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PubMed1988

Surgical management of esophageal strictures.

The cases of 50 consecutive patients requiring operative treatment for esophageal strictures were reviewed to evaluate results and develop principles of management. Forty-eight had gastroesophageal reflux disease and 2 had chronic lye strictures. Of the patients with gastroesophageal reflux disease, 21 had a Barrett's esophagus. Esophageal dilations had been performed in 29 patients, 12 of whom also had undergone previous surgical procedures. Preoperative dilations by our group were used to determine further intervention. Patients with dilatable strictures were randomized to either a Nissen or a Belsey operation. In this group, there were no operative deaths, and excellent or good clinical results were obtained in 28 of 34 (82%) patients, with no significant differences noted in the outcomes between the two operations. Patients with undilatable strictures, Barrett's ulcer, or mucosal dysplasia underwent resection plus colon interposition (N = 12) or resection plus gastric interposition (N = 4). Two of the patients in the Nissen operation group later required resection and colon interposition, bringing that total to 14. Resection plus colon interposition resulted in excellent or good results in 71% of patients, with a 7% operative mortality. These results suggest that a standard transthoracic antireflux procedure can be performed with a low risk when strictures are dilatable. Excellent or good results were obtained in 82% of patients, which is equivalent to results for more complex operations. There was no significant difference in the outcome for the transthoracic Nissen procedure compared with the Belsey procedure. In addition, when required, resection plus colon interposition provided excellent or good results in 71% of the patients.

Anastomosis, Surgical↗

PubMed2000

Virtual university applied to telesurgery: from teleeducation to telemanipulation.

UNLABELLED: PROBLEM/BACKGROUND: In order to improve patient care by minimal invasive surgery (MIS), we perfected a Virtual TeleSurgical University that allows for teleeducation, teleconcertation, surgical planning and telemanipulation, through new Virtual Reality and multimedia systems. TOOLS AND METHODS: The organization of this innovative school was federated around three major research programs. First, the TESUS program focused on the teletransmission of medical information, allowing for videoconferencing around the world and telementoring. Next, the WeBS-Surg program is a multimedia continuous surgical education system on internet, that allows for teleeducation and teleconcertation between world experts in MIS. Then, the MASTER program (Minimal Access Surgery by Telecommunications and Robotics) allowed the development of the third millenium Operating room. It included Virtual Reality systems that delineate automatically anatomical and pathological structures of a patients from him CT-scan, and that allow for an interactive surgical planning and force-feed-back simulation. It also included a telesurgical robot named Zeus controlled by surgeons through telemanipulation system. RESULTS: Tests and validation shows that all these systems improved all steps of the surgical procedure: preoperatively due to a better continuous education and a computer assisted surgical planning, and peroperatively due to teleconcertation, telementoring and telemanipulation systems. CONCLUSION: Revolutionary tools for minimal invasive surgery learning, planning and performing are all ready available. These tools represents the first prototype of the computer assisted tele-robotical surgery that will be the future of surgery.

Computer Simulation↗

PubMed1997

Evaluation of video imaging prediction in combined maxillary and mandibular orthognathic surgery.

The purpose of this study was to evaluate the accuracy of the soft tissue profile "line drawings" predicted by Quick Ceph Image in combined maxillary and mandibular orthognathic surgical procedures. Preoperative (mean = 27.7 days presurgical) and posttreatment (mean = 11.5 months postsurgical) lateral cephalograms of 40 white patients (10 males and 30 females) who had completed treatment that involved orthodontics, one-piece LeFort I osteotomy, and mandibular advancement by bilateral sagittal split osteotomy with or without genioplasty were used in the study. Forty-five lateral hard and soft tissue landmarks were digitized, using the "on-screen" digitizing option, for each cephalogram and for each computer predicted posttreatment tracing. A customized analysis consisting of 24 linear and 4 angular measurements was used to analyze the differences between the actual posttreatment cephalometric landmark measurements and computer predicted landmark measurements. Statistically significant differences between the posttreatment cephalometric soft tissue profiles and the computer predicted soft tissue profiles were analyzed for the total sample, patients grouped according to: magnitude and direction of maxillary movements, adjunctive genioplasty procedure, V-Y closure of the LeFort I incision, and gender and age differences. The results indicated that for some of the soft tissue landmarks, differences were found between the posttreatment and the computer predicted profiles. Differences between the predicted and actual posttreatment soft tissue profiles may be attributed to the inaccuracy of Quick Ceph Image's default soft to hard tissue ratios when predicting the soft tissue response to combined maxillary and mandibular orthognathic surgical procedures.

Adolescent↗

PubMed2005

Preoperative embolization in spinal and pelvic metastases.

The role of preoperative embolization should be evaluated for the surgical treatment of spinal and pelvic metastases. Selective embolization was performed in 32 patients (19 men, 13 women; mean age 63.4 years) before surgery by anterior resection of spinal metastases (n = 21) or pelvic metastases (n = 11). Evaluation parameters consisted of the intraoperative blood loss, the need for blood replacement, and the operating time. There was a significant difference in blood loss and transfusion requirements in the spinal group (P = 0.02) as well as in the pelvic group (P = 0.05) compared to a nonembolized control group of spinal (n = 20) and pelvic (n = 10) metastases. The operating time in the embolized group was shorter, but the difference was not significant. Surgical revision was required in two cases in the embolized spinal group owing to necrosis of the psoas muscle. No neurological deficit was observed that could be attributed to the embolization procedure. Preoperative embolization is thus a suitable method for reducing intraoperative blood loss and transfusion requirements in hypervascularized spinal and pelvic metastases.

Acetabulum↗

PubMed2006

Pedicled fat flap reconstruction of the atrophic or "empty" paraglottic space following resection of teflon granuloma or oversized implant.

OBJECTIVES: Loss of functional and supporting architecture in the paraglottic space (PGS) necessitates augmentation to restore phonation and prevent aspiration. Our previous PGS reconstructions using an inferiorly based sternohyoid muscle flap have shown a propensity to fibrose over time, tethering the vocal fold inferolaterally. Poor voice outcomes have led us to explore other reconstructive options such as the laterally based vascularized fat flap described below. Our objectives in the present study were 1) to discuss phonosurgical options for reestablishing PGS volume after removal of an oversized implant or after definitive resection of Teflon granuloma; and 2) to understand the surgical technique, indications, and functional prognosis of the laterally based fat flap used for augmenting the "e mpty" PGS. Fourteen cases of PGS reconstruction with a laterally based subplatysmal fat flap were retrospectively investigated for indications, functional outcome, and the need for subsequent phonosurgical procedures. Preoperative and postoperative voice and videostroboscopic findings were analyzed. RESULTS: Fat flap augmentation helped achieve subjective vocal improvement in patients with an empty PGS. A subset of our patients demonstrated fat flap atrophy within 12 months, prompting revision laryngoplasty. Viable flaps were encountered in each revision, facilitating future medialization attempts. CONCLUSIONS: Fat flap reconstruction of the PGS is a versatile, beneficial adjunct for revision medialization in select cases.

Adipose Tissue↗

PubMed2002

Biological parameters on computed tomography guided fine needle aspiration biopsy from peripheral primary non-small cell lung cancer.

Computed tomography (CT) guided fine needle aspiration biopsy (CT-guided FNAB) represents the procedure of choice for diagnosing peripheral primary lung cancer before surgery. The aim of the present study was to assess the reliability of the immunocytochemical evaluation of biological parameters and DNA flow cytometry on cellular material obtained from non-small cell lung cancer (NSCLC) patients by CT-guided FNAB. Thirty consecutive CT-guided FNABs obtained from NSCLC patients were submitted both to the immunocytochemical evaluation of p53, Ki67, bcl-2 and to flow cytometric DNA analysis. p53, Ki67 and bcl-2 were assessable in 60% (18/30), 53% (16/30) and 48% (10/21) of the cases, respectively. Flow cytometric DNA analysis was performed in 19 out of the 30 cases and 74% (14/19) of the histograms were evaluable. Cytofluorimetric S-phase fraction (SPF), was obtained in 57% (8/14) of the cases. The results of the current study suggest that CT-guided FNAB from primary NSCLC patients may represent an effective practice for the evaluation of biologic parameters and could be useful as a preoperative procedure. The role of neoadjuvant chemotherapy in operable NSCLC is still under debate. We suppose that in the future the presurgical characterization of NSCLC could suggest the opportunity of a neoadjuvant systemic treatment aimed to improve the clinical outcome. Moreover, in locally advanced or metastatic NSCLC immunocytochemistry could help to predict the response to chemotherapy and/or radiotherapy, avoiding ineffective treatments and supporting the development of more rational therapies.

Biopsy, Needle↗

PubMed2004

The use of a lateral stabilizer increases the incidence of wound trouble following the Nuss procedure.

BACKGROUND: A lateral stabilizer has been used to prevent bar displacement during the Nuss procedure for pectus excavatum repair in pediatric patients. We experienced wound troubles in patients who had a stabilizer placed within them. The aim of this study was to examine the effect of a lateral stabilizer and other clinical factors on wound troubles after the Nuss procedure. METHODS: 53 patients with pectus excavatum underwent repair by the Nuss procedure. Preoperative clinical data, operative data, and postoperative complications were examined in all patients. RESULTS: A lateral stabilizer was placed in 29 of the 53 patients. Short-term results were excellent in 42 patients (79.2%). Postoperative complications involved pneumothorax requiring drainage in two patients, atelectasis in one patient, pleural effusion in three patients, deterioration of scoliosis in one patient, erythema in one patient, persistent pain in two patients, bar displacement in four patients, and local wound complications (Seroma with dermatitis due to pressure damage) in five patients. All seromas with dermatitis due to pressure damage were initially aseptic around lateral stabilizers and became infected in four patients after resection of the seroma or spontaneous perforation. Removal of both the pectus bar and lateral stabilizer was performed in two of those four patients and the lateral stabilizer was removed in the other two patients to prevent catastrophic infection such as empyema or mediastinitis. The use of a lateral stabilizer increases the incidence of wound trouble (p = 0.041). CONCLUSIONS: Although the Nuss procedure has evolved into an effective method for pectus excavatum repair, the use of a lateral stabilizer increases the incidence of wound difficulties.

Adolescent↗

PubMed2002

[A case report of hemidiaphragmatic paresis caused by interscalene brachial plexus block].

A 76-yr-old woman was scheduled for left upper extremity orthopedic procedure. Preoperative examinations were within normal limits except forced vital capacity. Interscalene brachial plexus block with 0.25% bupivacaine 15 ml, was performed under general anesthesia. Her intraoperative course was uneventful. She, however, complained of the dyspnea after removal of a tracheal tube, and Spo2 dropped to 89%. A chest X-ray demonstrated the elevation of hemidiaphragm. She was diagnosed as ipsilateral hemidiaphragmatic paresis, treated with oxygen inhalation under deep breathing for approximately one hour, and then transferred to the common ward. We conclude that respiratory movement should be carefully observed following interscalene brachial plexus block especially in geriatric patients.

Aged↗

PubMed1989

Management of neuromuscular spinal deformities with Luque segmental instrumentation.

Forty-six patients who had a neuromuscular spinal deformity were treated with arthrodesis and Luque segmental spinal instrumentation and were followed for an average of three years. Twenty-two patients had cerebral palsy and twenty-four had another neuromuscular disease. In thirty-nine patients, the arthrodesis was extended to the sacrum. Eleven patients who had severe scoliosis as well as pelvic obliquity and decompensation of the torso had a combined anterior and posterior arthrodesis; the other thirty-five patients had a one-stage posterior procedure. Preoperatively, the average scoliosis was 74 degrees; this was corrected to 39 degrees at follow-up. Final corrections were similar for scoliosis and were better for pelvic obliquity and decompensation of the torso in patients who had combined anterior and posterior arthrodesis. The results for scoliosis and pelvic obliquity in patients who had a spastic deformity were similar to the results in patients who had a flaccid deformity. Correction of decompensation of the torso was better in patients who had a spastic deformity. Postoperatively, a brace was used in half of the patients in each group; this did not appear to affect the amount of correction in either group, although the result may have been influenced by the selection process. The rate of complications was 48 per cent. Pseudarthrosis occurred in three patients (6.5 per cent). There were no major neurological deficits related to the correction or to the use of sublaminar wires. Three patients died, one in the immediate postoperative period and the other two at eighteen months and four years after the original procedure, due to causes unrelated to the operation.

Adolescent↗

PubMedDate not supplied

Laparoscopic vaginal vault suspension using uterosacral ligaments: a review of 133 cases.

The objective of our study was to describe the surgical technique of laparoscopic vaginal vault suspension using the uterosacral ligaments. In addition, we performed a retrospective analysis of this laparoscopic technique on 133 patients with advanced symptomatic vaginal vault prolapse to evaluate the efficacy and durability of this laparoscopic technique. Efficacy and anatomic outcome were assessed by the Baden-Walker halfway scoring system before and after the surgical procedure. Preoperatively, all patients showed evidence of grade 2 or greater prolapse (descent to the level of the hymen). Fifty-one patients (38.4%) had uterovaginal prolapse, and 82 patients (61.6%) had vaginal vault prolapse. The patients were reevaluated at 1, 6, and 12 months postoperatively and yearly thereafter. The postoperative follow-up ranged from 2.0 to 7.3 years. Postoperatively, 116 patients (87.2%) had no recurrence of prolapse, and 17 patients (12.8%) had recurrence of prolapse. The major complication rate was 2.25%. We conclude that laparoscopic vaginal vault suspension is a safe, efficacious, and durable alternative for the management of vaginal vault prolapse.

Adnexa Uteri↗

PubMed2003

Preoperative core needle biopsy as an independent risk factor for wound infection after breast surgery.

OBJECTIVE: Diverging findings concerning the rate of postoperative wound infections in patients undergoing breast surgery have been reported, and little is known regarding the possible risk factors for these infections and their relative importance. We assessed risk factors for wound infection, placing particular emphasis on the influence of preoperative procedures such as core needle biopsy. METHODS: In a prospective evaluation of 326 patients undergoing breast surgery, we identified risk factors for wound infections by univariate analysis and subsequent step-wise multiple logistic regression. Assessment of wound infection was based on a simple wound scoring system. RESULTS: Of the 326 patients, 50 (15.3%) developed wound infections. As expected, after univariate analysis a higher proportion of postsurgical infections was observed in patients with diabetes (33.3% versus 14.3%; odds ratio [OR] = 3.00, 95% confidence interval [CI] 1.109, 8.157; P =.03) and malignant tumors (21.2% versus 6.8%; OR = 3.716, 95% CI 1.762, 7.849; P <.001). Patients with wound infections were significantly older than those without (mean age 63.73 versus 51.44 years, P <.001). Surprisingly, patients who underwent core needle biopsy, which in most cases was performed within 1-3 days before breast surgery, were also at significantly higher risk for developing a wound infection (22.3% versus 9.6%; OR = 2.718, 95% CI 1.454, 5.076; P =.001). This effect remained unchanged when controlled for potential confounders by step-wise multiple logistic regression. CONCLUSION: In breast surgery, the independent risk factors for wound infections are older age and preoperative core needle biopsy.

Age Factors↗

PubMed1980

[Angiographic embolization of renal tumors (author's transl)].

The authors present their experience with 38 cases of renal tumors which had angiographic embolization. Embolization is electively indicated as a preoperative procedure: the 4 divided by 5 days time lapse before the operation give rise to tissue modifications which permit a better resectability of the mass. Thus embolization achieves a good demarcation of the neoplastic mass from the surrounding tissues and reduces intraoperative bleeding. Emboli may be made of different materials like: fibrin sponge (Gelfoam), acrylic resin (Bucrylate) or steel (Gianturco coil). The association of both the steel coil and one of the other two types of emboli may be the method of choice. The metallic device is indicated for main vessel occlusion, while the others are more suitable for more peripheral branches. Selective or superselective catheterization in required for emboli introduction and care must be taken when occluding the renal artery to avoid reflux and to permit surgical clamping.

Catheterization↗

PubMed1993

[Preoperative cardiological evaluation. Report of 255 cases].

PURPOSE: To study preoperative cardiological consultations in a cardiology referral center in a general hospital. METHODS: Two hundred and fifty five patients were studied between June and December 1989; the ages ranged between 16 and 82 (mean 55) years, 120 (47%) were male and 135 (53%) female. A questionnaire was applied by the physicians during consultation. RESULTS: Main symptoms were thoracic pain in 30 (11.8%) cases, dyspnea in 57 (22.4%), palpitations in 13 (5.1%). Symptoms of cardiac disease were absent in 141 (55.3%) patients. On physical examination arterial hypertension was detected in 75 (29.4%) cases and a cardiac murmur in 21 (8.2%). Diagnosis of coronary artery disease was made in 30 (11.8%) cases--13 (5.1%) with history of previous myocardial infarction, aortic valve stenosis in 5 (1.9%), other valvular heart diseases in 14 (5.5%), cardiac arrhythmias in 11 (4.3%). Heart disease was absent in 90 (35.4%) patients. Sixty-five (25.5%) patients were on drug therapy for heart diseases. Consultations were obtained for patients that had been already admitted to the hospital in 171 (67%) cases. Cardiological follow up was recommended to 150 (58.8%) patients. Seven patients died; the cause of the death was related to the primary disease. Contraindication for surgery imposed by cardiological evaluation did not occur. CONCLUSION: In this study, patients with heart disease tolerated the surgical procedures. Preoperative cardiological evaluation added useful data for postoperative care and also for long term follow-up of the patients.

Adolescent↗

PubMed1978

Physiological approach to surgery for tricuspid atresia.

A modification of Fontan's approach to the surgical management of tricuspid atresia was employed in nine patients. A valved conduit was used to create continuity between the right atrium and the surgically modified right ventricular chamber. Six patients had had previous shunting procedures. Preoperative studies revealed various degrees of hypoplasia of the right ventricle beneath relatively normal pulmonary valves. At surgery, the atrial septal and ventricular septal defects were closed, the right ventricular chamber was enlarged, and right atrial-right ventricular continuity was established with a valved conduit. There was one operative death. The eight survivors have been clinically well as long as 3 1/2 years following surgery. Postoperative cardiac catheterization was performed in five patients. Ventricularized pressure tracings were recorded in the right ventricular chambers and the morphology of the atrial and pulmonary artery pressure curves were normal. In all instances, angiography demonstrated significant enlargement of a pulsatile right ventricular chamber. Thus, in many patients with tricuspid atresia, establishment of a four-chambered, four-valved heart is feasible, both from an anatomic and physiologic standpoint.

Adolescent↗

PubMed2003

[Beta-blocker therapy and risk reduction in non-cardiac surgery].

Cardiovascular complications are important causes of morbidity and mortality with major noncardiac procedures. Preoperative cardiac evaluation aims at assessing the patient's clinical risk profile in order to provide the more cost-effective strategy to reduce the risk of cardiac complications. Among different ways to reduce the incidence of perioperative cardiac complications, compelling evidence comes from the use of beta-blockers: in the absence of absolute contraindications, beta-blocker therapy should be administered to all patients at intermediate-high risk for coronary events who have to undergo noncardiac surgery. Even if the number of patients enrolled in these studies is relatively small, the use of beta-blockers before noncardiac surgery has been shown to be associated with a significant reduction in major cardiac events so that this therapy may reduce the need for additional noninvasive tests in some groups of patients. Coronary angiography and revascularization should have the same indications as if performed in the nonoperative setting.

Adrenergic beta-Antagonists↗

PubMed1991

[Clinicopathological estimation of intra-arterial infusion chemotherapy of locally advanced breast cancer].

The effect of intra-arterial infusion chemotherapy with adriamycin as a preoperating procedure was analyzed clinicopathologically in 30 cases with locally advanced breast cancer. A clinical response rate of 53.3% was obtained by the treatment and remarkable degenerative changes of tumor cells were noted histologically in the primary lesions. But there was no relationship between histological therapeutic effect and regression rate in tumors. A recurrence rate showed a higher correlation with histological therapeutic effect in comparison with clinical therapeutic effect. Especially, non-necrosis type that tumor cells were still alive mainly in the vessels showed significantly a higher recurrence rate in comparison with a central necrosis type or focal necrosis with fibrosis and hyalinization type. The local regional recurrence rate of patients receiving intra-arterial infusion chemotherapy was lower than that of patients, as the historical controls, receiving no therapy before operation. But prognostically, there was no significant difference in a survival rate between both groups. So, after operation, other alternative or multidisciplinary adjuvant chemo-endocrine therapy seems to be necessary for improving the survival rate.

Breast Neoplasms↗

PubMed2004

Initial experience with miniature axial flow ventricular assist devices for postcardiotomy heart failure.

BACKGROUND: The recently introduced Impella Recover (Impella CardioSystems AG, Aachen, Germany) microaxial flow left and right ventricular assist devices (LVAD/RVAD) were evaluated as they provide circulatory support in the setting of postcardiotomy heart failure refractory to high-dose inotropic and intra-aortic balloon pump (IABP) support. METHODS: Between May 2002 and November 2002, the Recover LVAD was implanted in six patients (64 +/- 11 years) with acute left heart failure following coronary artery bypass procedures. Preoperative left ventricular (LV) ejection fraction was compromised (28% +/- 12%, 12% to 45%). Three patients presented with unstable circulation or cardiogenic shock following acute myocardial infarction, with a predicted mortality rate of 44% +/- 11% (EuroSCORE). Intraoperatively, severe heart failure was present with a more than 70% mortality rate predicted by the IABP score. The Recover RVAD and LVAD were combined to provide biventricular assist device (BVAD) support in one case of post-transplant graft failure. RESULTS: The Recover LVAD delivered blood flows of up to 5 L/min. A moderate degree of hemolysis and a reduction in platelet count were noted. Four patients were weaned from the LVAD after 169 +/- 34 hours, two of whom remain long-term survivors. Full recovery of graft function allowed weaning of the patient from BVAD support after six days. CONCLUSIONS: The initial experience with the Impella Recover VADs proved the new systems to be advantageous regarding the ease of implantation and device removal, low anticoagulation requirements, and advanced weaning features. In cases of severe heart failure, survival was improved by using LVADs when compared to that predicted by solely continuing IABP and drug support.

Aged↗

PubMed1998

The appropriate use of colonoscopy in the curative management of colorectal cancer.

A total of 175 patients who underwent a curative resection for a colonic (n = 130) or a rectal cancer (n = 45) between 1986 and 1992 were entered into a routine colonoscopy program. Colonoscopies were performed 1 year after the operation, and then at 2-year intervals. The findings at colonoscopy, as well as those of preoperative colonoscopy (when performed), were recorded. Eleven anastomotic recurrences were diagnosed at an asymptomatic stage, at a mean follow-up of 14 months. All of them were identified in patients with a stage B or C primary rectosigmoid cancer. Eight patients underwent another potentially curative re-operation. Only perioperative colonoscopy (preoperative colonoscopy; first postoperative colonoscopy in patients for whom the preoperative procedure was incomplete or not performed) allowed diagnosis of second cancers (n = 7) and adenomatous polyps greater than 10 mm (n = 17). Further colonoscopies detected only polyps less than 10 mm. Positive examination rates for successive follow-up colonoscopies were 15, 20 and 23%, respectively; they were significantly higher in patients who had previously had adenomatous polyps than in patients who had not: 30% versus 6% (P < 0.025), 46% vs 5% (P < 0.005) and 38% vs 11% (P < 0.025), respectively. From these data, the following recommendations are made: (1) All colorectal cancer patients should have a total colonoscopy either before (whenever possible) or soon after operation; (2) Based on results of the perioperative colonoscopy, patients: should undergo their first follow-up colonoscopy only 3 yearly (presence of synchronous adenomatous polyps) or 5 yearly (absence of synchronous adenomatous polyps) after resection; (3) In patients with stage B or C primary rectosigmoid cancer, a surveillance of the suture line by rigid proctosigmoidoscopy should be added during the first 2 postoperative years: 6, 15 and 24 months after the operation.

Anastomosis, Surgical↗