Importance of mitral valve repair associated with left ventricular reconstruction for patients with ischemic cardiomyopathy: a real-time three-dimensional echocardiographic study

NASA Technical Reports Server (NTRS)

Qin, Jian Xin; Shiota, Takahiro; McCarthy, Patrick M.; Asher, Craig R.; Hail, Melanie; Agler, Deborah A.; Popovic, Zoran B.; Greenberg, Neil L.; Smedira, Nicholas G.; Starling, Randall C.;

Early improvement in left atrial remodeling and function after mitral valve repair or replacement in organic symptomatic mitral regurgitation assessed by three-dimensional echocardiography.

PubMed

Le Bihan, David C S; Della Togna, Dorival Julio; Barretto, Rodrigo B M; Assef, Jorge Eduardo; Machado, Lúcia Romero; Ramos, Auristela Isabel de Oliveira; Abdulmassih Neto, Camilo; Moisés, Valdir Ambrosio; Sousa, Amanda G M R; Campos, Orlando

2015-07-01

Left atrial (LA) dilation is associated with worse prognosis in various clinical situations including chronic mitral regurgitation (MR). Real time three-dimensional echocardiography (3DE) has allowed a better assessment of LA volumes and function. Little is known about LA size and function in early postoperative period in symptomatic patients with chronic organic MR. We aimed to investigate these aspects. By means of 3DE, 43 patients with symptomatic chronic organic MR were prospectively studied before and 30 days after surgery (repair or bioprosthetic valve replacement). Twenty subjects were studied as controls. Maximum (Vol-max), minimum, and preatrial contraction LA volumes were measured and total, passive, and active LA emptying fractions were calculated. Before surgery patients had higher LA volumes (P < 0.001) but smaller LA emptying fractions than controls (P < 0.01). After surgery there was a reduction in all 3 LA volumes and an increase in active atrial emptying fraction (AAEF). Multivariate analysis showed that independent predictors of early postoperative Vol-max reduction were preoperative diastolic blood pressure (coefficient = -0.004; P = 0.02), lateral mitral annular early diastolic velocity (e') (coefficient = 0.023; P = 0.008), and the mean transmitral diastolic gradient increment (coefficient = -0.035; P < 0.001). Furthermore, e' was also independently associated with AAEF increase (odds ratio = 1.66, P = 0.027). Early LA reverse remodeling and functional improvement occur after successful surgery of symptomatic organic MR regardless of surgical technique. Diastolic blood pressure and transmitral mean gradient augmentation are variables negatively related to Vol-max reduction. Besides, e' is positively correlated with both Vol-max reduction and AAEF increase. © 2014, Wiley Periodicals, Inc.

Inspiratory and expiratory computed tomographic volumetry for lung volume reduction surgery.

PubMed

Morimura, Yuki; Chen, Fengshi; Sonobe, Makoto; Date, Hiroshi

2013-06-01

Three-dimensional (3D) computed tomographic (CT) volumetry has been introduced into the field of thoracic surgery, and a combination of inspiratory and expiratory 3D-CT volumetry provides useful data on regional pulmonary function as well as the volume of individual lung lobes. We report herein a case of a 62-year-old man with severe emphysema who had undergone lung volume reduction surgery (LVRS) to assess this technique as a tool for the evaluation of regional lung function and volume before and after LVRS. His postoperative pulmonary function was maintained in good condition despite a gradual slight decrease 2 years after LVRS. This trend was also confirmed by a combination of inspiratory and expiratory 3D-CT volumetry. We confirm that a combination of inspiratory and expiratory 3D-CT volumetry might be effective for the preoperative assessment of LVRS in order to determine the amount of lung tissue to be resected as well as for postoperative evaluation. This novel technique could, therefore, be used more widely to assess local lung function.

Inspiratory and expiratory computed tomographic volumetry for lung volume reduction surgery

PubMed Central

Morimura, Yuki; Chen, Fengshi; Sonobe, Makoto; Date, Hiroshi

2013-01-01

Three-dimensional (3D) computed tomographic (CT) volumetry has been introduced into the field of thoracic surgery, and a combination of inspiratory and expiratory 3D-CT volumetry provides useful data on regional pulmonary function as well as the volume of individual lung lobes. We report herein a case of a 62-year-old man with severe emphysema who had undergone lung volume reduction surgery (LVRS) to assess this technique as a tool for the evaluation of regional lung function and volume before and after LVRS. His postoperative pulmonary function was maintained in good condition despite a gradual slight decrease 2 years after LVRS. This trend was also confirmed by a combination of inspiratory and expiratory 3D-CT volumetry. We confirm that a combination of inspiratory and expiratory 3D-CT volumetry might be effective for the preoperative assessment of LVRS in order to determine the amount of lung tissue to be resected as well as for postoperative evaluation. This novel technique could, therefore, be used more widely to assess local lung function. PMID:23460599

77 FR 67368 - Medicare and Medicaid Programs; Quarterly Listing of Program Issuances-July through September 2012

Federal Register 2010, 2011, 2012, 2013, 2014

2012-11-09

...) Facilities. XIII Medicare-Approved Lung JoAnna Baldwin, MS. (410) 786-7205 Volume Reduction Surgery Facilities. XIV Medicare-Approved Bariatric Kate Tillman, RN, (410) 786-9252 Surgery Facilities. MAS. XV...

[Lung volume reduction surgery for severe pulmonary emphysema in Iceland].

PubMed

Gunnarsson, Sverrir I; Johannsson, Kristinn B; Guðjónsdóttir, Marta; Jónsson, Steinn; Beck, Hans J; Magnusson, Bjorn; Gudbjartsson, Tomas

2011-12-01

Lung volume reduction surgery (LVRS) can benefit patients with severe emphysema. The aim of this study was to evaluate the outcome of LVRS performed in Iceland. A prospective study of 16 consecutive patients who underwent bilateral LVRS through median sternotomy between January 1996 and December 2008. All patients had disabling dyspnea, lung hyperinflation, and emphysema with upper lobe predominance. Preoperatively all patients underwent pulmonary rehabilitation. Spirometry, lung volumes, arterial blood gases and exercise capacity were measured before and after surgery. Mean follow-up time was 8.7 years. Mean age was 59.2 ± 5.9 years. All patients had a history of heavy smoking. There was no perioperative mortality and survival was 100%, 93%, and 63% at 1, 5, and 10 years, respectively. The forced expiratory volume in 1 second (FEV1) and the forced vital capacity (FVC) improved significantly after surgery by 35% (p<0.001) and 14% (p<0.05), respectively. The total lung capacity, residual volume and partial pressure of CO2 also showed statistically significant improvements but exercise capacity, O2 consumption and diffusing capacity of the lung for CO did not change. Prolonged air leak (≥ 7 days) was the most common complication (n=7). Five patients required reoperation, most commonly for sternal dehiscence (n=4). In this small prospective study, FEV1 and FVC increased and lung volumes and PaCO2 improved after LVRS. Long term survival was satisfactory although complications such as reoperations for sternal dehiscence were common and hospital stay therefore often prolonged.

Resident operative experience in general surgery, plastic surgery, and urology 5 years after implementation of the ACGME duty hour policy.

PubMed

Simien, Christopher; Holt, Kathleen D; Richter, Thomas H; Whalen, Thomas V; Coburn, Michael; Havlik, Robert J; Miller, Rebecca S

2010-08-01

Resident duty hour restrictions were implemented in 2002-2003. This study examines changes in resident surgical experience since these restrictions were put into place. Operative log data for 3 specialties were examined: general surgery, urology, and plastic surgery. The academic year immediately preceding the duty hour restrictions, 2002-2003, was used as a baseline for comparison to subsequent academic years. Operative log data for graduating residents through 2007-2008 were the primary focus of the analysis. Examination of associated variables that may moderate the relationship between fewer duty hours and surgical volume was also included. Plastic surgery showed no changes in operative volume following duty hour restrictions. Operative volume increased in urology programs. General surgery showed a decrease in volume in some operative categories but an increase in others. Specifically the procedures in vascular, plastic, and thoracic areas showed a consistent decrease. There was no increase in the percentage of programs' graduates falling below minimum requirements. Procedures in pancreas, endocrine, and laparoscopic areas demonstrated an increase in volume. Graduates in larger surgical programs performed fewer procedures than graduates in smaller programs; this was not the case for urology or plastic surgery programs. The reduction of duty hours has not resulted in an across the board decrease in operative volume. Factors other than duty hour reforms may be responsible for some of the observed findings.

Reduction of the Areolar Diameter After Ultrasound-Assisted Liposuction for Gynecomastia.

PubMed

Keskin, Mustafa; Sutcu, Mustafa; Hanci, Mustafa; Cigsar, Bulent

2017-08-01

One of the clinical aspects characterizing gynecomastia is the enlargement of the nipple-areolar complex (NAC) due to hypertrophic breast glands, and the excessive fatty tissue underneath. The purpose of this study was to quantify the reduction of the areolar diameter after ultrasound-assisted liposuction (UAL) of the male breast. The horizontal diameters of the NACs of 30 men who underwent UAL were measured before surgery, 1 month after surgery and 6 months after surgery in a standard fashion. Those patients with surgical gland removals of any kind were not included in this study. The mean age of the patients was 27.9 years, and all of the patients had bilateral grade I, II, or III gynecomastia. The mean diameter of the NACs before surgery was 35.36 mm (range, 26-55 mm), and after surgery, the mean diameter of the NACs was initially reduced to 28.8 mm (range, 23-44 mm) and later to 28.57 mm (range, 23-42 mm). The mean volume of breast tissue aspirated was 382 mL per breast, and the percentage of reduction was 17.3%. The reduction of areola diameter was statistically significant after first month. A significant positive correlation was identified between the liposuction volume and areolar diameter reduction. In cases of gynecomastia, the removal of the glandular and fatty tissue underneath the areola releases the expanding forces and pressure that enlarge it. In many cases of gynecomastia, UAL alone is effective in reducing the size of the NAC and allows the surgeon to avoid placing scars on the breast.

Brain volumes predict neurodevelopment in adolescents after surgery for congenital heart disease.

PubMed

von Rhein, Michael; Buchmann, Andreas; Hagmann, Cornelia; Huber, Reto; Klaver, Peter; Knirsch, Walter; Latal, Beatrice

2014-01-01

Patients with complex congenital heart disease are at risk for neurodevelopmental impairments. Evidence suggests that brain maturation can be delayed and pre- and postoperative brain injury may occur, and there is limited information on the long-term effect of congenital heart disease on brain development and function in adolescent patients. At a mean age of 13.8 years, 39 adolescent survivors of childhood cardiopulmonary bypass surgery with no structural brain lesions evident through conventional cerebral magnetic resonance imaging and 32 healthy control subjects underwent extensive neurodevelopmental assessment and cerebral magnetic resonance imaging. Cerebral scans were analysed quantitatively using surface-based and voxel-based morphometry. Compared with control subjects, patients had lower total brain (P = 0.003), white matter (P = 0.004) and cortical grey matter (P = 0.005) volumes, whereas cerebrospinal fluid volumes were not different. Regional brain volume reduction ranged from 5.3% (cortical grey matter) to 11% (corpus callosum). Adolescents with cyanotic heart disease showed more brain volume loss than those with acyanotic heart disease, particularly in the white matter, thalami, hippocampi and corpus callosum (all P-values < 0.05). Brain volume reduction correlated significantly with cognitive, motor and executive functions (grey matter: P < 0.05, white matter: P < 0.01). Our findings suggest that there are long-lasting cerebral changes in adolescent survivors of cardiopulmonary bypass surgery for congenital heart disease and that these changes are associated with functional outcome.

Predicting Structure-Function Relations and Survival following Surgical and Bronchoscopic Lung Volume Reduction Treatment of Emphysema.

PubMed

Mondoñedo, Jarred R; Suki, Béla

2017-02-01

Lung volume reduction surgery (LVRS) and bronchoscopic lung volume reduction (bLVR) are palliative treatments aimed at reducing hyperinflation in advanced emphysema. Previous work has evaluated functional improvements and survival advantage for these techniques, although their effects on the micromechanical environment in the lung have yet to be determined. Here, we introduce a computational model to simulate a force-based destruction of elastic networks representing emphysema progression, which we use to track the response to lung volume reduction via LVRS and bLVR. We find that (1) LVRS efficacy can be predicted based on pre-surgical network structure; (2) macroscopic functional improvements following bLVR are related to microscopic changes in mechanical force heterogeneity; and (3) both techniques improve aspects of survival and quality of life influenced by lung compliance, albeit while accelerating disease progression. Our model predictions yield unique insights into the microscopic origins underlying emphysema progression before and after lung volume reduction.

Predicting Structure-Function Relations and Survival following Surgical and Bronchoscopic Lung Volume Reduction Treatment of Emphysema

PubMed Central

Mondoñedo, Jarred R.

2017-01-01

Lung volume reduction surgery (LVRS) and bronchoscopic lung volume reduction (bLVR) are palliative treatments aimed at reducing hyperinflation in advanced emphysema. Previous work has evaluated functional improvements and survival advantage for these techniques, although their effects on the micromechanical environment in the lung have yet to be determined. Here, we introduce a computational model to simulate a force-based destruction of elastic networks representing emphysema progression, which we use to track the response to lung volume reduction via LVRS and bLVR. We find that (1) LVRS efficacy can be predicted based on pre-surgical network structure; (2) macroscopic functional improvements following bLVR are related to microscopic changes in mechanical force heterogeneity; and (3) both techniques improve aspects of survival and quality of life influenced by lung compliance, albeit while accelerating disease progression. Our model predictions yield unique insights into the microscopic origins underlying emphysema progression before and after lung volume reduction. PMID:28182686

Tumor Shrinkage Assessed by Volumetric MRI in Long-Term Follow-Up After Fractionated Stereotactic Radiotherapy of Nonfunctioning Pituitary Adenoma

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

Kopp, Christine, E-mail: Christine.Kopp@lrz.tu-muenchen.de; Theodorou, Marilena; Poullos, Nektarios

2012-03-01

Purpose: To evaluate tumor control and side effects associated with fractionated stereotactic radiotherapy (FSRT) in the management of residual or recurrent nonfunctioning pituitary adenomas (NFPAs). Methods and Materials: We assessed exact tumor volume shrinkage in 16 patients with NFPA after FSRT. All patients had previously undergone surgery. Gross tumor volume (GTV) was outlined on contrast-enhanced magnetic resonance imaging (MRI) before and median 63 months (range, 28-100 months) after FSRT. MRI was performed as an axial three-dimensional gradient echo T1-weighted sequence at 1.6-mm slice thickness without gap (3D MRI). Results: Mean tumor size of all 16 pituitary adenomas before treatment wasmore » 7.4 mL (3.3-18.9 mL). We found shrinkage of the treated pituitary adenoma in all patients. Within a median follow-up of 63 months (28-100 months) an absolute mean volume reduction of 3.8 mL (0.9-12.4 mL) was seen. The mean relative size reduction compared with the volume before radiotherapy was 51% (22%-95%). Shrinkage measured by 3D MRI was greater at longer time intervals after radiotherapy. A strong negative correlation between the initial tumor volume and the absolute volume reduction after FSRT was found. There was no correlation between tumor size reduction and patient age, sex, or number of previous surgeries. Conclusions: By using 3D MRI in all patients undergoing FSRT of an NFPA, tumor shrinkage is detected. Our data demonstrate that volumetric assessment based on 3D MRI adds additional information to routinely used radiological response measurements. After FSRT a mean relative size reduction of 51% can be expected within 5 years.« less

Physiologic Basis for Improved Pulmonary Function after Lung Volume Reduction

PubMed Central

Fessler, Henry E.; Scharf, Steven M.; Ingenito, Edward P.; McKenna, Robert J.; Sharafkhaneh, Amir

2008-01-01

It is not readily apparent how pulmonary function could be improved by resecting portions of the lung in patients with emphysema. In emphysema, elevation in residual volume relative to total lung capacity reduces forced expiratory volumes, increases inspiratory effort, and impairs inspiratory muscle mechanics. Lung volume reduction surgery (LVRS) better matches the size of the lungs to the size of the thorax containing them. This restores forced expiratory volumes and the mechanical advantage of the inspiratory muscles. In patients with heterogeneous emphysema, LVRS may also allow space occupied by cysts to be reclaimed by more normal lung. Newer, bronchoscopic methods for lung volume reduction seek to achieve similar ends by causing localized atelectasis, but may be hindered by the low collateral resistance of emphysematous lung. Understanding of the mechanisms of improved function after LVRS can help select patients more likely to benefit from this approach. PMID:18453348

Evaluation of late redislocation in patients who underwent open reduction and pelvic osteotomy as treament for developmental dysplasia of the hip.

PubMed

Tuhanioğlu, Ümit; Cicek, Hakan; Ogur, Hasan U; Seyfettinoglu, Firat; Kapukaya, Ahmet

2017-10-16

The goal in the treatment of developmental dysplasia of the hip (DDH) is to achieve a stable and concentric reduction and to create a congruent relationship between the femoral head and the acetabulum. This study discusses the causes of loss of reduction in DDH patients who had a concentrically reduced hip at the time of removal of the hip spica cast and cessation of brace use and who later appeared with hip redislocation after mobilisation and ambulation. In addition, the possible interventions in such cases are also discussed. A retrospective evaluation was made of 13 patients diagnosed with DDH who developed redislocation following primary surgery. 6 of them had undergone the 1st surgery in our department between 2008 and 2016 and 7 had udergone surgery in another centre. For comparison reasons a 2nd group was formed of 13 demographically and clinically matched patients who had no loss of reduction. The groups were compared in terms of acetabular index, pelvic length, pelvic width, abduction degree of plaster, ossifying nucleus diameter, acetabular depth, and acetabular volume parameters. The average age of the patients was 23 months at initial surgery and 29 months at the time of revision surgery. No significant difference was found between the groups in terms of acetabular inclination angle, ossifying nucleus diameter, pelvic size, pelvic width, centre edge angle, acetabular volume, and depth. Contracted inferomedial capsule was found in 1 patient who underwent revision surgery and intact transverse acetabular ligament was seen in 1 patient. The loss of reduction in the remaining 11 patients was associated with high total anteversion of the femoral head and acetabulum. Correction of increased combined anteversion by femoral osteotomy can create a safe zone in terms of redislocation and can significantly contribute to the stability provided by capsulorrhaphy and pelvic osteotomy.

Impact of left atrial volume reduction concomitant with atrial fibrillation surgery on left atrial geometry and mechanical function.

PubMed

Marui, Akira; Saji, Yoshiaki; Nishina, Takeshi; Tadamura, Eiji; Kanao, Shotaro; Shimamoto, Takeshi; Sasahashi, Nozomu; Ikeda, Tadashi; Komeda, Masashi

2008-06-01

Left atrial geometry and mechanical functions exert a profound effect on left ventricular filling and overall cardiovascular performance. We sought to investigate the perioperative factors that influence left atrial geometry and mechanical functions after the Maze procedure in patients with refractory atrial fibrillation and left atrial enlargement. Seventy-four patients with atrial fibrillation and left atrial enlargement (diameter > or = 60 mm) underwent the Maze procedure in association with mitral valve surgery. The maximum left atrial volume and left atrial mechanical functions (booster pump, reservoir, and conduit function [%]) were calculated from the left atrial volume-cardiac cycle curves obtained by magnetic resonance imaging. A stepwise multiple regression analysis was performed to determine the independent variables that influenced the postoperative left atrial geometry and function. The multivariate analysis showed that left atrial reduction surgery concomitant with the Maze procedure and the postoperative maintenance of sinus rhythm were predominant independent variables for postoperative left atrial geometry and mechanical functions. Among the 58 patients who recovered sinus rhythm, the postoperative left atrial geometry and function were compared between patients with (VR group) and without (control group) left atrial volume reduction. At a mean follow-up period of 13.8 months, sinus rhythm recovery rate was better (85% vs 68%, P < .05) in the VR group and maximum left atrial volume was less (116 +/- 25 mL vs 287 +/- 73 mL, P < .001) than in the control group. The maximum left atrial volume reduced with time only in the VR group (reverse remodeling). Postoperative booster pump and reservoir function in the VR group were better than in the control group (25% +/- 6% vs 11% +/- 4% and 34% +/- 7% vs 16% +/- 4%, respectively, P < .001), whereas the conduit function in the VR group was lower than in the control group, indicating that the improvement of the booster pump and reservoir function compensated for the conduit function to left ventricular filling. Left atrial reduction concomitant with the Maze procedure helped restore both contraction (booster pump) and compliance (reservoir) of the left atrium and facilitated left atrial reverse remolding. Left atrial volume reduction and postoperative maintenance of sinus rhythm may be desirable in patients with refractory AF and left atrial enlargement.

[Lung volume reduction surgery in advanced emphysema--results of the Washington University, St. Louis].

PubMed

Cooper, J D; Gaissert, H A; Patterson, G A; Pohl, M S; Yusen, R D; Trulock, E P

1996-01-01

The aim of lung volume reduction surgery is to alleviate the symptoms of severe emphysema and to improve the life quality of the patient. The appropriate candidates (approximately 20% of all emphysematic patients examined in our clinic) had considerable dyspnea, an increased lung capacity, and a heterogenous dissemination of the emphysema with regional destruction of the parenchyma, hyperinflation and poor perfusion. After preoperative physiotherapie with a specified rehabilitation aim, a resection of 20 to 30% of the total lung volume was performed via sternotomy. From January 1993 to February 1996, 150 patients underwent bilateral lung volume reduction (age range = 36 to 77 years). The mean forced expiratory volume in 1 s (FEV1) was preoperatively 25% of the predicted value, the total lung capacity (TLC) 142% and the residual volume (RV) 283%, 94% of these patients necessitated oxygen supply at rest or during exercise. The 90-day mortality was 4%. All patients except 1 were extubated immediately after operation. The median hospital stay was 10 days in the first 100 patients and 7 days in the last 50. An increase of the FEV1 by 51% and a decrease of the RV by 28% was observed 6 months after operation. The mean PaO2 was improved by 8 mm Hg while the percentage of oxygen dependent patients went down from 50 to 16%. In addition a raise of the perseverance capacity, a clear decrease of dyspnea and an improvement of the life quality were achieved. These results persist after 1 (n = 56) and 2 (n = 20) years after operation. Lung volume reduction leads to an improvement of the lung function, symptoms and the quality of life, which is superior to that achieved by maximal clinical intervention.

Lung volume reduction surgery in patients with emphysema and alpha-1 antitrypsin deficiency.

PubMed

Stoller, James K; Gildea, Thomas R; Ries, Andrew L; Meli, Yvonne M; Karafa, Matthew T

2007-01-01

The role of lung volume reduction surgery (LVRS) for individuals with alpha-1 antitrypsin (AAT) deficiency is unclear. To assess the role of LVRS in individuals with severe deficiency of AAT, outcomes within the National Emphysema Treatment Trial were analyzed. Of 1218 randomized subjects, 16 (1.3%) had severe AAT deficiency (serum level < 80 mg/dL) and a consistent phenotype (when available). Characteristics of these 16 patients include 87.5% male; median serum AAT level, 55.5 mg/dL; age, 66 years; forced expiratory volume in 1 second (FEV1), 27% predicted; and 50% had upper-lobe-predominant emphysema. All 10 subjects randomized to LVRS underwent the procedure. Although the small number of subjects hampered statistical analysis, 2-year mortality was higher with surgery (20% versus 0%) than with medical treatment. Comparison of outcomes between the 10 AAT-deficient and the 554 AAT-replete subjects undergoing LVRS showed a greater increase in exercise capacity at 6 months in replete subjects and a trend toward lower and shorter duration FEV1 rise in deficient individuals. This study extends to 49 cases the published experience of LVRS in severe AAT deficiency. Although the small number of subjects precludes firm conclusions, trends of lower magnitude and duration of FEV1 rise after surgery in AAT-deficient versus AAT-replete subjects and higher mortality in deficient individuals randomized to surgery versus medical treatment suggest caution in recommending LVRS in AAT deficiency.

Can lung volumes and capacities be used as an outcome measure for phrenic nerve recovery after cardiac surgeries?

PubMed

El-Sobkey, Salwa B; Salem, Naguib A

2011-01-01

Phrenic nerve is the main nerve drive to the diaphragm and its injury is a well-known complication following cardiac surgeries. It results in diaphragmatic dysfunction with reduction in lung volumes and capacities. This study aimed to evaluate the objectivity of lung volumes and capacities as an outcome measure for the prognosis of phrenic nerve recovery after cardiac surgeries. In this prospective experimental study, patients were recruited from Cardio-Thoracic Surgery Department, Educational-Hospital of College of Medicine, Cairo University. They were 11 patients with right phrenic nerve injury and 14 patients with left injury. On the basis of receiving low-level laser irradiation, they were divided into irradiated group and non-irradiated group. Measures of phrenic nerve latency, lung volumes and capacities were taken pre and post-operative and at 3-months follow up. After 3 months of low-level laser therapy, the irradiated group showed marked improvement in the phrenic nerve recovery. On the other hand, vital capacity and forced expiratory volume in the first second were the only lung capacity and volume that showed improvement consequent with the recovery of right phrenic nerve (P value <0.001 for both). Furthermore, forced vital capacity was the single lung capacity that showed significant statistical improvement in patients with recovered left phrenic nerve injury (P value <0.001). Study concluded that lung volumes and capacities cannot be used as an objective outcome measure for recovery of phrenic nerve injury after cardiac surgeries.

The Short-Term Effect of Weight Loss Surgery on Volumetric Breast Density and Fibroglandular Volume.

PubMed

Vohra, Nasreen A; Kachare, Swapnil D; Vos, Paul; Schroeder, Bruce F; Schuth, Olga; Suttle, Dylan; Fitzgerald, Timothy L; Wong, Jan H; Verbanac, Kathryn M

2017-04-01

Obesity and breast density are both associated with an increased risk of breast cancer and are potentially modifiable. Weight loss surgery (WLS) causes a significant reduction in the amount of body fat and a decrease in breast cancer risk. The effect of WLS on breast density and its components has not been documented. Here, we analyze the impact of WLS on volumetric breast density (VBD) and on each of its components (fibroglandular volume and breast volume) by using three-dimensional methods. Fibroglandular volume, breast volume, and their ratio, the VBD, were calculated from mammograms before and after WLS by using Volpara™ automated software. For the 80 women included, average body mass index decreased from 46.0 ± 7.22 to 33.7 ± 7.06 kg/m 2 . Mammograms were performed on average 11.6 ± 9.4 months before and 10.1 ± 7 months after WLS. There was a significant reduction in average breast volume (39.4 % decrease) and average fibroglandular volume (15.5 % decrease), and thus, the average VBD increased from 5.15 to 7.87 % (p < 1 × 10 -9 ) after WLS. When stratified by menopausal status and diabetic status, VBD increased significantly in all groups but only perimenopausal and postmenopausal women and non-diabetics experienced a significant reduction in fibroglandular volume. Breast volume and fibroglandular volume decreased, and VBD increased following WLS, with the most significant change observed in postmenopausal women and non-diabetics. Further studies are warranted to determine how physical and biological alterations in breast density components after WLS may impact breast cancer risk.

Weight versus volume in breast surgery: an observational study

PubMed Central

Parmar, Chetan; West, Malcolm; Pathak, Samir; Nelson, J; Martin, Lee

2011-01-01

Objectives The study hypothesis is to assess correlation of breast specimen weight versus volume. Design Consecutive patients undergoing breast surgery at a single tertiary referral centre during a 6-month period were included. Specimen weight was measured in grams. Direct volume measurements were performed using water displacement. Data including side of the breast, age and menstrual status of the patient were noted. Setting Knowledge of breast volume provides an objective guide in facilitating the achievements of balance in reconstructive operations. Surgeons use intraoperative weight measurements from individual breasts to calculate the breast volume assuming that weight is equal to the volume of the specimen. However, it is unclear whether weight accurately reveals the true volume of resection. Participants Forty-one patients were included in the study with 28 having bilateral surgeries, 13 having unilateral procedures giving a total of 69 breast specimens. Main outcome measures Breast specimen weight correlation to breast specimen volume. Results The mean age of the group was 42.4 years. Fifty-two specimens were from premenopausal patients and 17 were of postmenopausal. Thirty-five were left-sided. Twenty-six patients had bilateral breast reduction, two had bilateral mastectomy, nine had a unilateral mastectomy and four patients had a unilateral breast reduction. The difference between weight and volume of these breasts was 36.4 units (6.6% difference). The difference in measurement of weight and volume in premenopausal was 37.6 units compared to 32.6 units in postmenopausal women. The density was 1.07 and 1.06, respectively. This was statistically not significant. Conclusions No significant difference between volume and weight was seen in this series. Furthermore, we are unable to support the notion that premenopausal patients have a significant difference in the proportion of fatty and glandular tissue as there was little difference between the weight and the volume. An easy, clinically proper formula for the quantification of actual breast volume has yet to be derived. PMID:22140613

Weight versus volume in breast surgery: an observational study.

PubMed

Parmar, Chetan; West, Malcolm; Pathak, Samir; Nelson, J; Martin, Lee

2011-11-01

The study hypothesis is to assess correlation of breast specimen weight versus volume. Consecutive patients undergoing breast surgery at a single tertiary referral centre during a 6-month period were included. Specimen weight was measured in grams. Direct volume measurements were performed using water displacement. Data including side of the breast, age and menstrual status of the patient were noted. Knowledge of breast volume provides an objective guide in facilitating the achievements of balance in reconstructive operations. Surgeons use intraoperative weight measurements from individual breasts to calculate the breast volume assuming that weight is equal to the volume of the specimen. However, it is unclear whether weight accurately reveals the true volume of resection. Forty-one patients were included in the study with 28 having bilateral surgeries, 13 having unilateral procedures giving a total of 69 breast specimens. Breast specimen weight correlation to breast specimen volume. The mean age of the group was 42.4 years. Fifty-two specimens were from premenopausal patients and 17 were of postmenopausal. Thirty-five were left-sided. Twenty-six patients had bilateral breast reduction, two had bilateral mastectomy, nine had a unilateral mastectomy and four patients had a unilateral breast reduction. The difference between weight and volume of these breasts was 36.4 units (6.6% difference). The difference in measurement of weight and volume in premenopausal was 37.6 units compared to 32.6 units in postmenopausal women. The density was 1.07 and 1.06, respectively. This was statistically not significant. No significant difference between volume and weight was seen in this series. Furthermore, we are unable to support the notion that premenopausal patients have a significant difference in the proportion of fatty and glandular tissue as there was little difference between the weight and the volume. An easy, clinically proper formula for the quantification of actual breast volume has yet to be derived.

"Pulmonary valve replacement diminishes the presence of restrictive physiology and reduces atrial volumes": a prospective study in Tetralogy of Fallot patients.

PubMed

Pijuan-Domenech, Antonia; Pineda, Victor; Castro, Miguel Angel; Sureda-Barbosa, Carlos; Ribera, Aida; Cruz, Luz M; Ferreira-Gonzalez, Ignacio; Dos-Subirà, Laura; Subirana-Domènech, Teresa; Garcia-Dorado, David; Casaldàliga-Ferrer, Jaume

2014-11-15

Pulmonary valve replacement (PVR) reduces right ventricular (RV) volumes in the setting of long-term pulmonary regurgitation after Tetralogy of Fallot (ToF) repair; however, little is known of its effect on RV diastolic function. Right atrial volumes may reflect the burden of RV diastolic dysfunction. The objective of this paper is to evaluate the clinical, echocardiographic, biochemical and cardiac magnetic resonance (CMR) variables, focusing particularly on right atrial response and right ventricular diastolic function prior to and after elective PVR in adult patients with ToF. This prospective study was conducted from January 2009 to April 2013 in consecutive patients > 18 years of age who had undergone ToF repair in childhood and were accepted for elective PVR. Twenty patients (mean age: 35 years; 70% men) agreed to enter the study. PVR was performed with a bioporcine prosthesis. Concomitant RV reduction was performed in all cases when technically possible. Pulmonary end-diastolic forward flow (EDFF) decreased significantly from 5.4 ml/m(2) to 0.3 ml/m(2) (p < 0.00001), and right atrial four-chamber echocardiographic measurements and volumes by 25% (p = 0.0024): mean indexed diastolic/systolic atrial volumes prior to surgery were 43 ml/m(2) (SD+/-4.6)/63 ml/m(2) (SD+/-5.5), and dropped to 33 ml/m(2) (SD+/-3)/46 ml/m(2) (SD+/-2.55) post-surgery. All patients presented right ventricular diastolic and systolic volume reductions, with a mean volume reduction of 35% (p < 0.00001). Right ventricular diastolic dysfunction was common in a population of severely dilated RV patients long term after ToF repair. Right ventricular diastolic parameters improved as did right atrial volumes in keeping with the known reduction in RV volumes, after PVR. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

Lung Volume Reduction After Stereotactic Ablative Radiation Therapy of Lung Tumors: Potential Application to Emphysema

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

Binkley, Michael S.; Shrager, Joseph B.; Stanford Cancer Institute, Stanford University School of Medicine, Stanford, California

2014-09-01

Purpose: Lung volume reduction surgery (LVRS) improves dyspnea and other outcomes in selected patients with severe emphysema, but many have excessive surgical risk for LVRS. We analyzed the dose-volume relationship for lobar volume reduction after stereotactic ablative radiation therapy (SABR) of lung tumors, hypothesizing that SABR could achieve therapeutic volume reduction if applied in emphysema. Methods and Materials: We retrospectively identified patients treated from 2007 to 2011 who had SABR for 1 lung tumor, pre-SABR pulmonary function testing, and ≥6 months computed tomographic (CT) imaging follow-up. We contoured the treated lobe and untreated adjacent lobe(s) on CT before and after SABRmore » and calculated their volume changes relative to the contoured total (bilateral) lung volume (TLV). We correlated lobar volume reduction with the volume receiving high biologically effective doses (BED, α/β = 3). Results: 27 patients met the inclusion criteria, with a median CT follow-up time of 14 months. There was no grade ≥3 toxicity. The median volume reduction of the treated lobe was 4.4% of TLV (range, −0.4%-10.8%); the median expansion of the untreated adjacent lobe was 2.6% of TLV (range, −3.9%-11.6%). The volume reduction of the treated lobe was positively correlated with the volume receiving BED ≥60 Gy (r{sup 2}=0.45, P=.0001). This persisted in subgroups determined by high versus low pre-SABR forced expiratory volume in 1 second, treated lobe CT emphysema score, number of fractions, follow-up CT time, central versus peripheral location, and upper versus lower lobe location, with no significant differences in effect size between subgroups. Volume expansion of the untreated adjacent lobe(s) was positively correlated with volume reduction of the treated lobe (r{sup 2}=0.47, P<.0001). Conclusions: We identified a dose-volume response for treated lobe volume reduction and adjacent lobe compensatory expansion after lung tumor SABR, consistent across multiple clinical parameters. These data serve to inform our ongoing prospective trial of stereotactic ablative volume reduction (SAVR) for severe emphysema in poor candidates for LVRS.« less

Changes in subcutaneous fat cell volume and insulin sensitivity after weight loss.

PubMed

Andersson, Daniel P; Eriksson Hogling, Daniel; Thorell, Anders; Toft, Eva; Qvisth, Veronica; Näslund, Erik; Thörne, Anders; Wirén, Mikael; Löfgren, Patrik; Hoffstedt, Johan; Dahlman, Ingrid; Mejhert, Niklas; Rydén, Mikael; Arner, Erik; Arner, Peter

2014-07-01

Large subcutaneous fat cells associate with insulin resistance and high risk of developing type 2 diabetes. We investigated if changes in fat cell volume and fat mass correlate with improvements in the metabolic risk profile after bariatric surgery in obese patients. Fat cell volume and number were measured in abdominal subcutaneous adipose tissue in 62 obese women before and 2 years after Roux-en-Y gastric bypass (RYGB). Regional body fat mass by dual-energy X-ray absorptiometry; insulin sensitivity by hyperinsulinemic-euglycemic clamp; and plasma glucose, insulin, and lipid profile were assessed. RYGB decreased body weight by 33%, which was accompanied by decreased adipocyte volume but not number. Fat mass in the measured regions decreased and all metabolic parameters were improved after RYGB (P < 0.0001). Whereas reduced subcutaneous fat cell size correlated strongly with improved insulin sensitivity (P = 0.0057), regional changes in fat mass did not, except for a weak correlation between changes in visceral fat mass and insulin sensitivity and triglycerides. The curve-linear relationship between fat cell size and fat mass was altered after weight loss (P = 0.03). After bariatric surgery in obese women, a reduction in subcutaneous fat cell volume associates more strongly with improvement of insulin sensitivity than fat mass reduction per se. An altered relationship between adipocyte size and fat mass may be important for improving insulin sensitivity after weight loss. Fat cell size reduction could constitute a target to improve insulin sensitivity. © 2014 by the American Diabetes Association.

Why does the lung hyperinflate?

PubMed

Ferguson, Gary T

2006-04-01

Patients with chronic obstructive pulmonary disease (COPD) often have some degree of hyperinflation of the lungs. Hyperinflated lungs can produce significant detrimental effects on breathing, as highlighted by improvements in patient symptoms after lung volume reduction surgery. Measures of lung volumes correlate better with impairment of patient functional capabilities than do measures of airflow. Understanding the mechanisms by which hyperinflation occurs in COPD provides better insight into how treatments can improve patients' health. Both static and dynamic processes can contribute to lung hyperinflation in COPD. Static hyperinflation is caused by a decrease in elasticity of the lung due to emphysema. The lungs exert less recoil pressure to counter the recoil pressure of the chest wall, resulting in an equilibrium of recoil forces at a higher resting volume than normal. Dynamic hyperinflation is more common and can occur independent of or in addition to static hyperinflation. It results from air being trapped within the lungs after each breath due to a disequilibrium between the volumes inhaled and exhaled. The ability to fully exhale depends on the degree of airflow limitation and the time available for exhalation. These can both vary, causing greater hyperinflation during exacerbations or increased respiratory demand, such as during exercise. Reversibility of dynamic hyperinflation offers the possibility for intervention. Use of bronchodilators with prolonged durations of action, such as tiotropium, can sustain significant reductions in lung inflation similar in effect to lung volume reduction surgery. How efficacy of bronchodilators is assessed may, therefore, need to be reevaluated.

Lung cancer following bronchoscopic lung volume reduction for severe emphysema: a case and its management.

PubMed

Tummino, Celine; Maldonado, Fabien; Laroumagne, Sophie; Astoul, Philippe; Dutau, Hervé

2012-01-01

Bronchoscopic lung volume reduction using endobronchial valves has been suggested as a potentially safer alternative to surgery in selected cases. Complications of this technique include pneumothoraces, pneumonia, COPD exacerbations, hemoptysis, and valve migrations. We report the case of a male patient who developed a parenchymal mass in the treated lobe after valve insertion. Due to severe emphysema, transthoracic needle aspiration was not feasible. Removal of the valves was mandatory to perform transbronchialbiopsies which revealed a non-small cell primary lung cancer. This first description illustrates the potential risk of lung cancer development following bronchoscopic lung volume reduction and highlights the different approach to diagnosis and management of indeterminate peripheral lung lesions needed in this context. Copyright © 2011 S. Karger AG, Basel.

Measurement of breast volume using body scan technology(computer-aided anthropometry).

PubMed

Veitch, Daisy; Burford, Karen; Dench, Phil; Dean, Nicola; Griffin, Philip

2012-01-01

Assessment of breast volume is an important tool for preoperative planning in various breast surgeries and other applications, such as bra development. Accurate assessment can improve the consistency and quality of surgery outcomes. This study outlines a non-invasive method to measure breast volume using a whole body 3D laser surface anatomy scanner, the Cyberware WBX. It expands on a previous publication where this method was validated against patients undergoing mastectomy. It specifically outlines and expands the computer-aided anthropometric (CAA) method for extracting breast volumes in a non-invasive way from patients enrolled in a breast reduction study at Flinders Medical Centre, South Australia. This step-by-step description allows others to replicate this work and provides an additional tool to assist them in their own clinical practice and development of designs.

Survival after Lung Volume Reduction in Chronic Obstructive Pulmonary Disease

PubMed Central

Hogg, James C.; Chu, Fanny S. F.; Tan, Wan C.; Sin, Don D.; Patel, Sanjay A.; Pare, Peter D.; Martinez, Fernando J.; Rogers, Robert M.; Make, Barry J.; Criner, Gerard J.; Cherniack, Reuben M.; Sharafkhaneh, Amir; Luketich, James D.; Coxson, Harvey O.; Elliott, W. Mark; Sciurba, Frank C.

2007-01-01

Rationale: COPD is associated with reduced life expectancy. Objectives: To determine the association between small airway pathology and long-term survival after lung volume reduction in chronic obstructive pulmonary disease (COPD) and the effect of corticosteroids on this pathology. Methods: Patients with severe (GOLD-3) and very severe (GOLD-4) COPD (n = 101) were studied after lung volume reduction surgery. Respiratory symptoms, quality of life, pulmonary function, exercise tolerance, chest radiology, and corticosteroid treatment status were assessed preoperatively. The severity of luminal occlusion, wall thickening, and the presence of small airways containing lymphoid follicles were determined in resected lung tissue. Kaplan-Meier survival analysis and Cox proportional hazards models were used to determine the relationship between survival and small airway pathology. The effect of corticosteroids on this pathology was assessed by comparing treated and untreated groups. Measurements and Main Results: The quartile of subjects with the greatest luminal occlusion, adjusted for covariates, died earlier than subjects who had the least occlusion (hazard ratio, 3.28; 95% confidence interval, 1.55–6.92; P = 0.002). There was a trend toward a reduction in the number of airways containing lymphoid follicles (P = 0.051) in those receiving corticosteroids, with a statistically significant difference between the control and oral ± inhaled corticosteroid–treated groups (P = 0.019). However, corticosteroid treatment had no effect on airway wall thickening or luminal occlusion. Conclusions: Occlusion of the small airways by inflammatory exudates containing mucus is associated with early death in patients with severe emphysema treated by lung volume reduction surgery. Corticosteroid treatment dampens the host immune response in these airways by reducing lymphoid follicles without changing wall thickening and luminal occlusion. PMID:17556723

Safety of implanting sustained-release 5-fluorouracil into hepatic cross-section and omentum majus after primary liver cancer resection.

PubMed

Chen, Jiangtao; Zhang, Junjie; Wang, Chenyu; Yao, Kunhou; Hua, Long; Zhang, Liping; Ren, Xuequn

2016-09-01

This study was designed to evaluate the short-term safety of implanting sustained-release 5-fluorouracil (5-FU) into hepatic cross-section and omentum majus after primary liver cancer resection and its impact on related indexes of liver. Forty patients were selected and divided into an implantation group (n = 20) and a control group (n = 20). On the first day after admission, first week after surgery, and first month after surgery, fasting venous blood was extracted from patients for measuring hematological indexes. The reduction rate of alpha fetoprotein (AFP) on the first week and first month after surgery was calculated, and moreover, drainage volume of the abdominal cavity drainage tube, length of stay after surgery, and wound healing condition were recorded. We found that levels of alanine aminotransferase, aspartate amino transferase, blood urea nitrogen, creatinine, total bilirubin, albumin, and white blood cells measured on the first week and first month after surgery, length of stay, and wound healing of patients in the two groups had no significant difference (P >0.05). Drainage volume and reduction rate of AFP of two groups were significantly different on the first week and first month after surgery (P <0.05). Implanting sustained-release 5-FU into hepatic cross-section and omentum majus after primary liver cancer resection is proved to be safe as it has little impact on related indexes. © The Author(s) 2016.

[The volume of surgery on the abdominal cavity organs in patients with associated cardiovascular and respiratory system diseases].

PubMed

Bondarenko, M V

2004-08-01

The cardiovascular and respiratory disturbances are the main risk factor in acute and chronic surgical deseases of the abdominal cavity organs, including oncological. It is limits the possibility and volume of the diagnostics and surgical tactics choice. The complicated current of main disease is a risk factor of operation perform and the reason of the undertaking inadequate and palliative intervention, which significant reduce of the quality of life. Real by risk level reductions in surgery is a determination of tissues viability, estimation of compensatory reserve sick evidences for determination for operation performance including simultaneous and staged.

Intraoperative Ultrasound Guidance in Breast-Conserving Surgery Improves Cosmetic Outcomes and Patient Satisfaction: Results of a Multicenter Randomized Controlled Trial (COBALT).

PubMed

Haloua, Max H; Volders, José H; Krekel, Nicole M A; Lopes Cardozo, Alexander M F; de Roos, Wifred K; de Widt-Levert, Louise M; van der Veen, Henk; Rijna, Herman; Bergers, Elisabeth; Jóźwiak, Katarzyna; Meijer, Sybren; van den Tol, Petrousjka

2016-01-01

Ultrasound-guided breast-conserving surgery (USS) results in a significant reduction in both margin involvement and excision volumes (COBALT trial). Objective. The aim of the present study was to determine whether USS also leads to improvements in cosmetic outcome and patient satisfaction when compared with standard palpation-guided surgery (PGS). A total of 134 patients with T1–T2 invasive breast cancer were included in the COBALT trial (NTR2579) and randomized to either USS (65 patients) or PGS (69 patients). Cosmetic outcomes were assessed by a three-member panel using computerized software Breast Cancer Conservative Treatment cosmetic results (BCCT.- core) and by patient self-evaluation, including patient satisfaction. Time points for follow-up were 3, 6, and 12 months after surgery. Overall cosmetic outcome and patient satisfaction were scored on a 4-point Likert scale (excellent, good, fair, or poor), and outcomes were analyzed using a multilevel, mixed effect, proportional odds model for ordinal responses. Ultrasound-guided breast-conserving surgery achieved better cosmetic outcomes, with 20 % excellence overall and only 6 % rated as poor, whereas 14 % of PGS outcomes were rated excellent and 13 % as poor. USS also had consistently lower odds for worse cosmetic outcomes (odds ratio 0.55, p = 0.067) than PGS. The chance of having a worse outcome was significantly increased by a larger lumpectomy volume (ptrend = 0.002); a volume [40 cc showed odds 2.78-fold higher for a worse outcome than a volume B40 cc. USS resulted in higher patient satisfaction compared with PGS. Ultrasound-guided breast-conserving surgery achieved better overall cosmetic outcomes and patient satisfaction than PGS. Lumpectomy volumes[40 cc resulted in significantly worse cosmetic outcomes.

Real-time three-dimensional echocardiographic study of left ventricular function after infarct exclusion surgery for ischemic cardiomyopathy

NASA Technical Reports Server (NTRS)

Qin, J. X.; Shiota, T.; McCarthy, P. M.; Firstenberg, M. S.; Greenberg, N. L.; Tsujino, H.; Bauer, F.; Travaglini, A.; Hoercher, K. J.; Buda, T.;

Cosmetic surgery volume and its correlation with the major US stock market indices.

PubMed

Gordon, Chad R; Pryor, Landon; Afifi, Ahmed M; Benedetto, Paul X; Langevin, C J; Papay, Francis; Yetman, Randall; Zins, James E

2010-01-01

As a consumer-driven industry, cosmetic plastic surgery is subject to ebbs and flows as the economy changes. There have been many predictions about the short, intermediate, and long-term impact on cosmetic plastic surgery as a result of difficulties in the current economic climate, but no studies published in the literature have quantified a direct correlation. The authors investigate a possible correlation between cosmetic surgery volume and the economic trends of the three major US stock market indices. A volume analysis for the time period from January 1992 to October 2008 was performed (n = 7360 patients, n = 8205 procedures). Four cosmetic procedures-forehead lift (FL), rhytidectomy (Rh), breast augmentation (BA), and liposuction (Li)-were chosen; breast reduction (BRd), breast reconstruction (BRc), and carpal tunnel release (CTR) were selected for comparison. Case volumes for each procedure and fiscal quarter were compared to the trends of the S&P 500, Dow Jones (DOW), and NASDAQ (NASD) indices. Pearson correlation statistics were used to evaluate a relationship between the market index trends and surgical volume. P values <.05 were considered statistically significant. Three of the four cosmetic surgery procedures investigated (Rh, n = 1540; Li, n = 1291; BA, n = 1959) demonstrated a direct (ie, positive) statistical correlation to all three major market indices. FL (n =312) only correlated to the NASD (P = .021) and did not reach significance with the S&P 500 (P = .077) or DOW (P = .14). BRd and BRc demonstrated a direct correlation to two of the three stock market indices, whereas CTR showed an inverse (ie, negative) correlation to two of the three indices. This study, to our knowledge, is the first to suggest a direct correlation of four cosmetic and two reconstructive plastic surgery procedures to the three major US stock market indices and further emphasizes the importance of a broad-based plastic surgery practice in times of economic recession.

Influence of large hiatus hernia on cardiac volumes. A prospective observational cohort study by cardiovascular magnetic resonance.

PubMed

Milito, Pamela; Lombardi, Massimo; Asti, Emanuele; Bonitta, Gianluca; Fina, Dario; Bandera, Francesco; Bonavina, Luigi

2018-05-09

Large hiatus hernia (LHH) is often associated with post-prandial dyspnea, palpitations or chest discomfort, but its effect on cardiac volumes and performance is still debated. Before and 3-months after laparoscopic repair, 35 patients underwent cardiovascular magnetic resonance (CMR) in the fasting state and after a standardized meal. Preoperatively, LHH size increased significantly after meal (p < 0.010). Compared to the fasting state, a systematic trend of volume reduction of the cardiac chambers was observed. In addition, both the left ventricle stroke volume (p = 0.012) and the ejection fraction (p = 0.010) were significantly reduced. At 3-months after surgery there was a statistically significant increase in left atrial volume (p = 0.029), overall left ventricle volume (p < 0.05) and right ventricle end-systolic volume (p = 0.046). Both FEV 1 (Forced expiratory volume) (p = 0.02) and FVC (Forced Vital Capacity) (p = 0.01) values significantly improved after surgery. Cardiorespiratory symptoms significantly improved compared to pre-operative values (p < 0.01). The global heart function was significantly impaired by a standardized meal in the presence of a LHH. Restoration of the cardiac physiological status and improvement of clinical symptoms were noted after surgery. A multidisciplinary evaluation and CMR with a challenge meal may be added to routine pre-operative testing to select symptomatic patients for surgical hernia repair. Copyright © 2017 Elsevier B.V. All rights reserved.

Medicare patients' use of overpriced procedures before and after the Omnibus Budget Reconciliation Act of 1987.

PubMed Central

Escarce, J J

1993-01-01

OBJECTIVES. Under the Omnibus Budget Reconciliation Act of 1987, Medicare reduced physician fees for 12 procedures identified as overprices. This paper describes trends in the use of these procedures and other physician services by Medicare patients during the 4-year period surrounding the implementation of the 1987 budget act. METHODS. Medicare physician claims files were used to develop trends in physician-services use from 1986 to 1989. Services were grouped into four categories: overpriced procedures, other surgery, medical care, and ancillary tests. RESULTS. Growth in the volume of overpriced procedures slowed substantially after the 1987 budget act was implemented. Moreover, the reduction in the rate of volume growth for these procedures differed little among specialities or areas. In comparison, the rate of volume growth fell modestly for other surgery, was unchanged for medical care, and increased for ancillary tests. CONCLUSIONS. Increases do not necessarily occur in the volume of surgical procedures whose Medicare fees are reduced. Although the conclusions that may be drawn from a descriptive analysis are limited, these findings suggest that concerns that the resource-based Medicare fee schedule will lead to higher surgery rates may be unwarranted. PMID:8438971

Ultrasound-guided microwave ablation in the treatment of benign thyroid nodules in 435 patients

PubMed Central

Qian, Lin-Xue; Liu, Dong; Zhao, Jun-Feng

2017-01-01

The objective of the present study was to investigate the effectiveness and safety of ultrasound-guided microwave ablation in the treatment of benign thyroid nodules. A total of 474 benign thyroid nodules in 435 patients who underwent ultrasound-guided microwave ablation from September 2012 to August 2015 were included. Nodule volume and thyroid function were measured before treatment and at 1, 3, 6, and 12 months and subsequently after every 6 months. The nodule volume reduction rate and changes of thyroid function were evaluated. The volume of all thyroid nodules significantly decreased after ultrasound-guided microwave ablation. The average volume was 13.07 ± 0.95 ml before treatment, and 1.14 ± 0.26 ml at 12-months follow-up. The mean volume reduction rate was 90% and the final volume reduction rate was 94%. The volume reduction rate of mainly cystic nodules was significantly higher than that of simple solid and mainly solid nodules (all P < 0.05). The pretreatment volume of nodules was positively correlated with the final volume reduction rate at final follow-up (P = 0.004). No serious complications were observed after treatment. In conclusion, ultrasound-guided microwave ablation is an effective and safe technique for treatment of benign thyroid nodules, and has the potential for clinical applications. Impact statement Ultrasound-guided MWA is an effective and safe technique for the treatment of benign thyroid nodules. It can significantly reduce the nodule volume, improve the patients’ clinical symptoms, has less complication, guarantees quick recovery, meets patients' aesthetic needs, and shows less interference on the physiological and psychological aspects of the body. MWA should be a good complement to traditional open surgery and has potentials in clinical applications. PMID:28847173

Ultrasound-guided microwave ablation in the treatment of benign thyroid nodules in 435 patients.

PubMed

Liu, Yu-Jiang; Qian, Lin-Xue; Liu, Dong; Zhao, Jun-Feng

2017-09-01

The objective of the present study was to investigate the effectiveness and safety of ultrasound-guided microwave ablation in the treatment of benign thyroid nodules. A total of 474 benign thyroid nodules in 435 patients who underwent ultrasound-guided microwave ablation from September 2012 to August 2015 were included. Nodule volume and thyroid function were measured before treatment and at 1, 3, 6, and 12 months and subsequently after every 6 months. The nodule volume reduction rate and changes of thyroid function were evaluated. The volume of all thyroid nodules significantly decreased after ultrasound-guided microwave ablation. The average volume was 13.07 ± 0.95 ml before treatment, and 1.14 ± 0.26 ml at 12-months follow-up. The mean volume reduction rate was 90% and the final volume reduction rate was 94%. The volume reduction rate of mainly cystic nodules was significantly higher than that of simple solid and mainly solid nodules (all P < 0.05). The pretreatment volume of nodules was positively correlated with the final volume reduction rate at final follow-up ( P = 0.004). No serious complications were observed after treatment. In conclusion, ultrasound-guided microwave ablation is an effective and safe technique for treatment of benign thyroid nodules, and has the potential for clinical applications. Impact statement Ultrasound-guided MWA is an effective and safe technique for the treatment of benign thyroid nodules. It can significantly reduce the nodule volume, improve the patients' clinical symptoms, has less complication, guarantees quick recovery, meets patients' aesthetic needs, and shows less interference on the physiological and psychological aspects of the body. MWA should be a good complement to traditional open surgery and has potentials in clinical applications.

Absence of gender effect on amygdala volume in temporal lobe epilepsy.

PubMed

Silva, Ivaldo; Lin, Katia; Jackowski, Andrea P; Centeno, Ricardo da Silva; Pinto, Magali L; Carrete, Henrique; Yacubian, Elza M; Amado, Débora

2010-11-01

Sexual dimorphism has already been described in temporal lobe epilepsy with mesial temporal sclerosis (TLE-MTS). This study evaluated the effect of gender on amygdala volume in patients with TLE-MTS. One hundred twenty-four patients with refractory unilateral or bilateral TLE-MTS who were being considered for epilepsy surgery underwent a comprehensive presurgical evaluation and MRI. Amygdalas of 67 women (27 with right; 32 with left, and 8 with bilateral TLE) and 57 men (22 with right, 30 with left, and 5 with bilateral TLE) were manually segmented. Significant ipsilateral amygdala volume reduction was observed for patients with right and left TLE. No gender effect on amygdala volume was observed. Contralateral amygdalar asymmetry was observed for patients with right and left TLE. Although no gender effect was observed on amygdala volume, ipsilateral amygdala volume reductions in patients with TLE might be related to differential rates of cerebral maturation between hemispheres. Copyright © 2010 Elsevier Inc. All rights reserved.

Blood loss and transfusion requirements with epsilon-aminocaproic acid use during cranial vault reconstruction surgery.

PubMed

Thompson, Mark E; Saadeh, Charles; Watkins, Phillip; Nagy, Laszlo; Demke, Joshua

2017-02-01

To determine whether epsilon-aminocaproic acid (EACA) load of 50 mg∙kg -1 before skin incision, and infusion of 25 mg∙kg -1 ∙h -1 until skin closure during cranial vault reconstruction (CVR) were associated with decreased estimated blood loss and transfusion requirements. Antifibrinolytic medications decrease bleeding and transfusion requirements during cardiothoracic and orthopedic surgeries with high blood loss, but practical reductions in blood loss and transfusion requirements have not been consistently realized in children undergoing CVR. Current dosing recommendations are derived from adult extrapolations, and may or may not have clinical relevance. Retrospective case-controlled study of 45 consecutive infants and children undergoing primary craniosynostosis surgery at Covenant Children's Hospital during years 2010-2014. Exclusion criteria included revision surgery, and chromosomal abnormalities associated with bleeding disorders. Blood loss and blood transfusion volumes as a percent of estimated blood volume were compared in the presence of EACA while controlling for age, suture phenotype, use of bone grafting, and length of surgery. Secondary outcomes measures included volume of crystalloid infused, length of hospital stay, and any postoperative intubation requirement. When analyzed based on length of surgery, EACA did reduce blood loss and blood transfusion (R 2 =0.19, P=.005 and R 2 =0.18, P=.010, respectively) with shorter surgeries. Using a standardized dosing regimen of EACA during craniosynostosis surgery, we found statistical significance in blood loss and transfusion requirements in surgeries of the shortest duration. We suspect this may be due to our selected dosing regimen, which may be lower than recently recommended. This study contributes to the growing body of evidence supporting EACA in CVR for craniosynostosis. Copyright © 2016 Elsevier Inc. All rights reserved.

Harmonic scalpel versus electrocautery in breast reduction surgery: a randomized controlled trial.

PubMed

Burdette, Todd E; Kerrigan, Carolyn L; Homa, Karen; Homa, Karen A

2011-10-01

The authors hypothesized that the Harmonic Scalpel (Ethicon Endo-Surgery, Cincinnati, Ohio) might outperform electrocautery in bilateral breast reduction surgery, possibly resulting in (1) shorter operative times, (2) lower postoperative fluid drainage rates, and (3) reduced postoperative pain scores. Thirty-one patients were evaluated in a matched-pair design, with random (blinded) assignment of one side to the Harmonic Scalpel, with the other side defaulting to electrocautery. Main outcome measures were: (1) resection/hemostasis time, (2) drainage volume, and (3) postoperative pain. The authors also compared the learning curves, operative time versus specimen weights, complications, and costs for the devices. There was a statistically significant (but not clinically significant) difference between the median times for the Harmonic Scalpel (33 minutes) and electrocautery (31 minutes) (p=0.02). There was no statistical difference in drainage scores, and pain scores were equivalent. The analysis of specimen weight versus resection/hemostasis time showed no correlation. There were more complications on the breasts reduced with the Harmonic device, but due to the small sample size, the complication results were not statistically significant. Start-up costs for the devices were comparable, but the per-procedure cost for the Harmonic device was considerably higher. The Harmonic Scalpel is roughly equivalent to electrocautery in breast reduction surgery in terms of resection/hemostasis time, serous drainage, and postoperative pain. Though the Harmonic device may be excellent for other surgical procedures, its high cost suggests that surgeons and institutions can confidently forgo its use in breast reduction surgery. Therapeutic, II.

Planning the breast tumor bed boost: Changes in the excision cavity volume and surgical scar location after breast-conserving surgery and whole-breast irradiation

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

Oh, Kevin S.; Kong, F.-M.; Griffith, Kent A.

2006-11-01

Purpose: The aims of this study were to determine the changes in breast and excision cavity volumes after whole-breast irradiation and the adequacy of using the surgical scar to guide boost planning. Methods and Materials: A total of 30 women consecutively treated for 31 breast cancers were included in this study. Simulation CT scans were performed before and after whole-breast irradiation. CT breast volumes were delineated using clinically defined borders. Excision cavity volumes were contoured based on surgical clips, the presence of a hematoma, and/or other surgical changes. Hypothetical electron boost plans were generated using the surgical scar with amore » 3-cm margin and analyzed for coverage. Results: The mean CT breast volumes were 774 and 761 cc (p = 0.22), and the excision cavity volumes were 32.1 and 25.1 cc (p < 0.0001), before and after 40 Gy (39-42 Gy) of whole-breast irradiation, respectively. The volume reduction in the excision cavity was inversely correlated with time elapsed since surgery (R = 0.46, p < 0.01) and body weight (R = 0.50, p < 0.01). The scar-guided hypothetical plans failed to cover the excision cavity adequately in 62% and 53.8% of cases using the pretreatment and postradiation CTs, respectively. Per the hypothetical plans, the minimum dose to the excision cavity was significantly lower for tumors located in the inner vs. outer quadrants (p = 0.02) and for cavities >20 cc vs. <20 cc (p = 0.01). Conclusions: This study demonstrates a significant reduction in the volume of the excision cavity during whole-breast irradiation. Scar-guided boost plans provide inadequate coverage of the excision cavity in the majority of cases.« less

Lung volume reduction for emphysema.

PubMed

Shah, Pallav L; Herth, Felix J; van Geffen, Wouter H; Deslee, Gaetan; Slebos, Dirk-Jan

2017-02-01

Advanced emphysema is a lung disease in which alveolar capillary units are destroyed and supporting tissue is lost. The combined effect of reduced gas exchange and changes in airway dynamics impairs expiratory airflow and leads to progressive air trapping. Pharmacological therapies have limited effects. Surgical resection of the most destroyed sections of the lung can improve pulmonary function and exercise capacity but its benefit is tempered by significant morbidity. This issue stimulated a search for novel approaches to lung volume reduction. Alternative minimally invasive approaches using bronchoscopic techniques including valves, coils, vapour thermal ablation, and sclerosant agents have been at the forefront of these developments. Insertion of endobronchial valves in selected patients could have benefits that are comparable with lung volume reduction surgery. Endobronchial coils might have a role in the treatment of patients with emphysema with severe hyperinflation and less parenchymal destruction. Use of vapour thermal energy or a sclerosant might allow focal treatment but the unpredictability of the inflammatory response limits their current use. In this Review, we aim to summarise clinical trial evidence on lung volume reduction and provide guidance on patient selection for available therapies. Copyright © 2017 Elsevier Ltd. All rights reserved.

Bariatric Surgery Improves Hyperandrogenism, Menstrual Irregularities, and Metabolic Dysfunction Among Women with Polycystic Ovary Syndrome (PCOS).

PubMed

Christ, Jacob P; Falcone, Tommaso

2018-03-02

To characterize the impact of bariatric surgery on reproductive and metabolic features common to polycystic ovary syndrome (PCOS) and to assess the relevance of preoperative evaluations in predicting likelihood of benefit from surgery. A retrospective chart review of records from 930 women who had undergone bariatric surgery at the Cleveland Clinic Foundation from 2009 to 2014 was completed. Cases of PCOS were identified from ICD coding and healthy women with pelvic ultrasound evaluations were identified using Healthcare Common Procedure Coding System coding. Pre- and postoperative anthropometric evaluations, menstrual cyclicity, ovarian volume (OV) as well as markers of hyperandrogenism, dyslipidemia, and dysglycemia were evaluated. Forty-four women with PCOS and 65 controls were evaluated. Both PCOS and non-PCOS had significant reductions in body mass index (BMI) and markers of dyslipidemia postoperatively (p < 0.05). PCOS had significant reductions in androgen levels (p < 0.05) and percent meeting criteria for hyperandrogenism and irregular menses (p < 0.05). OV did not significantly decline in either group postoperatively. Among PCOS, independent of preoperative BMI and age, preoperative OV associated with change in hemoglobin A1c (β 95% (confidence interval) 0.202 (0.011-0.393), p = 0.04) and change in triglycerides (6.681 (1.028-12.334), p = 0.03), and preoperative free testosterone associated with change in total cholesterol (3.744 (0.906-6.583), p = 0.02) and change in non-HDL-C (3.125 (0.453-5.796), p = 0.03). Bariatric surgery improves key diagnostic features seen in women with PCOS and ovarian volume, and free testosterone may have utility in predicting likelihood of metabolic benefit from surgery.

[Outcomes, controversies and gastric volume after laparoscopic sleeve gastrectomy in the treatment of obesity].

PubMed

García-Díaz, Juan José; Ferrer-Márquez, Manuel; Moreno-Serrano, Almudena; Barreto-Rios, Rogelio; Alarcón-Rodríguez, Raquel; Ferrer-Ayza, Manuel

2016-01-01

Laparoscopic sleeve gastrectomy is a surgical procedure for the treatment of morbid obesity. However, there are still controversies regarding its efficiency in terms of weight reduction and incidence of complications. In this prospective study, the experience is presented of a referral centre for the treatment of morbid obesity with laparoscopic sleeve gastrectomy. A prospective study on 73 patients subjected to laparoscopic sleeve gastrectomy from February 2009 to September 2013. Patients were followed-up for a period of 12 months, evaluating the development of complications, reduction of gastric volume, and the weight loss associated with the surgery, as well as their impact on the improvement of comorbidities present at beginning of the study. There was a statistically a significantly reduction between the preoperative body mass index (BMI) and the BMI at 12 months after laparoscopic sleeve gastrectomy (p < 0.001), despite there being an increase in the gastric volume during follow-up, measured at one month and 12 months after surgery (p < 0.001). Five patients (6.85%) had complications, with none of them serious and with no deaths in the whole series. Laparoscopic sleeve gastrectomy is a safe and effective technique for the treatment of morbid obesity. Its use is associated with a significant reduction in the presence of comorbidities associated with obesity. Multicentre studies with a longer period of monitoring are required to confirm the efficacy and safety of this surgical technique. Copyright © 2015 Academia Mexicana de Cirugía A.C. Publicado por Masson Doyma México S.A. All rights reserved.

Sternotomy or bilateral thoracoscopy: pain and postoperative complications after lung-volume reduction surgery

PubMed Central

Boley, Theresa M.; Reid, Adam J.; Manning, Blaine T.; Markwell, Stephen J.; Vassileva, Christina M.; Hazelrigg, Stephen R.

2012-01-01

OBJECTIVES Video-assisted thoracoscopic surgery (VATS) and median sternotomy (MS) are two approaches in lung-volume reduction surgery (LVRS). This study focused on the two surgical approaches with regard to postoperative pain. METHODS In this prospective, non-randomized study, pain was measured preoperatively and postoperatively using the visual analog scale (VAS) and the brief pain inventory (BPI). Incentive spirometry (IS) assessed restriction of the thoracic cage due to pain. Factors associated with treatment complications, medication usage, hospital stay, operating times, and chest-tube duration differences were examined between groups. RESULTS Of 85 patients undergoing LVRS, 23 patients underwent reduction via MS and 62 patients via bilateral VATS. VAS scores revealed no difference in postoperative pain except for VAS scores on days 6 (PM) and 7 (PM). BPI scores yielded higher scores in the VATS group on postoperative day (POD) 1 in the reactive dimension, but no other overall differences. MS patients receiving tramadol consumed a higher mean amount than VATS patients on POD 5 and POD 6. IS change from baseline to postoperative were similar between groups, and increased pain correlated with decreased IS scores on POD 1. Chest-tube duration, complications, and pain medication were similar between groups. CONCLUSIONS Bilateral VATS and MS offer similar outcomes with regard to postoperative pain and complications. These results suggest that the choice of LVRS operative approach should be dependent on disease presentation, surgeon expertise, and patient preference, not based upon differences in perceived postoperative pain between MS and bilateral VATS. PMID:21601469

Preoperative Short-Course Concurrent Chemoradiation Therapy Followed by Delayed Surgery for Locally Advanced Rectal Cancer: A Phase 2 Multicenter Study (KROG 10-01)

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

Yeo, Seung-Gu; Department of Radiation Oncology, Soonchunhyang University College of Medicine, Cheonan; Oh, Jae Hwan

Purpose: A prospective phase 2 multicenter trial was performed to investigate the efficacy and safety of preoperative short-course concurrent chemoradiation therapy (CRT) followed by delayed surgery for patients with locally advanced rectal cancer. Methods and Materials: Seventy-three patients with cT3-4 rectal cancer were enrolled. Radiation therapy of 25 Gy in 5 fractions was delivered over 5 consecutive days using helical tomotherapy. Concurrent chemotherapy was administered on the same 5 days with intravenous bolus injection of 5-fluorouracil (400 mg/m{sup 2}/day) and leucovorin (20 mg/m{sup 2}/day). After 4 to 8 weeks, total mesorectal excision was performed. The primary endpoint was the pathologicmore » downstaging (ypStage 0-I) rate, and secondary endpoints included tumor regression grade, tumor volume reduction rate, and toxicity. Results: Seventy-one patients completed the planned preoperative CRT and surgery. Downstaging occurred in 20 (28.2%) patients, including 1 (1.4%) with a pathologic complete response. Favorable tumor regression (grade 4-3) was observed in 4 (5.6%) patients, and the mean tumor volume reduction rate was 62.5 ± 21.3%. Severe (grade ≥3) treatment toxicities were reported in 27 (38%) patients from CRT until 3 months after surgery. Conclusions: Preoperative short-course concurrent CRT followed by delayed surgery for patients with locally advanced rectal cancer demonstrated poor pathologic responses compared with conventional long-course CRT, and it yielded considerable toxicities despite the use of an advanced radiation therapy technique.« less

Staged bilateral single-port thoracoscopic lung volume reduction surgery: A report of 11 cases

PubMed Central

Zhang, Miao; Wang, Heng; Pan, Xue-Feng; Wu, Wen-Bin; Zhang, Hui

2016-01-01

The aim of the present study was to investigate the feasibility and efficacy of staged bilateral single-port thoracoscopic lung volume reduction surgery (LVRS) for patients with chronic obstructive pulmonary emphysema (COPE). Eleven male patients with a mean age of 60.27±12.11 years with bilateral COPE and bullae were admitted to the Department of Thoracic Surgery, Xuzhou Central Hospital from January 2013 to June 2014. The patients underwent staged bilateral single-port thoracoscopic LVRS. The hyperinflated bullae were resected using endoscopic staplers (Endo-GIA), followed by continuous suture and biological glue for reinforcement of the margin. In addition, pulmonary function, blood gas assay, 6-min walk distance (6MWD) and life quality evaluated by a short form 36-item health survey questionnaire (SF-36) were recorded before and after LVRS, respectively. All the patients survived after surgery. The chest tube drainage time was 9.09±1.31 days and postoperative hospital stay was 15.73±2.75 days, with 5 cases of persistent air leakage and 7 cases of pulmonary infection which were finally cured. The patients were followed up for 3 to 12 months, and the pulmonary function, partial pressure of oxygen (pO2), 6MWD and life quality after unilateral or bilateral LVRS were improved compared to these parameters before surgery. However, there was no significant difference between unilateral and bilateral LVRS in terms of life quality. In conclusion, staged bilateral single-port thoracoscopic LVRS may improve the short-term life quality of patients with COPE. PMID:27882084

Interstitial laser photocoagulation for benign thyroid nodules: time to treat large nodules.

PubMed

Amabile, Gerardo; Rotondi, Mario; Pirali, Barbara; Dionisio, Rosa; Agozzino, Lucio; Lanza, Michele; Buonanno, Luciano; Di Filippo, Bruno; Fonte, Rodolfo; Chiovato, Luca

2011-09-01

Interstitial laser photocoagulation (ILP) is a new therapeutic option for the ablation of non-functioning and hyper-functioning benign thyroid nodules. Amelioration of the ablation procedure currently allows treating large nodules. Aim of this study was to evaluate the therapeutic efficacy of ILP, performed according to a modified protocol of ablation, in patients with large functioning and non-functioning thyroid nodules and to identify the best parameters for predicting successful outcome in hyperthyroid patients. Fifty-one patients with non-functioning thyroid nodules (group 1) and 26 patients with hyperfunctioning thyroid nodules (group 2) were enrolled. All patients had a nodular volume ≥40 ml. Patients were addressed to 1-3 cycles of ILP. A cycle consisted of three ILP sessions, each lasting 5-10 minutes repeated at an interval of 1 month. After each cycle of ILP patients underwent thyroid evaluation. A nodule volume reduction, expressed as percentage of the basal volume, significantly occurred in both groups (F = 190.4; P < 0.0001 for group 1 and F = 100.2; P < 0.0001 for group 2). Receiver-operator-characteristic (ROC) curves were constructed for: (i) percentage of volume reduction; (ii) difference in nodule volume; (iii) total amount of energy delivered expressed in Joule. ROC curves identified the percentage of volume reduction as the best parameter predicting a normalized serum TSH (area under the curve 0.962; P < 0.0001). Intraoperative complications consisted in: (i) mild pain occurring in five (6.5%) patients, (ii) vasovagal reaction in two (2.6%) patients, (iii) fever within 24 hours from ILP in five (6.5%) patients. No major complications including persistent pain, laringeal nerve dysfunction, hypoparathyroidism, pseudocystic transformation, and/or neck fascitis were observed. ILP represents a valid alternative to surgery also for large benign thyroid nodules, both in terms of nodule size reduction and cure of hyperthyroidism (87% of cured patients after the last ILP cycle). ILP should not be limited to patients refusing or being ineligible for surgery and/or radioiodine. Copyright © 2011 Wiley-Liss, Inc.

The impact on revenue of increasing patient volume at surgical suites with relatively high operating room utilization.

PubMed

Dexter, F; Macario, A; Lubarsky, D A

2001-05-01

We previously studied hospitals in the United States of America that are losing money despite limiting the hours that operating room (OR) staff are available to care for patients undergoing elective surgery. These hospitals routinely keep utilization relatively high to maximize revenue. We tested, using discrete-event computer simulation, whether increasing patient volume while being reimbursed less for each additional patient can reliably achieve an increase in revenue when initial adjusted OR utilization is 90%. We found that increasing the volume of referred patients by the amount expected to fill the surgical suite (100%/90%) would increase utilization by <1% for a hospital surgical suite (with longer duration cases) and 4% for an ambulatory surgery suite (with short cases). The increase in patient volume would result in longer patient waiting times for surgery and more patients leaving the surgical queue. With a 15% reduction in payment for the new patients, the increase in volume may not increase revenue and can even decrease the contribution margin for the hospital surgical suite. The implication is that for hospitals with a relatively high OR utilization, signing discounted contracts to increase patient volume by the amount expected to "fill" the OR can have the net effect of decreasing the contribution margin (i.e., profitability). Hospitals may try to attract new surgical volume by offering discounted rates. For hospitals with a relatively high operating room utilization (e.g., 90%), computer simulations predict that increasing patient volume by the amount expected to "fill" the operating room can have the net effect of decreasing contribution margin (i.e., profitability).

Timing of surgery following neoadjuvant chemoradiotherapy in locally advanced rectal cancer - A comparison of magnetic resonance imaging at two time points and histopathological responses.

PubMed

West, M A; Dimitrov, B D; Moyses, H E; Kemp, G J; Loughney, L; White, D; Grocott, M P W; Jack, S; Brown, G

2016-09-01

There is wide inter-institutional variation in the interval between neoadjuvant chemoradiotherapy (NACRT) and surgery for locally advanced rectal cancer. We aimed to assess the association of magnetic resonance imaging (MRI) at 9 and 14 weeks post-NACRT; T-staging (ymrT) and post-NACRT tumour regression grading (ymrTRG) with histopathological outcomes; histopathological T-stage (ypT) and histopathological tumour regression grading (ypTRG) in order to inform decision-making about timing of surgery. We prospectively studied 35 consecutive patients (26 males) with MRI-defined resection margin threatened rectal cancer who had completed standardized NACRT. Patients underwent a MRI at Weeks 9 and 14 post-NACRT, and surgery at Week 15. Two readers independently assessed MRIs for ymrT, ymrTRG and volume change. ymrT and ymrTRG were analysed against histopathological ypT and ypTRG as predictors by logistic regression modelling and receiver operating characteristic (ROC) curve analyses. Thirty-five patients were recruited. Inter-observer agreement was good for all MR variables (Kappa > 0.61). Considering ypT as an outcome variable, a stronger association of favourable ymrTRG and volume change at Week 14 compared to Week 9 was found (ymrTRG - p = 0.064 vs. p = 0.010; Volume change - p = 0.062 vs. p = 0.007). Similarly, considering ypTRG as an outcome variable, a greater association of favourable ymrTRG and volume change at Week 14 compared to Week 9 was found (ymrTRG - p = 0.005 vs. p = 0.042; Volume change - p = 0.004 vs. 0.055). Following NACRT, greater tumour down-staging and volume reduction was observed at Week 14. Timing of surgery, in relation to NACRT, merits further investigation. NCT01325909. Copyright © 2016 Elsevier Ltd. All rights reserved.

[Prediction of the efficiency of endoscopic lung volume reduction by valves in severe emphysema].

PubMed

Bocquillon, V; Briault, A; Reymond, E; Arbib, F; Jankowski, A; Ferretti, G; Pison, C

2016-11-01

In severe emphysema, endoscopic lung volume reduction with valves is an alternative to surgery with less morbidity and mortality. In 2015, selection of patients who will respond to this technique is based on emphysema heterogeneity, a complete fissure visible on the CT-scan and absence of collateral ventilation between lobes. Our case report highlights that individualized prediction is possible. A 58-year-old woman had severe, disabling pulmonary emphysema. A high resolution thoracic computed tomography scan showed that the emphysema was heterogeneous, predominantly in the upper lobes, integrity of the left greater fissure and no collateral ventilation with the left lower lobe. A valve was inserted in the left upper lobe bronchus. At one year, clinical and functional benefits were significant with complete atelectasis of the treated lobe. The success of endoscopic lung volume reduction with a valve can be predicted, an example of personalized medicine. Copyright © 2016 SPLF. Published by Elsevier Masson SAS. All rights reserved.

Lung Volume Reduction Surgery for Respiratory Failure in Infants With Bronchopulmonary Dysplasia.

PubMed

Sohn, Bongyeon; Park, Samina; Park, In Kyu; Kim, Young Tae; Park, June Dong; Park, Sung-Hye; Kang, Chang Hyun

2018-04-01

Lung volume reduction surgery (LVRS) can be performed in patients with severe emphysematous disease. However, LVRS in pediatric patients has not yet been reported. Here, we report our experience with 2 cases of pediatric LVRS. The first patient was a preterm infant girl with severe bronchopulmonary dysplasia, pulmonary hypertension, and hypothyroidism. The emphysematous portion of the right lung was removed via sternotomy and right hemiclamshell incision. The patient was discharged on full-time home ventilator support for 3 months after the surgery. Since then, her respiratory function has improved continuously. She no longer needs oxygen supplementation or ventilator care. Her T-cannula was removed recently. The second patient was also a preterm infant girl with bronchopulmonary dysplasia. She was born with pulmonary hypertension and multiple congenital anomalies, including an atrial septal defect. Despite receiving the best supportive care, she could not be taken off the mechanical ventilator because of severe hypercapnia. We performed LVRS on the right lung via thoracotomy. She was successfully weaned off the mechanical ventilator 1 month after the surgery. She was discharged without severe complications at 3 months after the operation. At present, she is growing well with the help of intermittent home ventilator support. She can now tolerate an oral diet. Our experience shows that LVRS can be considered as a treatment option for pediatric patients with severe emphysematous lung. It is especially helpful for discontinuing prolonged mechanical ventilator care for patients with respiratory failure. Copyright © 2018 by the American Academy of Pediatrics.

Reduction of Pulmonary Function After Surgical Lung Resections of Different Volume

PubMed Central

Cukic, Vesna

2014-01-01

Introduction: In recent years an increasing number of lung resections are being done because of the rising prevalence of lung cancer that occurs mainly in patients with limited lung function, what is caused with common etiologic factor - smoking cigarettes. Objective: To determine how big the loss of lung function is after surgical resection of lung of different range. Methods: The study was done on 58 patients operated at the Clinic for thoracic surgery KCU Sarajevo, previously treated at the Clinic for pulmonary diseases “Podhrastovi” in the period from 01.06.2012. to 01.06.2014. The following resections were done: pulmectomy (left, right), lobectomy (upper, lower: left and right). The values of postoperative pulmonary function were compared with preoperative ones. As a parameter of lung function we used FEV1 (forced expiratory volume in one second), and changes in FEV1 are expressed in liters and in percentage of the recorded preoperative and normal values of FEV1. Measurements of lung function were performed seven days before and 2 months after surgery. Results: Postoperative FEV1 was decreased compared to preoperative values. After pulmectomy the maximum reduction of FEV1 was 44%, and after lobectomy it was 22% of the preoperative values. Conclusion: Patients with airway obstruction are limited in their daily life before the surgery, and an additional loss of lung tissue after resection contributes to their inability. Potential benefits of lung resection surgery should be balanced in relation to postoperative morbidity and mortality. PMID:25568542

USE OF POSITIVE PRESSURE IN THE BARIATRIC SURGERY AND EFFECTS ON PULMONARY FUNCTION AND PREVALENCE OF ATELECTASIS: RANDOMIZED AND BLINDED CLINICAL TRIAL

PubMed Central

BALTIERI, Letícia; SANTOS, Laisa Antonela; RASERA-JUNIOR, Irineu; MONTEBELO, Maria Imaculada Lima; PAZZIANOTTO-FORTI, Eli Maria

2014-01-01

Background In surgical procedures, obesity is a risk factor for the onset of intra and postoperative respiratory complications. Aim Determine what moment of application of positive pressure brings better benefits on lung function, incidence of atelectasis and diaphragmatic excursion, in the preoperative, intraoperative or immediate postoperative period. Method Randomized, controlled, blinded study, conducted in a hospital and included subjects with BMI between 40 and 55 kg/m2, 25 and 55 years, underwent bariatric surgery by laparotomy. They were underwent preoperative and postoperative evaluations. They were allocated into four different groups: 1) Gpre: treated with positive pressure in the BiPAP mode (Bi-Level Positive Airway Pressure) before surgery for one hour; 2) Gpos: BIPAP after surgery for one hour; 3) Gintra: PEEP (Positive End Expiratory Pressure) at 10 cmH2O during the surgery; 4) Gcontrol: only conventional respiratory physiotherapy. The evaluation consisted of anthropometric data, pulmonary function tests and chest radiography. Results Were allocated 40 patients, 10 in each group. There were significant differences for the expiratory reserve volume and percentage of the predicted expiratory reserve volume, in which the groups that received treatment showed a smaller loss in expiratory reserve volume from the preoperative to postoperative stages. The postoperative radiographic analysis showed a 25% prevalence of atelectasis for Gcontrol, 11.1% for Gintra, 10% for Gpre, and 0% for Gpos. There was no significant difference in diaphragmatic mobility amongst the groups. Conclusion The optimal time of application of positive pressure is in the immediate postoperative period, immediately after extubation, because it reduces the incidence of atelectasis and there is reduction of loss of expiratory reserve volume. PMID:25409961

Use of positive pressure in the bariatric surgery and effects on pulmonary function and prevalence of atelectasis: randomized and blinded clinical trial.

PubMed

Baltieri, Letícia; Santos, Laisa Antonela; Rasera, Irineu; Montebelo, Maria Imaculada Lima; Pazzianotto-Forti, Eli Maria

2014-01-01

In surgical procedures, obesity is a risk factor for the onset of intra and postoperative respiratory complications. Determine what moment of application of positive pressure brings better benefits on lung function, incidence of atelectasis and diaphragmatic excursion, in the preoperative, intraoperative or immediate postoperative period. Randomized, controlled, blinded study, conducted in a hospital and included subjects with BMI between 40 and 55 kg/m2, 25 and 55 years, underwent bariatric surgery by laparotomy. They were underwent preoperative and postoperative evaluations. They were allocated into four different groups: 1) Gpre: treated with positive pressure in the BiPAP mode (Bi-Level Positive Airway Pressure) before surgery for one hour; 2) Gpos: BIPAP after surgery for one hour; 3) Gintra: PEEP (Positive End Expiratory Pressure) at 10 cmH2O during the surgery; 4) Gcontrol: only conventional respiratory physiotherapy. The evaluation consisted of anthropometric data, pulmonary function tests and chest radiography. Were allocated 40 patients, 10 in each group. There were significant differences for the expiratory reserve volume and percentage of the predicted expiratory reserve volume, in which the groups that received treatment showed a smaller loss in expiratory reserve volume from the preoperative to postoperative stages. The postoperative radiographic analysis showed a 25% prevalence of atelectasis for Gcontrol, 11.1% for Gintra, 10% for Gpre, and 0% for Gpos. There was no significant difference in diaphragmatic mobility amongst the groups. The optimal time of application of positive pressure is in the immediate postoperative period, immediately after extubation, because it reduces the incidence of atelectasis and there is reduction of loss of expiratory reserve volume.

Quantitative measurement of radiofrequency volumetric tissue reduction by multidetector CT in patients with inferior turbinate hypertrophy.

PubMed

Bahadir, Osman; Kosucu, Polat

2012-12-01

To objectively assess the efficacy of radiofrequency thermal ablation of inferior turbinate hypertrophy. Thirty-five patients with nasal obstruction secondary to inferior turbinate hypertrophy were prospectively enrolled. Radiofrequency energy was delivered to four sites in each inferior turbinate. Patients were evaluated before and 8 weeks after intervention. Subjective evaluation of nasal obstruction was performed using a visual analogue scale (VAS), and objective evaluation of the turbinate volume reduction was calculated using multidetector CT. Volumetric measurements of the preoperative inferior turbinate were compared with postoperative values on both sides. The great majority of patients (91.4%) exhibited subjective postoperative improvement. Mean obstruction (VAS) improved significantly from 7.45±1.48 to 3.54±1.96. Significant turbinate volume reduction was achieved by the surgery on both right and left sides [(preoperative vs. postoperative, right: 6.55±1.62cm(3) vs. 5.10±1.47cm(3), (P<0.01); left: 6.72±1.53cm(3) vs. 5.00±1.37cm(3), (P<0.01)] respectively. Radiofrequency is a safe and effective surgical procedure in reducing turbinate volume in patients with inferior turbinate hypertrophy. Multidetector CT is an objective method of assessment in detecting radiofrequency turbinate volume reduction. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Respiratory physiotherapy in the pre and postoperative myocardial revascularization surgery.

PubMed

Cavenaghi, Simone; Ferreira, Lucas Lima; Marino, Lais Helena Carvalho; Lamari, Neuseli Marino

2011-01-01

The cardiovascular diseases are among the main death causes in the developed world. They have been increasing epidemically in the developing countries. In spite of several alternatives for the treatment of the coronary artery disease; the surgery of the myocardial revascularization is an option with proper indications of medium and long-term with good results. It provides the remission of the angina symptoms contributing to the increase of the expectation and improvement of the life quality. Most of patients undergoing myocardial revascularization surgery develop postoperative lung dysfunction with important reduction of the lung volumes, damages in the respiratory mechanism, decrease in the lung indulgence and increase of the respiratory work. The reduction of volumes and lung capacities can contribute to alterations in the gas exchanges, resulting in hypoxemia and decrease in the diffusion capacity. Taking this into account, the Physiotherapy has been requested more and more to perform in the pre as well as in the postoperative period of this surgery. This study aimed at updating the knowledge regarding the respiratory physiotherapy performance in the pre and postoperative period of the myocardial revascularization surgery enhancing the prevention of lung complications. The Physiotherapy uses several techniques in the preoperative period; such as: the incentive spirometry, exercises of deep breathing, cough, inspiratory muscle training, earlier ambulation and physiotherapeutic orientations. While in the postoperative period, the objective is the treatment after lung complications took place, performed by means of physiotherapeutic maneuvers and noninvasive respiratory devices, aiming at improving the respiratory mechanism, the lung reexpansion and the bronchial hygiene. Respiratory physiotherapy is an integral part in the care management of the patient with cardiopathy, either in the pre or in the postoperative period, since it contributes significantly to a better prognosis of these patients with the use of specific techniques.

Physician Reaction to Price Changes: An Episode-of-Care Analysis

PubMed Central

Lee, A. James; Mitchell, Janet B.

1994-01-01

Physicians may respond to fee reductions in a variety of ways. This episode-of-care analysis examines the impact of surgical fee reductions (mandated by the Omnibus Budget Reconciliation Acts [OBRAs] of 1986-87) on the overall pattern and cost of health care services provided in association with the surgical procedure itself. The study focuses on six procedure groups: cataract extractions; total hip replacement; total knee replacement; coronary artery bypass graft (CABG) surgery; upper gastrointestinal (GI) endoscopy; and prostatectomy. Only two of these procedures give significant evidence for the existence of a service volume offset to the fee reductions. PMID:10172299

Effectiveness and efficacy of minimally invasive lung volume reduction surgery for emphysema

PubMed Central

Pertl, Daniela; Eisenmann, Alexander; Holzer, Ulrike; Renner, Anna-Theresa; Valipour, A.

2014-01-01

Lung emphysema is a chronic, progressive and irreversible destruction of the lung tissue. Besides non-medical therapies and the well established medical treatment there are surgical and minimally invasive methods for lung volume reduction (LVR) to treat severe emphysema. This report deals with the effectiveness and cost-effectiveness of minimally invasive methods compared to other treatments for LVR in patients with lung emphysema. Furthermore, legal and ethical aspects are discussed. No clear benefit of minimally invasive methods compared to surgical methods can be demonstrated based on the identified and included evidence. In order to assess the different methods for LVR regarding their relative effectiveness and safety in patients with lung emphysema direct comparative studies are necessary. PMID:25295123

Effectiveness and efficacy of minimally invasive lung volume reduction surgery for emphysema.

PubMed

Pertl, Daniela; Eisenmann, Alexander; Holzer, Ulrike; Renner, Anna-Theresa; Valipour, A

2014-01-01

Lung emphysema is a chronic, progressive and irreversible destruction of the lung tissue. Besides non-medical therapies and the well established medical treatment there are surgical and minimally invasive methods for lung volume reduction (LVR) to treat severe emphysema. This report deals with the effectiveness and cost-effectiveness of minimally invasive methods compared to other treatments for LVR in patients with lung emphysema. Furthermore, legal and ethical aspects are discussed. No clear benefit of minimally invasive methods compared to surgical methods can be demonstrated based on the identified and included evidence. In order to assess the different methods for LVR regarding their relative effectiveness and safety in patients with lung emphysema direct comparative studies are necessary.

Single-Site Cannulation Venovenous Extracorporeal CO2 Removal as Bridge to Lung Volume Reduction Surgery in End-Stage Lung Emphysema.

PubMed

Redwan, Bassam; Ziegeler, Stephan; Semik, Michael; Fichter, Joachim; Dickgreber, Nicolas; Vieth, Volker; Ernst, Erik Christian; Fischer, Stefan

Lung volume reduction surgery (LVRS) is an important treatment option for end-stage lung emphysema in carefully selected patients. Here, we first describe the application of low-flow venovenous extracorporeal CO2 removal (LFVV-ECCO2R) as bridge to LVRS in patients with end-stage lung emphysema experiencing severe hypercapnia caused by acute failure of the breathing pump. Between March and October 2015, n = 4 patients received single-site LFVV-ECCO2R as bridge to LVRS. Indication for extracorporeal lung support was severe hypercapnia with respiratory acidosis and acute breathing pump failure. Two patients required continuous mechanical ventilation over a temporary tracheostomy and were bed ridden. The other two patients were nearly immobile because of severe dyspnea at rest. Length of preoperative ECCO2R was 14 (1-42) days. All patients underwent unilateral LVRS. Anatomical resection of the right (n = 3) or left (n = 1) upper lobe was performed. Postoperatively, both patients with previous mechanical ventilatory support were successfully weaned. ECCO2R in patients with end-stage lung emphysema experiencing severe hypercapnia caused by acute breathing pump failure is a safe and effective bridging tool to LVRS. In such patients, radical surgery leads to a significant improvement of the performance status and furthermore facilitates respiratory weaning from mechanical ventilation.

The Role of Oncoplastic Breast Surgery in Breast Cancer Treatment

PubMed Central

Emiroğlu, Mustafa; Sert, İsmail; İnal, Abdullah

2015-01-01

The aim of this study is to discuss indications, advantages, disadvantages, oncologic and aesthetic results of Oncoplastic Surgery (OBS). Pubmed and Medline database were searched for articles published between 1998 and 2014 for keywords: oncoplastic breast surgery, therapeutic mammoplasty, oncoplastic breast reduction, synchrenous reconstructions. Role of OBS in breast cancer surgery, its aspects to be considered, its value and results have been interpreted. This technique has advantages by providing more extensive tumourectomy, yielding better aesthetic results compared with breast conserving surgery, allowing oncoplastic reduction in breast cancer patients with macromastia, with higher patient satisfaction and quality of life and by being inexpensive due to single session practice. As for its disadvantages are: re-excision is more difficult, risk for mastectomy is higher, it is depent on the Surgeron’s experience, it has a risk for delay in adjuvant therapies and its requirement for additional imaging studies during management. Main indications are patients with small tumour/breast volume, macromastia, multifocality, procedures which can disrupt breast cosmesis such as surgeries for upper inner breas tquadrient tumours. Contraindications are positive margin problems after wide excision, diffuse malign microcalsifications, inflammatory breast cancer, history of radiotherapy and patients’ preferences. Despite low evidence level, Oncoplastic Breast Surgery seems to be both reliable and acceptable in terms of oncologic and aesthetic aspects. Oncoplastic Breast Surgery increase the application rate of breast conserving surgery by obviating practical limitations and improve the results of breast conserving surgery. Correct patient and technique choice in OBS is vital for optimization of post surgical PMID:28331682

Lung volume reduction surgery for diffuse emphysema.

PubMed

van Agteren, Joseph Em; Carson, Kristin V; Tiong, Leong Ung; Smith, Brian J

2016-10-14

Lung volume reduction surgery (LVRS) performed to treat patients with severe diffuse emphysema was reintroduced in the nineties. Lung volume reduction surgery aims to resect damaged emphysematous lung tissue, thereby increasing elastic properties of the lung. This treatment is hypothesised to improve long-term daily functioning and quality of life, although it may be costly and may be associated with risks of morbidity and mortality. Ten years have passed since the last version of this review was prepared, prompting us to perform an update. The objective of this review was to gather all available evidence from randomised controlled trials comparing the effectiveness of lung volume reduction surgery (LVRS) versus non-surgical standard therapy in improving health outcomes for patients with severe diffuse emphysema. Secondary objectives included determining which subgroup of patients benefit from LVRS and for which patients LVRS is contraindicated, to establish the postoperative complications of LVRS and its morbidity and mortality, to determine which surgical approaches for LVRS are most effective and to calculate the cost-effectiveness of LVRS. We identified RCTs by using the Cochrane Airways Group Chronic Obstructive Pulmonary Disease (COPD) register, in addition to the online clinical trials registers. Searches are current to April 2016. We included RCTs that studied the safety and efficacy of LVRS in participants with diffuse emphysema. We excluded studies that investigated giant or bullous emphysema. Two independent review authors assessed trials for inclusion and extracted data. When possible, we combined data from more than one study in a meta-analysis using RevMan 5 software. We identified two new studies (89 participants) in this updated review. A total of 11 studies (1760 participants) met the entry criteria of the review, one of which accounted for 68% of recruited participants. The quality of evidence ranged from low to moderate owing to an unclear risk of bias across many studies, lack of blinding and low participant numbers for some outcomes. Eight of the studies compared LVRS versus standard medical care, one compared two closure techniques (stapling vs laser ablation), one looked at the effect of buttressing the staple line on the effectiveness of LVRS and one compared traditional 'resectional' LVRS with a non-resectional surgical approach. Participants completed a mandatory course of pulmonary rehabilitation/physical training before the procedure commenced. Short-term mortality was higher for LVRS (odds ratio (OR) 6.16, 95% confidence interval (CI) 3.22 to 11.79; 1489 participants; five studies; moderate-quality evidence) than for control, but long-term mortality favoured LVRS (OR 0.76, 95% CI 0.61 to 0.95; 1280 participants; two studies; moderate-quality evidence). Participants identified post hoc as being at high risk of death from surgery were those with particularly impaired lung function, poor diffusing capacity and/or homogenous emphysema. Participants with upper lobe-predominant emphysema and low baseline exercise capacity showed the most favourable outcomes related to mortality, as investigators reported no significant differences in early mortality between participants treated with LVRS and those in the control group (OR 0.87, 95% CI 0.23 to 3.29; 290 participants; one study), as well as significantly lower mortality at the end of follow-up for LVRS compared with control (OR 0.45, 95% CI 0.26 to 0.78; 290 participants; one study). Trials in this review furthermore provided evidence of low to moderate quality showing that improvements in lung function parameters other than forced expiratory volume in one second (FEV 1 ), quality of life and exercise capacity were more likely with LVRS than with usual follow-up. Adverse events were more common with LVRS than with control, specifically the occurrence of (persistent) air leaks, pulmonary morbidity (e.g. pneumonia) and cardiovascular morbidity. Although LVRS leads to an increase in quality-adjusted life-years (QALYs), the procedure is relatively costly overall. Lung volume reduction surgery, an effective treatment for selected patients with severe emphysema, may lead to better health status and lung function outcomes, specifically for patients who have upper lobe-predominant emphysema with low exercise capacity, but the procedure is associated with risks of early mortality and adverse events.

Hand surgery volume and the US economy: is there a statistical correlation?

PubMed

Gordon, Chad R; Pryor, Landon; Afifi, Ahmed M; Gatherwright, James R; Evans, Peter J; Hendrickson, Mark; Bernard, Steven; Zins, James E

2010-11-01

To the best of our knowledge, there have been no previous studies evaluating the correlation of the US economy and hand surgery volume. Therefore, in light of the current recession, our objective was to study our institution's hand surgery volume over the last 17 years in relation to the nation's economy. A retrospective analysis of our institution's hand surgery volume, as represented by our most common procedure (ie, carpal tunnel release), was performed between January 1992 and October 2008. Liposuction and breast augmentation volumes were chosen to serve as cosmetic plastic surgery comparison groups. Pearson correlation statistics were used to estimate the relationship between the surgical volume and the US economy, as represented by the 3 market indices (Dow Jones, NASDAQ, and S&P500). A combined total of 7884 hand surgery carpal tunnel release (open or endoscopic) patients were identified. There were 1927 (24%) and 5957 (76%) patients within the departments of plastic and orthopedic surgery, respectively. In the plastic surgery department, there was a strong negative (ie, inverse relationship) correlation between hand surgery volume and the economy (P < 0.001). In converse, the orthopedic department's hand surgery volume demonstrated a positive (ie, parallel) correlation (P < 0.001). The volumes of liposuction and breast augmentation also showed a positive correlation (P < 0.001). To our knowledge, we have demonstrated for the first time an inverse (ie, negative) correlation between hand surgery volumes performed by plastic surgeons in relation to the US economy, as represented by the 3 major market indices. In contrast, orthopedic hand surgery volume and cosmetic surgery show a parallel (ie, positive) correlation. This data suggests that plastic surgeons are increasing their cosmetic surgery-to-reconstructive/hand surgery ratio during strong economic times and vice versa during times of economic slowdown.

Reduction of Costs for Pelvic Exenteration Performed by High Volume Surgeons: Analysis of the Maryland Health Service Cost Review Commission Database.

PubMed

Althumairi, Azah A; Canner, Joseph K; Gorin, Michael A; Fang, Sandy H; Gearhart, Susan L; Wick, Elizabeth C; Safar, Bashar; Bivalacqua, Trinity J; Efron, Jonathan E

2016-01-01

High volume hospitals (HVHs) and high volume surgeons (HVSs) have better outcomes after complex procedures, but the association between surgeon and hospital volumes and patient outcomes is not completely understood. Our aim was to evaluate the impact of surgeon and hospital volumes, and their interaction, on postoperative outcomes and costs in patients undergoing pelvic exenteration (PE) in the state of Maryland. A review of the Maryland Health Services Cost Review Commission database between 2000 and 2011 was performed. Patients were compared for demographics and clinical variables. The differences in length of hospital stay , length of intensive care unit (ICU) stay, operating room (OR) cost, and total cost were compared for surgeon volume and hospital volume controlling for all other factors. Surgery performed by HVS at HVH had the shortest ICU stay and lowest OR cost. When PE was performed by a low volume surgeon at an HVH, the OR cost and total cost were the highest and increased by $2,683 (P < 0.0001) and $16,076 (P < 0.0001), respectively. OR costs reduced when surgery was performed by an HVS at an HVH ($-1632, P = 0.008). PE performed by HVS at HVH is significantly associated with lower OR costs and ICU stay. We feel this is indicative of lower complication rates and higher quality care.

Colorectal Surgery Fellowship Improves In-hospital Mortality After Colectomy and Proctectomy Irrespective of Hospital and Surgeon Volume.

PubMed

Saraidaridis, Julia T; Hashimoto, Daniel A; Chang, David C; Bordeianou, Liliana G; Kunitake, Hiroko

2018-03-01

General surgery residents are increasingly pursuing sub-specialty training in colorectal (CR) surgery. However, the majority of operations performed by CR surgeons are also performed by general surgeons. This study aimed to assess in-hospital mortality stratified by CR training status after adjusting for surgeon and hospital volume. The Statewide Planning and Research Cooperative system database was used to identify all patients who underwent colectomy/proctectomy from January 1, 2000, to December 31, 2014, in the state of New York. Operations performed by board-certified CR surgeons were identified. The relationships between CR board certification and in-hospital mortality, in-hospital complications, length of stay, and ostomy were assessed using multivariate regression models. Two hundred seventy thousand six hundred eighty-four patients underwent colectomy/proctectomy over the study period. Seventy-two thousand two hundred seventy-nine (26.7%) of operations were performed by CR surgeons. Without adjusting for hospital and surgeon volume, in-hospital mortality was lower for those undergoing colectomy/proctectomy by a CR surgeon (OR 0.49, CI 0.44-0.54, p = 0.001). After controlling for hospital and surgeon volume, the odds of inpatient mortality after colectomy/proctectomy for those operated on by CR surgeons weakened to 0.76 (CI 0.68-0.86, p = 0.001). Hospital and surgeon volume accounted for 53% of the reduction in in-hospital mortality when CR surgeons performed colectomy/proctectomy. Patients who underwent surgery by a CR surgeon had a shorter inpatient stay (0.8 days, p = 0.001) and a decreased chance of colostomy (OR 0.86, CI 0.78-0.95, p < 0.001). For patients undergoing colectomy/proctectomy, in-hospital mortality decreased when the operation was performed by a CR surgeon even after accounting for hospital and surgeon volume.

Preoperative weight loss program targeting women with overweight and hypertrophy of the breast - a pilot study.

PubMed

Geiker, N R W; Horn, J; Astrup, A

2017-04-01

Among women with hypertrophic breasts, the clear majority are overweight or obese. Owing to increased risk of complications, women with a body mass index (BMI) above 25 kg m -2 are precluded from reduction mammaplasty. The primary aim was to investigate if intensive weight loss could ready women with overweight for breast reduction surgery. Six women, all overweight [BMI 30.9 {28.5; 35.8} kg m -2 ] with symptomatic hypertrophy of the breast, were included a 12-week weight loss program. All women desired reduction mammaplasty and were motivated for preoperational weight loss. The first 8 weeks consisted of a formula-based diet supplying 800 kcal daily, in the subsequent 4 weeks regular foods were reintroduced increasing the intake to 1200 kcal daily. Five women completed the trial, and achieved a median (range) weight loss of 10.2 (6.5; 19) kg. Initial breast volume was 1100-2500 mL per breast, this was reduced by 300 (200; 500) mL after the intervention; equivalent to approximately 19%. Waist, hip, upper arm and thorax circumference were significantly reduced following weight loss. At end of study, all the women still suffered from symptomatic breast hypertrophy to substantiate reduction mammaplasty. Surgeries were performed 2 months thereafter. A 12-week intensive preoperative weight loss program enabled women with obesity for breast reduction surgery. Breast size was reduced proportionally more than total weight loss among women with hypertrophy. © 2017 World Obesity Federation.

Effect of Esophageal Cancer Surgeon Volume on Management and Mortality From Emergency Upper Gastrointestinal Conditions: Population-based Cohort Study.

PubMed

Markar, Sheraz R; Mackenzie, Hugh; Askari, Alan; Faiz, Omar; Hanna, George B

2017-11-01

To study the influence of esophageal cancer surgeon volume upon mortality from upper gastrointestinal emergencies. Volume-outcome relationships led to the centralization of esophageal cancer surgery. Hospital Episode Statistics data were used to identify patients admitted to hospitals within England (1997-2012). The influence of esophageal high-volume (HV) cancer surgeon status (≥5 resections per year) upon 30-day and 90-day mortality from esophageal perforation (EP), paraesophageal hernia causing obstruction or gangrene (PEH) and perforated peptic ulcer (PPU) was analyzed, independent of HV esophageal cancer center status and patient and disease-specific confounding factors. A total of 3707, 12,411, and 57,164 patients with EP, PEH, and PPU, respectively, were included. The observed 90-day mortality was 36.5%, 11.5%, and 29.0% for EP, PEH, and PPU, respectively.Management by HV cancer surgeon was independently associated with significant reductions in 30-day and 90-day mortality from EP (odds ratio, OR 0.51, 95% confidence interval, CI, 0.40-0.66), PEH (OR=0.70, 95% CI 0.53-0.91), and PPU (OR=0.85, 95% CI 0.7-0.95). Subset analysis of those patients receiving primary surgery as treatment showed no change in mortality when performed by HV cancer surgeons.However HV cancer surgeons performed surgery as primary treatment more commonly for EP (OR=2.38, 95% CI 1.87-3.04) and PEH (OR=2.12, 95% CI 1.79-2.51). Furthermore surgery was independently associated with reduced mortality for all 3 conditions. The complex elective workload of HV esophageal cancer surgeons appears to lower the threshold for surgical intervention in specific upper gastrointestinal emergencies such as EP and PEH, which in turn reduces mortality.

Benign thyroid nodule unresponsive to radiofrequency ablation treated with laser ablation: a case report.

PubMed

Oddo, Silvia; Balestra, Margherita; Vera, Lara; Giusti, Massimo

2018-05-11

Radiofrequency ablation and laser ablation are safe and effective techniques for reducing thyroid nodule volume, neck symptoms, and cosmetic complaints. Therapeutic success is defined as a nodule reduction > 50% between 6 and 12 months after the procedure, but a percentage of nodules inexplicably do not respond to thermal ablation. We describe the case of a young Caucasian woman with a solid benign thyroid nodule who refused surgery and who had undergone radiofrequency ablation in 2013. The nodule did not respond in terms of either volume reduction or improvement in neck symptoms. After 2 years, given the patient's continued refusal of thyroidectomy, we proposed laser ablation. The nodule displayed a significant volume reduction (- 50% from radiofrequency ablation baseline volume, - 57% from laser ablation baseline), and the patient reported a significant improvement in neck symptoms (from 6/10 to 1/10 on a visual analogue scale). We conjecture that some benign thyroid nodules may be intrinsically resistant to necrosis when one specific ablation technique is used, but may respond to another technique. To the best of our knowledge, this is the first description of the effect of performing a different percutaneous ablation technique in a nodule that does not respond to radiofrequency ablation.

Impact of acute care surgery to departmental productivity.

PubMed

Barnes, Stephen L; Cooper, Christopher J; Coughenour, Jeffrey P; MacIntyre, Allan D; Kessel, James W

2011-10-01

The face of trauma surgery is rapidly evolving with a paradigm shift toward acute care surgery (ACS). The formal development of ACS has been viewed by some general surgeons as a threat to their practice. We sought to evaluate the impact of a new division of ACS to both departmental productivity and provider satisfaction at a University Level I Trauma Center. Two-year retrospective analysis of annual work relative value unit (wRVU) productivity, operative volume, and FTEs before and after establishment of an ACS division at a University Level I trauma center. Provider satisfaction was measured using a 10-point scale. Analysis completed using Microsoft Excel with a p value less than 0.05 significant. The change to an ACS model resulted in a 94% increase in total wRVU production (78% evaluation and management, 122% operative; p<0.05) for ACS, whereas general surgery wRVU production increased 8% (-15% evaluation and management, 14% operative; p<0.05). Operative productivity was substantial after transition to ACS, with 129% and 44% increases (p<0.05) in operative and elective case load, respectively. Decline in overall general surgery operative volume was attributed to reduction in emergent cases. Establishment of the ACS model necessitated one additional FTE. Job satisfaction substantially improved with the ACS model while allowing general surgery a more focused practice. The ACS practice model significantly enhances provider productivity and job satisfaction when compared with trauma alone. Fears of a productivity impact to the nontrauma general surgeon were not realized.

Characterization of Chronic Aortic and Mitral Regurgitation Undergoing Valve Surgery Using Cardiovascular Magnetic Resonance.

PubMed

Polte, Christian L; Gao, Sinsia A; Johnsson, Åse A; Lagerstrand, Kerstin M; Bech-Hanssen, Odd

2017-06-15

Grading of chronic aortic regurgitation (AR) and mitral regurgitation (MR) by cardiovascular magnetic resonance (CMR) is currently based on thresholds, which are neither modality nor quantification method specific. Accordingly, this study sought to identify CMR-specific and quantification method-specific thresholds for regurgitant volumes (RVols), RVol indexes, and regurgitant fractions (RFs), which denote severe chronic AR or MR with an indication for surgery. The study comprised patients with moderate and severe chronic AR (n = 38) and MR (n = 40). Echocardiography and CMR was performed at baseline and in all operated AR/MR patients (n = 23/25) 10 ± 1 months after surgery. CMR quantification of AR: direct (aortic flow) and indirect method (left ventricular stroke volume [LVSV] - pulmonary stroke volume [PuSV]); MR: 2 indirect methods (LVSV - aortic forward flow [AoFF]; mitral inflow [MiIF] - AoFF). All operated patients had severe regurgitation and benefited from surgery, indicated by a significant postsurgical reduction in end-diastolic volume index and improvement or relief of symptoms. The discriminatory ability between moderate and severe AR was strong for RVol >40 ml, RVol index >20 ml/m 2 , and RF >30% (direct method) and RVol >62 ml, RVol index >31 ml/m 2 , and RF >36% (LVSV-PuSV) with a negative likelihood ratio ≤ 0.2. In MR, the discriminatory ability was very strong for RVol >64 ml, RVol index >32 ml/m 2 , and RF >41% (LVSV-AoFF) and RVol >40 ml, RVol index >20 ml/m 2 , and RF >30% (MiIF-AoFF) with a negative likelihood ratio < 0.1. In conclusion, CMR grading of chronic AR and MR should be based on modality-specific and quantification method-specific thresholds, as they differ largely from recognized guideline criteria, to assure appropriate clinical decision-making and timing of surgery. Copyright © 2017 Elsevier Inc. All rights reserved.

Is there a role for homeopathy in breast cancer surgery? A first randomized clinical trial on treatment with Arnica montana to reduce post-operative seroma and bleeding in patients undergoing total mastectomy.

PubMed

Sorrentino, Luca; Piraneo, Salvatore; Riggio, Eliana; Basilicò, Silvia; Sartani, Alessandra; Bossi, Daniela; Corsi, Fabio

2017-01-01

This study aimed to evaluate the benefits of Arnica montana on post-operative blood loss and seroma production in women undergoing unilateral total mastectomy by administering Arnica Montana 1000 Korsakovian dilution (1000 K). From 2012 to 2014, 53 women were randomly assigned to A. montana or placebo and were followed up for 5 days. The main end point was the reduction in blood and serum volumes collected in drainages. Secondary end points were duration of drainage, a self-evaluation of pain, and the presence of bruising or hematomas. The per-protocol analysis revealed a lower mean volume of blood and serum collected in drainages with A. montana (-94.40 ml; 95% confidence interval [CI]: 22.48-211.28; P = 0.11). A regression model including treatment, volume collected in the drainage on the day of surgery, and patient weight showed a statistically significant difference in favor of A. montana (-106.28 ml; 95% CI: 9.45-203.11; P = 0.03). Volumes collected on the day of surgery and the following days were significantly lower with A. montana at days 2 ( P = 0.033) and 3 ( P = 0.0223). Secondary end points have not revealed significant differences. A. montana 1000 K could reduce post-operative blood and seroma collection in women undergoing unilateral total mastectomy. Larger studies are needed with different dilutions of A. montana to further validate these data.

Counterclockwise maxillomandibular advancement surgery and disc repositioning: can condylar remodeling in the long-term follow-up be predicted?

PubMed

Gomes, L R; Cevidanes, L H; Gomes, M R; Ruellas, A C; Ryan, D P; Paniagua, B; Wolford, L M; Gonçalves, J R

2017-12-01

This study investigated predictive risk factors of condylar remodeling changes after counterclockwise maxillomandibular advancement (CCW-MMA) and disc repositioning surgery. Forty-one female patients (75 condyles) treated with CCW-MMA and disc repositioning had cone beam computed tomography (CBCT) scans taken pre-surgery, immediately after surgery, and at an average 16 months post-surgery. Pre- and post-surgical three-dimensional models were superimposed using automated voxel-based registration on the cranial base to evaluate condylar displacements after surgery. Regional registration was performed to assess condylar remodeling in the follow-up period. Three-dimensional cephalometrics, shape correspondence (SPHARM-PDM), and volume measurements were applied to quantify changes. Pearson product-moment correlations and multiple regression analysis were performed. Highly statistically significant correlation showed that older patients were more susceptible to overall condylar volume reduction following CCW-MMA and disc repositioning (P≤0.001). Weak but statistically significant correlations were observed between condylar remodeling changes in the follow-up period and pre-surgical facial characteristics, magnitude of the surgical procedure, and condylar displacement changes. After CCW-MMA and disc repositioning, the condyles moved mostly downwards and medially, and were rotated medially and counterclockwise; displacements in the opposite direction were correlated with a greater risk of condylar resorption. Moreover, positional changes with surgery were only weakly associated with remodeling in the follow-up period, suggesting that other risk factors may play a role in condylar resorption. Copyright © 2017 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

A double-blind, placebo-controlled trial of epsilon-aminocaproic acid for reducing blood loss in coronary artery bypass grafting surgery.

PubMed

Kikura, Mutsuhito; Levy, Jerrold H; Tanaka, Kenichi A; Ramsay, James G

2006-02-01

Epsilon-aminocaproic acid is a plasmin inhibitor that potentially reduces perioperative bleeding when administered prophylactically to cardiac surgery patients. To evaluate the efficacy of epsilon-aminocaproic acid, a prospective placebo-controlled trial was conducted in patients undergoing primary coronary artery bypass grafting surgery. One hundred patients were randomly assigned to receive either epsilon-aminocaproic acid (100 mg/kg before skin incision followed by 1 g/hour continuous infusion until chest closure, 10 g in cardiopulmonary bypass circuit) or placebo, and the efficacy of epsilon-aminocaproic acid was evaluated by the reduction in postoperative thoracic-drainage volume and in donor-blood transfusion up to postoperative day 12. Postoperative thoracic-drainage volume was significantly lower in the epsilon-aminocaproic acid group compared with the placebo group (epsilon-aminocaproic acid, 649 +/- 261 mL; versus placebo, 940 +/- 626 mL; p=0.003). There were no significant differences between the epsilon-aminocaproic acid and placebo groups in the percentage of patients requiring donor red blood cell transfusions (epsilon-aminocaproic acid, 24%; versus placebo, 18%; p=0.62) or in the number of units of donor red blood cells transfused (epsilon-aminocaproic acid, 2.2 +/- 0.8 U; versus placebo, 1.9 +/- 0.8 U; p=0.29). Epsilon-aminocaproic acid did not reduce the risk of donor red blood cell transfusions compared with placebo (odds ratio: 1.2, 95% confidence interval; 0.4 to 3.2, p=0.63). Prophylactic administration of epsilon-aminocaproic acid reduces postoperative thoracic-drainage volume by 30%, but it may not be potent enough to reduce the requirement and the risk for donor blood transfusion in cardiac surgery patients. This information is useful for deciding on a therapy for hemostasis in cardiac surgery.

A rational approach to estimating the surgical demand elasticity needed to guide manpower reallocation during contagious outbreaks.

PubMed

Tsao, Hsiao-Mei; Sun, Ying-Chou; Liou, Der-Ming

2015-01-01

Emerging infectious diseases continue to pose serious threats to global public health. So far, however, few published study has addressed the need for manpower reallocation needed in hospitals when such a serious contagious outbreak occurs. To quantify the demand elasticity of the major surgery types in order to guide future manpower reallocation during contagious outbreaks. Based on a nationwide research database in Taiwan, we extracted the monthly volumes of major surgery types for the period 1998-2003, which covered the SARS period, in order to carry out a time series analysis. The demand elasticity of each surgery type was then estimated by autoregressive integrated moving average (ARIMA) analysis. During the study period, the surgical volumes of most selected surgery types either increased or remained steady. We categorized these surgery types into low-, moderate- and high-elastic groups according to their demand elasticity. Appendectomy, 'open reduction of fracture with internal fixation' and 'free skin graft' were in the low demand elasticity group. Transurethral prostatectomy and extracorporeal shockwave lithotripsy (ESWL) were in the high demand elasticity group. The manpower of the departments carrying out the surgeries with low demand elasticity should be maintained during outbreaks. In contrast, departments in charge of surgeries mainly with high demand elasticity, like urology departments, may be in a position to have part of their staff reallocated. Taking advantage of the demand variation during the SARS period in 2003, we adopted the concept of demand elasticity and used a time series approach to figure out an effective index of demand elasticity for various types of surgery that could be used as a rational reference to carry out manpower reallocation during contagious outbreak situations.

A Rational Approach to Estimating the Surgical Demand Elasticity Needed to Guide Manpower Reallocation during Contagious Outbreaks

PubMed Central

Tsao, Hsiao-Mei; Sun, Ying-Chou; Liou, Der-Ming

2015-01-01

Background Emerging infectious diseases continue to pose serious threats to global public health. So far, however, few published study has addressed the need for manpower reallocation needed in hospitals when such a serious contagious outbreak occurs. Aim To quantify the demand elasticity of the major surgery types in order to guide future manpower reallocation during contagious outbreaks. Materials and Methods Based on a nationwide research database in Taiwan, we extracted the monthly volumes of major surgery types for the period 1998–2003, which covered the SARS period, in order to carry out a time series analysis. The demand elasticity of each surgery type was then estimated by autoregressive integrated moving average (ARIMA) analysis. Results During the study period, the surgical volumes of most selected surgery types either increased or remained steady. We categorized these surgery types into low-, moderate- and high-elastic groups according to their demand elasticity. Appendectomy, ‘open reduction of fracture with internal fixation’ and ‘free skin graft’ were in the low demand elasticity group. Transurethral prostatectomy and extracorporeal shockwave lithotripsy (ESWL) were in the high demand elasticity group. The manpower of the departments carrying out the surgeries with low demand elasticity should be maintained during outbreaks. In contrast, departments in charge of surgeries mainly with high demand elasticity, like urology departments, may be in a position to have part of their staff reallocated. Conclusions Taking advantage of the demand variation during the SARS period in 2003, we adopted the concept of demand elasticity and used a time series approach to figure out an effective index of demand elasticity for various types of surgery that could be used as a rational reference to carry out manpower reallocation during contagious outbreak situations. PMID:25837596

Percutaneous treatment of symptomatic non-parasitic hepatic cysts. Initial experience with single-session sclerotherapy with polidocanol.

PubMed

Spârchez, Zeno; Radu, Pompilia; Zaharie, Florin; Al Hajjar, Nadim; Sparchez, Mihaela

2014-09-01

Hepatic cysts have a prevalence of 2.5-7% and most of them are asymptomatic. However, large cysts may cause complaints; in such cases an appropriate treatment is necessary (open surgery, laparoscopic deroofing, removal of cystic fluid and injection of a sclerosing agent. The aim of this study was to assess the efficacy and safety of a single session technique with polidocanol in the therapy of symptomatic non parasitic hepatic cysts. MATERIAL AND METHODS. The study included 13 patients with symptomatic liver cysts (range 4-10 cm). All patients underwent percutaneous aspiration of the liver cyst under ultrasound guidance followed by instillation of polidocanol (3%, 4-10 ml). The patients were followed up at 1, 3 and 12 months. The disappearance of the cyst or reduction in volume more than 90% was considered successful. If the fluid was accumulated at 1month the procedure was repeated. If after the second injection the fluid accumulation was more than 50% of the initial volume the case was considered a failure and a laparoscopic deroofing was performed. The procedure was successful in 10 patients, 9 after the first instillation and one after the second (76.9%). The mean initial volume of cysts was 228 ml, and the mean reduction in volume at 1, 3 and 12 months was 80.2%, 91.9% and 96.7%. The cyst resolution was gradual with clinically significant cyst reduction achievement within 1 year after therapy. In 3 patients the fluid reaccumulated at the same volume despite 2 instillations. Those 3 cases the procedure was considered failure and the patients were sent to surgery. In 2 patients (one successfully treated and one with treatment failure) bleeding during the first puncture and aspiration appeared and the therapy was postponed for 1 month. There were no significant adverse effects, and all the patients had relief of symptoms after therapy. This initial experience with percutaneous aspiration and polidocanol sclerosis of hepatic cysts demonstrated that the technique is efficient and safe.

The effect of lung volume reduction surgery on chronic obstructive pulmonary disease exacerbations.

PubMed

Washko, George R; Fan, Vincent S; Ramsey, Scott D; Mohsenifar, Zab; Martinez, Fernando; Make, Barry J; Sciurba, Frank C; Criner, Gerald J; Minai, Omar; Decamp, Malcolm M; Reilly, John J

2008-01-15

Lung volume reduction surgery (LVRS) has been demonstrated to provide a functional and mortality benefit to a select group of subjects with chronic obstructive pulmonary disease (COPD). The effect of LVRS on COPD exacerbations has not been as extensively studied, and whether improvement in postoperative lung function alters the risk of disease exacerbations is not known. To examine the effect, and mechanism of potential benefit, of LVRS on COPD exacerbations by comparing the medical and surgical cohorts of the National Emphysema Treatment Trial (NETT). A COPD exacerbation was defined using Centers for Medicare and Medicaid Services data and International Classification of Diseases, Ninth Revision, discharge diagnosis. There was no difference in exacerbation rate or time to first exacerbation between the medical and surgical cohorts during the year before study randomization (P = 0.58 and 0.85, respectively). Postrandomization, the surgical cohort experienced an approximate 30% reduction in exacerbation frequency (P = 0.0005). This effect was greatest in those subjects with the largest postoperative improvement in FEV(1) (P = 0.04) when controlling for changes in other spirometric measures of lung function, lung capacities, and room air arterial blood gas tensions. Finally, LVRS increased the time to first exacerbation in both those subjects with and those without a prior history of exacerbations (P = 0.0002 and P < 0.0001, respectively). LVRS reduces the frequency of COPD exacerbations and increases the time to first exacerbation. One explanation for this benefit may be the postoperative improvement in lung function.

Improvement in lung function and functional capacity in morbidly obese women subjected to bariatric surgery.

PubMed

Campos, Elaine Cristina de; Peixoto-Souza, Fabiana Sobral; Alves, Viviane Cristina; Basso-Vanelli, Renata; Barbalho-Moulim, Marcela; Laurino-Neto, Rafael Melillo; Costa, Dirceu

2018-03-15

To determine whether weight loss in women with morbid obesity subjected to bariatric surgery alters lung function, respiratory muscle strength, functional capacity and the level of habitual physical activity and to investigate the relationship between these variables and changes in both body composition and anthropometrics. Twenty-four women with morbid obesity were evaluated with regard to lung function, respiratory muscle strength, functional capacity, body composition, anthropometrics and the level of habitual physical activity two weeks prior to and six months after bariatric surgery. Regarding lung function, mean increases of 160 mL in slow vital capacity, 550 mL in expiratory reserve volume, 290 mL in forced vital capacity and 250 mL in forced expiratory volume in the first second as well as a mean reduction of 490 mL in inspiratory capacity were found. Respiratory muscle strength increased by a mean of 10 cmH2O of maximum inspiratory pressure, and a 72-meter longer distance on the Incremental Shuttle Walk Test demonstrated that functional capacity also improved. Significant changes also occurred in anthropometric variables and body composition but not in the level of physical activity detected using the Baecke questionnaire, indicating that the participants remained sedentary. Moreover, correlations were found between the percentages of lean and fat mass and both inspiratory and expiratory reserve volumes. The present data suggest that changes in body composition and anthropometric variables exerted a direct influence on functional capacity and lung function in the women analyzed but exerted no influence on sedentarism, even after accentuated weight loss following bariatric surgery.

[Condylar hyperplasia: qualitative and quantitative study of temporomandibular joints remodeling before and after condylectomy].

PubMed

Rojare, Camille; Wojcik, Thomas; Coussens, Camille; Ferri, Joël; Pertuzon, Bruno; Raoul, Gwénaël

2014-06-01

This retrospective study aimed to evaluate bone remodeling of temporo-mandibular joints (TMJ) using computed tomography (CT) before and after condylectomy for condylar hyperplasia. TMJ bone remodeling was studied by comparing the pre and postoperative CT scan of ten patients. Qualitative evaluation was performed by two-dimensional analysis. Three-dimensional analysis superimpositions were done after digital condylar units isolation. Condylar volume modifications were measured and compared on both sides. Lastly, before and after surgery, we studied the radio-clinic correlations. After surgery, all the operated condyles developed a new cortical bone. We noticed also a thickening of the glenoid fossa. Surgical condylectomy leaded to a 43.5% volume reduction on the operated side and 2.14% on the controlateral side. On the controlateral side, most of abnormalities seen preoperatively disappeared after surgery. For two patients, the condylar resection took away over 80% of the initial volume. For these patients, we observed major radiologic modifications on the controlateral TMJ associated with symptoms of dysfunction. These problems did not worsen their quality of life. Both TMJ presented with bone remodelling after condylectomy. In condylar hyperplasia, condylectomy provides orthopaedic results on dysmorphia and removal of the pathological prechondroblastic zone. In the future, an earlier detection of this pathology may help the surgeon to treat in childhood. This would limit surgical excision and would avoid important dysmorphia. © EDP Sciences, SFODF, 2014.

The IBV Valve trial: a multicenter, randomized, double-blind trial of endobronchial therapy for severe emphysema.

PubMed

Wood, Douglas E; Nader, Daniel A; Springmeyer, Steven C; Elstad, Mark R; Coxson, Harvey O; Chan, Andrew; Rai, Navdeep S; Mularski, Richard A; Cooper, Christopher B; Wise, Robert A; Jones, Paul W; Mehta, Atul C; Gonzalez, Xavier; Sterman, Daniel H

2014-10-01

Lung volume reduction surgery improves quality of life, exercise capacity, and survival in selected patients but is accompanied by significant morbidity. Bronchoscopic approaches may provide similar benefits with less morbidity. In a randomized, sham procedure controlled, double-blind trial, 277 subjects were enrolled at 36 centers. Patients had emphysema, airflow obstruction, hyperinflation, and severe dyspnea. The primary effectiveness measure was a significant improvement in disease-related quality of life (St. George's Respiratory Questionnaire) and changes in lobar lung volumes. The primary safety measure was a comparison of serious adverse events. There were 6/121 (5.0%) responders in the treatment group at 6 months, significantly >1/134 (0.7%) in the control group [Bayesian credible intervals (BCI), 0.05%, 9.21%]. Lobar volume changes were significantly different with an average decrease in the treated lobes of -224 mL compared with -17 mL for the control group (BCI, -272, -143). The proportion of responders in St. George's Respiratory Questionnaire was not greater in the treatment group. There were significantly more subjects with a serious adverse event in the treatment group (n=20 or 14.1%) compared with the control group (n=5 or 3.7%) (BCI, 4.0, 17.1), but most were neither procedure nor device related. This trial had technical and statistical success but partial-bilateral endobronchial valve occlusion did not obtain clinically meaningful results. Safety results were acceptable and compare favorably to lung volume reduction surgery and other bronchial valve studies. Further studies need to focus on improved patient selection and a different treatment algorithm. ClinicalTrials.gov NCT00475007.

Liposuction for Advanced Lymphedema: A Multidisciplinary Approach for Complete Reduction of Arm and Leg Swelling.

PubMed

Boyages, John; Kastanias, Katrina; Koelmeyer, Louise A; Winch, Caleb J; Lam, Thomas C; Sherman, Kerry A; Munnoch, David Alex; Brorson, Håkan; Ngo, Quan D; Heydon-White, Asha; Magnussen, John S; Mackie, Helen

2015-12-01

This research describes and evaluates a liposuction surgery and multidisciplinary rehabilitation approach for advanced lymphedema of the upper and lower extremities. A prospective clinical study was conducted at an Advanced Lymphedema Assessment Clinic (ALAC) comprised of specialists in plastic surgery, rehabilitation, imaging, oncology, and allied health, at Macquarie University, Australia. Between May 2012 and 31 May 2014, a total of 104 patients attended the ALAC. Eligibility criteria for liposuction included (i) unilateral, non-pitting, International Society of Lymphology stage II/III lymphedema; (ii) limb volume difference greater than 25 %; and (iii) previously ineffective conservative therapies. Of 55 eligible patients, 21 underwent liposuction (15 arm, 6 leg) and had at least 3 months postsurgical follow-up (85.7 % cancer-related lymphedema). Liposuction was performed under general anesthesia using a published technique, and compression garments were applied intraoperatively and advised to be worn continuously thereafter. Limb volume differences, bioimpedance spectroscopy (L-Dex), and symptom and functional measurements (using the Patient-Specific Functional Scale) were taken presurgery and 4 weeks postsurgery, and then at 3, 6, 9, and 12 months postsurgery. Mean presurgical limb volume difference was 45.1 % (arm 44.2 %; leg 47.3 %). This difference reduced to 3.8 % (arm 3.6 %; leg 4.3 %) by 6 months postsurgery, a mean percentage volume reduction of 89.6 % (arm 90.2 %; leg 88.2 %) [p < 0.001]. All patients had improved symptoms and function. Bioimpedance spectroscopy showed reduced but ongoing extracellular fluid, consistent with the underlying lymphatic pathology. Liposuction is a safe and effective option for carefully selected patients with advanced lymphedema. Assessment, treatment, and follow-up by a multidisciplinary team is essential.

A prospective, multicenter, randomized trial of the Onyx liquid embolic system and N-butyl cyanoacrylate embolization of cerebral arteriovenous malformations. Clinical article.

PubMed

Loh, Yince; Duckwiler, Gary R

2010-10-01

The Onyx liquid embolic system (Onyx) was approved in the European Union in 1999 for embolization of lesions in the intracranial and peripheral vasculature, including brain arteriovenous malformations (AVMs) and hypervascular tumors. In 2001 a prospective, equivalence, multicenter, randomized controlled trial was initiated to support a submission for FDA approval. The objective of this study was to verify the safety and efficacy of Onyx compared with N-butyl cyanoacrylate (NBCA) for the presurgical treatment of brain AVMs. One hundred seventeen patients with brain AVMs were treated with either Onyx (54 patients) or NBCA (63 patients) for presurgical endovascular embolization between May 2001 and April 2003. The primary end point was technical success in achieving ≥ 50% reduction in AVM volume. Secondary end points were operative blood loss and resection time. All adverse events (AEs) were reported and assigned a relationship to the Onyx or NBCA system, treatment, disease, surgery, or other/unknown. The Data Safety Monitoring Board adjudicated AEs, and a blinded, independent core lab assessed volume measurements. Patients were monitored through discharge after the final surgery or through a 3- and/or 12-month follow-up if resection had not been performed or was incomplete. The use of Onyx led to ≥ 50% AVM volume reduction in 96% of cases versus 85% for NBCA (p = not significant). The secondary end points of resection time and blood loss were similar. Serious AEs were also similar between the 2 treatment groups. Onyx is equivalent to NBCA in safety and efficacy as a preoperative embolic agent in reducing brain AVM volume by at least 50%.

Co-registered perfusion SPECT/CT: utility for prediction of improved postoperative outcome in lung volume reduction surgery candidates.

PubMed

Takenaka, Daisuke; Ohno, Yoshiharu; Koyama, Hisanobu; Nogami, Munenobu; Onishi, Yumiko; Matsumoto, Keiko; Yoshikawa, Takeshi; Matsumoto, Sumiaki; Sugimura, Kazuro

2010-06-01

To directly compare the capabilities of perfusion scan, SPECT, co-registered SPECT/CT, and quantitatively and qualitatively assessed MDCT (i.e. quantitative CT and qualitative CT) for predicting postoperative clinical outcome for lung volume reduction surgery (LVRS) candidates. Twenty-five consecutive candidates (19 men and six women, age range: 42-72 years) for LVRS underwent preoperative CT and perfusion scan with SPECT. Clinical outcome of LVRS for all subjects was also assessed by determining the difference between pre- and postoperative forced expiratory volume in 1s (FEV(1)) and 6-min walking distance (6MWD). All SPECT examinations were performed on a SPECT scanner, and co-registered to thin-section CT by using commercially available software. On planar imaging, SPECT and SPECT/CT, upper versus lower zone or lobe ratios (U/Ls) were calculated from regional uptakes between upper and lower lung fields in the operated lung. On quantitatively assessed CT, U/L for all subjects was assessed from regional functional lung volumes. On qualitatively assessed CT, planar imaging, SPECT and co-registered SPECT/CT, U/Ls were assessed with a 4-point visual scoring system. To compare capabilities of predicting clinical outcome, each U/L was statistically correlated with the corresponding clinical outcome. Significantly fair or moderate correlations were observed between quantitatively and qualitatively assessed U/Ls obtained with all four methods and clinical outcomes (-0.60

Clinical target volume delineation in glioblastomas: pre-operative versus post-operative/pre-radiotherapy MRI

PubMed Central

Farace, P; Giri, M G; Meliadò, G; Amelio, D; Widesott, L; Ricciardi, G K; Dall'Oglio, S; Rizzotti, A; Sbarbati, A; Beltramello, A; Maluta, S; Amichetti, M

2011-01-01

Objectives Delineation of clinical target volume (CTV) is still controversial in glioblastomas. In order to assess the differences in volume and shape of the radiotherapy target, the use of pre-operative vs post-operative/pre-radiotherapy T1 and T2 weighted MRI was compared. Methods 4 CTVs were delineated in 24 patients pre-operatively and post-operatively using T1 contrast-enhanced (T1PRECTV and T1POSTCTV) and T2 weighted images (T2PRECTV and T2POSTCTV). Pre-operative MRI examinations were performed the day before surgery, whereas post-operative examinations were acquired 1 month after surgery and before chemoradiation. A concordance index (CI) was defined as the ratio between the overlapping and composite volumes. Results The volumes of T1PRECTV and T1POSTCTV were not statistically different (248 ± 88 vs 254 ± 101), although volume differences >100 cm3 were observed in 6 out of 24 patients. A marked increase due to tumour progression was shown in three patients. Three patients showed a decrease because of a reduced mass effect. A significant reduction occurred between pre-operative and post-operative T2 volumes (139 ± 68 vs 78 ± 59). Lack of concordance was observed between T1PRECTV and T1POSTCTV (CI = 0.67 ± 0.09), T2PRECTV and T2POSTCTV (CI = 0.39 ± 0.20) and comparing the portion of the T1PRECTV and T1POSTCTV not covered by that defined on T2PRECTV images (CI = 0.45 ± 0.16 and 0.44 ± 0.17, respectively). Conclusion Using T2 MRI, huge variations can be observed in peritumoural oedema, which are probably due to steroid treatment. Using T1 MRI, brain shifts after surgery and possible progressive enhancing lesions produce substantial differences in CTVs. Our data support the use of post-operative/pre-radiotherapy T1 weighted MRI for planning purposes. PMID:21045069

[Obesity and heart failure].

PubMed

Weismann, D; Wiedmann, S; Bala, M; Frantz, S; Fassnacht, M

2015-02-01

Obesity is an important risk factor for the development of heart failure. In normotensive obese patients, a reduced peripheral resistance is typically observed and is accompanied by an increased fluid volume and an increase in cardiac work, resulting in hypertrophy and diastolic heart failure, which can be visualized with echocardiography. However, in the presence of arterial hypertension cardiac geometry is not different to hypertensive heart disease without obesity. Furthermore, the typical changes found with obesity, such as reduced peripheral resistance and increased blood volume, are no longer present. Obstructive sleep apnea (OSA) is very common in obesity and warrants screening but levels of the heart failure marker N-terminal pro-brain natriuretic peptide (NT-ProBNP) might be misleading as the values are lower in obesity than in normal weight controls. Body weight reduction is advisable but difficult to achieve and much more difficult to maintain. Furthermore, diet and exercise has not been proven to enhance life expectancy in obesity. However, with bariatric surgery, long-term weight reduction can be achieved and mortality can be reduced. With effective weight loss and improved clinical outcome after bariatric surgery, treatment of obesity has shifted much more into focus. Regardless of technical challenges in the work-up of obese patients, clinical symptoms suggestive of cardiac disorders warrant prompt investigation with standard techniques following recommendations as established for normal weight patients.

Atelectasis and survival after bronchoscopic lung volume reduction for COPD.

PubMed

Hopkinson, N S; Kemp, S V; Toma, T P; Hansell, D M; Geddes, D M; Shah, P L; Polkey, M I

2011-06-01

Bronchoscopic therapies to reduce lung volumes in chronic obstructive pulmonary disease are intended to avoid the risks associated with lung volume reduction surgery (LVRS) or to be used in patient groups in whom LVRS is not appropriate. Bronchoscopic lung volume reduction (BLVR) using endobronchial valves to target unilateral lobar occlusion can improve lung function and exercise capacity in patients with emphysema. The benefit is most pronounced in, though not confined to, patients where lobar atelectasis has occurred. Few data exist on their long-term outcome. 19 patients (16 males; mean±sd forced expiratory volume in 1 s 28.4±11.9% predicted) underwent BLVR between July 2002 and February 2004. Radiological atelectasis was observed in five patients. Survival data was available for all patients up to February 2010. None of the patients in whom atelectasis occurred died during follow-up, whereas eight out of 14 in the nonatelectasis group died (Chi-squared p=0.026). There was no significant difference between the groups at baseline in lung function, quality of life, exacerbation rate, exercise capacity (shuttle walk test or cycle ergometry) or computed tomography appearances, although body mass index was significantly higher in the atelectasis group (21.6±2.9 versus 28.4±2.9 kg·m(-2); p<0.001). The data in the present study suggest that atelectasis following BLVR is associated with a survival benefit that is not explained by baseline differences.

White Matter Volume Predicts Language Development in Congenital Heart Disease

PubMed Central

Rollins, Caitlin K.; Asaro, Lisa A.; Akhondi-Asl, Alireza; Kussman, Barry D.; Rivkin, Michael J.; Bellinger, David C.; Warfield, Simon K.; Wypij, David; Newburger, Jane W.; Soul, Janet S.

2016-01-01

Objective To determine whether brain volume is reduced at one year and whether these volumes are associated with neurodevelopment in biventricular congenital heart disease (CHD) repaired in infancy. Study design Infants with biventricular CHD (n = 48) underwent brain magnetic resonance imaging (MRI) and neurodevelopmental testing with the Bayley Scales of Infant Development-II (BSID-II) and the MacArthur-Bates Communicative Development Inventories (CDI) at one year. A multi-template based probabilistic segmentation algorithm was applied to volumetric MRI data. We compared volumes with those of 13 healthy control infants of comparable ages. In the CHD group, we measured Spearman correlations between neurodevelopmental outcomes and the residuals from linear regression of the volumes on corrected chronological age at MRI and sex. Results Compared with controls, CHD infant had reductions of 54 mL in total brain (P = 0.009), 40 mL in cerebral white matter (P < 0.001), and 1.2 mL in brainstem (P = 0.003) volumes. Within the CHD group, brain volumes were not correlated with BSID-II scores but did correlate positively with CDI language development. Conclusion Infants with biventricular CHD show total brain volume reductions at one year of age, driven by differences in cerebral white matter. White matter volume correlates with language development, but not broader developmental indices. These findings suggest that abnormalities in white matter development detected months after corrective heart surgery may contribute to language impairment. Trial registration ClinicalTrials.gov: NCT00006183 PMID:27837950

SF-36 Shows Increased Quality of Life Following Complete Reduction of Postmastectomy Lymphedema with Liposuction

PubMed Central

Bagheri, Shirin; Hansson, Emma; Manjer, Jonas; Troëng, Thomas; Brorson, Håkan

2017-01-01

Abstracts Background: Arm lymphedema after breast cancer surgery affects women both from physical and psychological points of view. Lymphedema leads to adipose tissue deposition. Liposuction and controlled compression therapy (CCT) reduces the lymphedema completely. Methods and Results: Sixty female patients with arm lymphedema were followed for a 1-year period after surgery. The 36-item short-form health survey (SF-36) was used to assess health-related quality of life (HRQoL). Patients completed the SF-36 questionnaire before liposuction, and after 1, 3, 6, and 12 months. Preoperative excess arm volume was 1365 ± 73 mL. Complete reduction was achieved after 3 months and was sustained during follow-up. The adipose tissue volume removed at surgery was 1373 ± 56 mL. One month after liposuction, better scores were found in mental health. After 3 months, an increase in physical functioning, bodily pain, and vitality was detected. After 1 year, an increase was also seen for social functioning. The physical component score was higher at 3 months and thereafter, while the mental component score was improved at 3 and 12 months. Compared with SF-36 norm data for the Swedish population, only physical functioning showed lower values than the norm at baseline. After liposuction, general health, bodily pain, vitality, mental health, and social functioning showed higher values at various time points. Conclusions: Liposuction of arm lymphedema in combination with CCT improves patients HRQoL as measured with SF-36. The treatment seems to target and improve both the physical and mental health domains. PMID:28135120

SF-36 Shows Increased Quality of Life Following Complete Reduction of Postmastectomy Lymphedema with Liposuction.

PubMed

Hoffner, Mattias; Bagheri, Shirin; Hansson, Emma; Manjer, Jonas; Troëng, Thomas; Brorson, Håkan

2017-03-01

Abstracts Background: Arm lymphedema after breast cancer surgery affects women both from physical and psychological points of view. Lymphedema leads to adipose tissue deposition. Liposuction and controlled compression therapy (CCT) reduces the lymphedema completely. Sixty female patients with arm lymphedema were followed for a 1-year period after surgery. The 36-item short-form health survey (SF-36) was used to assess health-related quality of life (HRQoL). Patients completed the SF-36 questionnaire before liposuction, and after 1, 3, 6, and 12 months. Preoperative excess arm volume was 1365 ± 73 mL. Complete reduction was achieved after 3 months and was sustained during follow-up. The adipose tissue volume removed at surgery was 1373 ± 56 mL. One month after liposuction, better scores were found in mental health. After 3 months, an increase in physical functioning, bodily pain, and vitality was detected. After 1 year, an increase was also seen for social functioning. The physical component score was higher at 3 months and thereafter, while the mental component score was improved at 3 and 12 months. Compared with SF-36 norm data for the Swedish population, only physical functioning showed lower values than the norm at baseline. After liposuction, general health, bodily pain, vitality, mental health, and social functioning showed higher values at various time points. Liposuction of arm lymphedema in combination with CCT improves patients HRQoL as measured with SF-36. The treatment seems to target and improve both the physical and mental health domains.

Impact of hospital volume on perioperative outcomes and costs of radical cystectomy: analysis of the Maryland Health Services Cost Review Commission database.

PubMed

Gorin, Michael A; Kates, Max; Mullins, Jeffrey K; Pierorazio, Phillip M; Matlaga, Brian R; Schoenberg, Mark P; Bivalacqua, Trinity J

2014-02-01

The objective of this study was to evaluate the impact of hospital case volume on perioperative outcomes and costs of radical cystectomy (RC) after controlling for differences in patient case mix. The Maryland Health Services Cost Review Commission database was queried for patients who underwent an open RC between 2000 and 2011. Patients were divided into tertiles based on hospital case volume. Groups were compared for differences in length of intensive care unit (ICU) stay, length of total hospital stay, rate of in-hospital deaths and procedure-related costs. In total, 1620 patients underwent a RC during the study period. Of these patients, 457 (28.2%) underwent surgery at 37 low volume centers, 465 (28.7%) at six mid volume centers and 698 (43.1%) at a single high volume center. The mean case volume of each group was 1.1, 7.0 and 63.5 RC/center/year, respectively. After controlling for marked differences in patient case mix, having surgery at the single high-volume center was independently associated with a decrease in length of ICU stay (coefficient = -0.41 days, 95% CI -0.78--0.05, p = 0.03), in-hospital mortality (OR 0.18, 95% CI 0.04-0.80, p = 0.02) and total medical costs (coefficient = -2.91k USD, 95% CI -4.15--1.67, p < 0.001). Decreased total costs were driven by reductions in charges associated with the operating room, drugs, radiology tests, labs, supplies and physical/occupational therapy (all p < 0.001). Undergoing RC at a high volume medical center was associated with improved outcomes and reduced costs. These data support the centralization of RC to high volume centers.

Is there a role for homeopathy in breast cancer surgery? A first randomized clinical trial on treatment with Arnica montana to reduce post-operative seroma and bleeding in patients undergoing total mastectomy

PubMed Central

Sorrentino, Luca; Piraneo, Salvatore; Riggio, Eliana; Basilicò, Silvia; Sartani, Alessandra; Bossi, Daniela; Corsi, Fabio

2017-01-01

Aim: This study aimed to evaluate the benefits of Arnica montana on post-operative blood loss and seroma production in women undergoing unilateral total mastectomy by administering Arnica Montana 1000 Korsakovian dilution (1000 K). Materials and Methods: From 2012 to 2014, 53 women were randomly assigned to A. montana or placebo and were followed up for 5 days. The main end point was the reduction in blood and serum volumes collected in drainages. Secondary end points were duration of drainage, a self-evaluation of pain, and the presence of bruising or hematomas. Results: The per-protocol analysis revealed a lower mean volume of blood and serum collected in drainages with A. montana (−94.40 ml; 95% confidence interval [CI]: 22.48-211.28; P = 0.11). A regression model including treatment, volume collected in the drainage on the day of surgery, and patient weight showed a statistically significant difference in favor of A. montana (−106.28 ml; 95% CI: 9.45-203.11; P = 0.03). Volumes collected on the day of surgery and the following days were significantly lower with A. montana at days 2 (P = 0.033) and 3 (P = 0.0223). Secondary end points have not revealed significant differences. Conclusions: A. montana 1000 K could reduce post-operative blood and seroma collection in women undergoing unilateral total mastectomy. Larger studies are needed with different dilutions of A. montana to further validate these data. PMID:28163953

Efficacy and Safety of Ethanol Ablation for Branchial Cleft Cysts.

PubMed

Ha, E J; Baek, S M; Baek, J H; Shin, S Y; Han, M; Kim, C-H

2017-12-01

Branchial cleft cyst is a common congenital lesion of the neck. This study evaluated the efficacy and safety of ethanol ablation as an alternative treatment to surgery for branchial cleft cyst. Between September 2006 and October 2016, ethanol ablation was performed in 22 patients who refused an operation for a second branchial cleft cyst. After the exclusion of 2 patients who were lost to follow-up, the data of 20 patients were retrospectively evaluated. All index masses were confirmed as benign before treatment. Sonography-guided aspiration of the cystic fluid was followed by injection of absolute ethanol (99%) into the lesion. The injected volume of ethanol was 50%-80% of the volume of fluid aspirated. Therapeutic outcome, including the volume reduction ratio, therapeutic success rate (volume reduction ratio of >50% and/or no palpable mass), and complications, was evaluated. The mean index volume of the cysts was 26.4 ± 15.7 mL (range, 3.8-49.9 mL). After ablation, the mean volume of the cysts decreased to 1.2 ± 1.1 mL (range, 0.0-3.5 mL). The mean volume reduction ratio at last follow-up was 93.9% ± 7.9% (range, 75.5%-100.0%; P < .001). Therapeutic success was achieved in all nodules (20/20, 100%), and the symptomatic ( P < .001) and cosmetic ( P < .001) scores had improved significantly by the last follow-up. In 1 patient, intracystic hemorrhage developed during the aspiration; however, no major complications occurred in any patient. Ethanol ablation is an effective and safe treatment for patients with branchial cleft cysts who refuse, or are ineligible for, an operation. © 2017 by American Journal of Neuroradiology.

Public Reporting of Hospital-Level Cancer Surgical Volumes in California: An Opportunity to Inform Decision Making and Improve Quality.

PubMed

Clarke, Christina A; Asch, Steven M; Baker, Laurence; Bilimoria, Karl; Dudley, R Adams; Fong, Niya; Holliday-Hanson, Merry L; Hopkins, David S P; Imholz, Elizabeth M; Malin, Jennifer; Moy, Lisa; O'Sullivan, Maryann; Parker, Joseph P; Saigal, Christopher S; Spurlock, Bruce; Teleki, Stephanie; Zingmond, David; Lang, Lance

2016-10-01

Most patients, providers, and payers make decisions about cancer hospitals without any objective data regarding quality or outcomes. We developed two online resources allowing users to search and compare timely data regarding hospital cancer surgery volumes. Hospital cancer surgery volumes for all California hospitals were calculated using ICD-9 coded hospital discharge summary data. Cancer surgeries included (bladder, brain, breast, colon, esophagus, liver, lung, pancreas, prostate, rectum, and stomach) were selected on the basis of a rigorous literature review to confirm sufficient evidence of a positive association between volume and mortality. The literature could not identify threshold numbers of surgeries associated with better or worse outcomes. A multidisciplinary working group oversaw the project and ensured sound methodology. In California in 2014, about 60% of surgeries were performed at top-quintile-volume hospitals, but the per-hospital median numbers of surgeries for esophageal, pancreatic, stomach, liver, or bladder cancer surgeries were four or fewer. At least 670 patients received cancer surgery at hospitals that performed only one or two surgeries for a particular cancer type; 72% of those patients lived within 50 miles of a top-quintile-volume hospital. There is clear potential for more readily available information about hospital volumes to help patient, providers, and payers choose cancer surgery hospitals. Our successful public reporting of hospital volumes in California represents an important first step toward making publicly available even more provider-specific data regarding cancer care quality, costs, and outcomes, so those data can inform decision-making and encourage quality improvement.

Favorable Changes in Cardiac Geometry and Function Following Gastric Bypass Surgery

PubMed Central

Owan, Theophilus; Avelar, Erick; Morley, Kimberly; Jiji, Ronny; Hall, Nathaniel; Krezowski, Joseph; Gallagher, James; Williams, Zachary; Preece, Kevin; Gundersen, Nancy; Strong, Michael B.; Pendleton, Robert C.; Segerson, Nathan; Cloward, Tom V.; Walker, James M.; Farney, Robert J.; Gress, Richard E.; Adams, Ted D.; Hunt, Steven C.; Litwin, Sheldon E.

2013-01-01

Objectives The objective of this study was to test the hypothesis that gastric bypass surgery (GBS) would favorably impact cardiac remodeling and function. Background GBS is increasingly used to treat severe obesity, but there are limited outcome data. Methods We prospectively studied 423 severely obese patients undergoing GBS and a reference group of severely obese subjects that did not have surgery (n = 733). Results At a 2-year follow up, GBS subjects had a large reduction in body mass index compared with the reference group (−15.4 ± 7.2 kg/m2 vs. −0.03 ± 4.0 kg/m2; p < 0.0001), as well as significant reductions in waist circumference, systolic blood pressure, heart rate, triglycerides, low-density lipoprotein cholesterol, and insulin resistance. High-density lipoprotein cholesterol increased. The GBS group had reductions in left ventricular (LV) mass index and right ventricular (RV) cavity area. Left atrial volume did not change in GBS but increased in reference subjects. In conjunction with reduced chamber sizes, GBS subjects also had increased LV midwall fractional shortening and RV fractional area change. In multivariable analysis, age, change in body mass index, severity of nocturnal hypoxemia, E/E', and sex were independently associated with LV mass index, whereas surgical status, change in waist circumference, and change in insulin resistance were not. Conclusions Marked weight loss in patients undergoing GBS was associated with reverse cardiac remodeling and improved LV and RV function. These data support the use of bariatric surgery to prevent cardiovascular complications in severe obesity. PMID:21292133

Distributed augmented reality with 3-D lung dynamics--a planning tool concept.

PubMed

Hamza-Lup, Felix G; Santhanam, Anand P; Imielińska, Celina; Meeks, Sanford L; Rolland, Jannick P

2007-01-01

Augmented reality (AR) systems add visual information to the world by using advanced display techniques. The advances in miniaturization and reduced hardware costs make some of these systems feasible for applications in a wide set of fields. We present a potential component of the cyber infrastructure for the operating room of the future: a distributed AR-based software-hardware system that allows real-time visualization of three-dimensional (3-D) lung dynamics superimposed directly on the patient's body. Several emergency events (e.g., closed and tension pneumothorax) and surgical procedures related to lung (e.g., lung transplantation, lung volume reduction surgery, surgical treatment of lung infections, lung cancer surgery) could benefit from the proposed prototype.

Magnetic Resonance Imaging-Guided Focused Ultrasound Surgery for the Treatment of Symptomatic Uterine Fibroids.

PubMed

Geraci, Laura; Napoli, Alessandro; Catalano, Carlo; Midiri, Massimo; Gagliardo, Cesare

2017-01-01

Uterine fibroids, the most common benign tumor in women of childbearing age, may cause symptoms including pelvic pain, menorrhagia, dysmenorrhea, pressure, urinary symptoms, and infertility. Various approaches are available to treat symptomatic uterine fibroids. Magnetic Resonance-guided Focused Ultrasound Surgery (MRgFUS) represents a recently introduced noninvasive safe and effective technique that can be performed without general anesthesia, in an outpatient setting. We review the principles of MRgFUS, describing patient selection criteria for the treatments performed at our center and we present a series of five selected patients with symptomatic uterine fibroids treated with this not yet widely known technique, showing its efficacy in symptom improvement and fibroid volume reduction.

Neck Circumference and Vocal Parameters in Women Before and After Bariatric Surgery.

PubMed

de Souza, Lourdes Bernadete Rocha; Pernambuco, Leandro de Araújo; dos Santos, Marquiony Marques; Pereira, Rayane Medeiros

2016-03-01

Morbidly obese patients may suffer from vocal disorders, as vocal production is directly related to the volume of the vocal tract, and the large-scale accumulation of fat in this region may interfere with voice production. The aim of this study was to analyze the neck circumference, fundamental frequency, and maximum phonation time of a group of morbidly obese women before and after bariatric surgery. An observational, longitudinal, and descriptive study was performed with patients of the Obesity and Related Diseases Surgery Unit of a university hospital. A total of 21 morbidly obese women aged 28-68 years, with a mean age of 41.33 years, participated in the study. Neck circumference was measured using a tape measure. To obtain fundamental frequency values, the patient was asked to produce the vowel [a] at normal intensity and pitch for an average period of 3 s. After recording, the participants were asked to produce the sustained vowels [a], [i], and [u] at normal intensity and pitch, with a stopwatch used to measure maximum phonation time. Eight months after surgery, patients were reassessed using the same data collecting procedures as were carried out prior to surgery. After surgery, there was an increase in the average value of fundamental frequency and maximum phonation time for all the vowels and a reduction in neck circumference. The differences were statistically significant. Weight reduction and a consequent decrease in neck circumference affected the changes in maximum phonation time and fundamental frequency values in the voices of these patients, after weight loss.

Overuse of surgery in patients with pancreatic cancer. A nationwide analysis in Italy

PubMed Central

Balzano, Gianpaolo; Capretti, Giovanni; Callea, Giuditta; Cantù, Elena; Carle, Flavia; Pezzilli, Raffaele

2016-01-01

Background According to current guidelines, pancreatic cancer patients should be strictly selected for surgery, either palliative or resective. Methods Population-based study, including all patients undergoing surgery for pancreatic cancer in Italy between 2010 and 2012. Hospitals were divided into five volume groups (quintiles), to search for differences among volume categories. Results There were 544 hospitals performing 10 936 pancreatic cancer operations. The probability of undergoing palliative/explorative surgery was inversely related to volume, being 24.4% in very high-volume hospitals and 62.5% in very low-volume centres (adjusted OR 5.175). Contrarily, the resection rate in patients without metastases decreased from 86.9% to 46.1% (adjusted OR 7.429). As for resections, the mortality of non-resective surgery was inversely related to volume (p < 0.001). Surprisingly, mortality of non-resective surgery was higher than that for resections (8.2% vs. 6.7%; p < 0.01). Approximately 9% of all resections were performed on patients with distant metastases, irrespective of hospital volume group. The excess cost for the National Health System from surgery overuse was estimated at 12.5 million euro. Discussion. Discrepancies between guidelines on pancreatic cancer treatment and surgical practice were observed. An overuse of surgery was detected, with serious clinical and economic consequences. PMID:27154812

Temporal lobe surgery in childhood and neuroanatomical predictors of long-term declarative memory outcome

PubMed Central

Skirrow, Caroline; Cross, J. Helen; Harrison, Sue; Cormack, Francesca; Harkness, William; Coleman, Rosie; Meierotto, Ellen; Gaiottino, Johanna; Vargha-Khadem, Faraneh

2015-01-01

The temporal lobes play a prominent role in declarative memory function, including episodic memory (memory for events) and semantic memory (memory for facts and concepts). Surgical resection for medication-resistant and well-localized temporal lobe epilepsy has good prognosis for seizure freedom, but is linked to memory difficulties in adults, especially when the removal is on the left side. Children may benefit most from surgery, because brain plasticity may facilitate post-surgical reorganization, and seizure cessation may promote cognitive development. However, the long-term impact of this intervention in children is not known. We examined memory function in 53 children (25 males, 28 females) who were evaluated for epilepsy surgery: 42 underwent unilateral temporal lobe resections (25 left, 17 right, mean age at surgery 13.8 years), 11 were treated only pharmacologically. Average follow-up was 9 years (range 5–15). Post-surgical change in visual and verbal episodic memory, and semantic memory at follow-up were examined. Pre- and post-surgical T1-weighted MRI brain scans were analysed to extract hippocampal and resection volumes, and evaluate post-surgical temporal lobe integrity. Language lateralization indices were derived from functional magnetic resonance imaging. There were no significant pre- to postoperative decrements in memory associated with surgery. In contrast, gains in verbal episodic memory were seen after right temporal lobe surgery, and visual episodic memory improved after left temporal lobe surgery, indicating a functional release in the unoperated temporal lobe after seizure reduction or cessation. Pre- to post-surgical change in memory function was not associated with any indices of brain structure derived from MRI. However, better verbal memory at follow-up was linked to greater post-surgical residual hippocampal volumes, most robustly in left surgical participants. Better semantic memory at follow-up was associated with smaller resection volumes and greater temporal pole integrity after left temporal surgery. Results were independent of post-surgical intellectual function and language lateralization. Our findings indicate post-surgical, hemisphere-dependent material-specific improvement in memory functions in the intact temporal lobe. However, outcome was linked to the anatomical integrity of the temporal lobe memory system, indicating that compensatory mechanisms are constrained by the amount of tissue which remains in the operated temporal lobe. Careful tailoring of resections for children undergoing epilepsy surgery may enhance long-term memory outcome. PMID:25392199

Differential Effects of Bariatric Surgery Versus Exercise on Excessive Visceral Fat Deposits

PubMed Central

Wu, Fu-Zong; Huang, Yi-Luan; Wu, Carol C.; Wang, Yen-Chi; Pan, Hsiang-Ju; Huang, Chin-Kun; Yeh, Lee-Ren; Wu, Ming-Ting

2016-01-01

Abstract The aim of the present study was to compare differential impacts of bariatric surgery and exercise-induced weight loss on excessive abdominal and cardiac fat deposition. Excessive fat accumulation around the heart may play an important role in the pathogenesis of cardiovascular disease. Recent evidences have suggested that bariatric surgery results in relatively less decrease in epicardial fat compared with abdominal visceral fat and paracardial fat. Sixty-four consecutive overweight or obese subjects were enrolled in the study. Clinical characteristics and metabolic profiles were recorded. The volumes of abdominal visceral adipose tissue (AVAT), abdominal subcutaneous adipose tissue (ASAT), epicardial (EAT), and paracardial adipose tissue (PAT) were measured by computed tomography in the bariatric surgery group (N = 25) and the exercise group (N = 39) at baseline and 3 months after intervention. Subjects in both the surgery and exercise groups showed significant reduction in body mass index (15.97%, 7.47%), AVAT (40.52%, 15.24%), ASAT (31.40, 17.34%), PAT (34.40%, 12.05%), and PAT + EAT (22.31%, 17.72%) (all P < 0.001) after intervention compared with baseline. In both the groups, the decrease in EAT was small compared with the other compartments (P < 0.01 in both groups). Compared with the exercise group, the surgery group had greater loss in abdominal and cardiac visceral adipose tissue (AVAT, ASAT, PAT, EAT+PAT) (P < 0.001), but lesser loss in EAT (P = 0.037). Compared with the exercise group, bariatric surgery results in significantly greater percentage loss of excessive fat deposits except for EAT. EAT, but not PAT, was relatively preserved despite weight reduction in both the groups. The physiological impact of persistent EAT deserves further investigation. PMID:26844473

Effect of lung volume reduction surgery on resting pulmonary hemodynamics in severe emphysema.

PubMed

Criner, Gerard J; Scharf, Steven M; Falk, Jeremy A; Gaughan, John P; Sternberg, Alice L; Patel, Namrata B; Fessler, Henry E; Minai, Omar A; Fishman, Alfred P

2007-08-01

To determine the effect of medical treatment versus lung volume reduction surgery (LVRS) on pulmonary hemodynamics. Three clinical centers of the National Emphysema Treatment Trial (NETT) screened patients for additional inclusion into a cardiovascular (CV) substudy. Demographics were determined, and lung function testing, six-minute-walk distance, and maximum cardiopulmonary exercise testing were done at baseline and 6 months after medical therapy or LVRS. CV substudy patients underwent right heart catheterization at rest prerandomization (baseline) and 6 months after treatment. A total of 110 of the 163 patients evaluated for the CV substudy were randomized in NETT (53 were ineligible), 54 to medical treatment and 56 to LVRS. Fifty-five of these patients had both baseline and repeat right heart catheterization 6 months postrandomization. Baseline demographics and lung function data revealed CV substudy patients to be similar to the remaining 1,163 randomized NETT patients in terms of age, sex, FEV(1), residual volume, diffusion capacity of carbon monoxide, Pa(O(2)), Pa(CO(2)), and six-minute-walk distance. CV substudy patients had moderate pulmonary hypertension at rest (Ppa, 24.8 +/- 4.9 mm Hg); baseline hemodynamic measurements were similar across groups. Changes from baseline pressures to 6 months post-treatment were similar across treatment groups, except for a smaller change in pulmonary capillary wedge pressure at end-expiration post-LVRS compared with medical treatment (-1.8 vs. 3.5 mm Hg, p = 0.04). In comparison to medical therapy, LVRS was not associated with an increase in pulmonary artery pressures.

Improvement in lung function and functional capacity in morbidly obese women subjected to bariatric surgery

PubMed Central

de Campos, Elaine Cristina; Peixoto-Souza, Fabiana Sobral; Alves, Viviane Cristina; Basso-Vanelli, Renata; Barbalho-Moulim, Marcela; Laurino-Neto, Rafael Melillo; Costa, Dirceu

2018-01-01

OBJECTIVE: To determine whether weight loss in women with morbid obesity subjected to bariatric surgery alters lung function, respiratory muscle strength, functional capacity and the level of habitual physical activity and to investigate the relationship between these variables and changes in both body composition and anthropometrics. METHODS: Twenty-four women with morbid obesity were evaluated with regard to lung function, respiratory muscle strength, functional capacity, body composition, anthropometrics and the level of habitual physical activity two weeks prior to and six months after bariatric surgery. RESULTS: Regarding lung function, mean increases of 160 mL in slow vital capacity, 550 mL in expiratory reserve volume, 290 mL in forced vital capacity and 250 mL in forced expiratory volume in the first second as well as a mean reduction of 490 mL in inspiratory capacity were found. Respiratory muscle strength increased by a mean of 10 cmH2O of maximum inspiratory pressure, and a 72-meter longer distance on the Incremental Shuttle Walk Test demonstrated that functional capacity also improved. Significant changes also occurred in anthropometric variables and body composition but not in the level of physical activity detected using the Baecke questionnaire, indicating that the participants remained sedentary. Moreover, correlations were found between the percentages of lean and fat mass and both inspiratory and expiratory reserve volumes. CONCLUSION: The present data suggest that changes in body composition and anthropometric variables exerted a direct influence on functional capacity and lung function in the women analyzed but exerted no influence on sedentarism, even after accentuated weight loss following bariatric surgery. PMID:29561930

Innovative practice model to optimize resource utilization and improve access to care for high-risk and BRCA+ patients.

PubMed

Head, Linden; Nessim, Carolyn; Usher Boyd, Kirsty

2017-02-01

Bilateral prophylactic mastectomy (BPM) has demonstrated breast cancer risk reduction in high-risk/ BRCA + patients. However, priority of active cancers coupled with inefficient use of operating room (OR) resources presents challenges in offering BPM in a timely manner. To address these challenges, a rapid access prophylactic mastectomy and immediate reconstruction (RAPMIR) program was innovated. The purpose of this study was to evaluate RAPMIR with regards to access to care and efficiency. We retrospectively reviewed the cases of all high-risk/ BRCA + patients having had BPM between September 2012 and August 2014. Patients were divided into 2 groups: those managed through the traditional model and those managed through the RAPMIR model. RAPMIR leverages 2 concurrently running ORs with surgical oncology and plastic surgery moving between rooms to complete 3 combined BPMs with immediate reconstruction in addition to 1-2 independent cases each operative day. RAPMIR eligibility criteria included high-risk/ BRCA + status; BPM with immediate, implant-based reconstruction; and day surgery candidacy. Wait times, case volumes and patient throughput were measured and compared. There were 16 traditional patients and 13 RAPMIR patients. Mean wait time (days from referral to surgery) for RAPMIR was significantly shorter than for the traditional model (165.4 v. 309.2 d, p = 0.027). Daily patient throughput (4.3 v. 2.8), plastic surgery case volume (3.7 v. 1.6) and surgical oncology case volume (3.0 v. 2.2) were significantly greater in the RAPMIR model than the traditional model ( p = 0.003, p < 0.001 and p = 0.015, respectively). A multidisciplinary model with optimized scheduling has the potential to improve access to care and optimize resource utilization.

Innovative practice model to optimize resource utilization and improve access to care for high-risk and BRCA+ patients

PubMed Central

Head, Linden; Nessim, Carolyn; Boyd, Kirsty Usher

2017-01-01

Background Bilateral prophylactic mastectomy (BPM) has shown breast cancer risk reduction in high-risk/BRCA+ patients. However, priority of active cancers coupled with inefficient use of operating room (OR) resources presents challenges in offering BPM in a timely manner. To address these challenges, a rapid access prophylactic mastectomy and immediate reconstruction (RAPMIR) program was innovated. The purpose of this study was to evaluate RAPMIR with regards to access to care and efficiency. Methods We retrospectively reviewed the cases of all high-risk/BRCA+ patients having had BPM between September 2012 and August 2014. Patients were divided into 2 groups: those managed through the traditional model and those managed through the RAPMIR model. RAPMIR leverages 2 concurrently running ORs with surgical oncology and plastic surgery moving between rooms to complete 3 combined BPMs with immediate reconstruction in addition to 1–2 independent cases each operative day. RAPMIR eligibility criteria included high-risk/BRCA+ status; BPM with immediate, implant-based reconstruction; and day surgery candidacy. Wait times, case volumes and patient throughput were measured and compared. Results There were 16 traditional patients and 13 RAPMIR patients. Mean wait time (days from referral to surgery) for RAPMIR was significantly shorter than for the traditional model (165.4 v. 309.2 d, p = 0.027). Daily patient throughput (4.3 v. 2.8), plastic surgery case volume (3.7 v. 1.6) and surgical oncology case volume (3.0 v. 2.2) were significantly greater in the RAPMIR model than the traditional model (p = 0.003, p < 0.001 and p = 0.015, respectively). Conclusion A multidisciplinary model with optimized scheduling has the potential to improve access to care and optimize resource utilization. PMID:28234588

Innovative practice model to optimize resource utilization and improve access to care for high-risk and BRCA+ patients.

PubMed

Head, Linden; Nessim, Carolyn; Usher Boyd, Kirsty

2016-12-01

Bilateral prophylactic mastectomy (BPM) has demonstrated breast cancer risk reduction in high-risk/ BRCA + patients. However, priority of active cancers coupled with inefficient use of operating room (OR) resources presents challenges in offering BPM in a timely manner. To address these challenges, a rapid access prophylactic mastectomy and immediate reconstruction (RAPMIR) program was innovated. The purpose of this study was to evaluate RAPMIR with regards to access to care and efficiency. We retrospectively reviewed the cases of all high-risk/ BRCA + patients having had BPM between September 2012 and August 2014. Patients were divided into 2 groups: those managed through the traditional model and those managed through the RAPMIR model. RAPMIR leverages 2 concurrently running ORs with surgical oncology and plastic surgery moving between rooms to complete 3 combined BPMs with immediate reconstruction in addition to 1-2 independent cases each operative day. RAPMIR eligibility criteria included high-risk/ BRCA + status; BPM with immediate, implant-based reconstruction; and day surgery candidacy. Wait times, case volumes and patient throughput were measured and compared. There were 16 traditional patients and 13 RAPMIR patients. Mean wait time (days from referral to surgery) for RAPMIR was significantly shorter than for the traditional model (165.4 v. 309.2 d, p = 0.027). Daily patient throughput (4.3 v. 2.8), plastic surgery case volume (3.7 v. 1.6) and surgical oncology case volume (3.0 v. 2.2) were significantly greater in the RAPMIR model than the traditional model ( p = 0.003, p < 0.001 and p = 0.015, respectively). A multidisciplinary model with optimized scheduling has the potential to improve access to care and optimize resource utilization.

Further Investigation on High-intensity Focused Ultrasound (HIFU) Treatment for Thyroid Nodules: Effectiveness Related to Baseline Volumes.

PubMed

Sennert, Michael; Happel, Christian; Korkusuz, Yücel; Grünwald, Frank; Polenz, Björn; Gröner, Daniel

2018-01-01

Several minimally invasive thermal techniques have been developed for the treatment of benign thyroid nodules. A new technique for this indication is high-intensity focused ultrasound (HIFU). The aim of this study was to assess effectiveness in varying preablative nodule volumes and whether outcome patterns that were reported during studies with other thermal ablative procedures for thyroid nodule ablation would also apply to HIFU. Over the last 2 years, 19 nodules in 15 patients (12 women) whose average age was 58.7 years (36-80) were treated with HIFU in an ambulatory setting. Patients with more than one nodule were treated in multiple sessions on the same day. The mean nodule volume was 2.56 mL (range 0.13-7.67 mL). The therapeutic ultrasound probe (Echopulse THC900888-H) used in this series functions with a frequency of 3 MHz, reaching temperatures of approximately 80°C-90°C and delivering an energy ranging from 87.6 to 320.3 J per sonication. To assess the effectiveness of thermal ablation, nodular volume was measured at baseline and at 3-month follow-up. The end point of the study was the volume reduction assessment after 3 months' follow-up. Therapeutic success was defined as volume reduction of more than 50% compared to baseline. This study was retrospectively analyzed using the Wilcoxon signed rank test and Kendall tau. The median percentage volume reduction of all 19 nodules after 3 months was 58%. An inverse correlation between preablative nodular volume and percentage volume shrinking was found (tau = -0.46, P < .05). Therapeutic success was achieved in 10 out of 19 patients (53%). HIFU of benign thyroid nodules can be carried out as an alternative therapy for nodules ≤3 mL if patients are refusing surgery or radioiodine therapy. Copyright © 2018 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.

White Matter Volume Predicts Language Development in Congenital Heart Disease.

PubMed

Rollins, Caitlin K; Asaro, Lisa A; Akhondi-Asl, Alireza; Kussman, Barry D; Rivkin, Michael J; Bellinger, David C; Warfield, Simon K; Wypij, David; Newburger, Jane W; Soul, Janet S

2017-02-01

To determine whether brain volume is reduced at 1 year of age and whether these volumes are associated with neurodevelopment in biventricular congenital heart disease (CHD) repaired in infancy. Infants with biventricular CHD (n = 48) underwent brain magnetic resonance imaging (MRI) and neurodevelopmental testing with the Bayley Scales of Infant Development-II and the MacArthur-Bates Communicative Development Inventories at 1 year of age. A multitemplate based probabilistic segmentation algorithm was applied to volumetric MRI data. We compared volumes with those of 13 healthy control infants of comparable ages. In the group with CHD, we measured Spearman correlations between neurodevelopmental outcomes and the residuals from linear regression of the volumes on corrected chronological age at MRI and sex. Compared with controls, infants with CHD had reductions of 54 mL in total brain (P = .009), 40 mL in cerebral white matter (P <.001), and 1.2 mL in brainstem (P = .003) volumes. Within the group with CHD, brain volumes were not correlated with Bayley Scales of Infant Development-II scores but did correlate positively with MacArthur-Bates Communicative Development Inventory language development. Infants with biventricular CHD show total brain volume reductions at 1 year of age, driven by differences in cerebral white matter. White matter volume correlates with language development, but not broader developmental indices. These findings suggest that abnormalities in white matter development detected months after corrective heart surgery may contribute to language impairment. ClinicalTrials.gov: NCT00006183. Copyright © 2016 Elsevier Inc. All rights reserved.

[Kinesiotaping--treatment of upper limb lymphoedema in patients after breast cancer surgery].

PubMed

Lubińska, Agnieszka; Mosiejczuk, Hanna; Rotter, Iwona

2015-01-01

The aim of this study was to examine the effectiveness of lymphatic kinesiotaping in patients after unilateral breast cancer surgery. Complex decongestive therapy in patients after right-side breast-conserving surgery was done once a week for 2 months (from November to December 2014). It involved manual lymph drainage and lymphatic application of kinesiotaping. An original kinesiology tape (Nitto Denko, Japan) was used for the treatment. Lymphoedema was measured at the beginning and at the end of treatment in centimetres in specific places: metatarsal, wrist, at the mid-length of the forearm, in the elbow and at the mid-length of the upper arm. The volume of oedema was assessed at the beginning and at the end of the treatment. The reduction of lymphoedema in different places. Kinesiotaping may be an alternative method in relation to the use of materials in complex decongestive therapy. However, this technique requires further research.

Microvascular transplants in head and neck reconstruction: 3D evaluation of volume loss.

PubMed

Bittermann, Gido; Thönissen, Philipp; Poxleitner, Philipp; Zimmerer, Ruediger; Vach, Kirstin; Metzger, Marc C

2015-10-01

Despite oversized latissimus dorsi free flap reconstruction in the head and neck area, esthetic and functional problems continue to exist due to the well-known occurrence of transplant shrinkage. The purpose of this study was to acquire an estimation of the volume and time of the shrinkage process. The assessment of volume loss was performed using a 3D evaluation of two postoperative CT scans. A retrospective review was conducted on all latissimus dorsi free flap reconstructions performed between 2004 and 2013. Inclusion criteria for the assessment were: resection of an oral carcinoma and microsurgical defect coverage with latissimus dorsi free flap; a first postoperative CT (CT1) performed between 3 weeks and a maximum of 3 months after reconstruction surgery; and an additional CT scan (CT2) performed at least one year postoperatively. The exclusion criterion was surgical intervention in the local area between the acquisition of CT1 and CT2. The effect of adjuvant radiation therapy was considered. Volume determination of the transplant was carried out in CT1 and CT2 by manual segmentation of the graft. Fifteen patients were recruited. 3D evaluation showed an average volume loss of 34.4%. In the consideration of postoperative radiotherapy the volume reduction was 39.2% in patients with radiotherapy and 31.3% in patients without radiotherapy. The reconstruction flap volume required for overcorrection of the surgical defect was investigated. This study indicates that a volume loss of more than 30% could be expected one or more years after latissimus dorsi free flap reconstruction. Clinical trial number DRKS00007534. Copyright © 2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

Breast Reduction Surgery

MedlinePlus

... considering breast reduction surgery, consult a board-certified plastic surgeon. It's important to understand what breast reduction surgery entails — including possible risks and complications — as ...

Research in Biological and Medical Sciences Including Biochemistry, Communicable Disease and Immunology, Internal Medicine, Physiology, Psychiatry, Surgery, and Veterinary Medicine. Volume 1

DTIC Science & Technology

1979-09-01

and R.P. MacDermott. Antibody-dependent cell-mediated antibacterial activity of human mononuclear cells. I. K-lymphocytes and monocytes are effective...malaria research. During the reporting period, research activities have included analyses of: 1) a hemagglutination inhibition test for early detection of...radioiodination or sodium borohydride reduction. Evaluate the potential roles of activity for each protein isolated. Compare the composition of isolated

Treatments of various otolaryngological cystic diseases by OK-4321: its indications and limitations.

PubMed

Ohta, Nobuo; Fukase, Shigeru; Suzuki, Yusuke; Ishida, Akihiro; Aoyagi, Masaru

2010-11-01

The aim of this study was to evaluate the indications for, and outcomes and limitations of, OK-432 therapy in various otolaryngological cystic diseases. A retrospective clinical study at Yamagata University School of Medicine and the Fukase Clinic in Japan. Between April 1996 and November 2009 we tried OK-432 therapy in 148 patients with otolaryngological cystic diseases. In cases of plunging ranulas, lymphangiomas, branchial cleft cysts, thyroglossal duct cysts, thyroid cysts, and cervical lymphocele, we aspirated as much of the fluid content of each cystic lesion as possible, and we then replaced the volume of aspirated fluid with about half the volume of OK-432 solution. Disappearance of the lesion was observed in 119 of 148 patients (80%). Marked reduction was observed in 20 of 148 patients (14%). Partial reduction was observed in four patients (3%), and no response was seen in five patients (3%). Plunging ranula, lymphangioma, thyroglossal duct cyst, thyroid cyst, auricular hematoma, and salivary mucocele showed better responses to OK-432 therapy than did branchial cleft cyst. Serious complications with OK-432 therapy were infrequent, and the therapy seemed to have no influence on future surgery. Our results confirmed that OK-432 therapy is simple, easy, safe, and effective and can be used as a substitute for surgery in the treatment of various otolaryngological cystic diseases.

Nationwide In-hospital Mortality Following Pancreatic Surgery in Germany is Higher than Anticipated.

PubMed

Nimptsch, Ulrike; Krautz, Christian; Weber, Georg F; Mansky, Thomas; Grützmann, Robert

2016-12-01

We aimed to determine the unbiased mortality rates for pancreatic surgery procedures at the national level through a comprehensive analysis of every inpatient case in Germany. Several studies have proclaimed a general improvement of perioperative outcomes following pancreatic surgery. These results are challenged by recent analyses of large US databases that found strong volume-outcome relationships, with high mortality in low-volume facilities. All inpatient cases with a pancreatic surgery procedure code in Germany from 2009 to 2013 were identified from nationwide administrative hospital data. We determined the absolute number of patients and the in-hospital death rate for crucial subcategories such as medical indications and types of surgical procedure. A total of 58,003 inpatient episodes of pancreatic surgery were identified between 2009 and 2013. Annual case numbers increased significantly, which was primarily attributed to patients aged 70 years and older. The overall in-hospital mortality rate (10.1%) did not significantly change during the study period. Major pancreatic resections were associated with mortality ranging from 7.3% (distal pancreatectomy) to 22.9% (total pancreatectomy). Postoperative interventions indicative of severe complications were documented frequently (eg, more than 6 blood transfusions in 20% of all patients and relaparotomy in 16%). Their occurrence was associated with a dramatic increase in mortality. At the national level in Germany, perioperative mortality is higher than anticipated from previous studies. The absence of a significant reduction in overall mortality challenges current health policies that aim to improve the outcomes of high-risk surgical procedures in Germany.

Effect of orbital bony decompression for Graves' orbitopathy on the volume of extraocular muscles.

PubMed

Alsuhaibani, Adel H; Carter, Keith D; Policeni, Bruno; Nerad, Jeffrey A

2011-09-01

To evaluate the change in the rectus muscle volume following orbital bony wall decompression for Graves' orbitopathy. We used a computer program (syngo Volume Evaluation) to measure the rectus muscles from the digital preoperative and postoperative orbital CT. Of the 25 patients (20 women and five men; mean age 46 (range 18-64) years) enrolled in the study. A significant increase (mean 0.23 ml (16.5%) of preoperative volume; p=0.005) in the volume of the medial rectus muscle (MRM) was detected postoperatively, whereas no significant changes were found in the volume of the other rectus muscles and between eyes that underwent surgery in the active and inactive phases of the disease. A significant negative association was observed between the time of postoperative CT scans and the change in the MRM volume (p=0.0004) (a mean increase of 68% of preoperative MRM volume for those measured between 3 and 9 months, and a mean decrease in the volume of 50% for those measured between 41 and 50 months). The change in the volume of the MRM may partly explain the variability in the proptosis reduction following orbital decompression.

Efficacy of complete decongestive therapy and manual lymphatic drainage on treatment-related lymphedema in breast cancer

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

Koul, Rashmi; Dufan, Tarek; Russell, Catherine

2007-03-01

Objective: To evaluate the results of combined decongestive therapy and manual lymphatic drainage in patients with breast cancer-related lymphedema. Methods and Materials: The data from 250 patients were reviewed. The pre- and posttreatment volumetric measurements were compared, and the correlation with age, body mass index, and type of surgery, chemotherapy, and radiotherapy was determined. The Spearman correlation coefficients and Wilcoxon two-sample test were used for statistical analysis. Results: Of the 250 patients, 138 were included in the final analysis. The mean age at presentation was 54.3 years. Patients were stratified on the basis of the treatment modality used for breastmore » cancer management. Lymphedema was managed with combined decongestive therapy in 55%, manual lymphatic drainage alone in 32%, and the home program in 13%. The mean pretreatment volume of the affected and normal arms was 2929 and 2531 mL. At the end of 1 year, the posttreatment volume of the affected arm was 2741 mL. The absolute volume of the affected arm was reduced by a mean of 188 mL (p < 0.0001). The type of surgery (p = 0.0142), age (p = 0.0354), and body mass index (p < 0.0001) were related to the severity of lymphedema. Conclusion: Combined decongestive therapy and manual lymphatic drainage with exercises were associated with a significant reduction in the lymphedema volume.« less

Restricted Albumin Utilization Is Safe and Cost Effective in a Cardiac Surgery Intensive Care Unit.

PubMed

Rabin, Joseph; Meyenburg, Timothy; Lowery, Ashleigh V; Rouse, Michael; Gammie, James S; Herr, Daniel

2017-07-01

Volume expansion is often necessary after cardiac surgery, and albumin is often administered. Albumin's high cost motivated an attempt to reduce its utilization. This study analyzes the impact limiting albumin infusion in a cardiac surgery intensive care unit. This retrospective study analyzed albumin use between April 2014 and April 2015 in patients admitted to a cardiac surgery intensive care unit. During the first 9 months, there were no restrictions. In January 2015, institutional guidelines limited albumin use to patients requiring more than 3 L crystalloid in the early postoperative period, hypoalbuminemic patients, and to patients considered fluid overloaded. Albumin utilization was obtained from pharmacy records and compared with outcome quality metrics. In all, 1,401 patients were admitted over 13 months. Albumin use, mortality, ventilator days, patients receiving transfusions, and length of stay were compared for 961 patients before and 440 patients after guidelines were initiated. After restrictive guidelines were instituted, albumin utilization was reduced from a mean of 280 monthly doses to a mean of 101 monthly doses (p < 0.001). There was also a trend toward reduced ventilator days. Mortality, length of stay, and transfusion requirements demonstrated no significant change. Based on an average wholesale price and an average monthly reduction of 180 albumin doses, the cardiac surgery intensive care unit demonstrated more than $45,000 of wholesale savings per month after restrictions were implemented. Albumin restriction in the cardiac surgery intensive care unit was feasible and safe. Significant reductions in utilization and cost with no changes in morbidity or mortality were demonstrated. These findings may provide a strategy for reducing cost while maintaining quality of care. Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Quantitative impact of pediatric sinus surgery on facial growth.

PubMed

Senior, B; Wirtschafter, A; Mai, C; Becker, C; Belenky, W

2000-11-01

To quantitatively evaluate the long-term impact of sinus surgery on paranasal sinus development in the pediatric patient. Longitudinal review of eight pediatric patients treated with unilateral sinus surgery for periorbital or orbital cellulitis with an average follow-up of 6.9 years. Control subjects consisted of two groups, 9 normal adult patients with no computed tomographic evidence of sinusitis and 10 adult patients with scans consistent with sinusitis and a history of sinus-related symptoms extending to childhood. Application of computed tomography (CT) volumetrics, a technique allowing for precise calculation of volumes using thinly cut CT images, to the study and control groups. Paired Student t test analyses of side-to-side volume comparisons in the normal patients, patients with sinusitis, and patients who had surgery revealed no statistically significant differences. Comparisons between the orbital volumes of patients who did and did not have surgery revealed a statistically significant increase in orbital volume in patients who had surgery. Only minimal changes in facial volume measurements have been found, confirming clinical impressions that sinus surgery in children is safe and without significant cosmetic sequelae.

Endoscopic transnasal approach for the treatment of isolated medial orbital blow-out fractures: a prospective study of preoperative and postoperative orbital volume change.

PubMed

Kim, KyoungHoon; Song, KyeongHo; Choi, SooJong; Bae, YongChan; Choi, ChiWon; Oh, HeungChan; Lee, JaeWoo; Nam, SuBong

2012-02-01

Endoscopic transnasal reduction is a safe and effective technique for the treatment of blow-out fractures of the medial orbital wall. However, because this approach does not use rigid permanent material for reconstruction of the fractured medial orbital wall, some degree of herniation of the orbital contents may occur after the intraethmoidal packing material is removed. The purpose of this study was to evaluate the change in orbital volume in patients with medial orbital wall fractures treated through an endoscopic transnasal approach. This study was a prospective analysis that includes 20 patients who underwent endoscopic transnasal reduction of medial orbital wall fractures between April 2007 and December 2008. Computer-assisted orbital volume measurements were made using axial computed tomography. The mean (standard deviation [SD]) volume increase was 2.00 (0.92) cm(3) and the mean (SD) dimension of the fractured orbital wall was 2.76 (0.83) cm(2). After endoscopic surgery, an average (SD) volume decrease of 2.15 (0.91) cm(3) was achieved with ethmoid sinus packing. After removal of the packing materials, 1.14 (0.78) cm(3) increase of the orbital volume was observed. The dimension of the orbital wall fracture significantly correlated with the increased preoperative orbital volume (P = 0.002, r = 0.609); the preoperative increase in the orbital volume also significantly correlated with volume relapse after removal of the packing (P = 0.023, r = 0.452). These findings suggest that in broad orbital wall fractures, reconstruction of the orbital wall by rigid materials or prolongation of the packing period should be considered, because orbital volume can increase again after packing removal, and may thus lead to postoperative complications.

Metopic synostosis: Measuring intracranial volume change following fronto-orbital advancement using three-dimensional photogrammetry.

PubMed

Freudlsperger, Christian; Steinmacher, Sahra; Bächli, Heidi; Somlo, Elek; Hoffmann, Jürgen; Engel, Michael

2015-06-01

There is still disagreement regarding the intracranial volumes of patients with metopic synostosis compared with healthy patients. This study aimed to compare the intracranial volume of children with metopic synostosis before and after surgery to an age- and sex-matched control cohort using three-dimensional (3D) photogrammetry. Eighteen boys with metopic synostosis were operated on using standardized fronto-orbital advancement. Frontal, posterior and total intracranial volumes were measured exactly 1 day pre-operatively and 10 days post-operatively, using 3D photogrammetry. To establish an age- and sex-matched control group, the 3D photogrammetric data of 634 healthy boys between the ages of 3 and 13 months were analyzed. Mean age at surgery was 9 months (SD 1.7). Prior to surgery, boys with metopic synostosis showed significantly reduced frontal and total intracranial volumes compared with the reference group, but similar posterior volumes. After surgery, frontal and total intracranial volumes did not differ statistically from the control group. As children with metopic synostosis showed significantly smaller frontal and total intracranial volumes compared with an age- and sex-matched control group, corrective surgery should aim to achieve volume expansion. Furthermore, 3D photogrammetry provides a valuable alternative to CT scans in the measurement of intracranial volume in children with metopic synostosis, which significantly reduces the amount of radiation exposure to the growing brain. Copyright © 2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

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

PubMed

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

2011-01-01

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

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

PubMed Central

2011-01-01

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

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

PubMed

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

2017-11-01

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

Economic analysis of the future growth of cosmetic surgery procedures.

PubMed

Liu, Tom S; Miller, Timothy A

2008-06-01

The economic growth of cosmetic surgical and nonsurgical procedures has been tremendous. Between 1992 and 2005, annual U.S. cosmetic surgery volume increased by 725 percent, with over $10 billion spent in 2005. It is unknown whether this growth will continue for the next decade and, if so, what impact it will it have on the plastic surgeon workforce. The authors analyzed annual U.S. cosmetic surgery procedure volume reported by the American Society of Plastic Surgeons (ASPS) National Clearinghouse of Plastic Surgery Statistics between 1992 and 2005. Reconstructive plastic surgery volume was not included in the analysis. The authors analyzed the ability of economic and noneconomic variables to predict annual cosmetic surgery volume. The authors also used growth rate analyses to construct models with which to predict the future growth of cosmetic surgery. None of the economic and noneconomic variables were a significant predictor of annual cosmetic surgery volume. Instead, based on current compound annual growth rates, the authors predict that total cosmetic surgery volume (surgical and nonsurgical) will exceed 55 million annual procedures by 2015. ASPS members are projected to perform 299 surgical and 2165 nonsurgical annual procedures. Non-ASPS members are projected to perform 39 surgical and 1448 nonsurgical annual procedures. If current growth rates continue into the next decade, the future demand in cosmetic surgery will be driven largely by nonsurgical procedures. The growth of surgical procedures will be met by ASPS members. However, meeting the projected growth in nonsurgical procedures could be a potential challenge and a potential area for increased competition.

Comparison of ketorolac 0.45% versus diclofenac 0.1% for macular thickness and volume after uncomplicated cataract surgery.

PubMed

Lee, Tae Hee; Choi, Won; Ji, Yong Sok; Yoon, Kyung Chul

2016-05-01

To compare the effects of ketorolac 0.45% and diclofenac 0.1% on macular thickness and volume after uncomplicated cataract surgery. A total of 76 eyes of 76 patients who underwent uncomplicated cataract surgery were included. Patients were treated with either diclofenac 0.1% (38 eyes) or ketorolac 0.45% (38 eyes) after surgery. The macular thickness and volume were obtained with optical coherence tomography (OCT). Central subfield thickness (CST, OCT 1 mm zone), total foveal thickness (TFT, OCT 3 mm zone), total macular thickness (TMT, OCT 6 mm zone), average macular thickness (AMT) and total macular volume (TMV) were compared between the two study groups. No significant differences between groups were found in macular thickness or volume 1 month after cataract surgery. Two months after surgery, the ketorolac group had significantly lower CST, TFT, TMT and AMT than the diclofenac group (p < 0.05 for all). Additionally, 1 and 2 months after surgery, changes from preoperative values in CST (both p = 0.04), AMT (p = 0.02 and p < 0.01, respectively) and TMV (both p = 0.04) were significantly less in the ketorolac group than in the diclofenac group. Following uncomplicated cataract surgery, topical ketorolac 0.45% was more effective than diclofenac 0.1% in preventing increases in macular thickness and volume. © 2015 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.

Patient and surgical factors influencing air leak after lung volume reduction surgery: lessons learned from the National Emphysema Treatment Trial.

PubMed

DeCamp, Malcolm M; Blackstone, Eugene H; Naunheim, Keith S; Krasna, Mark J; Wood, Douglas E; Meli, Yvonne M; McKenna, Robert J

2006-07-01

Although staple line buttressing is advocated to reduce air leak after lung volume reduction surgery (LVRS), its effectiveness is unknown. We sought to identify risk factors for air leak and its duration and to estimate its medical consequences for selecting optimal perioperative technique(s), such as buttressing technique, to preempt or treat post-LVRS air leak. Detailed air leak data were available for 552 of 580 patients receiving bilateral stapled LVRS in the National Emphysema Treatment Trial. Risk factors for prevalence and duration of air leak were identified by logistic and hazard function analyses. Medical consequences were estimated in propensity-matched pairs with and without air leak. Within 30 days of LVRS, 90% of patients developed air leak (median duration = 7 days). Its occurrence was more common and duration prolonged in patients with lower diffusing capacity (p = 0.06), upper lobe disease (p = 0.04), and important pleural adhesions (p = 0.007). Duration was also protracted in Caucasians (p < 0.0001), patients using inhaled steroids (p = 0.004), and those with lower 1-second forced expiratory volume (p = 0.0003). Surgical approach, buttressing, stapler brand, and intraoperative adjunctive procedures were not associated with fewer or less prolonged air leaks (p >/= 0.2). Postoperative complications occurred more often in matched patients experiencing air leak (57% vs 30%, p = 0.0004), and postoperative stay was longer (11.8 +/- 6.5 days vs 7.6 +/- 4.4 days, p = 0.0005). Air leak accompanies LVRS in 90% of patients, is often prolonged, and is associated with a more complicated and protracted hospital course. Its occurrence and duration are associated with characteristics of patients and their disease, not with a specific surgical technique.

The influence of kyphosis correction surgery on pulmonary function and thoracic volume.

PubMed

Zeng, Yan; Chen, Zhongqiang; Ma, Desi; Guo, Zhaoqing; Qi, Qiang; Li, Weishi; Sun, Chuiguo; Liu, Ning; White, Andrew P

2014-10-01

A clinical study. To measure the changes in pulmonary function and thoracic volume associated with surgical correction of kyphotic deformities. No prior study has focused on the pulmonary function and thoracic cavity volume before and after corrective surgery for kyphosis. Thirty-four patients with kyphosis underwent posterior deformity correction with instrumented fusion. Preoperative and postoperative pulmonary function was measured, and pulmonary function grade was evaluated as mild, significant, or severe. The change in preoperative to postoperative pulmonary function was analyzed, using 6 comparative subgroupings of patients on the basis of age, severity of kyphosis, location of kyphosis apex, length of follow-up time after surgery, degree of kyphosis correction, and number of segments fused. A second group of 19 patients also underwent posterior surgical correction of kyphosis, which had thoracic volume measured preoperatively and postoperatively with computed tomographic scanning. All of the pulmonary impairments were found to be restrictive. After surgery, most of the patients had improvement of the pulmonary function. Before surgery, the pulmonary function differences were found to be significant based on both severity of preoperative kyphosis (<60° vs. >60°) and location of the kyphosis apex (above T10 vs. below T10). Younger patients (younger than 35 yr) were more likely to exhibit statistically significant improvements in pulmonary function after surgery. However, thoracic volume was not significantly related to pulmonary function parameters. After surgery, average thoracic volume had no significant change. The major pulmonary impairment caused by kyphosis was found to be restrictive. Patients with kyphosis angle of 60° or greater or with kyphosis apex above T10 had more severe pulmonary dysfunction. Patients' age was significantly related to change in pulmonary function after surgery. However, the average thoracic volume had no significant change after surgery. 3.

Lung volume reduction of pulmonary emphysema: the radiologist task.

PubMed

Milanese, Gianluca; Silva, Mario; Sverzellati, Nicola

2016-03-01

Several lung volume reduction (LVR) techniques have been increasingly evaluated in patients with advanced pulmonary emphysema, especially in the last decade. Radiologist plays a pivotal role in the characterization of parenchymal damage and, thus, assessment of eligibility criteria. This review aims to discuss the most common LVR techniques, namely LVR surgery, endobronchial valves, and coils LVR, with emphasis on the role of computed tomography (CT). Several trials have recently highlighted the importance of regional quantification of emphysema by computerized CT-based segmentation of hyperlucent parenchyma, which is strongly recommended for candidates to any LVR treatment. In particular, emphysema distribution pattern and fissures integrity are evaluated to tailor the choice of the most appropriate LVR technique. Furthermore, a number of CT measures have been tested for the personalization of treatment, according to imaging detected heterogeneity of parenchymal disease. CT characterization of heterogeneous parenchymal abnormalities provides criteria for selection of the preferable treatment in each patient and improves outcome of LVR as reflected by better quality of life, higher exercise tolerance, and lower mortality.

Change in Seroma Volume During Whole-Breast Radiation Therapy

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

Sharma, Rajiv; Spierer, Marnee; Mutyala, Subhakar

2009-09-01

Purpose: After breast-conserving surgery, a seroma often forms in the surgical cavity. If not drained, it may affect the volume of tumor bed requiring a boost after whole-breast radiation therapy (WBRT). Our objective was to evaluate the change in seroma volume that occurs during WBRT, before boost planning. Methods and Materials: A retrospective review was performed of women receiving breast-conserving therapy with evidence of seroma at the time of WBRT planning. Computed tomography (CT) simulation was performed before WBRT and before the tumor bed boost. All patients received either a hypofractionated (42.4 Gy/16 fraction + 9.6 Gy/4 fraction boost) ormore » standard fractionated (50.4 Gy/28 fraction + 10 Gy/5 fraction boost) regimen. Seroma volumes were contoured and compared on CT at the time of WBRT simulation and tumor bed boost planning. Results: Twenty-four patients with evidence of seroma were identified and all patients received WBRT without drainage of the seroma. Mean seroma volume before WBRT and at boost planning were significantly different at 65.7 cm{sup 3} (SD, 50.5 cm{sup 3}) and 35.6 cm{sup 3} (SD, 24.8 cm{sup 3}), respectively (p < 0.001). Mean and median reduction in seroma volume during radiation were 39.6% (SD, 23.8%) and 46.2% (range, 10.7-76.7%), respectively. Fractionation schedule was not correlated with change in seroma volume. Length of time from surgery to start of radiation therapy showed an inverse correlation with change in seroma volume (Pearson correlation r = -0.53, p < 0.01). Conclusions: The volume of seroma changes significantly during WBRT. Consequently, the accuracy of breast boost planning is likely affected, as is the volume of normal breast tissue irradiated. CT-based boost planning before boost irradiation is suggested to ensure appropriate coverage.« less

Rectal distensibility and symptoms after stapled and Milligan-Morgan operation for hemorrhoids.

PubMed

Corsetti, Maura; De Nardi, Paola; Di Pietro, Salvatore; Passaretti, Sandro; Testoni, Pier Alberto; Staudacher, Carlo

2009-12-01

In a previous uncontrolled study, a reduction of rectal distensibility and volume thresholds for sensations have been related to the occurrence of fecal urgency and/or increased stool frequency after stapled hemorrhoidopexy. The aim of this study was to compare rectal symptoms and sensory-motor function after stapled hemorrhoidopexy and Milligan-Morgan hemorrhoidectomy. The clinical records of 12 (four women) and ten patients (four women) with third- and fourth-degree hemorrhoids, respectively, who underwent stapled hemorrhoidopexy or Milligan-Morgan's hemorrhoidectomy, were evaluated. One week before and 6 months after surgery, rectal motor and sensory response to distension was assessed by an electronic barostat, and bowel and rectal symptoms were recorded by means of a 7-day diary and Bristol Index scale and psychological symptoms with SCL-90 questionnaire. Rectal distensibility and volume thresholds for sensations were significantly lower after surgery (P < 0.02) in the stapled group. Increased stool frequency and/or fecal urgency arose in 41% of patients in the stapled group and associated with altered rectal distensibility. No difference within and between groups could be demonstrated in SCL-90 score. Rectal distensibility and volume thresholds for sensations decrease after stapled hemorrhoidopexy. Altered rectal distensibility was associated with rectal urgency and/or increased stool frequency.

A single-institution experience: the integrated vascular surgery residency's effect on fellowship and general surgery resident case volume and diversity.

PubMed

Carroll, Megan I; Downes, Kathryne; Miladinovic, Branko; Illig, Karl A; Armstrong, Paul A; Back, Martin R; Johnson, Brad L; Shames, Murray L

2014-01-01

To determine whether the formation of an integrated vascular surgery residency (0 + 5) has negatively impacted the case volume and diversity of the vascular surgery fellows (5 + 2) and chief general surgeons at the same institution. Operative data from the vascular integrated (0 + 5), independent (5 + 2), and general surgery residencies at a single institution were retrospectively reviewed and analyzed to determine vascular surgery case volumes from 2006-2012. National operative data (Residency Review Committee) were used for comparison of diversity and volume. Standard statistical methods were applied. During this period, the 5 + 2 fellows at our institution performed on average 741 (range, 554-1002) primary cases and 1091 (range, 844-1479) combined primary and secondary cases for the 2-year fellowship. Our integrated residency began in July 2007. Our fellows' primary case volumes remained relatively stable between 2006 and 2011, with a 4% increase in the number of cases, although their total (primary and secondary) case volumes fell 15%; by comparison, the equivalent national 50th percentile rates rose 16% during this time frame. Our institution's general surgery residents performed an average of 116 (range, 56-221) vascular cases individually during their 5-year residency from 2005-2011. From 2006-2011, the total case volume fell only 5%, while the national 50th percentile rate fell 24%. Across all years, however, resident and fellow volumes both continue to be above Accreditation Council for Graduate Medical Education minimum requirements, and the major vascular case volume at our institution in all groups studied remained statistically greater than or equal to the national 50th percentile of cases. Our first integrated resident to graduate finished in June 2012 with 931 total vascular cases and 249 general surgery cases for a total operative experience of 1180 cases during the 5-year residency. Finally, after an 8-year period (2003-2010) in which none of our general surgery residents pursued vascular training, 1 resident in each of the 2011, 2012, and 2013 graduating years has now done so. At our institution, the introduction of a 0 + 5 vascular residency has correlated with a modest drop (15%) in overall case volume for the 5 + 2 fellows, but the number of primary cases have actually increased slightly and they continue to meet or exceed Accreditation Council for Graduate Medical Education requirements and national 50th percentile rates. General surgery residents' vascular volumes, by contrast, have remained stable, and interest in vascular surgery by residents has increased. Our integrated vascular residents are projected to exceed the fellows' 50th percentile case volume and diversity targets during their residency experience. Copyright © 2014 Elsevier Inc. All rights reserved.

Lung Volume Reduction in Pulmonary Emphysema from the Radiologist's Perspective.

PubMed

Doellinger, F; Huebner, R H; Kuhnigk, J M; Poellinger, A

2015-08-01

Pulmonary emphysema causes decrease in lung function due to irreversible dilatation of intrapulmonary air spaces, which is linked to high morbidity and mortality. Lung volume reduction (LVR) is an invasive therapeutical option for pulmonary emphysema in order to improve ventilation mechanics. LVR can be carried out by lung resection surgery or different minimally invasive endoscopical procedures. All LVR-options require mandatory preinterventional evaluation to detect hyperinflated dysfunctional lung areas as target structures for treatment. Quantitative computed tomography can determine the volume percentage of emphysematous lung and its topographical distribution based on the lung's radiodensity. Modern techniques allow for lobebased quantification that facilitates treatment planning. Clinical tests still play the most important role in post-interventional therapy monitoring, but CT is crucial in the detection of postoperative complications and foreshadows the method's high potential in sophisticated experimental studies. Within the last ten years, LVR with endobronchial valves has become an extensively researched minimally-invasive treatment option. However, this therapy is considerably complicated by the frequent occurrence of functional interlobar shunts. The presence of "collateral ventilation" has to be ruled out prior to valve implantations, as the presence of these extraanatomical connections between different lobes may jeopardize the success of therapy. Recent experimental studies evaluated the automatic detection of incomplete lobar fissures from CT scans, because they are considered to be a predictor for the existence of shunts. To date, these methods are yet to show acceptable results. Today, surgical and various minimal invasive methods of lung volume reduction are in use. Radiological and nuclear medical examinations are helpful in the evaluation of an appropriate lung area. Imaging can detect periinterventional complications. Reduction of lung volume has not yet been conclusively proven to be effective and is a therapeutical option with little scientific evidence. © Georg Thieme Verlag KG Stuttgart · New York.

Resident Exposure to Peripheral Nerve Surgical Procedures During Residency Training

PubMed Central

Gil, Joseph A.; Daniels, Alan H.; Akelman, Edward

2016-01-01

Background Variability in case exposures has been identified for orthopaedic surgery residents. It is not known if this variability exists for peripheral nerve procedures. Objective The objective of this study was to assess ACGME case log data for graduating orthopaedic surgery, plastic surgery, general surgery, and neurological surgery residents for peripheral nerve surgical procedures and to evaluate intraspecialty and interspecialty variability in case volume. Methods Surgical case logs from 2009 to 2014 for the 4 specialties were compared for peripheral nerve surgery experience. Peripheral nerve case volume between specialties was performed utilizing a paired t test, 95% confidence intervals were calculated, and linear regression was calculated to assess the trends. Results The average number of peripheral nerve procedures performed per graduating resident was 54.2 for orthopaedic surgery residents, 62.8 for independent plastic surgery residents, 84.6 for integrated plastic surgery residents, 22.4 for neurological surgery residents, and 0.4 for surgery residents. Intraspecialty comparison of the 10th and 90th percentile peripheral nerve case volume in 2012 revealed remarkable variability in training. There was a 3.9-fold difference within orthopaedic surgery, a 5.0-fold difference within independent plastic surgery residents, an 8.8-fold difference for residents from integrated plastic surgery programs, and a 7.0-fold difference within the neurological surgery group. Conclusions There is interspecialty and intraspecialty variability in peripheral nerve surgery volume for orthopaedic, plastic, neurological, and general surgery residents. Caseload is not the sole determinant of training quality as mentorship, didactics, case breadth, and complexity play an important role in training. PMID:27168883

Incidence of cardiovascular complications in knee arthroplasty patients before and after implementation of a ropivacaine local infiltration analgesia protocol: A retrospective study.

PubMed

Lameijer, Joost R C; Verboom, Frederik; Grefkens, Joost; Jansen, Joris

2016-10-01

Local infiltration analgesia (LIA) during total knee arthroplasty has been shown to give statistically significant reduction in post-operative pain. The effects of using high volumes of ropivacaine combined with adrenaline as LIA on cardiovascular parameters in knee replacement have not been described before. The objective of this study was to investigate the cardiovascular safety of ropivacaine as part of high volume local infiltration analgesia (LIA) in total knee replacement surgery. This is a retrospective observational comparative cohort study conducted in two independent cohorts, one treated without and one treated with a local infiltration analgesia protocol, containing a total of 744 patients with a mean age of 68years (42 to 89) and 68years (21 to 88) respectively with a follow-up of 12months. No statistical difference in bradycardia during surgery, post-operative cardiovascular complications, and mortality was found after use of LIA. A statistically significant lower incidence of hypotension was found in the LIA group (P<0.01). This result has to be interpreted with care, due to the use of adrenaline in the LIA mixture, which could mask possible hypotension. No statistical difference was found in the occurrence of hypertension or tachycardia, despite the addition of adrenaline to the LIA mixture. No difference in mortality was found between the two groups (P=0.11). These results show safe use of high volume ropivacaine with adrenaline as local infiltration analgesia during total knee replacement surgery. Copyright © 2016 Elsevier B.V. All rights reserved.

Do Changes in Hospital Outpatient Payments Affect the Setting of Care?

PubMed Central

He, Daifeng; Mellor, Jennifer M

2013-01-01

Objective To examine whether decreases in Medicare outpatient payment rates under the Outpatient Prospective Payment System (OPPS) caused outpatient care to shift toward the inpatient setting. Data Sources/Study Setting Hospital inpatient and outpatient discharge files from the Florida Agency for Health Care Administration from 1997 through 2008. Study Design This study focuses on inguinal hernia repair surgery, one of the most commonly performed surgical procedures in the United States. We estimate multivariate regressions of inguinal hernia surgery counts in the outpatient setting and in the inpatient setting. The key explanatory variable is the time-varying Medicare payment rate specific to the procedure and hospital. Control variables include time-varying hospital and county characteristics and hospital and year-fixed effects. Principal Findings Outpatient hernia surgeries fell in response to OPPS-induced rate cuts. The volume of inpatient hernia repair surgeries did not increase in response to reductions in the outpatient reimbursement rate. Conclusions Potential substitution from the outpatient setting to the inpatient setting does not pose a serious threat to Medicare's efforts to contain hospital outpatient costs. PMID:23701048

A virtual reality-based method of decreasing transmission time of visual feedback for a tele-operative robotic catheter operating system.

PubMed

Guo, Jin; Guo, Shuxiang; Tamiya, Takashi; Hirata, Hideyuki; Ishihara, Hidenori

2016-03-01

An Internet-based tele-operative robotic catheter operating system was designed for vascular interventional surgery, to afford unskilled surgeons the opportunity to learn basic catheter/guidewire skills, while allowing experienced physicians to perform surgeries cooperatively. Remote surgical procedures, limited by variable transmission times for visual feedback, have been associated with deterioration in operability and vascular wall damage during surgery. At the patient's location, the catheter shape/position was detected in real time and converted into three-dimensional coordinates in a world coordinate system. At the operation location, the catheter shape was reconstructed in a virtual-reality environment, based on the coordinates received. The data volume reduction significantly reduced visual feedback transmission times. Remote transmission experiments, conducted over inter-country distances, demonstrated the improved performance of the proposed prototype. The maximum error for the catheter shape reconstruction was 0.93 mm and the transmission time was reduced considerably. The results were positive and demonstrate the feasibility of remote surgery using conventional network infrastructures. Copyright © 2015 John Wiley & Sons, Ltd.

Should breast reduction surgery be rationed? A comparison of the health status of patients before and after treatment: postal questionnaire survey.

PubMed

Klassen, A; Fitzpatrick, R; Jenkinson, C; Goodacre, T

1996-08-24

To assess the health status of patients before and after breast reduction surgery and to make comparisons with the health status of women in the general population. Postal questionnaire survey sent to patients before and six months after surgery. The three plastic surgery departments in the Oxford Regional Health Authority, during April to August 1993. 166 women (over the age of 16 years) referred for breast reduction; scores from the "short form 36" (SF-36) health questionnaire completed by women in the 1991-2 Oxford healthy life survey. Health status of breast reduction patients before and after surgery as assessed by the SF-36, the 28 item general health questionnaire, and Rosenberg's self esteem scale; comparisons between the health status of breast reduction patients and that of women in the general population; outcome of surgery as assessed retrospectively by patients. Differences between the health status of breast reduction patients and that of women in the general population were detected by the SF-36 both before and after surgery. Breast reduction surgery produced substantial change in patients' physical, social, and psychological function. The proportion of cases of possible psychiatric morbidity according to the general health questionnaire fell from 41% (22/54) before surgery to 11% (6/54) six months after treatment. Eighty six per cent (50/58) of patients expressed great satisfaction with the surgical result postoperatively. The study provides empirical evidence that supports the inclusion of breast reduction surgery in NHS purchasing contracts.

Should breast reduction surgery be rationed? A comparison of the health status of patients before and after treatment: postal questionnaire survey.

PubMed Central

Klassen, A.; Fitzpatrick, R.; Jenkinson, C.; Goodacre, T.

1996-01-01

OBJECTIVES: To assess the health status of patients before and after breast reduction surgery and to make comparisons with the health status of women in the general population. DESIGN: Postal questionnaire survey sent to patients before and six months after surgery. SETTING: The three plastic surgery departments in the Oxford Regional Health Authority, during April to August 1993. SUBJECTS: 166 women (over the age of 16 years) referred for breast reduction; scores from the "short form 36" (SF-36) health questionnaire completed by women in the 1991-2 Oxford healthy life survey. MAIN OUTCOME MEASURES: Health status of breast reduction patients before and after surgery as assessed by the SF-36, the 28 item general health questionnaire, and Rosenberg's self esteem scale; comparisons between the health status of breast reduction patients and that of women in the general population; outcome of surgery as assessed retrospectively by patients. RESULTS: Differences between the health status of breast reduction patients and that of women in the general population were detected by the SF-36 both before and after surgery. Breast reduction surgery produced substantial change in patients' physical, social, and psychological function. The proportion of cases of possible psychiatric morbidity according to the general health questionnaire fell from 41% (22/54) before surgery to 11% (6/54) six months after treatment. Eighty six per cent (50/58) of patients expressed great satisfaction with the surgical result postoperatively. CONCLUSION: The study provides empirical evidence that supports the inclusion of breast reduction surgery in NHS purchasing contracts. PMID:8776311

Association between provider volume and healthcare expenditures of patients with oral cancer in Taiwan: a population-based study.

PubMed

Chen, Li-Fu; Ho, Hsu-Chueh; Su, Yu-Chieh; Lee, Moon-Sing; Hung, Shih-Kai; Chou, Pesus; Lee, Ching-Chieh J; Lin, Li-Chu; Lee, Ching-Chih

2013-01-01

Oral cancer requires considerable utilization of healthcare services. Wide resection of the tumor and reconstruction with free flap are widely used. Due to high recurrence rate, close follow-up is mandatory. This study was conducted to explore the relationship between the healthcare expenditure of oncological surgery and one-year follow up and provider volume. From the National Health Insurance Research Database published by the Taiwanese National Health Research Institute, the authors selected a total of 1300 oral cancer patients who underwent tumor resection and free flap reconstruction in 2008. Hierarchical linear regression analysis was subsequently performed to explore the relationship between provider volume and expenditures of oncological surgery and one-year follow-up period. Emergency department (ED) visits and 30-day readmission rates were also analyzed. The mean expenditure for oncological surgery was $11080±4645 (all costs are given in U.S. dollars) and $10129±9248 for one-year follow up. For oncological surgery expenditure, oral cancer patients treated by low-volume surgeons had an additional $845 than those in high-volume surgeons in mixed model. For one-year follow-up expenditure, patients in low-volume hospitals had an additional $3439 than those in high-volume hospitals; patient in low-volume surgeons and medium-volume surgeons incurred an additional expenditure of $2065 and $1811 than those in high-volume surgeons. Oral cancer patients treated in low-volume hospitals incurred higher risk of 30-day readmission rate (odds ratio, 6.6; 95% confidence interval, 1.6-27). After adjusting for physician, hospital, and patient characteristics, low-volume provider performing wide excision with reconstructive surgery in oral cancer patients incurred significantly higher expenditure for oncological surgery and one-year healthcare per patient than did others with higher volumes. Treatment strategies adapted by high-volume providers should be further analyzed.

Increasing volume and complexity of pediatric epilepsy surgery with stable seizure outcome between 2008 and 2014: A nationwide multicenter study.

PubMed

Barba, Carmen; Specchio, Nicola; Guerrini, Renzo; Tassi, Laura; De Masi, Salvatore; Cardinale, Francesco; Pellacani, Simona; De Palma, Luca; Battaglia, Domenica; Tamburrini, Gianpiero; Didato, Giuseppe; Freri, Elena; Consales, Alessandro; Nozza, Paolo; Zamponi, Nelia; Cesaroni, Elisabetta; Di Gennaro, Giancarlo; Esposito, Vincenzo; Giulioni, Marco; Tinuper, Paolo; Colicchio, Gabriella; Rocchi, Raffaele; Rubboli, Guido; Giordano, Flavio; Lo Russo, Giorgio; Marras, Carlo Efisio; Cossu, Massimo

2017-10-01

The objective of the study was to assess common practice in pediatric epilepsy surgery in Italy between 2008 and 2014. A survey was conducted among nine Italian epilepsy surgery centers to collect information on presurgical and postsurgical evaluation protocols, volumes and types of surgical interventions, and etiologies and seizure outcomes in pediatric epilepsy surgery between 2008 and 2014. Retrospective data on 527 surgical procedures were collected. The most frequent surgical approaches were temporal lobe resections and disconnections (133, 25.2%) and extratemporal lesionectomies (128, 24.3%); the most frequent etiologies were FCD II (107, 20.3%) and glioneuronal tumors (105, 19.9%). Volumes of surgeries increased over time independently from the age at surgery and the epilepsy surgery center. Engel class I was achieved in 73.6% of patients (range: 54.8 to 91.7%), with no significant changes between 2008 and 2014. Univariate analyses showed a decrease in the proportion of temporal resections and tumors and an increase in the proportion of FCDII, while multivariate analyses revealed an increase in the proportion of extratemporal surgeries over time. A higher proportion of temporal surgeries and tumors and a lower proportion of extratemporal and multilobar surgeries and of FCD were observed in low (<50surgeries/year) versus high-volume centers. There was a high variability across centers concerning pre- and postsurgical evaluation protocols, depending on local expertise and facilities. This survey reveals an increase in volume and complexity of pediatric epilepsy surgery in Italy between 2008 and 2014, associated with a stable seizure outcome. Copyright © 2017 Elsevier Inc. All rights reserved.

A 4-Week Preoperative Ketogenic Micronutrient-Enriched Diet Is Effective in Reducing Body Weight, Left Hepatic Lobe Volume, and Micronutrient Deficiencies in Patients Undergoing Bariatric Surgery: a Prospective Pilot Study.

PubMed

Schiavo, Luigi; Pilone, Vincenzo; Rossetti, Gianluca; Barbarisi, Alfonso; Cesaretti, Manuela; Iannelli, Antonio

2018-03-03

Before bariatric surgery (BS), moderate weight loss, left hepatic lobe volume reduction, and micronutrient deficiency (MD) identification and correction are desirable. The objective of this study was to assess the safety and the effectiveness of a 4-week preoperative ketogenic micronutrient-enriched diet (KMED) in reducing body weight (BW), left hepatic lobe volume, and correcting MD in patients scheduled for BS. In this prospective pilot study, a cohort of morbidly obese patients (n = 27, 17 females, 10 males) with a mean body mass index (BMI) of 45.2 kg/m 2 scheduled for BS underwent a 4-week preoperative KMED. Their BW, BMI, fat mass (FM), fat-free mass (FFM), resting metabolic rate (RMR), left hepatic lobe volume, micronutrient status, and biochemical and metabolic patterns were measured before and after the 4-week KMED. Patient compliance was assessed by validated questionnaires (3-day estimated food records and 72-h recall). Qualitative methods (5-point Likert questionnaire) were used to measure diet acceptability and side effects. All patients completed the study. We observed highly significant decreases in BW (- 10.3%, p < 0.001, in males; - 8.2%, p < 0.001, in females), left hepatic lobe volume (- 19.8%, p < 0.001), and an amelioration of patient micronutrient status. All patients showed a high frequency of acceptability and compliance in following the diet. No adverse side effect was reported. This study demonstrates that a 4-week preoperative KMED is safe and effective in reducing BW, left hepatic lobe volume, and correcting MD in obese patients scheduled for BS.

Frequency and predictors of return to incentive spirometry volume baseline after cardiac surgery.

PubMed

Harton, Suzanne C; Grap, Mary Jo; Savage, Laura; Elswick, R K

2007-01-01

Incentive spirometry (IS) is routinely used in most clinical settings, but evaluation of patient efficacy of IS is not standardized. The purpose of this study was to describe the degree and predictors of return to preoperative IS volume after cardiac surgery. IS volumes were documented in 69 subjects (71% men; mean age, 59 years) undergoing cardiac surgery during the preoperative evaluation and twice daily postoperatively. Nineteen percent of subjects achieved their IS preoperative volume by hospital discharge. Based on highest volume achieved, subjects achieved an average of 75% of their preoperative volume by discharge, and only age and number of bypass grafts predicted return to preoperative IS volume. These data may assist nurses and patients to set realistic goals for postoperative IS volume achievement.

Lung volume reduction surgery for emphysema.

PubMed

Flaherty, K R; Martinez, F J

2000-12-01

Over the past decades, extensive literature has been published regarding surgical therapies for advanced COPD. Lung-volume reduction surgery would be an option for a significantly larger number of patients than classic bullectomy or lung transplantation. Unfortunately, the initial enthusiasm has been tempered by major questions regarding the optimal surgical approach, safety, firm selection criteria, and confirmation of long-term benefits. In fact, the long-term follow-up reported in patients undergoing classical bullectomy should serve to caution against unbridled enthusiasm for the indiscriminate application of LVRS. Those with the worst long-term outcome despite favourable short-term improvements after bullectomy have consistently been those with the lowest pulmonary function and significant emphysema in the remaining lung who appear remarkably similar to those being evaluated for LVRS. With this in mind, the National Heart, Lung and Blood Institute partnered with the Health Care Finance Administration to establish a multicenter, prospective, randomized study of intensive medical management, including pulmonary rehabilitation versus the same plus bilateral (by MS or VATS), known as the National Emphysema Treatment Trial. The primary objectives are to determine whether LVRS improves survival and exercise capacity. The secondary objectives will examine effects on pulmonary function and HRQL, compare surgical techniques, examine selection criteria for optimal response, identify criteria to determine those who are at prohibitive surgical risk, and examine long-term cost effectiveness. It is hoped that data collected from this novel, multicenter collaboration will place the role of LVRS in a clearer perspective for the physician caring for patients with advanced emphysema.

Comparison of Blood Loss in Laser Lipolysis vs Traditional Liposuction.

PubMed

Abdelaal, Mohammed Mahmoud; Aboelatta, Yasser Abdallah

2014-08-01

Laser-assisted liposuction has been associated with reduced blood loss. However, this clinical finding has not been evaluated objectively. In this study, the authors objectively estimated the blood loss volume associated with laser lipolysis vs traditional liposuction in various anatomic regions. In this prospective study, 56 patients underwent equal amounts of traditional and laser-assisted liposuction at 2 contralateral anatomic sites. Blood loss volumes were calculated from the lipoaspirates by measuring hemoglobin and red blood cell content. The data were analyzed statistically with repeated-measures analysis of variance and the Mann-Whitney U test. Laser lipolysis can reduce blood loss by more than 50% compared with traditional liposuction. Laser lipolysis resulted in significant reductions in mean blood loss volumes in the abdomen, flanks, back, and breast. The authors provide objective evidence that laser lipolysis significantly reduces blood loss compared with traditional liposuction. 3. © 2014 The American Society for Aesthetic Plastic Surgery, Inc.

Can technical factors explain the volume-outcome relationship in gastric bypass surgery?

PubMed

Smith, Mark D; Patterson, Emma; Wahed, Abdus S; Belle, Steven H; Courcoulas, Anita P; Flum, David; Khandelwal, Saurabh; Mitchell, James E; Pomp, Alfons; Pories, Walter J; Wolfe, Bruce

2013-01-01

The existence of a relationship between surgeon volume and patient outcome has been reported for different complex surgical operations. This relationship has also been confirmed for patients undergoing Roux-en-Y gastric bypass (RYGB) in the Longitudinal Assessment of Bariatric Surgery (LABS) study. Despite multiple studies demonstrating volume-outcome relationships, fewer studies investigate the causes of this relationship. The purpose of the present study is to understand possible explanations for the volume-outcome relationship in LABS. LABS includes a 10-center, prospective study examining 30-day outcomes after bariatric surgery. The relationship between surgeon annual RYGB volume and incidence of a composite endpoint (CE) has been published previously. Technical aspects of RYGB surgery were compared between high and low volume surgeons. The previously published model was adjusted for select technical factors. High-volume surgeons (>100 RYGBs/yr) were more likely to perform a linear stapled gastrojejunostomy, use fibrin sealant, and place a drain at the gastrojejunostomy compared with low-volume surgeons (<25 RYGBs/yr), and less likely to perform an intraoperative leak test. After adjusting for the newly identified technical factors, the relative risk of CE was .93 per 10 RYGB/yr increase in volume, compared with .90 for clinical risk adjustment alone. High-volume surgeons exhibited certain differences in technique compared with low-volume surgeons. After adjusting for these differences, the strength of the volume-outcome relationship previously found was reduced only slightly, suggesting that other factors are also involved. Copyright © 2013 American Society for Bariatric Surgery. All rights reserved.

“What Motivates Her”: Motivations for Considering Labial Reduction Surgery as Recounted on Women's Online Communities and Surgeons' Websites

PubMed Central

Zwier, Sandra

2014-01-01

Introduction Increasing numbers of women are seeking labial reduction surgery. We studied the motivations for considering labial reduction surgery as recounted on women's online communities and surgery provider's websites. Aims The study analyzed motivations for considering labial reduction surgery expressed by women on online communities, looked at the role of the women's age and nationality, compared findings with motivations indicated on the websites of an international sample of surgery providers, and identified similarities to and differences from what is known from extant studies. Methods Quantitative content analysis of the posts of 78 American, British, and Dutch women on online communities, and 40 international surgery providers' websites about labial reduction surgery was conducted. Main Outcome Measures Main outcome measures concerned the incidence and prominence of different motivational categories (functional/emotional and discomfort/enhancement related). Differences in motivations as a function of age, national background, and women's vs. surgeons' stated motivations were tested. Results Emotional discomfort regarding self-appearance and social and sexual relationships was found to be the most frequent and most prominent motivation for considering labial reduction surgery on women's online communities, regardless of age and national background. Functional discomfort and desired emotional enhancement ranked second. Very few age or national differences were found. The surgeons' websites recognized functional discomfort more and elaborated upon emotional issues in sexual relationships less than members of the online communities. Conclusions Feelings of emotional and psychosexual distress in addition to functional distress are a highly prevalent motivation among women considering labial reduction surgery. Emotional distress appears to be greater and more freely emphasized when women communicate on online communities, while functional issues appear to receive greater notice on surgery provider's websites. Zwier S. “What motivates her”: Motivations for considering labial reduction surgery as recounted on women's online communities and surgeons' websites. Sex Med 2014;2:16–23. PMID:25356297

Use of Intra-Arterial Chemotherapy and Embolization Before Limb Salvage Surgery for Osteosarcoma of the Lower Extremity

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

Zhang Huojun, E-mail: chyyzhj@hotmail.com; Yang Jijin, E-mail: yangjijin@live.com; Lu Jianping

We report our experience with the use of intra-arterial chemotherapy and embolization before limb salvage surgery in patients with osteosarcoma of the lower extremity. We evaluated the effect of this procedure on the degree of tumor necrosis and on the amount of blood loss during surgery. We reviewed the medical records of all patients who received intra-arterial chemotherapy and embolization before undergoing limb salvage surgery for osteosarcoma of the lower extremity at our institution between January 2003 and April 2008. Patient demographic, tumor characteristics, treatment details, postembolization complications, and surgical and pathological findings were recorded for each patient. We evaluatedmore » the operative time, estimated blood loss (EBL), and volume of blood transfusion during surgery and in the postoperative period in all patients in the study group. The same parameters were recorded for 65 other patients with lower extremity osteosarcoma who underwent limb salvage operation at our institution without undergoing preoperative intervention. The study included 47 patients (25 males and 22 females). Angiography showed that the tumors were hypervascular. Intra-arterial chemotherapy and embolization were performed successfully, resulting in a substantial reduction or complete disappearance of tumor stain in all patients. No major complications were encountered. At the time of surgery, performed 3-7 days after embolization, a fibrous edematous band around the tumor was observed in 43 of the 47 patients, facilitating surgery. The goal of limb salvage was achieved successfully in all cases. Percentage tumor necrosis induced by treatment ranged from 70.2% to 94.2% (average, 82.9%). EBL during surgery, EBL from drains in the postoperative period, total EBL, and transfusion volumes were significantly lower in the 47 study patients compared to the 65 patients who underwent surgery without preoperative treatment with intra-arterial chemotherapy and embolization. The mean operative time was also significantly less in the intervention group compared to the nonintervention group (73.2 vs. 88.5 min; p < 0.05). In conclusion, intra-arterial chemotherapy and embolization performed 3 to 7 days before limb salvage surgery in patients with lower extremity osteosarcomas can cause substantial tumor necrosis, reduce the EBL and transfusion requirements during surgery, and induce formation of a false capsule around the tumor, thus facilitating surgical excision of the tumors.« less

The Effects of Sleeve Gastrectomy and Gastric Bypass on Branched-Chain Amino Acid Metabolism 1 Year After Bariatric Surgery.

PubMed

Tan, Hong Chang; Khoo, Chin Meng; Tan, Matthew Zhen-Wei; Kovalik, Jean-Paul; Ng, Alvin Choong Meng; Eng, Alvin Kim Hock; Lai, Oi Fah; Ching, Jian Hong; Tham, Kwang Wei; Pasupathy, Shanker

2016-08-01

Weight loss, early after Roux-en-Y gastric bypass (GB) surgery, is associated with reduced concentrations of plasma branched-chain amino acids (BCAAs) and improved insulin sensitivity. Herein, we evaluated whether changes in BCAAs and insulin sensitivity persist with weight stabilization (1 year) after GB or sleeve gastrectomy (SG). We prospectively examined 22 severely obese patients (mean age 40.6 ± 2.1 years, BMI 38.8 ± 1.3 kg/m(2), and 59.1 % female) who underwent SG (n = 12) or GB (n = 10) for morbid obesity. Body fat composition was measured with dual X-Ray absorptiometry and abdominal fat volume with computed tomography. BCAAs and acylcarnitines were profiled using liquid chromatography with tandem mass spectrometry. Insulin resistance was calculated using the homeostasis model assessment for insulin resistance (HOMA-IR) formula. At 1-year follow-up, the decrease in BMI, body weight, total fat mass (TFM), fat free mass, and visceral adipose tissue (VAT) was similar between SG and GB. HOMA-IR was associated with BCAA concentrations, and both were decreased equally in both surgical groups. In multivariate analysis with BCAAs, TFM, and VAT as independent factors, only VAT remained significantly associated with insulin resistance. The metabolic benefits from bariatric surgery, including the changes in BCAA profile, are comparable between SG and GB. The reduction in BCAAs and improvement in the AC profiles after bariatric surgery persists up to 12 months after surgery and may not be surgical related but is influenced primarily by the amount of weight loss, in particular the reduction in visceral adiposity.

Preoperative left ventricular ejection fraction and left atrium reverse remodeling after mitral regurgitation surgery.

PubMed

Machado, Lucia R; Meneghelo, Zilda M; Le Bihan, David C S; Barretto, Rodrigo B M; Carvalho, Antonio C; Moises, Valdir A

2014-11-06

Left atrium enlargement has been associated with cardiac events in patients with mitral regurgitation (MR). Left atrium reverse remodeling (LARR) occur after surgical correction of MR, but the preoperative predictors of this phenomenon are not well known. It is therefore important to identify preoperative predictors for postoperative LARR. We enrolled 62 patients with chronic severe MR (prolapse or flail leaflet) who underwent successful mitral valve surgery (repair or replacement); all with pre- and postoperative echocardiography. LARR was defined as a reduction in left atrium volume index (LAVI) of ≥ 25%. Stepwise multiple regression analysis was used to identify independent predictors of LARR. LARR occurred in 46 patients (74.2%), with the mean LAVI decreasing from 85.5 mL/m2 to 49.7 mL/m2 (p <0.001). These patients had a smaller preoperative left ventricular systolic volume (p =0.022) and a higher left ventricular ejection fraction (LVEF) (p =0.034). LVEF was identified as the only preoperative variable significantly associated with LARR (odds ratio, 1.086; 95% confidence interval, 1.002-1.178). A LVEF cutoff value of 63.5% identified patients with LARR of ≥ 25% with a sensitivity of 71.7% and a specificity of 56.3%. LARR occurs frequently after mitral valve surgery and is associated with preoperative LVEF higher than 63.5%.

Intraoperative ultrasound guidance in breast-conserving surgery shows superiority in oncological outcome, long-term cosmetic and patient-reported outcomes: Final outcomes of a randomized controlled trial (COBALT).

PubMed

Volders, J H; Haloua, M H; Krekel, N M A; Negenborn, V L; Kolk, R H E; Lopes Cardozo, A M F; Bosch, A M; de Widt-Levert, L M; van der Veen, H; Rijna, H; Taets van Amerongen, A H M; Jóźwiak, K; Meijer, S; van den Tol, M P

2017-04-01

The multicenter randomized controlled COBALT trial demonstrated that ultrasound-guided breast-conserving surgery (USS) results in a significant reduction of margin involvement (3.1% vs. 13%) and excision volumes compared to palpation-guided surgery (PGS). The aim of the present study was to determine long term oncological and patient-reported outcomes including quality of life (QoL), together with their progress over time. 134 patients with T1-T2 breast cancer were randomized to USS (N = 65) or PGS (N = 69). Cosmetic outcomes were assessed with the Breast Cancer Conservative Treatment cosmetic results (BCCT.core) software, panel-evaluation and patient self-evaluation on a 4-point Likert-scale. QoL was measured using the EORTC QLQ-C30/-BR23 questionnaire. No locoregional recurrences were reported after mean follow-up of 41 months. Seven patients (5%) developed distant metastatic disease (USS 6.3%, PGS 4.4%, p = 0.466), of whom six died of disease (95.5% overall survival). USS achieved better cosmetic outcomes compared to PGS, with poor outcomes of 11% and 21% respectively, a result mainly attributable to mastectomies due to involved margins following PGS. There was no difference after 1 and 3 years in cosmetic outcome. Dissatisfied patients included those with larger excision volumes, additional local therapies and worse QoL. Patients with poor/fair cosmetic outcomes scored significantly lower on aspects of QoL, including breast-symptoms, body image and sexual enjoyment. By significantly reducing positive margin status and lowering resection volumes, USS improves the rate of good cosmetic outcomes and increases patient-satisfaction. Considering the large impact of cosmetic outcome on QoL, USS has great potential to improve QoL following breast-conserving therapy. Copyright © 2016 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.

Orthopaedic surgery in natural disaster and conflict settings: how can quality care be ensured?

PubMed

Alvarado, Oscar; Trelles, Miguel; Tayler-Smith, Katie; Joseph, Holdine; Gesline, Rodné; Wilna, Thélusma Eli; Mohammad Omar, Mohammad Karim; Faiz Mohammad, Niaz Mohammad; Muhima Mastaki, John; Chingumwa Buhu, Richard; Caluwaerts, An; Dominguez, Lynette

2015-10-01

Médecins sans Frontières (MSF) is one of the main providers of orthopaedic surgery in natural disaster and conflict settings and strictly imposes a minimum set of context-specific standards before any surgery can be performed. Based on MSF's experience of performing orthopaedic surgery in a number of such settings, we describe: (a) whether it was possible to implement the minimum standards for one of the more rigorous orthopaedic procedures--internal fixation--and when possible, the time frame, (b) the volume and type of interventions performed and (c) the intra-operative mortality rates and postoperative infection rates. We conducted a retrospective review of routine programme data collected between 2007 and 2014 from three MSF emergency surgical interventions in Haiti (following the 2010 earthquake) and three ongoing MSF projects in Kunduz (Afghanistan), Masisi (Democratic Republic of the Congo) and Tabarre (Haiti). The minimum standards for internal fixation were achieved in one emergency intervention site in Haiti, and in Kunduz and Tabarre, taking up to 18 months to implement in Kunduz. All sites achieved the minimum standards to perform amputations, reductions and external fixations, with a total of 9,409 orthopaedic procedures performed during the study period. Intraoperative mortality rates ranged from 0.6 to 1.9 % and postoperative infection rates from 2.4 to 3.5 %. In settings affected by natural disaster or conflict, a high volume and wide repertoire of orthopaedic surgical procedures can be performed with good outcomes when minimum standards are in place. More demanding procedures like internal fixation may not always be feasible.

Volumetric Evaluation of the Mammary Gland and Pectoralis Major Muscle following Subglandular and Submuscular Breast Augmentation.

PubMed

Roxo, Ana Claudia Weck; Nahas, Fabio Xerfan; Salin, Renan; de Castro, Claudio Cardoso; Aboudib, Jose Horacio; Marques, Ruy Garcia

2016-01-01

Besides being a procedure with high level of patient satisfaction, one of the main causes for reoperation after breast augmentation is related to contour deformities and changes in breast volume. Few objective data are available on postoperative volumetric analysis following breast augmentation. The aim of this study was to evaluate volume changes in the breast parenchyma and pectoralis major muscle after breast augmentation with the placement of silicone implants in the subglandular and submuscular planes. Fifty-eight women were randomly allocated either to the subglandular group (n = 24) or submuscular group (n = 24) and underwent breast augmentation in the subglandular or submuscular plane, respectively, or to a control group (n = 10) and received no intervention. Volumetric magnetic resonance imaging was performed at inclusion in all participants and either after 6 and 12 months in the control group or at 6 and 12 months after surgery in the intervention groups. Twelve months after breast augmentation, only the subglandular group had a significant reduction in glandular volume (mean, 22.8 percent), while patients in the submuscular group were the only ones showing significant reduction in muscle volume (mean, 49.80 percent). Atrophy of the breast parenchyma occurred after subglandular breast augmentation, but not following submuscular breast augmentation. In contrast, submuscular breast augmentation caused atrophy of the pectoralis major muscle. Therapeutic, II.

Compensatory Structural and Functional Adaptation after Radical Nephrectomy for Renal Cell Carcinoma According to Preoperative Stage of Chronic Kidney Disease.

PubMed

Choi, Don Kyoung; Jung, Se Bin; Park, Bong Hee; Jeong, Byong Chang; Seo, Seong Il; Jeon, Seong Soo; Lee, Hyun Moo; Choi, Han-Yong; Jeon, Hwang Gyun

2015-10-01

We investigated structural hypertrophy and functional hyperfiltration as compensatory adaptations after radical nephrectomy in patients with renal cell carcinoma according to the preoperative chronic kidney disease stage. We retrospectively identified 543 patients who underwent radical nephrectomy for renal cell carcinoma between 1997 and 2012. Patients were classified according to preoperative glomerular filtration rate as no chronic kidney disease--glomerular filtration rate 90 ml/minute/1.73 m(2) or greater (230, 42.4%), chronic kidney disease stage II--glomerular filtration rate 60 to less than 90 ml/minute/1.73 m(2) (227, 41.8%) and chronic kidney disease stage III--glomerular filtration rate 30 to less than 60 ml/minute/1.73 m(2) (86, 15.8%). Computerized tomography performed within 2 months before surgery and 1 year after surgery was used to assess functional renal volume for measuring the degree of hypertrophy of the remnant kidney, and the preoperative and postoperative glomerular filtration rate per unit volume of functional renal volume was used to calculate the degree of hyperfiltration. Among all patients (mean age 56.0 years) mean preoperative glomerular filtration rate, functional renal volume and glomerular filtration rate/functional renal volume were 83.2 ml/minute/1.73 m(2), 340.6 cm(3) and 0.25 ml/minute/1.73 m(2)/cm(3), respectively. The percent reduction in glomerular filtration rate was statistically significant according to chronic kidney disease stage (no chronic kidney disease 31.2% vs stage II 26.5% vs stage III 12.8%, p <0.001). However, the degree of hypertrophic functional renal volume in the remnant kidney was not statistically significant (no chronic kidney disease 18.5% vs stage II 17.3% vs stage III 16.5%, p=0.250). The change in glomerular filtration rate/functional renal volume was statistically significant (no chronic kidney disease 18.5% vs stage II 20.1% vs stage III 45.9%, p <0.001). Factors that increased glomerular filtration rate/functional renal volume above the mean value were body mass index (p=0.012), diabetes mellitus (p=0.023), hypertension (p=0.015) and chronic kidney disease stage (p <0.001). Patients with a lower preoperative glomerular filtration rate had a smaller reduction in postoperative renal function than those with a higher preoperative glomerular filtration rate due to greater degrees of functional hyperfiltration. Copyright © 2015 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

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

PubMed

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

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

Impact of surgeon volume and specialization on short-term outcomes in colorectal cancer surgery.

PubMed

Borowski, D W; Kelly, S B; Bradburn, D M; Wilson, R G; Gunn, A; Ratcliffe, A A

2007-07-01

Several studies have shown a relationship between surgeon volume and outcomes in colorectal cancer surgery. The aim of this study was to determine the impact of surgeon volume and specialization on primary tumour resection rate, restoration of bowel continuity following rectal cancer resection, anastomotic leakage and perioperative mortality. The Northern Region Colorectal Cancer Audit Group conducts a population-based audit of patients with colorectal cancer managed by surgeons. This study examined 8219 patients treated between 1998 and 2002. Outcomes were modelled using multivariate logistic regression analysis. Tumour resection was performed in 6949 (93.8 per cent) of 7411 patients. High-volume surgeons with an annual caseload of at least 18.5 (odds ratio (OR) 1.53 (95 per cent confidence interval (c.i.) 1.10 to 2.12); P = 0.012) and colorectal specialists (OR 1.42 (95 per cent c.i. 1.06 to 1.90); P = 0.018) were more likely to perform elective sphincter-saving rectal surgery. In elective surgery, the risk of perioperative death was lower for high-volume surgeons (OR 0.58 (95 per cent c.i. 0.44 to 0.76); P < 0.001), but this was not the case in emergency surgery. High-volume surgeons had lower perioperative mortality rates for elective surgery, and were more likely to use restorative rectal procedures. Copyright (c) 2007 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Reduction of peritoneal carcinomatosis by intraperitoneal administration of phospholipids in rats

PubMed Central

Otto, Jens; Jansen, Petra Lynen; Lucas, Stefan; Schumpelick, Volker; Jansen, Marc

2007-01-01

Background Intraperitoneal tumor cell attachment after resection of gastrointestinal cancer may lead to a developing of peritoneal carcinosis. Intraabdominal application of phospholipids shows a significant decrease of adhesion formation even in case of rising tumor cell concentration. Methods In experiment A 2*106 colonic tumor cells (DHD/K12/Trb) were injected intraperitonely in female BD-IX-rats. A total of 30 rats were divided into three groups with treatments of phospholipids at 6% or 9% and the control group. In experiment B a total of 100 rats were divided into ten groups with treatments of phospholipids at 9% and the control group. A rising concentration of tumor cells (10,000, 50,000, 100,000, 250,000 and 500,000) were injected intraperitonely in female BD-IX-rats of the different groups. After 30 days, the extent of peritoneal carcinosis was determined by measuring the tumor volume, the area of attachment and the Peritoneal Cancer Index (PCI). Results In experiment A, we found a significant reduction (control group: tumor volume: 12.0 ± 4.9 ml; area of tumor adhesion: 2434.4 ± 766 mm2; PCI 28.5 ± 10.0) of peritoneal dissemination according to all evaluation methods after treatment with phospholipids 6% (tumor volume: 5.2 ± 2.2 ml; area of tumor adhesion: 1106.8 ± 689 mm2; PCI 19.0 ± 5.0) and phospholipids 9% (tumor volume: 4.0 ± 3.5 ml; area of tumor adhesion: 362.7 ± 339 mm2; PCI 13.8 ± 5.1). In experiment B we found a significant reduction of tumor volume in all different groups of rising tumor cell concentration compared to the control. As detected by the area of attachment we found a significant reduction in the subgroups 1*104, 25*104 and 50*104. The reduction in the other subgroups shows no significance. The PCI could be reduced significantly in all subgroups apart from 5*104. Conclusion In this animal study intraperitoneal application of phospholipids resulted in reduction of the extent of peritoneal carcinomatosis after intraperitoneal administration of free tumor cells. This effect was exceptionally noticed when the amount of intraperitoneal tumor cells was limited. Consequently, intraperitoneal administration of phospholipids might be effective in reducing peritoneal carcinomatosis after surgery of gastrointestinal tumors in humans. PMID:17584925

Cellular and Morphological Alterations in the Vastus Lateralis Muscle as the Result of ACL Injury and Reconstruction.

PubMed

Noehren, Brian; Andersen, Anders; Hardy, Peter; Johnson, Darren L; Ireland, Mary Lloyd; Thompson, Katherine L; Damon, Bruce

2016-09-21

Individuals who have had an anterior cruciate ligament (ACL) tear and reconstruction continue to experience substantial knee extensor strength loss despite months of physical therapy. Identification of the alterations in muscle morphology and cellular composition are needed to understand potential mechanisms of muscle strength loss, initially as the result of the injury and subsequently from surgery and rehabilitation. We performed diffusion tensor imaging-magnetic resonance imaging and analyzed muscle biopsies from the vastus lateralis of both the affected and unaffected limbs before surgery and again from the reconstructed limb following the completion of rehabilitation. Immunohistochemistry was done to determine fiber type and size, Pax-7-positive (satellite) cells, and extracellular matrix (via wheat germ agglutinin straining). Using the diffusion tensor imaging data, the fiber tract length, pennation angle, and muscle volume were determined, yielding the physiological cross-sectional area (PCSA). Paired t tests were used to compare the effects of the injury between injured and uninjured limbs and the effects of surgery and rehabilitation within the injured limb. We found significant reductions before surgery in type-IIA muscle cross-sectional area (CSA; p = 0.03), extracellular matrix (p < 0.01), satellite cells per fiber (p < 0.01), pennation angle (p = 0.03), muscle volume (p = 0.02), and PCSA (p = 0.03) in the injured limb compared with the uninjured limb. Following surgery, these alterations in the injured limb persisted and the frequency of the IIA fiber type decreased significantly (p < 0.01) and that of the IIA/X hybrid fiber type increased significantly (p < 0.01). Significant and prolonged differences in muscle quality and morphology occurred after ACL injury and persisted despite reconstruction and extensive physical therapy. These results suggest the need to develop more effective early interventions following an ACL tear to prevent deleterious alterations within the quadriceps. Copyright © 2016 by The Journal of Bone and Joint Surgery, Incorporated.

Patterns of recurrence after surgery alone versus preoperative chemoradiotherapy and surgery in the CROSS trials.

PubMed

Oppedijk, Vera; van der Gaast, Ate; van Lanschot, Jan J B; van Hagen, Pieter; van Os, Rob; van Rij, Caroline M; van der Sangen, Maurice J; Beukema, Jannet C; Rütten, Heidi; Spruit, Patty H; Reinders, Janny G; Richel, Dick J; van Berge Henegouwen, Mark I; Hulshof, Maarten C C M

2014-02-10

To analyze recurrence patterns in patients with cancer of the esophagus or gastroesophageal junction treated with either preoperative chemoradiotherapy (CRT) plus surgery or surgery alone. Recurrence pattern was analyzed in patients from the previously published CROSS I and II trials in relation to radiation target volumes. CRT consisted of five weekly courses of paclitaxel and carboplatin combined with a concurrent radiation dose of 41.4 Gy in 1.8-Gy fractions to the tumor and pathologic lymph nodes with margin. Of the 422 patients included from 2001 to 2008, 418 were available for analysis. Histology was mostly adenocarcinoma (75%). Of the 374 patients who underwent resection, 86% were allocated to surgery and 92% to CRT plus surgery. On January 1, 2011, after a minimum follow-up of 24 months (median, 45 months), the overall recurrence rate in the surgery arm was 58% versus 35% in the CRT plus surgery arm. Preoperative CRT reduced locoregional recurrence (LRR) from 34% to 14% (P < .001) and peritoneal carcinomatosis from 14% to 4% (P < .001). There was a small but significant effect on hematogenous dissemination in favor of the CRT group (35% v 29%; P = .025). LRR occurred in 5% within the target volume, in 2% in the margins, and in 6% outside the radiation target volume. In 1%, the exact site in relation to the target volume was unclear. Only 1% had an isolated infield recurrence after CRT plus surgery. Preoperative CRT in patients with esophageal cancer reduced LRR and peritoneal carcinomatosis. Recurrence within the radiation target volume occurred in only 5%, mostly combined with outfield failures.

The Influence of Hospital Volume on Circumferential Resection Margin Involvement: Results of the Dutch Surgical Colorectal Audit.

PubMed

Gietelink, Lieke; Henneman, Daniel; van Leersum, Nicoline J; de Noo, Mirre; Manusama, Eric; Tanis, Pieter J; Tollenaar, Rob A E M; Wouters, Michel W J M

2016-04-01

This population-based study evaluates the association between hospital volume and CRM (circumferential resection margin) involvement, adjusted for other confounders, in rectal cancer surgery. A low hospital volume (<20 cases/year) was independently associated with a higher risk of CRM involvement (odds ratio=1.54; 95% CI: 1.12-2.11). To evaluate the association between hospital volume and CRM (circumferential resection margin) involvement in rectal cancer surgery. To guarantee the quality of surgical treatment of rectal cancer, the Association of Surgeons of the Netherlands has stated a minimal annual volume standard of 20 procedures per hospital. The influence of hospital volume has been examined for different outcome variables in rectal cancer surgery. Its influence on the pathological outcome (CRM) however remains unclear. As long-term outcomes are best predicted by the CRM status, this parameter is of essential importance in the debate on the justification of minimal volume standards in rectal cancer surgery. Data from the Dutch Surgical Colorectal Audit (2011-2012) were used. Hospital volume was divided into 3 groups, and baseline characteristics were described. The influence of hospital volume on CRM involvement was analyzed, in a multivariate model, between low- and high-volume hospitals, according to the minimal volume standards. This study included 5161 patients. CRM was recorded in 86% of patients. CRM involvement was 11% in low-volume group versus 7.7% and 7.9% in the medium- and high-volume group (P≤0.001). After adjustment for relevant confounders, the influence of hospital volume on CRM involvement was still significant odds ratio (OR) = 1.54; 95% CI: 1.12-2.11). The outcomes of this pooled analysis support minimal volume standards in rectal cancer surgery. Low hospital volume was independently associated with a higher risk of CRM involvement (OR = 1.54; 95% CI: 1.12-2.11).

Lung Function before and Two Days after Open-Heart Surgery.

PubMed

Urell, Charlotte; Westerdahl, Elisabeth; Hedenström, Hans; Janson, Christer; Emtner, Margareta

2012-01-01

Reduced lung volumes and atelectasis are common after open-heart surgery, and pronounced restrictive lung volume impairment has been found. The aim of this study was to investigate factors influencing lung volumes on the second postoperative day. Open-heart surgery patients (n = 107, 68 yrs, 80% male) performed spirometry both before surgery and on the second postoperative day. The factors influencing postoperative lung volumes and decrease in lung volumes were investigated with univariate and multivariate analyses. Associations between pain (measured by numeric rating scale) and decrease in postoperative lung volumes were calculated with Spearman rank correlation test. Lung volumes decreased by 50% and were less than 40% of the predictive values postoperatively. Patients with BMI >25 had lower postoperative inspiratory capacity (IC) (33 ± 14% pred.) than normal-weight patients (39 ± 15% pred.), (P = 0.04). More pain during mobilisation was associated with higher decreases in postoperative lung volumes (VC: r = 0.33, P = 0.001; FEV(1): r = 0.35, P ≤ 0.0001; IC: r = 0.25, P = 0.01). Patients with high BMI are a risk group for decreased postoperative lung volumes and should therefore receive extra attention during postoperative care. As pain is related to a larger decrease in postoperative lung volumes, optimal pain relief for the patients should be identified.

Lung Function before and Two Days after Open-Heart Surgery

PubMed Central

Urell, Charlotte; Westerdahl, Elisabeth; Hedenström, Hans; Janson, Christer; Emtner, Margareta

2012-01-01

Reduced lung volumes and atelectasis are common after open-heart surgery, and pronounced restrictive lung volume impairment has been found. The aim of this study was to investigate factors influencing lung volumes on the second postoperative day. Open-heart surgery patients (n = 107, 68 yrs, 80% male) performed spirometry both before surgery and on the second postoperative day. The factors influencing postoperative lung volumes and decrease in lung volumes were investigated with univariate and multivariate analyses. Associations between pain (measured by numeric rating scale) and decrease in postoperative lung volumes were calculated with Spearman rank correlation test. Lung volumes decreased by 50% and were less than 40% of the predictive values postoperatively. Patients with BMI >25 had lower postoperative inspiratory capacity (IC) (33 ± 14% pred.) than normal-weight patients (39 ± 15% pred.), (P = 0.04). More pain during mobilisation was associated with higher decreases in postoperative lung volumes (VC: r = 0.33, P = 0.001; FEV1: r = 0.35, P ≤ 0.0001; IC: r = 0.25, P = 0.01). Patients with high BMI are a risk group for decreased postoperative lung volumes and should therefore receive extra attention during postoperative care. As pain is related to a larger decrease in postoperative lung volumes, optimal pain relief for the patients should be identified. PMID:22924127

Ultrasound assessment of gastric volume in children after drinking carbohydrate-containing fluids.

PubMed

Song, I-K; Kim, H-J; Lee, J-H; Kim, E-H; Kim, J-T; Kim, H-S

2016-04-01

Gastric ultrasound is a valid tool for non-invasive assessment of the nature and volume of gastric contents in adults and children. Perioperative fasting guidelines recommend oral carbohydrates up to 2 h before elective surgery. We evaluated gastric volume in children using ultrasound before and after drinking carbohydrate fluids before surgery. Paediatric patients younger than 18 yr old undergoing elective surgery were enrolled. Initial ultrasound assessment of gastric volume was performed after fasting for 8 h. Two hours before surgery, patients were given carbohydrate drinks: 15 ml kg(-1) for patients younger than 3 yr old and 10 ml kg(-1) for those more than 3 yr old. Before induction of general anaesthesia, the gastric volume was reassessed. Parental satisfaction scores (0=totally satisfied, 10=totally dissatisfied) and complications were recorded. Of the 86 enrolled patients, 79 completed the study; three refused to ingest the requested volume, and surgery was delayed for more than 2 h in four patients. The mean (sd) of the initial and second ultrasound measurements were 2.09 (0.97) and 1.85 (0.94) cm(2), respectively (P=0.01; mean difference 0.24 cm(2), 95% confidence interval 0.06-0.43). The median (interquartile range) satisfaction score was 2.4 (0-6). Two instances of postoperative vomiting and one instance of postoperative nausea occurred. Carbohydrate fluids ingested 2 h before surgery reduced the gastric volume and did not cause serious complications in paediatric patients. Parents were satisfied with the preoperative carbohydrate drink. Children may benefit from drinking carbohydrate fluids up to 2 h before elective surgery. cris.nih.go.kr (KCT0001546). © The Author 2016. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Blood and Blood Product Conservation: Results of Strategies to Improve Clinical Outcomes in Open Heart Surgery Patients at a Tertiary Hospital.

PubMed

Khan, Junaid H; Green, Emily A; Chang, Jimmin; Ayala, Alexandria M; Barkin, Marilyn S; Reinys, Emily E; Stanton, Jeffrey; Stanten, Russell D

2017-12-01

Blood product usage is a quality outcome for patients undergoing cardiac surgery. To address an increase in blood product usage since the discontinuation of aprotinin, blood conservation strategies were initiated at a tertiary hospital in Oakland, CA. Improving transfusion rates for open heart surgery patients requiring Cardiopulmonary bypass (CPB) involved multiple departments in coordination. Specific changes to conserve blood product usage included advanced CPB technology upgrades, and precise individualized heparin dose response titration assay for heparin and protamine management. Retrospective analysis of blood product usage pre-implementation, post-CPB changes and post-Hemostasis Management System (HMS) implementation was done to determine the effectiveness of the blood conservation strategies. Statistically significant decrease in packed red blood cells, fresh frozen plasma, cryoprecipitate, and platelet usage over the stepped implementation of both technologies was observed. New oxygenator and centrifugal pump technologies reduced active circuitry volume and caused less damage to blood cells. Individualizing heparin and protamine dosing to a patient using the HMS led to transfusion reductions as well. Overall trends toward reductions in hospital length of stay and intensive care unit stay, and as a result, blood product cost and total hospitalization cost are positive over the period of implementation of both CPB circuit changes and HMS implementation. Although they are multifactorial in nature, these trends provide positive enforcement to the changes implemented.

Comparison of temporomandibular joint and ramus morphology between class II and class III cases before and after bi-maxillary osteotomy.

PubMed

Iguchi, Ran; Yoshizawa, Kunio; Moroi, Akinori; Tsutsui, Takamitsu; Hotta, Asami; Hiraide, Ryota; Takayama, Akihiro; Tsunoda, Tatsuya; Saito, Yuki; Sato, Momoko; Baba, Nana; Ueki, Koichiro

2017-12-01

The purpose of this study was to compare changes in temporomandibular joint (TMJ) and ramus morphology between class II and III cases before and after sagittal split ramus osteotomy (SSRO) and Le Fort I osteotomy. The subjects were 39 patients (78 sides) who underwent bi-maxillary surgery. They consisted of 2 groups (18 class II cases and 21 class III cases), and were selected randomly from among patients who underwent surgery between 2012 and 2016. The TMJ disc tissue and joint effusion were assessed by magnetic resonance imaging (MRI) and the TMJ space, condylar height, ramus height, ramus inclination and condylar square were assessed by computed tomography (CT), pre- and post-operatively. The number of joints with anterior disc displacement in class II was significantly higher than that in class III (p < 0.0001). However, there were no significant differences between the two classes regarding ratio of joint symptoms and ratio of joint effusion pre- and post-operatively. Class II was significantly better than class III regarding reduction ratio of condylar height (p < 0.0001) and square (p = 0.0005). The study findings suggest that condylar morphology could change in both class II and III after bi-maxillary surgery. The findings of the numerical analysis also demonstrated that reduction of condylar volume occurred frequently in class II, although TMJ disc position classification did not change significantly, as previously reported. Copyright © 2017 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

Clinical application of calculated split renal volume using computed tomography-based renal volumetry after partial nephrectomy: Correlation with technetium-99m dimercaptosuccinic acid renal scan data.

PubMed

Lee, Chan Ho; Park, Young Joo; Ku, Ja Yoon; Ha, Hong Koo

2017-06-01

To evaluate the clinical application of computed tomography-based measurement of renal cortical volume and split renal volume as a single tool to assess the anatomy and renal function in patients with renal tumors before and after partial nephrectomy, and to compare the findings with technetium-99m dimercaptosuccinic acid renal scan. The data of 51 patients with a unilateral renal tumor managed by partial nephrectomy were retrospectively analyzed. The renal cortical volume of tumor-bearing and contralateral kidneys was measured using ImageJ software. Split estimated glomerular filtration rate and split renal volume calculated using this renal cortical volume were compared with the split renal function measured with technetium-99m dimercaptosuccinic acid renal scan. A strong correlation between split renal function and split renal volume of the tumor-bearing kidney was observed before and after surgery (r = 0.89, P < 0.001 and r = 0.94, P < 0.001). The preoperative and postoperative split estimated glomerular filtration rate of the operated kidney showed a moderate correlation with split renal function (r = 0.39, P = 0.004 and r = 0.49, P < 0.001). The correlation between reductions in split renal function and split renal volume of the operated kidney (r = 0.87, P < 0.001) was stronger than that between split renal function and percent reduction in split estimated glomerular filtration rate (r = 0.64, P < 0.001). The split renal volume calculated using computed tomography-based renal volumetry had a strong correlation with the split renal function measured using technetium-99m dimercaptosuccinic acid renal scan. Computed tomography-based split renal volume measurement before and after partial nephrectomy can be used as a single modality for anatomical and functional assessment of the tumor-bearing kidney. © 2017 The Japanese Urological Association.

[The respiratory muscles in emphysema. The effects of thoracic distension].

PubMed

Cassart, M; Estenne, M

2000-04-01

Besides increasing the work of ventilation, emphysema increases lung volume which in itself has a deleterious effect on the inspiratory muscles. We review here the effects of an acute change in lung volume on the configuration of the rib cage and muscle function. We also discuss the effects of the chronic distension associated with emphysema. The effects produced by changes in muscle length and configuration on the mechanical force and action of inspiratory muscles is detailed with particular focus on the diaphragm and its structural adaptations to experimental emphysema. We also analyze the activation pattern of inspiratory and expiratory muscles during the breathing process in patients with emphysema. Finally, we discuss the effects of single-lung transplantation and reduction surgery on chest distension and improved inspiratory muscle function.

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

PubMed Central

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

2004-01-01

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

P16.07BEVACIZUMAB AS PALLIATIVE TREATMENT OF FAMILIAL SCHWANNOMATOSIS

PubMed Central

Clement, P.M.; Blockmans, D.; Bechter, O.E.; Van Calenbergh, F.; Legius, E.

2014-01-01

Familial schwannomatosis is a rare genetic disorder characterized by multiple schwannomas and chronic pain. There are, except for the schwannomas, no characteristic findings of neurofibromatosis type II. The only established treatments involve repeated surgery, radiotherapy including gamma knife radiosurgery, and analgesics. We describe a 42-year old female patient with familial schwannomatosis with numerous schwannomas. She underwent 12 resections for symptomatic schwannomas in the past two decades, and was treated with external beam radiotherapy at the skull base and the pelvic region in 2006 and 2010, respectively. Based on reports in neurofibromatosis type II and the expression of VEGF, the patient was treated after written informed consent with bevacizumab at a dose of 5 mg/kg every two weeks. She started treatment in November 2013. The treatment was well tolerated, and the patient observed a decreasing volume of a cervical schwannoma. The patient is free of pain, three months after the start of treatment. CT imaging confirmed an average volume reduction of about 25% in all lesions. In irradiated areas, the volume reduction seemed less pronounced than in previously untreated lesions. To our knowledge, this is the first report of a response to systemic treatment, observed in an adult patient with familial schwannomatosis. Treatment with bevacizumab could be considered as a palliative treatment in patients with this rare but debilitating disease.

Non invasive evaluation of cardiomechanics in patients undergoing MitrClip procedure

PubMed Central

2013-01-01

Background In the last recent years a new percutaneous procedure, the MitraClip, has been validated for the treatment of mitral regurgitation. MitraClip procedure is a promising alternative for patients unsuitable for surgery as it reduces the risk of death related to surgery ensuring a similar result. Few data are present in literature about the variation of hemodynamic parameters and ventricular coupling after Mitraclip implantation. Methods Hemodynamic data of 18 patients enrolled for MitraClip procedure were retrospectively reviewed and analyzed. Echocardiographic measurements were obtained the day before the procedure (T0) and 21 ± 3 days after the procedure (T1), including evaluation of Ejection Fraction, mitral valve regurgitation severity and mechanism, forward Stroke Volume, left atrial volume, estimated systolic pulmonary pressure, non invasive echocardiographic estimation of single beat ventricular elastance (Es(sb)), arterial elastance (Ea) measured as systolic pressure • 0.9/ Stroke Volume, ventricular arterial coupling (Ea/Es(sb) ratio). Data were expressed as median and interquartile range. Measures obtained before and after the procedure were compared using Wilcoxon non parametric test for paired samples. Results Mitraclip procedure was effective in reducing regurgitation. We observed an amelioration of echocardiographic parameters with a reduction of estimated systolic pulmonary pressure (45 to 37,5 p = 0,0002) and left atrial volume (110 to 93 p = 0,0001). Despite a few cases decreasing in ejection fraction (37 to 35 p = 0,035), the maintained ventricular arterial coupling after the procedure (P = 0,67) was associated with an increasing in forward stroke volume (60,3 to 78 p = 0,05). Conclusion MitraClip is effective in reducing mitral valve regurgitation and determines an amelioration of hemodynamic parameters with preservation of ventricular arterial coupling. PMID:23642140

The European Respiratory Society and European Society of Thoracic Surgeons clinical guidelines for evaluating fitness for radical treatment (surgery and chemoradiotherapy) in patients with lung cancer.

PubMed

Brunelli, Alessandro; Charloux, Anne; Bolliger, Chris T; Rocco, Gaetano; Sculier, Jean-Paul; Varela, Gonzalo; Licker, Marc; Ferguson, Mark K; Faivre-Finn, Corinne; Huber, Rudolf Maria; Clini, Enrico M; Win, Thida; De Ruysscher, Dirk; Goldman, Lee

2009-07-01

The European Respiratory Society (ERS) and the European Society of Thoracic Surgeons (ESTS) established a joint task force with the purpose to develop clinical evidence-based guidelines on evaluation of fitness for radical therapy in patients with lung cancer. The following topics were discussed, and are summarized in the final report along with graded recommendations: Cardiologic evaluation before lung resection; lung function tests and exercise tests (limitations of ppoFEV1; DLCO: systematic or selective?; split function studies; exercise tests: systematic; low-tech exercise tests; cardiopulmonary (high tech) exercise tests); future trends in preoperative work-up; physiotherapy/rehabilitation and smoking cessation; scoring systems; advanced care management (ICU/HDU); quality of life in patients submitted to radical treatment; combined cancer surgery and lung volume reduction surgery; compromised parenchymal sparing resections and minimally invasive techniques: the balance between oncological radicality and functional reserve; neoadjuvant chemotherapy and complications; definitive chemo and radiotherapy: functional selection criteria and definition of risk; should surgical criteria be re-calibrated for radiotherapy?; the patient at prohibitive surgical risk: alternatives to surgery; who should treat thoracic patients and where these patients should be treated?

A Tourette-like syndrome following cardiopulmonary bypass and hypothermia: MRI volumetric measurements.

PubMed

Singer, H S; Dela Cruz, P S; Abrams, M T; Bean, S C; Reiss, A L

1997-07-01

We present the case of an adolescent boy who developed a variety of simple and complex motor and vocal tics (Tourette-like syndrome), along with inattentiveness and obsessive-compulsive behaviors after cardiac surgery with cardiopulmonary bypass and profound hypothermia. A single photon emission computed tomography study 2 months after surgery showed reduced uptake in the left hemisphere and 2 years later a perfusion defect in the basal ganglia. Serial magnetic resonance imaging (MRI) studies were normal. Volumetric MRI studies were obtained 4 years after surgery and compared with published values for normal individuals and children with Tourette syndrome (TS), including subsets matched for age, sex, and handedness. Measurement of basal ganglia structures showed a right-dominant asymmetry of the caudate and putamen, in part similar to findings previously reported in patients with TS. Other volumetric abnormalities included a > 2-SD reduction of cortical gray matter, a small decrease of total cerebral volume, and increase in cerebral white matter. Although a variety of neurological problems may occur after cardiopulmonary bypass, to our knowledge this case represents the first report of a chronic tic disorder following cardiac surgery with cardiopulmonary bypass and hypothermia.

Radiofrequency turbinate volume reduction vs. radiofrequency-assisted turbinectomy for nasal obstruction caused by inferior turbinate hypertrophy.

PubMed

Kumar, Saumitra; Anand, Trivender Singh; Pal, Indranil

2017-02-01

Radiofrequency procedures are a well-accepted treatment for nasal obstruction. We conducted a randomized, noncontrolled study to compare the effectiveness of submucosal bipolar radiofrequency turbinate volume reduction (RFTVR) and bipolar radiofrequency-assisted turbinectomy (RFaT) in patients presenting with nasal obstruction caused by inferior turbinate hypertrophy. A total of 30 patients-15 males and 15 females, aged 15 to 60 years (mean: 32)-were randomly divided into one of the two homogeneous treatment groups. Outcomes were determined by comparisons of subjective symptom scores on a visual analog scale and by anterior active rhinomanometry at postoperative days 7, 14, and 28 and again at 6 months postoperatively. Both groups demonstrated significant and similar improvements in nasal airway function both subjectively and objectively. However, we noted that the incidence of adverse effects and postoperative morbidity was higher in the RFaT group. Therefore, we conclude that when surgery is indicated, RFTVR is the preferred treatment for nasal obstruction secondary to inferior turbinate hypertrophy. RFaT is equally effective, but it is associated with a slightly higher incidence of adverse effects.

Post-operative therapy following transoral robotic surgery for unknown primary cancers of the head and neck.

PubMed

Patel, Sapna A; Parvathaneni, Aarthi; Parvathaneni, Upendra; Houlton, Jeffrey J; Karni, Ron J; Liao, Jay J; Futran, Neal D; Méndez, Eduardo

2017-09-01

Our primary objective is to describe the post- operative management in patients with an unknown primary squamous cell carcinoma of the head and neck (HNSCC) treated with trans-oral robotic surgery (TORS). We conducted a retrospective multi-institutional case series including all patients diagnosed with an unknown primary HNSCC who underwent TORS to identify the primary site from January 1, 2010 to June 30, 2016. We excluded those with recurrent disease, ≤6months of follow up from TORS, previous history of radiation therapy (RT) to the head and neck, or evidence of primary tumor site based on previous biopsies. Our main outcome measure was receipt of post-operative therapy. The tumor was identified in 26/35 (74.3%) subjects. Post-TORS, 2 subjects did not receive adjuvant therapy due to favorable pathology. Volume reduction of RT mucosal site coverage was achieved in 12/26 (46.1%) subjects who had lateralizing tumors, ie. those confined to the palatine tonsil or glossotonsillar sulcus. In addition, for 8/26 (30.1%), the contralateral neck RT was also avoided. In 9 subjects, no primary was identified (pT0); four of these received RT to the involved ipsilateral neck nodal basin only without pharyngeal mucosal irradiation. Surgical management of an unknown primary with TORS can lead to deintensification of adjuvant therapy including avoidance of chemotherapy and reduction in RT doses and volume. There was no increase in short term treatment failures. Treatment after TORS can vary significantly, thus we advocate adherence to NCCN guideline therapy post-TORS to avoid treatment-associated variability. Published by Elsevier Ltd.

Integrating health status and survival data: the palliative effect of lung volume reduction surgery.

PubMed

Benzo, Roberto; Farrell, Max H; Chang, Chung-Chou H; Martinez, Fernando J; Kaplan, Robert; Reilly, John; Criner, Gerard; Wise, Robert; Make, Barry; Luketich, James; Fishman, Alfred P; Sciurba, Frank C

2009-08-01

In studies that address health-related quality of life (QoL) and survival, subjects who die are usually censored from QoL assessments. This practice tends to inflate the apparent benefits of interventions with a high risk of mortality. Assessing a composite QoL-death outcome is a potential solution to this problem. To determine the effect of lung volume reduction surgery (LVRS) on a composite endpoint consisting of the occurrence of death or a clinically meaningful decline in QoL defined as an increase of at least eight points in the St. George's Respiratory Questionnaire total score from the National Emphysema Treatment Trial. In patients with chronic obstructive pulmonary disease and emphysema randomized to receive medical treatment (n = 610) or LVRS (n = 608), we analyzed the survival to the composite endpoint, the hazard functions and constructed prediction models of the slope of QoL decline. The time to the composite endpoint was longer in the LVRS group (2 years) than the medical treatment group (1 year) (P < 0.0001). It was even longer in the subsets of patients undergoing LVRS without a high risk for perioperative death and with upper-lobe-predominant emphysema. The hazard for the composite event significantly favored the LVRS group, although it was most significant in patients with predominantly upper-lobe emphysema. The beneficial impact of LVRS on QoL decline was most significant during the 2 years after LVRS. LVRS has a significant effect on the composite QoL-survival endpoint tested, indicating its meaningful palliative role, particularly in patients with upper-lobe-predominant emphysema.

Enhanced Recovery After Surgery: A Review.

PubMed

Ljungqvist, Olle; Scott, Michael; Fearon, Kenneth C

2017-03-01

Enhanced Recovery After Surgery (ERAS) is a paradigm shift in perioperative care, resulting in substantial improvements in clinical outcomes and cost savings. Enhanced Recovery After Surgery is a multimodal, multidisciplinary approach to the care of the surgical patient. Enhanced Recovery After Surgery process implementation involves a team consisting of surgeons, anesthetists, an ERAS coordinator (often a nurse or a physician assistant), and staff from units that care for the surgical patient. The care protocol is based on published evidence. The ERAS Society, an international nonprofit professional society that promotes, develops, and implements ERAS programs, publishes updated guidelines for many operations, such as evidence-based modern care changes from overnight fasting to carbohydrate drinks 2 hours before surgery, minimally invasive approaches instead of large incisions, management of fluids to seek balance rather than large volumes of intravenous fluids, avoidance of or early removal of drains and tubes, early mobilization, and serving of drinks and food the day of the operation. Enhanced Recovery After Surgery protocols have resulted in shorter length of hospital stay by 30% to 50% and similar reductions in complications, while readmissions and costs are reduced. The elements of the protocol reduce the stress of the operation to retain anabolic homeostasis. The ERAS Society conducts structured implementation programs that are currently in use in more than 20 countries. Local ERAS teams from hospitals are trained to implement ERAS processes. Audit of process compliance and patient outcomes are important features. Enhanced Recovery After Surgery started mainly with colorectal surgery but has been shown to improve outcomes in almost all major surgical specialties. Enhanced Recovery After Surgery is an evidence-based care improvement process for surgical patients. Implementation of ERAS programs results in major improvements in clinical outcomes and cost, making ERAS an important example of value-based care applied to surgery.

Role of REM Sleep, Melanin Concentrating Hormone and Orexin/Hypocretin Systems in the Sleep Deprivation Pre-Ischemia

PubMed Central

Pace, Marta; Adamantidis, Antoine; Facchin, Laura; Bassetti, Claudio

2017-01-01

Study Objectives Sleep reduction after stroke is linked to poor recovery in patients. Conversely, a neuroprotective effect is observed in animals subjected to acute sleep deprivation (SD) before ischemia. This neuroprotection is associated with an increase of the sleep, melanin concentrating hormone (MCH) and orexin/hypocretin (OX) systems. This study aims to 1) assess the relationship between sleep and recovery; 2) test the association between MCH and OX systems with the pathological mechanisms of stroke. Methods Sprague-Dawley rats were assigned to four experimental groups: (i) SD_IS: SD performed before ischemia; (ii) IS: ischemia; (iii) SD_Sham: SD performed before sham surgery; (iv) Sham: sham surgery. EEG and EMG were recorded. The time-course of the MCH and OX gene expression was measured at 4, 12, 24 hours and 3, 4, 7 days following ischemic surgery by qRT-PCR. Results A reduction of infarct volume was observed in the SD_IS group, which correlated with an increase of REM sleep observed during the acute phase of stroke. Conversely, the IS group showed a reduction of REM sleep. Furthermore, ischemia induces an increase of MCH and OX systems during the acute phase of stroke, although, both systems were still increased for a long period of time only in the SD_IS group. Conclusions Our data indicates that REM sleep may be involved in the neuroprotective effect of SD pre-ischemia, and that both MCH and OX systems were increased during the acute phase of stroke. Future studies should assess the role of REM sleep as a prognostic marker, and test MCH and OXA agonists as new treatment options in the acute phase of stroke. PMID:28061506

Modeling radiation dosimetry to predict cognitive outcomes in pediatric patients with CNS embryonal tumors including medulloblastoma

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

Merchant, Thomas E.; Kiehna, Erin N.; Li Chenghong

2006-05-01

Purpose: Model the effects of radiation dosimetry on IQ among pediatric patients with central nervous system (CNS) tumors. Methods and Materials: Pediatric patients with CNS embryonal tumors (n = 39) were prospectively evaluated with serial cognitive testing, before and after treatment with postoperative, risk-adapted craniospinal irradiation (CSI) and conformal primary-site irradiation, followed by chemotherapy. Differential dose-volume data for 5 brain volumes (total brain, supratentorial brain, infratentorial brain, and left and right temporal lobes) were correlated with IQ after surgery and at follow-up by use of linear regression. Results: When the dose distribution was partitioned into 2 levels, both had amore » significantly negative effect on longitudinal IQ across all 5 brain volumes. When the dose distribution was partitioned into 3 levels (low, medium, and high), exposure to the supratentorial brain appeared to have the most significant impact. For most models, each Gy of exposure had a similar effect on IQ decline, regardless of dose level. Conclusions: Our results suggest that radiation dosimetry data from 5 brain volumes can be used to predict decline in longitudinal IQ. Despite measures to reduce radiation dose and treatment volume, the volume that receives the highest dose continues to have the greatest effect, which supports current volume-reduction efforts.« less

Domestic Travel and Regional Migration for Parathyroid Surgery Among Patients Receiving Care at Academic Medical Centers in the United States, 2012-2014.

PubMed

Hinson, Andrew M; Hohmann, Samuel F; Stack, Brendan C

2016-07-01

To improve outcomes after parathyroidectomy, several organizations advocate for selective referral of patients to high-volume academic medical centers with dedicated endocrine surgery programs. The major factors that influence whether patients travel away from their local community and support system for perceived better care remain elusive. To assess how race/ethnicity and insurance status influence domestic travel patterns and selection of high- vs low-volume hospitals in different regions of the United States for parathyroid surgery. A retrospective study was conducted of 36 750 inpatients and outpatients discharged after undergoing parathyroidectomy identified in the University HealthSystem Consortium database from January 1, 2012, to December 31, 2014 (12 quarters total). Each US region (Northeast, Mid-Atlantic, Great Lakes, Central Plains, Southeast, Gulf Coast, and West) contained 20 or more low-volume hospitals (1-49 cases annually), 5 or more mid-volume hospitals (50-99 cases annually), and multiple high-volume hospitals (≥100 cases annually). Domestic medical travelers were defined as patients who underwent parathyroidectomy at a hospital in a different US region from which they resided and traveled more than 150 miles to the hospital. Distance traveled, regional destination, and relative use of high- vs low-volume hospitals. A total of 23 268 of the 36 750 patients (63.3%) had parathyroidectomy performed at high-volume hospitals. The mean (SD) age of the study cohort was 71.5 (16.2) years (95% CI, 71.4-71.7 years). The female to male ratio was 3:1. Throughout the study period, mean (SD) distance traveled was directly proportional to hospital volume (high-volume hospitals, 208.4 [455.1] miles; medium-volume hospitals, 50.5 [168.4] miles; low-volume hospitals, 27.7 [89.5] miles; P < .001). From 2012 to 2014, the annual volume of domestic medical travelers increased by 15.0% (from 961 to 1105), while overall volume increased by 4.9% (from 11 681 to 12 252; P = .03). Nearly all (2982 of 3113 [95.8%]) domestic medical travelers had surgery at high-volume hospitals, and most of these patients (2595 of 3113 [83.4%]) migrated to hospitals in the Southeast. Domestic medical travelers were significantly more likely to be white (2888 of 3113 [92.8%]; P < .001) and have private insurance (1934 of 3113 [62.1%]; P < .001). Most patients with private insurance (12 137 of 17 822 [68.1%]) and Medicare (9433 of 15 121 [62.4%]) had surgery at high-volume hospitals, while the largest proportion of patients with Medicaid and those who were uninsured had surgery at low-volume hospitals (1059 of 2715 [39.0%]). Centralization of parathyroid surgery is a reality in the United States. Significant disparities based on race and insurance coverage exist and may hamper access to the highest-volume surgeons and hospitals. Academic medical centers with dedicated endocrine surgery programs should consider strategic initiatives to reduce disparities within their respective regions.

Volumetric changes in the upper airway after bimaxillary surgery for skeletal class III malocclusions: a case series study using 3-dimensional cone-beam computed tomography.

PubMed

Lee, Yoonjung; Chun, Youn-Sic; Kang, Nara; Kim, Minji

2012-12-01

Postsurgical changes of the airway have become a great point of interest and often have been reported to be a predisposing factor for obstructive sleep apnea after mandibular setback surgery. The purpose of this study was to evaluate the 3-dimensional volumetric changes in the upper airway space of patients who underwent bimaxillary surgery to correct Class III malocclusions. This study was performed retrospectively in a group of patients who underwent bimaxillary surgery for Class III malocclusion and had full cone-beam computed tomographic (CBCT) images taken before surgery and 1 day, 3 months, and 6 months after surgery. The upper and lower parts of the airway volume and the diameters of the airway were measured from 2 different levels. Presurgical measurements and the amount of surgical correction were evaluated for their effect on airway volume. Data analyses were performed by analysis of variance and multiple stepwise regression analysis. The subjects included 21 patients (6 men and 15 women; mean age, 22.7 yrs). The surgeries were Le Fort I impaction (5.27 ± 2.58 mm impaction from the posterior nasal spine) and mandibular setback surgery (9.20 ± 4.60 mm set back from the pogonion). No statistically significant differences were found in the total airway volume for all time points. In contrast, the volume of the upper part showed an increase (12.35%) and the lower part showed a decrease (14.07%), with a statistically significant difference 6 months after surgery (P < .05). Predictor variables affecting the upper and lower parts of the airway volume were presurgical A point to Nasion-perpendicular (A to N-perp) and vertical surgical correction of the pogonion and the posterior nasal spine (P < .05). Bimaxillary surgery for the correction of Class III malocclusion affected the morphology by increasing the upper part and decreasing the lower part of the airway, but not the total volume. Copyright © 2012 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.

Impact of neurosurgeon specialization on patient outcomes for intracranial and spinal surgery: a retrospective analysis of the Nationwide Inpatient Sample 1998-2009.

PubMed

McCutcheon, Brandon A; Hirshman, Brian R; Gabel, Brandon C; Heffner, Michael W; Marcus, Logan P; Cole, Tyler S; Chen, Clark C; Chang, David C; Carter, Bob S

2018-05-01

OBJECTIVE The subspecialization of neurosurgical practice is an ongoing trend in modern neurosurgery. However, it remains unclear whether the degree of surgeon specialization is associated with improved patient outcomes. The authors hypothesized that a trend toward increased neurosurgeon specialization was associated with improved patient morbidity and mortality rates. METHODS The Nationwide Inpatient Sample (NIS) was used (1998-2009). Patients were included in a spinal analysis cohort for instrumented spine surgery involving the cervical spine ( International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes 81.31-81.33, 81.01-81.03, 84.61-84.62, and 84.66) or lumbar spine (codes 81.04-81.08, 81.34-81.38, 84.64-84.65, and 84.68). A cranial analysis cohort consisted of patients receiving a parenchymal excision or lobectomy operation (codes 01.53 and 01.59). Surgeon specialization was measured using unique surgeon identifiers in the NIS and defined as the proportion of a surgeon's total practice dedicated to cranial or spinal cases. RESULTS A total of 46,029 and 231,875 patients were identified in the cranial and spinal analysis cohorts, respectively. On multivariate analysis in the cranial analysis cohort (after controlling for overall surgeon volume, patient demographic data/comorbidities, hospital characteristics, and admitting source), each percentage-point increase in a surgeon's cranial specialization (that is, the proportion of cranial cases) was associated with a 0.0060 reduction in the log odds of patient mortality (95% CI 0.0034-0.0086) and a 0.0042 reduction in the log odds of morbidity (95% CI 0.0032-0.0052). This resulted in a 15% difference in the predicted probability of mortality for neurosurgeons at the 75th versus the 25th percentile of cranial specialization. In the spinal analysis cohort, each percentage-point increase in a surgeon's spinal specialization was associated with a 0.0122 reduction in the log odds of mortality (95% CI 0.0074-0.0170) and a 0.0058 reduction in the log odds of morbidity (95% CI 0.0049-0.0067). This resulted in a 26.8% difference in the predicted probability of mortality for neurosurgeons at the 75th versus the 25th percentile of spinal specialization. CONCLUSIONS For both spinal and cranial surgery patient cohorts derived from the NIS database, increased surgeon specialization was significantly and independently associated with improved mortality and morbidity rates, even after controlling for overall case volume.

Physiological and computed tomographic predictors of outcome from lung volume reduction surgery.

PubMed

Washko, George R; Martinez, Fernando J; Hoffman, Eric A; Loring, Stephen H; Estépar, Raúl San José; Diaz, Alejandro A; Sciurba, Frank C; Silverman, Edwin K; Han, MeiLan K; Decamp, Malcolm; Reilly, John J

2010-03-01

Previous investigations have identified several potential predictors of outcomes from lung volume reduction surgery (LVRS). A concern regarding these studies has been their small sample size, which may limit generalizability. We therefore sought to examine radiographic and physiologic predictors of surgical outcomes in a large, multicenter clinical investigation, the National Emphysema Treatment Trial. To identify objective radiographic and physiological indices of lung disease that have prognostic value in subjects with chronic obstructive pulmonary disease being evaluated for LVRS. A subset of the subjects undergoing LVRS in the National Emphysema Treatment Trial underwent preoperative high-resolution computed tomographic (CT) scanning of the chest and measures of static lung recoil at total lung capacity (SRtlc) and inspiratory resistance (Ri). The relationship between CT measures of emphysema, the ratio of upper to lower zone emphysema, CT measures of airway disease, SRtlc, Ri, the ratio of residual volume to total lung capacity (RV/TLC), and both 6-month postoperative changes in FEV(1) and maximal exercise capacity were assessed. Physiological measures of lung elastic recoil and inspiratory resistance were not correlated with improvement in either the FEV(1) (R = -0.03, P = 0.78 and R = -0.17, P = 0.16, respectively) or maximal exercise capacity (R = -0.02, P = 0.83 and R = 0.08, P = 0.53, respectively). The RV/TLC ratio and CT measures of emphysema and its upper to lower zone ratio were only weakly predictive of postoperative changes in both the FEV(1) (R = 0.11, P = 0.01; R = 0.2, P < 0.0001; and R = 0.23, P < 0.0001, respectively) and maximal exercise capacity (R = 0.17, P = 0.0001; R = 0.15, P = 0.002; and R = 0.15, P = 0.002, respectively). CT assessments of airway disease were not predictive of change in FEV(1) or exercise capacity in this cohort. The RV/TLC ratio and CT measures of emphysema and its distribution are weak but statistically significant predictors of outcome after LVRS.

Ultralow-dose computed tomography imaging for surgery of midfacial and orbital fractures using ASIR and MBIR.

PubMed

Widmann, G; Dalla Torre, D; Hoermann, R; Schullian, P; Gassner, E M; Bale, R; Puelacher, W

2015-04-01

The influence of dose reductions on diagnostic quality using a series of high-resolution ultralow-dose computed tomography (CT) scans for computer-assisted planning and surgery including the most recent iterative reconstruction algorithms was evaluated and compared with the fracture detectability of a standard cranial emergency protocol. A human cadaver head including the mandible was artificially prepared with midfacial and orbital fractures and scanned using a 64-multislice CT scanner. The CT dose index volume (CTDIvol) and effective doses were calculated using application software. Noise was evaluated as the standard deviation in Hounsfield units within an identical region of interest in the posterior fossa. Diagnostic quality was assessed by consensus reading of a craniomaxillofacial surgeon and radiologist. Compared with the emergency protocol at CTDIvol 35.3 mGy and effective dose 3.6 mSv, low-dose protocols down to CTDIvol 1.0 mGy and 0.1 mSv (97% dose reduction) may be sufficient for the diagnosis of dislocated craniofacial fractures. Non-dislocated fractures may be detected at CTDIvol 2.6 mGy and 0.3 mSv (93% dose reduction). Adaptive statistical iterative reconstruction (ASIR) 50 and 100 reduced average noise by 30% and 56%, and model-based iterative reconstruction (MBIR) by 93%. However, the detection rate of fractures could not be improved due to smoothing effects. Crown Copyright © 2015. Published by Elsevier Ltd. All rights reserved.

A prospective randomized trial comparing subatmospheric wound therapy with a sealed gauze dressing and the standard vacuum-assisted closure device.

PubMed

Dorafshar, Amir H; Franczyk, Mieczyslawa; Gottlieb, Lawrence J; Wroblewski, Kristen E; Lohman, Robert F

2012-07-01

Two methods of subatmospheric pressure wound therapy--wall suction applied to a sealed gauze dressing (GSUC) and the vacuum-assisted closure device (VAC)--were compared in hospitalized patients at University of Chicago Medical Center. VAC therapy is widely used, but can be expensive and difficult to apply; it also fails in some patients. A randomized prospective study of 87 patients (N = 45 in the GSUC arm and N = 42 in the VAC arm) was undertaken between October 2006 and May 2008. The study comprised patients with acute wounds resulting from trauma, dehiscence, or surgery. Demographics and wound characteristics were similar in both groups. There were significant reductions in wound surface area and volume in each group. In the GSUC group, the reductions in wound surface area and volume were 4.5%/day and 8.4%/day, respectively (P < 0.001 for both), and in the VAC group, this was 4.9%/day and 9.8%/day, respectively (P < 0.001 for both). The reductions in wound surface area and volume were similar in both groups (P = 0.60 and 0.19, respectively, for the group-by-time interaction). The estimated difference (VAC - GSUC) was 0.4% (95% confidence interval: -1.0, 1.7) for wound surface area and 1.4% (95% confidence interval: -0.7, 3.5) for volume. The mean cost per day for GSUC therapy was $4.22 versus $96.51 for VAC therapy (P < 0.01) and the average time required for a GSUC dressing change was 19 minutes versus 31 minutes for a VAC dressing change (P < 0.01). The sum of pain intensity differences was 0.50 in the GSUC group compared with 1.73 for the VAC group (P = 0.02). GSUC is noninferior to VAC with respect to changes in wound volume and surface area in an acute care setting. In addition, GSUC dressings were easier to apply, less expensive, and less painful.

A systematic review of the impact of volume of surgery and specialization on patient outcome.

PubMed

Chowdhury, M M; Dagash, H; Pierro, A

2007-02-01

Volume of surgery and specialization may affect patient outcome. Articles examining the effects of one or more of three variables (hospital volume of surgery, surgeon volume and specialization) on outcome (measured by length of hospital stay, mortality and complication rate) were analysed. Reviews, opinion articles and observational studies were excluded. The methodological quality of each study was assessed, a correlation between the variables analysed and the outcome accepted if it was significant. The search identified 55,391 articles published between 1957 and 2002; 1075 were relevant to the study, of which 163 (9,904,850 patients) fulfilled the entry criteria. These 163 examined 42 different surgical procedures, spanning 13 surgical specialities. None were randomized and 40 investigated more than one variable. Hospital volume was reported in 127 studies; high-volume hospitals had significantly better outcomes in 74.2 per cent of studies, but this effect was limited in prospective studies (40 per cent). Surgeon volume was reported in 58 studies; high-volume surgeons had significantly better outcomes in 74 per cent of studies. Specialization was reported in 22 studies; specialist surgeons had significantly better outcomes than general surgeons in 91 per cent of studies. The benefit of high surgeon volume and specialization varied in magnitude between specialities. High surgeon volume and specialization are associated with improved patient outcome, while high hospital volume is of limited benefit. Copyright (c) 2007 British Journal of Surgery Society Ltd.

A novel atrial volume reduction technique to enhance the Cox maze procedure: initial results.

PubMed

Marui, Akira; Nishina, Takeshi; Tambara, Keiichi; Saji, Yoshiaki; Shimamoto, Takeshi; Nishioka, Masahiko; Ikeda, Tadashi; Komeda, Masashi

2006-11-01

Large left atrial diameter is reported to be a predictor for recurrent atrial fibrillation after the Cox maze procedure, and left atrial diameter by itself influences the chance of sinus rhythm recovery, as well as maintenance of sinus rhythm. However, additional cut-and-sew procedures to decrease left atrial diameter extend operative time and can cause bleeding. Thus we developed a no-bleeding, faster, and therefore less invasive left atrial volume reduction technique to enhance the Cox maze procedure. The modified Cox maze III procedure with cryoablation or the left atrial maze procedure in association with mitral valve surgery was performed in 80 patients with atrial fibrillation and enlarged left atria (> or =60 mm). Among them, 44 patients had the concomitant volume reduction technique (VR group); continuous horizontal mattress sutures for left atrial plication were placed on the left atrial wall along the pulmonary vein isolation line. Cryoablation was applied to the suture line so that the plicated left atrium is anatomically and electrically isolated. Another 36 patients did not have the volume reduction technique (control group). The VR group had preoperative left atrial diameters similar to those of the control group (67.1 +/- 7.8 vs 64.5 +/- 6.7 mm) and a longer preoperative duration of atrial fibrillation (14.1 +/- 5.4 vs 9.5 +/- 5.1 years, P < .05) but had smaller postoperative left atrial diameters (47.6 +/- 6.3 vs 62.1 +/- 7.9 mm, P < .01). There were no differences in mean crossclamp/bypass time and chest tube drainage for 12 hours between the groups. Twelve months after surgical intervention, the sinus rhythm recovery rate of the VR group was better than that of the control group (90% vs 69%, P < .05). Even in patients with long-standing atrial fibrillation and an enlarged left atrium, maze procedures concomitant with the novel left atrial volume reduction technique improved the sinus rhythm recovery rate without increasing complications. Although further study with a larger number of patients and a longer follow-up period is needed, this safe and thus far potent technique that catheter-based ablation cannot copy might extend indication of the Cox maze procedure for patients with tough atrial fibrillation.

The Surgical Workforce and Surgical Provider Productivity in Sierra Leone: A Countrywide Inventory.

PubMed

Bolkan, Håkon A; Hagander, Lars; von Schreeb, Johan; Bash-Taqi, Donald; Kamara, Thaim B; Salvesen, Øyvind; Wibe, Arne

2016-06-01

Limited data exist on surgical providers and their scope of practice in low-income countries (LICs). The aim of this study was to assess the distribution and productivity of all surgical providers in an LIC, and to evaluate correlations between the surgical workforce availability, productivity, rates, and volume of surgery at the district and hospital levels. Data on surgeries and surgical providers from 56 (93.3 %) out of 60 healthcare facilities providing surgery in Sierra Leone in 2012 were retrieved between January and May 2013 from operation theater logbooks and through interviews with key informants. The Sierra Leonean surgical workforce consisted of 164 full-time positions, equal to 2.7 surgical providers/100,000 inhabitants. Non-specialists performed 52.8 % of all surgeries. In rural areas, the densities of specialists and physicians were 26.8 and 6.3 times lower, respectively, compared with urban areas. The average individual productivity was 2.8 surgeries per week, and varied considerably between the cadres of surgical providers and locations. When excluding four centers that only performed ophthalmic surgery, there was a positive correlation between a facility's volume of surgery and the productivity of its surgical providers (r s = 0.642, p < 0.001). Less than half of all of the surgery in Sierra Leone is performed by specialists. Surgical providers were significantly more productive in healthcare facilities with higher volumes of surgery. If all surgical providers were as productive as specialists in the private non-profit sector (5.1 procedures/week), the national volume of surgery would increase by 85 %.

Contemporary surgical management of advanced end stage emphysema: an evidence based review.

PubMed

Sachithanandan, Anand; Badmanaban, Balaji

2012-06-01

Emphysema is a progressive unrelenting component of chronic obstructive pulmonary disease and a major source of mortality and morbidity globally. The prevalence of moderate to severe emphysema is approximately 5% in Malaysia and likely to increase in the future. Hence advanced emphysema will emerge as a leading cause of hospital admission and a major consumer of healthcare resources in this country in the future. Patients with advanced disease have a poor quality of life and reduced survival. Medical therapy has been largely ineffective for many patients however certain subgroups have disease amenable to surgical palliation. Effective surgical therapies include lung volume reduction surgery, lung transplantation and bullectomy. This article is a comprehensive evidence based review of the literature evaluating the rationale, efficacy, safety and limitations of surgery for advanced emphysema highlighting the importance of meticulous patient selection and local factors relevant to Malaysia.

Variability in spine surgery procedures performed during orthopaedic and neurological surgery residency training: an analysis of ACGME case log data.

PubMed

Daniels, Alan H; Ames, Christopher P; Smith, Justin S; Hart, Robert A

2014-12-03

Current spine surgeon training in the United States consists of either an orthopaedic or neurological surgery residency, followed by an optional spine surgery fellowship. Resident spine surgery procedure volume may vary between and within specialties. The Accreditation Council for Graduate Medical Education surgical case logs for graduating orthopaedic surgery and neurosurgery residents from 2009 to 2012 were examined and were compared for spine surgery resident experience. The average number of reported spine surgery procedures performed during residency was 160.2 spine surgery procedures performed by orthopaedic surgery residents and 375.0 procedures performed by neurosurgery residents; the mean difference of 214.8 procedures (95% confidence interval, 196.3 to 231.7 procedures) was significant (p = 0.002). From 2009 to 2012, the average total spinal surgery procedures logged by orthopaedic surgery residents increased 24.3% from 141.1 to 175.4 procedures, and those logged by neurosurgery residents increased 6.5% from 367.9 to 391.8 procedures. There was a significant difference (p < 0.002) in the average number of spinal deformity procedures between graduating orthopaedic surgery residents (9.5 procedures) and graduating neurosurgery residents (2.0 procedures). There was substantial variability in spine surgery exposure within both specialties; when comparing the top 10% and bottom 10% of 2012 graduates for spinal instrumentation or arthrodesis procedures, there was a 13.1-fold difference for orthopaedic surgery residents and an 8.3-fold difference for neurosurgery residents. Spine surgery procedure volumes in orthopaedic and neurosurgery residency training programs vary greatly both within and between specialties. Although orthopaedic surgery residents had an increase in the number of spine procedures that they performed from 2009 to 2012, they averaged less than half of the number of spine procedures performed by neurological surgery residents. However, orthopaedic surgery residents appear to have greater exposure to spinal deformity than neurosurgery residents. Furthermore, orthopaedic spine fellowship training provides additional spine surgery case exposure of approximately 300 to 500 procedures; thus, before entering independent practice, when compared with neurosurgery residents, most orthopaedic spine surgeons complete as many spinal procedures or more. Although case volume is not the sole determinant of surgical skills or clinical decision making, variability in spine surgery procedure volume does exist among residency programs in the United States. Copyright © 2014 by The Journal of Bone and Joint Surgery, Incorporated.

Effect of induction chemotherapy on estimated risk of radiation pneumonitis in bulky non–small cell lung cancer

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

Amin, Neha P., E-mail: npamin@gmail.com; Miften, Moyed; Thornton, Dale

2013-10-01

Patients with bulky non–small cell lung cancer (NSCLC) may be at a high risk for radiation pneumonitis (RP) if treated with up-front concurrent chemoradiation. There is limited information about the effect of induction chemotherapy on the volume of normal lung subsequently irradiated. This study aims to estimate the reduction in risk of RP in patients with NSCLC after receiving induction chemotherapy. Between 2004 and 2009, 25 patients with Stage IV NSCLC were treated with chemotherapy alone (no surgery or radiation therapy [RT]) and had computed tomography (CT) scans before and after 2 cycles of chemotherapy. Simulated RT plans were createdmore » for the prechemotherapy and postchemotherapy scans so as to deliver 60 Gy to the thoracic disease in patients who had either a >20% volumetric increase or decrease in gross tumor volume (GTV) from chemotherapy. The prechemotherapy and postchemotherapy scans were analyzed to compare the percentage of lung volume receiving≥20 Gy (V20), mean lung dose (MLD), and normal tissue complication probability (NTCP). Eight patients (32%) had a GTV reduction >20%, 2 (8%) had GTV increase >20%, and 15 (60%) had stable GTV. In the 8 responders, there was an absolute median GTV decrease of 88.1 cc (7.3 to 351.6 cc) or a 48% (20% to 62%) relative reduction in tumor burden. One had >20% tumor progression during chemotherapy, yet had an improvement in dosimetric parameters postchemotherapy. Among these 9 patients, the median decrease in V20, MLD, and NTCP was 2.6% (p<0.01), 2.1 Gy (p<0.01), and 5.6% (p<0.01), respectively. Less than one-third of patients with NSCLC obtain >20% volumetric tumor reduction from chemotherapy alone. Even with that amount of volumetric reduction, the 5% reduced risk of RP was only modest and did not convert previously ineligible patients to safely receive definitive thoracic RT.« less

TEG-Directed Transfusion in Complex Cardiac Surgery: Impact on Blood Product Usage.

PubMed

Fleming, Kevin; Redfern, Roberta E; March, Rebekah L; Bobulski, Nathan; Kuehne, Michael; Chen, John T; Moront, Michael

2017-12-01

Complex cardiac procedures often require blood transfusion because of surgical bleeding or coagulopathy. Thrombelastography (TEG) was introduced in our institution to direct transfusion management in cardiothoracic surgery. The goal of this study was to quantify the effect of TEG on transfusion rates peri- and postoperatively. All patients who underwent complex cardiac surgery, defined as open multiple valve repair/replacement, coronary artery bypass grafting with open valve repair/replacement, or aortic root/arch repair before and after implementation of TEG were identified and retrospectively analyzed. Minimally invasive cases were excluded. Patient characteristics and blood use were compared with t test and chi-square test. A generalized linear model including patient characteristics, preoperative and postoperative lab values, and autotransfusion volume was used to determine the impact of TEG on perioperative, postoperative, and total blood use. In total, 681 patients were identified, 370 in the pre-TEG period and 311 patients post-TEG. Patient demographics were not significantly different between periods. Mean units of red blood cells, plasma, and cryoprecipitate were significantly reduced after TEG was implemented (all, p < .0001); use of platelets was reduced but did not reach significance. Mean units of all blood products in the perioperative period and over the entire stay were reduced by approximately 40% (both, p < .0001). Total proportion of patients exposed to transfusion was significantly lower after introduction of TEG ( p < .01). Controlling for related factors on multivariate analysis, such as preoperative laboratory values and autotransfusion volume, use of TEG was associated with significant reduction in perioperative and overall blood product transfusion. TEG-directed management of blood product administration during complex cardiac surgeries significantly reduced the units of blood products received perioperatively but not blood usage more than 24 hours after surgery. Overall, fewer patients were exposed to allogenic blood. The use of TEG to guide blood product administration significantly impacted transfusion therapy and associated costs.

Surgical volume-to-outcome relationship and monitoring of technical performance in pediatric cardiac surgery.

PubMed

Kalfa, David; Chai, Paul; Bacha, Emile

2014-08-01

A significant inverse relationship of surgical institutional and surgeon volumes to outcome has been demonstrated in many high-stakes surgical specialties. By and large, the same results were found in pediatric cardiac surgery, for which a more thorough analysis has shown that this relationship depends on case complexity and type of surgical procedures. Lower-volume programs tend to underperform larger-volume programs as case complexity increases. High-volume pediatric cardiac surgeons also tend to have better results than low-volume surgeons, especially at the more complex end of the surgery spectrum (e.g., the Norwood procedure). Nevertheless, this trend for lower mortality rates at larger centers is not universal. All larger programs do not perform better than all smaller programs. Moreover, surgical volume seems to account for only a small proportion of the overall between-center variation in outcome. Intraoperative technical performance is one of the most important parts, if not the most important part, of the therapeutic process and a critical component of postoperative outcome. Thus, the use of center-specific, risk-adjusted outcome as a tool for quality assessment together with monitoring of technical performance using a specific score may be more reliable than relying on volume alone. However, the relationship between surgical volume and outcome in pediatric cardiac surgery is strong enough that it ought to support adapted and well-balanced health care strategies that take advantage of the positive influence that higher center and surgeon volumes have on outcome.

Histomorphometric study of alveolar bone healing in rats fed a boron-deficient diet.

PubMed

Gorustovich, Alejandro A; Steimetz, Tammy; Nielsen, Forrest H; Guglielmotti, María B

2008-04-01

Bone healing after tooth extraction in rats is a suitable experimental model to study bone formation. Thus, we performed a study to determine the effects of boron (B) deficiency on bone healing by using this model. The first lower right molar of weanling Wistar rats was extracted under anesthesia. The animals were divided into two groups: +B (adequate; 3 mg B/kg diet), and -B (boron-deficient; 0.07 mg/kg diet). The animals in both groups were killed in groups of 10 at 7 and 14 days after surgery. The guidelines of the NIH for the care and use of laboratory animals were observed. The mandibles were resected, fixed, decalcified, and embedded in paraffin. Buccolingually oriented sections were obtained at the level of the mesial alveolus and used for histometric evaluations. Total alveolar volume (TAV) and trabecular bone volume per total volume (BV/TV) in the apical third of the alveolus were determined. Percentages of osteoblast surface (ObS), eroded surface (ES), and quiescent surface (QS) were determined. No statistical significant differences in food intake and body weight were observed. Histomorphometric evaluation found -B rats had 36% and 63% reductions in BV/TV at 7 and 14 days, respectively. When compared with +B rats, -B rats had significant reductions (57% and 87%) in ObS concomitantly with increases (120% and 126%) in QS at 7 and 14 days, respectively. The findings show that boron deficiency results in altered bone healing because of a marked reduction in osteogenesis. 2008 Wiley-Liss, Inc

Acute native lung hyperinflation is not associated with poor outcomes after single lung transplant for emphysema.

PubMed

Weill, D; Torres, F; Hodges, T N; Olmos, J J; Zamora, M R

1999-11-01

Single-lung transplantation for emphysema may be complicated by acute native lung hyperinflation (ANLH) with hemodynamic and ventilatory compromise. Some groups advocate the routine use of independent lung ventilation, double-lung transplant, or right-lung transplant with or without contralateral lung volume reduction surgery in high-risk patients. The goal of this study was to determine the incidence of ANLH and identify its potential predictors. We reviewed 51 consecutive single-lung transplants for emphysema. Symptomatic ANLH was defined as mediastinal shift and diaphragmatic flattening on chest x-ray with hemodynamic or respiratory failure requiring cardiopressor agents or independent lung ventilation. Preoperative and postoperative physiologic and hemodynamic data were analyzed from both recipients and donors. Sixteen patients developed radiographic ANLH; 8 were symptomatic, 2 severely so. We could not identify high-risk patients before transplant by pulmonary function tests, predicted donor total lung capacity (TLC)/actual recipient TLC ratio, pulmonary artery pressures, or the side transplanted. There was a trend toward an increased incidence of symptomatic ANLH in patients with bullous emphysema on chest computed tomography, but this was accounted for primarily by patients with alpha1-antitrypsin deficiency (4/13 vs 4/38 with chronic obstructive pulmonary disease, P = 0.10). No patient required cardiopulmonary bypass or inhaled nitric oxide intraoperatively. Patients with acute native lung hyperinflation did not have increased reperfusion edema as measured by chest x-ray score or PaO2/F(I)O2 ratio. Compared to patients without ANLH, symptomatic patients had longer ventilator times (64.9+/-14.6 hours vs 40.4+/-3.9, P = 0.02, ANOVA) and longer lengths of stay (19.3+/-2.1 days vs 13.7+/-1.3, P = 0.07), but 30-day survival was 100%. Two symptomatic patients required independent lung ventilation or inhaled nitric oxide; the others were managed with decreased minute ventilation, early extubation, and cardiopressor agents. No patient required early lung volume reduction surgery or retransplantation. Acute native lung hyperinflation had no effect on FEV1 or 6-minute walk results at 1 year; survival at 1, 2, or 3 years; or the rate of acute rejection, infection, or bronchiolitis obliterans syndrome greater than grade 2. Acute native lung hyperinflation is common radiographically but is rarely clinically severe. Although there was a trend toward an increase in symptomatic ANLH in patients with bullous emphysema, a high-risk group could not be identified preoperatively. Our results do not support the routine use of bilateral lung transplant, the exclusive use of right single-lung transplant, simultaneous lung volume reduction surgery, or independent lung ventilation for patients with emphysema. Management strategies should be employed that limit overdistension of the native lung and lead to early extubation.

Reducing blood testing in pediatric patients after heart surgery: a quality improvement project.

PubMed

Delgado-Corcoran, Claudia; Bodily, Stephanie; Frank, Deborah U; Witte, Madolin K; Castillo, Ramon; Bratton, Susan L

2014-10-01

To safely optimize blood testing and costs for pediatric cardiac surgical patients without adversely impacting patient outcomes. This is a quality improvement cohort project with pre- and postintervention groups. University-affiliated pediatric cardiac ICU in a tertiary care children's hospital. All patients were surgical patients for whom Risk Adjustment for Congenital Heart Surgery categories allowed for stratification by complexity. The preintervention group was treated in 2010 and the postintervention group in 2011. Laboratory ordering processes were analyzed, and practice changed to limit standing blood test orders and requires individualized ordering. Three hundred nineteen patients were studied in 2010 and 345 in 2011. Groups were similar in median age, weight, length of stay (ICU length of stay), and Risk Adjustment for Congenital Heart Surgery category. There was a reduction in the total blood tests per patient (24 vs 38; p < 0.0001) and length of stay adjusted tests per patient-day (10.4 vs 14.4; p = 0.0001) in the postintervention group. The largest test reductions were blood gases and single electrolytes. Adverse outcomes, such as extubation failure (6.4% vs 5.6%), central catheter-associated bloodstream infection (2.2 vs 1.5), and hospital mortality (0.6% vs 0.6%), were not significantly different between the groups. Cost analysis demonstrated an overall laboratory cost savings of 32%. In addition, the volume of packed RBC transfusions was also significantly decreased in the postintervention group among the most complex patients (Risk Adjustment for Congenital Heart Surgery, 6). Blood testing rates were safely decreased in postoperative pediatric cardiac patients by changing laboratory ordering practices. In addition, packed RBC transfusion was decreased among the most complex patients.

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

Increased Hospital Surgical Volume Reduces Rate of 30- and 90-Day Readmission After Acoustic Neuroma Surgery.

PubMed

Babadjouni, Robin; Wen, Timothy; Donoho, Daniel A; Buchanan, Ian A; Cen, Steven Y; Friedman, Rick A; Amar, Arun; Russin, Jonathan J; Giannotta, Steven L; Mack, William J; Attenello, Frank J

2018-06-08

Hospital readmissions are commonly linked to elevated health care costs, with significant financial incentive introduced by the Affordable Care Act to reduce readmissions. To study the association between patient, hospital, and payer factors with national rate of readmission in acoustic neuroma surgery. All adult inpatients undergoing surgery for acoustic neuroma in the newly introduced Nationwide Readmissions Database from 2013 to 2014 were included. We identified readmissions for any cause with a primary diagnosis of neurological, surgical, or systemic complication within 30- and 90-d after undergoing acoustic neuroma surgery. Multivariable models were employed to identify patient, hospital, and administrative factors associated with readmission. Hospital volume was measured as the number of cases per year. We included patients representing a weighted estimate of 4890 admissions for acoustic neuroma surgery in 2013 and 2014, with 355 30-d (7.7%) and 341 90-d (9.1%) readmissions. After controlling for patient, hospital, and payer factors, procedural volume was significantly associated with 30-d readmission rate (OR [odds ratio] 0.992, p = 0.03), and 90-d readmission rate (OR 0.994, p = 0.047). The most common diagnoses during readmission in both 30- and 90-d cohorts included general central nervous system complications/deficits, hydrocephalus, infection, and leakage of cerebrospinal fluid (rhinorrhea/otorrhea). After controlling for patient, hospital, and payer factors, increased procedural volume is associated with decreased 30- and 90-d readmission rate for acoustic neuroma surgery. Future studies seeking to improve outcomes and reduce cost in acoustic neuroma surgery may seek to further evaluate the role of hospital procedural volume and experience.

Operative volume in the new era: a comparison of resident operative volume before and after implementation of 80-hour work week restrictions.

PubMed

Bruce, Pamela J; Helmer, Stephen D; Osland, Jacqueline S; Ammar, Alex D

2010-01-01

To determine the effect of the 80-hour work week restrictions on general surgery resident operative volume in a large, community-based, university-affiliated, general surgery residency program. We performed a retrospective review of Accreditation Council for Graduate Medical Education (ACGME) operative logs of general surgery residents graduating from a single residency. The control group consisted of the residents graduating in the 3 years prior to the work-hour restriction implementation (2001, 2002, and 2003). Our comparison group consisted of those residents graduating in the first 2 classes whose entire residency was conducted after the implementation of the 80-hour work week (2008 and 2009). Comparisons were made between the control and the comparison groups in the 19 ACGME defined categories, total number of major cases, total number of chief cases, and total number of teaching assist cases. Operative volumes in 13 categories (skin/soft tissue/breast, alimentary tract, abdominal, liver, pancreas, vascular, endocrine, pediatrics, endoscopy, laparoscopic-complex, total chief cases, total major cases, and teaching cases) were not significantly affected by the implementation of the 80-hour work week. One of the 19 categories (laparoscopic-basic) showed a significant increase in operative volume (p < 0.0001). In 4 of the 19 categories (head/neck, operative-trauma, thoracic, and plastics), operative volume was significantly decreased in the post-80-hour work week era (p < 0.05). Nonoperative trauma could not be assessed, as the category did not exist before the work-hour restrictions. Resident operative volume at our institution's general surgery residency program largely has been unaffected by implementation of the 80-hour work week. Residencies in general surgery can be structured in a manner to allow for compliance with duty-hour regulations while maintaining the required operative volume outlined by the ACGME defined categories. Copyright © 2010 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Does specialization improve outcome in abdominal aortic aneurysm surgery?

PubMed

Rosenthal, Rachel; von Känel, Oliver; Eugster, Thomas; Stierli, Peter; Gürke, Lorenz

2005-01-01

Specialization and high volume are reported to be related to a better outcome after abdominal aortic aneurysm repair. The aim of this study was to compare, in patients undergoing abdominal aortic aneurysm repair, the outcomes of those whose surgery was done by general surgeons with the outcomes of those whose surgery was done by specialist vascular surgeons. All patients undergoing abdominal aortic aneurysm repair at the Basel University Hospital (referral center) from January 1990 to December 2000 were included. Patients with endovascular treatment were excluded. Operations in group A (n = 189), between January 1990 and May 1995, were done by general surgeons. Operations in group B (n = 291), between June 1995 and December 2000, were done by vascular surgeons. In-hospital mortality and local and systemic complications were assessed. In-hospital mortality rates were significantly lower for group B (with specialist surgeons) than for group A, both overall (group B, 11.7%; group A, 21.7%; p = .003) and for emergency interventions (group B, 28.1%; group A, 41.9%; p = .042). The reduction in mortality for elective surgery in group B was not statistically significant (group B, 1.1%; group A, 4.9%; p = .054). There were significantly fewer pulmonary complications in group B compared with group A (p = .000). We conclude that in patients undergoing abdominal aortic aneurysm repair, those whose surgery is done by a specialized team have a significantly better outcome than those whose surgery is done by general surgeons.

Body contouring surgery following bariatric surgery and dietetically induced massive weight reduction: a risk analysis.

PubMed

de Kerviler, S; Hüsler, R; Banic, A; Constantinescu, M A

2009-05-01

This study analyzed the impact of weight reduction method, preoperative, and intraoperative variables on the outcome of reconstructive body contouring surgery following massive weight reduction. All patients presenting with a maximal BMI >/=35 kg/m(2) before weight reduction who underwent body contouring surgery of the trunk following massive weight loss (excess body mass index loss (EBMIL) >/= 30%) between January 2002 and June 2007 were retrospectively analyzed. Incomplete records or follow-up led to exclusion. Statistical analysis focused on weight reduction method and pre-, intra-, and postoperative risk factors. The outcome was compared to current literature results. A total of 104 patients were included (87 female and 17 male; mean age 47.9 years). Massive weight reduction was achieved through bariatric surgery in 62 patients (59.6%) and dietetically in 42 patients (40.4%). Dietetically achieved excess body mass index loss (EBMIL) was 94.20% and in this cohort higher than surgically induced reduction EBMIL 80.80% (p < 0.01). Bariatric surgery did not present increased risks for complications for the secondary body contouring procedures. The observed complications (26.9%) were analyzed for risk factors. Total tissue resection weight was a significant risk factor (p < 0.05). Preoperative BMI had an impact on infections (p < 0.05). No impact on the postoperative outcome was detected in EBMIL, maximal BMI, smoking, hemoglobin, blood loss, body contouring technique or operation time. Corrective procedures were performed in 11 patients (10.6%). The results were compared to recent data. Bariatric surgery does not increase risks for complications in subsequent body contouring procedures when compared to massive dietetic weight reduction.

Endoscopic therapy for weight loss: Gastroplasty, duodenal sleeves, intragastric balloons, and aspiration

PubMed Central

Kumar, Nitin

2015-01-01

A new paradigm in the treatment of obesity and metabolic disease is developing. The global obesity epidemic continues to expand despite the availability of diet and lifestyle counseling, pharmacologic therapy, and weight loss surgery. Endoscopic procedures have the potential to bridge the gap between medical therapy and surgery. Current primary endoscopic bariatric therapies can be classified as restrictive, bypass, space-occupying, or aspiration therapy. Restrictive procedures include the USGI Primary Obesity Surgery Endolumenal procedure, endoscopic sleeve gastroplasty using Apollo OverStitch, TransOral GAstroplasty, gastric volume reduction using the ACE stapler, and insertion of the TERIS restrictive device. Intestinal bypass has been reported using the EndoBarrier duodenal-jejunal bypass liner. A number of space-occupying devices have been studied or are in use, including intragastric balloons (Orbera, Reshape Duo, Heliosphere BAG, Obalon), Transpyloric Shuttle, and SatiSphere. The AspireAssist aspiration system has demonstrated efficacy. Finally, endoscopic revision of gastric bypass to address weight regain has been studied using Apollo OverStitch, the USGI Incisionless Operating Platform Revision Obesity Surgery Endolumenal procedure, Stomaphyx, and endoscopic sclerotherapy. Endoscopic therapies for weight loss are potentially reversible, repeatable, less invasive, and lower cost than various medical and surgical alternatives. Given the variety of devices under development, in clinical trials, and currently in use, patients will have multiple endoscopic options with greater efficacy than medical therapy, and with lower invasiveness and greater accessibility than surgery. PMID:26240686

Endoscopic therapy for weight loss: Gastroplasty, duodenal sleeves, intragastric balloons, and aspiration.

PubMed

Kumar, Nitin

2015-07-25

A new paradigm in the treatment of obesity and metabolic disease is developing. The global obesity epidemic continues to expand despite the availability of diet and lifestyle counseling, pharmacologic therapy, and weight loss surgery. Endoscopic procedures have the potential to bridge the gap between medical therapy and surgery. Current primary endoscopic bariatric therapies can be classified as restrictive, bypass, space-occupying, or aspiration therapy. Restrictive procedures include the USGI Primary Obesity Surgery Endolumenal procedure, endoscopic sleeve gastroplasty using Apollo OverStitch, TransOral GAstroplasty, gastric volume reduction using the ACE stapler, and insertion of the TERIS restrictive device. Intestinal bypass has been reported using the EndoBarrier duodenal-jejunal bypass liner. A number of space-occupying devices have been studied or are in use, including intragastric balloons (Orbera, Reshape Duo, Heliosphere BAG, Obalon), Transpyloric Shuttle, and SatiSphere. The AspireAssist aspiration system has demonstrated efficacy. Finally, endoscopic revision of gastric bypass to address weight regain has been studied using Apollo OverStitch, the USGI Incisionless Operating Platform Revision Obesity Surgery Endolumenal procedure, Stomaphyx, and endoscopic sclerotherapy. Endoscopic therapies for weight loss are potentially reversible, repeatable, less invasive, and lower cost than various medical and surgical alternatives. Given the variety of devices under development, in clinical trials, and currently in use, patients will have multiple endoscopic options with greater efficacy than medical therapy, and with lower invasiveness and greater accessibility than surgery.

Canary in a coal mine: does the plastic surgery market predict the american economy?

PubMed

Wong, Wendy W; Davis, Drew G; Son, Andrew K; Camp, Matthew C; Gupta, Subhas C

2010-08-01

Economic tools have been used in the past to predict the trends in plastic surgery procedures. Since 1992, U.S. cosmetic surgery volumes have increased overall, but the exact relationship between economic downturns and procedural volumes remains elusive. If an economic predicting role can be established from plastic surgery indicators, this could prove to be a very powerful tool. A rolling 3-month revenue average of an eight-plastic surgeon practice and various economic indicators were plotted and compared. An investigation of the U.S. procedural volumes was performed from the American Society of Plastic Surgeons statistics between 1996 and 2008. The correlations of different economic variables with plastic surgery volumes were evaluated. Lastly, search term frequencies were examined from 2004 to July of 2009 to study potential patient interest in major plastic surgery procedures. The self-payment revenue of the plastic surgery group consistently proved indicative of the market trends approximately 1 month in advance. The Standard and Poor's 500, Dow Jones Industrial Average, National Association of Securities Dealers Automated Quotations, and Standard and Poor's Retail Index demonstrated a very close relationship with the income of our plastic surgery group. The frequency of Internet search terms showed a constant level of interest in the patient population despite economic downturns. The data demonstrate that examining plastic surgery revenue can be a useful tool to analyze and possibly predict trends, as it is driven by a market and shows a close correlation to many leading economic indicators. The persisting and increasing interest in plastic surgery suggests hope for a recovering and successful market in the near future.

Trends in Medicare Service Volume for Cataract Surgery and the Impact of the Medicare Physician Fee Schedule.

PubMed

Gong, Dan; Jun, Lin; Tsai, James C

2017-08-01

To calculate the associations between Medicare payment and service volume for complex and noncomplex cataract surgeries. The 2005-2009 CMS Part B National Summary Data Files, CMS Part B Carrier Summary Data Files, and the Medicare Physician Fee Schedule. Conducting a retrospective, longitudinal analysis using a fixed-effects model of Medicare Part B carriers representing all 50 states and the District of Columbia from 2005 to 2009, we calculated the Medicare payment-service volume elasticities for noncomplex (CPT 66984) and complex (CPT 66982) cataract surgeries. Service volume data were extracted from the CMS Part B National Summary and Carrier Summary Data Files. Payment data were extracted from the Medicare Physician Fee Schedule. From 2005 to 2009, the proportion of total cataract services billed as complex increased from 3.2 to 6.7 percent. Every 1 percent decrease in Medicare payment was associated with a nonsignificant change in noncomplex cataract service volume (elasticity = 0.15, 95 percent CI [-0.09, 0.38]) but a statistically significant increase in complex cataract service volume (elasticity = -1.12, 95 percent CI [-1.60, -0.63]). Reduced Medicare payment was associated with a significant increase in complex cataract service volume but not in noncomplex cataract service volume, resulting in a shift toward performing a greater proportion of complex cataract surgeries from 2005 to 2009. © Health Research and Educational Trust.

Training our Future Endocrine Surgeons: A Look at the Endocrine Surgery Operative Experience of U.S. Surgical Residents

PubMed Central

Zarebczan, Barbara; Rajamanickam, Victoria; Leverson, Glen; Chen, Herbert; Sippel, Rebecca S

2010-01-01

Background Over the last 10 years the number of endocrine procedures performed in the US has increased significantly. We sought to determine if this has translated into an increase in operative volume for general surgery and otolaryngology residents. Method We evaluated records from the Resident Statistic Summaries of the RRC for US general surgery and otolaryngology residents for the years 2004-2008, specifically examining data on thyroidectomies and parathyroidectomies. Results Between 2004 and 2008, the average endocrine case volume of US general surgery and otolaryngology residents increased by approximately 15%, but otolaryngology residents performed over twice as many operations as US general surgery residents. The growth in case volume was mostly due to increases in the number of thyroidectomies performed by US general surgery and otolaryngology residents (17.9 to 21.8, p=0.007 and 46.5 to 54.4, p=0.04). Overall, otolaryngology residents also performed more parathyroidectomies than their general surgery counterparts (11.6 vs. 8.8, p=0.007). Conclusion Although there has been an increase in the number of endocrine cases performed by graduating US general surgery residents, this is significantly smaller than that of otolaryngology residents. In order to remain competitive, general surgery residents wishing to practice endocrine surgery may need to pursue additional fellowship training. PMID:21134536

Training our future endocrine surgeons: a look at the endocrine surgery operative experience of U.S. surgical residents.

PubMed

Zarebczan, Barbara; McDonald, Robert; Rajamanickam, Victoria; Leverson, Glen; Chen, Herbert; Sippel, Rebecca S

2010-12-01

During the last 10 years, the number of endocrine procedures performed in the United States has increased significantly. We sought to determine whether this has translated into an increase in operative volume for general surgery and otolaryngology residents. We evaluated records from the Resident Statistic Summaries of the Residency Review Committee (RRC) for U.S. general surgery and otolaryngology residents for the years 2004-2008, specifically examining data on thyroidectomies and parathyroidectomies. Between 2004 and 2008, the average endocrine case volume of U.S. general surgery and otolaryngology residents increased by approximately 15%, but otolaryngology residents performed more than twice as many operations as U.S. general surgery residents. The growth in case volume was mostly from increases in the number of thyroidectomies performed by U.S. general surgery and otolaryngology residents (17.9 to 21.8, P = .007 and 46.5 to 54.4, P = .04). Overall, otolaryngology residents also performed more parathyroidectomies than their general surgery counterparts (11.6 vs 8.8, P = .007). Although there has been an increase in the number of endocrine cases performed by graduating U.S. general surgery residents, this is significantly smaller than that of otolaryngology residents. To remain competitive, general surgery residents wishing to practice endocrine surgery may need to pursue additional fellowship training. Copyright © 2010 Mosby, Inc. All rights reserved.

The Different Volume Effects of Small-Bowel Toxicity During Pelvic Irradiation Between Gynecologic Patients With and Without Abdominal Surgery: A Prospective Study With Computed Tomography-Based Dosimetry

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

Huang, E.-Y.; Graduate Institute of Clinical Medical Sciences, Chang Gung University College of Medicine, Kaohsiung, Taiwan; School of Traditional Chinese Medicine, Chang Gung University College of Medicine, Kaohsiung, Taiwan

Purpose: To evaluate the effect of abdominal surgery on the volume effects of small-bowel toxicity during whole-pelvic irradiation in patients with gynecologic malignancies. Methods and Materials: From May 2003 through November 2006, 80 gynecologic patients without (Group I) or with (Group II) prior abdominal surgery were analyzed. We used a computed tomography (CT) planning system to measure the small-bowel volume and dosimetry. We acquired the range of small-bowel volume in 10% (V10) to 100% (V100) of dose, at 10% intervals. The onset and grade of diarrhea during whole-pelvic irradiation were recorded as small-bowel toxicity up to 39.6 Gy in 22more » fractions. Results: The volume effect of Grade 2-3 diarrhea existed from V10 to V100 in Group I patients and from V60 to V100 in Group II patients on univariate analyses. The V40 of Group I and the V100 of Group II achieved most statistical significance. The mean V40 was 281 {+-} 27 cm{sup 3} and 489 {+-} 34 cm{sup 3} (p < 0.001) in Group I patients with Grade 0-1 and Grade 2-3 diarrhea, respectively. The corresponding mean V100 of Group II patients was 56 {+-} 14 cm{sup 3} and 132 {+-} 19 cm{sup 3} (p = 0.003). Multivariate analyses revealed that V40 (p = 0.001) and V100 (p = 0.027) were independent factors for the development of Grade 2-3 diarrhea in Groups I and II, respectively. Conclusions: Gynecologic patients without and with abdominal surgery have different volume effects on small-bowel toxicity during whole-pelvic irradiation. Low-dose volume can be used as a predictive index of Grade 2 or greater diarrhea in patients without abdominal surgery. Full-dose volume is more important than low-dose volume for Grade 2 or greater diarrhea in patients with abdominal surgery.« less

Multicenter prospective study of magnetic resonance imaging prior to breast-conserving surgery for breast cancer.

PubMed

Liu, Qian; Liu, Yinhua; Xu, Ling; Duan, Xuening; Li, Ting; Qin, Naishan; Kang, Hua; Jiang, Hongchuan; Yang, Deqi; Qu, Xiang; Jiang, Zefei; Yu, Chengze

2014-01-01

This multicenter prospective study aimed to assess the utility of dynamic enhanced magnetic resonance imaging (MRI) prior to breast-conserving surgery for breast cancer. The research subjects were drawn from patients with primary early resectable breast cancer treated in the breast disease centers of six three-level hospitals in Beijing from 1 January 2010 to 31 December 2012. The participants were allocated to a breast-conserving surgery group (breast-conserving group) or a total mastectomy group (total mastectomy group). Enhanced MRI was used to measure breast volume, longest diameter of tumor and tumor volume. The correlations between these measurements and those derived from histopathologic findings were assessed. The relationships between the success rate of breast-conserving surgery and MRI- and pathology-based measurement results were statistically analyzed in the breast-conserving group. The study included 461 cases in the total mastectomy group and 195 in the breast-conserving group. Allocation to these groups was based on clinical indications and patient preferences. The cut-off for concurrence between MRI- and pathology-based measurements of the longest diameter of tumor was set at 0.3 cm. In the total mastectomy group, the confidence interval for 95% concurrence of these measurements was 35.41%-44.63%. Correlation coefficients for MRI and histopathology-based measurements of breast volume, tumor volume and tumor volume/breast volume ratio were r = 0.861, 0.569, and 0.600, respectively (all P < 0.001). In the breast-conserving group, with 0.30 cm taken as the cut-off for concurrence, the 95% confidence interval for MRI and pathology-based measurements of the longest diameter of tumor was 29.98%-44.01%. The subjective and objective success rates for breast-conserving surgery were 100% and 88.54%, respectively. There were significant correlations between dynamic enhanced MRI- and histopathology-based measurements of the longest diameter of breast lesions, breast and tumor volumes, and breast volume/tumor volume ratios. Preoperative MRI examination improves the success rate of breast-conserving surgery.

Cost-utility analysis of bariatric surgery compared with conventional medical management in Germany: a decision analytic modeling.

PubMed

Borisenko, Oleg; Mann, Oliver; Duprée, Anna

2017-08-03

The objective was to evaluate cost-utility of bariatric surgery in Germany for a lifetime and 10-year horizon from a health care payer perspective. State-transition Markov model provided absolute and incremental clinical and monetary results. In the model, obese patients could undergo surgery, develop post-surgery complications, experience diabetes type II, cardiovascular diseases or die. German Quality Assurance in Bariatric Surgery Registry and literature sources provided data on clinical effectiveness and safety. The model considered three types of surgeries: gastric bypass, sleeve gastrectomy, and adjustable gastric banding. The model was extensively validated, and deterministic and probabilistic sensitivity analyses were performed to evaluate uncertainty. Cost data were obtained from German sources and presented in 2012 euros (€). Over 10 years, bariatric surgery led to the incremental cost of €2909, generated additional 0.03 years of life and 1.2 quality-adjusted life years (QALYs). Bariatric surgery was cost-effective at 10 years with an incremental cost-effectiveness ratio of €2457 per QALY. Over a lifetime, surgery led to savings of €8522 and generated an increment of 0.7 years of life or 3.2 QALYs. The analysis also depicted an association between surgery and a reduction of obesity-related adverse events (diabetes, cardiovascular disorders). Delaying surgery for up to 3 years, resulted in a reduction of life years and QALYs gained, in addition to a moderate reduction in associated healthcare costs. Bariatric surgery is cost-effective at 10 years post-surgery and may result in a substantial reduction in the financial burden on the healthcare system over the lifetime of the treated individuals. It is also observed that delays in the provision of surgery may lead to a significant loss of clinical benefits.

Liberal perioperative fluid administration is an independent risk factor for morbidity and is associated with longer hospital stay after rectal cancer surgery.

PubMed

Boland, M R; Reynolds, I; McCawley, N; Galvin, E; El-Masry, S; Deasy, J; McNamara, D A

2017-02-01

INTRODUCTION Recent studies have advocated the use of perioperative fluid restriction in patients undergoing major abdominal surgery as part of an enhanced recovery protocol. Series reported to date include a heterogenous group of high- and low-risk procedures but few studies have focused on rectal cancer surgery alone. The aim of this study was to assess the effects of perioperative fluid volumes on outcomes in patients undergoing elective rectal cancer resection. METHODS A prospectively maintained database of patients with rectal cancer who underwent elective surgery over a 2-year period was reviewed. Total volume of fluid received intraoperatively was calculated, as well as blood products required in the perioperative period. The primary outcome was postoperative morbidity (Clavien-Dindo grade I-IV) and the secondary outcomes were length of stay and major morbidity (Clavien-Dindo grade III-IV). RESULTS Over a 2-year period (2012-2013), 120 patients underwent elective surgery with curative intent for rectal cancer. Median total intraoperative fluid volume received was 3680ml (range 1200-9670ml); 65/120 (54.1%) had any complications, with 20/120 (16.6%) classified as major (Clavien-Dindo grade III-IV). Intraoperative volume >3500ml was an independent risk factor for the development of postoperative all-cause morbidity (P=0.02) and was associated with major morbidity (P=0.09). Intraoperative fluid volumes also correlated with length of hospital stay (Pearson's correlation coefficient 0.33; P<0.01). CONCLUSIONS Intraoperative fluid infusion volumes in excess of 3500ml are associated with increased morbidity and length of stay in patients undergoing elective surgery for rectal cancer.

[Volume Growth of Inpatient Treatments for Spinal Disease - Analysis of German Nationwide Hospital Discharge Data from 2005 to 2014].

PubMed

Nimptsch, Ulrike; Bolczek, Claire; Spoden, Melissa; Schuler, Ekkehard; Zacher, Josef; Mansky, Thomas

2018-04-01

Marked volume growth of inpatient treatments for spinal disease has been observed since diagnosis related groups (DRG) were introduced as payment for inpatient services in Germany. This study aims to analyse this increase by population and stratified by types of treatment. Using German nationwide hospital discharge data (DRG statistics), inpatient treatments for spinal disease with or without surgery were identified. Trends in case numbers were analysed from 2005 to 2014 with consideration of demographic changes, in order to explore which age groups and which types of treatment are affected by volume growth. In 2014 (2005), 289 000 (177 000) inpatient treatments with surgery and 463 000 (287 000) treatments without surgery were identified. After adjusting for demographic factors, treatments with and without surgery exhibited a relative volume growth of + 50%. This increase affected higher age groups and women, in particular. Depending on the type of treatment, very different degrees of volume growth were observed. For example, disc surgeries adjusted for demographic change increased by about + 5%, whereas spinal fusion and vertebral replacement surgeries, kypho-/vertebroplasties and decompression of the spine more than doubled. Within the non-surgically treated cases, local pain therapies of the spine increased after adjustment for demographic changes by about + 142%. The conservatively treated cases showed a demographically adjusted increase of + 22%. Apart from demographic changes, this analysis cannot resolve the underlying causes of volume growth in treatments for spinal disease. However, the stratified analysis of various subgroups may help to classify these developments in a more differentiated manner. The results may support a more targeted debate about potential over- or misallocation of inpatient services in this area. Georg Thieme Verlag KG Stuttgart · New York.

Radiotherapy in Prostate Cancer Patients With Pelvic Lymphocele After Surgery: Clinical and Dosimetric Data of 30 Patients.

PubMed

Jereczek-Fossa, Barbara Alicja; Colangione, Sarah Pia; Fodor, Cristiana; Russo, Stefania; Cambria, Raffaella; Zerini, Dario; Bonora, Maria; Cecconi, Agnese; Vischioni, Barbara; Vavassori, Andrea; Matei, Deliu Victor; Bottero, Danilo; Brescia, Antonio; Musi, Gennaro; Mazzoleni, Federica; Orsi, Franco; Bonomo, Guido; De Cobelli, Ottavio; Orecchia, Roberto

2015-08-01

The purpose of the study was to evaluate the feasibility of irradiation after prostatectomy in the presence of asymptomatic pelvic lymphocele. The inclusion criteria for this study were: (1) patients referred for postoperative (adjuvant or salvage) intensity modulated radiotherapy (IMRT; 66-69 Gy in 30 fractions); (2) detection of postoperative pelvic lymphocele at the simulation computed tomography [CT] scan; (3) no clinical symptoms; and (4) written informed consent. Radiotherapy toxicity and occurrence of symptoms or complications of lymphocele were analyzed. Dosimetric data (IMRT plans) and the modification of lymphocele volume during radiotherapy (cone beam CT [CBCT] scan) were evaluated. Between January 2011 and July 2013, in 30 of 308 patients (10%) treated with radiotherapy after prostatectomy, pelvic lymphocele was detected on the simulation CT. The median lymphocele volume was 47 cm(3) (range, 6-467.3 cm(3)). Lymphocele was not included in planning target volume (PTV) in 8 cases (27%). Maximum dose to lymphocele was 57 Gy (range, 5.7-73.3 Gy). Radiotherapy was well tolerated. In all but 2 patients, lymphoceles remained asymptomatic. Lymphocele drainage-because of symptom occurrence-had to be performed in 2 patients during IMRT and in one patient, 7 weeks after IMRT. CBCT at the end of IMRT showed reduction in lymphocele volume and position compared with the initial data (median reduction of 37%), more pronounced in lymphoceles included in PTV. Radiotherapy after prostatectomy in the presence of pelvic asymptomatic lymphocele is feasible with acceptable acute and late toxicity. The volume of lymphoceles decreased during radiotherapy and this phenomenon might require intermediate radiotherapy plan evaluation. Copyright © 2015 Elsevier Inc. All rights reserved.

Perfusion scintigraphy and patient selection for lung volume reduction surgery.

PubMed

Chandra, Divay; Lipson, David A; Hoffman, Eric A; Hansen-Flaschen, John; Sciurba, Frank C; Decamp, Malcolm M; Reilly, John J; Washko, George R

2010-10-01

It is unclear if lung perfusion can predict response to lung volume reduction surgery (LVRS). To study the role of perfusion scintigraphy in patient selection for LVRS. We performed an intention-to-treat analysis of 1,045 of 1,218 patients enrolled in the National Emphysema Treatment Trial who were non-high risk for LVRS and had complete perfusion scintigraphy results at baseline. The median follow-up was 6.0 years. Patients were classified as having upper or non-upper lobe-predominant emphysema on visual examination of the chest computed tomography and high or low exercise capacity on cardiopulmonary exercise testing at baseline. Low upper zone perfusion was defined as less than 20% of total lung perfusion distributed to the upper third of both lungs as measured on perfusion scintigraphy. Among 284 of 1,045 patients with upper lobe-predominant emphysema and low exercise capacity at baseline, the 202 with low upper zone perfusion had lower mortality with LVRS versus medical management (risk ratio [RR], 0.56; P = 0.008) unlike the remaining 82 with high perfusion where mortality was unchanged (RR, 0.97; P = 0.62). Similarly, among 404 of 1,045 patients with upper lobe-predominant emphysema and high exercise capacity, the 278 with low upper zone perfusion had lower mortality with LVRS (RR, 0.70; P = 0.02) unlike the remaining 126 with high perfusion (RR, 1.05; P = 1.00). Among the 357 patients with non-upper lobe-predominant emphysema (75 with low and 282 with high exercise capacity) there was no improvement in survival with LVRS and measurement of upper zone perfusion did not contribute new prognostic information. Compared with optimal medical management, LVRS reduces mortality in patients with upper lobe-predominant emphysema when there is low rather than high perfusion to the upper lung.

Impact of bariatric surgery on apolipoprotein C-III levels and lipoprotein distribution in obese human subjects.

PubMed

Maraninchi, Marie; Padilla, Nadège; Béliard, Sophie; Berthet, Bruno; Nogueira, Juan-Patricio; Dupont-Roussel, Jeanine; Mancini, Julien; Bégu-Le Corroller, Audrey; Dubois, Noémie; Grangeot, Rachel; Mattei, Catherine; Monclar, Marion; Calabrese, Anastasia; Guérin, Carole; Desmarchelier, Charles; Nicolay, Alain; Xiao, Changting; Borel, Patrick; Lewis, Gary F; Valéro, René

Elevated apolipoprotein C-III (apoC-III) has been postulated to contribute to the atherogenic dyslipidemia seen in obesity and insulin-resistant states, mainly by impairing plasma triglyceride-rich lipoprotein (TRL) metabolism. Bariatric surgery is associated with improvements of several obesity-associated metabolic abnormalities, including a reduction in plasma triglycerides (TGs) and an increase in plasma high-density lipoprotein cholesterol (HDL-C). We investigated the specific effect of bariatric surgery on apoC-III concentrations in plasma, non-HDL, and HDL fractions in relation to lipid profile parameters evolution. A total of 132 obese subjects undergoing bariatric surgery, gastric bypass (n = 61) or sleeve gastrectomy (n = 71), were studied 1 month before surgery and 6 and 12 months after surgery. Plasma apoC-III, non-HDL-apoC-III, and HDL-apoC-III concentrations were markedly reduced after surgery and strongly associated with reduction in plasma TG. This decrease was accompanied by a redistribution of apoC-III from TRL to HDL fractions. In multivariate analysis, plasma apoC-III was the strongest predictor of TG reduction after surgery, and the increase of HDL-C was positively associated with plasma adiponectin and negatively with body mass index. Marked reduction of apoC-III and changes in its distribution between TRL and HDL consistent with a better lipid profile are achieved in obese patients after bariatric surgery. These apoC-III beneficial modifications may have implications in dyslipidemia improvement and contribute to cardiovascular risk reduction after surgery. Copyright © 2017 National Lipid Association. Published by Elsevier Inc. All rights reserved.

Strategies for Small Volume Resuscitation: Hyperosmotic-Hyperoncotic Solutions, Hemoglobin Based Oxygen Carriers and Closed-Loop Resuscitation

NASA Technical Reports Server (NTRS)

Kramer, George C.; Wade, Charles E.; Dubick, Michael A.; Atkins, James L.

2004-01-01

Introduction: Logistic constraints on combat casualty care preclude traditional resuscitation strategies which can require volumes and weights 3 fold or greater than hemorrhaged volume. We present a review of quantitative analyses of clinical and animal data on small volume strategies using 1) hypertonic-hyperosmotic solutions (HHS); 2) hemoglobin based oxygen carriers (HBOCs) and 3) closed-loop infusion regimens.Methods and Results: Literature searches and recent queries to industry and academic researchers have allowed us to evaluate the record of 81 human HHS studies (12 trauma trials), 19 human HBOCs studies (3trauma trials) and two clinical studies of closed-loop resuscitation.There are several hundreds animal studies and at least 82 clinical trials and reports evaluating small volume7.2%-7.5% hypertonic saline (HS) most often combined with colloids, e.g., dextran (HSD) or hetastarch(HSS). HSD and HSS data has been published for 1,108 and 392 patients, respectively. Human studies have documented volume sparing and hemodynamic improvements. Meta-analyses suggest improved survival for hypotensive trauma patients treated with HSD with significant reductions in mortality found for patients with blood pressure < 70 mmHg, head trauma, and penetrating injury requiring surgery. HSD and HSS have received regulatory approval in 14 and 3 countries, respectively, with 81,000+ units sold. The primary reported use was head injury and trauma resuscitation. Complications and reported adverse events are surprisingly rare and not significantly different from other solutions.HBOCs are potent volume expanders in addition to oxygen carriers with volume expansion greater than standard colloids. Several investigators have evaluated small volume hyperoncotic HBOCs or HS-HBOC formulations for hypotensive and normotensive resuscitation in animals. A consistent finding in resuscitation with HBOCs is depressed cardiac output. There is some evidence that HBOCs more efficiently unload oxygen from plasma hemoglobin as well as facilitate RBC unloading. We analyzed one volunteer study, 15 intraoperative trials, and 3 trauma studies using HBOCs. Perioperative studies generally suggest ability to deliver oxygen, but one trauma trial using HBOCs (HemAssist) for treatment of trauma resulted in a dramatic increase in mortality, while an intraoperative trauma study using Polyheme demonstrated reductions in blood use and lower mortality compared to historic controls of patients refusing blood. Transfusion reductions with HBOC use have been modest. Two HBOCs (Hemopure and Polyheme) are now in new or planned large-scale multicenter prehospital trials of trauma treatment. A new implementation of small volume resuscitation is closed-loop resuscitation (CLR), which employs microprocessors to titrate just enough fluid to reach a physiologic target . Animal studies suggest less risk of rebleeding in uncontrolled hemorrhage and a reduction in fluid needs with CLR. The first clinical application of CLR was treatment of burn shock and the US Army. Conclusions: Independently sponsored civilian trauma trials and clinical evaluations in operational combat conditions of different small volume strategies are warranted.

Safety and efficacy of cryolipolysis for non‐invasive reduction of submental fat

PubMed Central

Burns, A. Jay; Zelickson, Brian D.

2015-01-01

Background and Objectives Cryolipolysis has previously received FDA clearance for fat reduction in the abdomen, flanks, and thighs. There is also interest in small volume fat reduction for areas such as the chin, knees, and axilla. This article reports the results of a cryolipolysis pivotal IDE study for reduction of submental fullness. Study Design/Material and Methods A prototype small volume vacuum applicator (CoolMini applicator, CoolSculpting System, ZELTIQ Aesthetics) was used to treat 60 subjects in the submental area. At each treatment visit, a single treatment cycle was delivered at −10°C for 60 minutes, the same temperature and duration used in current commercially‐available cryolipolysis vacuum applicators. At the investigator's discretion, an optional second treatment was delivered 6 weeks after the initial treatment. The primary efficacy endpoint was 80% correct identification of baseline photographs by independent physician review. The primary safety endpoint was monitoring incidence of device‐ and/or procedure‐related serious adverse events. Secondary endpoints included assessment of fat layer thickness by ultrasound and subject satisfaction surveys administered 12 weeks after final cryolipolysis treatment. Results Independent photo review from 3 blinded physicians found 91% correct identification of baseline clinical photographs. Ultrasound data indicated mean fat layer reduction of 2.0 mm. Patient questionnaires revealed 83% of subjects were satisfied, 80% would recommend submental cryolipolysis to a friend, 77% reported visible fat reduction, 77% felt that their appearance improved following the treatment, and 76% found the procedure to be comfortable. No device‐ or procedure‐related serious adverse events were reported. Conclusion The results of this clinical evaluation of 60 patients treated in a pivotal IDE study demonstrate that submental fat can be reduced safely and effectively with a small volume cryolipolysis applicator. Patient surveys revealed that submental cryolipolysis was well‐tolerated, produced visible improvement in the neck contour, and generated high patient satisfaction. These study results led to FDA clearance of cryolipolysis for submental fat treatment. Lasers Surg. Med. 48:3–13, 2016. © 2015 The Authors. Lasers in Surgery and Medicine Published by Wiley Periodicals, Inc. PMID:26607045

Ethical and equity issues in lung transplantation and lung volume reduction surgery.

PubMed

Glanville, A R

2006-01-01

New medical and scientific disciplines are often developed in haste with rampant enthusiasm and scant regard for the balance between action and thoughtful deliberation. Driven by the desire to prolong life and provide a better quality of life for desperately sick individuals, the twin modalities of lung transplantation and lung volume reduction therapy have only just reached their majority. Both are invested with the capacity to help and to harm so it is right to consider carefully their ethical and equitable distribution. Much has been learned in the last 20 years to assist in these deliberations. First, how can we ensure equity of access to transplant services and equality of outcomes? How do we balance resource allocation of a precious and scarce resource with individual recipient needs? Does the concept of distributive justice prevail in our daily work in this field? How do we honour the donor and their family? How do we as practitioners avoid ethical dilemmas related to personal bias and justifiable reward for services rendered? Finally, how do we learn to incorporate ethical forethought and planning guided by experts in the area into everyday behaviour?

CT volumetry can potentially predict the local stage for gastric cancer after chemotherapy

PubMed Central

Wang, Zhi-Cong; Wang, Chen; Ding, Ying; Ji, Yuan; Zeng, Meng-Su; Rao, Sheng-Xiang

2017-01-01

PURPOSE We aimed to evaluate the value of CT tumor volumetry for predicting T and N stages of gastric cancer after chemotherapy, with pathologic results as the reference standard. METHODS This study retrospectively evaluated 42 patients diagnosed with gastric cancer, who underwent chemotherapy followed by surgery. Pre- and post-treatment CT tumor volumes (VT) were measured in portal venous phase and volume reduction ratios were calculated. Correlations between pre- and post-treatment VT, reduction ratio, and pathologic stages were analyzed. Receiver operator characteristic (ROC) analyses were also performed to assess diagnostic performance for prediction of downstaging to T0–2 stage and N0 stage. RESULTS Pretreatment VT, post-treatment VT, and VT reduction ratio were significantly correlated with T stage (rs=0.329, rs=0.546, rs= −0.422, respectively). Post-treatment VT and VT reduction ratio were significantly correlated with N stage (rs=0.442 and rs= −0.376, respectively). Pretreatment VT, post-treatment VT, and VT reduction ratio were significantly different between T0–2 and T3,4 stage tumors (P = 0.05, P < 0.001, and P = 0.002, respectively). The differences between N0 and ≥N1 groups were also statistically significant (P = 0.005 for post-treatment VT, P = 0.016 for VT reduction ratio, respectively). The area under the ROC curve (AUC) for identification of T0–2 groups was 0.70 for pretreatment VT, 0.88 for post-treatment VT, and 0.82 for VT reduction ratio, respectively. AUC was 0.78 for post-treatment VT and 0.74 for VT reduction ratio for identification of N0 groups. CONCLUSION CT tumor volumetry, particularly post-treatment measurement of VT, is potentially valuable for predicting histopathologic T and N stages after chemotherapy in patients with gastric cancer. PMID:28703101

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

PubMed

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

2011-10-01

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

Chest physiotherapy during anesthesia for children with cystic fibrosis: effects on respiratory function.

PubMed

Tannenbaum, E; Prasad, S A; Dinwiddie, R; Main, Eleanor

2007-12-01

Physiotherapists sometimes use elective surgical procedures for children with cystic fibrosis as an opportunity to perform physiotherapy treatments during anesthesia. These treatments theoretically facilitate direct endotracheal airway clearance and compensate for any post-operative respiratory deterioration related to the anaesthetic and surgery. MATERIALS, PATIENTS, AND METHODS: Children were randomized either to receive physiotherapy or not following anesthesia and intubation. Respiratory mechanics (C(rs) and R(rs)), tidal volume, and peak inspiratory pressure (PIP) were measured immediately before and after physiotherapy. FEV(1) was measured before and after surgery and post-operative physiotherapy requirements were recorded. Eighteen patients, mean age 12 years (range 2.8-15 years) were recruited, with nine in each group. Both groups showed a non-significant decline in FEV(1) the day after surgery compared with pre-operative values (-5.8%: physiotherapy and -7.1%: control). Both PIP and R(rs) increased significantly following physiotherapy (within- and between-groups, P < 0.05). In addition, there was a significant within-group reduction in C(rs) after physiotherapy which approached significance between-groups (P = 0.07). There were no significant within- or between-group differences in tidal volume following treatment in either group. The unanticipated decline in respiratory function immediately following physiotherapy was short-lived and not discernible in longer term outcomes measured by FEV(1) or physiotherapy requirements post-operatively. If respiratory physiotherapy under anesthesia is considered necessary and the benefits of removing secretions are deemed to outweigh the short-term risks, it may be necessary for the anaesthetist to consider modifying ventilatory support to counteract any short-term negative effects of the treatment.

Surgery for oesophageal cancer at Galway University Hospital 1993-2008.

PubMed

Chang, K H; McAnena, O J; Smith, M J; Salman, R R; Khan, M F; Lowe, D

2010-12-01

Surgical volume and outcome remain controversial in the management of oesophageal cancer. To assess the outcome of oesophagectomy for cancer at Galway University Hospital (GUH). Between 1994 and 2008, patients who underwent oesophagectomy were analysed. During the study period, 126 oesophagectomies were performed for cancer. The average surgeon volume was 9 cases per year. The 30-day and overall in-hospital mortality rates were 6.3 and 7.9%, respectively. Restructuring of our critical care services has led to a reduction in 30-day mortality from 8.2 to 5.1%. The use of neoadjuvant chemoradiotherapy has increased from 17 to 35% during the study period. In patients who underwent resection, the 3 and 5-year overall survival rates were 45 and 29%, respectively. Operative morbidity and mortality at GUH are comparable with worldwide outcomes. Improved resources and national restructuring of cancer services have significantly improved the quality of care and outcomes of patients.

Lymph node flap transfer for patients with secondary lower limb lymphedema.

PubMed

Batista, Bernardo N; Germain, Michel; Faria, José Carlos M; Becker, Corinne

2017-01-01

Previous authors have shown benefits from the use of lymph node flap transfer (LNFT) to treat lymphedema of the arms, but there is little evidence for its use for lower limb lymphedema. We performed a retrospective analysis of a series of patients suffering from secondary lower limb lymphedema treated with a free LNFT. 52 cases of LNFT to treat 41 legs in 38 patients with secondary lymphedema were retrospectively reviewed. The causes of the lymphedema included lymphedema secondary to hysterectomy for uterine cancer, melanoma resections on the leg, lymphoma treatment and testicular cancer, cosmetic surgery to the limb, lipoma resection at the inguinal region, and a saphenectomy. Patients had been suffering with lymphedema for an average of 9.1 ± 7.3 years at the time of LNFT. Eleven patients (28.9%) presented with minor complications treated conservatively. For 23 legs there was enough data to follow limb volume evolution after a single LNFT. Total volume reduction in eight legs (two patients with no measures of the healthy limb and three bilateral) was 7.1 ± 8.6%. Another group of 15 patients with unilateral lymphedema had an average 46.3 ± 34.7% reduction of excess volume. Better results (>30% REV) were associated with smaller preoperative excess volume (P = 0.045). Patients with secondary leg lymphedema can benefit from LNFT. Results in patients with mild presentations seem to be better than in more severe cases. © 2014 Wiley Periodicals, Inc. Microsurgery 37:29-33, 2017. © 2015 Wiley Periodicals, Inc.

Accessibility to surgical robot technology and prostate-cancer patient behavior for prostatectomy.

PubMed

Sugihara, Toru; Yasunaga, Hideo; Matsui, Hiroki; Nagao, Go; Ishikawa, Akira; Fujimura, Tetsuya; Fukuhara, Hiroshi; Fushimi, Kiyohide; Ohori, Makoto; Homma, Yukio

2017-07-01

To examine how surgical robot emergence affects prostate-cancer patient behavior in seeking radical prostatectomy focusing on geographical accessibility. In Japan, robotic surgery was approved in April 2012. Based on data in the Japanese Diagnosis Procedure Combination database between April 2012 and March 2014, distance to nearest surgical robot and interval days to radical prostatectomy (divided by mean interval in 2011: % interval days to radical prostatectomy) were calculated for individual radical prostatectomy cases at non-robotic hospitals. Caseload changes regarding distance to nearest surgical robot and robot introduction were investigated. Change in % interval days to radical prostatectomy was evaluated by multivariate analysis including distance to nearest surgical robot, age, comorbidity, hospital volume, operation type, hospital academic status, bed volume and temporal progress. % Interval days to radical prostatectomy became wider for distance to nearest surgical robot <30 km. When a surgical robot emerged within 30 and 10 km, the prostatectomy caseload in non-robot hospitals reduced by 13 and 18% within 6 months, respectively, while the robot hospitals gained +101% caseload (P < 0.01 for all) Multivariate analyses including 9759 open and 5052 non-robotic minimally invasive radical prostatectomies in 483 non-robot hospitals revealed a significant inverse association between distance to nearest surgical robot and % interval days to radical prostatectomy (B = -17.3% for distance to nearest surgical robot ≥30 km and -11.7% for 10-30 km versus distance to nearest surgical robot <10 km), while younger age, high-volume hospital, open-prostatectomy provider and temporal progress were other significant factors related to % interval days to radical prostatectomy widening (P < 0.05 for all). Robotic surgery accessibility within 30 km would make patients less likely select conventional surgery. The nearer a robot was, the faster the caseload reduction was. © The Author 2017. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Desmopressin use for minimising perioperative blood transfusion

PubMed Central

Desborough, Michael J; Oakland, Kathryn; Brierley, Charlotte; Bennett, Sean; Doree, Carolyn; Trivella, Marialena; Hopewell, Sally; Stanworth, Simon J; Estcourt, Lise J

2017-01-01

Background Blood transfusion is administered during many types of surgery, but its efficacy and safety are increasingly questioned. Evaluation of the efficacy of agents, such as desmopressin (DDAVP; 1-deamino-8-D-arginine-vasopressin), that may reduce perioperative blood loss is needed. Objectives To examine the evidence for the efficacy of DDAVP in reducing perioperative blood loss and the need for red cell transfusion in people who do not have inherited bleeding disorders. Search methods We searched for randomised controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (2017, issue 3) in the Cochrane Library, MEDLINE (from 1946), Embase (from 1974), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (from 1937), the Transfusion Evidence Library (from 1980), and ongoing trial databases (all searches to 3 April 2017). Selection criteria We included randomised controlled trials comparing DDAVP to placebo or an active comparator (e.g. tranexamic acid, aprotinin) before, during, or immediately after surgery or after invasive procedures in adults or children. Data collection and analysis We used the standard methodological procedures expected by Cochrane. Main results We identified 65 completed trials (3874 participants) and four ongoing trials. Of the 65 completed trials, 39 focused on adult cardiac surgery, three on paediatric cardiac surgery, 12 on orthopaedic surgery, two on plastic surgery, and two on vascular surgery; seven studies were conducted in surgery for other conditions. These trials were conducted between 1986 and 2016, and 11 were funded by pharmaceutical companies or by a party with a commercial interest in the outcome of the trial. The GRADE quality of evidence was very low to moderate across all outcomes. No trial reported quality of life. DDAVP versus placebo or no treatment Trial results showed considerable heterogeneity between surgical settings for total volume of red cells transfused (low-quality evidence) and for total blood loss (very low-quality evidence) due to large differences in baseline blood loss. Consequently, these outcomes were not pooled and were reported in subgroups. Compared with placebo, DDAVP may slightly decrease the total volume of red cells transfused in adult cardiac surgery (mean difference (MD) -0.52 units, 95% confidence interval (CI) -0.96 to -0.08 units; 14 trials, 957 participants), but may lead to little or no difference in orthopaedic surgery (MD -0.02, 95% CI -0.67 to 0.64 units; 6 trials, 303 participants), vascular surgery (MD 0.06, 95% CI -0.60 to 0.73 units; 2 trials, 135 participants), or hepatic surgery (MD -0.47, 95% CI -1.27 to 0.33 units; 1 trial, 59 participants). DDAVP probably leads to little or no difference in the total number of participants transfused with blood (risk ratio (RR) 0.96, 95% CI 0.86 to 1.06; 25 trials; 1806 participants) (moderate-quality evidence). Whether DDAVP decreases total blood loss in adult cardiac surgery (MD -135.24 mL, 95% CI -210.80 mL to -59.68 mL; 22 trials, 1358 participants), orthopaedic surgery (MD -285.76 mL, 95% CI -514.99 mL to -56.53 mL; 5 trials, 241 participants), or vascular surgery (MD -582.00 mL, 95% CI -1264.07 mL to 100.07 mL; 1 trial, 44 participants) is uncertain because the quality of evidence is very low. DDAVP probably leads to little or no difference in all-cause mortality (Peto odds ratio (pOR) 1.09, 95% CI 0.51 to 2.34; 22 trials, 1631 participants) or in thrombotic events (pOR 1.36, 95% CI, 0.85 to 2.16; 29 trials, 1984 participants) (both low-quality evidence). DDAVP versus placebo or no treatment for people with platelet dysfunction Compared with placebo, DDAVP may lead to a reduction in the total volume of red cells transfused (MD -0.65 units, 95% CI -1.16 to -0.13 units; 6 trials, 388 participants) (low-quality evidence) and in total blood loss (MD -253.93 mL, 95% CI -408.01 mL to -99.85 mL; 7 trials, 422 participants) (low-quality evidence). DDAVP probably leads to little or no difference in the total number of participants receiving a red cell transfusion (RR 0.83, 95% CI 0.66 to 1.04; 5 trials, 258 participants) (moderate-quality evidence). Whether DDAVP leads to a difference in all-cause mortality (pOR 0.72, 95% CI 0.12 to 4.22; 7 trials; 422 participants) or in thrombotic events (pOR 1.58, 95% CI 0.60 to 4.17; 7 trials, 422 participants) is uncertain because the quality of evidence is very low. DDAVP versus tranexamic acid Compared with tranexamic acid, DDAVP may increase the volume of blood transfused (MD 0.6 units, 95% CI 0.09 to 1.11 units; 1 trial, 40 participants) and total blood loss (MD 142.81 mL, 95% CI 79.78 mL to 205.84 mL; 2 trials, 115 participants) (both low-quality evidence). Whether DDAVP increases or decreases the total number of participants transfused with blood is uncertain because the quality of evidence is very low (RR 2.42, 95% CI 1.04 to 5.64; 3 trials, 135 participants). No trial reported all-cause mortality. Whether DDAVP leads to a difference in thrombotic events is uncertain because the quality of evidence is very low (pOR 2.92, 95% CI 0.32 to 26.83; 2 trials, 115 participants). DDAVP versus aprotinin Compared with aprotinin, DDAVP probably increases the total number of participants transfused with blood (RR 2.41, 95% CI 1.45 to 4.02; 1 trial, 99 participants) (moderate-quality evidence). No trials reported volume of blood transfused or total blood loss and the single trial that included mortality as an outcome reported no deaths. Whether DDAVP leads to a difference in thrombotic events is uncertain because the quality of evidence is very low (pOR 0.98, 95% CI 0.06 to 15.89; 2 trials, 152 participants). Authors’ conclusions Most of the evidence derived by comparing DDAVP versus placebo was obtained in cardiac surgery, where DDAVP was administered after cardiopulmonary bypass. In adults undergoing cardiac surgery, the reduction in volume of red cells transfused and total blood loss was small and was unlikely to be clinically important. It is less clear whether DDAVP may be of benefit for children and for those undergoing non-cardiac surgery. A key area for researchers is examining the effects of DDAVP for people with platelet dysfunction. Few trials have compared DDAVP versus tranexamic acid or aprotinin; consequently, we are uncertain of the relative efficacy of these interventions. PMID:28691229

Relationship between volume and in-hospital mortality in digestive oncological surgery.

PubMed

Pérez-López, Paloma; Baré, Marisa; Touma-Fernández, Ángel; Sarría-Santamera, Antonio

2016-03-01

The results previously obtained in Spain in the study of the relationship between surgical caseload and in-hospital mortality are inconclusive. The aim of this study is to evaluate the volume-outcome association in Spain in the setting of digestive oncological surgery. An analytical, cross-sectional study was conducted with data from patients who underwent surgical procedures with curative intent of esophageal, gastric, colorectal and pancreatic neoplasms between 2006-2009 with data from the Spanish MBDS. In-hospital mortality was used as outcome variable. Control variables were patient, health care and hospital characteristics. Exposure variable was the number of interventions for each disease, dividing the hospitals in 3 categories: high volume (HV), mid volume (MV) and low volume (LV) according to the number of procedures. An inverse, statistically significant relationship between procedure volume and in-hospital mortality was observed for both volume categories in both gastric (LV: OR=1,50 [IC 95%: 1,28-1,76]; MV: OR=1,49 (IC 95%: 1,28-1,74)) and colorectal (LV: OR=1,44 [IC 95%: 1,33-1,55]; MV: OR=1,24 [IC 95%: 1,15-1,33]) cancer surgery. In pancreatic procedures, this difference was only statistically significant between LV and HV categories (LV: OR=1,89 [IC 95%: 1,29-2,75]; MV: OR=1,21 [IC 95%: 0,82-1,79]). Esophageal surgery also showed an inverse relationship, which was not statistically significant (LV: OR=1,89 [IC 95%: 0,98-3,64]; MV: OR=1,05 [IC 95%: 0,50-2,21]). The results of this study suggest the existence in Spain of an inverse relationship between caseload and in-hospital mortality in digestive oncological surgery for the procedures analyzed. Copyright © 2015 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.

Recent trends in National Institutes of Health funding for surgery: 2003 to 2013.

PubMed

Hu, Yinin; Edwards, Brandy L; Brooks, Kendall D; Newhook, Timothy E; Slingluff, Craig L

2015-06-01

The purpose of this study is to compare the compositions of federally funded surgical research between 2003 and 2013, and to assess differences in funding trends between surgery and other medical specialties. The National Institutes of Health (NIH) Research Portfolio Online Reporting Tool database was queried for grants within core surgical disciplines during 2003 and 2013. Funding was categorized by award type, methodology, and discipline. Application success rates for surgery and 5 nonsurgical departments were trended over time. Inflation-adjusted NIH funding for surgical research decreased 19% from $270 M in 2003 to $219 M in 2013, with a shift from R-awards to U-awards. Proportional funding to outcomes research almost tripled, while translational research diminished. Nonsurgical departments have increased NIH application volume over the last 10 years; however, surgery's application volume has been stagnant. To preserve surgery's role in innovative research, new efforts are needed to incentivize an increase in application volume. Copyright © 2015 Elsevier Inc. All rights reserved.

Clinical observation of biomimetic mineralized collagen artificial bone putty for bone reconstruction of calcaneus fracture

PubMed Central

Pan, Yong-Xiong; Yang, Guang-Gang; Li, Zhong-Wan; Shi, Zhong-Min; Sun, Zhan-Dong

2018-01-01

Abstract This study investigated clinical outcomes of biomimetic mineralized collagen artificial bone putty for bone reconstruction in the treatment of calcaneus fracture. Sixty cases of calcaneal fractures surgically treated with open reduction and internal fixation in our hospital from June 2014–2015 were chosen and randomly divided into two groups, including 30 cases treated with biomimetic mineralized collagen artificial bone putty as treatment group, and 30 cases treated with autogenous ilia as control group. The average follow-up time was 17.2 ± 3.0 months. The results showed that the surgery duration and postoperative drainage volume of treatment group were significantly lower than control group; there were no statistically significant differences in the fracture healing time, American Orthopaedic Foot and Ankle Society scores at 3 and 12 months after surgery, Böhler’s angle, Gissane’s angle and height of calcaneus between the two groups. There were no significant differences in wound complication and reject reaction between the two groups, while significant difference in donor site complication. As a conclusion, the implantation of biomimetic mineralized collagen artificial bone putty in the open reduction of calcaneal fracture resulted in reliable effect and less complications, which is suitable for clinical applications in the treatment of bone defect in calcaneal fractures. PMID:29644087

Electromagnetic Spectroscopy of Normal Breast Tissue Specimens Obtained From Reduction Surgeries: Comparison of Optical and Microwave Properties

PubMed Central

Lazebnik, Mariya; Zhu, Changfang; Palmer, Gregory M.; Harter, Josephine; Sewall, Sarah; Ramanujam, Nirmala; Hagness, Susan C.

2009-01-01

Techniques utilizing electromagnetic energy at microwave and optical frequencies have been shown to be promising for breast cancer detection and diagnosis. Since different biophysical mechanisms are exploited at these frequencies to discriminate between healthy and diseased tissue, combining these two modalities may result in a more powerful approach for breast cancer detection and diagnosis. Toward this end, we performed microwave dielectric spectroscopy and optical diffuse reflectance spectroscopy measurements at the same sites on freshly-excised normal breast tissues obtained from reduction surgeries at the University of Wisconsin Hospital, using microwave and optical probes with very similar sensing volumes. We found that the microwave dielectric constant and effective conductivity are correlated with tissue composition across the entire measurement frequency range (|r|~0.5–0.6, p<0.01), and that the optical absorption coefficient at 460 nm and optical scattering coefficient are correlated with tissue composition (|r|~ 0.4–0.6, p<0.02). Finally, we found that the optical absorption coefficient at 460 nm is correlated with the microwave dielectric constant and effective conductivity (r=−0.55, p<0.01). Our results suggest that combining optical and microwave modalities for analyzing breast tissue samples may serve as a crosscheck and provide complementary information about tissue composition. PMID:18838370

Electromagnetic spectroscopy of normal breast tissue specimens obtained from reduction surgeries: comparison of optical and microwave properties.

PubMed

Lazebnik, Mariya; Zhu, Changfang; Palmer, Gregory M; Harter, Josephine; Sewall, Sarah; Ramanujam, Nirmala; Hagness, Susan C

2008-10-01

Techniques utilizing electromagnetic energy at microwave and optical frequencies have been shown to be promising for breast cancer detection and diagnosis. Since different biophysical mechanisms are exploited at these frequencies to discriminate between healthy and diseased tissue, combining these two modalities may result in a more powerful approach for breast cancer detection and diagnosis. Toward this end, we performed microwave dielectric spectroscopy and optical diffuse reflectance spectroscopy measurements at the same sites on freshly excised normal breast tissues obtained from reduction surgeries at the University of Wisconsin Hospital, using microwave and optical probes with very similar sensing volumes. We found that the microwave dielectric constant and effective conductivity are correlated with tissue composition across the entire measurement frequency range (|r| approximately 0.5-0.6, p<0.01) and that the optical absorption coefficient at 460 nm and optical scattering coefficient are correlated with tissue composition (|r| approximately 0.4-0.6, p<0.02). Finally, we found that the optical absorption coefficient at 460 nm is correlated with the microwave dielectric constant and effective conductivity (r=-0.55, p<0.01). Our results suggest that combining optical and microwave modalities for analyzing breast tissue samples may serve as a crosscheck and provide complementary information about tissue composition.

[Development and evaluation of individualized fluid therapy in the elderly patients with coronary heart disease undergoing gastrointestinal surgery: a randomized, controlled trial].

PubMed

Zheng, Hong; Guo, Hai; Ye, Jian-rong; Chen, Lin

2012-06-01

To develop and evaluate an individualized fluid therapy in the elderly patients with coronary heart disease undergoing gastrointestinal surgery. In this prospective study, 60 coronary heart disease patients undergoing gastrointestinal surgery were included in the First Affiliated Hospital of Xinjiang Medical University from March 2009 to March 2012. Patients were randomized into the intervention group and the control group with 30 patients in each group. Individualized fluid therapy was used during surgery and postoperative period in the ICU, which was determined based on target controlled fluid therapy according to cardiac index, stroke volume, and stroke volume variation. Traditional fluid therapy was used in the control group in the intraoperative and postoperative period. The two groups were compared in terms of postoperative hemodynamic parameters, total fluid volume, incidence of adverse cardiac events, and recovery of bowel function. Compared with the control group, mean arterial pressure was significantly increased at the commencement of the surgery. The cardiac index was significantly elevated during surgery and at the end of the surgery. Stroke volume was significantly increased after induction of anesthesia, during the surgery, and at the early stay of ICU period(all P<0.05). Serum lactic acid in the intervention group was significantly lower at the end of surgery and during ICU stay than that in the control group (all P<0.05). During surgery and 24-hour stay in ICU, the total fluid volume, crystal usage, and urine were significantly less, while colloidal fluid use was significantly more in the intervention group as compared to the control group(all P<0.05). The perioperative adverse cardiac event rate was 36.7%(11/30) in the intervention group, lower than 56.7%(17/30) in the control group, but the difference was no statistically significance(P>0.05). In the intervention group, defecation time, time to first flatus, resumption of liquid intake, length of ICU stay and hospital stay were significantly less compared with the control group(P<0.05). In the elderly patients with coronary arterial disease undergoing gastrointestinal surgery, individualized fluid therapy can effectively decrease adverse cardiac events, improve postoperative gastrointestinal function, and reduce length of hospital stay.

Sudden generalized lung atelectasis during thoracotomy following thoracic lavage in 3 dogs.

PubMed

Drynan, Eleanor; Musk, Gabrielle; Raisis, Anthea

2012-08-01

To describe sudden onset of generalized pulmonary atelectasis following thoracic lavage in 3 dogs. Thoracic lavage was performed following ligation of a patent ductus arteriosus in case 1, prior to closure of a large traumatic full thickness wound in the chest wall in case 2, and during investigation of an idiopathic spontaneous pneumothorax in case 3. In each case anesthesia and surgery were uneventful until thoracic lavage was performed, after which sudden generalized pulmonary atelectasis was observed. The atelectasis was visualized and was associated with oxyhemoglobin desaturation, decreased end-tidal carbon dioxide partial pressure (ETCO(2)), and a marked increase in the peak inspiratory pressure (PIP) required to achieve visible lung inflation. Occlusion of the endotracheal tube and cervical trachea was directly eliminated as the cause of atelectasis in cases 1 and 2, and indirectly eliminated in case 3. Improvement in pulmonary function occurred in all cases in response to increased PIP ± positive end expiratory pressure (PEEP). Generalized atelectasis should be considered a possible complication of thoracic lavage performed during thoracotomy. In the cases presented here, it is suspected that pre-existing reduction in lung volume (due to inadequate ventilation, surgical compression, absorption atelectasis) was exacerbated by the addition of the lavage fluid to the thoracic cavity. This pre-existing lung collapse is believed to have resulted in reduction of lung volume and that further reduction below the critical closing volume occurred following instillation of saline into the thorax resulting in the subsequent development of generalized atelectasis. The performance of regular arterial blood gas analyses and different ventilation protocols may have prevented the marked atelectasis that was observed in these cases. © Veterinary Emergency and Critical Care Society 2012.

Hospital volume of throughput and periprocedural and medium‐term adverse events after percutaneous coronary intervention: retrospective cohort study of all 17 417 procedures undertaken in Scotland, 1997–2003

PubMed Central

Burton, K R; Slack, R; Oldroyd, K G; Pell, A C H; Flapan, A D; Starkey, I R; Eteiba, H; Jennings, K P; Northcote, R J; Hillis, W Stewart; Pell, J P

2006-01-01

Objective To determine whether percutaneous coronary intervention (PCI) hospital volume of throughput is associated with periprocedural and medium‐term events, and whether any associations are independent of differences in case mix. Design Retrospective cohort study of all PCIs undertaken in Scottish National Health Service hospitals over a six‐year period. Methods All PCIs in Scotland during 1997–2003 were examined. Linkage to administrative databases identified events over two years' follow up. The risk of events by hospital volume at 30 days and two years was compared by using logistic regression and Cox proportional hazards models. Results Of the 17 417 PCIs, 4900 (28%) were in low‐volume hospitals and 3242 (19%) in high‐volume hospitals. After adjustment for case mix, there were no significant differences in risk of death or myocardial infarction. Patients treated in high‐volume hospitals were less likely to require emergency surgery (adjusted odds ratio 0.18, 95% confidence interval (CI) 0.07 to 0.54, p  =  0.002). Over two years, patients in high‐volume hospitals were less likely to undergo surgery (adjusted hazard ratio 0.52, 95% CI 0.35 to 0.75, p  =  0.001), but this was offset by an increased likelihood of further PCI. There was no net difference in coronary revascularisation or in overall events. Conclusion Death and myocardial infarction were infrequent complications of PCI and did not differ significantly by volume. Emergency surgery was less common in high‐volume hospitals. Over two years, patients treated in high‐volume centres were as likely to undergo some form of revascularisation but less likely to undergo surgery. PMID:16709693

Hospital volume of throughput and periprocedural and medium-term adverse events after percutaneous coronary intervention: retrospective cohort study of all 17,417 procedures undertaken in Scotland, 1997-2003.

PubMed

Burton, K R; Slack, R; Oldroyd, K G; Pell, A C H; Flapan, A D; Starkey, I R; Eteiba, H; Jennings, K P; Northcote, R J; Hillis, W Stewart; Pell, J P

2006-11-01

To determine whether percutaneous coronary intervention (PCI) hospital volume of throughput is associated with periprocedural and medium-term events, and whether any associations are independent of differences in case mix. Retrospective cohort study of all PCIs undertaken in Scottish National Health Service hospitals over a six-year period. All PCIs in Scotland during 1997-2003 were examined. Linkage to administrative databases identified events over two years' follow up. The risk of events by hospital volume at 30 days and two years was compared by using logistic regression and Cox proportional hazards models. Of the 17,417 PCIs, 4900 (28%) were in low-volume hospitals and 3242 (19%) in high-volume hospitals. After adjustment for case mix, there were no significant differences in risk of death or myocardial infarction. Patients treated in high-volume hospitals were less likely to require emergency surgery (adjusted odds ratio 0.18, 95% confidence interval (CI) 0.07 to 0.54, p = 0.002). Over two years, patients in high-volume hospitals were less likely to undergo surgery (adjusted hazard ratio 0.52, 95% CI 0.35 to 0.75, p = 0.001), but this was offset by an increased likelihood of further PCI. There was no net difference in coronary revascularisation or in overall events. Death and myocardial infarction were infrequent complications of PCI and did not differ significantly by volume. Emergency surgery was less common in high-volume hospitals. Over two years, patients treated in high-volume centres were as likely to undergo some form of revascularisation but less likely to undergo surgery.

Trends in the Prevalence of Severe Obesity and Bariatric Surgery Access: A State-Level Analysis from 2011 to 2014.

PubMed

Henkel, Dana S; Mora-Pinzon, Maria; Remington, Patrick L; Jolles, Sally A; Voils, Corrine I; Gould, Jon C; Kothari, Shanu N; Funk, Luke M

2017-07-01

Understanding what proportion of the eligible population is undergoing bariatric surgery at the state level provides critical insight into characterizing bariatric surgery access. We sought to describe statewide trends in severe obesity demographics and report bariatric surgery volume in Wisconsin from 2011 to 2014. Self-reported data from the Behavioral Risk Factor Surveillance System (BRFSS) were used to calculate prevalence rates of severe obesity (class II and III) in Wisconsin. Bariatric surgery volume data were analyzed from the Wisconsin Hospital Association. A survey was sent to all American Society for Metabolic and Bariatric Surgery member bariatric surgeons in Wisconsin to assess perspectives on bariatric surgery access, insurance coverage, and referral processes. The prevalence of severe obesity in Wisconsin increased by 30% from 2011 to 2014 (10.4%-13.2%; P = .035); the odds of severe obesity nearly doubled for adults age 20-39 (odds ratio [OR] 1.9, 95% confidence interval [CI] 1.3-3.0). During this time, the volume of bariatric surgery declined by 4.2%; (1432 to 1372; P < .001), whereas the rates of bariatric surgery per 1000 persons with severe obesity declined by 25.7% (3.5 to 2.6/1000). A majority (72%) of bariatric surgeon respondents felt bariatric surgery access either worsened or remained the same over the last 4 years. Severe obesity increased significantly in Wisconsin over a 4-year period, whereas bariatric surgery rates among severely obese persons have remained largely unchanged and are substantially below the national average. Combining the state-level obesity survey data and bariatric surgery administrative data may be a useful approach for tracking bariatric surgery access throughout the United States.

Forehead lift

MedlinePlus

... both sides even. If you have already had plastic surgery to lift your upper eyelids, a forehead ... brow lifting. In: Rubin JP, Neligan PC, eds. Plastic Surgery: Volume 2: Aesthetic Surgery . 4th ed. Philadelphia, ...

Evidence-Based Medicine: Reduction Mammaplasty.

PubMed

Greco, Richard; Noone, Barrett

2017-01-01

After reading this article, the participant should be able to: 1. Understand the multiple reduction mammaplasty techniques available for patients and describe the advantages and disadvantages associated with each. 2. Describe the indications for the treatment of macromastia in patients younger than 18 years. 3. Identify the preoperative indications for breast imaging before surgery. 4. Describe the benefits of breast infiltration with local anesthesia with epinephrine before surgery. 5. Understand the use of deep venous thrombosis prophylaxis in breast reduction surgery. 6. Describe when the use of drains is indicated after breast reduction surgery. The goal of this Continuing Medical Education module is to summarize key evidence-based data available to plastic surgeons to improve their care of patients with breast hypertrophy. The authors' goal is to present the current controversies regarding their treatment and provide a discussion of the various options in their care. The article was prepared to accompany practice-based assessment with ongoing surgical education for the Maintenance of Certification Program of the American Board of Plastic Surgery.

Promise and Limitations of Big Data Research in Plastic Surgery.

PubMed

Zhu, Victor Zhang; Tuggle, Charles Thompson; Au, Alexander Francis

2016-04-01

The use of "Big Data" in plastic surgery outcomes research has increased dramatically in the last 5 years. This article addresses some of the benefits and limitations of such research. This is a narrative review of large database studies in plastic surgery. There are several benefits to database research as compared with traditional forms of research, such as randomized controlled studies and cohort studies. These include the ease in patient recruitment, reduction in selection bias, and increased generalizability. As such, the types of outcomes research that are particularly suited for database studies include determination of geographic variations in practice, volume outcome analysis, evaluation of how sociodemographic factors affect access to health care, and trend analyses over time. The limitations of database research include data which are limited only to what was captured in the database, high power which can cause clinically insignificant differences to achieve statistical significance, and fishing which can lead to increased type I errors. The National Surgical Quality Improvement Project is an important general surgery database that may be useful for plastic surgeons because it is validated and has a large number of patients after over a decade of collecting data. The Tracking Operations and Outcomes for Plastic Surgeons Program is a newer database specific to plastic surgery. Databases are a powerful tool for plastic surgery outcomes research. It is critically important to understand their benefits and limitations when designing research projects or interpreting studies whose data have been drawn from them. For plastic surgeons, National Surgical Quality Improvement Project has a greater number of publications, but Tracking Operations and Outcomes for Plastic Surgeons Program is the most applicable database for plastic surgery research.

Bariatric surgery interest around the world: what Google Trends can teach us.

PubMed

Linkov, Faina; Bovbjerg, Dana H; Freese, Kyle E; Ramanathan, Ramesh; Eid, George Michel; Gourash, William

2014-01-01

Bariatric surgery may prove an effective weight loss option for those struggling with severe obesity, but it is difficult to determine levels of interest in such procedures at the population level through traditional approaches. Analysis of Google Trend information may give providers and healthcare systems useful information regarding Internet users' interest in bariatric procedures. The objective of this study was to gather Google Trend information on worldwide Internet searches for "bariatric surgery", "gastric bypass", "gastric sleeve", "gastric plication", and "lap band" from 2004-2012 and to explore temporal relationships with relevant media events, economic variations, and policy modifications. Data were collected using Google Trends. Trend analyses were performed using Microsoft Excel Version 14.3.5 and Minitab V.16.0. Trend analyses showed that total search volume for the term "bariatric surgery" has declined roughly 25% since January 2004, although interest increased approximately 5% from 2011 to 2012. Interest in lap band procedures declined 30% over the past 5 years, while "gastric sleeve" has increased 15%. Spikes in search numbers show an association with events such as changing policy and insurance guidelines and media coverage for bariatric procedures. This report illustrates that variations in Internet search volume for terms related to bariatric surgery are multifactorial in origin. Although it is impossible to ascertain if reported Internet search volume is based on interest in potentially undergoing bariatric surgery or simply general interest, this analysis reveals that search volume appears to mirror real world events. Therefore, Google Trends could be a way to supplement understanding about interest in bariatric procedures. © 2013 American Society for Bariatric Surgery Published by American Society for Metabolic and Bariatric Surgery All rights reserved.

Laser ablation and 131-iodine: a 24-month pilot study of combined treatment for large toxic nodular goiter.

PubMed

Chianelli, M; Bizzarri, G; Todino, V; Misischi, I; Bianchini, A; Graziano, F; Guglielmi, R; Pacella, C M; Gharib, H; Papini, E

2014-07-01

It is normally recognized that the preferred treatment in large toxic thyroid nodules should be thyroidectomy. The aim of the study was to assess the efficacy of combined laser ablation treatment (LAT) and radioiodine 131 (131I) treatment of large thyroid toxic nodules with respect to rapidity of control of local symptoms, of hyperthyroidism, and of reduction of administered 131I activity in patients at refusal or with contraindications to surgery. We conducted a pilot study at a single center specializing in thyroid care. Fifteen patients were treated with LAT, followed by 131I (group A), and a series of matched consecutive patients were treated by 131I only (group B). Laser energy was delivered with an output power of 3 W (1800 J per fiber per treatment) through two 75-mm, 21-gauge spinal needles. Radioiodine activity was calculated to deliver 200 Gy to the hyperfunctioning nodule. Thyroid function, thyroid peroxidase antibody, thyroglobulin antibody, ultrasound, and local symptoms were measured at baseline and up to 24 months. Nodule volume reduction at 24 months was: 71.3 ± 13.4 vs 47.4 ± 5.5%, group A (LAT+131I) vs group B (131I), respectively; P < .001). In group A (LAT+131I), a reduction in radioiodine-administered activity was obtained (-21.1 ± 8.1%). Local symptom score demonstrated a more rapid reduction in group A (LAT+131I). In three cases, no 131I treatment was needed after LAT. In this pilot study, combined LAT/131I treatment induced faster and greater improvement of local and systemic symptoms compared to 131I only. This approach seems a possible alternative to thyroidectomy in patients at refusal of surgery.

Occupational leg oedema is more reduced by antigraduated than by graduated stockings.

PubMed

Mosti, G; Partsch, H

2013-05-01

Elastic compression stockings exerting a progressive pressure, higher at the calf than at the ankle (progressive elastic compression stockings, PECS), have already proved to be more comfortable, easier to put on and more effective in improving venous pumping function compared to graduated compression elastic stockings (GECS). Nevertheless, PECS could have a negative effect on the prevention and treatment of oedema or even favour oedema formation. The aim of the present study was to investigate if, in normal volunteers, PECS are able to prevent leg swelling during their working shift. A total of 30 normal volunteers (14 males, 16 females aged 36.4 ± 6.6 years) staying standing or sitting during their shift were enrolled into the study. Their leg volume was measured at the beginning and at the end of their working shift on 2 consecutive days. On one day, the volunteers did not put on any stockings; on the other day, they wore GECS on one leg and PECS on the other. The difference between the leg volume measured at the end of the shift and the basal volume in the morning was called 'occupational oedema'. Interface pressure at points B1 and C was measured immediately after stockings' application and before removal. The volunteers were asked to report about difficulty of putting on the stockings and comfort during wearing time. The results were submitted to statistical analysis. The GECS and PECS groups had similar baseline leg volumes (3143 vs. 3154 ml) and occupational oedema (134 vs. 137.5 ml); after putting on the stockings, occupational oedema was reduced in both legs but the reduction was significantly greater with PECS (20 vs. 40 ml with GECS) (P < 0.05). Interface pressure at ankle level is higher with GECS both in supine and in standing position while at calf level it is higher with PECS both in supine and standing position. PECS are easier to put on and slightly more comfortable. PECS are easier to put on and more comfortable and produce a significantly higher reduction of occupational oedema compared with GECS in normal volunteers. Nevertheless leg volumetry, providing a global leg-volume evaluation, is not able to localise the oedema reduction and to assess if it occurs more in the calf or the ankle area. Theoretically, despite a global volume reduction, PECS could even promote a slight oedema formation at ankle level over-compensated by a greater oedema reduction at calf level. Further studies need to concentrate on patients with venous disease and on the local distribution of this global effect. Copyright © 2013 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Quality of Life and Aesthetic Plastic Surgery: A Systematic Review and Meta-analysis.

PubMed

Dreher, Rodrigo; Blaya, Carolina; Tenório, Juliana L C; Saltz, Renato; Ely, Pedro B; Ferrão, Ygor A

2016-09-01

Quality of life (QoL) is an important outcome in plastic surgery. However, authors use different scales to address this subject, making it difficult to compare the outcomes. To address this discrepancy, the aim of this study was to perform a systematic review and a random effect meta-analysis. The search was made in two electronic databases (LILACS and PUBMED) using Mesh and non-Mesh terms related to aesthetic plastic surgery and QoL. We performed qualitative and quantitative analyses of the gathered data. We calculated a random effect meta-analysis with Der Simonian and Laird as variance estimator to compare pre- and postoperative QoL standardized mean difference. To check if there is difference between aesthetic surgeries, we compared reduction mammoplasty to other aesthetic surgeries. Of 1,715 identified, 20 studies were included in the qualitative analysis and 16 went through quantitative analysis. The random effect of all aesthetic surgeries shows that QoL improved after surgery. Reduction mammoplasty has improved QoL more than other procedures in social functioning and physical functioning domains. Aesthetic plastic surgery increases QoL. Reduction mammoplasty seems to have better improvement compared with other aesthetic surgeries.

Volume-based characterization of postocclusion surge.

PubMed

Zacharias, Jaime; Zacharias, Sergio

2005-10-01

To propose an alternative method to characterize postocclusion surge using a collapsible artificial anterior chamber to replace the currently used rigid anterior chamber model. Fundación Oftamológica Los Andes, Santiago, Chile. The distal end of a phacoemulsification handpiece was placed inside a compliant artificial anterior chamber. Digital recordings of chamber pressure, chamber volume, inflow, and outflow were performed during occlusion break of the phacoemulsification tip. The occlusion break profile of 2 different consoles was compared. Occlusion break while using a rigid anterior chamber model produced a simultaneous increase of chamber inflow and outflow. In the rigid chamber model, pressure decreased sharply, reaching negative pressure values. Alternatively, with the collapsible chamber model, a delay was observed in the inflow that occurs to compensate the outflow surge. Also, the chamber pressure drop was smaller in magnitude, never undershooting below atmospheric pressure into negative values. Using 500 mm Hg as vacuum limit, the Infiniti System (Alcon) performed better that the Legacy (Alcon), showing an 18% reduction in peak volume variation. The collapsible anterior chamber model provides a more realistic representation of the postocclusion surge events that occur in the real eye during cataract surgery. Peak volume fluctuation (mL), half volume recovery time(s), and volume fluctuation integral value (mL x s) are proposed as realistic indicators to characterize the postocclusion surge performance. These indicators show that the Infiniti System has a better postocclusion surge behavior than the Legacy System.

High Case Volumes and Surgical Fellowships are Associated with Improved Outcomes for Bariatric Surgery Patients: A Justification of Current Credentialing Initiatives for Practice and Training

PubMed Central

Kohn, Geoffrey P; Galanko, Joseph A; Overby, D Wayne; Farrell, Timothy M

2010-01-01

Background Recent years have seen the establishment of bariatric surgery credentialing processes, centers-of-excellence programs and fellowship training positions. The effects of center-of-excellence status and of the presence of training programs have not previously been examined. The objective of this study is to examine the effects of case volume, center-of-excellence status and training programs on early outcomes of bariatric surgery. Study Design Data were obtained from the Nationwide Inpatient Sample from 1998 to 2006. Quantification of patients’ comorbidities was made using the Charlson Index. Using logistic regression modeling, annual case volumes were analyzed for an association with each institution’s center-of-excellence status and training program status. Risk-adjusted outcome measures were calculated for these hospital-level parameters. Results Data from 102,069 bariatric operations were obtained. Adjusting for comorbidities, greater bariatric case volume was associated with improvements in the incidence of total complications (odds ratio [OR] = 0.99937 for each single case increase, p=0.01), in-hospital mortality (OR = 0.99717, p<0.01), and most other complications. Hospitals with a Fellowship Council-affiliated gastrointestinal surgery training program were associated with risk-adjusted improvements in rates of splenectomy (OR = 0.2853, p<0.001) and bacterial pneumonias (OR = 0.65898, p=0.02). Center-of-excellence status, irrespective of the accrediting entity, had minimal independent association with outcome. A surgical residency program had a varying association with outcomes. Conclusions The hypothesized positive volume-outcome relationship of bariatric surgery is shown without arbitrarily categorizing hospitals to case volume groups, by analysis of volume as a continuous variable. Institutions with a dedicated fellowship training program have also been shown, in part, to be associated with improved outcomes. The concept of volume-dependent center-of-excellence programs is supported, though no independent association with the credentialing process is noted. PMID:20510799

[Preoperative and follow-up cardiac magnetic resonance imaging of candidates for surgical ventricular restoration].

PubMed

Rodríguez Masi, M; Martín Lores, I; Bustos García de Castro, A; Cabeza Martínez, B; Maroto Castellanos, L; Gómez de Diego, J; Ferreirós Domínguez, J

2016-01-01

To assess pre and post-operative cardiac MRI (CMR) findings in patients with left endoventriculoplasty repair for ventricular aneurysm due to ischemic heart disease. Data were retrospectively gathered on 21 patients with diagnosis of ventricular aneurysm secondary to ischemic heart disease undergoing left endoventriculoplasty repair between January 2007 and March 2013. Pre and post-operative CMR was performed in 12 patients. The following data were evaluated in pre-operative and post-operative CMR studies: quantitative analysis of left ventricular ejection fraction (LVEF), left ventricular end-diastolic (LVEDV) and end-systolic (LVESV) volume index, presence of valvular disease and intracardiac thrombi. The time between surgery and post-operative CRM studies was 3-24 months. Significant differences were found in the pre and post-operative LVEF, LVEDV and LVESV data. EF showed a median increase of 10% (IQR 2-15) (p=0.003). The LVEDV showed a median decrease of 38 ml/m(2) (IQR 18-52) (p=0.006) and the LVESV showed a median decrease of 45 ml/m(2) (IQR:12-60) (p=0.008). Post-operative ventricular volume reduction was significantly higher in those patients with preoperative LVESV >110 ml/m(2) (59 ml/m(2) and 12 ml/m(2), p=0.006). In patients with ischemic heart disease that are candidates for left endoventriculoplasty, CMR is a reliable non-invasive and reproducible technique for the evaluation of the scar before the surgery and the ventricular volumes and its evolution after endoventricular surgical repair. Copyright © 2014 SERAM. Published by Elsevier España, S.L.U. All rights reserved.

Comparison of pre/post-operative CT image volumes to preoperative digitization of partial hepatectomies: a feasibility study in surgical validation

NASA Astrophysics Data System (ADS)

Dumpuri, Prashanth; Clements, Logan W.; Li, Rui; Waite, Jonathan M.; Stefansic, James D.; Geller, David A.; Miga, Michael I.; Dawant, Benoit M.

2009-02-01

Preoperative planning combined with image-guidance has shown promise towards increasing the accuracy of liver resection procedures. The purpose of this study was to validate one such preoperative planning tool for four patients undergoing hepatic resection. Preoperative computed tomography (CT) images acquired before surgery were used to identify tumor margins and to plan the surgical approach for resection of these tumors. Surgery was then performed with intraoperative digitization data acquire by an FDA approved image-guided liver surgery system (Pathfinder Therapeutics, Inc., Nashville, TN). Within 5-7 days after surgery, post-operative CT image volumes were acquired. Registration of data within a common coordinate reference was achieved and preoperative plans were compared to the postoperative volumes. Semi-quantitative comparisons are presented in this work and preliminary results indicate that significant liver regeneration/hypertrophy in the postoperative CT images may be present post-operatively. This could challenge pre/post operative CT volume change comparisons as a means to evaluate the accuracy of preoperative surgical plans.

Validity for the simplified water displacement instrument to measure arm lymphedema as a result of breast cancer surgery.

PubMed

Sagen, Ase; Kåresen, Rolf; Skaane, Per; Risberg, May Arna

2009-05-01

To evaluate concurrent and construct validity for the Simplified Water Displacement Instrument (SWDI), an instrument for measuring arm volumes and arm lymphedema as a result of breast cancer surgery. Validity design. Hospital setting. Women (N=23; mean age, 64+/-11y) were examined 6 years after breast cancer surgery with axillary node dissection. Not applicable. The SWDI was included for measuring arm volumes to estimate arm lymphedema as a result of breast cancer surgery. A computed tomography (CT) scan was included to examine the cross-sectional areas (CSAs) in square millimeters for the subcutaneous tissue, for the muscle tissue, and for measuring tissue density in Hounsfield units. Magnetic resonance imaging (MRI) with T2-weighted sequences was included to show increased signal intensity in subcutaneous and muscle tissue areas. The affected arm volume measured by the SWDI was significantly correlated to the total CSA of the affected upper limb (R=.904) and also to the CSA of the subcutaneous tissue and muscles tissue (R=.867 and R=.725), respectively (P<.001). The CSA of the subcutaneous tissue for the upper limb was significantly larger compared with the control limb (11%). Tissue density measured in Hounsfield units did not correlate significantly with arm volume (P>.05). The affected arm volume was significantly larger (5%) than the control arm volume (P<.05). Five (22%) women had arm lymphedema defined as a 10% increase in the affected arm volume compared with the control arm volume, and an increased signal intensity was identified in all 5 women on MRI (T2-weighted, kappa=.777, P<.001). The SWDI showed high concurrent and construct validity as shown with significant correlations between the CSA (CT) of the subcutaneous and muscle areas of the affected limb and the affected arm volume (P>.001). There was a high agreement between those subjects who were diagnosed with arm lymphedema by using the SWDI and the increased signal intensity on MRI, with a kappa value of .777 (P<.001). High construct validity for the SWDI was confirmed for arm lymphedema as a volume increase, but it was not confirmed for lymphedema without an increase in arm volume (swelling). The SWDI is a simple and valid tool for estimating arm volume and arm lymphedema after breast cancer surgery.

Red Blood Cell Transfusion Need for Elective Primary Posterior Lumbar Fusion in A High-Volume Center for Spine Surgery

PubMed Central

Ristagno, Giuseppe; Beluffi, Simonetta; Tanzi, Dario; Belloli, Federica; Carmagnini, Paola; Croci, Massimo; D’Aviri, Giuseppe; Menasce, Guido; Pastore, Juan C.; Pellanda, Armando; Pollini, Alberto; Savoia, Giorgio

2018-01-01

(1) Background: This study evaluated the perioperative red blood cell (RBC) transfusion need and determined predictors for transfusion in patients undergoing elective primary lumbar posterior spine fusion in a high-volume center for spine surgery. (2) Methods: Data from all patients undergoing spine surgery between 1 January 2014 and 31 December 2016 were reviewed. Patients’ demographics and comorbidities, perioperative laboratory results, and operative time were analyzed in relation to RBC transfusion. Multivariate logistic regression analysis was performed to identify the predictors of transfusion. (3) Results: A total of 874 elective surgeries for primary spine fusion were performed over the three years. Only 54 cases (6%) required RBC transfusion. Compared to the non-transfused patients, transfused patients were mainly female (p = 0.0008), significantly older, with a higher ASA grade (p = 0.0002), and with lower pre-surgery hemoglobin (HB) level and hematocrit (p < 0.0001). In the multivariate logistic regression, a lower pre-surgery HB (OR (95% CI) 2.84 (2.11–3.82)), a higher ASA class (1.77 (1.03–3.05)) and a longer operative time (1.02 (1.01–1.02)) were independently associated with RBC transfusion. (4) Conclusions: In the instance of elective surgery for primary posterior lumbar fusion in a high-volume center for spine surgery, the need for RBC transfusion is low. Factors anticipating transfusion should be taken into consideration in the patient’s pre-surgery preparation. PMID:29385760

Venous hemodynamic changes in the surgical treatment of primary varicose vein of the lower limbs.

PubMed

Kim, Ick-Hee; Joh, Jin-Hyun; Kim, Dong-Ik

2004-08-31

Venous hemodynamic changes after the surgery of primary varicose veins were evaluated. (Materials and methods) We retrospectively analyzed 1,211 patients (1,407 limbs) who underwent surgery for primary varicose veins from 1994 to 2002. The venous hemodynamics were evaluated using air- plethysmography (APG) preoperatively and one month postoperatively in the viewpoints of ambulatory venous pressure (AVP), venous volume (VV), venous filling index (VFI), and ejection fraction (EF). (Results) The surgical modalities included 958 cases of greater saphenous vein high ligation (GSV HL) and stripping with varicosectomy (VS), 222 cases of short saphenous vein (SSV) HL and VS, 143 cases of external banding valvuloplasty of GSV and VS, and 44 cases using VNUS and VS. The reduction rate of VV was 20.9 +/- 14.1% in the GSV stripping group, 12.0 +/- 14.7% in the GSV valvuloplasty group, 18.3 +/- 16.1% in the VNUS group, and 20.6 +/- 15.9% in the SSV group. The reduction rate of VFI was 63.6 +/- 20.7% in the GSV stripping group, 38.8 +/- 40.9% in the GSV valvuloplasty group, 60.1 +/- 23.9% in the VNUS group, and 37.6 +/- 30.2% in the SSV group. The increasing rate of EF was 25.0 +/- 28.2% in the GSV stripping group, 21.0 +/- 30.0% in the GSV valvuloplasty group, 29.4 +/- 31.9% in the VNUS group, and 30.0 +/- 36.5% in the SSV group. The reduction rate of AVP was 25.4 +/- 32.2% in the GSV stripping group, -6.1 +/- 58.1% in the GSV valvuloplasty group, 28.4 +/- 38.5% in the VNUS group, and 14.1 +/- 49.0% in the SSV group. All of the patients showed improvements in venous hemodynamics by showing a decrease in VV, VFI, AVP, and an increase in EF. However, there was no difference in the change of venous hemodynamics according to the type of surgery.

Operative experience in an orthopaedic surgery residency program: the effect of work-hour restrictions.

PubMed

Baskies, Michael A; Ruchelsman, David E; Capeci, Craig M; Zuckerman, Joseph D; Egol, Kenneth A

2008-04-01

The implementation of Section 405 of the New York State Public Health Code and the adoption of similar policies by the Accreditation Council for Graduate Medical Education in 2002 restricted resident work hours to eighty hours per week. The effect of these policies on operative volume in an orthopaedic surgery residency training program is a topic of concern. The purpose of this study was to evaluate the effect of the work-hour restrictions on the operative experiences of residents in a large university-based orthopaedic surgery residency training program in an urban setting. We analyzed the operative logs of 109 consecutive orthopaedic surgery residents (postgraduate years 2 through 5) from 2000 through 2006, representing a consecutive interval of years before and after the adoption of the work-hour restrictions. Following the implementation of the new work-hour policies, there was no significant difference in the operative volume for postgraduate year-2, 3, or 4 residents. However, the average operative volume for a postgraduate year-5 resident increased from 274.8 to 348.4 cases (p = 0.001). In addition, on analysis of all residents as two cohorts (before 2002 and after 2002), the operative volume for residents increased by an average of 46.6 cases per year (p = 0.02). On the basis of the findings of this study, concerns over the potential adverse effects of the resident work-hour polices on operative volume for orthopaedic surgery residents appear to be unfounded.

Goal-directed fluid therapy in major elective rectal surgery.

PubMed

Srinivasa, Sanket; Taylor, Matthew H G; Singh, Primal P; Lemanu, Daniel P; MacCormick, Andrew D; Hill, Andrew G

2014-12-01

Goal-Directed Fluid Therapy (GDFT) has been previously shown to decrease complications and hospital length of stay in major colorectal surgery but the data are not specific to rectal surgery and may be potentially outdated. This study investigated whether GDFT provides clinical benefits in patients undergoing major elective rectal surgery. There were 81 consecutive patients in this cohort study. Twenty-seven patients were allotted to GDFT using the Oesophageal Doppler Monitor (ODM) and received boluses of colloid fluid based on corrected flow time and stroke volume. These patients were compared with a historical cohort of the previous 54 patients managed without the ODM. The primary endpoint of the study was 30-day total complications which were defined and graded. Secondary endpoints included hospital length of stay (LOS) and fluid volumes administered. There were no differences at baseline between the two groups. Patients in the treatment group received a higher volume of colloid fluids (1000 mL vs. 500 mL; p < 0.01) but there were no differences in overall fluid volumes administered intraoperatively (3000 mL vs. 3000 mL; p = 0.41). A non-significant trend (p = 0.06) suggested that patients allotted to GDFT had decreased fluid requirement in the first 24 h after surgery. There were no differences in median total fluid volumes (12700 mL vs. 10407 mL; p = 0.95), total complications (22 [81%] vs. 44 [81%]; p = 1.00) or median hospital LOS (9 days vs. 10 days; p = 0.92) between the two groups. Intraoperative GDFT did not improve clinical outcomes following major elective rectal surgery. Copyright © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

A randomised controlled trial of fluid restriction compared to oesophageal Doppler-guided goal-directed fluid therapy in elective major colorectal surgery within an Enhanced Recovery After Surgery program.

PubMed

Phan, T D; D'Souza, B; Rattray, M J; Johnston, M J; Cowie, B S

2014-11-01

There is continued controversy regarding the benefits of goal-directed fluid therapy, with earlier studies showing marked improvement in morbidity and length-of-stay that have not been replicated more recently. The aim of this study was to compare patient outcomes in elective colorectal surgery patients having goal-directed versus restrictive fluid therapy. Inclusion criteria included suitability for an Enhanced Recovery After Surgery care pathway and patients with an American Society of Anesthesiologists Physical Status score of 1 to 3. Patients were intraoperatively randomised to either restrictive or Doppler-guided goal-directed fluid therapy. The primary outcome was length-of-stay; secondary outcomes included complication rate, change in haemodynamic variables and fluid volumes. Compared to restrictive therapy, goal-directed therapy resulted in a greater volume of intraoperative fluid, 2115 (interquartile range 1350 to 2560) ml versus 1500 (1200 to 2000) ml, P=0.008, and was associated with an increase in Doppler-derived stroke volume index from beginning to end of surgery, 43.7 (16.3) to 54.2 (21.1) ml/m(2), P <0.001, in the latter group. Length-of-stay was similar, 6.5 (5 to 9) versus 6 (4 to 9) days, P=0.421. The number of patients with any complication (minor or major) was similar; 0% (30) versus 52% (26), P=0.42, or major complications, 1 (2%) versus 4 (8%), P=0.36, respectively. The increased perioperative fluid volumes and increased stroke volumes at the end of surgery in patients receiving goal-directed therapy did not translate to a significant difference in length-of-stay and we did not observe a difference in the number of patients experiencing minor or major complications.

Resection and Resolution of Bone Marrow Lesions Associated with an Improvement of Pain after Total Knee Replacement: A Novel Case Study Using a 3-Tesla Metal Artefact Reduction MRI Sequence.

PubMed

Kurien, Thomas; Kerslake, Robert; Haywood, Brett; Pearson, Richard G; Scammell, Brigitte E

2016-01-01

We present our case report using a novel metal artefact reduction magnetic resonance imaging (MRI) sequence to observe resolution of subchondral bone marrow lesions (BMLs), which are strongly associated with pain, in a patient after total knee replacement surgery. Large BMLs were seen preoperatively on the 3-Tesla MRI scans in a patient with severe end stage OA awaiting total knee replacement surgery. Twelve months after surgery, using a novel metal artefact reduction MRI sequence, we were able to visualize the bone-prosthesis interface and found complete resection and resolution of these BMLs. This is the first reported study in the UK to use this metal artefact reduction MRI sequence at 3-Tesla showing that resection and resolution of BMLs in this patient were associated with an improvement of pain and function after total knee replacement surgery. In this case it was associated with a clinically significant improvement of pain and function after surgery. Failure to eradicate these lesions may be a cause of persistent postoperative pain that is seen in up to 20% of patients following TKR surgery.

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.

Physiological and Computed Tomographic Predictors of Outcome from Lung Volume Reduction Surgery

PubMed Central

Washko, George R.; Martinez, Fernando J.; Hoffman, Eric A.; Loring, Stephen H.; Estépar, Raúl San José; Diaz, Alejandro A.; Sciurba, Frank C.; Silverman, Edwin K.; Han, MeiLan K.; DeCamp, Malcolm; Reilly, John J.

2010-01-01

Rationale: Previous investigations have identified several potential predictors of outcomes from lung volume reduction surgery (LVRS). A concern regarding these studies has been their small sample size, which may limit generalizability. We therefore sought to examine radiographic and physiologic predictors of surgical outcomes in a large, multicenter clinical investigation, the National Emphysema Treatment Trial. Objectives: To identify objective radiographic and physiological indices of lung disease that have prognostic value in subjects with chronic obstructive pulmonary disease being evaluated for LVRS. Methods: A subset of the subjects undergoing LVRS in the National Emphysema Treatment Trial underwent preoperative high-resolution computed tomographic (CT) scanning of the chest and measures of static lung recoil at total lung capacity (SRtlc) and inspiratory resistance (Ri). The relationship between CT measures of emphysema, the ratio of upper to lower zone emphysema, CT measures of airway disease, SRtlc, Ri, the ratio of residual volume to total lung capacity (RV/TLC), and both 6-month postoperative changes in FEV1 and maximal exercise capacity were assessed. Measurements and Main Results: Physiological measures of lung elastic recoil and inspiratory resistance were not correlated with improvement in either the FEV1 (R = −0.03, P = 0.78 and R = –0.17, P = 0.16, respectively) or maximal exercise capacity (R = –0.02, P = 0.83 and R = 0.08, P = 0.53, respectively). The RV/TLC ratio and CT measures of emphysema and its upper to lower zone ratio were only weakly predictive of postoperative changes in both the FEV1 (R = 0.11, P = 0.01; R = 0.2, P < 0.0001; and R = 0.23, P < 0.0001, respectively) and maximal exercise capacity (R = 0.17, P = 0.0001; R = 0.15, P = 0.002; and R = 0.15, P = 0.002, respectively). CT assessments of airway disease were not predictive of change in FEV1 or exercise capacity in this cohort. Conclusions: The RV/TLC ratio and CT measures of emphysema and its distribution are weak but statistically significant predictors of outcome after LVRS. PMID:19965810

Giant prolactinomas: are they really different from ordinary macroprolactinomas?

PubMed

Espinosa, Etual; Sosa, Ernesto; Mendoza, Victoria; Ramírez, Claudia; Melgar, Virgilio; Mercado, Moisés

2016-06-01

Giant prolactinomas (gPRLomas) are rare tumors of the lactotroph defined by an unusually large size (>4 cm) and serum PRL levels >1000 ng/mL. The purpose of this study is to characterize the clinical spectrum of gPRLomas comparing them with non-giant prolactinomas. This is a retrospective study at a large referral center. Data from patients harboring gPRLomas and macroprolactinomas were retrieved from medical records of the Prolactinoma Clinic. Analysis was focused on clinical, biochemical, and tumor volume characteristics, as well as on the response to treatment with dopamine agonists. Among 292 patients with prolactinomas followed between 2008 and 2015, 47 (16 %) met the diagnostic criteria for gPRLomas (42 males). The most common complaint was a visual field defect; headache was reported by 79 % and sexual dysfunction was present in over half of the patients. Median basal PRL level and tumor volume were 6667 ng/mL (3750-10,000) and 32 cm(3) (20-50), respectively; hypogonadotropic hypogonadism was documented in 87 %. Cabergoline treatment resulted in the normalization of PRL levels in 68 % and in the reduction of >50 % in tumor volume in 87 % of the gPRLoma patients. The composite goal of PRL normalization and >50 % tumor reduction was achieved by 55 % (n = 26) of patients with gPRL and by 66 % (n = 100) of patients with no giant macroprolactinomas (p = 0.19). Recovery of hypogonadism and improvement of visual fields defects occurred in 32 % and 68 % of the patients, respectively. Cabergoline treatment was equally effective in patients with gPRLoma and those with macroprolactinomas in regard of achieving treatment goals, although the median CBG dose was slightly higher in the gPRLoma group (2 vs. 1.5 mg/w). Six patients required surgery. Beyond their impressive dimensions and the huge amount of PRL they secrete, the clinical behavior of gPRLoma is not different from macroprolactinomas. These tumors are highly responsive to cabergoline treatment, and pituitary surgery is seldom required.

Intracavitary ultrasound phased arrays for thermal therapies

NASA Astrophysics Data System (ADS)

Hutchinson, Erin

Currently, the success of hyperthermia and thermal surgery treatments is limited by the technology used in the design and fabrication of clinical heating devices and the completeness of the thermometry systems used for guidance. For both hyperthermia and thermal surgery, electrically focused ultrasound generated by phased arrays provides a means of controlling localized energy deposition in body tissues. Intracavitary applicators can be used to bring the energy source close to a target volume, such as the prostate, thereby minimizing normal tissue damage. The work performed in this study was aimed at improving noninvasive prostate thermal therapies and utilized three research approaches: (1) Acoustic, thermal and optimization simulations, (2) Design and fabrication of multiple phased arrays, (3) Ex vivo and in vivo experimental testing of the heating capabilities of the phased arrays. As part of this study, a novel aperiodic phased array design was developed which resulted in a 30- 45% reduction in grating lobe levels when compared to conventional phased arrays. Measured acoustic fields generated by the constructed aperiodic arrays agreed closely with the fields predicted by the theoretical simulations and covered anatomically appropriate ranges. The power capabilities of these arrays were demonstrated to be sufficient for the purposes of hyperthermia and thermal surgery. The advantage of using phased arrays in place of fixed focus transducers was shown by demonstrating the ability of electronic scanning to increase the size of the necrosed tissue volume while providing a more uniform thermal dose, which can ultimately reduce patient treatment times. A theoretical study on the feasibility of MRI (magnetic resonance imaging) thermometry for noninvasive temperature feedback control was investigated as a means to improve transient and steady state temperature distributions achieved in hyperthermia treatments. MRI guided ex vivo and in vivo experiments demonstrated that the heating capabilities of the constructed phased arrays were adequate for hyperthermia and thermal surgery treatments. (Copies available exclusively from MIT Libraries, Rm. 14-0551, Cambridge, MA 02139-4307. Ph. 617-253-5668; Fax 617-253- 1690.)

Minimizing bleeding complications in spinal tumor surgery with preoperative Onyx embolization via dual-lumen balloon catheter.

PubMed

Ladner, Travis R; He, Lucy; Lakomkin, Nikita; Davis, Brandon J; Cheng, Joseph S; Devin, Clinton J; Mocco, J

2016-02-01

Intraoperative bleeding is a significant risk in surgery for highly vascular spinal tumors, but preoperative embolization can safely decrease intraoperative blood loss in extrinsic spine tumors. Onyx, widely used for cerebrovascular embolization, has been increasingly used as an embolic agent for preoperative spinal tumor embolization. The Scepter catheter, a dual-lumen balloon catheter, may improve tumor parenchymal penetration without the danger and limitations of significant embolic reflux. This may reduce bleeding risk during spinal surgery. Eleven consecutive cases of preoperative Onyx embolization of extrinsic spinal tumors were identified, all of whom had subsequent spinal surgery. Demographic data and clinical variables were collected. Patients were divided into Scepter (n=6) and non-Scepter (n=5) groups. The Mann-Whitney U test was used to compare continuous outcome variables and the Fisher exact test was used to compare categorical variables. Estimated blood loss in the Scepter group was significantly lower than in the non-Scepter group (584±124 vs 2400±738 mL, p=0.004). The volume of intraoperative transfusion was also significantly lower (1.2±0.4 vs 5.8±1.7 units, p=0.004). There was no significant difference in the number of vessels embolized, vials of Onyx used, use of coiling adjunct, contrast load, radiation dose, or fluoroscopy time per pedicle (p>0.05). The addition of the Scepter catheter to preoperative Onyx embolization is safe and feasible. In this small series, the Scepter catheter was associated with a reduction of intraoperative bleeding by 76% and a 79% lower transfusion volume. This was not accompanied by any unwanted increase in vials of Onyx used, contrast load, radiation dose, or fluoroscopy time. 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/

An economic model to evaluate cost-effectiveness of computer assisted knee replacement surgery in Norway.

PubMed

Gøthesen, Øystein; Slover, James; Havelin, Leif; Askildsen, Jan Erik; Malchau, Henrik; Furnes, Ove

2013-07-06

The use of Computer Assisted Surgery (CAS) for knee replacements is intended to improve the alignment of knee prostheses in order to reduce the number of revision operations. Is the cost effectiveness of computer assisted surgery influenced by patient volume and age? By employing a Markov model, we analysed the cost effectiveness of computer assisted surgery versus conventional arthroplasty with respect to implant survival and operation volume in two theoretical Norwegian age cohorts. We obtained mortality and hospital cost data over a 20-year period from Norwegian registers. We presumed that the cost of an intervention would need to be below NOK 500,000 per QALY (Quality Adjusted Life Year) gained, to be considered cost effective. The added cost of computer assisted surgery, provided this has no impact on implant survival, is NOK 1037 and NOK 1414 respectively for 60 and 75-year-olds per quality-adjusted life year at a volume of 25 prostheses per year, and NOK 128 and NOK 175 respectively at a volume of 250 prostheses per year. Sensitivity analyses showed that the 10-year implant survival in cohort 1 needs to rise from 89.8% to 90.6% at 25 prostheses per year, and from 89.8 to 89.9% at 250 prostheses per year for computer assisted surgery to be considered cost effective. In cohort 2, the required improvement is a rise from 95.1% to 95.4% at 25 prostheses per year, and from 95.10% to 95.14% at 250 prostheses per year. The cost of using computer navigation for total knee replacements may be acceptable for 60-year-old as well as 75-year-old patients if the technique increases the implant survival rate just marginally, and the department has a high operation volume. A low volume department might not achieve cost-effectiveness unless computer navigation has a more significant impact on implant survival, thus may defer the investments until such data are available.

Taking the Initiative: Risk-Reduction Strategies and Decreased Malpractice Costs.

PubMed

Raper, Steven E; Rose, Deborah; Nepps, Mary Ellen; Drebin, Jeffrey A

2017-11-01

To heighten awareness of attending and resident surgeons regarding strategies for defense against malpractice claims, a series of risk reduction initiatives have been carried out in our Department of Surgery. We hypothesized that emphasis on certain aspects of risk might be associated with decreased malpractice costs. The relative impact of Department of Surgery initiatives was assessed when compared with malpractice experience for the rest of the Clinical Practices of the University of Pennsylvania (CPUP). Surgery and CPUP malpractice claims, indemnity, and expenses were obtained from the Office of General Counsel. Malpractice premium data were obtained from CPUP finance. The Department of Surgery was assessed in comparison with all other CPUP departments. Cost data (yearly indemnity and expenses), and malpractice premiums (total and per physician) were expressed as a percentage of the 5-year mean value preceding implementation of the initiative program. Surgery implemented 38 risk reduction initiatives. Faculty participated in 27 initiatives; house staff participated in 10 initiatives; and advanced practitioners in 1 initiative. Department of Surgery claims were significantly less than CPUP (74.07% vs 81.07%; p < 0.05). The mean yearly indemnity paid by the Department of Surgery was significantly less than that of the other CPUP departments (84.08% vs 122.14%; p < 0.05). Department of Surgery-paid expenses were also significantly less (83.17% vs 104.96%; p < 0.05), and surgical malpractice premiums declined from baseline, but remained significantly higher than CPUP premiums. The data suggest that educating surgeons on malpractice and risk reduction may play a role in decreasing malpractice costs. Additional extrinsic factors may also affect cost data. Emphasis on risk reduction appears to be cumulative and should be part of an ongoing program. Copyright © 2017 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Is current surgery resident and GI fellow training adequate to pass FES?

PubMed

Gardner, Aimee K; Scott, Daniel J; Willis, Ross E; Van Sickle, Kent; Truitt, Michael S; Uecker, John; Brown, Kimberly M; Marks, Jeffrey M; Dunkin, Brian J

2017-01-01

The purpose of this study was to assess the adequacy of current surgical residency and gastroenterology (GI) fellowship flexible endoscopy training as measured by performance on the FES examination. Fifth-year general surgery residents and GI fellows across six institutions were invited to participate. All general surgery residents had met ACGME/ABS case volume requirements as well as additional institution-specific requirements for endoscopy. All participants completed FES testing at the end of their respective academic year. Procedure volumes were obtained from ACGME case logs. Curricular components for each specialty and institution were recorded. Forty-eight (28 surgery and 20 GI) trainees completed the examination. Average case numbers for residents were 76 ± 26 colonoscopies and 45 ± 12 EGDs. Among GI fellows, PGY4 s (N = 10) reported 99 ± 64 colonoscopies and 147 ± 79 EGDs. PGY5 s (N = 3) reported 462 ± 307 colonoscopies and 411 ± 260 EGDs. PGY6 GI fellows (N = 7) reported 515 ± 111 colonoscopies and 418 ± 146 EGDs. The overall pass rate for all participants was 75 %, with 68 % of residents and 85 % of fellows passing both the cognitive and skills components. For surgery residents, pass rates were 75 % for manual skills and 85.7 % for cognitive. On the skills examination, Task 2 (loop reduction) was associated with the lowest performance. Skills scores correlated with both colonoscopy (r = 0.46, p < 0.001) and EGD experience (r = 0.46, p < 0.001). Receiver operating characteristics curves were examined among the resident cohort. The minimum number of total cases associated with passing the FES skills component was 103. Significant variability existed in curricular components across institutions. These data suggest that current flexible endoscopy training may not be sufficient for all trainees to pass the examination. Implementing additional components of the FEC may prove beneficial in achieving more uniform pass rates on the FES examination.

Blood Infusion and the Risk of Haemorrhage in Patients Undergoing Cardiac Surgery with Extracorporeal Circulation.

PubMed

Luque-Oliveros, Manuel; Garcia-Carpintero, Maria Angeles; Cauli, Omar

2017-01-01

Patients undergoing cardiac surgery with extracorporeal circulation (ECC) frequently present haemorrhages as a complication associated with high morbidity and mortality. One of the factors that influences this risk is the volume of blood infused during surgery. The objective of this study was to determine the optimal volume of autologous blood that can be processed during cardiac surgery with ECC. We also determined the number of salvaged red blood cells to be reinfused into the patient in order to minimize the risk of haemorrhage in the postoperative period. This was an observational retrospective cross-sectional study performed in 162 ECC cardiac surgery patients. Data regarding the sociodemographic profiles of the patients, their pathologies and surgical treatments, and the blood volume recovered, processed, and reinfused after cell salvage were collected. We also evaluated the occurrence of postoperative haemorrhage. The volume of blood infused after cell salvage had a statistically significant effect (p < 0.01) on the risk of post-operative haemorrhage; the receiver operating characteristic sensitivity was 0.813 and the optimal blood volume cut-off was 1800 ml. The best clinical outcome (16.7% of patients presenting haemorrhages) was in patients that had received less than 1800 ml of recovered and processed autologous blood, which represented a volume of up to 580 ml reinfused red blood cells. The optimum thresholds for autologous processed blood and red blood cells reinfused into the patient were 1800 and 580 ml, respectively. Increasing these thresholds augmented the risk of haemorrhage as an immediate postoperative period complication. Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.org.

Reduction Mammoplasty: A Comparison Between Operations Performed by Plastic Surgery and General Surgery.

PubMed

Kordahi, Anthony M; Hoppe, Ian C; Lee, Edward S

2015-01-01

Reduction mammoplasty is an often-performed procedure by plastic surgeons and increasingly by general surgeons. The question has been posed in both general surgical literature and plastic surgical literature as to whether this procedure should remain the domain of surgical specialists. Some general surgeons are trained in breast reductions, whereas all plastic surgeons receive training in this procedure. The National Surgical Quality Improvement Project provides a unique opportunity to compare the 2 surgical specialties in an unbiased manner in terms of preoperative comorbidities and 30-day postoperative complications. The National Surgical Quality Improvement Project database was queried for the years 2005-2012. Patients were identified as having undergone a reduction mammoplasty by Current Procedural Terminology codes. RESULTS were refined to include only females with an International Classification of Diseases, Ninth Revision, code of 611.1 (hypertrophy of breasts). Information was collected regarding age, surgical specialty performing procedure, body mass index, and other preoperative variables. The outcomes utilized were presence of superficial surgical site infection, presence of deep surgical site infection, presence of wound dehiscence, postoperative respiratory compromise, pulmonary embolism, deep vein thrombosis, perioperative transfusion, operative time, reintubation, reoperation, and length of hospital stay. During this time period, there were 6239 reduction mammaplasties performed within the National Surgical Quality Improvement Project database: 339 by general surgery and 5900 by plastic surgery. No statistical differences were detected between the 2 groups with regard to superficial wound infections, deep wound infections, organ space infections, or wound dehiscence. There were no significant differences noted between within groups with regard to systemic postoperative complications. Patients undergoing a procedure by general surgery were more likely to experience a failure of skin flaps, necessitating a return to the operative room (P < .05). Operative time was longer in procedures performed by general surgery (P < .05). Several important differences appear to exist between reduction mammaplasties performed by general surgery and plastic surgery. A focused training in reduction mammoplasty appears to be beneficial to the patient. The limitations of this study include a lack of long-term follow-up with regard to aesthetic outcome, nipple malposition, nipple sensation, and late wound sequelae.

[The correlations between corneal sensation, tear meniscus volume, and tear film osmolarity after femtosecond laser-assisted LASIK].

PubMed

Zhang, Luyan; Sun, Xiyu; Yu, Ye; Xiong, Yan; Cui, Yuxin; Wang, Qinmei; Hu, Liang

2016-01-01

To investigate the correlations between corneal sensation, tear meniscus volume, and tear film osmolarity after femtosecond laser-assisted LASIK (FS-LASIK) surgery. In this prospective clinical study, 31 patients undergoing FS-LASIK for myopia were recruited. The upper and lower tear meniscus volumes (UTMV and LTMV) were measured by customized anterior segment optical coherence tomography, tear film osmolarity was measured by a TearLab Osmolarity test device, central corneal sensation was measured by a Cochet-Bonner esthesiometer preoperatively, at 1 week, 1 and 3 months postoperatively. Repeated measures analysis of variance was used to evaluate whether the tear film osmolarity, tear meniscus volume, and corneal sensation were changed after surgery. The correlations between these variables were analyzed by the Pearson correlation analysis. The tear film osmolarity was (310.03 ± 16.48) mOsms/L preoperatively, (323.51 ± 15.92) mOsms/L at 1 week, (319.93 ± 14.27) mOsms/L at 1 month, and (314.97±12.91) mOsms/L at 3 months. The UTMV was (0.42±0.15), (0.25± 0.09), (0.30±0.11), and (0.35±0.09) μL, respectively; the LTMV was (0.60±0.21),(0.37±0.08), (0.44± 0.14), and (0.52±0.17) μL, respectively. The tear film osmolarity was significantly higher at 1 week and 1 month postoperatively compared with the baseline (P=0.001, 0.004), and reduced to the preoperative level at 3 months (P=0.573). The UTMV, LTMV, and corneal sensation values presented significant decreases at all postoperative time points (all P<0.05). The Pearson correlation analysis showed the postoperative UTMV had a weak relationship with corneal sensation at 1 week after surgery (r=0.356,P=0.005). There were significant correlations between the preoperative LTMV and corneal sensation at 1 week, 1 and 3 months (respectively, r=0.422, 0.366, 0.352;P=0.001, 0.004, 0.006). No significant correlations were found between the tear film osmolarity, tear meniscus volume, and corneal sensation after surgery (all P>0.05). The tear film osmolarity, tear meniscus volume, and corneal sensation became aggravated due to the FS-LASIK surgery procedures. There were significant correlations between the preoperative tear meniscus volume and recovery of corneal sensation early after surgery. A higher tear meniscus volume before surgery may contribute to a faster corneal sensation recovery.

Factors influencing the difference between forecasted and actual drug sales volumes under the price-volume agreement in South Korea.

PubMed

Park, Sun-Young; Han, Euna; Kim, Jini; Lee, Eui-Kyung

2016-08-01

This study analyzed factors contributing to increases in the actual sales volumes relative to forecasted volumes of drugs under price-volume agreement (PVA) policy in South Korea. Sales volumes of newly listed drugs on the national formulary are monitored under PVA policy. When actual sales volume exceeds the pre-agreed forecasted volume by 30% or more, the drug is subject to price-reduction. Logistic regression assessed the factors related to whether drugs were the PVA price-reduction drugs. A generalized linear model with gamma distribution and log-link assessed the factors influencing the increase in actual volumes compared to forecasted volume in the PVA price-reduction drugs. Of 186 PVA monitored drugs, 34.9% were price-reduction drugs. Drugs marketed by pharmaceutical companies with previous-occupation in the therapeutic markets were more likely to be PVA price-reduction drugs than drugs marketed by firms with no previous-occupation. Drugs of multinational pharmaceutical companies were more likely to be PVA price-reduction drugs than those of domestic companies. Having more alternative existing drugs was significantly associated with higher odds of being PVA price-reduction drugs. Among the PVA price-reduction drugs, the increasing rate of actual volume compared to forecasted volume was significantly higher in drugs with clinical usefulness. By focusing the negotiation efforts on those target drugs, PVA policy can be administered more efficiently with the improved predictability of the drug sales volumes. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Cataract surgery among Medicare beneficiaries.

PubMed

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

2012-10-01

To present descriptive epidemiology of cataract surgery among Medicare recipients in the United States. Cataract surgery performed on Medicare beneficiaries in 2003 and 2004. Medicare claims data were used to identify all cataract surgery claims for procedures performed in the United States in 2003-2004. Standard assumptions were used to limit the claims to actual cataract surgery procedures performed. Summary statistics were created to determine the number of procedures performed for each outcome of interest: cataract surgery rates by age, sex, race and state; surgical volume by facility type and surgeon characteristics; time interval between first- and second-eye cataract surgery. The national cataract surgery rate for 2003-2004 was 61.8 per 1000 Medicare beneficiary person-years. The rate was significantly higher for females and for those aged 75-84 years. After adjustment for age and sex, blacks had approximately a 30% lower rate of surgery than whites. While only 5% of cataract surgeons performed more than 500 cataract surgeries annually, these surgeons performed 26% of the total cataract surgeries. Increasing surgical volume was found to be highly correlated with use of ambulatory surgical centers and reduced time interval between first- and second-eye surgery in the same patient. The epidemiology of cataract surgery in the United States Medicare population documents substantial variation in surgical rates by race, sex, age, and by certain provider characteristics.

Does Categorization Method Matter in Exploring Volume-Outcome Relation? A Multiple Categorization Methods Comparison in Coronary Artery Bypass Graft Surgery Surgical Site Infection.

PubMed

Yu, Tsung-Hsien; Tung, Yu-Chi; Chung, Kuo-Piao

2015-08-01

Volume-infection relation studies have been published for high-risk surgical procedures, although the conclusions remain controversial. Inconsistent results may be caused by inconsistent categorization methods, the definitions of service volume, and different statistical approaches. The purpose of this study was to examine whether a relation exists between provider volume and coronary artery bypass graft (CABG) surgical site infection (SSI) using different categorization methods. A population-based cross-sectional multi-level study was conducted. A total of 10,405 patients who received CABG surgery between 2006 and 2008 in Taiwan were recruited. The outcome of interest was surgical site infection for CABG surgery. The associations among several patient, surgeon, and hospital characteristics was examined. The definition of surgeons' and hospitals' service volume was the cumulative CABG service volumes in the previous year for each CABG operation and categorized by three types of approaches: Continuous, quartile, and k-means clustering. The results of multi-level mixed effects modeling showed that hospital volume had no association with SSI. Although the relation between surgeon volume and surgical site infection was negative, it was inconsistent among the different categorization methods. Categorization of service volume is an important issue in volume-infection study. The findings of the current study suggest that different categorization methods might influence the relation between volume and SSI. The selection of an optimal cutoff point should be taken into account for future research.

Surgery of the Future | NIH MedlinePlus the Magazine

MedlinePlus

... including tools for imaging the body, biomaterials, and robotics,” says Margot Kern, who led the development of ... Bioengineering (NIBIB) Surgery of the Future website MedlinePlus: Robotic Surgery Summer 2017 Issue: Volume 12 Number 2 ...

Impact of integrated programs on general surgery operative volume.

PubMed

Jensen, Amanda R; Nickel, Brianne L; Dolejs, Scott C; Canal, David F; Torbeck, Laura; Choi, Jennifer N

2017-03-01

Integrated residencies are now commonplace, co-existing with categorical general surgery residencies. The purpose of this study was to define the impact of integrated programs on categorical general surgery operative volume. Case logs from categorical general, integrated plastics, vascular, and thoracic surgery residents from a single institution from 2008 to 2016 were collected and analyzed. Integrated residents have increased the number of cases they perform that would have previously been general surgery resident cases from 11 in 2009-2010 to 1392 in 2015-2016. Despite this, there was no detrimental effect on total major cases of graduating chief residents. Multiple integrated programs can co-exist with a general surgery program through careful collaboration and thoughtful consideration to longitudinal needs of individual trainees. As additional programs continue to be created, both integrated and categorical program directors must continue to collaborate to insure the integrity of training for all residents. Copyright © 2017 Elsevier Inc. All rights reserved.

Utility of Early Post-operative High Resolution Volumetric MR Imaging after Transsphenoidal Pituitary Tumor Surgery

PubMed Central

Patel, Kunal S.; Kazam, Jacob; Tsiouris, Apostolos J.; Anand, Vijay K.; Schwartz, Theodore H.

2014-01-01

Objective Controversy exists over the utility of early post-operative magnetic resonance imaging (MRI) after transsphenoidal pituitary surgery for macroadenomas. We investigate whether valuable information can be derived from current higher resolution scans. Methods Volumetric MRI scans were obtained in the early (<10 days) and late (>30 days) post-operative periods in a series of patients undergoing transsphenoidal pituitary surgery. The volume of the residual tumor, resection cavity, and corresponding visual field tests were recorded at each time point. Statistical analyses of changes in tumor volume and cavity size were calculated using the late MRI as the gold standard. Results 40 patients met the inclusion criteria. Pre-operative tumor volume averaged 8.8 cm3. Early postoperative assessment of average residual tumor volume (1.18 cm3) was quite accurate and did not differ statistically from late post-operative volume (1.23 cm3, p=.64), indicating the utility of early scans to measure residual tumor. Early scans were 100% sensitive and 91% specific for predicting ≥ 98% resection (p<.001, Fisher’s exact test). The average percent decrease in cavity volume from pre-operative MRI (tumor volume) to early post-operative imaging was 45% with decreases in all but 3 patients. There was no correlation between the size of the early cavity and the visual outcome. Conclusions Early high resolution volumetric MRI is valuable in determining the presence or absence of residual tumor. Cavity volume almost always decreases after surgery and a lack of decrease should alert the surgeon to possible persistent compression of the optic apparatus that may warrant re-operation. PMID:25045791

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

PubMed

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

2011-03-01

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

Pre-operative renal volume predicts peak creatinine after congenital heart surgery in neonates.

PubMed

Carmody, J Bryan; Seckeler, Michael D; Ballengee, Cortney R; Conaway, Mark; Jayakumar, K Anitha; Charlton, Jennifer R

2014-10-01

Acute kidney injury is common in neonates following surgery for congenital heart disease. We conducted a retrospective analysis to determine whether neonates with smaller pre-operative renal volume were more likely to develop post-operative acute kidney injury. We conducted a retrospective review of 72 neonates who underwent congenital heart surgery for any lesion other than patent ductus arteriosus at our institution from January 2007 to December 2011. Renal volume was calculated by ultrasound using the prolate ellipsoid formula. The presence and severity of post-operative acute kidney injury was determined both by measuring the peak serum creatinine in the first 7 days post-operatively and by using the Acute Kidney Injury Network scoring system. Using a linear change point model, a threshold renal volume of 17 cm³ was identified. Below this threshold, there was an inverse linear relationship between renal volume and peak post-operative creatinine for all patients (p = 0.036) and the subgroup with a single morphologic right ventricle (p = 0.046). There was a non-significant trend towards more acute kidney injury using Acute Kidney Injury Network criteria in all neonates with renal volume ≤17 cm³ (p = 0.11) and in the subgroup with a single morphologic right ventricle (p = 0.17). Pre-operative renal volume ≤17 cm³ is associated with a higher peak post-operative creatinine and potentially greater risk for post-operative acute kidney injury for neonates undergoing congenital heart surgery. Neonates with a single right ventricle may be at higher risk.

LORENZ: a system for planning long-bone fracture reduction

NASA Astrophysics Data System (ADS)

Birkfellner, Wolfgang; Burgstaller, Wolfgang; Wirth, Joachim; Baumann, Bernard; Jacob, Augustinus L.; Bieri, Kurt; Traud, Stefan; Strub, Michael; Regazzoni, Pietro; Messmer, Peter

2003-05-01

Long bone fractures belong to the most common injuries encountered in clinical routine trauma surgery. Preoperative assessment and decision making is usually based on standard 2D radiographs of the injured limb. Taking into account that a 3D - imaging modality such as computed tomography (CT) is not used for diagnosis in clinical routine, we have designed LORENZ, a fracture reduction planning tool based on such standard radiographs. Taking into account the considerable success of so-called image free navigation systems for total knee replacement in orthopaedic surgery, we assume that a similar tool for long bone fracture reposition should have considerable impact on computer-aided trauma surgery in a standard clinical routine setup. The case for long bone fracture reduction is, however, somewhat more complicated since not only scale independent angles indicating biomechanical measures such as varus and valgus are involved. Reduction path planning requires that the individual anatomy and the classification of the fracture is taken into account. In this paper, we present the basic ideas of this planning tool, it's current state, and the methodology chosen. LORENZ takes one or more conventional radiographs of the broken limb as input data. In addition, one or more x-rays of the opposite healthy bone are taken and mirrored if necessary. A most adequate CT model is being selected from a database; currently, this is achieved by using a scale space approach on the digitized x-ray images and comparing standard perspective renderings to these x-rays. After finding a CT-volume with a similar bone, a triangulated surface model is generated, and the surgeon can break the bone and arrange the fragments in 3D according to the x-ray images of the broken bone. Common osteosynthesis plates and implants can be loaded from CAD-datasets and are visualized as well. In addition, LORENZ renders virtual x-ray views of the fracture reduction process. The hybrid surface/voxel rendering engine of LORENZ also features full collision detection of fragments and implants by using the RAPID collision detection library. The reduction path is saved, and a TCP/IP interface to a robot for executing the reduction was added. LORENZ is platform independent and was programmed using Qt, AVW and OpenGL. We present a prototype for computer-aided fracture reduction planning based on standard radiographs. First test on clinical CT-Xray image pairs showed good performance; a current effort focuses on improving the speed of model retrieval by using orthonormal image moment decomposition, and on clinical evaluation for both training and surgical planning purposes. Furthermore, user-interface aspects are currently under evaluation and will be discussed.

Iliac screw for reconstructing posterior pelvic ring in Tile type C1 pelvic fractures.

PubMed

Li, Yonggang; Sang, Xiguang; Wang, Zhiyong; Cheng, Lin; Liu, Hao; Qin, Tao; Di, Kai

2018-06-18

It is often difficult to achieve stable fixation in Tile type C1 pelvic fractures and there is no standard fixation technique for these types of injuries. Iliac screw fixation can be used for treating Type C1 pelvic fractures. A retrospective review was performed on 47 patients who underwent iliac screw fixation in posterior column of ilium (PCI) for Tile type C1 pelvic fractures from July 2007 to December 2014. All patients were treated with fracture reduction, sacral nerve root decompression (if needed), internal fixation by iliac screw and connecting rod. The data on surgical time, intraoperative bleeding volume, postoperative neurologic functions and postoperative complications were analyzed. Patients were follow-up for at least 12months. The mean surgical time was 148minutes, and the mean intraoperative bleeding volume was 763ml. Patients were encouraged in-bed activities immediately after surgery. The postoperative Majeed functional score was 48-100 points (mean 80.2), corresponding to an excellent and good recovery of 91.5%. Postoperative X-radiographs and CT scans indicated satisfactory fracture reduction. Iliac screw fixation combined with sacral nerve canal decompression could effectively restore pelvic alignment and improve neurological functions for complex pelvic trauma. Copyright © 2018 Elsevier Masson SAS. All rights reserved.

Trends in Hospital Volume and Operative Mortality for High-Risk Surgery

PubMed Central

Finks, Jonathan F.; Osborne, Nicholas H.; Birkmeyer, John D.

2011-01-01

BACKGROUND There were numerous efforts in the United States during the previous decade to concentrate selected surgical procedures in high-volume hospitals. It remains unknown whether referral patterns for high-risk surgery have changed as a result and how operative mortality has been affected. METHODS We used national Medicare data to study patients undergoing one of eight different cancer and cardiovascular operations from 1999 through 2008. For each procedure, we examined trends in hospital volume and market concentration, defined as the proportion of Medicare patients undergoing surgery in the top decile of hospitals by volume per year. We used regression-based techniques to assess the effects of volume and market concentration on mortality over time, adjusting for case mix. RESULTS Median hospital volumes of four cancer resections (lung, esophagus, pancreas, and bladder) and of repair of abdominal aortic aneurysm (AAA) rose substantially. Depending on the procedure, higher hospital volumes were attributable to an increasing number of cases nationwide, an increasing market concentration, or both. Hospital volumes rose slightly for aortic-valve replacement but fell for coronary-artery bypass grafting and carotid endarterectomy. Operative mortality declined for all eight procedures, ranging from a relative decline of 8% for carotid endarterectomy (1.3% mortality in 1999 and 1.2% in 2008) to 36% for AAA repair (4.4% in 1999 and 2.8% in 2008). Higher hospital volumes explained a large portion of the decline in mortality for pancreatectomy (67% of the decline), cystectomy (37%), and esophagectomy (32%), but not for the other procedures. CONCLUSIONS Operative mortality with high-risk surgery fell substantially during the previous decade. Although increased market concentration and hospital volume have contributed to declining mortality with some high-risk cancer operations, declines in mortality with other procedures are largely attributable to other factors. (Funded by the National Institute on Aging.) PMID:21631325

Variation in rates of breast cancer surgery: A national analysis based on French Hospital Episode Statistics.

PubMed

Rococo, E; Mazouni, C; Or, Z; Mobillion, V; Koon Sun Pat, M; Bonastre, J

2016-01-01

Minimum volume thresholds were introduced in France in 2008 to improve the quality of cancer care. We investigated whether/how the quality of treatment decisions in breast cancer surgery had evolved before and after this policy was implemented. We used Hospital Episode Statistics for all women having undergone breast conserving surgery (BCS) or mastectomy in France in 2005 and 2012. Three surgical procedures considered as better treatment options were analyzed: BCS, immediate breast reconstruction (IBR) and sentinel lymph node biopsy (SLNB). We studied the mean rates and variation according to the hospital profile and volume. Between 2005 and 2012, the volume of breast cancer surgery increased by 11% whereas one third of the hospitals no longer performed this type of surgery. In 2012, the mean rate of BCS was 74% and similar in all hospitals whatever the volume. Conversely, IBR and SLNB rates were much higher in cancer centers (CC) and regional teaching hospitals (RTH) [IBR: 19% and 14% versus 8% on average; SLNB: 61% and 47% versus 39% on average]; the greater the hospital volume, the higher the IBR and SLNB rates (p < 0.0001). Overall, whatever the surgical procedure considered, inter-hospital variation in rates declined substantially in CC and RTH. We identified considerable variation in IBR and SLNB rates between French hospitals. Although more complex and less standardized than BCS, most clinical guidelines recommended these procedures. This apparent heterogeneity suggests unequal access to high-quality procedures for women with breast cancer. Copyright © 2015 Elsevier Ltd. All rights reserved.

The impact and outcomes of establishing an integrated interdisciplinary surgical team to care for the diabetic foot.

PubMed

Armstrong, David G; Bharara, Manish; White, Matthew; Lepow, Brian; Bhatnagar, Sugam; Fisher, Timothy; Kimbriel, Heather R; Walters, Jodi; Goshima, Kaoru R; Hughes, John; Mills, Joseph L

2012-09-01

This study aimed to quantify the impact of an integrated diabetic foot surgical service on outcomes and changes in surgical volume and focus. We abstracted registry data from 48 consecutive months at a single institution, evaluating all patients with diabetic foot complications requiring surgery or vascular intervention, and compared outcomes in the 24 months before and after integrating podiatric surgery with vascular surgical limb-salvage service. The service performed 2923 operations; 790 (27.0%) were related to treatment of diabetic foot complications in 374 patients. Of these, 502 were classified as non-vascular diabetic foot surgery and 288 were vascular interventions. Urgent surgery was significantly reduced after team implementation (77.7% vs 48.5%, p < 0.0001; OR = 3.7, 95% CI: 2.4-5.5). The high/low amputation ratio decreased from 0.35 to 0.27 due to an increase in low-level (midfoot) amputations (8.2% vs 26.1%, p < 0.0001; OR = 4.0, 95% CI: 2.0-83.3). A 45.7% reduction in below-knee amputations was realized with a stable above-knee/below-knee amputation ratio (0.73-0.81). One-third of patients required vascular intervention. Vascular reconstructions increased 44.1% following institution of the team. Initial revascularization was endovascular in 70.6% of patients. Repeat endovascular intervention or conversion to open bypass was required in 37.1% of these patients, almost double the reintervention rate of those receiving open bypass first (18.9%). Interdisciplinary diabetic foot surgery teams may significantly impact surgery type, with greater focus on proactive and preventive, rather than reactive and ablative, procedures. Although endovascular limb-sparing procedures have become increasingly applicable, open bypass remains critical to success. Copyright © 2012 John Wiley & Sons, Ltd.

Pricing hospital care: Global budgets and marginal pricing strategies.

PubMed

Sutherland, Jason M

2015-08-01

The Canadian province of British Columbia (BC) is adding financial incentives to increase the volume of surgeries provided by hospitals using a marginal pricing approach. The objective of this study is to calculate marginal costs of surgeries based on assumptions regarding hospitals' availability of labor and equipment. This study is based on observational clinical, administrative and financial data generated by hospitals. Hospital inpatient and outpatient discharge summaries from the province are linked with detailed activity-based costing information, stratified by assigned case mix categorizations. To reflect a range of operating constraints governing hospitals' ability to increase their volume of surgeries, a number of scenarios are proposed. Under these scenarios, estimated marginal costs are calculated and compared to prices being offered as incentives to hospitals. Existing data can be used to support alternative strategies for pricing hospital care. Prices for inpatient surgeries do not generate positive margins under a range of operating scenarios. Hip and knee surgeries generate surpluses for hospitals even under the most costly labor conditions and are expected to generate additional volume. In health systems that wish to fine-tune financial incentives, setting prices that create incentives for additional volume should reflect knowledge of hospitals' underlying cost structures. Possible implications of mis-pricing include no response to the incentives or uneven increases in supply. Copyright © 2015 The Authors. Published by Elsevier Ireland Ltd.. All rights reserved.

Lung-protective ventilation in abdominal surgery.

PubMed

Futier, Emmanuel; Jaber, Samir

2014-08-01

To provide the most recent and relevant clinical evidence regarding the use of prophylactic lung-protective mechanical ventilation in abdominal surgery. Evidence is accumulating, suggesting an association between intraoperative mechanical ventilation strategy and postoperative pulmonary complications in patients undergoing abdominal surgery. Nonprotective ventilator settings, especially high tidal volume (>10-12 ml/kg), very low level of positive end-expiratory pressure (PEEP, <5 cm H2O), or no PEEP, may cause alveolar overdistension and repetitive tidal recruitment leading to ventilator-associated lung injury in patients with healthy lungs. Stimulated by the previous findings in patients with acute respiratory distress syndrome, the use of lower tidal volume ventilation is becoming increasingly more common in the operating room. However, lowering tidal volume, though important, is only part of the overall multifaceted approach of lung-protective mechanical ventilation. Recent data provide compelling evidence that prophylactic lung-protective mechanical ventilation using lower tidal volume (6-8 ml/kg of predicted body weight), moderate PEEP (6-8 cm H2O), and recruitment maneuvers is associated with improved functional or physiological and clinical postoperative outcome in patients undergoing abdominal surgery. The use of prophylactic lung-protective ventilation can help in improving the postoperative outcome.

Assessing the effects of ketorolac and acetazolamide on macular thickness by optical coherence tomography following cataract surgery.

PubMed

Turan-Vural, Ece; Halili, Elvin; Serin, Didem

2014-06-01

We aimed to evaluate the efficacy of topical ketorolac 0.5 % solution and oral acetazolamide 250 mg/day delivery during the first month after uneventful phacoemulsification surgery by measuring the macular thickness using optical coherence tomography. Our nonmasked randomized prospective study comprised 87 eyes of 80 patients. Complete follow-up was achieved on 84 eyes of 77 eligible patients. Postoperatively, the patients were divided into three groups. One group received ketorolac 0.5 %, the other group received acetazolamide 250 mg/day, and the control group was given no agent. Macular thickness and volume were measured at 1 week and 1 month after surgery by optical coherence tomography. Foveal thickness, parafoveal thickness, and perifoveal thickness were determined to be significantly elevated at postoperative 1 week and 1 month in the control group. Foveal, perifoveal, and parafoveal volumes were also significantly high at postoperative week 1 and month 1 in the control group. There was no significant difference between the ketorolac and acetazolamide groups. The correlation analysis between best-corrected visual acuity, and volume and thickness revealed a negative correlation in the acetazolamide group. Use of acetazolamide after cataract surgery is as effective as ketorolac on macular thickness and volume.

Shop for quality or volume? Volume, quality, and outcomes of coronary artery bypass surgery.

PubMed

Auerbach, Andrew D; Hilton, Joan F; Maselli, Judith; Pekow, Penelope S; Rothberg, Michael B; Lindenauer, Peter K

2009-05-19

Care from high-volume centers or surgeons has been associated with lower mortality rates in coronary artery bypass surgery, but how volume and quality of care relate to each other is not well understood. To determine how volume and differences in quality of care influence outcomes after coronary artery bypass surgery. Observational cohort. 164 hospitals in the United States. 81,289 patients 18 years or older who had coronary artery bypass grafting from 1 October 2003 to 1 September 2005. Hospital and surgeon case volumes were estimated by using a data set. Quality measures were defined by whether patients received specific medications and by counting the number of measures missed. Hierarchical models were used to estimate effects of volume and quality on death and readmission up to 30 days. After adjustment for clinical factors, lowest surgeon volume and highest hospital volume were associated with higher mortality rates and lower readmission risk, respectively. Patients who did not receive aspirin (odds ratio, 1.89 [95% CI, 1.65 to 2.16) or beta-blockers (odds ratio, 1.29 [CI, 1.12 to 1.49]) had higher odds for death, after adjustment for clinical risk factors and case volume. Adjustment for individual quality measures did not alter associations between volume and readmission or death. However, if no quality measures were missed, mortality rates at the lowest-volume centers (adjusted mortality rate, 1.05% [CI, 0.81% to 1.29%]) and highest-volume centers (adjusted mortality rate, 0.98% [CI, 0.72% to 1.25%]) were similar. Because administrative data were used, the quality measures may not replicate measures collected through chart abstraction. Maximizing adherence to quality measures is associated with improved mortality rates, independent of hospital or surgeon volume. California HealthCare Foundation.

Haptic computer-assisted patient-specific preoperative planning for orthopedic fractures surgery.

PubMed

Kovler, I; Joskowicz, L; Weil, Y A; Khoury, A; Kronman, A; Mosheiff, R; Liebergall, M; Salavarrieta, J

2015-10-01

The aim of orthopedic trauma surgery is to restore the anatomy and function of displaced bone fragments to support osteosynthesis. For complex cases, including pelvic bone and multi-fragment femoral neck and distal radius fractures, preoperative planning with a CT scan is indicated. The planning consists of (1) fracture reduction-determining the locations and anatomical sites of origin of the fractured bone fragments and (2) fracture fixation-selecting and placing fixation screws and plates. The current bone fragment manipulation, hardware selection, and positioning processes based on 2D slices and a computer mouse are time-consuming and require a technician. We present a novel 3D haptic-based system for patient-specific preoperative planning of orthopedic fracture surgery based on CT scans. The system provides the surgeon with an interactive, intuitive, and comprehensive, planning tool that supports fracture reduction and fixation. Its unique features include: (1) two-hand haptic manipulation of 3D bone fragments and fixation hardware models; (2) 3D stereoscopic visualization and multiple viewing modes; (3) ligaments and pivot motion constraints to facilitate fracture reduction; (4) semiautomatic and automatic fracture reduction modes; and (5) interactive custom fixation plate creation to fit the bone morphology. We evaluate our system with two experimental studies: (1) accuracy and repeatability of manual fracture reduction and (2) accuracy of our automatic virtual bone fracture reduction method. The surgeons achieved a mean accuracy of less than 1 mm for the manual reduction and 1.8 mm (std [Formula: see text] 1.1 mm) for the automatic reduction. 3D haptic-based patient-specific preoperative planning of orthopedic fracture surgery from CT scans is useful and accurate and may have significant advantages for evaluating and planning complex fractures surgery.

The Regionalization of Total Ankle Arthroplasties and Ankle Fusions in New York State: A 10-Year Comparative Analysis.

PubMed

Buza, John A; Liu, James X; Jancuska, Jeffrey; Bosco, Joseph A

2017-06-01

Total ankle arthroplasty (TAA) provides an alternative to ankle fusion (AF). The purpose of this study is to (1) determine the extent of TAA regionalization, as well as examine the growth of TAA performed at high-, medium-, and low-volume New York State institutions and (2) compare this regionalization and growth with AF. The New York Statewide Planning and Research Cooperative System (SPARCS) administrative data were used to identify 737 primary TAA and 7453 AF from 2005 to 2014. The volume of TAA and AF surgery in New York State was mapped according to patient and hospital 3-digit zip code. The number of TAA per year grew 1500% (from 11 to 177) from 2005 to 2014, while there was a 35.6% reduction (from 895 to 576) in yearly AF procedures. TAA recipients were widely distributed throughout the state, while TAA procedures were regionalized to a few select metropolitan centers. AF procedures were performed more uniformly than TAA. The number of TAA has continued to increase at high- (15 to 91) and medium-volume (14 to 67) institutions where it has decreased at low-volume institutions (44 to 19). The increased utilization of TAA is attributed to relatively few high-volume centers located in major metropolitan centers. Level IV: well-designed case-control or cohort studies.

Analysis of laser surgery in non-melanoma skin cancer for optimal tissue removal

NASA Astrophysics Data System (ADS)

Fanjul-Vélez, Félix; Salas-García, Irene; Arce-Diego, José Luis

2015-02-01

Laser surgery is a commonly used technique for tissue ablation or the resection of malignant tumors. It presents advantages over conventional non-optical ablation techniques, like a scalpel or electrosurgery, such as the increased precision of the resected volume, minimization of scars and shorter recovery periods. Laser surgery is employed in medical branches such as ophthalmology or dermatology. The application of laser surgery requires the optimal adjustment of laser beam parameters, taking into account the particular patient and lesion. In this work we present a predictive tool for tissue resection in biological tissue after laser surgery, which allows an a priori knowledge of the tissue ablation volume, area and depth. The model employs a Monte Carlo 3D approach for optical propagation and a rate equation for plasma-induced ablation. The tool takes into account characteristics of the specific lesion to be ablated, mainly the geometric, optical and ablation properties. It also considers the parameters of the laser beam, such as the radius, spatial profile, pulse width, total delivered energy or wavelength. The predictive tool is applied to dermatology tumor resection, particularly to different types of non-melanoma skin cancer tumors: basocellular carcinoma, squamous cell carcinoma and infiltrative carcinoma. The ablation volume, area and depth are calculated for healthy skin and for each type of tumor as a function of the laser beam parameters. The tool could be used for laser surgery planning before the clinical application. The laser parameters could be adjusted for optimal resection volume, by personalizing the process to the particular patient and lesion.

Improved laparoscopic nephron-sparing surgery for renal cell carcinoma based on the precise anatomy of the nephron.

PubMed

Guo, Gang; Cai, Wei; Zhang, Xu

2016-11-01

The aim of the present study was to investigate a method of laparoscopic nephron-sparing surgery (LNSS) for renal cell carcinoma (RCC) based on the precise anatomy of the nephron, and to decrease the incidence of hemorrhage and urinary leakage. Between January 2012 and December 2013, 31 patients who presented to the General Hospital of the People's Liberation Army (Beijing, China) were treated for RCC. The mean tumor size was 3.4±0.7 cm in diameter (range, 1.2-6.0 cm). During surgery, the renal artery was blocked, and subsequently, an incision in the renal capsule and renal cortex was performed, at 3-5 mm from the tumor edge. Subsequent to the incision of the renal parenchyma, scissors with blunt and sharp edge were used to separate the base of the tumor from the normal renal medulla, in the direction of the ray medullary in the renal pyramids. The basal blood vessels were incised following the hemostasis of the region using bipolar coagulation. The minor renal calyces were stripped carefully and the wound was closed with an absorbable sutures. The arterial occlusion time, duration of surgery, intraoperative bleeding volume, post-operative drainage volume, pathological results and complications were recorded. The surgery was successful for all patients. The estimated average intraoperative bleeding volume was 55.7 ml, the average surgical duration was 95.5 min, the average arterial occlusion time was 21.2 min, the average post-operative drainage volume was 92.3 ml and the average post-operative length of hospital stay was 6.1 days. No hemorrhage or urinary leakage was observed in the patients following the surgery. LNSS for RCC based on the precise anatomy of the nephron was concluded to be effective and feasible. The surgery is useful for the complete removal of tumors and guarantees a negative margin, which may also decrease the incidence of hemorrhage and urinary leakage following surgery.

Maintaining oncologic integrity with minimally invasive resection of pediatric embryonal tumors.

PubMed

Phelps, Hannah M; Ayers, Gregory D; Ndolo, Josephine M; Dietrich, Hannah L; Watson, Katherine D; Hilmes, Melissa A; Lovvorn, Harold N

2018-05-08

Embryonal tumors arise typically in infants and young children and are often massive at presentation. Operative resection is a cornerstone in the multimodal treatment of embryonal tumors but potentially disrupts therapeutic timelines. When used appropriately, minimally invasive surgery can minimize treatment delays. The oncologic integrity and safety attainable with minimally invasive resection of embryonal tumors, however, remains controversial. Query of the Vanderbilt Cancer Registry identified all children treated for intracavitary, embryonal tumors during a 15-year period. Tumors were assessed radiographically to measure volume (mL) and image-defined risk factors (neuroblastic tumors only) at time of diagnosis, and at preresection and postresection. Patient and tumor characteristics, perioperative details, and oncologic outcomes were compared between minimally invasive surgery and open resection of tumors of comparable size. A total of 202 patients were treated for 206 intracavitary embryonal tumors, of which 178 were resected either open (n = 152, 85%) or with minimally invasive surgery (n = 26, 15%). The 5-year, relapse-free, and overall survival were not significantly different after minimally invasive surgery or open resection of tumors having a volume less than 100 mL, corresponding to the largest resected with minimally invasive surgery (P = .249 and P = .124, respectively). No difference in margin status or lymph node sampling between the 2 operative approaches was detected (p = .333 and p = .070, respectively). Advantages associated with minimally invasive surgery were decreased blood loss (P < .001), decreased operating time (P = .002), and shorter hospital stay (P < .001). Characteristically, minimally invasive surgery was used for smaller volume and earlier stage neuroblastic tumors without image-defined risk factors. When selected appropriately, minimally invasive resection of pediatric embryonal tumors, particularly neuroblastic tumors, provides acceptable oncologic integrity. Large tumor volume, small patient size, and image-defined risk factors may limit the broader applicability of minimally invasive surgery. Copyright © 2018 Elsevier Inc. All rights reserved.

The Effect of Topical Tranexamic Acid on Bleeding Reduction during Functional Endoscopic Sinus Surgery.

PubMed

Baradaranfar, Mohammad Hossein; Dadgarnia, Mohammad Hossein; Mahmoudi, Hossein; Behniafard, Nasim; Atighechi, Saeid; Zand, Vahid; Baradaranfar, Amin; Vaziribozorg, Sedighe

2017-03-01

Bleeding is a common concern during functional endoscopic sinus surgery (FESS) that can increase the risk of damage to adjacent vital elements by reducing the surgeon's field of view. This study aimed to explore the efficacy of topical tranexamic acid in reducing intraoperative bleeding. This double-blind, randomized clinical trial was conducted in 60 patients with chronic rhinosinusitis with polyposis (CRSwP) who underwent FESS. Patients were randomly divided into two groups; tranexamic or saline treatment. During surgery, normal saline (400 mL) or tranexamic acid (2 g) in normal saline with a total volume of 400 mL were used in the saline and tranexamic groups, respectively, for irrigation and suctioning. The surgeons' assessment of field of view during surgery and intraoperative blood loss were recorded. Mean blood loss was 254.13 mL in the saline group and 235.6 mL in the tranexamic group (P=0.31). No statistically significant differences between the two groups were found in terms of other investigated variables, such as surgical field quality based on Boezzart's scale (P=0.30), surgeon satisfaction based on a Likert scale (P=0.54), or duration of surgery (P=0.22). Use of tranexamic acid (2 g in 400 mL normal saline) through washing of the nasal mucosa during FESS did not significantly reduce blood loss or improve the surgical field of view. Further studies with larger sample sizes and higher drug concentrations, and using other methods of administration, such as spraying or applying pledgets soaked in tranexamic acid, are recommended.

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

PubMed

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

2003-07-16

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

Internal Fixation of Complicated Acetabular Fractures Directed by Preoperative Surgery with 3D Printing Models.

PubMed

Liu, Zhao-Jie; Jia, Jian; Zhang, Yin-Guang; Tian, Wei; Jin, Xin; Hu, Yong-Cheng

2017-05-01

The purpose of this article is to evaluate the efficacy and feasibility of preoperative surgery with 3D printing-assisted internal fixation of complicated acetabular fractures. A retrospective case review was performed for the above surgical procedure. A 23-year-old man was confirmed by radiological examination to have fractures of multiple ribs, with hemopneumothorax and communicated fractures of the left acetabulum. According to the Letounel and Judet classification, T-shaped fracture involving posterior wall was diagnosed. A 3D printing pelvic model was established using CT digital imaging and communications in medicine (DICOM) data preoperatively, with which surgical procedures were simulated in preoperative surgery to confirm the sequence of the reduction and fixation as well as the position and length of the implants. Open reduction with internal fixation (ORIF) of the acetabular fracture using modified ilioinguinal and Kocher-Langenbeck approaches was performed 25 days after injury. Plates that had been pre-bent in the preoperative surgery were positioned and screws were tightened in the directions determined in the preoperative planning following satisfactory reduction. The duration of the operation was 170 min and blood loss was 900 mL. Postoperative X-rays showed that anatomical reduction of the acetabulum was achieved and the hip joint was congruous. The position and length of the implants were not different when compared with those in preoperative surgery on 3D printing models. We believe that preoperative surgery using 3D printing models is beneficial for confirming the reduction and fixation sequence, determining the reduction quality, shortening the operative time, minimizing preoperative difficulties, and predicting the prognosis for complicated fractures of acetabulam. © 2017 Chinese Orthopaedic Association and John Wiley & Sons Australia, Ltd.

Safe transition to surgery: working differently to make blood transfusion process safer for elective surgery.

PubMed

Badjie, Karafa S W; Rogers, James C; Jenkins, Sarah M; Bundy, Kevin L; Stubbs, James R; Cima, Robert R

2015-09-01

Our institutional policy allows patients who are scheduled for elective surgery with no history of a pregnancy or blood transfusion in the preceding 3 months to have a presurgical sample (PSS) collected and tested up to 56 days before their scheduled surgery; however, our PSS TS completion rate in eligible patients before the morning of surgery was 83%. In 2011, a team was charged to develop a standardized process along with other process improvements while ensuring no increase in transfusion-related events. The team followed the DMAIC framework in appraising the effectiveness and efficiency of the current state process including baseline data collection such as PSS TS completion rate, number of eligible patients needing a PSS TS on the day of surgery, benchmarking, SSBO utilization, and future state mapping. First quarter (Q1) 2011 versus Q1 2012 postimplementation results showed significant improvements of the process including a 53% decrease in PSS TS on the day of surgery; a 13% increase in PSS TS completion before the morning of surgery; a 26% reduction in total XM RBCs; and a 58.8% reduction in XM RBCs not issued, plus a 47% decrease in RBC wastage. Q1 2011 versus Q1 2013 showed a 41% reduction in total XM RBCs and an 88.4% reduction in XM RBCs not issued but overall RBCs issued versus returned increased slightly and represents a future opportunity for improvement. The redesigned, transformational process eliminated SSBO and improved ordering process and PSS TS completion rate as well as blood product ordering and utilization. © 2015 AABB.

Cataract Surgery among Medicare Beneficiaries

PubMed Central

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

2014-01-01

Purpose To present descriptive epidemiology of cataract surgery among Medicare recipients in the United States. Setting Cataract surgery performed on Medicare beneficiaries in 2003 and 2004. Methods Medicare claims data were used to identify all cataract surgery claims for procedures performed in the United States in 2003-2004. Standard assumptions were used to limit the claims to actual cataract surgery procedures performed. Summary statistics were created to determine the number of procedures performed for each outcome of interest: cataract surgery rates by age, race, and gender; surgical volume by facility type, surgeon characteristics, and state; time interval between first- and second-eye cataract surgery. Results The national cataract surgery rate for 2003-2004 was 61.8 per 1000 Medicare beneficiary person-years. The rate was significantly higher for females and for those 75-84. After adjustment for age and gender, blacks had approximately a 30% lower rate of surgery than whites. While only 5% of cataract surgeons performed more than 500 cataract surgeries annually, these surgeons performed 26% of the total cataract surgeries. Increasing surgical volume was found to be highly correlated with use of ambulatory surgical centers and reduced time interval between first- and second-eye surgery in the same patient. Conclusions The epidemiology of cataract surgery in the United States Medicare population documents substantial variation in surgical rates by race, gender, age, and by certain provider characteristics. PMID:22978526

Sonography-guided hydrostatic reduction of ileocolic intussusception in children: analysis of failure and success in consecutive patients presenting timely to the hospital.

PubMed

Menke, Jan; Kahl, Fritz

2015-03-01

In children with ileocolic intussusception sonography is increasingly being used for diagnosis, whereas fluoroscopy is frequently used for guiding non-invasive reduction. This study assessed the success rate of radiation-free sonography-guided hydrostatic reduction in children with ileocolic intussusception, using novel well-defined success rate indices. All children were evaluated who presented from 2005 to 2013 to the local university hospital with ileocolic intussusception. The patients were treated with sonography-guided hydrostatic reduction unless primary surgery was clinically indicated. The according success rate was determined by indices of Bekdash et al. They represent the ratio of persistently successful non-surgical reductions versus four different denominators, depending on including/excluding cases with primary surgery and including/excluding cases requiring bowel resection/intervention. Fifty-six consecutive patients were included (age, 3 months to 7.8 years). About 80% of the patients presented until 24 h and 20% until 48 h after the onset of symptoms. Seven patients underwent primary surgery, with bowel resection required in three cases. Hydrostatic reduction was attempted in 49 patients, being permanently successful in 41 cases (selective reduction rate 41/49 = 83.7%; crude reduction rate 41/56 = 73.2%). The remaining eight patients underwent secondary surgery, with just two patients not requiring surgical bowel resection/intervention (corrected selective reduction rate 41/43 = 95.3%). The composite reduction rate was 87.2% (successful/feasible reductions, 41/47). Radiation-free sonography-guided hydrostatic reduction has a good success rate in children with ileocolic intussusception. It may be particularly valuable in centers that are already experienced with using sonography for the diagnosis.

Dynamics of vascular volume and hemodilution of lactated Ringer’s solution in patients during induction of general and epidural anesthesia*

PubMed Central

Li, Yu-hong; Lou, Xian-feng; Bao, Fang-ping

2006-01-01

Objective: To investigate the dynamics of vascular volume and the plasma dilution of lactated Ringer’s solution in patients during the induction of general and epidural anesthesia. Methods: The hemodilution of i.v. infusion of 1000 ml of lactated Ringer’s solution over 60 min was studied in patients undergoing general (n=31) and epidural (n=22) anesthesia. Heart rate, arterial blood pressure and hemoglobin (Hb) concentration were measured every 5 min during the study. Surgery was not started until the study period had been completed. Results: General anesthesia caused the greater decrease of mean arterial blood pressure (MAP) (mean 15% versus 9%; P<0.01) and thereby followed by a more pronounced plasma dilution, blood volume expansion (VE) and blood volume expansion efficiency (VEE). A strong linear correlation between hemodilution and the reduction in MAP (r=−0.50; P<0.01) was found. At the end of infusion, patients undergoing general anesthesia retained 47% (SD 19%) of the infused fluid in the circulation, while epidural anesthesia retained 29% (SD 13%) (P<0.001). Correspondingly, a fewer urine output (mean 89 ml versus 156 ml; P<0.05) and extravascular expansion (454 ml versus 551 ml; P<0.05) were found during general anesthesia. Conclusion: We concluded that the induction of general anesthesia caused more hemodilution, volume expansion and volume expansion efficiency than epidural anesthesia, which was triggered only by the lower MAP. PMID:16909476

Brain volume reduction after whole-brain radiotherapy: quantification and prognostic relevance.

PubMed

Hoffmann, Christian; Distel, Luitpold; Knippen, Stefan; Gryc, Thomas; Schmidt, Manuel Alexander; Fietkau, Rainer; Putz, Florian

2018-01-22

Recent studies have questioned the value of adding whole-brain radiotherapy (WBRT) to stereotactic radiosurgery (SRS) for brain metastasis treatment. Neurotoxicity, including radiation-induced brain volume reduction, could be one reason why not all patients benefit from the addition of WBRT. In this study, we quantified brain volume reduction after WBRT and assessed its prognostic significance. Brain volumes of 91 patients with cerebral metastases were measured during a 150-day period after commencing WBRT and were compared with their pretreatment volumes. The average daily relative change in brain volume of each patient, referred to as the "brain volume reduction rate," was calculated. Univariate and multivariate Cox regression analyses were performed to assess the prognostic significance of the brain volume reduction rate, as well as of 3 treatment-related and 9 pretreatment factors. A one-way analysis of variance was used to compare the brain volume reduction rate across recursive partitioning analysis (RPA) classes. On multivariate Cox regression analysis, the brain volume reduction rate was a significant predictor of overall survival after WBRT (P < 0.001), as well as the number of brain metastases (P = 0.002) and age (P = 0.008). Patients with a relatively favorable prognosis (RPA classes 1 and 2) experienced significantly less brain volume decrease after WBRT than patients with a poor prognosis (RPA class 3) (P = 0.001). There was no significant correlation between delivered radiation dose and brain volume reduction rate (P = 0.147). In this retrospective study, a smaller decrease in brain volume after WBRT was an independent predictor of longer overall survival. © The Author(s) 2017. Published by Oxford University Press on behalf of the Society for Neuro-Oncology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

Does surgery help in reducing stigma associated with drug refractory epilepsy in children?

PubMed

Bajaj, Jitin; Tripathi, Manjari; Dwivedi, Rekha; Sapra, Savita; Gulati, Sheffali; Garg, Ajay; Tripathi, Madhavi; Bal, Chandra S; Chandra, Sarat P

2018-03-01

Epilepsy has several comorbidities and associated stigma. Stigma associated with epilepsy is well known and prevalent worldwide. Surgical treatment is an established treatment for drug refractory epilepsy. Following surgery in children, it is possible that the stigma may reduce, but such an effect has not been studied earlier. Analysis of prospectively collected data was performed for pediatric patients at a single tertiary center for treating epilepsy. Child stigma scale, as described by Austin et al., was used to evaluate stigma both pre- and postoperatively. Analysis was done using Paired t test. In this study, following surgery, there was significant reduction of stigma (P<0.001). This was proportional to the reduction in seizures, though there were 9 (30%) patients, who due to persistent neurodisability did not have any reduction of stigma despite having good seizure outcome. Surgery in drug-resistant epilepsy helps in reducing stigma. Seizure reduction is probably not the only factor responsible for a change in stigma outcome. Copyright © 2018 Elsevier Inc. All rights reserved.

A comparison of two methods of infiltration in breast reduction surgery.

PubMed

Armour, A D; Rotenberg, B W; Brown, M H

2001-08-01

The superwet technique has been shown in previous studies to dramatically reduce blood loss in breast reduction surgery, compared with standard infiltration. A retrospective chart review of 303 consecutive patients undergoing bilateral breast reduction surgery was undertaken to demonstrate additional differences in complication rate, operative time, or sponge use in the operating room. In this series, 132 consecutive patients received standard infiltration along incision lines (25 cc per breast of 1:100,000 epinephrine), and 171 patients received superwet infiltration with 240 cc per breast of 1:1,000,000 epinephrine. The average operative time was significantly reduced in the superwet group, from 78.5 minutes to 70.7 minutes (p < 0.01 level). The average number of sponges used intraoperatively was also decreased significantly (p < 0.01), from 26 to 20 sponges. Complication rates were equally low in both groups, demonstrating the safety of the superwet technique. In addition to limiting blood loss, the superwet infiltration effectively reduces operative time and sponge use without increasing complications in breast reduction surgery.

Use of body plethysmography to measure effect of bimaxillary orthognathic surgery on airway resistance and lung volumes.

PubMed

Rezaeetalab, Fariba; Kazemian, Mozhgan; Vaezi, Touraj; Shaban, Barratollah

2015-12-01

Bimaxillary orthognathic surgery can cause changes to respiration and the airways. We used body plethysmography to evaluate its effect on airway resistance and lung volumes in 20 patients with class III malocclusions (8 men and 12 women, aged 17 - 32 years). Lung volumes (forced vital capacity; forced inspiratory volume/one second; forced expiratory volume/one second: forced vital capacity; peak expiratory flow; maximum expiratory flow 25-75; maximum inspiratory flow; total lung capacity; residual volume; residual volume:total lung capacity), and airway resistance were evaluated one week before, and six months after, operation. Bimaxillary operations to correct class III malocclusions significantly increased airway resistance, residual volume, total lung capacity, and residual volume:total lung capacity. Other variables also changed after operation but not significantly so. Orthognathic operations should be done with caution in patients who have pre-existing respiratory diseases. Copyright © 2015 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

A novel vaporization-enucleation technique for benign prostate hyperplasia using 120-W HPS GreenLight™ laser: Seoul technique II in comparison with vaporization and previously reported modified vaporization-resection technique.

PubMed

Yoo, Sangjun; Park, Juhyun; Cho, Sung Yong; Cho, Min Chul; Jeong, Hyeon; Son, Hwancheol

2017-12-01

We developed a novel vaporization-enucleation technique (Seoul II), which consists of vaporization-enucleation of the prostate using 120-W HPS GreenLight laser, and enucleated prostate resection using bipolar devices for tissue removal. We compared the outcomes of the Seoul II with vaporization and a previously reported modified vaporization-resection technique (Seoul I). Among patients with benign prostate hyperplasia who underwent transurethral surgery using GreenLight laser at our institute, 347 patients with prostate volume ≥ 40 ml were included. The impact of surgical techniques on efficacy and postoperative functional outcomes was compared. No difference was found in baseline characteristics, although the prostate volume was marginally greater in Seoul II (p = 0.051). Prostate volume reduction per operation time (p < 0.001) and lasing time (p = 0.016) were greater in Seoul II. At postoperative 12 months, the International Prostate Symptom Score (I-PSS) was lower (p = 0.011), and the decrement in I-PSS was greater in Seoul II (p = 0.001) than other techniques. In multivariate analysis, postoperative 12-month I-PSS for Seoul II was significantly superior to vaporization (p < 0.001), although it was similar to Seoul I. The maintenance of immediate postoperative I-PSS decrement, until postoperative 12 months was superior in Seoul II compared with vaporization (p = 0.014) and Seoul I (p = 0.048). Seoul II showed improved efficacy and voiding functional maintenance over postoperative 12 months in patients with prostate volume ≥ 40 ml compared with vaporization and Seoul I. This technique could be easily accepted by clinicians who are familiar with GreenLight lasers and add flexibility to surgery without additional equipment.

Trends in refractive surgery at an academic center: 2007-2009.

PubMed

Kuo, Irene C

2011-05-14

The United States officially entered a recession in December 2007, and it officially exited the recession in December 2009, according to the National Bureau of Economic Research. Since the economy may affect not only the volume of excimer laser refractive surgery, but also the clinical characteristics of patients undergoing surgery, our goal was to compare the characteristics of patients completing excimer laser refractive surgery and the types of procedures performed in the summer quarter in 2007 and the same quarter in 2009 at an academic center. A secondary goal was to determine whether the volume of astigmatism- or presbyopia-correcting intraocular lenses (IOLs) has concurrently changed because like laser refractive surgery, these "premium" IOLs involve out-of-pocket costs for patients. Retrospective case series. Medical records were reviewed for all patients completing surgery at the Wilmer Laser Vision Center in the summer quarter of 2007 and the summer quarter of 2009. Outcome measures were the proportions of treated refractive errors, the proportion of photorefractive keratectomy (PRK) vs. laser-assisted in-situ keratomileusis (LASIK), and the mean age of patients in each quarter. Chi-square test was used to compare the proportions of treated refractive errors and the proportions of procedures; two-tailed t-test to compare the mean age of patients; and two-tailed z-test to compare proportions of grouped refractive errors in 2007 vs. 2009; alpha = 0.05 for all tests. Refractive errors were grouped by the spherical equivalent of the manifest refraction and were considered "low myopia" for 6 diopters (D) of myopia or less, "high myopia" for more than 6 D, and "hyperopia" for any hyperopia. Billing data were reviewed to obtain the volume of premium IOLs. Volume of laser refractive procedures decreased by at least 30%. The distribution of proportions of treated refractive errors did not change (p = 0.10). The proportion of high myopes, however, decreased (p = 0.05). The proportions of types of procedure changed, with an increase in the proportion of PRK between 2007 and 2009 (p = 0.02). The mean age of patients did not change [42.4 ± 14.4 (standard deviation) years in 2007 vs. 39.6 ± 14.5 years in 2009; p = 0.4]. Astigmatism-correcting IOL and presbyopia-correcting IOL volumes increased 15-fold and three-fold, respectively, between 2007 and 2009. Volume of excimer laser refractive surgery decreased by at least 30% between 2007 and 2009. No significant change in mean age or in the distribution of refractive error was seen, although the proportion of high myopes decreased between summer quarters of 2007 and 2009. PRK gained as a proportion of total cases. Premium IOL volume increased, but still comprised a very small proportion of total IOL volume.

Trends in refractive surgery at an academic center: 2007-2009

PubMed Central

2011-01-01

Background The United States officially entered a recession in December 2007, and it officially exited the recession in December 2009, according to the National Bureau of Economic Research. Since the economy may affect not only the volume of excimer laser refractive surgery, but also the clinical characteristics of patients undergoing surgery, our goal was to compare the characteristics of patients completing excimer laser refractive surgery and the types of procedures performed in the summer quarter in 2007 and the same quarter in 2009 at an academic center. A secondary goal was to determine whether the volume of astigmatism- or presbyopia-correcting intraocular lenses (IOLs) has concurrently changed because like laser refractive surgery, these "premium" IOLs involve out-of-pocket costs for patients. Methods Retrospective case series. Medical records were reviewed for all patients completing surgery at the Wilmer Laser Vision Center in the summer quarter of 2007 and the summer quarter of 2009. Outcome measures were the proportions of treated refractive errors, the proportion of photorefractive keratectomy (PRK) vs. laser-assisted in-situ keratomileusis (LASIK), and the mean age of patients in each quarter. Chi-square test was used to compare the proportions of treated refractive errors and the proportions of procedures; two-tailed t-test to compare the mean age of patients; and two-tailed z-test to compare proportions of grouped refractive errors in 2007 vs. 2009; alpha = 0.05 for all tests. Refractive errors were grouped by the spherical equivalent of the manifest refraction and were considered "low myopia" for 6 diopters (D) of myopia or less, "high myopia" for more than 6 D, and "hyperopia" for any hyperopia. Billing data were reviewed to obtain the volume of premium IOLs. Results Volume of laser refractive procedures decreased by at least 30%. The distribution of proportions of treated refractive errors did not change (p = 0.10). The proportion of high myopes, however, decreased (p = 0.05). The proportions of types of procedure changed, with an increase in the proportion of PRK between 2007 and 2009 (p = 0.02). The mean age of patients did not change [42.4 ± 14.4 (standard deviation) years in 2007 vs. 39.6 ± 14.5 years in 2009; p = 0.4]. Astigmatism-correcting IOL and presbyopia-correcting IOL volumes increased 15-fold and three-fold, respectively, between 2007 and 2009. Conclusions Volume of excimer laser refractive surgery decreased by at least 30% between 2007 and 2009. No significant change in mean age or in the distribution of refractive error was seen, although the proportion of high myopes decreased between summer quarters of 2007 and 2009. PRK gained as a proportion of total cases. Premium IOL volume increased, but still comprised a very small proportion of total IOL volume. PMID:21569564

Comparison of Diaphragmatic Breathing Exercise, Volume and Flow Incentive Spirometry, on Diaphragm Excursion and Pulmonary Function in Patients Undergoing Laparoscopic Surgery: A Randomized Controlled Trial

PubMed Central

Anand, R.

2016-01-01

Objective. To evaluate the effects of diaphragmatic breathing exercises and flow and volume-oriented incentive spirometry on pulmonary function and diaphragm excursion in patients undergoing laparoscopic abdominal surgery. Methodology. We selected 260 patients posted for laparoscopic abdominal surgery and they were block randomization as follows: 65 patients performed diaphragmatic breathing exercises, 65 patients performed flow incentive spirometry, 65 patients performed volume incentive spirometry, and 65 patients participated as a control group. All of them underwent evaluation of pulmonary function with measurement of Forced Vital Capacity (FVC), Forced Expiratory Volume in the first second (FEV1), Peak Expiratory Flow Rate (PEFR), and diaphragm excursion measurement by ultrasonography before the operation and on the first and second postoperative days. With the level of significance set at p < 0.05. Results. Pulmonary function and diaphragm excursion showed a significant decrease on the first postoperative day in all four groups (p < 0.001) but was evident more in the control group than in the experimental groups. On the second postoperative day pulmonary function (Forced Vital Capacity) and diaphragm excursion were found to be better preserved in volume incentive spirometry and diaphragmatic breathing exercise group than in the flow incentive spirometry group and the control group. Pulmonary function (Forced Vital Capacity) and diaphragm excursion showed statistically significant differences between volume incentive spirometry and diaphragmatic breathing exercise group (p < 0.05) as compared to that flow incentive spirometry group and the control group. Conclusion. Volume incentive spirometry and diaphragmatic breathing exercise can be recommended as an intervention for all patients pre- and postoperatively, over flow-oriented incentive spirometry for the generation and sustenance of pulmonary function and diaphragm excursion in the management of laparoscopic abdominal surgery. PMID:27525116

Comparison of Diaphragmatic Breathing Exercise, Volume and Flow Incentive Spirometry, on Diaphragm Excursion and Pulmonary Function in Patients Undergoing Laparoscopic Surgery: A Randomized Controlled Trial.

PubMed

Alaparthi, Gopala Krishna; Augustine, Alfred Joseph; Anand, R; Mahale, Ajith

2016-01-01

Objective. To evaluate the effects of diaphragmatic breathing exercises and flow and volume-oriented incentive spirometry on pulmonary function and diaphragm excursion in patients undergoing laparoscopic abdominal surgery. Methodology. We selected 260 patients posted for laparoscopic abdominal surgery and they were block randomization as follows: 65 patients performed diaphragmatic breathing exercises, 65 patients performed flow incentive spirometry, 65 patients performed volume incentive spirometry, and 65 patients participated as a control group. All of them underwent evaluation of pulmonary function with measurement of Forced Vital Capacity (FVC), Forced Expiratory Volume in the first second (FEV1), Peak Expiratory Flow Rate (PEFR), and diaphragm excursion measurement by ultrasonography before the operation and on the first and second postoperative days. With the level of significance set at p < 0.05. Results. Pulmonary function and diaphragm excursion showed a significant decrease on the first postoperative day in all four groups (p < 0.001) but was evident more in the control group than in the experimental groups. On the second postoperative day pulmonary function (Forced Vital Capacity) and diaphragm excursion were found to be better preserved in volume incentive spirometry and diaphragmatic breathing exercise group than in the flow incentive spirometry group and the control group. Pulmonary function (Forced Vital Capacity) and diaphragm excursion showed statistically significant differences between volume incentive spirometry and diaphragmatic breathing exercise group (p < 0.05) as compared to that flow incentive spirometry group and the control group. Conclusion. Volume incentive spirometry and diaphragmatic breathing exercise can be recommended as an intervention for all patients pre- and postoperatively, over flow-oriented incentive spirometry for the generation and sustenance of pulmonary function and diaphragm excursion in the management of laparoscopic abdominal surgery.

Blood transfusion in pediatric cardiac surgery.

PubMed

Durandy, Yves

2010-11-01

The aim of the study is to measure the volume of homologous blood needed for one pediatric patient during his hospital stay. Over a 4-month period, all the patients operated upon with a blood prime or requiring blood transfusion during their hospital stay were included in this study.The cardiopulmonary bypass protocol associates a miniaturized bypass circuit, vacuum-assisted venous drainage, and microplegia. The volume of each blood product opened is known and the volume of blood product remaining, following the last transfusion, is measured. Data collected areas follows: patient weight; hemoglobin level before surgery,during bypass, and in intensive care after the last transfusion;time to extubation; and degree of inotropic support.Forty-six patients weighing 5.1 1.5 kg were included in this study. Cardiopulmonary bypass priming volume was 100 mL for patients up to 3.5 kg, 120 mL for patients between 3.6 and 7.5 kg, and 160 mL for patients between 7.6 and 8.6 kg. The volume of blood transfusion was 271 112 mL, hemoglobin level before surgery was 10.3 1.7 g/dL, hemoglobin level during surgery was 11.0 1.5 g/dL, and hemoglobin level after the last transfusion was 12.3 2.4 g/dL. Time to extubation was 12 3.3 h, and inotropic support was enoximone in 37 patients,whereas 6 patients needed enoximone and epinephrine.No patient needed reexploration for bleeding and one patient received a platelet transfusion.The mean blood transfusion volume was equivalent to 60% of the patient’s total blood volume (estimated to be 80 mL/kg).

Hospital volume, complications, and cost of cancer surgery in the elderly.

PubMed

Nathan, Hari; Atoria, Coral L; Bach, Peter B; Elkin, Elena B

2015-01-01

Hospital surgical volume has been shown to correlate with short-term outcomes after cancer surgery, but the relationship between volume and cost of care is unclear. We sought to characterize variation in payments for cancer surgery and assess the relationship between hospital volume and payments. Using 2000 to 2007 Surveillance, Epidemiology, and End Results-Medicare data, we assessed risk-adjusted 30-day episode Medicare payments for elderly patients undergoing one of six procedures for resection of cancer. Payments for the index hospitalization, readmissions, physician services, emergency room visits, and postdischarge ancillary care were analyzed, as were data on 30-day mortality and complications. The analysis included 31,191 colectomies, 2,670 cystectomies, 1,514 pancreatectomies, 2,607 proctectomies, 12,228 prostatectomies, and 10,151 pulmonary lobectomies. There was substantial variation in cost; differences between the first and third terciles of cost varied from 27% for cystectomy to 40% for colectomy. The majority of variation (66% to 82%) was attributable to payments for the index admission rather than readmissions or physician services. There were no meaningful associations between total risk-adjusted payments and hospital volume. Surgical mortality was low, but complication rates ranged from 10% (prostatectomy) to 56% (lobectomy). Complication rates were not correlated with hospital volume, but occurrence of complications was associated with 47% to 70% higher costs. We found substantial variation in Medicare payments for these six cancer procedures. Cost was strongly associated with postoperative complications and primarily driven by differences in the cost of the index hospitalization. Efforts to prevent and cost-effectively manage complications are more likely to reduce costs than volume-based referral of cancer surgery alone. © 2014 by American Society of Clinical Oncology.

Effect of lung-protective ventilation with lower tidal volumes on clinical outcomes among patients undergoing surgery: a meta-analysis of randomized controlled trials.

PubMed

Gu, Wan-Jie; Wang, Fei; Liu, Jing-Chen

2015-02-17

In anesthetized patients undergoing surgery, the role of lung-protective ventilation with lower tidal volumes is unclear. We performed a meta-analysis of randomized controlled trials (RCTs) to evaluate the effect of this ventilation strategy on postoperative outcomes. We searched electronic databases from inception through September 2014. We included RCTs that compared protective ventilation with lower tidal volumes and conventional ventilation with higher tidal volumes in anesthetized adults undergoing surgery. We pooled outcomes using a random-effects model. The primary outcome measures were lung injury and pulmonary infection. We included 19 trials (n=1348). Compared with patients in the control group, those who received lung-protective ventilation had a decreased risk of lung injury (risk ratio [RR] 0.36, 95% confidence interval [CI] 0.17 to 0.78; I2=0%) and pulmonary infection (RR 0.46, 95% CI 0.26 to 0.83; I2=8%), and higher levels of arterial partial pressure of carbon dioxide (standardized mean difference 0.47, 95% CI 0.18 to 0.75; I2=65%). No significant differences were observed between the patient groups in atelectasis, mortality, length of hospital stay, length of stay in the intensive care unit or the ratio of arterial partial pressure of oxygen to fraction of inspired oxygen. Anesthetized patients who received ventilation with lower tidal volumes during surgery had a lower risk of lung injury and pulmonary infection than those given conventional ventilation with higher tidal volumes. Implementation of a lung-protective ventilation strategy with lower tidal volumes may lower the incidence of these outcomes. © 2015 Canadian Medical Association or its licensors.

Right heart chamber geometry and tricuspid annulus morphology in patients undergoing mitral valve repair with and without tricuspid valve annuloplasty.

PubMed

Tamborini, Gloria; Fusini, Laura; Muratori, Manuela; Gripari, Paola; Ghulam Ali, Sarah; Fiorentini, Cesare; Pepi, Mauro

2016-06-01

According to current recommendations, patients could benefit from tricuspid valve (TV) annuloplasty at the time mitral valve (MV) surgery if tricuspid regurgitation is severe or if tricuspid annulus (TA) dilatation is present. Therefore, an accurate pre-operative echocardiographic study is mandatory for left but also for right cardiac structures. Aims of this study are to assess right atrial (RA), right ventricular (RV) and TA geometry and function in patients undergoing MV repair without or with TV annuloplasty. We studied 103 patients undergoing MV surgery without (G1: 54 cases) or with (G2: 49 cases) concomitant TV annuloplasty and 40 healthy subjects (NL) as controls. RA, RV and TA were evaluated by three-dimensional (3D) transthoracic echocardiography. Comparing the pathological to the NL group, TA parameters and 3D right chamber volumes were significantly larger. RA and RV ejection fraction and TA% reduction were lower in pathological versus NL, and in G2 versus G1. In pathological patients, TA area positively correlated to systolic pulmonary pressure and negatively with RV and RA ejection fraction. Patients undergoing MV surgery and TV annuloplasty had an increased TA dimensions and a more advanced remodeling of right heart chambers probably reflecting an advanced stage of the disease.

IRCAD recommendation on safe laparoscopic cholecystectomy.

PubMed

Conrad, Claudius; Wakabayashi, Go; Asbun, Horacio J; Dallemagne, Bernard; Demartines, Nicolas; Diana, Michele; Fuks, David; Giménez, Mariano Eduardo; Goumard, Claire; Kaneko, Hironori; Memeo, Riccardo; Resende, Alexandre; Scatton, Olivier; Schneck, Anne-Sophie; Soubrane, Olivier; Tanabe, Minoru; van den Bos, Jacqueline; Weiss, Helmut; Yamamoto, Masakazu; Marescaux, Jacques; Pessaux, Patrick

2017-11-01

An expert recommendation conference was conducted to identify factors associated with adverse events during laparoscopic cholecystectomy (LC) with the goal of deriving expert recommendations for the reduction of biliary and vascular injury. Nineteen hepato-pancreato-biliary (HPB) surgeons from high-volume surgery centers in six countries comprised the Research Institute Against Cancer of the Digestive System (IRCAD) Recommendations Group. Systematic search of PubMed, Cochrane, and Embase was conducted. Using nominal group technique, structured group meetings were held to identify key items for safer LC. Consensus was achieved when 80% of respondents ranked an item as 1 or 2 (Likert scale 1-4). Seventy-one IRCAD HPB course participants assessed the expert recommendations which were compared to responses of 37 general surgery course participants. The IRCAD recommendations were structured in seven statements. The key topics included exposure of the operative field, appropriate use of energy device and establishment of the critical view of safety (CVS), systematic preoperative imaging, cholangiogram and alternative techniques, role of partial and dome-down (fundus-first) cholecystectomy. Highest consensus was achieved on the importance of the CVS as well as dome-down technique and partial cholecystectomy as alternative techniques. The put forward IRCAD recommendations may help to promote safe surgical practice of LC and initiate specific training to avoid adverse events. © 2017 Japanese Society of Hepato-Biliary-Pancreatic Surgery.

Does transfusion of residual cardiopulmonary bypass circuit blood increase postoperative bleeding? A prospective randomized study in patients undergoing on pump cardiopulmonary bypass

PubMed Central

Duara, Rajnish; Misra, Manoranjan; Bhuyan, Ritwick Raj; Sarma, P. Sankara; Jayakumar, Karunakaran

2008-01-01

Objective: Homologous blood transfusion after open heart surgery puts a tremendous load on the blood banks. This prospective randomized study evaluates the efficacy of infusing back residual cardiopulmonary bypass (CPB) circuit i.e., pump blood as a means to reduce homologous transfusion after coronary artery bypass surgery (CABG) and whether its use increases postoperative drainage. Materials and Methods: Sixty-seven consecutive patients who underwent elective CABGs under CPB were randomized into 2 groups: (1) cases where residual pump blood was used and (2) controls where residual pump blood was not used. Patients were monitored for hourly drainage on the day of surgery and the 1st postoperative day and the requirements of homologous blood and its products. Data were matched regarding change in Hemoglobin, Packed Cell Volume and coagulation parameters till 1st postoperative day. All cases were followed up for three years. Results: There was a marginal reduction in bleeding pattern in the early postoperative period in the cases compared to controls. The requirement of homologous blood and its products were also reduced in the cases. Conclusions: The use of CPB circuit blood is safe in the immediate postoperative period. The requirement of homologous blood transfusion can come down if strict transfusion criteria are maintained. PMID:20041077

Interventional radiology of the thyroid gland: critical review and state of the art

PubMed Central

Quarchioni, Simone; Bruno, Federico; Ierardi, Anna Maria; Arrigoni, Francesco; Giordano, Aldo Victor; Carducci, Sergio; Varrassi, Marco; Carrafiello, Giampaolo; Caranci, Ferdinando; Splendiani, Alessandra; Di Cesare, Ernesto; Masciocchi, Carlo

2018-01-01

Thyroid nodules are a common incidental finding during a routinely ultrasound (US) exam unrelated to the thyroid gland in the healthy adult population with a prevalence of 20–76%. As treated before with surgery, in the last years new minimally invasive techniques have been developed as an alternative to surgery. The aim of this review, based on newly revised guidelines, is to provide some information regarding the basic principles, indications, materials, techniques, and results of mini-invasive procedures or treatments for thyroid nodules. We performed a narrative review including both newest and representative papers and guidelines based on the different procedures of ablation techniques developed in the last years for the diagnosis and the treatment of thyroid nodules. All examined papers referred very good results in term of volume nodule reduction, improvement in related symptoms and cosmetic problems, with a very low rate of complications and side effects for all the minimally invasive technique analyzed. Obviously, some differents between technique based on different kind of thyroid nodules and different indication were found. In conclusion, many thyroid nodules nowadays could be treated thanks to the advent of new mini-invasive technique that are less expensive and present a lower risk of major complications and side effects compared to surgery. PMID:29770309

Prognostic value of three-dimensional ultrasound for fetal hydronephrosis

PubMed Central

WANG, JUNMEI; YING, WEIWEN; TANG, DAXING; YANG, LIMING; LIU, DONGSHENG; LIU, YUANHUI; PAN, JIAOE; XIE, XING

2015-01-01

The present study evaluated the prognostic value of three-dimensional ultrasound for fetal hydronephrosis. Pregnant females with fetal hydronephrosis were enrolled and a novel three-dimensional ultrasound indicator, renal parenchymal volume/kidney volume, was introduced to predict the postnatal prognosis of fetal hydronephrosis in comparison with commonly used ultrasound indicators. All ultrasound indicators of fetal hydronephrosis could predict whether postnatal surgery was required for fetal hydronephrosis; however, the predictive performance of renal parenchymal volume/kidney volume measurements as an individual indicator was the highest. In conclusion, ultrasound is important in predicting whether postnatal surgery is required for fetal hydronephrosis, and the three-dimensional ultrasound indicator renal parenchymal volume/kidney volume has a high predictive performance. Furthermore, the majority of cases of fetal hydronephrosis spontaneously regress subsequent to birth, and the regression time is closely associated with ultrasound indicators. PMID:25667626

INCREASED MYOCARDIAL STIFFNESS DUE TO CARDIAC TITIN ISOFORM SWITCHING IN A MOUSE MODEL OF VOLUME OVERLOAD LIMITS ECCENTRIC REMODELING

PubMed Central

Hutchinson, Kirk R; Saripalli, Chandra; Chung, Charles S.; Granzier, Henk

2014-01-01

We investigated the cellular and molecular mechanisms of diastolic dysfunction in pure volume overload induced by aortocaval fistula (ACF) surgery in the mouse. Four weeks of volume overload resulted in significant biventricular hypertrophy; protein expression analysis in left ventricular (LV) tissue showed a marked decrease in titin's N2BA/N2B ratio with no change in phosphorylation of titin's spring region. Titin-based passive tensions were significantly increased; a result of the decreased N2BA/N2B ratio. Conscious echocardiography in ACF mice revealed eccentric remodeling and pressure volume analysis revealed systolic dysfunction: reductions in ejection fraction (EF), +dP/dt, and the slope of the endsystolic pressure volume relationships (ESPVR). ACF mice also had diastolic dysfunction: increased LV end-diastolic pressure and reduced relaxation rates. Additionally, a decrease in the slope of the end diastolic pressure volume relationship (EDPVR) was found. However, correcting for altered geometry of the LV normalized the change in EDPVR and revealed, in line with our skinned muscle data, increased myocardial stiffness in vivo. ACF mice also had increased expression of the signaling proteins FHL-1, FHL-2, and CARP that bind to titin's spring region suggesting that titin stiffening is important to the volume overload phenotype. To test this we investigated the effect of volume overload in the RBM20 heterozygous (HET) mouse model, which exhibits reduced titin stiffness. It was found that LV hypertrophy was attenuated and that LV eccentricity was exacerbated. We propose that pure volume overload induces an increase in titin stiffness that is beneficial and limits eccentric remodeling. PMID:25450617

Hand Surgery Questions on the Orthopaedic In-Training Examination: Analysis of Content and Reference.

PubMed

Martin, Adam S; McMains, M Craig; Shacklett, Andrew G; Awan, Hisham M

2018-06-01

To provide an updated analysis of the hand surgery section of the Orthopaedic In-Training Examination (OITE) from 2009 to 2015. The goal was to contribute to the existing literature on the analysis of OITE questions, to aid both residents and residency programs in preparation for the OITE and board examination. The authors analyzed all OITE questions pertaining to hand surgery between 2009 and 2015. Hand questions were analyzed for category and subcategory of content, cited reference, treatment intervention, and imaging modality used. Hand-related questions comprised 157 of the 1,872 OITE questions (8.4%). Nine general topic areas were identified, the most common of which were fracture-dislocation, tendon/ligament, nerve, congenital, and amputation. Trends existed in the recommended references; the 5 journals and 2 textbooks that were consistently cited included the Journal of Hand Surgery (American Volume), the Journal of the American Academy of Orthopaedic Surgeons, the Journal of Bone and Joint Surgery (American Volume), the Journal of Hand Surgery (European Volume), Hand Clinics, Orthopaedic Knowledge Update, and Green's Operative Hand Surgery, respectively. Knowledge regarding topics and resources used for OITE hand questions could be mutually beneficial to both residents and residency programs. This information would consolidate resident OITE and board examination study time. Furthermore, this analysis could help residency programs develop or improve educational conferences and journal clubs. An understanding of question content and sources should enable efficient learning and improved scores on this section of the examination. Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

Quantitative estimation of a ratio of intracranial cerebrospinal fluid volume to brain volume based on segmentation of CT images in patients with extra-axial hematoma.

PubMed

Nguyen, Ha Son; Patel, Mohit; Li, Luyuan; Kurpad, Shekar; Mueller, Wade

2017-02-01

Background Diminishing volume of intracranial cerebrospinal fluid (CSF) in patients with space-occupying masses have been attributed to unfavorable outcome associated with reduction of cerebral perfusion pressure and subsequent brain ischemia. Objective The objective of this article is to employ a ratio of CSF volume to brain volume for longitudinal assessment of space-volume relationships in patients with extra-axial hematoma and to determine variability of the ratio among patients with different types and stages of hematoma. Patients and methods In our retrospective study, we reviewed 113 patients with surgical extra-axial hematomas. We included 28 patients (age 61.7 +/- 17.7 years; 19 males, nine females) with an acute epidural hematoma (EDH) ( n = 5) and subacute/chronic subdural hematoma (SDH) ( n = 23). We excluded 85 patients, in order, due to acute SDH ( n = 76), concurrent intraparenchymal pathology ( n = 6), and bilateral pathology ( n = 3). Noncontrast CT images of the head were obtained using a CT scanner (2004 GE LightSpeed VCT CT system, tube voltage 140 kVp, tube current 310 mA, 5 mm section thickness) preoperatively, postoperatively (3.8 ± 5.8 hours from surgery), and at follow-up clinic visit (48.2 ± 27.7 days after surgery). Each CT scan was loaded into an OsiriX (Pixmeo, Switzerland) workstation to segment pixels based on radiodensity properties measured in Hounsfield units (HU). Based on HU values from -30 to 100, brain, CSF spaces, vascular structures, hematoma, and/or postsurgical fluid were segregated from bony structures, and subsequently hematoma and/or postsurgical fluid were manually selected and removed from the images. The remaining images represented overall brain volume-containing only CSF spaces, vascular structures, and brain parenchyma. Thereafter, the ratio between the total number of voxels representing CSF volume (based on values between 0 and 15 HU) to the total number of voxels representing overall brain volume was calculated. Results CSF/brain volume ratio varied significantly during the course of the disease, being the lowest preoperatively, 0.051 ± 0.032; higher after surgical evacuation of hematoma, 0.067 ± 0.040; and highest at follow-up visit, 0.083 ± 0.040 ( p < 0.01). Using a repeated regression analysis, we found a significant association ( p < 0.01) of the ratio with age (odds ratio, 1.019; 95% CI, 1.009-1.029) and type of hematoma (odds ratio, 0.405; 95% CI, 0.303-0.540). Conclusion CSF/brain volume ratio calculated from CT images has potential to reflect dynamics of intracranial volume changes in patients with space-occupying mass.

A Quantitative Analysis of the Relationship between Medicare Payment and Service Volume for Glaucoma Procedures from 2005 through 2009.

PubMed

Gong, Dan; Jun, Lin; Tsai, James C

2015-05-01

To calculate the association between Medicare payment and service volume for 6 commonly performed glaucoma procedures. Retrospective, longitudinal database study. A 100% dataset of all glaucoma procedures performed on Medicare Part B beneficiaries within the United States from 2005 to 2009. Fixed-effects regression model using Medicare Part B carrier data for all 50 states and the District of Columbia, controlling for time-invariant carrier-specific characteristics, national trends in glaucoma service volume, Medicare beneficiary population, number of ophthalmologists, and income per capita. Payment-volume elasticities, defined as the percent change in service volume per 1% change in Medicare payment, for laser trabeculoplasty (Current Procedural Terminology [CPT] code 65855), trabeculectomy without previous surgery (CPT code 66170), trabeculectomy with previous surgery (CPT code 66172), aqueous shunt to reservoir (CPT code 66180), laser iridotomy (CPT code 66761), and scleral reinforcement with graft (CPT code 67255). The payment-volume elasticity was nonsignificant for 4 of 6 procedures studied: laser trabeculoplasty (elasticity, -0.27; 95% confidence interval [CI], -1.31 to 0.77; P = 0.61), trabeculectomy without previous surgery (elasticity, -0.42; 95% CI, -0.85 to 0.01; P = 0.053), trabeculectomy with previous surgery (elasticity, -0.28; 95% CI, -0.83 to 0.28; P = 0.32), and aqueous shunt to reservoir (elasticity, -0.47; 95% CI, -3.32 to 2.37; P = 0.74). Two procedures yielded significant associations between Medicare payment and service volume. For laser iridotomy, the payment-volume elasticity was -1.06 (95% CI, -1.39 to -0.72; P < 0.001): for every 1% decrease in CPT code 66761 payment, laser iridotomy service volume increased by 1.06%. For scleral reinforcement with graft, the payment-volume elasticity was -2.92 (95% CI, -5.72 to -0.12; P = 0.041): for every 1% decrease in CPT code 67255 payment, scleral reinforcement with graft service volume increased by 2.92%. This study calculated the association between Medicare payment and service volume for 6 commonly performed glaucoma procedures and found varying magnitudes of payment-volume elasticities, suggesting that the volume response to changes in Medicare payments, if present, is not uniform across all Medicare procedures. Copyright © 2015 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.

Perfusion Scintigraphy and Patient Selection for Lung Volume Reduction Surgery

PubMed Central

Chandra, Divay; Lipson, David A.; Hoffman, Eric A.; Hansen-Flaschen, John; Sciurba, Frank C.; DeCamp, Malcolm M.; Reilly, John J.; Washko, George R.

2010-01-01

Rationale: It is unclear if lung perfusion can predict response to lung volume reduction surgery (LVRS). Objectives: To study the role of perfusion scintigraphy in patient selection for LVRS. Methods: We performed an intention-to-treat analysis of 1,045 of 1,218 patients enrolled in the National Emphysema Treatment Trial who were non–high risk for LVRS and had complete perfusion scintigraphy results at baseline. The median follow-up was 6.0 years. Patients were classified as having upper or non–upper lobe–predominant emphysema on visual examination of the chest computed tomography and high or low exercise capacity on cardiopulmonary exercise testing at baseline. Low upper zone perfusion was defined as less than 20% of total lung perfusion distributed to the upper third of both lungs as measured on perfusion scintigraphy. Measurements and Main Results: Among 284 of 1,045 patients with upper lobe–predominant emphysema and low exercise capacity at baseline, the 202 with low upper zone perfusion had lower mortality with LVRS versus medical management (risk ratio [RR], 0.56; P = 0.008) unlike the remaining 82 with high perfusion where mortality was unchanged (RR, 0.97; P = 0.62). Similarly, among 404 of 1,045 patients with upper lobe–predominant emphysema and high exercise capacity, the 278 with low upper zone perfusion had lower mortality with LVRS (RR, 0.70; P = 0.02) unlike the remaining 126 with high perfusion (RR, 1.05; P = 1.00). Among the 357 patients with non–upper lobe–predominant emphysema (75 with low and 282 with high exercise capacity) there was no improvement in survival with LVRS and measurement of upper zone perfusion did not contribute new prognostic information. Conclusions: Compared with optimal medical management, LVRS reduces mortality in patients with upper lobe–predominant emphysema when there is low rather than high perfusion to the upper lung. PMID:20538961

Long-term follow-up of patients receiving lung-volume-reduction surgery versus medical therapy for severe emphysema by the National Emphysema Treatment Trial Research Group.

PubMed

Naunheim, Keith S; Wood, Douglas E; Mohsenifar, Zab; Sternberg, Alice L; Criner, Gerard J; DeCamp, Malcolm M; Deschamps, Claude C; Martinez, Fernando J; Sciurba, Frank C; Tonascia, James; Fishman, Alfred P

2006-08-01

The National Emphysema Treatment Trial defined subgroups of patients with severe emphysema in whom lung-volume-reduction surgery (LVRS) improved survival and function at 2 years. Two additional years of follow-up provide valuable information regarding durability. A total of 1218 patients with severe emphysema were randomized to receive LVRS or medical treatment. We present updated analyses (4.3 versus 2.4 years median follow-up), including 40% more patients with functional measures 2 years after randomization. The intention-to-treat analysis of 1218 randomized patients demonstrates an overall survival advantage for LVRS, with a 5-year risk ratio (RR) for death of 0.86 (p = 0.02). Improvement was more likely in the LVRS than in the medical group for maximal exercise through 3 years and for health-related quality of life (St. George's Respiratory Questionnaire [SGRQ]) through 4 years. Updated comparisons of survival and functional improvement were consistent with initial results for four clinical subgroups of non-high-risk patients defined by upper-lobe predominance and exercise capacity. After LVRS, the upper-lobe patients with low exercise capacity demonstrated improved survival (5-year RR, 0.67; p = 0.003), exercise throughout 3 years (p < 0.001), and symptoms (SGRQ) through 5 years (p < 0.001 years 1 to 3, p = 0.01 year 5). Upper-lobe-predominant and high-exercise-capacity LVRS patients obtained no survival advantage but were likely to improve exercise capacity (p < 0.01 years 1 to 3) and SGRQ (p < 0.01 years 1 to 4). Effects of LVRS are durable, and it can be recommended for upper-lobe-predominant emphysema patients with low exercise capacity and should be considered for palliation in patients with upper-lobe emphysema and high exercise capacity.

Factors associated with reoperation in hypospadias surgery - A nationwide, population-based study.

PubMed

Lu, Yu-Chuan; Huang, Wei-Yi; Chen, Yu-Fen; Chang, Hong-Chiang; Pong, Yuan-Hung; Shih, Tsung-Hsien; Huang, Kuo-How

2017-04-01

To analyze the preoperative factors associated with the need for secondary surgery following primary urethroplasty. This study utilized a subset of the National Health Insurance Research Database, which includes the data on all paid medical benefit claims from 1997 to 2007, for 1 million beneficiaries in 2005. We analyzed the claims data for all patients with hypospadias who had undergone primary urethroplasty. The characteristics of the patients, surgeons, and hospitals associated with surgical outcomes were analyzed to investigate possible associations with the need for secondary surgery. Among 52,705 live male newborn babies, 218 were diagnosed with hypospadias, of whom 89 received repair surgery. A total of 75 (84.3%) male newborn babies received single hypospadias surgery, and 14 (15.7%) underwent more than two surgical procedures. Univariate analysis demonstrated that the type of hypospadias and the surgeon caseload volume were significantly associated with the need for additional hypospadias surgery (p = 0.02 and p = 0.03, respectively). In multivariate analysis, the type of hypospadias (distal vs. proximal, odds ratio, 0.25; p = 0.03) and the surgeon caseload volume (high vs. low, odds ratio, 0.04; p = 0.05) were significantly correlated with secondary operation. The type of hypospadias and the surgeon caseload volume were significantly associated with the need for secondary hypospadias surgery. The findings of this study provide important information on the outcomes of hypospadias repair for parents and specialists. Copyright © 2017. Published by Elsevier Taiwan.

Changes in Dietary Intake and Eating Behavior in Adolescents After Bariatric Surgery: an Ancillary Study to the Teen-LABS Consortium.

PubMed

Sarwer, David B; Dilks, Rebecca J; Spitzer, Jacqueline C; Berkowitz, Robert I; Wadden, Thomas A; Moore, Renee H; Chittams, Jesse L; Brandt, Mary L; Chen, Mike K; Courcoulas, Anita P; Harmon, Carroll M; Helmrath, Michael A; Michalsky, Marc P; Xanthakos, Stavra A; Zeller, Meg H; Jenkins, Todd M; Inge, Thomas H

2017-12-01

A growing number of studies suggest that bariatric surgery is safe and effective for adolescents with severe obesity. However, surprisingly little is known about changes in dietary intake and eating behavior of adolescents who undergo bariatric surgery. Investigate changes in dietary intake and eating behavior of adolescents with obesity who underwent bariatric surgery (n = 119) or lifestyle modification (LM) (n = 169). University-based health systems METHODS: A prospective investigation of 288 participants (219 female and 69 male) prior to bariatric surgery or LM and again 6, 12, and 24 months (surgery patients only) after treatment. Measures included changes in weight, macronutrient intake, eating behavior, and relevant demographic and physiological variables. Adolescents who underwent bariatric surgery experienced significantly greater weight loss than those who received LM. The two groups differed in self-reported intake of a number of macronutrients at 6 and 12 months from baseline, but not total caloric intake. Patients treated with surgery, compared to those treated with LM, also reported significantly greater reductions in a number of disordered eating symptoms. After bariatric surgery, greater weight loss from postoperative month 6 to 12 was associated with self-reported weight consciousness, craving for sweets, and consumption of zinc. Adolescents who underwent bariatric surgery, compared to those who received LM, reported significantly greater reductions in weight after 1 year. They also reported greater reductions in disordered eating symptoms. These findings provide new information on changes in dietary intake and eating behavior among adolescents who undergo bariatric surgery.

The endogenous preproglucagon system is not essential for gut growth homeostasis in mice.

PubMed

Wismann, Pernille; Barkholt, Pernille; Secher, Thomas; Vrang, Niels; Hansen, Henrik B; Jeppesen, Palle Bekker; Baggio, Laurie L; Koehler, Jacqueline A; Drucker, Daniel J; Sandoval, Darleen A; Jelsing, Jacob

2017-07-01

The prevalence of obesity and related co-morbidities is reaching pandemic proportions. Today, the most effective obesity treatments are glucagon-like peptide 1 (GLP-1) analogs and bariatric surgery. Interestingly, both intervention paradigms have been associated with adaptive growth responses in the gut; however, intestinotrophic mechanisms associated with or secondary to medical or surgical obesity therapies are poorly understood. Therefore, the objective of this study was to assess the local basal endogenous and pharmacological intestinotrophic effects of glucagon-like peptides and bariatric surgery in mice. We used in situ hybridization to provide a detailed and comparative anatomical map of the local distribution of GLP-1 receptor ( Glp1r ), GLP-2 receptor ( Glp2r ), and preproglucagon ( Gcg ) mRNA expression throughout the mouse gastrointestinal tract. Gut development in GLP-1R-, GLP-2R-, or GCG-deficient mice was compared to their corresponding wild-type controls, and intestinotrophic effects of GLP-1 and GLP-2 analogs were assessed in wild-type mice. Lastly, gut volume was determined in a mouse model of vertical sleeve gastrectomy (VSG). Comparison of Glp1r , Glp2r , and Gcg mRNA expression indicated a widespread, but distinct, distribution of these three transcripts throughout all compartments of the mouse gastrointestinal tract. While mice null for Glp1r or Gcg showed normal intestinal morphology, Glp2r -/- mice exhibited a slight reduction in small intestinal mucosa volume. Pharmacological treatment with GLP-1 and GLP-2 analogs significantly increased gut volume. In contrast, VSG surgery had no effect on intestinal morphology. The present study indicates that the endogenous preproglucagon system, exemplified by the entire GCG gene and the receptors for GLP-1 and GLP-2, does not play a major role in normal gut development in the mouse. Furthermore, elevation in local intestinal and circulating levels of GLP-1 and GLP-2 achieved after VSG has limited impact on intestinal morphometry. Hence, although exogenous treatment with GLP-1 and GLP-2 analogs enhances gut growth, the contributions of endogenously-secreted GLP-1 and GLP-2 to gut growth may be more modest and highly context-dependent.

Twelve-month prostate volume reduction after MRI-guided transurethral ultrasound ablation of the prostate.

PubMed

Bonekamp, David; Wolf, M B; Roethke, M C; Pahernik, S; Hadaschik, B A; Hatiboglu, G; Kuru, T H; Popeneciu, I V; Chin, J L; Billia, M; Relle, J; Hafron, J; Nandalur, K R; Staruch, R M; Burtnyk, M; Hohenfellner, M; Schlemmer, H-P

2018-06-25

To quantitatively assess 12-month prostate volume (PV) reduction based on T2-weighted MRI and immediate post-treatment contrast-enhanced MRI non-perfused volume (NPV), and to compare measurements with predictions of acute and delayed ablation volumes based on MR-thermometry (MR-t), in a central radiology review of the Phase I clinical trial of MRI-guided transurethral ultrasound ablation (TULSA) in patients with localized prostate cancer. Treatment day MRI and 12-month follow-up MRI and biopsy were available for central radiology review in 29 of 30 patients from the published institutional review board-approved, prospective, multi-centre, single-arm Phase I clinical trial of TULSA. Viable PV at 12 months was measured as the remaining PV on T2-weighted MRI, less 12-month NPV, scaled by the fraction of fibrosis in 12-month biopsy cores. Reduction of viable PV was compared to predictions based on the fraction of the prostate covered by the MR-t derived acute thermal ablation volume (ATAV, 55°C isotherm), delayed thermal ablation volume (DTAV, 240 cumulative equivalent minutes at 43°C thermal dose isocontour) and treatment-day NPV. We also report linear and volumetric comparisons between metrics. After TULSA, the median 12-month reduction in viable PV was 88%. DTAV predicted a reduction of 90%. Treatment day NPV predicted only 53% volume reduction, and underestimated ATAV and DTAV by 36% and 51%. Quantitative volumetry of the TULSA phase I MR and biopsy data identifies DTAV (240 CEM43 thermal dose boundary) as a useful predictor of viable prostate tissue reduction at 12 months. Immediate post-treatment NPV underestimates tissue ablation. • MRI-guided transurethral ultrasound ablation (TULSA) achieved an 88% reduction of viable prostate tissue volume at 12 months, in excellent agreement with expectation from thermal dose calculations. • Non-perfused volume on immediate post-treatment contrast-enhanced MRI represents only 64% of the acute thermal ablation volume (ATAV), and reports only 60% (53% instead of 88% achieved) of the reduction in viable prostate tissue volume at 12 months. • MR-thermometry-based predictions of 12-month prostate volume reduction based on 240 cumulative equivalent minute thermal dose volume are in excellent agreement with reduction in viable prostate tissue volume measured on pre- and 12-month post-treatment T2w-MRI.

Practice Patterns for Neurosurgical Utilization and Outcome in Acute Intracerebral Hemorrhage: Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trials 1 and 2 Studies.

PubMed

Guo, Rui; Blacker, David J; Wang, Xia; Arima, Hisatomi; Lavados, Pablo M; Lindley, Richard I; Chalmers, John; Anderson, Craig S; Robinson, Thompson

2017-12-01

The prognosis in acute spontaneous intracerebral hemorrhage (ICH) is related to hematoma volume, where >30 mL is commonly used to define large ICH as a threshold for neurosurgical decompression but without clear supporting evidence. To determine the factors associated with large ICH and neurosurgical intervention among participants of the Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trials (INTERACT). We performed pooled analysis of the pilot INTERACT1 (n = 404) and main INTERACT2 (n = 2839) studies of ICH patients (<6 h of onset) with elevated systolic blood pressure (SBP, 150-220 mm Hg) who were randomized to intensive (target SBP < 140 mm Hg) or contemporaneous guideline-recommended (target SBP < 180 mm Hg) management. Neurosurgical intervention data were collected at 7 d postrandomization. Multivariable logistic regression was used to determine associations. There were 372 (13%) patients with large ICH volume (>30 mL), which was associated with nonresiding in China, nondiabetic status, severe neurological deficit (National Institutes of Health stroke scale [NIHSS] score ≥ 15), lobar location, intraventricular hemorrhage extension, raised leucocyte count, and hyponatremia. Significant predictors of those patients who underwent surgery (226 of 3233 patients overall; 83 of 372 patients with large ICH) were younger age, severe neurological deficit (lower Glasgow coma scale score, and NIHSS score ≥ 15), baseline ICH volume > 30 mL, and intraventricular hemorrhage. Early identification of severe ICH, based on age and clinical and imaging parameters, may facilitate neurosurgery and intensive monitoring of patients. Copyright © 2017 by the Congress of Neurological Surgeons

Variable Operative Experience in Hand Surgery for Plastic Surgery Residents.

PubMed

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

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

Spatial beam shaping for lowering the threshold energy for femtosecond laser pulse photodisruption

NASA Astrophysics Data System (ADS)

Hansen, Anja; Ripken, Tammo; Heisterkamp, Alexander

2011-10-01

High precision femtosecond laser surgery is achieved by focusing femtosecond (fs) laser pulses in transparent tissues to create an optical breakdown leading to tissue dissection through photodisruption. For moving applications in ophthalmology from corneal or lental applications in the anterior eye to vitreal or retinal surgery in the posterior eye the applied pulse energy needs to be minimized in order to avoid harm to the retina. However, the aberrations of the anterior eye elements cause a distortion of the wave front and consequently an increase in size of the irradiated area and a decrease in photon density in the focal volume. Therefore, higher pulse energy is required to still surpass the threshold irradiance. In this work, aberrations in an eye model consisting of a plano-convex lens for focusing and 2-hydroxyethylmethacrylate (HEMA) in a water cuvette as eye tissue were corrected with a deformable mirror in combination with a Hartmann-Shack-sensor. The influence of an adaptive optics aberration correction on the pulse energy required for photodisruption was investigated. A reduction of the threshold energy was shown in the aberration-corrected case and the spatial confinement raised the irradiance at constant pulse energy. As less energy is required for photodisruption when correcting for wave front aberrations the potential risk of peripheral damage is reduced, especially for the retina during laser surgery in the posterior eye segment. This offers new possibilities for high precision fs-laser surgery in the treatment of several vitreal and retinal pathologies.

Multi-slice computed tomography-assisted endoscopic transsphenoidal surgery for pituitary macroadenoma: a comparison with conventional microscopic transsphenoidal surgery.

PubMed

Tosaka, Masahiko; Nagaki, Tomohito; Honda, Fumiaki; Takahashi, Katsumasa; Yoshimoto, Yuhei

2015-11-01

Intraoperative computed tomography (iCT) is a reliable method for the detection of residual tumour, but previous single-slice low-resolution computed tomography (CT) without coronal or sagittal reconstructions was not of adequate quality for clinical use. The present study evaluated the results of multi-slice iCT-assisted endoscopic transsphenoidal surgery for pituitary macroadenoma. This retrospective study included 30 consecutive patients with newly diagnosed or recurrent pituitary macroadenoma with supradiaphragmatic extension who underwent endoscopic transsphenoidal surgery using iCT (eTSS+iCT group), and control 30 consecutive patients who underwent conventional endoscope-assisted transsphenoidal surgery (cTSS group). The tumour volume was calculated by multiplying the tumour area by the slice thickness. Visual acuity and visual field were estimated by the visual impairment score (VIS). The resection extent, (preoperative tumour volume - postoperative residual tumour volume)/preoperative tumour volume, was 98.9% (median) in the eTSS+iCT group and 91.7% in the cTSS group, and had significant difference between the groups (P = 0.04). Greater than 95 and >90% removal rates were significantly higher in the eTSS+iCT group than in the cTSS group (P = 0.02 and P = 0.001, respectively). However, improvement in VIS showed no significant difference between the groups. The rate of complications also showed no significant difference. Multi-slice iCT-assisted endoscopic transsphenoidal surgery may improve the resection extent of pituitary macroadenoma. Multi-slice iCT may have advantages over intraoperative magnetic resonance imaging in less expensive, short acquisition time, and that special protection against magnetic fields is not needed.

Effect of the full implementation of the European Working Time Directive on operative training in adult cardiac surgery.

PubMed

Mahesh, Balakrishnan; Sharples, Linda; Codispoti, Massimiliano

2014-01-01

Surgical specialties rely on practice and apprenticeship to acquire technical skills. In 2009, the final reduction in working hours to 48 per week, in accordance with the European Working Time Directive (EWTD), has also led to an expansion in the number of trainees. We examined the effect of these changes on operative training in a single high-volume [>1500 procedures/year] adult cardiac surgical center. Setting: A single high-volume [>1500 procedures/year] adult cardiac surgical center. Design: Consecutive data were prospectively collected into a database and retrospectively analyzed. Procedures and Main Outcome Measures: Between January 2006 and August 2010, 6688 consecutive adult cardiac surgical procedures were analyzed. The proportion of cases offered for surgical training were compared for 2 non-overlapping consecutive time periods: 4504 procedures were performed before the final implementation of the EWTD (Phase 1: January 2006-December 2008) and 2184 procedures after the final implementation of the EWTD (Phase 2: January 2009-August 2010). Other predictors of training considered in the analysis were grade of trainee, logistic European system for cardiac operative risk evaluation (EuroSCORE), type of surgical procedure, weekend or late procedure, and consultant. Logistic regression analysis was used to determine the predictors of training cases (procedure performed by trainee) and to evaluate the effect of the EWTD on operative surgical training after correcting for confounding factors. Proportion of training cases rose from 34.6% (1558/4504) during Phase 1 to 43.6% (953/2184) in Phase 2 (p < 0.0001), despite higher mean logistic EuroSCORE [4.29 (6.8) during Phase 1 vs 4.95 (7.2) during Phase 2, p < 0.0001] and higher proportion of cases performed out of hours [153 (3.4) during Phase 1 vs 116 (5.3) during Phase 2, p < 0.0001]. During Phase 1, senior trainees (last 2 years of training) performed 803 (17.8%) procedures, whereas other trainees (first 4 years of training) performed 755(16.8%) cases. During Phase 2, senior trainees performed 763 (34.9%) procedures, whereas other trainees performed 190 (8.7%) cases (p < 0.0001). Independent positive predictors of training cases emerging from the multivariable logistic regression model included consultant in charge, final EWTD, and senior trainees. Independent negative predictors of training cases included logistic EuroSCORE, out-of-hours' procedures, and surgery other than coronary artery bypass grafts. Implementation of the final phase of EWTD has not decreased training in a high-volume center. The positive adjustment of trainers' attitudes and efforts to match trainees' needs allow maintenance of adequate training, despite reduction in working hours and increasing patients' risk profile. Copyright © 2014 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Aortic valve bypass surgery in severe aortic valve stenosis: Insights from cardiac and brain magnetic resonance imaging.

PubMed

Mantini, Cesare; Caulo, Massimo; Marinelli, Daniele; Chiacchiaretta, Piero; Tartaro, Armando; Cotroneo, Antonio Raffaele; Di Giammarco, Gabriele

2018-04-13

To investigate and describe the distribution of aortic and cerebral blood flow (CBF) in patients with severe valvular aortic stenosis (AS) before and after aortic valve bypass (AVB) surgery. We enrolled 10 consecutive patients who underwent AVB surgery for severe AS. Cardiovascular magnetic resonance imaging (CMR) and brain magnetic resonance imaging were performed as baseline before surgery and twice after surgery. Quantitative flow measurements were obtained using 1.5-T magnetic resonance imaging (MRI) scanner phase-contrast images of the ascending aorta, descending thoracic aorta (3 cm proximally and distally from the conduit-to-aorta anastomosis), and ventricular outflow portion of the conduit. The evaluation of CBF was performed using 3.0-T MRI scanner arterial spin labeling (ASL) through sequences acquired at the gray matter, dorsal default-mode network, and sensorimotor levels. Conduit flow, expressed as the percentage of total antegrade flow through the conduit, was 63.5 ± 8% and 67.8 ± 7% on early and mid-term postoperative CMR, respectively (P < .05). Retrograde perfusion from the level of the conduit insertion in the descending thoracic aorta toward the aortic arch accounted for 6.9% of total cardiac output and 11% of total conduit flow. We did not observe any significant reduction in left ventricular stroke volume at postoperative evaluation compared with preoperative evaluation (P = .435). No differences were observed between preoperative and postoperative CBF at the gray matter, dorsal default-mode network, and sensorimotor levels (P = .394). After AVB surgery in patients with severe AS, cardiac output is split between the native left ventricular outflow tract and the apico-aortic bypass, with two-thirds of the total antegrade flow passing through the latter and one-third passing through the former. In our experience, CBF assessment confirms that the flow redistribution does not jeopardize cerebral blood supply. Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Ex vivo hydrodynamics after central and paracommissural edge-to-edge technique: A further step toward transcatheter tricuspid repair?

PubMed

Stock, Sina; Bohm, Heidemarie; Scharfschwerdt, Michael; Richardt, Doreen; Meyer-Saraei, Roza; Tsvelodub, Stanislav; Sievers, Hans-Hinrich

2018-03-01

Transcatheter approaches in heart valve disease became tremendously important and are currently established in the aortic position, but transcatheter tricuspid repair is still in its beginning and remains challenging. Replicating the surgical edge-to-edge technique, for example, with the MitraClip System (Abbott Vascular, Santa Clara, Calif), represents a promising option and has been reported successfully in small numbers of cases. However, up to now, few data considering the edge-to-edge technique as a transcatheter approach are available. This study aims to determine the ex vivo hydrodynamics after the central and paracommissural edge-to-edge technique in different pathologies. Because of basal or apical dislocation of papillary muscles, leaflet prolapse or tethering was simulated in porcine tricuspid valves mounted on a flexible holding device. Central and paracommissural edge-to-edge techniques were evaluated successively in these pathologies. Regurgitant volume and mean transvalvular gradient were determined in a pulse duplicator. In this ex vivo model, the isolated edge-to-edge technique reduced tricuspid regurgitation. In the prolapse model, regurgitant volume decreased significantly after central edge-to-edge technique (from 49.4 ± 13.6 mL/stroke to 39.3 ± 14.1 mL/stroke). In the tethering model, both the central and the paracommissural edge-to-edge techniques led to a significant decrease (from 48.7 ± 13.9 to 43.6 ± 15.6 and to 41.1 ± 13.8 mL/stroke). In all cases, the reduction of regurgitant volume was achieved at the cost of significantly increased mean transvalvular gradient. This study provides a reduction of tricuspid regurgitation after the edge-to-edge technique in the specific experimental setup. Whether this reduction is sufficient to treat tricuspid regurgitation successfully in clinical practice remains to be established. Transcatheter approaches need to be evaluated further, probably with regard to concomitant annuloplasty for higher reduction of tricuspid regurgitation. Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Cosmetic breast surgery - discharge

MedlinePlus

... Higdon KK. Reduction mammaplasty. In: Neligan PC, ed. Plastic Surgery . 3rd ed. Philadelphia, PA: Elsevier Saunders; 2013: ... Gabriel A. Breast augmentation. In: Neligan PC, ed. Plastic Surgery . 3rd ed. Philadelphia, PA: Elsevier Saunders; 2013: ...

[Application of temporomandibular joint dics reduction in the operation of condylar sagittal fracture].

PubMed

Wenli, Zeng; Wuchao, Zhou; Jingkun, Zhang; Yisen, Shao; Weihong, Xi

2017-10-01

To explore the selection of temporomandibular joint (TMJ) disc reduction and fixation methods in condylar sagittal fracture surgery. A total of 36 patients with condylar fractures were chosen. The follow-up period was more 6 months. All 36 cases of condylar sagittal fracture were fixed with long screw. In the operation, the displaced joint disc was repositioned and fixed. The fixed method included direct suture (22 cases) and anchorage (14 cases). Clinical followups were performed before surgery and 1 month, 3 months, 6 months and 1 year after surgery. Clinicians recorded data related to the Fricton craniomandibular index (CMI) and evaluated the postoperative joint function during followup before surgery and 6 months after surgery. In both groups, function of TMJ significantly improved after surgery. The CMI decreased from 0.213±0.162 and 0.273±0.154 to 0.059±0.072 and 0.064±0.068 (P<0.05), respectively. No statistical difference was observed between the two groups in palpation index (PI), dysfunction index (DI) and CMI (P>0.05) before or after surgery. Both methods could effectively improve the dysfunction of the TMJ caused by trauma. The selection of joint disc reduction and fixation methods is based on the displacement and damage degree of the joint disc.

Bariatric surgery and long-term nutritional issues

PubMed Central

Lupoli, Roberta; Lembo, Erminia; Saldalamacchia, Gennaro; Avola, Claudia Kesia; Angrisani, Luigi; Capaldo, Brunella

2017-01-01

Bariatric surgery is recognized as a highly effective therapy for obesity since it accomplishes sustained weight loss, reduction of obesity-related comorbidities and mortality, and improvement of quality of life. Overall, bariatric surgery is associated with a 42% reduction of the cardiovascular risk and 30% reduction of all-cause mortality. This review focuses on some nutritional consequences that can occur in bariatric patients that could potentially hinder the clinical benefits of this therapeutic option. All bariatric procedures, to variable degrees, alter the anatomy and physiology of the gastrointestinal tract; this alteration makes these patients more susceptible to developing nutritional complications, namely, deficiencies of macro- and micro-nutrients, which could lead to disabling diseases such as anemia, osteoporosis, protein malnutrition. Of note is the evidence that most obese patients present a number of nutritional deficits already prior to surgery, the most important being vitamin D and iron deficiencies. This finding prompts the need for a complete nutritional assessment and, eventually, an adequate correction of pre-existing deficits before surgery. Another critical issue that follows bariatric surgery is post-operative weight regain, which is commonly associated with the relapse of obesity-related co-morbidities. Nu-tritional complications associated with bariatric surgery can be prevented by life-long nutritional monitoring with the administration of multi-vitamins and mineral supplements according to the patient’s needs. PMID:29204255

Comparison of Flow and Volume Incentive Spirometry on Pulmonary Function and Exercise Tolerance in Open Abdominal Surgery: A Randomized Clinical Trial.

PubMed

Kumar, Amaravadi Sampath; Alaparthi, Gopala Krishna; Augustine, Alfred Joseph; Pazhyaottayil, Zulfeequer Chundaanveetil; Ramakrishna, Anand; Krishnakumar, Shyam Krishnan

2016-01-01

Surgical procedures in abdominal area lead to changes in pulmonary function, respiratory mechanics and impaired physical capacity leading to postoperative pulmonary complications, which can affect up to 80% of upper abdominal surgery. To evaluate the effects of flow and volume incentive spirometry on pulmonary function and exercise tolerance in patients undergoing open abdominal surgery. A randomized clinical trial was conducted in a hospital of Mangalore city in Southern India. Thirty-seven males and thirteen females who were undergoing abdominal surgeries were included and allocated into flow and volume incentive spirometry groups by block randomization. All subjects underwent evaluations of pulmonary function with measurement of Forced Vital Capacity (FVC), Forced Expiratory Volume in the first second (FEV1), Peak Expiratory Flow (PEF). Preoperative and postoperative measurements were taken up to day 5 for both groups. Exercise tolerance measured by Six- Minute Walk Test during preoperative period and measured again at the time of discharge for both groups. Pulmonary function was analysed by post-hoc analysis and carried out using Bonferroni's 't'-test. Exercise tolerance was analysed by Paired 'T'-test. Pulmonary function (FVC, FEV1, and PEFR) was found to be significantly decreased in 1(st), 2(nd) and 3(rd) postoperative day when compared with preoperative day. On 4(th) and 5(th) postoperative day the pulmonary function (FVC, FEV1, and PEFR) was found to be better preserved in both flow and volume incentive spirometry groups. The Six-Minute Walk Test showed a statistically significant improvement in pulmonary function on the day of discharge than in the preoperative period. In terms of distance covered, the volume- incentive spirometry group showed a greater statistically significant improvement from the preoperative period to the time of discharge than was exhibited by the flow incentive spirometry group. Flow and volume incentive spirometry can be safely recommended to patients undergoing open abdominal surgery as there have been no adverse events recorded. Also, these led to a demonstrable improvement in pulmonary function and exercise tolerance.

Comparison of Flow and Volume Incentive Spirometry on Pulmonary Function and Exercise Tolerance in Open Abdominal Surgery: A Randomized Clinical Trial

PubMed Central

Kumar, Amaravadi Sampath; Augustine, Alfred Joseph; Pazhyaottayil, Zulfeequer Chundaanveetil; Ramakrishna, Anand; Krishnakumar, Shyam Krishnan

2016-01-01

Introduction Surgical procedures in abdominal area lead to changes in pulmonary function, respiratory mechanics and impaired physical capacity leading to postoperative pulmonary complications, which can affect up to 80% of upper abdominal surgery. Aim To evaluate the effects of flow and volume incentive spirometry on pulmonary function and exercise tolerance in patients undergoing open abdominal surgery. Materials and Methods A randomized clinical trial was conducted in a hospital of Mangalore city in Southern India. Thirty-seven males and thirteen females who were undergoing abdominal surgeries were included and allocated into flow and volume incentive spirometry groups by block randomization. All subjects underwent evaluations of pulmonary function with measurement of Forced Vital Capacity (FVC), Forced Expiratory Volume in the first second (FEV1), Peak Expiratory Flow (PEF). Preoperative and postoperative measurements were taken up to day 5 for both groups. Exercise tolerance measured by Six- Minute Walk Test during preoperative period and measured again at the time of discharge for both groups. Pulmonary function was analysed by post-hoc analysis and carried out using Bonferroni’s ‘t’-test. Exercise tolerance was analysed by Paired ‘T’-test. Results Pulmonary function (FVC, FEV1, and PEFR) was found to be significantly decreased in 1st, 2nd and 3rd postoperative day when compared with preoperative day. On 4th and 5th postoperative day the pulmonary function (FVC, FEV1, and PEFR) was found to be better preserved in both flow and volume incentive spirometry groups. The Six-Minute Walk Test showed a statistically significant improvement in pulmonary function on the day of discharge than in the preoperative period. In terms of distance covered, the volume- incentive spirometry group showed a greater statistically significant improvement from the preoperative period to the time of discharge than was exhibited by the flow incentive spirometry group. Conclusion Flow and volume incentive spirometry can be safely recommended to patients undergoing open abdominal surgery as there have been no adverse events recorded. Also, these led to a demonstrable improvement in pulmonary function and exercise tolerance. PMID:26894090

Changes in lung volumes and gas trapping in patients with large hiatal hernia.

PubMed

Naoum, Christopher; Kritharides, Leonard; Ing, Alvin; Falk, Gregory L; Yiannikas, John

2017-03-01

Studies assessing hiatal hernia (HH)-related effects on lung volumes derived by body plethysmography are limited. We aimed to evaluate the effect of hernia size on lung volumes (including assessment by body plethysmography) and the relationship to functional capacity, as well as the impact of corrective surgery. Seventy-three patients (70 ± 10 years; 54 female) with large HH [mean ± standard deviation, intra-thoracic stomach (ITS) (%): 63 ± 20%; type III in 65/73] had respiratory function data (spirometry, 73/73; body plethysmography, 64/73; diffusing capacity, 71/73) and underwent HH surgery. Respiratory function was analysed in relation to hernia size (groups I, II and III: ≤50, 50%-75% and ≥75% ITS, respectively) and functional capacity. Post-operative changes were quantified in a subgroup. Total lung capacity (TLC) and vital capacity (VC) correlated inversely with hernia size (TLC: 97 ± 11%, 96 ± 13%, 88 ± 10% predicted in groups I, II and III, respectively, P = 0.01; VC: 110 ± 17%, 111 ± 14%, 98 ± 14% predicted, P = 0.02); however, mean values were normal and only 14% had abnormal lung volumes. Surgery increased TLC (93 ± 11% vs 97 ± 10% predicted) and VC (105 ± 15% vs 116 ± 18%), and decreased residual volume/total lung capacity (RV/TLC) ratio (39 ± 7% vs 37 ± 6%) (P < 0.01 for all). Respiratory changes were modest relative to the marked functional class improvement. Among parameters that improved following HH surgery, decreased TLC and forced expiratory volume in 1 s and increased RV/TLC ratio correlated with poorer functional class pre-operatively. Increasing HH size correlates with reduced TLC and VC. Surgery improves lung volumes and gas trapping; however, the changes are mild and within the normal range. © 2015 John Wiley & Sons Ltd.

A comparison of aspiration, antazoline sclerotherapy and surgery in the treatment of hydrocele.

PubMed

Roosen, J U; Larsen, T; Iversen, E; Berg, J B

1991-10-01

Of 98 hydroceles (mean volume 125 ml) in a consecutive series of 92 patients, treated initially by aspiration, 14% (mean volume 70 ml) were cured. The 76 recurring hydroceles (mean volume 146 ml) were then randomised to either antazoline sclerotherapy on an out-patient basis or surgery. Cure rates were 89 and 100%, respectively, at follow-up 6 months later. Operated patients were admitted for a mean duration of 2.5 days. The results indicated that aspiration alone was inadequate, and sclerotherapy is advocated as the first choice of treatment for hydrocele.

Postoperative Pulmonary Atelectasis and Collapse, and its Prophylaxis with Intravenous Bicarbonate

PubMed Central

O'Driscoll, M.

1970-01-01

Of 181 patients undergoing major abdominal surgery 116 developed chest complications associated with a metabolic acidosis, low Pco2, depressed tidal volume, increased respiratory rate, but no increase in minute volume. In a matched group of 116 patients given intravenous bicarbonate postoperatively only 15 developed chest complications. This suggests that respiratory physiological dead space decreases in patients with pulmonary collapse and atelectasis following surgery. Acidotic respiration proved inefficient in the postoperative period, and intravenous bicarbonate had a very pronounced effect on the tidal and minute volumes of acidotic patients with pulmonary collapse and atelectasis. PMID:5470431

Magnetic resonance imaging characteristics and the prediction of outcome of vestibular schwannomas following Gamma Knife radiosurgery.

PubMed

Wu, Chih-Chun; Guo, Wan-Yuo; Chung, Wen-Yuh; Wu, Hisu-Mei; Lin, Chung-Jung; Lee, Cheng-Chia; Liu, Kang-Du; Yang, Huai-Che

2017-12-01

OBJECTIVE Gamma Knife surgery (GKS) is a promising treatment modality for patients with vestibular schwannomas (VSs), but a small percentage of patients have persistent postradiosurgical tumor growth. The aim of this study was to determine the clinical and quantitative MRI features of VS as predictors of long-term tumor control after GKS. METHODS The authors performed a retrospective study of all patients with VS treated with GKS using the Leksell Gamma Knife Unit between 2005 and 2013 at their institution. A total of 187 patients who had a minimum of 24 months of clinical and radiological assessment after radiosurgery were included in this study. Those who underwent a craniotomy with tumor removal before and after GKS were excluded. Study patients comprised 85 (45.5%) males and 102 (54.5%) females, with a median age of 52.2 years (range 20.4-82.3 years). Tumor volumes, enhancing patterns, and apparent diffusion coefficient (ADC) values were measured by region of interest (ROI) analysis of the whole tumor by serial MRI before and after GKS. RESULTS The median follow-up period was 60.8 months (range 24-128.9 months), and the median treated tumor volume was 3.54 cm 3 (0.1-16.2 cm 3 ). At last follow-up, imaging studies indicated that 150 tumors (80.2%) showed decreased tumor volume, 20 (10.7%) had stabilized, and 17 (9.1%) continued to grow following radiosurgery. The postradiosurgical outcome was not significantly correlated with pretreatment volumes or postradiosurgical enhancing patterns. Tumors that showed regression within the initial 12 months following radiosurgery were more likely to have a larger volume reduction ratio at last follow-up than those that did not (volume reduction ratio 55% vs 23.6%, respectively; p < 0.001). Compared with solid VSs, cystic VSs were more likely to regress or stabilize in the initial postradiosurgical 6-12-month period and during extended follow-up. Cystic VSs exhibited a greater volume reduction ratio at last follow-up (cystic vs solid: 67.6% ± 24.1% vs 31.8% ± 51.9%; p < 0.001). The mean preradiosurgical maximum ADC (ADC max ) values of all VSs were significantly higher for those with tumor regression or stabilization at last follow-up compared with those with progression (2.391 vs 1.826 × 10 -3 mm 2 /sec; p = 0.010). CONCLUSIONS Loss of central enhancement after radiosurgery was a common phenomenon, but it did not correlate with tumor volume outcome. Preradiosurgical MRI features including cystic components and ADC max values can be helpful as predictors of treatment outcome.

Impact of Medicare payment reductions on access to surgical services.

PubMed Central

Mitchell, J B; Cromwell, J

1995-01-01

OBJECTIVE. This study evaluates the impact of surgical fee reductions under Medicare on the utilization of surgical services. DATA SOURCES. Medicare physician claims data were obtained from 11 states for a five-year time period (1985-1989). STUDY DESIGN. Under OBRA-87, Medicare reduced payments for 11 surgical procedures. A fixed effects regression method was used to determine the impact of these payment reductions on access to care for potentially vulnerable Medicare beneficiaries: joint Medicaid-eligibles, blacks, and the very old. DATA COLLECTION/EXTRACTION METHODS. Medicare claims and enrollment data were used to construct a cross-section time-series of population-based surgical rates from 1985 through 1989. PRINCIPAL FINDINGS. Reductions in surgical fees led to small but significant increases in use for three procedures, small decreases in use for two procedures, and no impact on the remaining six procedures. There was little evidence that access to surgery was impaired for potentially vulnerable enrollees; in fact, declining fees often led to greater rates of increases for some subgroups. CONCLUSIONS. Our results suggest that volume responses by surgeons to payment changes under the Medicare Fee Schedule may be smaller than HCFA's original estimates. Nevertheless, both access and quality of care should continue to be closely monitored. PMID:8537224

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

PubMed Central

Chen, Jenny T.; Nayar, Harry S.

2017-01-01

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

Validation of the breast evaluation questionnaire for breast hypertrophy and breast reduction.

PubMed

Lewin, Richard; Elander, Anna; Lundberg, Jonas; Hansson, Emma; Thorarinsson, Andri; Claudelin, Malin; Bladh, Helena; Lidén, Mattias

2018-06-13

There is a lack of published, validated questionnaires for evaluating psychosocial morbidity in patients with breast hypertrophy undergoing breast reduction surgery. To validate the breast evaluation questionnaire (BEQ), originally developed for the assessment of breast augmentation patients, for the assessment of psychosocial morbidity in patients with breast hypertrophy undergoing breast reduction surgery. Validation study Subjects: Women with macromastia Methods: The validation of the BEQ, adapted to breast reduction, was performed in several steps. Content validity, reliability, construct validity and responsiveness were assessed. The original version was adjusted according to the results for content validity and resulted in item reduction and a modified BEQ (mBEQ) that was then assessed for reliability, construct validity and responsiveness. Internal and external validation was performed for the modified BEQ. Convergent validity was tested against Breast-Q (reduction) and discriminate validity was tested against the SF-36. Known-groups validation revealed significant differences between the normal population and patients undergoing breast reduction surgery. The BEQ showed good reliability by test-re-test analysis and high responsiveness. The modified BEQ may be reliable, valid and responsive instrument for assessing women who undergo breast reduction.

Comparison of esophageal Doppler and plethysmographic variability index to guide intraoperative fluid therapy for low-risk patients undergoing colorectal surgery.

PubMed

Warnakulasuriya, Samantha R; Davies, Simon J; Wilson, R Jonathan T; Yates, David R A

2016-11-01

This study aims to investigate if there is equivalence in volumes of fluid administered when intravenous fluid therapy is guided by Pleth Variability Index (PVI) compared to the established technology of esophageal Doppler in low-risk patients undergoing major colorectal surgery. Randomized controlled trial. Operating room. Forty low-risk patients undergoing elective colorectal surgery. Patients were monitored by esophageal Doppler and PVI probes and were randomized to have fluid therapy directed by using one of these technologies, with 250 mL boluses of colloid to maintain a maximal stroke volume, or a PVI of less than 14%. Absolute volumes of fluid volumes given intraoperatively were measured as were 24 hours fluid volumes. Perioperative measurements of lactate and base excess were recorded as were postoperative complications. There was no significant difference between PVI and esophageal Doppler groups in mean total fluid administered (1286 vs 1520 mL, P=.300) or mean intraoperative fluid balance (+839 v+1145 mL, P=.150). PVI offers an entirely non-invasive alternative for goal-directed fluid therapy in this group of patients. Copyright © 2016 Elsevier Inc. All rights reserved.

Acute Hyperglycemia Does Not Affect Brain Swelling or Infarction Volume After Middle Cerebral Artery Occlusion in Rats.

PubMed

McBride, Devin W; Matei, Nathanael; Câmara, Justin R; Louis, Jean-Sébastien; Oudin, Guillaume; Walker, Corentin; Adam, Loic; Liang, Xiping; Hu, Qin; Tang, Jiping; Zhang, John H

2016-01-01

Stroke disproportionally affects diabetic and hyperglycemic patients with increased incidence and is associated with higher morbidity and mortality due to brain swelling. In this study, the intraluminal suture middle cerebral artery occlusion (MCAO) model was used to examine the effects of blood glucose on brain swelling and infarct volume in acutely hyperglycemic rats and normo-glycemic controls. Fifty-four rats were distributed into normo-glycemic sham surgery, hyperglycemic sham surgery, normo-glycemic MCAO, and hyperglycemic MCAO. To induce hyperglycemia, 15 min before MCAO surgery, animals were injected with 50 % dextrose. Animals were subjected to 90 min of MCAO and sacrificed 24 h after reperfusion for hemispheric brain swelling and infarct volume calculations using standard equations. While normo-glycemic and hyperglycemic animals after MCAO presented with significantly higher brain swelling and larger infarcts than their respective controls, no statistical difference was observed for either brain swelling or infarct volume between normo-glycemic shams and hyperglycemic shams or normo-glycemic MCAO animals and hyperglycemic MCAO animals. The findings of this study suggest that blood glucose does not have any significant effect on hemispheric brain swelling or infarct volume after MCAO in rats.

Ultrasound-guided breast-sparing surgery to improve cosmetic outcomes and quality of life. A prospective multicentre randomised controlled clinical trial comparing ultrasound-guided surgery to traditional palpation-guided surgery (COBALT trial)

PubMed Central

2011-01-01

Background Breast-conserving surgery for breast cancer was developed as a method to preserve healthy breast tissue, thereby improving cosmetic outcomes. Thus far, the primary aim of breast-conserving surgery has been the achievement of tumour-free resection margins and prevention of local recurrence, whereas the cosmetic outcome has been considered less important. Large studies have reported poor cosmetic outcomes in 20-40% of patients after breast-conserving surgery, with the volume of the resected breast tissue being the major determinant. There is clear evidence for the efficacy of ultrasonography in the resection of nonpalpable tumours. Surgical resection of palpable breast cancer is performed with guidance by intra-operative palpation. These palpation-guided excisions often result in an unnecessarily wide resection of adjacent healthy breast tissue, while the rate of tumour-involved resection margins is still high. It is hypothesised that the use of intra-operative ultrasonography in the excision of palpable breast cancer will improve the ability to spare healthy breast tissue while maintaining or even improving the oncological margin status. The aim of this study is to compare ultrasound-guided surgery for palpable tumours with the standard palpation-guided surgery in terms of the extent of healthy breast tissue resection, the percentage of tumour-free margins, cosmetic outcomes and quality of life. Methods/design In this prospective multicentre randomised controlled clinical trial, 120 women who have been diagnosed with palpable early-stage (T1-2N0-1) primary invasive breast cancer and deemed suitable for breast-conserving surgery will be randomised between ultrasound-guided surgery and palpation-guided surgery. With this sample size, an expected 20% reduction of resected breast tissue and an 18% difference in tumour-free margins can be detected with a power of 80%. Secondary endpoints include cosmetic outcomes and quality of life. The rationale, study design and planned analyses are described. Conclusion The COBALT trial is a prospective, multicentre, randomised controlled study to assess the efficacy of ultrasound-guided breast-conserving surgery in patients with palpable early-stage primary invasive breast cancer in terms of the sparing of breast tissue, oncological margin status, cosmetic outcomes and quality of life. Trial Registration Number Netherlands Trial Register (NTR): NTR2579 PMID:21410949

Evaluation of supply-side initiatives to improve access to coronary bypass surgery.

PubMed

Sobolev, Boris G; Fradet, Guy; Kuramoto, Lisa; Sobolyeva, Rita; Rogula, Basia; Levy, Adrian R

2012-09-11

Guided by the evidence that delaying coronary revascularization may lead to symptom worsening and poorer clinical outcomes, expansion in cardiac surgery capacity has been recommended in Canada. Provincial governments started providing one-time and recurring increases in budgets for additional open heart surgeries to reduce waiting times. We sought to determine whether the year of decision to proceed with non-emergency coronary bypass surgery had an effect on time to surgery. Using records from a population-based registry, we studied times between decision to operate and the procedure itself. We estimated changes in the length of time that patients had to wait for non-emergency operation over 14 calendar periods that included several years when supplementary funding was available. We studied waiting times separately for patients who access surgery through a wait list and through direct admission. During two periods when supplementary funding was available, 1998-1999 and 2004-2005, the weekly rate of undergoing surgery from a wait list was, respectively, 50% and 90% higher than in 1996-1997, the period with the longest waiting times. We also observed a reduction in the difference between 90th and 50th percentiles of the waiting-time distributions. Forty percent of patients in the 1998, 1999, 2004 and 2005 cohorts (years when supplementary funding was provided) underwent surgery within 16 to 20 weeks following the median waiting time, while it took between 27 and 37 weeks for the cohorts registered in the years when supplementary funding was not available. Times between decision and surgery were shorter for direct admissions than for wait-listed patients. Among patients who were directly admitted to hospital, time between decision and surgery was longest in 1992-1993 and then has been steadily decreasing through the late nineties. The rate of surgery among these patients was the highest in 1998-1999, and has not changed afterwards, even for years when supplementary funding was provided. Waiting times for non-emergency coronary bypass surgery shortened after supplementary funding was granted to increase volume of cardiac surgical care in a health system with publicly-funded universal coverage for the procedure. The effect of the supplementary funding was not uniform for patients that access the services through wait lists and through direct admission.

Bloodless surgery in a pediatric Jehovah's Witness.

PubMed

Allen, Jerry; Berrios, Lindsay; Solimine, Mike; Knott-Craig, Christopher J

2013-12-01

Pediatric cardiac surgery in Jehovah's Witness patients who refuse the use of blood products remains a challenge because of the extreme hemodilution caused by priming the circuit and subsequent cardiopulmonary bypass. We report our successful strategy for reducing the prime volume for a 2-year-old Jehovah's Witness patient who required open heart surgery. We modified our conventional bypass circuit requirements for this size child by incorporating a lower prime oxygenator and reducing the size of the venous line and circuit, which decreased the circuit prime volume. We managed to reduce our initial sanguineous prime volume from 315 to 210 mL. The prime was further reduced to 160 mL by minimizing circuit length at the field and with venous prime sequestration prebypass. The postbypass hematocrit was 31%. Bloodless pediatric cardiac surgery in Jehovah's Witness patients can be performed safely. Incorporating a lower prime oxygenator into a revised circuit alleviated the need for blood transfusion and allowed us to achieve our calculated flow rate of 2.6 L/min/m2 while maintaining a hematocrit of 31%.

The willingness to pay for wait reduction: the disutility of queues for cataract surgery in Canada, Denmark, and Spain.

PubMed

Bishai, D M; Lang, H C

2000-03-01

We estimate demand curves for a one month reduction in waiting time for cataract surgery based on survey data collected in 1992 in Manitoba, Barcelona, and Denmark. Patients answered, "Would you be willing to pay [Bid, B] to reduce your waiting time for cataract surgery to less than one month?" Controlling for SES and visual status, Barcelonan patients have greater WTP for shortened waiting time than the Danes and Manitobans. We estimate the value (in 1992 $) of lost consumer surplus due to the cataract surgery queue at $128 per patient in Manitoba, $160 in Denmark, and $243 in Barcelona.

GSTM1 Gene Expression Correlates to Leiomyoma Volume Regression in Response to Mifepristone Treatment

PubMed Central

Engman, Mikael; Varghese, Suby; Lagerstedt Robinson, Kristina; Malmgren, Helena; Hammarsjö, Anna; Byström, Birgitta; L Lalitkumar, Parameswaran Grace; Gemzell-Danielsson, Kristina

2013-01-01

Progesterone receptor modulators, such as mifepristone are useful and well tolerated in reducing leiomyoma volume although with large individual variation. The objective of this study was to investigate the molecular basis for the observed leiomyoma volume reduction, in response to mifepristone treatment and explore a possible molecular marker for the selective usage of mifepristone in leiomyoma patients. Premenopausal women (N = 14) were treated with mifepristone 50 mg, every other day for 12 weeks prior to surgery. Women were arbitrarily sub-grouped as good (N = 4), poor (N = 4) responders to treatment or intermediate respondents (N = 3). Total RNA was extracted from leiomyoma tissue, after surgical removal of the tumour and the differential expression of genes were analysed by microarray. The results were analysed using Ingenuity Pathway Analysis software. The glutathione pathway was the most significantly altered canonical pathway in which the glutathione-s transferase mu 1 (GSTM1) gene was significantly over expressed (+8.03 folds) among the good responders compared to non responders. This was further confirmed by Real time PCR (p = 0.024). Correlation of immunoreactive scores (IRS) for GSTM1 accumulation in leiomyoma tissue was seen with base line volume change of leiomyoma R = −0.8 (p = 0.011). Furthermore the accumulation of protein GSTM1 analysed by Western Blot correlated significantly with the percentual leiomyoma volume change R = −0.82 (p = 0.004). Deletion of the GSTM1 gene in leiomyoma biopsies was found in 50% of the mifepristone treated cases, with lower presence of the GSTM1 protein. The findings support a significant role for GSTM1 in leiomyoma volume reduction induced by mifepristone and explain the observed individual variation in this response. Furthermore the finding could be useful to further explore GSTM1 as a biomarker for tailoring medical treatment of uterine leiomyomas for optimizing the response to treatment. Clinical Trials identifier www.clinicaltrials.gov: NCT00579475, Protocol date: November 2004. http://clinicaltrials.gov/ct2/show/NCT00579475 PMID:24324590

The Effect of Bariatric Surgery on Diabetic Retinopathy: Good, Bad, or Both?

PubMed

Gorman, Dora M; le Roux, Carel W; Docherty, Neil G

2016-10-01

Bariatric surgery, initially intended as a weight-loss procedure, is superior to standard lifestyle intervention and pharmacological therapy for type 2 diabetes in obese individuals. Intensive medical management of hyperglycemia is associated with improved microvascular outcomes. Whether or not the reduction in hyperglycemia observed after bariatric surgery translates to improved microvascular outcomes is yet to be determined. There is substantial heterogeneity in the data relating to the impact of bariatric surgery on diabetic retinopathy (DR), the most common microvascular complication of diabetes. This review aims to collate the recent data on retinal outcomes after bariatric surgery. This comprehensive evaluation revealed that the majority of DR cases remain stable after surgery. However, risk of progression of pre-existing DR and the development of new DR is not eliminated by surgery. Instances of regression of DR are also noted. Potential risk factors for deterioration include severity of DR at the time of surgery and the magnitude of glycated hemoglobin reduction. Concerns also exist over the detrimental effects of postprandial hypoglycemia after surgery. In vivo studies evaluating the chronology of DR development and the impact of bariatric surgery could provide clarity on the situation. For now, however, the effect of bariatric surgery on DR remains inconclusive.

Magnetic resonance-guided focused ultrasound surgery (MRgFUS) of uterine fibroids in Singapore.

PubMed

Han, Nian-Lin R; Ong, Chiou Li

2014-11-01

Uterine fibroids are the most common type of gynaecologic benign tumours, occurring in 25% to 50% of women during their reproductive lives. About half of the affected women have clinically significant symptoms, including abnormal bleeding, menstrual pain, frequent urination, constipation and abdominal distension. Magnetic resonance-guided focused ultrasound surgery (MRgFUS) has been used to treat patients with benign lesions and a variety of malignancies. The objective of this study is to evaluate symptom relief before and after MR-guided ultrasound ablation of fibroids. A total of 37 patients with symptomatic uterine fibroids were treated in this study. MRgFUS treatment led to a significant, time-dependent decrease in not only Symptom Severity Scores (SSS), but also the mean fibroid volume. The average reductions in volume were 41.6% and 52.6% at 6 months and 12 months respectively (P <0.05). The mean SSS of the 37 patients was 41.7 ± 2.8 before treatment whereas the average SSS was 26.9 ± 3.6, 20.7 ± 3.4, 18.5 ± 3.6, 16.5 ± 7.1, 9.8 ± 3.6 at 3 months, 6 months, 1 year, 2 years, and 3 to 4 years respectively. The decrease in scores was significant at all time points up to 3 to 4 years (P <0.05 and P <0.001). MRgFUS is a safe and effective non-invasive treatment for patients with symptomatic fibroids.

Long-term Effects of Large-volume Liposuction on Metabolic Risk Factors for Coronary Heart Disease

PubMed Central

Mohammed, B. Selma; Cohen, Samuel; Reeds, Dominic; Young, V. Leroy; Klein, Samuel

2009-01-01

Abdominal obesity is associated with metabolic risk factors for coronary heart disease (CHD). Although we previously found that using liposuction surgery to remove abdominal subcutaneous adipose tissue (SAT) did not result in metabolic benefits, it is possible that postoperative inflammation masked the beneficial effects. Therefore, this study provides a long-term evaluation of a cohort of subjects from our original study. Body composition and metabolic risk factors for CHD, including oral glucose tolerance, insulin resistance, plasma lipid profile, and blood pressure were evaluated in seven obese (39 ± 2 kg/m2) women before and at 10, 27, and 84–208 weeks after large-volume liposuction. Liposuction surgery removed 9.4 ± 1.8 kg of body fat (16 ± 2% of total fat mass; 6.1 ± 1.4 kg decrease in body weight), primarily from abdominal SAT; body composition and weight remained the same from 10 through 84–208 weeks. Metabolic endpoints (oral glucose tolerance, homeostasis model assessment of insulin resistance, blood pressure and plasma triglyceride (TG), high-density lipoprotein (HDL)-cholesterol, and low-density lipoprotein (LDL)-cholesterol concentrations) obtained at 10 through 208 weeks were not different from baseline and did not change over time. These data demonstrate that removal of a large amount of abdominal SAT by using liposuction does not improve CHD metabolic risk factors associated with abdominal obesity, despite a long-term reduction in body fat. PMID:18820648

Variability of Arthroscopy Case Volume in Orthopaedic Surgery Residency.

PubMed

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

2016-05-01

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

Analysis of National Trends in Hospital Acquired Conditions Following Major Urological Surgery Before and After Implementation of the Hospital Acquired Condition Reduction Program,,✰✰✰.

PubMed

Rude, Tope L; Donin, Nicholas M; Cohn, Matthew R; Meeks, William; Gulig, Scott; Patel, Samir N; Wysock, James S; Makarov, Danil V; Bjurlin, Marc A

2018-06-07

To define the rates of common Hospital Acquired Conditions (HACs) in patients undergoing major urological surgery over a period of time encompassing the implementation of the Hospital Acquired Condition Reduction program, and to evaluate whether implementation of the HAC reimbursement penalties in 2008 was associated with a change in the rate of HACs. Using American College of Surgeons National Surgical Quality Improvement Program (NSQIP) data, we determined rates of HACs in patients undergoing major inpatient urological surgery from 2005 to 2012. Rates were stratified by procedure type and approach (open vs. laparoscopic/robotic). Multivariable logistic regression was used to determine the association between year of surgery and HACs. We identified 39,257 patients undergoing major urological surgery, of whom 2300 (5.9%) had at least one hospital acquired condition. Urinary tract infection (UTI, 2.6%) was the most common, followed by surgical site infection (SSI, 2.5%) and venous thrombotic events (VTE, 0.7%). Multivariable logistic regression analysis demonstrated that open surgical approach, diabetes, congestive heart failure, chronic obstructive pulmonary disease, weight loss, and ASA class were among the variables associated with higher likelihood of HAC. We observed a non-significant secular trend of decreasing rates of HAC from 7.4% to 5.8% HACs during the study period, which encompassed the implementation of the Hospital Acquired Condition Reduction Program. HACs occurred at a rate of 5.9% after major urological surgery, and are significantly affected by procedure type and patient health status. The rate of HAC appeared unaffected by national reduction program in this cohort. Better understanding of the factors associated with HACs is critical in developing effective reduction programs. Copyright © 2018. Published by Elsevier Inc.

Epsilon-aminocaproic acid influence in postoperative [corrected] bleeding and hemotransfusion [corrected] in mitral valve surgery.

PubMed

Benfatti, Ricardo Ádala; Carli, Amanda Ferreira; Silva, Guilherme Viotto Rodrigues da; Dias, Amaury Edgardo Mont'serrat Ávila Souza; Goldiano, José Anderson; Pontes, José Carlos Dorsa Vieira

2010-01-01

The epsilon aminocaproic acid is an antifibrinolytic used in cardiovascular surgery to inhibit the fibrinolysis and to reduce the bleeding after CPB. [corrected] To analyze the influence of the using of epsilon aminocaproic acid in the bleeding and in red-cell transfusion requirement in the first twenty-four hours postoperative of mitral valve surgery. Prospective studying, forty-two patients, randomized and divided in two equal groups: group #1 control and group #2--epsilon aminocaproic acid. In Group II were infused five grams of EACA in the induction of anesthesia, after full heparinization, CPB perfusate after reversal of heparin and one hour after the surgery, totaling 25 grams. In group I, saline solution was infused only in those moments. Group #1 showed average bleeding volume of 633.57 ± 305,7 ml, and Group #2, an average of 308.81 ± 210.1 ml, with significant statistic difference (P = 0.0003). Average volume of red-cell transfusion requirement in Groups 1 and 2 was, respectively, 942.86 ± 345.79 ml and 214.29 ± 330.58 ml, with significant difference (P < 0.0001). The epsilon aminocaproic acid was able to reduce the bleeding volume and the red-cell transfusion requirement in the immediate postoperative of patients submitted to mitral valve surgery.

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

PubMed

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

2014-07-01

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

Intraoperative laser speckle contrast imaging improves the stability of rodent middle cerebral artery occlusion model

NASA Astrophysics Data System (ADS)

Yuan, Lu; Li, Yao; Li, Hangdao; Lu, Hongyang; Tong, Shanbao

2015-09-01

Rodent middle cerebral artery occlusion (MCAO) model is commonly used in stroke research. Creating a stable infarct volume has always been challenging for technicians due to the variances of animal anatomy and surgical operations. The depth of filament suture advancement strongly influences the infarct volume as well. We investigated the cerebral blood flow (CBF) changes in the affected cortex using laser speckle contrast imaging when advancing suture during MCAO surgery. The relative CBF drop area (CBF50, i.e., the percentage area with CBF less than 50% of the baseline) showed an increase from 20.9% to 69.1% when the insertion depth increased from 1.6 to 1.8 cm. Using the real-time CBF50 marker to guide suture insertion during the surgery, our animal experiments showed that intraoperative CBF-guided surgery could significantly improve the stability of MCAO with a more consistent infarct volume and less mortality.

[Measurement of air leak volume after lung surgery using web-camera].

PubMed

Onuki, Takamasa; Matsumoto, T

2005-05-01

Persistent air leak from the lung is one of the major complications after lung operations, especially in the latest thoracic surgery, where a shorter hospital stay tends to be necessary. However, air leak volume has been rarely measured clinically because accustomed tools of gas flow meter were types which needed contact measure, and those were unstable in long-term use and high cost. We tried to measure air leak volume as follows: (1) Bubble was made in the water seal part of a drain bag. (2) The movement of bubbles was recorded with a web-camera. (3) The data from the movie was analyzed by Linux computer on-line. We believe this method is clinically applicable as a routine work after lung surgery because of non-contact type of measurements, its stableness in long-term, easiness to be handled, and reasonable in cost.

Outcome of medial hamstring lengthening in children with spastic paresis: A biomechanical and morphological observational study

PubMed Central

Jaspers, Richard T.; Rutz, Erich; Harlaar, Jaap; van der Sluijs, Johannes A.; Witbreuk, Melinda M.; van Hutten, Kim; Romkes, Jacqueline; Freslier, Marie; Brunner, Reinald; Becher, Jules G.

2018-01-01

To improve gait in children with spastic paresis due to cerebral palsy or hereditary spastic paresis, the semitendinosus muscle is frequently lengthened amongst other medial hamstring muscles by orthopaedic surgery. Side effects on gait due to weakening of the hamstring muscles and overcorrections have been reported. How these side effects relate to semitendinosus morphology is unknown. This study assessed the effects of bilateral medial hamstring lengthening as part of single-event multilevel surgery (SEMLS) on (1) knee joint mechanics (2) semitendinosus muscle morphology and (3) gait kinematics. All variables were assessed for the right side only. Six children with spastic paresis selected for surgery to counteract limited knee range of motion were measured before and about a year after surgery. After surgery, in most subjects popliteal angle decreased and knee moment-angle curves were shifted towards a more extended knee joint, semitendinosus muscle belly length was approximately 30% decreased, while at all assessed knee angles tendon length was increased by about 80%. In the majority of children muscle volume of the semitendinosus muscle decreased substantially suggesting a reduction of physiological cross-sectional area. Gait kinematics showed more knee extension during stance (mean change ± standard deviation: 34±13°), but also increased pelvic anterior tilt (mean change ± standard deviation: 23±5°). In most subjects, surgical lengthening of semitendinosus tendon contributed to more extended knee joint angle during static measurements as well as during gait, whereas extensibility of semitendinosus muscle belly was decreased. Post-surgical treatment to maintain muscle belly length and physiological cross-sectional area may improve treatment outcome of medial hamstring lengthening. PMID:29408925

Outcome of medial hamstring lengthening in children with spastic paresis: A biomechanical and morphological observational study.

PubMed

Haberfehlner, Helga; Jaspers, Richard T; Rutz, Erich; Harlaar, Jaap; van der Sluijs, Johannes A; Witbreuk, Melinda M; van Hutten, Kim; Romkes, Jacqueline; Freslier, Marie; Brunner, Reinald; Becher, Jules G; Maas, Huub; Buizer, Annemieke I

2018-01-01

To improve gait in children with spastic paresis due to cerebral palsy or hereditary spastic paresis, the semitendinosus muscle is frequently lengthened amongst other medial hamstring muscles by orthopaedic surgery. Side effects on gait due to weakening of the hamstring muscles and overcorrections have been reported. How these side effects relate to semitendinosus morphology is unknown. This study assessed the effects of bilateral medial hamstring lengthening as part of single-event multilevel surgery (SEMLS) on (1) knee joint mechanics (2) semitendinosus muscle morphology and (3) gait kinematics. All variables were assessed for the right side only. Six children with spastic paresis selected for surgery to counteract limited knee range of motion were measured before and about a year after surgery. After surgery, in most subjects popliteal angle decreased and knee moment-angle curves were shifted towards a more extended knee joint, semitendinosus muscle belly length was approximately 30% decreased, while at all assessed knee angles tendon length was increased by about 80%. In the majority of children muscle volume of the semitendinosus muscle decreased substantially suggesting a reduction of physiological cross-sectional area. Gait kinematics showed more knee extension during stance (mean change ± standard deviation: 34±13°), but also increased pelvic anterior tilt (mean change ± standard deviation: 23±5°). In most subjects, surgical lengthening of semitendinosus tendon contributed to more extended knee joint angle during static measurements as well as during gait, whereas extensibility of semitendinosus muscle belly was decreased. Post-surgical treatment to maintain muscle belly length and physiological cross-sectional area may improve treatment outcome of medial hamstring lengthening.

Relationship between Arm Morbidity and Patient-Reported Outcomes Following Surgery in Women with Node-Negative Breast Cancer: NSABP Protocol B-32

PubMed Central

Kopec, Jacek A.; Colangelo, Linda H.; Land, Stephanie R.; Julian, Thomas B.; Brown, Ann M.; Anderson, Stewart J.; Krag, David N.; Ashikaga, Takamaru; Costantino, Joseph P.; Wolmark, Norman; Ganz, Patricia A.

2012-01-01

Background The impact of arm morbidity following breast cancer surgery on patient-observed changes in daily functioning and health-related quality of life (HRQoL) have not been well-studied. Objective To examine the association of objective measures such as range of motion (ROM) and lymphedema, with patient-reported outcomes (PROs) in the arm and breast, upper extremity function, activities, and HRQoL. Methods The National Surgical Adjuvant Breast and Bowel Project Protocol B-32 was a randomized trial comparing sentinel node resection (SNR) with axillary dissection (AD) in women with node-negative breast cancer. ROM and arm volume were measured objectively. PROs included symptoms; arm function; limitations in social, recreational, occupational, and other regular activities; and a global index of HRQoL. Statistical methods included cross-tabulations and multivariable linear regression models. Results In all, 744 women provided at least 1 postsurgery assessment. About one-third of the patients experienced arm mobility restrictions. A similar number of patients avoided the use of the arm 6 months after surgery. Limitations in work and other regular activities were reported by about a quarter of the patients. In this multivariable analysis, arm mobility and sensory neuropathy were predictors of patient-reported arm function and overall HRQoL. Predictors for activity limitations also included side of surgery (dominant vs nondominant). Edema was not significant after adjustment for sensory neuropathy and ROM. Limitations Arm mobility and edema were measured simultaneously only once during the follow-up (6 months). Conclusion Clinical measures of sensory neuropathy and restrictions in arm mobility following breast cancer surgery are associated with self-reported limitations in activity and reductions in overall HRQoL. PMID:22951047

[Benefit from bio-enteric Intra-gastric balloon (BIB) to modify lifestyle and eating habits in severely obese patients eligible for bariatric surgery].

PubMed

Zago, S; Kornmuller, A M; Agagliati, D; Saber, B; Ferrari, D; Maffeis, P; Labate, M; Bauducco, E; Manghisi, L; Martignone, L; Spanu, M; Rovera, G M

2006-02-01

The therapeutic model for severe obesity includes bariatric surgery, representing the safest way to keep weight down and to prevent relapses. The selection of patients for the most suitable type of surgery implies multidisciplinary approach (nutritionist, dietist, clinical psychologist and surgeon). The intragastric balloon may represent a relatively invasive method to help the medical team to select and prepare severely obese patients for restrictive bariatric surgery. In our study we considered 48 severely obese patients: initial weight 111+/-14.8 kg, BMI 43+/-5.02, excess weight 77.47+/-16.14%. These patients have been treated with intragastric balloon (BIB) filled to a volume of 500 cc for 6 months. We considered variations induced by BIB treatment on a number of parameters--clinical, anthropometric, food intake, partition of nourishing elements and psychological and psychometric data. At the end of the treatment the patients showed significant reductions of excess weight (67.35+/-20.19%), of weight (103.4+/-16.72 kg) and food intake, without modification of the items in the EDI2 test, but with important motivational support for a change in life style between the beginning and the end of the treatment, clearly resulting from the medical, dietist and clinical-psychological follow-up. BIB is a relatively invasive means capable of modifying eating habits in the short term; it induces weight loss, may help to reduce the anaesthesiological risk and to foster a change in the patient's behaviour. In our experience treatment with BIB is useful from the educational point of view and can be used to select patients for bariatric surgery only within a multidisciplinary team. Further clinical studies are necessary.

The Effect of Topical Tranexamic Acid on Bleeding Reduction during Functional Endoscopic Sinus Surgery

PubMed Central

Baradaranfar, Mohammad Hossein; Dadgarnia, Mohammad Hossein; Mahmoudi, Hossein; Behniafard, Nasim; Atighechi, Saeid; Zand, Vahid; Baradaranfar, Amin; Vaziribozorg, Sedighe

2017-01-01

Introduction: Bleeding is a common concern during functional endoscopic sinus surgery (FESS) that can increase the risk of damage to adjacent vital elements by reducing the surgeon’s field of view. This study aimed to explore the efficacy of topical tranexamic acid in reducing intraoperative bleeding. Materials and Methods: This double-blind, randomized clinical trial was conducted in 60 patients with chronic rhinosinusitis with polyposis (CRSwP) who underwent FESS. Patients were randomly divided into two groups; tranexamic or saline treatment. During surgery, normal saline (400 mL) or tranexamic acid (2 g) in normal saline with a total volume of 400 mL were used in the saline and tranexamic groups, respectively, for irrigation and suctioning. The surgeons’ assessment of field of view during surgery and intraoperative blood loss were recorded. Results: Mean blood loss was 254.13 mL in the saline group and 235.6 mL in the tranexamic group (P=0.31). No statistically significant differences between the two groups were found in terms of other investigated variables, such as surgical field quality based on Boezzart’s scale (P=0.30), surgeon satisfaction based on a Likert scale (P=0.54), or duration of surgery (P=0.22). Conclusion: Use of tranexamic acid (2 g in 400 mL normal saline) through washing of the nasal mucosa during FESS did not significantly reduce blood loss or improve the surgical field of view. Further studies with larger sample sizes and higher drug concentrations, and using other methods of administration, such as spraying or applying pledgets soaked in tranexamic acid, are recommended. PMID:28393053

Trends and Utilization of Laser Prostatectomy in Ambulatory Surgical Procedures for the Treatment of Benign Prostatic Hyperplasia in New York State (2000-2011).

PubMed

Chughtai, Bilal I; Simma-Chiang, Vannita; Lee, Richard; Isaacs, Abby; Te, Alexis E; Kaplan, Steven A; Sedrakyan, Art

2015-06-01

There has been a significant change in surgical treatment of benign prostatic hypertrophy (BPH) over the last two decades. Most importantly, laser surgery (coagulation, vaporization, or enucleation) has been growing in popularity as an alternative to standard transurethral prostatectomy (TURP) or other procedures. Our goal was to analyze the trends of BPH surgeries and compare outcomes of laser surgery to TURP, the two most common alternative surgeries. We used the New York Statewide Planning and Research Cooperation System (SPARCS) data to identify patients diagnosed as having BPH who underwent BPH-related surgery from October 2000 to December 2011. Age, insurance, individual comorbidities, and average hospital volumes were assessed. Bivariate and multivariate regression models were used to analyze predictors of laser use. In-hospital outcomes were then compared between laser and TURP in a balanced propensity-matched cohort. Ninety thousand six hundred seventy patients underwent BPH surgery. Laser surgery usage increased from 6.4% to 44.5% over 10 years (p<0.0001). TURP declined significantly from 72.2% to 48.3% (p<0.0001). Patients with Medicaid were less likely to undergo laser therapy than those with private insurance (odds ratio [OR]: 0.58, 95% confidence interval [CI]: 0.48, 0.69). Mid- and high-volume institutions were more likely to use laser treatment than low-volume centers (OR: 2.26, 95% CI: 1.22, 4.2; OR: 4.07, 95% CI: 1.75, 9.46, respectively). In the matched cohort, both laser and TURP patients had similar complication rates with more frequent electrolyte disorders in TURP patients (2.9% vs 2.3%, p=0.001). TURP remains the most common procedure. However, the rate of use has declined over time. In contrast, laser use has significantly increased. Laser treatment was utilized more in younger patients, in those privately insured, in hospitals with high volumes of BPH procedures, and in patients with fewer comorbid conditions. Both surgeries are safe with no differences in terms of occurrences of morbidity and complications.

Cell Salvage Used in Scoliosis Surgery: Is It Really Effective?

PubMed

Liu, Jia-Ming; Fu, Bi-Qi; Chen, Wen-Zhao; Chen, Jiang-Wei; Huang, Shan-Hu; Liu, Zhi-Li

2017-05-01

Scoliosis surgery usually is associated with large volume of intraoperative blood loss, and cell salvage is used commonly to filter and retranfusion autologous blood to patients. The efficacy of using cell salvage in scoliosis surgery, however, is still controversial. The purpose of this study is to make clear that intraoperative use of cell salvage is effective to decrease the volume of perioperative allogenic blood transfusion in scoliosis surgery. A meta-analysis was conducted to identify the relevant studies from PubMed, Embase, Medline, Cochrane library, and Google scholar until July 2016. All randomized trials and controlled clinical studies comparing the clinical outcomes of using cell salvage versus noncell salvage in scoliosis surgery were retrieved for the meta-analysis. The data were analyzed by RevMan 5.3. A total of 7 studies with 562 patients were included in this meta-analysis. Based on the analysis, the volumes of perioperative and postoperative allogenic red blood cell (RBC) transfusion in cell salvage group were significantly less than those in control group (P = 0.04 and P = 0.01); however, no significant difference was detected in the amount of intraoperative allogenic RBC transfusion and the risk of patients needing allogenic blood transfusion between the 2 groups (P = 0.14 and P = 0.61). Both the hemoglobin and hematocrit levels on the first day after surgery were significantly greater in cell salvage group than those in control group (P = 0.002 and P < 0.001). No significant differences, however, were noted in neither hemoglobin nor hematocrit level at the time of discharge between the 2 groups (P = 0.76 and P = 0.32). One of the included study reported the number of patients with complications related to transfusion in the two groups, which was not significant different (P = 0.507). Cell salvage significantly reduced the volumes of perioperative and postoperative allogenic RBC transfusion in scoliosis surgery and increased the hemoglobin and hematocrit levels on the first day postoperatively. In addition, it seemed not to increase the rate of transfusion complications during the surgery. Copyright © 2017 Elsevier Inc. All rights reserved.

A randomized trial of exercise on well-being and function following breast cancer surgery: the RESTORE trial.

PubMed

Anderson, Roger T; Kimmick, Gretchen G; McCoy, Thomas P; Hopkins, Judith; Levine, Edward; Miller, Gary; Ribisl, Paul; Mihalko, Shannon L

2012-06-01

This study aimed to determine the effect of a moderate, tailored exercise program on health-related quality of life, physical function, and arm volume in women receiving treatment for nonmetastatic breast cancer. Women who were within 4-12 weeks of surgery for stage I-III breast cancer were randomized to center-based exercise and lymphedema education intervention or patient education. Functional assessment of cancer therapy-breast cancer (FACT-B), 6-min walk, and arm volume were performed at 3-month intervals through 18 months. Repeated measures analysis of covariance was used to model the total meters walked over time, FACT-B scores, and arm volume. Models were adjusted for baseline measurement, baseline affected arm volume, number of nodes removed, age, self-reported symptoms, baseline SF-12 mental and physical component scores, visit, and treatment group. Of the recruited 104 women, 82 completed all 18 months. Mean age (range) was 53.6 (32-82) years; 88% were Caucasian; 45% were employed full time; 44% were overweight; and 28% obese. Approximately, 46% had breast-conserving surgery; 79% had axillary node dissection; 59% received chemotherapy; and 64% received radiation. The intervention resulted in an average increase of 34.3 ml (SD = 12.8) versus patient education (p = 0.01). Changes in FACT-B scores and arm volumes were not significantly different. With this early exercise intervention after breast cancer diagnosis, a significant improvement was achieved in physical function, with no decline in health-related quality of life or detrimental effect on arm volume. Starting a supervised exercise regimen that is tailored to an individual's strength and stamina within 3 months following breast cancer surgery appears safe and may hasten improvements in physical functioning.

Which Kind of Provider’s Operation Volumes Matters? Associations between CABG Surgical Site Infection Risk and Hospital and Surgeon Operation Volumes among Medical Centers in Taiwan

PubMed Central

Yu, Tsung-Hsien; Tung, Yu-Chi; Chung, Kuo-Piao

2015-01-01

Background Volume-infection relationships have been examined for high-risk surgical procedures, but the conclusions remain controversial. The inconsistency might be due to inaccurate identification of cases of infection and different methods of categorizing service volumes. This study takes coronary artery bypass graft (CABG) surgical site infections (SSIs) as an example to examine whether a relationship exists between operation volumes and SSIs, when different SSIs case identification, definitions and categorization methods of operation volumes were implemented. Methods A population-based cross-sectional multilevel study was conducted. A total of 7,007 patients who received CABG surgery between 2006 and 2008 from19 medical centers in Taiwan were recruited. SSIs associated with CABG surgery were identified using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9 CM) codes and a Classification and Regression Trees (CART) model. Two definitions of surgeon and hospital operation volumes were used: (1) the cumulative CABG operation volumes within the study period; and (2) the cumulative CABG operation volumes in the previous one year before each CABG surgery. Operation volumes were further treated in three different ways: (1) a continuous variable; (2) a categorical variable based on the quartile; and (3) a data-driven categorical variable based on k-means clustering algorithm. Furthermore, subgroup analysis for comorbidities was also conducted. Results This study showed that hospital volumes were not significantly associated with SSIs, no matter which definitions or categorization methods of operation volume, or SSIs case identification approaches were used. On the contrary, the relationships between surgeon’s volumes varied. Most of the models demonstrated that the low-volume surgeons had higher risk than high-volume surgeons. Conclusion Surgeon volumes were more important than hospital volumes in exploring the relationship between CABG operation volumes and SSIs in Taiwan. However, the relationships were not robust. Definitions and categorization methods of operation volume and correct identification of SSIs are important issues for future research. PMID:26053035

What Is the Standard Volume to Increase a Cup Size for Breast Augmentation Surgery? A Novel Three-Dimensional Computed Tomographic Approach.

PubMed

King, Nina-Marie; Lovric, Vedran; Parr, William C H; Walsh, W R; Moradi, Pouria

2017-05-01

Breast augmentation surgery poses many challenges, and meeting the patient's expectations is one of the most important. Previous reports equate 100 cc to a one-cup-size increase; however, no studies have confirmed this between commercially available bras. The aim of this study was to identify the volume increase between cup sizes across different brands and the relationship with implant selection. Five bra cup sizes from three different companies were analyzed for their volume capacity. Three methods were used to calculate the volume of the bras: (1) linear measurements; (2) volume measurement by means of water displacement; and (3) volume calculation after three-dimensional reconstruction of serial radiographic data (computed tomography). The clinical arm consisted of 79 patients who underwent breast augmentation surgery from February 1, 2014, to June 30, 2016. Answers from a short questionnaire in combination with the implant volume were analyzed. Across all three brands, the interval volume increase varied between sizes, but not all were above 100 cc. There was some variation in the volume capacity of the same cup size among the different brands. The average incremental increase in bra cup size across all three brands in the laboratory arm was 135 cc. The mean volume increase per cup size was 138.23 cc in the clinical arm. This article confirms that there is no standardization within the bra manufacturing industry. On the basis of this study, patients should be advised that 130 to 150 cc equates to a one-cup-size increase. Bras with narrower band widths need 130 cc and wider band widths require 150 cc to increase one cup size.

Effects of Lung Volume Reduction Surgery on Gas Exchange and Breathing Pattern During Maximum Exercise

PubMed Central

Criner, Gerard J.; Belt, Patricia; Sternberg, Alice L.; Mosenifar, Zab; Make, Barry J.; Utz, James P.; Sciurba, Frank

2009-01-01

Background: The National Emphysema Treatment Trial studied lung volume reduction surgery (LVRS) for its effects on gas exchange, breathing pattern, and dyspnea during exercise in severe emphysema. Methods: Exercise testing was performed at baseline, and 6, 12, and 24 months. Minute ventilation (V̇e), tidal volume (Vt), carbon dioxide output (V̇co2), dyspnea rating, and workload were recorded at rest, 3 min of unloaded pedaling, and maximum exercise. Pao2, Paco2, pH, fraction of expired carbon dioxide, and bicarbonate were also collected in some subjects at these time points and each minute of testing. There were 1,218 patients enrolled in the study (mean [± SD] age, 66.6 ± 6.1 years; mean, 61%; mean FEV1, 0.77 ± 0.24 L), with 238 patients participating in this substudy (mean age, 66.1 ± 6.8 years; mean, 67%; mean FEV1, 0.78 ± 0.25 L). Results: At 6 months, LVRS patients had higher maximum V̇e (32.8 vs 29.6 L/min, respectively; p = 0.001), V̇co2, (0.923 vs 0.820 L/min, respectively; p = 0.0003), Vt (1.18 vs 1.07 L, respectively; p = 0.001), heart rate (124 vs 121 beats/min, respectively; p = 0.02), and workload (49.3 vs 45.1 W, respectively; p = 0.04), but less breathlessness (as measured by Borg dyspnea scale score) [4.4 vs 5.2, respectively; p = 0.0001] and exercise ventilatory limitation (49.5% vs 71.9%, respectively; p = 0.001) than medical patients. LVRS patients with upper-lobe emphysema showed a downward shift in Paco2 vs V̇co2 (p = 0.001). During exercise, LVRS patients breathed slower and deeper at 6 months (p = 0.01) and 12 months (p = 0.006), with reduced dead space at 6 months (p = 0.007) and 24 months (p = 0.006). Twelve months after patients underwent LVRS, dyspnea was less in patients with upper-lobe emphysema (p = 0.001) and non–upper-lobe emphysema (p = 0.007). Conclusion: During exercise following LVRS, patients with severe emphysema improve carbon dioxide elimination and dead space, breathe slower and deeper, and report less dyspnea. PMID:19420196

[Comparative study on graft of autogeneic iliac bone and tissue engineered bone].

PubMed

Shen, Bing; Xie, Fu-lin; Xie, Qing-fang

2002-11-01

To compare the clinical results of repairing bone defect of limbs with tissue engineering technique and with autogeneic iliac bone graft. From July 1999 to September 2001, 52 cases of bone fracture were randomly divided into two groups (group A and B). Open reduction and internal fixation were performed in all cases as routine operation technique. Autogeneic iliac bone was implanted in group A, while tissue engineered bone was implanted in group B. Routine postoperative treatment in orthopedic surgery was taken. The operation time, bleeding volume, wound healing and drainage volume were compared. The bone union was observed by the X-ray 1, 2, 3, and 5 months after operation. The sex, age and disease type had no obvious difference between groups A and B. all the wounds healed with first intention. The swelling degree of wound and drainage volume had no obvious difference. The operation time in group A was longer than that in group B (25 minutes on average) and bleeding volume in group A was larger than that in group B (150 ml on average). Bone union completed within 3 to 7 months in both groups. But there were 2 cases of delayed union in group A and 1 case in group B. Repair of bone defect with tissue engineered bone has as good clinical results as that with autogeneic iliac bone graft. In aspect of operation time and bleeding volume, tissue engineered bone graft is superior to autogeneic iliac bone.

Association of Very Low-Volume Practice With Vascular Surgery Outcomes in New York.

PubMed

Mao, Jialin; Goodney, Philip; Cronenwett, Jack; Sedrakyan, Art

2017-08-01

Little research has focused on very low-volume surgery, especially in the context of decreasing vascular surgery volume with the adoption of endovascular procedures. To investigate the existence and outcomes of open abdominal aortic aneurysm repair (OAR) and carotid endarterectomy (CEA) performed by very low-volume surgeons in New York. This cohort study examined inpatient data of patients undergoing elective OAR or CEA from 2000 to 2014 from all New York hospitals. Surgeons who performed 1 or less designated procedure per year on average were considered very low volume, as opposed to higher-volume surgeons. Temporal trends of the existence of very low-volume practice were evaluated. Hierarchical logistic regression was used to compare in-hospital outcomes and health care resource use between patients treated by very low-volume surgeons and higher-volume surgeons for both OAR and CEA, adjusting for patient, surgeon, and hospital characteristics. There were 8781 OAR procedures and 68 896 CEA procedures included in the study. The mean (SD) patient age was 71.7 (8.4) years for OAR and 71.5 (9.1) years for CEA. A total of 614 surgeons performed OAR and 1071 performed CEA in New York during the study period. Of these, 318 (51.8%) and 512 (47.8%), respectively, were very low-volume surgeons. Very low-volume surgeons were less likely to be vascular surgeons. The number and proportion of very low-volume surgeons decreased over years. Compared with patients treated by higher-volume surgeons, those treated by very low-volume surgeons were more likely to have higher in-hospital mortality (odds ratio [OR], 2.09; 95% CI, 1.41-3.08) following OAR and higher risks of postoperative myocardial infarction (OR, 1.83; 95% CI, 1.03-3.26) and stroke (OR, 1.78; 95% CI, 1.21-2.62) following CEA. Patients treated by very low-volume surgeons also had greater health care resource use following both surgeries, including prolonged length of stay (OR, 1.37; 95% CI, 1.11-1.70) following OAR as well as higher charges (OR, 1.28; 95% CI, 1.01-1.62) and increased 30-day readmission (OR, 1.30; 95% CI 1.04-1.62) following CEA. The OAR and CEA procedures performed by very low-volume surgeons resulted in worse postoperative outcomes and greater lengths of stay. Although the percentage of very low-volume surgeons declined from 2000 to 2014, it remains concerning, given ready access to higher-volume surgeons. Future research is needed to understand the existence of this practice pattern in other surgical fields. Efforts to eliminate this practice pattern are warranted to ensure high-quality care for all patients.

Mandibular Reconstruction with Lateral Tibial Bone Graft: An Excellent Option for Oral and Maxillofacial Surgery.

PubMed

Miceli, Ana Lucia Carpi; Pereira, Livia Costa; Torres, Thiago da Silva; Calasans-Maia, Mônica Diuana; Louro, Rafael Seabra

2017-12-01

Autogenous bone grafts are the gold standard for reconstruction of atrophic jaws, pseudoarthroses, alveolar clefts, orthognathic surgery, mandibular discontinuity, and augmentation of sinus maxillary. Bone graft can be harvested from iliac bone, calvarium, tibial bone, rib, and intraoral bone. Proximal tibia is a common donor site with few reported problems compared with other sites. The aim of this study was to evaluate the use of proximal tibia as a donor area for maxillofacial reconstructions, focusing on quantifying the volume of cancellous graft harvested by a lateral approach and to assess the complications of this technique. In a retrospective study, we collected data from 31 patients, 18 women and 13 men (mean age: 36 years, range: 19-64), who were referred to the Department of Oral and Maxillofacial Surgery at the Servidores do Estado Federal Hospital. Patients were treated for sequelae of orthognathic surgery, jaw fracture, nonunion, malunion, pathology, and augmentation of bone volume to oral implant. The technique of choice was lateral access of proximal tibia metaphysis for graft removal from Gerdy tubercle under general anesthesia. The mean volume of bone harvested was 13.0 ± 3.7 mL (ranged: 8-23 mL). Only five patients (16%) had minor complications, which included superficial infection, pain, suture dehiscence, and unwanted scar. However, none of these complications decreases the result and resolved completely. We conclude that proximal tibia metaphysis for harvesting cancellous bone graft provides sufficient volume for procedures in oral and maxillofacial surgery with minimal postoperative morbidity.

Feast or famine? The variable impact of coexisting fellowships on general surgery resident operative volumes.

PubMed

Hanks, John B; Ashley, Stanley W; Mahvi, David M; Meredith, Wayne J; Stain, Steven C; Biester, Thomas W; Borman, Karen R

2011-09-01

Nearly 80% of general surgery residents (GSR) pursue Fellowship training. We hypothesized that fellowships coexisting with general surgery residencies do not negatively impact GSR case volumes and that fellowship-bound residents (FBR) preferentially seek out cases in their chosen specialty ("early tracking"). To test our hypotheses, we analyzed the Accreditation Council for Graduate Medical Education Surgical Operative Log data from 2009 American Board of Surgery qualifying examination applicants (N = 976). General surgery programs coexisted with 35 colorectal (CR), 97 vascular (Vasc), 80 minimally invasive (MIS), and 12 Endocrine (Endo) fellowships. We analyzed (1) operative cases for general surgery residency programs with and without coexisting Fellowships, comparing caseloads for FBR and all GSR and (2) operative cases of FBR in their chosen specialties compared to all other GSR. Group means were compared using ANOVA with significance set at P < 0.01. Coexisting fellowships had minimal impact on GSR caseloads. Endocrine fellowships actually enhanced case volumes for all residents. CR impact was neutral while MIS and vascular fellowships resulted in small declines. Endo, CR, and Vasc but not MIS FBR performed significantly more cases in their future specialties than their GSR counterparts, consistent with self-directed, prefellowship tracking. Tracking seems to be additive and FBR do not sacrifice other GSR cases. Our data establish that the impact of Fellowships on GSR caseloads is minimal. Our data confirm that FBR seek out cases in their future specialties ("early tracking").

The Feasibility of 3D Printing Technology on the Treatment of Pilon Fracture and Its Effect on Doctor-Patient Communication.

PubMed

Zheng, Wenhao; Chen, Chunhui; Zhang, Chuanxu; Tao, Zhenyu; Cai, Leyi

2018-01-01

The aim of this study was to assess the feasibility and effectiveness of the three-dimensional (3D) printing technology in the treatment of Pilon fractures. 100 patients with Pilon fractures from March 2013 to December 2016 were enrolled in our study. They were divided randomly into 3D printing group ( n = 50) and conventional group ( n = 50). The 3D models were used to simulate the surgery and carry out the surgery according to plan in 3D printing group. Operation time, blood loss, fluoroscopy times, fracture union time, and fracture reduction as well as functional outcomes including VAS and AOFAS score and complications were recorded. To examine the feasibility of this approach, we invited surgeons and patients to complete questionnaires. 3D printing group showed significantly shorter operation time, less blood loss volume and fluoroscopy times, higher rate of anatomic reduction and rate of excellent and good outcome than conventional group ( P < 0.001, P < 0.001, P < 0.001, P = 0.040, and P = 0.029, resp.). However, no significant difference was observed in complications between the two groups ( P = 0.510). Furthermore, the questionnaire suggested that both surgeons and patients got high scores of overall satisfaction with the use of 3D printing models. Our study indicated that the use of 3D printing technology to treat Pilon fractures in clinical practice is feasible.

Benchmarking surgical incident reports using a database and a triage system to reduce adverse outcomes.

PubMed

Antonacci, Anthony C; Lam, Steven; Lavarias, Valentina; Homel, Peter; Eavey, Roland D

2008-12-01

To study the profile of incidents affecting quality outcomes after surgery by developing a usable operating room and perioperative clinical incident report database and a functional electronic classification, triage, and reporting system. Previously, incident reports after surgery were handled on an individual, episodic basis, which limited the ability to perceive actuarial patterns and meaningfully improve outcomes. Clinical incident reports were experientially generated in the second largest health care system in New York City. Data were entered into a functional classification system organized into 16 categories, and weekly triage meetings were held to electronically review and report summaries on 40 to 60 incident reports per week. System development and deployment reviewed 1041 reports after 19,693 operative procedures. During the next 4 years, 3819 additional reports were generated from 83,988 operative procedures and were reported electronically to the appropriate departments. Number of incident reports generated annually. A significant decrease in volume-adjusted clinical incident reports occurred (from 53 to 39 reports per 1000 procedures) from 2001 to 2005 (P < .001). Reductions in incident reports were observed for ambulatory conversions (74% reduction), wasted implants (65%), skin breakdown (64%), complications in the operating room (42%), laparoscopic conversions (32%), and cancellations (23%) as a result of data-focused process and clinical interventions. Six of 16 categories of incident reports accounted for more than 88% of all incident reports. These data suggest that effective review, communication, and summary feedback of clinical incident reports can produce a statistically significant decrease in adverse outcomes.

The Feasibility of 3D Printing Technology on the Treatment of Pilon Fracture and Its Effect on Doctor-Patient Communication

PubMed Central

Zheng, Wenhao; Chen, Chunhui; Zhang, Chuanxu; Tao, Zhenyu

2018-01-01

Purpose The aim of this study was to assess the feasibility and effectiveness of the three-dimensional (3D) printing technology in the treatment of Pilon fractures. Methods 100 patients with Pilon fractures from March 2013 to December 2016 were enrolled in our study. They were divided randomly into 3D printing group (n = 50) and conventional group (n = 50). The 3D models were used to simulate the surgery and carry out the surgery according to plan in 3D printing group. Operation time, blood loss, fluoroscopy times, fracture union time, and fracture reduction as well as functional outcomes including VAS and AOFAS score and complications were recorded. To examine the feasibility of this approach, we invited surgeons and patients to complete questionnaires. Results 3D printing group showed significantly shorter operation time, less blood loss volume and fluoroscopy times, higher rate of anatomic reduction and rate of excellent and good outcome than conventional group (P < 0.001, P < 0.001, P < 0.001, P = 0.040, and P = 0.029, resp.). However, no significant difference was observed in complications between the two groups (P = 0.510). Furthermore, the questionnaire suggested that both surgeons and patients got high scores of overall satisfaction with the use of 3D printing models. Conclusion Our study indicated that the use of 3D printing technology to treat Pilon fractures in clinical practice is feasible. PMID:29581985

Volumetric analysis of the pharynx in patients with obstructive sleep apnea (OSA) treated with maxillomandibular advancement (MMA).

PubMed

Faria, Ana Célia; da Silva-Junior, Savio Nogueira; Garcia, Luis Vicente; dos Santos, Antonio Carlos; Fernandes, Maria Regina França; de Mello-Filho, Francisco Veríssimo

2013-03-01

Maxillomandibular advancement (MMA) has been reported to be the most effective surgical treatment of obstructive sleep apnea (OSA). Most reports about MMA aim to confirm the efficiency of this treatment modality, but few describe the anatomical changes produced in the pharynx by the surgery. Thus, the objective of the present investigation was to quantify the anatomical changes of the pharynx that occur in patients with OSA after MMA surgery using magnetic resonance (MR). Twenty patients with a polysomnographic diagnosis of OSA participated in the study. All patients were submitted to image acquisition by MR performed during wakefulness. Polysomnography and MR were performed preoperatively and 6 months after MMA. Volume analysis (in cubic millimeters) was performed as the sum of the areas multiplied by their thickness, with no intervals between sections. The pharyngeal air space of the region between the hard palate and the base of the epiglottis was divided into a retropalatal (RP) region and a retrolingual (RL) region. Postoperative MR showed a mean volumetric increase of 26.72 % in the RP region and of 27.2 % in the RL region. MMA increases the air space of the pharynx by expanding the facial skeletal structure to which the soft tissues of the pharynx and tongue are fixed, with a consequent reduction of collapsibility in the presence of negative pressure during inspiration. This reduced possibility of pharyngeal collapse may contribute to the reduction of obstructive events.

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

PubMed

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

2011-03-01

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

Stable reconstruction using halo vest for unstable upper cervical spine and occipitocervical instability.

PubMed

Ogihara, Nobuhide; Takahashi, Jun; Hirabayashi, Hiroki; Hashidate, Hiroyuki; Mukaiyama, Keijiro; Kato, Hiroyuki

2012-02-01

Upper cervical or occipitocervical disorders such as rheumatoid arthritis present as atlantoaxial subluxation, vertical subluxation of the axis, and subaxial subluxation, which produce myelopathy and severe pain. In such cases, occipitocervical reconstruction surgery may be indicated, and several reports have described reduction of subluxation by fixing the halo vest before this surgery. The purpose of this study was to evaluate the efficacy of using the halo vest before the surgery for unstable upper cervical spine and for occipitocervical instability. Twenty-eight patients (9 men and 19 women; mean age, 61.8 years at surgery) who presented with atlantoaxial or occipitocervical fusion were studied. In all cases, the halo vest was fixed in the conscious condition, and subluxation was reduced before the surgery. The mean follow-up period was 45 months. Roentgenologic measurement and clinical evaluation were performed before the surgery and at the final follow-up. Using the halo vest resulted in significant reductions in the atlantodental interval, the space available for the spinal cord, and the Ranawat value (p < 0.05), and these were maintained until the final follow-up. The mean Japanese Orthopedic Association score significantly improved from 9.5 before surgery to 12.2 at the final follow-up (p = 0.01). Nineteen cases (68%) improved by more than 1 grade by Ranawat's classification after surgery and 16 cases (57%) maintained the same at the follow-up visit. Conscious preoperative reduction using the halo vest for occipitocervical disorders is a useful and safe technique.

Dexmedetomidine and Mannitol for Awake Craniotomy in a Pregnant Patient.

PubMed

Handlogten, Kathryn S; Sharpe, Emily E; Brost, Brian C; Parney, Ian F; Pasternak, Jeffrey J

2015-05-01

We describe the use of dexmedetomidine for an awake neurosurgical procedure in a pregnant patient and quantify the effect of mannitol on intrauterine volume. A 27-year-old woman underwent a craniotomy, with intraprocedural motor and speech mapping, at 20 weeks of gestation. Sedation was maintained with dexmedetomidine. Mannitol at 0.25 g/kg IV was administered to control brain volume during surgery. Internal uterine volume was estimated at 1092 cm before surgery and decreased to 770 and 953 cm at 9 and 48 hours, respectively, after baseline assessment. No adverse maternal or fetal effects were noted during the intraoperative period or up to 48 hours postoperatively.

Fluid extravasation during hip arthroscopy.

PubMed

Stafford, Giles H; Malviya, Ajay; Villar, Richard N

2011-01-01

The amount of fluid that may be lost into the soft tissues during hip arthroscopic surgery is unknown. We measured the volumes of irrigation fluid infused, operating time, fluid pressures and volumes of fluid recovered in 36 therapeutic hip arthroscopies. We excluded those where fluid was lost to the floor, leaving 28 patients. The majority were undergoing surgery for the treatment of femoroacetabular impingement. In 5 patients an intra-articular contrast medium was instilled, in order to establish the likely location of any extravasated fluid. The mean operating time was 68 minutes (31 to 120), and the mean infusion pressure was 46 mm Hg (30 to 70). The mean volume of infused fluid was 9677 ml (95% confidence interval (CI) 7715 to 11638) and the mean volume of fluid recovered was 8544 ml (95% CI 6715 to 10373). The mean fluid extravasation loss into the peri-articular tissues was 1132 ml (95% CI 808 ml to 1456 ml). There was a significant correlation between the volume of extravasated fluid and both the length of operation and the volume of infused fluid used. We had no adverse events in our series. During arthroscopic hip surgery more than a litre of irrigation fluid may be extravasated into the soft tissues. In order to reduce problems related to this we attempt to keep operating times low, and maintain intra-operative fluid pressures as low as possible.

The correlation between hematoma volume and outcome in ruptured posterior fossa arteriovenous malformations indicates the importance of surgical evacuation of hematomas.

PubMed

Yilmaz, Adem; Musluman, Ahmet Murat; Kanat, Ayhan; Cavusoglu, Halit; Terzi, Yuksel; Aydin, Yunus

2011-01-01

The correlation between hematoma volume and outcome in ruptured arteriovenous malformations (AVM) with accompanying posterior fossa hematoma was retrospectively evaluated. Microsurgery operations were performed on 127 patients with intracranial AVM between January 1998 and January 2009 at our clinic. Fifteen (11.8%) patients were identified as suffering from posterior fossa AVM, and twelve of these patients presented with a cerebellar hematoma. All patients were clinically evaluated according to the following criteria: modified Rankin Scale (mRS) prior to surgery, Spetzler-Martin grade (SMG) of the AVMs, hematoma volume prior to surgery, and mRS following surgery. Postoperative mRS scores were significantly lower than preoperative scores (p=0.0001). Postoperative outcomes were concordant with the SMG of the AVMs (r=0.67, p=0.033), hematoma volume (r=0.537, p=0.072) and preoperative mRS scores (r=0.764, p=0.004). These analyses show that the postoperative mRS score is strongly correlated with a preoperative mRS score, hematoma volume and SMG. Posterior fossa AVMs present an increased risk for hemorrhage and for increased morbidity and mortality. Cases with hematoma should be operated on an urgent basis. We conclude that hematoma volume is a factor that impacts postoperative results and prognosis. SMG and preoperative mRS scores were also correlated with outcome.

76 FR 58543 - Draft Policy Statement on Volume Reduction and Low-Level Radioactive Waste Management

Federal Register 2010, 2011, 2012, 2013, 2014

2011-09-21

...-Level Radioactive Waste Management AGENCY: Nuclear Regulatory Commission. ACTION: Reopening of comment... for public comment a draft Policy Statement on Volume Reduction and Low-Level Radioactive Waste Management that updates the 1981 Policy Statement on Low-Level Waste Volume Reduction. The revised Policy...

Frontal gray matter abnormalities predict seizure outcome in refractory temporal lobe epilepsy patients.

PubMed

Doucet, Gaelle E; He, Xiaosong; Sperling, Michael; Sharan, Ashwini; Tracy, Joseph I

2015-01-01

Developing more reliable predictors of seizure outcome following temporal lobe surgery for intractable epilepsy is an important clinical goal. In this context, we investigated patients with refractory temporal lobe epilepsy (TLE) before and after temporal resection. In detail, we explored gray matter (GM) volume change in relation with seizure outcome, using a voxel-based morphometry (VBM) approach. To do so, this study was divided into two parts. The first one involved group analysis of differences in regional GM volume between the groups (good outcome (GO), e.g., no seizures after surgery; poor outcome (PO), e.g., persistent postoperative seizures; and controls, N = 24 in each group), pre- and post-surgery. The second part of the study focused on pre-surgical data only (N = 61), determining whether the degree of GM abnormalities can predict surgical outcomes. For this second step, GM abnormalities were identified, within each lobe, in each patient when compared with an ad hoc sample of age-matched controls. For the first analysis, the results showed larger GM atrophy, mostly in the frontal lobe, in PO patients, relative to both GO patients and controls, pre-surgery. When comparing pre-to-post changes, we found relative GM gains in the GO but not in the PO patients, mostly in the non-resected hemisphere. For the second analysis, only the frontal lobe displayed reliable prediction of seizure outcome. 81% of the patients showing pre-surgical increased GM volume in the frontal lobe became seizure free, post-surgery; while 77% of the patients with pre-surgical reduced frontal GM volume had refractory seizures, post-surgery. A regression analysis revealed that the proportion of voxels with reduced frontal GM volume was a significant predictor of seizure outcome (p = 0.014). Importantly, having less than 1% of the frontal voxels with GM atrophy increased the likelihood of being seizure-free, post-surgery, by seven times. Overall, our results suggest that using pre-surgical GM abnormalities within the frontal lobe is a reliable predictor of seizure outcome post-surgery in TLE. We believe that this frontal GM atrophy captures seizure burden outside the pre-existing ictal temporal lobe, reflecting either the development of epileptogenesis or the loss of a protective, adaptive force helping to control or limit seizures. This study provides evidence of the potential of VBM-based approaches to predict surgical outcomes in refractory TLE candidates.

Frontal gray matter abnormalities predict seizure outcome in refractory temporal lobe epilepsy patients

PubMed Central

Doucet, Gaelle E.; He, Xiaosong; Sperling, Michael; Sharan, Ashwini; Tracy, Joseph I.

2015-01-01

Developing more reliable predictors of seizure outcome following temporal lobe surgery for intractable epilepsy is an important clinical goal. In this context, we investigated patients with refractory temporal lobe epilepsy (TLE) before and after temporal resection. In detail, we explored gray matter (GM) volume change in relation with seizure outcome, using a voxel-based morphometry (VBM) approach. To do so, this study was divided into two parts. The first one involved group analysis of differences in regional GM volume between the groups (good outcome (GO), e.g., no seizures after surgery; poor outcome (PO), e.g., persistent postoperative seizures; and controls, N = 24 in each group), pre- and post-surgery. The second part of the study focused on pre-surgical data only (N = 61), determining whether the degree of GM abnormalities can predict surgical outcomes. For this second step, GM abnormalities were identified, within each lobe, in each patient when compared with an ad hoc sample of age-matched controls. For the first analysis, the results showed larger GM atrophy, mostly in the frontal lobe, in PO patients, relative to both GO patients and controls, pre-surgery. When comparing pre-to-post changes, we found relative GM gains in the GO but not in the PO patients, mostly in the non-resected hemisphere. For the second analysis, only the frontal lobe displayed reliable prediction of seizure outcome. 81% of the patients showing pre-surgical increased GM volume in the frontal lobe became seizure free, post-surgery; while 77% of the patients with pre-surgical reduced frontal GM volume had refractory seizures, post-surgery. A regression analysis revealed that the proportion of voxels with reduced frontal GM volume was a significant predictor of seizure outcome (p = 0.014). Importantly, having less than 1% of the frontal voxels with GM atrophy increased the likelihood of being seizure-free, post-surgery, by seven times. Overall, our results suggest that using pre-surgical GM abnormalities within the frontal lobe is a reliable predictor of seizure outcome post-surgery in TLE. We believe that this frontal GM atrophy captures seizure burden outside the pre-existing ictal temporal lobe, reflecting either the development of epileptogenesis or the loss of a protective, adaptive force helping to control or limit seizures. This study provides evidence of the potential of VBM-based approaches to predict surgical outcomes in refractory TLE candidates. PMID:26594628

Perioperative mortality in cats and dogs undergoing spay or castration at a high-volume clinic.

PubMed

Levy, J K; Bard, K M; Tucker, S J; Diskant, P D; Dingman, P A

2017-06-01

High volume spay-neuter (spay-castration) clinics have been established to improve population control of cats and dogs to reduce the number of animals admitted to and euthanazed in animal shelters. The rise in the number of spay-neuter clinics in the USA has been accompanied by concern about the quality of animal care provided in high volume facilities, which focus on minimally invasive, time saving techniques, high throughput and simultaneous management of multiple animals under various stages of anesthesia. The aim of this study was to determine perioperative mortality for cats and dogs in a high volume spay-neuter clinic in the USA. Electronic medical records and a written mortality log were used to collect data for 71,557 cats and 42,349 dogs undergoing spay-neuter surgery from 2010 to 2016 at a single high volume clinic in Florida. Perioperative mortality was defined as deaths occurring in the 24h period starting with the administration of the first sedation or anesthetic drugs. Perioperative mortality was reported for 34 cats and four dogs for an overall mortality of 3.3 animals/10,000 surgeries (0.03%). The risk of mortality was more than twice as high for females (0.05%) as for males (0.02%) (P=0.008) and five times as high for cats (0.05%) as for dogs (0.009%) (P=0.0007). High volume spay-neuter surgery was associated with a lower mortality rate than that previously reported in low volume clinics, approaching that achieved in human surgery. This is likely to be due to the young, healthy population of dogs and cats, and the continuous refinement of techniques based on experience and the skills and proficiency of teams that specialize in a limited spectrum of procedures. Copyright © 2017 Elsevier Ltd. All rights reserved.

Technique for systematic bone reduction for fixed implant-supported prosthesis in the edentulous maxilla.

PubMed

Bidra, Avinash S

2015-06-01

Bone reduction for maxillary fixed implant-supported prosthodontic treatment is often necessary to either gain prosthetic space or to conceal the prosthesis-tissue junction in patients with excessive gingival display (gummy smile). Inadequate bone reduction is often a cause of prosthetic failure due to material fractures, poor esthetics, or inability to perform oral hygiene procedures due to unfavorable ridge lap prosthetic contours. Various instruments and techniques are available for bone reduction. It would be helpful to have an accurate and efficient method for bone reduction at the time of surgery and subsequently create a smooth bony platform. This article presents a straightforward technique for systematic bone reduction by transferring the patient's maximum smile line, recorded clinically, to a clear radiographic smile guide for treatment planning using cone beam computed tomography (CBCT). The patient's smile line and the amount of required bone reduction are transferred clinically by marking bone with a sterile stationery graphite wood pencil at the time of surgery. This technique can help clinicians to accurately achieve the desired bone reduction during surgery, and provide confidence that the diagnostic and treatment planning goals have been achieved. Copyright © 2015 Editorial Council for the Journal of Prosthetic Dentistry. Published by Elsevier Inc. All rights reserved.

Effects of hypertonic saline (7.5%) on extracellular fluid volumes compared with normal saline (0.9%) and 6% hydroxyethyl starch after aortocoronary bypass graft surgery.

PubMed

Järvelä, K; Koskinen, M; Kaukinen, S; Kööbi, T

2001-04-01

To compare the effects of hypertonic (7.5%) saline (HS), normal (0.9%) saline (NS), and 6% hydroxyethyl starch (HES) on extracellular fluid volumes in the early postoperative period after cardiopulmonary bypass. A prospective, randomized, double-blind study. University teaching hospital. Forty-eight patients scheduled for elective coronary artery bypass graft surgery. Patients were randomly allocated to receive 4 mL/kg of HS, NS, or HES during 30 minutes when volume loading was needed during the postoperative rewarming period in the intensive care unit. Plasma volume was measured using a dilution of iodine-125-labeled human serum albumin. Extracellular water and cardiac output were measured by whole-body impedance cardiography. Plasma volume had increased by 19 +/- 7% in the HS group and by 10 +/- 3% in the NS group (p = 0.001) at the end of the study fluid infusion. After 1-hour follow-up time, the plasma volume increase was greatest (23 +/- 8%) in the group receiving HES (p < 0.001). The increase of extracellular water was greater than the infused volume in the HS and HES groups at the end of the infusion. One-hour diuresis after the study infusion was greater in the HS group (536 +/- 280 mL) than in the NS (267 +/- 154 mL, p = 0.006) and HES groups (311 +/- 238 mL, p = 0.025). The effect of HS on plasma volume was short-lasting, but it stimulated excretion of excess body fluid accumulated during cardiopulmonary bypass and cardiac surgery. HS may be used in situations in which excess free water administration is to be avoided but the intravascular volume needs correction. Copyright 2001 by W.B. Saunders Company

The Regionalization of Lumbar Spine Procedures in New York State: A 10-Year Analysis.

PubMed

Jancuska, Jeffrey; Adrados, Murillo; Hutzler, Lorraine; Bosco, Joseph

2016-01-01

A retrospective review of an administrative database. The purpose of this study is to determine the current extent of regionalization by mapping lumbar spine procedures according to hospital and patient zip code, as well as examine the rate of growth of lumbar spine procedures performed at high-, medium-, and low-volume institutions in New York State. The association between hospital and spine surgeon volume and improved patient outcomes is well established. There is no study investigating the actual process of patient migration to high-volume hospitals. New York Statewide Planning and Research Cooperative System (SPARCS) administrative data were used to identify 228,695 lumbar spine surgery patients from 2005 to 2014. The data included the patients' zip code, hospital of operation, and year of discharge. The volume of lumbar spine surgery in New York State was mapped according to patient and hospital 3-digit zip code. New York State hospitals were categorized as low, medium, and high volume and descriptive statistics were used to determine trends in changes in hospital volume. Lumbar spine surgery recipients are widely distributed throughout the state. Procedures are regionalized on a select few metropolitan centers. The total number of procedures grew 2.5% over the entire 10-year-period. High-volume hospital caseload increased 50%, from 7253 procedures in 2005 to 10,915 procedures in 2014. The number of procedures at medium and low-volume hospitals decreased 30% and 13%, respectively. Despite any concerted effort aimed at moving orthopedic patients to high-volume hospitals, migration to high-volume centers occurred. Public interest in quality outcomes and cost, as well as financial incentives among medical centers to increase market share, potentially influence the migration of patients to high-volume centers. Further regionalization has the potential to exacerbate the current level of disparities among patient populations at low and high-volume hospitals. 3.

Progressive contralateral hippocampal atrophy following surgery for medically refractory temporal lobe epilepsy.

PubMed

Elliott, Cameron A; Gross, Donald W; Wheatley, B Matt; Beaulieu, Christian; Sankar, Tejas

2016-09-01

Determine the extent and time course of volumetric changes in the contralateral hippocampus following surgery for medically refractory temporal lobe epilepsy (TLE). Serial T1-weighted MRI brain scans were obtained in 26 TLE patients pre- and post-temporal lobe epilepsy surgery as well as in 12 control subjects of similar age. Patients underwent either anterior temporal lobectomy (ATL) or selective amygdalohippocampectomy (SAH). Blinded, manual hippocampal volumetry (head, body, and tail) was performed in two groups: 1) two scan group [ATL (n=6); SAH (n=10)], imaged pre-surgery and on average at 5.4 years post-surgery; and 2) longitudinal group [ATL (n=8); SAH (n=2)] imaged pre-surgery and on post-operative day 1, 2, 3, 6, 60, 120 and a delayed time point (average 2.4 years). In the two scan group, there was atrophy by 12% of the unresected contralateral hippocampus (p<0.001), with atrophy being most pronounced (27%) in the hippocampal body (p<0.001) with no significant differences seen for the hippocampal head or tail. In the longitudinal group, significant atrophy was also observed for the whole hippocampus and the body with atrophy seen as early as post-operative day #1 which progressed significantly over the first post-operative week (1.3%/day and 3.0%./day, respectively) before stabilizing over the long-term to a 13% reduction in total volume. There was no significant difference in atrophy compared by surgical approach (ATL vs. SAH; p=0.94) or side (p=0.31); however, atrophy was significantly more pronounced in patients with ongoing post-operative seizures (hippocampal body, p=0.019; whole hippocampus, p=0.048). There were no detectable post-operative neuropsychological deficits attributable to contralateral hippocampal atrophy. Significant contralateral hippocampal atrophy occurs following TLE surgery, which begins immediately and progresses over the first post-operative week. The observation that seizure free patients had significantly less atrophy of the contralateral hippocampus after surgery suggests the possibility of an early post-operative imaging marker to predict surgical outcome. Copyright © 2016 Elsevier B.V. All rights reserved.

Global safe anaesthesia and surgery initiatives: implications for anaesthesia in the Pacific region.

PubMed

Cooper, M G; Wake, P B; Morriss, W W; Cargill, P D; McDougall, R J

2016-05-01

In 2015 three major events occurred for global anaesthesia and surgery. In January, the World Bank published Disease Control Priorities 3rd edition (DCP 3rd edition). This volume, Essential Surgery, highlighted the cost effective role of anaesthesia and surgery in global health. In April, the Lancet Commission on Global Surgery released its report "Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development". The report focuses on five key areas to promote change including: access to timely surgery, surgical workforce and procedural capability, surgical volume, data collection such as perioperative mortality rate, and financial protection. In May, the 68th World Health Assembly (WHA) voted in favour of Resolution A68/31: Strengthening emergency and essential surgical and anaesthesia care as a component of universal health coverage. The resolution was passed unanimously and it is the first time that surgery and anaesthesia have received such prominence at WHA level. These three events all have profound implications for the provision and access of safe anaesthesia and surgery in the Pacific region in the next 15 years. This article considers some of the regional factors that affect these five key areas, especially with regard to anaesthetic specialist workforce density in different parts of the region. There are many challenges to improve anaesthesia access, safety, and workforce density in the Pacific region. Future efforts, initiatives and support will help address these problems.

The use of contraception for patients after bariatric surgery.

PubMed

Ostrowska, Lucyna; Lech, Medard; Stefańska, Ewa; Jastrzębska-Mierzyńska, Marta; Smarkusz, Joanna

2016-01-01

Obesity in women of reproductive age is a serious concern regarding reproductive health. In many cases of infertility in obese women, reduction of body weight may lead to spontaneous pregnancy, without the need for more specific methods of treatment. Bariatric surgery is safe and is the most effective method for body weight reduction in obese and very obese patients. In practice there are two bariatric techniques; gastric banding, which leads to weight loss through intake restriction, and gastric bypass, leads to weight loss through food malabsorption. Gastric bypass surgery (the more frequently performed procedure), in most cases, leads to changes in eating habits and may result in vomiting, diarrhea and rapid body mass reduction. There are reliable data describing the continuous increase in the number of women who are trying to conceive, or are already pregnant, following bariatric surgery. Most medical specialists advise women to avoid pregnancy within 12-18 months after bariatric surgery. This allows for time to recover sufficiency from the decreased absorption of nutrients caused by the bariatric surgery. During this period there is a need for the use of reliable contraception. As there is a risk for malabsorption of hormones taken orally, the combined and progestogen-only pills are contraindicated, and displaced by non-oral hormonal contraception or non-hormonal methods, including intrauterine devices and condoms.

Effects of daikenchuto, a Japanese herb, on intestinal motility after total gastrectomy: a prospective randomized trial.

PubMed

Akamaru, Yusuke; Takahashi, Tsuyoshi; Nishida, Toshirou; Omori, Takeshi; Nishikawa, Kazuhiro; Mikata, Shoki; Yamamura, Noriyuki; Miyazaki, Satoru; Noro, Hiroshi; Takiguchi, Shuji; Mori, Masaki; Doki, Yuichiro

2015-03-01

This study aimed to assess the efficacy of daikenchuto (DKT), a commonly prescribed, traditional Japanese herbal medicine, on postoperative intestinal dysfunction after gastric cancer surgery. Patients with gastric cancer scheduled for a total gastrectomy were randomly assigned before surgery to receive either no treatment (n = 40; control group) or DKT (7.5 g/day, t.i.d.) for 3 months (n = 41) postoperatively. We examined gastrointestinal motility, stool attributes, the quantity of bowel gas, the quality of life, and the incidence of postoperative ileus. During the hospital stay, significant differences were observed between the DKT group and controls in the number of stools per day (1.1 ± 0.6 vs 0.8 ± 0.4, respectively; P = 0.037) and stool consistencies (Bristol scale ratings were 3.7 ± 0.8 vs 3.1 ± 0.8, respectively; P = 0.041). The DKT group showed significant reductions in gas volume scores, calculated from abdominal radiographs, at 7 days, 1 month, and 3 months after surgery. The groups did not show significant differences in quality of life scores (based on the Gastrointestinal Symptom Rating Scale) or in the incidence of postoperative ileus. DKT improved bowel movements, stool properties, and bowel gas. These results suggested that DKT promoted early postoperative bowel functions after total gastrectomy.

The impact of a dedicated patent ductus arteriosus ligation team on neonatal health-care outcomes.

PubMed

Resende, M H F; More, K; Nicholls, D; Ting, J; Jain, A; McNamara, P J

2016-06-01

The decision to perform patent ductus arteriosus (PDA) ligation is controversial. Patient selection is oftentimes poorly standardized, leading to delays in referral and inappropriate intervention. A system for PDA ligation categorization and triaging process was introduced in 2006 at a quaternary hospital in Canada to streamline referrals and enhance perioperative care. We aimed to evaluate the impact of this dedicated PDA ligation triaging system comparing pre- and postimplementation of this system. We performed a retrospective chart review. Demographic and cardiorespiratory data of neonates ⩽30 weeks gestation age at birth, who were referred for and/or had a PDA ligation performed during two distinct epochs (EPOCH 1 (2003 to 2005) and EPOCH 2 (2010 to 2012)), were analyzed. All surgeries were performed at The Hospital for Sick Children, the regional referral center for PDA ligation. The primary outcome was incidence of PDA ligation and procedural cancellations. Secondary outcomes included postoperative need for cardiovascular or respiratory support. Subgroup analysis was performed in neonates <1000 vs >1000 g at the time of surgery during both epochs. A total of 198 neonates underwent surgery with no difference in baseline demographics between epochs. The incidence of PDA ligation as a proportion of total live births under 30 weeks in Central East Region of Ontario was lower in the second epoch (EPOCH 1: 117/1092 (10.7%) vs EPOCH 2: 81/1520 (5.3%)). During the second epoch, 24% of referrals for surgery were canceled after review by our PDA ligation team. There were no overall differences in the proportion of neonates with oxygenation failure, ventilation failure or Post-Ligation Cardiac Syndrome (PLCS), after surgery, between epochs. The proportion of neonates who developed systemic hypotension was higher in patients <1000 g (n=34 (34%) vs n=17 (17.4%), P=0.01) at the time of surgery. In addition, we identified a reduction in the proportion of neonates <1000 g who developed PLCS in EPOCH 2. On the contrary, there was an increase in the proportion of neonates >1000 g who developed ventilation failure in EPOCH 2. The presence of dedicated triaging and management system enhances efficiency of referral process through careful selection of patients for PDA ligation and optimizes perioperative management. We demonstrated a reduction in the incidence of PDA ligation without any negative impact on short-term neonatal morbidity. The use of targeted neonatal echocardiography in the assessment of PDA shunt volume and guiding postoperative decision making is likely to have contributed to these findings.

Mid-term results of cardiac autotransplantation as method to treat permanent atrial fibrillation and mitral disease.

PubMed

Troise, Giovanni; Cirillo, Marco; Brunelli, Federico; Tasca, Giordano; Amaducci, Andrea; Mhagna, Zen; Tomba, Margherita Dalla; Quaini, Eugenio

2004-06-01

The results of current surgical options for the treatment of permanent atrial fibrillation (AF) associated with mitral surgery are widely different, particularly in very enlarged left atria. The aim of this study was to assess the mid-term efficacy of cardiac autotransplantation for this goal, through a consistent reduction of left atrium volume and a complete isolation of the pulmonary veins. From April 2000 to September 2002, 30 patients (male/female 5/25) underwent cardiac autotransplantation for the treatment of mitral valve disease and concomitant permanent AF (>1 year). Surgical technique of bicaval heart transplantation was modified maintaining the connection of inferior vena cava in all but three cases. Twenty-eight patients had mitral valve replacement and two had mitral valve repair. Associated procedures were: aortic valve replacement (6 cases), tricuspid valve repair (2 cases), coronary re-vascularization (2 cases) and right atrium volume reduction (4 cases). No hospital death occurred; 1 patient died 3 months post-operatively for pneumonia. At a mean follow-up of 21.1+/-7.7 months (range 6-35), 26 patients (89.7%) were in sinus rhythm and 3 (10.3%) in AF. Santa Cruz Score was 0 in 3 patients, 2 in 2 patients and 4 in the remaining 24 patients (82.7%). Mean left atrial diameter and volume decreased from 65.1+/-16.4 mm (range 50-130 mm) to 49.9+/-8.4 mm (range 37-78) (P < 0.001) and from 118.3+/-68.4 ml (range 60-426) to 69.4+/-34.1 ml (range 31-226) (P = 0.001), respectively, after the operation. Cardiac autotransplantation is a safe and effective option for the treatment of permanent AF in patients with mitral valve disease and severe dilation of left atrium.

A novel implantable catheter system with transcutaneous port for intermittent convection-enhanced delivery of carboplatin for recurrent glioblastoma.

PubMed

Barua, Neil U; Hopkins, Kirsten; Woolley, Max; O'Sullivan, Stephen; Harrison, Rob; Edwards, Richard J; Bienemann, Alison S; Wyatt, Marcella J; Arshad, Azeem; Gill, Steven S

2016-01-01

Inadequate penetration of the blood-brain barrier (BBB) by systemically administered chemotherapies including carboplatin is implicated in their failure to improve prognosis for patients with glioblastoma. Convection-enhanced delivery (CED) of carboplatin has the potential to improve outcomes by facilitating bypass of the BBB. We report the first use of an implantable CED system incorporating a novel transcutaneous bone-anchored port (TBAP) for intermittent CED of carboplatin in a patient with recurrent glioblastoma. The CED catheter system was implanted using a robot-assisted surgical method. Catheter targeting accuracy was verified by performing intra-operative O-arm imaging. The TBAP was implanted using a skin-flap dermatome technique modeled on bone-anchored hearing aid surgery. Repeated infusions were performed by attaching a needle administration set to the TBAP. Drug distribution was monitored with serial real-time T2-weighted magnetic resonance imaging (MRI). All catheters were implanted to within 1.5 mm of their planned target. Intermittent infusions of carboplatin were performed on three consecutive days and repeated after one month without the need for further surgical intervention. Infused volumes of 27.9 ml per day were well tolerated, with the exception of a single seizure episode. Follow-up MRI at eight weeks demonstrated a significant reduction in the volume of tumor enhancement from 42.6 ml to 24.6 ml, and was associated with stability of the patient's clinical condition. Reduction in the volume of tumor enhancement indicates that intermittent CED of carboplatin has the potential to improve outcomes in glioblastoma. The novel technology described in this report make intermittent CED infusion regimes an achievable treatment strategy.

Outcomes of Radiofrequency Ablation Therapy for Large Benign Thyroid Nodules: A Mayo Clinic Case Series.

PubMed

Hamidi, Oksana; Callstrom, Matthew R; Lee, Robert A; Dean, Diana; Castro, M Regina; Morris, John C; Stan, Marius N

2018-03-21

To assess the effectiveness, tolerability, and complications of radiofrequency ablation (RFA) in patients with benign large thyroid nodules (TNs). This is a retrospective review of 14 patients with predominantly solid TNs treated with RFA at Mayo Clinic in Rochester, Minnesota, from December 1, 2013, through October 30, 2016. All the patients declined surgery or were poor surgical candidates. The TNs were benign on fine-needle aspiration, enlarging or causing compressive symptoms, and 3 cm or larger in largest diameter. We evaluated TN volume, compressive symptoms, cosmetic concerns, and thyroid function. Median TN volume reduction induced by RFA was 44.6% (interquartile range [IQR], 42.1%-59.3%), from 24.2 mL (IQR, 17.7-42.5 mL) to 14.4 mL (IQR, 7.1-19.2 mL) (P<.001). Median follow-up was 8.6 months (IQR, 3.9-13.9 months). Maximum results were achieved by 6 months. Radiofrequency ablation did not affect thyroid function. In 1 patient with subclinical hyperthyroidism due to toxic adenoma, thyroid function normalized 4 months after ablation of the toxic nodule. Compressive symptoms resolved in 8 of 12 patients (67%) and improved in the other 4 (33%). Cosmetic concerns improved in all 8 patients. The procedure had no sustained complications. In this population, RFA of benign large TNs performed similarly to the reports from Europe and Asia. It induces a substantial volume reduction of predominantly solid TNs, improves compressive symptoms and cosmetic concerns, and does not affect normal thyroid function. Radiofrequency ablation has an acceptable safety profile and should be considered as a low-risk alternative to conventional treatment of symptomatic benign TNs. Copyright © 2017 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.

Analysis of Cosmetic Topics on the Plastic Surgery In-Service Training Exam.

PubMed

Silvestre, Jason; Taglienti, Anthony J; Serletti, Joseph M; Chang, Benjamin

2015-08-01

The Plastic Surgery In-Service Training Exam (PSITE) is a multiple-choice examination taken by plastic surgery trainees to provide an assessment of plastic surgery knowledge. The purpose of this study was to evaluate cosmetic questions and determine overlap with national procedural data. Digital syllabi of six consecutive PSITE administrations (2008-2013) were analyzed for cosmetic surgery topics. Questions were classified by taxonomy, focus, anatomy, and procedure. Answer references were tabulated by source. Relationships between tested material and national procedural volume were assessed via Pearson correlation. 301 questions addressed cosmetic topics (26% of all questions) and 20 required image interpretations (7%). Question-stem taxonomy favored decision-making (40%) and recall (37%) skills over interpretation (23%, P < .001). Answers focused on treatments/outcomes (67%) over pathology/anatomy (20%) and diagnoses (13%, P < .001). Tested procedures were largely surgical (85%) and focused on the breast (25%), body (18%), nose (13%), and eye (10%). The most common surgeries were breast augmentation (12%), rhinoplasty (11%), blepharoplasty (10%), and body contouring (6%). Minimally invasive procedures were lasers (5%), neuromodulators (4%), and fillers (3%). Plastic and Reconstructive Surgery (58%), Clinics in Plastic Surgery (7%), and Aesthetic Surgery Journal (6%) were the most cited journals, with a median 5-year publication lag. There was poor correlation between PSITE content and procedural volume data (r(2) = 0.138, P = .539). Plastic surgeons receive routine evaluation of cosmetic surgery knowledge. These data may help optimize clinical and didactic experiences for training in cosmetic surgery. © 2015 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com.

Does Body Mass Index Reduction by Bariatric Surgery Affect Laryngoscopy Difficulty During Subsequent Anesthesia?

PubMed

Shimonov, Mordechai; Schechter, Pinhas; Boaz, Mona; Waintrob, Ronen; Ezri, Tiberiu

2017-03-01

The effect of body mass index (BMI) reduction following bariatric surgery on subsequent airway management has not been investigated. This study aimed to investigate the association between BMI reduction and airway assessment and management measured by Mallampati class (MC) and laryngoscopy grade (LG). We conducted a retrospective study over 6 years to compare the BMI changes, MC and LG in patients having weight reduction bariatric surgery followed by subsequent surgery. Data was extracted from the anesthesia records of patients undergoing laparoscopic band insertion (LBI) and laparoscopic sleeve gastrectomy (LSG). Difficult airway was defined as Malampati class 3 and 4 on a 1-4 difficulty scale or laryngoscopy grade >2 on a 1-4 difficulty scale and need for unplanned fiberoptic intubation. Changes in these variables were correlated with weight reduction. Statistical analysis included t test, univariante, and multivariant logistic regression. Five hundred forty-six patients underwent LSG and 83 patients had LBI during the study period. Of those patients, 65 patients had subsequent surgical procedures after the bariatric procedure. Of the 65 patients identified, 62 were eligible. BMI decreased by approximately13 kg/m 2 (p = 0.000) which roughly represents a 30 % reduction between the two surgical procedures. Mallampati class decreased significantly (p = 0.000) while laryngoscopy grade did not (p = 0.419). Our study revealed that a significant reduction in BMI was associated with a significant decrease in Mallampati class. There was no significant decrease in laryngoscopy grade, and there was no case of unplanned fiberoptic intubation.

Evaluation of breast reduction surgery effect on body posture and gait pattern using three-dimensional gait analysis.

PubMed

Sahin, Ismail; Iskender, Salim; Ozturk, Serdar; Balaban, Birol; Isik, Selcuk

2013-06-01

Breast hypertrophy is a significant health burden with symptoms of back and shoulder pain, intertrigo, and shoulder grooving from the bra straps. Women often rely on surgery to relieve these symptoms, and they are mostly satisfied with the results. The satisfaction from surgery usually is evaluated by subjective measures. Objective evidence testing of the surgical outcomes is lacking. In this study, 10 women with breast hypertrophy underwent reduction mammaplasty. Their surgical outcomes were evaluated using three-dimensional gait analysis before surgery and 2 months afterward. A statistical difference was sought between the kinematic data of the spine, hip, knee, and ankle joints. The average maximum anterior pelvic tilt angles decreased 41 %, and the average maximum spine anterior flexion angles decreased 30 %. The difference between the pre- and postoperative values was statistically significant. The analysis of the kinematic data showed no significant difference in the hip, knee, or ankle joint angles postoperatively. The outcomes of breast reduction surgery have been evaluated mostly by subjective means until recently. As an objective evidence for surgical gain in the current study, reduction mammaplasty resulted in the patients' improved body posture when walking. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Healing response of apicomarginal defects to two guided tissue regeneration techniques in periradicular surgery: a double-blind, randomized-clinical trial.

PubMed

Marín-Botero, M L; Domínguez-Mejía, J S; Arismendi-Echavarría, J A; Mesa-Jaramillo, A L; Flórez-Moreno, G A; Tobón-Arroyave, S I

2006-05-01

To compare healing responses to periosteal sliding grafts and polyglactin 910 periodontal mesh used as guided tissue regeneration (GTR) materials/techniques when both periapical and periradicular bone loss are present. Thirty patients with suppurative chronic apical periodontitis with apicomarginal communication were selected and allocated randomly into two groups according to the barrier technique to be used during periradicular surgery: periosteal graft group (n = 15) and bioabsorbable membrane group (n = 15). Clinical and radiological evaluations were completed prior to surgery, a week later and every 3 months after surgery up to 12 months to measure the periodontal pocket depth (PD), clinical attachment level (CAL), gingival margin position (GMP), size of periapical lesion, percentage reduction of the periapical rarefaction, and periapical healing. Both groups showed highly significant (P < 0.001) reductions in periodontal PD, CAL and size of periapical lesion at 12 months whilst GMP was unaltered. No significant difference between the experimental groups was evident for these parameters, or for the percentage reduction of size of the periapical lesion and clinical-radiographic healing. Guided tissue regeneration applied to apicomarginal defects using sliding periosteal grafts and use of bioabsorbable membranes led to similar enhancements of the clinical outcome of periradicular surgery in terms of periapical healing, gain of periodontal support, PD reduction and minimal recession of the gingival margin.

Medical malpractice predictors and risk factors for ophthalmologists performing LASIK and PRK surgery.

PubMed Central

Abbott, Richard L

2003-01-01

PURPOSE: To identify physician predictors in laser-assisted in-situ keratomileusis (LASIK) and photorefractive keratectomy (PRK) surgery that correlate with a higher risk for malpractice liability claims and lawsuits. METHODOLOGY: A retrospective, longitudinal, cohort study comparing physician characteristics of 100 consecutive Ophthalmic Mutual Insurance Company (OMIC) LASIK and PRK claims and suits to demographic and practice pattern data for all active refractive surgeons insured by OMIC between 1996 and 2002. Background information and data were obtained from OMIC underwriting applications, a physician practice pattern survey, and claims file records. Using an outcome of whether or not a physician had a prior history of a claim or suit, logistic regression analyses were used separately for each predictor as well as controlling for refractive surgery volume. RESULTS: Logistic regression analysis demonstrated that the most important predictor of filing a claim was surgical volume, with those performing more surgery having a greater risk of incurring a claim (odds ratio [OR], 31.4 for >1,000/year versus 0 to 20/year; 95% confidence interval [CI], 7.9 - 125; P = .0001). Having one or more prior claims was the only other predictor examined that remained statistically significant after controlling for patient volume (OR, 6.4; 95% CI 2.5 - 16.4; P = .0001). Physician gender, advertising, preoperative time spent with patient, and comanagement appeared to be strong predictors in multivariate analyses when surgical volume was greater than 100 cases per year. CONCLUSION: The chances of incurring a malpractice claim or suit for PRK or LASIK correlates significantly with higher surgical volume and a history of a prior claim or suit. Additional risk factors that increase in importance with higher surgical volume include gender, advertising, preoperative time spent with patient, and comanagement with optometrists. These findings may be used in the future to help improve the quality of care for patients undergoing refractive surgery and provide data for underwriting criteria and risk management protocols to proactively manage and reduce the risk of claims and lawsuits against refractive surgeons. PMID:14971582

Significant Reduction of Late Toxicities in Patients With Extremity Sarcoma Treated With Image-Guided Radiation Therapy to a Reduced Target Volume: Results of Radiation Therapy Oncology Group RTOG-0630 Trial.

PubMed

Wang, Dian; Zhang, Qiang; Eisenberg, Burton L; Kane, John M; Li, X Allen; Lucas, David; Petersen, Ivy A; DeLaney, Thomas F; Freeman, Carolyn R; Finkelstein, Steven E; Hitchcock, Ying J; Bedi, Manpreet; Singh, Anurag K; Dundas, George; Kirsch, David G

2015-07-10

We performed a multi-institutional prospective phase II trial to assess late toxicities in patients with extremity soft tissue sarcoma (STS) treated with preoperative image-guided radiation therapy (IGRT) to a reduced target volume. Patients with extremity STS received IGRT with (cohort A) or without (cohort B) chemotherapy followed by limb-sparing resection. Daily pretreatment images were coregistered with digitally reconstructed radiographs so that the patient position could be adjusted before each treatment. All patients received IGRT to reduced tumor volumes according to strict protocol guidelines. Late toxicities were assessed at 2 years. In all, 98 patients were accrued (cohort A, 12; cohort B, 86). Cohort A was closed prematurely because of poor accrual and is not reported. Seventy-nine eligible patients from cohort B form the basis of this report. At a median follow-up of 3.6 years, five patients did not have surgery because of disease progression. There were five local treatment failures, all of which were in field. Of the 57 patients assessed for late toxicities at 2 years, 10.5% experienced at least one grade ≥ 2 toxicity as compared with 37% of patients in the National Cancer Institute of Canada SR2 (CAN-NCIC-SR2: Phase III Randomized Study of Pre- vs Postoperative Radiotherapy in Curable Extremity Soft Tissue Sarcoma) trial receiving preoperative radiation therapy without IGRT (P < .001). The significant reduction of late toxicities in patients with extremity STS who were treated with preoperative IGRT and absence of marginal-field recurrences suggest that the target volumes used in the Radiation Therapy Oncology Group RTOG-0630 (A Phase II Trial of Image-Guided Preoperative Radiotherapy for Primary Soft Tissue Sarcomas of the Extremity) study are appropriate for preoperative IGRT for extremity STS. © 2015 by American Society of Clinical Oncology.

Design of the Endobronchial Valve for Emphysema Palliation Trial (VENT): a non-surgical method of lung volume reduction.

PubMed

Strange, Charlie; Herth, Felix J F; Kovitz, Kevin L; McLennan, Geoffrey; Ernst, Armin; Goldin, Jonathan; Noppen, Marc; Criner, Gerard J; Sciurba, Frank C

2007-07-03

Lung volume reduction surgery is effective at improving lung function, quality of life, and mortality in carefully selected individuals with advanced emphysema. Recently, less invasive bronchoscopic approaches have been designed to utilize these principles while avoiding the associated perioperative risks. The Endobronchial Valve for Emphysema PalliatioN Trial (VENT) posits that occlusion of a single pulmonary lobe through bronchoscopically placed Zephyr endobronchial valves will effect significant improvements in lung function and exercise tolerance with an acceptable risk profile in advanced emphysema. The trial design posted on Clinical trials.gov, on August 10, 2005 proposed an enrollment of 270 subjects. Inclusion criteria included: diagnosis of emphysema with forced expiratory volume in one second (FEV1) < 45% of predicted, hyperinflation (total lung capacity measured by body plethysmography > 100%; residual volume > 150% predicted), and heterogeneous emphysema defined using a quantitative chest computed tomography algorithm. Following standardized pulmonary rehabilitation, patients were randomized 2:1 to receive unilateral lobar placement of endobronchial valves plus optimal medical management or optimal medical management alone. The co-primary endpoint was the mean percent change in FEV1 and six minute walk distance at 180 days. Secondary end-points included mean percent change in St. George's Respiratory Questionnaire score and the mean absolute changes in the maximal work load measured by cycle ergometry, dyspnea (mMRC) score, and total oxygen use per day. Per patient response rates in clinically significant improvement/maintenance of FEV1 and six minute walk distance and technical success rates of valve placement were recorded. Apriori response predictors based on quantitative CT and lung physiology were defined. If endobronchial valves improve FEV1 and health status with an acceptable safety profile in advanced emphysema, they would offer a novel intervention for this progressive and debilitating disease. ClinicalTrials.gov: NCT00129584.

Application of positive airway pressure in restoring pulmonary function and thoracic mobility in the postoperative period of bariatric surgery: a randomized clinical trial

PubMed Central

Brigatto, Patrícia; Carbinatto, Jéssica C.; Costa, Carolina M.; Montebelo, Maria I. L.; Rasera-Júnior, Irineu; Pazzianotto-Forti, Eli M.

2014-01-01

Objective: To evaluate whether the application of bilevel positive airway pressure in the postoperative period of bariatric surgery might be more effective in restoring lung volume and capacity and thoracic mobility than the separate application of expiratory and inspiratory positive pressure. Method: Sixty morbidly obese adult subjects who were hospitalized for bariatric surgery and met the predefined inclusion criteria were evaluated. The pulmonary function and thoracic mobility were preoperatively assessed by spirometry and cirtometry and reevaluated on the 1st postoperative day. After preoperative evaluation, the subjects were randomized and allocated into groups: EPAP Group (n=20), IPPB Group (n=20) and BIPAP Group (n=20), then received the corresponding intervention: positive expiratory pressure (EPAP), inspiratory positive pressure breathing (IPPB) or bilevel inspiratory positive airway pressure (BIPAP), in 6 sets of 15 breaths or 30 minutes twice a day in the immediate postoperative period and on the 1st postoperative day, in addition to conventional physical therapy. Results: There was a significant postoperative reduction in spirometric variables (p<0.05), regardless of the technique used, with no significant difference among the techniques (p>0.05). Thoracic mobility was preserved only in group BIPAP (p>0.05), but no significant difference was found in the comparison among groups (p>0.05). Conclusion: The application of positive pressure does not seem to be effective in restoring lung function after bariatric surgery, but the use of bilevel positive pressure can preserve thoracic mobility, although this technique was not superior to the other techniques. PMID:25590448

Safety and efficacy of endovascular therapy and gamma knife surgery for brain arteriovenous malformations in China: Study protocol for an observational clinical trial.

PubMed

Jin, Hengwei; Huo, Xiaochuan; Jiang, Yuhua; Li, Xiaolong; Li, Youxiang

2017-09-01

Brain arteriovenous malformations (BAVMs) are associated with high morbidity and mortality. The treatment of BAVM remains controversial. Microinvasive treatment, including endovascular therapy and gamma knife surgery, has been the first choice in many conditions. However, the overall clinical outcome of microinvasive treatment remains unknown and a prospective trial is needed. This is a prospective, non-randomized, and multicenter observational registry clinical trial to evaluate the safety and efficacy of microinvasive treatment for BAVMs. The study will require up to 400 patients in approximately 12 or more centers in China, followed for 2 years. Main subjects of this study are BAVM patients underwent endovascular therapy and/or gamma knife surgery. The trial will not affect the choice of treatment modality. The primary outcomes are perioperative complications (safety), and postoperative hemorrhage incidence rate and complete occlusion rate (efficacy). Secondary outcomes are elimination of hemorrhage risk factors (coexisting aneurysms and arteriovenous fistula), volume reduction and remission of symptoms. Safety and efficacy of endovascular therapy, gamma knife surgery, and various combination modes of the two modalities will be compared. Operative complications and outcomes at pretreatment, post-treatment, at discharge and at 3 months, 6 months and 2 years follow-up intervals will be analyzed using the modified Rankin Scale (mRS). The most confusion on BAVM treatment is whether to choose interventional therapy or medical therapy, and the choice of interventional therapy modes. This study will provide evidence for evaluating the safety and efficacy of microinvasive treatment in China, to characterize the microinvasive treatment strategy for BAVMs.

Assessment of volume reduction effect after lung lobectomy for cancer.

PubMed

Ueda, Kazuhiro; Murakami, Junichi; Sano, Fumiho; Hayashi, Masataro; Kobayashi, Taiga; Kunihiro, Yoshie; Hamano, Kimikazu

2015-07-01

Lung lobectomy results in an unexpected improvement of the remaining lung function in some patients with moderate-to-severe emphysema. Because the lung function is the main limiting factor for therapeutic decision making in patients with lung cancer, it may be advantageous to identify patients who may benefit from the volume reduction effect, particularly those with a poor functional reserve. We measured the regional distribution of the emphysematous lung and normal lung using quantitative computed tomography in 84 patients undergoing lung lobectomy for cancer between January 2010 and December 2012. The volume reduction effect was diagnosed using a combination of radiologic and spirometric parameters. Eight patients (10%) were favorably affected by the volume reduction effect. The forced expiratory volume in one second increased postoperatively in these eight patients, whereas the forced vital capacity was unchanged, thus resulting in an improvement of the airflow obstruction postoperatively. This improvement was not due to a compensatory expansion of the remaining lung but was associated with a relative decrease in the forced end-expiratory lung volume. According to a multivariate analysis, airflow obstruction and the forced end-expiratory lung volume were independent predictors of the volume reduction effect. A combined assessment using spirometry and quantitative computed tomography helped to characterize the respiratory dynamics underlying the volume reduction effect, thus leading to the identification of novel predictors of a volume reduction effect after lobectomy for cancer. Verification of our results by a large-scale prospective study may help to extend the indications for lobectomy in patients with oncologically resectable lung cancer who have a marginal pulmonary function. Copyright © 2015 Elsevier Inc. All rights reserved.

The influence of a balanced volume replacement concept on inflammation, endothelial activation, and kidney integrity in elderly cardiac surgery patients.

PubMed

Boldt, Joachim; Suttner, Stephan; Brosch, Christian; Lehmann, Andreas; Röhm, Kerstin; Mengistu, Andinet

2009-03-01

A balanced fluid replacement strategy appears to be promising for correcting hypovolemia. The benefits of a balanced fluid replacement regimen were studied in elderly cardiac surgery patients. In a randomized clinical trial, 50 patients aged >75 years undergoing cardiac surgery received a balanced 6% HES 130/0.42 plus a balanced crystalloid solution (n = 25) or a non-balanced HES in saline plus saline solution (n = 25) to keep pulmonary capillary wedge pressure/central venous pressure between 12-14 mmHg. Acid-base status, inflammation, endothelial activation (soluble intercellular adhesion molecule-1, kidney integrity (kidney-specific proteins glutathione transferase-alpha; neutrophil gelatinase-associated lipocalin) were studied after induction of anesthesia, 5 h after surgery, 1 and 2 days thereafter. Serum creatinine (sCr) was measured approximately 60 days after discharge. A total of 2,750 +/- 640 mL of balanced and 2,820 +/- 550 mL of unbalanced HES were given until the second POD. Base excess (BE) was significantly reduced in the unbalanced (from +1.21 +/- 0.3 to -4.39 +/- 1.0 mmol L(-1) 5 h after surgery; P < 0.001) and remained unchanged in the balanced group (from 1.04 +/- 0.3 to -0.81 +/- 0.3 mmol L(-1) 5 h after surgery). Evolution of the BE was significantly different. Inflammatory response and endothelial activation were significantly less pronounced in the balanced than the unbalanced group. Concentrations of kidney-specific proteins after surgery indicated less alterations of kidney integrity in the balanced than in the unbalanced group. A total balanced volume replacement strategy including a balanced HES and a balanced crystalloid solution resulted in moderate beneficial effects on acid-base status, inflammation, endothelial activation, and kidney integrity compared to a conventional unbalanced volume replacement regimen.

Does Certification as Bariatric Surgery Center and Volume Influence the Outcome in RYGB-Data Analysis of German Bariatric Surgery Registry.

PubMed

Stroh, Christine; Köckerling, F; Lange, V; Wolff, S; Knoll, C; Bruns, C; Manger, Th

2017-02-01

To examine the association between the certification as bariatric surgery center and volume and patient outcome, data collected in the German Bariatric Surgery Registry were evaluated. All data were registered prospectively in cooperation with the Institute of Quality Assurance in Surgery at Otto-von-Guericke University Magdeburg. Data collection began in 2005 for all bariatric procedures in an online database. Participation in the quality assurance study is required for all certified bariatric surgery centers in Germany. Descriptive evaluation and matched pairs analysis were performed. Patients were matched via propensity score taking into account BMI, age, and incidence of comorbidities. During the period from 2005 to 2013, 3083 male and 10,639 female patients were operated on with the RYGB primary approach. In Centers of Competence (77.2 %) and non-accredited hospitals (76.3 %), the proportion of female patients was significantly lower than in Centers of Reference/Excellence (78.7 %; p = 0.002). The mean age in Centers of Reference/Excellence (41.2 years) was significantly lower than in Centers of Competence (43.2 years; p < 0.05). Propensity score analysis was performed to compare matched patients with regard to BMI, age, and incidence of comorbidities. The rate of general and surgical postoperative complications and mortality rate was significantly lower in certified Centers of Reference/Excellence compared to Centers of Competence with 29 and non-certified hospitals. There is evidence of improved patient outcome in certified bariatric surgery centers with higher volume. The study supports the concept of certification. There are different factors which can and cannot be preoperatively modified and influence the perioperative outcome.

[Dental implantation and soft tissue augmentation after ridge preservation in a molar site: a case report].

PubMed

Zhao, L P; Zhan, Y L; Hu, W J; Wang, H J; Wei, Y P; Zhen, M; Xu, T; Liu, Y S

2016-12-18

For ideal implant rehabilitation, an adequate bone volume, optical implant position, and stable and healthy soft tissue are required. The reduction of alveolar bone and changes in its morphology subsequent to tooth extraction will result in insufficient amount of bone and adversely affect the ability to optimally place dental implants in edentulous sites. Preservation of alveolar bone volume through ridge preservation has been demonstrated to reduce the vertical and horizontal contraction of the alveolar bone crest after tooth extraction and reduce the need for additional bone augmentation procedures during implant placement. In this case, a patient presented with a mandible molar of severe periodontal disease, the tooth was removed as atraumatically as possible and the graft material of Bio-Oss was loosely placed in the alveolar socket without condensation and covered with Bio-Gide to reconstruct the defects of the alveolar ridge. Six months later, there were sufficient height and width of the alveolar ridge for the dental implant, avoiding the need of additional bone augmentation and reducing the complexity and unpredictability of the implant surgery. Soft tissue defects, such as gingival and connective tissue, played crucial roles in long-term implant success. Peri-implant plastic surgery facilitated development of healthy peri-implant structure able to withstand occlusal forces and mucogingival stress. Six months after the implant surgery, the keratinized gingiva was absent in the buccal of the implant and the vestibular groove was a little shallow. The free gingival graft technique was used to solve the vestibulum oris groove supersulcus and the absence of keratinized gingiva around the implant. The deepening of vestibular groove and broadening of keratinized gingiva were conducive to the long-term health and stability of the tissue surrounding the implant. Implant installation and prosthetic restoration showed favorable outcome after six months.

Treatment of Obesity: Weight Loss and Bariatric Surgery

PubMed Central

Wolfe, Bruce M.; Kvach, Elizaveta; Eckel, Robert H.

2016-01-01

This review focuses on the mechanisms underlying, and indications for, bariatric surgery in the reduction of cardiovascular disease (CVD) as well as other expected benefits of this intervention. The fundamental basis for bariatric surgery for the purpose of accomplishing weight loss is the determination that severe obesity is a disease associated with multiple adverse effects on health which can be reversed or improved by successful weight loss in patients who have been unable to sustain weight loss by non-surgical means. An explanation of possible indications for weight loss surgery as well as specific bariatric surgical procedures is presented, along with review of the safety literature of such procedures. Procedures that are less invasive or those that involve less gastrointestinal rearrangement accomplish considerably less weight loss but have substantially lower perioperative and longer-term risk. The ultimate benefit of weight reduction relates to the reduction of the co-morbidities, quality of life and all-cause mortality. With weight loss being the underlying justification for bariatric surgery in ameliorating CVD risk, current evidence-based research is discussed concerning body fat distribution, dyslipidemia, hypertension, diabetes, inflammation, obstructive sleep apnea and others. The rationale for bariatric surgery reducing CVD events is discussed and juxtaposed with impacts on all-cause mortalities. Given the improvement of established obesity-related CVD risk factors following weight loss, it is reasonable to expect a reduction of CVD events and related mortality following weight loss in populations with obesity. The quality of the current evidence is reviewed and future research opportunities and summaries are stated. PMID:27230645

Volume guarantee ventilation during surgical closure of patent ductus arteriosus.

PubMed

Keszler, Martin; Abubakar, Kabir

2015-01-01

Surgical closure of patent ductus arteriosus (PDA) is associated with adverse outcomes. Surgical exposure requires retraction of the lung, resulting in decreased aeration and compliance. Optimal respiratory support for PDA surgery is unknown. Experience with volume guarantee (VG) ventilation at our institution led us to hypothesize that surgery would be better tolerated with automatic adjustment of pressure by VG to maintain tidal volume (VT) during retraction. The objective of this study was to describe ventilator support, VT, and oxygenation of infants supported with VG during PDA surgery. Ventilator variables, oxygen saturation, and heart rate were recorded during PDA surgery in a convenience sample of infants during PDA closure on VG. Pressure limit increased 11% and set VT was 26% lower during lung retraction. Fentanyl and pancuronium/vecuronium were used for anesthesia/muscle relaxation. Longitudinal data were analyzed by analysis of variance for repeated measures. Seven infants, 25.4 ± 1.5 weeks and 723 ± 141 g, underwent closure of PDA on VG at a mean age 29.9 days. No air leak, bradycardia, or death occurred. Target VT was maintained with a modest increase in inflation pressure. Oxygenation remained adequate. VG avoided hypoxemia and maintained adequate VT with only a modest increase in peak inflation pressure and thus may be a useful mode during PDA surgery. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

The efficacy of tolvaptan in the perioperative management of chronic kidney disease patients undergoing open-heart surgery.

PubMed

Yamada, Mitsutomo; Nishi, Hiroyuki; Sekiya, Naosumi; Horikawa, Kohei; Takahashi, Toshiki; Sawa, Yoshiki

2017-04-01

The perioperative management of chronic kidney disease (CKD) patients undergoing open-heart surgery is challenging. In this study, we evaluated the effects of tolvaptan in CKD patients after open-heart surgery. Between 2010 to 2015, 731 patients underwent open-heart surgery in our hospital. We consecutively selected 71 patients with stage IIIa-IV CKD and divided them into two groups. Those who received tolvaptan postoperatively were defined as the "Tolvaptan group" (n = 25) and those who did not were defined as the "Non-tolvaptan group" (n = 46). We compared the urine volume of postoperative days (POD) 1 and 2, the number of days to return to preoperative body weight (BW), and the change in the postoperative estimated glomerular filtration rate (eGFR). In the tolvaptan group, the urine volume was significantly larger (P = .04) and the duration to preoperative BW tended to be shorter. Overall, the postoperative change in the eGFR tended to be better in the tolvaptan group (P = .008). In particular, we found a significantly better trend in CKD stage IV (P = .04) patients and in the patients, whose cardiopulmonary bypass (CPB) time was longer than 120 min (P = .03). Tolvaptan can safely be used for CKD patients undergoing open-heart surgery and can provide a feasible urine volume without leading to a deterioration of their renal function.

Adoption of robotics in a general surgery residency program: at what cost?

PubMed

Mehaffey, J Hunter; Michaels, Alex D; Mullen, Matthew G; Yount, Kenan W; Meneveau, Max O; Smith, Philip W; Friel, Charles M; Schirmer, Bruce D

2017-06-01

Robotic technology is increasingly being utilized by general surgeons. However, the impact of introducing robotics to surgical residency has not been examined. This study aims to assess the financial costs and training impact of introducing robotics at an academic general surgery residency program. All patients who underwent laparoscopic or robotic cholecystectomy, ventral hernia repair (VHR), and inguinal hernia repair (IHR) at our institution from 2011-2015 were identified. The effect of robotic surgery on laparoscopic case volume was assessed with linear regression analysis. Resident participation, operative time, hospital costs, and patient charges were also evaluated. We identified 2260 laparoscopic and 139 robotic operations. As the volume of robotic cases increased, the number of laparoscopic cases steadily decreased. Residents participated in all laparoscopic cases and 70% of robotic cases but operated from the robot console in only 21% of cases. Mean operative time was increased for robotic cholecystectomy (+22%), IHR (+55%), and VHR (+61%). Financial analysis revealed higher median hospital costs per case for robotic cholecystectomy (+$411), IHR (+$887), and VHR (+$1124) as well as substantial associated fixed costs. Introduction of robotic surgery had considerable negative impact on laparoscopic case volume and significantly decreased resident participation. Increased operative time and hospital costs are substantial. An institution must be cognizant of these effects when considering implementing robotics in departments with a general surgery residency program. Copyright © 2017 Elsevier Inc. All rights reserved.

Gamma Knife radiosurgery for large vestibular schwannomas greater than 3 cm in diameter.

PubMed

Huang, Cheng-Wei; Tu, Hsien-Tang; Chuang, Chun-Yi; Chang, Cheng-Siu; Chou, Hsi-Hsien; Lee, Ming-Tsung; Huang, Chuan-Fu

2018-05-01

OBJECTIVE Stereotactic radiosurgery (SRS) is an important alternative management option for patients with small- and medium-sized vestibular schwannomas (VSs). Its use in the treatment of large tumors, however, is still being debated. The authors reviewed their recent experience to assess the potential role of SRS in larger-sized VSs. METHODS Between 2000 and 2014, 35 patients with large VSs, defined as having both a single dimension > 3 cm and a volume > 10 cm 3 , underwent Gamma Knife radiosurgery (GKRS). Nine patients (25.7%) had previously undergone resection. The median total volume covered in this group of patients was 14.8 cm 3 (range 10.3-24.5 cm 3 ). The median tumor margin dose was 11 Gy (range 10-12 Gy). RESULTS The median follow-up duration was 48 months (range 6-156 months). All 35 patients had regular MRI follow-up examinations. Twenty tumors (57.1%) had a volume reduction of greater than 50%, 5 (14.3%) had a volume reduction of 15%-50%, 5 (14.3%) were stable in size (volume change < 15%), and 5 (14.3%) had larger volumes (all of these lesions were eventually resected). Four patients (11.4%) underwent resection within 9 months to 6 years because of progressive symptoms. One patient (2.9%) had open surgery for new-onset intractable trigeminal neuralgia at 48 months after GKRS. Two patients (5.7%) who developed a symptomatic cyst underwent placement of a cystoperitoneal shunt. Eight (66%) of 12 patients with pre-GKRS trigeminal sensory dysfunction had hypoesthesia relief. One hemifacial spasm completely resolved 3 years after treatment. Seven patients with facial weakness experienced no deterioration after GKRS. Two of 3 patients with serviceable hearing before GKRS deteriorated while 1 patient retained the same level of hearing. Two patients improved from severe hearing loss to pure tone audiometry less than 50 dB. The authors found borderline statistical significance for post-GKRS tumor enlargement for later resection (p = 0.05, HR 9.97, CI 0.99-100.00). A tumor volume ≥ 15 cm 3 was a significant factor predictive of GKRS failure (p = 0.005). No difference in outcome was observed based on indication for GKRS (p = 0.0761). CONCLUSIONS Although microsurgical resection remains the primary management choice in patients with VSs, most VSs that are defined as having both a single dimension > 3 cm and a volume > 10 cm 3 and tolerable mass effect can be managed satisfactorily with GKRS. Tumor volume ≥ 15 cm 3 is a significant factor predicting poor tumor control following GKRS.

A simple brain atrophy measure improves the prediction of malignant middle cerebral artery infarction by acute DWI lesion volume.

PubMed

Beck, Christoph; Kruetzelmann, Anna; Forkert, Nils D; Juettler, Eric; Singer, Oliver C; Köhrmann, Martin; Kersten, Jan F; Sobesky, Jan; Gerloff, Christian; Fiehler, Jens; Schellinger, Peter D; Röther, Joachim; Thomalla, Götz

2014-06-01

In patients with malignant middle cerebral artery infarction (MMI) decompressive surgery within 48 h improves functional outcome. In this respect, early identification of patients at risk of developing MMI is crucial. While the acute diffusion weighted imaging (DWI) lesion volume was found to predict MMI with high predictive values, the potential impact of preexisting brain atrophy on the course of space-occupying middle cerebral artery (MCA) infarction and the development of MMI remains unclear. We tested the hypothesis that the combination of the acute DWI lesion volume with simple measures of brain atrophy improves the early prediction of MMI. Data from a prospective, multicenter, observational study, which included patients with acute middle cerebral artery main stem occlusion studied by MRI within 6 h of symptom onset, was analyzed retrospectively. The development of MMI was defined according to the European randomized controlled trials of decompressive surgery. Acute DWI lesion volume, as well as brain and cerebrospinal fluid volume (CSF) were delineated. The intercaudate distance (ICD) was assessed as a linear brain atrophy marker by measuring the hemi-ICD of the intact hemisphere to account for local brain swelling. Binary logistic regression analysis was used to identify significant predictors of MMI. Cut-off values were determined by Classification and Regression Trees analysis. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the resulting models were calculated. Twenty-one (18 %) of 116 patients developed a MMI. Malignant middle cerebral artery infarctions patients had higher National Institutes of Health Stroke Scale scores on admission and presented more often with combined occlusion of the internal carotid artery and MCA. There were no differences in brain and CSF volume between the two groups. Diffusion weighted imaging lesion volume was larger (p < 0.001), while hemi-ICD was smaller (p = 0.029) in MMI patients. Inclusion of hemi-ICD improved the prediction of MMI. Best cut-off values to predict the development of MMI were DWI lesion volume > 87 ml and hemi-ICD ≤ 9.4 mm. The addition of hemi-ICD to the decision tree strongly increased PPV (0.93 vs. 0.70) resulting in a reduction of false positive findings from 7/23 (30 %) to 1/15 (7 %), while there were only slight changes in specificity, sensitivity and NPV. The absolute number of correct classifications increased by 4 (3.4 %). The integration of hemi-ICD as a linear marker of brain atrophy, that can easily be assessed in an emergency setting, may improve the prediction of MMI by lesion volume based predictive models.

[Breast-reduction surgery--a long-term survey of indications and outcomes].

PubMed

Kneser, U; Jaeger, K; Bach, A D; Polykandriotis, E; Ohnolz, J; Kopp, J; Horch, R E

2004-10-14

Between 1986 and 2003, breast-reduction surgery was performed in a total of 814 women. The indication was established on the basis of physical complaints, chronic back pain, stiff neck or recurrent intertrigo in the foldbeneath the breasts. A proportion of the patients were interviewed postoperatively using a questionnaire, to determine the impact of the operation on their quality of life. 91% of those surveyed reported a postoperative improvement in the perception of their own body, and 80% were satisfied with the reduced size of their breasts. In conclusion, in the hands of an experienced breast surgeon, breast-reduction surgery for the proper indication results in a reliable and safe diminishment in breast size and tightening of slack tissue, leading to a significant enhancement in the patient's quality of life.

Drinking 300 mL of clear fluid two hours before surgery has no effect on gastric fluid volume and pH in fasting and non-fasting obese patients.

PubMed

Maltby, J Roger; Pytka, Saul; Watson, Neil C; Cowan, Robert A McTaggart; Fick, Gordon H

2004-02-01

To determine whether, in obese [body mass index (BMI) > 30 kg.m(2)] patients, oral intake of 300 mL clear liquid two hours before elective surgery affects the volume and pH of gastric contents at induction of anesthesia. A single-blind, randomized study of 126 adult patients, age > or = 18 yr, ASA physical status I or II, BMI > 30 kg.m(2) who were scheduled for elective surgery under general anesthesia. Patients were excluded if they had diabetes mellitus, symptoms of gastroesophageal reflux, or had taken medication within 24 hr that affects gastric secretion, gastric fluid pH or gastric emptying. All patients fasted from midnight and were randomly assigned to fasting or fluid group. Two hours before their scheduled time of surgery, all patients drank 10 mL of water containing phenol red 50 mg. Those in the fluid group followed with 300 mL clear liquid of their choice. Immediately following induction of general anesthesia and tracheal intubation, gastric contents were aspirated through a multiorifice Salem sump tube. The fluid volume, pH and phenol red concentration were recorded. Median (range) values in fasting vs fluid groups were: gastric fluid volume 26 (3-107) mL vs 30 (3-187) mL, pH 1.78 (1.31-7.08) vs 1.77 (1.27-7.34) and phenol red retrieval 0.1 (0-30)% vs 0.2 (0-15)%. Differences between groups were not statistically significant. Obese patients without comorbid conditions should follow the same fasting guidelines as non-obese patients and be allowed to drink clear liquid until two hours before elective surgery, inasmuch as obesity per se is not considered a risk factor for pulmonary aspiration.

Potential predictors for the amount of intra-operative brain shift during deep brain stimulation surgery

NASA Astrophysics Data System (ADS)

Datteri, Ryan; Pallavaram, Srivatsan; Konrad, Peter E.; Neimat, Joseph S.; D'Haese, Pierre-François; Dawant, Benoit M.

2011-03-01

A number of groups have reported on the occurrence of intra-operative brain shift during deep brain stimulation (DBS) surgery. This has a number of implications for the procedure including an increased chance of intra-cranial bleeding and complications due to the need for more exploratory electrodes to account for the brain shift. It has been reported that the amount of pneumocephalus or air invasion into the cranial cavity due to the opening of the dura correlates with intraoperative brain shift. Therefore, pre-operatively predicting the amount of pneumocephalus expected during surgery is of interest toward accounting for brain shift. In this study, we used 64 DBS patients who received bilateral electrode implantations and had a post-operative CT scan acquired immediately after surgery (CT-PI). For each patient, the volumes of the pneumocephalus, left ventricle, right ventricle, third ventricle, white matter, grey matter, and cerebral spinal fluid were calculated. The pneumocephalus was calculated from the CT-PI utilizing a region growing technique that was initialized with an atlas-based image registration method. A multi-atlas-based image segmentation method was used to segment out the ventricles of each patient. The Statistical Parametric Mapping (SPM) software package was utilized to calculate the volumes of the cerebral spinal fluid (CSF), white matter and grey matter. The volume of individual structures had a moderate correlation with pneumocephalus. Utilizing a multi-linear regression between the volume of the pneumocephalus and the statistically relevant individual structures a Pearson's coefficient of r = 0.4123 (p = 0.0103) was found. This study shows preliminary results that could be used to develop a method to predict the amount of pneumocephalus ahead of the surgery.

The dynamic volume changes of polymerising polymethyl methacrylate bone cement.

PubMed

Muller, Scott D; Green, Sarah M; McCaskie, Andrew W

2002-12-01

The Swedish hip register found an increased risk of early revision of vacuum-mixed cemented total hip replacements. The influence of cement mixing technique on the dynamic volume change in polymerising PMMA is not well understood and may be relevant to this observation. Applying Archimedes' principle, we have investigated the dynamic volume changes in polymerising cement and determined the influence of mixing technique. All specimens showed an overall volume reduction: hand-mixed 3.4% and vacuum-mixed 6.0%. Regression analysis of sectional porosity and volume reduction showed a highly significant relationship. Hand-mixed porous cement showed a transient volume increase before solidification. However, vacuum-mixed cement showed a progressive volume reduction throughout polymerisation. Transient expansion of porous cement occurs at the critical time of micro-interlock formation, possibly improving fixation. Conversely, progressive volume reduction of vacuum-mixed cement throughout the formation of interlock may damage fixation. Stable fixation of vacuum-mixed cement may depend on additional techniques to offset the altered volumetric behaviour of vacuum-mixed cement.

Administration of goserelin acetate after uterine artery embolization does not change the reduction rate and volume of uterine myomas.

PubMed

Vilos, George A; Vilos, Angelos G; Abu-Rafea, Basim; Pron, Gaylene; Kozak, Roman; Garvin, Greg

2006-05-01

To determine if goserelin immediately after uterine artery embolization (UAE) affected myoma reduction. Randomized pilot study (level 1). Teaching hospital. Twenty-six women. All patients underwent UAE, and then 12 patients received 10.8 mg of goserelin 24 hours later. The treatment group was 5 years older: 43 versus 37.7 years. Uterine and myoma volumes were measured by ultrasound 2 weeks before UAE and at 3, 6, and 12 months. Uterine and fibroid volumes. Pretreatment uterine volume was 477 versus 556 cm3, and dominant fibroid volume was 257 versus 225 cm3 in the control versus goserelin groups. Analysis of variance measurements indicated that the change over time did not significantly differ between the two groups. By 12 months, the control group had a mean uterine volume reduction of 58%, while the goserelin group had a reduction of 45%. Dominant fibroid changes over time did not differ between the two groups. At 12 months, the mean fibroid volume had decreased by 86% and 58% in the control and goserelin groups, respectively. The addition of goserelin therapy to UAE did not alter the reduction rate or volume of uterine myomas.

Lowering threshold energy for femtosecond laser pulse photodisruption through turbid media using adaptive optics

NASA Astrophysics Data System (ADS)

Hansen, A.; Ripken, Tammo; Krueger, Ronald R.; Lubatschowski, Holger

2011-03-01

Focussed femtosecond laser pulses are applied in ophthalmic tissues to create an optical breakdown and therefore a tissue dissection through photodisruption. The threshold irradiance for the optical breakdown depends on the photon density in the focal volume which can be influenced by the pulse energy, the size of the irradiated area (focus), and the irradiation time. For an application in the posterior eye segment the aberrations of the anterior eye elements cause a distortion of the wavefront and therefore an increased focal volume which reduces the photon density and thus raises the required energy for surpassing the threshold irradiance. The influence of adaptive optics on lowering the pulse energy required for photodisruption by refining a distorted focus was investigated. A reduction of the threshold energy can be shown when using adaptive optics. The spatial confinement with adaptive optics furthermore raises the irradiance at constant pulse energy. The lowered threshold energy allows for tissue dissection with reduced peripheral damage. This offers the possibility for moving femtosecond laser surgery from corneal or lental applications in the anterior eye to vitreal or retinal applications in the posterior eye.

Certification Examination Cases of Candidates for Certification by the American Board of Plastic Surgery: Trends in Practice Profiles Spanning a Decade (2000–2009)

PubMed Central

Chung, Kevin C.; Song, Jae W.; Shauver, Melissa J.; Cullison, Terry M.; Noone, R. Barrett

2011-01-01

Background To evaluate the case mix of plastic surgeons in their early years of practice by examining candidate case-logs submitted for the Oral Examination. Methods De-identified data from 2000–2009 consisting of case-logs submitted by young plastic surgery candidates for the Oral Examination were analyzed. Data consisted of exam year, CPT (Current Procedural Terminology) Codes and the designation of each CPT code as cosmetic or reconstructive by the candidate, and patient age and gender. Subgroup analyses for comprehensive, cosmetic, craniomaxillofacial, and hand surgery modules were performed by using the CPT code list designated by the American Board of Plastic Surgery Maintenance of Certification in Plastic Surgery ( ) module framework. Results We examined case-logs from a yearly average of 261 candidates over 10 years. Wider variations in yearly percent change in median cosmetic surgery case volumes (−62.5% to 30%) were observed when compared to the reconstructive surgery case volumes (−18.0% to 25.7%). Compared to cosmetic surgery cases per candidate, which varied significantly from year-to-year (p<0.0001), reconstructive surgery cases per candidate did not vary significantly (p=0.954). Subgroup analyses of proportions of types of surgical procedures based on CPT code categories, revealed hand surgery to be the least performed procedure relative to comprehensive, craniomaxillofacial, and cosmetic surgery procedures. Conclusions Graduates of plastic surgery training programs are committed to performing a broad spectrum of reconstructive and cosmetic surgical procedures in their first year of practice. However, hand surgery continues to have a small presence in the practice profiles of young plastic surgeons. PMID:21788850

Automating measurement of subtle changes in articular cartilage from MRI of the knee by combining 3D image registration and segmentation

NASA Astrophysics Data System (ADS)

Lynch, John A.; Zaim, Souhil; Zhao, Jenny; Peterfy, Charles G.; Genant, Harry K.

2001-07-01

In osteoarthritis, articular cartilage loses integrity and becomes thinned. This usually occurs at sites which bear weight during normal use. Measurement of such loss from MRI scans, requires precise and reproducible techniques, which can overcome the difficulties of patient repositioning within the scanner. In this study, we combine a previously described technique for segmentation of cartilage from MRI of the knee, with a technique for 3D image registration that matches localized regions of interest at followup and baseline. Two patients, who had recently undergone meniscal surgery, and developed lesions during the 12 month followup period were examined. Image registration matched regions of interest (ROI) between baseline and followup, and changes within the cartilage lesions were estimate to be about a 16% reduction in cartilage volume within each ROI. This was more than 5 times the reproducibility of the measurement, but only represented a change of between 1 and 2% in total femoral cartilage volume. Changes in total cartilage volume may be insensitive for quantifying changes in cartilage morphology. A combined used of automated image segmentation, with 3D image registration could be a useful tool for the precise and sensitive measurement of localized changes in cartilage from MRI of the knee.

Patient satisfaction after zygoma and mandible reduction surgery: an outcome assessment.

PubMed

Choi, Bong-Kyoon; Goh, Raymond C W; Moaveni, Zachary; Lo, Lun-Jou

2010-08-01

An ovoid and slender face is considered attractive in Oriental culture, and facial bony contouring is frequently performed in Asian countries to achieve this desired facial profile. Despite their popularity, critical analyses of patients' satisfaction after facial-bone contouring surgery is lacking in the current literature. Questionnaires were sent to 90 patients who had undergone zygoma and/or mandibular contouring by a single surgeon at the Craniofacial Center, Chang Gung Memorial Hospital, Taiwan. The number of patients who had mandibular angle reduction and zygoma reduction were 78 and 36, respectively. The questionnaire contained 20 questions, concerning aesthetic and surgical results, psychosocial benefits and general outcome. Medical records were also reviewed for correlation with the questionnaire findings. The survey response rate was 52.2% (47 patients). A total of 95.7% were satisfied with the symmetry of their face after surgery, and 97.9% felt that there was improvement in their final facial appearance. As many as 61.7% could not feel an objectionable new jaw line or bony step and 66.0% could not detect any visible deformity. A total of 87.2% could not detect bony regrowth after surgery. Complication after surgery was experienced by 17.0% of patients, but all of these recovered without long-term consequences. All patients noted a positive psychosocial influence, and 97.9% of patients said that they would undergo the same surgery again under similar circumstances and would recommend the same surgery to friends. The majority of patients with square face seeking facial bone contouring surgery are satisfied with their final appearance. Of equal importance is the ability for this type of surgery to have a positive influence on the patient's psychosocial environment. Copyright 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

The impact of transsphenoidal surgery on glucose homeostasis and insulin resistance in acromegaly.

PubMed

Stelmachowska-Banaś, Maria; Zieliński, Grzegorz; Zdunowski, Piotr; Podgórski, Jan; Zgliczyński, Wocjiech

2011-01-01

Impaired glucose tolerance and overt diabetes mellitus are frequently associated with acro-megaly. The aim of this study was to find out whether these alterations could be reversed after transsphenoidal surgery. Two hundred and thirty-nine acromegalic patients were studied before and 6-12 months after transsphenoidal surgery. Diagnosis of active acromegaly was established on the basis of widely recognized criteria. In each patient, glucose and insulin concentrations were assessed during the 75 γ oral glucose tolerance test (OGTT). To estimate insulin resistance, we used homeostasis model assessment (HOMA-IR) and the quantitative insulin sensitivity check index (QUICKI). At the moment of diagnosis, diabetes mellitus was present in 25% of the acromegalic patients. After surgery, the pre-valence of diabetes mellitus normalized to the level present in the general Polish population. We found a statistically significant reduction after surgery in plasma glucose levels both fasting (89.45 ± 13.92 mg/dL vs. 99.12 ± 17.33 mg/dL, p < 0.001) and during OGTT. Similarly, a prominent reduction in insulin secretion was found after surgery compared to the moment of diagnosis (15.44 ± 8.80 mIU/mL vs. 23.40 ± 10.24 mIU/mL, p < 0.001). After transsphenoidal surgery, there was a significant reduction in HOMA-IR (3.08 vs. 6.76, p < 0.0001) and a significant increase in QUICKI (0.32 vs. 0.29, p < 0.001). There were no statistically significant differences after surgery in fasting glucose and insulin levels between patients with controlled and in-adequately controlled disease. We conclude that in acromegalic patients glucose homeostasis alterations and insulin sensitivity can be normalized after transsphenoidal surgery, even if strict biochemical cure criteria are not fulfilled.

Volumetric analysis of maxillary sinuses of Zulu and European crania by helical, multislice computed tomography.

PubMed

Fernandes, C L

2004-11-01

The volumes of the maxillary sinuses are of interest to surgeons operating endoscopically as variation in maxillary sinus volume may mean variation in anatomical landmarks. Other surgical disciplines, such as dentistry, maxillo-facial surgery and plastic surgery, may benefit from this information. To compare the maxillary sinus volumes of dried crania from cadavers of European and Zulu descent, with respect to ethnic group and gender. Helical, multislice computed tomography (CT) was performed using 1-mm coronal slices. The area for each slice was obtained by tracing the outline of each slice. The CT machine calculated a volume by totalling the slices for each sinus. Ethnic and gender variations were found in the different groups. It was found that European crania had significantly larger antral volumes than Zulu crania and men had larger volumes than women. Race and gender interaction was also assessed, as was maxillary sinus side. A variation in maxillary sinus volume between different ethnic groups and genders exists, and surgeons operating in this region should be aware of this.

[Study on reductive surgery for pelvic organ prolapse concomitant with anti-incontinence sling for treatment of occult stress urinary incontinence].

PubMed

Zhang, Xiaolong; Lu, Yongxian; Shen, Wenjie; Liu, Jingxia; Ge, Jing; Liu, Xin; Zhao, Ying; Niu, Ke; Zhang, Yinghui; Wang, Wenying; Qiu, Chengli

2014-06-01

To evaluate the clinical outcome of anti-incontinence sling in the treatment of occult stress urinary incontinence (OSUI) during reductive surgery for advanced pelvic organ prolapse (POP). From Jun. 2003 to Dec. 2012, 78 patients with OSUI underwent reductive surgery for advanced POP such as high uterosacral ligament suspension, sacrospinous ligament suspension and sacral colpopexy in the First Affiliated Hospital, General Hospital of People's Liberation Army. Among them, 41 patients received reductive surgery alone was enrolled in non-concomitant anti-incontinence group and the other 37 patients who underwent same surgery with tension-free vaginal tape (TVT) or tension-free vaginal tape-obturator technique (TVT-O) was in anti-incontinence group. The patient's demography, objective and subjective outcomes, as well as complications and injures were compared between the two groups. The pelvic organ prolapse quantitation (POP-Q) was used to evaluate the objective outcomes of POP. Urinary distress inventory (UDI-6) and incontinence impact questionnaire short form (IIQ-7) were used to evaluate the subjective outcomes of stress urinary incontinence (SUI). Compared with the non-concomitant anti-incontinence group, the objective outcomes of reductive surgery exhibited no significant differences (100%, 78/78), and only the operation time of anti-incontinence group slightly increased 16 minutes. The occurrence rate of postoperative SUI was 12% (5/41), 15% (6/41), 17% (7/41) respectively after the operation at 2-month, 6-month and 12-month follow up in the non-concomitant anti-incontinence group; and the occurrence rate of the anti-incontinence group was 3% (1/37), 3% (1/37), 3% (1/37); but none of patients in the two groups require further surgery for stress urinary incontinence. Mean score of UDI-6 and IIQ-7 in all the patients decreased significantly after operation at 2-month, 6-month and 12-month follow up (all P < 0.01). However, there was no statistic difference between the two groups (P > 0.05). It is still difficult to make decision for concomitant anti-incontinence procedure in those patients with OSUI, who are undergoing reductive surgery because of advanced POP. Whether the patients will benefit more from anti-incontinence sling depends largely on strict preoperative evaluation for the severity of SUI. The patients with severe SUI are supposed to benefit most from anti-incontinence sling. However, a two-step approach to correct the postoperative stress urinary incontinence is also reasonable.

Iodine retention during evaporative volume reduction

DOEpatents

Godbee, H.W.; Cathers, G.I.; Blanco, R.E.

1975-11-18

An improved method for retaining radioactive iodine in aqueous waste solutions during volume reduction is disclosed. The method applies to evaporative volume reduction processes whereby the decontaminated (evaporated) water can be returned safely to the environment. The method generally comprises isotopically diluting the waste solution with a nonradioactive iodide and maintaining the solution at a high pH during evaporation.

Liposuction breast reduction: a prospective trial in African American women.

PubMed

Moskovitz, Martin J; Baxt, Sherwood A; Jain, Aridaman K; Hausman, Robert E

2007-02-01

Recently published case reports and outcome studies support the use of liposuction alone as an effective technique for ameliorating symptoms of breast hypertrophy. This study is the first prospective trial to examine the effectiveness of liposuction breast reduction as a primary modality of breast reduction. In addition, this study examines the role that liposuction breast reduction can play in the treatment of African American women, given the known scarring difficulties that darker skinned patients can encounter with traditional breast reduction surgery. Twenty African American women were recruited through newspaper and Internet advertisements. Patients aged 20 to 60 years were serially accepted to the study. Patients with a chief complaint of breast ptosis were excluded. No other exclusion criteria were used. Previously validated questionnaire instruments were used preoperatively and postoperatively to measure breast-related symptoms, general patient health perception, bodily pain, and self-esteem. Comorbid conditions, demographics, financial status, prior treatments, and smoking history were also documented. Seventeen patients completed the preoperative and postoperative questionnaires. An average of 1075 cc of tissue was removed per breast during liposuction breast reduction surgery. Postoperative assessment showed a significant decrease in breast-related symptoms, a significant decrease in patient pain, and a significant improvement in overall patient health perception. Liposuction breast reduction is a useful breast reduction modality in the properly selected patient. African American women, who may traditionally forego breast reduction surgery because of scarring, are excellent candidates for this type of reduction procedure.

Trends in Penile Prosthetics: Influence of Patient Demographics, Surgeon Volume, and Hospital Volume on Type of Penile Prosthesis Inserted in New York State.

PubMed

Kashanian, James A; Golan, Ron; Sun, Tianyi; Patel, Neal A; Lipsky, Michael J; Stahl, Peter J; Sedrakyan, Art

2018-02-01

Penile prostheses (PPs) are a discrete, well-tolerated treatment option for men with medical refractory erectile dysfunction. Despite the increasing prevalence of erectile dysfunction, multiple series evaluating inpatient data have found a decrease in the frequency of PP surgery during the past decade. To investigate trends in PP surgery and factors affecting the choice of different PPs in New York State. This study used the New York State Department of Health Statewide Planning and Research Cooperative (SPARCS) data cohort that includes longitudinal information on hospital discharges, ambulatory surgery, emergency department visits, and outpatient services. Patients older than 18 years who underwent inflatable or non-inflatable PP insertion from 2000 to 2014 were included in the study. Influence of patient demographics, surgeon volume, and hospital volume on type of PP inserted. Since 2000, 14,114 patients received PP surgery in New York State; 12,352 PPs (88%) were inflatable and 1,762 (12%) were non-inflatable, with facility-level variation from 0% to 100%. There was an increasing trend in the number of annual procedures performed, with rates of non-inflatable PP insertion decreasing annually (P < .01). More procedures were performed in the ambulatory setting over time (P < .01). Important predictors of device choice were insurance type, year of insertion, hospital and surgeon volume, and the presence of comorbidities. Major influences in choice of PP inserted include racial and socioeconomic factors and surgeon and hospital surgical volume. Use of the SPARCS database, which captures inpatient and outpatient services, allows for more accurate insight into trends in contrast to inpatient sampling alone. However, SPARCS is limited to patients within New York State and the results might not be generalizable to men in other states. Also, patient preference was not accounted for in these analyses, which can play a role in PP selection. During the past 14 years, there has been an increasing trend in inflatable PP surgery for the management of erectile dysfunction. Most procedures are performed in the ambulatory setting and not previously captured by prior studies using inpatient data. Kashanian JA, Golan R, Sun T, et al. Trends in Penile Prosthetics: Influence of Patient Demographics, Surgeon Volume, and Hospital Volume on Type of Penile Prosthesis Inserted in New York State. J Sex Med 2018;15:245-250. Copyright © 2017 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.

Measuring hospital performance in congenital heart surgery: Administrative vs. clinical registry data

PubMed Central

Pasquali, Sara K.; He, Xia; Jacobs, Jeffrey P.; Jacobs, Marshall L.; Gaies, Michael G.; Shah, Samir S.; Hall, Matthew; Gaynor, J. William; Peterson, Eric D.; Mayer, John E.; Hirsch-Romano, Jennifer C.

2015-01-01

Background In congenital heart surgery, hospital performance has historically been assessed using widely available administrative datasets. Recent studies have demonstrated inaccuracies in case ascertainment (coding and inclusion of eligible cases) in administrative vs. clinical registry data, however it is unclear whether this impacts assessment of performance on a hospital-level. Methods Merged data from the Society of Thoracic Surgeons (STS) Database (clinical registry), and Pediatric Health Information Systems Database (administrative dataset) on 46,056 children undergoing heart surgery (2006–2010) were utilized to evaluate in-hospital mortality for 33 hospitals based on their administrative vs. registry data. Standard methods to identify/classify cases were used: Risk Adjustment in Congenital Heart Surgery (RACHS-1) in the administrative data, and STS–European Association for Cardiothoracic Surgery (STAT) methodology in the registry. Results Median hospital surgical volume based on the registry data was 269 cases/yr; mortality was 2.9%. Hospital volumes and mortality rates based on the administrative data were on average 10.7% and 4.7% lower, respectively, although this varied widely across hospitals. Hospital rankings for mortality based on the administrative vs. registry data differed by ≥ 5 rank-positions for 24% of hospitals, with a change in mortality tertile classification (high, middle, or low mortality) for 18%, and change in statistical outlier classification for 12%. Higher volume/complexity hospitals were most impacted. Agency for Healthcare Quality and Research methods in the administrative data yielded similar results. Conclusions Inaccuracies in case ascertainment in administrative vs. clinical registry data can lead to important differences in assessment of hospital mortality rates for congenital heart surgery. PMID:25624057

What is the Utility Of a Limb Lengthening and Reconstruction Service in an Academic Department of Orthopaedic Surgery?

PubMed

Rozbruch, S Robert; Rozbruch, Elizabeth S; Zonshayn, Samuel; Borst, Eugene W; Fragomen, Austin T

2015-10-01

Limb lengthening and reconstruction surgery is a relatively new subspecialty of orthopaedic surgery in the United States. Despite increased awareness and practice of the specialty, it is rarely vested as a separate clinical service in an academic department of orthopaedic surgery. We have had experience growing such a dedicated service within an academic department of orthopaedic surgery over the past 9 years. We explored (1) the use of a limb deformity service (LDS) in an academic department of orthopaedic surgery by examining data on referral patterns, our clinical volume, and academic productivity; and (2) the surgical breadth of cases comprising the patients of the LDS in an academic department of orthopaedic surgery by examining data on caseload by anatomic sites, category, and surgical techniques/tools. We (SRR, ATF, EWB) retrospectively examined data on numbers of surgical cases and outpatient visits from the limb lengthening and complex reconstruction service at the Hospital for Special Surgery from 2005 to 2013 to evaluate growth. We studied 672 consecutive surgical cases performed by our service for a sample period of 1 year, assessing referral patterns within and outside our medical center, anatomic region, surgical category, and surgical technique/tool. Academic productivity was measured by review of our service's publications. During the time period studied (2005-2013), outpatient and surgical volume significantly increased by 120% (1530 to 3372) and 105% (346 to 708), respectively, on our LDS. Surgical volume growth was similar to the overall growth of the department of orthopaedic surgery. Referrals were primarily from orthopaedic surgeons (56%) and self/Internet research (25%). Physician referrals were predominantly from our own medical center (83%). Referrals from within our institution came from a variety of clinical services. Forty-nine peer-reviewed articles and 23 book chapters were published by staff members of our service. Anatomic surgical sites, surgical categories, and technique/tools used on our LDS were diverse, yet procedures were specialized to the discipline of limb deformity. There is a substantial role for an LDS within an academic department of orthopaedic surgery. With establishment of a dedicated service comes focus and resources that establish an environment for growth in volume, intramural and extramural referral, and purposeful research and education. The majority of referrals were from orthopaedic surgeons from our own medical center, suggesting needfulness. The LDS provides patients access to specialized surgery. The number of intramural referrals suggests that the specialty service helps retain patients within our academic orthopaedic department. Future research will try to determine if such a dedicated service leads to improved outcomes, efficiency, and value. Level IV, retrospective study.

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

PubMed Central

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

2011-01-01

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

Recent trends in National Institutes of Health Funding for Surgery: 2003 to 2013

PubMed Central

Hu, Yinin; Edwards, Brandy L.; Brooks, Kendall D.; Newhook, Timothy; Slingluff, Craig L.

2015-01-01

BACKGROUND The purpose of this study is to compare the compositions of federally-funded surgical research between 2003 and 2013, and to assess differences in funding trends between surgery and other medical specialties. DATA SOURCES The NIH RePORTER database was queried for grants within core surgical disciplines during 2003 and 2013. Funding was categorized by award type, methodology, and discipline. Application success rates for surgery and five non-surgical departments were trended over time. RESULTS Inflation-adjusted NIH funding for surgical research decreased 19% from $270M in 2003 to $219M in 2013, with a shift from R-awards to U-awards. Proportional funding to outcomes research almost tripled, while translational research diminished. Non-surgical departments have increased NIH application volume over the last 10 years; however, surgery’s application volume has been stagnant. CONCLUSIONS To preserve surgery’s role in innovative research, new efforts are needed to incentivize an increase in application volume. PMID:25929766

Subperiosteal orbital abscess: volumetric criteria for surgical drainage.

PubMed

Tabarino, Florian; Elmaleh-Bergès, Monique; Quesnel, Stéphanie; Lorrot, Mathie; Van Den Abbeele, Thierry; Teissier, Natacha

2015-02-01

To investigate predictive factors of surgical management of subperiosteal orbital abscess in children. A retrospective monocentric study was conducted between 2000 and 2011 with children hospitalized for acute pediatric orbital cellulitis (APOC). Clinical, biological and radiological data as well as medical and surgical management were collected and analyzed. All patients received intravenous antibiotics and underwent a CT-scan. Orbit and subperiosteal intraorbital abscess dimensions were measured on axial and coronal planes and the abscess volume was calculated using a spheroid model. Eighty-three children with APOC (mean age: 4.5 years) were included, 53 were boys (63.9%). Thirty-two children (38.6%) presented with a subperiosteal orbital abscess. Mean abscess volume was 570mm(3) and mean exophthalmos was 4.7mm. Twenty patients were treated surgically, 11 of which by an endoscopic approach. A positive correlation was observed between the volume of the abscess or exophthalmos and surgical drainage: 57.9% of patients underwent surgery when exophthalmos was >4mm, 29.4% between 2 and 4mm, and none when <2mm. All patients with an abscess volume >500mm(3) or >5% of orbital volume were operated on whereas only 30% or 39% of patients, respectively, in case of smaller volumes (P<0.05). Surgery for subperiosteal orbital abscess is usually performed in case of visual complications or unfavorable medical outcome. The importance of the exophthalmos and the volume of the abscess measured on the CT-scan are predictive factors of surgery in children with subperiosteal orbital abscess without visual complications. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

Antidiabetic Effects of Gastric Banding Surgery in Morbidly Obese Patients with Type 2 Diabetes Mellitus.

PubMed

Kim, Yu-Jeng; Choi, Ha-Neul; Lee, Hong-Chan; Yim, Jung-Eun

2017-07-01

This study was performed to investigate the effect of gastric banding surgery on the improvement of glycated hemoglobin (HbA 1c ) of morbidly obese (MO) patients with type 2 diabetes mellitus (T2DM) with the consideration that obesity was associated with insulin resistance and T2DM. We retrospectively reviewed the medical records of 38 MO with T2DM patients and 50 MO patients. Pre-surgery and post-surgery data were analyzed a year later. The medical data from these patients, including sex, age, height, weight, body composition, HbA 1c , triglyceride, total cholesterol, aspartate transaminase (AST), and alanine transaminase (ALT) were measured. There were significant reductions of body weight and body mass index (BMI), body fat, body fat percentage, waist-hip ratio, visceral fat, and obesity in each group before and after gastric banding surgery. Results of AST, ALT, and HbA 1c had significant reductions in each group. For HbA 1c , treatment rate was 71% in the MO group with T2DM with significant reduction of 22.8%. It is thought that a gastric banding surgery is one of the breakthrough methods not only for weight loss but also for the prevention of complication of the obese patients with T2DM. Thus, gastric banding surgery could be effective in controlling HbA 1c in obese patients with type 2 diabetes mellitus.

The analgesic effect of wound infiltration with local anaesthetics after breast surgery: a qualitative systematic review.

PubMed

Byager, N; Hansen, M S; Mathiesen, O; Dahl, J B

2014-04-01

Wound infiltration with local anaesthetics is commonly used during breast surgery in an attempt to reduce post-operative pain and opioid consumption. The aim of this review was to evaluate the effect of wound infiltration with local anaesthetics compared with a control group on post-operative pain after breast surgery. A systematic review was performed by searching PubMed, Google Scholar, the Cochrane database and Embase for randomised, blinded, controlled trials of wound infiltration with local anaesthetics for post-operative pain relief in female adults undergoing breast surgery. The analgesic effect was evaluated in a qualitative analysis by assessment of significant difference between groups (P < 0.05) in pain scores and supplemental analgesic consumption. Ten trials including 699 patients were included in the final analysis. Three trials investigated mastectomy, four trials partial or segmental mastectomy, and three trials breast reduction, excision of benign lump and unspecified breast surgery, respectively. Six trials demonstrated a small and short-lasting, but statistically significant reduction of post-operative pain scores, and four trials observed a statistically significant reduction in post-operative, supplemental opioid consumption that was, however, of limited clinical relevance. Wound infiltration with local anaesthetics may have a modest analgesic effect in the first few hours after surgery. Pain after breast surgery is, however, generally mild to moderate, and other non-invasive analgesic methods may be preferable in this surgical population. © 2014 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.

Investigation of clinical and dosimetric factors associated with postoperative pulmonary complications in esophageal cancer patients treated with concurrent chemoradiotherapy followed by surgery.

PubMed

Wang, Shu-lian; Liao, Zhongxing; Vaporciyan, Ara A; Tucker, Susan L; Liu, Helen; Wei, Xiong; Swisher, Stephen; Ajani, Jaffer A; Cox, James D; Komaki, Ritsuko

2006-03-01

To assess the association of clinical and especially dosimetric factors with the incidence of postoperative pulmonary complications among esophageal cancer patients treated with concurrent chemoradiation therapy followed by surgery. Data from 110 esophageal cancer patients treated between January 1998 and December 2003 were analyzed retrospectively. All patients received concurrent chemoradiotherapy followed by surgery; 72 patients also received irinotecan-based induction chemotherapy. Concurrent chemotherapy was 5-fluorouracil-based and in 97 cases included taxanes. Radiotherapy was delivered to a total dose of 41.4-50.4 Gy at 1.8-2.0 Gy per fraction with a three-dimensional conformal technique. Surgery (three-field, Ivor-Lewis, or transhiatal esophagectomy) was performed 27-123 days (median, 45 days) after completion of radiotherapy. The following dosimetric parameters were generated from the dose-volume histogram (DVH) for total lung: lung volume, mean dose to lung, relative and absolute volumes of lung receiving more than a threshold dose (relative V(dose) and absolute V(dose)), and absolute volume of lung receiving less than a threshold dose (volume spared, or VS(dose)). Occurrence of postoperative pulmonary complications, defined as pneumonia or acute respiratory distress syndrome (ARDS) within 30 days after surgery, was the endpoint for all analyses. Fisher's exact test was used to investigate the relationship between categorical factors and incidence of postoperative pulmonary complications. Logistic analysis was used to analyze the relationship between continuous factors (e.g., V(dose) or VS(dose)) and complication rate. Logistic regression with forward stepwise inclusion of factors was used to perform multivariate analysis of those factors having univariate significance (p < 0.05). The Mann-Whitney test was used to compare length of hospital stay in patients with and without lung complications and to compare lung volumes, VS5 values, and absolute and relative V5 values in male vs. female patients. Pearson correlation analysis was used to determine correlations between dosimetric factors. Eighteen (16.4%) of the 110 patients developed postoperative pulmonary complications. Two of these died of progressive pneumonia. Hospitalizations were significantly longer for patients with postoperative pulmonary complications than for those without (median, 15 days vs. 11 days, p = 0.003). On univariate analysis, female gender (p = 0.017), higher mean lung dose (p = 0.036), higher relative volume of lung receiving > or = 5 Gy (V5) (p = 0.023), and smaller volumes of lung spared from doses > or = 5-35 Gy (VS5-VS35) (p < 0.05) were all significantly associated with an increased incidence of postoperative pulmonary complications. No other clinical factors were significantly associated with the incidence of postoperative pulmonary complications in this cohort. On multivariate analysis, the volume of lung spared from doses > or = 5 Gy (VS5) was the only significant independent factor associated with postoperative pulmonary complications (p = 0.005). Dosimetric factors but not clinical factors were found to be strongly associated with the incidence of postoperative pulmonary complications in this cohort of esophageal cancer patients treated with concurrent chemoradiation plus surgery. The volume of the lung spared from doses of > or = 5 Gy was the only independent dosimetric factor in multivariate analysis. This suggests that ensuring an adequate volume of lung unexposed to radiation might reduce the incidence of postoperative pulmonary complications.

Initial treatment of sigmoid volvulous by colonoscopy.

PubMed Central

Starling, J R

1979-01-01

The initial management of acute, nonstrangulated sigmoid volvulous is to attempt proctosigmoidoscopic, rectal tube, or barium enema reduction and evacuation. If unsuccessful emergency surgery is necessary. The flexible colonoscope offers an additional therapeutic modality to effectuate preoperative reduction of the twisted sigmoid colon if attempts with conventional methods fail. Three cases of acute sigmoid volvulous are presented which illustrate for the first time successful reduction of acute sigmoid volvulous by colonoscopy after failure of the usual methods of treatment. Instead of emergency surgery all of these patients had elective resection with primary colocolostomy. Patients with acute sigmoid volvulous refractile to reduction by conventional modalities should have an attempt at flexible colonoscopic reduction. Images Fig. 1. Fig. 2. Fig. 3. Fig. 4. PMID:464675

Fluoride Induces a Volume Reduction in CA1 Hippocampal Slices Via MAP Kinase Pathway Through Volume Regulated Anion Channels

PubMed Central

Lee, Jaekwang; Han, Young-Eun; Favorov, Oleg; Tommerdahl, Mark; Whitsel, Barry

2016-01-01

Regulation of cell volume is an important aspect of cellular homeostasis during neural activity. This volume regulation is thought to be mediated by activation of specific transporters, aquaporin, and volume regulated anion channels (VRAC). In cultured astrocytes, it was reported that swelling-induced mitogen-activated protein (MAP) kinase activation is required to open VRAC, which are thought to be important in regulatory volume decrease and in the response of CNS to trauma and excitotoxicity. It has been also described that sodium fluoride (NaF), a recognized G-protein activator and protein phosphatase inhibitor, leads to a significant MAP kinase activation in endothelial cells. However, NaF's effect in volume regulation in the brain is not known yet. Here, we investigated the mechanism of NaF-induced volume change in rat and mouse hippocampal slices using intrinsic optical signal (IOS) recording, in which we measured relative changes in intracellular and extracellular volume as changes in light transmittance through brain slices. We found that NaF (1~5 mM) application induced a reduction in light transmittance (decreased volume) in CA1 hippocampus, which was completely reversed by MAP kinase inhibitor U0126 (10 µM). We also observed that NaF-induced volume reduction was blocked by anion channel blockers, suggesting that NaF-induced volume reduction could be mediated by VRAC. Overall, our results propose a novel molecular mechanism of NaF-induced volume reduction via MAP kinase signaling pathway by activation of VRAC. PMID:27122993

High Volume Washing of the Abdomen in Increasing Survival After Surgery in Patients With Pancreatic Cancer That Can Be Removed by Surgery

ClinicalTrials.gov

2017-10-25

Acinar Cell Carcinoma; Ampulla of Vater Adenocarcinoma; Cholangiocarcinoma; Duodenal Adenocarcinoma; Pancreatic Adenocarcinoma; Pancreatic Ductal Adenocarcinoma; Pancreatic Intraductal Papillary Mucinous Neoplasm, Pancreatobiliary-Type; Periampullary Adenocarcinoma

Low tidal volume mechanical ventilation against no ventilation during cardiopulmonary bypass heart surgery (MECANO): study protocol for a randomized controlled trial.

PubMed

Nguyen, Lee S; Merzoug, Messaouda; Estagnasie, Philippe; Brusset, Alain; Law Koune, Jean-Dominique; Aubert, Stephane; Waldmann, Thierry; Grinda, Jean-Michel; Gibert, Hadrien; Squara, Pierre

2017-12-02

Postoperative pulmonary complications are a leading cause of morbidity and mortality after cardiac surgery. There are no recommendations on mechanical ventilation associated with cardiopulmonary bypass (CPB) during surgery and anesthesiologists perform either no ventilation (noV) at all during CPB or maintain low tidal volume (LTV) ventilation. Indirect evidence points towards better pulmonary outcomes when LTV is performed but no large-scale prospective trial has yet been published in cardiac surgery. The MECANO trial is a single-center, double-blind, randomized, controlled trial comparing two mechanical ventilation strategies, noV and LTV, during cardiac surgery with CPB. In total, 1500 patients are expected to be included, without any restrictions. They will be randomized between noV and LTV on a 1:1 ratio. The noV group will receive no ventilation during CPB. The LTV group will receive 5 breaths/minute with a tidal volume of 3 mL/kg and positive end-expiratory pressure of 5 cmH2O. The primary endpoint will be a composite of all-cause mortality, early respiratory failure defined as a ratio of partial pressure of oxygen/fraction of inspired oxygen <200 mmHg at 1 hour after arrival in the ICU, heavy oxygenation support (defined as a patient requiring either non-invasive ventilation, mechanical ventilation or high-flow oxygen) at 2 days after arrival in the ICU or ventilator-acquired pneumonia defined by the Center of Disease Control. Lung recruitment maneuvers will be performed in the noV and LTV groups at the end of surgery and at arrival in ICU with an insufflation at +30 cmH20 for 5 seconds. Secondary endpoints are those composing the primary endpoint with the addition of pneumothorax, CPB duration, quantity of postoperative bleeding, red blood cell transfusions, revision surgery requirements, length of stay in the ICU and in the hospital and total hospitalization costs. Patients will be followed until hospital discharge. The MECANO trial is the first of its kind to compare in a double-blind design, a no-ventilation to a low-tidal volume strategy for mechanical ventilation during cardiac surgery with CPB, with a primary composite outcome including death, respiratory failure and postoperative pneumonia. ClinicalTrials.gov, NCT03098524 . Registered on 27 February 2017.

Chronic elbow dislocation: a rare complication of tennis elbow surgery. Successful treatment by open reduction and external fixator.

PubMed

Degreef, I; De Smet, L

2007-06-01

A case is presented of chronic dislocation of the elbow after tennis elbow surgery combined with posterior interosseous nerve (PIN) release. An open reduction with repair of the collateral ligaments was performed. Postoperative rehabilitation involved the use of an articulated external fixator and there was a successful outcome. Possible causes of the dislocation are discussed.

Safety and efficacy of bariatric surgery in Mexico: A detailed analysis of 500 surgeries performed at a high-volume center.

PubMed

Guilbert, L; Joo, P; Ortiz, C; Sepúlveda, E; Alabi, F; León, A; Piña, T; Zerrweck, C

2018-06-19

Bariatric surgery is the best method for treating obesity and its comorbidities. Our aim was to provide a detailed analysis of the perioperative outcomes in Mexican patients that underwent surgery at a high-volume hospital center. A retrospective study was conducted on all the patients that underwent bariatric surgery at a single hospital center within a time frame of 4 and one-half years. Demographics, the perioperative variables, complications (early and late), weight loss, failure, and type 2 diabetes mellitus remission were all analyzed. Five hundred patients were included in the study, 83.2% of whom were women. Mean patient age was 38.8 years and BMI was 44.1kg/m 2 . The most common comorbidities were high blood pressure, dyslipidemia, and diabetes. Laparoscopic gastric bypass surgery was performed in 85.8% of the patients, sleeve gastrectomy in 13%, and revision surgeries in 1%. There were 9.8% early complications and 12.2% late ones, with no deaths. Overall weight loss as the excess weight loss percentage at 12 and 24 months was 76.9 and 77.6%. The greatest weight loss at 12 months was seen in the patients that underwent laparoscopic gastric bypass. A total of 11.4% of the patients had treatment failure. In the patients with type 2 diabetes mellitus, 68.7% presented with complete disease remission and 9.3% with partial remission. There was improvement in 21.8% of the cases. In our experience at a high-volume hospital center, bariatric surgery is safe and effective, based on the low number of adverse effects and consequent weight loss and type 2 diabetes mellitus control. Long-term studies with a larger number of patients are needed to determine the final impact of those procedures. Copyright © 2018 Asociación Mexicana de Gastroenterología. Publicado por Masson Doyma México S.A. All rights reserved.

Comparison of Intravenous Morphine with Sublingual Buprenorphine in Management of Postoperative Pain after Closed Reduction Orthopedic Surgery

PubMed Central

Soltani, Ghasem; Khorsand, Mahmood; Shamloo, Alireza Sepehri; Jarahi, Lida; Zirak, Nahid

2015-01-01

Background: Postoperative pain is a common side effect following surgery that can significantly reduce surgical quality and patient’s satisfaction. Treatment options are morphine and buprenorphine. We aimed to compare the efficacy of a single dose of intravenous morphine with sublingual buprenorphine in postoperative pain control following closed reduction surgery. Methods: This triple blind clinical trial was conducted on 90 patients referred for closed reduction orthopedic surgery. They were older than 18 years and in classes I and II of the American Society of Anesthesiologists (ASA) with an operation time of 30-90 minutes. Patients were divided into two groups of buprenorphine (4.5µg/kg sublingually) and morphine (0.2mg/kg intravenously). Baseline characteristics, vital signs, pain score, level of sedation and pharmacological side effects were recorded in the recovery room (at 0 and 30 minutes), and in the ward (at 3, 6 and 12 hours). SPSS version 19 software was used for data analysis and the significance level was set at P<0.05. Results: Ninety patients were studied, 60 males and 30 females with a mean age of 37.7±16.2 years. There was no significant difference between the two groups in terms of baseline characteristics. Pain score in the morphine group was significantly higher than the buprenorphine group with an average score of 2.5 (P<0.001). Postoperative mean heart rate in the buprenorphine group was four beats lower than the morphine group (P<0.001). Also, in the buprenorphine 48.6% and in the morphine group 86.7% of cases were conscious in recovery (P=0.001) with a higher rate of pruritus in the latter group (P=0.001). Conclusion: Sublingual buprenorphine administration before anesthesia induction in closed reduction surgery can lead to better postoperative pain control in comparison to intravenous morphine. Due to simple usage and longer postoperative sedation, sublingual buprenorphine is recommended as a suitable drug in closed reduction surgery. PMID:26550594

Comparison of Intravenous Morphine with Sublingual Buprenorphine in Management of Postoperative Pain after Closed Reduction Orthopedic Surgery.

PubMed

Soltani, Ghasem; Khorsand, Mahmood; Shamloo, Alireza Sepehri; Jarahi, Lida; Zirak, Nahid

2015-10-01

Postoperative pain is a common side effect following surgery that can significantly reduce surgical quality and patient's satisfaction. Treatment options are morphine and buprenorphine. We aimed to compare the efficacy of a single dose of intravenous morphine with sublingual buprenorphine in postoperative pain control following closed reduction surgery. This triple blind clinical trial was conducted on 90 patients referred for closed reduction orthopedic surgery. They were older than 18 years and in classes I and II of the American Society of Anesthesiologists (ASA) with an operation time of 30-90 minutes. Patients were divided into two groups of buprenorphine (4.5µg/kg sublingually) and morphine (0.2mg/kg intravenously). Baseline characteristics, vital signs, pain score, level of sedation and pharmacological side effects were recorded in the recovery room (at 0 and 30 minutes), and in the ward (at 3, 6 and 12 hours). SPSS version 19 software was used for data analysis and the significance level was set at P<0.05. Ninety patients were studied, 60 males and 30 females with a mean age of 37.7±16.2 years. There was no significant difference between the two groups in terms of baseline characteristics. Pain score in the morphine group was significantly higher than the buprenorphine group with an average score of 2.5 (P<0.001). Postoperative mean heart rate in the buprenorphine group was four beats lower than the morphine group (P<0.001). Also, in the buprenorphine 48.6% and in the morphine group 86.7% of cases were conscious in recovery (P=0.001) with a higher rate of pruritus in the latter group (P=0.001). Sublingual buprenorphine administration before anesthesia induction in closed reduction surgery can lead to better postoperative pain control in comparison to intravenous morphine. Due to simple usage and longer postoperative sedation, sublingual buprenorphine is recommended as a suitable drug in closed reduction surgery.

Variable versus conventional lung protective mechanical ventilation during open abdominal surgery (PROVAR): a randomised controlled trial.

PubMed

Spieth, P M; Güldner, A; Uhlig, C; Bluth, T; Kiss, T; Conrad, C; Bischlager, K; Braune, A; Huhle, R; Insorsi, A; Tarantino, F; Ball, L; Schultz, M J; Abolmaali, N; Koch, T; Pelosi, P; Gama de Abreu, M

2018-03-01

Experimental studies showed that controlled variable ventilation (CVV) yielded better pulmonary function compared to non-variable ventilation (CNV) in injured lungs. We hypothesized that CVV improves intraoperative and postoperative respiratory function in patients undergoing open abdominal surgery. Fifty patients planned for open abdominal surgery lasting >3 h were randomly assigned to receive either CVV or CNV. Mean tidal volumes and PEEP were set at 8 ml kg -1 (predicted body weight) and 5 cm H 2 O, respectively. In CVV, tidal volumes varied randomly, following a normal distribution, on a breath-by-breath basis. The primary endpoint was the forced vital capacity (FVC) on postoperative Day 1. Secondary endpoints were oxygenation, non-aerated lung volume, distribution of ventilation, and pulmonary and extrapulmonary complications until postoperative Day 5. FVC did not differ significantly between CVV and CNV on postoperative Day 1, 61.5 (standard deviation 22.1) % vs 61.9 (23.6) %, respectively; mean [95% confidence interval (CI)] difference, -0.4 (-13.2-14.0), P=0.95. Intraoperatively, CVV did not result in improved respiratory function, haemodynamics, or redistribution of ventilation compared to CNV. Postoperatively, FVC, forced expiratory volume at the first second (FEV 1 ), and FEV 1 /FVC deteriorated, while atelectasis volume and plasma levels of interleukin-6 and interleukin-8 increased, but values did not differ between groups. The incidence of postoperative pulmonary and extrapulmonary complications was comparable in CVV and CNV. In patients undergoing open abdominal surgery, CVV did not improve intraoperative and postoperative respiratory function compared with CNV. NCT 01683578. Copyright © 2017 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.

Compensatory Hypertrophy After Living Donor Nephrectomy.

PubMed

Chen, K W; Wu, M W F; Chen, Z; Tai, B C; Goh, Y S B; Lata, R; Vathsala, A; Tiong, H Y

2016-04-01

Previous studies have shown that kidney volume enhances the estimation of glomerular filtration rate (eGFR) in kidney donors. This study aimed to describe the phenomenon of compensatory hypertrophy after donor nephrectomy as measured on computerized tomographic (CT) scans. An institutional Domain Specific Review Board (DSRB)-approved study involved approaching kidney donors to have a follow up CT scan from 6 months to 1 year after surgery; 29 patients participated; 55% were female. Clinical chart review was performed, and the patient's remaining kidney volume was measured before and after surgery based on CT scans. eGFR was determined with the use of the Modification of Diet in Renal Disease equation. Mean parenchymal volume of the remaining kidney for this population (mean age, 44.3 ± 8.5 y) was 204.7 ± 82.5 cc before surgery and 250.5 ± 113.3 cc after donor nephrectomy. Compensatory hypertrophy occurred in 79.3% of patients (n = 23). Mean increase in remaining kidney volume was 22.4 ± 23.2% after donor nephrectomy in healthy individuals. Over a median follow-up of 52.9 ± 19.8 months, mean eGFR was 68.9 ± 12.4 mL/min/1.73 m(2), with 24.1% of patients (n = 7) in chronic kidney disease grade 3. Absolute and relative change in kidney volume was not associated with sex, race, surgical approach, or background of hypertension (P = NS). There was a trend of decreased hypertrophy with increasing age (P = .5; Spearman correlation, -0.12). In healthy kidney donors, compensatory hypertrophy of the remaining kidney occurs in 79.3% of the patients, with an average increment of about 22.4%. Older patients may have a blunted compensatory hypertrophy response after surgery. Copyright © 2016 Elsevier Inc. All rights reserved.

Predictors of resource utilization in transsphenoidal surgery for Cushing disease.

PubMed

Little, Andrew S; Chapple, Kristina

2013-08-01

The short-term cost associated with subspecialized surgical care is an increasingly important metric and economic concern. This study sought to determine factors associated with hospital charges in patients undergoing transsphenoidal surgery for Cushing disease in an effort to identify the drivers of resource utilization. The authors analyzed the Nationwide Inpatient Sample (NIS) hospital discharge database from 2007 to 2009 to determine factors that influenced hospital charges in patients who had undergone transsphenoidal surgery for Cushing disease. The NIS discharge database approximates a 20% sample of all inpatient admissions to nonfederal US hospitals. A multistep regression model was developed that adjusted for patient demographics, acuity measures, comorbidities, hospital characteristics, and complications. In 116 hospitals, 454 transsphenoidal operations were performed. The mean hospital charge was $48,272 ± $32,060. A multivariate regression model suggested that the primary driver of resource utilization was length of stay (LOS), followed by surgeon volume, hospital characteristics, and postoperative complications. A 1% increase in LOS increased hospital charges by 0.60%. Patient charges were 13% lower when performed by high-volume surgeons compared with low-volume surgeons and 22% lower in large hospitals compared with small hospitals. Hospital charges were 12% lower in cases with no postoperative neurological complications. The proposed model accounted for 46% of hospital charge variance. This analysis of hospital charges in transsphenoidal surgery for Cushing disease suggested that LOS, hospital characteristics, surgeon volume, and postoperative complications are important predictors of resource utilization. These findings may suggest opportunities for improvement.

Assessment and monitoring of flow limitation and other parameters from flow/volume loops.

PubMed

Dueck, R

2000-01-01

Flow/volume (F/V) spirometry is routinely used for assessing the type and severity of lung disease. Forced vital capacity (FVC) and timed vital capacity (FEV1) provide the best estimates of airflow obstruction in patients with asthma, chronic obstructive pulmonary disease (COPD) and emphysema. Computerized spirometers are now available for early home recognition of asthma exacerbation in high risk patients with severe persistent disease, and for recognition of either infection or rejection in lung transplant patients. Patients with severe COPD may exhibit expiratory flow limitation (EFL) on tidal volume (VT) expiratory F/V (VTF/V) curves, either with or without applying negative expiratory pressure (NEP). EFL results in dynamic hyperinflation and persistently raised alveolar pressure or intrinsic PEEP (PEEPi). Hyperinflation and raised PEEPi greatly enhance dyspnea with exertion through the added work of the threshold load needed to overcome raised pleural pressure. Esophageal (pleural) pressure monitoring may be added to VTF/V loops for assessing the severity of PEEPi: 1) to optimize assisted ventilation by mask or via endotracheal tube with high inspiratory flow rates to lower I:E ratio, and 2) to assess the efficacy of either pressure support ventilation (PSV) or low level extrinsic PEEP in reducing the threshold load of PEEPi. Intraoperative tidal volume F/V loops can also be used to document the efficacy of emphysema lung volume reduction surgery (LVRS) via disappearance of EFL. Finally, the mechanism of ventilatory constraint can be identified with the use of exercise tidal volume F/V loops referenced to maximum F/V loops and static lung volumes. Patients with severe COPD show inspiratory F/V loops approaching 95% of total lung capacity, and flow limitation over the entire expiratory F/V curve during light levels of exercise. Surprisingly, patients with a history of congestive heart failure may lower lung volume towards residual volume during exercise, thereby reducing airway diameter and inducing expiratory flow limitation.

Influence of national centralization of oesophagogastric cancer on management and clinical outcome from emergency upper gastrointestinal conditions.

PubMed

Markar, S R; Mackenzie, H; Wiggins, T; Askari, A; Karthikesalingam, A; Faiz, O; Griffin, S M; Birkmeyer, J D; Hanna, G B

2018-01-01

In England in 2001 oesophagogastric cancer surgery was centralized. The aim of this study was to evaluate whether centralization of oesophagogastric cancer to high-volume centres has had an effect on mortality from different emergency upper gastrointestinal conditions. The Hospital Episode Statistics database was used to identify patients admitted to hospitals in England (1997-2012). The influence of oesophagogastric high-volume cancer centre status (20 or more resections per year) on 30- and 90-day mortality from oesophageal perforation, paraoesophageal hernia and perforated peptic ulcer was analysed. Over the study interval, 3707, 12 441 and 56 822 patients with oesophageal perforation, paraoesophageal hernia and perforated peptic ulcer respectively were included. There was a passive centralization to high-volume cancer centres for oesophageal perforation (26·9 per cent increase), paraoesophageal hernia (19·5 per cent increase) and perforated peptic ulcer (23·0 per cent increase). Management of oesophageal perforation in high-volume centres was associated with a reduction in 30-day (HR 0·58, 95 per cent c.i. 0·45 to 0·74) and 90-day (HR 0·62, 0·49 to 0·77) mortality. High-volume cancer centre status did not affect mortality from paraoesophageal hernia or perforated peptic ulcer. Annual emergency admission volume thresholds at which mortality improved were observed for oesophageal perforation (5 patients) and paraoesophageal hernia (11). Following centralization, the proportion of patients managed in high-volume cancer centres that reached this volume threshold was 88·0 per cent for oesophageal perforation, but only 30·3 per cent for paraoesophageal hernia. Centralization of low incidence conditions such as oesophageal perforation to high-volume cancer centres provides a greater level of expertise and ultimately reduces mortality. © 2017 BJS Society Ltd Published by John Wiley & Sons Ltd.

Real-Time Magnetic Resonance-Guided Stereotactic Laser Amygdalohippocampotomy for Mesial Temporal Lobe Epilepsy

PubMed Central

Willie, Jon T.; Laxpati, Nealen G.; Drane, Daniel L.; Gowda, Ashok; Appin, Christina; Hao, Chunhai; Brat, Daniel J.; Helmers, Sandra L.; Saindane, Amit; Nour, Sherif G.; Gross, Robert E.

2014-01-01

Background Open surgery effectively treats mesial temporal lobe epilepsy (MTLE), but carries risks of neurocognitive deficits, which may be reduced with minimally invasive alternatives. Objective To describe technical and clinical outcomes of stereotactic laser amygdalohippocampotomy (SLAH) with real-time magnetic resonance thermal imaging (MRTI) guidance. Methods Under general anesthesia and utilizing standard stereotactic methods, 13 adult patients with intractable MTLE (with and without mesial temporal sclerosis, MTS) prospectively underwent insertion of a saline-cooled fiber-optic laser applicator into amygdalohippocampal structures from an occipital trajectory. Computer-controlled laser ablation was performed during continuous MRTI followed by confirmatory contrast-enhanced anatomic imaging and volumetric reconstruction. Clinical outcomes were determined from seizure diaries. Results A mean 60% volume of the amygdalohippocampal complex was ablated in 13 patients (9 with MTS) undergoing 15 procedures. Median hospitalization was one day. With follow-up ranging from 5-26 (median 14) months, 77% (10/13) of patients achieved meaningful seizure reduction, of which 54% (7/13) were free of disabling seizures. Of patients with preoperative MTS, 67% (6/9) achieved seizure freedom. All recurrences were observed by<6 months. Variances in ablation volume and length did not account for individual clinical outcomes. Whereas no complications of laser therapy itself were observed, one significant complication, a visual field defect, resulted from deviated insertion of a stereotactic aligning rod, which was corrected prior to ablation. Conclusion Real-time MR-guided SLAH is a technically novel, safe, and effective alternative to open surgery. Further evaluation with larger cohorts over time is warranted. PMID:24618797

Effect of provider volume on resource utilization for surgical procedures of the knee.

PubMed

Jain, Nitin; Pietrobon, Ricardo; Guller, Ulrich; Shankar, Anoop; Ahluwalia, Ajit S; Higgins, Laurence D

2005-05-01

Operating-room time and patient disposition on discharge are important determinants of healthcare resource utilization and cost. We examined the relation between these determinants and hospital/surgeon volume for anterior cruciate ligament (ACL) reconstruction and meniscectomy procedures. Patients undergoing ACL reconstruction (18,390 cases) and meniscectomy (123,012 cases) were extracted from the State Ambulatory Surgery Databases for the years 1997-2000. Surgeon and hospital volume were divided into low-, intermediate-, and high-volume categories. Multivariate logistic regression models were used to estimate the adjusted association between surgeon and hospital volume and patient discharge status and operating-room time. Patients undergoing ACL reconstruction or meniscectomy performed by low-volume surgeons were significantly more likely to be non-routinely discharged as compared to high-volume surgeons (adjusted odds ratio 3.5, 95% confidence interval 1.7-7.2 for ACL reconstruction; adjusted odds ratio 2.0, 95% confidence interval 1.6-2.3 for meniscectomy). The mean operating-room time for performing ACL reconstruction or meniscectomy was significantly higher in low- and intermediate-volume surgeons and hospitals as compared to high-volume surgeons and hospitals (p < or = 0.001). High-volume providers utilize healthcare resources more efficiently. Our findings may help surgeons and hospitals in optimizing resource utilization and cost for routinely-performed ambulatory surgery procedures.

0 + 5 Vascular Surgery Residents' Operative Experience in General Surgery: An Analysis of Operative Logs from 12 Integrated Programs.

PubMed

Smith, Brigitte K; Kang, P Chulhi; McAninch, Chris; Leverson, Glen; Sullivan, Sarah; Mitchell, Erica L

2016-01-01

Integrated (0 + 5) vascular surgery (VS) residency programs must include 24 months of training in core general surgery. The Accreditation Council for Graduate Medical Education currently does not require specific case numbers in general surgery for 0 + 5 trainees; however, program directors have structured this time to optimize operative experience. The aim of this study is to determine the case volume and type of cases that VS residents are exposed to during their core surgery training. Accreditation council for graduate medical education operative logs for current 0 + 5 VS residents were obtained and retrospectively reviewed to determine general surgery case volume and distribution between open and laparoscopic cases performed. Standard statistical methods were applied. A total of 12 integrated VS residency programs provided operative case logs for current residents. A total of 41 integrated VS residents in clinical years 2 through 5. During the postgraduate year-1 training year, residents participated in significantly more open than laparoscopic general surgery cases (p < 0.0001). This difference was consistent over the first 3 years of training. The most frequently logged open general surgery cases are hernia repair (20%), skin and soft tissue (7.4%), and breast (6.3%). Residents in programs with core surgery over 3 years participated in significantly more general surgery operations compared with residents in programs with core surgery spread out over 4 years (p = 0.035). 0 + 5 VS residents perform significantly more open operations than laparoscopic operations during their core surgery training. The majority of these operations are minor, nonabdominal procedures. The 0 + 5 VS residency program general surgery operative training requirements should be reevaluated and case minimums defined. The general surgery training component of 0 + 5 VS residencies may need to be restructured to meet the needs of current and future trainees. Copyright © 2016 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Variation among cleft centres in the use of secondary surgery for children with cleft palate: a retrospective cohort study

PubMed Central

Sitzman, Thomas J; Hossain, Monir; Carle, Adam C; Heaton, Pamela C; Britto, Maria T

2017-01-01

Objectives To test whether cleft centres vary in their use of secondary cleft palate surgery, also known as revision palate surgery, and if so to identify modifiable hospital factors and surgeon factors that are associated with use of secondary surgery. Design Retrospective cohort study. Setting Forty-three paediatric hospitals across the USA. Patients Children with cleft lip and palate who underwent primary cleft palate repair from 1999 to 2013. Main outcome measures Time from primary cleft palate repair to secondary palate surgery. Results We identified 4939 children who underwent primary cleft palate repair. At 10 years after primary palate repair, 44% of children had undergone secondary palate surgery. Significant variation existed among hospitals (p<0.001); the proportion of children undergoing secondary surgery by 10 years ranged from 9% to 77% across hospitals. After adjusting for patient demographics, primary palate repair before 9 months of age was associated with an increased hazard of secondary palate surgery (initial HR 6.74, 95% CI 5.30 to 8.73). Postoperative antibiotics, surgeon procedure volume and hospital procedure volume were not associated with time to secondary surgery (p>0.05). Of the outcome variation attributable to hospitals and surgeons, between-hospital differences accounted for 59% (p<0.001), while between-surgeon differences accounted for 41% (p<0.001). Conclusions Substantial variation in the hazard of secondary palate surgery exists depending on a child’s age at primary palate repair and the hospital and surgeon performing their repair. Performing primary palate repair before 9 months of age substantially increases the hazard of secondary surgery. Further research is needed to identify other factors contributing to variation in palate surgery outcomes among hospitals and surgeons. PMID:29479567

A Decline in Intraoperative Renal Near-Infrared Spectroscopy Is Associated With Adverse Outcomes in Children Following Cardiac Surgery.

PubMed

Gist, Katja M; Kaufman, Jonathan; da Cruz, Eduardo M; Friesen, Robert H; Crumback, Sheri L; Linders, Megan; Edelstein, Charles; Altmann, Christopher; Palmer, Claire; Jalal, Diana; Faubel, Sarah

2016-04-01

Renal near-infrared spectroscopy is known to be predictive of acute kidney injury in children following cardiac surgery using a series of complex equations and area under the curve. This study was performed to determine if a greater than or equal to 20% reduction in renal near-infrared spectroscopy for 20 consecutive minutes intraoperatively or within the first 24 postoperative hours is associated with 1) acute kidney injury, 2) increased acute kidney injury biomarkers, or 3) other adverse clinical outcomes in children following cardiac surgery. Prospective single center observational study. Pediatric cardiac ICU. Children less than or equal to age 4 years who underwent cardiac surgery with the use of cardiopulmonary bypass during the study period (June 2011-July 2012). None. A reduction in near-infrared spectroscopy was not associated with acute kidney injury. Nine of 12 patients (75%) with a reduction in renal near-infrared spectroscopy did not develop acute kidney injury. The remaining three patients had mild acute kidney injury (pediatric Risk, Injury, Failure, Loss, End stage-Risk). A reduction in renal near-infrared spectroscopy was associated with the following adverse clinical outcomes: 1) a longer duration of mechanical ventilation (p = 0.05), 2) longer intensive care length of stay (p = 0.05), and 3) longer hospital length of stay (p < 0.01). A decline in renal near-infrared spectroscopy in combination with an increase in serum interleukin-6 and serum interleukin-8 was associated with a longer intensive care length of stay, and the addition of urine interleukin-18 to this was associated with a longer hospital length of stay. In this cohort, the rate of acute kidney injury was much lower than anticipated thereby limiting the evaluation of a reduction in renal near-infrared spectroscopy as a predictor of acute kidney injury. A greater than or equal to 20% reduction in renal near-infrared spectroscopy was significantly associated with adverse outcomes in children following cardiac surgery. The addition of specific biomarkers to the model was predictive of worse outcomes in these patients. Thus, real-time evaluation of renal near-infrared spectroscopy using the specific levels of change of a 20% reduction for 20 minutes may be useful in predicting prolonged mechanical ventilation and other adverse outcomes in children undergoing cardiac surgery.

Risk factors for revision within 10 years of total knee arthroplasty.

PubMed

Dy, Christopher J; Marx, Robert G; Bozic, Kevin J; Pan, Ting Jung; Padgett, Douglas E; Lyman, Stephen

2014-04-01

An in-depth understanding of risk factors for revision TKA is needed to minimize the burden of revision surgery. Previous studies indicate that hospital and community characteristics may influence outcomes after TKA, but a detailed investigation in a diverse population is warranted to identify opportunities for quality improvement. We asked: (1) What is the frequency of revision TKA within 10 years of primary arthroplasty? (2) Which patient demographic factors are associated with revision within 10 years of TKA? (3) Which community and institutional characteristics are associated with revision within 10 years of TKA? We identified 301,955 patients who underwent primary TKAs in New York or California from 1997 to 2005 from statewide databases. Identifier codes were used to determine whether they underwent revision TKA. Patient, community, and hospital characteristics were analyzed using multivariable regression modeling to determine predictors for revision. The frequency of revision was 4.0% at 5 years after the index arthroplasty and 8.9% at 9-years. Patients between 50 and 75 years old had a lower risk of revision than patients younger than 50 years (hazard ratio [HR], 0.47; 95% CI, 0.44, 0.50). Black patients were at increased risk for needing revision surgery (HR, 1.39; 95% CI, 1.29, 1.49) after adjustment for insurance type, poverty level, and education. Women (HR, 0.82; 95% CI, 0.79, 0.86) and Medicare recipients (HR, 0.82; 95% CI, 0.79, 0.86) were less likely to undergo revision surgery, whereas those from the most educated (HR, 1.09; 95% CI, 1.02, 1.16) and the poorest communities (HR, 1.08; 95% CI, 1.01, 1.15) had modest increases in risk of revision. Mid-volume hospitals (200-400 annual cases) had a reduction of early revision (HR, 0.91; 95% CI, 0.83, 0.99) compared with those performing less than 200 cases annually, whereas higher-volume hospitals (greater than 400 cases) showed little effect compared with low-volume hospitals. Patient, community, and institutional characteristics affect the risk for revision within 10 years of index TKA. These data can be used to develop process improvement and implant surveillance strategies among high-risk patients. Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Maxillary distraction osteogenesis in the adolescent cleft patient: three-dimensional computed tomography analysis of linear and volumetric changes over five years.

PubMed

Chen, Philip Kuo-Ting; Por, Yong-Chen; Liou, Eric Jein-Wein; Chang, Frank Chun-Shin

2011-07-01

To assess the results of maxillary distraction osteogenesis with the Rigid External Distraction System using three-dimensional computed tomography scan volume-rendered images with respect to stability and facial growth at three time frames: preoperative (T0), 1-year postoperative (T1), and 5-years postoperative (T2). Retrospective analysis. Tertiary. A total of 12 patients with severe cleft maxillary hypoplasia were treated between June 30, 1997, and July 15, 1998. The mean age at surgery was 11 years 1 month. Le Fort I maxillary distraction osteogenesis. Distraction was started 2 to 5 days postsurgery at a rate of 1 mm per day. The consolidation period was 3 months. No face mask was used. A paired t test was used for statistical analysis. Overjet, ANB, and SNA and maxillary, pterygoid, and mandibular volumes. From T0 to T1, there were statistically significant increments of overjet, ANB, and SNA and maxillary, pterygoid, and mandibular volumes. The T1 to T2 period demonstrated a reduction of overjet (30.07%) and ANB (54.42%). The maxilla showed a stable SNA and a small but statistically significant advancement of the ANS point. There was a significant increase in the mandibular volume. However, there was no significant change in the maxillary and pterygoid volumes. Maxillary distraction osteogenesis demonstrated linear and volumetric maxillary growth during the distraction phase without clinically significant continued growth thereafter. Overcorrection is required to take into account recurrence of midface retrusion over the long term.

Robot-assisted hysterectomy for endometrial and cervical cancers: a systematic review.

PubMed

Nevis, Immaculate F; Vali, Bahareh; Higgins, Caroline; Dhalla, Irfan; Urbach, David; Bernardini, Marcus Q

2017-03-01

Total and radical hysterectomies are the most common treatment strategies for early-stage endometrial and cervical cancers, respectively. Surgical modalities include open surgery, laparoscopy, and more recently, minimally invasive robot-assisted surgery. We searched several electronic databases for randomized controlled trials and observational studies with a comparison group, published between 2009 and 2014. Our outcomes of interest included both perioperative and morbidity outcomes. We included 35 observational studies in this review. We did not find any randomized controlled trials. The quality of evidence for all reported outcomes was very low. For women with endometrial cancer, we found that there was a reduction in estimated blood loss between the robot-assisted surgery compared to both laparoscopy and open surgery. There was a reduction in length of hospital stay between robot-assisted surgery and open surgery but not laparoscopy. There was no difference in total lymph node removal between the three modalities. There was no difference in the rate of overall complications between the robot-assisted technique and laparoscopy. For women with cervical cancer, there were no differences in estimated blood loss or removal of lymph nodes between robot-assisted and laparoscopic procedure. Compared to laparotomy, robot-assisted hysterectomy for cervical cancer showed an overall reduction in estimated blood loss. Although robot-assisted hysterectomy is clinically effective for the treatment of both endometrial and cervical cancers, methodologically rigorous studies are lacking to draw definitive conclusions.

Effect of portal access system and surgery type on surgery times during laparoscopic ovariectomy and salpingectomy in captive African lions and cheetahs.

PubMed

Hartman, Marthinus Jacobus; Monnet, Eric; Kirberger, Robert Murco; Schoeman, Johan Petrus

2016-03-02

A prospective randomized study was used to compare surgery times for laparoscopic ovariectomy and salpingectomy in female African lion (Panthera leo) (n = 14) and cheetah (Acinonyx jubatus) (n = 20) and to compare the use of a multiple portal access system (MPAS) and single portal access system (SPAS) between groups. Two different portal techniques were used, namely MPAS (three separate ports) in lions and SPAS (SILS™ port) in cheetahs, using standard straight laparoscopic instruments. Portal access system and first ovary was not randomized. Five different surgery times were compared for the two different procedures as well as evaluating the use and application of MPAS and SPAS. Carbon dioxide volumes for lions were recorded. In adult lionesses operative time (OPT) (P = 0.016) and total surgical time (TST) (P = 0.032) were significantly shorter for salpingectomy compared to ovariectomy. Similarly in cheetahs OPT (P = 0.001) and TST (P = 0.005) were also shorter for salpingectomy compared to ovariectomy. In contrast, in lion cubs no difference was found in surgery times for ovariectomy and salpingectomy. Total unilateral procedure time was shorter than the respective bilateral time for both procedures (P = 0.019 and P = 0.001) respectively and unilateral salpingectomy was also faster than unilateral ovariectomy (P = 0.035) in cheetahs. Port placement time, suturing time and TST were significantly shorter for SPAS compared to MPAS (P = 0.008). There was, however, no difference in OPT between SPAS and MPAS. Instrument cluttering with SPAS was found to be negligible. There was no difference in mean volume CO2 required to complete ovariectomy in lions but the correlation between bodyweight and total volume of CO2 in lions was significant (rs = 0.867; P = 0.002). Laparoscopic salpingectomy was faster than ovariectomy in both adult lions and cheetahs. Using SPAS, both unilateral procedures were faster than bilateral procedures in cheetahs. Placement and suturing of SPAS in cheetahs was easier and faster compared to three separate ports in lions and lion cubs. The use of standard straight instruments during SPAS did not prolong surgery. Surgery was faster in cubs and CO2 required for laparoscopic sterilization in lions could be determined. Predictable surgery times and CO2 volumes will facilitate the accurate planning and execution of surgery in lions and cheetahs.

Sulfur hexafluoride (SF6) versus perfluoropropane (C3F8) tamponade and short term face-down position for macular hole repair: a randomized prospective study.

PubMed

Casini, Giamberto; Loiudice, Pasquale; De Cillà, Stefano; Radice, Paolo; Nardi, Marco

2016-01-01

To compare early visual and anatomical outcomes after either sulfur hexafluoride (SF 6 ) or perfluoropropane (C 3 F 8 ) tamponade for macular hole repair. 147 eyes affected by primary full-thickness macular hole underwent pars plana vitrectomy with dye assisted removal of the internal limiting membrane and gas tamponade. Prone position was prescribed for 48 h after surgery. All patients were divided into 3 groups depending on the size of the hole: small (<250 µm), medium (>250-<400 µm) or large (>400 µm). Eyes within the same group randomly received either SF 6 (70 eyes) or C 3 F 8 (77 eyes). A complete ophthalmic evaluation, including best corrected visual acuity and anatomic status of the macular holes, was conducted preoperatively, at 1 week and 1 month after surgery. Macular hole volume was calculated using optical coherence tomography scans. The Wilcoxon Signed Ranks Test, the Mann-Whitney Test, the Spearman's rank-order correlation coefficient and the study of variance for repeated measures were used for statistical analysis. Mean best-corrected visual acuity improved from 0.92 logMAR to 0.28 logMAR (P < 0.001). A reduction of the dimensions of macular holes was observed in all cases, with a total repair of 90 % (63/70 eyes) in the SF 6 group and 91 % in the C 3 F 8 group (70/77 eyes). There was a negative correlation between the initial minor diameter, the volume of the hole and the rate of anatomic success. Short-term anatomical and visual outcomes were similar in eyes treated with either SF 6 or C 3 F 8 , independently of the stage of the macular hole. The initial volume and the minor diameter of the hole may be considered as valid tools for predicting surgical success. Age and gender did not appear to have influenced the prognosis.

Visceral obesity, not elevated BMI, is strongly associated with incisional hernia after colorectal surgery.

PubMed

Aquina, Christopher T; Rickles, Aaron S; Probst, Christian P; Kelly, Kristin N; Deeb, Andrew-Paul; Monson, John R T; Fleming, Fergal J

2015-02-01

High BMI is often used as a proxy for obesity and has been considered a risk factor for the development of an incisional hernia after abdominal surgery. However, BMI does not accurately reflect fat distribution. The purpose of this work was to investigate the relationship among different obesity measurements and the risk of incisional hernia. This was a retrospective cohort study. The study included a single academic institution in New York from 2003 to 2010. The study consists of 193 patients who underwent colorectal cancer resection. Preoperative CT scans were used to measure visceral fat volume, subcutaneous fat volume, total fat volume, and waist circumference. A diagnosis of incisional hernia was made either through physical examination in medical chart documentation or CT scan. Forty-one patients (21.2%) developed an incisional hernia. The median time to hernia was 12.4 months. After adjusting for patient and surgical characteristics using Cox regression analysis, visceral obesity (HR 2.04, 95% CI 1.07-3.91) and history of an inguinal hernia (HR 2.40, 95% CI 1.09-5.25) were significant risk factors for incisional hernia. Laparoscopic resection using a transverse extraction site led to a >75% reduction in the risk of incisional hernia (HR 0.23, 95% CI 0.07-0.76). BMI > 30 kg/m was not significantly associated with incisional hernia development. Limitations include the retrospective design without standardized follow-up to detect hernias and the small sample size attributed to inadequate or unavailable CT scans. Visceral obesity, history of inguinal hernia, and location of specimen extraction site are significantly associated with the development of an incisional hernia, whereas BMI is poorly associated with hernia development. These findings suggest that a lateral transverse location is the incision site of choice and that new strategies, such as prophylactic mesh placement, should be considered in viscerally obese patients.

The Value of Intraoperative Magnetic Resonance Imaging in Endoscopic and Microsurgical Transsphenoidal Pituitary Adenoma Resection.

PubMed

Pal'a, Andrej; Knoll, Andreas; Brand, Christine; Etzrodt-Walter, Gwendolin; Coburger, Jan; Wirtz, Christian Rainer; Hlaváč, Michal

2017-06-01

The routine use of intraoperative magnetic resonance imaging (iMRI) helps to achieve gross total resection in transsphenoidal pituitary surgery. We compared the added value of iMRI for extent of resection in endoscopic versus microsurgical transsphenoidal adenomectomy. A total of 96 patients with pituitary adenoma were included. Twenty-eight consecutive patients underwent endoscopic transsphenoidal tumor resection. For comparison, we used a historic cohort of 68 consecutive patients treated microsurgically. We evaluated the additional resection after conducting iMRI using intraoperative and late postoperative volumetric tumor analysis 3 months after surgery. Demographic data, clinical symptoms, and complications as well as pituitary function were evaluated. We found significantly fewer additional resections after conducting iMRI in the endoscopic group (P = 0.042). The difference was even more profound in Knosp grade 0-2 adenomas (P = 0.029). There was no significant difference in Knosp grade 3-4 adenomas (P = 0.520). The endoscopic approach was associated with smaller intraoperative tumor volume (P = 0.023). No significant difference was found between both techniques in postoperative tumor volume (P = 0.228). Satisfactory results of pituitary function were significantly more often associated with an endoscopic approach in the multiple regression analysis (P = 0.007; odds ratio, 17.614; confidence interval 95%, 2.164-143.396). With the endoscopic approach, significantly more tumor volume reduction was achieved before conducting iMRI, decreasing the need for further resection. This finding was even more pronounced in adenomas graded Knosp 0-2. In the case of extensive and invasive adenomas with infiltration of cavernous sinus and suprasellar or parasellar extension, additional tumor resection and increase in the extent of resection was achieved with iMRI in both groups. The endoscopic approach seems to result in better endocrine outcomes, especially in Knosp grade 0-2 pituitary adenomas. Copyright © 2017 Elsevier Inc. All rights reserved.

RT-06GAMMA KNIFE SURGERY AFTER NAVIGATION-GUIDED ASPIRATION FOR CYSTIC METASTATIC BRAIN TUMORS

PubMed Central

Chiba, Yasuyoshi; Mori, Kanji; Toyota, Shingo; Kumagai, Tetsuya; Yamamoto, Shota; Sugano, Hirofumi; Taki, Takuyu

2014-01-01

Metastatic brain tumors over 3 cm in diameter (volume of 14.1ml) are generally considered poor candidates for Gamma Knife surgery (GKS). We retrospectively assessed the method and efficacy of GKS for large cystic metastatic brain tumors after navigation-guided aspiration under local anesthesia. From September 2007 to April 2014, 38 cystic metastatic brain tumors in 32 patients (12 males, 20 females; mean age, 63.2 years) were treated at Kansai Rosai Hospital. The patients were performed navigation-guided cyst aspiration under local anesthesia, then at the day or the next day, were performed GKS and usually discharged on the day. The methods for preventing of leptomeningeal dissemination are following: 1) puncture from the place whose cerebral thickness is 1 cm or more; 2) avoidance of Ommaya reservoir implantation; and 3) placement of absorbable gelatin sponge to the tap tract. Tumor volume, including the cystic component, decreased from 25.4 ml (range 8.7-84.7 ml) to 11.4 ml (range 2.9-36.7 ml) following aspiration; the volume reduction was approximately 51.6%. Follow-up periods in the study population ranged from 0 to 24 months (median 3.5 months). The overall median survival was 6.7 months. There was no leptomeningeal dissemination related to the aspiration. One patient experienced radiation necrosis after GKS, one patient experienced re-aspiration by failure of aspiration, and two patients experienced surgical resections and one patient experienced re-aspiration by cyst regrowth after GKS. Long-term hospitalization is not desirable for the patients with brain metastases. In japan, Long-term hospitalization is required for surgical resection or whole brain radiation therapy, but only two days hospitalization is required for GKS after navigation-guided aspiration at our hospital. This GKS after navigation-guided aspiration is more effective and less invasive than surgical resection or whole brain radiation therapy.

A qualitative study of patients' views on the effects of breast-reduction surgery: a 2-year follow-up survey.

PubMed

Shakespeare, V; Postle, K

1999-04-01

The objectives of this study were to discover the views of patients about the effects of breast-reduction surgery carried out 2 years previously, to detect any change from perceptions at 3-6 months after surgery, and to determine whether the benefits of this operation are maintained long term. Qualitative research methods were employed, comprising: (a) an open-format survey of opinions; (b) semi-structured telephone interviews with a smaller number of patients; and (c) assessment of self-concept using a well-known scalar measure (the Rosenberg Self-esteem Scale). The subjects were 93 patients treated at the regional Plastic Surgery Service in Salisbury, who had previously participated in a quantitative study at 3-6 months after surgery. Sixty patients responded to the 2-year follow-up. Benefits of breast reduction most valued by patients did not change significantly with time and were: relief of pain and discomfort, which led to increased physical activity and better general health; greatly increased choice and fit of attractive clothes and underwear; improved personal and social life, leading to enhanced relationships with partner or friends; and greatly improved self-confidence in all areas of life. The interaction of all these factors led to improved self-image and improved quality of life. The main disadvantage of the operation for a small number of patients was the persistence of painful, disfiguring scarring which in two cases had a detrimental effect on social and personal relationships and led to a deterioration in quality of life. Improvement in self-esteem after surgery was maintained in 55 out of the 60 2-year responders. The results indicate that breast reduction confers significant health gains which are maintained in the long term.

Surgery for advanced epithelial ovarian cancer.

PubMed

Hacker, Neville F; Rao, Archana

2017-05-01

Cytoreductive surgery for patients with advanced epithelial ovarian cancer has been practised since the pioneering work of Tom Griffiths in 1975. Further research has demonstrated the prognostic significance of the extent of metastatic disease pre-operatively, and of complete cytoreduction post-operatively. Patients with advanced epithelial ovarian cancer should be referred to high volume cancer units, and managed by multidisciplinary teams. The role of thoracoscopy and resection of intrathoracic disease is presently investigational. In recent years, there has been increasing use of neoadjuvant chemotherapy and interval cytoreductive surgery in patients with poor performance status, which is usually due to large volume ascites and/or large pleural effusions. Neoadjuvant chemotherapy reduces the post-operative morbidity, but if the tumour responds well to the chemotherapy, the inflammatory response makes the surgery more difficult. Post-operative morbidity is generally tolerable, but increases in older patients, and in those having multiple, aggressive surgical procedures, such as bowel resection or diaphragmatic stripping. Primary cytoreductive surgery should be regarded as the gold standard for most patients until a test is developed which would allow the prediction of platinum resistance pre-operatively. Copyright © 2016. Published by Elsevier Ltd.

Recent advances in fixation of the craniomaxillofacial skeleton.

PubMed

Meslemani, Danny; Kellman, Robert M

2012-08-01

Fixation of the craniomaxillofacial skeleton is an evolving aspect for facial plastic, oral and maxillofacial, and plastic surgery. This review looks at the recent advances that aid in reduction and fixation of the craniomaxillofacial skeleton. More surgeons are using resorbable plates for craniomaxillofacial fixation. A single miniplate on the inferior border of the mandible may be sufficient to reduce and fixate an angle fracture. Percutaneous K-wires may assist in plating angle fractures. Intraoperative computed tomography (CT) may prove to be useful for assessing reduction and fixation. Resorbable plates are becoming increasingly popular in orthognathic surgery and facial trauma surgery. There are newer operative techniques for fixating the angle of the mandible. Also, the utilization of the intraoperative CT provides immediate feedback for accurate reduction and fixation. Prebent surgical plates save operative time, decrease errors, and provide more accurate fixation.

The effect of yoga in stress reduction for dental students performing their first periodontal surgery: A randomized controlled study

PubMed Central

Shankarapillai, Rajesh; Nair, Manju Anathakrishnan; George, Roy

2012-01-01

Context: The dental students experience a lot of stress, which increase when they perform their first surgical procedure. Yoga as an anxiolytic tool in anxiety reduction has been practiced over centuries in India. Aim: To assess the efficacy of yoga in reducing the state trait anxiety of dental students before their first periodontal surgery performance. Settings and Design: A randomized controlled study using a two-way split plot design (pre-post-test) was conducted in the department of periodontics, Pacific Dental College, Udaipur, India. Materials and Methods: One hundred clinical dental students who were ready to perform their first periodontal surgery were selected. Students were randomly assigned to two groups and were given a 60-min session on stress reduction. Group A, yogic intervention group, were instructed to do yoga and their performances were monitored for a period of one week and Group B, control group, were given a lecture on stress reduction without any yoga instructions. The investigator who was unaware of the groups had taken the state trait anxiety score of the students three times a) before assigning them to each group, b) prior to the surgical procedure and c) immediately after the performance of surgery. Statistical Analysis Used: Analyses of variance (ANOVA) by SPSS V.16. Results: The statistical results showed a significant reduction in the VAS and state trait anxiety of Group A compared to Group B (ANOVA; P<0.001). Conclusions: This study concludes that Yogic breathing has a significant effect on the reduction of state trait anxiety level of dental students. PMID:22346066

Clinical and radiological outcomes of surgical treatment for symptomatic arachnoid cysts in adults.

PubMed

Wang, Yongqian; Wang, Fei; Yu, Mingkun; Wang, Weiping

2015-09-01

We retrospectively analyzed 63 patients (31 males and 32 females) with arachnoid cysts managed over a 15 year period at our institution. Surgical indications and modalities for the treatment of intracranial arachnoid cysts are controversial, although endoscopic fenestration is often recommended as a standard procedure. In our cohort, clinical postoperative results and radiological assessments based on the presenting symptoms, cyst location, cyst volume and surgical modalities were recorded. The most common symptoms included headaches (66.7%), dizziness (46%) and seizures (36.5%). Cyst wall excision with microsurgical craniotomy was carried out in 28 patients (44.4%), cyst fenestration in 16 (25.4%), cystoperitoneal or ventriculoperitoneal shunting in 15 (23.8%) and endoscopic fenestration in four patients (6.3%). A satisfactory clinical outcome was achieved in 51 patients (80.9%) and cyst reduction was achieved in 49 (77.8%), at the last follow-up. Clinical improvement correlated significantly with volume reduction in patients with suprasellar and infratentorial cysts (r=0.495; p=0.022) while a similar result was not found after surgery in patients with frontal and temporal cysts. Surgical complications were not correlated with surgical modalities, occurring in only seven patients (11.1%). The various surgical modalities did not influence outcomes. Patients with nonspecific symptoms such as headache may obtain favourable outcomes from surgical treatment with no severe complications, although, intracranial hypertension and neurological deficits are more definite surgical indications for arachnoid cysts. Copyright © 2015 Elsevier Ltd. All rights reserved.

Surgical approach in treatment of translation/rotation injuries of the lower cervical spine in 21 patients.

PubMed

Llácer-Ortega, Jose L; Riesgo-Suárez, Pedro; Piquer-Belloch, Jose; Rovira-Lillo, Vicente

2012-05-01

The management of lower cervical spine injuries with a dislocation of one or both facet joints and a displacement of a vertebra over the adjacent stills generates considerable controversy. We describe our experience in surgical approach of these injuries. We present 21 cases treated between 2003-2010. Neurological status was evaluated with Frankel scale. Diagnosis was done by radiograph (XR), computed tomography (CT) and/or magnetic resonance image (MRI). Cervical traction was placed in 10 cases before surgery. Posterior and/or anterior approach was used for reduction and stabilization. The 21 cases presented were treated by surgery. Posterior approach was initially used in 17 cases and complete reduction was achieved in 13 of them. The 4 cases where we only got a partial reduction, surgery had to be delayed for different reasons. Anterior approach was initially used in 4 of the 21 cases. In 3 of them, reduction was previously obtained by traction and the fourth case anterior approach was used initially due to an important spinal cord compression. Permanent stabilization was achieved in 19 of the 21 cases. In 1 of the other 2 cases an important deformity was detected after the anterior approach. The other case had a minimal progression after a posterior approach with no increase in successive check-ups. In the first 10 cases, we used traction before surgery but reduction was achieved only in 3 of them. As the number of cases increased we rather used posterior approach in the first place, without even trying a preoperative traction. There was no case of neurological deterioration after surgery. Translation/rotation injuries of the lower cervical spine are unstable and surgical treatment must be indicated. It is our impression that posterior approach allows a better reduction and stabilization of this injuries and should be used initially without even trying a preoperative traction. Copyright © 2011 Sociedad Española de Neurocirugía. Published by Elsevier España. All rights reserved.

A combination of three-dimensional printing and computer-assisted virtual surgical procedure for preoperative planning of acetabular fracture reduction.

PubMed

Zeng, Canjun; Xing, Weirong; Wu, Zhanglin; Huang, Huajun; Huang, Wenhua

2016-10-01

Treatment of acetabular fractures remains one of the most challenging tasks that orthopaedic surgeons face. An accurate assessment of the injuries and preoperative planning are essential for an excellent reduction. The purpose of this study was to evaluate the feasibility, accuracy and effectiveness of performing 3D printing technology and computer-assisted virtual surgical procedures for preoperative planning in acetabular fractures. We hypothesised that more accurate preoperative planning using 3D printing models will reduce the operation time and significantly improve the outcome of acetabular fracture repair. Ten patients with acetabular fractures were recruited prospectively and examined by CT scanning. A 3-D model of each acetabular fracture was reconstructed with MIMICS14.0 software from the DICOM file of the CT data. Bone fragments were moved and rotated to simulate fracture reduction and restore the pelvic integrity with virtual fixation. The computer-assisted 3D image of the reduced acetabula was printed for surgery simulation and plate pre-bending. The postoperative CT scan was performed to compare the consistency of the preoperative planning with the surgical implants by 3D-superimposition in MIMICS14.0, and evaluated by Matta's method. Computer-based pre-operations were precisely mimicked and consistent with the actual operations in all cases. The pre-bent fixation plates had an anatomical shape specifically fit to the individual pelvis without further bending or adjustment at the time of surgery and fracture reductions were significantly improved. Seven out of 10 patients had a displacement of fracture reduction of less than 1mm; 3 cases had a displacement of fracture reduction between 1 and 2mm. The 3D printing technology combined with virtual surgery for acetabular fractures is feasible, accurate, and effective leading to improved patient-specific preoperative planning and outcome of real surgery. The results provide useful technical tips in planning pelvic surgeries. Copyright © 2016 Elsevier Ltd. All rights reserved.

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

PubMed

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

2012-04-01

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

Volume and health outcomes: evidence from systematic reviews and from evaluation of Italian hospital data.

PubMed

Amato, Laura; Fusco, Danilo; Acampora, Anna; Bontempi, Katia; Rosa, Alessandro Cesare; Colais, Paola; Cruciani, Fabio; D'Ovidio, Mariangela; Mataloni, Francesca; Minozzi, Silvia; Mitrova, Zuzana; Pinnarelli, Luigi; Saulle, Rosella; Soldati, Salvatore; Sorge, Chiara; Vecchi, Simona; Ventura, Martina; Davoli, Marina

2017-01-01

BACKGROUND Improving quality and effectiveness of healthcare is one of the priorities of health policies. Hospital or physician volume represents a measurable variable with an impact on effectiveness of healthcare. An Italian law calls for the definition of «qualitative, structural, technological, and quantitative standards of hospital care». There is a need for an evaluation of the available scientific evidence in order to identify qualitative, structural, technological, and quantitative standards of hospital care, including the volume of care above or below which the public and private hospitals may be accredited (or not) to provide specific healthcare interventions. OBJECTIVES To identify conditions/interventions for which an association between volume and outcome has been investigated. To identify conditions/interventions for which an association between volume and outcome has been proved. To analyze the distribution of Italian health providers by volume of activity. To measure the association between volume of care and outcomes of the health providers of the Italian National Health Service (NHS). METHODS Systematic review An overview of systematic reviews was performed searching PubMed, EMBASE, and The Cochrane Library up to November 2016. Studies were evaluated by 2 researchers independently; quality assessment was performed using the AMSTAR checklist. For each health condition and outcome, if available, total number of studies, participants, high volume cut-off values, and metanalysis have been reported. According to the considered outcomes, health topics were classified into 3 groups: positive association: a positive association was demonstrated in the majority of studies/participants and/or a pooled measure (metanalysis) with positive results was reported; lack of association: both studies and/or metanalysis showed no association; no sufficient evidence of association: both results of single studies and metanalysis do not allow to draw firm conclusions on the association between volume and outcome. Analysis of the distribution of Italian hospitals by volume of activity and the association between volume of activity and outcomes: the Italian National Outcome evaluation Programme 2016 The analyses were performed using the Hospital Information System and the National Tax Register (year 2015). For each condition, the number of hospitals by volume of activity was calculated. Hospitals with a volume lower than 3-5 cases/year were excluded. For conditions with more than 1,500 cases/year and frequency of outcome ≥1%, the association between volume of care and outcome was analyzed estimating risk-adjusted outcomes. RESULTS Bibliographic searches identified 80 reviews, evaluating 48 different clinical areas. The main outcome considered was intrahospital/30-day mortality. The other outcomes vary depending on the type of condition or intervention in study. The relationship between hospital volume and outcomes was considered in 47 out of 48 conditions: 34 conditions showed evidence of a positive association; • 14 conditions consider cancer surgery for bladder, breast, colon, rectum, colon rectum, oesophagus, kidney, liver, lung, ovaries, pancreas, prostate, stomach, head and neck; • 11 conditions consider cardiocerebrovascular area: nonruptured and ruptured abdominal aortic aneurysm, acute myocardial infarction, brain aneurysm, carotid endarterectomy, coronary angioplasty, coronary artery bypass, paediatric heart surgery, revascularization of lower limbs, stroke, subarachnoid haemorrhage; • 2 conditions consider orthopaedic area: knee arthroplasty, hip fracture; • 7 conditions consider other areas: AIDS, bariatric surgery, cholecystectomy, intensive care unit, neonatal intensive care unit, sepsis, and traumas; for 3 conditions, no association was demonstrated: hip arthroplasty, dialysis, and thyroidectomy. for the remaining 10 conditions, the available evidence does not allow to draw firm conclusions about the association between hospital volume and considered outcomes: surgery for testicular cancer and intracranial tumours, paediatric oncology, aortofemoral bypass, cardiac catheterization, appendectomy, colectomy, inguinal hernia, respiratory failure, and hysterectomy. The relationship between volume of clinician/surgeon and outcomes was assessed only through the literature re view; to date, it is not possible to analyze this association for Italian health provider hospitals, since information on the clinician/surgeon on the hospital discharge chart is missing. The literature found a positive association for 21 conditions: 9 consider surgery for cancer: bladder, breast, colon, colon rectum, pancreas, prostate, rectum, stomach, and head and neck; 5 consider the cardiocerebrovascular area: ruptured and nonruptured abdominal aortic aneurysm, carotid endarterectomy, paediatric heart surgery, and revascularization of the lower limbs; 2 consider the orthopaedic area: knee and hip arthroplasty; 5 consider other areas: AIDS, bariatric surgery, hysterectomy, intensive care unit, and thyroidectomy. The analysis of the distribution of Italian hospitals concerned the 34 conditions for which the systematic review has shown a positive volume-outcome association. For the following, it was possible to conduct the analysis of the association using national data: unruptured abdominal aortic aneurysm, coronary angioplasty, hip arthroplasty, knee arthroplasty, coronary artery bypass, cancer surgery (colon, liver, breast, pancreas, lung, prostate, kidney, and stomach), laparoscopic cholecystectomy, hip fracture, stroke, acute myocardial infarction. For these conditions, the association between volume and outcome of care was observed. For laparoscopic cholecystectomy and surgery of the breast and stomach cancer, the association between the volume of the discharge (o dismissal) operating unit and the outcome was analyzed. The outcomes differ depending on the condition studied. The shape of the relationship is variable among different conditions, with heterogeneous slope of the curves. DISCUSSION For many conditions, the overview of systematic reviews has shown a strong evidence of association between higher volumes and better outcomes. The quality of the available reviews can be considered good for the consistency of the results between the studies and for the strength of the association; however, this does not mean that the included studies are of good quality. Analyzing national data, potential confounders, including age and comorbidities, have been considered. The systematic review of the literature does not permit to identify predefined volume thresholds. The analysis of national data shows a strong improvement in outcomes in the first part of the curve (from very low to higher volumes) for most conditions. In some cases, the improvement in outcomes remains gradual or constant with the increasing volume of care; in other, the analysis could allow the identification of threshold values beyond which the outcome does not further improve. However, a good knowledge of the relationship between effectiveness of treatments and costs, the geographical distribution and the accessibility to healthcare services are necessary to choose the minimum volumes of care, under which specific health procedures could not been provided in the NHS. Some potential biases due to the use of information systems data should also be considered. The different way of coding among hospitals could lead to a different selection of cases for some conditions. Regarding the definition of the exposure (volume of care), a possible bias could result from misclassification of health providers with high volume of activity. Performing the intervention in different departments/ units of the same hospital would result in an overestimation of the volume of care measured for hospital rather than for department/unit. For the conditions with a further fragmentation within the same structure, the association between volumes of discharge department and outcomes has also been evaluated. In this case, the two curves were different. The limit is to attribute the outcome to the discharge unit, which in case of surgery may not be the intervention unit. A similar bias could occur if the main determinant of the outcome of treatment was the caseload of each surgeon. The results of the analysis may be biased when different operators in the same hospital/unit carried out the same procedure. In any case, the observed association between volumes and outcome is very strong, and it is unlikely to be attributable to biases of the study design. Another aspect on which there is still little evidence is the interaction between volume of the hospital and of the surgeon. A MEDICARE study suggests that in some conditions, especially for specialized surgery, the effect of the surgeon's volume of activity is different depending on the structure volume, whereas it would not differ for some less specialized surgery conditions. The data here presented still show extremely fragmented volumes of both clinical and surgical areas, with a predominance of very low volume structures. Health systems operate, by definition, in a context of limited resources, especially when the amount of resources to allocate to the health system is reduced. In such conditions, the rationalization of the organization of health services based on the volume of care may make resources available to improve the effectiveness of interventions. The identification and certification of services and providers with high volume of activity can help to reduce differences in the access to non-effective procedures. To produce additional evidence to guide the reorganization of the national healthcare system, it will be necessary to design further primary studies to evaluate the effectiveness and safety of policies aimed at concentrating interventions in structures with high volumes of activity.

Role of Prophylactic Tranexamic Acid in Reducing Blood Loss during Elective Caesarean Section: A Randomized Controlled Study.

PubMed

Lakshmi, Sj Dhivya; Abraham, Reena

2016-12-01

Obstetric haemorrhage accounts for 20-25% of maternal mortality and morbidity. Anti-fibrinolytics are being widely used in field of surgery. It is also used to reduce heavy menstrual blood loss. To analyse the effectiveness of Tranexamic Acid (TXA) in reducing blood loss during elective caesarean section. This interventional, randomized, parallel group study was done in the Department of Obstetrics and Gynaecolgy, PSG IMSR, Coimbatore, from June 2014 to May 2015. It was conducted on 120 women undergoing caesarean section. They were allocated to either Study or Control group by computer generated random number tables. TXA was given prior to surgery in study group in addition to the routine care {10 units of oxytocin added to the intravenous drip soon after baby delivery} whereas, the control group had routine care alone. Blood loss was measured in both groups by gravimetric method. Haemoglobin before and after surgery was estimated and the percentage of difference was compared. Primary outcome variables were volume of blood loss and percentage fall in haemoglobin before and after surgery. Secondary outcomes were duration of surgery, proportion of subjects with >500ml of blood loss, need for additional uterotonics and side effects. Unpaired t-test and Chi-square test were used to compare the outcome variables. There was significant reduction in blood loss calculated from placental delivery till end of surgery: 347.17ml in study group versus 517.72ml in control group (p<0.001). Another parameter studied was the percentage of fall in haemoglobin before and after surgery and the number of subjects who had more than 10% fall in haemoglobin. 9.3% of subjects in study group and 39% of subjects in control group had more than 10% fall in haemoglobin (p<0.01). There were no immediate post-operative complications to the mother and neonate. TXA significantly reduced the amount of blood loss during Lower Segment Caesarean Section (LSCS). Use of TXA was not associated with adverse effects. Thus, TXA can be used safely and effectively in subjects undergoing LSCS.

Declining operative experience for junior level residents: Is this an unintended consequence of minimally invasive surgery?

PubMed Central

Mullen, Matthew G.; Salerno, Elise P.; Michaels, Alex D.; Hedrick, Traci L.; Sohn, Min-Woong; Smith, Philip W.; Schirmer, Bruce D.; Friel, Charles M.

2016-01-01

Introduction Our group has previously demonstrated an upward shift from junior to senior resident participation in common general surgery operations, traditionally performed by junior level residents. The objective of this study was to evaluate if this trend would correct over time. We hypothesized that junior resident case volume would improve. Methods A sample of essential laparoscopic and open general surgery procedures (appendectomy, inguinal herniorrhaphy, cholecystectomy, and partial colectomy) was chosen for analysis. The ACS NSQIP Participant Use Files were queried for these procedures between 2005–2012. Cases were stratified by participating resident post-graduate year (PGY) with ‘junior resident’ defined as PGY1–3. Logistic regression was performed to determine change in junior resident participation for each type of procedure over time. Results 185,335 cases were included in the study. For three of the operations we considered, the prevalence of laparoscopic surgery increased from 2005–2012 (all p<0.001). Cholecystectomy was an exception, which showed an unchanged proportion of cases performed laparoscopically across the study period (p=0.119). Junior resident participation decreased by 4.5%/year (p<0.001) for laparoscopic procedures and by 6.2%/year (p<0.001) for open procedures. The proportion of laparoscopic surgeries performed by junior level residents decreased for appendectomy by 2.6%/year (p<0.001) and cholecystectomy by 6.1%/year (p<0.001), whereas it was unchanged for inguinal herniorrhaphy (p=0.75) and increased for partial colectomy by 3.9%/year (p=0.003). A decline in junior resident participation was seen for all open surgeries, with appendectomy decreasing by 9.4%/year (p<0.001), cholecystectomy by 4.1%/year (p<0.002), inguinal herniorrhaphy by 10%/year (p<0.001) and partial colectomy by 2.9%/year (p<0.004). Conclusions Along with the proliferation of laparoscopy for common general surgical procedures there has been a concomitant reduction in the participation of junior level residents. As previously thought, familiarity with laparoscopy has not translated to redistribution of basic operations from senior to junior residents. This trend has significant implications for general surgery resident education. PMID:27066854

[Femtosecond laser in cataract surgery. A critical appraisal].

PubMed

Menapace, R M; Dick, H B

2014-01-01

The use of femtosecond lasers (FSL) is increasingly spreading in cataract surgery. Potential advantages over standard manual cataract surgery are the superior precision of corneal incisions and capsular openings as well as the reduction of ultrasound energy for lens nucleus work-up. Exact positioning and dimensioning of the anterior capsular opening should help reduce decentration and tilt of the intraocular lens (IOL) optics and thus achieve better target refraction. Together with the possibility to correct low-grade corneal astigmatism by precise arcuate incision, FSL technology is expected to convert cataract surgery from a purely curative into a refractive procedure. Apart from own experiences this review article critically analyses the pertinent literature published so far as well as congress presentations and personal reports of other FSL surgeons. The advantages and disadvantages are scrutinized with regard to their impact on the surgical and refractive results and compared with those experienced by the authors with manual cataract surgery over several decades. Economic and healthcare political aspects are also addressed. The use of FSL surgery improves the precision and reproducibility of corneal incisions and the capsular opening and reduces the amount of ultrasound energy required for lens nucleus work-up. However, the clinical benefits must be put into perspective due to the subsequent surgical manipulation of the incisions (during lens emulsification, aspiration and IOL injection), the lacking possibility to visualize the crystalline lens equator as the reference for correct capsulotomy centration and the relativity of ultrasound energy consumption on the corneal endothelial trauma. This is of particular relevance against the background of the significantly higher costs. Conversely, tears of the anterior capsule edge which, apart from interfering with correct IOL positioning, may entail serious complications presently occur more frequently with all FSL instruments. From the economic and healthcare political viewpoint, thought should be given to the possible acquisition of the cataract surgical business by the industry or investors, as cataract surgery is a high-volume standardized procedure with enormous future potential. This could fundamentally change our currently decentralized and individualized structures and subsequently the steam of patient and make surgeons largely dependent or superfluous.

Reductions in pulmonary function detected in patients with lymphangioleiomyomatosis: An analysis of the Japanese National Research Project on Intractable Diseases database.

PubMed

Hayashida, Mie; Yasuo, Masanori; Hanaoka, Masayuki; Seyama, Kuniaki; Inoue, Yoshikazu; Tatsumi, Koichiro; Mishima, Michiaki

2016-05-01

In lymphangioleiomyomatosis (LAM), predicting lung disease progression is essential for treatment planning. However, no previous Japanese studies have attempted to predict the reductions in pulmonary function that occur in LAM patients. The data for 89 LAM patients who had undergone ≥3 spirometry tests and whose data had been registered in the Japanese National Research Project on Intractable Diseases database between October 2009 and March 2014 were analyzed after excluding patients who had undergone (1) a lung transplant; (2) mTOR inhibitor treatment; or (3) thoracic drainage, pleurodesis, surgery, or thoracic duct ligation during the study period. The rates of change (slope) in pulmonary parameters were calculated, and their associations with clinical background factors were investigated. Among the whole study population, the median (quartiles) slope of forced expiratory volume in one second (FEV1) was -46.7 (-95.2; -15.0)mL per year. Episodes of conservatively treated pneumothorax during the study period were found to be associated with rapid reductions in FEV1 (% predicted). Pregnancy during the study period was associated with a reduction in FEV1 (% predicted). When the patients were divided into those who exhibited initial FEV1 (% predicted) values of >70% (Group A) and ≤70% (Group B), Group B displayed significantly faster reductions in FEV1 (% predicted) than Group A. LAM patients whose initial FEV1 (% predicted) values are ≤70% subsequently exhibit rapid reductions in their FEV1 values, and hence, require treatment. However, the FEV1 reduction rate varies markedly among individuals and should be monitored in all cases. Copyright © 2015 The Japanese Respiratory Society. Published by Elsevier B.V. All rights reserved.

Intermittent fasting attenuates increases in neurogenesis after ischemia and reperfusion and improves recovery.

PubMed

Manzanero, Silvia; Erion, Joanna R; Santro, Tomislav; Steyn, Frederik J; Chen, Chen; Arumugam, Thiruma V; Stranahan, Alexis M

2014-05-01

Intermittent fasting (IF) is neuroprotective across a range of insults, but the question of whether extending the interval between meals alters neurogenesis after ischemia remains unexplored. We therefore measured cell proliferation, cell death, and neurogenesis after transient middle cerebral artery occlusion (MCAO) or sham surgery (SHAM) in mice fed ad libitum (AL) or maintained on IF for 3 months. IF was associated with twofold reductions in circulating levels of the adipocyte cytokine leptin in intact mice, but also prevented further reductions in leptin after MCAO. IF/MCAO mice also exhibit infarct volumes that were less than half those of AL/MCAO mice. We observed a 30% increase in basal cell proliferation in the hippocampus and subventricular zone (SVZ) in IF/SHAM, relative to AL/SHAM mice. However, cell proliferation after MCAO was limited in IF mice, which showed twofold increases in cell proliferation relative to IF/SHAM, whereas AL/MCAO mice exhibit fivefold increases relative to AL/SHAM. Attenuation of stroke-induced neurogenesis was correlated with reductions in cell death, with AL/MCAO mice exhibiting twice the number of dying cells relative to IF/MCAO mice. These observations indicate that IF protects against neurological damage in ischemic stroke, with circulating leptin as one possible mediator.

Intermittent fasting attenuates increases in neurogenesis after ischemia and reperfusion and improves recovery

PubMed Central

Manzanero, Silvia; Erion, Joanna R; Santro, Tomislav; Steyn, Frederik J; Chen, Chen; Arumugam, Thiruma V; Stranahan, Alexis M

2014-01-01

Intermittent fasting (IF) is neuroprotective across a range of insults, but the question of whether extending the interval between meals alters neurogenesis after ischemia remains unexplored. We therefore measured cell proliferation, cell death, and neurogenesis after transient middle cerebral artery occlusion (MCAO) or sham surgery (SHAM) in mice fed ad libitum (AL) or maintained on IF for 3 months. IF was associated with twofold reductions in circulating levels of the adipocyte cytokine leptin in intact mice, but also prevented further reductions in leptin after MCAO. IF/MCAO mice also exhibit infarct volumes that were less than half those of AL/MCAO mice. We observed a 30% increase in basal cell proliferation in the hippocampus and subventricular zone (SVZ) in IF/SHAM, relative to AL/SHAM mice. However, cell proliferation after MCAO was limited in IF mice, which showed twofold increases in cell proliferation relative to IF/SHAM, whereas AL/MCAO mice exhibit fivefold increases relative to AL/SHAM. Attenuation of stroke-induced neurogenesis was correlated with reductions in cell death, with AL/MCAO mice exhibiting twice the number of dying cells relative to IF/MCAO mice. These observations indicate that IF protects against neurological damage in ischemic stroke, with circulating leptin as one possible mediator. PMID:24549184

Surgery of the turbinates and “empty nose” syndrome

PubMed Central

Scheithauer, Marc Oliver

2011-01-01

Surgical therapy of the inferior and/or middle turbinate is indicated when conservative treatment options have failed. The desired goal is a reduction of the soft tissue volume of the turbinates regarding the individual anatomic findings, whilst simultaneously conserving as much mucosa as possible. As the turbinates serve as a functional entity within the nose, they ensure climatisation, humidification and cleaning of the inhaled air. Thus free nasal breathing means a decent quality of life, as well. Regarding the multitude of different surgical techniques, we confirm that no ideal standard technique for turbinate reduction has been developed so far. Moreover, there is a lack of prospective and comparable long-term studies, which makes it difficult to recommend evidence-based surgical techniques. However, the anterior turbinoplasty seems to fulfil the preconditions of limited tissue reduction and mucosa-preservation, and therefore it is the method of choice today. Radical resection of the turbinates may lead to severe functional disturbances developing a secondary atrophic rhinitis. The “empty nose” syndrome is a specific entity within the secondary atrophic rhinitis where intranasal changes in airflow result in disturbed climatisation and also interfere with pulmonary function. Results deriving from an actual in vivo study of climatisation and airflow in “empty nose” patients are presented. PMID:22073107

Three-dimensional airways reconstruction in syndromic pedriatric patients following mandibular distraction osteogenesis.

PubMed

Spinelli, Giuseppe; Agostini, Tommaso; Arcuri, Francesco; Conti, Marco; Raffaini, Mirco

2015-05-01

Airway obstruction, associated with mandibular hypoplasia, is a frequent complication in syndromic pediatric patients. The clinical signs of airway obstruction change from mild positional obstruction to severe respiratory distress with cyanosis. The young age of the patients makes medical management extremely complex. The purpose was to evaluate the success of surgery, evaluating the expansion of the respiratory volumes measured by computer tomography analyzed through a software (SimPlant Pro 15). Twelve patients with mandibular hypoplasia and respiratory distress were treated between December 2010 and December 2013. Eleven of them had tracheostomy in the preoperative period. The goal of surgery was to prevent permanent tracheostomy or to remove it, if present. Volume and surface area increased by an average of 279.2% and 89.4%, respectively. Tracheostomy was avoided in 1 patient who underwent surgery precociously, and it was removed in 10 patients. Only 1 case failed in volume airway augmentation, and tracheostomy was not removed. Computer tomography can calculate the cross-sectional areas of the airway in 3 planes of space: coronal, sagittal, and axial. In most patients, changes in airways have been accompanied by improvements in sleep and breathing, allowing for the removal of tracheostomy with an improved quality of life. Three-dimensional reconstruction of airways revealed a useful tool to better understand the success of surgery. IV.

NEW TECHNIQUE FOR OBESITY SURGERY: INTERNAL GASTRIC PLICATION TECHNIQUE USING INTRAGASTRIC SINGLE-PORT (IGS-IGP) IN EXPERIMENTAL MODEL.

PubMed

Müller, Verena; Fikatas, Panagiotis; Gül, Safak; Noesser, Maximilian; Fuehrer, Kirs Ten; Sauer, Igor; Pratschke, Johann; Zorron, Ricardo

2017-01-01

Bariatric surgery is currently the most effective method to ameliorate co-morbidities as consequence of morbidly obese patients with BMI over 35 kg/m2. Endoscopic techniques have been developed to treat patients with mild obesity and ameliorate comorbidities, but endoscopic skills are needed, beside the costs of the devices. To report a new technique for internal gastric plication using an intragastric single port device in an experimental swine model. Twenty experiments using fresh pig cadaver stomachs in a laparoscopic trainer were performed. The procedure was performed as follow in ten pigs: 1) volume measure; 2) insufflation of the stomach with CO2; 3) extroversion of the stomach through the simulator and installation of the single port device (Gelpoint Applied Mini) through a gastrotomy close to the pylorus; 4) performance of four intragastric handsewn 4-point sutures with Prolene 2-0, from the gastric fundus to the antrum; 5) after the performance, the residual volume was measured. Sleeve gastrectomy was also performed in further ten pigs and pre- and post-procedure gastric volume were measured. The internal gastric plication technique was performed successfully in the ten swine experiments. The mean procedure time was 27±4 min. It produced a reduction of gastric volume of a mean of 51%, and sleeve gastrectomy, a mean of 90% in this swine model. The internal gastric plication technique using an intragastric single port device required few skills to perform, had low operative time and achieved good reduction (51%) of gastric volume in an in vitro experimental model. A cirurgia bariátrica é atualmente o método mais efetivo para melhorar as co-morbidades decorrentes da obesidade mórbida com IMC acima de 35 kg/m2. Técnicas endoscópicas foram desenvolvidas para tratar pacientes com obesidade leve e melhorar as comorbidades, mas habilidades endoscópicas são necessárias, além dos custos. Relatar uma nova técnica para a plicatura gástrica interna utilizando um dispositivo intragástrico de portal único em modelo experimental de suínos. Foram realizados 20 experimentos utilizando estômagos de cadáver de porco fresco em um instrutor laparoscópico. O procedimento foi realizado da seguinte forma em dez porcos: 1) medida de volume; 2) insuflação do estômago com CO2; 3) extroversão do estômago através do simulador e instalação do dispositivo de uma única via (Gelpoint Applied Mini) através de uma gastrotomia próxima ao piloro; 4) realização de quatro suturas de quatro pontos intra-gástricas com Prolene 2-0, desde o fundo gástrico até o antro; 5) medição do volume residual. A gastrectomia vertical foi também realizada em mais dez suínos e o volume gástrico pré e pós-procedimento foi medido. A técnica de plicatura gástrica interna foi realizada com sucesso nos dez experimentos com suínos. O tempo médio do procedimento foi de 27±4 min. Produziu redução do volume gástrico em média de 51%, e a gastrectomia vertical em média de 90% neste modelo suíno. A técnica de plicatura gástrica interna, utilizando um dispositivo intragástrico de uma única via, exigiu poucas habilidades para ser realizada, teve baixo tempo operatório e obteve boa redução (51%) do volume gástrico em um modelo experimental in vitro.

Reductive Augmentation of the Breast.

PubMed

Chasan, Paul E

2018-06-01

Although breast reduction surgery plays an invaluable role in the correction of macromastia, it almost always results in a breast lacking in upper pole fullness and/or roundness. We present a technique of breast reduction combined with augmentation termed "reductive augmentation" to solve this problem. The technique is also extremely useful for correcting breast asymmetry, as well as revising significant pseudoptosis in the patient who has previously undergone breast augmentation with or without mastopexy. An evolution of techniques has been used to create a breast with more upper pole fullness and anterior projection in those patients desiring a more round, higher-profile appearance. Reductive augmentation is a one-stage procedure in which a breast augmentation is immediately followed by a modified superomedial pedicle breast reduction. Often, the excision of breast tissue is greater than would normally be performed with breast reduction alone. Thirty-five patients underwent reductive augmentation, of which 12 were primary surgeries and 23 were revisions. There was an average tissue removal of 255 and 227 g, respectively, per breast for the primary and revision groups. Six of the reductive augmentations were performed for gross asymmetry. Fourteen patients had a previous mastopexy, and 3 patients had a previous breast reduction. The average follow-up was 26 months. Reductive augmentation is an effective one-stage method for achieving a more round-appearing breast with upper pole fullness both in primary breast reduction candidates and in revisionary breast surgery. This technique can also be applied to those patients with significant asymmetry. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .