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Biomedical subjects

G D Adamson

Publications and source records attributed to G D Adamson.

At least 19 recordsLinked to original sources
PubMed2006

Competence assessment of laparoscopic operative and cognitive skills: Objective Structured Clinical Examination (OSCE) or Observational Clinical Human Reliability Assessment (OCHRA).

BACKGROUND: There is no agreed system that is acknowledged as the ideal assessment of laparoscopic operative and cognitive skills. A new approach that combines Objective Structured Clinical Examination (OSCE) and Observational Clinical Human Reliability Assessment (OCHRA) was developed and used to assess trainees' operative and cognitive skills during laparoscopic training courses. METHODS: Performance of 60 trainees participating in 3-day essential laparoscopic skills training (cognitive and psychomotor) courses were assessed and scored using both OSCE and OCHRA. RESULTS: The study showed significant inverse correlations between the number of technical errors identified by OCHRA and the scores obtained by OSCE for individual tasks performed either by electro-surgical hook or laparoscopic scissors (r = -0.864 and r = -0.808, respectively). Significant differences between trainees were observed in relation to both overall OSCE scores and OCHRA parameters: execution time, total errors, and consequential errors (P < 0.001). CONCLUSIONS: OCHRA provides a discriminative feedback assessment of laparoscopic operative skills. OCHRA and OSCE are best regarded as complementary assessment tools for operative and cognitive skills. The present study has documented significant variance between surgical trainees in the acquisition of both cognitive and operative skills.

Cholecystectomy, Laparoscopic↗
PubMed2005

Multimedia article. Laparoscopic transection choledochoduodenostomy.

Choledochoduodenostomy is a well-established procedure and is indicated in patients with multiple ductal calculi and dilated common bile duct (>or=2.0 cm) because these patients require drainage for good long-term results without recurrence of jaundice or cholangitis. The technique most commonly used is that of a side-to-side hand-sutured anastomosis between the supraduodenal common bile duct and the duodenum. The merit of this technique is its simplicity, although it is prone to duodenobiliary reflux and to occasional symptomatic inspissation with food debris causing cholangitis (sump syndrome). It is the technique that has been adopted by most centers for laparoscopic choledochoduodelaostomy. The alternative operation, transection choledochoduodenostomy, excludes the distal (transpancreatic) segment of the bile duct from the end-to-side anastomosis of the transected common bile duct with the second part of the duodenum. The long-term results of this procedure are excellent, and for this reason we have used it for laparoscopic drainage of the common bile duct in six elderly patients (four females and two males; age range, 61-72 years) with multiple occluding ductal calculi and grossly dilated bile duct. Three of these patients (including the one shown in the multimedia video) were admitted acutely with bacterial cholangitis and required emergency insertion of pigtail stent to overcome the acute septic illness. There were no conversions. The first operation lasted 4 h but the operating times in the last two patients were 2.0 and 2.5 h. The results have been excellent, with no deaths and a low postoperative morbidity (chest infection in one patient) and median postoperative hospital stay of 5 days.

Aged↗
PubMed2003

Multimedia article. Laparoscopic infracolic necrosectomy for infected pancreatic necrosis.

Infected pancreatic necrosis carries a high morbidity and mortality from sepsis and multisystem organ failure. Following confirmation of the infection by CT-guided fine needle aspiration, treatment consists of broad spectrum antibiotics (imipenim-cilastin) followed by emergency open (laparotomy) digital necrosectomy and insertion of drains for postoperative lavage with hyperosmolar dialysate as advocated by Beger et al. This video shows an alternative laparoscopic technique to open necrosectomy and has been used in Dundee since 1994. After elevation of the transverse colon, the lesser sac is opened through the root of the transverse colon between the middle and left colic vessels. The necrosectomy is accomplished from inside the lesser sac under vision with a combination of pulsed irrigation and graspers. On completion of the necrosectomy, two large drains are inserted into the lesser sac for postoperative irrigation. The experience with this technique has been favorable with a patient survival of 85%.

Bacterial Infections↗
PubMed1998

Sonohysterographic screening before in vitro fertilization.

OBJECTIVE: To evaluate the use of sonohysterography for uterine screening before IVF. DESIGN: Prospective screening with sonohysterography and comparison with available hysterosalpingographic and hysteroscopic evaluations. SETTING: Private practice. PATIENT(S): Seventy-two women undergoing IVF-ET using their own or donor eggs. INTERVENTION(S): Sonohysterography was performed by instilling saline into the uterine cavity through an intracervical balloon catheter; there was concurrent vaginal sonographic visualization in all cases. MAIN OUTCOME MEASURE(S): Sonohysterographic findings and pregnancy rates. RESULT(S): Cavitary lesions were detected in 8 (11.1%) of 72 sonohysterographic examinations. Six of 8 cases were confirmed and treated by hysteroscopy. After sonohysterographic evaluation, 35 (48.6%) of 72 patients conceived, resulting in 25 ongoing or delivered pregnancies, 5 chemical pregnancies, and 5 spontaneous abortions. No statistically significant difference was observed in the pregnancy outcome for patients undergoing IVF who had sonohysterography compared with that for patients undergoing IVF during the same period who previously had a uterine evaluation by a different method. The estimated cost savings per patient undergoing sonohysterography instead of in-office hysteroscopy was $275. CONCLUSION(S): Sonohysterography offers advantages over in-office hysteroscopy and hysterosalpingography for evaluation of the uterus before IVF.

Adult↗
PubMed1998

Efficacy of treatment for unexplained infertility.

OBJECTIVE: To analyze the efficacy and cost-effectiveness of alternative treatments for unexplained infertility. DESIGN: Retrospective analysis of 45 published reports. SETTING: Clinical practices. PATIENT(S): Couples who met criteria for unexplained infertility. Women with Stage I or Stage II endometriosis were included. INTERVENTION(S): Observation; clomiphene citrate (CC); gonadotropins (hMG); IUI; and GIFT and IVF. MAIN OUTCOME MEASURE(S): Clinical pregnancy rate. RESULT(S): Combined pregnancy rates per initiated cycle, adjusted for study quality, were as follows: no treatment = 1.3%-4.1%; IUI = 3.8%; CC = 5.6%; CC + IUI = 8.3%; hMG = 7.7%; hMG + IUI = 17.1%; IVF = 20.7%; GIFT = 27.0%. The estimated cost per pregnancy was $10,000 for CC + IUI, $17,000 for hMG + IUI, and $50,000 for IVF. CONCLUSION(S): Clomiphene citrate + IUI is a cost-effective treatment for unexplained infertility. If this treatment fails, hMG + IUI and assisted reproduction are efficacious therapeutic options.

Cost-Benefit Analysis↗
PubMed1998

Minimum intrauterine pressure required for uterine distention.

Study Objective. To determine the minimum intrauterine pressure required to distend the uterine cavity during hysteroscopy using saline as a distending medium. Design. Nonrandomized, prospective study (Canadian Task Force classification II-2). Setting. Ambulatory surgery suites. Patients. Seven women from the practice of the principal investigator. Intervention. Hysteroscopy was performed and intrauterine perfusion pressure was measured. Measurements and Main Results. Intrauterine perfusion pressure required to separate the anterior and posterior uterine walls was measured using a Cobe CDX pressure transducer kit. The uterine cavity was distended when intrauterine perfusion pressure reached a median of 40 mm Hg (range 25-50 mm Hg). Conclusion. This preliminary study suggests that a liquid with the same viscosity as normal saline distends the uterine cavity at a pressure of approximately 40 mm Hg. This pressure is lower than that at which spillage from fallopian tubes occurs, suggesting that it may theoretically be possible to ablate the endometrial lining with heated liquid without spilling liquid into the peritoneal cavity. Further study with larger numbers of patients is required to verify this finding.

Female↗
PubMed1997

Therapeutic efficacy and bone mineral density response during and following a three-month re-treatment of endometriosis with nafarelin (Synarel).

OBJECTIVE: Our goal was to determine the effects of a repeated course of the gonadotropin-releasing hormone agonist nafarelin on symptoms and signs of endometriosis and lumbar and distal radius bone mineral density. STUDY DESIGN: Forty-five women previously treated for 6 months with nafarelin, who had recurrent symptoms and signs of endometriosis, received 400 mcg/day of nafarelin intranasally for 3 months. Efficacy was evaluated by changes in severity of symptoms and signs. Lumbar bone mineral density was measured by dual-energy x-ray absorptiometry and distal radius bone mineral density by single-photon absorptiometry. Bone mineral density was also measured in 10 control volunteers. RESULTS: Repeated 3-month treatment significantly alleviated recurrent symptoms and signs of endometriosis. Lumbar bone mineral density decreased significantly by a mean of 2% at the end of treatment; this loss was restored within 3 to 6 months after treatment completion. No bone mineral density decline occurred in the radius. Bone mineral density changes in the control group were statistically insignificant. CONCLUSIONS: A repeated 3-month course of nafarelin treatment significantly relieved recurrent endometriotic symptoms and signs without sustained loss of bone mineral density.

Adult↗
PubMed1997

Prediction of pregnancy in infertile women based on the American Society for Reproductive Medicine's revised classification of endometriosis.

OBJECTIVE: To estimate the empirical relationship between the revised American Society for Reproductive Medicine's classification of endometriosis and pregnancy rates after treatment. DESIGN: Retrospective analysis. PATIENT(S): Patients seen by four practicing physicians. INTERVENTION(S): Medical and/or surgical therapy for endometriosis. MAIN OUTCOME MEASURE(S): Pregnancy defined as ongoing or delivered. RESULT(S): There were no significant differences in pregnancy rates across stages of endometriosis. There was a slight decline in pregnancy rates among patients with Stage IV endometriosis, but statistical significance was not achieved. CONCLUSION(S): The use of an arbitrary weighted system for assigning scores to individual categories of disease, or for computing a total score, has limited the overall effectiveness of the classification system to predict pregnancy.

Adult↗
PubMed1997

Surgical treatment of endometriosis.

Surgical resection of endometriosis, previously possible only by means of laparotomy, can now be accomplished through laparoscopic techniques. The requirements for surgery, surgical principles, operative techniques, and results are summarized in this article, with emphasis on the laparoscopic approach.

Algorithms↗
PubMed1997

Multicenter feasibility study of a new coaxial falloposcopy system.

We compared falloposcopy employing a new coaxial system with traditional laparoscopic chromotubation and hysterosalpingography in a prospective, multicenter clinical trial at five tertiary infertility centers. Based on findings at hysterosalpingography or laparoscopic chromotubation, the 16 women (22 tubes) in group 1 had a presumed diagnosis of proximal tubal obstruction, and the 4 (7 tubes) in group 2 had unexplained infertility. Cannulation was successfully achieved in 83.3% of tubes. In group 1, 85% (17/20) of visualized tubes were patent and 35% (7/20) were normal. In group 2, 40% (2/5) of visualized tubes were abnormal. Management was changed in 52.4% of women as a result of falloposcopic findings. Falloposcopy with this new coaxial system allows improved visualization with less bulky and less traumatic instruments. The system provides valuable information regarding the fallopian tube lumen that correlates poorly with that obtained with more traditional techniques.

Adult↗
PubMed1997

Treatment of endometriosis-associated infertility.

The choice of treatment options for endometriosis-associated infertility has been both controversial and complex, largely because of lack of data. In the last 10 years, better data from numerous studies with improved design support laparoscopic ablation and/or resection of lesions as the most successful for both minimal/mild and moderate/severe/extensive disease. Laparotomy should be performed when necessary. Observation alone is sometimes indicated in young women with minimal/mild disease. Hormonal suppression has no identifiable role, except perhaps for severe/extensive disease, before IVF or GIFT. Ovarian stimulation with clomiphene or gonadotropins and concomitant intrauterine insemination is indicated for minimal/mild disease. IVF and GIFT are often best for those who have failed other treatments, have advanced age, prolonged infertility, and/or multiple-factor infertility.

Clomiphene↗
PubMed1995

Stability of in vitro fertilization-embryo transfer success rates from the 1989, 1990, and 1991 Clinic-Specific Outcome Assessments.

OBJECTIVE: To determine if the differences in IVF-ET success rates among clinics are due to chance alone. DESIGN: Retrospective analysis of data reported by individual clinics. SETTING: One hundred seventy-five clinics in 1989, 192 clinics in 1990, and 208 clinics in 1991 that reported IVF-ET success rates to the Society for Assisted Reproductive Technology and the American Society for Reproductive Medicine (formerly The American Fertility Society). PATIENTS: Women < 40 years of age with no male factor. INTERVENTION: In vitro fertilization-ET. MAIN OUTCOME MEASURE: Delivery rate per retrieval and delivery rate per transfer. RESULTS: The hypothesis that the differences among IVF-ET success rates for clinics is due to chance alone can be rejected. Seven clinics were found to have pregnancy rates significantly higher than average and six clinics were found to have pregnancy rates significantly lower than average. Significant correlations were found between different years in the success rates for individual clinics but not for success as a function of the number of patients treated. CONCLUSIONS: Success rates for a few clinics are significantly different from the average success rate, but success rates must be used with caution in selecting a clinic.

Adult↗
PubMed1995

Threshold intrauterine perfusion pressures for intraperitoneal spill during hydrotubation and correlation with tubal adhesive disease.

OBJECTIVE: To determine the minimum intrauterine perfusion pressure that will produce spill from the fallopian tubes into the peritoneal cavity and to correlate this pressure with the extent of tubal adhesive disease. DESIGN: Hydrotubation was performed at laparoscopy and intrauterine perfusion pressure was measured. The extent of peritubal and fimbrial adhesions was graded at laparoscopy. SETTING: Ambulatory surgery suites. PATIENTS: Ten patients with infertility and/or pelvic pain were enrolled in the study. Data from nine patients were analyzed. INTERVENTIONS: Measurement of intrauterine perfusion pressures. MAIN OUTCOME MEASURES: The minimum pressure that produced spill of dye from each fallopian tube and the correlation between extent of external tubal pathology and this threshold pressure. RESULTS: The median threshold pressure at which dye spilled from at least one fallopian tube was 100 mm Hg, and no spill occurred at pressures < 70 mm Hg. The threshold pressure was correlated negatively with the extent of tubal disease. CONCLUSIONS: Fluid with the same viscosity as hydrotubation dye will not spill into the peritoneal cavity through normal fallopian tubes until the intrauterine perfusion pressure exceeds 70 mm Hg. The threshold pressure is higher when tubal adhesive disease that can be visualized by laparoscopy is present.

Adult↗
PubMed1994

Surgical treatment of endometriosis-associated infertility: meta-analysis compared with survival analysis.

OBJECTIVE: Our purpose was to evaluate the role of surgery in the treatment of endometriosis associated with infertility. STUDY DESIGN: We used a prospective cohort analysis of pregnancy rates and variables affecting pregnancy rates for surgical, medical, and no treatment. Our studies were combined with those reported by Hughes et al. (Fertil Steril 1993; 59:963-70), and the meta-analysis was expanded to include additional comparisons. Treatment was performed by a single surgeon in a referral reproductive endocrinology and surgery private practice. Results from 579 women with endometriosis and infertility in our study and the meta-analysis of 25 studies by Hughes et al. were examined. Interventions consisted of no treatment, medical treatment, or surgical treatment by laparoscopy or laparotomy. The main outcome measure was pregnancy rates. RESULTS: For minimal and mild disease, no treatment, laparoscopy, and laparotomy had equivalent 3-year estimated cumulative life-table pregnancy rates (67% +/- 12%, 68% +/- 4%, and 74% +/- 8%, respectively) that were higher than medical treatment pregnancy rates (Breslow p = 0.003). For moderate and severe disease, all but 11 patients were treated surgically. The 3-year estimated cumulative life-table pregnancy rates were 62% + 6% [corrected] for 120 laparoscopy cases and 44% + 6% [corrected] for 102 laparotomy cases (Breslow p = 0.054). For endometriomas, 48 laparoscopy patients had a 3-year estimated cumulative life-table pregnancy rate of 52% +/- 9% and 52 laparotomy patients had a 3-year estimated cumulative life-table pregnancy rate of 46% +/- 9% (Breslow p = 0.48). For 28 patients with complete cul-de-sac obliteration, the 3-year estimated cumulative life-table pregnancy rates were 30% +/- 14% after laparoscopy and 24% +/- 12% after laparotomy (Breslow p = 0.084). Comparison of our results with the expanded meta-analysis revealed deficiencies in the design of meta-analysis studies and the impact of our using life-table pregnancy rates controlled for factors influencing outcome (survival analysis with fixed covariates) rather than the simple pregnancy rates used in the meta-analysis. Benefits of sophisticated statistical techniques, including propensity scores, to adjust for noncomparability of groups in prospective cohort studies were identified. CONCLUSION: Both our study and the meta-analysis show that either no treatment or surgery is superior to medical treatment for minimal and mild endometriosis associated with infertility. For moderate and severe disease, surgery is usually used. In these patients experienced surgeons utilizing good clinical judgment can achieve results at operative laparoscopy at least equivalent to those at laparotomy, even in cases involving endometriomas and complete cul-de-sac obliteration. Prospective randomized trials should be performed to confirm these findings.

Cohort Studies↗