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Biomedical subjects

Ronald F Sing

Publications and source records attributed to Ronald F Sing.

At least 19 recordsLinked to original sources
PubMed2006

Laparoscopic ventral hernia repair in obese patients: a new standard of care.

HYPOTHESIS: Ventral abdominal hernias represent a frequent and often formidable clinical problem, especially in obese patients. Because laparoscopic ventral hernia repair (LVHR) results in few complications and a low recurrence rate, the use of minimally invasive techniques in this subgroup of patients may minimize perioperative complications and failure rates. DESIGN: Retrospective review of prospectively collected data. SETTING: Tertiary care hospital. PATIENTS: One hundred sixty-three obese patients (body mass index [calculated as weight in kilograms divided by the square of height in meters], > or =30) who underwent LVHR at our institution between July 1, 1998, and December 31, 2003. INTERVENTION: Laparoscopic ventral hernia repair with an expanded polytetrafluoroethylene mesh. MAIN OUTCOME MEASURES: Patient age, sex, body mass index, size of fascial defect and mesh, operating time, operative blood loss, length of hospitalization, complications, and hernia recurrences. RESULTS: Ninety-eight women and 65 men, with a mean body mass index of 38, underwent LVHR. Twenty patients (12.3%) had 21 postoperative complications. There was no perioperative mortality. The mean length of hospital stay was 2.6 days. The recurrence rate was 5.5% at a mean follow-up of 25 months (range, 1-73 months). CONCLUSIONS: A low rate of conversion to laparotomy, minimal perioperative morbidity, and the absence of perioperative mortality in this series indicate the safety of LVHR in obese patients with complex hernias. In addition, a success rate of more than 94.5% suggests improved efficacy of LVHR compared with the historical rates among control subjects undergoing open surgery. In experienced hands, LVHR may be the approach of choice for most patients with a body mass index of 30 or more.

Adult↗
PubMed2006

Extended interval for retrieval of vena cava filters is safe and may maximize protection against pulmonary embolism.

BACKGROUND: Retrieval of optional vena cava filters (VCF) has been demonstrated to be safe and feasible in injured patients in 4 recent studies. However, 2 pulmonary emboli PE were reported in these studies with mean implant durations less than 19 days. In light of these occurrences, we changed our practice for VCF retrieval when patients had recovered from their injuries and at least 30 days after their discharge, or had been stable on therapeutic anticoagulation for deep venous thrombosis (DVT) or PE for at least 2 weeks. The aim of the current study was to assess the safety of this approach. METHODS: A review of prospectively collected data on optional VCF over a 16-month period. The filters were inserted prophylactically per an institutional practice guideline or for the presence of DVT or PE with a contraindication and/or complication to anticoagulation. All patients underwent duplex imaging of the lower extremities and had pre- and post- retrieval cavagrams. Demographics, duration of implantation, and complications were recorded. RESULTS: Eighty-three patients had optional VCF inserted since the change in our clinical practice. Indications included prophylaxis for high-risk trauma patients (n = 58), DVT or PE with acute contraindication to therapeutic anticoagulation (n = 22), or complications of anticoagulation (n = 3). Two patients developed lower extremity DVT after filter insertion and 1 patient developed a vena cava thrombosis. Retrieval was successful in 47 of 54 cases (87%) attempted. Median implantation duration was 142 days (range 17-475). A filter strut fracture occurred during retrieval without further consequences. No post-insertion or post-retrieval PE occurred in this study. CONCLUSION: Extended intervals for retrieval of VCF are safe and may maximize protection against pulmonary embolism.

Adolescent↗
PubMed2006

Nine-year experience with insertion of vena cava filters in the intensive care unit.

BACKGROUND: Vena cava filter insertion (VCF) is traditionally performed in a radiology suite or in the operating room. We reviewed our experience of bedside VCF insertion in the intensive care unit (ICU) performed by general surgeons. METHODS: A prospective, observational study of bedside VCF insertion in the ICU was performed by general surgeons between February 1996 and June 2005. Demographic data and procedural complications were recorded. RESULTS: Four hundred three patients underwent bedside VCF insertion. Complications included 1 groin hematoma, 2 misplacements, and a right ventricular perforation from a dilator requiring surgical repair. DVT occurred in 38 patients (8.5%); 14 occurred at the insertion site. There were 2 pulmonary embolisms (<1%) after VCF. Contrast-related renal failure occurred in 2 of the first 35 patients; carbon dioxide gas is now used for contrast in high-risk patients. CONCLUSIONS: Bedside insertion of VCF in the ICU by surgeons is safe and effective.

Adult↗
PubMed2006

Vena cava filters in spinal cord injuries: evolving technology.

BACKGROUND: Asymptomatic deep venous thrombosis (DVT) has been reported in 60% to 100% of persons with spinal cord injury (SCI). Several guidelines have been published detailing recommended venous thromboembolism (VTE) prophylaxis after acute SCI. Low-molecular-weight heparin, intermittent pneumatic compression (IPC) devices, and/or graduated compression stockings are recommended. Vena cava filters (VCFs) are recommended for secondary prophylaxis in certain situations. OBJECTIVE: To clarify the use of vena cava filters in patients with SCI. METHODS: Literature review. RESULTS: Prophylactic use of vena cava filters has expanded in trauma patients, including individuals with SCI. Filter placement effectively prevents pulmonary emboli and has a low complication rate. Indications include pulmonary embolus while on anticoagulant therapy, presence of pulmonary embolus and contraindication for anticoagulation, and documented free-floating ileofemoral thrombus. VCFs should be considered in patients with complete motor paralysis caused by lesions in the high cervical cord (C2 and C3), with poor cardiopulmonary reserve, or with thrombus in the inferior vena cava despite anticoagulant prophylaxis. Three optional retrievable filters that are approved for use are discussed. CONCLUSION: Retrievable VCFs are a safe, feasible option for secondary prophylaxis of VTE in patients with SCI. Objective criteria for temporary and permanent placement need to be defined.

Anticoagulants↗
PubMed2006

Long-term outcomes of laparoscopic resection of gastric gastrointestinal stromal tumors.

OBJECTIVE: Gastric gastrointestinal stromal tumors (GISTs) are rare neoplasms that require excision for cure. Although the feasibility of minimally invasive resection of gastric GIST has been established, the long-term safety and efficacy of these techniques are unclear. We hypothesized that complete resection of gastric GISTs using a combination of laparoscopic or laparoendoscopic techniques results in low perioperative morbidity and an effective long-term control of the disease. METHODS: Between August 1996 and June 2005, 50 consecutive patients undergoing laparoscopic or laparoendoscopic resection of gastric GISTs were identified in a prospectively collected database. Outcome measures included patient demographics and outcomes, operative findings, morbidity, and histopathologic characteristics of the tumor. Patient and tumor characteristics were analyzed to identify risk factors for tumor recurrence. RESULTS: Fifty patients, mean age 60 years (range, 34-84 years), underwent 47 local and 3 segmental laparoscopic gastric resections. GI bleeding and dyspepsia were the most common symptoms. Mean tumor size was 4.4 cm (range, 1.0-8.5 cm) with the majority of the lesions located in the proximal stomach. Mean operative time was 135 minutes (range, 49-295 minutes), the mean blood loss was 85 mL (range, 10-450 mL), and the mean length of hospitalization was 3.8 days (range 1-10 days). There were no major perioperative complications or mortalities. All lesions had negative resection margins (range, 2-45 mm). Nine patients had 10 or more mitotic figures per 50 high power fields, while 11 had ulceration and/or necrosis of the lesion. At a mean follow-up of 36 months, 46 (92%) patients were disease free, 1 patient was alive with disease, 1 patient with metastases died of a cardiac event, and 2 (4%) patients died of metastatic disease. No local or port site recurrences have been identified. Patient age, tumor size, mitotic index, tumor ulceration, and necrosis were statistically associated with tumor recurrence. The presence of 10 or more mitotic figures per 50 high power fields was an independent predictor of disease progression (P = 0.006). CONCLUSION: A laparoscopic approach to surgical resection of gastric GIST is associated with low morbidity and short hospitalization. As found in historical series of open operative resection, the tumor mitotic index predicts local recurrence. The long-term disease-free survival of 92% in our study establishes laparoscopic resection as safe and effective in treating gastric GISTs. Given these findings as well as the advantages afforded by minimally invasive surgery, a laparoscopic approach may be the preferred resection technique in most patients with small- and medium-sized gastric GISTs.

Adult↗
PubMed2006

Timing of pulmonary emboli after trauma: implications for retrievable vena cava filters.

BACKGROUND: Four recent reports of the retrieval of optional vena cava filters (VCF) in trauma patients had average implant durations of 10, 19, and 19 days (one not specified). Two patients in these studies had pulmonary emboli after VCF removal. No evidence-based guidelines exist on the appropriate time to remove optional VCF. The purpose of this study was to examine the timing of pulmonary emboli (PE) and determine the optimal time to remove optional VCFs. METHODS: A multicenter retrospective chart review of trauma patients who had a postinjury PE between January 2001 and December 2004 was performed. We examined the demographics, prophylaxis at the time of PE (pharmacologic [unfractionated or low molecular weight heparin] or sequential compression devices [SCD]), diagnostic test used, timing of PE from the date of injury, and survival outcome. RESULTS: In all, 146 patients were identified, mean age 45.1 (+/- 21.1 SD); Injury Severity Score 18.0 (+/- 12.1 SD). Diagnosis was obtained by spiral computed tomography (N = 93), pulmonary arteriogram (N = 18), V/Q (N = 26), autopsy (N = 6), clinical (N = 6), and unknown (N = 3). Overall mortality was 17.8% (N = 26). Pulmonary embolism was felt to contribute to or was the cause of death in 85% (N = 22) of these patients. Two late PE deaths occurred (days 21 and 43). Sixty (37%) patients had pharmacologic prophylaxis at the time of PE and 83 (50.9%) had SCDs. Average time from injury to PE was 7.9 days (+/- 8.1 SD), the longest being 43 days postinjury. Eleven percent of PE occurred after 21 days, including fatal PE. CONCLUSIONS: Clinical criteria defining the time to remove optional VCFs without exposing patients to the risk of PE by removing a filter too soon should be determined.

Humans↗
PubMed2006

Audience response system technology improves accuracy and reliability of trauma outcome judgments.

BACKGROUND: Peer-review judgments are necessary for effective trauma performance improvement (PI), but may be influenced by peer pressure and the tendency to vote with the majority. Incorporation of Audience Response System (ARS) technology into trauma PI should result in improved outcome assessments. METHODS: We compared 30 months of nonanonymous trauma care judgments with 30 months of anonymous judgments obtained with the use of a keypad-based ARS. Statistical methods included the chi2 test and the Wilcoxon rank sum test. RESULTS: Use of the ARS resulted in a 28% reduction in deaths judged nonpreventable and a 24% reduction in trauma care judged to be appropriate (p < 0.0001). Unanimous outcome judgments were also significantly reduced (p < 0.0001). CONCLUSIONS: Outcome judgments obtained anonymously were significantly more divergent and less positive than those obtained nonanonymously. Anonymously derived outcome judgments may provide a better opportunity to identify adverse outcomes and thereby potentially improve trauma PI and trauma care.

Data Collection↗
PubMed2006

Abdominal wall reconstruction after temporary abdominal closure: A ten-year review.

Abdominal wall reconstruction (AWR) is often required for hernias created after temporary abdominal closure (TAC). Demographic and clinical data from patients undergoing TAC and AWR between January 1, 1992, and December 31, 2002, were collected and univariate analysis performed. Temporary abdominal closure and AWR were performed in 21 patients. Complications developed in 12 patients (57.1%) after TAC; associated risk factors were mesh placement (P = .04) and skin grafting (P = .04). Successful AWR included mesh (n = 6), component separation (n = 6), primary repair (n = 4), and 3 combination techniques. Six patients (28.6%) developed intraoperative complications, and 14 (66.7%) developed postoperative complications. Intraoperative complications were increased in patients with tissue expanders (P = .01). Postoperative complications (P = .04) were less likely with component separation. The complication rate with TAC and AWR is high. Tissue expanders are associated with an increased risk of intraoperative complications with AWR, whereas component separation is associated with a reduction in postoperative complications.

Abdominal Wall↗
PubMed2006

Advantages of laparoscopic appendectomy in the elderly.

Laparoscopic appendectomy (LA) has gained in popularity in recent years. The number of elderly patients undergoing appendectomy has increased as that segment of the population has increased in number; however, the utility and benefits of LA in the elderly population are not well established. We hypothesized that LA in the elderly has distinctive advantages in perioperative outcomes over open appendectomy (OA). We queried the 1997 to 2003 North Carolina Hospital Association Patient Data System for all patients with the primary ICD-9 procedure code for OA and LA. Patients > or = 65 years of age (elderly) were identified and reviewed. Outcomes including length of stay (LOS), charges, complications, discharge location, and mortality were compared between the groups. There were 29,244 appendectomies performed in adult patients (>18 years old) with 2,722 of these in the elderly. The annual percentage of LA performed in the elderly increased from 1997 to 2003 (11.9-26.9%, P < 0.0001). When compared with OA, elderly patients undergoing LA had a shorter LOS (4.6 vs 7.3 days, P = 0.0001), a higher rate of discharge to home (91.4 vs 78.9%, P = 0.0001) as opposed to a step-down facility, fewer complications (13.0 vs 22.4%, P = 0.0001), and a lower mortality rate (0.4 vs 2.1%, P = 0.007). When LA was compared with OA in elderly patients with perforated appendicitis, LA resulted in a shorter LOS (6.8 vs 9.0 days, P = 0.0001), a higher rate of discharge to home (86.6 vs 70.9%, P = 0.0001), but equivalent total charges (dollars 22,334 vs dollars 23,855, P = 0.93) and mortality (1.0 vs 2.98%, P = 0.10). When elderly patients that underwent LA were compared with adult patients (18-64 years old), they had higher total charges (dollars 16,670 vs dollars 11,160, P = 0.0001) but equivalent mortality (0.37 vs 0.15%, P = 0.20). The use of laparoscopy in the elderly has significantly increased in recent years. In general, the safety and efficacy of LA is demonstrated by a reduction in mortality, complications, and LOS when compared with OA. The laparoscopic approach to the perforated appendix in the elderly patient has advantages over OA in terms of decreased LOS and a higher rate of discharge to home as opposed to rehabilitation centers, nursing homes, or skilled nursing care. When compared with all younger adults, the laparoscopic approach in the elderly was associated with equal mortality rates even though hospitalization charges were higher. Laparoscopy may be the preferred approach in elderly patients who require appendectomy.

Aged↗
PubMed2006

Asymptomatic thrombus trapping in vena cava filters: a case series.

The prophylactic use of vena cava filters (VCFs) remains controversial. Class I data supporting the placement of prophylactic VCFs are lacking. In addition, there are concerns regarding the long-term effects of permanent VCF placement in patients with a relatively brief period of thromboembolic risk. Venous thromboembolism can be a lethal event, occurring without a prodrome. Yet, this condition is potentially preventable. The efficacy of VCFs is difficult to determine, as it is likely that when a VCF actually traps a thrombus, the event is clinically asymptomatic. We present three cases of asymptomatic thrombus trapping in VCFs, recognized through incidental radiographic studies.

Adolescent↗
PubMed2006

Utility of neurosurgical consultation for mild traumatic brain injury.

Trauma patients presenting with a Glasgow Coma Scale (GCS) score of 14-15 are considered to have mild traumatic brain injury (TBI) with overall good neurologic outcomes. Current practice consists of initial stabilization, followed by a head CT, and neurosurgical consultation. Aside from serial neurologic examinations, patients with a GCS of 15 rarely require neurosurgical intervention. In this study, we examined the added value of neurosurgical consultation in the care of patients after TBI with a GCS of 15. We retrospectively reviewed the medical records of patients presenting after blunt trauma with an abnormal head CT and GCS of 15 between January 2004 and January 2005. Patients with a normal head CT and <48 hours hospital stay were excluded. Data included demographics, mechanisms of injury, Injury Severity Score, the radiologists' dictated interpretations of the head CT, and neurosurgical interventions. Fifty-six patients met the inclusion criteria. The mean age was 41+/-2.3 years, and the mean Injury Severity Scores was 10.2 +/-0.6. Mechanisms of injury included 64 per cent motor vehicle crash, 16 per cent motorcycle crash, 13 per cent fall, and 7 per cent all-terrain vehicle crash. The initial CT scans showed 43 per cent parenchymal contusions, 38 per cent subarachnoid hemorrhage, 14 per cent subdural hematomas, and 5 per cent epidural hematomas. All patients received a routine follow-up head CT, and 16 per cent showed changes (five improved and four were worse compared with initial CT scans). None of these patients received a neurosurgical intervention, and two were transferred to a rehabilitation service. In this era of limited resources, trauma patients who present with a GCS score of 15 after mild TBI can be safely managed without neurosurgical consultation, even in the presence of an abnormal head CT scan.

Accidental Falls↗
PubMed2005

Laparoscopic adrenalectomy for malignancy.

The superiority of the minimally invasive approach to adrenal resections has been well documented for benign pathology. With technical advances and increased experience, surgeons have successfully performed laparoscopic adrenalectomies for metastatic and primary malignancies of the adrenal gland. The technique of laparoscopic adrenalectomy as it pertains to malignant lesions is presented. A review of the literature demonstrates the safety and efficacy of laparoscopic adrenalectomy for metastatic colorectal, lung, and renal tumors. For primary adrenal malignancies, radical resections can be effectively performed laparoscopically; however, continued long-term follow-up is needed to establish the minimally invasive technique as the preferred approach.

Adrenal Gland Neoplasms↗
PubMed2005

Laparoscopic restoration of intestinal continuity after Hartmann's procedure.

BACKGROUND: Colostomy closure after a Hartmann's procedure typically requires a laparotomy. It also carries the risk of significant morbidity including anastomotic leak, wound infection, and incisional hernia. The aim of this study was to review our experience with laparoscopic restoration of intestinal continuity after Hartmann's procedure. METHODS: After institutional review board approval, we retrospectively reviewed the medical records of patients undergoing laparoscopic colostomy reversal between July 1997 and July 2004. RESULTS: Twenty-two patients were identified; all patients had left colon colostomies. A laparoscopic technique was used in 21 patients, and 1 patient underwent hand-assisted colostomy reversal concurrently with right radical nephrectomy. The laparoscopic approach was successful in 20 cases, and there were 2 conversions to open (9%) secondary to dense adhesions around the rectal stump. The mean time to closure of the colostomy was 168 days (range 69-385 days). The mean operative time was 158 minutes (range 84-356 minutes). The estimated blood loss averaged 114 mL (range 30-250 mL). The average length of hospitalization was 4.2 days (range 2-6 days). Bowel function returned on an average of 3.5 days (range 2-5 days). Three patients (14%) developed postoperative wound infections. There were no anastomotic leaks and no mortality. At a mean follow-up of 14.7 months, the only long-term complication has been a small hernia at a colostomy site. CONCLUSIONS: Laparoscopic colostomy reversal after Hartmann's procedure can be performed with low morbidity and a short hospital stay. The need for conversion to open surgery is uncommon despite patients' previous surgeries. A laparoscopic approach to colostomy takedown is safe and feasible and may result in a reduction in complications and length of stay as has been seen with other minimally invasive procedures.

Adult↗
PubMed2005

Guide wire entrapment by inferior vena cava filters: an experimental study.

BACKGROUND: In situ vena cava filters are at risk for complications with the use of J-tipped guide wires. The purpose of this study was to evaluate the impact of two commonly used J-tipped guide wires on the stability of the four most recently released vena cava filters in an in vitro flow model. STUDY DESIGN: Four filters (OptEase [F1], Günther Tulip [F2], Vena Tech LP [F3], and Recovery [F4]) were inserted into an in vitro flow model. Two J-tipped guide wires (0.032-inch [GW-1], 0.035-inch [GW-2]) were passed through each filter (n = 50 passes per wire) for a distance of 10 cm. The inserter was blind as to the effects of the wire. The filters were monitored by an independent observer for adverse events occurring between the filters and the guide wires. These were defined as: migrations (>1 cm), change of position (tilt>10 degrees), and entrapment of the wire (unable to remove wire). Descriptive statistics, chi-square, and Fisher's exact test were used (p < 0.05 considered significant). RESULTS: GW-1 resulted in a lower incidence of entrapment, migration, and tilt for all filters compared with GW-2 (F1, p = 0.003; F2, p < 0.0001; F3, p < 0.0001; F4, p = 0.0004). GW-1 resulted in entrapment in 0%, migration in 7.5%, and tilt in 10.5% of insertions. GW-2 resulted in entrapment in 1%, migration in 26.5%, and tilt in 5.5% of insertions. The incidence of adverse events for GW-1 was significantly different compared with all filters (F1, 0%; F2, 46%; F3, 4%; and F4, 22%; p < 0.0001). Similarly, the incidence of adverse events for GW-2 was significantly different when evaluating all filters (F1, 12%; F2, 48%; F3, 22%; F4 60%; p < 0.0001). CONCLUSIONS: The smaller-diameter guide wire resulted in a decreased incidence of adverse events for all filters, but there is still risk for complications. Knowledge of potential complications associated with vena cava filters and the postinsertion use of guide wires are essential to avoid potential mishaps.

Catheterization↗