS™ as well as subjective improvement in overall posture. The Alexander technique training program resulted in a significant improvement in posture. Improved surgical ergonomics, endurance and posture decrease surgical fatigue and the incidence of repetitive stress injuries to laparoscopic surgeons. Further studies of the influence of the Alexander technique on surgical posture, minimally invasive surgery ergonomics and open surgical techniques are warranted to explore and validate the benefits for surgeons. Copyright © 2011 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

Current management of surgical oncologic emergencies.

PubMed

Bosscher, Marianne R F; van Leeuwen, Barbara L; Hoekstra, Harald J

2015-01-01

For some oncologic emergencies, surgical interventions are necessary for dissolution or temporary relieve. In the absence of guidelines, the most optimal method for decision making would be in a multidisciplinary cancer conference (MCC). In an acute setting, the opportunity for multidisciplinary discussion is often not available. In this study, the management and short term outcome of patients after surgical oncologic emergency consultation was analyzed. A prospective registration and follow up of adult patients with surgical oncologic emergencies between 01-11-2013 and 30-04-2014. The follow up period was 30 days. In total, 207 patients with surgical oncologic emergencies were included. Postoperative wound infections, malignant obstruction, and clinical deterioration due to progressive disease were the most frequent conditions for surgical oncologic emergency consultation. During the follow up period, 40% of patients underwent surgery. The median number of involved medical specialties was two. Only 30% of all patients were discussed in a MCC within 30 days after emergency consultation, and only 41% of the patients who underwent surgery were discussed in a MCC. For 79% of these patients, the surgical procedure was performed before the MCC. Mortality within 30 days was 13%. In most cases, surgery occurred without discussing the patient in a MCC, regardless of the fact that multiple medical specialties were involved in the treatment process. There is a need for prognostic aids and acute oncology pathways with structural multidisciplinary management. These will provide in faster institution of the most appropriate personalized cancer care, and prevent unnecessary investigations or invasive therapy.

Outcomes of surgical intervention for anomalous aortic origin of a coronary artery: A large contemporary prospective cohort study.

PubMed

Mery, Carlos M; De León, Luis E; Molossi, Silvana; Sexson-Tejtel, S Kristen; Agrawal, Hitesh; Krishnamurthy, Rajesh; Masand, Prakash; Qureshi, Athar M; McKenzie, E Dean; Fraser, Charles D

2018-01-01

The purpose of this study was to prospectively analyze the outcomes of patients with anomalous aortic origin of a coronary artery undergoing surgical intervention according to a standardized management algorithm. All patients aged 2 to 18 years undergoing surgical intervention for anomalous aortic origin of a coronary artery between December 2012 and April 2017 were prospectively included. Patients underwent stress nuclear perfusion imaging, stress cardiac magnetic resonance imaging, and retrospectively electrocardiogram-gated computed tomography angiography preoperatively. Patients were cleared for exercise at 3 months postoperatively if asymptomatic and repeat stress nuclear perfusion imaging, stress cardiac magnetic resonance imaging, and computed tomography angiography showed normal results. A total of 44 patients, with a median age of 14 years (8-18 years), underwent surgical intervention: 9 (20%) for the anomalous left coronary artery and 35 (80%) for the anomalous right coronary artery. Surgical procedures included unroofing in 35 patients (80%), translocation in 7 patients (16%), ostioplasty in 1 patient (2%), and side-side-anastomosis in 1 patient (2%). One patient who presented with aborted sudden cardiac death from an anomalous left coronary and underwent unroofing presented 1 year later with a recurrent episode and was found to have an unrecognized myocardial bridge and persistent compression of the coronary requiring reintervention. At last follow-up, 40 patients (91%) are asymptomatic and 4 patients have nonspecific chest pain; 42 patients (95%) have returned to full activity, and 2 patients are awaiting clearance. Surgical treatment for anomalous aortic origin of a coronary artery is safe and should aim to associate the coronary ostium with the correct sinus, away from the intercoronary pillar. After surgery, the majority of patients are cleared for exercise and remain asymptomatic. Longer follow-up is needed to assess the true efficacy of surgery in the prevention of sudden cardiac death. Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

A current profile and assessment of north american cholecystectomy: results from the american college of surgeons national surgical quality improvement program.

PubMed

Ingraham, Angela M; Cohen, Mark E; Ko, Clifford Y; Hall, Bruce Lee

2010-08-01

Cholecystectomy is among the most common surgical procedures performed in the United States. The current state of cholecystectomy outcomes, including variations in hospital performance, is unclear. The objective of this study is to compare the risk factors, indications, and 30-day outcomes, as well as variations in hospital performance associated with laparoscopic (LC) versus open cholecystectomy (OC) at 221 hospitals during a 4-year period. Using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database (2005-2008), patients were identified who underwent cholecystectomy and related procedures (cholangiogram and/or common bile duct exploration). Four outcomes were studied, ie, 30-day overall morbidity, serious morbidity, surgical site infections, and mortality. Forward stepwise logistic regressions yielded patient-level predicted probabilities, and hospital-level observed-to-expected ratios were determined. Of 65,511 patients, 58,659 (89.5%) underwent LC; 6,852 (10.5%) underwent OC. OC patients were considerably older with a higher comorbidity burden. LC patients were less likely to experience any morbidity (3.1% versus 17.8%; p < 0.0001), a serious morbidity (1.4% versus 11.1%; p < 0.0001), or a surgical site infection (1.3% versus 8.4%; p < 0.0001), and less likely to die (0.3% versus 2.8%; p < 0.0001). Observed-to-expected ratios for overall morbidity ranged from 0 to 3.55; for serious morbidity, 0 to 3.23; for surgical site infection, 0 to 7.02; for mortality, 0 to 13.05. Although overall incidence of adverse events is low after LC, substantial morbidity and mortality are associated with OC. Additionally, controlling for patient- and operation-related factors, considerable variations exist in hospital performance when evaluating 30-day outcomes after cholecystectomy. Copyright 2010 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Sex Differences in Emotional Evaluation of Film Clips: Interaction with Five High Arousal Emotional Categories.

PubMed

Maffei, Antonio; Vencato, Valentina; Angrilli, Alessandro

2015-01-01

The present study aimed to investigate gender differences in the emotional evaluation of 18 film clips divided into six categories: Erotic, Scenery, Neutral, Sadness, Compassion, and Fear. 41 female and 40 male students rated all clips for valence-pleasantness, arousal, level of elicited distress, anxiety, jittery feelings, excitation, and embarrassment. Analysis of positive films revealed higher levels of arousal, pleasantness, and excitation to the Scenery clips in both genders, but lower pleasantness and greater embarrassment in women compared to men to Erotic clips. Concerning unpleasant stimuli, unlike men, women reported more unpleasantness to the Compassion, Sadness, and Fear compared to the Neutral clips and rated them also as more arousing than did men. They further differentiated the films by perceiving greater arousal to Fear than to Compassion clips. Women rated the Sadness and Fear clips with greater Distress and Jittery feelings than men did. Correlation analysis between arousal and the other emotional scales revealed that, although men looked less aroused than women to all unpleasant clips, they also showed a larger variance in their emotional responses as indicated by the high number of correlations and their relatively greater extent, an outcome pointing to a masked larger sensitivity of part of male sample to emotional clips. We propose a new perspective in which gender difference in emotional responses can be better evidenced by means of film clips selected and clustered in more homogeneous categories, controlled for arousal levels, as well as evaluated through a number of emotion focused adjectives.

Perioperative hair removal: A review of best practice and a practice improvement opportunity.

PubMed

Spencer, Maureen; Barnden, Marsha; Johnson, Helen Boehm; Fauerbach, Loretta Litz; Graham, Denise; Edmiston, Charles E

2018-06-01

The current practice of perioperative hair removal reflects research-driven changes designed to minimize the risk of surgical wound infection. An aspect of the practice which has received less scrutiny is the clean-up of the clipped hair. This process is critical. The loose fibers represent a potential infection risk because of the micro-organisms they can carry, but their clean-up can pose a logistical problem because of the time required to remove them. Research has demonstrated that the most commonly employed means of clean-up, the use of adhesive tape or sticky mitts, can be both ineffective and time-consuming in addition to posing an infection risk from cross-contamination. Recently published research evaluating surgical clippers fitted with a vacuum-assisted hair collection device highlights the potential for significant practice improvement in the perioperative hair removal clean-up process. These improvements include not only further mitigation of potential infection risk but also substantial OR time and cost savings.

Evaluation and Impact of Workflow Interruptions During Robot-assisted Surgery.

PubMed

Allers, Jenna C; Hussein, Ahmed A; Ahmad, Nabeeha; Cavuoto, Lora; Wing, Joseph F; Hayes, Robin M; Hinata, Nobuyuki; Bisantz, Ann M; Guru, Khurshid A

2016-06-01

To analyze and categorize causes for interruptions during robot-assisted surgery. We analyzed 10 robot-assisted prostatectomies that were performed by 3 surgeons from October 2014 to June 2015. Interruptions to surgery were defined in terms of duration, stage of surgery, personnel involved, reasons, and impact of the interruption on the surgical workflow. The main reasons for interruptions included the following: console surgeons switching (29%); preparation of the surgical equipment, such as cleaning or changing the camera (29%) or an instrument (27%); or when a suture, stapler, or clip was needed (12%). The most common interruption duration was 10-29 seconds (47.6%), and the least common interruption duration was greater than 90 seconds (3.6%). Additionally, about 14% of the interruptions were considered avoidable, whereas the remaining 86% of interruptions were necessary for surgery. By identifying and analyzing interruptions, we can develop evidence-based strategies to improve operating room efficiency, lower costs, and advance patient safety. Copyright © 2016 Elsevier Inc. All rights reserved.

Multiple intracranial aneurysms and moyamoya disease associated with microcephalic osteodysplastic primordial dwarfism type II: surgical considerations.

PubMed

Waldron, James S; Hetts, Steven W; Armstrong-Wells, Jennifer; Dowd, Christopher F; Fullerton, Heather J; Gupta, Nalin; Lawton, Michael T

2009-11-01

Microcephalic osteodysplastic primordial dwarfism type II (MOPD II) is a rare genetic syndrome characterized by extremely small stature and microcephaly, and is associated in 25% of patients with intracranial aneurysms and moyamoya disease. Although aneurysmal subarachnoid hemorrhage and stroke are leading causes of morbidity and death in these patients, MOPD II is rarely examined in the neurosurgical literature. The authors report their experience with 3 patients who presented with MOPD II, which includes a patient with 8 aneurysms (the most aneurysms reported in the literature), and the first report of a patient with both moyamoya disease and multiple aneurysms. The poor natural history of these lesions indicates aggressive microsurgical and/or endovascular therapy. Microsurgery, whether for aneurysm clip placement or extracranial-intracranial bypass, is challenging due to tight surgical corridors and diminutive arteries in these patients, but is technically feasible and strongly indicated when multiple aneurysms must be treated or cerebral revascularization is needed.

Percutaneous Antegrade Varicocele Embolization Via the Testicular Vein in a Patient with Recurrent Varicocele After Surgical Repair

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

Guevara, Carlos J., E-mail: guevarac@mir.wustl.edu; El-Hilal, Alexander H., E-mail: elhilala@mir.wustl.edu; Darcy, Michael D., E-mail: darcym@mir.wustl.edu

This is a case report of an adolescent male who underwent surgical ligation for a left-sided varicocele that recurred 2 years later. Standard retrograde embolization via the left renal vein was not possible, because there was no connection from the renal vein to the gonadal vein following surgical ligation. The patient was treated via antegrade access of the spermatic vein at the inguinal level with subsequent coil embolization.

Safety and Efficacy of a New Bipolar Energy Device for Parenchymal Dissection in Laparoscopic Liver Resection.

PubMed

Dural, Cem; Akyuz, Muhammet; Yazici, Pinar; Aksoy, Erol; Aucejo, Federico; Quintini, Cristiano; Miller, Charles; Fung, John; Berber, Eren

2016-02-01

Despite emerging technologies, parenchymal transection still remains challenging in liver resection. The aim of this study is to assess the safety and efficacy of a new articulating vessel sealer for laparoscopic hepatectomy. Our hypothesis was that this new device would facilitate parenchymal transection and reduce intraoperative costs in laparoscopic hepatectomy. Within 18 months, a 5 cm bipolar articulating vessel sealer was used in 32 laparoscopic liver resections (LLR). By excluding 4 patients who underwent concomitant colorectal resections, the outcomes of the remaining 28 patients (group 1) were compared with 28 patients who underwent LLR by the same surgical group using other energy devices (group 2). Tumor type was malignant in 71% of patients (n=20) in group 1 and 89% of the patients (n=25) in group 2 (P=0.360). The number and size of tumors were similar in both groups, as well as the type of resections performed. In group 1, there was a less number of adjunctive devices (ie, energy, clip appliers, staplers) used (median 2) compared with group 2 (median 3, P=0.032). Parenchymal transection time (mean±SEM 28.2±3.5 vs. 55.2±4.1 min, respectively, P<0.001) and total operative time (200.1±13.7 vs. 242.7±14.4 min, respectively, P=0.036) were shorter for group 1 versus group 2. Estimated blood loss, transfusion rate, margin status, and length of stay were similar between the groups. There was no mortality. Morbidity was 11% (n=3) in group 1 and 18% (n=5) in group 2 (P=NS). The overall intraoperative costs were an average of $3000 less in group 1 (95% confidence interval, $1090-$4930, P=0.0029) compared with group 2. This study demonstrates the safety and efficacy of a new energy device for LLR. Our experience suggested that this new device provided the functionality of both a vessel sealer and a stapler with its large jaw and articulation.

Gastric cancer perforation: experience from a tertiary care hospital.

PubMed

Kandel, Bishnu Prasad; Singh, Yogendra; Singh, Keshav Prasad; Khakurel, Mahesh

2013-01-01

Gastric cancer perforation can occurs in advanced stage of the disease and is often associated with a high morbidity and mortality. Peritonitis due to perforation needs emergency laparotomy and different surgical procedures can be performed for definitive treatment. Surgical procedures largely depend on the stage of the disease and general condition of the patient. This study was carried out to evaluate the outcome and role of different surgical procedures in gastric cancer perforation. Medical record of patients with gastric perforation, who were treated during ten years period, was reviewed retrospectively. Data regarding clinical presentation, surgical procedures, staging and survival of patients were obtained. Features suggestive of diffuse peritonitis were evident in all cases. The majority of the patients underwent emergency surgery except one who died during resuscitation. The majority of patients were in stage III and stage IV. Surgical procedure includes simple closure and omental patch in five patients, simple closure and gastrojejunostomy in nine patients, gastrectomy in six patients and Devine's antral exclusion in one patient. Surgical site infection was the most common (45.5%) postoperative complication. Four patients died within one month of the surgery. Three patients who underwent gastrectomy survived for one year and one patient survived for five years. Although gastric cancer perforation usually occurs in advanced stage of the disease, curative resection should be considered as far as possible.

Surgical reconstruction for tuberculous airway stenosis: management for patients with concomitant tracheal malacia.

PubMed

Tsukioka, Takuma; Takahama, Makoto; Nakajima, Ryu; Kimura, Michitaka; Tei, Keiko; Yamamoto, Ryoji

2015-07-01

Surgical reconstruction is commonly recommended for the treatment of tuberculous airway stenosis. The clinical conditions underlying tuberculous airway stenosis often involve both cicatricial stenosis and malacia. Surgical reconstruction alone may not improve the respiratory symptoms of patients with both types of airway stenosis. This study retrospectively reviewed patients who underwent surgical reconstruction for tuberculous airway stenosis to investigate the most appropriate treatment for this complicated condition. Twelve patients with tuberculous airway stenosis underwent surgical reconstruction at our institute from January 2003 to December 2013. The clinical courses of these patients were retrospectively reviewed. The 12 patients were 2 men and 10 women with a mean age of 36 years (range 17-61 years). The site of stenosis was the left main bronchus in six patients, trachea in four patients, and right main bronchus in two patients. The procedure performed was sleeve lobectomy in five patients, bronchial resection in four patients, and tracheal resection in three patients. Additional airway stenting was performed in two patients with concomitant malacia of the lower trachea. The performance status and Hugh-Jones classification improved postoperatively in all patients. The forced expiratory volume in 1 s as a percent of forced vital capacity and percent of forced expiratory volume in 1 s improved significantly. Surgical reconstruction is an acceptable treatment for tuberculous airway stenosis. Additional airway stenting may be needed in patients with symptomatic malacia.

Surgical Management of Aneurysmal Hematomas: Prognostic Factors and Outcome.

PubMed

Meneghelli, P; Cozzi, F; Hasanbelliu, A; Locatelli, F; Pasqualin, Alberto

2016-01-01

From 1991 until 2013, 304 patients with intracranial hematomas from aneurysmal rupture were managed surgically in our department, constituting 17 % of all patients with aneurysmal rupture. Of them, 242 patents presented with isolated intracerebral hematomas (in 69 cases associated with significant intraventricular hemorrhage), 50 patients presented with combined intracerebral and subdural hematomas (in 11 cases associated with significant intraventricular hemorrhage), and 12 presented with an isolated subdural hematoma. The surgical procedure consisted of simultaneous clipping of the aneurysm and evacuation of the hematoma in all cases. After surgery, 16 patients (5 %) submitted to an additional decompressive hemicraniectomy, and 66 patients (21 %) submitted to a ventriculo-peritoneal shunt. Clinical outcomes were assessed at discharge and at 6 months, using the modified Rankin Scale (mRS); a favorable outcome (mRS 0-2) was observed in 10 % of the cases at discharge, increasing to 31 % at 6 months; 6-month mortality was 40 %. Applying uni- and multivariate analysis, the following risk factors were associated with a significantly worse outcome: age >60; preoperative Hunt-Hess grades IV-V; pupillary mydriasis (only on univariate); midline shift >10 mm; hematoma volume >30 cc; and the presence of hemocephalus (i.e., packed intraventricular hemorrhage). Based on these results, an aggressive surgical treatment should be adopted for most cases with aneurysmal hematomas, excluding patients with bilateral mydriasis persisting after rescue therapy.

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.

Can Image-Defined Risk Factors Predict Surgical Complications in Localized Neuroblastoma?

PubMed

Yoneda, Akihiro; Nishikawa, Masanori; Uehara, Shuichiro; Oue, Takaharu; Usui, Noriaki; Inoue, Masami; Fukuzawa, Masahiro; Okuyama, Hiroomi

2016-02-01

Image-defined risk factors (IDRFs) have been propounded for predicting the surgical risks associated with localized neuroblastoma (NB) since 2009. In 2011, a new guideline (NG) for assessing IDRFs was published. According to the NG, the situation in which "the tumor is only in contact with renal vessels," should be considered to be "IDRF-present." Previously, this situation was diagnosed as "IDRF absent." In this study, we evaluated the IDRFs in localized NB patients to clarify the predictive capability of IDRFs for surgical complications, as well as the usefulness of the NG. Materials and A total of 107 localized patients with NB were included in this study. The enhanced computed tomography and magnetic resonance images from the time of their diagnoses were evaluated by a single radiologist. We also analyzed the association of clinical factors, including the IDRFs (before and after applying the NG), with surgical complications. Of the 107 patients, 33 and 74 patients were diagnosed as IDRF-present (OP group), and IDRF-absent (ON group) before the NG, respectively. According to the NG, there were 76 and 31 patients who were classified as IDRF-present (NP group) and IDRF absent (NN group), respectively. Thus, 43 (40%) patients in the ON group were reassigned to the NP group after the NG. Surgical complications were observed in 17 of 82 patients who underwent surgical resection. Of the patients who underwent secondary operations, surgical complication rates were 55% in the OP group and 44% in the NP group. According to a univariate analysis, non-INSS 1, IDRFs before and after the NG and secondary operations were significantly associated with surgical complications. In a multivariate analysis, non-INSS 1 status and IDRFs after the NG were significantly associated with surgical complications. Georg Thieme Verlag KG Stuttgart · New York.

Automated revision of CLIPS rule-bases

NASA Technical Reports Server (NTRS)

Murphy, Patrick M.; Pazzani, Michael J.

1994-01-01

This paper describes CLIPS-R, a theory revision system for the revision of CLIPS rule-bases. CLIPS-R may be used for a variety of knowledge-base revision tasks, such as refining a prototype system, adapting an existing system to slightly different operating conditions, or improving an operational system that makes occasional errors. We present a description of how CLIPS-R revises rule-bases, and an evaluation of the system on three rule-bases.

Mayo Clinic experience with modified Vecchietti procedure for vaginal agenesis: it is easy, safe, and effective.

PubMed

Nahas, Samar; Yi, Johnny; Magrina, Javier

2013-01-01

To evaluate the surgical outcome and the anatomic and sexual function in 10 women with Rokitansky syndrome who underwent the laparoscopic Vecchietti procedure at our center. Retrospective analysis. Data were analyzed on the basis of short-term and long-term surgical outcome and sexual function. All patients underwent clinical follow-up at 1, 2, and 6 months after surgery. In all 10 patients, the procedure produced anatomic and functional success. The laparoscopic Vecchietti technique is safe, simple, and effective for treatment of vaginal agenesis. Results are comparable to those of all European studies, and the procedure should gain more popularity in North America. Copyright © 2013 AAGL. All rights reserved.

CLIPS: A proposal for improved usability

NASA Technical Reports Server (NTRS)

Patton, Charles R.

1990-01-01

This paper proposes the enhancement of the CLIPS user interface to improve the over-all usability of the CLIPS development environment. It suggests some directions for the long term growth of the user interface, and discusses some specific strengths and weaknesses of the current CLIPS PC user interface. Every user of CLIPS shares a common experience: his/her first interaction with the system itself. As with any new language, between the process of installing CLIPS on the appropriate computer and the completion of a large application, an intensive learning process takes place. For those with extensive programming knowledge and LISP backgrounds, this experience may have been mostly interesting and pleasant. Being familiar with products that are similar to CLIPS in many ways, these users enjoy a relatively short training period with the product. Already familiar with many of the functions they wish to employ, experienced users are free to focus on the capabilities of CLIPS that make it uniquely useful within their working environment.

Progress in carotid artery surgery at the base of the skull.

PubMed

Sandmann, W; Hennerici, M; Aulich, A; Kniemeyer, H; Kremer, K W

1984-11-01

From 1977 to 1984, 752 reconstructions of the supra-aortic arteries were performed at our service. In a group of 31 patients presenting with transient ischemic attacks (13) or minor strokes (15), preoperative multiplane angiograms identified lesions from various causes in extremely high locations (fibromuscular dysplasia, 10; atherosclerosis, 6; traumatic changes, 10; spontaneous dissection, 3; and mycotic aneurysms and others, 4) in 34 internal carotid arteries (aneurysms, 10; and stenosis, 24). Surgery was performed on 30 patients. Flow restoration was achieved by resection and vein graft replacement (20), gradual dilatation (5), thromboendarterectomy (6), and tangential clip for exclusion of a lateral aneurysm (1). Only one patient was treated with an extracranial-intracranial anastomosis because the stenosis extended into the carotid siphon. One patient was treated with heparin. Exposure of the internal carotid artery (ICA) at the base of the skull required dissection of the digastric muscle, careful mobilization of the cranial nerves, and detachment of the styloid process in 29 patients. Partial resection of the mastoid process was helpful in two patients. The carotid bone canal was opened from the lateral side in four cases to allow the most distal anastomosis 1 cm within the carotid canal. Back-bleeding was controlled by a balloon catheter. A shunt was impossible to use and clamping time averaged 62 +/- 40 minutes. Except for one recurrent stroke and two transient ischemic attacks no other neurologic deficits occurred. Cranial nerve damage could not be avoided in 21 cases (nervus recurrens, 7; nervus glossopharyngeus, 16; and nervus facialis, 4) but disappeared clinically within a 1- to 6-month period in all but two. Each surgical patient underwent control angiography, which demonstrated 30 arteries to be patent, two became occluded, and one had an insignificant stenosis. We conclude that standard surgical techniques are unsuitable for repair of highly located lesions of the ICA. Although extracranial-intracranial anastomosis has been proposed in patients with planned ligation of the ICA, the anatomic reconstruction remains advantageous because flow is restored to normal and the source of emboli is eliminated. With the use of a special approach, graft replacement can be performed up to the base of the skull.

Seismic signals hard clipping overcoming

NASA Astrophysics Data System (ADS)

Olszowa, Paula; Sokolowski, Jakub

2018-01-01

In signal processing the clipping is understand as the phenomenon of limiting the signal beyond certain threshold. It is often related to overloading of a sensor. Two particular types of clipping are being recognized: soft and hard. Beyond the limiting value soft clipping reduces the signal real gain while the hard clipping stiffly sets the signal values at the limit. In both cases certain amount of signal information is lost. Obviously if one possess the model which describes the considered signal and the threshold value (which might be slightly more difficult to obtain in the soft clipping case), the attempt of restoring the signal can be made. Commonly it is assumed that the seismic signals take form of an impulse response of some specific system. This may lead to belief that the sine wave may be the most appropriate to fit in the clipping period. However, this should be tested. In this paper the possibility of overcoming the hard clipping in seismic signals originating from a geoseismic station belonging to an underground mine is considered. A set of raw signals will be hard-clipped manually and then couple different functions will be fitted and compared in terms of least squares. The results will be then analysed.

CLIPS: The C language integrated production system

NASA Technical Reports Server (NTRS)

Riley, Gary

1994-01-01

Expert systems are computer programs which emulate human expertise in well defined problem domains. The potential payoff from expert systems is high: valuable expertise can be captured and preserved, repetitive and/or mundane tasks requiring human expertise can be automated, and uniformity can be applied in decision making processes. The C Language Integrated Production System (CLIPS) is an expert system building tool, developed at the Johnson Space Center, which provides a complete environment for the development and delivery of rule and/or object based expert systems. CLIPS was specifically designed to provide a low cost option for developing and deploying expert system applications across a wide range of hardware platforms. The commercial potential of CLIPS is vast. Currently, CLIPS is being used by over 5,000 individuals throughout the public and private sector. Because the CLIPS source code is readily available, numerous groups have used CLIPS as the basis for their own expert system tools. To date, three commercially available tools have been derived from CLIPS. In general, the development of CLIPS has helped to improve the ability to deliver expert system technology throughout the public and private sectors for a wide range of applications and diverse computing environments.

Pars plana Ahmed valve and vitrectomy in patients with glaucoma associated with posterior segment disease.

PubMed

Wallsh, Josh O; Gallemore, Ron P; Taban, Mehran; Hu, Charles; Sharareh, Behnam

2013-01-01

To assess the safety and efficacy of a modified technique for pars plana placement of the Ahmed valve in combination with pars plana vitrectomy in the treatment of glaucoma associated with posterior segment disease. Thirty-nine eyes with glaucoma associated with posterior segment disease underwent pars plana vitrectomy combined with Ahmed valve placement. All valves were placed in the pars plana using a modified technique, without the pars plana clip, and using a scleral patch graft. The 24 eyes diagnosed with neovascular glaucoma had an improvement in intraocular pressure from 37.6 mmHg to 13.8 mmHg and best-corrected visual acuity from 2.13 logarithm of minimum angle of resolution to 1.40 logarithm of minimum angle of resolution. Fifteen eyes diagnosed with steroid-induced glaucoma had an improvement in intraocular pressure from 27.9 mmHg to 14.1 mmHg and best-corrected visual acuity from 1.38 logarithm of minimum angle of resolution to 1.13 logarithm of minimum angle of resolution. Complications included four cases of cystic bleb formation and one case of choroidal detachment and explantation for hypotony. Ahmed valve placement through the pars plana during vitrectomy is an effective option for managing complex cases of glaucoma without the use of the pars plana clip.